Maria De Santis: Well, thank you very much, Neeraj. It's such a pleasure to have a chat with you on the nutritional topic from the APCCC, which we were just attending. And yes, so I'm happy to answer questions or maybe give you a short introduction on what I presented at the meeting.
Neeraj Agarwal: Absolutely. We are really looking forward to this very important discussion on nutrition in patients, our patients who are diagnosed with metastatic prostate cancer, even localized prostate cancer, receiving systemic therapies. And it's such an important topic. And really most of the clinicians, they don't feel like they have expertise to talk about nutrition in these patients, even though this is such one of the most important topics because of the metabolic syndrome, which is induced by all these systemic therapies we use in our patients. So first of all, we really enjoyed your talk. And I would like to start with how do you approach the topic of nutrition when you are starting a patient with prostate cancer with systemic therapy?
Maria De Santis: I could not agree more that we all do not feel very comfortable in talking about nutrition because we have not been trained in nutritional aspects. However, for the patients, nutrition is so important. On the one hand, because of the medical implications, and on the other hand, because they are flooded with advice for nutrition, diet, supplementation and practices like fasting from the family members and friends and neighbors. And they hear, "Eat this, avoid that," and, "Try a supplement," or, "A diet was good for my neighbor." So there is a lot of confusion out there. And also sometimes financial burdens with regards to supplements and unapproved diets, for example. So I think it is a topic which is really important to sort for our patients and to discuss it in details.
The goal of my talk was to give an overview of the evidence, which is not that great, so we have a positive evidence here. And however, also guidelines, recommendations, and also to provide practical advice for our patients. First of all, when I introduce the topic, I try to explain to my patients what ADT causes, including fat mass increase and muscle mass reduction, sarcopenia, the metabolic risk, insulin resistance and fatigue, and explain to them that nutrition is very important for the function, for the quality of life, and also for the long-term outcomes with ADT, because ADT can make them really sick and induce additional comorbidities. Our goal should be to preserve the muscle mass, to improve the treatment tolerance and with that, to improve the quality of life.
And also, I try to explain to them that we should not focus only on the weight, weight gain or weight loss, but also on the whole-body composition. And there is sometimes a misunderstanding with that regard. So what we try to do, and there are also ESMO recommendations with that, is that we need to screen the patient, not only with the weight change, but the body mass index, but also the functional status. And also consider body composition tools like the computed tomography, for example. And we should not forget that even the overweight patient can be malnourished. Here comes another factor into the play, the key principles are activity level and the clinical condition and to balance the influences of nutrition and moving and having exercise. And this is the important part I usually start with, discussing with the patient.
Neeraj Agarwal: Those are very good points. Increased body weight doesn't mean increased muscle mass. It may have more fat mass, and that's why it is so important to customize the recommendations for nutrition. And we'll come to the other aspect you mentioned about beyond nutrition, which are beyond the scope of this discussion, obviously, but how to build muscle mass with resistance training. We'll touch upon that briefly because that is not the focus of discussion today.
But I'd like to bring back nutrition into the discussion, the focus. How do you approach nutrition in patients who have lost weight, who are cachectic because of, say, metastatic prostate cancer? We know that's a bad prognostic risk factor even in metastatic disease, versus patients who are overweight, versus patients who have normal weight. How do you approach nutrition differently in these patients?
Maria De Santis: Yeah, well, this is an important aspect, and there is not one-size-fits-all. And as you correctly said, I think it depends on the actual weight and then also on the habits and the diet, the normal diet of the patient. What usually happens is that those patients don't have enough protein intake, and there are those recommendations with regards to protein intake to have around one gram per kilo protein per day, and this can be quite a lot. A 70 kilo patient would then have 56 to 84 gram protein per day. And this means quite something in particular when the patient is not on a meat diet. With that, the composition of the diet is pretty important. And for many patients, also, meat is not a good option because they don't like meat so much. But then with vegetarian diet, it is more difficult to have a decent protein intake.
The protein density of vegetarian food is only moderate and not as high as meat. And the portion sizes need to be much larger with a vegetarian diet when it comes to protein intake. The protein quality is sometimes incomplete and the patients need more planning for their dishes and for shopping when they have a vegetarian diet. So sometimes things become complicated and sometimes additional protein drinks, energy drinks, including proteins are necessary to have a balanced diet and to balance out the lack of protein or deficits in protein in the diet. This is a general recommendation.
And for overweight patients, the reduction in sugar and reduction in carbohydrates are pretty important, but in the same place to have enough proteins in their diet. So only fasting is not the right way to go, this is for overweight patients. They need exercise, they need proteins and they need a lower carbohydrate diet. And the patients that have weight loss, very often we also have to look not only in the nutrition, but also in the treatment. Sometimes we have to reduce the treatment doses to avoid the weight loss because also, ADT and also our hormonal treatments can induce weight loss. So all parts of effects, weight gain and weight loss, are possible with hormonal treatments.
