Beetroot as a Potential Functional Food for Cancer Chemoprevention, a Narrative Review

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Beetroot as a Potential Functional Food for Cancer Chemoprevention, a Narrative Review
http://www.jcpjournal.org
                                                                                                              pISSN 2288-3649 · eISSN 2288-3657
Review                                                                                                     https://doi.org/10.15430/JCP.2021.26.1.1

Beetroot as a Potential Functional Food for Cancer
Chemoprevention, a Narrative Review
Mei Lan Tan1,2, Shahrul Bariyah Sahul Hamid2
1
School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, 2Advanced Medical and Dental Institute, Universiti
Sains Malaysia, Kepala Batas, Pulau Pinang, Malaysia

    Patients with cancer are prone to several debilitating side effects including fatigue, insomnia, depression and cognitive disturbanc-
    es. Beetroot (Beta vulgaris L.) as a health promoting functional food may be potentially beneficial in cancer. As a source of poly-
    phenols, flavonoids, dietary nitrates and other useful nutrients, beetroot supplementation may provide a holistic means to prevent
    cancer and manage undesired effects associated with chemotherapy. The main aim of this narrative review is to discuss beetroot’s
    nutrient composition, current studies on its potential utility in chemoprevention and cancer-related fatigue or treatment-related side
    effects such as cardiotoxicity. This review aims to provide the current status of knowledge and to identify the related research gaps
    in this area. The flavonoids and polyphenolic components present in abundance in beetroot support its significant antioxidant and
    anti-inflammatory capacities. Most in vitro and in vivo studies have shown promising results; however, the molecular mechanisms
    underlying chemopreventive and chemoprotective effects of beetroot have not been completely elucidated. Although recent clinical
    trials have shown that beetroot supplementation improves human performance, translational studies on beetroot and its functional
    benefits in managing fatigue or other symptoms in patients with cancer are still lacking.

    Key Words Beetroot, Betacyanin, Betaxanthin, Betanin, Cancer

INTRODUCTION                                                                          of ailments including cardiovascular-related conditions, ane-
                                                                                      mia, sexual weakness and bladder stones [2]. Some recent
Patients with cancer are prone to several debilitating effects                        clinical studies have also indicated the usefulness of beetroot
due to chemotherapy or the disease itself. The behavioural                            in managing blood pressure and cardiovascular health [3-6].
disturbances experienced by patients with cancer include                              Beetroot has also gained popularity as a supplement to boost
fatigue, insomnia, depression, and cognitive disturbances.                            energy and improve performance in athletes [7-10].
These symptoms are very common and may persist for                                       Interestingly, in the Traditional Persian Medicine practic-
months or years even after completion of treatment and may                            es, beetroot is one of the foods used in the prevention and
affect patient’s quality of life. Functional foods have long been                     managing of metastatic progression of cancer [11]. It is also
linked to improve human performance and health, and hence                             widely used in other medicinal systems including the Arab,
are considered beneficial as part of the cancer patients’ diet.                       traditional Chinese and Ayurvedic medicine. Beetroot, juiced
   Beetroot (Beta vulgaris L.) is one of high-nutrient vege-                          or blended, is a popular functional food among breast, pros-
tables used for salads and juices, and a valuable source of                           tate and colorectal cancer patients as reported in Trinidad. A
natural pigments. It belongs to the botanical order Amaran-                           study at two clinical sites on the island revealed that beetroot
thaceae –Chenopodiaceae , which is cultivated commercially.                           is being consumed by patients for the purpose of treatment,
Beetroot, also known as table or garden beet, is usually                              health improvement and amelioration of side effects asso-
grown for its roots. It has a characteristic earthy mushy aroma                       ciated with chemotherapy treatment [12]. Similarly, beetroot
and flavour, mainly due to the presence of geosmin, a volatile                        is also the most frequently used alternative dietetic measure
bicyclic alcoholic compound [1]. Beetroot is known for its an-                        among patients with cancer in Germany [13] and among a
tioxidant activities and widely used as a remedy for a variety                        majority of gastrointestinal cancer patients in Serbia [14].

Received February 3, 2021, Revised February 27, 2021, Accepted March 5, 2021
Correspondence to Mei Lan Tan, E-mail: tanml@usm.my, https://orcid.org/0000-0001-6565-699X

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-
                commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2021 Korean Society of Cancer Prevention

                                                                                                                              J Cancer Prev 26(1):1-17, March 30, 2021
Tan and Hamid

   Red beetroot is highly popular and widely used for cancer                beet, beetroot, sugar beet, beta vulgaris, cancer, antioxidant,
patients in some parts of the world. Although there is pau-                 anti-inflammatory, cardioprotective, anti-tumor, chemopre-
city of data indicating its direct role in cancer treatment and             vention, fatigue, performance and clinical trials using Boolean
chemoprevention its antioxidant, anti-inflammatory and other                operator “AND” in various combinations. Articles were first
supplementary effects are potentially beneficial for patients               screened by year (2000 to 2021), followed by title, language
with cancer at certain stages of disease including during                   and abstract. Only relevant articles were selected, and addi-
chemotherapy and post-chemotherapy. This narrative review                   tional articles were sourced by examining the bibliographic
aims highlight to provide the valuable phytochemical compo-                 list. Flowchart illustrating the brief search strategy is shown in
nents present in red beetroot, the current knowledge on its                 Figure 1.
health benefits as a possible chemopreventive functional food
and to identify related research gaps in this area of research.             Phytochemical and nutritional composition of
                                                                            beetroot
DATA ANALYSIS
                                                                            Phytochemicals present in beetroot are found to be beneficial
To summarize the current literature on beetroot and cancer,                 for the human health. Betalains, pigments derived from beta-
three databases such as Pubmed, Sciencedirect and Sprin-                    lamic acid, are an important group of bioactive phytochemi-
gerlink were screened. The search terms used included                       cals in beetroot. Structurally, betalains are compounds with

         Flowchart illustrating search strategy

                               Pubmed: https://pubmed.ncbi.nlm.nih.gov/

     Database                  Springer link: https://link.springer.com/

                               Sciencedirect: https://www.sciencedirect.com/

                              Beet sugar AND beta vulgaris
                              Beet vulgaris AND beet root
                              Beet vulgaris AND cancer
                              Beet vulgaris AND anti-oxidants
                              Beet vulgaris AND anti-inflammatory
                              Beet vulgaris AND cardioprotective
                              Beet vulgaris AND anti-tumor
                              Beet vulgaris AND chemoprevention
                              Beet vulgaris AND fatigue
                              Beet vulgaris AND performance
                              Beet vulgaris AND clinical trials
                              Beet vulgaris AND clinical trials AND cancer
    Search terms              Beet vulgaris AND clinical trials AND cancer AND breast cancer
                              Beet root AND cancer
                              Beet root AND anti-oxidants
                              Beet root AND anti-inflammatory
                              Beet root AND cardioprotective
                              Beet root AND anti-tumor
                              Beet root AND chemoprevention
                              Beet root AND fatigue
                              Beet root AND performance
                              Beet root AND clinical trials
                              Beet root AND clinical trials AND cancer
                              Beet root AND clinical trials AND clinical trial AND cancer
                              Beet root AND clinical trials AND clinical trial AND cancer AND functional

                                  Year 2000 2020
                                  Title
 Screening criteria
                                  Abstract
                                  Language (English)

                                 Review papers
                                 Commentary
     Excluded
                                 Book chapters
                                 Conference abstracts

                                                                                                           Figure 1. Flowchart illustrating the
                               Relevant articles were selected, and additional articles were sourced by
     Selection                                                                                             search strategy for studies related
                                examining the bibliographic list of the selected articles
                                                                                                           to beetroot and cancer.

