Cancer Prevention

>> coordinator: welcome and thank you allfor holding. i would like to inform participants that your lines have been placed on a listen-onlymode until the question and answer portion. today's conference is also being recorded.if you have any objections you may disconnect. if you need operator assistance press starthen zero, i'll now turn the call over to melissa glim. you may begin. >> melissa glim: hi my name is melissa glimand i am a contractor in the national cancer institute office of communication and publicliaison. i want to welcome you to the frontiers of nutrition and cancer prevention onlinewebinar series brought to you by the national cancer institute division of cancer prevention.

to ensure uninterrupted streaming of the onlineportion of this presentation please close any additional programs and windows on yourdesktop. this will make things move faster for you. if you have any technical difficulties duringthe presentation please press star zero for operator assistance or you can call the technicalsupport number for the system. as a reminder this webinar is being recordedand will be archived on the nutrition science research group�s website. we will post theaddress at the end. before we get started i would like to give you a quick moment tofamiliarize yourself with the live meeting desktop.

the question and answer box labeled q&a islocated on the top navigation bar and you can keep it open by clicking on it and thendragging the box to the right side of your screen. you may type your questions here at any timeduring the presentation. the speakers will answer them during the q&a period after eachpresentation if time permits. but like i said type them as you think of them because itmakes it easier for us to record them. now i would like to introduce you to our speakerfor today, for today's workshop. dr. gabriela riscuta is a program and activity directorof the nutrition science research group, division of cancer prevention at the national cancerinstitute.

>> dr. gabriela riscuta: with that said iwould like to welcome you all to our fifth presentation in the frontiers in nutritionand cancer prevention online webinar series. i am very pleased to introduce today's event,cancer prevention through immunomodulation: does diet play a role? before we get started i want to thank my colleagueson the steering committee and planning committee and the nutrition science research group inthe division of cancer prevention at the national cancer institute and a special thank you toall colleagues at the communication and public liaison for making this event happen. we are excited that many people, a total of1,190 registrants have joined the call today.

we have physicians, nurses, registered dietitiansand nutritionists, public health officials, researchers, and academics with us from allover united states and some other 20 countries like jamaica, canada, turkey, mexico, spain,brazil, taiwan, india, and so on. so we expect a large variety of interest andquestions when we get to that point. so for again for today's event cancer preventionthrough immunomodulation that dietary role. we chose this topic because we all are interestedin preventing cancer and if the diet plays a role it would be great to hear from theexperts in that field what we should be eating, when, and how. they will introduce us to the strengths andevidence, the weakness of the data regarding

the immunomodulation through the diet. andour first speaker is dr. simin meydani, dr. meydani is the director of the jean mayerusda human nutrition research center on aging at tufts university and she's a professorof nutrition and immunology at the friedman school of nutrition science and policy attufts graduate program in immunology. she will present today whether the immunomodulationof the immune response plays a role in cancer prevention. dr. meydani. >> dr. simin meydani: thank you dr. riscuta,i would like to thank the national cancer institute and dr. riscuta for the opportunityto present and participate in this webinar and thank you all very much for joining.

so dysregulated immune and inflammatory responsedoes play a very important role in cancer initiation and progression and i would liketo take a moment to distinguish between the inflammatory responses and cell-mediated responsesbecause at times they have different and opposing roles in terms of cancer risk. in terms of inflammation it is the increaseand unregulated information that has been demonstrated to play a significant role interms of both initiation and progression of cancer and there is a good amount of evidencethat it could also contribute in terms of predictability of survival and how a patientwill fare in terms of their recovery. on the other hand, cell-mediated and innateadaptive immune responses for example those

that are mediated by t-cells or are the naturalkiller cells decline in their responses plays a role in terms of increasing susceptibilityto cancer and also determining the pathogenesis of this. so i would like you to make the distinctionbetween the increase in inflammation and decrease in cell-mediated immune responses. inflammation is a link to cancer as i saideven though we have known about this since 17th century but it has only in recent decadesthat a majority of the evidence linking inflammation to cancer has been obtained. both inflammatory cells and the mediatorsthat they produce play an important role in

initiation and progression of cancer. forexample tumor associated macrophages have been shown to be critical for a few typesof cancer for example breast cancer and an increased number of both neutrophils and macrophageshave been observed in tumor cells. and both of them do play a significant role in termsof pathogenesis of cancer and producing inflammatory markers that contribute to cancer. in terms of inflammatory mediators many havebeen identified. i have listed some of them on this slide and there is the extent of evidencefor their involvement for the different molecules varies. crp and tnf alpha and eicosanoidsa good amount of evidence that they do play an important role in terms of pathogenesisof cancer.

and we know that for example its predictivevalue in using crp in terms of determining the prognosis of cancer. now the other moleculesthat i have listed nf-kappa b, which is a transcription factor and single lipids theyare related to information and cancer in terms of a single lipid both direct evidence butalso mediating formation of the other inflammatory markers for example in case of nf-kappa b. and as you can see in this next slide theyare all related to each other for example a single lipid, singles in one phosphate inparticular, which has been shown to be engaged and involved in cancer is involved in inductionin inflammatory molecules such as cytokines as well as eicosanoids it's involved in inductionof the key enzymes in the pathway of eicosanoid

formation. and but on the other hand the inflammatorymarkers can look back and induce and cause formation of some the important single lipidsfor example if it's singled in one phosphate. it's also important to keep in mind that thecomponents of the different inflammatory markers also play a regulatory role in controllingeach other�s formation. so for example some of the cytokines havebeen shown to be involved in induction of crp and as i mentioned they didn't, cytokinesthemselves, they also do play on each other and have a regulatory role. now one of the and i don't need to tell youthat the incidence of cancer increases with

age both incidence and mortality obviouslyup to a certain age and then the people that you see less incidence those are the oneswho are the survivors and do not have to do this. but there is a steady increase in incidenceof cancer and mortality with age and it is interesting to note that one of the characteristicsof aging, which has been documented in the recent years is that with aging there is increasein chronic inflammation, what they call - they refer to as inflamed aging. in this slide it shows compared productionof several inflammatory markers from macrophages of young and old mice. and as you can seefor interleukin-1, il-6 well and there is

