Nutritional Interventions Have Potential to Improve Cancer Outcomes

When a patient faces cancer treatment, the prevailing nutritional advice often boils down to a simple recipe: just get the calories in. However, many providers are moving away from this advice and instead investigating how tailored nutrition strategies could enhance treatment efficacy. Many oncologists and oncology registered dietitians (RDs) want to see more evidence-based, personalized nutritional interventions derived from large-scale randomized controlled trials (RCTs). They, along with their patients, want to understand how nutrition can improve outcomes, not just for specific cancer types, but for each patient's unique physiological and nutritional needs. “Nutritional interventions can modulate treatment-related toxicities, improve patient outcomes, and potentially enhance the therapeutic efficacy of treatments,” said Dawn Mussallem, DO, DipABLM, Lifestyle Medicine Physician at the Mayo Clinic in Jacksonville, FL. Malnutrition Before & During Treatment Individualized nutritional care plans can also help patients address deficiencies, which are often present before treatment begins. “Only about 6-12 percent of U.S. adults meet criteria for ideal metabolic health,” Mussallem added. “This shortfall is tied to diets heavy in added sugars, refined carbs, and unhealthy fats—hallmarks of ultra-processed foods.” Malnutrition is linked to both low body mass index and obesity, the latter being a paradoxical form where excess energy intake coexists with micronutrient deficiencies. These deficiencies may result from poor diet, limited food access, absorption issues, or metabolic changes linked to obesity-related inflammation (Obesity Facts 2022; https://doi.org/10.1159/000519503). “For cancer patients, maintaining a diet that supports both metabolic health and treatment tolerance is especially important,” she added. The National Cancer Institute reports that malnutrition independently predicts survival outcomes with sarcopenic obesity linked to the worst prognosis. An estimated 40-80 percent of cancer patients experience malnutrition during their illness, often caused by the tumor itself and its treatments. This condition significantly reduces quality of life and increases treatment-related toxicities (J Clin Med 2019; https://doi.org/10.3390/jcm8081211). Through targeted nutritional support—such as dietary counseling—patients can preserve or even improve their nutritional status (CA Cancer J Clin 2022; https://doi.org/10.3322/caac.21721). Ideally, a nutritional assessment and individualized plan would occur prior to treatment, Mussallem noted. Driving More Evidence-Based Guidelines Still, there is a lack of high-quality evidence linking dietary interventions to cancer outcomes. One meta-analysis found that most RCTs on dietary interventions in cancer are small and focus on nonclinical endpoints, such as adherence to diet rather than directly measuring the impact of dietary interventions on cancer outcomes (J Natl Cancer Inst 2024; https://doi.org/10.1093/jnci/djae051). On the other hand, obesity is well-established as a risk factor for poor cancer outcomes, and weight management has been shown to improve recurrence rates and overall survival, particularly in breast and prostate cancer patients. This suggests that properly designed dietary interventions may lead to improved cancer outcomes (J Natl Cancer Inst 2024; https://doi.org/10.1093/jnci/djae122). Is there any one diet to recommend? Not surprising, the answer is no. As part of its Exercise, Diet, and Weight Management During Cancer Treatment guideline, ASCO sought to consolidate all of the evidence from RCTs of dietary interventions during cancer treatment (J Clin Oncol 2022; https://doi.org/10.1200/JCO.22.00687). The expert panel concluded that there was insufficient evidence to recommend any particular diet to reduce treatment-related side effects or improve cancer outcomes. Often, a cancer diagnosis motivates patients to make lifestyle changes, but it can be difficult to provide evidence-based advice given how few data are available, added Jennifer A. Ligibel, MD, Professor of Medicine at Harvard Medical School and Senior Physician in the Breast Oncology Center at the Dana-Farber Cancer Institute. In the absence of quality data and advice from their oncology teams, people may seek advice from alternative sources. Many times, patients will find information about a more extreme diet or use of a supplement from a preclinical study and believe it will translate into benefit for their cancer, Ligibel noted. “As much as we all want to see this field move forward, it is important to wait for research in humans. Human cancer tends to be much more complex than is reflected in pre-clinical models, and people can make themselves miserable by believing that they need to adhere to a strict diet based on data from an animal model or cell line.” Ligibel added, “A healthy diet is an important thing for people no matter what stage of cancer they have or what treatment they are receiving. However, we need more data to be able to tell people exactly what they should be eating to recover more quickly from their treatment or to be more likely to avoid a recurrence or progression of their cancer.” With more RCTs on dietary approaches during treatment, oncologists and RDs can better understand whether diet impacts side effects of therapy and the trajectory of the cancer itself, she noted. At Dana-Farber, several studies are investigating diet and exercise interventions during and after treatment. In the largest of these, Ligibel is leading the Breast Cancer Weight Loss (BWEL) Trial, a Phase III trial testing the impact of a telephone-based weight loss program on disease recurrence and survival in 3,180 women with breast cancer in the U.S. and Canada. Preliminary results indicate that the weight loss program significantly improved metabolic and inflammatory biomarkers linked to cancer recurrence and overall health in patients with obesity treated for early breast cancer. Results were presented at the 2024 