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The Ketogenic Diet: Considerations for Cancer Survivorship

  • Cancer (RA Murphy, Section Editor)
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Abstract

Purpose of Review

This article aims to evaluate the current practice of the ketogenic diet (KD) in oncology by discussing feasibility, impact on quality of life, and implications for dietetic practice. Articles discussed were selected based on an adult oncology population with emphasis on publications from the last 5 years.

Recent Findings

There is a paucity of randomized prospective trials and articles reviewed were heterogeneous in nature, limiting the ability to draw conclusions about the KDs role in cancer care and survivorship. Despite the lack of evidence, patients with cancer are interested in KD. The authors highlight barriers to supporting implementation of KD and recommend the inclusion of a registered dietitian with experience in KD to ensure safety and support the nutrition goals of patients with cancer.

Summary

Thorough, well-designed randomized control trials are needed to elucidate the potential advantages of this diet therapy in cancer care and survivorship.

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References

Papers of particular interest, published recently, have been highlighted as: •   Of importance •• Of major importance

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Authors and Affiliations

  1. Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada

    Cara Miller, Karina Austin, Lawren Fischer, Eleah Stringer & Satnam Sidhu

  2. Michael Smith Health Research BC, Vancouver, Canada

    Eleah Stringer

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  1. Cara Miller
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Correspondence to Lawren Fischer.

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Eleah Stringer is funded by Michael Smith Health Research BC and the Lotte & John Hecht Memorial Foundation. Cara Miller, Lawren Fischer, Karina Austin, and Satnam Sidhu have nothing to declare.

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Appendices

Appendix 1. Articles Reviewed

  1. 1.

    Anderson CM, Loth E, Opat E, Bodeker K, Ahmann L, Parkhurst J, et al. A phase 1 trial of ketogenic diet with concurrent chemoradiation (CRT) in head and neck squamous cell carcinoma (HNSCC). Elsevier Inc; 2016;94(4):898.

  2. 2.

    Augustus E, Granderson I, Rocke KD. The impact of a ketogenic dietary intervention on the quality of life of stage II and III cancer patients: a randomized controlled trial in the caribbean. United States; 2021;73(9):1590–600.

  3. 3.

    Cohen CW, Fontaine KR, Arend RC, Soleymani T, Gower BA. Favorable effects of a ketogenic diet on physical function, perceived energy, and food cravings in women with ovarian or endometrial cancer: a randomized, controlled trial. 2018 Aug 30;10(9):1187. https://doi.org/10.3390/nu10091187.

  4. 4.

    Dobrowolska K, Regulska-Ilow B. The legitimacy and safety of using alternative diets in cancer. Poland; 2020;71(3):241–50.

  5. 5.

    Elsakka AMA, Bary MA, Abdelzaher E, Elnaggar M, Kalamian M, Mukherjee P, et al. Management of glioblastoma multiforme in a patient treated with ketogenic metabolic therapy and modified standard of care: a 24-month follow-up. 2018;5. Available from: https://www.frontiersin.org/article/10.3389/fnut.2018.00020.

  6. 6.

    Haskins C, Cohen J, Kotecha R, Kaiser A. Low carbohydrate diets in cancer therapeutics: current evidence. 2021;8. Available from: https://www.frontiersin.org/article/10.3389/fnut.2021.662952.

  7. 7.

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  8. 8.

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  9. 9.

    Iyikesici MS. Feasibility study of metabolically supported chemotherapy with weekly carboplatin/paclitaxel combined with ketogenic diet, hyperthermia and hyperbaric oxygen therapy in metastatic non-small cell lung cancer. England; 2019;36(1):446–55.

  10. 10.

    Iyikesici MS. Long-term survival outcomes of metabolically supported chemotherapy with gemcitabine-based or FOLFIRINOX regimen combined with ketogenic diet, hyperthermia, and hyperbaric oxygen therapy in metastatic pancreatic cancer. Switzerland: The Author(s) Published by S. Karger AG, Basel; 2020b;27(1):31–9.

  11. 11.

    İyikesici MS, Slocum AK, Winters N, Kalamian M, Seyfried TN. Metabolically supported chemotherapy for managing end-stage breast cancer: a complete and durable response. İyikesici et al.; 2021 Apr 26;13(4):e14686.

  12. 12.

    Kämmerer U, Klement RJ, Joos FT, Sütterlin M, Reuss-Borst M. Low carb and ketogenic diets increase quality of life, physical performance, body composition, and metabolic health of women with breast cancer. 2021 Mar 23;13(3):1029. https://doi.org/10.3390/nu13031029.

  13. 13.

    Khodabakhshi A, Akbari ME, Mirzaei HR, Mehrad-Majd H, Kalamian M, Davoodi SH. Feasibility, safety, and beneficial effects of MCT-based ketogenic diet for breast cancer treatment: a randomized controlled trial study. United States; 2020a;72(4):627–34.

  14. 14.

    Khodabakhshi A, Akbari ME, Mirzaei HR, Seyfried TN, Kalamian M, Davoodi SH. Effects of ketogenic metabolic therapy on patients with breast cancer: a randomized controlled clinical trial. England: Elsevier Ltd and European Society for Clinical Nutrition and Metabolism; 2021 Mar;40(3):751–8.

  15. 15.

