Breast Cancer Survivorship: Physical Activity

Transcription

1 WORKING EVERYDAY TO PROVIDE THE HIGHEST QUALITY OF LIFE FOR PEOPLE WITH CANCER Breast Cancer Survivorship: What is the Role of Diet and Physical Activity WENDY DEMARK-WAHNEFRIED, PHD, RD PROFESSOR AND WEBB CHAIR OF NUTRITION SCIENCES ASSOCIATE DIRECTOR OF CANCER PREVENTION & CONTROL UNIVERSITY OF ALABAMA AT BIRMINGHAM

2 Objectives To briefly review cancer survivorship To review the diet and physical activity guidelines for cancer prevention and survivorship and the body of evidence that supports them.

3 Projections ,060 Individuals Diagnosed with Breast Cancer (peak year /100,000) 226,870 will be Female Relative 5-year Overall Survival Rate 90% 39,510 Women will die of breast cancer

4 Estimated Number of Cancer Survivors in the United States t From 1971 to ,000,000 10,000,000 8,000,000 Number 6,000,000 4,000,000, 2,000,000 0 Year Data source: Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, Ruhl J, Howlader N, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Cronin K, Chen HS, Feuer EJ, Stinchcomb DG, Edwards BK (eds). SEER Cancer Statistics Review, , National Cancer Institute. Bethesda, MD, based on November 2009 SEER data submission, posted to the SEER web site, 2010.

5 Estimated Number of Persons Alive in the U.S. Diagnosed with Cancer on January 1, 2007 by Site Thyroid 4% Other 15% Female Breast 22% Melanoma 7% Urinary Tract (Bladder, Kidney, Renal Pelvis) 7% Prostate 19% Hematologic (HD,NHL,Leukemia, ALL, Myeloma) 8% Gynecologic Colorectal 9% 9% Data source: Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, Ruhl J, Howlader N, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Cronin K, Chen HS, Feuer EJ, Stinchcomb DG, Edwards BK (eds). SEER Cancer Statistics Review, , National Cancer Institute. Bethesda, MD, based on November 2009 SEER data submission, posted to the SEER web site, 2010.

6 Cancer Survivorship: The Bad News Cancer Survivors at greater risk -Progressive disease - Second primaries - Cardiovascular Disease (More Breast Cancer Survivors will diet of heart disease than will die of their cancer) - Diabetes - Osteoporosis - Sarcopenia - Functional decline - Subsets prone to depression & fatigue - $277 Billion annually on cancer : 2/3 s of these costs due to downstream effects (ACS 2011)

7 Diet & Exercise Guidelines for Cancer Survivors Weight American Cancer Society (2012) Achieve & maintain a healthy weight throughout life Physical Adopt a physically active lifestyle Activity (>150 min/week of moderate or 75 min/week of vigorous activity Dietary Consume a healthy diet with Pattern emphasis on plant sources Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups of vegetables and fruits each day Choose whole grains in preference to refined grains Limit it processed & red meat World Cancer Fund - American Institute for Cancer Research (2007) Be as lean as possible without becoming underweight Be physically active every day in any way for at least 30 minutes. Avoid sugary drinks. Limit energydense 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 Other - Limit consumption of salty foods Alcohol At most 1 ( ) - 2 ( ) drinks/day If drink limit to 1-2 drinks/day Supplements Rely on food as a source of nutrients Don t use supplements to protect against cancer CA Cancer J Clin 2012 Jan-Feb;62(1):30-67http://onlinelibrary.wiley.com/doi/ World Cancer Research Fund-American Institute for Cancer Research 2 nd Expert Research Report,

8 Increases in Cancer Risk with 160 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

9 Obesity and Cancer-related Mortality Males Prostate (> 35) 1.34 NHL (> 35) 1.49 All cancers (> 40) 1.52 Kidney (> 35) 1.70 Multiple l Myeloma (> 35) 1.71 Gallbladder (> 30) Females 1.76 Colon and rectum (> 35) 1.84 Esophagus (> 30) Multiple myeloma (> 35) Stomach (> 35) Colon and rectum (> 35) 1.46 Pancreas (> 35) Ovarian (> 35) Liver (> 35) Liver (> 35) All cancers (> 40) NHL (> 35) 1.95 Breast (> 40) Gallbladder (> 30) 2.13 Esophagus (> 30) 2.64 Pancreas (> 40) 2.76 Cervical (> 35) 3.20 Kidney y( (> 40) 4.75 Uterus (> 40) Relative Risk of Death (95% confidence interval) Calle EE et al. NEJM.348:1625, 2003.

