Presentation on theme: "Nutrition and Prevention of Cancer Recurrence"— Presentation transcript:
1Nutrition and Prevention of Cancer Recurrence Andréa Fimrite, RDNAngie Bowman, RDNBCCA Nutrition Consultants
2ObjectivesRecognize the special nutritional needs of cancer survivors during active cancer treatmentAdvise cancer survivors about nutrition and physical activity during the recovery phase and beyondControversial nutritional issues facing cancer survivorsDiscuss dietary and physical activity strategies that might influence cancer recurrences.Nutritional issues such as supplements, high dose vitamins, complementary and alternative nutritional methods, etc.
3Cancer Survivor Anyone who has been diagnosed with cancer DIAGNOSIS REST OF LIFE
4Challenges of Cancer Survivors Highly motivated to seek information about diet and lifestyle changesOften receive conflicting dietary adviceClaims abound on the use of dietary alternativesCurrently there are many gaps and inconsistencies in the scientific evidenceBut 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, internetor herbal supplements as alternatives to standard therapywhen there is ample scientific evidence on an issue choices can be easy but when we don’t have good evidence choices are difficultthe 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
5ACS’ Guidelines on Nutrition and Physical Activity for Cancer Prevention (handout)similar to those recommended by other agencies interested in dietary prevention of chronic diseasesshould be regarded as the basis for a healthy diet in cancer survivors with no apparent nutrition problemsspecial 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 preventionThe goal of these prevention guidelines is to reduce cancer incidenceWe all know that adequate dietary intake can improve the nutritional status of nearly all cancer survivorsThere 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)
6Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide to Informed ChoicesPublished in CA Cancer Journal for Clinicians, Volume 53, Number 5, September/October 2003Working group looked at a wide range of issues and choices about foods, physical activity, nutritional supplements and nutritional complementary and alternative therapiesNOT a comprehensive review on the effects of nutrition & physical activity in cancer patientsWorking group of 15 members 5 RD, 1 MD, 6 PhD (Lawrence Kushi), 1 MEd, 1 MS RN, 2 MPH and 2 cancer survivorsIt 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.
7NOT a specific set of guidelines or recommendations Assumes the patient is already receiving appropriate medical careA set of suggestions based on both scientific evidence and important practical issues to help patients make informed choices on self care strategiesAssumes…. 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
8The Phases of Cancer Survival Phase 1: Active TreatmentPhase 2: Recovery from TreatmentPhase 3: Preventing Cancer Recurrence, Second Primary Cancers and Nutrition-Related DiseasePhase 4: Living with Advanced CancerNutritional Issues During the Phases of Cancer SurvivalPhase 1: surgery, radiation therapy, chemotherapy,Phase 2: recovery phase in which the body needs to be restoredPhase3: Health Maintenance Phase to prevent both cancer recurrence, second primary tumours and other preventable diseasesPhase 4: Living with advanced cancerSurvivors 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.
9Phase 1: Nutritional Issues During Active Treatment Energy balance is the most important goalEnergy intakeEnergy expenditureNutritional supplements ??Energy intakethe need for caloric intake is usually increased during cancer treatmentsnausea, 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 Expenditurecancer treatment can cause fatiquelight 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 reductionNutritional Supplementsuse of nutritional products such as Boost, Ensure etc can be helpful on a temporary basis to assist with intake of calories and nutrientsuse 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 damageNo 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.
10Phase 2: Nutritional Issues After Treatment is Completed Most important goal Rebuild muscle strength and correct problemsAdequate food intakePhysical activityRecovery from TreatmentAfter treatment the nutrition and physical activity plan should help rebuild muscle strength and correct problems such as anemia or impaired organ functioningAdequate food intake and physical activity are crucial to recoveryAdequate food intakeNeed 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 deficienciesPhysical Activityrequired to rebuild muscle strengthrefer patients with treatment related complications or other disabilities to appropriate health care provider
11Phase 3: Preventing Cancer Recurrence, Second Primary Cancers and Nutrition Related Disease Limited data on nutritional factors that influence cancer recurrenceReasonable to recommend cancer survivors follow guidelines for cancer preventionBreast cancer recurrence- risk increased by obesity and ?diets low in fruits/vegetables and ?high in fatProstate cancer recurrence- risk may be increased by high saturated fat intake and reduced by micronutrient supplementation(SELECT Trial)Phase 3very little research on nutritional influences of cancer recurrenceIn 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.
12Phase 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 cancerAdapt food choices and eating patterns to meet changing needsEffective management of symptoms and side effectsLiving with Advanced CancerAlthough advanced cancer is often accompanied by substantial weight loss, malnutrition and weight loss are not inevitableEffective 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.
13Specific Nutritional Issues for Cancer Survivors Physical ActivityAlcoholDietary SupplementsFlaxseedGarlicGingerTeasFood SafetyCaloric IntakeBody Weight ChangesDietary FatsCarbohydrates and ProteinFruits and Vegetables
14Food SafetyVery important for patients undergoing immunosuppressive cancer treatmentsPatients 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”
15Caloric IntakePast 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 therapyCaloric Intake….This theory is now known to be wrongResearch 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.
