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Guidelines for Cancer Survivors

What You Should Do if You Have or Have Ever Had Cancer

One in 25 North Americans are now cancer survivors and 68 percent live more than five years after receiving their diagnosis. The American Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer survivorship to evaluate the scientific evidence to make recommendation to prevent recurrences of cancer and prolong the lives of people who have had cancer (CA: Cancer Journal for Clinicians, published online April 27, 2012).

The American Cancer Society recommends that people who have had cancers should:

• eat a diet low in red meat, fried foods, refined carbohydrates, desserts, and high-fat dairy and high in fruits, vegetables, and whole grains

• lose excess weight

• Get support feeding if they are rapidly losing weight from chemotherapy, radiation, or disease progression

• take nutritional supplements only if a nutrient deficiency is clinically or biochemically demonstrated: low levels of vitamin D or B12, or significant osteoporosis

• Exercise at least 150 minutes a week, and do strength training at least twice a week.

The following recommendations are taken from the report. Almost every sentence is followed by a journal reference that you can find in the report at
http://onlinelibrary.wiley.com/doi/10.3322/caac.21142/full

EXERCISE:
At least 20 prospective observational studies have shown that physically active cancer survivors have a lower risk of cancer recurrences and improved survival compared with those who are inactive. Guidelines written by an expert panel convened by the American College of Sports Medicine (ACSM) recommend that individuals avoid inactivity and return to normal activity as soon as possible after diagnosis or treatment. More than 20 observational studies have demonstrated that higher levels of physical activity are associated with a lower risk of disease recurrence and improved survival.

DIET:
A diet high in fruits, vegetables, whole grains, poultry, and fish was found to be associated with reduced mortality compared with a diet with a high intake of refined grains, processed and red meats, desserts, high-fat dairy products, and French fries, in women after breast cancer diagnosis and treatment.

Similarly, a 43 percent reduction in overall mortality was observed in a study of breast cancer survivors in association with a dietary pattern characterized by the high intake of vegetables and whole grains. Breast cancer survivors who reported eating at least 5 servings of vegetables and fruits each day and having weekly physical activity equivalent to 30 minutes of walking for 6 days per week were observed to have a higher survival rate, although a significant survival advantage was not observed for either of these behaviors alone.

In patients with colorectal cancer, one observational study of over 1000 survivors found that a diet characterized by a higher intake of red meat, processed meat, refined grains, and sugary desserts was associated with a statistically significant increase in cancer recurrence and poorer overall survival.

A higher saturated fat intake predicted shorter disease-specific survival and in another, greater monounsaturated fat intake predicted longer survival.129, 130

A vegan diet, which excludes all animal foods and animal products, can meet protein needs if nuts, seeds, legumes, and cereal-grain products are consumed in sufficient quantities, although supplemental vitamin B12 will be necessary to meet needs for that vitamin.

As dietary vitamin D in the United States comes primarily from fortified dairy foods, a vegan diet may also need to include supplemental vitamin D if adequate exposure to the sun or ultraviolet light is not obtained.

Saturated fat intake (but not total fat) is associated with worse survival,269 and the other found that monounsaturated fat intake is associated with better survival.129. There is little evidence that other types of fat (omega-3 fatty acids, found primarily in fish and also walnuts; monounsaturated fatty acids, found in olive and canola oils; or other polyunsaturated fats) reduce cancer risk. ORGANIC FOODS:
At present, no epidemiologic studies in humans demonstrate whether such foods are more effective in reducing cancer incidence, recurrence, or progression than similar foods produced by other farming and production methods. The term organic is used to describe foods grown without pesticides and genetic modifications or meat, poultry, eggs, and dairy products obtained from animals that are given no antibiotics or growth hormones.

OVERWEIGHT:
Obesity is a major risk factor for cancers. Full fat cells turn on your immunity to cause inflammation that causes excess cell growth.

Many patients begin cancer treatment already overweight or obese. In the United States, obesity is a well-established risk factor for some of the most common cancers.52 Results of the Women's Intervention Nutrition Study (WINS) found that a low-fat diet that resulted in a 6-pound weight loss (approximately 4% of initial weight) reduced the risk of recurrence among postmenopausal breast cancer survivors. 91

Wight management is now considered a priority standard of care for overweight women diagnosed with early stage breast cancer.8, 192

RAPID WEIGHT LOSS:
For survivors who cannot meet their nutritional needs through foods alone, fortified, commercially prepared or homemade nutrient-dense beverages or foods can improve the intake of energy and nutrients.

