Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Lifestyle Medicine for Improving Cancer Outcomes Dr Shireen Kassam Consultant Haematologist and Lifestyle Medicine Physician 12 June 2024 About me/disclosures • Haematologist and Certified Lifestyle Medicine Physician • Founder & director of Plant-Based Health Professionals UK • Education on plant-based diets and cancer at University of Winchester • Author • Vegan since 2013Learning objectives • Describe the role of nutrition & lifestyle for cancer prevention • Discuss the impact of nutrition & lifestyle approaches for improving quality of life and survival after a cancer diagnosisWhat my patients ask me? • Is it something I did? • Is it genetic? • Is there anything I can do to improve my chances? • What about supplementsRates of cancer are rising • Cancer is a leading cause of death globally, 1 in 6 deaths • 1 in 2 people in the UK will develop cancer in their lifetime • Commonest cancer sites are lung, breast, prostate, colorectal cancer • At most genes contribute to 10% of cases • 40% of cases are preventable (Cancer Research UK, WCRF) https://gco.iarc.who.int/media/globocan/factsheets/populations/826-united-kingdom-fact-sheet.pdf Preventing cancer • Modifiable risk factors account for 44.4% of cancer deaths and 42% of disability adjusted life years • Behavioural and metabolic risk factors • Leading risk factors smoking, alcohol use and high BMI S0140-6736(22)01438-600(10352):563-591. doi: 10.1016/ Rates of cancer rising in the young https://www.theguardian.com/society/2023/sep/05/cancer-cases-in-under-50s-worldwide-up-nearly-80-in-three-decades-study-finds Nat Rev Clin Oncol. 2022 Oct;19(10):656-673. doi: 10.1038/s41571-022-00672-8ncer from 1990 to 2019. BMJ Oncology 2023;2:e000049. doi:10.1136/ bmjonc-2023-000049 5 of 9 recommendations relate directly to dietary factors Dietandcancerreport.org 2018 https://www.wcrf-uk.org/preventing-cancer/ Cancer prevention Strong evidence Possible evidence No evidence Plant-based diet pattern ↓ Dairy ↑↓ Acrylamide Red and processed meat ↑ Organic foods ↓ Juicing Sugar-sweetened beverages ↑* Arsenic in food ↑ Genetically modified crops Processed foods ↑* Coffee ↓ Gluten-free diet Alcohol ↑ Plastic containers & Irradiated food Teflon-coated cookware ↑ Healthy body weight ↓ Adequate sleep ↓ Microwaving foods Physical activity ↓ Soya ↓ Artificial sweeteners Tobacco smoking ↑ (Green tea) ↓ Supplements *Mainly due to increasing risk of weight gain American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention 2020 https://doi.org/10.3322/caac.21591 Cancer guidelines really do work ➢ 18 studies (11 cohort; 7 case-control) Risk of any cancer was 27% lower with ➢ greater adherence to recommendations ➢ Fully adhering to one additional recommendation assoc. with a 10% reduction in cancer risk. Significant reductions in risk of breast ➢ (26%), colorectal (34%), lung (33%) cancers Cancer. 2023; 129(17): 2655-2670. doi:10.1002/cncr.34842 Lifestyle interventions do work • Swedish Women’s Lifestyle and Health Cohort Study, 29,930 women • 2 questionnaires, filled in 1991/92 & 2003 • Followed women for cancer from 2003-2012 • Assessed the effect of changes in smoking, alcohol consumption, body mass index, physical activity and a lifestyle score • Improvement in lifestyle factors over 12 years reduced cancer risk by 20% • Smoking cessation and weight loss had the greatest impact cohort study, Acta Oncologica, 60:7, 827-834, DOI: 10.1080/0284186X.2021.1919756yle and healthLifestyle trumps genetics • Gene–environment interactions in colorectal cancer risk • 346,297 participants, UK Biobank cohort followed for 5.8 years • Healthy lifestyle scores using 8 lifestyle factors • Polygenic risk score using 95 genetic risk variants • Healthy lifestyle significantly reduced the risk of CRC in all genetic groups Those at highest genetic risk had a 42% reduction in CRC risk • with healthy lifestyle • Author's conclusion: ‘Our study provides strong evidence to support lifestyle modifications for CRC primary prevention.’ Am J Clin Nutr. 2021 Apr 6;113(4):810-820. doi: 10.1093/ajcn/nqaa404.The real solution: Lifestyle medicine Perm J 2018;22:17-025 lifestylemedicine.org Impact of healthier lifestyles on cancer Nearly 2 million participants • • Not smoking, limited alcohol, healthy diet and body weight, physical activity • 29% ↓ in cancer incidence • 52% ↓ in cancer mortality Br J Cancer. 2020 Mar;122(7):1085-1093. doi: 10.1038/s41416-020-0741-xAddressing key cancer drivers of cancer Exposure to Inflammation carcinogens Unhealthy gut Cellular microbiome stress Insulin Elevated resistance Cancer growth hormones Front. Med. | https://doi.org/10.3389/fmed.2020.585744Public awareness getting cancer, with the exact same amount unaware that not being physically active increases the risk (51 per cent), https://www.wcrf-uk.org/uk/latest/press-releases/more-public-awareness-around-preventing-cancerImpact of chronic illness on cancer risk Chronic disease % Lifestyle % • Common chronic diseases Lung 3.7 Non-ideal BMI 1.9 accounted for more than a fifth of new cancer cases and more Kidney 7.9 Alcohol 5.7 CVD 24.7 Insufficient fruit/veg 8.8 than a third of cancer deaths Diabetes 4.8 Insufficient exercise 12.3 • Combined, these factors shorten Raised uric acid 4 Smoking 18.6 your life by 13-16 years Total 38.9 Total 39.7 Physical activity reduced this Population attributable risk of cancer mortality • excess risk by 40% Huakang Tu et al. BMJ 2018;360:bmj.k134Foods that promote health https://www.lifestylemedicine.org Diet and cancer •∽1 million cancer deaths per year due to poor diet 1 in 20 cancers due to unhealthy diet in UK • •20 million years lost in disability & premature death • High sodium • Low fibre • Insufficient fruit, vegetables, whole grains, beans • Too high in red and processed meat Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2019 https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/diet-and-cancerCancer and diet • 472,377 participants followed for 11.4 yrs • Regular meat-eaters (n = 247,571) • Low meat-eaters (n = 205,385) • Fish-eaters (n = 10,696), • Vegetarians (n = 8685, including 466 vegans) • Vegetarians 14%  cancer • Vegetarian women 18%  breast cancer • Vegetarian men 31%  prostate cancer Risk of cancer in regular and low meat-eaters, fish-eaters, and vegetarians: a prospective analysis of UK Biobank participants.BMC Med 20, 73 (2022). https://doi.org/10.1186/s12916-022-02256-wImpact of eating a healthy plant-based diet Cancer PDI Healthy Unhealthy PDI PDI 1 Total cancer risk 15%↓ - - Prostate cancer (<65 years) 2 44%↓ - Total 16%↓ Lethal 44%↓ Fatal 38%↓ Breast3 - 21%↓ 20%↑ Lung cancer mortality 4 neutral 34%↓ neutral Oesophagus 5 63↓ 28↓ neutral Stomach 66↓ 58↓ 76%↑ Pancreas 57↓ 26↓ neutral 6 Cancer mortality 16%↓ 10%↑ 1Int J Cancer. 2018 Nov 1;143(9):2168-2176. doi: 10.1002/ijc.31593. Am J Clin Nutr. 2022 Mar 4;115(3):662-670. doi: 10.1093/ajcn/nqab365 5Am J Clin Nutr. 2023 Mar;117(3):467-476. 6oi: 10.1016/j.ajcnut.2022.11.019 Food Funct. 2023 Jul 17;14(14):6470-6481. doi: 10.1039/d3fo01803b Nutrients. 