Marie Cantwell PhD, MPH Marie Cantwell PhD, MPH

Centre of Excellence for Public Health Centre of Excellence for Public Health

Queen’s University Belfast Queen’s University Belfast

Cancer – Chronic conditionCancer – Chronic condition

Dietary management of cancer patients is typically seen during the patients active treatment phase – weight loss, anorexia, cachexia, nausea, vomitting

Long term survival- No advice for patients in terms of diet and lifestyle similar to cardiac rehab or dietary management of diabetes

Cancer SurvivorshipCancer Survivorship• 62% 5 year survival over all adult cancers

• 60, 000 cancer survivors (diagnosed in the previous 5 years) in Ireland

• Increased risk for developing secondary cancers, other chronic diseases (CVD diabetes)

• Environmental factors such as diet and physical activity contribute

• Unhealthy behaviours tend to cluster in the population at large and specifically among cancer survivors

Aziz; J Nutr 2002; 132: 3494S

Major Lifestyle Opportunities for Cancer Major Lifestyle Opportunities for Cancer SurvivorsSurvivors

Opportunity Prevalence

Inadequate diet 75%Physical inactivity 54%Smoking 26%Overweight/obese 68%

US-NHIS interview, ages 40-64 years

Coups EJ & Ostroff JS Prev Med 2005; 40:702-11

Lifestyle Interventions in Breast Lifestyle Interventions in Breast Cancer SurvivorsCancer Survivors

Randomised Controlled TrialsRandomised Controlled Trials

WHEL Study (Women’s Healthy Eating and Living WHEL Study (Women’s Healthy Eating and Living Study)Study)

RCT 3088 early stage breast cancer survivors (1995-2000); age 27-74 yrsDiet intervention counselling

5 vegetable servings 16 oz vegetable juice 3 servings fruit

30g fibre15-20% calories fat

Control (print material, 5 a day)

Primary outcome: breast cancer events, death- no effect on disease free survival

Secondary outcomes 1. Significant diet change 2. Significant change in selected biomarkers (carotenoids, oestradiol (total and bioavailable)3. No significant weight change (I year)

Pierce et al. JAMA 2007;278-289

Randomised

Women’s healthy Eating and Living Women’s healthy Eating and Living Study (WHEL)Study (WHEL)

• Among survivors of early stage breast cancer, adoption of a diet that was very high in vegetables, fruit, fibre and low in fat did not reduce additional breast cancer events or mortality during a 7.3 year follow up period

WINSWINSRisk of RecurrenceRisk of Recurrence

low fat diet vs. controllow fat diet vs. control

Women’s Intervention Nutrition Study Women’s Intervention Nutrition Study (WINS)- role of low fat diet (WINS)- role of low fat diet

• Lifestyle intervention reducing dietary fat intake (target 20% E), with modest influence on body weight, may improve relapse-free survival of breast cancer

• 24% reduction in risk for recurrence; subset analyses suggest that this effect was even greater among women with oestrogen receptor-negative disease

Chlebowski et al, 2006, J Natl Cancer Inst 98(24):1767-76.

Prospective Cohort StudiesProspective Cohort Studies

Prospective Cohort StudiesProspective Cohort Studies

1. Healthy Eating Activity and Lifestyle (HEAL) study (USA multicentre) n = 1182

2. Life after Cancer Epidemiology (LACE) USA multicentre n=2321

3. Shanghai Breast Cancer Survivors Study n= 5000

4. Pathways Northern California n= 4000

5. DietCompLyf Study –UK multicentre n= 3000

Weight management and Breast Weight management and Breast Cancer Survival Cancer Survival

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

>0.5 loss maintain 0.5-2.0gain

>2.0 gain

recurrencebreast cancer mortalityall cause mortality

Change in BMI after diagnosis & association with Change in BMI after diagnosis & association with recurrence & mortalityrecurrence & mortality

Data from cohort of 5204 Breast Cancer Survivors in Nurses Health Study R

elative Risk

Physical Activity and Breast Physical Activity and Breast cancer survivalcancer survival

Observational Cohort Study of Observational Cohort Study of Exercise After Diagnosis & Association with Recurrence & Mortality Data from Cohort of 2987 Breast Cancer Survivors in Nurse’s Health Study

Holmes et al. JCO 20:2479-86, 2005

Rela

tive

Risk

Level of Exercise (MET hrs/week)

Ongoing work - Cancer SurvivorsOngoing work - Cancer Survivors

A randomised controlled trial to evaluate A randomised controlled trial to evaluate the efficacy of a 6 month dietary and the efficacy of a 6 month dietary and physical activity intervention for prostate physical activity intervention for prostate cancer patients receiving androgen cancer patients receiving androgen deprivation therapydeprivation therapy

• Androgen deprivation treatment (72%)

• Outcomes of interest: body composition, fatigue and QoL

Side effects of Androgen Deprivation Therapy

Body composition-Decrease in lean body mass

Decrease in muscle strength

Decrease in bone mass and BMD

Increase in fat mass

Increase in total body weightFatigue-

Quality of Life-

Others- Impotence Hot flashes Growth of breast tissue  OsteoporosisAnaemia

Ongoing ResearchOngoing Research

DietCompLyf study - Role of diet, lifestyle and complementary therapies on breast cancer survival study

Prospective Cohort Study:

50 centres

3000 breast cancer patients

Collected FFQ, Food Diaries, Serum, Urine

1. Change in food /nutrient intake after breast cancer 1. Change in food /nutrient intake after breast cancer diagnosis – diagnosis – Louiza ValentzisLouiza Valentzis

2. Dietary patterns and breast cancer survival and 2. Dietary patterns and breast cancer survival and quality of life in a cohort of breast cancer survivors- quality of life in a cohort of breast cancer survivors- Sarah Brennan, Marice LunnySarah Brennan, Marice Lunny

ConclusionsConclusions

• Adjuvant treatments for breast cancer lowers disease mortality 25-40%

• Weight maintenance after breast cancer may lower disease mortality 40%∼

• Moderate exercise after breast cancer may lower disease mortality 40-50%∼

ConclusionsConclusions• Advising weight maintenance and exercise after breast cancer may help

our patients as much as standard treatments

• Important in our sedentary & obesigenic environment.

• Diagnosis of cancer –”Teachable moment”

• Often demonstrate an enhanced motivation to change their lifestyle behaviours

• Interventions that address multiple risk factors such as diet and physical activity in more diverse populations and for other cancer sites, are required

Thank you for your attentionThank you for your attention

American Cancer Society

•Achieve or maintain a healthy weight

•Choose foods that help maintain a healthy weight

•Eat a variety of foods with an emphasis on plant foods

•Eat 5 or more servings of a variety of vegetables & fruit each day

•Choose wholegrain in preference to processed (refined grains & sugars)

•Limit consumption of red meats especially those high in fat and processed

•If you drink alcoholic beverages limit consumption

Dietary Intake and body weight change Dietary Intake and body weight change during WINS and WHEL Interventionduring WINS and WHEL Intervention