10 Change in BMI after Diagnosis of Breast Cancer & Association with Recurrence & Mortality Data from Cohort of 5204 Breast Cancer Survivors in Nurse s Health Study 1.8 ve Risk Relati >0.5 loss maintain gain >2.0 gain Change in BMI recurrence breast cancer mortality all cause mortality Kroenke et al. JCO 23: , 2005

11 Why do Women Gain Weight After Breast Cancer Diagnosis? Associated with some forms of hormonal therapy & chemotherapy Most research focused on weight gain in patients with breast cancer who were treated with chemotherapy Early studies show mean gains of kg; recent studies show mean gains of kg Greater gains among black women, & those who are sedentary & with less education. Early reports suggested increased dietary intake is responsible for weight gain studies were small and not well-controlled

12 53 Young Women w/breast Cancer Observed During Year Following Diagnosis (36 on Adjuvant Chemotherapy & 17 Localized Treatment Only) measured. Dietary Intake (3-day recalls) Physical Activity (Stanford 5 City) Metabolic Rate (Indirect Calorimetry) Body Composition (DXA) -No difference in intake or RMR -Significant decrease in PA among Significant decrease in PA among women receiving adj. chemo

13 Change in Body Composition Post-Diagnosis among Breast Cancer Patients receiving Adjuvant chemotherapy baseline 6 mths 12 mths Baseline 6-mth 12-mth Demark-Wahnefried, et al. JCO 2001

14 Sarcopenic Obesity Unique pattern of weight gain characterized by gains in body fat without concurrent gains in lean tissue Occurs with a variety of medical conditions, prolonged physical inactivity, and menopause/aging. Recommended treatment: exercise Recommended treatment: exercise (especially resistance training)

15 Pilot Study (N=10) To determine whether an exercise (strength th training i + aerobic activity) it - diet (< 20% fat, plant-based, calcium-rich diet) is feasible & shows promise of preventing adverse body composition changes among premenopausal women who receive adjuvant chemotherapy for breast cancer.

16 Body Composition Changes Post-diagnosis in Premenopausal Breast Cancer Patients t on Adjuvant Chemotherapy: Pilot Study Results Ch hange (kg g) baseline 6 mths 12 mths at Dx 6M Demark-Wahnefried, et al. JCO 2001; Demark-Wahnefried, et al. Clin Exerc Physiol 2001

17 Diet & Exercise Guidelines for Cancer Survivors Weight American Cancer Society (2012) Achieve & maintain a healthy weight throughout life Physical Adopt a physically active lifestyle Activity (>150 min/week of moderate or 75 min/week of vigorous activity Dietary Consume a healthy diet with Pattern emphasis on plant sources Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups of vegetables and fruits each day Choose whole grains in preference to refined grains Limit it processed & red meat World Cancer Fund - American Institute for Cancer Research (2007) Be as lean as possible without becoming underweight Be physically active every day in any way for at least 30 minutes. Avoid sugary drinks. Limit energydense 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 Other - Limit consumption of salty foods Alcohol At most 1 ( ) - 2 ( ) drinks/day If drink limit to 1-2 drinks/day Supplements Rely on food as a source of nutrients Don t use supplements to protect against cancer CA Cancer J Clin 2012 Jan-Feb;62(1):30-67http://onlinelibrary.wiley.com/doi/ World Cancer Research Fund-American Institute for Cancer Research 2 nd Expert Research Report,

18 Exercise NHIS data suggest that survivors may be 9% more likely to exercise than general population, but only ~30% adhere to ACSM guidelines Systematic reviews, consensus reports & studies in interim suggest exercise is safe & has consistent positive effects on - vigor/vitality - cardiorespiratory fitness - quality of life - depression - anxiety - fatigue Data are accumulating to suggest a protective effect for recurrence and survival (i.e., CHALLENGE trial)

19 Exercise After Diagnosis & Association with Recurrence & Mortality Data from Cohort of 2987 Breast Cancer Survivors in Nurse s Health Study ve Risk Relati < Level of Exercise (MET hrs/week) recurrence breast cancer mortality all cause mortality Holmes et al. JCO 20: , 2005

20 Diet & Exercise Guidelines for Cancer Survivors Weight American Cancer Society (2012) Achieve & maintain a healthy weight throughout life Physical Adopt a physically active lifestyle Activity (>150 min/week of moderate or 75 min/week of vigorous activity Dietary Consume a healthy diet with Pattern emphasis on plant sources Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups of vegetables and fruits each day Choose whole grains in preference to refined grains Limit it processed & red meat World Cancer Fund - American Institute for Cancer Research (2007) Be as lean as possible without becoming underweight Be physically active every day in any way for at least 30 minutes. Avoid sugary drinks. Limit energydense 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 Other - Limit consumption of salty foods Alcohol At most 1 ( ) - 2 ( ) drinks/day If drink limit to 1-2 drinks/day Supplements Rely on food as a source of nutrients Don t use supplements to protect against cancer CA Cancer J Clin 2012 Jan-Feb;62(1):30-67http://onlinelibrary.wiley.com/doi/ World Cancer Research Fund-American Institute for Cancer Research 2 nd Expert Research Report,