2      J Cancer Prev 26(1):1-17, March 30, 2021
Beetroot and Cancer

positive nitrogen in a polyene system and this cyclic amine                                  Other classes of phytochemicals found in beetroot include
reactive group has been considered an important contributor                               phenolics and flavonoids. Some betalains are also phenolic
to their reducing properties [15]. According to a recent study,                           compounds, namely, isobetanin, prebetanin and neobet-
red beetroot has the richest source of betalains among all                                anin, vulgaxanthin I, vulgaxanthin II and indicaxanthin [24].
tested plants such as prickly pear (Opuntia ficus-indica ) and                            Other phenolic compounds isolated from beetroot include
white beetroot varieties [16]. Betalains are synthesised from                             5,5,6,6-tetrahydroxy-3,3-biindolyl, N-trans-feruloyltyramine,
tyrosine into the yellow-orange betaxanthins and red–violet                               N-trans-feruloylhomovanillylamine, and phenolic acids such
betacyanins [17]. Betalamic acid (Fig. 2A) is the common                                  as 4-hydroxybenzoic acid, chlorogenic acid, caffeic acid,
chromophore for all betalain compounds. The pigment clas-                                 catechin hydrate and epicatechin [25-27]. On the other hand,
sification as either betaxanthin (Fig. 2B) or betacyanin is                               flavonoids are, in general, secondary metabolites with a poly-
dependent on the way in which betalamic acid is added as                                  phenolic structure. They are typical biologically active com-
a residue (Fig. 2C). Betaxanthins (Fig. 2B), are betalamic                                pounds with health-promoting properties and are important
acid conjugated with an amine or amino acid. Meanwhile, the                               components used for various applications. The flavonoids
betacyanins (Fig. 2C) are the end products of spontaneous                                 present in beetroot include betagarin, betavulgarin, cochlio-
Schiff base condensation between the conjugated betalamic                                 philin A and dihydroisorhamnetin [28]. Other flavonoid com-
acid moiety and the closed structure of cyclo-DOPA (cyc-                                  pounds isolated are 3,5-dihydroxy-6,7-methylenedioxyflava-
lo-3,4-dihydroxy-phenylalanine) [17]. This reaction changes                               none, 2,5-dihydroxy-6,7-methylenedioxyisoflavone, quercetin,
the absorption from 480 nm (betaxanthins, yellow) to 540                                  rutin and kaempferol [20,24,28-31]. The major contributor to
nm (betacyanins, violet). The colour is due to the presence                               the earthy flavor in red beet is geosmin (trans -1,10-dimethyl-
of double bonds resonating in the structures. Red beetroot                                trans -9-decanol) [32,33]. Another unique feature of beetroot
contains a large amount of betacyanins but lower levels of                                is its high concentration of volatile compounds such as pyr-
betanidin and betaxanthins [18]. More than 80% of total red                               idine and 4-methylpyridine. Additional components present
beetroot pigments are made of betacyanins, mainly betanin                                 include furfural, isopentanol, ethanol, dimethyl sulfide and
(betanidin 5-O -β-glucoside) (Fig. 2D) and its isomer, isobet-                            isovaleraldehyde [32]. A summary of the phytochemical and
anin (Fig. 2E). The concentration of betanin in red beet was                              nutritional components is shown in Table 1.
reported to be 300 to 600 mg/kg [19]. Other betacyanins re-                                  The basic nutritional composition of beetroot includes sug-
ported include prebetanin, neobetanin, amaranthin, lampran-                               ars, dietary fibre, fatty acids, minerals and vitamins (Table
thin I and lampranthin II [20-23].                                                        1) [27,34]. Among sugars present, sucrose is the main com-

A                                   B                                          C    R3        O
                                                    R1           R2
             O                                           N
                                                             +

                                                                                         O                                         OH
                                                                                                                      +
                                                                                    R4                            N
                                                                                                                               O

    HO                          O        HO                                O
                 N
                 H                                               N
                                                                 H                                HO                                    O
         O                 OH                                                                                             N
                                                    O                 OH                                                  H
                                                                                                              O                    OH

                  D    HO
                                    OH                                E        HO
                                                                                             OH

                                            OH                                                        OH
                      HO                                                   HO
                                    O                                                        O

                            O                                                       O

                       HO                                    OH                HO                                         OH
                                                                                                                                            Figure 2. Chemical structures of:
                                                +                                                         +
                                            N                                                         N
                                                         O                                                        O                         (A) Betalamic acid; (B) Betaxanthin,
                                                                                                                                            where R1 is an amine or amino acid
                                                                                                                                            and R2 is normally hydrogen; (C)
                                                                                                                                            Betacyanins (when R3 and R4 are
                                HO                                O                      HO                                    O            hydrogen, the structure corresponds
                                                    N
                                                    H
                                                                                                              N
                                                                                                              H                             to betanidin); (D) Betanin; (E)
                                        O                    OH                                   O                       OH                Isobetanin.

