Diet, Lifestyle and Cancer Survival Marie Cantwell PhD, MPH Centre of Excellence for Public Health Queen’s University Belfast

Cancer – Chronic condition Dietary management of cancer patients is typically seen during the patients active treatment phase – weight loss, anorexia, cachexia, nausea, vomitting Long term survival- No advice for patients in terms of diet and lifestyle similar to cardiac rehab or dietary management of diabetes

Cancer Survivorship 62% 5 year survival over all adult cancers 60, 000 cancer survivors (diagnosed in the previous 5 years) in Ireland Increased risk for developing secondary cancers, other chronic diseases (CVD diabetes) Environmental factors such as diet and physical activity contribute Unhealthy behaviours tend to cluster in the population at large and specifically among cancer survivors Aziz; J Nutr 2002; 132: 3494S

Major Lifestyle Opportunities for Cancer Survivors Opportunity Prevalence Inadequate diet 75% Physical inactivity 54% Smoking 26% Overweight/obese 68% US-NHIS interview, ages 40-64 years Coups EJ & Ostroff JS Prev Med 2005; 40:702-11

Lifestyle Interventions in Breast Cancer Survivors Randomised Controlled Trials

WHEL Study (Women’s Healthy Eating and Living Study) RCT 3088 early stage breast cancer survivors (1995-2000); age 27-74 yrs Diet intervention counselling 5 vegetable servings 16 oz vegetable juice 3 servings fruit 30g fibre 15-20% calories fat Control (print material, 5 a day) Primary outcome: breast cancer events, death- no effect on disease free survival Secondary outcomes 1. Significant diet change 2. Significant change in selected biomarkers (carotenoids, oestradiol (total and bioavailable) 3. No significant weight change (I year) Pierce et al. JAMA 2007;278-289 Randomised

Women’s healthy Eating and Living Study (WHEL) Among survivors of early stage breast cancer, adoption of a diet that was very high in vegetables, fruit, fibre and low in fat did not reduce additional breast cancer events or mortality during a 7.3 year follow up period

WINS Risk of Recurrence low fat diet vs. control

Women’s Intervention Nutrition Study (WINS)- role of low fat diet Lifestyle intervention reducing dietary fat intake (target 20% E), with modest influence on body weight, may improve relapse-free survival of breast cancer 24% reduction in risk for recurrence; subset analyses suggest that this effect was even greater among women with oestrogen receptor-negative disease Chlebowski et al, 2006, J Natl Cancer Inst 98(24):1767-76.

Prospective Cohort Studies

Prospective Cohort Studies 1. Healthy Eating Activity and Lifestyle (HEAL) study (USA multicentre) n = 1182 2. Life after Cancer Epidemiology (LACE) USA multicentre n=2321 3. Shanghai Breast Cancer Survivors Study n= 5000 4. Pathways Northern California n= 4000 5. DietCompLyf Study –UK multicentre n= 3000

Weight management and Breast Cancer Survival

Change in BMI after diagnosis & association with recurrence & mortality Data from cohort of 5204 Breast Cancer Survivors in Nurses Health Study Relative Risk

Physical Activity and Breast cancer survival

Observational Cohort Study of Exercise After Diagnosis & Association with Recurrence & Mortality Data from Cohort of 2987 Breast Cancer Survivors in Nurse’s Health Study Relative Risk Level of Exercise (MET hrs/week) Holmes et al. JCO 20:2479-86, 2005

Ongoing work - Cancer Survivors

A randomised controlled trial to evaluate the efficacy of a 6 month dietary and physical activity intervention for prostate cancer patients receiving androgen deprivation therapy Androgen deprivation treatment (72%) Outcomes of interest: body composition, fatigue and QoL

Side effects of Androgen Deprivation Therapy Body composition- Decrease in lean body mass Decrease in muscle strength Decrease in bone mass and BMD Increase in fat mass Increase in total body weight Fatigue- Quality of Life- Others- Impotence Hot flashes Growth of breast tissue  Osteoporosis Anaemia

Ongoing Research DietCompLyf study - Role of diet, lifestyle and complementary therapies on breast cancer survival study Prospective Cohort Study: 50 centres 3000 breast cancer patients Collected FFQ, Food Diaries, Serum, Urine Women with histologically confirmed invasive primary breast cancer grade I to III May enter the study after their active treatment for primary breast cancer has finished, from 9 months to 15 months post diagnosis Age up to and including 75 years old

1. Change in food /nutrient intake after breast cancer diagnosis – Louiza Valentzis 2. Dietary patterns and breast cancer survival and quality of life in a cohort of breast cancer survivors- Sarah Brennan, Marice Lunny

Conclusions Adjuvant treatments for breast cancer lowers disease mortality 25-40% Weight maintenance after breast cancer may lower disease mortality ∼ 40% Moderate exercise after breast cancer may lower disease mortality ∼ 40-50%

Conclusions Advising weight maintenance and exercise after breast cancer may help our patients as much as standard treatments Important in our sedentary & obesigenic environment. Diagnosis of cancer –”Teachable moment” Often demonstrate an enhanced motivation to change their lifestyle behaviours Interventions that address multiple risk factors such as diet and physical activity in more diverse populations and for other cancer sites, are required

Thank you for your attention

American Cancer Society Achieve or maintain a healthy weight Choose foods that help maintain a healthy weight Eat a variety of foods with an emphasis on plant foods Eat 5 or more servings of a variety of vegetables & fruit each day Choose wholegrain in preference to processed (refined grains & sugars) Limit consumption of red meats especially those high in fat and processed If you drink alcoholic beverages limit consumption

Dietary Intake and body weight change during WINS and WHEL Intervention