An American Cancer Society Guide for Informed Choices Downloaded from Colleen Doyle, MS, RD; Lawrence H

Downloaded from

Nutrition and Physical Activity During and After Cancer Treatment: An American caonline.amcancersoc.org Cancer Society Guide for Informed Choices Colleen Doyle, Lawrence H. Kushi, Tim Byers, Kerry S. Courneya, Wendy Demark-Wahnefried, Barbara Grant, Anne McTiernan, Cheryl L. Rock, Cyndi Thompson, Ted Gansler, Kimberly S. Andrews and for the 2006 Nutrition, Physical Activity and Cancer Survivorship Advisory Committee CA Cancer J Clin 2006;56;323-353 DOI: 10.3322/canjclin.56.6.323 by on August 5, 2009 (©American Cancer Society, Inc.)

This information is current as of August 5, 2009

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://caonline.amcancersoc.org/cgi/content/full/56/6/323

To subscribe to the print issue of CA: A Cancer Journal for Clinicians, go to (US individuals only): http://caonline.amcancersoc.org/subscriptions/

CA: A Cancer Journal for Clinicians is published six times per year for the American Cancer Society by Wiley-Blackwell. A bimonthly publication, it has been published continuously since November 1950. CA is owned, published, and trademarked by the American Cancer Society, 250 Williams Street NW, Atlanta GA 30303. (©American Cancer Society, Inc.) All rights reserved. Print ISSN: 0007-9235. Online ISSN: 1542-4863. CA Cancer J Clin 2006;56:323–353

Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices Downloaded from Colleen Doyle, MS, RD; Lawrence H. Kushi, ScD; Tim Byers, MD, MPH; Ms. Doyle is Director, Nutrition and Kerry S. Courneya, PhD; Wendy Demark-Wahnefried, PhD, RD, LDN; Barbara Grant, MS, Physical Activity, American Cancer Society, Atlanta, GA. RD; Anne McTiernan, MD, PhD; Cheryl L. Rock, PhD, RD; Cyndi Thompson, PhD; Dr. Kushi is Associate Director for Ted Gansler, MD, MBA; Kimberly S. Andrews; for The 2006 Nutrition, Physical Activity Etiology and Prevention Research, and Cancer Survivorship Advisory Committee Kaiser Permanente, Oakland, CA. Dr. Byers is Professor, Department caonline.amcancersoc.org of Preventive Medicine and Biometrics; and Deputy Director, University of ABSTRACT Cancer survivors are often highly motivated to seek information about food Colorado Cancer Center, Aurora, CO. choices, physical activity, and dietary supplement use to improve their treatment outcomes, Dr. Courneya is Professor and Can- quality of life, and survival. To address these concerns, the American Cancer Society (ACS) ada Research Chair in Physical Activity and Cancer, Faculty of Physical Edu- convened a group of experts in nutrition, physical activity, and cancer to evaluate the scientiﬁc cation, University of Alberta, Edmon- evidence and best clinical practices related to optimal nutrition and physical activity after the diag- ton, Alberta.

nosis of cancer. This report summarizes their ﬁndings and is intended to present health care Dr. Demark-Wahnefried is Pro- by on August 5, 2009 (©American Cancer Society, Inc.) fessor, School of Nursing and Depart- providers with the best possible information from which to help cancer survivors and their fam- ment of Surgery, Duke University ilies make informed choices related to nutrition and physical activity. The report discusses nutri- Medical Center, Durham, NC. tion and physical activity issues during the phases of cancer treatment and recovery, living after Ms. Grant is Oncology Nutritionist, Saint Alphonsus Regional Medical recovery from treatment, and living with advanced cancer; select nutrition and physical activ- Center, Cancer Care Center, Boise, ID. ity issues such as body weight, food choices, and food safety; issues related to select cancer Dr. McTiernan is Full Member, Fred sites; and common questions about diet, physical activity, and cancer survivorship. (CA Cancer Hutchinson Cancer Research Center, Cancer Prevention Research Program, J Clin 2006;56:323–353.) © American Cancer Society, Inc., 2006. Seattle, WA. Dr. Rock is Professor, Department of Family and Preventive Medicine, INTRODUCTION School of Medicine, University of California, San Diego, La Jolla, CA. 1 Over 10 million persons in the United States are cancer survivors. Anyone who Dr. Thompson is Assistant Professor, has been diagnosed with cancer, from the time of diagnosis through the rest of life, University of Arizona Department of is considered a cancer survivor. Many cancer survivors are highly motivated to seek Nutritional Sciences, Tucson, AZ. information about food choices, physical activity, dietary supplement use, and com- Dr. Gansler is Director of Medical plementary nutritional therapies to improve their response to treatment, speed recov- Content, Health Promotions, American Cancer Society, Atlanta, GA. ery, reduce risk of recurrence, and improve their quality of life.2 Ms. Andrews is Research Associate, Nutritional needs change for most persons during the phases of cancer survivor- Cancer Control Science, American ship. Although many cancer survivors live with active or advanced disease, a large and Cancer Society, Atlanta, GA. growing number live extended, cancer-free lives. Sixty-ﬁve percent of Americans diag- This article is available online at nosed with cancer now live more than 5 years.1 The need for informed lifestyle choices http://CAonline.AmCancerSoc.org for cancer survivors becomes particularly important as they look forward to successful completion of therapy and search for the best strategies to recover from treatment and improve their long-term outcomes. For long-term cancer survivors, an appropriate weight, a healthful diet, and a physically active lifestyle aimed at preventing recurrence, second primary cancers, and other chronic diseases should be a priority. For some, managing nutritional needs while living with advanced cancer becomes a particular challenge.

Volume 56 • Number 6 • November/December 2006 323 Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices

After receiving a diagnosis of cancer, survivors within the context of the individual survivor’s soon find there are few clear answers to even the overall medical and health situation. This report simplest questions, such as Should I change what is not intended to imply that nutrition and phys- I eat? Should I exercise more? Should I lose weight? ical activity are more important than other clin- Should I take dietary supplements? Cancer sur- ical or self-care approaches. For example, although vivors receive a wide range of advice from many we present nutritional suggestions for persons sources about foods they should eat, foods they with nausea or fatigue, we recognize that other should avoid, how they should exercise, and medical interventions may be more important

what types of supplements or herbal remedies in controlling these symptoms. In writing these Downloaded from they should take. Unfortunately, this advice is suggestions, we have assumed that survivors are often conflicting. receiving appropriate medical and supportive care and are seeking information on self-care strategies to provide further relief of symptoms OVERVIEW OF THE REPORT and to enhance health and improve the quality of their lives. caonline.amcancersoc.org To synthesize evidence-based research, the American Cancer Society (ACS) convened a NUTRITION AND PHYSICAL ACTIVITY ACROSS group of experts in nutrition, physical activity, THE CONTINUUM OF CANCER SURVIVORSHIP and cancer to evaluate the scientific evidence and best clinical practices related to nutrition The continuum of cancer survivorship in- and physical activity after the diagnosis of can- cludes treatment, recovery, living after recov- cer. This report summarizes their findings and ery, and, for some, living with advanced cancer. updates the most recent report published in Survivors in each of these phases have different by on August 5, 2009 (©American Cancer Society, Inc.) 2003.3 Although this report is intended for health needs and challenges with respect to nutrition care providers caring for cancer survivors, it can and physical activity. Both the characteristics of also be used directly by survivors and their fam- the cancer and therapeutic methods influence ilies. The underlying premise in creating this these needs. report is that, even when the scientific evidence is incomplete, reasonable conclusions can be made on several issues that can guide choices CANCER AND CANCER TREATMENT about body weight, foods, physical activity, and Nutrition During Cancer Treatment nutritional supplement use. This report presents information in four sec- Even before treatment begins, cancer can tions. The first section addresses nutrition and cause profound metabolic and physiological alter- physical activity issues across the phases of can- ations that can affect the nutritional needs for cer survivorship, including treatment, recovery, protein, carbohydrate, fat, vitamin, and miner- living after recovery from treatment, and living als.4 Symptoms such as anorexia, early satiety, with advanced cancer. The second section dis- changes in taste and smell, and disturbances of the cusses selected nutrition and physical activity gastrointestinal tract are common side effects of issues, including body weight, food choices, cancer treatment and can lead to inadequate alcohol, food safety, and physical activity. The nutrient intake and subsequent malnutrition.5,6 third section provides information regarding Substantial weight loss and poor nutritional sta- selected cancer sites (breast, colorectal, hema- tus have been documented in more than 50% tological, lung, prostate, head and neck, and of patients at the time of diagnosis, although the upper gastrointestinal). The fourth section in- prevalence of malnutrition and weight loss varies cludes common questions about diet, physical widely across cancer types.7,8 Maintaining energy activity, and cancer survivorship. balance or preventing weight loss is therefore It is important for both health care providers vital for survivors at risk for unintentional weight and cancer survivors to consider the nutritional loss, such as those who are already malnourished and physical activity issues discussed in this report or those who receive directed treatment to the

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TABLE 1 Suggestions for Helping Survivors Providing short-term individualized nutritional Locate Specialized Dietary Counseling support can improve appetite and dietary intake • Survivors should ask their oncologist for a referral to see a and decrease the toxicities associated with cancer 4 registered dietitian. treatments. Examples of individualized nutri- • If a dietitian does not work in the clinic or medical center tional therapies include the following: where they receive their cancer treatment and care, an • For survivors experiencing a reduced appetite, appointment with a dietitian associated with their primary care clinic can be arranged. consuming smaller, more frequent meals with- • Survivors and providers can also consult the American out liquids can help to increase food intake. Dietetic Association’s website [www.eatright.org], using the • For survivors who cannot meet their nutri- Downloaded from “Find a Nutrition Professional” feature and putting “Oncology Nutrition” in the expertise/specialty tab, or call the American tional needs through foods alone, fortified and Dietetic Association at 1-800-366-1655 to identify a dietitian commercially-prepared or homemade nutrient- in their area. dense beverages or foods may improve the intake of energy and nutrients. • For survivors who are unable to meet their gastrointestinal tract.9 Other patients begin the nutritional needs through these measures, caonline.amcancersoc.org cancer treatment process in a state of overweight other means of short-term nutritional sup- or obesity, and for some, weight gain can be a port may be needed, such as pharmacother- complication of treatment.10 Nutritional screen- apy, enteral nutrition via tube feeding, or ing and assessment for survivors should begin intravenous parenteral nutrition. while treatment is being planned and should The use of dietary supplements such as vita- focus on both the current nutritional status and mins, minerals, and herbal preparations during anticipated symptoms related to treatment that cancer treatment remains controversial. For exam- could affect nutritional status.11 ple, it may be counterproductive for survivors by on August 5, 2009 (©American Cancer Society, Inc.) All of the major modalities of cancer treat- to take folate supplements or to eat fortified food ment, including surgery, radiation, and chemother- products that contain high levels of folate when apy, can significantly impact nutritional needs, receiving methotrexate, a chemotherapy drug alter regular eating habits, and adversely affect that acts by interfering with folate metabolism.4 how the body digests, absorbs, and uses food.4,11 Many dietary supplements contain levels of anti- Commonly experienced symptoms of cancer oxidants (such as vitamins C and E) that exceed and side effects of treatment that may impact the amount recommended in the Dietary Refer- nutritional status include changes in taste or smell, ence Intakes for optimal health.19–22 At the pres- loss of appetite, nausea, vomiting, changes in ent time, most cancer experts advise against taking bowel habits, weight change, loss of lean mass higher doses of supplements with antioxidant and sarcopenia, pain, and fatigue.12–14 If these activity during treatment because antioxidants occur, usual food choices and eating patterns may could prevent the cellular oxidative damage to need to be temporarily adjusted to optimize cancer cells that is required for treatments such as intake and meet nutritional needs. radiotherapy and chemotherapy to be effective.23,24 During active cancer treatment, the overall In contrast, others have noted that the possible goals of nutritional care for survivors should be harm from antioxidants is only hypothetical and to prevent or reverse nutrient deficiencies, to that there may be a net benefit to help protect preserve lean body mass, to minimize nutrition- normal cells from the collateral damage associated related side effects (such as decreased appetite, with these therapies.25 Whether antioxidants or nausea, taste changes, or bowel changes), and to any other dietary supplements specifically are maximize quality of life. Recent studies confirm beneficial or harmful is a critical question with- the benefit of dietary counseling during cancer out a clear scientific answer at this time.26–29 treatment for improving outcomes, such as fewer Given this uncertainty, until more evidence is treatment-related symptoms, improved quality available that suggests more benefit than harm, of life, and better dietary intake.15–18 Suggestions it is prudent for cancer survivors receiving chemo- for finding an oncology nutrition expert to pro- therapy or radiation therapy to avoid exceeding vide dietary counseling are provided in Table 1. more than 100% of the daily value for antioxidant-

