Cancer Survivorship E-Learning Series for Primary Care Providers The Importance of Prevention in Cancer Survivorship: Empowering Survivors to Live Well Colleen Doyle, MS, RD Director, Nutrition and Physical Activity National Home Office American Cancer Society Learning Objectives At the end of this presentation, you will be able to: • Describe guideline-supported recommendations for secondary cancer prevention to cancer survivors regarding tobacco, obesity, physical activity, nutrition, alcohol and sun protection. Cancer Survivorship • Approximately 14 million cancer survivors in the United States • Sixty-four percent of survivors has survived 5 years or more; 40% has survived 10 years or more; and 15% has survived 20 years or more after diagnosis • The number of cancer survivors is projected to increase by 31%, to almost 18 million, by 2022, which represents an increase of more than 4 million survivors in 10 years Siegel, R (2012), CA: A Cancer Journal for Clinicians. Howlader N, SEER Cancer Statistics Review, 1975–2009 de Moor, Cancer Epidemiology Biomarkers & Prev, 2013 Why “Prevention” is Critical for Survivors Cancer survivors are at greater risk for recurrence and for developing secondary cancers due to: • • • • the effects of treatment, unhealthy lifestyle behaviors, underlying genetics, risk factors that contributed to the first cancer May also be at increased risk for chronic diseases such as cardiovascular disease, diabetes, and osteoporosis Rock, et al. CA Cancer J Clin, 2012 Key Lifestyle-Related Risk Factors For Developing Cancer 1. 2. 3. 4. 5. Tobacco Use Poor Diets Physical Inactivity Excessive Alcohol Consumption Sun Exposure And What About Cancer Survivors? Tobacco-Related Cancers • • • • • • • • • Oral cavity and pharynx Esophagus Larynx Lung, trachea and bronchus Urinary bladder Renal pelvis Uterine cervix Pancreas Kidney Tobacco-Related Cardiovascular Diseases • • • • • • Hypertension Ischemic heart disease Atherosclerosis Pulmonary heart disease Aortic aneurysm Stroke Tobacco-Related Respiratory Diseases • • • • Chronic bronchitis Emphysema Asthma Pneumonia Impact of Tobacco Use Among Cancer Survivors • Continued smoking may reduce the effectiveness of treatment • May worsen side effects of treatment • Contributes to complications post-surgery; poor wound healing • Increases the likelihood of a second cancer National Cancer Institute: PDQ® Smoking in Cancer Care. Bethesda, MD For People Who Do Not Smoke…. • The most important ways to reduce cancer risk are to eat well, live a physically active life, and maintain a healthy weight Kushi, et al. CA Cancer J Clin, 2012 ACS Nutrition & Physical Activity Guidelines for Cancer Survivors • Achieve and maintain a healthy weight. • Engage in regular physical activity • Achieve a dietary pattern that emphasizes plant foods, including vegetables, fruit and whole grains Rock, et al. CA Cancer J Clin, 2012 Nutrition and Physical Activity Guidelines for Cancer Survivors Achieve and Maintain a Healthy Weight • If overweight or obese, limit consumption of high calorie foods and beverages and increase physical activity to promote weight loss. • Excess weight is associated with increased risk of recurrence and decreased survival among breast, prostate, colorectal cancer survivors, and possibly others Weight Change After Diagnosis & Association with Recurrence & Mortality 1.8 1.4 1.2 1 recurrence breast cancer mortality all cause mortality 0.8 0.6 0.4 Data from Cohort of 5204 Breast Cancer Survivors in Nurse’s Health Study 0.2 >0.5 loss maintain Kroenke et al. JCO 23: 1370-8, 2005 0.5-2.0 gain Change in BMI >2.0 gain 0 Relative Risk 1.6 Adiposity and Breast Cancer Outcome Patterson et al. Maturitas 66 (2010) 5–15 What About Losing Weight? Dietary Fat Intake • Women’s Intervention Nutrition Study (WINS) – Control - 51 gm fat per day – Intervention - 33 gm fat per day; 6 lb lower mean body weight • Recurrence/new breast cancer – 12.4% control group – 9.8% intervention group Chlebowski, et al. J Natl Cancer Inst, 2006 Reducing Breast Cancer Recurrence with Weight Loss: A Vanguard Trial • Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial • A randomized controlled study with the primary endpoint of clinically significant weight loss in 700 