Dietary and physical activity recommendations for cancer survivors

Andrea Holmes (biography and disclosures) Disclosures: Andrea Holmes works for BC Ministry of Health, HealthLink BC. Mitigating Statement: HealthLink BC is the province’s non-emergency health information and advice service. Residents of British Columbia can call 8-1-1 to speak with a health service navigator, nurse, dietitian, pharmacist or exercise professional. HealthLink BC dietitians and exercise professional provide free and personalized advice, and answer food, nutrition and activity questions. Referrals are not required to access HealthLink BC services. Health care providers can refer their clients to our programs and services if needed.

What frequently asked question I have noticed:

Breast and prostate cancer survivors want to know what to eat to prevent cancer from coming back.

Most people eat several times a day with some control over what and how much they eat, making diet an appealing focus for patients who want to improve their health after completing cancer treatments.  Yet, eating well is difficult.  Some cancer survivors are unable to separate the truth about healthy eating from the misinformation and many struggle to implement lasting dietary change. A cancer diagnosis is often described as a “teachable moment,” a time when an individual is open and motivated to make positive changes.¹ As primary care practitioners, physicians are optimally positioned to help patients turn this opportunity into action.

Data that answers this question:

Growing evidence links diet to breast and prostate cancer survivorship. The 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Breast Cancer Survivors report concluded lower all-cause mortality is positively associated with eating patterns that emphasize dietary fibre, soy foods, lower total and saturated fat intakes, along with maintaining a healthy body weight and being physically active.² For prostate cancer survivors, observational research suggests a higher intake of tomato based foods and cruciferous vegetables is linked to benefits, while excess body weight at the time of the diagnosis, or unintended excess weight gain after diagnosis and selenium supplementation may negatively impact survivorship.^3-5 Among both breast and prostate cancer survivors an overall healthy diet is positively associated with lower all-cause mortality.^6-8   A healthy diet was defined as one rich in vegetables, fruits, whole grains, and legumes and low in refined grains, processed meats, red meats and high fat dairy products.

Of the potential links studied, the evidence between breast cancer survival and body weight is the most consistent and promising. Randomized controlled trials (RCTs) in overweight breast cancer survivors examining diet alone or in combination with exercise to produce modest weight loss (5% of body weight) resulted in improvements in biomarkers associated with cancer growth (insulin, estrogen, as well as inflammatory markers). This suggests a biologically plausible mechanism by which intentional weight loss can positively impact prognosis.^9-10  RCTs designed to test the impact of intentional weight loss with cancer specific survival as an endpoint are in progress.¹⁰

While it is not clear whether dietary change will impact cancer progression or recurrence, there are other significant reasons for patients to focus on their eating patterns. More than 80% of female breast cancers and about 75% of prostate cancers are diagnosed at an early stage.¹¹ With high survival rates of 87% and 95% at 5 years respectively,¹¹ more people are living long enough to develop new primary cancers or other chronic health conditions. In Canada, cardiovascular disease (CVD) is the second leading cause of death after cancer, accounting for 25% of all deaths¹² and is a leading cause of death in individuals treated for cancer.¹³ CVD and cancer share multiple risk factors (including unhealthy diet, obesity and lack of physical activity),^19-20,33 and coupled with the cardiotoxic potential of cancer treatments,^19-20 calls attention to the importance of CVD as a health consideration for cancer survivors.³²

Overweight and obesity are risk factors for 12 types of cancers (including breast and prostate),¹⁴ CVD, and type 2 diabetes. An estimated 60% of Canadians have overweight and obesity,¹⁵  and this includes many breast and prostate cancer survivors at the time of diagnosis.¹⁶  Furthermore, breast and prostate treatment is commonly accompanied by weight gain and changes in body composition, characterized by increased adiposity and decreased lean mass.^16-17 Sarcopenic obesity in breast cancer survivors is linked to higher overall mortality.¹⁸ Healthy diet and physical activity, lifestyle factors which have been associated with better health in cancer survivors,²¹ are important for achieving and maintaining a healthier body weight, for decreasing risk of new cancer, and for preventing and managing CVD risk factors.²²  

The American Society for Clinical Oncology (ASCO) recommends physicians have conversations with their patients on the benefits of weight loss if needed, the potential for weight gain with cancer treatments, and the positive impact of physical activity and healthy eating patterns on long-term health.¹⁴

What I recommend (practice tips):

