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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay- per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email editorial.bmjopen@bmj.com http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from BMJ Open The impact of diet on mortality in cancer survivors: A systematic review of current epidemiological literature ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2016-014530 Article Type: Research Date Submitted by the Author: 03-Oct-2016 Complete List of Authors: Jochems, Sylvia; Maastricht University, NUTRIM; University of Birmingham, Cancer and Genomic Sciences Van Osch, Frits; Maastricht University, NUTRIM; University of Birmingham, Cancer and Genomic Sciences Bryan, Richard; University of Birmingham Wesselius, Anke; Maastricht University, NUTRIM van Schooten, Frederik; Maastricht University, Toxicology Cheng, Kar Keung; University of Birmingham, Department of Public Health and Epidemiology Zeegers, Maurice; University of Maastricht, NUTRIM School of Nutrition, Metabolism and Toxicology <b>Primary Subject http://bmjopen.bmj.com/ Epidemiology Heading</b>: Secondary Subject Heading: Oncology, Public health Keywords: cancer survivors, mortality, diet on September 26, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from Page 1 of 110 BMJ Open 1 2 3 The impact of diet on mortality in cancer survivors: 4 5 6 A systematic review of current epidemiological literature 7 8 9 10 11 12 Sylvia H.J. Jochems (1, 2), Frits H.M. van Osch (1, 2), Richard T. Bryan (1), Anke Wesselius 13 14 (2), Frederik J. van Schooten (2), K.K. Cheng (3), Maurice P. Zeegers (2, 4) 15 For peer review only 16 17 18 19 (1) Institute of Cancer and Genomic Sciences, University of Birmingham, B15 2TT 20 21 Birmingham, United Kingdom 22 23 (2) NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht 24 25 University, 6200 MD Maastricht, The Netherlands 26 27 (3) Institute of Applied Health Research, Public Health, Epidemiology and Biostatistics, 28 29 30 University of Birmingham, B15 2TT Birmingham, United Kingdom 31 32 (4) CAPHRI School for Public Health and Primary Care, Maastricht University, 6200 http://bmjopen.bmj.com/ 33 34 MD Maastricht, The Netherlands 35 36 37 38 39 40 on September 26, 2021 by guest. Protected copyright. 41 Corresponding author contact information: 42 43 Sylvia H.J. Jochems 44 45 s.jochems@maastrichtuniversity.nl 46 47 Institute of Cancer and Genomic Sciences, University of Birmingham, 48 49 50 B15 2TT Birmingham, United Kingdom 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from BMJ Open Page 2 of 110 1 2 3 ABSTRACT 4 5 Background: It is plausible that dietary changes after a successful cancer treatment could 6 7 improve prognosis. 8 9 10 Objective: To determine whether there is an association between dietary intake prior to or 11 12 after cancer diagnosis and mortality in cancer survivors. 13 14 Design: Systematic review - Medline, EMBASE and the Cochrane Library were searched 15 For peer review only 16 from their inception to June 2016. Additional studies were identified by hand-searching and 17 18 19 citation tracking. Two authors independently assessed study quality and extracted the data. 20 21 Setting: A wide range of settings within primary and secondary care in Asia, Europe and 22 23 North America. 24 25 Participants: Cancer survivors of common cancers with a ten-year survival rate of 50% or 26 27 more including bladder, bowel, breast, cervical, kidney, laryngeal, prostate, testicular and 28 29 30 uterine cancer, malignant melanoma, and (non-)Hodgkin lymphoma. 31 32 Primary and secondary outcome measures: Mortality (overall, cancer-specific, death from http://bmjopen.bmj.com/ 33 34 other causes) amongst cancer survivors. 35 36 Results: A total of 2 RCTs and 58 observational studies were identified. Results of this 37 38 39 systematic review suggest that adoption of a low-fat diet did not affect survival amongst 40 on September 26, 2021 by guest. Protected copyright. 41 breast cancer survivors. Alcohol consumption is unlikely to be associated with survival 42 43 amongst breast and bowel cancer survivors. In contrast, pre-diagnosis alcohol consumption 44 45 amongst non-Hodgkin lymphoma survivors seems to negatively impact their overall life 46 47 expectancy. Multivitamin supplement use and fruit and vegetable consumption do not appear 48 49 50 to improve breast cancer survivors’ mortality. Other studies addressing diet and mortality 51 52 amongst groups of cancer survivors were too limited or could not be identified. 53 54 Conclusions: Evidence as of yet is still too limited to determine whether dietary behaviour 55 56 prior to or after diagnosis could influence mortality in cancer survivors. Nonetheless, the 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from Page 3 of 110 BMJ Open 1 2 3 findings of this literature review together with results of well conducted reviews on dietary 4 5 constituents and micronutrients could guide future development of new guidelines for 6 7 nutrition in cancer survivorship. 8 9 10 11 12 Strengths and limitations of this study 13 14 - This systematic review provides an evaluation of studies addressing the relationship 15 For peer review only 16 between dietary intake and mortality amongst different groups of survivors 17 18 19 - Most included literature in this systematic review on diet and mortality in cancer 20 21 survivors has been obtained from results of observational studies 22 23 - By examining both food groups and dietary patterns, a translatable real-life condition 24 25 for clinical recommendations will be provided 26 27 28 29 30 31 32 http://bmjopen.bmj.com/ 33 34 35 36 37 38 39 40 on September 26, 2021 by guest. Protected copyright. 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-014530 on 19 February 2018. Downloaded from BMJ Open Page 4 of 110 1 2 3 INTRODUCTION 4 5 As cancer survival rates continue to improve, there is an increased need to identify 6 7 modifiable lifestyle factors amongst cancer survivors in order to improve long-term health. 8 9 1 10 Adherence to a diet rich in fruit and vegetables could decrease the risk of cancer and 11 2-4 12 increase overall life expectancy . The suggestion that epigenetic abbreviations occurring in 13 14 cancer could be altered by nutrients 5-7 makes it plausible that dietary changes after successful 15 For peer review only 16 cancer treatment could improve prognosis 8. 17 18 9 10 19 Although cancer survivors are susceptible to health promotion , a recent study has 20 11 21 indicated that survivors had poorer diets than individuals without cancer . A possible 22 23 explanation could be the difficulty for cancer survivors in adopting a healthier diet without 24 25 clear evidence that it will improve their survival 12-14. 26 27 While dietary guidelines have been well documented for the prevention of cancer 15, 28 29 30 many questions remain about nutrition after cancer treatment. In 2012, experts from the 31 32 American Institute for Cancer Research and World Cancer Research Fund concluded that http://bmjopen.bmj.com/ 33 34 there was still a lack of sufficient studies evaluating the role of foods and drinks in cancer 35 36 survivorship to establish adequate evidence-based nutritional guidelines for survivors. Hence, 37 38 39 cancer survivors are advised to follow the guidelines on nutrition for primary cancer 40 on September 26, 2021 by guest. Protected copyright. 15 16 41 prevention . Healthcare providers could play a substantial role in promoting healthier 42 43 dietary choices 17 if there was clear evidence regarding the advice they could provide. 44 45 We have conducted a structured summary and evaluation of randomised controlled 46 47 trials and observational studies addressing the relationship between the highest and the lowest 48 49 50 intake of dietary patterns and food groups and mortality amongst different groups of 51 18 52 survivors of common cancers with a ten-year survival rate of 50% or more to provide a 53 54 clear overview of the current status in nutritional research in this patient group.
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