Sunday, August 25, 2013

Starvation and cancer growth: Sauer vs Lisanti

Preamble: There has been some puzzlement recently among the LC hard core about the main stream antagonism against LC as an approach to disease management. I share their puzzlement. Stan currently has a post here and Wooo has one here. Why do people have to fake data to support an incorrect idea or to abandon techniques which work? Weird. But that's their problem. What frightens me more is when people have an idea in serious science but are disturbing in the conclusions which they come to based on it (I don't usually doubt the data, I'm innocent that way). It particularly scares me when supportive citations are cherry picked while closely related contradictory citations are omitted. Especially when the omitted citations have enormous explanatory power. I came across this unpleasant clash of research thinking accidentally through ron's comment on a Protons post. I was unaware of Sauer's work but have been meaning to blog about cancer and metabolic coupling for some time. Finding that Sauer was in the citation list of Lisanti's coupling paper has pushed me enough to stick this post up. The refs (all free full text) you need to make up your own mind are in the text below. I'm not sure that "enjoy" is quite the correct word. Here we go.

Over in the comments to the Protons summary post ron linked to this paper showing, rather nicely, that sustained fasting markedly promotes cancer xenograft growth. Sauer comments in the paper that the group had noticed this previously and this study appears to be a formalisation of that observation. They had an "Oh, that's interesting" moment and, being scientists, investigated rather than burying it. Here is one of a choice of several graphs:

The bottom lines are the tumour weights, the top lines the animal weights.

Sooooooooo, living with normal-for-starvation levels of ketones and and free fatty acids promotes cancer growth in these particular models, like wildfire.

I have been heard to comment, on more than one occasion, that I have personally been "fasting" for the last 10 years. I just keep replenishing my fat loss using dietary butter. I have had elevated ketones and free fatty acids, 24/7, for much of the last 10 years, probably to starvation levels.

I sort of like Sauer. He wanted to know what happened in starvation to promote cancer growth. As a 1980s physiologist he then did lots of operations on lots of rats which we would rather not go in to in great detail. But he got results.

Amongst the things they did was to perfuse cancer xenografts in live rats with blood from non cancer bearing rats who were in the fed or fasted state. Joined the "donor" rats directly to the arterial supply to the tumour, using various bits of tubing, all very cunning. The cancers only grew rapidly when perfused with blood from starved rats.

They then took blood from fed rats and engineered it in to various reconstituted blood-like fluids resembling the blood from starved rats, by adding assorted fatty acids, and perfused the tumours to see what it was that made them grow.

Palmitic, stearic and oleic FFA supplementation was inactive in promoting tumour growth.

Linoleic and arachidonic promoted growth, really well. That is very scary.

Aside: When people come to look in earnest at ketogenic diets for cancer management the omega 6 content of adipocytes is going to be one hell of a confounder. You will almost need to eliminate weight loss in order to eliminate or at best reduce the release of omega 6 PUFA if the patient has been living on soy oil or Flora for a lifetime... Not easy. End aside.

Got high cholesterol? Want to lower it? Use polyunsaturated acid based margarine! Want to grow a cancer? Hmmmmmm.

Personally I'll settle for butter or 90% cocoa chocolate with palmitic or stearic acids. I suppose I ought to 'fess up about ketones. Well, no. There has to be a pause here.

If you had a concept which ought to show that ketones were a super-fuel for cancer (there are folks with this viewpoint) you might want to cite Sauer and the papers which show that something about fasting or ketosis promotes cancer growth. Which is exactly what this group did in this paper:

"Ketones and lactate “fuel” tumor growth and metastasis. Evidence that epithelial cancer cells use oxidative mitochondrial metabolism".