How should one respond to the patient who asks, “What should I be eating?” While cancer survivors can have unique health needs, the WCRF/AICR offers eating guidelines for cancer survivors in their Cancer Prevention Recommendations.² Similar guidance is provided  in the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors,²³ the ASCO endorsed guidelines for breast²⁴ and prostate¹⁷ cancer survivors, and by the National Comprehensive Cancer Network.²⁶ The key dietary recommendations include:

1. Eating wholegrains, vegetables, fruits and legumes
2. Limiting consumption of ‘fast foods’ and other processed foods high in fat, starches or sugars
3. Limiting red meats and processed meats
4. Limiting sugar sweetened drinks
5. Limiting alcohol
6. Not using dietary supplements for cancer prevention

HealthLink BC healthy eating resources for prostate and breast cancer survivors addressing these recommendations are available for your patients.

Since these key dietary recommendations are similar to healthy eating messages for more general audiences they are likely to be familiar to patients. Yet, many cancer survivors are not following these recommendations.²⁶ Why is there a disconnect between what is known about healthy eating and actual dietary practices?

In this era of unprecedented access to information through a range of media, coupled with inadequate heath literacy, patients are likely to feel confused or question their health care providers. As health professionals, we need to open up the conversation to address the “noise” that obscures healthy eating messages.

When a patient is ready to make dietary changes it is critical to offer behavior modification guidance, as education alone may not produce long-lasting changes. Clinical trials such as the ENERGY,²⁷ WHEL,²⁸ and MEAL²⁹ studies among others^30-31 have shown that when provided with adequate support, including dietitian delivered individualized recommendations to promote caloric restriction, counselling on behavior change strategies and physical activity, cancer survivors can make sustainable dietary changes. Yet, outside of the clinical trial setting patients are rarely provided with this same type and level of support.

Services are available for patients at HealthLink BC that bridge this gap. Cancer survivors can access a registered dietitian and a qualified exercise professional for education and behavior change counselling. We offer a client-centred interprofessional collaborative approach, assisting with the setting of priorities, establishing goals, and creating individualized action plans that support self-care and improved health literacy. Clients may choose one or several telepractice-based sessions over weeks to months to support a gradual shift to the healthiest eating and activity patterns they can achieve and maintain. A 16-session program is available for women who have completed treatment for early stage breast cancer and seek to make evidence informed behavioural changes.  Visit our website for information on how to refer your patients.

While there is great potential for positive dietary change to improve the overall health of cancer survivors, challenges also lie in supporting successful behaviour change. Starting the conversation with your patient is critical, so is connecting them to credible evidence informed and client centred resources.

Handouts for Patients

About Dietitian Services at HealthLink BC https://www.healthlinkbc.ca/dietitian-services

• HealthLink BC  Eating & Activity Program for After Breast Cancer
  • Education and support to change eating and physical activity habits for weight loss and improved health after treatment for early stage breast cancer
    • Learn about healthy eating and being physically active
    • Learn what makes it hard to eat healthy and be active
    • Learn how to change habits to healthier habits
    • Develop strategies to maintain long-term change
  • Individual telephone calls (16) with Registered Dietitian (RD) or Qualified Exercise Professional (QEP) over 6 months, weekly for 8 weeks, then 8 biweekly session; No cost
  • Developed with BC Cancer, curriculum based on Diabetes Prevention Program adapted for Canadian content and breast cancer survivors

• HealthLink BC Patient Resources: Printable handouts available at: www.healthlinkbc.ca (search for the title), by mail, call 8-1-1 or email
  • Breast Cancer: Healthy Eating After a Diagnosis https://www.healthlinkbc.ca/hlbc/files/healthyeating/pdf/breast-cancer-healthy-eating-after-diagnosis.pdf
  • Eating Guidelines for After a Prostate Cancer Diagnosis https://www.healthlinkbc.ca/hlbc/files/healthyeating/pdf/prostate-cancer-diagnosis.pdf
  • Cancer Prevention Eating Guidelines https://www.healthlinkbc.ca/hlbc/files/healthyeating/pdf/cancer-prevention-eating-guidelines.pdf
  • Plant-based Diet Guidelines https://www.healthlinkbc.ca/hlbc/files/healthyeating/pdf/plant-based-diet-guidelines.pdf
  • Lifestyle Steps for Healthy Weight Loss: Getting Started & Taking Action https://www.healthlinkbc.ca/healthy-eating/healthy-weight/nutrition
  • HealthLinkBC File #68e Food Sources of Calcium and Vitamin D  (available in 8 languages) https://www.healthlinkbc.ca/healthlinkbc-files/sources-calcium-vitamin-d
  • HealthLinkBC File #68k Vitamin and Mineral Supplements for Adults (available in 8 languages) https://www.healthlinkbc.ca/healthlinkbc-files/supplements-adults

