Effect of synbiotic supplementation on matrix metalloproteinase enzymes,quality of life and dietary intake and weight changes in rectal cancer patients undergoing neoadjuvant chemoradiotherapy

Abstract

BACKGROUND:

Probiotic/synbiotic has the important role of in altering intestinal bacteria, reducing inflammation and improvement of intestinal diseases.

OBJECTIVE:

We aimed to investigate the effect of synbiotic supplementation on matrix metalloproteinase (MMP) enzymes, hs-CRP, quality of life, dietary intake and weight changes in rectal cancer patients undergoing neoadjuvant chemoradiotherapy (CRT).

METHODS:

In this study, 46 rectal cancer patients were recruited. Patients were allocated to the synbiotic (n = 23) group or placebo groups (n = 23) receiving 2 synbiotic or placebo capsules for six weeks. Anthropometric measurements, quality of life, dietary intakes, and serum levels of MMP-2, MMP-9, and hs-CRP were compared before and after intervention with the use of statistical tests.

RESULTS:

The mean energy, carbohydrate, and protein intake of patients increased in the synbiotic group, while in the placebo group, post intervention, significant reduction was noticed in these parameters (P < 0.05). Synbiotic supplementation caused improvement in global health status, symptom scale scores and scores of functional scale. At the end of intervention, the elevation in hs-CRP, MMP-2, and MMP-9 levels in the placebo group was approximately two and four times higher than the synbiotic group respectively.

CONCLUSION:

According to our results, synbiotic supplementation may be helpful in cancer patients undergoing CRT. However, further studies must consider synbiotic as a new complementary treatment.

Keywords

Rectal cancer synbiotic supplementation preoperative chemoradiotherapy dietary intake quality of life

1 Introduction

Rectal cancer is one of the most common cancers in Asia [1]. CRC patients are treated with pre/postoperative pelvic chemoradiotherapy (CRT) in stage II and III [2]. Despite improvements in the management of rectal cancer, CRT triggers a pro-inflammatory response that mediates incidence of side effects, the resistance of tumors to treatment, distant metastases, and so on [3 –6]. The side effects of pelvic CRT are gastrointestinal symptoms including intestinal inflammation, abdominal pain, nausea, vomiting, diarrhea, loss of appetite, malnutrition, and depression [7, 8]. These symptoms have negative effects on patients’ dietary intake and quality of life [9, 10]. According to the findings of previous studies, increased inflammatory factors, changes in bacterial flora (dysbiosis) and intestine mucosal injury induced by CRT could cause gastrointestinal symptoms [11 –13]. It has been mentioned that using new adjuvant anti-inflammatory therapeutic approaches may be helpful in incrementing tumor response to treatment and reducing toxicity and metastasis [4]. Treatment of these symptoms with various drugs is associated with inconclusive clinical results or more severe complications. Therefore, researchers have recently investigated the effect of different supplements, such as probiotic/prebiotic, on side effects of cancer treatments. Synbiotics are a mix of probiotic (specific host beneficial microorganism) and prebiotic (probiotic growth-promoting ingredient) that might have better effects than just pro/prebiotic. The findings of different studies have been revealed that using probiotics, prebiotics or synbiotic in Irritable Bowel Syndrome, inflammatory bowel disease patients ameliorate inflammatory condition, decrease diarrhea and infection, reduce symptoms of diseases, enhance immunity, and alter bacterial flora [14 –25]. Furthermore, Nascimento et al. reported that synbiotic supplementation reduced proctitis symptoms and improved quality of life in patients with prostate cancer [26].

Considering the probable effects of synbiotic in the improvement of dysbiosis and consequently reducing the complication of treatment and metastasis, and due to the lack of any published article about the effect of synbiotic supplementation in rectal cancer patients undergoing CRT and to the best of our knowledge, there is no published article about the effect of synbiotic supplementation in rectal cancer patients undergoing CRT. Therefore, this study was carried out to investigate the effect of synbiotic supplementation on matrix metalloproteinase (MMP) enzymes, hs-CRP, quality of life, dietary intake, and weight changes in rectal cancer patients undergoing neoadjuvant CRT.