Nice title. These are the refs they used:

21. Sauer LA, Dauchy RT. Stimulation of tumor growth in
adult rats in vivo during acute streptozotocin-induced
diabetes. Cancer Res 1987; 47:1756-61.
22. Goodstein ML, Richtsmeier WJ, Sauer LA. The effect
of an acute fast on human head and neck carcinoma
xenograft. Growth effects on an ‘isolated tumor vascular
pedicle’ in the nude rat. Arch Otolaryngol Head
Neck Surg 1993; 119:897-902.

Now, this group is very, very good. They have this concept that fibroblasts are enslaved by cancer cells and forced to perform glycolysis but then abort their own TCA and ox phos, supplying lactate and ketones, both derived from pyruvate, to the cancer cells which then use their own mitochondria to fuel cancer cell growth. It's probably correct.

In support of this concept they injected, intraperitoneally, half a gram per kg of lactate or half a gram per kg of beta hydroxybutyrate daily and got increased metastasis with lactate and increase cancer growth with beta hydroxybutyrate. Probably this really happens.

But there are some holes in this study. The ketones supplied to the mice carrying the cancer xeonografts were given by intraperitoneal injection and no one knows what blood levels were reached. Possibly quite high for a while. They never measured them, that I can see. Even well funded dieters measure their ketones.... Let's assume they go so high, whole body, as to actually mimic the sort of levels produced in the minute extracellular gap between a slave fibroblast converting glucose to ketones and pumping them directly on to the surface of an adjacent master cancer cell. We don't know what that level is either, but both get the desired effect on cancer growth to support the paradigm.

BTW, another complete aside, the locally-supplied, fibroblast-generated ketones and lactate are UTTERLY glycolysis dependent. If the Warburg effect is not happening in cancer cells, the reverse Warburg effect looks to be VERY susceptible to sudden onset normoglycaemia affecting the fibroblasts in metabolically coupled systems. The ketones/lactate come from glucose in this set up, not from lipolysis or anaerobic exercise! End aside.

So the question is, when comparing Sauer and Lisanti, what happens when you feed an in-vivo cancer xenograft with PHYSIOLOGICAL doses of ketones by continuous perfusion, using starvation levels?

Sauer of course, did check this. He took blood from fed rats, added ketones to it without omega 6 FFAs and used the blood to directly perfuse a series of cancer xenografts. He doesn't actually give us a concentration for the ketones he used (Edit; without looking up ref 10: OK, I checked ref 10, 4-ish mmol/l in the control rats, just about where I live) but he does appear to be a very interested in teasing out the cause of the effect, so I'll buy that he used the concentration he had measured in the blood of starved rats, which supported cancer growth so well.

When he had finished with the neutral  effects of palmitic, stearic and oleic acids and the growth promoting effects of linoleic and arachidonic acids, this is what he has to say about ketones:

"Finally, perfusion of normolipemic blood enriched in the ketone bodies (10) had no effect on [3H]thymidine incorporation in tumors growing in fed adult rats (data not shown)."

Doesn't bode too well for therapies based on the Reverse Warburg effect from Lisanti's group targeting mitochondria. Did they not read all of Sauer's papers? Or did they really read them all and cherry picked the ones they wanted? Which idea scares you most? The cancers grow under the influence of omega 6 PUFA derivatives, NOT ketones. Sauer says so. Believe which ever group you like. I'm biased and I rather like Sauer.



It is very simple to fit omega 6 PUFA FFAs in to the Protons concept of cancer fuelling. I'm still working at why omega 3 fatty acids are protective in these models, they shouldn't be. In cirrhosis models they behave exactly as they should do, promoting cirrhosis as the omega 6s do, but more so. There is a link missing here somewhere. Sigh! I hate "higher level signalling" as an explanation, always seems like a cop out to me. What happens at basic energy metabolism level should give the answer...

Also Sauer specifically looked at cancer utilisation of ketones, lactate and assorted other fuels in some detail here. Some cancers can and do use ketones, but I don't see plasma ketones or lactate as superfuels for cancers in the real world. They get used, but I still see local glycolysis in fibroblasts as the major pathway supplying them. I'm fine with the Reverse Warburg effect. Targeting mitochondria will be a booboo.


