1. Nutrition and Prevention of Cancer Recurrence
Andréa Fimrite, RDN
Angie Bowman, RDN
BCCA Nutrition Consultants

2. Objectives
Recognize the special nutritional needs of cancer survivors during active cancer treatment
Advise cancer survivors about nutrition and physical activity during the recovery phase and beyond
Controversial nutritional issues facing cancer survivors
Discuss dietary and physical activity strategies that might influence cancer recurrences.
Nutritional issues such as supplements, high dose vitamins, complementary and alternative nutritional methods, etc.

3. Cancer Survivor Anyone who has been diagnosed with cancer
DIAGNOSIS REST OF LIFE

4. Challenges of Cancer Survivors
Highly motivated to seek information about diet and lifestyle changes
Often receive conflicting dietary advice
Claims abound on the use of dietary alternatives
Currently there are many gaps and inconsistencies in the scientific evidence
But they soon discover that it is difficult to find answers to even the simplest questions, such as: Should I follow a low fat diet? Should I lose weight? Should I take supplements?
There have been a couple of large conferences for cancer survivors sponsored by AICR and through these conferences they have been able to organize their voice and concerns regarding nutrition and lifestyle issues after cancer.
From friends, family, and health care providers as well as media, health food stores, internet
or herbal supplements as alternatives to standard therapy
when there is ample scientific evidence on an issue choices can be easy but when we don’t have good evidence choices are difficult
the state of scientific evidence regarding the effects of nutritional factors on clinical outcomes among cancer survivors is not sufficient at this time to support a firm set of guidelines, however, cancer survivors and their caregivers desperately need a credible framework of accurate info

5. ACS’ Guidelines on Nutrition and Physical Activity for Cancer Prevention
(handout)
similar to those recommended by other agencies interested in dietary prevention of chronic diseases
should be regarded as the basis for a healthy diet in cancer survivors with no apparent nutrition problems
special nutritional issues and needs of cancer survivors are addressed in…
The ACS guidelines on Diet, Nutrition and Cancer Prevention are a very similar to AICR, CCS, Heart and Stroke and Diabetes guidelines for the disease prevention
The goal of these prevention guidelines is to reduce cancer incidence
We all know that adequate dietary intake can improve the nutritional status of nearly all cancer survivors
There are many special nutritional issues and needs of cancer survivors that are not specifically addressed by the prevention guidelines that are addressed in ...( show document)

6. Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide to Informed Choices
Published in CA Cancer Journal for Clinicians, Volume 53, Number 5, September/October 2003
Working group looked at a wide range of issues and choices about foods, physical activity, nutritional supplements and nutritional complementary and alternative therapies
NOT a comprehensive review on the effects of nutrition & physical activity in cancer patients
Working group of 15 members 5 RD, 1 MD, 6 PhD (Lawrence Kushi), 1 MEd, 1 MS RN, 2 MPH and 2 cancer survivors
It is this document that I will be basing my presentation on today however due to time limitations I will not be able to cover some of the reviews of complementary dietary interventions nor will I be able to go through the nutrition information according to common cancer sites that is also included in this document. There is also an excellent “Question and Answer” section which addresses a lot of the questions we get asked on a daily basis from cancer survivors.

7. NOT a specific set of guidelines or recommendations
Assumes the patient is already receiving appropriate medical care
A set of suggestions based on both scientific evidence and important practical issues to help patients make informed choices on self care strategies
Assumes…. For example although this article has a section on nutritional suggestions for nausea and fatigue they also recognize that other medical interventions are likely to have a greater impact
….self care strategies to relieve symptoms and enhance health and quality of life

8. The Phases of Cancer Survival
Phase 1: Active Treatment
Phase 2: Recovery from Treatment
Phase 3: Preventing Cancer Recurrence, Second Primary Cancers and Nutrition-Related Disease
Phase 4: Living with Advanced Cancer
Nutritional Issues During the Phases of Cancer Survival
Phase 1: surgery, radiation therapy, chemotherapy,
Phase 2: recovery phase in which the body needs to be restored
Phase3: Health Maintenance Phase to prevent both cancer recurrence, second primary tumours and other preventable diseases
Phase 4: Living with advanced cancer
Survivors in each phase have different needs and challenges with respect to nutrition and physical activity. The Primary site of the cancer and the therapeutic modalities applied may also influence these needs.