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type vitamins such as vitamins C and E during with bone disease or signiﬁcant impairments such the treatment phase.19–22 as arthritis or peripheral neuropathy, careful attention should be given to balance and safety to Exercise During Cancer Treatment reduce the risk for falls and injuries. The pres- An increasing number of studies have examined ence of a caregiver or exercise professional dur- the therapeutic value of exercise during primary ing exercise sessions can be helpful. If the disease cancer treatment.30–32 Most of these studies have or treatment necessitates periods of bed rest, then examined women with early-stage breast cancer reduced fitness and strength, as well as loss of lean

receiving adjuvant therapies (eg, chemotherapy, body mass, can be expected. Physical therapy Downloaded from radiotherapy) and persons with various cancers during bed rest is therefore advisable to main- immediately after bone marrow transplantation. tain strength and range of motion and to help to Despite methodologic limitations and small sam- counteract the fatigue and depression that are ple sizes, existing evidence strongly suggests that often experienced under those circumstances. exercise is not only safe and feasible during can- Some clinicians advise some survivors to wait to cer treatment, but that it can also improve phys- determine their physical response to chemother- caonline.amcancersoc.org ical functioning and some aspects of quality of apy before beginning an exercise program. life.30–33 It is unknown if exercise has any effects on cancer treatment completion rates or on the Recovery efﬁcacy of cancer treatments. However, one ani- After cancer therapy has been completed, the mal study reported that exercise did not interfere next phase of cancer survival is recovery. In this with the efﬁcacy of chemotherapy.34 Although phase, many survivors’ symptoms and side effects there is not a strong biological rationale for con- of treatment that impact nutritional and physi-

cerns about adverse effects of exercise during cal well-being begin to diminish and resolve. by on August 5, 2009 (©American Cancer Society, Inc.) treatment, research into this question is needed. Typically, survivors recover from the acute effects The decision regarding how to maintain or of their specific treatment within a few weeks when to initiate physical activity should be indi- after completing therapy, though in some vidualized to the survivor’s condition and per- instances, toxic effects of treatment may persist. sonal preferences. In some circumstances, a training In addition, late-occurring effects of treatment program to improve cardiopulmonary fitness may appear long after treatment has been com- before cancer treatments might aid recovery, pleted.37,38 Examples of continuing side effects although adequate research has not been done or complications of cancer treatment relevant in this area. Cross sectional research among men to nutritional status include persistent anorexia, who received radiation therapy for prostate can- changed sense of taste, inability to replenish lean cer, however, suggests that men who exercise body mass after completion of therapy, and per- routinely have signiﬁcantly decreased risk of erec- sistent diarrhea or constipation. tile dysfunction post-treatment.35 Likewise, resist- Survivors require ongoing nutritional assess- ance training programs may be helpful in ment and guidance in this phase of survival.13,14,39 hindering rapidly occurring adverse body com- For those who emerge from treatment under- position changes (ie, sarcopenic obesity and weight or who have compromised nutritional osteopenia) that may occur among some cancer status, continued supportive care, including patients who receive systemic therapy.36 Persons dietary counseling and pharmacotherapy (eg, receiving chemotherapy and radiation therapy drugs to relieve symptoms and stimulate who are already on an exercise program may need appetite), is helpful in the recovery process.15,40 temporarily to exercise at a lower intensity and After treatment, a program of regular physical progress at a slower pace, but the principal goal activity is essential to aid in the process of recov- should be to maintain activity as much as possi- ery and improve fitness. ble. For those who were sedentary before diagnosis, low-intensity activities such as stretching Living After Recovery and brief, slow walks should be adopted and During this phase, setting and achieving life- slowly advanced. For older persons and those long goals for an appropriate weight, a physically

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Convincing data exist that obesity is associ- TABLE 2 American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention ated with breast cancer recurrence, and evidence on obesity and prognosis is also accumulating for Maintain a healthy weight throughout life. other cancers.49–51 Therefore, achieving and main- • Balance caloric intake with physical activity. • Avoid excessive weight gain throughout the lifecycle. taining a healthy weight, as well as consuming a • Achieve and maintain a healthy weight if currently overweight nutrient-rich diet and maintaining a physically or obese. active lifestyle, are important to improve overall Adopt a physically active lifestyle. health and well-being and survival. • Adults: engage in at least 30 minutes of moderate-to- An increasing number of studies have exam- Downloaded from vigorous physical activity, above usual activities, on 5 or more days of the week. Forty-five to 60 minutes of intentional ined exercise during recovery and long-term 30–32 physical activity are preferable. survival after cancer treatment. Most research • Children and adolescents: engage in at least 60 minutes per has been conducted among women with breast day of moderate-to-vigorous physical activity at least 5 days cancer or those who have received bone mar- per week. row transplants. Exercise has been shown to

Consume a healthy diet, with an emphasis on plant sources. caonline.amcancersoc.org • Choose foods and beverages in amounts that help achieve improve cardiovascular ﬁtness, muscle strength, and maintain a healthy weight. body composition, fatigue, anxiety, depression, • Eat five or more servings of a variety of vegetables and fruits self-esteem, happiness, and several components each day. • Choose whole grains in preference to processed [refined] of quality of life (physical, functional, and emo- 30 grains. tional) in cancer survivors. A few recent cohort • Limit consumption of processed and red meats. studies have examined the association between If you drink alcoholic beverages, limit consumption. physical activity and cancer recurrence, cancer- • Drink no more than one drink per day for women or two per speciﬁc mortality, and all-cause mortality in can-

day for men. cer survivors.52–55 Data from almost 3,000 breast by on August 5, 2009 (©American Cancer Society, Inc.) cancer survivors in the Nurses’ Health Study active lifestyle, and a healthy diet are important showed that higher levels of post-treatment phys- to promote overall health, quality of life, and ical activity were associated with a 26% to 40% longevity.41 The ACS has established nutrition reduction in the risk of breast cancer recurrence, and physical activity guidelines for the preven- breast cancer-specific mortality, and all-cause tion of cancer (Table 2).42 Although it may seem mortality. The risk reduction was seen with as lit- reasonable to assume that following these guide- tle as 1 to 3 hours per week of moderate inten- lines would also favorably affect cancer recur- sity activity with further reductions for those rence or survival rates, few data are available to performing 3 to 5 hours per week.55 Similar directly support this assumption. In some instances, associations have been reported between phys- there is evidence for such a link, as with obesity ical activity and clinical outcomes in colorectal and breast cancer recurrence, but in many instances cancer survivors.52–54 Although preliminary, these the evidence linking food choices and physical data suggest that physical activity may be impor- activity to cancer recurrence and survival is lim- tant for reducing the risk of recurrence and ited or unclear. Although the scientiﬁc evidence extending survival for some cancer survivors. for advice on nutrition and physical activity after cancer is much less certain than for cancer pre- Living With Advanced Cancer vention, it is likely that following the ACS Guidelines on diet, nutrition, and cancer pre- Although some persons are cured or experi- vention may be helpful for reducing the risk of ence cancer as a controllable chronic disease, developing second cancers.42 It is also important others live with advanced cancer. For these per- to realize that, because persons who have been sons, a healthy diet and physical activity are impor- diagnosed with cancer may be at increased risk tant factors in establishing and maintaining a sense for other cancers and for cardiovascular disease, of well-being and enhancing quality of life. Al- diabetes, and osteoporosis, the guidelines estab- though advanced cancer may be accompanied lished to prevent those diseases are especially by substantial weight loss, it is not inevitable that important for cancer survivors.43–48 persons with cancer lose weight or experience

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malnutrition.4 Many persons with advanced can- ventions should focus on increasing food intake cer may need to adapt food choices and eating to achieve a positive energy balance and there- patterns to meet nutritional needs and to man- fore increase weight.59 Physical activity may be age symptoms and adverse effects such as pain, useful to the underweight survivor when tai- constipation, and loss of appetite. For persons lored to provide stress reduction and to increase with poor appetite, weight loss, or both, con- strength, but high levels of physical activity make vincing evidence exists that some medications weight gain more difficult.30 (eg, megestrol acetate) enhance appetite.56–59 In the United States, obesity is a problem of 66 Furthermore, using nonsteroidal anti-inflamma- epidemic proportions and is a well-established Downloaded from tory drugs or omega-3 fatty acid oral supple- risk factor for some of the most common can- ments may stabilize or improve nutritional status, cers.49 Increased body weight has been associated body weight, and functional status.60–63 with increased risk for cancers at several specific Additional nutritional support such as nutrient- sites, including the breast (postmenopausal), col- dense beverages can be provided for those who orectum, esophagus, liver, gallbladder, pancreas, cannot eat enough solid food to maintain energy kidney, uterus, and for advanced prostate can- caonline.amcancersoc.org intake. The use of tube feedings and total par- cer.49,67–70 Thus, many cancer survivors are over- enteral nutrition should be individualized with weight or obese at the time of diagnosis. Increasing clear recognition of the associated risks for com- evidence indicates that being overweight increases plications. Both the American Society for Par- the risk for recurrence and reduces the likelihood enteral and Enteral Nutrition and the American of survival for many cancers.10,50,68,71–74 Dietetic Association recommend that total par- For cancer survivors who are overweight or enteral nutrition should be used selectively and obese, modest weight loss (ie, a maximum of 2

with caution.64,65 pounds per week)75,76 can be encouraged during by on August 5, 2009 (©American Cancer Society, Inc.) In principle, some level of physical activity is treatment, as long as the treating oncologists desirable for persons with advanced cancer, but approve, weight loss is monitored closely, and there is limited research on exercise in such indi- weight loss does not interfere with treatment. viduals. Thus, the evidence of benefit from exer- Safe weight loss should be achieved through a cise for advanced cancer survivors is insufficient well-balanced diet that is reduced in energy den- to make specific recommendations. Recommen- sity and increased physical activity tailored to dations for nutrition and physical activity for per- the specific needs of the person being treated. sons who are living with advanced cancer are best After cancer treatment, weight gain or loss should made based on individual needs and abilities. be managed with a combination of dietary and physical activity strategies. For some who need to gain weight, this means increasing energy SELECTED ISSUES IN NUTRITION AND PHYSICAL intake (food intake) to exceed energy expended, ACTIVITY FOR CANCER SURVIVORS and for others who need to lose weight, this Body Weight means increasing energy expenditure (via increased physical activity) to exceed energy intake. Throughout the cancer continuum, individ- Emerging evidence suggests that reducing the uals should strive to achieve and maintain a energy density of the diet by emphasizing low- healthy weight.43 Some cancer survivors can be energy density foods (eg, water- and fiber-rich malnourished and underweight at diagnosis or as vegetables, fruits, and soups; cooked whole grains) a result of aggressive cancer treatments. For these and limiting intake of fat and sugars promotes persons, further loss of weight can impair their healthy weight control.77 The mechanism by quality of life, interfere with completion of treat- which this strategy may be useful is that food ment, delay healing, and increase risk of compli- volume is not reduced, which may help to avoid cations. In survivors with these difficulties, dietary hunger and feelings of deprivation. Limiting por- intake and factors affecting energy expenditure tion sizes of energy dense foods is an important should be carefully assessed. For those at risk for accompanying strategy.78–81 Increased physical unintentional weight loss, multifaceted inter- activity is also an important element to prevent