• Other Provincial Nutrition Resources
  • BC Cancer Vancouver Centre: Call 604-877-6000 ext.2013
    • Healthy Lifestyle Sessions
      • Session 1: Cancer protective lifestyle & hot topics
      • Session 2: grocery store tour & cooking demo
    • Patient Education Day – March 2019
  • Prostate Cancer Supportive Care Program: Vancouver, Kelowna, Prince George, Victoria, Surrey
    • https://pcscprogram.ca/
    • Monthly Group Nutrition Education & One-On-One Sessions http://www.bccancer.bc.ca/our-services/services/nutrition#Group–classes

References

1. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol. 2005;23(24):5814-5830. DOI: 10.1200/JCO.2005.01.230. (View)
2. World Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: a Global Perspective. Continuous Update Project Expert Report 2018. Published 2018. Accessed May 24, 2018. (View)
3. Peisch SF, Van Blarigan EL, Chan JM, Stampfer MJ, Kenfield SA. Prostate cancer progression and mortality: a review of diet and lifestyle factors. World J Urol. 2017;35(6):867-874. DOI: 10.1007/s00345-016-1914-3. (View)
4. Chan JM, Van Blarigan EL, Kenfield SA. What should we tell prostate cancer patients about (secondary) prevention? Curr Opin Urol. 2014;24(3):318-323. DOI: 10.1097/MOU. (View)
5. Hackshaw-McGeagh LE, Perry RE, Leach VA, et al. A systematic review of dietary, nutritional, and physical activity interventions for the prevention of prostate cancer progression and mortality. Cancer Causes Control. 2015;26:1521-1550. DOI: 10.1007/s10552-015-0659-4. (View)
6. Yang M, Kenfield SA, Van Blarigan EL, et al. Dietary patterns after prostate cancer diagnosis in relation to disease-specific and total mortality. Cancer Prev Res (Phila). 2015;8:545-551. DOI: 10.1158/1940-6207.CAPR-14-0442. (View)
7. Terranova CO, Protani MM, Reeves MM. Overall dietary intake and prognosis after breast cancer: a systematic review. Nutr Cancer. 2018;70(2):153-163. DOI: 10.1080/01635581.2018.1412478. (Request with CPSBC or view with UBC)
8. Kenfield SA, DuPre N, Richman EL, Stampfer MJ, Chan JM, Giovannucci EL. Mediterranean diet and prostate cancer risk and mortality in the Health Professionals Follow-up Study. Eur Urol. 2014;65(5):887-894. DOI: 10.1016/j.eururo.2013.08.009. (View)
9. Picon-Ruiz M, Morata-Raifa C, Valle-Goffin JJ, Friedman ER, Singerland JM. Obesity and adverse breast cancer risk and outcome: mechanistic insights and strategies for intervention. CA Cancer J Clin. 2017;67:378-397. DOI: 10.3322/caac.21408. (View)
10. Demark-Wahnefried W, Schmitz KH, Alfano CM, et al. Weight management and physical activity throughout the cancer care continuum. CA Cancer J Clin. 2018;68:64-89. DOI: 10.3322/caac.21441. (View)
11. Canadian Cancer Society, Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics 2018: A 2018 special report on cancer incidence by stage. Published June 2018. Accessed August 30, 2018. (View)
12. Public Health Agency of Canada. Health Status of Canadians 2016: Report of the Chief Public Health Officer – How are we unhealthy? – Cancer. Updated December 15, 2016. Accessed November 13, 2018. (View)
13. Overholser LS, Callaway C. Preventive health in cancer survivors: what should we be recommending? J Natl Compr Canc Netw. 2018;16(10):1251-1258. DOI: 10.6004/jnccn.2018.7083. (Request with CPSBC or view with UBC)
14. Ligibel JA, Alfano CM, Courneya KS, et al. American Society of Clinical Oncology position statement on obesity and cancer. J Clin Oncol. 2014;32(31):3568-3574. DOI: 10.1200/JCO.2014.58.4680. (View)
15. Statistics Canada. Body composition of adults, 2012 to 2013. Updated Novemebr 27, 2015. Accessed September 10, 2018. (View)
16. Demark-Wahnefried W, Campbell K, Hayes SC. Weight management and its role in breast cancer rehabilitation. Cancer. 2012;118(8 suppl):2277-2287. DOI: 10.1002/cncr.27466. (View)
17. Skolarus TA, Wolf AM, Erb NL, et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin. 2014;64(4):225-249. DOI: 10.3322/caac.21234. (View)
