New Nutrition and Exercise Guidelines for Cancer Survivors

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New Nutrition and Exercise Guidelines for Cancer Survivors CME/CE

News Author: Laurie Barclay, MD

CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: December 8, 2006; Valid for credit through December 8, 2007

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;

Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;

Nurses - 0.3 nursing contact hours (None of these credits is in the area of pharmacology)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

Physicians should only claim credit commensurate with the extent of their participation in the activity.

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December 8, 2006 — The American Cancer Society (ACS) has issued nutrition and physical activity guidelines for cancer survivors during phases of treatment and recovery and for others living with advanced cancer. The new recommendations appear in the November/December issue of CA: A Cancer Journal for Clinicians.

"Cancer survivors are often highly motivated to seek information about food choices, physical activity, and dietary supplement use to improve their treatment outcomes, quality of life, and survival," write Ted Gansler, MD, MBA, of the 2006 Nutrition, Physical Activity and Cancer Survivorship Advisory Committee, and colleagues. "To address these concerns, the 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 from which to help cancer survivors and their families make informed choices related to nutrition and physical activity."

More than 10 million Americans are cancer survivors, defined as anyone who has been diagnosed as having cancer, from the time of diagnosis through the rest of life. Topics covered in the new guidelines include nutrition and physical activity issues during the phases of cancer treatment and recovery, living after recovery from treatment, and living with advanced cancer; nutrition and physical activity issues including body weight, food choices, and food safety; issues related to specific cancer sites (breast, colorectal, hematologic, lung, prostate, head and neck, and upper gastrointestinal); and common questions about diet, physical activity, and surviving cancer.

These guidelines, intended for healthcare providers caring for cancer survivors as well as for direct use by survivors and their families, update the most recent recommendations published in 2003.

"It is important for both health care providers and cancer survivors to consider the nutritional and physical activity issues discussed in this report within the context of the individual survivor's overall medical and health situation," the authors write. "This report is not intended to imply that nutrition and physical activity are more important than other clinical or self-care approaches.... In writing these suggestions, we have assumed that survivors are receiving appropriate medical and supportive care and are seeking information on self-care strategies to provide further relief of symptoms and to enhance health and improve the quality of their lives."

For survivors at risk for unintentional weight loss, including those who are already malnourished or those who receive directed treatment to the gastrointestinal tract, it is crucial to maintain energy balance or prevent weight loss. Most cancer therapies, including surgery, radiation, and chemotherapy, can significantly affect nutritional needs, eating habits, and digestion.

Individualized nutritional therapies may include:

For survivors with decreased appetite, consuming smaller, more frequent meals without liquids can help increase food intake.

For survivors who cannot meet nutritional requirements through food alone, fortified and commercially prepared or homemade nutrient-dense beverages or foods may improve the energy and nutrient intake.

For survivors who are unable to meet their nutritional needs with these means, other means of short-term nutritional support may include pharmacotherapy, enteral nutrition via tube feeding, or intravenous parenteral nutrition. However, using dietary supplements, such as vitamins, minerals, and herbal preparations, during cancer treatment is still controversial. Folate may interfere with the efficacy of methotrexate, and antioxidants may prevent the cellular oxidative damage to cancer cells that are required for efficacy of radiotherapy and chemotherapy.

"Despite methodologic limitations and small sample sizes, existing evidence strongly suggests that exercise is not only safe and feasible during cancer treatment, but that it can also improve physical functioning and some aspects of quality of life," the authors write. "It is unknown if exercise has any effects on cancer treatment completion rates or on the efficacy of cancer treatments.... Persons receiving chemotherapy and radiation therapy who are already on an exercise program may need temporarily to exercise at a lower intensity and progress at a slower pace, but the principal goal should be to maintain activity as much as possible."

After completion of therapy, survivors require ongoing nutritional assessment and guidance. Although the ACS has established nutrition and physical activity guidelines for cancer prevention, there are insufficient data at present to support the reasonable assumption that following these guidelines would also decrease cancer recurrence or improve survival.

These guidelines include maintaining a healthy weight throughout life, balancing caloric intake with physical activity, avoiding excessive weight gain, adopting a physically active lifestyle, consuming a healthy diet emphasizing plant sources, limiting consumption of processed and red meats, and limiting consumption of alcoholic beverages to no more than one drink per day for women or 2 per day for men. The recommended amounts and type of fat, protein, and carbohydrate to reduce cardiovascular disease risk are also appropriate for cancer survivors.

Omega-3 fatty acids may have specific benefits for cancer survivors, including reducing cachexia, improving quality of life, and perhaps enhancing the effects of some forms of treatment. Adequate protein intake is essential during all stages of cancer treatment, recovery, and long-term survival. Whole grains and whole-grain food products are preferred to refined grains. Higher vegetables and fruit intake have been specifically associated with a reduced incidence of cancer at several sites, including the colorectum, stomach, lung, oral cavity, and esophagus.

The guidelines recommend following specific recommendations regarding food safety. Except in specific situations, use of supplements containing more than the recommended daily amounts is not recommended.