significant increase in the production bymacrophages with age and so is production of eicosanoid prostaglandin e2. the anti-inflammatory il-10 also increasesto it's a compensatory mechanism but the collective effects of increase in the pro-inflammatorythree markers overtakes the increase in the anti-inflammatory marker that you would seewith aging. and so whether this increase in inflammationplays a role in the highest susceptibility of the aging and higher mortality of themfrom cancer is under investigation and there is evidence that indeed it does play a role. what is - it might be interesting to knowwhat is the mechanism of increased inflammation

or production of inflammatory markers forexample peg2 because you will see it brings back some of the molecules that we mentionedearlier. just to review for those of you who mightnot be familiar eicosanoids such as prostaglandin e2 are formed from arachidonic acid from themembrane phospholipid to the function of the enzyme called cyclooxygen. in particular cyclooxygenase 2 is to - isinvolved in, which is an inducible form of oxygenase, is the enzyme that is involvedin production of, that is induced under inflammatory and a stressed condition. when we compare the expression of cyclooxygenaseit is two between young and old macrophages,

we see that there is significant increasein the express of cox-2 in old macrophages. and we do not see the same thing with cox-1so this - the increase with age-specific to cyclooxygenase-2. and we were interested tofind out what the mechanism of this increase with age in cox-2, oxygenase-2 is to an expressionis so a series of studies and looked at several factors that have shown to be involved inupregulation of cox-2 such as some of the cytokines. and we ruled them out and we were left withglutathione, which is an antioxidant and ceramide, which is a single lipid. so both decreasein glutathione and increase in ceramide have been shown to cause increase in expressionof cox-2.

and indeed if you just to make sure that everyoneknows the relationship ceramide is produced from the single lipid the single myelin throughthe function of the enzyme of single myelinase. and glutathione can inhibit function of thesingle my single myelinase. so if you have lower level of glutathione), which is thecase in aging and under oxidative stress then there is more formation of ceramide, whichcan cause upregulation of cyclooxygenase-2. and we can show that through a series of studiesthat indeed the reason for the increase formation or increased expression of cox-2 with agingis that with aging there is a higher level of ceramide in macrophages, which causes activationof nf-kappa b and then causes higher expression of cox-2.

and this event in aging seems to be very similarto what happens in terms of inflammatory production of higher level of inflammatory markers incancer. so i wanted to bring your attention the parallel that existed in inflammationand aging and cancer and the fact that this agent does increase in incidence and mortalityfrom cancer. another point that i would like to bring toyour attention is that there are cells of the immune system that are involved both interms of producing inflammatory markers but also in terms of resistance to cancer andkilling the tumor cells. in particular i want to bring your attentionto neutrophils and lymphocytes because change in the ratio of the neutrophils and lymphocyteshas been identified as a good predictor of

progression of cancer for example in termsof breast cancer and also some other types of cancer. so they're both low absolute number of lymphocytesand high number of neutrophils, which would result in a high neutrophil to lymphocyteratio has been identified as one of the good indicators of determining progression of cancerin patients. and i think that will make sense because withhigher number of neutrophils and lower lymphocytes you are shifting the balance of resistancemediated immunity in unity and susceptibility by increase in inflammatory production ofinflammatory markers. so if you have higher ratio of neutrophilsto lymphocytes you would predict that it would

be higher inflammation but also less cell-mediatedimmunity, which would be involved in killing off tumor and other aspects of resistanceto cancer. now what i would like to spend the rest ofthe time is focusing on nutrients that have been shown to change inflammation and cell-mediatedimmunity and of course there are many different nutrients and food components that have beenstudied in this relationship. but i�m focusing on those that have beenshown to impact both the inflammation as well as cell-mediated immunity. and i have selectedsome of them because recently there has been controversy in their role in cancer promotionand hope that some of the - the data that i will show you will help you understand thereason for the controversy.

and some of the other ones, for example pre-biotics,i have some selected to focus on because it's a new area of research in terms of nutritionand unity and cancer prevention, which involves microbiota. so in terms of vitamin e we have done as wellas other several studies that have shown vitamin e is intimately involved in regulation ofcell-mediated immunity and particularly of the t-cell mediated function. for example in the studies that we have donein older subjects who have lower t-cell mediated function we have been able to show that supplementationwith different doses of vitamin e 60, 200, and 800 iu for about five months can significantimprove their ability to respond to vaccines.

for example in this case hepatitis b vaccineas well as increased measure of t-cell mediated function, which is called delay type hypersensitivity skin response. what i'd like to bring to your attention thatthe optimum dose of vitamin e in this case is the 200 international unit, which is - notthe highest dose that we use in this and i think again to bring your attention to theimportance of the optimal dose and the appropriate dose to be used in terms of cancer preventionwhen it comes to the nutrients. on the other hand we have also evidence thatvitamin e supplementation can reduce inflammation. in this case this was a study in which wesupplemented young and old mice with adequate or high level of vitamin e for a period ofa month and then compared production of pge2

from macrophages of young and old mice. and as you can see in young mice there isno effect of vitamin e on pge2 production but in the old mice there is a significantreduction. and you'll notice that as i mentioned before the old mice have higher pge2 productionto begin with. so again to bring your attention to the pointthat the effect of nutrients on solitary marker production will depend on the baseline levelof inflammation that exists in the animal or the subject then that again could be oneof the reasons that there is controversy in the literature when it comes to the impactof some of the nutrients on inflammation and also in cancer.