2022 Dec 12;14(24):5288. doi: 10.3390/nu14245288. JAMA Netw Open. 2023 Mar 1;6(3):e234714. doi: 10.1001/jamanetworkopen.2023.4714 Plant-based diets in digestive cancers Diet patterns high in healthy plant-based • foods including vegetarian and vegan diets • Plant-based diets played a protective role in the risk of digestive system neoplasms. •  29% pancreatic •  24% colorectal •  19% gastric  49% liver • Front Public Health. 2022 Jun 3;10:892153. doi: 10.3389/ fpubh.2022.892153Ultra-processed foods and cancer ‘the available suggestive evidence shows a consistent significant association between intake of UPFs and the risk of overall and several cancers, including colorectal, breast and pancreatic cancer’. 2023 Jun;42(6):919-928. doi: 10.1016/j.clnu.2023.03.018tematic review and meta-analysis. Clin Nutr. A word on dairy • Reduces the risk of colorectal cancer: BUT IT’S THE CALCIUM! • Increases the risk of prostate cancer • May increase the risk of breast and endometrial cancer • by 32%, ↓prostate cancer by 70%iry for soya milk ↓ breast cancer • Bottom line: Dairy is not necessary and there are better choices to make for cancer prevention Int J Epidemiol. 2020 Oct 1;49(5):1526-1537. doi: 10.1093/ije/dyaa007. PMID: 32095830 Cancer Causes Control. 1998 Dec;9(6):553-7. doi: 10.1023/a:1008819500080 Alcohol ‘Recommendation: It is best not to drink alcohol’ ACS 2020 cancer prevention guideline Alcohol and Cancer: A Statement of the American Society of Clinical Oncology DOI: 10.1200/JCO.2017.76.1155 Journal of Clinical Oncology 36, no. 1 (January 01, 2018) 83-93Alcohol: Do not be fooledExercise and cancer •  risk of at least 13 cancers • Healthful weight • insulin resistance, insulin and IGF-1 levels • Oestrogen and other growth hormone levels • Inflammation and oxidative stress • Immune function • Alters metabolism of bile acids, exposure of the GI tract to these suspected carcinogens • time for food to to travel through GI tract • Alters genes expression • Prevents shortening of telomeres JAMA Internal Medicine. May 16, 2016. DOI:10.1001/jamainternmed.2016.1548.Lifestyle interventions during cancer treatmentCancer and the gut microbiome FIBRE Polyphenols Variety of plants Fermented foods American Gut: an Open Platform for Citizen Science Microbiome Research. mSystems. 2018 May 15;3(3):e00031-18. doi: 10.1128/mSystems.00031-18. Microbiome, cancer and immunotherapy High fibre foods, including green vegetables, cabbage, • and mushrooms, associated with healthier gut microbiome and longer remission • Patients consuming the most fibre (>20g per day vs <20g per day) had a better response to treatment • For every 5-g increase in daily dietary fibre intake corresponded with a 30% lower risk of progression or death. SCIENCE 23 Dec 2021, Vol 374, Issue 6575, DOI: 10.1126/science.aaz7015.2895The gut microbiome: what the oncologist ought to know British Journal of Cancer (2021) 125:1197 – 1209 Supplements and cancer • Higher than nutritional doses do not prevent cancer May cause harm • • of lung cancer in smokersncreases risk • risk of prostate canceray increase the • Interactions with chemotherapy • Curcumin and cyclophosphamide/ doxorubicin • Green tea and bortezomibSupplements and cancer • 1134 patients enrolled in a breast cancer treatment study • Antioxidant supplement (vitamins A, C, and E; carotenoids; coenzyme Q10) before and during treatment was associated with an increased risk of recurrence and, to a lesser extent, death • Iron supplementation was also associated with increased risk of recurrence and death • ‘caution among patients when considering the use of supplements, other than a multivitamin, during chemotherapy’. DOI: 10.1200/JCO.19.01203 Journal of Clinical Oncology 38, no. 8 (March 10, 2020) 804-814.Vitamin D and cancer • Total cancer incidence • 10 trials, 6537 cases; 3-10 year follow-up • Total cancer mortality • 5 trials, 1591 deaths; 3-10 years follow-up No impact on cancer incidence • • Supplementation reduced risk of death from cancer by 13% • Aim to achieve circulating levels of 25(OH)D 54–135 nmol/l • To consistently raise the level above 75 nmol/l, at least 1500–2000 IU/day intake of vitamin D may be required for adults Ann Oncol. 