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Nutrition and Life-style Guidelines for People with Cancer

Sandra Goodman PhD, John MacLaren and Walter Barker PhD

Journal of Nutritional and Environmental Medicine. Vol 4 No. 2: Pages 199-214. 1994.

http://informahealthcare.com/doi/ref/10.3109/13590849409034555

 

Consensus Statement based on a National Nutritional Seminar

held in Bristol on 20 July 1992. The statement was drawn up on behalf of the seminar participants by an independent working party, with Dr Sandra Goodman as the chief author.

Sandra Goodman Phd, John MacLaren, Walter Barker Phd
Journal of Nutritional and Environmental Medicine Jan 1994, Vol. 4, No. 2, Pages 199-214

Abstract

The significance of nutritional and life-style guidelines for people with cancer is examined in this consensus document. It is based on a seminar convened by the Bristol Cancer Help Centre, when more than 20 nutritional, medical and other professionals were asked to review and discuss all aspects of nutrition related to cancer care. Subsequently, a seminar working party compiled the consensus document. The broad range of issues addressed include: the desirability for flexible approaches to individual circumstances; the importance of and the principles of selection concerning the selection of high quality food and its preparation; the potential of premier quality nutritional supplements; and the need for laboratory assessment for individuals with cancer. The document offers a detailed list of foods to be eaten liberally, in moderation, and those to be avoided; it also includes lists of suggested daily supplement levels. The issues of individual empowerment in relation to individual treatment and care are critically explored.

Keywords: nutrition, cancer, diet, life-style, supplements, food, empowerment

Historical Introduction

The Bristol Cancer Help Centre, which hosted the Seminar, was founded in 1980 in response to the urgent unmet needs of people with cancer, needs which were not addressed at the time, nor accommodated by the NHS.  As reflected by Dr Michael Weir, Medical Director of the Centre during 1992, "the NHS approach of removing the tumour is now being shown to have very definite limitations ...  there was no real reflection of what we were trying to achieve ...  no proper preventive programme, no screening for treatment or rehabilitation ..."

Since its opening by Prince Charles in 1983 at Grove House in Clifton, the Bristol Cancer Help Centre has been an innovative pioneer in providing accommodation facilities and supportive advice to a wide cross-section of people about many aspects of cancer care and treatment.  While public attention may have focussed in the early days on the so-called "Bristol Diet",[1] in reality the Centre provides a well-rounded and professional medical, educational and counselling service, offering the public sound training and advice on diet, stress reduction, relaxation and visualisation, massage and healing.  In the words of one member of the Centre's staff, "our basic reason for being here is to hold people who are in terrible distress through that preliminary period when all is chaos in their lives, and help them emerge with a plan of action which makes sense to them.  In the process of this assessment, education and information giving, we also want to achieve the function of empowerment... finding a programme that is meaningful to them as individuals." 

Research published in The Lancet,[2] showing a negative correlation between treatment at Bristol and survival, has been shown to have been fundamentally flawed in many aspects, and The Bristol Cancer Help Centre has continued to strive to base its work on information from a wide range of reputable sources and to offer highly professional medical, educational, counselling and other therapeutic services.

Since the Centre was founded in 1980, medical and nutritional research on cancer has bur­geoned, pointing to the important links between nutrition, the promotion of robust health and immunity from disease, and the prevention of cancer.[3]  Numerous epidemiological studies have demonstrated that a diet low in fat and high in fibre, much of it derived from whole grains, fruit and vegetables, offers significant protection from cancer and other diseases.[3,4-11]  Published research has corroborated the significant preventive and therapeutic benefits of certain immune-enhancing and free radical inhibitory nutrient supplements.[3,12-21]  These research findings have already been incorporated into government policy papers in the UK,[22] Europe and the US,[23] urging the public to adopt healthier diets and lifestyles;[24]  research data based on individuals in those countries who eat these healthy diets reflect a significantly lower incidence of cancer.[3,25-30]

In order to provide a wide forum for a review and discussion  of all aspects of nutrition relating to cancer care, The Bristol Cancer Help Centre convened a seminar in July 1992 under the chairmanship of Dr.  Walter Barker of the University of Bristol.  It was attended by 22 profes­sionals drawn from diverse disciplinary backgrounds including nutritional research, medical practice, epidemiology, dietary therapy, and the agricultural and health food industries.

Transcripts of the full proceedings of the Seminar were then edited by a smaller working party of participants who met in the autumn to discuss further and clarify issues raised in the Seminar.   They decided on the framework and broad contents of a Consensus Statement.  Dr. Sandra Goodman, a member of the working party, wrote the draft statement for circulation and review by all the Seminar participants.  A number of amendments suggested by participants have been incorporated into this final document.

The nutritional and lifestyle guidelines offered within the Consensus Statement are thus a reflec­tion of the wide-ranging nature and depth of the practical and philosophical debate about the fundamental issues raised at the Seminar.

Only two participants did not want their names appended.  The list of the remaining Seminar participants appears at the end of the end of the document.