and similarly they have observed in humansthat supplementation with vitamin e for a period of a month and these are older subjectscan result in significant reduction in production of pge2 by the peripheral blood mononuclearcell. you can see that in placebo there's no effectbut in the vitamin e treatment group after a month of supplementation there's a significantreduction in pge2 production and that is associated with a significant increase in their plasmalevel of vitamin e. similarly we see a reduction in the levelof plasma lipid peroxide, which would be expected because vitamin e is an antioxidant. now we were interested in looking at someof the other inflammatory markers for example

tnf-alpha. and what we noticed was that ifyou look at the entire population that we had supplemented with vitamin e we did notsee a significant effect in - of vitamin e on reducing tnf-alpha. so that was surprising and we had noticedthat in general when we supplement with vitamin e, whether we're looking at t-cell functionor inflammatory markers, not everyone responds to vitamin e supplementation. so we were interested to see whether therewere genetic differences that contributes to the lack of this on some subjects. so ina study that we did using 200 international unit supplementation with vitamin e in about640 older people we looked at the relationship

between the genetic background of the subjectand the response to vitamin e. single nucleotide polymorphism in the promoterregion of the cytokines, for example tnf-alpha, has been shown to be important in terms ofthe ability of the subject to produce - to produce tnf-alpha. so certain variants of changes in certainvariants in the promoter region of tnf-alpha for example can result in the differencesin the ability of the subjects to produce higher or lower level of vitamin e and i'msorry of that particular cytokine, which then could, you know, make a subject more proneto inflammation as opposed to another subject. so when we looked at or we broke down thepopulation of the subjects into - based on

their genetic background we noticed that thesubjects who had the g/g variant in their promoter region of their tnf-alpha gene theydid not respond to vitamin e in terms of a reduction in tnf-alpha production. if anything there seemed to be a slight increasebut this was not significant. however the subjects who had the a/g or the a/a variantshowed a significant reduction in their tnf-alpha production. and these two subjects that actually producemore tnf-alpha compared to the g/g value and so again here it shows two points. one thatthe subjects who are prone to inflammation seem to be responding to vitamin e and thatthe impact of vitamin e in terms of reducing

tnf-alpha production is dependent on theirgenetic background. if i may have the next slide, no i think weare on the wrong slide. okay so just to conclude that a point to keep in mind is that the impactof nutrients on inflammatory markers might depend on the genetic background and againanother point that might explain some of the controversies in the literature that we haveseen recently. okay so another nutrient that has been shownto be engaged in the immune system is that it is vitamin b6. low b6 has been observedin cancer patients and has been shown to be associated with increased risk of breast cancerand also with increased risk of colon cancer. and it's also interesting to note that a significantportion of the elder - of older people have

low b6 levels. a colleague of mine dr. pauljacques -- his group have looked at the relationship between vitamin b6 and inflammatory markersin the framingham population. and they looked at a series of markers ofinflammation and came up with an inflammation, an inflammatory score for the subjects. andwhen they looked at the relationship between the blood level of peroxyl phosphate, whichis an indicator of vitamin b6 status and the inflammatory score they noticed that in thegroup that had the lowest percentage of b6, low plp levels they had the lowest inflammatoryscore. and those who had higher percentage of peoplewith plasma plp level less than 20 mole per ml had the highest inflammatory score againpointing to the fact that b6 low level of

b6 is associated with higher inflammation. and this is interesting because plp or b6has also been indicated to be involved in single lipid metabolism and so that adequatelevel of plp can preserve - can reduce the level of - can - is involved in controllingor regulating metabolism of a single lipid so that if you have low levels of plp youcan reduce degradation of sphingosine phosphate and lead to an accumulation of a sphingosinephosphate, which is as i showed you in some of the earlier slides can cause increasedinflammation of inflammatory markers. vitamin b6 has also been shown to be involvedin the regulation of t-cell mediated function. we did a study a few years ago in which wetook older subjects and depleted them for

two weeks from b6 and then gave them incrementallevels of adequate level of b6 up to - different levels for each of them for three weeks. and what we observed was that when the subjectswere depleted from b6 there was a significant reduction in the t-cell mediated functionand as we repleted them with b6 we saw improvement in their lymphocyte proliferation showingindeed b6 was essential for the function of the t-cells. and if we plot plasma level of plp againstthe function of the t-cells, which is measured by the ability to proliferate you can seethat there is a very nice correlation between the two.

what is also interesting is that in this studywe noticed that there was a - with b6 deficiency there was a significant reduction in the percentageof lymphocytes at the same time that there was a significant increase in the percentageof neutrophils. if you recall, i mentioned that neutrophilto lymphocyte ratio is thought to be a good predictor of cancer prognosis. and so onecould speculate that with b6 deficiency if you are increasing the ratio of neutrophilsto lymphocytes that the susceptibility or at least prognosis of cancer might not bevery good. and so perhaps the adequate level of b6 wouldbe needed in terms of optimal response in terms of resistance to tumors.

another dietary component, which in recentyears has been a subject of controversy when it comes to cancer is fish oil. fish oil isknown to again have a very strong anti-inflammatory effect and because of that it has shown tobe beneficial in many diseases that have inflammation as their - involved in their pathogenesisand initiation. and again fish oils work through the way thatthey have an inflammatory, anti-inflammatory effect is through iccosome pathway. a fewyears back we did a study to look at the impact of fish oils on the inflammation as well ast-cell mediated function. and what we noticed was that feeding a dietthat was high in fish would cause significant reduction in many of the inflammatory markersincluding some of the cytokines and prostaglandins.

but surprisingly we also saw a significantreduction in the ability - in the t-cell mediated function by looking at dth. so while the fishoil has beneficial effects in terms of reducing inflammation it does seem to have an adverseeffect in t-cell mediated function. and we believe that this adverse effect of fish oilhas to do with the fact that with consumption of fish oil this increased requirement forantioxidants such as vitamin e. so we tested that in a study in which we fedsubjects fish oil with different levels of vitamin e, 100, 200 or 400 iu per day andlooked at their t-cell mediated function by again looking at dth. and as we can see here when we give the fishoil with vitamin e, 100 and 200 iu per day

we do not see the reduction in dth in factwe see an enhancement compared to the baseline level. so this indicates that if we would want toprevent the adverse effects of fish oil on t-cell mediated function we need to make surethat the subjects are consuming adequate level of vitamin e. and that again could explain some of the controversiesthat have been observed recently. and again the point that i want to make is that nutrient- nutrient interaction may influence efficacy of fish oil and other nutrient interventionsin terms of prevention of cancer and initiation. and finally in the last few minutes i wouldlike to bring your attention to a new area

of research as it relates to the nutritionimmunity and cancer and that has to do with the gut microbiota and some of the recentobservation that for example i've demonstrated in this publication. that commensal bacteria are involved in thedevelopment of gamma delta t-17 cells that are important for example in terms of preventionof lung cancer. and in this study what they were able to show was that in this study theywere able to show that if you use antibiotic treatment in the mice you can impair gammadelta t-17 cells and increase susceptibility to cancer. and related to that we can change the - wecan change the gut microbiota through use

of prebiotics and probiotics as has been shownin this study in which the prebiotic was fed and they were able to show that there wasa significant change in the commensal bacteria by feeding this prebiotic increased in someof their beneficial bacteria. and this was associated with a significantdecrease in the inflammatory market such as tnf-alpha and il-6 as well as a significantimprovement in the function of the natural killer cell activity. and which points outto the importance of commensal bacteria and its modification by dietary components interms of prevention of cancer. so i'd like to summarize by saying that thisregulated immune and inflammatory response has played a role in nutrition and progressionof different cancers.