    Khodabakhshi A, Seyfried TN, Kalamian M, Beheshti M, Davoodi SH. Does a ketogenic diet have beneficial effects on quality of life, physical activity or biomarkers in patients with breast cancer: a randomized controlled clinical trial. 2020b Aug 22;19(1):87–020-00596-y.

  16. 16.

    Kirkham AA, King K, Joy AA, Pelletier AB, Mackey JR, Young K, et al. Rationale and design of the diet restriction and exercise-induced adaptations in metastatic breast cancer (DREAM) study: a 2-arm, parallel-group, phase II, randomized control trial of a short-term, calorie-restricted, and ketogenic diet plus exercise during intravenous chemotherapy versus usual care. 2021;21(1):1093. Available from: https://doi.org/10.1186/s12885-021-08808-2.

  17. 17.

    *Klassen PN, Goldenberg BA, Lambert P, Vagianos K, Kim CA. Ketogenic and low-sugar diets for patients with cancer: perceptions and practices of medical oncologists in Canada. Germany; 2020 Nov;28(11):5243–9.

  18. 18.

    Klein P, Tyrlikova I, Zuccoli G, Tyrlik A, Maroon JC. Treatment of glioblastoma multiforme with “classic” 4:1 ketogenic diet total meal replacement. 2020;8(1):24. Available from: https://doi.org/10.1186/s40170-020-00230-9.

  19. 19.

    Klement RJ. Restricting carbohydrates to fight head and neck cancer-is this realistic? 2014 Sep;11(3):145–61.

  20. 20.

    Klement RJ. The emerging role of ketogenic diets in cancer treatment. England; 2019 Mar;22(2):129–34.

  21. 21.

    Klement RJ, Bandyopadhyay PS, Champ CE, Walach H. Application of Bayesian evidence synthesis to modelling the effect of ketogenic therapy on survival of high grade glioma patients. 2018 Aug 20;15(1):12–018-0084-y.

  22. 22.

    **Klement RJ, Champ CE, Kämmerer U, Koebrunner PS, Krage K, Schäfer G, et al. Impact of a ketogenic diet intervention during radiotherapy on body composition: III—final results of the KETOCOMP study for breast cancer patients. 2020a;22(1):94. https://doi.org/10.1186/s13058-020-01331-5.

  23. 23.

    **Klement RJ, Meyer D, Kanzler S, Sweeney RA. Ketogenic diets consumed during radio-chemotherapy have beneficial effects on quality of life and metabolic health in patients with rectal cancer. Germany:. Springer-Verlag GmbH Germany, part of Springer Nature; 2022 Feb;61(1):69–84.

  24. 24.

    **Klement RJ, Schäfer G, Sweeney RA. A ketogenic diet exerts beneficial effects on body composition of cancer patients during radiotherapy: an interim analysis of the KETOCOMP study. 2020b;10(3):180–7. Available from: https://www.sciencedirect.com/science/article/pii/S2225411018310046.

  25. 25.

    **Klement RJ, Sweeney RA. Impact of a ketogenic diet intervention during radiotherapy on body composition: II. Protocol of a randomised phase I study (KETOCOMP). England: European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd; 2016a Apr;12:e1–6.

  26. 26.

    **Klement RJ, Sweeney RA. Impact of a ketogenic diet intervention during radiotherapy on body composition: I. Initial clinical experience with six prospectively studied patients. BioMed Central; 2016b;9:143. Available from: https://pubmed.ncbi.nlm.nih.gov/26946138https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779584/.

  27. 27.

    **Klement RJ, Weigel MM, Sweeney RA. A ketogenic diet consumed during radiotherapy improves several aspects of quality of life and metabolic health in women with breast cancer. England: Elsevier Ltd and European Society for Clinical Nutrition and Metabolism; 2021 Jun;40(6):4267–74.

  28. 28.

    van der Louw EJTM, Olieman JF, van den Bemt PMLA, Bromberg JEC, Oomen-de Hoop E, Neuteboom RF, et al. Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study. 2019 Jun 21;11:1758835919853958.

  29. 29.

    Ma DC, Anderson CM, Rodman SN, Buranasudja V, McCormick ML, Davis A, et al. Ketogenic diet with concurrent chemoradiation in head and neck squamous cell carcinoma: preclinical and phase 1 trial results. by Radiation Research Society. All rights of reproduction in any form reserved; 2021 Aug 1;196(2):213–24.

  30. 30.

    Mann SDO, Sidhu MDO, Gowin KDO. Understanding the mechanisms of diet and outcomes in colon, prostate, and breast cancer; malignant gliomas; and cancer patients on immunotherapy. 2020 Jul 26;12(8):2226. https://doi.org/10.3390/nu12082226.

  31. 31.

    Maroon J, Bost J, Amos A, Zuccoli G. Restricted calorie ketogenic diet for the treatment of glioblastoma multiforme. United States; 2013 Aug;28(8):1002–8.

  32. 32.

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Appendix 2. Recommended Resources on Implementation of the Ketogenic Diet and Monitoring in Cancer Care

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Miller, C., Austin, K., Fischer, L. et al. The Ketogenic Diet: Considerations for Cancer Survivorship. Curr Nutr Rep 11, 682–694 (2022). https://doi.org/10.1007/s13668-022-00439-8

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