Background

Follicular lymphoma (FL), the second most common non-Hodgkin's lymphoma (NHL), is characterised by a classic histological appearance, an indolent course and an incurable nature.1 ,2 Current treatment protocols for FL include close observation or immunotherapy when patients are asymptomatic, and immunotherapies, chemotherapies and/or radiotherapies during symptomatic periods.2 ,3 Although patients with FL have high therapeutic response rates, they can also experience high rates of relapse and a reduction in asymptomatic periods over time.4 ,5 Therefore, treatment options that can manage FL symptoms and maintain asymptomatic periods with low toxicity and cost would be beneficial. Despite evidence supporting the potential role of diet in outcome survival in FL6 and various other cancers,6–13 dietary modifications are not yet a standard part of treatment protocols. The case reported here establishes a basis for further studies evaluating water-only fasting and a minimally processed plant foods diet free of added sugar, oil and salt (SOS) in the treatment and management of FL cases.

Case presentation

On 23 June 2014, a 42-year-old woman presented to her primary care provider with a palpable mass in her right inguinal region. She was otherwise asymptomatic, denying symptoms such as fatigue, weight changes or pallor. The patient consumed the Standard American Diet,14 weighed 81.6 kg and had a body mass index (BMI) of 29.4 kg/m² (table 1). She had never smoked tobacco or used illicit drugs, and drank <3 alcoholic drinks/week. The patient's family history revealed that her father passed away from late stage cancer of undetermined origin and that distant paternal relatives had a history of renal cancer, but family history did not reveal incidence of blood or lymph cancers.

On presentation to her primary care physician, the patient was immediately sent for a CT scan and various serological tests, including a complete blood count (CBC). The CT scan obtained on 23 June 2014 revealed bilateral enlargement of the inguinal lymph nodes reflecting a notable change compared to a scan on 29 October 2012, which was obtained for an unrelated medical visit. The largest node in the right inguinal region measured 45×20 mm (figure 1) in the transaxial long and short axis, and the largest on the left side measured 21×15 mm (figure 2). Lymph nodes at iliac chains and pelvic sidewalls were not enlarged. There was no evidence of free fluid in the patient's pelvis and the CBC was unremarkable. On 11 July 2014, the patient underwent a surgical excisional biopsy of the left inguinal lymph node, which confirmed the diagnosis of low-grade (grade 1 of 3) follicular centre cell lymphoma. Flow cytometry showed CD-positive monotypic B cells making up 15% of the specimen in a polyclonal B-cell background, without identification of large cell components or Burkitt's lymphoma. A chest CT scan on 15 July 2014 revealed asymmetric enlarged lymph nodes in the right axilla, the largest measuring 28×19 mm. On the basis of the diagnosis of stage IIIa, grade 1 FL with an unremarkable CBC, the patient was advised to have observational follow-ups at 3-month intervals. The patient then contacted TrueNorth Health (TNH) with an expressed interest in medically supervised, water-only fasting and was determined an appropriate candidate based on the presence of adequate nutrient and electrolyte reserves, normal creatinine and haemoglobin levels, a normal glomerular filtration rate and no contraindicating conditions.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

CT images of right inguinal region. (A) Before and (B) after water-only fast.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

CT images of left inguinal region. (A) Before and (B) after water-only fast.

Diagnosis

Diagnosis of stage IIIA, grade 1 FL was established by excisional biopsy, according to the diagnostic criteria outlined by the 2008 WHO classification of lymphomas.15

Treatment

For over 30 years, TNH has safely implemented dietary modifications, including water-only fasting and an exclusively plant foods, SOS-free diet, to restore and maintain health in human patients. Water-only fasting is the complete abstinence of all foods and beverages with the exception of water.16 It is our experience that extended water-only fasting is superior to intermittent fasting in the treatment of chronic health conditions. The health promoting biological changes that occur during fasting include promotion of ketogenesis, decreased oxidative stress and inflammation, and increased stress resistance, lipolysis and autophagy.16 ,17 Fasting also modulates levels of hormones and growth factors, which in turn decreases rates of cellular proliferation and increases rates of apoptosis.17 Therefore, it is thought—and emerging research is demonstrating—that fasting could potentially prevent and treat various health conditions, including some malignancies.17

Prior to arriving at TNH, the patient began an exclusively plant foods, SOS-free diet. On 3 November 2014, the patient began to fast by completely abstaining from all foods and beverages with the exception of distilled water ad libitum (minimum of 40 ounces daily) for a period of 21 days. During the water-only fast, the patient's activities were restricted because even moderate activity doubles energy use. We have further observed, during the supervision of over 15 000 fasting patients, that restricted activity also minimises the frequency of orthostatic hypotension, arrhythmia, dehydration and electrolyte disturbances—side effects reported by others who have encouraged unrestricted activity during fasting.16 The patient was allowed to engage in quiet activities (eg, reading, listening to music and watching instructional videos), participate in educational classes, and attend medical and psychological consultations. The patient's weight, blood pressure and vital signs were monitored on a twice daily basis.

The water-only fasting period was followed by 10 days of supervised refeeding beginning with the consumption of 12 ounces of unsalted vegetable broth every 3 h for 9 h on the first day. On the second day, the patient consumed 12 ounces of juice made from fresh, raw fruits and vegetables, every 3 h for 9 h. On the third day, the patient consumed a diet of fresh, raw fruits and vegetables and was instructed to eat until comfortably full. Following this transitional period, a diet of minimally processed plant foods, including fresh, raw fruits and vegetables, steamed and baked vegetables, whole grains and legumes, and approximately 1 ounce/day of raw unsalted nuts and seeds, was introduced. Cooked meals were prepared with recipes that met specific guidelines18 and excluded all meat, fish, fowl, eggs and dairy products, as well as added sugar, oil and salt. Bread products and other highly processed foods were also excluded. The patient was allowed to eat this specific SOS free, plant foods diet, with the exception of nuts and seeds, ad libitum. The patient was encouraged to continue consuming this diet after leaving TNH.

Outcome and follow-up

The patient did not experience any notable adverse side effects while fasting. Following the fast, her weight had reduced from 78.0 to 68.9 kg (table 1) at a rate of approximately 0.4 kg/day, her BMI had reduced from 28.62 to 25.29 kg/m² (table 1) and her CBC remained unremarkable. A physical examination demonstrated that the patient's enlarged lymph nodes had reduced in size. She then underwent a follow-up CT scan on 11 March 2015, and it was confirmed that the right inguinal node had reduced from 45×20 to 26×3 mm (figure 1), left inguinal node had reduced from 21×15 to 11×2 mm (figure 2) and the axillary node had reduced from 28×19 to 15×10 mm. The inguinal nodes no longer demonstrated increased fluorodeoxyglucose uptake.

On 31 January 2015, at 6-month follow-up, the patient reported strict compliance with the exclusively plant foods, SOS-free diet. Her weight was 63 kg, BMI was 23.13 kg/m² (table 1) and the lymph nodes were non-palpable. Similarly, at 9-month follow-up, on 2 August 2015, the patient reported diet compliance, her weight and BMI had further reduced to 59.9 kg and 21.96 kg/m², respectively (table 1), and her lymph nodes remained non-palpable.