ONCOLOGY NUTRITION

Diet and Cancer Treatment

Complementary Therapies

Palliative Care

Survivorship 


DIET AND CANCER PREVENTION

The history of B-carotene and cancers: from observational to intervention studies.  What lessons can be drawn for future research on polyphenols?1-3
Serge Hercberg

An important question being raised by nutritionists today is whether available scientific data support an important role for polyphenols in the prevention of pathologic conditions that represent an important public health burden, such as cardiovascular diseases, cancers, and osteoporosis.  More broadly, when can we consider scientific knowledge sufficient to allow specific public health implications and recommendations?  The history of the relationship between B-carotene and cancer illustrates the complexity of the research process leading to the demonstration of a causal relationship between nutritional factors and the prevention of disease.  The B-carotene story, which has developed in the past 30 y, is particularly significant and illustrative because of apparent controversies that are far from resolved.  This is an extremely interesting example from which many lessons can be learned.  For B-carotene, we need to collect sufficient information from experimental, clinical, and epidemiologic research before we support any specific public health recommendations.  The same principles must be applied to recommendations regarding polyphenols (in particular, which polyphenols, at which doses, to achieve which benefits for which populations).  If these questions are not answered, then we run the risk of needing to renounce recommendations regarding polyphenols in the future, damaging the credibility of nutritional recommendations for public health.

American Journal of Clinical Nutrition. 2005: 81(suppl):218S-22S.

Does diet affect breast cancer risk?
MD Holmes, WC Willett

The role of specific dietary factors in breast cancer causation is not completely resolved. Results from prospective studies do not support the concept that fat intake in middle life has a major relation to breast cancer risk. However, weight gain in middle life contributes substantially to breast cancer risk. Alcohol is the best established dietary risk factor, probably by increasing endogenous estrogen levels. Hypotheses relating diet during youth to risk decades later will be difficult to test. Nevertheless, available evidence is strong that breast cancer risk can be reduced by avoiding weight gain during adult years, and by limiting alcohol consumption.

Breast Cancer Research. 2004; 6(4);170-8.



Pilot study to explore effects of low-fat, flaxseed-supplemented diet on proliferation of benign prostatic epithelium and prostate-specific antigen
W Demark-Wahnefried, CN Robertson, PJ Walther, TJ Polascik, DF Paulson, RT Vollmer

OBJECTIVES: Dietary factors may influence the prostate and have an impact on prostatic growth and disease. A small number of studies have suggested that flaxseed-supplemented, fat-restricted diets may thwart prostate cancer growth in both animals and humans. Unknown, however, is the potential effect of such a diet on benign prostatic epithelium. METHODS: We undertook a pilot study to explore whether a flaxseed-supplemented, fat-restricted diet affects the proliferation rates in benign epithelium. We also explored the effects on circulating levels of prostate-specific antigen (PSA), total testosterone, and cholesterol. Fifteen men who were scheduled to undergo repeat prostate biopsy were instructed to follow a low-fat (less than 20% kcal), flaxseed-supplemented (30 g/day) diet and were provided with a supply of flaxseed to last throughout the 6-month intervention period. The PSA, total testosterone, and cholesterol levels were determined at baseline and at 6 months of follow-up. Reports from the original and repeat biopsies were compared, and proliferation (MIB-1) rates were quantified in the benign prostatic epithelium. RESULTS: Statistically significant decreases in PSA (8.47 +/- 3.82 to 5.72 +/- 3.16 ng/mL; P = 0.0002) and cholesterol (241.1 +/- 30.8 to 213.3 +/- 51.2 mg/dL; P = 0.012) were observed. No statistically significant change was seen in total testosterone (434.5 +/- 143.6 to 428.3 +/- 92.5 ng/dL). Although 6-month repeat biopsies were not performed in 2 cases because of PSA normalization, of the 13 men who underwent repeat biopsy, the proliferation rates in the benign epithelium decreased significantly from 0.022 +/- 0.027 at baseline to 0.007 +/- 0.014 at 6 months of follow-up (P = 0.0168). CONCLUSIONS: These pilot data suggest that a flaxseed-supplemented, fat-restricted diet may affect the biology of the prostate and associated biomarkers. A randomized controlled trial is needed to determine whether flaxseed supplementation, a low-fat diet, or a combination of the two regimens may be of use in controlling overall prostatic growth.

