Optimal Nutritional Goals for the Cancer Survivor

Transcription

1 W O R K I N G E V E R Y D A Y T O P R O V I D E T H E H I G H E S T Q U A L I T Y O F L I F E F O R P E O P L E W I T H C A N C E R Optimal Nutritional Goals for the Cancer Survivor W E N D Y D E M AR K - WAH N E F R I E D, P H D, R D P R O F E S S O R A N D W E B B C H A I R O F N U T R I T I O N S C I E N C E S A S S O C I AT E D I R E C T O R O F C A N C E R P R E V E N T I O N & C O N T R O L U N I V E R S I T Y O F A L A B A M A AT B I R M I N G H A M

2 Disclosures AFFILIATION/FINANCIAL INTERESTS (prior 12 months) Grants/Research Support: Scientific Advisory Board/Consultant: Speakers Bureau: CORPORATE ORGANIZATION No Corporate Sponsorship Stock Shareholder: Other

3 Objectives By the end of this presentation, the observer should be able to Recognize trends in cancer prevalence, mortality and survivorship. Identify common issues in cancer survivorship. Identify diet and physical activity guidelines for cancer survivorship and outline the rationale that supports them. List some of the gaps in knowledge related to nutrition and cancer survivorship Identify reliable sources for nutrition and cancer information.

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6 Number of Cancer Survivors is Steadily Rising Good News! 14.5 M!

7 Cancer Survivorship: The Bad News Cancer Survivors at greater risk - Progressive disease - Second primaries - Cardiovascular Disease - Diabetes - Osteoporosis - Sarcopenia - Functional decline

8 % with Limitations: Survivors vs. General Population Hewitt, Rowland, Yancik. J Gerontol. 58:82, 2003

9 Possible Solutions Diet Exercise Depression Fatigue Adverse Body Composition Functional Decline Comorbidity Recurrence Growing evidence Growing evidence Possible benefit Probable benefit Convincing benefit

10 Cancer-Related Diet & Physical Activity Recommendations WCRF- AICR (2007) American Cancer Society (2012) Weight Physical Activity (PA) Dietary Pattern Be as lean as possible without becoming underweight Regular PA, >30 min/day Avoid sugary drinks. Limit energy-dense foods (foods high in sugar & fat, and low in fiber) Eat more of a variety of vegetables, fruits, whole grains and legumes Limit consumption of processed & red meat Achieve & maintain a healthy weight Avoid inactivity; PA >150/week; strength training 2 x week Diet High F&V & Whole Grains Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups fruits & vegetables/day Whole vs. refined grains Limit consumption of processed & red meat Other Limit salty foods - Alcohol If drink limit to 1-2 drinks/day If drink limit to 1-2 drinks/day Supplements Do not use supplements to protect against cancer Rock et al. CA Cancer J Clin 2012; WCRF-AICR 2 nd Expert Research Report,

11 Weight Management & Energy Balance Anorexia/Cachexia Patients with select respiratory, G.I. & childhood cancers Patients living with advanced cancer Increasing weight to desired range important for recovery, well-being, functional status Diet & exercise key roles +/- pharmacotherapy Overweight/Obesity Risk factors for several cancers, as well as cancerrelated mortality Increased weight at diagnosis is a poor prognostic factor Weight gain common during & after treatment linked with comorbidity, functional decline & maybe recurrent/progressive CA

12 Worldwide rates of obesity and overweight Worldwide 35% of adults are overweight and 11% are obese (2008) doubled since 1980 prevalence higher in select survivor groups (breast & prostate) 65% of the world's population live in countries where overweight and obesity kills more people than underweight. Medical costs for obese people are $1,429 (USD) higher than those of normal weight

13 Increases in Cancer Risk with Overweight & Obesity Probable Evidence that Cancer of the Ovary & Gallbladder are Weight-Related Breast (post-menopause) Colon Endometrium Kidney Esophagus Pancreas Overweight Obesity WHO: IARC 2002/WCRF AICR 2007

14 Obesity and Cancer-related Mortality Males Females Multiple myeloma (> 35) Colon and rectum (> 35) Ovarian (> 35) Liver (> 35) All cancers (> 40) NHL (> 35) Breast (> 40) Gallbladder (> 30) Esophagus (> 30) Pancreas (> 40) Cervical (> 35) Kidney (> 40) Uterus (> 40) Prostate (> 35) NHL (> 35) All cancers (> 40) Kidney (> 35) Multiple Myeloma (> 35) Gallbladder (> 30) Colon and rectum (> 35) Esophagus (> 30) Stomach (> 35) Pancreas (> 35) Liver (> 35) Relative Risk of Death (95% confidence interval) Calle EE et al. NEJM.348:1625, 2003.