                                                                                                                                                      http://www.jcpjournal.org   3
Tan and Hamid

Table 1. Phytochemical and nutritional composition of beetroot
    No                    Class                                    Compound (synonym)                                  References
    1       Betalains           Betaxanthin                                                                  [15,16]
                                Betacyanin          Betanin (betanidin 5-O-beta-glucoside)                   [17,27]
                                                    Isobetanin (isobetanidin 5-O-beta-glucoside)
                                                    Prebetanin (betanidin 5-O-(6'-sulfate)-beta-glucoside)
                                                    Neobetanin (neobetanidin 5-O-beta-glucoside)
                                                    Amaranthin (betanidin 5-O-sophorobiuronic acid)          [20-23]
                                                    Lampranthin I
                                                    Lampranthin II
    2       Phenolics           Betalains           Vulgaxanthin I                                           [20,67]
                                                    Vulgaxanthin II
                                                    Indicaxanthin
                                                    Betanin (betanidin 5-O-beta-glucoside)
                                                    Isobetanin (isobetanidin 5-O-beta-glucoside)
                                                    Prebetanin (betanidin 5-O-(6'-sulfate)-beta-glucoside)
                                                    Neobetanin (neobetanidin 5-O-beta-glucoside)
                                Non-betalains       5,5,6,6-tetrahydroxy-3,3-biindolyl                       [25-27,34]
                                                    5,6-dihydroxyindolecarboxylic acid
                                                    N-trans-feruloyltyramine
                                                    N-trans-feruloylhomovanillylamine
                                                    4-hydroxybenzoic acid
                                                    Chlorogenic acid
                                                    Caffeic acid
                                                    Catechin hydrate
                                                    Epicatechin
    3       Flavonoids                              Betagarin (5,2-dimethoxy-6,7-methylenedioxyflavanone)    [20,24,26,28-31,34]
                                                    Betavulgarin (2′-hydroxy-5-methoxy-6,7-
                                                    methylenedioxyisoflavone)
                                                    Cochliophilin A (5-hydroxy-6,7-methylenedioxyflavone)
                                                    Dihydroisorhamnetin (3,4',5,7-tetrahydroxy-3'-
                                                    methoxyflavanone)
                                                    3,5-dihydroxy-6,7-methylenedioxyisoflavanone
                                                    2,5-dihydroxy-6,7-methylenedioxyisoflavone
                                                    Quercetin (3,5,7,3',4'-pentahydroxyflavone)
                                                    Rutin (3,3',4',5,7-pentahydroxyflavone-3-rutinoside)
                                                    Kaempferol (3,4',5,7-tetrahydroxyflavone)
    4       Volatiles                               4-methylpyridine                                         [32,33]
                                                    Pyridine
                                                    Dimethylsulfide
                                                    Isovaleraldehyde
                                                    Ethanol
                                                    Isopentanol
                                                    Furfural (2-Furaldehyde)
                                                    Geosmin (trans l, lO-dimethyl-trans-9-decalol)
    5       Nutritional         Mineral             Calcium                                                  [34,35,39,42]
                                                    Magnesium
                                                    Potassium
                                                    Sodium
                                Vitamin             Vitamin A
                                                    Vitamin C
                                Carbohydrate        Sucrose
                                Fat                 Fatty acids
                                Amino acid          Essential amino acids (EAA)
                                                    Non-essential amino acids (NEAA) – Glutamic acid
                                                    Gamma-aminobutyric acid (GABA)
                                Others              Dietary nitrate (NO3-)
                                                    Dietary fiber

4        J Cancer Prev 26(1):1-17, March 30, 2021
Beetroot and Cancer

ponent. Fatty acids are present in combination of saturated,          consumption may increases the protection against free radi-
monounsaturated and polyunsaturated acids which occur in              cals. Several earlier studies have also indicated that beetroot
minimal amounts. Minerals such as sodium, potassium, cal-             is an essential source of natural antioxidants [25,49-53]. Ap-
cium and magnesium are present in relatively high concen-             parently, the antioxidant effects of beetroot is not limited to its
trations while aluminium, barium, boron, copper, iron, manga-         tubers, but also evident in its leaves [54].
nese and zinc are found at lower levels. Beetroot are also rich          The antioxidant and anti-inflammatory capacity of beetroot
in both vitamins A and C [27]. Moreover, beetroot contains a          has been evaluated in both in vitro and in vivo experiments.
substantial amount of both non-essential and essential amino          Beetroot ethanol extract (lyophilized) has shown substantial
acids. Examples are methionine, threonine, lysine, leucine,           antioxidant, electron-donating ability and radical scavenging
isoleucine, tryptophan, phenylalanine, valine, tyrosine, cys-         activities and was found to inhibit the nitric oxide production in
teine, alanine, histidine, arginine, serine, proline, glycine and     lipopolysaccharide-treated mouse macrophage RAW 264.7
aspartic acid [27]. Interestingly, a large amount of glutamine        cells [55]. Antioxidant activity, evaluated using the cell-free
is also present in beets [35]. Glutamine is a non-essential           system and three standard spectrophotometric tests, have
amino acid and is a precursor in nucleotide, glucose and pro-         shown that red beetroot extracts displayed the strongest an-
tein synthesis [36]. Its metabolism produces large quantities         tioxidant potential as compared with other vegetable extracts
of glutamate, a component required for glutathione synthesis.         [16]. However, in the same study, there were no significant
Glutathione is important for the maintenance of the cellular          cytotoxic nor any protective effects against oxidative DNA
redox state [37,38]. In addition, γ-aminobutyric acid (GABA)          damage in HT29 (human colon adenocarcinoma) cells chal-
and β-alanine were also isolated from the red beetroot                lenged with reactive oxygen species (ROS) when 10% (v/v)
[35,39]. Interestingly, GABA is known to be potentially useful        water extracts of red beetroot was tested [16]. Similarly, the
as a component of functional food. As an important inhibitory         water extracts were not found to induce the activity of phase
neurotransmitter in the nervous systems, GABA has antioxi-            II detoxification enzymes significantly. This is in contrary to
dant, anti-anxiety, anti-hypertensive properties [40,41].             earlier published studies. Esatbeyoglu and co-workers report-
   Dietary nitrate found in green leafy and root vegetables           ed that betanin significantly reduced H2O2-induced DNA dam-
such as beetroot is an important source of nitric oxide (NO)          age in HT29 cells [56]. Betanin at a low concentration (15
formed via the nitrate-nitrite-NO pathway [42]. Ingested in-          µM) functioned as a free radical scavenger and as an inducer
organic NO3- is metabolized in vivo to bioactive nitrite (NO2-)       of endogenous cellular enzymatic antioxidant defence mech-
and NO2- exerts its effects by conversion to functional nitro-        anisms [56]. However, the exact amount of betanin contained
gen oxides, including NO [43]. NO is an important biologically        in the 10% (v/v) water extract used in the earlier study was
active and signalling molecule involved in a multiple physi-          unclear and hence, difficult to compare with results of studies
ologic process, especially regulation of blood pressure and           that used betanin alone.
blood flow. It is a potent dilator, reduces systemic blood pres-         In another study, the antioxidant capacity of betanin was
sure and inhibits atherogenesis by reducing inflammatory cell         also found to be prominent as it significantly diminished the
recruitment and platelet aggregation [44]. NO-mediated sig-           intracellular ROS level elevated by phorbol myristate ace-
nalling is crucial for protecting the heart against cellular injury   tate (PMA) stimulation (~3 fold) and significantly enhanced
or death. It also regulates mitochondrial respiration by inhibit-     caspase-3 activity in stimulated neutrophils [57]. Betanin
ing cytochrome c oxidase [45]. Dietary nitrate is an important        also decreased the content of DNA in the Comet tails in the
component of the “Dietary Approaches to Stop Hypertension             PMA-stimulated neutrophils [57]. Similar observation was
(DASH)” diet to lower blood pressure and the Mediterranean            found in another work using Caco-2 intestinal cells. Betanin
diet to lower cardiovascular and cancer risk [46]. Nitrate and        was found to reduce DNA damage caused by H2O2 and sig-
nitrite are known to reduce blood pressure, protect tissues           nificantly enhanced caspase-3 activity in both neutrophils and
against ischemic injury, reduce oxidative stress, improves mi-        Caco-2 cells [58]. Based on these findings, betanin is likely to
tochondrial function and enhances exercise performance.               be responsible for the effect of beetroot products on oxidative
                                                                      DNA damage and apoptosis in neutrophils. Since cytokines
Properties of beetroot that are potentially                           and other inflammatory mediators produced by the white
chemopreventive                                                       blood cells are direct contributors to cancer initiation, promo-
                                                                      tion and metastasis, functional food which mitigates chronic
Antioxidant and anti-inflammatory activities                          inflammation is thought to be an important cancer prevention
   Red beetroot has been ranked among the ten most potent             strategy.
antioxidant vegetables [47]. Betacyanins are known to be a               Beetroot juice containing 79.3 mg/100 mL of betaxanthines
class of compounds with radical scavenging and antioxidant            and 159.6 mg/100 mL of betacyanins was found to be pro-
activities [18,48]. On the other hand, betanin, consisting of         tective against N-nitrosodiethylamine (NDEA)-induced oxida-
a phenolic and a cyclic amine group, is shown to be a very            tive stress and liver injury in male rats. NDEA is a food-born
good electron donor, acting as antioxidants [18]. Hence, its          carcinogen and is present in smoked or salted meat [59].