Urology. 2004 May; 63(5); 900-4.

Cancer Epidemiology Biomarkers & Prevention. 2004; 13(9); 1422-1435



Mediterranean diet and cancer
C La Vecchia

Objective: To analyse the role of various aspects of the Mediterranean diet in several common epithelial cancers, including digestive and selected non-digestive tract neoplasms.  Design: Systematic analysis of data from a series of case-control studies.  Setting: Northern Italy, between 1983 and 1998.  Subjects: Over 12,000 cases of 20 cancer sites and 10,000 controls.  Results: For most epithelial cancers, the risk decreased with increasing vegetable and fruit consumption, with relative risk (RR) between 0.3 and 0.7 for the highest versus the lower tertile.  For digestive tract cancers, population-attributable risks for low intake of vegetables anf fruit ranged between 15 and 40%.  A protective effect was observed also fro breast, female genital tract, urinary tract and a few other epithelial neoplasms.  A number of antioxidants and other micronutrients showed an inverse relationship with cancer risk, but the main components responsible for the favourable effect of a diet rich in vegetables and fruit remain undefined.  Fish tended to be another favourable diet indicator.  In contrast, subjects reporting frequent red meat intake showed RRs above unity for several common neoplasms.  Intake of whole-grain foods was related to a reduced risk of several types of cancer, particularly of the upper digestive tract.  This may be due to a favourable role of fibre, but the issue is still open to discussion.  In contrast, refined grain intake and, consequently, glycaemic load and glycaemic index were associated with increased risk of different types of cancer including, among others, breast and colorectal.  Conclusions: A low-risk diet for cancer in the Mediterranean would imply increasing the consumption of fruit and vegetables, as well as avoiding increasing the intakes of meat and refined carbohydrates.  Further, olive oil and other unsaturated fats, which are also typical aspects of the Mediterranean diet, should be preferred to saturated ones.

Public Health Nutrition. 2004; 7(7);965-968

Phytoestrogen Intake and Endometrial Cancer Risk
Pamela L. Horn-Ross, Esther M. John, Alison J. Canchola, Susan L. Stewart, Marion M. Lee
Affiliations of authors: P. L. Horn-Ross, E. M. John, A. J. Canchola, S. L. Stewart, Northern California Cancer Center, Union City, CA; M. M. Lee, Department of Epidemiology and Biostatistics, University of California, San Francisco.

Correspondence to: Pamela L. Horn-Ross, Ph.D., Northern California Cancer Center, 32960 Alvarado-Niles Rd., Suite 600, Union City, CA 94587 (e-mail: phornros@nccc.org).

Background: The development of endometrial cancer is largely related to prolonged exposure to unopposed estrogens. Phytoestrogens (i.e., weak estrogens found in plant foods) may have antiestrogenic effects. We evaluated the associations between dietary intake of seven specific compounds representing three classes of phytoestrogens (isoflavones, coumestans, and lignans) and the risk of endometrial cancer. Methods: In a case–control study from the greater San Francisco Bay Area, we collected dietary information from 500 African American, Latina, and white women aged 35–79 years who were diagnosed with endometrial cancer between 1996 and 1999 and from 470 age- and ethnicity-matched control women identified through random-digit dialing. Unconditional logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results: Isoflavone (OR = 0.59, 95% CI = 0.37 to 0.93 for the highest versus lowest quartile of exposure) and lignan (OR = 0.68, 95% CI = 0.44 to 1.1) consumptions were inversely related to the risk of endometrial cancer. These associations were slightly stronger in postmenopausal women (OR = 0.44, 95% CI = 0.26 to 0.77 and OR = 0.57, 95% CI = 0.34 to 0.97 for isoflavones and lignans, respectively). Obese postmenopausal women consuming relatively low amounts of phytoestrogens had the highest risk of endometrial cancer (OR = 6.9, 95% CI = 3.3 to 14.5 compared with non-obese postmenopausal women consuming relatively high amounts of isoflavones); however, the interaction between obesity and phytoestrogen intake was not statistically significant. Conclusion: Some phytoestrogenic compounds, at the levels consumed in the typical American-style diet, are associated with reduced risk of endometrial cancer.