Research substantiating many of the findings reflected in the Consensus Statement is drawn from a wide base in the scientific literature.[3]  A considerable number of these and many other refer­ences are being collated by the Bristol Cancer Help Centre and will be available for consulta­tion.[3]

The Range of Issues Discussed

In addition to a detailed review and discussion of specific foods and dietary supplements recom­mended for people in various stages of their cancer treatment programme, in which consensus was largely reached, important issues were debated concerning psychological, philosophical, medical and lifestyle approaches to cancer treatment, on which there was also general consen­sus.  These included:

1. The uniqueness of each individual situation with respect to medical condition, constitution, personality and outlook on life.
2. The need for a flexible rather than prescriptive approach to any dietary, counselling and treatment programme.
3. The requirement, as far as possible, for accurate laboratory assessment of the individual's nutritional status.
4. The importance of individual psychological and dietary counselling.
5. The need for increased awareness of the importance of nutrition for health, the promotion of a diet rich in whole, unprocessed foods, and the therapeutic value of dietary supplements both as an adjunct to cancer treatment and within a health-maintenance programme.
6. The recognition of the deep significance attributed to and comfort derived from food, and the need to confront the widespread existence of eating disorders which affect people with cancer as well as the public at large.
7. The continued need to co-ordinate a wholly integrated approach to cancer treatment, encompassing the full range of treatment options  -  including the provision of sufficient time to enable the individual to give his/her fully informed consent and be maximally empowered in the programme to be undertaken.
8. The vital importance of addressing and implementing quality of life issues, including stress reduction, exercise, recreation and enjoyment of fulfilling personal goals.
9. The need to inform people of the existence of a broad range of specialised diets and allergy testing services, and the necessity of meeting the specialised dietary needs of people with can­cer.
10. The need to confront the financial consequences of these recommendations and to work towards making nutritional supplements and nutritional-status laboratory tests more  widely available to people with cancer on restricted incomes.
    These areas of debate are elaborated upon in this statement, following the presentation of the nutritional and lifestyle guidelines proposed by the participants.

Guidelines for Food and Drink

The Importance of High Quality Nutrition

"We are what we eat".  What is taken into our bodies as food and drink provides the nutrients which strengthen the immune system, build protein, muscle and connective tissue and literally fuel every metabolic process from thinking, breathing and digestion to the elimination of waste.  Despite the considerable divergence of philosophical and dietary approaches represented on the Seminar panel, there was consensus on the importance of obtaining the highest quality of nutrients from food, especially for people with cancer.  It was felt strongly that the medical profession does not accord enough importance to nutrition as a factor in ill-health and as a means of re-achieving good health, despite the existence, within the medical profession itself, of a highly regarded branch of medicine known as “Nutritional Medicine”, and despite the availabili­ty of considerable expertise in nutritional counselling from professionally qualified dietary therapists.

Cancer provokes great stress on the entire metabolic functioning processes of assimilation, digestion, and absorption of nutrients, and the elimination of waste products.  These processes are vital to maintaining liver function, regenerating free radical quenching enzyme systems such as glutathione peroxidase and superoxide dismutase, keeping the cytochrome electron transport systems functioning, and enabling the immune system, including T-lymphocytes, antibodies, natural killer cells and macrophages to attack, engulf and destroy foreign invaders.  With the complex processes of abnormal cell division, proliferation and invasion which occur with cancer, there is a great requirement for food to provide high levels of easily assimilable, immune- and metabolically regenerating nutrients.[31]

Principles of Dietary Selection and Composition

There was broad agreement that there is no one correct diet and that every person should, within the general guidelines provided, be encouraged to choose the food which suits and fits in with the numerous variables pertinent to his or her situation.  In other words, although there are a plethora of diets which claim to combat cancer, including raw diets such as Gerson[32] and cooked diets such as Macrobiotics,[33] the panel felt that while these might have merit for individuals at some stage of their own programmes, many of these programmes are rigid and do not take into account the individual's personal circumstances.  Practices associated with these pro­grammes, such as fasting and enemas, were beyond the scope of inquiry of this group.  Never­theless, there was agreement that people expressing interest in such approaches should be pro­vided with information on how to contact the relevant organizations.

The over-riding emphasis in diet selection is to eat and drink foods which are as ‘pure’ and chemically unadulterated as possible.  This pertains to water, fresh produce, grains, meat, fish, dairy produce and eggs.  Selection should be made from a  wide variety of fresh produce, whole food or food which has suffered the least amount of processing, preferably grown organically, or with minimal application of pesticides. 

Some of the concerns voiced about eating meat, fish, eggs and dairy produce pertained to their environmental and/or chemical contamination through the widespread agricultural practices of feeding livestock with antibiotics and hormones, thus adding to potential dietary sources of toxicity.  While there was little or no support for a rigid adherence to vegetarian or vegan regimes, there was widespread acknowledgement that whole grains, vegetables and fruits offer the most assimi­lable and least stressful food for the digestive system.[34-36]  These groups of food do not overload or overwork the liver with chemical poisons, as may be the case with meat, chicken and eggs, are less mucous-forming and do not usually provoke the allergic reactions which may occur with dairy products.[37]

Foods and Substances to Avoid or Consume in Minimal Amounts[3,22]

Tobacco.  The numerous deleterious effects of smoking and its links with cancer, heart disease and hypertension do not need to be re-emphasised here.  In addition to depressing immune func­tions, smoking also drains Vitamin C levels, inhibits pancreatic function, and may have an adverse effect upon B vitamins.  Everyone should be encouraged to give up smoking for health reasons, even more so if they have cancer.