16Body Weight ChangesIntentional weight loss during cancer treatment is not recommendedSome cancer survivors may gain weight during and after treatmentsDuring treatment, a healthy eating plan that meets but does not exceed caloric needs (along with physical activity) is advisableHealthy weight loss is best initiated after the recovery phaseObesity is associated with increased risk and poorer prognosis of breast and ?colon cancersBody Weight ChangesIntentional 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)
17Dietary FatsCurrent evidence indicates total fat NOT important cause of cancersType of fat are associated with cancer and heart disease risk:saturated fats riskmonounsaturated, omega risk
18Dietary 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 diets2 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 StudyWHEL Women’s Healthy Eating and Living StudyIt 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
19Carbohydrates and Protein Carbohydrates rich in essentail nutritients, pyhtochemicals and fibre - whole grains, vegetables, legumes and fruitProtein choices low in saturated fat, 10% of intake (but higher in elderly)
20Fruits and VegetablesMay be associated with lower incidence of colorectal, lung, oral, esophageal, and stomach cancersFew studies have examined F/V benefits for improving cancer survivalWHEL StudyBenefits of eating F/V might be much greater than are the effects of any vitamin they containRecommend at least 5 servings of F/V each day - with emphasis on vegWHEL 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 riskVegetables 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 vegetables1/2 cup cooked or chopped or juice1/4 cup dried1 piece of fresh fruit
21Physical ActivityRegular physical activity is associated with reduced risk of colorectal cancer, CHD, osteoporosis & DMThe impact on the prognosis of people with cancer is less clearRegular physical activity….and may be beneficial for the prevention of other cancers as well including breast cancer.
22Physical Activity (cont’d) Activity levels tend to decrease after cancer diagnosis and treatmentVery few studies have looked at the effect of exercise on prevention of cancer recurrence or disease progressionStudies with survivors have shown that regular exercise can…After diagnosis and during treatment peoples’ lifestyle patterns changeBCCA study launched recently looking at the effect of different types of exercise on women receiving treatment for breast cancer.
23Benefits of Moderate Regular Physical Activity for Cancer Survivors reduce anxietyreduce depressionimprove moodboost self esteemreduce symptoms of fatigue,beneficial effects on heart rate, lean body mass and respiratory capacityRead the slide contentsThus consistent with other recommendations regarding physical activity, cancer survivors and their family members should be encouraged to engage in moderate regular physical activity.
24Physical activity recommendations for cancer survivors Moderate regular physical activity on most if not all days of the weekBefore beginning any exercise program, cancer survivors should undergo a complete health assessment to develop an individualized plan that maximizes benefits while reducing risks of injuryRead first pointModerate 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)
25Physical 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 programSurvivors with metastasis to the bone or bone loss due to therapy should be careful to prevent bone fracturesSurvivors with chemo induced neuropathy that effects their balance should choose activities that avoid the risk of fallsRead 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)
26Physical 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 pointAs the level of activity improves, more challenging programs can be tolerated and additional benefits can be gainedMany community programs provide physical activity programs for people with special needs.(Read first point)(Read second point)
27Alcohol Evidence that alcohol intake both +/- health effects Individualize advice depending on cancer type, stage, risk for recurrence and comorbid conditionsExample of chemotherapeutic agent is Methotrexate
28Alcohol (cont’d)Evidence is substantial that alcohol may increase the risk of primary cancers of the head/neck, liver, and possibly breast and colonThere is less evidence related to alcohol and survival from cancerConsistent evidence, general population modest alcohol intake associated with risk of CVDIf alcohol is consumed, cancer survivors should be encouraged to limit its use to no more than 1-2 drinks per daySurvivors with head/neck cancer or survivors who have previously had problems controlling their intake should avoid alcohol completelyOne alcoholic drink= 5oz. of red or white wine12 oz. of beer1 oz of hard liquorAlcohol and breast cancer..the mechanism for this effect is not known but may be related to the effects of alcohol on estrogen levels in womenNutritional 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
29Dietary SupplementsDietary supplements = vitamins, minerals, herbs, botanicals, amino acids and glandular productsIn 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 & vegetablesDuring cancer treatment, probable benefit to a multivitamin/mineral supplementDietary 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)...
30Dietary Supplements (cont’d) DRI’s identify the UL for most health peopleOnly 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/recurrenceCaution with high dose supplements -beta-carotene!(Read first point)Beta Carotene- was actually found to increase lung cancer risk in heavy cigarette smokersFolic Acid supplementation can alter the efficacy of methotrexate as a chemotherapeutic agentZinc high dose supplementation can depress immunity and increase risk of pneumoniaThere is no good evidence that taking supplements of vitamins A,C, or E at doses above the recommended levels is associated with any clinical benefitRead 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.
31Flax Seed and Fish Oils (omega 3 fa) Associated with reduction of heart diseasePreclinical studies show conflicting results for omega 3/lignan effects on tumour growth and metastasisEvidence is insufficient to recommend dietary supplementation of flax or fish oils to reduce risk of cancer recurrence or to improve prognosis
32Fish Oil Studies...Nutritional supplements with added fish oils combined with Megace during treatment to promote weight gain and muscle protein and enhance appetiteFish oils use in enhancing cancer therapy and lessening side effects
33Flax Seed StudiesLooking at the different effects of flax on breast, prostate, colon and skin cancerResults are too limited to make conclusions, more work needs to be done especially long term studies
34GarlicStudies on progress investigating cancer prevention, antibacterial, or antifungal effects of garlic - no conclusive evidence to dateLarge doses potentially harmful - stomach pain, gas, vomiting, inhibition of platelet formation
35GingerHas 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 responseTaste and aroma of ginger may be calmingLarge doses of ginger have been shown to have antiplatelet activity
36TeasEpidemiologic evidence mixed regarding cancer risk amongst black or green tea drinkersTea contain high levels of catechins and polyphenols known to affect cancer cell growth in vitroVery little research has been done on the effects of tea consumption among cancer survivorsModerate amounts of green or black tea can be considered safe