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weight gain, promote weight loss, and most risk for recurrence and increase overall survival important, to promote maintenance of weight in women who have been diagnosed with early loss in patients who are overweight or obese.82 stage breast cancer (the Women’s Intervention For those who need to lose weight, even if ideal Nutrition Study [WINS] and the Women’s weight reduction is not achieved, it is likely that Healthy Eating and Living [WHEL] Study).85,86 any weight loss achieved by physical activity and Preliminary results from the recently-completed healthful eating is beneficial, with weight losses WINS suggest that women assigned to the low- of 5% to 10% still likely to have significant health fat diet arm of the study (targeting 20% of energy 43 benefits. Although the evidence related to these from fat) exhibited a 24% reduction in risk for Downloaded from weight management strategies does not come recurrence; subset analyses suggest that this effect from studies of cancer survivors, it is likely that was even greater among women with estrogen these common-sense approaches can apply in the receptor-negative disease.87 Results from the special circumstances of the cancer experience. WHEL Study are anticipated by 2008. A smaller number of observational follow-up studies of Nutrition and Food Choices diet and survival after the diagnosis of prostate can- caonline.amcancersoc.org cer have also been reported. In one of these stud- During all phases of cancer survival, even for ies, higher saturated fat intake predicted shorter those with no apparent nutritional problems, disease-specific survival, and in another, greater the principles outlined in the American Cancer monounsaturated fat intake predicted longer Society Guidelines on Nutrition and Physical Activity survival.88,89 for Cancer Prevention should be regarded as the Currently, the recommended level of fat in the basis for a healthful diet.42 These guidelines are diet is 20% to 35% of energy, with saturated fat similar to those recommended by several other intake limited to Ͻ10% and trans fatty acids by on August 5, 2009 (©American Cancer Society, Inc.) organizations, agencies, and expert panels as a limited to Ͻ3% of total energy intake.82 Some reasonable basis for the dietary prevention of studies have suggested that omega-3 fatty acids other chronic diseases and cancer.43,46,83 may have specific benefits for cancer survivors, Balancing Fat, Protein, and such as ameliorating cachexia, improving quality of life, and perhaps enhancing the effects of Carbohydrate Intake some forms of treatment.90,91 These findings are Protein, carbohydrate, and fat all contribute not certain, however, and more research is energy (calories) to the diet, and each of these needed.92 However, including foods that are dietary constituents is available from a wide vari- rich in omega-3 fatty acids (eg, fish, walnuts) ety of foods. Informed choices about foods that in the diet should still be encouraged because provide these macronutrients should be based this is associated with a lower risk for cardio- in goals of achieving variety and nutrient ade- vascular diseases and a lower overall mortality quacy. Many cancer survivors are at high risk rate,43,45,46 and evidence is largely lacking for a for other chronic diseases, such as heart disease. detrimental effect. Therefore, the recommended amounts and type Adequate protein intake is essential during of fat, protein, and carbohydrate to reduce car- all stages of cancer treatment, recovery, and long- diovascular disease risk are also appropriate for term survival. The best choices to meet protein cancer survivors.42–46 needs are foods that are also low in saturated fat Several studies have been conducted on the (eg, fish, lean meat and poultry, eggs, nonfat and relationship between fat intake and survival after low-fat dairy products, nuts, seeds, and legumes). the diagnosis of breast cancer, and the results An intake of 10% to 35% of energy from protein, across these studies are inconsistent, with some or at least 0.8 g/kg body weight, is recommended studies suggesting increased fat intake may de- for the general population82 and will generally crease survival, whereas others suggest no effect.84 meet the protein needs of adult cancer survivors. Two large clinical trials, one recently completed Healthful carbohydrate sources are foods that and the other still ongoing, were designed to are rich in essential nutrients, phytochemicals, test whether a reduction in fat intake can reduce and fiber, such as vegetables, fruit, whole grains,

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and legumes. These foods should provide the as soft drinks and many fruit-flavored drinks) majority of carbohydrate in the diet. The rec- add substantial amounts of calories to the diet ommended level of carbohydrate in the diet is and thus can promote weight gain. In addition, 45% to 65% of energy intake for the general most foods that are high in sugar do not con- population.82 Vegetables and fruits contain numer- tribute many nutrients to the diet and often ous dietary constituents that potentially affect replace more nutritious food choices. Therefore, cancer progression, such as essential vitamins limiting sugar consumption is recommended. and minerals, biologically active phytochemi- Vegetarian diets can be healthy or unhealthy,

cals, and fiber. Additionally, these are low energy depending on one’s food choices. Vegetarian Downloaded from dense foods that promote satiety, and thus may diets differ with respect to inclusion of dairy promote healthy weight management.93 Whole foods, fish, and/or eggs, but avoiding red meat fruit (instead of juice) adds more fiber and fewer is a universal feature. Fish, dairy foods, or both calories to the diet. When fruit juice is chosen, contain sufficient quantity and quality of protein, 100% fruit juice is the preferred choice. and a vegetarian diet that contains these foods Whole grains are rich in a variety of com- typically has a nutrient content similar to an caonline.amcancersoc.org pounds (in addition to fiber) that have impor- omnivorous diet. A vegan diet, which excludes tant biologic activity, including hormonal and all animal foods and animal products, can meet antioxidant effects. For example, whole grains protein needs if nuts, seeds, legumes, and cereal- contain antioxidants, such as phenolic acids, grain products are consumed in sufficient quan- flavonoids, and tocopherols; compounds with tities, although supplemental vitamin B12 will weak hormonal effects such as lignans; and com- be necessary to meet needs for that vitamin. As pounds that may influence lipid metabolism, dietary vitamin D in the United States comes

such as phytosterols and unsaturated fatty acids. primarily from fortified dairy foods, a vegan by on August 5, 2009 (©American Cancer Society, Inc.) All of these compounds and their biologic effects diet may also need to include supplemental vita- have been hypothesized to reduce risk and pro- min D if adequate exposure to the sun or ultra- gression of cancer as well as cardiovascular dis- violet light is not obtained. Vegetarian diets can ease.94 Choosing whole grains and whole grain have many healthful characteristics because they food products as a source of fiber, rather than tend to be low in saturated fat and high in fiber, relying on fiber supplements, adds nutritional vitamins, and phytochemicals. A vegetarian diet value to the diet. is consistent with the ACS Nutrition Guidelines Refined grains have been milled, a process for the Prevention of Cancer. However, no that removes the bran and germ. This results in direct evidence has determined whether consum- levels of vitamins and minerals that are lower ing a vegetarian diet has any additional benefit than the unrefined, whole grain counterpart. for the prevention of cancer recurrence over an Examples of refined grain products include white omnivorous diet high in vegetables, fruits, and flour, degermed cornmeal, white bread, and whole grains, and low in red meats. white rice. In the United States, most refined Vegetables and Fruits grain products have been enriched, which means that micronutrients such as thiamin, riboflavin, Higher intakes of vegetables and fruits have niacin, iron, and folate have been added back to been specifically associated with a lower incidence the product after processing. Thus, they are not of cancer at several sites, including the colorectum, completely without nutritional value, but many stomach, lung, oral cavity, and esophagus.44 Few of the potentially helpful constituents, such as studies exist, however, on the relationship between fiber and other biologically active phytochem- a diet including many vegetables and fruits and icals, have not been added back. the risk for reducing cancer recurrence or increas- Sugar intake has not been shown to directly ing survival after cancer. In the observational stud- increase risk or progression of cancer. However, ies that have examined the relationship between sugars (including honey, raw sugar, brown sugar, intakes of vegetables and fruit (or nutrients indica- high-fructose corn syrup, and molasses) and bev- tive of those foods) and risk for recurrence of erages that are major sources of these sugars (such breast cancer, the findings have been mixed,84

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although plasma carotenoids (a marker of veg- alcohol overuse, but also for cancer. For this rea- etable and fruit intake) have been associated with son, it is important for the health care provider greater likelihood of recurrence-free survival in one to tailor advice on alcohol consumption to the study.95 In the single study that examined diet individual cancer survivor. The cancer type and and survival after the diagnosis of ovarian can- stage of disease, treatment, risk factors for recur- cer, higher intake of vegetables, especially cru- rence or new primary cancers, and comorbid ciferous vegetables, was found to be associated conditions should be considered in making rec- with longer survival.96 A recent observational ommendations. For example, alcohol, even in

study of diet after diagnosis and risk of prostate the small amounts found in mouthwashes, can be Downloaded from cancer progression found those who consumed irritating to survivors with oral mucositis and more tomato sauce had longer survival.97 can exacerbate that condition. Therefore, it is The benefits of eating a variety of vegeta- reasonable to recommend that alcohol intake bles and fruits probably exceed the health- should be avoided or limited among survivors promoting effects of any individual constituents with mucositis and among those beginning head in these foods because the various vitamins, and neck radiotherapy or chemotherapeutic reg- caonline.amcancersoc.org minerals, and other phytochemicals in these imens that put them at risk for mucositis. whole foods act in synergy. It is reasonable to Many studies have found a link between alco- recommend that cancer survivors adopt the hol intake and risk for some primary cancers, general recommendations issued by the ACS including cancers of the mouth, pharynx, lar- for cancer prevention to eat at least five serv- ynx, esophagus, liver, breast, and probably colon ings of a variety of vegetables and fruit each cancer.44,98,100 In persons who have already day. This can be achieved by eating a mini- received a diagnosis of cancer, alcohol intake mum of 2 1/2 cups of vegetables and fruits could also affect the risk for new primary can- by on August 5, 2009 (©American Cancer Society, Inc.) each day. Colorful choices such as dark green cers of these sites. Alcohol intake can increase and orange vegetables are typically good sources the circulating levels of estrogens, which theo- of nutrients and healthful phytochemicals. retically could increase the risk for recurrence Fresh, frozen, canned, raw, cooked, or dried of breast cancer. In most studies of breast can- vegetables and fruits all contribute nutrients cer survivors conducted to date, there is little and other biologically active constituents to evidence of an effect of alcohol on increased the diet. Cooking vegetables and fruits, espe- risk of recurrence or decreased survival.73 How- cially with methods such as microwaving or ever, the level of alcohol intake in these studies steaming in preference to boiling in large of women with breast cancer has generally been amounts of water, preserves the bioavailability so low that the results of these studies should of water-soluble nutrients and can improve not be interpreted as indicating alcohol intake absorption of others. For example, the antiox- after cancer diagnosis does not increase risk of idant lycopene is better absorbed from cooked recurrence or new primary cancers.101 Therefore, tomato and tomato products than from raw the degree of risk present should be considered tomatoes. At present, no research exists to in recommendations regarding individual alco- demonstrate that organically grown vegetables hol consumption. and fruits are superior in their content of potential cancer-preventive constituents. Food Safety Food safety is of special concern for cancer Alcohol survivors, especially during episodes of iatrogenic Substantial observational evidence indicates immunosuppression that can occur with certain that alcohol intake has both positive and nega- cancer treatment regimens.102 Survivors can tive health effects.44,98,99 Alcoholic drinks up to become susceptible to developing infections due one or two drinks per day (for women and men, to treatment-induced leukopenia and neutrope- respectively) can lower risk for heart disease, but nia. During any immunosuppressive cancer treat- higher levels do not offer additional beneﬁt and ment, survivors should take extra precautions to may increase risk not only for complications of prevent infection, and they should be particu-