Suzanne Looms said...

Thank you Peter. Depressing crap from current researchers, but that seems the norm these days. You seem to be doing a great job for cancer survivors of rebelling against (life threatening) disinformation.

Puddleg said...

Wow, that had me on the edge of my seat!
The explanation around omega 3s may be something like this; that they are impeding whatever action of LA and AA is taking place; this could be some CYP-mediated alteration. Or, omega-3 stimulates beta-oxidation of all fats including itself and omega-6s before they become active.
I don't think the omega-3 cirrhosis mechanism is so clear cut - it certainly applies in alcohol toxicity, but alcohol is inducing a CYP that converts omega 3s (and retinol, so perhaps other lipids) to polar compounds. Drugs might do this too but other stressors might not. And omega 3 protects against steatosis by stimulating lipid peroxidation, the opposite of what omega 6 does.
Omega 3 is probably something that can be useful applied with some clinical discretion.
I wonder how fasting these rats would have affected their ascorbate metabolism, if all their ascorbate is made from glucose. Ascorbate I seem to recall inhibits angiogenesis in some way.

Jack said...
This comment has been removed by the author.
Unknown said...

Synchronicity, or at least coincidence: I found this just today on the Dr. Vince and Deanna Tedone's ALS forum:
You might want to share the following link with anyone you know who has cancer. It's an interview with Dr. D'Agostino - "Eat Fats, Starve Cancer."

Dr. Dominic D’Agostino is a professor at the University of South Florida doing some remarkable research. In his experiments on mice, he has seen that a ketogenic diet and hyperbaric oxygen therapy can “starve” tumor cells. Comprised of roughly 5% carbohydrates (from non-starchy vegetables), 15-20% quality protein, and 75%+ healthy fats, the ketogenic diet is what helped Elaine Cantin heal her breast cancer, as she shared in our interview.

Dr. T and Dr. D. were my inspiration for helping my partner treat his Parkinson's with ketogenic supplements - with much success, as I wrote about in the LCH forum earlier this year.

Puddleg said...

Sorry, DHA protects against steatosis by stimulating beta-oxidation (via its peroxidation in situ), at least in hepatocytes (which is the model Sauer used).
Steatosis is a fairly large risk factor for cirrhosis, OR 5 or so. So, phases and stages of influence, as seems to be normal with cancer (e.g. folate - seems to both prevent and promote). What prevents carcinogenesis at one stage might possibly promote angiogenesis or inhibit immunity at another. Nature of the beast.
Differential effects of fish oil and corn oil on hepatic lipids in absence of alcohol - massive.

js290 said...

Work that Dr. D'Agostino collaborated on: The Ketogenic Diet and Hyperbaric Oxygen Therapy Prolong Survival in Mice with Systemic Metastatic Cancer

Apparently, Dr. Seyfried has raised similar questions as Peter in regards to Lisanti's work.

Puddleg said...

@ js290
"Abnormal tumor vasculature creates hypoxic pockets which promote cancer progression and further increase the glycolytic-dependency of cancers"
This sounds like Warburg or reverse-Warburg; the very architecture of cancer also helping force the generation of lactate.

mehitabel said...

@Lacie, @js290 -- I'm a buttinsky on several cancer boards and have seen Hyperbaric Oxygen therapy fail.

jmo, I think it's an opportunistic add-on to ketogenic diet and I gave Dr. D. in Florida an earful on his blog...and to his credit....he left it up.!/2012/12/starving-cancer-ketogenic-diet-key-to.html

The main points being these links indicate HBO therapy increases serum malondialdehyde -- one serious, scary carcinogen.

And this link indicates HBO accelerates tumor growth after treatment.

