Il digiuno preventivo e terapeutico in oncologia

Lizzia Raffaghellolizziaraffaghello@gaslini.org

Laboratorio di OncologiaIstituto Giannina Gaslini

Genova

• Calorie restriction is defined as reduction of calorie intake by 20–40% withoutmalnutrition.

• Fasting is distinct from calorie restriction, in which the meal frequency is notmaintained.

• Starvation is instead a chronic nutritional insufficiency that is commonly used as asubstitute for the word fasting, particularly in lower eukaryotes, but is also usedto define extreme forms of fasting, which can result in degeneration and death.

• Intermittent fasting represents an alternate day fasting or 2 days a week fasting.

• Periodic fasting lasts three/four days every 3-4 weeks.

• Fasting mimicking diet causes changes in markers associated with stressresistance or longevity (IGF-1, IGFBP-1, ketone bodies and glucose) that aresimilar to those caused by fasting .

FASTING AND CALORIE RESTRICTION

• Calorie Restriction (CR) without malnutrition is the most powerful nutritionalintervention that has consistently been shown to increase maximal and averagelifespan in a variety of organisms, including yeasts, worms, flies, spiders, fish androdents.

• CR extends longevity by preventing chronic diseases, and by preserving metabolic andbiological functions at more youthful-like state.

• In rodents, the CR-mediated preventive effects are widespread with major reductionsin the occurrence and/or progression of cancer, nephropathy, cardiomyopathy,obesity, type 2 diabetes, neuro-degenerative disease, and several autoimmunediseases.

• Moreover, unlike ad-libitum fed rodents, ~30% of the CR rodents die in old agewithout any pathological sign of disease.

• CR also increases life span and protects against diabetes, cancer, and cardiovasculardisease in rhesus monkeys, and in humans it causes changes that protect againstthese age-related pathologies.

CALORIE RESTRICTION

Colman RJ et al., Science, 2009

Calorie restriction (CR) has been reported to extendlifespan and healthspan.

CR reduced by 50% the incidence of cardiovasculardisease and cancer, and completely preventedglucose intolerance and type 2 diabetes.

CR protects monkeys against age-associatedsarcopenia and grey matter volume shrinkage ofseveral key subcortical regions.

CALORIE RESTRICTION IN NON HUMAN PRIMATES

FASTING-INDUCED METABOLIC, MOLECULAR, CELLULAR AND ORGAN SYSTEM ADAPTATIONS

Longo VD et al. Trends in Pharmacological Sciences 2010

NUTRIENT SENSING PRO-AGING AND PRO-CANCER PATHWAYS

Longo VD et al. Science, 2003

Longo VD et al. Science Translational Medicine 2011

GHR DEFICIENCY IS ASSOCIATED WITH A MAJOR REDUCTION IN PRO-AGING SIGNALING, CANCER AND DIABETES IN HUMANS

No cancer, no diabetes in GRH deficient subjects

Longo VD et al. Science Translational Medicine 2011

Levine ME et al. Cancer Metabolism 2014

• Low protein diet during middle age is likely to be beneficial for cancer prevention, overall mortalityand possibly diabetes through a process that may involve regulation of circulating IGF-1 and insulinlevels.

• In contrast, at older ages, in which IGF-1 decline possibly increasing the risk of frailty and mortality,low protein intake should be avoided.

• At older ages moderate/high protein intake should be adopted in order to guarantee a positivenitrogen balance, maintain healthy weight and muscle mass, regain muscle lost from sacopenia andprotect against frailty

LOW PROTEIN INTAKE IS ASSOCIATED WITH A MAJOR REDUCTION IN IGF-1, CANCER, AND OVERALL MORTALITY IN THE 65 AND YOUNGER BUT NOT

OLDER POPULATION

A PERIODIC DIET THAT MIMICS FASTING PROMOTES MULTI-SYSTEM REGENERATION, ENHANCED COGNITIVE PERFORMANCE, AND HEALTHSPAN

Brandhorst S et al. Cell Metabolism 2015

FMD: 34-54% REDUCTION OF CALORIE INTAKE WITH A COMPOSITION OF 10% PROTEINS,35-45% CARBOHYDRATES 45-55% FATS

• FMD reduces total, visceral and subcutaneous adipose fat.

• FMD causes a reduction in the liver, heart and kidneys weight but notin the brain, lungs and spleen. Renal function and histology do notchange upon diet. Upon refeeding there is a liver muscle- and nervoussystem- regeneration and rejuvenation. Reduction of tissue mineraldensity that occurs during aging is attenuated by FMD.