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larly careful to avoid eating foods that may con- related health issues, evidence suggests that many tain unsafe levels of pathogenic microorganisms. were taking similar supplements prior to diag- Because chemotherapy can impair the immune nosis109 or report taking them to treat other health response, raw vegetables and fruits may increase conditions.107 One additional rationale for dietary the risk for infection in some patients during supplementation among cancer patients stems immune-suppressant treatment (ie, some chem- from observations of lower cancer risk among otherapies and radiotherapies) as a result of bac- those who eat diets rich in vegetables and fruits. teria on these foods.102 By following safe food There is little evidence, however, that dietary

practices, cancer survivors and their caregivers supplements can reproduce the benefit of a nutri- Downloaded from can reduce the risk of food-borne illness. Refer ent- and phytochemical-rich diet. to the general guidelines for food safety as shown The VITAL (Vitamins and Lifestyle) cancer in Table 3. patient cohort study provides estimates of the frequency with which cancer survivors use spe- Dietary Supplements cific dietary supplements. Data collected from Dietary supplements include vitamins, miner- more than 10,800 cancer survivors showed sig- caonline.amcancersoc.org als, herbs, botanicals, amino acids, and glandular nificant differences across cancer sites, includ- products. Across various studies, the use of dietary ing the use of cranberry extract among patients supplements is reported by 25% to 80% of can- with bladder cancer, folic acid supplementation cer survivors,103–106 and most reports of dietary sup- among patients with colorectal and uterine can- plement use among survivors suggest that fre- cer, and vitamin A supplementation among quency of dietary supplementation is higher than women diagnosed with ovarian cancer, as well the general population or controls who have not as both men and women who had been diag- been diagnosed with cancer.106 Cancer patients nosed with melanoma. Interestingly, although by on August 5, 2009 (©American Cancer Society, Inc.) use supplements for a variety of reasons, includ- there is little direct evidence of a beneficial effect ing following the advice of health care providers of vitamin E in breast cancer survival, this study or others, treating a symptom, to feel better, reported increased vitamin E use among breast and/or as a general insurance of adequate nutri- cancer patients (49.2% of women previously ent intake, as is the case among those taking diagnosed with breast cancer), a practice that multivitamin-mineral supplements.107,108 In addi- was also reported by 46% of breast cancer sur- tion, although it might be assumed that cancer survivors in another study.106 The quantity of vita- vivors take dietary supplements to treat cancer- min E intake in this study also indicated that supplementation levels were much higher than for healthy adults (averaging 268 mg/d and 34 3 TABLE General Guidelines for Food Safety mg/d, respectively). • Wash hands thoroughly before eating. During and after cancer treatment, there is a • Keep all aspects of food preparation clean, including washing probable benefit of taking a standard multiple hands before food preparation and washing fruits and vitamin and mineral supplement that contains vegetables thoroughly. • Use special care in handling raw meats, fish, poultry, and eggs. approximately 100% of the Daily Value because • Thoroughly clean all utensils, countertops, cutting boards, during these times, it may be difficult to eat a and sponges that have contacted raw meat; keep raw meats diet with adequate amounts of these micronu- and ready-to-eat foods separate. 110,111 • Cook to proper temperatures; meat, poultry, and seafood trients. One report among children with should be thoroughly cooked, and beverages (milk and cancer showed that diets were inadequate in vita- juices) should be pasteurized. min C and E and total carotenoids. In this same • Store foods promptly at low temperatures to minimize bacterial growth (below 40ЊF). study, diets with sufficient vitamin E were asso- • When eating in restaurants, avoid foods that may have poten- ciated with lower risk for infection, and diets tial bacterial contamination such as salad bars, sushi, raw or adequate in vitamin C were associated with fewer undercooked meat, fish, shellfish, poultry, and eggs. delays in treatment related to low blood counts,112 • If there is any question or concern about water purity (eg, well water), it can be checked for bacterial content by suggesting that working to improve dietary ade- contacting local public health departments. quacy through food selections may improve health during treatment for cancer. In contrast,

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the use of very large doses of vitamins, miner- abreast of recent research in this area, particu- als, and other dietary supplements is not recom- larly related to potential drug interactions. It is mended.113,114 There is reason for caution in most prudent to encourage cancer survivors to taking high-dose supplements. The best exam- obtain the potentially beneficial compounds ple of this risk comes from studies of beta-carotene from food. A daily multivitamin supplement in and lung cancer. Although many observational amounts equivalent to 100% of the Daily Value epidemiologic studies suggested that dietary beta- is a good choice for anyone who, for whatever carotene was associated with lower risk for lung reasons, cannot eat a healthful diet,110,111 but the 115 cancer, two clinical trials showed that high- need for vitamin and mineral supplements in Downloaded from dose beta-carotene supplements actually increased higher doses should be assessed and discussed on (not decreased) the rate of occurrence of lung an individual basis. cancer.113,114 In addition, one recent trial suggests that beta-carotene supplements may increase Physical Activity Issues for Cancer Survivors colorectal adenoma recurrence in persons who smoke cigarettes, consume alcohol, or both.116 Physical activity may have beneﬁts through- caonline.amcancersoc.org High doses of beta-carotene taken as a supple- out the spectrum of the cancer experience, but ment clearly do not result in the same effects as cancer survivors are often more likely to become consumption of dietary patterns that include sedentary for several reasons. Survivors tend to foods rich in beta-carotene. Because other vita- decrease their physical activity levels after their mins and micronutrients at high doses have not diagnosis of cancer, and most continue lower been studied in large clinical trials, the adverse levels of activity through treatment and beyond, effects of high-dose beta-carotene should sug- rarely returning to their prediagnosis levels of gest caution in the use of high-dose nutritional activity.119–121 Because being sedentary is a risk by on August 5, 2009 (©American Cancer Society, Inc.) supplements. There are, however, some indica- factor for the incidence of several of the most tions for lower-dose nutrient supplementation common types of cancer, such as breast cancer by cancer patients and survivors. These include and colorectal cancer, many survivors from these the following: cancers will tend to have been sedentary before • Biochemically demonstrated nutrient defi- diagnosis. In addition, some therapies may reduce ciency (eg, low plasma vitamin D levels, B12 the capacity to exercise because of adverse effects deficiency) where dietary approaches have on cardiopulmonary, neurologic, and muscular been inadequate. systems. Thus, both preexisting reduced levels • Nutrient intakes persistently below recom- of fitness, stamina, and strength and the new mended intake levels. stresses of cancer diagnosis, treatment, and recov- • To meet public health recommended levels ery challenge cancer survivors who want to of intake (ie, calcium or vitamin D supple- increase their physical activity levels. For these rea- mentation for bone health, folate among sons, exercise that is of low or moderate inten- women of child-bearing age planning preg- sity for a healthy person may seem to be of high nancy) if not contraindicated due to cancer intensity for some cancer survivors. therapy. Physical activity capabilities and effects will • Known health sequelae related to cancer ther- differ among cancer survivors depending on apy (ie, bone loss requiring calcium and/or their diagnosis, treatment modalities, and the vitamin D supplementation). spectrum of cancer survival.122 Many cancer Open dialogue between patients and health survivors are at increased risk for comorbid care providers should occur regarding dietary conditions that can be reduced through increased supplementation to assure there is no contraindi- physical activity.123 The effects of physical activ- cation in relation to the prescribed cancer ther- ity on cardiovascular disease and diabetes have apy or for longer-term health effects.117,118 In not been studied in cancer survivors, but it is turn, health care providers should make an effort reasonable to expect that the beneficial effects not only to provide time to review dietary sup- of physical activity on such outcomes would plement decisions with patients, but also to stay not differ from those observed in the general

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population. Similarly, resistance exercise has TABLE 4 Suggested Ways to Increase been reported to improve bone strength in per- Physical Activity

sons without cancer; thus, resistance exercise • Use stairs rather than an elevator. programs may be expected to favorably decrease • If you can, walk or bike to your destination. risk of osteoporosis in cancer survivors, although • Exercise with your family, friends, and coworkers. • such effects have not yet been studied. Women Take an exercise break to stretch or take a short walk. • Walk to visit nearby friends or coworkers instead of sending who experience menopause during or after an e-mail. treatment and men with prostate cancer who • Plan active vacations rather than only driving trips. • Wear a pedometer every day and increase your daily steps.

are treated with long-term androgen-suppres- Downloaded from • Use a stationary bicycle or treadmill while watching TV. sive medications are at high risk for osteoporo- sis124,125 and may therefore be especially likely to benefit from resistance training to increase bone strength. Additional positive outcomes of Although some cancer survivors can adopt exercise training can include improved lean body an exercise program independently, many will mass and balance, with resulting reduced risk benefit from referral to an exercise specialist. caonline.amcancersoc.org for falls and subsequent fractures. Clinical trials Survivors should seek individuals who have been are underway that are testing the effects of aer- certiﬁed by an exercise-related professional organ- obic and resistance exercise on bone density in ization, such as the American College of Sports postmenopausal breast cancer survivors. Medicine. A physical therapist is the appropri- Cancer survivors with lymphedema may also ate resource for survivors with injuries, pain, or benefit from exercise, specifically range-of- speciﬁc postsurgical issues such as lymphedema motion exercises, with approval from their treat- or amputation. Exercise physiologists receive

ing physicians. The benefits and risks of resis- college training and are certified by various pro- by on August 5, 2009 (©American Cancer Society, Inc.) tance training in survivors with lymphedema fessional organizations to develop individualized have not been investigated systematically. There exercise programs. Personal trainers are also pop- have been some concerns that physical activ- ular choices for persons who want to increase ity involving the affected limbs may have adverse their fitness and activity levels. Recommendations effects on lymphedema. However, this is an on the type, frequency, duration, and intensity area that is understudied, and the few results, of exercise should be individualized to the sur- including from a randomized trial, an early pilot vivor’s age, previous fitness activities, type of clinical study, and a small cohort study, suggest cancer, stage of treatment, type of therapy, and that resistance training does not adversely affect comorbid conditions. Table 4 contains some lymphedema.126–128 suggested ways to increase physical activity. No clinical trials have reported the effect of Particular issues for cancer survivors may affect physical activity on the risk for cancer recur- their ability to exercise. Effects of treatment may rence or survival, but several clinical trials have also promote the risk for exercise-related injuries assessed the effect of physical activity interven- and adverse effects. Specific precautions should tions on quality of life and other psychosocial be heeded: outcomes in cancer survivors. The exercise pro- • Survivors with severe anemia should delay grams in these trials were primarily 3 days per exercise, other than activities of daily living, week of moderate to vigorous activity that was until the anemia is improved. progressively increased in duration to approxi- • Survivors with compromised immune func- mately 45-minute sessions during a period of tion should avoid public gyms and other pub- 3 or 4 months. These studies have shown that lic places until their white blood cell counts such exercise programs can reduce anxiety and return to safe levels. Survivors who have com- depression, improve mood, boost self-esteem, pleted a bone marrow transplant are usually and reduce symptoms of fatigue.30 In general, advised to avoid such exposures for 1 year physical activity is likely to be beneficial for after transplantation. most cancer survivors who have completed their • Survivors suffering from severe fatigue from primary treatments. their therapy may not feel up to an exercise

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program, so they may be encouraged to do be one of the most important lifestyle pursuits. 10 minutes of stretching exercises daily. The majority of studies conducted over several • Survivors undergoing radiation should avoid decades indicate that overweight or obesity at chlorine exposure to irradiated skin (eg, from the time of diagnosis is a poor prognostic factor swimming pools). and may be associated with less favorable nodal • Survivors with indwelling catheters should status, as well as a variety of undesirable outcomes avoid water or other microbial exposures that (eg, contralateral disease, recurrence, comorbid may result in infections, as well as resistance disease, and/or disease-specific or overall mor- 10,69,130–134 training of muscles in the area of the catheter tality). Given that overweight and obe- Downloaded from to avoid dislodgment. sity are well-established risk factors for worse • Survivors with significant peripheral neu- prognosis, and many women are overweight ropathies or ataxia may have a reduced abil- when diagnosed with breast cancer, weight man- ity to use the affected limbs because of agement is a concern for a substantial propor- weakness or loss of balance. They may do bet- tion of breast cancer survivors. A compounding ter with a stationary reclining bicycle, for problem is the fact that additional weight gain is caonline.amcancersoc.org example, than walking on a treadmill. frequently reported after diagnosis.135–137 Studies For the general population, the ACS recom- have provided conflicting evidence as to the mends at least 30 to 60 minutes of moderate to effect of post-diagnosis weight gain on progno- vigorous physical activity at least 5 days per week sis, although the largest of these found that those to reduce the risk for cancer, cardiovascular dis- who gained more than 13 pounds were 50% ease, and diabetes.42,46,123 These levels of activ- more likely to relapse and 60% more likely to ity have not been studied systematically in cancer die than were women who gained less weight.138 survivors, but aside from specific circumstances Analyses conducted on a cohort of nonsmok- by on August 5, 2009 (©American Cancer Society, Inc.) related to treatment or other cancer-specific con- ing breast cancer survivors within the Nurses’ ditions such as outlined above, there is no rea- Health Study cohort corroborated these find- son to think that these recommendations would ings. Women who increased their body mass not also be beneficial for cancer survivors. There- index (BMI) by 0.5 to 2 units were found to fore, although daily and regular activity may be have a 40% greater chance of recurrence, and preferred and may be a goal, any steps that are those who gained more than 2 BMI units had taken to move from a sedentary to an active 53% greater chance of recurrence compared with lifestyle should be encouraged. If an individual has those who did not gain more than 0.5 BMI been completely sedentary, encouragement to units.139 In that study, survivors in whom weight take short walks may be appropriate. If someone decreased did not experience significantly poorer already exercises three times a week, encourage- outcomes. However, other recent studies have ment to increase this to five times a week may not found an effect of weight gain on progno- be appropriate. For survivors wanting maximum sis.140 Although it must be borne in mind that benefit, the message should be that the health unexplained weight loss may be a symptom of benefits of exercise are generally linear, with recurrent disease and should be monitored increasing health benefit with a higher volume of closely,141 there is a vast difference between weight physical activity. Caution should be noted that loss that is intentional or purposeful versus that extremely high levels of exercise might increase which is unexplained or a consequence of dis- the risk for infections,129 and the risk of exercise- ease. Indeed, given accumulating data to suggest related injuries should also be minimized. that overweight and obesity adversely influence not only cancer-specific outcomes, but also overall

