Nutrition and Prevention of Cancer Recurrence

Andréa Fimrite, RDNAngie Bowman, RDN

BCCA Nutrition Consultants

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

Cancer Survivor

• Anyone who has been diagnosed with cancer

DIAGNOSIS REST OF LIFE

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

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…

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

• 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

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

Phase 1: Nutritional Issues During Active

Treatment

• Energy balance is the most important goal

• Energy intake

• Energy expenditure

• Nutritional supplements ??

Phase 2: Nutritional Issues After Treatment is

Completed

• Most important goal Rebuild muscle strength and correct problems

• Adequate food intake

• Physical activity

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 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

Specific Nutritional Issues for Cancer Survivors

• Food Safety• Caloric Intake• Body Weight

Changes• Dietary Fats• Carbohydrates and

Protein• Fruits and

Vegetables

• Physical Activity• Alcohol• Dietary

Supplements• Flaxseed• Garlic• Ginger• Teas

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)

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

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

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-3 risk

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)

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)

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

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

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…

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

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

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

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

Alcohol

• Evidence that alcohol intake both +/- health effects

• Individualize advice depending on cancer type, stage, risk for recurrence and comorbid conditions

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

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 (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!

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

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

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

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

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

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

Questions?

BCCA NUTRITIONISTS

• Andrea Corwin• Shirley Hobenshield• Chris Ko• Shelly Monkman• Danielle Moreau• Charitini Orphanidou • Satnam Sekhon • Cheri Van Patten