• FMD reduces the percentage of tumors (lymphoma) and theinflammation incidence (reactive lymphonodes and chronic hepaticinflammation) and dermatitis.

• In the blood, FMD promotes rejuvenation of the blood profile, reversesthe shift in the lymphoid to myeloid ratio (responsible of increasedanemia and myeloid malignancies) and the decline of platelets andhemoglobin. The rejuvenating effect of FMD were due to an inductionof mesenchymal progenitors which usually decrease during aging.

• FMD improves motor learning and short/long memory thanks to itsability to promote neurogenesis.

• Chemotherapy (CT) has established itself as one of the pillars of cancertreatment.

• The benefits of CT are frequently paid at a very high price since patientsexperience side effects that can be very severe or even lethal, limit CT doseintensity and can persist indefinitely in post-treatment survivorship.

• However, toxicity remains an underestimated issue in the management of cancerpatients.

• Indeed, toxicity is rarely the focus of clinical investigations since, historically and“understandably”, clinicians have been more concerned with cure than toxicity.

CHEMOTHERAPY: EFFICACY AND TOXICITY

Cell-sufficiency in growth signals

Insensitivity to anti-growth signals

HYPOTHESES

1. Short-term starvation (STS) increases resistance to chemotherapy in normal cells byreducing proto-oncogene product activity and causing entry into a non-dividing“protected mode”.

2. In contrast, tumor cells expressing activated oncogenes would be unable to turn on theprotective response due to uncontrolled activation of growth promoting signalingcascades.

.PROLONGED FASTING REDUCES IGF-1/PKA TO PROMOTE HEMATOPOIETIC-STEM-CELL-BASED REGENERATION AND REVERSE IMMUNOSUPPRESSION

Cheng CW et al. Cell Stem Cell 2014

FASTING REGULATES EGR1 AND PROTECTS FROM GLUCOSE- AND DEXAMETHASONE-DEPENDENT SENSITIZATION TO CHEMOTHERAPY

Di Biase S, et al Plos Biology 2017

Dexamethasone and rapamycin, commonlyadministered to cancer patients, elevateglucose and sensitize cardiomyocytes andmice to the cancer drug doxorubicin (DXR).Such toxicity can be reversed by reducingcirculating glucose levels by fasting or insulin.

In yeast, glucose activates PKA to accelerateaging by inhibiting transcription factorsMsn2/4. t fasting or glucose restrictionregulate PKA and AMP-activated proteinkinase (AMPK) to protect against DXR in partby activating the mammalian Msn2/4ortholog early growth response protein 1(EGR1).

Increased expression of the EGR1-regulated cardioprotective peptides atrialnatriuretic peptide (ANP) and B-typenatriuretic peptide (BNP) in heart tissue mayalso contribute to DXR resistance.

“CHEMOTHERAPY TOXICITY- WHEN LESS IS MORE”

Laviano A, et al. N Eng J Med 2012

X

DIFFERENTIAL STRESS RESISTANCE MODEL INDUCED BY FASTING

Lee, Raffaghello et al. Sci Transl Med. 2012

In the presence of chemotherapy drugs, fasting can promote the protection of normal butnot cancer cells (differential stress resistance, DSR) since oncogenic pathways play centralroles in inhibiting stress resistance and therefore cancer cells are unable to switch to thestress response mode.

Tumor cells that were fasted appear to attempt to compensate for the lack of nutrients andgrowth factors by increasing translation and, as a result, may consume even more energy,eventually promoting oxidative stress and cell death.

REDUCED LEVELS OF IGF-I MEDIATE DIFFERENTIAL PROTECTION OF NORMAL AND CANCER CELLS IN RESPONSE TO FASTING AND IMPROVE

CHEMOTHERAPEUTIC INDEX

CP: Cyclophosphamide; 5-FU: 5-Fluorouracil; DXR: DoxorubicinLee, Raffaghello et al, Cancer Research, 2010

DIFFERENTIAL STRESS RESISTANCE (DSR) AGAINST 2 CYCLES OF HIGH-DOSE DXR IN MELANOMA BEARING LID MICE

Di Biase S et al. Cancer Cell 2016

FASTING-MIMICKING DIET REDUCES HO-1 TO PROMOTE T CELL-MEDIATED TUMOR CYTOTOXICITY

FMD increases the levels of common lymphoid progenitor cells (CLPs) and of circulating CD8+

lymphocytes.

The combination of the FMD and doxorubicin increased the number of cytotoxic CD8+ tumor-infiltrating lymphocytes (TILs).

The FMD-induced recruitment of TILs was mediated by heme oxygenase-1 (HO-1) and wassignificantly correlated with a lower number of regulatory T cells in the tumor bed.