there are several food components that havebeen shown to reduce inflammation and improve cell-mediated immune responses. and when itcomes to the impact of nutrients on cancer we need to take into account nutrients, nutrientsand nutrient gene interaction as well as the dose of the nutrients. and there are several areas, new areas ofresearch that certainly is worth considering in terms of modulation of the immune systemby food components and resistance to cancer. so i'd like to stop and be happy to answerany questions if there is any time left. >> dr. gabriela riscuta: yes thank you dr.meydani this is a great presentation yet we - i'm going to just give to you only one quickquestion because we're a little bit late and

but this will be really quick. so anna clift is asking what ages qualifyas old or young in the studies you presented? >> dr. simin meydani: so the cutoff that weare currently using is 65 and over and older so it would be old people. >> dr. gabriela riscuta: thank you so muchand i have two other questions but i will forward them to you and we'll answer laterbecause we have to move to our next speaker, dr. suzanna cunningham-rundles and she isa professor of immunology in pediatrics and vice chair for academic affairs and directorat weill cornell cellular immunology lab at cornell university.

>> woman:am i doing this? >> dr. gabriela riscuta: dr. cunningham-rundleswill address the mushroom beta glucans and cancer prevention. when dr. cunningham allfinished we will have a hopefully time for a few questions, dr. cunningham-rundles. >> dr. cunningham-rundles: thank you verymuch dr. riscuta for the opportunity to present our studies and those of others on the importanttopic of mushrooms. in particular mushroom beta glucans have been shown in a number ofmodels and also in humans to have an impact on bone marrow recovery from cancer chemotherapyand therefore may play a role in cancer prevention. the role of mushrooms in nutrition and diethas historically thought to be that of health

promotion. we have to remember that mushroomsare actually edible fungi rather than the plants and vegetables that they are normallyconsidered to be. and this is true whether you are talking aboutcultivated mushrooms such as white button, cremini or portobello or some of the oneswe commonly see in supermarkets or the wild edible species, which are collected all overthe world. obviously there are many elements in - presentin mushrooms that may play an important role in health including the presence of nutrientssuch as proteins, carbohydrates. we're going to talk primarily about beta glucans as bioactivecomponent. but there are other elements too includingmicronutrients as stressed by dr. meydani

that may also be important. interestinglymushrooms are a good source of certain vitamins such as b12, which is highly bio availablealthough not present in very large amounts. and also vitamin b2 - d2 there is ergosterol,which can be converted by sunlight and is looking as if it's quite important in termsof being able to maintain normal levels. we also have to remember that wild mushroomsmay contain toxins some of them can be fatal and they also contain toxic elements. so thesource and the actual constituents of mushrooms may be extremely important. i'm having a little trouble with my slideshere. >> melissa glim: do you need us to forwardyour slides?

>> dr. cunningham-rundles: i'm having troublegetting back to the slides that i plan to show yes but i'm okay now. so on this slidewe see that there has been also a very significant growth in mushroom and truffle productionover the world over the last several decades. and it's not only in china and other partsof the world but also in the united states. so this represents the likelihood that inthe future we will see even more inclusion of mushroom in diet. i�m still having thistrouble. all right it's a slide problem. >> melissa glim: is this the slide you want? >> dr. cunningham-rundles: i'm actually notseeing my slide i'm trying to control it better. okay no it's still there, thank you.

>> melissa glim: okay we could set - we canmove the slides forward for you. >> dr. cunningham-rundles: okay if you'llmove the slides then. so the role of mushrooms in health and medicine is a very big subjectbut essentially we might want to think about some of the things that consumption of mushroomsmay do with respect to health effects. and this is important actually for any modeof action in a condition such as cancer, which is a rather complex setting for any patient.one of the things that has been very useful about mushrooms is and will be increasinglyso in the future is the substitution for high fat meats. and that's because of factors actually chemicalsin mushrooms that produce an effect that makes

people accept it as a substitute. there havealso been as dr. meydani suggested some new studies relevant to the changes in mucosalmicrobiota and the microbiome and i think it's likely this will represent a future forinvestigation in cancer subjects. other elements that have been found to beaffected including glucose homeostasis and anti-inflammatory effects as dr. meydani mentionedmay have their own relevance as well and overall there has been an interest in seeing riskreduction in obesity, metabolic syndrome, colitis and cancer in individuals who undertaketo have more mushrooms in their diet. now the bioactive components of mushroomsmust be considered to include the fruiting bodies in mycelia, which are not necessarilypresent in the preparations that one gets

or makes from things that they find in thesupermarket. and these of course include probiotic, prebioticsare also present in mushrooms that you buy in the supermarket. but the presence of polysaccharidesuch as beta glucans, which act as mimics of bacteria and activate pattern recognitionreceptors may or may not be present in a significant amount in the mushrooms that you guy in asupermarket. now on the next slide we see that the bioactivityof raw mushrooms has been studied to see if in fact without cooking there is an impact- this is actually looking at anti-inflammation and the experiments here are addressing theeffect of chopped and prepared rather high amounts of mushrooms on murine raw macrophages,dr. meydani also mentioned this model.

these cells have been preactivated so they'respontaneously producing large amounts of nitric oxide and tumor necrosis factor alpha. andas you can see these preparations did cause a marked reduction in both nitric oxide andtumor necrosis factor alpha. but note if you can see the green line inmost of the panels not all of them but not for example in some mushrooms such as thebutton mushrooms you also see an impact on cell viability. now this probably represents a contaminantor another component in mushrooms that would have been present in these rather highly concentratedpreparations made from raw mushrooms. next slide. so the critical question i thinkor one of the critical questions is whether

or not whole mushroom extracts actually havesignificant amounts of bioactive substance to elicit immune response in a predictablemanner. yu and cantorna looked at this a few yearsago and they found in fact that although it's variable if you look at these mushrooms likecremini, maitake, oyster shiitake, which you actually do find a lot in supermarkets comparedto white button mushrooms. and it was also true of the brown version,which is called honey nut that there's not such a great effect but compared to lps that'slipopolysaccharide the bacterial component that's also referred to as end of toxin butis the chief element in gram negative bacteria that leads to activation of immune responseand we're looking here at tnf-alpha production.