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Tan and Hamid

The metabolic activation of NDEA by the hepatic microsomal         root were demonstrated in both in vitro as well as in vivo
cytochrome P450 system produces ethyl diazonium ion as a           (animal) studies. Betanin is also a major betacyanin com-
reactive intermediate which elicits DNA alkylation and subse-      ponent isolated from Opuntia ficus-indica . Several in vitro
quently promotes carcinogenesis. In this study, rats treated       studies have indicated that betanin possesses cytotoxic and
with beetroot juice prior to NDEA administration exhibited a       growth inhibitory activities against different cancer cell lines.
significant reduction of DNA damage in blood leukocytes.           For example, the proliferation of human chronic myeloid
Beetroot juice also restored the activity of some of the antiox-   leukemia cell line (K562 cells) treated with betanin was re-
idant enzymes in the liver and prevented xenobiotic-induced        duced in a concentration- and time dependent manner with
oxidative stress [59]. In addition, beetroot juice was found to    an IC50 value of 40 μM. Betanin-treated K562 cells appeared
reduce the levels of liver injury biomrkers including ALT, SDH,    to undergo intrinsic apoptosis mediated by the mitochondrial
GGT and bilirubin and reduced DNA damage triggered by              release of cytochrome c into the cytosol [66]. Betanin exerted
NDEA treatment [60]. The protective effect of beetroot juice       its pro-apoptotic activities through activation of procaspase-3
against oxidative damages and the metabolic alterations in-        cleavage and caspase-3 activity followed by the loss of mi-
duced by beetroot feeding may likely safeguard against liver       tochondrial transmembrane potential [58]. This indicates that
damage [60]. Furthermore, the ethanol extract of beetroot          betanin elicits the release of ROS and triggers apoptotic cell
was found to exert similar protective effects on hepatotoxicity    death, further supporting its cancer preventive activity.
by altering various indicators of liver damage induced by lipo-       In addition, both betanin and betaine extracted from beet-
polysaccharide or alcohol in experimental rats [55].               roots have demonstrated anti-proliferative effects against
   The anti-inflammatory effects of betalains and beetroot ex-     hepatocellular cells [67]. On the other hand, betacyanins
tract appear to be mediated by interfering with the NF-κB sig-     tested in combination with vitexin-2-O -xyloside, produced a
nalling cascade [2]. The transcription factor NF-κB promotes       synergistic effect in inhibiting the proliferation of human uri-
immunity directly by activating gene targets that up-regulates     nary bladder cancer cells (T24) but not on normal human skin
the inflammatory molecules such as chemokines and cyto-            keratocytes. When used concurrently, both compounds in-
kines that stimulate the phagocytic cells [61]. In an animal       creased the pro-apoptotic BAX protein levels and down regu-
model study to investigate the protective effect of beetroot       lated expression of BIRC5 (survivin) and CTNNB1 (β-catenin)
extract on gentamicin-induced nephrotoxicity, up-regulation of     which are prosurvival components [68]. In yet another study,
nuclear expression of NF-κB (p65), production of TNF-α and         doxorubicin and red beetroot extract exerted synergistic cyto-
interleukin-16 (IL-6), myeloperoxidase activity, and the nitric    toxicity against human pancreatic, prostate and breast cancer
oxide level were significantly down regulated upon beetroot        cell lines [69]. Since there is similarity in the configuration and
supplementation [2]. Beetroot extract treatment also signifi-      chemical structure of both betanin and doxorubicin, a possi-
cantly reduced the expression of cleaved caspase-3 and Bax         ble mechanisms may include DNA intercalation [69].
protein and up-regulated the anti-apoptotic Bcl-2 protein in          Furthermore, Nowacki and co-workers [70] found that
the kidney cells. It ameliorated the extent of histologic renal    betanin-enriched beetroot extract induced apoptosis in
injury and reduced inflammatory infiltration in the tubules [2].   breast cancer cells. Betanin/isobetanin-enriched concen-
   Betalains were also reported to supress COX-2 expres-           trate produced from red beetroots inhibited proliferation of
sion, a pro-inflammatory enzyme responsible for prosta-            cancer cells and induced their death but has limited effects
glandin biosynthesis [62-64]. The COX-2 inhibitory effects of      towards normal cells. The concentrate appeared to inhibit
betanin were found to be comparable to or greater than com-        aggregated cancer cell proliferation (3D cell culture) through
pounds such as lycopene, chlorophyll, bixin, b-carotene and        inhibition of the cell cycle progression, by decreasing the G1
cyanidin-3-O -glucoside. Its activities were also comparable       cell number, promoting the increase of S phase and down
to anti-inflammatory drugs such as celecoxib and ibuprofen         regulating cyclin A2 and cyclin B1 levels in the breast cancer
[64]. Betanin-rich beetroot supplements, in sufficient doses,      cells [70]. Further, expression of FAS, TRAILR4, Bad and
were capable of exhibiting anti-inflammatory effects in a way      p53 (apoptotic-related proteins) was significantly induced and
similar to synthetic drugs [65]. The anti-inflammatory effects     the mitochondrial membrane potential was clearly MCF-7
of betanin were also demonstrated in the neutrophils from          cells treated with betanin-enriched red beetroot. Suggesting
patients with bowel disease neutrophils. Betanin treatment         that both intrinsic and extrinsic pathways were involved [70].
for 24 hours in neutrophils isolated from blood of patients with   Although lysosomal vacuole formation was observed in the
Crohn’s disease and ulcerative colitis showed an increased         extract-treated MCF-7 cells, there was insufficient evidence
DNA damage in these cells, hence demonstrating a reduced           of autophagy. In a recent study, betavulgarin, isolated from
neutrophil activity in inflammatory conditions [58].               beetroot was found to suppress the growth, migration, colony
                                                                   formation, and mammosphere formation in breast cancer
Anti-proliferative and other chemopreventive                       cell lines. This compound also reduced the proportion of
properties                                                         the CD44+/CD24- subpopulation and the expression of the
The anti-proliferative and chemopreventive activities of beet-     self-renewal-related genes such as c-Myc , Nanog and Oct4 .