9. Phase 1: Nutritional Issues During Active Treatment
Energy balance is the most important goal
Energy intake
Energy expenditure
Nutritional supplements ??
Energy intake
the need for caloric intake is usually increased during cancer treatments
nausea, vomiting, taste changes, loss of appetite, bowel changes all interfere wit our usual eating patterns.
Food choices at this time should be easy to chew, swallow, digest and absorb and should also be appealing.
Adjust usual food choices and usual food patterns.
Energy Expenditure
cancer treatment can cause fatique
light regular physical activity during treatment should be encouraged to improve appetite, stimulate digestion, prevent constipation, maintain energy level and muscle mass and provide relaxation or stress reduction
Nutritional Supplements
use of nutritional products such as Boost, Ensure etc can be helpful on a temporary basis to assist with intake of calories and nutrients
use of other supplements is quite controversial
“it is counterproductive for patients to take vitamin supplements that contain high levels of folic acid or to eat foods fortified with hi amount of folic acid, when on Methotrexate. (metho interferes with folate metabolism)
Antioxidants(Vitamins C, E and phytochemicals or antioxidant minerals)?may reduce the effectiveness of RT or CX.
?May help protect normal cells from treatment collateral damage
No good answer or evidence at this time there fore it would be prudent to advise patients not to exceed the upper intake limits for vitamins and to avoid other nutritional supplements that contain antioxidant compounds.

10. Phase 2: Nutritional Issues After Treatment is Completed
Most important goal Rebuild muscle strength and correct problems
Adequate food intake
Physical activity
Recovery from Treatment
After treatment the nutrition and physical activity plan should help rebuild muscle strength and correct problems such as anemia or impaired organ functioning
Adequate food intake and physical activity are crucial to recovery
Adequate food intake
Need a balanced diet sufficient in caloric intake and sufficiently varied to provide adequate micronutrients (refer to ACS Prevention Guidelines)
long term treatment issues such as dysphagia, xerostomia, malabsorption can lead to weight loss, muscle wasting and nutrient deficiencies
Physical Activity
required to rebuild muscle strength
refer patients with treatment related complications or other disabilities to appropriate health care provider

11. Phase 3: Preventing Cancer Recurrence, Second Primary Cancers and Nutrition Related Disease
Limited data on nutritional factors that influence cancer recurrence
Reasonable to recommend cancer survivors follow guidelines for cancer prevention
Breast cancer recurrence- risk increased by obesity and ?diets low in fruits/vegetables and ?high in fat
Prostate cancer recurrence- risk may be increased by high saturated fat intake and reduced by micronutrient supplementation(SELECT Trial)
Phase 3
very little research on nutritional influences of cancer recurrence
In the absence of data it seems reasonable to recommend…. Since the same factors that increase cancer incidence might also be important in promoting cancer recurrence after treatment.
Data is most compelling for breast cancer where….
Prostate cancer recurrence might also ….
ACS Guidelines for Diet and Cancer Prevention (handout) may be the most effective method for preventing the growth of second primary cancers.

12. Phase 4: Living with Advanced Cancer
Nutrition is an important factor in establishing a sense of well being and quality of life in survivors with advanced cancer
Adapt food choices and eating patterns to meet changing needs
Effective management of symptoms and side effects
Living with Advanced Cancer
Although advanced cancer is often accompanied by substantial weight loss, malnutrition and weight loss are not inevitable
Effective management of symptoms such as pain, constipation & loss of appetite can help promote optimal nutrition support. Various medications and physical activity can help to increase appetite and if needed nutrition can be provided in other ways for those who cannot eat.