Alcohol.  As with smoking, the adverse effects of excessive alcohol are legion.  Alcohol depletes body stores of B vitamins, calcium, magnesium and zinc, and disrupts essential fatty acid metabolism.  Excessive alcohol consumption also damages the liver, brain, nervous system and heart, and increases the risk of developing cancer of the liver, oesophagus, larynx and mouth.  High doses on any one occasion can be particularly damaging.

Tea, coffee and caffeine drinks.  A powerful central nervous system stimulant, caffeine has widespread effects on digestion, cardiac action, blood pressure and cholesterol levels.  Con­sumption of tea reduces the absorption of iron by two-thirds and inhibits the absorption of zinc, which is vital for immune function.

Excessive salt, chemical preservatives and processed foods.  A diet rich in fresh, whole foods will have a balanced proportion of minerals to maintain the body's fluid and electrolyte balance.  Excessive salt, often derived from eating processed and prepared foods to which salt has been added, is linked to high blood pressure.  Many of the preservatives added to processed and prepared foods provoke toxic and allergic symptoms, and thereby contribute to an already tox­ified metabolism and over-taxed immune system.  Refined and processed foods such as white flour and rice, which have the vitamins, minerals and fibre of the seed coat removed, are often devoid of much nutritional value;  such foods should be eaten in their natural forms, i.e. as whole grain flour and brown rice.

Sugar.  Consumption of refined, simple sugars, including white sugar, brown sugar and even honey, is linked to a wide range of damaging health conditions, including cardiac disease, hyper­tension and high cholesterol, diabetes and hypoglycemia, gastrointestinal disease, gallstones, kidney stones and renal failure, obesity, tooth decay, reduced resistance to infection, skin condi­tions and allergies.  A diet rich in fresh foods will provide an ample store of complex carbohy­drates for energy and metabolism.

Saturated fat, hydrogenated margarine, processed polyunsaturated fats, deep-fried foods.  Diets high in saturated and polyunsaturated fat content contribute in complex ways to cancer and heart disease, the two major  killers in ‘developed’ countries.  This is due to the numerous immune inhibitory and enhanced inflammatory effects of these fat products which, due to their high arachidonic content, favour synthesis of leukotrienes;  these promote inflammatory reactions and series-2 prostaglandin products which increase blood clotting.  In addition to the negative role of polyunsaturated fats in prostaglandin metabolism, there is also the danger of free radical forma­tion from hydrogenated fats and heating of polyunsaturated oils.  Olive oil, a mono-unsaturated oil, extra virgin grade, should preferably be used for cooking, and cold-pressed, unrefined polyunsaturated oils such as safflower, sunflower, corn and soya oils can be used in salad dress­ings.  The use of small amounts of butter is preferred over margarines, which are almost all hydrogenated and polyunsaturated.  Patients with essential fatty acid deficiencies may need laboratory investigation and specific recommendations on fat sources.

Red meat, pink meat, smoked and cured meats.  There is an increased risk of cancer, especially colon cancer, with even moderate consumption of red and pink meat (pork).  There are also the cancer-causing effects of the chemicals used to smoke and cure meats.  This is in addition to the overworking of the liver in its efforts to detoxify and process hormone and antibiotic residues.

Foods to Eat in Moderate Amounts[3,22]

Eggs.  Due to the high levels of saturated fat, the  remote possibility of salmonella infection and the possible presence of residues of antibiotics, egg consumption  -  a good source of vitamin B₁₂, especially for people who avoid meat  -  should not be more than 4 to 7 per week.

Dairy Products.  Because of the high saturated fat content of dairy products, their tendency to be mucous-forming, and the allergic reactions which a significant minority of people have to dairy products, the consumption of most dairy products, other than low-fat yogurt, should be reduced where possible.

Fish and White Meat.  Fish is an excellent source of protein which is easily assimilated and can be eaten once per day.  Due to concerns over chemical pollution and the use of antibiotics in fish farming, deep sea fish are arguably freer from such contamination.  Oily fish are particularly recommended, such as salmon, tuna, mackerel, herrings and pilchards;  they are excellent sources of omega-3 essential fatty acids.  Because of the chemical feed, hormones and antibiot­ics used in the poultry industry, white meat (chicken and turkey) should be eaten only once or twice per week  -  ideally these should be organically grown or at least Conservation grade.  Fish and white meat can be boiled, grilled, broiled, baked, stewed, stir-fried, sliced and eaten in salads, pureed and eaten as a dip (taramasalata).

