‘The do’s and don’ts for Cancer patients and their Treating Oncologists’
Islam the Religion of Allah (the sustainer of the worlds) is based on five principal pillars (also known as arkan al Islam), and Ramadan fasting is one of the important pillars of Islamic Faith. As stated in the Holy Quran “whoever of you sights the crescent on the first night of the month of Ramadan (i.e., is present at his home), he/she must observe Saum (fasting) that month, and whoever is ill or on a journey, the same number of days which one did not observe Saum, must be made up from other days.” The Holy Quran clearly states that fasting is beneficial to non exempted subjects: “and that your fast is better for you if only you know.”(Al Quran, Surah Baqarah 2:184). However, Islam forbids fasting if this would be harmful to an individual. Even though some subjects among which patients are also exempted from observing this religious duty, they may be eager to share this particular moment of the year with their families. Depending on the period of the year and geographic location, the duration of fasting may vary from place to place.
Muslims nearly form 1.8 billion of total 7.7 billion world population and constituting around 24% of the world’s population. Therefore, Muslim patients form a significant number of the 18.1 million cancer cases diagnosed yearly worldwide as per the data by W.H.O released in September 2018. With the advances in cancer care in last two decades and going by the current cure rates, more and more cancer patients are going to be cured and live longer and as many cancers are becoming chronic diseases ,we are going to face more and more Muslim cancer patients to ask about the fasting during Ramadan.
Oncologists at the beginning of Ramadan do often face the question “Doctor, can I fast?” Most Oncologists base their reply on personal experiences and judgment and not on any solid scientific evidence. Many Oncologists, may feel guilty if they advise patients against fasting and may prefer to be neutral and just say “Look, fast if you can.” and most of the Oncologists generally have a negative attitude towards fasting. However, there are no guidelines or standardized protocols that can help Oncologists to properly address the issue of patients with cancer and fasting in Ramadan and correctly advise them. Very less is known in medical literature about fasting and cancer care. The quality of life and compliance to anti cancer treatment is of utmost concern for both the treating Oncologist and the patient.
It is a common saying that religion promotes healthy lifestyles. However, the relationship between religion and cancer has been often overlooked or poorly addressed from a scientific point of view especially in terms of physiology during fasting in patients suffering from cancer. There is well documented scientific evidence that people who do not consume tobacco, alcohol or pork due to religious obligations have lower cancer related morbidity rates from many cancers than the general population. It is known that fasting induces changes in genome organization, chromatin remodeling, and metabolic pathways and modulating, for example, glucose, insulin like growth factor (IGF), other related enzymes and proteins and may increase the effec¬tiveness of chemotherapy. Fasting could have a positive impact on drug pharmacokinet¬ics and could contribute to reduce its side effects, improve the chemotherapeutic index, and overcome partially the issue of drug resistance. Fasting has a beneficial impact on the renewal of stem cells and on the immune system, especially on natural killer cells, as well as on the oxidant system, thus enabling cancer growth control. The impact of fasting has been assessed on different anti cancer drugs and the effects of fasting on tumors have been assessed both on neo-adjuvant and adjuvant chemotherapy. Fasting seems to sensitize tumor cells and increase the outcome of anti cancer drugs. We know that avoiding starchy and sugary foods and caloric restriction has a role in controlling cancer and we know that obesity is a risk factor for various cancers like breast, uterus, prostate to name a few.
A diagnosis of cancer is always difficult to cope with. The level of spirituality and religiosity plays a major role in supporting the patient during treatment and can influence the clinical outcome. The communication between the patient and the Oncologist for the purpose of Ramadan fasting should be open and broad. At times the situation is rather delicate and the Oncologist, if not culturally competent or sensitive, could be left with dilemmas because of the cultural and religious beliefs and attitudes of the patient. Oncologists should carefully assess the health conditions of patients and discourage them to fast if patient is very old, has widespread cancer, have aggressive forms of cancer, are weak and frail, poor in nutrition, have associated illnesses like diabetes, need round the clock fluids and other supportive treatment for cure of cancer or have a history of non-compliance to drugs and dietary advices. On the contrary, patients with a strong motivation to fast should be encouraged, in that spirituality/religiosity plays a major role in cancer. Many cancer patients feels more active being involved in the religious activities, and less depressed and isolated. There is solid scien¬tific evidence that fasting activates certain neuroendocrine pathways leading to the release of neurotrophic factors, which can enhance the mood and relieve the pain in patients suffering from cancer.
Patients who decided to go on fasting after the diagnosis of cancer and who should be encouraged are those with good performance status and body strength, young cancer patients, those without any associated illnesses (like diabetes mellitus), having early stage cancer, those being treated with single agent anticancer drug, patients on oral chemotherapeutic agents, or disease free patients on follow-up. Oncologists are concerned about the possibility of fasting and its negative impact on patients’ health receiving active treatment for cancer and the compliance to drugs. The management of patients suffering from cancer and who is willing to fast is very complex and should involve a multidisciplinary team, made up of an Oncologist and other supportive staff who should be aware of the importance of cultural and spiritual beliefs in medicine, and particularly in Oncology practice.
Important factors that hesitates the Oncologist and the patients to stop fasting are fear that fasting state would lead to a decrease in the actual performance, preventing the administration of anti cancer drugs and leading to the disease progression. When discussing fasting with the patient, Oncologists can adopt the safe trial technique where they allow the patient to fast, but with instructions as to when they should stop (e.g., when there is severe weakness, vomiting, diarrhea, or inadequate oral intake which may be harmful. Close contact with the treating Oncologist is of utmost importance. If the advice is “fast if you can,” then this should be under medical supervision. For example, giving supplementary IV fluids during Iftaar time or modifying the treatment schedule so that drugs are given between sunset and dawn might be of help in some situations. The issue of fasting in cancer patients should be discussed among Oncologists and the knowledgeable religious authorities to avoid conflicting advice that can harm cancer patients. Oncologists need to be aware of the religious aspects of fasting. An ideal practice would involve the patient, treating Oncologist and the religious scholar in the decision making.
(Author is a Practicing Medical Oncologist)