NUTRITION AND PHYSICAL ACTIVITY ISSUES health and quality of life, weight management is BY SELECTED CANCER SITES now considered a standard of care for overweight women diagnosed with early stage breast can- Breast Cancer cer.10,142,143 A decade of previous research,144–147 For a woman diagnosed with breast cancer, as well as more recent studies, also suggests that achieving or maintaining a desirable weight may the weight gain experienced by women who

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have been treated with adjuvant chemotherapy large clinical trials, one recently completed and or hormonal treatment seems to be the result of the other an ongoing study, were designed to test increases in adipose tissue mass, with no change whether change in diet composition can reduce or a decrease in lean body mass.137,148,149 This risk for recurrence and increase overall survival unfavorable shift in body composition suggests in women who have been diagnosed with breast that interventions should be aimed at not only cancer. The recently-completed WINS was a curbing weight gain during treatment, but also randomized multicenter clinical trial testing at preserving muscle mass. Moderate physical whether a reduction in fat intake as an adjuvant

activity (especially resistance training) during to standard breast cancer therapy can reduce dis- Downloaded from and after treatment may help survivors maintain ease recurrence and increase survival for women lean muscle mass while avoiding excess body with localized breast cancer. This trial was con- fat.136,150 Even if an ideal weight is not achieved, ducted among 2,437 postmenopausal women it has been established in the general population with early stage breast cancer, with 975 women that a weight loss of 5% to 10% over 6 to 12 randomly assigned to the low-fat dietary inter- months is sufﬁcient to reduce the levels of fac- vention group. Unpublished results suggest that caonline.amcancersoc.org tors associated with chronic disease risk, such as study participants in the low-fat diet arm of the elevated plasma lipids and fasting insulin levels. study (targeting 20% of energy from fat) exhib- Although overweight women should deﬁnitely ited a 24% reduction in risk for recurrence, with be encouraged to lose weight after active treat- a greater reduction in risk observed in the sub- ment, modest weight loss (1–2 pounds per week) group of women with estrogen receptor-nega- could also be pursued safely during therapy as tive cancer.87 long as it is approved by the treating oncologists, Eating more vegetables is inconsistently related

is monitored closely, and does not interfere with to reducing breast cancer risk, and the evidence by on August 5, 2009 (©American Cancer Society, Inc.) treatments.151,152 that fruit intake is related to recurrence or survi- Several studies have examined exercise during val is weak.156,157 In the ongoing WHEL Study, and after treatment in breast cancer survivors.150,153 the major intervention is on increased vegetable Few studies are large randomized clinical trials, and fruit intake, although the intervention group but the evidence consistently suggests a benefit women are also encouraged to reduce fat and from exercise during and after breast cancer treat- increase fiber intakes.158 Results from the WHEL ment on various measures of quality of life, as Study are anticipated by 2008. In a recent cross- well as physical fitness (eg, cardiovascular endur- sectional study of women assigned to the con- ance, flexibility, and body composition) and fac- trol arm of the WHEL Study, higher levels of tors such as self-esteem, anxiety, depression, and baseline serum carotenoid concentrations (a bio- fatigue.150 There are good reasons to suspect that logic marker of vegetable and fruit intake) were the benefits of physical activity for the primary found to be associated with longer recurrence- prevention of breast cancer, heart disease, dia- free survival.95 Vegetables can reduce the total betes, and overall mortality rate would also extend energy density in the diet, and both vegetables to breast cancer survivors.55 Furthermore, recent and fiber are associated with improved satiety. studies suggest that breast cancer survivors who Recent data on breast cancer survivors partici- are physically active have significantly lower rates pating in the Nurses’ Health Study, who were of recurrence, as well as disease-specific and over- followed for a mean period of nearly 10 years all mortality, than those who are sedentary.55,133 postdiagnosis, suggest that those who consume a Research is currently under way to evaluate prudent diet, with higher intakes of fruits, veg- various components of the prudent dietary etables, and whole grains and lower intakes of pattern on cancer-specific outcomes, as well as sugars, refined grains, and animal products, may overall health. To date, evidence that dietary fat not have significantly lower rates of recurrence or intake could be associated with risk for recur- cancer-specific mortality, although women who rence or survival is not strongly or consistently report this eating pattern have significantly lower supportive, especially when total energy intake and rates of mortality from other diseases, when com- the degree of obesity are considered.154,155 Two pared to those who eat typical western diets.159

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Low folate intake (determined in large part effects, studies on soy and breast carcinogene- by low dietary intakes of fruit, vegetables, legumes, sis have produced conflicting results.167–170 For and grains) has been hypothesized to be related the breast cancer survivor, current epidemio- to increased breast cancer risk.160–162 Folate might logic and laboratory evidence suggests there are ameliorate the adverse effects of alcohol on breast unlikely to be harmful effects when soy is pro- cancer risk because some studies have shown that vided in the diet consistent with amounts in a the increased risk associated with alcohol is more typical Asian diet; whether such levels of soy pronounced among women reporting lower intake may result in beneficial effects is also 162–164 167 intakes of folate. A specific relationship unclear. This amount would be provided by Downloaded from between folate intake and risk for recurrence or as many as three servings per day of soy foods, survival in women who have been diagnosed such as tofu and soy milk. However, because with breast cancer has not been observed in stud- higher doses of soy may have estrogenic effects170 ies that have addressed that question.165 and because higher levels of estrogens clearly Although alcohol intake has been linked with increase the risk for breast cancer progression,166 an increase in the risk for primary breast can- it is prudent for breast cancer survivors to avoid caonline.amcancersoc.org cer,100 there is limited evidence from studies of the high doses of soy and soy isoflavones that breast cancer survivors of a relationship with the are provided by more concentrated sources such risk for recurrence and survival.73,166 This is in as soy powders and isoflavone supplements. part due to the fact that alcohol intake among As we consider results from the WINS trial87 women in these studies of breast cancer prog- and await results of the WHEL Study,86 it is nosis is generally at very low levels.101 Theoreti- important to remember that nutrition and phys- cally, however, alcohol intake could affect the ical activity recommendations to reduce the risks risk for a second primary breast cancer, for which for primary breast cancer and heart disease are by on August 5, 2009 (©American Cancer Society, Inc.) all breast cancer survivors are at increased risk. especially important for breast cancer survi- Alcohol is an unusual factor, however, because vors.42,46,171,172 Diets should emphasize vegeta- it presents both risks and benefits. In the gen- bles and fruits, low amounts of saturated fats, eral population, clear and consistent evidence and sufficient dietary fiber. If soy foods are con- links moderate alcohol intake (1–2 drinks per sumed, intakes should be kept in moderation, day) with a lower risk for cardiovascular dis- and concentrated sources of isoflavones should ease.99 For breast cancer survivors, the decision be avoided. Most importantly, breast cancer sur- to drink alcoholic beverages at moderate levels vivors should strive to achieve and maintain a is complex because they must consider their lev- healthy weight through appropriate diet and reg- els of risk for both cardiovascular disease and ular physical activity.84 In addition, regular phys- recurrent breast cancer. ical activity should be maintained regardless of There is considerable public and scientific any weight concerns. interest in the role of soy foods in the prevention of breast cancer, although evidence from human Colorectal Cancer studies in support for such a role is limited.167–170 Many epidemiologic studies indicate that col- The interest in soy foods stems from the obser- orectal cancer risk is increased by diets high in vation that they are consumed commonly in red and processed meats and low in vegetables most Asian countries, where the rates of breast and fruits and by sedentary lifestyles and obesity. cancer are lower than in the United States and Excess alcohol consumption may also increase other western countries, and several epidem- the risk for this cancer.173 Whether these or other iologic studies in Asia or in Asian-American dietary factors also influence prognosis of col- populations suggest that soy food intake may orectal cancer is largely unknown. Only a few decrease the risk of breast cancer. Soy contains studies have tried to determine whether dietary high levels of plant isoflavones that exert a vari- factors influence prognosis after colorectal can- ety of anticancer activities in laboratory stud- cer diagnosis, and their findings have varied. ies.167 Perhaps because soy has the potential to Findings from two studies suggest that increased produce both estrogenic and antiestrogenic body weight is associated with shorter survival.72,174

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Three additional studies suggest that higher lev- Overweight or obesity seems to adversely affect els of physical activity may be associated with prognosis for patients who receive hematopoi- better clinical outcomes in colorectal cancer sur- etic stem cell transplantation, although the evi- vivors.52–54 dence is limited. In a study that focused on Because colorectal cancers arise from adeno- clinical data from patients who underwent autol- matous polyps, the prevention of polyp recurrence ogous stem cell transplantation, obesity had sig- has been a focus of considerable clinical research. nificant adverse effects on treatment-related To date, trials have failed to show benefits in toxicity and mortality, overall survival, and 179 preventing new polyp growth during a 3- or 4- disease-free survival. Downloaded from year period from antioxidant vitamins, fiber sup- Preliminary research has examined the effects plements, or modest dietary changes to increase of exercise in survivors of hematologic cancers. fruit and vegetable intake.175 Calcium supple- Most of these studies have been conducted in ments, however, provided a modest benefit in the context of acute recovery from bone marrow preventing polyp recurrence.176 Clinical trials or stem cell transplantation.180–184 Overall, these testing the effects of folate, vitamin D, and sele- studies have reported some beneficial effects of caonline.amcancersoc.org nium are underway. After a diagnosis of colorec- exercise on functional capacity and aerobic fit- tal cancer, the most important determinants of ness, muscular strength, fatigue, and psychoso- survival seem to be adherence to the full treat- cial functioning and quality of life. More recently, ment regimen (especially if chemotherapy is rec- several studies have examined hematologic can- ommended) and colonoscopic surveillance to cer survivors outside the context of stem cell identify new lesions. transplantation. Three studies have shown positive associations Observational studies have reported associa-

among exercise, physical ﬁtness, and quality of tions between exercise and quality of life in non- by on August 5, 2009 (©American Cancer Society, Inc.) life among colorectal cancer survivors.120,177,178 Hodgkin lymphoma185 and multiple myeloma186 Two recent studies have shown a positive asso- survivors. One uncontrolled intervention trial ciation between physical activity and survival in found that chronically fatigued Hodgkin disease colorectal cancer survivors.53,54 Moreover, the survivors reported reduced fatigue after 20 weeks evidence for a relation between physical activ- of aerobic exercise.187 Another study of patients ity and the primary prevention of colon cancer with various cancers (mostly non-Hodgkin lym- is convincing.49 Consequently, there is emerg- phoma and breast cancer) treated with high-dose ing evidence that physical activity may improve chemotherapy and stem cell transplantation showed quality of life, reduce risk of recurrence, and that a 6-week program of daily walking improved extend survival after colorectal cancer. both physical performance and fatigue.182 Colorectal cancer survivors should be advised The conditioning regimen of intensive to maintain a healthy weight, eat a well-balanced chemotherapy, often in conjunction with total diet consistent with guidelines for cancer and body irradiation, is associated with several spe- heart disease prevention, and participate in reg- cific side effects that have significant adverse ular physical activity. Colorectal cancer survivors nutritional consequences, such as nausea, vom- with chronic bowel problems or surgery that iting, diarrhea, oropharyngeal mucositis, and affects normal nutrient absorption should be esophagitis. Total body irradiation damages the referred to a registered dietitian to modify their gastrointestinal mucosa, resulting in malabsorp- diets to accommodate these changes and main- tion and diarrhea because these epithelial cells tain optimal health. are highly susceptible to the effects of radiation. Nutritional problems also result from adverse Hematologic Cancers and Cancers Treated With effects of various drug therapies, such as oral Bone Marrow Transplantation or Hematopoietic Stem Cell Transplantation immunosuppressive agents and antibiotics that may be necessary for post-transplant manage- A possible relationship between dietary fac- ment. Finally, the common complication of graft- tors and outcomes of hematologic cancers has versus-host disease (in patients who receive an been examined in only a few studies to date. allogeneic transplant) results in abdominal pain,