Resistance exercise may improve bone strength and decrease risk for osteoporosis, and stretching exercise may improve range of motion in cancer survivors with lymphedema. In general, exercise programs may reduce anxiety and depression, improve mood, boost self-esteem, and reduce fatigue.

"The benefits of eating a variety of vegetables and fruits probably exceed the health promoting effects of any individual constituents in these foods because the various vitamins, minerals, and other phytochemicals in these whole foods act in synergy," the authors conclude. "It is reasonable to recommend that cancer survivors adopt the general recommendations issued by the ACS for cancer prevention to eat at least five servings of a variety of vegetables and fruit each day. ... Colorful choices such as dark green and orange vegetables are typically good sources of nutrients and healthful phytochemicals."

CA Cancer J Clin. 2006;56:323-353.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

Identify nutritional issues in patients with cancer.

List recommendations for managing nutritional issues in patients with cancer.

Clinical Context

More than 10 million persons in the United States are cancer survivors, and 65% of Americans diagnosed with cancer now live more than 5 years with a need for informed recommendations on nutrition and lifestyle, and yet the advice given by healthcare professionals is often conflicting.

The current report by a panel of experts in nutrition, physical activity, and cancer convened by the ACS, based on current available evidence and updated from the 2003 report, has been prepared to guide healthcare professionals and patients about clinical practice recommendations for nutrition and lifestyle after a diagnosis of cancer. The sections address phases of survivorship, nutrition and physical activity, and selected cancer sites with specific recommendations. Even when evidence is incomplete, reasonable conclusions and recommendations are made based on noncancer studies to guide choices about body weight, foods, physical activity, and nutritional supplement use.

Study Highlights

At diagnosis and during cancer treatment, anorexia, early satiety, taste, smell, and gastrointestinal tract disturbances are most prevalent, with malnutrition and weight loss occurring in more than 50% of patients.

The goal is to prevent deficiencies, preserve lean body mass, maximize quality of life, and consider effects of radiation, surgery, and chemotherapy.

For cancer survivors, smaller, more frequent meals and intake of nutrient-dense foods can increase caloric intake.

Short-term measures, such as pharmacotherapy, enteral, or intravenous parenteral feeding, can be considered.

The American Society for Parenteral and Enteral Nutrition and the American Dietetic Association recommend using total parenteral nutrition selectively.

Maintenance of a healthy weight is recommended as obesity has been linked to increased cancer risk.

Exercise has been shown to be safe and can improve prognosis in breast and colorectal cancer.

In the Nurses Health Study, as little as 1 to 3 hours per week of moderate intensity exercise was associated with a 26% to 40% reduction in risk for recurrent, breast-cancer–specific, and all-cause mortality.

Patients who are immunocompromised should avoid public gyms until their white blood counts return to normal.

Those undergoing irradiation should avoid chronic exposure to chlorine in swimming pools.

Careful attention should be paid to balance to prevent falls.

For patients who are obese or overweight, slow weight loss (no more than 2 lbs per week) using a well-balanced diet and increased physical activity to achieve 5% to 10% weight loss can confer survival benefits.

A low-fat diet with avoidance of trans fatty acids (< 3% of total calories) and saturated fats (< 10% of daily calories) can improve survival for patients with breast and prostate cancer.

At least 5 servings of colorful fruits and vegetables are recommended daily and considered protective for cancers, including lung, oral, esophageal, stomach, and colon cancer.

Sugars do not contribute nutritional value and limiting sugar consumption is recommended.

Patients who may be immunosuppressed should avoid foods with pathogenic organisms and practice food safety guidelines.

The role of soy foods and supplements is uncertain, but soy is an excellent source of protein that can be recommended.

High doses of soy isoflavones as supplements are not recommended for those with estrogen-receptor–positive breast cancer.

There is no clear answer for whether antioxidants help or harm, and no more than 100% of the daily recommended dose should be taken.

No direct evidence has determined whether consuming a vegetarian diet is healthful or harmful and individuals should be guided by the nutritional content.

Alcohol intake advice should be tailored to individual survivors. Benefits relate to cardiovascular protection and are not specific for any cancers.

Survivors with oral mucositis should avoid alcohol, which can irritate the mucosa.

Cancer survivors should consume at least 8 cups of liquid daily.

The role of calcium, folate, and selenium in preventing polyp recurrence in colorectal cancer is uncertain.

Current evidence suggests that adherence to treatment and colonoscopic surveillance are the most important prognostic indicators.

Low microbial diets are recommended for transplant recipients.

High-dose beta-carotenes may increase risk for lung cancer.

Pearls for Practice

Malnutrition is the primary issue during cancer diagnosis and treatment, and exercise, healthy weight maintenance, and a balanced diet are key recommendations after treatment to prevent relapse and improve prognosis.

Nutritional supplements, such as soy isoflavones, beta-carotene, and antioxidants, should be used with caution in cancer survivors, and low microbial diets are recommended for immunocompromised and transplant patients.

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Target Audience

This article is intended for primary care clinicians, oncologists, palliative care specialists, and other specialists who care for patients with cancer.

Goal

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

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For Nurses