13. Specific Nutritional Issues for Cancer Survivors
Physical Activity
Alcohol
Dietary Supplements
Flaxseed
Garlic
Ginger
Teas
Food Safety
Caloric Intake
Body Weight Changes
Dietary Fats
Carbohydrates and Protein
Fruits and Vegetables

14. Food Safety
Very important for patients undergoing immunosuppressive cancer treatments
Patients should be careful to avoid eating foods that may contain unsafe levels of pathogenic micro organisms
(handout)
(Read Overhead)
To make food as safe as possible, patients should follow the general guidelines for food safety as shown in your handout “General Guidelines for Food Safety”

15. Caloric Intake
Past belief, starvation would deprive a growing tumour of needed nutrition, therefore “nutritional intake should be severely restricted to treat cancer”
Research has shown that starvation does not increase survival, but is detrimental due to high nutritional needs during and after therapy
Caloric Intake
….This theory is now known to be wrong
Research has shown….
Cancer survivors should therefore be encouraged to consume enough calories (as protein, carbohydate, and fat) to maintain weight and optimal body nutrient stores.

16. Body Weight Changes
Intentional weight loss during cancer treatment is not recommended
Some cancer survivors may gain weight during and after treatments
During treatment, a healthy eating plan that meets but does not exceed caloric needs (along with physical activity) is advisable
Healthy weight loss is best initiated after the recovery phase
Obesity is associated with increased risk and poorer prognosis of breast and ?colon cancers
Body Weight Changes
Intentional weight loss- Weight loss can contribute to fatigue, delay and lengthen recovery, and adversely affect quality of life. Therefore, should only be attempted after the active treatment and recovery phases are complete.
Weight gain-some cancer survivors, especially breast cancer patients, may gain weight during and after treatment. Menopausal status, nodal status and type,duration and intensity of treatment influence such weight gains.Whether overweight survivors who experience weight gain through treatment worsen their prognosis is unknown.
During treatment….protein metabolism in cancer patients has been shown to be elevated leading in some cases to skeletal muscle wasting. Even moderate physical activity can lead to improved well being, strength and weight stabilization.
Healthy weight loss - …or when treatment and recovery is complete/
Obesity-…and maintaining body weight within healthy ranges may help reduce risks of variety of chronic diseases( ie CHD, DM)

17. Dietary Fats
Current evidence indicates total fat NOT important cause of cancers
Type of fat are associated with cancer and heart disease risk:
saturated fats risk
monounsaturated, omega risk

18. Dietary fats (cont’d)
Some studies suggest that women on lower fat diets before diagnosis tend to have less aggressive cancers than do those on high fat diets
2 trials testing the effects of low fat diets on recurrence and survival from breast cancer (WINS and WHEL)
Thus, although dietary fats might have little to with breast cancer prevention, the levels of fat in the diet might somehow affect the growth of breast cancers that do develop.
WINS Women’s Intervention Nutrition Study
WHEL Women’s Healthy Eating and Living Study
It is hoped that more direct evidence regarding the impact of low-fat dietary patterns on breast cancer recurrence will eventually emerge from these 2 trials.
NO specific recommendations regarding low fat diets in the management of cancer can be made at this time.
If individuals and their families choose to follow very low fat regimens (20% of calories from fat) they should ensure that the diets are balanced and contain enough fat soluable vitamins and calories to maintain healthy body weight

19. Carbohydrates and Protein
Carbohydrates rich in essentail nutritients, pyhtochemicals and fibre - whole grains, vegetables, legumes and fruit
Protein choices low in saturated fat, 10% of intake (but higher in elderly)