Neeraj Agarwal: Just to summarize, for three different categories of patients, so starting with patients with normal body weight, one gram per kilogram protein is the ideal protein intake, which may be challenging for patients who are purely vegetarian, but that's a general recommendation. Patients who are overweight, they need to maintain that one gram per kilogram, but diminished carbohydrate intake to attain a normal body weight is highly desired because they're at a higher risk of metabolic syndrome with androgen deprivation therapy and other treatments. And patients who have lost body weight because of prostate cancer, cachectic, underweight, disease control is obviously very important with the anti-cancer therapy in addition to the protein intake. Is that correct?
Maria De Santis: Oh, that is very correct. Thank you for summarizing so well [inaudible 00:10:18] topic.
Neeraj Agarwal: No, this is great. I'm learning, frankly. So coming to, you mentioned exercise. What kind of exercise you recommend? Because nutrition is so closely intertwined with exercise. And obviously, this is not our expertise. As a medical oncologist, I don't think we had formal course curriculum in nutrition and exercise, but what kind of exercise do you recommend, especially for patients who are overweight and for all patients in general who are starting androgen deprivation therapy?
Maria De Santis: Well, I think that the important part is the resistance exercise when it comes to increasing the muscle mass. In general, the patients should have both. They should have the resistance exercise and also the cardiovascular training. But for the muscle part, the resistance exercise is the important bit, together with protein intake. And then the recommendation is usually, it is not my special topic, but the recommendation is usually you have at least half an hour, three times a week. And for many patients, I think this is quite something many are not used to a very organized and whole-body resistance exercise.
Neeraj Agarwal: That's very useful to know, because most patients, I'll be honest with you, in my experience, if they are walking or they're working in their yard or in their home, they think this is enough exercise. And it is very important to notice that that's a misperception and resistance training, focusing on overall muscle mass, regardless of, it's not only biceps and triceps, it's also core muscles, proximal muscles of the hip, which prevent falls in these patients. Fall is such an important complication in our patients with metastatic prostate cancer. So the whole-body resistance training is as important as the nutrition.
Maria De Santis: Yes, I could not agree more, yeah. And with that, the patients and we all learn about our muscles a lot, we feel the muscles that we have never thought we would have with that kind of training.
Neeraj Agarwal: That's important, exactly. I cannot agree with you more. Any online tool which can help our patients in getting to understand more about nutrition, but also exercise? Anything you recommend or you use in your practice beyond your own program? Obviously, you have an interdisciplinary program in a prestigious university hospital, but many of our community colleagues do not have access to those programs. Any recommendation for those patients or those physicians?
Maria De Santis: Well, at the university clinic, we are kind of spoiled. We have programs with our Sports Medicine Department, of course, but otherwise there are lots of apps out there. And some are also supported by the guidelines and by our societies like asthma, et cetera, where patients can learn more about the composition of their diet. They can look up the protein part of their food, for example. They can also make photos and artificial intelligence that then tells them how much protein is on their plate. So I think there are very interesting and helpful tools for the patients. I think it is worthwhile recommending such tools because some patients also really love it and they enjoy having that app and knowing what they eat and how they can improve their diet.
Neeraj Agarwal: I agree with you. Artificial intelligence, including ChatGPT, is making it so much easier nowadays for our patients to figure out how much protein is there in their diet. I love the fact that you said you can take the picture of your plate and ask AI-based tools, how much protein they are taking in that particular meal. Is that right?
Maria De Santis: Yeah, that's right. And I also tried it out for myself, and it is amazing how correct the AI works here. It's really good.
Neeraj Agarwal: So the bottom line is patients with prostate cancer, regardless of whether they have localized high-risk prostate cancer or metastatic prostate cancer, who are being treated with androgen deprivation therapy and many other therapies nowadays, they are at a very high risk of developing metabolic syndrome and risk of metabolic syndrome, such as vascular disease leading to ultimately, cardiovascular risk, increased risk of cardiovascular disease, stroke risk, renal disease and so on. And it's very important for them to focus on nutrition from their first day of diagnosis. And it's more important than ever for all of us as clinicians taking care of our patients, to talk about nutrition and resistance training. Any last words, Maria?
Maria De Santis: Well, I think that ESMO is pretty correct, that nutrition is part of our supportive care and it is not optional. And that we need to train our patients and also train ourselves to counsel our patients for nutrition for their diet, and include it in our care when it comes to hormonal therapy and many other therapies that we use in prostate cancer.
Neeraj Agarwal: Thank you very much for sharing your words of wisdom and for taking the time today.
Maria De Santis: Thank you, Neeraj. A real pleasure.