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nausea, severe diarrhea, malabsorption, and sub- sis. Two small studies sought to determine stantial nitrogen losses. Patients who do not receive whether dietary intervention with selected veg- nutrition support or specialized nutritional sup- etables improved survival among those with port typically eat poorly for a prolonged period advanced lung cancer.195,196 Weight loss was less and are at high risk of poor nutritional status.188–190 and survival was longer in the intervention groups As an infection prevention strategy, low- in those studies, but these preliminary ﬁndings microbial diets are often prescribed for trans- need to be confirmed by larger studies. Three plant recipients. A low-microbial or low-bacteria randomized clinical trials that included lung can-

diet is primarily a cooked-food diet because the cer survivors, among others, encouraged par- Downloaded from major limitation imposed is on fresh or uncooked ticipants to increase energy intake.197–199 Although food items.191 Because many food restrictions successful in increasing energy intake, none of are imposed with this strategy, the nutrient ade- the strategies used within these studies prevented quacy of actual food intake of patients who are weight loss. prescribed the low-microbial diet should be Lung cancer treatment is often aggressive and monitored. Prevention of malnutrition and cor- causes adverse effects. Furthermore, many lung caonline.amcancersoc.org rection of energy and nutrient inadequacies has cancer survivors have low blood nutrient levels been incorporated into the standardized post- even before diagnosis as a result of inadequate transplant treatment at most transplant centers. diets, the adverse effects of smoking, or both, In a recent review of the evidence relating to on micronutrient status. During treatment and the relative effectiveness of enteral nutrition ver- the immediate recovery period, lung cancer sur- sus parenteral nutrition support, the issue could vivors may benefit from eating foods that are not be evaluated due to lack of evaluable data.192 energy-dense and are easy to swallow. Small, fre-

Recent trends include prescribing less parenteral quent meals may be easier to manage than three by on August 5, 2009 (©American Cancer Society, Inc.) nutrition support and more enteral nutrition large meals per day. Medications, omega-3 fatty support,191 which could reduce risk of medical acid supplements, and nutritional support via complications and control costs. energy-dense dietary supplements or enteral nutrition may be helpful for those experienc- 59 Lung Cancer ing weight loss. If nutrient deficiencies are present or survivors cannot eat enough to ade- Lung cancer is largely due to cigarette smok- quately meet micronutrient needs, a multivita- ing, but diets low in vegetables and fruits have also min–mineral supplement is advisable, either in been associated with increased lung cancer risk, pill or liquid form. The potential role of phys- even after accounting for tobacco use.115 This ical activity in improving outcomes in lung can- observation led to the idea that perhaps beta- cer survivors has not been characterized. carotene, found in vegetables and fruits, might Recommendations for nutrition and physi- reduce lung cancer risk, but two large random- cal activity for persons who are living with lung ized clinical trials showed that high-dose beta- cancer are best made based on individual needs. carotene supplementation actually increased the Striving toward a healthy weight by adjusting risk for lung cancer.113,114 The possible effect food intake and physical activity is a reasonable (either beneﬁcial or harmful) of nutritional sup- goal, as is ensuring that nutritional needs are met plements other than beta-carotene after the diag- with a well-balanced diet and a multivitamin– nosis of lung cancer has not been studied. One mineral supplement, if needed to achieve adequate clinical trial of selenium and skin cancer noted levels of intake. a reduced incidence of lung cancer in associa- 193 tion with selenium supplementation. A new Prostate Cancer clinical trial is now under way to attempt to replicate and extend this work among lung can- Most research on diet and prostate cancer has cer survivors.194 focused on prostate cancer incidence.200,201 Be- Few studies have examined the relation because asymptomatic prostate cancer is very com- tween dietary factors and lung cancer progno- mon in older men, the same dietary factors that

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are associated with reduced prostate cancer inci- among prostate cancer survivors, under the dence might also reduce the rate of prostate can- assumption that the phytoestrogens may be ben- cer growth after diagnosis, thus preventing or eficial. Although some studies suggest that soy slowing progression of early stage prostate can- foods may decrease the risk for prostate cancer, cer. In recent years, a few studies have tried to no rigorous studies have examined the effects of determine directly whether such dietary factors soy or other phytoestrogens on the progression may prolong survival from prostate cancer or of prostate cancer after diagnosis, although stud- may influence biomarkers (eg, prostate-specific ies are underway. One small study of flaxseed, a

antigen levels) that are associated with outcomes concentrated source of lignan phytoestrogens, Downloaded from for men with prostate cancer. suggested some potentially beneficial effects on A high intake of foods from animal sources, prostate-specific antigen levels205; it is not known especially foods high in saturated fat, has been whether these findings result in better prognoses. associated with increased risk for prostate can- Several epidemiologic studies have shown that 155,200 cers. Whether this increased risk is due to men who have high levels of calcium in their caonline.amcancersoc.org saturated fat per se or to the consumption of red diets, from both supplements and dairy prod- meat and high-fat dairy products is unclear. The ucts, might be at increased risk for aggressive observation that fatty fish intake may decrease forms of prostate cancer.206 The possible effects prostate cancer mortality rates suggests that, if of calcium after prostate cancer treatment, how- fat is important, the type of fat may play a key role. ever, are not known. Prostate cancer survivors There are now two follow-up studies of dietary undergoing androgen-suppressive therapy are at factors and survival in prostate cancer survivors. high risk for osteoporosis. It is not known if cal- One found that saturated fat intake (but not total cium or vitamin D supplements would be use- fat) is associated with worse survival,202 and the by on August 5, 2009 (©American Cancer Society, Inc.) ful or detrimental in these cases. It would seem other found that monounsaturated fat intake is prudent for men to adopt a diet that contains at associated with better survival.88 Based on what least 600 IU per day and to consume adequate, we currently know and on the role of saturated but not excessive amounts of calcium (ie, exceed- fat in cardiovascular disease and potential role ing 1,200 mg/d), as well as to pursue active in prostate and colon cancer incidence, decreas- lifestyles that include routine weight-bearing ing saturated fat intake is likely very beneficial in this population.45,46 exercises. The role of vitamin D and related Most studies of prostate cancer prevention have compounds in the prevention of prostate cannot shown an association between vegetable and cer recurrence is being studied; two preliminary fruit intake and prostate cancer risk.42,44,201 A pos- studies suggest that vitamin D may reduce sible beneficial effect of lycopene, found in toma- prostate-specific antigen levels, administered toes and tomato products, watermelon, and pink either separately or in conjunction with chemo- grapefruit, has captured attention,203 but it is therapy, although further research is needed to unclear whether this association is causal or spu- determine the longer-term effects of vitamin D 207,208 rious.204 In one study in which the relationship supplementation. between dietary intakes and prostate cancer recur- Vitamin E supplementation in a large pre- rence was examined, intakes of fish and tomato vention trial intended to affect lung cancer was sauce were observed to be associated with reduced shown to be associated with a reduced risk for risk.97 Although benefits to prostate health from prostate cancer, but vitamin E had no effect on vegetables and fruits are far from certain, a diet survival in the men in whom prostate cancer high in vegetables and fruits has been found to developed in that study.113,209 Selenium supple- reduce the risk for cardiovascular diseases.46 ments reduced prostate cancer incidence in a Therefore, it is probably beneficial for prostate small trial intended to prevent skin cancers.193,210 cancer survivors to eat plenty of micronutrient- Trials are now under way to assess the effects of and phytochemical-rich vegetables and fruits. both vitamin E and selenium on both prostate Increased consumption of soy foods (eg, tofu cancer prevention and suppression of tumor and soy milk) is a common self-care strategy growth after diagnosis.211,212

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Studies that have examined the association Studies on the causes of head and neck can- between obesity or physical activity and the risk cers suggest that vegetable and fruit intake may for primary prostate cancer have not shown a be associated with decreased risk for develop- consistent relationship,49 although one large cohort ing these cancers, but few studies have consid- study did ﬁnd that prostate cancer survivors who ered whether these dietary factors or physical were obese had higher mortality rates.68 Two activity influence prognosis in survivors with follow-up studies of men in whom prostate can- these cancers. A clinical trial of the effects of a cer was diagnosed have not found a relationship beta-carotene supplement (versus placebo) among

between obesity and the risk for recurrence and survivors with head and neck cancers found that Downloaded from survival.88,202,213 However, one study found that those receiving beta-carotene had no changes obesity was associated with a higher risk of bio- in cancer recurrence or survival rates.220 chemical failure rates in men treated with radi- Persons with esophageal or gastric cancer may cal prostatectomy.214 Two trials have examined have symptoms that compromise food and nutri- the effects of exercise in prostate cancer survivors. ent intake and absorption, and the effects of One trial investigated the effects of resistance treatment may result in long-term nutritional caonline.amcancersoc.org exercise training 3 times weekly for 12 weeks in complications. A common problem in survivors patients receiving androgen deprivation therapy with esophageal cancer is reﬂux.4 Eating a high- and reported improvements in quality of life, protein, low-fat, high-carbohydrate diet helps fatigue, and muscular ﬁtness.215 The other trial increase lower esophageal sphincter pressure. showed increased physical functioning from a Chocolate, fat, alcohol, coffee, spearmint, pep- home-based walking program 3 times weekly permint, garlic, and onion may decrease lower for 4 weeks during radiation therapy.216 esophageal sphincter pressure and should be

Men in whom prostate cancer has been diag- avoided. Acidic foods, such as tomato-based by on August 5, 2009 (©American Cancer Society, Inc.) nosed should consume diets that are rich in veg- products and orange juice, may cause irritation. etables and fruit and low in saturated fat and Nutritional management for persons who have pursue a physically active lifestyle. Based on stud- gastric cancer is based on determining the por- ies of prostate cancer incidence, it may also be tion of the stomach involved or that which has prudent to consume diets that are moderate in been surgically resected. For example, if the calcium and low in dairy intake, although such pyloric sphincter has been affected, rapid tran- dietary suggestions need to be considered in the sit of food through the stomach may occur and context of increased risk of fractures from anti- call for smaller, more frequent feedings. androgen therapy and physical activity patterns. In the case of pancreatic cancer, there is increas- Although the evidence relating these recom- ing evidence that supplementation with omega- mendations to prostate cancer recurrence is lim- 3 fatty acids has a favorable effect on short-term ited, there are likely substantial other benefits, weight status, performance status, or related fac- most prominently decreasing cardiovascular dis- tors.61,221–223 A preliminary study examined the ease risk, which is the major cause of death in Gonzalez dietary and supplementation regimen, prostate cancer survivors. with results suggesting an improvement in survival rates. Because these results were in a self-selected Upper Gastrointestinal and Head group of patients, findings are not definitive. and Neck Cancers However, a study funded by the National Cancer Research on the primary prevention of head Institute is under way to determine whether this and neck, esophageal, gastric, and pancreatic regimen has a beneﬁcial effect.224 A small study cancers suggests the importance of diets that found that thalidomide (200 mg daily) was asso- emphasize vegetable and fruit intake and, in the ciated with slower loss of weight among persons case of pancreatic cancer, prevent obesity.67,217–219 with advanced pancreatic cancer.225 After the diagnosis of these cancers, however, Head and neck cancers can directly compro- little is known regarding whether such dietary pat- mise food intake, and high proportions of patients terns or other dietary or physical activity factors are malnourished at the time of diagnosis. Com- may affect prognosis. prehensive care of these survivors includes appro-