15 Prognostic Effects of Weight Gain Among Individuals with Breast and Prostate Cancer: Results of 2 Meta-Analyses Group (year) Chan et al. (2014) # of studies ,075 women with breast cancer Sample RR (95% CI) for every 5 kg/m 2 increase in BMI from pre- to post-dx Breast CA Specific Mortality 1.29 ( ) Total Mortality 1.08 ( ) Cao & Ma (2011) 6 cohort 18,203 men with prostate cancer Biochemical Recurrence 1.21 ( ) Prostate CA Specific Mortality 1.20 ( )

16 Potential Mechanisms Whereby Obesity Influences Cancer Inflammation Adipokines/Growth Factors Sex Steroids Obesity Binding Proteins/Receptors Insulin Cancer Increased Substrate Levels (glucose & free fatty acids) Diabetes other Comorbidities Metformin, Statins and Other Pharmacologic Agents Adapted from Irwin et al.

17 Weight Loss Interventions 1 st trial de Waard 102 post-menopausal breast cancer survivors Europ J Cancer Prev 2:233, weight loss trials in breast cancer (2-18 months). No adverse events. 57% resulted in >5% loss of body weight. Clinically significant benefits in Hb A1C, insulin, inflammatory markers, QoL, lipids, physical functioning and B/P with 5-9% weight loss. In field or in analysis SUCCESS-C pre/post breast cancer (n=1,400-1,600) 2-yrs, telephone counseling + mailed materials vs. mailed materials LISA 336 post menopausal, telephone counseling + mailed materials vs. mailed materials DIANA-5 pre/post breast cancer (n=1,417) 5-yrs, clinic-based vs. mailed materials Choice 259 post menopausal low CHO vs. low fat vs. control ENERGY pre/post menopausal (N=692), Clinic based+ telephone counseling + mailed materials vs. standard care Reeves M et al. Obesity Rev doi /obr/

18 Interest in Obesity & Cancer Increasing IOM Workshop on Cancer Survival and Recurrence Oct Nov 1;32(31):

19 2012 American Cancer Society (ACS) Nutrition & Physical Activity Guidelines for Cancer Survivors Achieve and maintain a healthy weight If overweight or obese, limit high calorie foods & beverages increase physical activity to promote weight loss Engage in regular physical activity Avoid inactivity; resume normal activities as soon as possible following dx Exercise >150 minutes/week Include strength training exercises at least 2 days/week Achieve a dietary pattern that is high in vegetables, fruits and whole grains Follow ACS Guidelines on Nutrition & Physical Activity for Cancer Prevention - Choose foods & beverages in amounts that achieve/maintain a healthy weight - Limit processed and red meat - Eat > 2.5 cups of vegetables & fruits/day - Choose whole grains instead of refined grain products - If you drink ETOH, drink <1 drink/day for & 2 drinks/day for Supplements Try to obtain nutrients through diet, first. Consider only if a nutrient deficiency is biochemically or clinically observed, or if intakes fall persistently below recommended levels as assessed by an RD. CA CANCER J CLIN (2012) DOI /CAAC

20 Cochrane Review: Exercise on Quality of Life Post-treatment 40 trials with 3694 participants Mishra et al. Cochrane Database Rev 2012 Outcome # studies/n Evidence Qual Positive effects Overall QOL, <12 weeks 11/826 Low 0.48 ( ) Overall QOL, 6 mo 2/115 Moderate 0.46 ( ) Anxiety, <12 weeks 4/455 Low (-0.4 to -0.07) Emotional well being 8/632 Low 0.33 (0.05 to 0.61) Fatigue, <12 weeks 10/745 Moderate (-1.50 to -0.14) Fatigue, 12 wks-6 mo 3/246 Low (-0.83 to -0.02) Pain, <12 weeks 4/289 Moderate (-0.55 to -0.04) Sexuality, 6 mo 2/193 Moderate 0.40 (-0.72 to -0.20) Sleep disturbance, <12 weeks 8/438 Moderate (-0.72 to -0.20) Social functioning, <12 weeks 5/386 Very low 0.45 (0.02 to 0.87) Social functioning, 6 months 2/110 Moderate 0.49 (0.11 to 0.87)

21 Forest plot of the relations of change in physical activity (PA) from pre- to post-diagnosis to total mortality and cancer mortality. Schmid D, and Leitzmann M F Ann Oncol 2014;25: The Author Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please journals.permissions@oup.com.