overweight or obese breast cancer survivors, with demonstration of improvements in quality of life and comorbidities • Sets the stage for a larger cancer outcome study that has sufficient statistical power to assess the effects of weight loss on cancer outcomes in overweight or obese breast cancer survivors Rock, et al. Contemp Clin Trials, 2013 Nutrition and Physical Activity Guidelines for Cancer Survivors • Engage in regular physical activity – Avoid inactivity and return to normal daily activities as soon as possible following diagnosis. – Aim to exercise at least 150 minutes per week. – Include strength training exercises at least two days per week. Physical Activity and Cancer Survivors • Consistent with American College of Sports & Medicine Guidelines for Survivors • During treatment – Safe and feasible – Improves quality of life – reduce stress, anxiety • Recent meta-analysis of 78 trials – Reduces fatigue • Recent meta-analysis of 44 studies Schmitz, et al. Med Sci Sports Exerc. 2010 Precautions! • Delay exercise if anemic • Compromised immune function – avoid gyms • Severe fatigue – do gentle stretching instead • Radiation – avoid chlorine • Indwelling catheters – avoid swimming, weight lifting in area of catheter • Neuropathy – watch balance (stationary bike instead of treadmill) Post-Diagnosis Exercise Associations Breast cancer: – Reduction of breast cancer deaths by 34% – All cause mortality by 41% – Recurrence by 24% Colon cancer: – Reduction of colon cancer death, all cause mortality and recurrence by up to 50% Also associated with reduced recurrence of prostate and ovarian cancers Ibrahim, et al. Med Oncol. 2011; Meyerhardt, et al. J Clin Oncol. 2006 Diet • Achieve a dietary pattern that emphasizes plant foods, including vegetables, fruit and whole grains. • • • fish and poultry low-fat dairy healthy fats Dietary Fat Intake • Women’s Intervention Nutrition Study (WINS) – Control - 51 gm fat per day – Intervention - 33 gm fat per day; 6 lb lower mean body weight • Recurrence/new breast cancer – 12.4% control group – 9.8% intervention group Chlebowski, et al. J Natl Cancer Inst, 2006 “Eating Fruits and Vegetables Doesn’t Help Breast Cancer Survivors” Women’s Healthy Eating and Living Trial (WHEL) Study in breast cancer survivors that showed high intake of fruits, vegetables DID NOT reduce risk of recurrence Pierce. Curr Opin Obstet Gyncol, 2009 Diet and Colon Cancer Recurrence • JAMA study: – The “Western Diet” increased risk of colon cancer recurrence by 3.5 times Meyerhardt, et al. JAMA, 2007 Percentage of Survivors Meeting ACS Recommendations 100 90 80 70 60 50 40 30 20 10 0 5 A Day Breast Physical Activity Prostate Colorectal Bladder Not Smoking Uterine Melanoma Blanchard, Courneya, & Stein (2008). Cancer Survivors’ Compliance with Lifestyle Behavior Recommendations and their Relationships with Health-Related Quality of Life: Results from the American Cancer Society’s Studies of Cancer Survivors (SCS). Journal of Clinical Oncology, 26 (19), 2198-2204. Centers for Disease Control and Prevention Surveillance of Health Behaviors Among Survivors 15% smoke 28% are obese 32% report no leisure time activity Underwood, et al. CDC Surveillance Summaries, 2012 Alcohol If you drink alcoholic beverages, limit consumption Drink no more than one drink per day for women or two per day for men Drink is 12 oz of regular beer, 5 oz of wine, 1.5 oz liquor ACS Sun Safety Recommendations • Limit UV exposure – “Slip! Slop! Slap!...and Wrap” • • • • • Protect skin with clothing Wear a hat Use a broad-spectrum sunscreen that’s at least SPF 30 Wear sunglasses that block UVA and UVB light Stay in the shade, especially during hottest part of the day • Avoid other sources of UV light Sun Safety Practices of Survivors • ?? • Survivors of childhood cancer self-report lower tanning practices than siblings. Buchanan, 2009, Cancer “We’re Working on Creating a World with Less Cancer and More Birthdays.” And You Can Help Encourage And Support Smoking Cessation Be An Advocate For Change In Your Community Be A Good Role Model Promote Fruits, Vegetables, Whole Grains Primary Care Physicians Encourage Activity, And Sun Safety What We Can Accomplish, Together 400 lives saved per day to 1,000 lives saved per day