Journal of the National Cancer Institute. August 6, 2003; 95(15); 1158-1164.


Prevention of lung cancer.
Stover DE
Division of General Medicine, Pulmonary Service Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021

This is a review of current concepts in lung cancer prevention including primary or smoking prevention, secondary prevention or smoking cessation and tertiary prevention or chemoprevention of lung cancer.

Comprehensive Therapy 2003 Spring; 29(1); 28-34.




DIET AND CANCER TREATMENT

Nutrition Support Improves Patient Outcomes, Treatment Tolerance and Admission Characteristics in Oesophageal Cancer
C  Odelli et at

Patients with oesophageal cancer undergoing chemoradiation with curative intent are at high risk of malnutrition and its complications, including increased side effects of treatment.  We have developed a nutrition pathway (NP), involving the early then periodic nutrition assessment of all patients presenting to the multidisciplinary oesophageal clinic who were planned to receive definitive chemoradiation.
Patients were assessed as a 'low', 'moderate' or 'severe' nutrition risk, and were provided with appropriate nutrition intervention ranging from preventative advice (low risk), oral nutrition support (moderate risk) to enteral feeding (severe risk).  Outcomes for 24 patients treated before implementation of the NP were compared with those of 24 patients treated using the NP. 
Patients managed using the NP experienced less weight loss (mean weight change -4.2 kg + 6.4 cf. -8.9 kg + 5.9, P=0.03), greater radiotherapy completion rates (92% cf. 50%, P = 0.001), +5.4 cf. 13.5 days + 14.1, P = 0.002).
Early and regular nutrition assessment/intervention and a multidisciplinary approach to nutrition care results in improved treatment tolerance for patients with oesophageal cancer receiving chemoradiation.

Clinical Oncology 2005 17: 639-645


Prevention and treatment of mucositis: a guide for nurses.
A Wohlschlaeger

Oral mucositis is a frequent and potentially severe complication that can occur following chemotherapy or irradiation.  Not only is mucositis painful but it can also result in impaired nutrition, infection, and treatment delays. Pediatric oncology nurses have a challenge to try to provide the most appropriate mouth care regimen specific to each individual patient. This review of the  literature can serve as a guide for helping to prevent and to treat mucositis. It provides information about the chemotherapeutic agents responsible for causing mucositis, many of the preventive approaches used to reduce the incidence of mucositis, and the current treatments available for active mucositis. It also discusses dietary recommendations and the role of the nurse caring for the patient with mucositis.

Journal of Pediatric Oncology Nursing.Sep-Oct 2004; 21(5);281-7.



Radiation-Induced Xerostomia: How Dry Is Your Patient?
Susan D. Bruce, RN, BSN, OCN

Most patients receiving radiation therapy to the head and neck region will experience some type of oral complication.  Xerostomia is one of the most severe symptoms that patients experience and may become a lifelong problem.  This article reviews normal salivary function, effects of radiation therapy on oral mucosa, impact of xerostomia on quality of life, and current treatment strategies used to manage this debilitating side effect.  Oncology nurses can have a significant impact on patient outcomes through diligent assessment and ongoing education regarding symptom management.

Clinical Journal of Oncology Nursing February 2004; 8(1); 61-67


The Antioxidant Conundrum in Cancer
Harold E. Seifried, Sharon S. McDonald, Darrell E. Anderson,
Peter Greenwald and John A. Milner
Division of Cancer Prevention, National Cancer Institute, NIH, Bethesda, Maryland 20852 (H.E.S., P.G., J.A.M.), and The Scientific Consulting Group, Inc., Gaithersburg, Maryland (S.S.M., D.E.A.)