2 Method and material

This study was a parallel randomized double-blind and placebo-controlled study which was approved by the Ethics Committee of the Tabriz University of medical sciences and registered as an IRCT study (IRCT: 201503181197N18). 46 volunteer patients were selected from rectal cancer patients who were referred by the radiotherapy department of Shahid Madani University hospital, Tabriz, Iran, from June 2015 to July 2016. All patients were candidates to receive preoperative neoadjuvant CR and written informed consent for participation was obtained from each patient. The sample size was calculated based on the data of diarrhea factor obtained from Chitapanarux et al.’s study [7]. We estimated alpha of 0.05 and power of 80% for calculating the sample size. The sample size was computed as 23 patients per group. Inclusion criteria were rectal cancer patients in stage II and III according to TNM (tumor, node, metastasis) classification. Subsequently, exclusion criteria were clinically relevant pulmonary, cardiovascular, hepatic and kidney dysfunction, immunological disorders, other cancers, pregnancy, lactation, ongoing or recent infections (within last 30 d), BMI < 18.5 kg/m², taking antibiotics in the last three weeks, taking of probiotics/prebiotics or synbiotic and mineral supplements, intolerance of synbiotic or placebo.

All patients received pelvic radiotherapy (RT) with a dose of 1.8 Gy/day, five times weekly for about 5–6 weeks. The prescribed total dose was 45 Gy. Also, patients received an intravenous dose of 325 mg/m² 5-fluorouracil with 20 mg/m² locoverin daily during the five days in the beginning and at the end of the RT. Patients were randomly assigned to receive synbiotic or placebo capsules. Synbiotic capsules (Protexin, United Kingdom) contained 1×10⁸ CFU/gr of Lactobacillus casei PXN 37, Lactobacillus rhamnosus PXN 54, Streptococcus thermophilus PXN 66, Bifidobacteriumbreve PXN 25, Lactobacillus acidophilus PXN 35, Bifidobacteriumlongum PXN 30, Lactobacillus bulgaricus PXN 39, FOS (Fructooligosaccharide), magnesium stearate (source: mineral and vegetable), and vegetable capsule (hydroxypropyl methyl cellulose). Placebo capsules were made up of magnesium stearate and silicon dioxide, and their appearance was like synbiotic capsules.

Patients were randomly assigned to synbiotic or placebo groups by a block randomization procedure and the subjects were matched in each block based on the course of CRT. Patients and persons involved in doing the assessment and chemical analysis were blinded to group assignments.

Patients received synbiotic or placebo capsules two times a day before meals (morning and evening) for six weeks. The supplementation began one week before starting the CRT to the end of the radiotherapy. All patients returned drug packages weekly and received other packages and followed up for any side effects of supplementation weekly. Patients who had used 80% capsules were included in the analysis. Clinical evaluation was performed at the onset and at the end of CRT. At the onset of the study, height was measured using a mounted tape, with the subject’s arms hanging freely by their sides, and recorded to the nearest 0.5 cm. After ensuring that subjects were barefoot and wore light clothing, their weight was recorded to the nearest 0.1 kg with a Seca scale before and after the intervention. Body mass index was calculated by dividing weight (in kg) by the square of height (in meters). The Harpenden Skin fold Calliper measured the triceps skinfold (RH 15 9LB. England). Patients instructed for filling food record questionnaires and then dietary intakes were evaluated by 24-hour food recall and food record (2 days). Information about the calorie and macronutrients intakes were obtained through the analysis by Nutritionist IV for Windows software. Quality of life of patients was assessed using the European Organization for Research and Treatment of Cancer’s 30-item quality of life questionnaire version 3.0 (EORTC QLQ-C30), downloaded from the EORTC website [27].

The EORTC QLQ-C30, which is composed of three scales, is a valid and reliable tool for evaluating the quality of life in cancer patients. The scales include Global Health Status∖QoL, functional scales, and symptom scale/items. Functional scales include physical, role, emotional, cognitive, and social functioning. High scores for the QoL and functional scales show a high QoL and a high level of healthy functioning, respectively. Symptom scale/items include fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties; higher scores represent a high level of problems. The scores of items are transformed into 0–100 point scales. This questionnaire has been translated into Persian and validated for use with Iranian cancer patients, previously [28]. Anthropometric measurements, dietary records, and quality of life questionnaires were completed by nutritionists who were blind to the study design and type of treatment used. Before and after the intervention, and after an overnight fasting period, blood samples from each participant were collected. The patient’s serum was centrifuged and then stored at –80°C until analysis. Serum high-sensitivity C-reactive proteins (hs-CRP) were determined by enzyme-linked immunosorbent assay (ELISA) kits (Bender Med Systeme Bioscience, Vienna, Austria), and the immunoturbidimetric method which is widely used in laboratory routine. Serums MMP-2 and MMP-9 were analyzed by ELISA kits (endermed, German). Methods of analysis were described in the manufacturer’s protocol.

