INTRODUCTION

Wheat germ, if left in flour, has an adverse effect on the functional properties of dough and therefore on breadmaking quality. Therefore, most germ is milled as part of mill feed, and a smaller portion is separated during the milling process. Separated wheat germ is traditionally included in healthy foods, is consumed as is, or serves as raw material for extracts rich in vitamin E. During the 1990s, a new, fermented wheat germ extract for human consumption was invented by Professor Máté Hidvégi in Hungary.1 The standardized manufacturing technology included the extraction of wheat germ, the fermentation of the extract, followed by separation of the fermentation liquid, microencapsulation, drying, and granulation. The resulting powder was named FWGEpulvis (or simply FWGE), and the granulate is also known as FWGE. For a 70-kg weight adult, the single daily dosage of FWGE contains 8.5 g of FWGE pulvis plus flavoring ingredients, such as fructose and arome. After being dissolved in 150 ml of cold water, FWGEshould be drunk preferably before a meal. The product has been approved as a dietary food for special medical purposes in cancer patients by the National Institute of Food Safety and Nutrition of Hungary. FWGEhas been consumed by cancer patients for more than 6 years. Since its invention, a series of in vitro and in vivo studies and clinical trials have been carried out to determine whether FWGE could help cancer patients struggling with both the effects of their disease and the side effects of standard anticancer therapy (SAT). 

 Effects on metastases were studied both with the primary tumors intact and after their surgical removal. Vitamin C alone had a significant inhibitory effect on metastases in some of these tumor models but not in others. However, combined treatment with FWGE  plus vitamin C administered simultaneously profoundly inhibited metastases in all tumor models. Interestingly, in some tumor models, treatment with FWGE  alone had a greater inhibitory effect on metastasis formation than did FWGE  plus vitamin C. It was therefore recommended that if vitamin C is being administered, FWGE  should be consumed at least 2 hours before or after treatment with vitamin C-containing preparations.

Cytostatic Drugs

To determine whether FWGE   beneficial effects might or might not compromise the efficacy of a variety of cytostatic drugs commonly used in cancer treatment, researchers tested FWGE  alone and in combination with those drugs in malignant cell lines and in animals with cancer.5 In vitro, FWGE  neither increased nor decreased the effect on viability of MCF-7, HepG2, or Vero cells resulting from treatment with dacarbazine (DTIC), 5-fluorouracil (5-FU), or doxorubicin. In mice with transplanted 3LL-HH tumors, the combination of FWGE  with cyclophosphamide, vinorelbine, and doxorubicin did not lessen those drugs’ inhibition of tumor growth.

 FWGE produced no toxic effects in the mice, and its addition to the treatment regimen did not increase the toxicity of the drug treatment. Strong synergism in antimetastatic activities was seen with the combined use of FWGE  and cytostatic drugs: DTIC plus FWGE  in B16 mouse melanoma, muscle/lung metastasis model and 5-FU plus FWGE  in C38 mouse colorectal carcinoma, spleen/liver metastasis model resulted in statistically complete eradication of lung and liver metastases, respectively.6 These results make us confident that FWGE  may be administered along with these conventional chemotherapy drugs with little risk of negatively affecting the cytostatic drugs’ efficacy, or increasing their undesirable side effects.

Cytokines

FWGE   may safely be administered together with the cytokine preparations used in clinical practice. The antineutropenic efficacy of the hematopoietic cytokines plus FWGE  in combination is better than that of the cytokines alone.3

Tamoxifen

Researchers at the National Institute of Chemical Safety in Budapest conducted an in vitro study of the effects of a tamoxifen plus FWGE
combination administered to cultures of the MCF-7 (ER+) breast cell line as a preclinical model of human breast cancer.7 MCF-7 cells were treated with tamoxifen and/or FWGE  for 24, 48, and 72 h. Cytotoxicity was measured by MTT assay; the percentages of mitosis and apoptosis were determined by hematoxylin and eosin staining and by immunochemistry, and estrogen receptor activation was studied by semiquantitative determination of the estrogen-responsive pS2 gene mRNA production. 

The percentage of apoptotic and proliferating cell fraction (S-phase) was determined by flow cytometry. Tamoxifen had no effect on the percentage of apoptotic cell fraction, while significantly reducing the ratio of S-phase cells. After an exposure time of 48 h, FWGE increased apoptosis significantly. Tamoxifen + FWGE increased apoptosis significantly after 24 h, with a negligible effect on mitosis and S phase. Estrogen receptor activity of MCF-7 cells treated for 24, 48, and 72 h was enhanced by FWGE and decreased by tamoxifen as well as by tamoxifen + FWGE . The increase in apoptosis by the combined use of tamoxifen + FWGE suggests that the addition of FWGE to tamoxifen may enhance the efficacy of tamoxifen in ER+ breast cancer. There is no contraindication to their combination in clinical practice.