22 2012 American Cancer Society (ACS) Nutrition & Physical Activity Guidelines for Cancer Survivors Achieve and maintain a healthy weight If overweight or obese, limit high calorie foods & beverages increase physical activity to promote weight loss Engage in regular physical activity Avoid inactivity; resume normal activities as soon as possible following dx Exercise >150 minutes/week Include strength training exercises at least 2 days/week Achieve a dietary pattern that is high in vegetables, fruits and whole grains Follow ACS Guidelines on Nutrition & Physical Activity for Cancer Prevention - Choose foods & beverages in amounts that achieve/maintain a healthy weight - Limit processed and red meat - Eat > 2.5 cups of vegetables & fruits/day - Choose whole grains instead of refined grain products - If you drink ETOH, drink <1 drink/day for & 2 drinks/day for Supplements Try to obtain nutrients through diet, first. Consider only if a nutrient deficiency is biochemically or clinically observed, or if intakes fall persistently below recommended levels as assessed by an RD. CA CANCER J CLIN (2012) DOI /CAAC

23 Red Meat Consumption & Cancer Related Mortality Pooled analysis of 37,698 men from the Health Professionals Follow-up Study and 83,644 women from the Nurses' Health Study 9464 cancer deaths during 2.96 million person-years of follow-up. Total Red Meat Q1 (ref) Q2 Q3 Q4 Q5 P Trend HR (95% CI) for 1 svg day -1 increase < ( ) Not Processed < ( ) Processed < ( ) Substitution estimates of 1 serving/day of other foods (e.g., fish, poultry, nuts, legumes, low-fat dairy, and whole grains) for 1 serving/day of red meat were associated with a 7% to 19% lower mortality risk. Estimates suggest that 9.3% of deaths in men and 7.6% in women could have been prevented at follow-up if there was a reduction in 0.5 servings/day (~42 g/day) of red meat. Pan A et al. Arch Intern Med March 12, 2012

24 Dietary Patterns Prudent vs. Western Team (year) Sample Diet CA Mortality HR (95% CI) Other Cause Mortality HR (95% CI) Kroenke (2005) Kwan (2009) Vrieling (2013) Meyerhardt (2007) 2619 Breast CA 1901 Breast CA 2522 Postmenopausal Breast 1009 Stage III CRC Prudent 1.07 ( ) 0.54 ( ) Western 1.01 ( ) 2.31 ( ) Prudent 0.79 ( ) 0.35 ( ) Western 1.20 ( ) 2.15 ( ) Prudent 0.89 ( ) 0.81 ( ) Western 3.69 ( ) 0.99 ( ) Prudent 1.13 ( ) 1.32 ( ) Western 2.85 ( ) 2.32 ( ) Diet Quality: 3-of-4 studies show significant protective effect for overall mortality, one shows significant protection for cancer specific mortality (George 2011 & 2014; Izano 2013; Kim 2011)

25 Women s Healthy Eating & Living (WHEL) Study Sample: 3088 early stage breast cancer survivors dx d within 4 yrs Intervention: 5 vegetable servings plus 16 oz of vegetable juice; 3 fruit servings; 30 g of fiber; and 15% to 20% of energy intake from fat Follow-up: Up to 10 years Intervention Total Breast Cancer Events Total Breast Cancer Deaths Total Deaths Control Comments: No weight loss, baseline F&V ~ 7.4 servings/day Pierce JP et al. JAMA 298: 289, 2007 Pierce JP et al. JAMA 298: 289, 2007

26 Results of the Women s Intervention Nutrition Study (WINS) Show Reduced Rates of Recurrence in Patients Assigned to a Low Fat Diet (n=2,437) Recurrence Rates (% of population) 25 Low Fat Diet 20 Regular Diet P = P =.034 P = All Patients ER positive ER negative Chlebowski et al. JNCI 98:1767, 2006

27 Alcohol Direct association with cancers of the kidney, head and neck and primary risk of breast cancer ( no amount of alcohol is safe If you are a survivor of head and neck cancer you should not drink alcohol since it will increase your chance complication and reduce survival If you are a survivor of other cancers the choice is less clear it may increase your risk of recurrence (breast cancer) but also decrease your risk of death due to cardiovascular disease

28 Associations Between Alcohol-Use and Second Primaries (Select Studies) Team (yr) Lin et al. (2005) Trentham- Dietz et al. (2008) Knight et al. (2009) Do et al. (2003) Leon et al. (2009) Li et al. (2009) Primary CA Sample HNSCC 123 SPT in 1257 Cases Breast CA Breast CA HNSCC 10,953 BCA cases 488 Breast SPT 132 CRC SPT 113 Endometrial SPT 36 Ovarian SPT 708 Asynchronous contralateral BC vs unilateral Ctrls 201 SPT in 1181 pts in 13 cis RA RCT HNSCC 257 MSPT vs. 257 matched Ctrls ER+ Breast CA 365 Asynchronous contralateral BC vs. 726 unilateral Ctrls Median F/U 73M 84M 60M (mean) 12M 48M vs 126M 101M Results HR (95%CI) Daily Drinkers at dx 2.1 ( ) >7 drinks/wk 1-yr post-dx 1.09 ( ) 1.92 ( ) 0.84 ( ) 0.55 ( ) Ever Reg Drank 1.3 ( ) Post-dx Drinker 1.2 ( ) Continued Drinking 1.3 ( ) Continued Drinking 5.2 ( ) Current Drinker 1.9 ( )