The health-related effects of interactions between reactive oxygen species (ROS) and dietary antioxidants and the consequences of dietary antioxidant supplementation on human health are by no means clear.  Although ROS, normal byproducts of aerobic metabolism, are essential for various defense mechanisms in most cells, they can also cause oxidative damage to DNA, proteins, and lipids, resulting in enhanced disease risk.  Dietary antioxidants (e.g., vitamin E, vitamin C, ß-carotene, and selenium), as well as endogenous antioxidant mechanisms, can help maintain an appropriate balance between the desirable and undesirable cellular effects of ROS.  However, any health-related effects of interactions between dietary antioxidants and ROS likely depend on the health status of an individual and may also be influenced by genetic susceptibilities.  Clinical studies of antioxidant supplementation and changes in either oxidative status, disease risk, or disease outcome have been carried out in healthy individuals, populations at risk for certain diseases, and patients undergoing disease therapy.  The use of antioxidants during cancer therapy is currently a topic of heated debate because of an overall lack of clear research findings.  Some data suggest antioxidants can ameliorate toxic side effects of therapy without affecting treatment efficacy, whereas other data suggest antioxidants interfere with radiotherapy or chemotherapy.  Overall, examination of the evidence related to potential interactions between ROS and dietary antioxidants and effects on human health indicates that consuming dietary antioxidant supplements has pros and cons for any population and raises numerous questions, issues, and challenges that make this topic a fertile field for future research.  Overall, current knowledge makes it premature to generalize and make specific recommendations about antioxidant usage for those at high risk for cancer or undergoing treatment.

Cancer Research August 1, 2003; 63; 4295-4298 


 Dysphagia in patients with nasopharyngeal cancer after radiation therapy: a videofluoroscopic swallowing study.
Chang YC, Chen SY, Lui LT, Wang TG, Wang TC, Hsiao TY, Li YW, Lien IN. Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan, Republic of China.

This study evaluated swallowing status and the factors influencing swallowing in patients with nasopharyngeal carcinoma (NPC) after radiation therapy. During the period from July 1995 to June 1999, this cross-sectional study used videofluoroscopic swallowing study (VFSS) to evaluate 184 NPC patients who had completed radiation therapy [113 cases had completed radiation therapy < or = 12 months prior to evaluation (acute group) and 71 cases had completed radiation therapy > 12 months prior to evaluation (chronic group)]. The numbers of patients with tumors in each of the four stages were as follows: 24 in stage I, 45 in stage II, 41 in stage III, and 74 in stage IV. Swallowing abnormalities of the acute and chronic groups were correlated with multiple variables, including gender, age, the stage of the tumor, use of either neoadjuvant chemotherapy or radiosensitizer, and radiation modality. The analytical results indicated that the chronic group had a significantly higher proportion of swallowing abnormalities. Radiation modality, chemotherapy, and tumor staging were not significantly associated with swallowing dysfunction. Trend analysis revealed a progressive deterioration of most parameters of swallowing function in this group of patients. These findings indicate that swallowing function continues to deteriorate over time, even many years after radiation therapy in patients with NPC. Our results indicate that the time elapsed since radiation therapy correlates with the severity of dysphagia in NPC patients.

Dysphagia. 2003 Spring;18(2);135-43


Antioxidants and Cancer Therapy: A Systematic Review
Elena J. Ladas, Judith S. Jacobson, Deborah D. Kennedy, Katherine Teel, Aaron Fleischauer, and Kara M. Kelly