20. Fruits and Vegetables
May be associated with lower incidence of colorectal, lung, oral, esophageal, and stomach cancers
Few studies have examined F/V benefits for improving cancer survival
WHEL Study
Benefits of eating F/V might be much greater than are the effects of any vitamin they contain
Recommend at least 5 servings of F/V each day - with emphasis on veg
WHEL Study -currently in progress is testing the effect of a diet high in vegetables, fruit, fibre and low in fat on survival of women diagnosed with early stage breast cancer. Results expected to be known by the end of 2004.
Benefits….as it is quite likely that the various vitamins and other phytochemicals in these whole foods act in synergy to reduce cancer risk
Vegetables and fruits are low in fat, contribute to fibre and micronutrients and are generally more healthful than many other food choices.
1 serving = 1 cup of leafy vegetables
1/2 cup cooked or chopped or juice
1/4 cup dried
1 piece of fresh fruit

21. Physical Activity
Regular physical activity is associated with reduced risk of colorectal cancer, CHD, osteoporosis & DM
The impact on the prognosis of people with cancer is less clear
Regular physical activity….and may be beneficial for the prevention of other cancers as well including breast cancer.

22. Physical Activity (cont’d)
Activity levels tend to decrease after cancer diagnosis and treatment
Very few studies have looked at the effect of exercise on prevention of cancer recurrence or disease progression
Studies with survivors have shown that regular exercise can…
After diagnosis and during treatment peoples’ lifestyle patterns change
BCCA study launched recently looking at the effect of different types of exercise on women receiving treatment for breast cancer.

23. Benefits of Moderate Regular Physical Activity for Cancer Survivors
reduce anxiety
reduce depression
improve mood
boost self esteem
reduce symptoms of fatigue,
beneficial effects on heart rate, lean body mass and respiratory capacity
Read the slide contents
Thus consistent with other recommendations regarding physical activity, cancer survivors and their family members should be encouraged to engage in moderate regular physical activity.

24. Physical activity recommendations for cancer survivors
Moderate regular physical activity on most if not all days of the week
Before beginning any exercise program, cancer survivors should undergo a complete health assessment to develop an individualized plan that maximizes benefits while reducing risks of injury
Read first point
Moderate activities are activities that make a person breathe as hard as they would during a brisk walk. Activities such as walking, biking, and swimming are considered of moderate intensity, as well as activities such as yard work or brisk house cleaning. Ideally at least 30 minutes of activity should be accumulated each day.
(Read second point)

25. Physical activity recommendations for cancer survivors (cont’d)
Individuals confined to bed rest, even those with advanced cancer, can benefit !
Survivors with disabilities should consult specialist to assist in development of individualized program
Survivors with metastasis to the bone or bone loss due to therapy should be careful to prevent bone fractures
Survivors with chemo induced neuropathy that effects their balance should choose activities that avoid the risk of falls
Read first point….Prolonged bed rest can result in reduced fitness, reduced endurance and decreased muscle strength all of which can increase the effort required for performing daily activities. Even for those with advanced cancer exercise can help counteract the fatigue spiral and feelings of low energy.
Modest levels of physical activity can help maintain mobility, relieve muscle tension and provide a mental and emotional boost.
(read second point)..for instance some cancers can cause electrolyte imbalances. In these situations it is important to ensure adequate hydration and electrolyte balance .
Bone mets….by avoiding activities that involve jumping or twisting the hips.
(Read fourth point)

26. Physical activity recommendations for cancer survivors(cont’d)
Community programs that are designed for individuals beginning or resuming physical activity should be recommended as a starting point
As the level of activity improves, more challenging programs can be tolerated and additional benefits can be gained
Many community programs provide physical activity programs for people with special needs.
(Read first point)
(Read second point)

27. Alcohol Evidence that alcohol intake both +/- health effects
Individualize advice depending on cancer type, stage, risk for recurrence and comorbid conditions
Example of chemotherapeutic agent is Methotrexate