Bianchi G et al. Oncotarget, 2015

A MODEL OF SHORT TERM STARVATION EFFECTS ON THE METABOLISM OF THE TUMOR CELL

FASTING PLUS TYROSINE KINASE INHIBITORS IN CANCER

Caffa I, et al. Oncotarget 2016

FASTING ENHANCES THE RESPONSE OF GLIOMA TO RADIOTHERAPY

Safdie F et al., Plos One 2012

1. Ten patients affected by different tumors fasted 48-140 hours before and 5-56 hours after chemotherapy.

2. Fasting is safe and can reduce chemotherapy-associated side effects such as fatigue, weakness, and gastrointestinal side effects

3. In those patients whose cancer progression could be assessed, fasting did not prevent the chemotherapy-induced reduction of tumor volume or tumor markers

THE EFFECTS OF SHORT-TERM FASTING ON TOLERANCE TO (NEO) ADJUVANT CHEMOTHERAPY IN HER2-NEGATIVE BREAST CANCER PATIENTS: A

RANDOMIZED PILOT STUDY

Stefanie de Groot et al. BMC Cancer. 2015.

Fasting partially prevented chemotherapy-induced reductions in erythrocyte as well as thrombocyte counts and DNA damage in leucocytes

• Fasting for 72 h around chemotherapy administration is safe and feasible for cancerpatients.

• The COMET assay indicated reduced DNA damage in leukocytes from subjects who fastedfor ≥48 h.

SAFETY AND FEASIBILITY OF FASTING IN COMBINATION WITH PLATINUM-BASED CHEMOTHERAPY

Dorff TB et al. BMC Cancer. 2016Dorff TB et al. BMC Cancer. 2016

1.Short-Term Fasting During Chemotherapy in Patients With Ovarian and Breast cancerpatientsBerlin, Germany, NCT01954836, completed.

2.Effects of Short-term Fasting on Tolerance to Chemotherapy in Breast cancer patientsLeiden University Medical Center, NCT01304251, completed.

3. Short-Term Fasting Before Chemotherapy in Treating Patients With CancerMayo Clinic, NCT01175837, recruiting.

4.Short-Term Fasting: Impact on Toxicity in patients with advanced urothelial and pulmonary malignanciesUSC Norris Cancer Center, NCT00936364, completed.

5. Fasting and Nutritional Therapy in Patients With Advanced Metastatic Prostate CancerBerlin, Charitè University, NCT02710721, recruiting.

NIH.GOV APPROVED CLINICAL STUDIES ON SHORT-TERM FASTING DURINGCHEMOTHERAPY IN CANCER PATIENTS

• A major limitation to the clinical application of fasting is represented by patientcompliance because patients are already under a very stressful condition and canview fasting as an additional stress.

• Only 28% of the patients said they would be willing to undergo a complete 3-4day fasting as required by these protocols. However, 70% of the patients saidthey would agree to a dietary intervention as long as this were in the form of adefined calorie-restricted diet.

• It has been designed a specific very low calorie/low aminoacid medical foodregime which results in similar benchmark changes in IGF-1, IGFBP1, glucose,insulin, ketone bodies and oxidative stress resistance compared to fasting andachieves maximal protection against chemotherapy toxicity in mice.

FASTING MIMICKING DIET

FASTING MIMICKING DIET PROTECTS AGAINST THE TOXICITY OF DOXORUBICIN IN ANIMAL MODELS

FMD

FMD

FMDFMDFMDFMDFMD

FMD

FMD

Umpublished resultsUmpublished results

FASTING MIMICKING DIET DELAYS THE TUMOR GROWTH IN COMBINATION WITH CHEMOTHERAPY IN ANIMAL MODELS

FMD +

Umpublished results

ONGOING CLINICAL STUDIES WITH FASTING MIMICKING DIET AND ENROLLED PATIENTS AS OF MARCH 31th 2016

Adriana AmaroUlrich Pfeffer

Functional Genomics, IRCCS AOU San Martino - IST, Genoa

Silvia RaveraDepartment of Pharmacy,

University of GenoaGenoa

Giovanna BianchiRoberto MartellaChiara Traverso

Vito PistoiaLaboratorio di OncologiaIstituto G. Gaslini, Genoa

Valter LongoUniversity of Southern California,

Los Angeles; IFOM, Milan

Laura EmioniteMichele Cilli

Animal Facility, IRCCS AOU San Martino - IST Genoa

Cecilia MariniGianmario Sambuceti

Nuclear Medicine Department,University of Genoa and IRCCS AOU

San Martino – IST, Genoa

Irene CaffaAlessio Nencioni

University of GenoaGenoa