you can see that they did in fact stimulatea good amount of production of this cytokine, these particular cells were not activated.so yu and cantorna then studied spleen cells taken from mice that had been fed mushroomsin diet at relatively small amounts such as might be comparable to what a human wouldget in diet and found that the spleen cells did not become activated. so what we're seeing here is the importanceof the cell type, the type of the experiment that's done and the results that you're lookingat and above all if there's another stimulant on board it's very important with respectto immune cells to know whether they've been activated by something else.

so in light of this it's possible as yu andcantorna suggested to see that mushroom extracts in amounts that would be present, extractsthat could be made quite simply from common mushrooms affect common immune pathways, whichare involved in immune response to infection and to cancer. specifically i'm thinking here of neoplastictransformation differentiating that from metastasis, which is really quite a different process.so yu and cantorna showed that whole mushroom extract stimulated the production of tumornecrosis alpha and interferon-gamma, which are considered pro-inflammatory in a healthyhost defense protective way and also are good against tumor cells in bone marrow derivedmacrophages, which were not activated and

not transformed. and also listed although that�s now shownon the slide or the previous one elicit very little il-10, which is actually a good sign.and in fact that when the whole mushroom extracts were presented to cells that were preactivatedthe same cells they actually they suppressed il-10. so i think you can see then from this thata certain amount of specificity can be achieved in particular systems and of course this isalso what happens biologically that's part of the way the immune system works becauseit's compartmentalized. so we now know quite a bit about how betaglucans is to activate immune signaling pathways.

i�m showing a structure of one of them andthere are actually very many types of beta glucans and as you can see on the second bulleton this slide beta glucan bioactivity varies all over the map. and it does depend on many characteristics,solubility is a major characteristic. particulate glucans behave very, very differently thansoluble ones do, but part of this also is composition, molecular weight and degree ofbranching. some beta glucans can also include proteolyticglucans, which have direct anti-tumor effects. most of the glucans that we're talking abouthere don't have direct cytotoxic effect on either normal cells or cancer cells.

and like all biological response modifiersthe effects have to be considered as largely non-specific. so specificity has to be broughtinto play by other elements in the system. next slide, thank you. now on this slide i�mshowing you different beta glucan extracts and how they have variable anti-tumor activityin clinical trials. i think there must have been a slide before this or maybe it's afterthat shows effects in vitro but i'll just go on with what we have here. you can see that lentinan, which is actuallyused a great deal in asia has been shown to have adjuvant activity with chemotherapy andbiologic drugs. these biologic drugs would be considered things like monoclonal antibodiesthat actually target specific tumors.

and the effects of these has been somewhatvariable on survival but some interesting positive effects were observed and the processof mode of delivery was really through oral activity but injection is also very powerful. krestin, which is a component of coriolusversicolor it's a purified and highly prepared extract has adjuvant effects with chemotherapyand improves survival in gastric cancer patients when taken orally. maitake fractions and there a number of thesethey're beta glucan containing but some are not from grifola frondosa a very famous mushroomcalled the dancing mushroom. there are a number of experiments showing that grifola will actuallyenhance this platinum therapy by direct effects

on the bone marrow and also has effects ont-cells and in k-cell responses and promoting bone marrow recovery after paclitaxel - that�sfrom studies from my lab, lin et al., 2010 - and this was orally active. we also did a study in breast cancer patientswhere these were post chemotherapy and we found effects on immune response and we'reable from this to develop an idea of the appropriate dose level for getting effects on immune responsewithout suppression because it must be pointed out that you can have overdoses of some ofthese elements. and some beta glucans tend to hang along quitea bit in the blood and that could of course be a risk.

now meta-analyses of mushroom extracts haveappeared and they have given some assurance that ultimately we may be able to have betterquality studies and clearer ideas of how they work. enough so that the pharmacologist whowrote this article said that scientific investigations in case studies we have to say primarily fromasian medicine have shown that fungi have very promising pharmacologic potential. when we actually look at the studies and wecan see on the top cancer gastric there are eight randomized clinical trials involvingmore than 8,000 patients with purified psk there was a definite improving effect on survival. but some of the others are less clear althoughstill promising. in the five studies not actually

fully randomized of non-resectable recurrentstomach cancer probably fairly late stage disease with lentinan as an adjuvant to chemotherapythat was prolongation of life. and finally this most important study becauseit was a cochrane report showed that in ganoderma lucidum used as an adjuvant with chemo orradiation therapy primarily in lung cancer although it wasn't only lung cancer. there was improvement in quality of life andthere were some immune response markers that definitely showed improvement and this isa recent, fairly recent study. so i think we can see that things are definitelygoing up in terms of the trend towards better quality studies that will allow us to geta clear handle on how beta glucans work in

the clinic. so i think it jumped on our - i don't knowwhat slide you have. can you - hello did i get disconnected? hello i don't know whatslide we have, we have 15? >> melissa glim: fourteen. >> dr. cunningham-rundles: fourteen okay good.so just very briefly to mention that we now know a great deal more about how oral betaglucan may work and that is that it actually isn't appearing freely in the blood at allbut is actually picked up in the gastrointestinal tract in peyer's patches with - by dendriticcells and macrophages and then delivered to circulation.

some studies have shown spleen but othersshow that it goes more quickly then to the bone marrow and that therefore it's able toactivate tumor specific dc's and inhibit tumor growth. an earlier report showed some of the pharmacokineticsof this of oral administration you can see through dectin fluorescence because the dectinreceptor is actually quite important for beta glucan activity in a number of studies. andas you can see on this slide it actually was quite increased in the galt. let's go to the next slide. so bone marrowrecovery after chemotherapy is absolutely critical for immune recovery and for protectionagainst ultimately events of the tumor.