DIETARY SUPPLEMENTS:
Because of emerging evidence on detrimental effects from even the modest use of dietary supplements in the oncology population, many cancer experts continue to advise against taking supplements during and after treatment, or suggest limiting use to those dietary supplements needed to treat a deficiency or promote another aspect of health. One reason for concern involves the theory that a subgroup of dietary supplements, antioxidants, could prevent the cellular oxidative damage to cancer cells that is required for treatments such as radiation therapy and chemotherapy to be effective.22 If interested in supplementation, individuals should first assess whether they are nutrient deficient, avoid ingesting supplements that exceed more than 100% of the Daily Value, and consider limiting dietary supplement use to therapeutic interventions for chronic conditions such as osteoporosis and macular degeneration, for which scientific evidence supports the likelihood of benefits and low risk of harm.

VITAMIN PILLS:
A 2006 meta-analysis found no association between antioxidant or vitamin A supplementation and all-cause mortality among cancer patients, although the authors noted that this report was limited by the small number of trials, particularly those of high quality.146 The use of multivitamins or vitamins E or C was not associated with protection from cancer death in a cohort of 77,719 Washington state residents followed over a 10-year period.147 In 2 large observational studies, the use of a full range of dietary supplements or multivitamins in particular was not associated with breast cancer recurrence, breast cancer-specific mortality, or overall mortality among women diagnosed with early stage breast cancer.148, 149 A similar finding was reported for multivitamin use among colorectal cancer survivors.150 In addition, one trial suggests that beta-carotene supplements may increase the rate of colorectal adenoma recurrence in persons who smoke cigarettes, consume alcohol, or both.151 A randomized clinical trial of 540 head and neck cancer patients receiving radiation therapy in which participants were randomized to either 400 IU/day of vitamin E or placebo found that supplement use was associated with significantly higher cause-specific and all-cause mortality.152 In addition, the recent Selenium and Vitamin E Cancer Prevention Trial (SELECT) found that men who were assigned supplemental selenium or vitamin E had a higher incidence of diabetes and prostate cancer, respectively.153

EXERCISE DURING CANCER TREATMENT:
Existing evidence strongly suggests that exercise is not only safe and feasible during cancer treatment, but that it can also improve physical functioning, fatigue, and multiple aspects of quality of life.28

WHY DIET, EXERCISE AND WEIGHT CONTROL IMPORTANT:
Because individuals who have been diagnosed with cancer are at a significantly higher risk of developing second primary cancers,45 and may also be at an increased risk of chronic diseases such as cardiovascular disease, diabetes, and osteoporosis, the guidelines established to prevent those diseases are especially important for cancer survivors.46-51

VITAMIN D:
Some observational studies have reported that breast cancer survivors have high rates of vitamin D insufficiency,154 suggesting the need for vitamin D supplementation. Although supplemental vitamin D may help to meet nutritional needs for this vitamin, circulating concentrations have not been shown to affect the risk of breast cancer recurrence.155 Two observational studies have found that a higher circulating prediagnosis vitamin D or higher postdiagnosis vitamin D level is associated with significant improvements in overall and/or colorectal cancer-specific mortality among colorectal cancer survivors.156, 157 A recent review, however, suggests that taking vitamin D supplements has not been proven to improve outcomes in cancer patients.158 These findings underscore the need to first assess whether nutrient status is indeed deficient before initiating supplements, since individuals who are truly deficient may derive some benefit, whereas those who take additional supplements but who are already well-nourished are unlikely to benefit and may incur harm. ALCOHOL: Alcoholic drinks up to one or 2 drinks per day (for women and men, respectively) can lower the risk of heart disease, but higher levels do not offer additional benefit and may increase the risk not only of complications of alcohol overuse, but also of specific cancers.168 Therefore, it is reasonable to recommend that alcohol intake should be avoided or limited among survivors with mucositis and among those beginning head and neck radiation therapy or chemotherapeutic regimens that put them at risk for mucositis. Among cancer survivors, the prevalence of alcohol use generally mirrors that in the general population, although among some survivor groups (ie, survivors of prostate and head and neck cancers) it is higher.169

VITAMIN AND MINERAL SUPPLEMENTS:
Survivors are strongly encouraged to obtain their needed nutrients through foods, as opposed to supplements. While dietary supplements are indicated in cases of nutrient deficiency (either that which is confirmed through laboratory testing or through the clinical presence of disease [eg., osteoporosis or osteopenia]), given the growing literature on the adverse effects of nutritional intake beyond normal levels,161, 317 A concern exists that supplements may do more harm than good.

DIETARY SUPPLEMENTS:
There is no evidence at this time that dietary supplements can reduce the risk of recurrence or improve the likelihood of survival.

Posted 3/16/12

May 30th, 2013
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About the Author: Gabe Mirkin, MD

Sports medicine doctor, fitness guru and long-time radio host Gabe Mirkin, M.D., brings you news and tips for your healthful lifestyle. A practicing physician for more than 50 years and a radio talk show host for 25 years, Dr. Mirkin is a graduate of Harvard University and Baylor University College of Medicine. He is board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology. The Dr. Mirkin Show, his call-in show on fitness and health, was syndicated in more than 120 cities. Read More
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