2.1 Statistical analysis

SPSS version 16.0 software package was used for statistical analysis. Normality of variables distribution was evaluated using Kolmogorov-Smirnov test and descriptive analyses. Quantitative variables were grouped and were described as mean±SD. Comparable variables at baseline were analyzed by chi-square test. Differences within groups from baseline to end-of-intervention were described with a paired t-test. Differences between two groups were compared by using independent sample t-test. Analysis of covariance (ANCOVA) test was used for adjusting the effect of confounding factors (baseline values of variables). The impact of synbiotic treatment on the improvement of the quality of life and symptoms was also measured as the number needed to treat (NNT), computed as the inverse of the absolute risk reduction. A P-value of less than 0.05 was considered statistically significant.

3 Results

From 46 rectal cancer patients who were recruited, 38 completed the study (n = 19; synbiotic n = 19; control groups). Two subjects died on the very first day; four patients due to personal reasons, while two, following diagnosis metastasis and hepatitis, withdrew from the study (Fig. 1). Baseline characteristics of patients are shown in Table 1. We did not see any significant differences in baseline variable between two groups. Anthropometric measurements and dietary intakes of patients in both groups are presented in Table 2.

Fig. 1

Flow chart of the study.

Table 1

Baseline characteristics of study groups

	Synbiotic group	Placebo group	p ^a
	(n = 19)	(n = 19)
	mean±SD^¥	mean±SD^¥
Age (year)	57.58±12.78	62.89±13.93	0.22
Height (m)	1.68±0.09	1.66±0.09	0.64
Weight (kg)	70.57±11.38	70.61±12.44	0.99
BMI* (kg/m²)	24.98±3.52	25.55±4.77	0.68
TSF**(mm)	9.63±3.16	10.07±3.04	0.66
Gender n(%)			0.14^¶
Male	13 (68.4%)	12(63.2%)
Female	6 (31.6%)	7 (36.8%)
Stage rectal cancer, n %
II	12(63.2%)	13(68.4%)
III	7(36.8%)	6(31.6%)	0.73^¶

^¥SD = standard deviation; ^*BMI = body mass index; ^**TSF = Triceps skin fold; ^a = comparison of difference between groups by independent t-test. ^¶ = comparison of difference between groups by Chi-square test.

Table 2

The anthropometric measures and dietary intake of patients before and after intervention in study groups

	Synbiotic Group (n = 19)			Placebo group (n = 19)
	Before	After	p ^a	dif	Before	After	p ^a	Dif	p ^b	p ^c
	mean±SD^¶	mean±SD^¶		mean±SD^¶	mean±SD^¶	mean±SD^¶		mean±SD^¶
Weight (kg)	70.57±11.38	69.91±11.88	0.15	– 0.66±1.93	70.61±12.44	69.42±13.90	0.12	– 1.19±3.24	0.54	0.53
BMI * (kg/m²)	24.98±3.52	24.73±3.56	0.13	– 0.25±0.70	25.55±4.77	25.09±5.15	0.11	– 0.45±1.21	0.53	0.50
TSF** (mm)	9.63±3.16	9.65±3.11	0.76	.00±0.20	10.07±3.04	9.93±2.99	0.12	– 0.14±0.38	0.17	0.18
Energy (kal/d)	1630.51±479.48	1703.13±521.95	0.43	72.61±399.47	1807.80±745.39	1501.50±528.71	0.01	– 306.32±462.41	0.01	0.46
Carbohydrate (g/d)	231.97±74.82	252.94±81.36	0.26	20.98±77.02	264.20±120.49	219.06±88.35	0.024	– 45.13±79.88	0.01	0.02
Carbohydrate (% of energy)	56.21±11.33	58.49±8.47	0.18	2.29±13.52	58.11±8.41	57.14±18.09	0.57	– 0.97±18.19	0.18
Protein (g/d)	50.32±21.77	52.74±21.35	0.62	.2.42±19.98	62.77±29.02	41.93±16.00	0.03	– 20.83±25.14	0.03	0.008
Protein (% of energy)	12.22±6.61	11.64±4.37	0.27	– 0.53±6.11	12.88±4.05	11.15±5.76	0.01	– 3.06±5.13	0.50
Fa t(g/d)	57.20±19.42	57.15±24.56	0.99	– 0.05±25.09	59.19±26.34	53.26±24.85	0.28	– 5.92±22.52	0.69	0.49
Fat (% of energy)	31.57±6.30	29.81±9.31	0.58	– 1.49±11.27	29.04±7.59	31.69±10.37	0.28	2.95±11.03	0.81

*BMI = body mass index; **TSF = Triceps skin fold; ^¶SD = standard deviation; ^a = comparison within group by paired t-test; ^b = comparison difference between groups by independent t-test. ^C = comparison difference between groups by analysis of covariance (ANCOVA) after adjusted for baseline values.