Foods to Eat Liberally[3,22]

Wholegrains, 3-4 servings per day.  Brown and wild rice, barley, oats, millet, rye, wheat and corn are excellent sources of complex carbohydrates, vitamins, minerals, protein and fibre;  they are exceedingly low in fat.  Individuals who are allergic or intolerant to wheat and corn should avoid or minimize intake of these grains.  Also available in less whole form such as, for example, steel-cut oats, bulgar wheat, corn grits or buckwheat flakes, extruded into pasta or ground into whole-grain rather than refined flour, grains can be pressure-cooked, boiled or steamed, and  provide the basis for many delicious, nutritious and satisfying meals.

Vegetables, 3-4 servings each day.  Many vegetables, including broccoli, Brussel sprouts, cauli­flower, cabbage, carrots, beets and leafy greens, kale, turnip greens, mustard greens and dande­lion greens, are excellent sources of B-carotene, which has been shown in laboratory and epidemiological studies to have anti-tumour effects.  An enormous range and variety of vegeta­bles abound, including immune-enhancing onions, garlic and root ginger.  Certain  classes of fungi, like the Shitake mushroom, have anti-viral  properties.  Potatoes are an excellent source of complex carbohydrates and have a good content of Vitamin C.  Vegetables may be liquefied and consumed as juices, eaten raw in salads, whole, chopped, sliced and shredded, boiled, steamed, sauteed, braised, stewed or stir-fried, or fried in patties (onion and cauliflower bhajis).  Instead of merely dressing up a meat or fish dish, vegetables, combined with grains, seeds and nuts, can provide colourful, low-fat and nutritious meals.

Fruits, 3-4 servings each day.  Again, a wide selection should be encouraged from the enormous variety of fruits available.  Citrus fruits such as oranges, lemons, limes and grapefruits are rich in Vitamin C, while nectarines, apricots, bananas, plums, melons and mangoes are rich in beta-carotene.  With year-round supplies available throughout the UK, fruits provide fibre, complex sugars, vitamins and minerals.  Fruit can be eaten raw, juiced, stewed, cooked, dried (prefera­bly not sulphured) and rehydrated.

Legumes (Pulses) - Peas, Beans and Lentils, 1-2 servings per day.  Peas, beans and lentils provide important sources of protein, fibre, vitamins and minerals;  they are very low in fat.  Again, a wide variety of legumes are available - adzuki beans, kidney beans, black-eyed beans, soybeans, navy beans, mung beans, chick peas, lima, pinto and butter beans, plus an equally varied assortment of lentils.  Legumes can be sprouted (alfalfa and bean sprouts) and eaten in salads, pressure-cooked, boiled, stewed, pureed or eaten as a paste (such as humous, a blend of chick peas, garlic, lemon juice and olive oil).

Seeds, several servings per day.  Sesame and sunflower seeds are low in fat, a good source of protein, Vitamin E and essential fatty acids, and rich in minerals, particularly phosphorous, calcium and potassium.  Pumpkin seeds are exceptionally rich in phosphorus.  Seeds can be eaten whole, chopped and mixed with nuts and dried fruits, or sprinkled on to cereal.

Nuts. These provide an abundant source of complete protein, good sources of Vitamins A, B and E, as well as the minerals calcium, phosphorus, potassium, iron and magnesium.  Nuts such as almonds, cashews, hazelnuts, macadamia, peanut, pecan and pistachio are also excellent sources of mono-unsaturated as well as poly-unsaturated fats.  Hazel nuts are one of the best nut sources of the Essential Fatty Acid (EFA) Linoleic acid, as well as selenium, while pistachio nuts are the best source of iron.  Nuts should not be combined with animal protein, as this combination is not well digested.

Water. Filtered to remove chemical and mineral contaminants, water should be consumed liberally throughout the day.  In addition to water with lemon juice/ginger, hot or room temperature, herbal teas and coffee substitutes can be drunk in moderation.  Very cold and iced drinks should never be drunk, as these shock the digestive system.  The same caution applies to boiling hot drinks.  Vegetable and fruit juices can also be consumed several times per day.

Additional Nutritional and Lifestyle Suggestions

Number and Frequency of Meals

Three or four small meals throughout the day are preferred over one or two large meals, as this maintains better blood nutrient and glucose levels and encourages better digestion and assimila­tion of food.

Personal and Psychological Support

Stress is a major factor in cancer, and everything possible should be done to reduce anxiety and fear and to promote calmness and psychological well-being.  Eating in a peaceful and cheerful environment, slowly and with awareness, gratitude and enjoyment, and paying particular atten­tion to thorough chewing, will promote greater psychological harmony.  It is difficult to over­come pain, depression, self-pity and anger, especially when confronted with the drastic effects of cancer and its treatment; these feelings need to be felt, explored and expressed;   hopefully this in time can lead to a more balanced equanimity.[38]

Exercise

Movement and exercise enhance circulation and lymphatic cleansing, and promote the release of the body's own neuro-endorphin pain0 and depression-relieving chemicals.  Even moderate exer­cise improves and maintains muscle tone and cardio-vascular fitness and thus is beneficial to good health.[39]  Exercise is broadly interpreted here to include a wide range of activities, from gentle stretching, Tai Chi and Yoga to walking, swimming, and more vigorous activities.  As with the dietary guidelines, exercise ought to be relaxing, non-competitive and non-prescriptive.  The duration and level of strenuousness should be entirely at the discretion of the individual, whether this includes a few moments of stretching, a half hour's brisk walk or playing golf or tennis.  The amount of exercise undertaken will depend upon the person's general fitness, energy level and motivation.  If the person has been accustomed to leading a highly active life, then cutting off exercise could lead to depression, and individuals should be encouraged to par­ticipate in activities from which they derive enjoyment.