2019 May 1;30(5):733-743. doi: 10.1093/annonc/mdz059. PMID: 30796437; PMCID: PMC6821324. Lifestyle approaches after cancer diagnosis and treatmentDo the cancer guidelines work? • Prospective cohort study of 992 patients with stage III colon cancer • Lifestyle assessed during and 6 months after chemo • 7-year median follow-up • Higher adherence to guidelines, 42% lower risk of death • 5-year survival probability, 85% for healthy habits vs 76% for patients without 9% absolute reduction in risk of death at 5 years • Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial. JAMA Oncol. 2018 Jun 1;4(6):783-790. doi: 10.1001/jamaoncol.2018.0126 Early-Stage Prostate Cancer • Lifestyle trial • Low-fat plant-based diet Stress management • • Group support • Physical activity Urol. 2005 Sep;174(3):1065-9;Prostate cancer lifestyle trial Changes in PSA level after 1 year At 2 year follow up 27% of the control group vs 5% of lifestyle group had undergone a conventional cancer treatment (p<0.05) Urol. 2005 Sep;174(3):1065-9; Urology. 2008 Dec;72(6):1319-23. doi: 10.1016/j.urologyProstate cancer and lifestyle changes www.pnas.org/cgi/doi/10.1073/pnas.0803080105 Lancet Oncol 2008; 9: 1048–57Prostate cancer and exercise Intervention group had a significant decrease in PSA levels JAMA Oncol. Published online August 19, 2021. doi:10.1001/jamaoncol.2021.3067Prostate cancer and diet • 3505 participants in the Health Professionals Follow-Up Study (1986–2016) Non metastatic prostate cancer • • 48% radical prostatectomy, 35% radiation • Overall and healthful plant-based diet indices; Quality of life • Consuming more healthful plant-based foods was also associated with improved sexual function, urinary irritation/ obstruction, urinary incontinence, and hormonal/vitality https://doi.org/10.1002/cncr.35172Diet and cancer survival ➢ ‘Plant-based diets… might have the potential to improve cancer prognosis, especially for breast, colorectal and prostate cancer survivors’ ➢ ‘future studies should focus on the investigation .….specific plant-based dietary approaches that exclude meat products or animal products per se’ Plant-Based Diets and Cancer Prognosis: a Review of Recent Research. Curr Nutr Rep. 2022 Dec;11(4):695-716. doi: 10.1007/s13668-022-00440-1 Exercise and cancer • Strong evidence that exercise during and after cancer treatment can reduce anxiety, depressive symptoms, and fatigue and improve health-related quality of life and physical function Some evidence that exercise is beneficial for • bone health and sleep quality Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Medicine & Science in Sports & Exercise: November 2019 - Volume 51 - Issue 11 - p 2375-2390 doi: 10.1249/MSS.0000000000002116 Exercise during cancer treatment ➢ Exercise interventions during active treatment reduce fatigue; preserve cardiorespiratory fitness, physical functioning, and strength; and in some populations, improve QoL and reduce anxiety and depression ➢ Benefits preop for people with lung cancer Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022 May 16:JCO2200687. doi: 