Purpose:  Many patients with cancer take antioxidant nutritional supplements during cancer treatment to alleviate treatment toxicities and to improve long-term outcomes, but little is known about the efficacy and safety of antioxidant use during cancer treatment.  We reviewed English-language manuscripts published in the biomedical literature, reporting the results of observational studies of antioxidant status and cancer outcomes and of intervention trials of antioxidants among patients receiving chemotherapy with or without radiation for various malignancies.  Methods:  We searched the Medline database and the bibliographies of the retrieved manuscripts, reviews, and books on antioxidants and cancer.  They retrieved studes are grouped by study design, malignancy, and end points.  Results:  More than 100 citations were retrieved; 52 met our criteria, 31 were observational studies, and 21 were intervention trials.  The studies varied in study design, timing of observation/intervention, intervention protocol, malignancy, and anticancer regimen.  Conclusion:  These inconsistencies preclude a definitive conclusion as to the effect of chemotherapy on antioxidants status in patients undergoing anticancer therapy.  However, our review suggests that total antioxidant status (measured by total radical antioxidant parameter) declines during cancer treatment.  Adequately powered trials or observational studies among patients with a specific cancer diagnosis receivng a specific treatment regimen are needed to address patients' and physicians' concerns regarding these associations.

Journal of Clinical Oncology. February 1, 2004; 22(3); 517-528




COMPLEMENTARY THERAPIES


Complementary and alternative therapies for cancer
Cassileth BR, Deng G
 
Many cancer patients use therapies promoted as literal alternatives to conventional medical care. Such "alternative" modalities are unproven or were studied and found worthless. These can be harmful. An even greater proportion of cancer patients uses "complementary" therapies along with mainstream cancer treatment. Most are helpful adjunctive approaches that control symptoms and enhance quality of life. This review describes alternative as well as complementary therapies commonly used today by cancer patients. Herbal remedies also are discussed. Evidence regarding the efficacy and safety of complementary/alternative medicine (CAM) is reviewed, and implications for oncologists are discussed. To encourage open communication of CAM use by patients, oncologists should be knowledgeable about the most popular remedies and know where to find reliable information for themselves and for their patients.

Oncologist. 2004; 9(1); 80-9

Advising Cancer Patients on Natural Health Products - A Structured Approach
Mario L de Lemos, Leela John, Lynne Nakashima, Robin K O'Brien,  and
Suzanne CM Taylor

Reprints: Mário L de Lemos PharmD MRPharmS, Provincial Systemic Therapy Program, British Columbia Cancer Agency, 600 W. 10th Ave., Vancouver BC V5Z 4E6 fax 604-708-2024, mdelemos@bccancer.bc.ca

Background: Many patients with cancer (45-60%) use natural health products (NHPs).  Pharmacists often find it difficult to advise these patients effectively.  Objective: To explore pharmacists' perceptions of the information needed to advise cancer patients on NHPs and develop a structured counseling approach.  Methods: A qualitative study was conducted using a focus group of pharmacists from an integrated cancer care organization in Canada.  The outcome measures were the definitions of and reasons for the information needed to advise patients on NHPs and a counseling approach using laymen terms.  Results: Eight focus group sessions took place, from which 6 categories of informatin emerged: role of the advisor, evaluations of evidence, assessment of efficacy, assessment of toxicity, monitoring parameters, and provision of a closure.  A patient counseling approach was developed based on this information.  Conclusions: The findings provided a description of and rationale for categories of information needed to advise cancer patients on NHPs.  A structured, step-by-step approach to counseling these patients was developed.  Key Words: cancer, complementary therapies, counseling, evidence-based medicine, patient education.

Annals of Pharmacotherapy. September 2004; 38;


Herbal Remedies in the United States: Potential Adverse Interactions With Anticancer Agents
Alex Sparreboom, Michael C. Cox, Milin R. Acharya, William D. Figg
From the Clinical Pharmacology Research Core, Medical Oncology Clinical Research Unit, Center for Cancer Research, National Cancer Institute, Bethesda, MD

Address reprint requests to Alex Sparreboom, PhD, Clinical Pharmacology Research Core, Medical Oncology Clinical Research Unit, National Cancer Institute, 9000 Rockville Pike, Bldg 10, Room 5A01, Bethesda, Maryland 20892; e-mail: sparreba@mail.nih.gov

