An ongoing trial is seeking to find out if a patient with an MPN can improve their health status through nutritional interventions.
Currently, the only way to prevent progression of myeloproliferative neoplasms (MPNs) is through stem cell transplant. However, there are other factors, such as inflammation, that can affect the disease. This leads researchers to believe that diet may play a key role for these patients.
A group of researchers NUTRIENT trial (NUTR
itional Intervention among myE
rial), which will ultimately help craft dietary interventions for people with MPNs. The study kicked off with an online survey of more than 900 patients with MPNs of which 95 percent said they would be interested in changing their diet if it could change the disease course.
In an interview with CURE
, two researchers on the study, Robyn M. Scherber, M.D., Ph.D., fellow at the Oregon Health and Science University and research consultant at the Mayo Clinic in Arizona and Angela Fleischman, M.D., Ph.D., assistant professor in the department of Medicine, Division of Hematology/Oncology at UC Irvine, discussed what the future of nutrition intervention may be for patients with MPNs.
Can you talk about your reasoning behind running this trial?
Essential thrombocythemia (ET), polycythemia vera (PV) and myelofibrosis (MF) are unique types of blood cancers. Unlike many other blood cancers that may take someone’s life in a short timeframe, these diseases, called the myeloproliferative neoplasms (MPNs), can remain unchanged for years and require only minimal treatment. Although treatments are available, these do not ultimately prevent progression of the disease with the exception of bone marrow transplantation. This long disease course gives us a unique perspective to understand how cancers develop over time and gives us an unparalleled opportunity to intervene early in the disease with treatments that are safe and potentially effective.
Inflammation plays a critical role in MPN disease. First, inflammation contributes to the features of the disease that patients experience on a day-to-day basis. This includes disease-related symptom burden and features of the disease such as blood clots, bone marrow scarring and low or high blood counts. Secondly, inflammation contributes to MPN disease progression. Inflammation helps to drive the cancer cells to grow as well as contributes to fibrosis, or scarring of the bone marrow, that can develop over time. Our most common current therapies for MPNs often impact inflammation, including aspirin, interferon (that has both the role of stimulating as well as suppressing inflammation) and Jakafi (ruxolitinib). There is also some early data in MPN mouse models that over-the-counter anti-inflammatories may impact the disease course. However, despite these treatments many patients are considered “low risk” and are not eligible for medication treatments. In these patients there remains an unmet need to help control symptoms and reduce inflammation.
What makes us think that diet may be important for MPN patients? Over our years of study, we have found that patients with MPNs can have symptoms that may be specifically impacted by diet. This can include getting full too quickly, abdominal discomfort, nausea and weight loss. We have also found that individuals with MF often have unusually low cholesterol levels and large amounts of weight loss that can negatively impact survival. On the other hand, patients with ET and PV tend to be overweight and that can contribute to the development of inflammation. To date, there have been no studies regarding the diet of MPN patients. In turn, we, as physicians, cannot offer clear recommendations in terms of what the best diet may be for MPN patients or how the dietary needs of MPN patients may differ. When we look at more well-studied diets such as the Mediterranean diet, there is evidence that markers of inflammation as well as markers of abnormal blood clotting in the blood improve. In diseases where there are lots of inflammation, such as inflammatory bowel disease, there have been trials that have demonstrated that a diet that emphasizes low inflammation can not only make patients feel better, but help to improve the disease itself. This got us thinking about the relevance of diet in MPNs. What if we were to look at how a diet low in processed foods and high in foods rich with anti-inflammatory compounds? Could this change not only patients’ symptoms, but help to slow the progression of the disease itself?
What do you expect to find? Are these expectations based on similar studies done for other cancer types?
It is our hope that changing the diet for MPN patients has two effects — both to improve symptoms as well as to improve inflammation. Although different diets have been looked at in other cancer types, these trials are usually small and few studies have looked specifically at types of blood cancers. There are currently other non-medication study efforts that are ongoing for MPN patients. In an online yoga
intervention, we found that patients felt significantly better after having participated in a 12-week program. There are also efforts underway to see how a cognitive/behavioral intervention using Acceptance and Commitment Therapy (ACT) changes fatigue in MPN patients.
From our perspective, we feel very confident that patients will likely feel better if they eat better and use a diet that helps them to improve disease-related symptoms such as abdominal discomfort, boating, constipation, getting full too fast, nausea and weight loss. The major question is whether we can make a diet that improves inflammation and possibly change the natural course of MPN disease. This may mean less blood clots, improved blood counts, less bone marrow scarring and even a smaller spleen. This may also mean less growth of cancer cells that ultimately means less transformation of MPNs into other more aggressive cancer types.
How is this trial being run?
We are still in the beginning stages of our study of diet in MPN patients, called the NUTRIENT Trial. Although we are the two main investigators, we have a wonderful team of collaborators that are helping us with this project. Dr. Ruben Mesa at the Mayo Clinic in Arizona brings with him his expertise in symptom burden and non-pharmacologic therapies in MPN patients. Dr. Carol Johnston is a registered dietician with expertise in dietary interventions and anti-inflammatory properties in food.
We are currently working on collecting information what will help us to create a dietary intervention. We recently completed an online nutritional survey among MPN patients. The preliminary results from over 900 MPN patients indicate that over 95 percent of those surveyed would be interested in changing their diet if it could improve symptoms and 98 percent would be interested in changing their diet if it could change the disease course. The next part of this study will be to better understand the dietary needs and preferences of MPN patients. On April 22, 2017 we will be holding a patient education conference at the University of California, Irvine. After this conference we will be holding a series of “focus” or interest groups to talk about what we can do to tailor the diet. Our goal is to learn from patients directly about what they want in a dietary intervention and how we can make it easy to learn about and follow a new diet.
Over the summer of 2017 we will take some time to make a dietary intervention, which will likely include an online educational curriculum with recipes and even videos explaining the diet. In late 2017 and into early 2018, we anticipate having our first smaller group of patients enrolled to try out the curriculum and to help us determine if the diet is feasible and something that people can follow. We will also be looking at whether symptoms and blood markers of nutrition and inflammation change while on this diet. If all goes well, over the next few years we will look into making this a large online trial where we will enroll people from across the country to look at the impact of diet compared to usual care.
Can patients still participate? How so, and what are the benefits of doing so?
There are still many options for individuals to participate! As we mentioned above, we will be holding a series of focus groups in April 2017, so if anyone is in the Irvine area we welcome you to come to our educational conference and stay for the focus/interest groups. During this time, we will also welcome you to some good food and get to meet other individuals with similar blood disorders as well as talk with some leaders and educators in the field of MPNs. We have put together http://www.wearempn.org/
where you can find more information about the conference and focus groups. You can also sign up for our mailing list that will let us keep you updated on future trials as they become available.
Is there anything else you'd like to mention?
It is tempting to tell everyone to go out and try to eat anti-inflammatory foods, but until we know more about the diet, including whether the diet is feasible and even safe, we would recommend continuing to eat a normal and healthy diet. However, we do ask that you stay tuned in and potentially consider helping us with further trials down the road to help us better understand how diet impacts MPN disease.