6     J Cancer Prev 26(1):1-17, March 30, 2021
Beetroot and Cancer

Interestingly, betavulgarin inhibited the Stat3/Sox2 signaling     juice for 1 month, the patient experienced an increase in cell
and induced breast cancer stem cell death [71].                    counts and up-regulation of the uric acid level. Interestingly,
   Oral consumption of red beetroot food color, in the form of     her condition was reversed when beetroot-carrot juice was
commercial dye E162, inhibited N-nitrosomethylbenzylamine          reintroduced. This observation provides single but limited
(NMBA)-induced tumor formation in the rat esophagus. The           evidence for the effectiveness of the beetroot-carrot juice in
number of NMBA-induced esophageal papillomas were sig-             eliminating malignant leukemic cells [77].
nificantly reduced by almost half in animals receiving the food       Polyphenol-rich foods are generally known to have an-
color as compared with controls [72]. In addition, the levels      ti-neoplastic effects. A clinical trial demonstrated significant
of inflammation and angiogenesis in the beetroot-treated           short-term reduction of the prostate-specific antigen (PSA)
animals were also reduced with a concurrent increase in the        level following supplementation with polyphenol-rich diet
apoptotic rate. The mechanisms of chemoprevention with red         among elderly men [78]. Reduction in the serum PSA level is
beetroot appeared to involve reduction of cell proliferation,      an endpoint biomarker for hormone-refractory human pros-
angiogenesis, inflammation and stimulation of apoptosis.           tate cancer intervention. Since beetroot contains significant
Since red beetroot color contains betanins, these effects may      polyphenolic flavonoid antioxidants, its ability to inhibit mani-
be mediated through inhibition of oxygen radical-induced sig-      festation of biomarkers of cancer is expected. However, there
nal transduction [72].                                             is certainly limited information on the direct effects of beetroot
   In another study, oral administration of betanin in Institute   and its chemical composition on tumour markers i.e., cancer
of Cancer Research (ICR) mice inhibited PMA-induced pro-           antigen (CA) 125, 15-3, 19-9 and carcinoembryonic antigen
motion of mouse skin tumors and glycerol-induced promotion         (CEA). Prospective clinical studies using beetroot may pro-
of lung tumors as compared with control [73]. Betanin, in the      vide better insight into its underlying mechanisms when given
form of beetroot extract, also significantly decreased tumor       along with standard therapies. A summary of cancer preven-
multiplicity and burden in two mouse lung tumor models [74].       tion effects of beetroot is shown in Table 2.
Subsequent immunohistochemical characterization revealed
that betanin reduced angiogenesis and induced apoptosis in         Cardioprotective activities
treated mice as well as in human cancer cells in vitro [74].       Dietary supplementation of beetroot juice has been shown
   Apart from fresh beetroot juice, beetroot juice fermented       to mitigate anthracycline-induced cardiotoxicity [79]. Doxo-
with Lactobacillus paracasei 0920 and Lactobacillus brevis         rubicin and epirubicin are anthracyclines and are usually
0944 significantly reduced the number of carcinogen-induced        part of breast cancer treatment protocol. Anthracyclines are
aberrant crypt foci in N-nitroso-N-methylurea-treated rats.        important chemotherapeutic agents but unfortunately, chronic
Hence, supplementation of diet with lacto-fermented beetroot       administration of anthracyclines induces cardiomyopathy and
juice was postulated to provide protection against precancer-      congestive heart failure [80]. For example, doxorubicin, a
ous aberrant crypt formation [75]. In a separate animal study,     quinone-containing anthracycline antibiotic, is widely used to
beetroot minimized radiation-induced DNA damage of sple-           treat solid tumors such as breast and ovarian cancer. How-
nocytes. Beetroot extract given orally three times to C57BL/6      ever, its clinical use is hampered by its adverse reaction such
mice and, at day 10 after γ-ray irradiation, boosted differenti-   as cardiomyopathy and congestive heart failure. Although
ation of hematopoietic stem cells (HSCs) into burst-forming        epirubicin or idarubicin, as second-generation analogs, may
units-erythroid [76]. Furthermore, beetroot-treated mice also      show improvements in their therapeutic index, there is still
displayed increased levels of red blood cells, hematocrit and      risk of cardiomyopathy [80]. One of the commonly known
hemoglobin. Beetroot supplementation stimulated differentia-       mechanisms of doxorubicin-induced cardiotoxicity is genera-
tion of HSCs and preserved integrity of bone marrow [76].          tion of ROS, which induces the apoptosis of the cardiomyo-
   Clinical experiences on beetroot extracts or juice in cancer    cytes [80]. Thus, doxorubicin elicits the formation of hydrogen
are currently lacking to support the findings of both in vitro     peroxide and superoxide anions (O2−) through redox cycling
and animal studies. Only an isolated case report on an elder-      of their aglycones which explains its anti-tumor activities [81].
ly patient diagnosed with chronic lymphocytic leukemia and            Inflammation provoked due to ROS generation and ox-
her clinical experiences with beetroot juice was published.        idative stress is a major adverse effect, especially on the
The patient who refused chlorambucil after a recurrence of         heart [82,83]. Hence, improving the antioxidant defences of
disease, was started with beetroot-carrot juice [77]. In the       cardiomyocytes is an important strategy to protect against
clinical follow-up duration, administration of beetroot-carrot     doxorubicin-induced oxidative death [84]. In an animal study
juice alone induced a reduction in lymphocyte and peripheral       to determine the protective effect of beetroot juice against
blood leukocytes count by 14.7% and 43.13%, respectively           doxorubicin-induced cardiotoxicity, the combination of beet-
with a concurrent decrease in the uric acid level. Adminis-        root juice with doxorubicin significantly reduced doxorubicin
tration of beetroot-carrot juice for 15 days resulted in an im-    toxicity in rat cardiomyocytes by reducing generation of ROS
proved appetite, a sense of general well-being and increased       [84]. Therefore, beetroot juice supplement is postulated to be
vigor. However, upon discontinuation of the beetroot-carrot        cardioprotective in patients treated with anthracycline chemo-

                                                                                                          http://www.jcpjournal.org   7
8
                                           Table 2. A summary of cancer prevention effects of beetroot in in vitro or in vivo models
                                             No          Test items and dose                    Experimental model                      Dose and treatment duration                Cancer preventive effects                 References
                                                                                                                                                                                                                                          Tan and Hamid

                                            In vitro antioxidant and anti-inflammatory activities
                                              1       Beetroot ethanol extract       • Cell-free system using DPPH                    25-100 µg/mL                        • Good antioxidant, electron-donating ability       [55]
                                                       (lyophilized)                 • NO inhibitory efficacy in mouse                                                       and radical scavenging activity
                                                                                        macrophage RAW 264.7 cell line                                                     • Increases inhibition rate of NO production
                                                                                                                                                                              in LPS-treated cells
                                              2      Water extracts of beetroot      • Cell-free system using standard chemical                                           • Strongest antioxidant potential as                [16]
                                                                                        tests                                                                                 compared with other plants
                                                                                     • Cellular antioxidant activity assay in         • 10% (v/v) extracts (24 h)        • No significant cytotoxic nor any protective
                                                                                        HT29 (human colon adenocarcinoma)                                                     effect against oxidative DNA damage in