Purpose: Interest in the use of herbal products has grown dramatically in the Western world. Recent estimates suggest an overall prevalence for herbal preparation use of 13% to 63% among cancer patients. With the narrow therapeutic range associated with most anticancer drugs, there is an increasing need for understanding possible adverse drug interactions in medical oncology.  Methods: In this article, a literature overview is provided of known or suspected interactions of the 15 best-selling herbs in the United States with conventional allopathic therapies for cancer.  Results: Herbs with the potential to significantly modulate the activity of drug-metabolizing enzymes (notably cytochrome P450 isozymes) and/or the drug transporter P-glycoprotein include garlic (Allium sativum), ginkgo (Ginkgo biloba), echinacea (Echinacea purpurea), ginseng (Panax ginseng), St John's wort (Hypericum perforatum), and kava (Piper methysticum). All of these products participate in potential pharmacokinetic interactions with anticancer drugs.  Conclusion: It is suggested that health care professionals and consumers should be aware of the potential for adverse interactions with these herbs, question their patients on their use of them, especially among patients whose disease is not responding to treatments as expected, and urge patients to avoid herbs that could confound their cancer care.

Journal of Clinical Oncology, Vol 22, No 12 (June 15), 2004: pp. 2489-2503

OBJECTIVE: To quantify change in intake of kilocalories, macronutrients, and fruit and vegetable servings after diagnosis of breast cancer, and to correlate these changes with subject characteristics and with self-reported global change in dietary patterns. DESIGN: Food frequency questionnaires were completed by women newly diagnosed with breast cancer shortly after diagnosis.  They were asked to recall intake 1 year before diagnosis. Two years after the initial interview another food frequency questionnaire was completed recalling intake during the previous year. At the 2-year follow-up interview women were also asked if they had changed their intake of fruit, vegetables, and fat since diagnosis. SUBJECTS/SETTING: Two hundred sixty New Mexico women with newly diagnosed breast cancer between July 1997 and March 1999. ANALYSIS: Two-year change scores for kilocalories, macronutrients, and fruit and vegetable servings were calculated and tested for difference from zero using paired t tests or Wilcoxon signed rank tests. Subjects' characteristics were related to change in kilocalories and linear regression was used to determine the relative importance of  these characteristics. Amount of change in fruit and vegetable servings and fat intake were calculated using food frequency data for women who reported increasing their intake of fruits and vegetables or decreasing their intake of fat after diagnosis. RESULTS: Small but significant decreases in intake of total energy and macronutrients were found 2 years postdiagnosis, with younger women reporting the greatest decreases. Fat as a percentage of diet increased over this period. There was no change in mean intake of fruit and vegetable servings. There is agreement between change as measured by food frequency questionnaire and change reported by more global questions on dietary habits; however, the amount of change measured was small. Women reporting an increase in fruit and vegetable intake postdiagnosis described an increase of one-quarter serving of fruit and one-third serving of vegetables per day. CONCLUSIONS: Breast cancer diagnosis results in modest dietary changes. Small changes in fruit and vegetable consumption suggest that efforts are needed to encourage increased consumption of these foods.

Journal of the American Dietetic Association. Oct 2004;104(10);1561-8.



Nutrition and Survival After the Diagnosis of Breast Cancer: A Review of the Evidence
Cheryl L. Rock, Wendy Demark-Wahnefried
Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA, and Department of Surgery, Duke University Medical Center, Durham, NC

Purpose: To review and summarize evidence from clinical and epidemiologic studies that have examined the relationship between nutritional factors, survival, and recurrence after the diagnosis of breast cancer.  Materials and methods: Relevant clinical and epidemiologic studies were identified through a MEDLINE search.  References of identified reports also were used to identify additional published articles for critical review.  Results: Several nutritional factors modify the progression of disease and prognosis after the diagnosis of breast cancer.  Overweight or obesity is associated with poorer prognosis in the majority of the studies that have examined this relationship.  Treatment-related weight gain also may influence disease-free survival, reduce quality of life, and increase risk for comorbid conditions.  Five of 12 studies that examined the relationship between dietary fat and survival found an inverse association, which was not evident on energy adjustment in most of these studies.  The majority of the studies that examined intakes of vegetables or nutrients provided by vegetables and fruit found an inverse relationship with survival.  Alcohol intake was not associated with survival in the majority of the studies that examined this relationship.  Conclusion: Much remains to be learned about the role of nutritional factors in survival after the diagnosis of breast cancer.  Healthy weight control with an emphasis on exercise to preserve or increase lean muscle mass and a diet that includes nutrient-rich vegetables can be recommended.  Diets that have adequate vegetables, fruit, whole grains, and low-fat dairy foods and that are low in saturated fat may help to lower overall disease risk in this population.