As shown in Table 2, after supplementation, mean body weight decreased in synbiotic and placebo groups.

The six weeks supplementation resulted in slight increase of the mean daily energy (72.61±399.47 kcal/d), carbohydrate (20.98±77.02 gr/d) and protein intake (2.42±19.98 gr/d), while in the placebo group, significant reduction was observed in the mean energy (– 306.32±462.41 kcal/d; P = 0.01), carbohydrate (– 45.13±79.88 gr/d; P = 0.024), and protein (– 20.84±25.14 gr/d; P = 0.03) intake. Comparison of changes in energy (kcal/d), carbohydrate (gr/d) and protein (gr/d) showed that there was a statistically significant difference between two groups.

Table 3 shows the findings of quality of life scores at the baseline and after intervention in both groups. Mean global health status scores increased in synbiotic (from 69.73±15.76 to 74.12±23.55) and placebo groups (from 68.42±23.98 to 68.85±20.75).

Table 3

Comparison of quality of life scores between two study groups before and after intervention

Scale	Synbiotic group (n = 19)				Placebo group (n = 19)
	Before	After	P ^a	Difference	Before	After	p ^a	Difference	P ^b	P ^C
	mean±SD*	mean±SD*		mean±SD*	mean±SD*	mean±SD*		mean±SD*
Global health status/QoL^**	69.73 ± 15.76	74.12 ± 23.55	0.39	4.38 ± 22.11	68.42 ± 23.98	68.85 ± 20.75	0.94	0.43 ± 25.22	0.61	0.60
Functional scales	84.01 ± 17.90	83.50 ± 17.31	0.81	– 0.98 ± 17.67	72.66 ± 22.72	67.26 ± 17.67	0.33	– 5.40 ± 23.52	0.52	0.57
physical functioning	85.26±19.19	87.71±11.38	0.52	2.45±16.36	71.22±23.31	68.77±25.34	0.61	– 2.45±20.87	0.42
role functioning	84.21±25.13	81.57±24.14	0.71	– 2.63±30.56	69.29±32.51	61.40±22.25	0.26	– 7.89±29.59	0.59
emotional functioning	80.09±22.16	83.33±20.97	0.61	3.24±26.52	73.68±24.73	65.78±17.09	0.24	– 7.89±28.79	0.23
cognitive functioning	90.35±12.80	88.59±17.61	0.49	– 1.75±10.96	82.45±22.54	84.21±18.81	0.81	1.75±31.37	0.64
social functioning	82.45±25.74	76.31±30.08	0.36	– 6.14±28.97	66.66±32.86	56.14±24.97	0.09	– 10.52±25.58	0.62
Symptom scales	18.45 ± 11.82	16.95 ± 11.96	0.52	– 1.49 ± 10.12	21.37 ± 13.19	24.88 ± 12.65	0.29	3.50 ± 14.18	0.22	0.75
fatigue	16.95±19.72	22.80±23.26	0.21	5.84±19.72	29.23±27.01	39.76±19.70	0.09	10.52±26.05	0.53
nausea and vomiting	4.38±15.55	3.50±8.92	0.71	– 0.87±10.35	10.52±18.60	17.54±27.48	0.17	7.01±21.74	0.16
pain	16.66±21.51	28.07±29.42	0.10	11.40±28.89	22.80±18.60	31.57±18.33	0.07	8.77±20.31	0.74
dyspnea	10.52±19.41	5.26±16.71	0.08	– 5.26±12.48	10.52±15.91	7.01±13.96	0.16	– 3.50±10.51	0.64
insomnia	21.05±27.68	15.78±20.39	0.42	– 5.26±27.80	17.54±20.39	22.80±22.36	0.42	5.26±27.80	0.25
Appetite loss	12.28±27.68	10.52±19.41	0.71	– 1.75±20.70	12.07±16.51	14.05±90.16	0.72	– 7.01±30.58	0.81
Constipation	28.07±37.28	22.80±38.57	0.52	– 5.26±35.59	10.52±22.36	1.75±7.64	0.13	– 8.77±24.44	0.72
Diarrhea	33.33±36.85	26.31±32.54	0.49	– 7.01±43.85	45.61±40.38	57.89±31.11	0.27	12.28±47.41	0.20
Financial difficulties	24.56±33.03	15.78±28.03	0.05	– 8.77±18.73	17.54±25.74	24.56±26.85	0.16	7.01±21.02	0.02

^*SD = standard deviation; ** QoL = quality of life; ^a = comparison within group by paired t-test; ^b = comparison of difference between groups by independent t-test; ^C = comparison difference between groups by analysis of covariance (ANCOVA) after adjusted for baseline values.