Enjoyment and Fulfilment

At a time of crisis, there is often a perception by people that events in their lives are out of control and that other people are making decisions which will determine whether they live or die.  To some greater or lesser degree this in fact may be true, depending on the situation; however, calm reflection and support for the individual may provide him/her with the empowerment which will enable the regaining of control of his/her life.  One practical sug­gestion is that individuals should set aside a standard and set time of the day  -  without answer­ing telephone calls or the door  -  which they devote to doing something they really enjoy or want to do.  This time could be spent in reflection, meditation, reading, painting, or anything else of the individual's choosing.  The act of focusing upon one’s own ‘special time’ can greatly enhance self-motivation and self-determination.  Individuals should be encouraged and supported to enable them to do things which they find enjoyable and fulfilling.

Guidelines on Nutritional Supplements

The Role and Importance of Supplements

There has been a major debate among various professional groups and organizations within the health industry about whether or not individuals should obtain their nutrients from food, or whether there is a need to take supplements.  Extreme positions are taken at either end of the spectrum, with some dietary groups, such as Macrobiotics, who focus greatly on the health-providing properties of certain groups of foods, arguing that taking supplements is akin to taking drugs, and is therefore unnatural. 

At the other extreme are programmes such as the Life Extension Programme and the  individualized programmes of various nutritional  practitioners who recommend high doses of a large number of vitamins, minerals and other immune-enhancing formulations.  Certain specialised cancer diets, such as Gerson, focus greatly upon detoxification and immune enhancement through colon cleansing, liver flushes, and raw juices, while Chinese and Ayurvedic medicine have special powerful herbs for cancer treatment. 

Suffice it to say that for people who have cancer, where the standard medical treatment includes radiation treatment and chemotherapy using powerful drugs, the niceties of debate about whether vitamins should be describable as drugs because of their therapeutic function, would appear to be nonsensical.  A wealth of research published during the past few decades, in the most prestigious of scientific and medical journals, has documented the anti-tumour, immune-enhancing and free radical quenching properties of numerous vitamins and minerals, in both animal and human studies.[3]

Recommendations for Individual Nutritional Assessment

These guidelines are appropriate for general use, but the overwhelming opinion of the panel was that a more accurate picture of the individual's nutritional status would emerge if laboratory tests were used to determine the actual body levels of these nutrients, since certain minerals, for example iron, compete for receptor sites and thus block the absorption of certain minerals, for example zinc;  while tea, to cite a different example, greatly inhibits the absorption of iron, which can be re­stored by the injection of Vitamin C.[40]  Moreover, the reason for a particular deficiency may be due to its non-absorption rather than its deficiency in the diet. 

In the light of these and other considerations, there was general agreement that in the absence of precise nutritional data, the recommendations cited can serve only as general guidelines.  However, as noted above, the participants strongly supported:

1. individual nutritional assessment;
2. the more widespread availability of laboratory nutritional tests;
3. greater incorporation of nutritional therapy into the standard medical treatment of people with cancer;
4. increased research into the use of nutritional therapy as adjuncts to chemo and radiotherapy, on the grounds that nutritional supplements can greatly reduce some of the worst side-effects of these treatments. 

General Guidelines for Nutritional Supplements

The Seminar participants suggested levels of nutritional supplements which would be appropriate for individuals in both the active and maintenance stages of cancer treatment (Table 1). These nutrients are obtainable from high quality multi-vitamin/mineral, anti-oxidant and individ­ual Vitamin formulations supplied within a number of preparations on the market.  Comments and elaborations from the Seminar participants about these and other supplements are included here as additional explanation.

                                         Table 1 Suggested Daily Supplement Levels[41]

Nutrient	Active Cancer	Maintenance Level
Vitamin A/	10,000 IU	7,500 IU
Beta-Carotene	25,000 IU	10,000 IU
Vitamin B complex	50 mg	50 mg
Vitamin C	6-10 gm	1-3 gm
Vitamin E	200-400 IU	100 IU
Zinc (elemental)	15-25 mg	15 mg
Selenium	200 mcg	100 mcg
Chromium GTF	100 mcg	50 mcg
Magnesium	100-200 mg	100-200 mg

 

 

 

 

 

 

 

 

 

Vitamin A and B-Carotene

Low serum levels of Vitamin A are correlated with an increased risk of cancer, while beta-caro­tene, a precursor to vitamin A and one of nature's most potent anti-oxidants, has been shown in published research to inhibit tumour formation.[42]  Due to the greater potential risks of taking large doses of Vitamin A, the majority of participants favoured the use of beta-carotene, except when individuals are unable to convert beta-carotene to Vitamin A.   It was noted that beta-carotene will in future have to be expressed in milligrams not in IUs, and also noted that the US uses a different formula for conversion from the UK and European pharmacopoeias.