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priate nutritional assessment and support, and food choices, physical activity, and dietary sup- physical activity and physical therapy to improve plement use to improve their quality of life and overall health before, during, and after treat- survival. Health professionals who counsel patients ment. Poor nutrient intake can stem from difﬁ- should emphasize that no one study provides the culties in biting, chewing, and swallowing that last word on any subject, and that individual news follow surgery and from dry mouth, mucositis, reports may overemphasize what seem to be con- and taste alterations resulting from radiation ther- tradictory or conﬂicting results because they seem apy. Many long-term survivors of head and neck to be new, different, or challenge conventional

cancer will experience at least some degree of wisdom. In brief news stories, reporters cannot Downloaded from aspiration associated with substantial weight loss, always put new research findings in their proper diminished swallowing efficiency, and lower context. The best advice about diet and physi- quality of life scores.226 During and after treat- cal activity is that it is rarely advisable to change ment, the texture, temperature, consistency, diet or activity levels based on a single study or nutrient content, and frequency of oral feedings news report. The following questions and answers may need to be changed. Acidic, salty, spicy, and address common concerns of cancer survivors caonline.amcancersoc.org very hot or cold foods may not be well toler- regarding diet and physical activity. ated. Sugar-free gums and mints and the use of oral rinses and gels may provide limited relief of Alcohol symptoms and enhance appetite. Liquid, pureed, or juiced foods may be better tolerated during Does alcohol increase the risk treatment and recovery. Chemoradiation may of cancer recurrence? have a significant effect on patients’ eating abil- Many studies have found a link between alco- ity, which should improve by 12 months after hol intake and risk for some primary cancers, by on August 5, 2009 (©American Cancer Society, Inc.) 227 treatment. Health care providers may offer including cancers of the mouth, pharynx, lar- alternate forms of feeding if eating and drinking ynx, esophagus, liver, breast, and probably colon by mouth cannot support nutritional needs. cancer.44,99,100 In persons who have already When tube feeding is started immediately after received a diagnosis of cancer, alcohol intake surgery for esophageal or gastric cancer, it may could also affect the risk for new primary can- reduce both the duration of intensive care unit cers of these sites. Alcohol intake can increase 228 treatment and total hospital stay. Several small the circulating levels of estrogens, which theo- studies have shown that physical activity may retically could increase the risk for recurrence improve functioning, reduce pain and disabil- of estrogen receptor–positive breast cancer, but ity, and be related to quality of life in head and studies conducted to date have not been well 229–231 neck cancer survivors. suited to address this question.101 In the absence of more definitive information, survivors of head and neck and upper gas- Should alcohol be avoided during trointestinal cancers should strive to follow the cancer treatment? ACS Nutrition and Physical Activity Guidelines for the Prevention of Cancer. High intakes of The cancer type and stage of disease, as well vegetables and fiber have been shown to be ben- as treatment, should be considered in making eficial.232 Because food intake can be compro- recommendations on alcohol use during treat- mised due to the effects of disease or therapy, ment. Alcohol, even in the small amounts found consultation with a registered dietitian for indi- in mouthwashes, can be irritating to survivors vidualized recommendations is recommended.233 with oral mucositis and can exacerbate that condition.234 Therefore, it is reasonable to recommend that alcohol intake should be avoided or COMMON QUESTIONS ABOUT DIET, PHYSICAL limited among survivors with mucositis and ACTIVITY, AND CANCER SURVIVORSHIP among those beginning head and neck radio- Cancer survivors often request information therapy or chemotherapeutic regimens that put and advice from their healthcare providers about them at risk for mucositis. It is unknown whether

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similar effects may occur in adjuvant therapy for ing chemotherapy or radiation therapy to avoid other gastrointestinal cancers. dietary supplements exceeding 100% of the Daily Value for antioxidant-type vitamins.19–22 Antioxidants Fat What do antioxidants have to do with cancer? Will eating less total fat lower risk of cancer Antioxidants exist naturally in many forms and help prevent oxidative damage to tissues. recurrence or improve survival?

Because oxidative damage may be important in Several studies have been conducted on the Downloaded from the development of cancer, it has long been relationship between fat intake and survival after thought that antioxidants may help prevent can- the diagnosis of breast cancer, with inconsistent cer. Studies suggest that people who eat more results.84 Preliminary results from a large clini- vegetables and fruits, which are rich sources of cal trial of early-stage breast cancer survivors antioxidants (including vitamin C, vitamin E, suggest that low-fat diets may reduce the risk of carotenoids, and many other antioxidant phy- recurrence, particularly in women with estro- caonline.amcancersoc.org tochemicals), may have a lower risk for some gen receptor–negative disease.87 It is important types of cancer.235 Because cancer survivors may to note that although there is not conclusive evi- be at increased risk for second cancers, they dence that total fat consumption influences can- should be encouraged to consume a variety of cer outcomes, diets high in fat tend to be high antioxidant-rich foods each day. So far, clinical in calories and may contribute to obesity, which studies of antioxidant vitamin or mineral sup- in turn is associated with increased cancer inci- plements have not yet demonstrated a reduction dence at several sites, increased risk of recur- 236,237 in cancer incidence. The best advice rence, and reduced likelihood of survival for by on August 5, 2009 (©American Cancer Society, Inc.) presently is to consume antioxidants through many cancer sites (see Obesity). food sources rather than supplements. Do different types of fat influence cancer Is it safe to take antioxidant supplements incidence and survival? during cancer treatment? There is evidence that certain types of fat, such Many dietary supplements contain levels of as saturated fats, may have an effect on increas- antioxidants (such as vitamins C and E) that sub- ing cancer risk.44,45,238 There is little evidence that stantially exceed the amount recommended in the other types of fat (omega-3 fatty acids, found pri- Dietary Reference Intakes for optimal health.19–22 marily in fish), monounsaturated fatty acids (found At the present time, most oncologists advise in olive and canola oils), or other polyunsaturated against taking higher doses of supplements with fats reduce cancer risk. In one study, saturated fat antioxidant activity during chemotherapy or intake was inversely associated with prostate can- radiotherapy because antioxidants could repair cer–specific survival, and in another, monoun- cellular oxidative damage to cancer cells that saturated fat intake and risk of death from prostate contributes to the effectiveness of these treat- cancer were inversely associated.88,89 In addition, ments.23,24 Others, however, have noted that the excess saturated fat intake is a known risk factor possible harm from antioxidants is only hypothet- for cardiovascular diseases, a major cause of mor- ical and that there may be a net benefit to help bidity and mortality in all populations, including protect normal cells from the collateral damage cancer survivors. Although trans fats have adverse associated with these therapies.25 Whether antiox- cardiovascular effects, such as raising blood cho- idants or any other dietary supplements specifi- lesterol levels,46,75 their relationship to cancer cally are beneficial or harmful during chemo- incidence or survival has not been determined. therapy or radiotherapy is a critical question Regardless, survivors (especially those at increased without a clear scientific answer at this time.26–28 cardiovascular disease risk) should consume as Given this uncertainty, until more evidence is few trans fats as possible. Major sources of trans available that suggests more benefit than harm, fats are margarines and snack foods that contain it is prudent for cancer survivors currently receiv- partially hydrogenated oils.

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Fiber of processed and red meats. There is no evidence available regarding the effect of processed meat, Can dietary ﬁber prevent cancer or meat cooked at high temperature, or meat in improve cancer survival? general on cancer recurrence or progression.

Dietary ﬁber includes a wide variety of plant Obesity carbohydrates that are not digestible by humans. Specific categories of fiber are “soluble” (like Does being overweight increase risk of cancer oat bran) or “insoluble” (like wheat bran and recurrence and second primary cancers?

cellulose). Soluble fiber helps lower the risk of Increasing evidence indicates that being over- Downloaded from coronary heart disease by reducing blood cho- weight increases the risk for recurrence and lesterol levels. Fiber is also associated with reduces the likelihood of survival for many can- improved bowel function. Good sources of fiber cers.10,50,71,74 Increased body weight has been are beans, vegetables, whole grains, and fruits. associated with increased death rates for all can- Associations between fiber and cancer incidence cers combined and for increased incidence for are weak, but consumption of these foods is still cancers at several specific sites, including can- caonline.amcancersoc.org recommended because they contain other nutri- cer of the esophagus, colon and rectum, liver, ents that may help reduce cancer risk and pro- gallbladder, pancreas, kidney, non-Hodgkin lym- vide other health benefits, such as reduced risk phoma, and multiple myeloma, in addition to of coronary heart disease.43 cancers of the stomach and prostate in men and cancers of the breast, uterus, cervix, and ovary Food Safety in women.49,68 Because of other proven health Are there special food safety precautions for benefits to losing weight, people who are over- by on August 5, 2009 (©American Cancer Society, Inc.) individuals undergoing cancer treatment? weight are encouraged to stop gaining weight, then to lose weight and prevent re-gain. The Infection is of special concern for cancer sur- avoidance of excessive weight gain during adult- vivors, especially during episodes of immunosup- hood is important not only to reduce cancer pression and leukopenia that can occur with certain incidence and risk of recurrence, but the risk of cancer treatment regimens.102 During immuno- other chronic diseases as well.42,46,75 suppressive cancer treatment, survivors should be particularly careful to avoid eating foods that may Organic Foods contain unsafe levels of pathogenic microorgan- Are foods labeled organic recommended isms. General food safety practices, such as wash- for cancer survivors? ing hands before eating, thoroughly washing vegetables and fruits, and keeping foods at proper The term organic is popularly used to designate temperatures, should be encouraged, and sur- plant foods grown without pesticides and genetic vivors should receive specific instructions regard- modifications, or meat, poultry, eggs, and dairy ing food safety as outlined in Table 3. products that come from animals that are given no antibiotics or growth hormones. Use of organic Meat: Cooking and Preserving on food labels and packaging is regulated by the US Department of Agriculture to meet these Should I avoid meats? and other criteria. It is commonly thought that Several epidemiologic studies have linked high organic foods may be more healthful because consumption of red meat and processed meats they reduce exposure to agricultural chemicals. with increased risk of colorectal, prostate, and It has also been suggested that their nutrient stomach cancers.218,238–240 Some research sug- composition may be better than their convention- gests that frying, broiling, or grilling meats at ally grown counterparts. Whether this translates very high temperatures creates chemicals that into health benefits from consumption of organic might increase incidence of some types of can- foods is unknown. At present, no epidemiologic cer. For these reasons, ACS Guidelines for can- studies in humans exist to demonstrate whether cer prevention recommend limiting consumption such foods are more effective in reducing can-