"We did not find any cancer enhancing effect during the HBO therapy. However, acceleration in tumor growth was observed following completion of HBO therapy. At the same time, mice subjected to HBO therapy lived shorter as compared to those not exposed to HBO therapy..."


@Peter -- thank you so much for giving voice to Sauer's work. I had no idea of its quality and significance.

The Lisanti study has been criticised by many, but i haven't read the omega-6s nailed so well. Dr. Eugene Fine, cancer researcher at Albert Einstein College of Medicine -- is probably not looking at omega-6s as closely as you but is looking at the majority of cancers in the real world, and echoing your conclusions.

"So I’d have nothing in principle against his research purporting to show this effect (four papers appearing in Cell, September 2011). However, his pathologic slide of a tumor shows that it consists of perhaps 75% stroma and 25% tumor by area, or close to 90% stroma by volume. This is quite different from the vast majority of human cancers, which are predominantly made up of cancer cells. Granted, some human breast cancers do indeed have more stroma than usual, but not the majority of tissue. Further, most human cancer types that have been tested have shown over-expression of glucose transporters and of FDG uptake within the cancer cells, not within the stroma. So my biggest concerns are that a) he’s dealing with an artifact of a human cancer growing in a mouse, which doesn’t represent what happens in humans and b) he hasn’t actually shown glycolysis in the stromal cells (the essence of what he terms the reverse Warburg effect and c) an injection of a ketone body is not at all the same as systemic ketosis due to reduced insulin signaling."


all the best,

Dissertante said...

Great post. Just out of curiosity, what are your thoughts on Peter Attia's latest post, in which he states that some people cannot lose fat without restricting fat? Cheers.

GFranke said...

Despite the cancer-promoting effects of omega-6 oils, all but one of the human trials of ketogenic diets for cancer I can get my hands on about have put patients on vegetable oil diets (the other one used MCTs For example Schmidt et al 2011 ( had their participants eat two "liquid meals" a day composed of the following ingredients.

Highly fermented yoghurt-drink:
skimmed milk
plant oil mixture

Vegetable oil mixture:
line seed oil
canola oil
walnut oil
grape seed oil
pumpkin seed oil

Protein preparation:

Additionally: "patients were encouraged to add additional servings (1 tablespoon each) of the oil mixture or other oils from olives, flaxseed and hempseed to the three principle meals." Despite poor compliance and lots of adverse reactions, they concluded the diet "might improve aspects of quality of life and blood parameters in some patients with advanced metastatic tumors."

A recent research protocol from Fine at indicates "unsaturated oils for cooking."

Two clinical trials are starting up based on the hydrogenated-soybean-oil-based ( KetoCal shake.

I'm waiting to get the full text on this one but since the diet was provided parenterally I'm going to assume it's based on vegetable oil.

What a nightmare!

Brad Reid said...

Peter, too interesting with ties between epigenetics and diet . . . not to post. I always assume anything with mentions of mice and diets and so forth will be of general interest. Brad Reid

Puddleg said...

This is what I was looking for:

Rapid induction of apoptosis in prostate cancer cells by selenium: reversal by metabolites of arachidonate 5-lipoxygenase

Now, Sauer's omega-6 fed cancer cells were hepatoma cells, and selenium deficiency favours the survival of hepatoma cells over hepatocytes.

Acquired Tolerance of Hepatocellular Carcinoma Cells to Selenium Deficiency
A Selective Survival Mechanism?

So - TaDa!
We can tie together these omega 6 pro-cancer effects with the carcinogenesis of selenium deficiency.

The lipoxygenase may be what is inhibited by omega 3 EFAs.

ItsTheWooo said...

Fantastic blog Peter.

Still the best on the interwebs after all this time. No one else produces these insights, particularly not in an easy to digest witty format that is a pleasure to read.

Unfortunately this info does not bode well for my penchant of consuming dietary o6 like almonds and eggs; however I wonder if being relatively low body fat without excessive blood lipids in general would be protective even if one tends to be ketotic.