Vitamin B complex

B vitamins should preferably be taken in the form of a B complex.  Higher doses than those shown in Table 1 should only be taken on laboratory evidence of a vitamin B deficiency.  Vitamin B₆ should not normally be taken on its own unless there is a proven deficiency.

Vitamin C

There has been more scientific research documenting Vitamin C's extensive therapeutic properties than on any other single nutrient (with the possible exception of iron).[43]  Vitamin C enhances the immune function of B and T cell lymphocytes, has extensive anti-viral activity, and is a potent anti-oxidant, working on its own and in conjunction with Vitamin E.[44]  It also plays a powerful role in cholesterol synthesis, the regulation of arteriosclerosis and has been used exten­sively in cancer treatment.[45]

Due to a genetic mutation, humans have lost the ability to synthesize Vitamin C, whereas most animals retain the capacity to generate massive levels of Vitamin C as the need arises.4[6]  An overdose of Vitamin C is virtually impossible  -  the only side effect of taking more than the body requires is diarrhoea;  in fact, one of the methods used to determine the body's actual need of Vitamin C at a given time is to titrate to bowel tolerance, that is, to the level just below the onset of diarrhoea.

Studies carried out over a ten-year period by Cameron and Pauling in Scotland indicated that 10 gms of Vitamin C per day improved the quality of life and survival of cancer patients over those of a control population.[47]  The inability of American researchers to replicate these findings has been attributed by Pauling and others to the research teams' failure to observe the full protocol for the required period.[48,49]

It was generally agreed that Vitamin C should be taken in divided doses 3-4 times per day.  There was divided opinion between the acid and salt forms and no general agreement about the best form to take.  It was noted that Vitamin C reduces the side effects of chemotherapy and radiation therapy;[50]  the panel was not aware of any reasons for stopping Vitamin C supplementation during radiation or chemotherapy.  The suggestion was made to request the drug companies to research the positive interactions between Vitamin C and their chemotherapy drugs.

Vitamin E

Vitamin E is a potent anti-oxidant which helps in the elimination of free radicals, particularly in partnership with Vitamin C.[51,52]  Suggestions that Vitamin E may be oestrogenic need to be verified.

Omega-6 Fatty Acids

These fats are essential. When supplements are needed, organically grown Evening Primrose Oil is superior.  It should not be solvent-extracted and it should be handled and stored in a way that minimizes oxidation.

When linseed oil is used as a mixed essential fatty acid supplement, it should be cold-pressed and stored in a refrigerator.  Nitrogen or argon is used to displace the air in the container to help prevent oxidation.  Note that the linseed oil used on furniture and cricket bats is toxic and must never be used as a supplement.

There was a general consensus that in the absence of a proven deficiency, omega-6 supplements, including Evening Primrose Oil, should not be given to people with hormone-related cancers.  However the evidence for this view still needs clarification.[53]

Omega-3 Fatty Acids

These are also essential.[54-55]  Supplements are available in the form of linseed oil and high quality fish oils.  See also references to fish and white meat above.

Calcium

Supplemental calcium is indicated only if dietary sources of calcium do not equal 1000-1500 mgs daily.

Magnesium

Since magnesium is often deficient in stressful conditions, supplemental magnesium is indicated if laboratory tests show a deficiency.  Patients with renal (kidney) problems should avoid this supplement.

Zinc

Zinc is vital for the metabolism of Vitamin A and has important roles in many of the body's systems, including its immune functions, maintaining the integrity of sense organs, reproduc­tion, mental function and wound healing.[41]  People with cancer may have an increased need for zinc,[56,57] and anorexics may not receive adequate dietary sources of zinc.  Zinc supplementation may reduce copper absorption, while various foods interfere with zinc absorption, including soya, cow's milk, iron supplements, wholewheat bread and bran.  Despite the fact that zinc is a tissue growth factor, a consensus was reached that 15-30 mg elemental zinc was a totally safe dosage for people with cancer.  Zinc should be taken separately from other supplements and not with food.[41]

Selenium

Epidemiological research has indicated that low selenium levels are correlated with an increased risk of cancer,[58,59] while animal studies indicate that selenium inhibits tumour formation.[60-63]  Selenium is also required for the anti-oxidant enzyme glutathione peroxidase, an integral part of the body's defences against free radicals.  It was generally agreed that the optimal supplementa­tion level  -  preferably of seleno-methionine  -  was 200 mcg per day and that selenium doses of 800 mcg could be excessive.

Chromium GTF

Chromium functions as an insulin co-factor which potentiates insulin levels.  The preferred form is Chromium GTF (glucose tolerance factor) in which chromium is combined with B₃ (nicotin­ic acid) and three amino acids.  It has been shown that 98% of people in the US are chromium deficient after the age of 25.  It was generally agreed that 100 mcg per day chromium was appropriate for people with cancer.[41]

Manganese

Manganese and zinc levels are linked, so that if zinc is deficient it is likely that manganese will also be deficient.[41]  Since manganese induces metallothionein, the major zinc-transport protein, manganese supplements could be given for several days as a mechanism to kick-start zinc uptake into normal cells.  However it was agreed that general manganese supplementation was not necessary unless there was a severe zinc deficiency.