28. Alcohol (cont’d)
Evidence is substantial that alcohol may increase the risk of primary cancers of the head/neck, liver, and possibly breast and colon
There is less evidence related to alcohol and survival from cancer
Consistent evidence, general population modest alcohol intake associated with risk of CVD
If alcohol is consumed, cancer survivors should be encouraged to limit its use to no more than 1-2 drinks per day
Survivors with head/neck cancer or survivors who have previously had problems controlling their intake should avoid alcohol completely
One alcoholic drink= 5oz. of red or white wine
12 oz. of beer
1 oz of hard liquor
Alcohol and breast cancer..the mechanism for this effect is not known but may be related to the effects of alcohol on estrogen levels in women
Nutritional contribution of alcohol- people who are heavy drinkers may substitute alcohol for nutrient rich foods and this is obviously a concern for survivors who have increased needs.
Anti oxidant flavonoids in red wine? Effects on enhancing cancer survival are unknown, but these beneficial phytonutrients can be obtained from other fruit and vegetables

29. Dietary Supplements
Dietary supplements = vitamins, minerals, herbs, botanicals, amino acids and glandular products
In U.S. reported 25-80% of cancer survivors use!
Little evidence that any nutritional supplements can reproduce the apparent benefits of a diet high in fruits & vegetables
During cancer treatment, probable benefit to a multivitamin/mineral supplement
Dietary Supplements definition- includes nutrients, vitamins and minerals that are essential for human health as well as a wide variety of non essential nutrients such as phytochemicals, hormones and herbs.
(read first point)
(read second point)… as can the intake of high doses of herbal and botanical supplements.
One of the rationales for taking nutritional supplements stems from the observation that people who eat diets high in F/V (rich in vitamins and minerals) have a lower cancer risk. However (read third point)...

30. Dietary Supplements (cont’d)
DRI’s identify the UL for most health people
Only few studies epidemiological or clinical studies to confirm safety or efficacy of high doses of single vitamins and minerals - (beta carotene, zinc, antioxidants effects) in cancer survival/recurrence
Caution with high dose supplements -
beta-carotene!
(Read first point)
Beta Carotene- was actually found to increase lung cancer risk in heavy cigarette smokers
Folic Acid supplementation can alter the efficacy of methotrexate as a chemotherapeutic agent
Zinc high dose supplementation can depress immunity and increase risk of pneumonia
There is no good evidence that taking supplements of vitamins A,C, or E at doses above the recommended levels is associated with any clinical benefit
Read second point -The effects of illness and it’s treatment can weaken the body and the immune system. Use a balanced MVM once or twice per day to correct possible deficiencies.

31. Flax Seed and Fish Oils (omega 3 fa)
Associated with reduction of heart disease
Preclinical studies show conflicting results for omega 3/lignan effects on tumour growth and metastasis
Evidence is insufficient to recommend dietary supplementation of flax or fish oils to reduce risk of cancer recurrence or to improve prognosis

32. Fish Oil Studies...
Nutritional supplements with added fish oils combined with Megace during treatment to promote weight gain and muscle protein and enhance appetite
Fish oils use in enhancing cancer therapy and lessening side effects

33. Flax Seed Studies
Looking at the different effects of flax on breast, prostate, colon and skin cancer
Results are too limited to make conclusions, more work needs to be done especially long term studies

34. Garlic
Studies on progress investigating cancer prevention, antibacterial, or antifungal effects of garlic - no conclusive evidence to date
Large doses potentially harmful - stomach pain, gas, vomiting, inhibition of platelet formation

35. Ginger
Has antinausea properties and is useful in management of motion sickness, when nausea is triggered by a local effect (I.e. acts on stomach)
Chemotherapy induced nausea is CNS stimulated response and therefore often requires specific medication to block/prevent stimulation of the emetic response
Taste and aroma of ginger may be calming
Large doses of ginger have been shown to have antiplatelet activity

36. Teas
Epidemiologic evidence mixed regarding cancer risk amongst black or green tea drinkers
Tea contain high levels of catechins and polyphenols known to affect cancer cell growth in vitro
Very little research has been done on the effects of tea consumption among cancer survivors
Moderate amounts of green or black tea can be considered safe

37. Questions?

38. BCCA NUTRITIONISTS Andrea Corwin Shirley Hobenshield Chris Ko
Shelly Monkman
Danielle Moreau
Charitini Orphanidou
Satnam Sekhon
Cheri Van Patten