FWGE AND IMMUNITY

Evidence of the immunomodulatory effects of FWGE was first obtained in a study on the effect of the compound on immune function in mice.8 Results in this study showed that FWGE significantly increased the degree of blastic transformation of peripheral blood T lymphocytes stimulated by concanavalin A. In other experiments, C57B1 mice were given skin transplants from the coisogenic mice strain B10LP, which normally could be expected to be tolerated for 16–25 days before rejection. Thymectomized control (untreated) mice rejected the transplants at a gender mean of 52 (male) or 41 (female) days. Thymectomized mice treated with FWGE rejected the grafts at a mean of 29 days (male) or 33 days (female). Control (untreated) mice not thymectomized rejected the transplants at a gender mean of 21 or 29 days. 

 Based on these results, a double-blind clinical study with FWGE  in lupus patients was recently initiated.10 In mice, FWGE proved effective in the restoration of hemopoiesis in bone marrow impairment induced by sublethal irradiation and/or cyclophosphamide therapy.11 Elevation of the platelet count started on postirradiation day 7, and the baseline level was achieved on day 21. At the same time, no substantial increase was detected in the WBC count. As regards cyclophosphamide therapy, restoration of thrombopoiesis as well as of erythropoiesis could be observed as a result of FWGE  treatment. These results are in consonance with the 5-year long clinical observation that FWGE has no hematotoxic side effect. A decrease in febrile neutropenia episodes during intensive chemotherapy of FWGE -treated pediatric cancer may help confirm the clinical relevance of bone marrow protection assessed in the experimental setting.

MOLECULAR TARGETS OF FWGE 

Although the one (or more) molecule of fermented wheat germ extract responsible for the wide variety of biologic effects of this medical food has not yet been identified, molecular targets of FWGE , which could explain the effects, are (at least, partially) known.

PARP

Proliferation, differentiation, and cell death are under similar molecular control in all mammalian cells. Cancer cells develop severe defects in the regulation of homeostasis and cell proliferation, including resistance to apoptosis.

 FWGE inhibited the growth of leukemia cells in a dose-dependent manner. Laser scanning cytometry and gel electrophoresis with Western immunoblotting of stained cells indicated that the growth-inhibiting effect was consistent with a strong induction of apoptosis by activating the caspase-3–catalyzed cleavage of the poly(ADP-ribose) polymerase (PARP) enzyme.12 PARP is a key player in DNA repair. The activity of this enzyme is extremely high in cancer cells.13 Cleavage of PARP results in genomic instability, leading to DNA fragmentation and thus to apoptosis in tumor cells. As the activity of PARP is accelerated in cancer cells, these cells can be selectively sensitized by PARP inhibitors (such as FWGE ) to agents (such as 5-fluorouracil [FU] or DTIC), inducing base excisions or lesions in DNA. It has also been indicated that besides apoptosis induction, the mechanism through which FWGE mitigates metastasis involves decreasing cell motility. It was further demonstrated that although FWGE induced apoptosis in different leukemic human cells, it did not trigger programmed cell death in their healthy, resting counterpart, peripheral blood mononuclear cells.

MHC-I

FWGE treatment resulted in a decrease in the MHC class I (MHC-I) protein level on the surface of tumor cells, and hence it may expose them to natural killer (NK) cell activity.14 As inhibition of tyrosine phosphatase activity also resulted in elevated downregulation of MHC-I molecules, control of protein tyrosine phosphorylation in this process was indicated.

 Involvement of lymphocyte-specific signaling molecules, the nonreceptor tyrosine kinase p56lck, and the receptor tyrosine phosphatase CD45 in the FWGE -triggered cell response has been excluded. A way for tumors to survive in the host environment is to evade the defense control of the host by mimicking themselves as normal cells for the survey of the immune system. Natural killer cells, which play an important role in antitumor defense, recognize and are blocked by the expression of MHC-I molecules on their target cells.15 Consequently, tumor cells develop an effective camouflage by expressing high levels of MHC-I to avoid recognition by NK cells. This is a common characteristic of metastatic tumor cells to avoid NK surveillance.16 As FWGE reduces the MHC-I level on human tumor cells, it may sensitize them against NK killing, thus reducing their metastatic activity.