18. Cann BJ, Cespedes Feliciano EM, Prado CM. Association of muscle and adiposity measured by computed tomography with survival in patients with nonmetastatic breast cancer. JAMA Oncol. 2018;4(6):798-804. DOI: 10.1001/jamaoncol.2018.0137. (Request with CPSBC or view with UBC)
19. Mehta LS, Watson KE, Barac A, et al. Cardiovascular disease and breast cancer: where these entities intersect: A scientific statement from the American Heart Association. Circulation. 2018;137(8):e30-e68. DOI: 10.1161/CIR.0000000000000556. (View with CPSBC or UBC)
20. Levine GN, D;Amico AV, Berger P, et al. Androgen-deprivation therapy in prostate cancer and cardiovascular risk: A science advisory from the American Heart Association, American Cancer Society, and American Urological Association. Circulation. 2010;121:833-840. DOI: 10.1161/CIRCULATIONAHA.109.192695. (View)
21. Hoedjes M, van Stanlen MM, Joe STA, et al. Toward the optimal strategy for sustained weight loss in overweight cancer survivors: a systematic review of the literature. J Cancer Surviv. 2017;11:360-385. DOI: 10.1007/s11764-016-0594-8. (View)
22. LeFevre ML, US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161(8):587-593. DOI: 10.7326/M14-1796. (View with CPSBC or UBC)
23. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):243-274. DOI: 10.3322/caac.21142. (View)
24. Runowicz CD, Leach Dr, Henry NL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. CA Cancer J Clin. 2016;66:43-73. DOI: 10.3322/caac.21319. (View)
25. Delinger CS, Sanft T, Baker KS, et al. Survivorship, Version 2.2018: NCCN Clinical Practice Guidelines in Oncology. 2018;15(10):1216-1247. J Natl Compr Canc Netw. DOI: 10.6004/jnccn.2018.0078. (View or view on org)
26. Basen-Engquist K, Algano CM, Maitin-Shepard M, et al. Moving Research into Practice: Physical Activity, Nutrition, and Weight Management for Cancer Patients and Survivors. National Academy of Medicine Perspectives. Published October 29, 2018. Accessed November 13, 2018. (View)
27. Rock CL, Flatt SW, Byers TE, et al. Results of the exercise and nutrition to enhance recovery and good health for you (ENERGY) trial: A behavioral weight loss intervention in overweight or obese breast cancer survivors. J Clin Oncol. 2015;33(28):3169-3176. DOI: 10.1200/JCO.2015.61.1095. (View)
28. Pierce JP, Natarajan L, Caan BJ, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women’s Healthy Eating and Living (WHEL) randomized trial. JAMA. 2007;298(3):289-298. DOI: 10.1001/jama.298.3.289. (View)
29. American Urological Association 2018 Annual Meeting Conferences Highlights: AUA 2018: The Men’s Eating and Living (MEAL) Study: A Randomized Clinical Trial of a Diet Intervention in Men on Active Surveillance for Prostate Cancer. Presented May 2018. Accessed November 13, 2018. (View)
30. Reeves MM, Terranova CO, Eakin EG, Demark-Wahnefried W. Weight loss intervention trials in women with breast cancer: a systematic review. Obes Rev. 2014;15:749-768. DOI: 10.1111/obr.12190. (Request with CPSBC or view with UBC)
31. Chlebowski RT, Reeves MM. Weight loss randomized intervention trials in female cancer survivors. J Clin Oncol. 2016;34:4238-4248. DOI: 10.1200/JCO.2016.69.4026. (View)
32. Abdel-Qadir H, Austin PC, Lee DS, et al. A population-based study of cardiovascular mortality following early-stage breast cancer. JAMA Cardiol. 2017;2(1):88-93. DOI: 10.1001/jamacardio.2016.3841. (Request with CPSBC or view with UBC)
33. Johnson CB, Davis MK, Law A, Sulpher J. Shared risk factors for cardiovascular disease and cancer: implications for preventive health and clinical care in oncology patients. Can J Cardiology. 2016;32:900-907. DOI: 10.1016/j.cjca.2016.04.008. (View with CPSBC or UBC)

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Dietary and physical activity recommendations for cancer survivors

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