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cer incidence, recurrence, or progression than cancer growth. Nonetheless, overweight and similar foods produced by other farming and obesity have been associated with increased inci- production methods. dence of many types of cancer49 and with risk of recurrence of some cancers, and physical activ- Physical Activity ity is a key component of maintaining and achiev- Should I exercise during cancer treatment ing a healthy body weight. In addition, physical and recovery? activity has a beneficial effect on preventing cardiovascular disease, diabetes, and osteoporo- Evidence strongly suggests that exercise is not 49,123 sis. Therefore, cancer survivors should be Downloaded from only safe and feasible during cancer treatment, encouraged to adopt a physically active lifestyle. but that it can also improve physical functioning and various aspects of quality of life.30–33,150 Phytochemicals Moderate exercise has been shown to improve What are phytochemicals, and do they fatigue, anxiety, and self-esteem, as well as car- reduce cancer risk? diovascular fitness, muscle strength, and body caonline.amcancersoc.org composition. Persons receiving chemotherapy The term phytochemicals refers to a wide vari- and radiation therapy who are already on an ety of compounds produced by plants. Some have either antioxidant or hormone-like actions exercise program may need to temporarily exer- 44 cise at a lower intensity and progress at a slower both in plants and in people who eat them. pace compared with persons who are not receiv- Studies examining the effects of phytochemi- ing cancer treatment. The principal goal should cals or specific plant foods such as vegetables or be to maintain activity as much as possible. fruits on cancer recurrence or progression are very limited, and the little evidence that exists is by on August 5, 2009 (©American Cancer Society, Inc.) Are there special precautions survivors inconsistent or comes from only a few studies. should consider? Because consumption of vegetables and fruits reduces incidence of some types of cancer, Particular issues for cancer survivors may affect researchers are searching for specific compo- or contraindicate their ability to exercise. Some nents that might account for the beneficial effects. effects of treatment may also increase the risk There is no evidence that phytochemicals taken for exercise-related injuries and adverse effects. as supplements are as beneficial as the vegeta- For example, survivors with severe anemia should bles, fruits, beans, and grains from which they delay activity until the anemia is improved; sur- are extracted. vivors with compromised immune function should avoid public gyms and other public places Soy Products until their white blood cell counts return to safe levels; survivors undergoing radiation should Is including soy-based foods in the diet avoid swimming pools because chlorine expo- recommended for cancer survivors? sure may irritate irradiated skin. For those who Soy-derived foods are an excellent source of were sedentary before diagnosis, low-intensity protein and in this respect, a good alternative activities should be adopted and slowly advanced. to meat. Soy contains several phytochemicals, For older persons and those with bone disease some of which have weak estrogenic activity (due to skeletal metastases or to severe osteo- and seem to protect against hormone-depend- porosis) or significant impairments such as arthri- ent cancers in animal studies. Other compounds tis or peripheral neuropathy, careful attention have antioxidant properties, are protease inhibi- should be given to balance to reduce the risk tors, and may have anti-angiogenic activity. There for falls and injuries. is considerable public and scientific interest in Can regular exercise reduce the risk the role of soy foods in the prevention of cancer in general and breast cancer in particular, although of cancer recurrence? scientific support for such a role is inconsistent.167–170 It is not known whether exercise will reduce For the breast cancer survivor, current evi- the chances of cancer recurrence or will slow dence suggests neither specific benefits nor harm-

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ful effects when soy is provided in the moderate may reduce the risk of some types of cancer, amounts observed in most traditional Asian diets and some recent studies suggest there may be a (no more than three servings per day) as part of beneficial effect on recurrence or survival for a healthy diet.167 However, because higher doses breast, prostate, and ovarian cancers. However, of soy may have estrogenic effects170 and because there is no evidence at this time that supple- higher levels of estrogens clearly increase the risk ments can provide these beneﬁts. Many health- for progression of estrogen receptor–positive breast ful compounds are found in vegetables and fruits, cancer,167 it is prudent for breast cancer survivors and it is likely that these compounds work syn-

to avoid the high doses of soy and soy isoflavones ergistically to exert their beneficial effect. There Downloaded from that are provided by more concentrated sources are likely to be important, but as yet poorly un- such as soy powders and isoflavone supplements. derstood or unidentified, components of whole food that are not included in supplements. The Sugar small amount of dried powder in the pills that Does sugar “feed” cancer? are represented as being equivalent to vegetables and fruits frequently contains only a small caonline.amcancersoc.org No. Sugar intake has not been shown to fraction of the levels contained in the whole directly increase risk or progression of cancer. foods. Food is the best source of vitamins and However, sugars (including honey, raw sugar, minerals. brown sugar, high-fructose corn syrup, and molasses) and beverages that are major sources Vegetables and Fruits of these sugars (such as soft drinks and fruit- Will eating vegetables and fruits lower risk flavored beverages) add substantial amounts of of cancer recurrence? calories to the diet and thus can promote weight by on August 5, 2009 (©American Cancer Society, Inc.) gain, which adversely affects cancer outcomes. Greater consumption of vegetables and fruits In addition, most foods and beverages that are has been associated in the majority of epidemi- high in sugar do not contribute many nutrients ologic studies with a lower risk of lung, oral, to the diet and often replace more nutritious esophageal, stomach, and colon cancer.241 Few food choices. Therefore, limiting sugar con- studies exist, however, on whether a diet includ- sumption is recommended. ing many vegetables and fruits can reduce the risk of cancer recurrence or improve survival. Supplements Some recent studies suggest increasing intake Would survivors benefit from using vitamin of vegetables may exert a beneficial effect on recurrence or survival for breast, prostate, and and mineral supplements? ovarian cancers.95–97 Nonetheless, cancer sur- During and after cancer treatment, there is a vivors should be encouraged to consume at least probable benefit of taking a standard multiple five servings of a variety of vegetables and fruits vitamin and mineral supplement that contains each day because of their other health benefits. approximately 100% of the Daily Value because, Because it is not known which of the many during these times, it may be difficult to eat a compounds in vegetables and fruits are most diet with adequate amounts of these micronu- protective, the best advice is to consume five trients. The use of very large doses of vitamins, or more servings of a variety of colorful veg- minerals, and other dietary supplements is not etables and fruits each day. recommended237 because some evidence exists Is there a difference in the nutritional value of that indicates that high-dose supplements can increase cancer risk.113,114 fresh, frozen, and canned vegetables and fruits? Yes, but they can all be good choices. Fresh Can nutritional supplements lower cancer foods are usually considered to have the most incidence or risk of recurrence? nutritional value. Often, though, frozen foods There is strong evidence that a diet rich in can be more nutritious than fresh foods because vegetables, fruits, and other plant-based foods they are often picked ripe and quickly frozen;

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nutrients can be lost in the time between harvest Water and Other Fluids and consumption for fresh foods. Canning is How much water and other fluids more likely to reduce the heat-sensitive and water-soluble nutrients because of the high heat should I drink? temperatures necessary in the canning process.242 Many symptoms of fatigue, light-headedness, Be aware that some fruits are packed in heavy and nausea can be due to dehydration; survivors syrup, and some canned vegetables are high in should therefore be encouraged to try to remain sodium. Choose vegetables and fruits in a vari- adequately hydrated. Consumption of water and ety of forms. other liquids may reduce the incidence of blad- Downloaded from 244 Does cooking affect the nutritional value der and colon cancer. Drinking at least eight cups of liquid a day is usually recommended for of vegetables? the general public and is a reasonable recom- Boiling vegetables, especially for long peri- mendation for survivors, with the exception of ods, can leach out their content of water- those who have a specific medical reason for soluble vitamins. Microwaving and steaming are restricting fluid intake. caonline.amcancersoc.org the best ways to preserve the nutritional content in vegetables. ACS 2006 NUTRITION, PHYSICAL ACTIVITY AND Should I be juicing my vegetables and fruits? CANCER SURVIVORSHIP ADVISORY COMMITTEE Juicing can add variety to the diet and can be a good way to consume vegetables and fruits, Volunteer Members: Noreen M. Aziz, especially for those who have difficulty chew- MD, PhD, MPH; Senior Program Director, ing or swallowing. Juicing also improves the Office of Cancer Survivorship, Division of Cancer by on August 5, 2009 (©American Cancer Society, Inc.) body’s absorption of some of the nutrients in Control & Population Sciences, National Cancer vegetables and fruits. However, juices may be Institute, NIH/DHHS, Bethesda, MD; Abby F. less filling than whole vegetables and fruits and Bloch, PhD, RD, FADA; Nutrition Consultant, contain less fiber. Fruit juice, in particular, can New York, NY; Jean K. Brown, PhD, RN, contribute excess calories to one’s diet if large FAAN; Acting Dean and Professor in Nursing, amounts are consumed. Commercially juiced Nutrition, and Rehabilitation Science, University products should be 100% vegetable or fruit juices at Buffalo School of Nursing, Buffalo, NY; Tim and should be pasteurized to eliminate harmful Byers, MD, MPH; Professor, Department of microorganisms. This is true for the general pop- Preventive Medicine and Biometrics; and Deputy ulation, but is of particular concern for people Director, University of Colorado Cancer Center, who may be immunocompromised, such as can- Aurora, CO; Bette Caan, DrPH; Senior cer patients undergoing chemotherapy. Research Scientist, Division of Research, Kaiser Permanente, Oakland, CA; June M. Chan, Vegetarian Diets ScD; Assistant Professor and Program Director, Genitourinary Cancer Epidemiology and Popu- Do vegetarian diets reduce risk of lation Science, University of California, San cancer recurrence? Francisco, CA; Kerry S. Courneya, PhD; No direct evidence has determined whether Professor and Canada Research Chair in Physical consuming a vegetarian diet has any additional Activity and Cancer, Faculty of Physical benefit for the prevention of cancer recurrence Education, University of Alberta, Edmonton, over an omnivorous diet high in vegetables, fruits, Alberta; Wendy Demark-Wahnefried, PhD, and whole grains and low in red meats. However, RD, LDN; Professor, School of Nursing and vegetarian diets can have many healthful charac- Department of Surgery, Duke University Medical teristics because they tend to be low in saturated Center, Durham, NC; Brandy M. Gazo, MA, fat and high in fiber, vitamins, and phyto- MSSW; Research Program Coordinator, Lance chemicals,243 and are consistent with the ACS Armstrong Foundation, Austin, TX; Barbara Nutrition Guidelines for the Prevention of Cancer. Grant, MS, RD; Oncology Nutritionist, Saint

Volume 56 • Number 6 • November/December 2006 347 Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices

Alphonsus Regional Medical Center, Cancer California, San Diego, La Jolla, CA; Julia H. Care Center, Boise, ID; Kathryn K. Hamilton, Rowland, PhD; Director, Office of Cancer MA, RD, CDN; Outpatient Oncology Dietitian, Survivorship, Division of Cancer Control and Carol G. Simon Cancer Center, Morristown Population Sciences, National Cancer Institute, Memorial Hospital, Morristown, NJ; Carolyn NIH/DHHS, Bethesda, MD; Cyndi Katzin, MSPH, CNS; Certified Nutrition Thompson, PhD; Assistant Professor, University Specialist, Los Angeles, CA; Lawrence H. Kushi, of Arizona Department of Nutritional Sciences, ScD; Associate Director for Etiology & Prevention Tucson, AZ

Research, Division of Research, Kaiser Perm- American Cancer Society Staff Mem- Downloaded from anente, Oakland, CA; Anne McTiernan, MD, bers: Terri Ades, RN, MS, AOCN; Director PhD; Full Member, Fred Hutchinson Cancer of Cancer Information; Kimberly S. Andrews; Research Center, Cancer Prevention Research Research Associate, Cancer Control Science; Program, Seattle, WA; Marion Morra, MA, Colleen Doyle, MS, RD; Director, Nutrition ScD; President, Morra Communications, and Physical Activity; Ted Gansler, MD, Milford, CT; Margaret S. Pierce, MSN, MPH, MBA; Director of Medical Content; Greta caonline.amcancersoc.org AOCN, APRN, BC; Assistant Professor, Greer; Manager, Cancer Survivors Network; University of Tennessee, College of Nursing, Sheri Knecht, RD, CNSD, LDN; Dietitian Knoxville, TN; Cheryl L. Rock, PhD, RD; on Call, South-Atlantic Division; Kristina Professor, Department of Family and Preventive Ratley, RD, LDN; Dietitian on Call, South- Medicine, School of Medicine, University of Atlantic Division

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78. Nestle M. Increasing portion sizes in American for Healthcare Research and Quality. February supplement use among adults diagnosed with can- diets: more calories, more obesity. J Am Diet Assoc 2005. cer. J Am Diet Assoc 2003;103:323–328. 2003;103:39–40. 93. Tohill BC, Seymour J, Serdula M, et al. What 110. Willett WC, Stampfer MJ. Clinical practice. 79. Nielsen SJ, Popkin BM. Patterns and trends epidemiologic studies tell us about the relation- What vitamins should I be taking, doctor? N Engl in food portion sizes, 1977–1998. JAMA 2003; ship between fruit and vegetable consumption and J Med 2001;345:1819–1824. 289:450–453. body weight. Nutr Rev 2004;62:365–374. 111. Fletcher RH, Fairfield KM. Vitamins for 80. Rolls BJ, Morris EL, Roe LS. Portion size of 94. Slavin J. Why whole grains are protective: bio- chronic disease prevention in adults: clinical appli- food affects energy intake in normal-weight and logical mechanisms. Proc Nutr Soc 2003;62: cations. 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