ICAM-1

Endothelial cells of the vasculature of human solid tumors are known to have decreased expression of ICAM-1 compared to normal endothelial cell tissue, and this phenomenon can be considered a tumor-derived escape mechanism because the development of an efficient leukocyte infiltrate of the tumor is impaired.17 It has been shown that FWGE upregulates the expression of intercellular adhesion molecule-1 (ICAM-1) on tumor-derived endothelial cells and also potentiates the similar effect of the primary anticancer cytokine, tumor necrosis factor-alpha (TNF-α).18

Cyclooxygenases

Cyclooxygenases (COX-1 and COX-2 enzymes) were incubated with increasing concentrations of FWGE . The inhibition of COX-1 and COX-2 in the presence of FWGE was then determined, and IC50 values (FWGE concentration resulting in 50% enzyme inhibition) were calculated. For COX-1 activity, the IC50 was 100 µg/ ml, whereas a concentration of 300 µg/ml inhibited COX-2 activity to 50% of the control.22 These significant results demonstrate the COX-inhibiting capacity of FWGE , and no selectivity towards one of the COX enzymes could be observed. The nonselective inhibition of COX enzymes by FWGE may partly explain this extract’s anti-inflammatory activities against adjuvant arthritis in rats and rheumatoid arthritis in humans, the results of which are currently in publication. As inhibition of COX enzymes is also generally considered a preventive tool in colorectal cancer, these results may also shed light on the mechanism of the chemopreventive activity of FWGE against carcinogenic chemically induced experimental colon cancer. It was examined whether FWGE might inhibit colon carcinogenesis in mammals, using as a model F-344 rats.23 One hundred 4-week-old rats were divided into four groups. Group 1: untreated controls; Group 2: rats given the carcinogen azoxymethane (AOM) in three subcutaneous injections 1 week apart; Group 3: animals that started to receive FWGE via gastric tube 2 weeks prior to the first injection of AOM, daily and continuously thereafter until all animals were killed 32 weeks later; 

Group 4: animals that received the basal diet and FWGE only. At autopsy, no tumors were found in the untreated controls and in Group 4 (FWGE only) animals. In Group 2 (AOM only) 83.0% developed colon tumors with a mean of 2.3 tumors per animal; in Group 3 (FWGE and AOM) 44.8% (P <.001) developed tumors with 1.3 (P <.004) tumors per animal. All the tumors were neoplastic. There were 4.85 aberrent crypt foci per cm2 in Group 2 (AOM only) compared to 2.03 in Group 3 (AOM plus FWGE ) (P <.0001). These results showed a powerful anticarcinogenic effect associated with the prophylactic use of FWGE as a cancer preventative in animals.

Oral Cavity Cancer

An open-label, nonrandomized, controlled, phase-II clinical study was performed in the Semmelweis University Clinic of Oral and Maxillofacial Surgery, Budapest. Forty-three patients with a definitive diagnosis of less than 3 months of either locally advanced oral cavity squamous cell carcinoma (OCC) (UICC stage II-III) or locally advanced stage IV (i.e., T4a N0-N1M0) were enrolled. Twenty-one consecutive patients received SAT, consisting of radical surgery + postoperative irradiation and/ or adjuvant chemotherapy, and 22 consecutive patients received SAT + 12 months of FWGE treatment. The objective was to assess whether FWGE has any influence on the outcome of locally advanced OCC when applied concomitantly with SAT.

 The end-point was disease progression. As regards baseline characteristics (age, clinical stage, chemotherapy, and site of primary tumor), there was no significant difference between the two groups apart from the previous treatment with radiotherapy drawback to the FWGE group (3 of 22 in the FWGE group vs 9 of 21 in the control group) (P < .05). At end-point, incidences of local recurrences and disease progression differed significantly between the two groups: 4.5% and 9.09% in the SAT + FWGE , 57.1% and 61.9% in the control group (SAT alone), respectively (P < .001). Risk analysis revealed that the 12 months of FWGE treatment significantly reduced the risk of overall progression (death, new loco-regional recurrences, new distant metastases) by 85% (Mantel-Haenszel test, P < .001).24 Based on these results and taking into consideration the results obtained in a noncomparative quality of life (QOL) study (QLQ-C30 questionnaire of the European Organization for Research and Treatment of Cancer [EORTC], Brussels) of 50 patients with head and neck cancer treated at the Oto-rhino-laryngology Clinic of Semmelweis University, in which patients experienced substantial improvement in cachectic symptoms, and long-term delay of progression in five of six advancedstage salivary gland tumor patients, supportive use of FWGE in this manner may improve QOL and enhance the antitumor efficacy of SAT.25

Colorectal Cancer

Between 1998 and 1999, an open-label, pilot-scale, nonrandomized, controlled, phase II clinical study was carried out in the Uzsoki Hospital of Budapest to document whether or not supportive FWGE treatment adds any benefit to SAT in colorectal cancer.26 Altogether 30 patients with advanced colorectal cancer (CRC) had been enrolled.