부인암생존자의건강관리 - 암생존자의식이와운동요법

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1 제 32 차대한부인종양학회춘계학술대회 부인암생존자의건강관리 - 암생존자의식이와운동요법 Mi-Kyung Kim, MD, PhD Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cheil General Hospital & Women s Healthcare Center Dankook University College of Medicine

2 Contents 부인암생존자의건강문제 건강생활양식 체중관리 건강한식습관 신체활동 / 운동

3 Cancer survivorship 암생존자수 : 11 년 100 만명 15 년 130 만명추산 진단후경과기간별암유병자분율 : 2012 국가암등록사업, 2012 년

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6 자궁경부암생존자의질병이환상태 * * * * Shin DW and Yun YH et al. Oncology,

7 암생존자건강관리영역 포괄적진료 원발암 / 이차암관리 만성질환관리 건강증진 예방접종 상담진료 개인맞춤형검사를통한조기발견 대사증후군, 당뇨병, 고지혈증, 골다공증.. 금연, 금주, 건강체중유지, 영양, 운동,.. 감염질환 ( 폐렴, 독감등 ) 예방 성기능, 정신사회적문제

8 Weight management

9 BMI and overall survival For each 5 kg/m 2 increment of BMI before, <12 months after, and 12 months after diagnosis, increased risks of 17%, 11%, and 8% for total mortality WHO weight categorization according to BMI - Underweight: BMI < 18.5 kg/m 2 - Normal: BMI kg/m 2 - Overweight: BMI kg/m 2 - Obese: BMI 30 kg/m 2 Chan et al., Ann Oncol, 2014

10 Weight loss 10% was related to a 40% increased risk of death (HR, 1.41; 95% CI, ) in US and over three times the risk of death (HR, 3.25; 95% CI: 2.24, 4.73) in Shanghai. Caan BJ et al. Cancer Epidemiol Biomarkers Prev 2012

11 General principles of weight management Maintain a healthy weight BMI kg/m 2 Underweight survivors: weight gain Overweight/obese survivors: weight loss Benefits of weight loss 5-10% weight loss still has significant health benefits Improve QoL and physical functioning Prevent comorbidities, cancer recurrence or death

12 General principles of weight management Principles of weight loss Limit the intake of foods and beverages high in fat and added sugars Substitute high-calorie foods with low-calorie, nutrient-dense foods (vegetables, fruits, whole grains) Portion control by using smaller plates Monitor weight daily Track diet, calories, and physical activity routines No current evidence to support the use of weight loss supplements in cancer survivors

13 General principles of weight management Principles of weight gain Increase frequency of feeding Avoid fluid intake with meals Assess swallowing, taste/smell disorders, GI motility as appropriate

14 Nutrition

15 General principles of nutrition Achieve a dietary pattern that is high in vegetables, fruits, and whole grains Limit amounts of red and processed meats, refined grains and sugars Heart-healthy recommendations : for cancer prevention and also for competing causes of death

16 Dietary composition AHA recommendation Fat: 25-35% of energy Carbohydrate: 50-60% Protein: 10-35% Recommended sources of dietary components Fat: olive or canola oil, avocados, seeds and nuts, fish (omega-3 fatty acids) Carbohydrates: fruits, vegetables, whole grains Protein: poultry, fish, legumes, low-fat dairy foods, and nuts

17 Dietary composition Examples of food plate volumes Vegetables and fruits: 50% (Vegetables 30%, fruits 20%) Whole grains: 30% Protein: 20%

18 Dietary supplements Vitamins, minerals, herbs/botanicals, amino acids, a concentrate/constituent extract,.. No clear evidence on the effect of dietary supplements for cancer prevention, control, or recurrence Trend towards higher mortality among those using post-diagnosis dietary supplement with a poor diet

19 Dietary supplements Inoue-Choi M et al., Cancer Epidermiol Biomarkers Prev 2014

20 Dietary supplements Supplement use is not recommended for most survivors Except in cases of documented deficiencies, either biochemically (e.g. low plasma vitamin D levels) or clinically (e.g. low bone density) All efforts should be made to obtain nutrients from dietary intake. Supplement should be considered if nutrient intakes fall persistently below 2/3 of the recommended intake levels.

21 Physical activity for cancer survivors

22 Risk of sedentary lifestyle Grontved and Hu. JAMA 2011

23 Survival outcomes according to the physical activity level 충분한운동과균형잡힌식이 사망률감소 생존율향상 운동량증가 Holmes MD, Chen WY, Feskanich D, Kroenke Pierce JP, CH, Stefanick Colditz ML, GA. Flatt JAMA SW, 2005 Natarajan L, Sternfeld B, Madlensky L, et al. JCO 2007

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25 Cardiorespiratory fitness in gynecological cancer survivors : the Cooper Center Longitudinal Study Peel et al., Gynecol Oncol, 2015

26 Benefits of exercise Improve health-related fitness outcomes Cardiorespiratory fitness Muscle strength Body composition Balance Improve quality of life Improve fatigue, psychosocial distress, depression, and self-esteem

27 Evidence of positive effects of physical activity : meta-analysis of RCTs * Median duration of physical activity = 13 weeks (3-60 weeks) Fong et al., BMJ, 2012