we know that slow bone marrow recovery afterchemotherapy and peyer's host defense. dr. meydani made the point about increased numbersof neutrophils and lymphocides in cancer patients. and depending upon the stage this can alsobe a sign that there is some sort of pathogen or reactivation of the pathogen, which isleading to an increased egress of neutrophils from the bone marrow into peripheral blood. but overall it is a sign that the host ishaving problems controlling infection and as all of us know death in cancer patientsis often really from infection. so there is interest in ways and means to support therecovering bone marrow. now in very recent studies suggested thatfasting may actually enhance hematopoietic

recovery, this is prolonged fasting afterchemotherapy. and of course this is an extreme example and obviously a study that was donein mice. so i think that the use of foods of any kindand even beta glucans although they aren't the extracts are simply not really foods assuch, they are really medicinalized if you will. actually it has to be thought aboutvery carefully and the doses have to be considered but we have found in previous studies thatwe've reported that beta glucans strongly support hematopoietic cell recovery and itactually stimulates neutrophil and monocyte differentiation at the level of the committedhematopoietic stem cell and progenitor cell leading to actually improved peripheral monocyteand neutrophil activity in a mouse model.

so as shown on the next slide we were interestedin studying maitake beta glucan on neutrophil and monocyte function in myelodysplastic syndrome.this syndrome it's syndrome because there are many different forms of it but it's characterizedby ineffective erythropoiesis ultimately leading to anemia. and but in the marrow it's actually hypercellularand there's also a lot of dysplastic changes, which ultimately lead to the peripheral cytopeniaand there's significant risk of infection in untreated patients who often are maintainedonly by transfusion when they become anemic. and ultimately the great problem is that manydo progress and often very acutely and suddenly to acute myologenous leukemia. so you canrecognize that this is a setting and i have

to add with respect to what dr. meydani mentionedthat patients with mds are primarily older. so this is a disease that could be regardedas directly related to or certainly implicating aging in immune response as well and thereforeshould be considered in that way. but the main issue for us was the idea thatwe could look at what's really like a pre-malignant condition where patients would not be treatedbut the patients are often neutropenic. now interestingly a large body of evidencesupports the fact that the increased risk of infections in patients with myelodysplasiaof this sort is really not the reduced number of neutrophils although eventually that doeshave an impact. but it's primarily due to reduced neutrophiland monocyte function. so we reasoned that

because maitake beta glucan in fact stimulatesgranulocyte colony stimulating factor of production directly in certain types of macrophages. for example in the bone marrow and specificallythese we think are committed progenitor cells that it might promote the recovery of peripheralblood leukocytes after bone marrow injury. and we then regarded of course mds as sortof a conditional bone marrow injury type problem although the basis of it is this preneoplasticcondition rather than some kind of chemotherapeutic injury. so on the next and last slide - this signalingpathway popped in again let's get beyond that and we'll skip this because now we don't needto talk about it and i'm hoping we'll get

to the last slide. this is all out of orderbut if we can get to that last - yes this is it. so we very recently have submitted for publicationour study, which shows that mds patients who took oral maitake beta glucan over 12 weeksas a group showed an increase production of reactive oxygen species. dr. meydani mentioned this in associationwith host defense and under some conditions it can be - it can mean many different thingsbut essentially for monocytes and neutrophils production of these species is absolutelyessential for killing bacteria after phagocytosis. and so as you can see if you look at the panelthis is a whisker plot so you can see the

high, the low and the mean and you can seewhat the whole group looked like. and you can see that if you look across fromthe pre to the post that the box gets very small and thin so that at the very end comparedto normal healthy controls you can see that the patients actually became normalized intheir reaction. and in this particular top panel we're lookingat granulocyte, which is - those are primarily neutrophils and peripheral blood so we usuallyjust call them neutrophils. but neutrophils response to e.coli, whichis extremely helpful as a pathogenic response because it's critical for defense and it'sa good measure of cellular immunity. so as you can see it was greatly improvedover the course of the study and i should

mention to that our healthy controls wereage matched so these were also older individuals. and we saw that with respect to monocyteswe even noticed that the pre-treatment monocyte response to e. coli was significantly reducedin mds patients compared to healthy controls. this is a very conserved function and we'vepreviously done studies in patients with various different conditions including breast cancerand it's usually fairly robust. so when it goes down it probably representsthe problems in the bone marrow and the difficulties in producing normally matured and functionallyactive cells and as you can see here compared to the normal controls on the far right themonocyte response really did substantially improve after treatment.

so in conclusion i think we can see that mushroomscontain unusually �bio - powerful bioactive materials and some of them such as beta glucanshave direct effects on immune response through impact on the maturation and differentiationof cells. that oral beta glucan being taken as it isdirectly it seems to the lymphoid organs specifically in many cases directly to the bone marrowmay be able to impact an impaired process not only where chemotherapy has weakened anddamaged the bone marrow but potentially also in certain source of pre-malignant conditions,thank you very much. >> dr. gabriela riscuta: thank you so muchdr. cunningham-rundles. great presentation and yes we have time for one question foryou and this question comes from ms. pamela

maxwell and i'm going to read the questionto you. she's asking what would be the next step inresearch mainly how do you recommend a study design to learn more about the type of mushroomand the quantity needed to bring the desired effect of - for someone that would like toincrease their consumption of mushrooms? >> dr. cunningham-rundles: well clearly weneed some sort of phase one study. we actually did this in our breast cancer patients withmaitake beta glucan but they're expensive and hard to conduct because you have to havea lot of groups. and of course the goal of phase one usually is just to find toxicity,we didn't find any toxicity, which was good. but a secondary objective is to look at efficacyand impact.