At the end of the supplementation, mean scores of functional scale decreased in both the synbiotic (from 84.01±17.90 to 83.50±17.31) and placebo groups (from 72.66±22.72 to 67.26±17.67). In contrast to the placebo group, there were increased scores in physical functioning (from 85.26±19.19 to 87.71±11.38) and emotional functioning (from 80.09±22.16 to 83.33±20.97) in the synbiotic group.

After supplementation, mean symptom scale scores decreased in the synbiotic group (from 18.45±11.82 to 16.95±11.96) while in the placebo group, this score increased (from 21.37±13.19 to 24.88±12.65). Regarding the symptom scales, nausea and vomiting scores (from 4.38±15.55 to 3.50±8.92), insomnia (from 21.05±27.68 to 15.78±20.39), appetite loss (from 12.28±27.68 to 10.52±19.41), and diarrhea (from 33.33±36.85 to 26.31±32.54) decreased slightly in the synbiotic group but these parameters increased significantly in the placebo group.

Due to the clinical importance of quality of life in cancer-treated patients, we calculated the number needed to treat (NNT) based on the quality of life data. NNT for improvement in global health status and symptom scale were 5 (95% CI, – 2, 10) and 3 (95% CI, – 2,– 15), respectively.

At the end of the study, the mean serum hs-CRP increased in supplemented (from 6.26±7.71 to 7.49±7.20 mg/l) and placebo group (from 9.62±9.1 to 12.95±9.5 mg/l). But as shown in Table 4 the elevation in hs-CRP levels in the placebo group was approximately two times higher than the synbiotic group.

Table 4

The mean of biochemical factors before and after intervention in both synbiotic and placebo groups

	Synbiotic group (n = 19)				Placebo group (n = 19)
	Before	After	P ^a	Difference	Before	After	p ^a	Difference	P ^b	P ^C
	mean±SD*	mean±SD*		mean±SD*	mean±SD*	mean±SD*		mean±SD*
MMP-2^** (ng/ml)	343.11±34.12	354.06±21.83	0.75	5.95±18.74	468.52±89.89	408.83±64.03	0.32	9.58±63.35	0.95	0.64
MMP-9 ^***(ng/ml)	392.26±36.28	438.77±50.25	0.43	55.55±68.18	420.74±55.11	622.35±220.74	0.42	211.28±236.85	0.52	0.44
hs-CRP (mg/l)	6.26±7.71	7.49±7.20	0.60	1.23±10.11	9.62±9.1	12.95±9.5	0.31	2.84±11.60	0.65	0.10

^*SD = standard deviation; ^**MMP-2 = matrix metalloproteinase 2; ^***MMP-9 = matrix metalloproteinase 9; ^a = comparison within group by paired t-test; ^b = comparison of difference between groups by independent t-test. ^C = comparison difference between groups by analysis of covariance (ANCOVA) after adjusted for baseline values.

After the six weeks supplementation, changes in serum MMP-2 revealed that the increment in the synbiotic group was lower than in the placebo group (5.95±18.74 vs.9.58±63.35 ng/ml).

In addition, the mean serum MMP-9 increased in both groups. Although, less variation of serum MMP-9 levels was seen in the synbiotic group as compared with the placebo group (55.55±68.18 vs. 211.28±236.85 ng/ml).

During the study, no adverse effects of administrated capsules were reported in both study groups.

4 Discussion

In our study, the mean body weight and BMI of patients decreased in both groups. Furthermore, findings of our study showed that patients’ energy, carbohydrate, and protein intake increased slightly in the synbiotic group, while these parameters decreased significantly in the placebo group (p < 0.05). In this study, there was no significant difference in TSF measurement which may be due to the short period of study and it has been proposed that subcutaneous fat needs more time to change. In terms of quality of life, mean global health status scores increased in both groups. In addition, the blood parameters increased in both groups after CRT, which can be associated with the effects of treatment.

Despite the insignificant increase in these parameters, patients who received synbiotic experienced less increment when compared with the placebo group.