28 Health behaviors and their associations with HRQoL among gynecological cancer survivors Beesley VL et al., Cancer Causes Control, 2008

29 Pre-exercise screening Assess baseline level of activity Assess treatable barriers to exercise Pain, fatigue, emotional distress, nutritional deficits.. Assess comorbidities and treatement effects Cardiovascular disease Arthritis / musculoskeletal issues Lymphedema Peripheral neuropathy Poor bone health Screening tool: PAR-Q test

30 ACS and ACSM guidelines on PA Avoid inactivity and return to normal daily activities ASAP following diagnosis Aim to exercise 150 minutes of moderateintensity activity or 75 minutes of vigorousintensity activity or equivalent combination Includes strength training exercises 2 days/week that include major muscle groups Stretch major muscle groups on a routine basis

31 ACSM s Exercise Guidelines for Cancer Survivors Schmitz KH et al., Med Sci Sports Exerc, 2010

32 Resistance training recommendations Health benefits improvement in muscle strength and endurance, functional status, and bone density Multi-joint exercises, involving all major muscle groups (chest, shoulders, arms, back, abdomen, and legs) Resistance training prescription Frequency: 2-3 times/week Intensity: 2-3 sets of repetitions per set Time: 20 minutes per session Rest: 2-3 minutes rest period between sets and exercises

33 암생존자의권장운동 유연성운동 유산소운동 근력운동 균형운동 스트레칭, 요가 관절가동범위유지하거나늘리는동작 관절유연성, 통증걷기, 감소달리기, 자전거타기 심폐기능향상 체중부하운동, 저항성밴드운동 암치료과정중소실된근육과근력회복 하지근력단련 낙상위험감소 Garber et al., MSSE, 2011; WHO, 2010

34 Special considerations Lymphedema Use compression garments during exercise Periodic evaluation of lymphedema exacerbation Gradually increase resistance by smallest increment with monitoring Peripheral neuropathy Assess stability, balance, and gait before exercise Consider alternative aerobic exercise (e.g. stationary biking, water aerobics)

35 Efficacy of physical activity intervention in gyn cancer survivors Stage I-III ovarian(12/33) and EM cancer (11/33) patients during or post-treatment (<3yrs) 12 week, home-based, moderate intensity, physical activity behavioural change intervention (walking + strengthening exercises) : face to face consultation + telephone calls Significant improvements in fatigue : mean difference in MFSI-SF scores: at 6 months, p=0.011

36 Efficacy of physical activity intervention in gyn cancer survivors Stage I-II, obese (BMI>25) endometrial cancer patients following TAH/BSO (n=75) 6 month lifestyle intervention consisting of nutrition, exercise and behavioural modification counseling Physical activity: moderate aerobic activity (emphasized) + resistance exercises Mean difference in weight change at 12 months (study control group) : -4.6 kg (p<0.001) Mean difference in PA minutes at 6 and 12 months : 100 (p=0.038) and 89 mins (p=0.020)

37 Conclusions Healthy lifestyle has been associated with improved overall health and quality of life, reduced risk of recurrence and death. Healthy lifestyle Maintain a healthy body weight throughout life Engage in physical activity regularly Maintain a healthy diet (high in vegetables, fruits, and whole grains / low in red and processed meats, sugars and fats) Minimize alcohol intake / Avoid tobacco products

38 Thank You for your attention Mi-Kyung Kim, MD, PhD

39 Fatigue management

40 Cancer-related fatigue (CRF) Persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning The time course is unique to the cancer survivor, and can last up to several years.

41 Mechanisms of CRF Psychological factors Sleep and mood disturbances Chronic stress Anxiety (e.g. chronic fear of recurrence) Cognitive disturbance Depression Physiological factors Cytokines: TNF-α, IL-1, IL-6, interferons Altered hypothalamic-pituitary-adrenal activation Cachexia Anemia Neuromuscular dysfunction

42 Mechanisms of CRF Neuromuscular dysfunction (Muscle fatigue) Loss of maximal force generating capacity of muscle Decrement in muscle endurance rather than strength Affecting factors Central: depression, anxiety, sleep disturbance, etc. Peripheral: cachexia, anemia, decreased physical activity, muscle disuse (deconditioning), mitochondrial dysfunction, impaired cardiovascular autonomic function (baroreflexes)

43 Mechanisms of CRF Cancer Cancer therapy Anemia Cachexia Immune function (Pro-inflammatory cytokines) Neuromuscular Function (Muscle fatigue) Fatigue (CRF) Central nervous system (Hypothalamic-pituitary-adrenal axis) Stress Sleep Depression Anxiety Inactivity QoL

44 Management of CRF Evaluation Medical history Disease status evaluation: r/o cancer recurrence Assessment of treatable contributing factors Screening for emotional distress, sleep disturbance, and pain Lab: CBC, LFT with electrolytes, TSH, etc.

45 Management of CRF Physical activity intervention Beneficial effect on mood Positive effects on immune function (cytokines) Improvement of muscle function Psychological intervention Nutrition consultation Cognitive behavioral therapy Consider psychostimulants, if failed to other interventions