I would also argue that ironically this provides much stronger evidence for the relationship of cancer with conventional diets, insulin resistance and obesity; insulin resistance obesity features fat metabolism defects and elevated FFA as a result of impaired glucose tolerance. Attempting to oxidize glucose when your mitochondria are gimpy leads to very high insulin and severe obesity with normal glucose/FFA. On the other hand, it may lead to high insulin and hyperglycemia + elevated FFA from an inability to normally respond to insulin.

Perhaps the special relationship between cancers and obesity is not only IGF-1/insulin activation of growth factors, hyperglycemia... but *also* disturbed fat tissue insulin signalling leading to elevated FFA which happens to be significantly made of O6.

I would assume many LCers are better off ketogenic simply because removing the glucose portion of diet and not substantially increasing O6 portion (LC tends to result in spontaneous caloric reduction for obese people) would actually improve metabolism and fatty acid regulation, especially for diabetic insulin resistant people.

Puddleg said...

@ Woo, Volek and Westman have papers showing membrane fatty acids are conserved on ketogenic diets, meaning there is less flux through arachidonic acid>Cox2>LOX and fewer inflammatory consequences. Also, in fat burning mode, it's likely that PUFAs are consumed for fuel more consistently. How far this is protective, no-one knows, but it does make a measurable difference. And low-carb has always worked, even in dark days of lipid ignorance, trans-fats, and non-existence of omega-3 as a thing.

Purposelessness said...

Something to ponder: omega 6 oils, even the unhydrogenated ones were recently shown to contain tans fats, nuts may lack that,as do eggs. And the omega 6 content of almonds isn't even that high ...

js290 said...

@George Henderson: I chatted with Dr. Ron Rosedale briefly about PUFA's at AHS13. He sort of hinted that if your keto-adapted, PUFA's would just be used as fuel. If not, then they find different ways to wreck havoc... oxidizing, finding their way into cell membranes, etc. Definitely not an endorsement for processed seed oils, but keto-adapted people eating natural sources of fats that include PUFAs probably won't fall apart.

I just finished reading Chris Masterjohn's article on Know your Fats. Lots of good info there if you haven't read it already.

Eric Thurston said...

A question for Lacie.
I have Parkinson's and would like to read about your partner's experience with ketogenic supplements. Could you give me a link? Many thanks.

Eric Thurston

Unknown said...

Eric: I've posted a first person account of my partner's experience with ketogenic supplementation in the private Low Carb Hezbollah forum: (registration required)

For research, I started with Richard Veech's 2001 hypothesis paper on ketones for neurodegeneration:
and then just follow his trail forward: (rat study)
Vanitallie's 2005 study involved 28 human subjects with PD:

There has been very little recent research on ketones and PD, but Veech, Vanitallie, and D'Agostino all believe there's overlap between ALS, Alzheimer's, Huntington's, MS, and PD. I ended up at Deanna Tedone's site, where D'Agostino helped her father develop a multi-supplement protocol for ALS patients.
Not all of those supplements are effective for PD, but my partner takes the 18g of Primaforce AAKG and liposomal or IV glutathione. He tried MCT oil and coconut oil per Dr. Mary Newport's work with her husband:
but the AAKG is much easier to digest and accommodates higher dosing.

And of course, where it all began:
If not for Peter's work in this area, we'd be in a much different place - a "not particularly pleasant" one, as he so acerbically put it.

P1 said...

For those who did not read Sauer, can you comment on the protocol he used to test Omega-3 versus the protocol he used for Omega-6?

Since these two compete against each other over limited pathways, it would be interesting to see if his protocol guaranteed that each was being tested completely independently of the other.

Peter said...

P1, he never looked at this. His interest was in the tumour promoters produced from omega 6s and the switching effect of EPA on adipocyte FFA export. The problem was from the crappy fatty acids in omega 6 fed rats and EPA's ability to keep them locked away...