To the best of our knowledge, there was no study about the effect of synbiotic supplementation on dietary intake or weight status of rectal cancer patients undergoing neoadjuvant CRT and this study was the first clinical trial which investigated the effect of synbiotic supplementation in these patients. Therefore, we compared our results with similar animal studies. Our results were like the results of previous animal studies. Bowen et al. used VSL#3 probiotic before and after irinotecan administration (chemotherapy) in rat model and found that the probiotic group experienced less weight loss than the placebo group and the probiotic prevented chemotherapy induced diarrhea [29]. Also, Bultzingslowen et al. reported that Lactobacillus plantarum supplementation also improved anorexia, body weight, and food intake in rats treated with 5-fluorouracil [30].

Surprisingly, despite increased patients’ energy and carbohydrate intake in the synbiotic group, weight decreased in these patients, which might be due to improvement in patients’ physical activity and quality of life during the study. Lee et al. reported that probiotic supplementation for about 12 weeks improved colorectal cancer-related quality of life, mental health scores, and bowel symptoms in patients diagnosed with stage II or III colorectal cancer [31]. Moreover, Ohigashi et al. reported improvement in the quality of life and functional outcome after administration probiotic to colorectal resection patients [32]. Nascimento et al. found that synbiotic supplementation reduced proctitis symptoms and improved quality of life significantly in prostate cancer patients during radiation therapy [26].

Zhang et al. reported that consumption of probiotics in rectal cancer patients before surgery minimized the postoperative occurrence of infectious complications and reduced serum interleukin-6 and CRP [16].

In a clinical trial, Anderson et al. found that probiotic supplementation in CRC patients with elective surgical reduced serum hs-CRP and IL-6 levels [33]. Our findings contrast with the studies mentioned above, which found synbiotic supplementation reduced serum hs-CRP.

Discrepancy in the results of present findings with the studies mentioned previously may be due to using different probiotic species and doses, duration of supplementation, genetic differences of individuals, and their health condition. Moreover, in the studies mentioned above, patients who were candidates for surgical resection of tumors received synbiotic supplementation, while in our study, patients treated with CRT—which induces inflammation responses—were supplemented with synbiotic.

Albeit, it should be noted that in our study, the elevation in serum hs-CRP (1.23±10.11 vs. 2.84±11.60 mg/l) in the synbiotic group was less than the placebo group. It can be ascribed to immune modulation and anti-inflammatory properties of synbiotic that prevents further increase and improvement of inflammation.

Considerable evidence is available from in-vitro studies that probiotics have anti-metastatic effects on human cervical and colon adenocarcinoma cell lines by influencing MMP-2 and MMP-9 activity [34, 35]. Kerem et al. observed that using a soluble fiber decrease the increased MMP-2 activity in radiotherapy exposed rats [36].

In the present study, serum MMP-2 and MMP-9 levels increased insignificantly in both groups after CRT. According to our observations, the increments of MMP-2 and MMP-9 in the placebo group were two times and four times higher than the synbiotic group, respectively. There are several reasons for the inconsistency of our results with previous findings. Firstly, the observed differences between our results and studies may be due to the fact that the laboratory environment and animal model cannot reflect the real condition of the disease. Secondly, mentioned studies measured values in the mucosa or intestinal tissue while we measured them in serum. In the present study, serum MMP9 level increased remarkably in the placebo group while the increase in the synbiotic group was lower than the placebo group (55.55±68.18 vs. 211.28±236.85 ng/ml). One of the reasons that the differences were insignificant may be due to a small sample size. So, these findings revealed that synbiotic supplementation may reduce inflammation due to CRT by anti-inflammatory properties and thus synbiotic supplementation prevents further increment of MMP-9 in cancer patients.

The limitation of this study is its small sample size which makes it impossible to generalize the results to the population. The major strength of our study is that it is the first clinical trial to investigate the effect of synbiotic supplementation in rectal cancer patients undergoing CRT as well as the high acceptance of synbiotic supplementation.

5 Conclusion

On the basis of NNT results in improving quality of life and side effects, and preventing the further elevation of matrix metalloproteinase enzymes and inflammatory factor in comparison with the placebo group, it seems that the use of synbiotic supplement along with routine treatments may be helpful in these patients. However, to consider synbiotic as a new complementary treatment, further studies with large sample size and different doses of synbiotic supplementation are warranted.

Financial support

This study is funded (funding number 5/71/1614) by Nutrition Research Center, Tabriz University of Medical Sciences.

Conflict of interest

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Footnotes

Acknowledgments

The authors are grateful for the financial support of the Nutrition Research Center, Tabriz University of Medical Sciences. The authors also are deeply indebted to all patients who participated in this study. This article was written based on a dataset of a MS thesis (Fatemeh Farshi Radvar) registered in Tabriz University of Medical Sciences.