J Cancer Prev 26(1):1-17, March 30, 2021
                                                                                        cells                                                                                 ROS challenged cells
                                                                                     • Activity of phase II detoxification            • 10% (v/v) (6-24 h)               • No significant ability to induce activity of
                                                                                        enzymes: glutathione S-transferases                                                   phase II detoxification enzymes
                                                                                        (GST) and quinone oxidoreductase
                                                                                        (NQO1)
                                              3      Betanin (red beet extract       • Comet assay in HT-29 cells                     • 15 µM betanin (14 h)             • Prevents DNA damage                               [56]
                                                      diluted with dextrin; CAS-     • Nrf2 dual luciferase reporter gene assay       • 1-15 µM betanin (24 h)           • Induces Nrf2 at 15 µM betanin
                                                      Nr.: 7659-95-2)                   in Huh7 cells
                                                                                     • Antioxidant enzyme heme oxygenase-1            • 25 µM betanin (24 h)             • Increases in HO-1 protein concentration
                                                                                        (HO-1) expression in Huh7 cells
                                                                                     • Glutathione (GSH) concentration in Huh7        • 1-15 µM betanin (24 h)           • Increases cellular GSH
                                                                                        cells
                                              4      Betanin (ABCR GmbH              • In vitro PMA-induced DNA damage in             • 200 µM betanin (30 min)          • Diminishes intracellular ROS level                [57]
                                                      & Co. KG, Karlsruhe,              isolated human neutrophils (PMNs)                                                     elevated by PMA stimulation (~3 fold)
                                                      Germany)                       • DNA damage (Comet assay) in isolated           • 20-200 µM (24 h)                 • Decreases the percentage of DNA in the
                                                                                        human neutrophils                                                                     comet tails of the stimulated neutrophils
                                                                                     • Fluorometric analysis of caspase-3             • 20-300 µM (24 h)                 • Enhances caspase-3 activity in stimulated
                                                                                        activity                                                                              neutrophils
                                              5      Betanin (ABCR GmbH &            • In vitro H2O2-induced DNA damage in            • 200 µM (24 h)                    • Betanin reduces DNA damage (~14%)                 [58]
                                                      Co. KG)                           isolated human neutrophils and Caco-2                                                 caused by H2O2
                                                                                        intestinal cells                               • 200 µM (24 h; neutrophils)       • Enhances caspase-3 activity in neutrophils
                                                                                     • Caspase-3 activity                             • 20-200 µM (24 h; Caco-2 cells)      and Caco-2 cells
                                                                                                                                                                           • Triggers apoptotic cell death
                                            In vivo antioxidant and anti-inflammatory activities
                                              6      Beetroot juice                  • NDEA and CCl4-induced oxidative stress         • 8 mL/kg/day for 28 days          • Reduces DNA damage in blood leukocytes            [59]
                                                       (79.3 mg/100 mL                  rat model                                                                          • Restores the activity of some of the
                                                       betaxanthins and 159.6                                                                                                 antioxidant enzymes in the liver
                                                       mg/100 mL betacyanins)                                                                                              • Prevents xenobiotic-induced oxidative
                                                                                                                                                                              stress
                                              7      Beetroot juice (79.3            • Phase I and phase II enzymes, DNA              • 8 mL/kg/day for 28 days          • Reduces biomarker levels of liver injury          [60]
                                                      mg/100 mL betaxanthins            damage and NDEA-induced liver injury                                                  such as ALT, SDH, GGT and bilirubin
                                                      and 159.6 mg/100 mL               model in rats                                                                      • Reduces DNA damage triggered by NDEA
                                                      betacyanins                                                                                                             treatment
Table 2. Continued
                              No         Test items and dose                    Experimental model                   Dose and treatment duration              Cancer preventive effects                References
                               8     Beetroot ethanol extract        • Alcohol induced liver damage model          • 200 or 400 mg/kg for 4 weeks   • Decreases serum AST, ALT and γ-GTP               [55]
                                      (lyophilized)                     in rats                                                                          concentrations
                                                                                                                                                      •D  ecreases fat accumulation and
                                                                                                                                                         inflammatory cell infiltration
                                                                                                                                                      • Improves morphological characteristics
                                                                                                                                                         of damaged liver lesion
                                                                                                                                                      •E  xert protective effects in hepatotoxicity
                               9     Beetroot ethanol extract        • Gentamicin-induced nephrotoxicity           • 250 and 500 mg/kg weight for   • Inhibits gentamicin-induced up-                  [2]
                                      (evaporated dry)                  in rats                                        20 days before gentamicin         regulation of inflammatory markers and
                                                                     • Oxidative/nitrosative stress,                  treatment and there after         nitric oxide level
                                                                        inflammatory and apoptotic markers             concurrently with gentamicin   • Reduces the expression of apoptotic
                                                                                                                       for 8 days                        markers in the kidney cells.
                                                                                                                                                      • Reduces inflammatory infiltration in the
                                                                                                                                                         kidney tubules
                             In vitro antiproliferative and other chemopreventive activities
                              10       Betanin and betaine             • MTT assay in HepG2 cells                  •0
                                                                                                                      -200 µg/mL                     • Inhibits cell proliferation in a dose            [67]
                                        isolated from beetroot                                                                                           dependent manner
                                        extracts                                                                    • 800 µg/mL                      • Inhibits HepG2 cells by 25%
                              11     Betacyanins purified from       • Sulforhodamine B (SRB), apoptosis           • 50 µg/mL at 24, 48 and 72 h    • Betacyanins and vitexin-2-O-xyloside             [68]
                                      beetroot                          marker assay in urinary bladder cancer                                           synergistically inhibit proliferation of
                                                                        cells (T24) and normal human skin                                                tumor cells and not normal cells
                                                                        keratinocytes (NCTC 2544)                                                     • Induces apoptosis markers in tumor
                                                                                                                                                         cells
                              12     Beetroot extract (diluted       • Trypan blue cell viability assay in human   •0
                                                                                                                      .29-290 µg/mL at 72 h          • Synergistic antiproliferative effects when       [69]
                                      with dextrin)                     pancreatic (PaCa), breast (MCF-7) and                                            used in combination with doxorubicin
                                                                        prostate cancer (PC-3) cell lines                                             • IC50 values reduced to almost 40%
                              13     Betanin/isobetanin              • Cell proliferation, apoptosis and           • 48 h                           • Decreases cancer cell proliferation and          [70]
                                      enriched powder from              autophagy assay in mouse melanoma           • IC50 about 25 µM for B16F10       viability.
                                      beetroot                          cell line (B16F10), human breast cancer       and MCF-7 cells and 35 µM       • Increases the expression of apoptosis-
                                                                        lines (MCF-7, MDA-MB-231), human              for MDA-MB-231 cells               related proteins and autophagosome
                                                                        colorectal cells (HT-29) and normal                                              vesicles
                                                                        human fibroblasts (MRC-5)
                              14     Betavulgarin isolated from      • Breast cancer cells (MDA-MB-231             • MDA-MB-231 (≥ 100 µM) and      • Suppresses proliferation, migration,             [71]
                                      beetroot                          and MCF-7)                                     MCF-7 cells at ≥ 50 µM for        colony formation, and mammosphere
                                                                                                                       24 h                              formation
                                                                                                                                                      • Reduces the size of the CD44+/CD24−
                                                                                                                                                         subpopulation
                                                                                                                                                      • Reduces the expression of the self-
                                                                                                                                                         renewal-related genes, c-Myc , Nanog
                                                                                                                                                         and Oct4
                                                                                                                                                      • Inhibits the Stat3/Sox2 signaling
                                                                                                                                                         pathway and induces breast cancer

http://www.jcpjournal.org
                                                                                                                                                         stem cells death

