Nutritional Support

*Brain and Spinal Tumors - Primary and Secondary*

[312] Marks WJ Jr et al. Gene delivery of AAV2-neurturin for Parkinson's disease: A double-blind, randomised, controlled [321] Tabouret E, Chinot O, Metellus P, Tallet A, Viens P, Goncalves A. Recent trends in epidemiology of brain metastases: An overview. Anticancer Research. 2012;**32**(11):4655-4662

[322] Gordon RJ. Why has economic growth slowed when innovation appears to be accelerating? CEPR Discussion Papers 13039, C.E.P.R. Discussion

[323] Scannell JW, Blanckley A, Boldon H, Warrington B. Diagnosing the decline in pharmaceutical R&D efficiency. Nature Reviews. Drug Discovery. 2012;**11**(3):191-200

[324] Dubois P, de Mouzon O, Scott-Morton F, Seabright P. Market size and pharmaceutical innovation. The RAND Journal of Economics.

[325] Prasad V, Mailankody S. Research and development spending to bring a single cancer drug to market and revenues after approval. JAMA Internal Medicine. 2017;**177**(11):1569-1575

[326] Shambaugh J, Nunn R, Breitwieser A, Liu P. The state of competition and dynamism: Facts about concentration, start-ups, and related policies. The Hamilton Project. 2018:1-36

[327] Vaishampayan UN. Changing face of metastatic prostate cancer: The law of diminishing returns holds true. Current

Opinion in Oncology. 2017

2015;**46**(4):844-871

Papers. 2018

Adenoviral vectors: Systemic delivery and tumor targeting. Cancer Gene

[315] Perez OD et al. Design and selection of Toca 511 for clinical use: Modified retroviral replicating vector with improved stability and gene expression. Molecular Therapy. 2012;**20**:1689-1698

[316] Hickey MJ, Kasahara N, Mueller BM, Kruse CA. Combining cellular and gene therapy approaches for treatment of intracranial tumors. Oncoimmunology. 2013;**2**(10):e25989

[317] Reinshagen C, Bhere D, Choi SH, Hutten S, Nesterenko I, Wakimoto H, et al. CRISPR-enhanced engineering of therapy-sensitive cancer cells for self-targeting of primary and metastatic tumors. Science Translational Medicine.

[318] Cooper ML, Choi J, Staser K, Ritchey JK, Devenport JM, Eckardt K, et al. An 'off-the-shelf' fratricideresistant CAR-T for the treatment of T cell hematologic malignancies. Leukemia. 2018;**32**(9):1970-1983

[319] Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. New York: Simon & Schuster; 2010

[320] Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA: A Cancer Journal for Clinicians. 2018;**68**(1):7-30

trial. Lancet. 2010;**9**:1164-1172

[313] Green NK, Seymour LW.

Therapy. 2002;**9**:1036-1042

[314] Ostertag D, Amundson KK, Espinoza FL, Martin B, Buckley T, Galvao da Silva AP, et al. Brain tumor eradication and prolonged survival from intratumoral conversion of 5-fluorocytosine to 5-fluorouracil using a nonlytic retroviral replicating vector. Neuro-Oncology. 2012;**14**(2):145-159

**252**

2018;**10**(449)

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**Chapter 15**

**Abstract**

*Meredith Morgan*

when adhering to the KD.

nutritionist, brain cancer

**1. Introduction**

A Nutrition Perspective on the

Ketogenic Diet as Therapy for

Glioblastoma multiforme is the most deadly primary brain tumor. Current therapies have not demonstrated improved outcomes for patients; generally the median life expectancy is 8–15 months. Due to brain tumor cells dependence on glucose as a sole energy source, there is potential to target treatments towards glucose metabolism. The ketogenic diet (KD) is a high fat, low carbohydrate diet that has proven successful in the animal model. However, human studies are limited and there currently is not enough research to conclude the KD is an effective therapy. A few aspects need to be addressed for inclusion in protocols of future studies: (1) when to initiate the KD during treatment; (2) how much carbohydrate per day to provide to patients; (3) how to ensure patient compliance to diet; (4) the optimum duration of the diet; (5) how to mitigating patient weight loss. In addition, the registered dietitian nutritionist (RD or RDN) is a vital, and underutilized, member of the health care team. The inclusion of a RD to future KD protocol, as well as oncology practices, can enhance patient outcomes and help future patients overcome barriers

**Keywords:** nutrition, ketogenic diet, glioblastoma multiforme, registered dietitian

In 2013, it was estimated that there were 23,130 cases of primary brain cancer in the United States and 14,080 deaths from the disease [1]. One type of tumor is glioblastoma multiforme (GBM), which is the most deadly primary brain tumor in children and adults [2]. Most cases of GBM occur in patients over the age of 50 years old [3]. Current median life expectancy for these patients is 8–15 months; 1 year survival is 34.6% and 5 year survival is less than 5% [1, 3]. Standard treatment is typically palliative in nature and includes surgery (maximal tumor resection), radiation, as well as chemotherapy [2, 3]. While there are new therapies, which include gene therapy, immune modulating therapy and anti-angiogenic therapy, these have not demonstrated improved outcomes for this disease [4]. Overall, the current aims

of therapies are to increase life expectancy and enhance quality of life [3].

These nutritional issues may occur anywhere along the digestive tract-from

Patients with cancer often have a "wide range of nutrition related problems" [5].

salivary dysfunctions to changes in stooling and often involve weight loss [5]. Other

Malignant Brain Cancer

## **Chapter 15**