References

Pourhoseingholi

. Increased burden of colorectal cancer in Asia. World J Gastrointest Oncol. 2012;4(4):68–70.

, Wang

, Ma

, Tan

, Yan

, Xue

, et al. A Review of Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. International Journal of Biologic Scien. 2016;12(8):1022.

Kim

, Hong

, Wo

. Treatment of Stage II–III Rectal Cancer Patients. Current Oncol Reports. 2014;16(1):362.

Deorukhkar

, Krishnan

. Targeting inflammatory pathways for tumor radiosensitization. Biochem Pharmacol. 2010;80(12):1904–14.

Valentini

, Van Stiphout

, Lammering

, Gambacorta

, Barba

, Bebenek

, et al. Nomograms for predicting local recurrence, distant metastases, and overall survival for patients with locally advanced rectal cancer on the basis of European randomized clinical trials. J Clin Oncol. 2011;29(23):3163–72.

Afrin

, Giampieri

, Gasparrini

, Forbes-Hernández

, Cianciosi

, Reboredo-Rodriguez

, et al. Dietary phytochemicals in colorectal cancer prevention and treatment: A focus on the molecular mechanisms involved. Biotechnol Advance. 2020;38:107322.

Chitapanarux

, Chitapanarux

, Traisathit

, Kudumpee

, Tharavichitkul

, Lorvidhaya

. Randomized controlled trial of live lactobacillus acidophilus plus bifidobacterium bifidum in prophylaxis of diarrhea during radiotherapy in cervical cancer patients. Radiation Oncol. 2010;5(1):31.

Stansborough

, Al-Dasooqi

, Bateman

, Keefe

, Gibson

. Radiotherapy-induced gut toxicity: Involvement of matrix metalloproteinases and the intestinal microvasculature. Inter J Radiation Biol. 2016;92(5):241–8.

Yamano

, Yoshimura

, Kobayashi

, Beppu

, Hamanaka

, Babaya

, et al. Malnutrition in rectal cancer patients receiving preoperative chemoradiotherapy is common and associated with treatment tolerability and anastomotic leakage. Inter J Colorectal Dis. 2016;31(4):877–84.

10.

Touchefeu

, Montassier

, Nieman

, Gastinne

, Potel

, Bruley des Varannes

, et al. Systematic review: the role of the gut microbiota in chemotherapy-or radiation-induced gastrointestinal mucositis–current evidence and potential clinical applications. Aliment PharmacolTherapeut. 2014;40(5):409–21.

11.

Horvat

, Krebs

, Potrč

, Ivanecz

, Kompan

. Preoperative synbiotic bowel conditioning for elective colorectal surgery. Wiener Klinische Wochenschrift. 2010;122(2):26–30.

12.

Bruheim

, Guren

, Skovlund

, Hjermstad

, Dahl

, Frykholm

, et al. Late side effects and quality of life after radiotherapy for rectal cancer. Inter J Radiat Oncol Biol Physics. 2010;76(4):1005–11.

13.

Delia

, Sansotta

, Donato

, Frosina

, Messina

, De Renzis

, et al. Use of probiotics for prevention of radiation-induced diarrhea. World journal of gastroenterology: WJG. 2007;13(6):912.

14.

Lomax

, Calder

. Prebiotics, immune function, infection and inflammation: a review of the evidence. Br J Nutr. 2008;101(5):633–58.

15.

Raman

, Ambalam

, Kondepudi

, Pithva

, Kothari

, Patel

, et al. Potential of probiotics, prebiotics and synbiotics for management of colorectal cancer. Gut Microbe. 2013;4(3):181–92.

16.

Zhang

J-W

, Du

, Yang

B-R

, Gao

, Fang

W-J

, Ying

C-M

. Preoperative probiotics decrease postoperative infectious complications of colorectal cancer. Am J Med Scien. 2012;343(3):199–205.

17.

Liu

, Qin

, Yang

, Xia

, Liu

, Yang

, et al. Randomised clinical trial: the effects of perioperative probiotic treatment on barrier function and post-operative infectious complications in colorectal cancer surgery–a double-blind study. Aliment PharmacolTherapeut. 2011;33(1):50–63.

18.

Peitsidou

, Karantanos

, Theodoropoulos

. Probiotics, prebiotics, synbiotics: is there enough evidence to support their use in colorectal cancer surgery? Digest Surgery. 2012;29(5):426–38.

19.

Oliveira

ALd

, Aarestrup

. Nutritional status and systemic inflammatory activity of colorectal patients on symbiotic supplementation. ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 2012;25(3):147–53.

20.