Copper

Although copper levels are often elevated rather than depressed, it is important to determine whether copper is deficient, especially if zinc and manganese are being supplemented, since zinc reduces absorption of copper.

European Moves to Restrict Access to Supplements

As a highly relevant aside, it should be noted that the UK is currently considering whether to accept EC regulations requiring the re-classification as drugs of nutritional supplements in any quantity above minute doses, making the sale of any larger quantity a prescription-only item, and thereby restricting public access to these life-saving and therapeutically active products.[64]  It should be emphasized that while adverse reactions from vitamin supplements are exceedingly rare and death due to that cause virtually unknown, the medical profession and pharmacological industry have long acknowledged the exceedingly serious and often life-threatening side-effects of many, if not most pharmaceutical drugs.

Nutritional Supplements and Chemo and Radiotherapy

There was general agreement that the immune-enhancing and anti-oxidant effects of various supplements offer positive health support to individuals with cancer, and it was reported that these supplements often counteracted many of the side effects of chemo and radiotherapy.[50,65-69]  The seminar participants were unaware of any research or other evidence pointing to a recom­mendation for the cessation of supplementation during chemo and radiotherapy treatment.  Research by the drug companies into the basis of the positive interactions between these nutri­ents and chemotherapy drugs was suggested. 

Other Related Aspects of Nutrition and Cancer Treatment

More Time Needed Prior to Treatment

There was general consensus that in most cases people need more time to consider their situation before embarking on a treatment programme for cancer.  There is seldom justification for immediate hospital admission.  Time is needed to consider the diagnosis, to explore fully the treatment options and to have all their ramifications fully explained.[38]  There may well be a need to build up the individual's immune and nutritional status to better withstand some of the negative impact of chemo and radiotherapy treatments. 

Given that in certain cancers the long range morbidity and mortality statistics of people treated with chemotherapy and radiotherapy are no better than those not treated in these ways,[70] there was considerable concern among many of the seminar participants about the damage to the immune and organ systems, provoked by such aggressive treatments.[31,38,49,71-72]  There was also serious concern about secondary and tertiary cancers provoked by radiation treatments in the first instance.[73,74]  It was felt that if people are to be subjected to treatments which in themselves may provoke new cancers or other serious conditions, they should be informed of the level of risk and encouraged to choose what they see as the best option.

Higher Profile for Nutritional Prevention and Treatment Guidelines

With research documenting evidence of a significant dietary link to many cancers, there was general consensus among seminar participants about the limitations of medical education regard­ing the crucial role played by good nutrition in building robust health, or, by poor nutrition in contributing to the development of cancers and other illness.  These limitations have led to an ignorance among many in the medical profession and among many oncologists in particular, of the crucial significance of nutritional factors in both aetiological and therapeutic terms.  It was felt that there is an urgent need for nutritional research information to be better incorporated into mainstream medical practice and medical training.[22,75]  The fact that a great deal of this research has been undertaken and published by medical teams adds to the need to ensure wider propagation of what is already known in this field.[3] 

Special Dietary Needs of People with Cancer

There is a need to address the dietary problems of people unable to digest fibre following cancer treatment, and for the profound problems of anorexia brought about in many people with cancer.[76-78]

How are People Empowered?

The entire approach to cancer treatment should be person-centred in the first instance, rather than single-mindedly focused on dealing with the physical expression of the cancers themselves or on the person's nutritional status, in isolation.  Thus, for example, practitioners imposing a dietary regime of food and supplements on patients are behaving in much the same way as consultants who prescribe surgery or drug therapy to their patients.  Since every person is unique by virtue of his/her genetics, personality, biochemistry and life agenda, the utmost attention needs to be taken to orient care from the point of view of the individual.  Perhaps the most crucial factors in survival with cancer and a return to good health are the intangible factors residing within the individual   -  self-motivation, empowerment, and the decision to change oneself and take con­trol. 

The interplay of each person's personality type, individual constitution and condition are perhaps the most challenging aspects of the support given by the Bristol Cancer Help Centre, in its endeavours to provide access to information in a form which can be absorbed and used positive­ly.

There was a strong consensus that the individual with cancer should be in the driver's seat and have the moral, psychological and spiritual authority to decide and participate in his/her own treatment.  The entire approach to devising treatment programmes has to take into account the particular individual's very unique situation, for as eloquently stated by several participants, "if you give some people information, questionnaires and sets of choices, they absolutely gobble it up and it is really empowering ...  other people are floored ...  they do not see it as their re­sponsibility to go into things themselves ...  But ...  people have to take away something which they can do for themselves..."

The skill and manner in which health and nutritional information is presented to the individual will certainly influence his/her attitude to the entire situation.  As one participant commented:  "To stand here with a group of introductory patients and say ‘you seriously need to change your diet’ ...  is being ... prescrip­tive."