but i personally think we need to do a coupleof things. one is to find fairly homogenous populations. two is to use different mushroomsthat have very well quantified and described beta glucan or other bioactive componentsthat we can measure. and then three we need to look for biomarkersusually things that are in blood. i think - of course i'm very interested in the hematopoiesisso that's one way so that we can accurately track what happens. and finally although i didn't talk about itit is possible to measure levels of beta glucan in blood and that could also be of some use. >> dr. gabriela riscuta: good thank you andanother question from alice shapiro is your

work with beta glucans in humans being conductedunder an ind? >> dr. cunningham-rundles: yes of course. >> dr. gabriela riscuta: okay thank you somuch. we have one more question, is the benefit from mushroom extract equal with the benefitof eating mushrooms? >> dr. cunningham-rundles: you mean are anymushrooms so rich in these beta glucans that they alone would be sufficient is that whatis meant by the question? >> dr. gabriela riscuta: no i think what itmeant is taking the beta glucan as a supplement as an extract would be equal - would providethe same benefit as eating whole mushrooms. >> dr. cunningham-rundles: oh. if that's allyou wanted to select and choose out only beta

glucan yes i think there's definitely roomfor supplementation but i would also advise considering the huge power that mushroomsapparently have and also remembering what dr. meydani said about the microbiome. i believethat those components you would not get in your extract. so it would be a shame to chooseone over the other. so i would advise both. >> dr. gabriela riscuta: okay thank you iwould advise the mushrooms too. and thank you so much for a great presentation now wehave to move towards our third speaker and this is dr. hilakivi-clarke and dr. hilakivi-clarkeis a professor of oncology at lombardi cancer center at georgetown university. she will discuss the role of soy isoflavonesin cancer prevention through immunomodulation.

when she will finish we will have time fora few questions again. so, dr. hilakivi-clarke. >> dr. hilakivi-clarke: thank you very muchand thanks for the invitation to present to you today. so edamame beans the foundationof traditional soy foods and they are used also to make other soy products such as soymilk and tofu. western soy products can be very differentbecause they are often made from isolates from protein isolates from the whole soy.and soy isoflavones they are classified as phytoestrogens, which are plant-derived compoundswith estrogen activity. they are naturally present as glucosides,so bounded with the glucose molecule but when they are fermented or digested in our gutthey form aglycones and those are genestien,

daidzein, and glycitien, and in some individuals,daidzein is further made into equol. different foods have very different isoflavonecontents for example one cup of miso soup has four times the level of genestein thansoy milk has. and as you can see in this table at the verybottom the western food product meatless soy sausage only have very low levels of genestein.there is an inverse correlation between soy isoflavone intake and breast cancer incidence. soy intake is very low in europe, a littlehigher in the u.s., but in asia it's considerably higher and the blood genestein levels in thetypical asian person who consumes soy foods daily is between one to five micromolar.

the map shows you the incidents of breastcancer in different parts of the world and the incidents is very high in u.s. and westernworld and then low in asian countries because of that correlation it has been proposed thatthere is an association between high intake of soy foods and low breast cancer risk. clearly this link is not caused by some geneticfactors in asian women because when they migrate to the west to the u.s. for example theirdaughters and granddaughters then acquire the same level of breast cancer incidenceas caucasian women. soy foods have proposed to have several healthbenefits and that is to prevent breast cancer and its reoccurrence. it has been proposedto promote cardiovascular health, prevent

osteoporosis, help to control menopausal symptomsand have some cognitive benefits. but it still remains controversial whether any of thesehealth benefits really exist. there is a problem concerning soy food consumption and breastcancer, or it has been proposed that there�s a problem for the reason that estrogens playan important role in breast cancer susceptibility or gets breast cancer and who does not. so the high lifetime levels of estrogens havebeen linked to increase breast cancer risk. and if you look at the chemical structureson here of genestein it is very similar to that of estradiol. and we also know that when the most effectiveprevention and treatment for breast cancer

are anti-estrogens that inhibit the actionof estradiol. and indeed in studies that have been done using human breast cancer cellseither in culture or when they inoculated to nude mice. it has been shown that the concentrationsof genestein you can see here i have circled it, is one to ten clearly induced proliferationof these human breast cancer cells in culture and also similar there�s growth when theyare inoculated to nude mice. i think i need to have the next set of slides.so i will briefly go through what is known about soy food intake and breast cancer riskand these findings are obtained in observational human studies.

so it means that there are no interventionstudies per se where women would have been fed with soy foods. this is just representingtheir natural intake and breast cancer. there are several meta analyses that havelooked whether there is a link between soy food intake and prevention of breast cancerand they all have shown that amongst asian women and asian american women soy intakereduces the risk of breast cancer by about 30 percent. if you compare in this figure the low intake,which is less than 5 milligrams of isoflavones per day to high intake, which is over 20 milligramsper day. however in western women there is no indication that soy intake would reducebreast cancer risk.

but here if you look at what is high intakeit is over point-8 milligrams per day and that is lower than the low intake limit inthe studies done in asian and asian americans. so what would explain possibly these differencesin asian women and caucasian women? one obvious explanation is the level of soy intake, whichis much higher in asian women. another one is that soy foods are consumedthrough the lifetime in asia while in the west women tend to start to consume them asadults or close to the menopause when they want to reduce the menopausal symptoms. so the timing is very different and it hasbeen shown very consistently both in human studies and animal studies that solid foodand life-long dietary consumption of soy foods

reduces incidence of breast cancer. how about soy food intake among breast cancerpatients and survival? so here i've summarized a couple of studies again some meta analyses,some dividing the individuals to different ethnic groups and in the left side you cansee the effects of soy food intake of the breast cancer diagnosis and mortality of breastcancer. there doesn't seem to be too much of an effect.in one study there is an indication of reduced mortality by a high intake of soy foods. butfor example in the lower figure on the left side asian women or u.s. women or u.s. womenwhere no asian women were included there doesn't seem to be any beneficial effect on mortality,but importantly there's no adverse effect

either. then if one looks at the figures on the rightside that show breast cancer reoccurrence and soy food intake those studies indicatethat there is a benefit: the higher the soy intake of the breast cancer diagnosis, thelower the risk of reoccurrence. and that seems to be true both for asian womenand women living in the west. but i want to point out here that none - that these areall observational studies and most likely women have been consuming soy well beforethey got breast cancer. so these results don�t indicate that startingto consume soy after breast cancer diagnosis is safe that we don't know yet. so what mightexplain the beneficial effects of soy foods

particularly genestein in terms of reducingbreast cancer risk? several different explanations have been suggestedand these studies have been done mainly in cell culture. and you can see here that forexample it has been suggested to inhibit angiogenesis, but if you look at the dose that this requiredfor that to happen it's 150 micromolar. and if you remember i pointed out that thelevels in humans are 1 to 4 micromolar amongst those that consume soy foods daily. so itis possible that the relevance of these findings or the relevance of these findings to explainhow genestein might reduce breast cancer is not clear. so finally i am going to talk a little bitabout genestein and its immunomodulatory properties