Journal of Clinical Oncology August 1, 2002; 20(15); 3302-3316


Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices
Jean K. Brown, PhD, RN, Tim Byers, MD, MPH, Colleen Doyle, MS, RD, Kerry S. Courneya, PhD, Wendy Demark-Wahnefried, PhD, RD, LDN, Lawrence H. Kushi, ScD, Anne McTiernan, MD, PhD, Cheryl L. Rock, PhD, RD, Noreen Aziz, MD, PhD, MPH, Abby S. Bloch, PhD, RD, Barbara Eldrige, MS, RD, Kathryn Hamilton, MA, RD, CDN, Carolyn Katzin, MSPH, CNS, Amy Koonce, Julie Main, Connie Mobley PhD, RD, Marion E. Morra, MA, ScD, Margaret S. Pierce, RN, MPH, MSN and Kimberly Andrews Sawyer

Cancer survivors are often highly motivated to seek information about food choices, physical activity, dietary supplement use, and complementary nutritional therapies to improve their treatment outcomes, quality of life, and survival.  To address these concerns, the Amercian Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer.  This report summarizes their findings and is intended to present health care providers with the best possible information on which to help cancer survivors and their families make informed choices related to nutrition and physical activity.  The report discusses nutrition and physical activity issues during the phases of cancer treatment and recovery, living after recovery from treatment, and living with advanced cancer, selected nutritional and physical activity issues such as body weight, food choices, and complementary and alternative nutritional options; and selected issues related to breast, colorectal, lung, prostate, head and neck, and upper gastrointestinal cancers.  In addition, handouts containing commonly asked questions and answers and a resource list are provided for survivors and families.  Tables that grade the scientific evidence for benefit versus harm related to nutrition and physical activity for breast, colorectal, lung, and prostate cancers are also included for this growing body of knowledge to provide guidance for informed decision making and to identify areas for future research.

CA A Cancer Journal for Clinicians September/October 2003; 53(5); 268-291


Waist-to-Hip Ratio and Breast Cancer Mortality
MJ Borugian, SB Sheps, C Kim-Sing, IA Olivotto, C Van Patten, BP Dunn, A Coldman, JD Potter, RPGallagher, & TG Hislop.

Reprint requests to Dr. Marilyn J. Borugian, Cancer Control Research Program, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6 (email: mborugia@bccancer.bc.ca)

High insulin levels have been associated with increased risk of breast cancer and poorer survival after a breast cancer diagnosis.  Waist-to-hip ratio (WHR) is a marker for insulin resistance and hyperinsulinemia.  In this study, the authors tested the hypothesis that elevated WHR is directly related to breast cancer mortality.  For indentification of modifiable factors affecting survival, data were collected on 603 patients with incident breast cancer who visited the Vancouver Cancer Centre of the British Columbia Cancer Agency (Vancouver, British Columbia, Canada) in 1991-1992, including body measurements and information on demographic, medical, reproductive, and dietary factors.  These patients were followed for up to 10 years.  Cox proportional hazards regression models were used to relate the variables to breast cancer mortality (n = 112).  After adjustment for age, body mass index, family history, estrogen receptor (ER) status, tumor stage at diagnosis, and systemic treatment (chemotherapy or tamoxifen), WHR was directly related to breast cancer mortality in postmenopausal women (for highest quartile vs. lowest, relative risk = 3.3, 95% confidence interval: 1.1, 10.4) but not in premenopausal women (relative risk = 1.2, 95% confidence interval: 0.4, 3.4).  Stratification according to ER status showed that the increased mortality was restricted to ER-positive postmenopausal women.  Elevated WHR was confirmed as a predictor of breast cancer mortality, with menopausal status and ER status at diagnosis found to be important modifiers of that relation.