9
                                                                                                                                                                                                                    Beetroot and Cancer
10
                                           Table 2. Continued
                                             No         Test items and dose                   Experimental model                  Dose and treatment duration                Cancer preventive effects              References
                                            In vivo antiproliferative and other chemopreventive activities
                                                                                                                                                                                                                                     Tan and Hamid

                                             15      E162-water (78 µg/mL            • N-nitrosomethylbenzylamine (NMBA)-      • 35 weeks                           • Reduces NMBA-induced esophageal                [72]
                                                       E162 dye powder in               induced tumors in the rat esophagus                                              papillomas by 45%
                                                       water)                           (F344 rats)                                                                   • Reduces rates of cell proliferation in
                                                                                                                                                                         cancerous lesions
                                                                                                                                                                      • Reduces level of angiogenesis and
                                                                                                                                                                         inflammation
                                                                                                                                                                      • Increases rate of apoptosis
                                             16      Beetroot extract (betanin)    • Mouse skin and lung carcinogenesis        • 0.0025% (w/v) betanin in           • Inhibits TPA-induced promotion of mice         [73]
                                                      (TCI America, Portland,         model                                        drinking water for 20 weeks           skin tumors
                                                      OR, USA)                                                                                                        • Reduces 60% of lung tumors

J Cancer Prev 26(1):1-17, March 30, 2021
                                             17      Betanin extract (betanin)     • VC and B(a)P-induced lung tumors in       • 25 and 100 µg/mL betanin in        • Decreases tumor multiplicity and tumor         [74]
                                                      (TCI America)                   mice                                         drinking water for 20 weeks           load
                                                                                                                                                                      • Induces caspase-3 expression
                                                                                                                                                                      • Inhibits angiogenesis
                                             18      Beetroot extract (extracted   • γ-ray irradiation in C57BL/6 mice         • 400 mg/mouse orally three          • Stimulates cell proliferation                  [76]
                                                      with 70% ethanol)                                                            times                              • Minimizes DNA damage of splenocytes
                                                                                                                                                                      • Repopulates S-phase cells
                                                                                                                                                                      • Boosts differentiation of HSCs into
                                                                                                                                                                         burst-forming units
                                                                                                                                                                      • Enhances level of hematocrit and
                                                                                                                                                                         hemoglobin and RBC
                                            Chemoprevention clinical studies
                                            19    Beetroot-carrot juice            • Case report of a patient diagnosed with   • 330 mL of fresh raw beetroot-      • Decreases leukocyte and lymphocyte             [77]
                                                                                      B-cell chronic lymphocytic leukemia          carrot juice orally (beetroot         count from
                                                                                      (B-CLL)                                      200 g + carrots 250 g) 2 h         • Reduces level of uric acid in blood
                                                                                                                                   before breakfast 6 times/week      • Increases appetite,
                                                                                                                                   for 1.5 month                      • Improves fatigue
                                                                                                                                • 330 mL of fresh beetroot-          • Decreases leukocyte, lymphocyte and
                                                                                                                                   carrot juice 6 times per week,        reticulocyte counts
                                                                                                                                   in combination with the            • Improves renal function
                                                                                                                                   chlorambucil protocol 8 mg/        • Improved blood urea, serum creatinine
                                                                                                                                   day for 37 days                       and uric acid levels
                                                                                                                                                                      • Decreases LDH level
                                             20      Beetroot (concentrated        • Untreated squamous cell cancer of         • 10 g Beetroot powder mixed         • Duration of study from December          ClinicalTrials.
                                                      organic beetroot crystals)      the head and neck (Randomized phase          with 4-8 oz                           2014-May 2018                             gov Identifier:
                                                                                      II Trial)                                 • 12 weeks                           • Unpublished                               NCT02058849
                                             21      Dietary supplement:           • Malignant breast tissue neoplasm          • 5-day dietary nitrate              • Duration of study from May 2019-June     ClinicalTrials.
                                                      beetroot juice                                                               intervention programme,               2020                                      gov Identifier:
                                                                                                                                   taking 3 doses of                  • Unpublished                               NCT03944226
                                                                                                                                   7 cl (centiliter) (0.4 g nitrate
                                                                                                                                   per dose) concentrated
                                                                                                                                   beetroot juice
                                           NO, nitric oxide; LPS, lipopolysaccharide; ROS, reactive oxygen species; NDEA, N-nitrosodiethylamine; ALT, alanine aminotransferase; SDH, sorbitol dehydrogenase; GGT, gamma
                                           glutamyl transferase; AST, aspartate aminotransferase; MTT, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide; VC, vinyl carbamate; B(a)P, benzo(a)pyrene; RBC, red blood
                                           cell.
Beetroot and Cancer