There is no doubt that the nutritional and lifestyle guidelines described in this consensus state­ment can form the foundations for a health recovery programme; with the added passion and commitment of the individual's mind and spirit, the effects upon the immune system will be that much the stronger.  Disinterest and misery in following an unwanted dietary regime is not a desired goal, and without the enthusiastic cooperation of the person with cancer, there seems little justification in forcing it down anyone's throat. 

There is also the serious issue of critically evaluating the success rates of the conventional cancer treatments on offer, namely surgery, radiotherapy and chemotherapy and "whether the body can ever really recover from chemo or radiotherapy...  The survival for many of the major tumours is no better now than it was for our grandparents ...  people developing some kinds of cancer now have got the same survival prospects as their grandparents had..."[70]

In view of the limitations of the ‘kill the tumour’ approach, integrated treatment programmes which combine the individual's own will, strong nutritional support and appropriate medical treatment must offer a greater chance of success for an enhanced quality of life.  This is not to say that such aggressive treatments should be shunned in all situations.  However, greater in­volvement of the individual in making fully informed decisions about such treatments, and the integration of nutritional expertise into all treatment programmes, can only improve the outcome and quality of life.

The need for much wider access to nutritional laboratory tests was also strongly endorsed.  At present, these are only performed by specialist laboratories.  However, the ease and cost effectiveness of performing tests for vitamin and mineral status compare favourably with the standard assays now routinely performed on blood and urine.  Thus, the improved availability of nutritional laboratory services could only enhance the service available through the NHS.  However, even when such tests are carried out and deficiencies are identified, individuals with cancer whose income is limited may not have the resources to buy nutritional supplements at the required levels.

Moreover, because of the low importance accorded to nutritional status by many medical doc­tors, nutritional supplements are not usually prescribed at high enough doses to actually change blood levels.  There has to be increased emphasis on providing doctors with sufficient education and factual knowledge to enable them to prescribe appropriate nutritional levels in cancer treat­ment.  Where this is not funded by the NHS, for example if people require long-term nutritional supplementation at a maintenance level after surgery or chemo or radio-therapy, means should be found to provide them with the financial resources to buy the recommended nutritional supplements. 

These are issues beyond the scope of one organization such as the Bristol Cancer Help Centre.  However, given the importance accorded by so many professionals to better diet and nutrition, it is difficult to envisage how any effective health programmes can work without the educational structure and financial resources to help people gain access to both the information and supplements required.

There was strong agreement about the need for a shift, indeed a reversal of the prevailing myth of cancer as a progressive, irreversible condition.  There are many documented cases of unex­pected cancer survival.  These are linked to one or more of a number of factors, including the body's inherent capacity for self-healing within a homeostasis which occurs independently of treatment, the slow progression of certain cancers,[79,80] and, of course, the effects of successful treatment regimes.  In all these situations the active participation of the individual in choosing the diet, regime or other therapeutic practices can only favour greater success with the treatment of cancer.

September 1993

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Participants at the Seminar, 20 July 1992

Dr Walter Barker, Director, Nutrition Intervention Programme, Early Childhood Development Unit, University of Bristol and chairperson of the Seminar Working Party

Dr David Benton, Psychologist and Nutritional Researcher, Swansea University

Mrs Ute Brookman, Nutritional Therapist with the Bristol Centre since its inception

Dr Hugh Coates, Springhill Centre, specialising in food quality in agriculture

Dr Nadya Coates, Biochemist, Physician specialising in neuro-endocrinology and Co-Director, Springhill Centre

Ms. Helen Cooke, Patient Services Manager and Nurse, Bristol Centre

Dr Rosy Daniel, GP and Director of The Observatory, a complementary healing centre, and Senior Doctor at the Bristol Centre

Dr Sandra Goodman, Molecular Biologist, Author of Vitamin C - The Master Nutrient (Keats, 1991), principal writer of the Consensus Statement and member of the Seminar Working Party

Dr Patricia Holborrow, Research Scientist on melanoma and polyunsaturated fats

Dr John MacLaren Howard, Technical Director, Biolab Medical Unit, involved in trace element and vitamin research since 1958 and member of the Seminar Working Party

Dr Kenneth Kahn, associated with the Kelly Programme in the USA

Mr Eric Llewellyn, Co-Founder of Nature's Own

Dr Rosemary McMahon, background in Community Medicine in the Third World, specialising in nutritional intervention as an adjunct to orthodox therapies

Mr Tony Neate, Co-Founder and retired from Nature's Own, Counsellor and Nutritional Counsellor

Dr Chris Parsons, G.P., Osteopath specialising in Nutritional Medicine

Dr Derek Pheby, Director of the Cancer Epidemiology Unit, University of Bristol

Mrs Pat Pilkington, one of the two Founders of the Bristol Cancer Help Centre

Dr Graham Rooth, Psychiatrist

Dr Kathryn Thirlaway, Swansea University, Research Scientist now working at the London Hospital Medical Schools

Dr Michael Weir, Medical Director, Bristol Cancer Help Centre, 1992.