American Journal of Epidemiology 2003; 158(10); 963-968

Diet and Breast Cancer: Evidence That Extremes in Diet Are Associated With Poor Survival
Pamela J. Goodwin, Marguerite Ennis, Kathleen I. Pritchard, Jarley Koo, Maureen E. Trudeau, Nicky Hood
From the Department of Medicine, Department of Surgery, Division of Clinical Epidemiology, Samuel Lunenfeld Research Institute Mount Sinai Hospital, Toronto-Sunnybrook Regional Cancer Centre, St. Michael's Hospital, University of Toronto, Toronto, Canada.

Address reprint requests to Pamela J. Goodwin, MD, Mount Sinai Hospital, 1284-600 University Ave, Toronto, Ontario M5G 1X4, Canada; email: pgoodwin@mtsinai.on.ca.

Purpose: Diet has been postulated to influence breast cancer prognosis; however, existing evidence is weak and inconsistent. Previous studies have sought evidence of a linear relationship between diet and breast cancer outcomes. Because of a U-shaped association of body mass index (BMI) with survival in breast cancer, we hypothesized that a nonlinear association also existed for dietary variables.  Patients and Methods: Four hundred seventy-seven women with surgically resected T1 to T3, N0/1, M0 breast cancer completed the Block Food Frequency Questionnaire 9.3 ± 4.6 weeks (mean ± standard deviation) after diagnosis, reporting intake over the preceding 12 months. Data on tumor-related factors, treatment, and outcomes were obtained prospectively from medical records. A series of Cox models was performed, modeling the association of dietary factors with breast cancer survival linearly and quadratically, adjusting for total energy intake, tumor- and treatment-related variables, and BMI.  Results: Significant nonlinear survival associations were
found for protein, oleic acid, cholesterol, polyunsaturated-saturated fat ratio, and for percentage of calories from fat and percentage of calories from carbohydrates in multivariate models. The shape of the survival associations varied across nutrients. Hazard ratios for highest risk quintiles ranged from 2.1 to 6.5. For total fat, adjustment for BMI reduced the multivariate P value obtained from nonlinear Cox models from .05 to .10. No significant linear associations were identified.  Conclusion: The association of key dietary variables with breast cancer survival may be U-shaped rather than linear. Our data suggest that midrange intake of most major energy sources is associated with the most favorable outcomes, and extremes are associated with less favorable outcomes. This research was funded by the Canadian Breast Cancer Research Initiative (grants 6301, 9045, and 12093) and the Medical Research Council of Canada (currently Canadian Institutes of Health Research).

Journal of Clinical Oncology. July 2003; 21(13); 2500-2507


Diet and Breast Cancer: Can Dietary Factors Influence Survival?
Cheryl L. Rock

Breast cancer accounts for over one third of invasive cancers in women.  Earlier detection and improved initial treatments have resulted in an increasing number of women who have completed standard treatments but who remain at risk for breast cancer recurrence or early death.  Epidemiological studies have linked diet composition with prognosis, and many women attempt to modify their diets and improve nutritional status following diagnosis.  The hypothesis that dietary factors may reduce risk for secondary cancer events and increase survival in this population is currently under study in two large randomized clinical trials: the Women's Intervention Nutrition Study (WINS) and the Women's Healthy Eating and Living (WHEL) Study.  The WHEL Study is testing the effect of a diet high in vegetables, fruit, and fiber, and low in fat, on disease-free survival in women with early stage breast cancer.  Hypothesized mechanisms include effects of diet modification on gonadal hormones, retinoid-like activities of carotenoids, and other protective effects of biologically active dietary constituents.

Journal of Mammary Gland Biology and Neoplasia.  January 2003; 8(1); 119-132


Revised April 2005