San Antonio Breast Cancer Symposium. Primary results of the study testing the impact of the weight loss program on cancer recurrence are anticipated in the next few years. Emergence of Precision Nutrition Other oncologists are exploring precision nutrition—tailoring dietary interventions to a patient's unique nutritional needs and tumor profile—to enhance cancer treatment outcomes. Nicole Simone, MD, Radiation Oncologist and researcher at Jefferson Health in Philadelphia, is pioneering the integration of precision medicine with precision nutrition to transform cancer care. By tailoring diets to both the patient and their tumor, she aims to optimize treatment outcomes. “We found that, at the basic science level, changing nutrient types and not overfeeding allows radiation and chemotherapy to work better,” Simone said. “It improves survival in models and now is translated to patients as well. It's an area we need to focus more on.” While reducing fats and processed sugars—known to fuel cancer growth in preclinical models—is a universal recommendation, Simone takes personalization further. Using genetic sequencing, she identifies the molecular drivers of a patient's tumor and crafts dietary plans based on their unique molecular and metabolic profile. For instance, in patients with tumors driven by c-MYC overexpression, Simone recommends a diet rich in pectin (found in oranges and carrots), choline (from egg yolks, yogurt, and almonds), and turmeric (present in spices and mustard). Collaborating with researchers at Johns Hopkins University and Harvard, her NIH-funded lab is working to expand these dietary strategies to target additional gene mutations. In an upcoming neoadjuvant prostate cancer trial, Simone will use a patient's tumor molecular profile and body mass index (BMI) to design a dietary intervention between biopsy and prostatectomy. The intervention's impact will be measured using the GenomeDX score, which assesses the risk of metastasis. Simone anticipates the intervention will reduce BMI, lower key biomarkers, and decrease the likelihood of cancer spreading. “Weight management is critical, especially as some cancer therapies slow metabolism and cause metabolic dysfunction,” noted Simone, who largely focuses on hormonally driven cancers like breast and prostate. “The same caloric intake that once worked for a patient to maintain their weight may no longer be effective. We must guide patients on how dietary changes can impact outcomes.” Collaborating With RDs As evidence-based recommendations grow, RDs like Rosa Becerra-Soberon, MSOM, RDN, LDN, CBP, BI, can tailor nutritional care plans. Working with Top Nutrition Coaching in Tampa, FL, she recommends patients “see an RD to create a nutrition road map and involve patient family and friends, which can make a big difference in their nutritional status and ability to continue treatments. The key is to have a nutritional plan before starting a treatment, during, and after to prevent common side effects like nausea and vomiting, which reduce appetite.” Once a plan is made, Becerra-Soberon recommends weekly follow-ups with patients to monitor nutritional status and adjust their plans accordingly. Experts say it is crucial to evaluate cancer patients throughout their treatment journey, as nutritional status is dynamic and factors such as comorbidities impact a patient's nutritional needs (Nutrients 2021; https://doi.org/10.3390/nu13061980). Becerra-Soberon has seen firsthand how nutritional interventions improve quality of life. “I had a patient who was in a wheelchair because he was so weak and undernourished. After two nutrition interventions, he was no longer using the wheelchair. His dream was to ride his bicycle, which he did. Nutrition is a game changer for the patients.” Sarah Washburn, MS, RDN, CSO, Oncology Dietitian Nutritionist at the Simms Mann UCLA Center for Integrative Oncology, also helps patients reach their goals. She considers the whole person—not just nutritional status but also their cultural considerations, other health conditions, personal preferences, and specific diagnoses. She calls out head/neck, gastrointestinal, and gynecological cancers as being challenging to ensure optimal nutrition during treatment. According to a review published in Nutrients, the risk of malnutrition is particularly prevalent in cancers of the pancreas, esophagus, and other gastrointestinal organs, as well as head and neck and lung cancers (2021; https://doi.org/10.3390/nu13061980). At UCLA Health, Washburn collaborates with oncologists, surgeons, nurses, social workers, psychologists, and others to deliver holistic care. She emphasizes educating oncologists on the importance of early nutrition consultations. This team approach integrates diverse expertise, resulting in a nutrition referral process from various team members, including nurses and clinical social workers, while RDs participate in rounds and other multidisciplinary activities. Patients at cancer centers without dedicated dietitians can still access nutritional support through reputable organizations. The Academy of Nutrition and Dietetics connects patients with board-certified specialists in oncology nutrition in their area. Additionally, the Leukemia and Lymphoma Society offers online access to dietitians for personalized guidance during treatment. Patients can also find resources on websites such as oncologynutrition.org, cancer.org, and aicr.org. Washburn is hopeful about the future of nutrition in cancer care. “We need more clinical trials and better methodologies to study nutrition to understand the nuances of how specific foods can impact treatment outcomes,” she said. “Precision nutrition is the buzzword right now, but we don't want food to feel mechanistic. It should be enjoyable, sustainable, and empowering.” Washburn concluded, “People need to be heard. By listening to their concerns and helping them navigate the science, we can make nutrition a powerful tool in their cancer journey.” Erin DiGirolamo is a contributing writer.

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