Roller

, Clune

, Collins

, Rechkemmer

, Watzl

. Consumption of prebiotic inulin enriched with oligofructose in combination with the probiotics Lactobacillus rhamnosus and Bifidobacterium lactis has minor effects on selected immune parameters in polypectomised and colon cancer patients. Br J Nutr. 2007;97(04):676–84.

21.

Pitsouni

, Alexiou

, Saridakis

, Peppas

, Falagas

. Does the use of probiotics/synbiotics prevent postoperative infections in patients undergoing abdominal surgery? A meta-analysis of randomized controlled trials. Eur J Clin Pharmacol. 2009;65(6):561–70.

22.

Visich

. The prophylactic use of probiotics in the prevention of radiation therapy-induced diarrhea. Clin J Oncol Nurs. 2010;14(4):467.

23.

Komatsu

, Sakamoto

, Norimizu

, Shingu

, Asahara

, Nomoto

, et al. Efficacy of perioperative synbiotics treatment for the prevention of surgical site infection after laparoscopic colorectal surgery: a randomized controlled trial. Surgery Today. 2016;46(4):479–90.

24.

Shadnoush

, Hosseini

, Mehrabi

, Delpisheh

, Alipoor

, Faghfoori

, et al. Probiotic yogurt affects pro-and anti-inflammatory factors in patients with inflammatory bowel disease. Iran J Pharmaceutical Res. 2013;12(4):929.

25.

Uchida

, Takahashi

, Inoue

, Morotomi

, Otake

, Nakazawa

, et al. Immunonutritional effects during synbiotics therapy in pediatric patients with short bowel syndrome. Pediatric Surgery Inter. 2007;23(3):243–8.

26.

Nascimento

, Aguilar-Nascimento

, Caporossi

, Castro-Barcellos

, Motta

. Efficacy of synbiotics to reduce acute radiation proctitis symptoms and improve quality of life: a randomized, double-blind, placebo-controlled pilot trial. Inter J Radiation Oncol BiolPhysic. 2014;90(2):289–95.

27.

Montazeri

, Hole

, Milroy

, McEwen

, Gillis

. Does knowledge of cancer diagnosis affect quality of life? A methodological challenge. BMC Cancer. 2004;4(1):21.

28.

Safaee

, Moghimi Dehkordi

. Validation study of a quality of life (QOL) questionnaire for use in Iran. Asian Pac J Cancer Prev. 2007;8(4):543–6.

29.

Bowen

, Stringer

, Gibson

, Yeoh

, Hannam

, Keefe

. VSL# 3 probiotic treatment reduces chemotherapy-induced diarrhoea and weight loss. Cancer Biol Therapy. 2007;6(9):1445–50.

30.

Bültzingslöwen

, Adlerberth

, Wold

, Dahlén

, Jontell

. Oral and intestinal microflora in 5-fluorouracil treated rats, translocation to cervical and mesenteric lymph nodes and effects of probiotic bacteria. Oral Microbiol Immunol. 2003;18(5):278–84.

31.

Lee

J-Y

, Chu

S-H

, Jeon

, Lee

M-K

, Park

J-H

, Lee

D-C

, et al. Effects of 12 weeks of probiotic supplementation on quality of life in colorectal cancer survivors: a double-blind, randomized, placebo-controlled trial. Digest Liver Dis. 2014;46(12):1126–32.

32.

Ohigashi

, Hoshino

, Ohde

, Onodera

. Functional outcome, quality of life, and efficacy of probiotics in postoperative patients with colorectal cancer. Surgery Today. 2011;41(9):1200–6.

33.

Anderson

, McNaught

, Jain

, MacFie

. Randomised clinical trial of synbiotic therapy in elective surgical patients. Gut. 2004;53(2):241–5.

34.

Nouri

, Karami

, Neyazi

, Modarressi

, Karimi

, Khorramizadeh

, et al. Dual anti-metastatic and anti-proliferative activity assessment of two probiotics on HeLa and HT-29 cell lines. Cell J (Yakhteh). 2016;18(2):127.

35.

Escamilla

, Lane

, Maitin

. Cell-free supernatants from probiotic Lactobacillus casei and Lactobacillus rhamnosus GG decrease colon cancer cell invasion in vitro. NutrCancer. 2012;64(6):871–8.

36.

Kerem

, Bedirli

, Karahacioglu

, Pasaoglu

, Sahin

, Bayraktar

, et al. Effects of soluble fiber on matrix metalloproteinase-2 activity and healing of colon anastomosis in rats given radiotherapy. Clin Nutr. 2006;25(4):661–70.