therapeutic drugs. The clinical application of beetroot juice as    cognitive–behavioral interventions.
an adjunct therapy to combat against cardiotoxicity caused             Functional foods have been increasingly accepted as part
by anthracycline drugs is promising and would have a benefi-        of a healthy lifestyle and foods. A nitrate-dietary supplemen-
cial public health impact [79].                                     tation with beetroot juice is postulated as a nutritional strategy
                                                                    in patients undergoing chemotherapy and post-chemothera-
Ameliorating cancer-related fatigue                                 py due its antioxidant and chemopreventive activities. Symp-
Fatigue is a common adverse condition which affects the             toms of fatigue may be ameliorated with beetroot supplemen-
quality of life of patients with cancer [85]. It is one of the      tation due its high content of dietary nitrates and subsequent
most frequently reported complaints among cancer patients           production of NO. NO is a ubiquitous signalling molecule with
[86,87]. As high as 60% to 93% of patients undergoing ra-           important physiological functions in human tissues [105].
diotherapy and 80% to 96% of patients on chemotherapy                  NO plays a crucial role in skeletal muscle metabolic and
experienced fatigue [87,88]. Fatigue is reported as one of the      vascular control. Beetroot juice contains high levels of in-
most distressing symptoms associated with cancer and its            organic nitrate (NO3−), which serves as a precursor of NO.
treatment [89]. It is an independent predictor of poor quality      Beetroot supplementation provides dietary inorganic nitrate
of life and patient satisfaction [90]. In addition, the degree of   (NO3−) which positively affect muscle metabolic and hae-
anemia was also found to be predictive of the degree of fa-         modynamic function [106,107]. Oral NO3− intake, either as
tigue among patients with cancer [91].                              beetroot juice or pure sodium NO3−, are found to enhance en-
   Off-treatment fatigue, weakness, and less vitality were          durance exercise performance and capacity in young healthy
more prevalent among women who had breast cancer as                 volunteers [107-112]. In humans, acute (2 to 3 hours) and
compared with women who had benign breast problems [92].            chronic (3 to 6 days) dietary nitrate consumption has been
In an epidemiology study, breast cancer survivors were found        shown to improve exercise tolerance and reduce blood pres-
to be complaining of lethargy more frequently than the refer-       sure [112,113]. In addition, beetroot supplementation ame-
ence group. A significant number of the breast cancer survi-        liorates the muscle metabolic perturbations that occur during
vors experienced sleep disturbances, pain and depression            exercise, improves muscle oxygenation and elevates human
which were associated with severe fatigue [93]. In one me-          mitochondrial efficiency [113-115]. In healthy elderly subjects,
ta-analysis, one in four breast cancer survivors suffered from      serum nitrate concentrations were found to be inversely as-
severe fatigue. Some of the risk factors included chemother-        sociated with general fatigue scores based on a self-rating
apy, higher disease stages and combination cancer therapy           scale (Multidimensional Fatigue Inventory) [116,117]. Similar-
[94]. In one longitudinal study, persistent fatigue continued to    ly, in another study, the level of the job strain appeared to be
be a challenge for breast carcinoma survivors [95].                 directly proportional to the fatigue among women but inverse-
   The pathogenesis of cancer-related fatigue is currently not      ly associated with NO levels. NO has the capability to buffer
well understood. However, its development may be caused             the association between fatigue and job strain [118]. Hence,
by a variety of mechanisms [96]. Cancer-related fatigue could       based on these observations, beetroot juice supplementation
be related to the effects of cancer or its treatment on sleep       and its ability to increase exercise performance and tolerance
or circadian rhythms, muscle energy metabolism and central          in healthy subjects may ameliorate cancer-related fatigue.
nervous system [97]. Findings from animal and human re-             Currently, there are yet any studies to provide direct evidence
search suggest that several cancer-related symptoms, nota-          supporting beetroot’s effects on combating fatigue among pa-
bly fatigue and stress, may involved the actions of proinflam-      tients with cancer.
matory cytokines [98]. In addition, there were studies which
showed links between fatigue and inflammatory markers.              CONCLUSION AND FUTURE
Fatigued cancer survivors are characterized by an increased         PERSPECTIVES
level of TNF-α, monocyte production of IL-6, elevated plasma
IL-1 receptor antagonist and soluble IL-6 receptor (sIL-6R/         Beetroot is a vegetable rich in micro-nutrients and bioactive
CD126) levels, etc., indicative of immune activation [99,100].      constituents with health beneficial properties and has been
Furthermore, the pathogenesis of fatigue is also thought to be      gaining attention as a health promoting functional food. The
related to hormonal changes such as deprivation of androgen         multiple bioactive constituents include the water-soluble
or premature menopause in women [101-103]. The usual ap-            betalains consisting of betacyanins and betaxanthins, poly-
proaches to treatment of cancer-related fatigue include either      phenols, flavonoids and saponins. Beetroot extracts and
pharmacologic management or non-pharmacologic interven-             betacyanins have been extensively studied both in vitro and
tion such as patient education. Interestingly, in a systematic      in vivo. A variety of studies have demonstrated that beetroot
review of 77 randomized controlled trials involving non-phar-       extracts and betanin pigments were effective in preventing
macologic treatments of cancer-related fatigue, results were        experimentally induced carcinogenesis. On the other hand,
promising for non-pharmacologic intervention [104]. These           the flavonoids and polyphenolic components present in abun-
include psychoeducation, hypnosis, exercise, relaxation and         dance in beetroot support its significant anti-inflammatory

                                                                                                           http://www.jcpjournal.org   11
Tan and Hamid

and antioxidant capacities. Although most in vitro and in vivo                     Functional properties of beetroot
studies have shown promising results, the molecular mecha-
nisms of betanin chemoprevention have not been completely
elucidated and clinical studies on beetroot and cancer are still
lacking. In addition, the different extract preparation methods
and the lack of pharmacokinetic studies with betanin alone               Antioxidant
                                                                                                                     Chemopreventive
make it difficult to determine if the therapeutic concentration
or dosage used in these studies are indeed achievable in hu-
man plasma concentration.
   In fact, despite containing the richest amount of anti-ox-
idant compounds, the red beet extract showed neither
stronger cytotoxic effect towards HT29 human colon cancer
                                                                      Anti-inflammatory                              Improves fatigue
cells, nor the ability to up-regulate the enzymes involved in
detoxification as compared with other vegetable or herbal
extracts [16]. Although beetroot supplementation has been                                       Cardioprotective
studied in humans, most clinical studies were performed on            Figure 3. Functional properties of beetroot.
a limited sample size and focussed on exercise performance
and endurance in healthy cohorts. Two relevant clinical trials
involving beetroot and cancer are listed in the ClinicalTrials.       [32]. In addition, their possible interactions with anticancer
gov (US National Library of Medicine) database, which have            drugs should also be considered, since a recent case report
yet to be published. So far, there has been no clinical study         described a woman who developed methotrexate intoxication
which specifically examines the association between beetroot          after drinking beetroot juice as a herbal remedy [121].
supplementation and chemo-prevention or cancer-related                   In summary, beetroot is a valuable vegetable to be con-
symptoms such as fatigue, quality of life and well-being or           sumed for health maintenance and has great potential to
prognosis of disease. Evidence supporting the use of beet-            be used for chemoprevention and in patients with cancer to
root in managing fatigue and/or managing the harsh side               manage fatigue and other side effects of chemotherapy (Fig.
effects of chemotherapy is inevitable for its clinical applica-       3). However, long term safety assessment of dietary beetroot
tion. Both epidemiological and randomized clinical studies on         supplementation and relevant translational studies are nec-
beetroot supplementation and patient with cancer are certain-         essary for the clinical setting.
ly warranted.
   Although beetroot, especially nitrates and the betalains, are      ACKNOWLEDGMENTS
well absorbed and has good bioavailability in humans, there
are still insufficient data on its efficacy and long term safety      The authors would like to acknowledge the Smartfund Chal-
of beetroot supplementation to propose the food as a long-            lenge Grant (MOSTI) and FRGS Grant (KPT).
term strategy in managing diseases like cancer. In pregnan-
cy, nitrate-rich dietary supplementation may be problematic           CONFLICTS OF INTEREST
as it may cause a wide range of unexpected maternal and
fatal adverse reactions such as thyroid problems, alteration          No potential conflicts of interest were disclosed.
in embryonic cells, methemoglobinemia and other disorders
[119]. Hence, intake of excessive beetroot during pregnancy           ORCID
may pose a health hazard. Although beetroot intake pro-
vokes no immediate negative health consequences, long                 Mei Lan Tan, https://orcid.org/0000-0001-6565-699X
term supplementation of beetroot juice should be cautioned            Shahrul Bariyah Sahul Hamid,
in patients with metabolic syndromes or diabetes due to its            https://orcid.org/0000-0002-2843-026X
high sucrose content. In addition, due to beetroot’s rich ox-
alate content, this vegetable can be harmful if taken in large        REFERENCES
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12     J Cancer Prev 26(1):1-17, March 30, 2021
Beetroot and Cancer

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