10.1200/JCO.22.00687Exercise and cancer survival •Breast cancer: Survivors who were the most physically active have approx 40% lower risk of death from any cause and death from breast cancer •Colorectal cancer: Physical activity after diagnosis associated with a 30-40% lower risk of death from colorectal cancer and death from any cause •Prostate cancer: Limited evidence suggests that physical activity after a prostate cancer diagnosis is associated with a 30-45% lower risk of death from prostate cancer and death from any cause.doi: 10.1249/MSS.0000000000002116vember 2019 - Volume 51 - Issue 11 - pExercise and cancer survival BMJ 2020;370:m2031 http://dx.doi.org/10.1136/bmj.m2031 Physical Activity and ‘Chemo Brain’ •hysical activity before and during chemotherapy prevents decline in cognitive function Patients With Breast Cancer Before, During, and After Chemotherapy in a Prospective, Nationwide Study. J Clin Oncol. 2021 Oct 10;39(29):3283-3292. doi: 10.1200/JCO.20.03514Integrative medicine for cancer pain Recommendations for ➢ Acupuncture/acupressure ➢ Reflexology ➢ Massage ➢ HypnotherapyIntegrative medicine for anxiety and depression Recommendations for ➢ Mindfulness-based interventions ➢ Yoga ➢ Hypnotherapy ➢ Relaxation therapies ➢ Music therapy ➢ ReflexologyIntegrative medicine for cancer fatigue Recommendations for ➢ Exercise ➢ CBT ➢ Mindfulness-based programs, ➢ Tai chi or qigong  Clin Oncol. 2024 May 16:JCO2400541. doi: 10.1200/JCO.24.00541Living well after a diagnosis of cancer ➢ 35,564 people with cancer followed for 14 yrs Non- ➢ Impact of 5 healthy lifestyle factors smoker ➢ 44% reduction in the risk of CVD & 38% reduction in the risk of Moderate 6-8 hours T2D alcohol sleep ➢ Each lifestyle factor was associated with reduction of 10% and 13 in developing CVD and T2D, respectively ➢ Same lifestyle factors reduce the risk of second cancers Physical Healthy activity diet J Am Coll Cardiol CardioOnc. 2021 Dec, 3 (5) 663–674Ongoing challenges Rising burden of cancer globally • • Aging population • Rising incidence in the young Increasing co-morbidities • • Overemphasis on treatment vs prevention • Money mostly spent on developing treatments that will benefit only a few • Poor investment by policy makers in making healthy lifestyles and environment accessible to all communitiesThere are no healthy people on an unhealthy planet.Cancer thriver Sept 2020, age 77 •76kg, BMI 25.4 TG 2.33 mmol/l • •HbA1c 45 mmol/mol •PMH: Ischaemic heart disease, hypertension, high cholesterol, Whipple’s for pancreatic cancer 2004 Intervention: Healthy plant-based diet, daily walks, resistance exercise 2x/week April 2021 to present •70kg, BMI 23.3 •TG 1.24 mmol/l HbA1c 37 mmol/mol •Conclusions ➢ A large proportion of cancers are preventable ➢ Diet and lifestyle factors are a major contributing factor ➢ Diet and lifestyle interventions can have a significant impact on cancer outcomes My top tips 1 2 3 4 5 6 7 8 Eat a variety Swap meat Add soya Swap dairy Use herbs Add nuts Exercise Avoid of healthy for beans foods for soya and spices and seeds regularly alcohol plant foods milk British Journal of General Practice 2021; 71 (704): 127. DOI: https://doi.org/10.3399/bjgp21X715121 Short course survivorship/inchester.ac.uk/study/further-study-options/short-courses/lifestyle-medicine-for-cancer-prevention-and- 8-week online course For health professionals 5-6 hours of study/week 30 CPD/CME hours ACLM maintenance of certification https://www.winchester.ac.uk/study/further-study-options/cpd/plant-based-nutrition/PodcastOrder worldwide from wherever you buy your books