21 Dietary Patterns: Western (High Meat & Refined Carbohydrates) vs. Prudent (Plant-based, Unrefined) Sample Diet Adjusted RR (95% CI)* P-value 2619 breast cancer pts within Nurses Health Study, 9-yr follow-up Western CA Specific Mortality 1.01 ( ) 0.99 Other Cause Mortality 2.31 ( ) 0.04 Prudent CA Specific Mortality 1.07 ( ) 0.57 Other Cause Mortality 0.54 ( ) 0.03 * Uppermost vs. lowest quintile Kroenke et al. JCO 23:9295, 2005

22 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 Control Total Breast Cancer Events Total Breast Cancer Deaths Total Deaths 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

23 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) 25 Low Fat Diet Recurrence e Rates (% of popula ation) Regular Diet P =.018 P =.034 P =.277 All Patients ER positive ER negative Chlebowski et al. JNCI 98:1767, 2006

24 Diet & Exercise Guidelines for Cancer Survivors Weight American Cancer Society (2012) Achieve & maintain a healthy weight throughout life Physical Adopt a physically active lifestyle Activity (>150 min/week of moderate or 75 min/week of vigorous activity Dietary Consume a healthy diet with Pattern emphasis on plant sources Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups of vegetables and fruits each day Choose whole grains in preference to refined grains Limit it processed & red meat World Cancer Fund - American Institute for Cancer Research (2007) Be as lean as possible without becoming underweight Be physically active every day in any way for at least 30 minutes. Avoid sugary drinks. Limit energydense 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 Other - Limit consumption of salty foods Alcohol At most 1 ( ) - 2 ( ) drinks/day If drink limit to 1-2 drinks/day Supplements Rely on food as a source of nutrients Don t use supplements to protect against cancer CA Cancer J Clin 2012 Jan-Feb;62(1):30-67http://onlinelibrary.wiley.com/doi/ World Cancer Research Fund-American Institute for Cancer Research 2 nd Expert Research Report,

25 Alcohol Linear association with cancers of the kidney, head and neck and primary risk of breast cancer ( no amount of alcohol is safe ) Prevalence of risky drinking (>2 drinks/day in men or >1 di drink/day in women) among survivors similar il to general population 1-2 Drinks/day is cardioprotective

26 For Breast Cancer Survivors Alcohol Data are Conflicting Pros Reding et al. (n=1,286) 30% increased survival in breast cancer pts who drink >0-3 drinks/week 40% increased survival for 3-7 drinks/week Cons Kwan et al. (n=1897) 35% increased recurrence 51% increased risk of breast cancer-related death (risk accentuated in obese) T th Di t t l Li et al. (n=1091) (n=10,953) 40% increased risk of 55% lower risk of ovarian contralateral cancer in survivors who drink Trentham-Dietz et al. cancer in breast cancer survivors who drink CEBP 17: , & Breast Cancer Res Treat. 105: , 2007 JCO 28:4410-6, 2010 and JCO 27:5312-8, 2009

27 Diet & Exercise Guidelines for Cancer Survivors Weight American Cancer Society (2012) Achieve & maintain a healthy weight throughout life Physical Adopt a physically active lifestyle Activity (>150 min/week of moderate or 75 min/week of vigorous activity Dietary Consume a healthy diet with Pattern emphasis on plant sources Choose foods & beverages in amounts that achieve & maintain a healthy weight Eat > 2.5 cups of vegetables and fruits each day Choose whole grains in preference to refined grains Limit it processed & red meat World Cancer Fund - American Institute for Cancer Research (2007) Be as lean as possible without becoming underweight Be physically active every day in any way for at least 30 minutes. Avoid sugary drinks. Limit energydense 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 Other - Limit consumption of salty foods Alcohol At most 1 ( ) - 2 ( ) drinks/day If drink limit to 1-2 drinks/day Supplements Rely on food as a source of nutrients Don t use supplements to protect against cancer CA Cancer J Clin 2012 Jan-Feb;62(1):30-67http://onlinelibrary.wiley.com/doi/ World Cancer Research Fund-American Institute for Cancer Research 2 nd Expert Research Report,

28 Dietary Supplements & Cancer Several cell culture & animal studies showing a benefit of various single nutrients and foods 40-89% of Survivors take Supplements 40-50% take additional supplements after diagnosis ATBC & CARET trials shows show increased risk of lung cancer in b-carotene arms Trial by Bairati et al. (2006) on 540 head & neck cancer pts. (6.5 yr follow-up) shows HR of 1.38 (95% CI: ) in those receiving 400 IU of vitamin E Meta-analyses by Miller et al. (2005) & Bjelakovic et al. (2007) 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)

29 Thank you! Questions?