29 2012 American Cancer Society (ACS) Nutrition & Physical Activity Guidelines for Cancer Survivors Achieve and maintain a healthy weight If overweight or obese, limit high calorie foods & beverages increase physical activity to promote weight loss Engage in regular physical activity Avoid inactivity; resume normal activities as soon as possible following dx Exercise >150 minutes/week Include strength training exercises at least 2 days/week Achieve a dietary pattern that is high in vegetables, fruits and whole grains Follow ACS Guidelines on Nutrition & Physical Activity for Cancer Prevention - Choose foods & beverages in amounts that achieve/maintain a healthy weight - Limit processed and red meat - Eat > 2.5 cups of vegetables & fruits/day - Choose whole grains instead of refined grain products - If you drink ETOH, drink <1 drink/day for & 2 drinks/day for Supplements Try to obtain nutrients through diet, first. Consider only if a nutrient deficiency is biochemically or clinically observed, or if intakes fall persistently below recommended levels as assessed by an RD. CA CANCER J CLIN (2012) DOI /CAAC

30 Dietary Supplements & Cancer Several cell culture & animal studies showing a benefit of various single nutrients and foods ATBC & CARET trials shows show increased risk of lung cancer in b-carotene arms SELECT trial shows higher risk of prostate cancer with vitamin E and higher risk of diabetes with selenium. Several meta-analyses show significantly higher mortality with vitamin E & b-carotene Results of NIH-AARP (n=295,344) show increased risk of fatal prostate cancer among men taking >7 multi-vitamins/week (RR: 1.98; 95% CI: ) Lawson et al. (2007)

31 RCT of b-carotene (50 mg/d) vs. Placebo (51M median follow-up) 254 Cases w/ Stage I/II Head & Neck Squamous Cell Cancer SPT or local recurrence, P = 0.59 HR = 0.69 (95%CI ) SPT Head & Neck HR = 1.44 (95%CI ) SPT Lung Mayne S T et al. Cancer Res 61: , 2001

32 RCT of a- Tocopherol + b-carotene vs. Placebo (52M median follow-up) 540 Cases w/ Stage I/II Head & Neck Squamous Cell Cancer Cancer-free survival (no recurrence & no SPT among participants randomly assigned to the supplement arm (solid line) or to the placebo arm (dotted line) Second Primary HR 2.88 (95%CI ) Bairati et al. JNCI ;97:481-8, 2005

33 Bottom Line on Supplements Rely on Food as a Source of Nutrients But, if considering supplements -Have dietitian analyze diet for deficiency - Check blood levels of nutrients - Consider lowest dosage & most complex preparation - If currently on supplements wean off slowly. V.S. Miracle Calcium in a Bottle

34 Synergy between Lifestyle Practices? Early stage breast cancer survivors in Multi-ethnic Cohort (n=670) Compared with inactive survivors consuming poorquality diets, survivors engaging in any physical activity and consuming better-quality diets had an 89% reduced risk of death from any cause HR: 0.11 ( ) and a 91% reduced risk of death from breast cancer HR: 0.09 ( ). (George et al. 2011) In 1490 early stage breast cancer survivors a combination of 5+ daily servings of F&V + accumulating 540+ MET-min/w associated with a doubling of survival HR: 0.56 ( ) (Pierce et al. 2007) In 2193 post-menopausal breast cancer survivors from Iowa Woman s Health Study those who were most adherent vs. least adherent (6-8 vs. 0-4) to AICR/WCRF guidelines had a 33% lower mortality rate (Inoue-Choi et al. 2013)

35 Rates of Overweight & Obesity among Cancer Survivors: Results of Two National Surveys Overweight Obese Total U.S. Survivors 37.0% 21.9% 58.9% Canadian Survivors 34.4% 18.4% 52.8% Bellizzi et al. JCO 2005; Courneya et al. CANCER 2008

36 Many cancer survivors do not adhere to recommendations (ACS Cancer Survivors II Study, n=9,105) Blanchard et al, JCO 2008.

37 Optimal timing More Research is Needed Specific content, sequencing and dose Impact on array of outcomes Mechanisms of action Factors that moderate effect (cancer-type, tumor characteristics, treatment, age, co-morbidity, gender, etc.) Optimal delivery channel (dissemination) Cost-effectiveness

38 Resources American Cancer Society: Academy of Nutrition and Dietetics: American Institute for Cancer Research: Centers for Disease Control: National Center for Complementary & Alternative Medicine:

39 March th Birmingham, AL Interactive Poster Sessions on Obesity and E-cigarettes Preconference Workshop: Underserved Cancer Survivors