and perhaps this could explain the cancerpreventive effects of genestein. genestein has been shown to inhibit severalinterleukins, in particular il-6, also inhibit the cytokines tnf-alpha and nf kappa b, inhibitmacrophages that you heard earlier that are bad in terms of cancer growth, and rankl.but it also stimulates cytotoxic t-cells and natural killer cells. so this is just to very quickly summarizewhat we think about the role of three different factors in carcinogenesis particularly breastcancer. high hormone levels and impaired dna repairability lead to increased carcinogenesis. immune systems, well-functioning immune systemsinhibit carcinogenesis. but cancer cells also

are created inflammatory environment and thisinflammatory response is then - can promote the growth of the cancer cells. and i just want to very briefly show you thesecouple of slides about the immune system in general. i know that the two previous speakersalready mentioned them very detailed but i just want to remind you that there are fourdifferent kinds of immune cells: t cells that are further divided into cytotoxic t cellsand then cd4 helper cells, macrophages, natural killer cells, and dendritic cells. and thesecells release cytokines and chemokines that affect the tumor cells and some of them likeinterleukin-12 activates nk cells, cytotoxic t-cells and other cytokines that lead - thatboost the immune system of the tumor cells

and suppress tumor growth while some others like il-6 and perhaps il-10then lead to increased tumor growth. and it's very difficult just by looking at one particularinterleukin or t-cell action to determine whether there is a good or bad effect in termsof the cancer cell growth because some of them can have both effects. and when we think about how genestein playsa role now first in the event that lead to tumor initiation so as has been pointed outearlier and in cancer inflammation occurs and it produces reactive oxygen species andreleases cytokines and they then might cause mutations in epithelial cells and lead totumor initiation or they can also induce epigenetic

changes that can induce tumor initiation. genestein, let's see whether i can use this- genestein has been shown to directly imped inflammation, prevent the cytokines, or inhibitthe growth production genestein also might play a role in improvingantitumor immune responses. so there are the immune-surveillance part of the immune responsesand the tumor promoting inflammation and genestein has been shown to activate nk cells and alsotrail, that would then lead to the good events that would block the tumor growth. and on the other hand genestein has been shownto inhibit tnf-alpha and interleukin-6 that would then prevent these inflammatory responsescreated by tumor and together lead to better

anti-tumor immune responses. and finally it is possible that genesteinalso plays a role in preventing therapy induced inflammation and stimulates anti-tumor activity.so when a tumor is saturated with chemo or radiotherapy that induces an inflammatoryresponse in the tumor cells. and that inflammatory or immune response canhave a negative effect induce of cytokines that would embed the activity of the chemoand radiotherapy or it could have a good effect by inducing t-cells that then prevent thetumor cell growth. and it has been shown that genestein stimulatesthis anti-tumor immuno response and inhibits the cytokines that activate pro-survival genesso it could play a role in improving the response

to different therapies. and finally i want t point out that it ispossible that in order to see the protectiveness of genestein normally functioning immune systemis required and that might explain the results that have been obtained in the nude mice orin the cell culture experiments using mcf-7 cells because there is no immune system there. but in a study done by guo et al., they showedthat if they used mice that have an intact immune system and fed them genestein beforetumors were initiated and they looked at melanoma cell growth and also looked the growth ofcarcinogenic mammary tumors and they found that now in the animal that had an intactimmune system genesteinreducing tumor initiation.

but the study also showed that the feedingstarted after the tumors were there then it didn't have very much of an effect. so it is possible that genestein- inducedmodulation of immune responses, the increased t-cell activity and natural killer cell activityand reduction in inf-gamma levels and then on the other hand reduced cd4 t-cell activityis responsible for reduced mammary tumorogenesis. and if you are interested i did go into detailsabout how these different immune responses are activated or initiated by genestein andi just would like to refer you to a couple of good reviews where you can get more information.okay thank you. >> dr. gabriela riscuta: thank you, thankyou so much dr. hilakivi-clarke for the great

presentation. we have time for a few questionsnow and i would also like to remind the participants to look for an email from us with informationabout continuing education credits and a link for a brief evaluation. and now i have a question for you from missromina from argentina and she is asking if you have some data regarding the amount andthe frequency of soy consumption in asian countries. so basically how much and how oftena woman should be consuming soy in order to get any benefits as with regards to breastcancer prevention. >> dr. hilakivi-clarke: the suggested amountis two to three servings per day and that's my understanding the typical asian soy foodconsumption.

>> dr. gabriela riscuta: so every day, twoto three servings every day. and then i have another question from victoria and she's askingif it would make any difference if someone would consume organic soy versus geneticallyengineered soy and also she's asking if consuming fermented soy versus non-fermented soy. >> dr. hilakivi-clarke: this is a questionthat is almost always asked and i don't think that there are studies that would show whetherthere is a difference, so. >> dr. gabriela riscuta: okay, well thankyou so much for all of these great presentations. i would like to thank you all. dr. simin meydani,dr. susanna cuningham-rundles and dr. leena hilakivi-clarke for their insightful presentations.

and i would like to thank the audience forparticipating today. i hope we were able to accomplish our goal and especially invited- presented very intriguing information as it relates to diet and cancer prevention throughimmunomodulation. as you have heard there are a number of vitaminslike vitamin e, vitamin b6, foods like mushrooms and soy that exhibit particularly strong immuneproperties and they may be able to modulate immune response and therefore participatingcancer prevention for several mechanisms for increasing their immune response. of course there are more foods to study andwe need a lot more studies in order to determine and to understand the interaction betweenfood genes, microbiome, exact amounts, the

timing. but through hard work i believe we are lookingfor a bright future and we hope that indeed diet will play a very important role in thefuture in cancer prevention. if you have more questions that you would like to address pleaseemail the questions to me gabriela dot riscuta at nih dot gov and i will forward your questionsto your invited experts and i would like again to thank you all for joining us today. goodbye. >> coordinator: thank you this does concludethe conference you may disconnect at this time. end