Doi:10.1016/j.clon.2007.06.002

Clinical Oncology (2007) 19: 616e627doi:10.1016/j.clon.2007.06.002 Lifestyle During and After Cancer Treatment *Bedford Hospital, Cranfield University & Addenbrooke’s Hospital Cambridge University NHS Trust, c/o The Primrose Unit, Bedford Hospital, Bedford MK42 9DJ, UK; yCranfield Health, c/o Cranfield University, Wharley End, Cranfield MK43 0SU, UK ABSTRACT:The aim of this overview was to examine the evidence for links between lifestyle during and after cancer treatment andquality of life, risk of treatment side-effects, rate of progression and prevention of relapse. The reviewed studies weredivided into categories according to the role lifestyle plays in progression, during treatment, and in relapse prevention.
The evaluated evidence was utilised to show potential lifestyle interventions to facilitate well-being and quality-of-lifeinitiatives. There is now persuasive evidence that dietary choice and exercise can improve the physical andpsychological function of patients with cancer. There is also persuasive evidence that lifestyle choice can prevent canceror the reoccurrence of cancer in susceptible individuals, and possibly improve survival. Thomas, R., Davies N. (2007).
Clinical Oncology 19, 616e627 ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Key words: cancernet.co.uk, diet, exercise, lifestyle, progression, treatment Historically, the link between cancer and lifestyle was Nutritional deficiencies and malnutrition are associated with highlighted by the increased incidence in Asian men and poor tolerance and lower dose intensity and hence indirectly women after migration to North America and Europe, reduce therapeutic outcome The link between im- implying environmental factors in addition to genetics alone proved lifestyle and better disease response rates is more Several cohort studies have subsequently confirmed the difficult to prove, but emerging reliable data have been risks of a stereotypical Western lifestyle, which include high published evaluating patients with indolent or relapsing fat and red meat consumption, a low intake of fresh prostate cancer, where slow progression allows time for vegetables and fruit, and low levels of exercise alternative interventions These include a number of Obesity could account for 14% of male and 20% of female epidemiological and cohort studies, which have shown that cancer deaths in the UK . A lack of physical activity is dietary and lifestyle factors can mediate the transformation particularly related to colorectal cancer and cohort studies of latent prostate cancer into clinically apparent cancers have shown a lower risk in the order of 40e50% compared with and may influence this process . More convincingly, those with a sedentary lifestyle The Harvard Center for however, are two recent prospective studies that have Cancer Control, for example, estimates that at least 15% of generated copious media attention . The first in- colon cancers could be prevented by 30 min daily exercise volved a randomised study of 93 volunteers with early Cynics may argue that lifestyle change after a diagnosis prostate cancer from the USA who had opted not to undergo of cancer is analogous to closing the stable door after the conventional therapies. They were randomly assigned to horse has bolted. On the contrary, emerging evidence intensive nutritional counselling and lifestyle changes, or shows that lifestyle can influence the rate of cancer not, as part of their active surveillance. The lifestyle progression, improve quality of life, reduce side-effects changes in this study included a vegan diet supplemented and risks during therapy, reduce the incidence of relapse, with soy, vitamin E, fish oils, selenium and vitamin C, and improve overall survival. Furthermore, there is in- together with a moderate exercise programme and stress creasing enthusiasm from patients to be involved in their management techniques, such as yoga. Prostate-specific own management decisions, which in practical terms often antigen (PSA) levels decreased by 4% at 12 months in the concerns diet and lifestyle activities . This paper reviews intervention group, but increased by 6% in the control group; published evidence for the benefits of an improved lifestyle this was statistically significant (P ! 0.05). As a secondary after a diagnosis of cancer and argues that as oncologists end point, serum taken from patients from the intervention we should be formally introducing lifestyle advice into group and introduced to prostate cell lines in vitro was eight times more likely to inhibit their growth than serum taken ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
LIFESTYLE DURING AND AFTER CANCER TREATMENT from the control group (70% vs 6%, P ! 0.001). Furthermore, of patients receiving radiotherapy, has been shown to changes in PSA and cell line growth strongly correlated with influence a patient’s nutritional state, increase morbidity, and negatively affect chemotherapy dose intensity .
The second study, a prospective phase II study, evaluated Regular light exercise has been shown to improve fatigue 48 men with PSA relapse after radiotherapy or prostatectomy, and quality-of-life issues for patients with cancer, partic- comparing PSA doubling time before and after the consump- tion of about 200 ml pomegranate juice. There was a signif-icant prolongation of PSA doubling time from a mean of15 months at baseline to 54 months after treatment. As a secondary end point, the patients’ baseline oxidative state Thromboembolism remains a significant risk for patients with was significantly lower at baseline and after pomegranate malignancy, particularly those who are immobile, have under- consumption, measured using three separate serum analyses gone a recent surgery, or who are receiving or have previously (serum induced proliferation and apoptosis of LNCaP cells, received chemotherapy . Although strategies such as serum lipid peroxidation and serum nitric oxide levels) compression stockings, warfarin and low molecular weight Other intervention strategies have focused on the cyclo- heparin are essential, exercise remains a practical additional oxygenase-2 (COX-2) pathway, which over-expresses in aid in reducing this life-threatening complication .
about 75% of malignancies In humans, several retro-spective and prospective analyses have found an associationwith the use of non-steroidal anti-inflammatory drugs (NSAIDs) and a lower incidence of prostate, bowel and breast Body composition, particularly weight gain during and after cancers . In the UK, a prospective study evaluated adjuvant chemotherapy, is becoming an ever-increasing dietary intervention supplemented by oral sodium salicy- significant concern. Women with breast cancer, for exam- lates for its COX properties and copper, manganese gluco- ple, report a 45% incidence of significant weight gain, often nates and vitamin C for their antioxidant effects Within at a time in their lives that makes losing it difficult. The this study, a small cohort of men with progressive early or reasons are multifactorial, but whatever the cause, pro- relapsing prostate cancer had stabilisation of PSA with spective exercise intervention studies have shown signifi- a mean duration of 17.2 months. It is not clear whether any cant improvement in body fat and lean mass indices one of the four components of the supplement was . Likewise, exercise improves bone mineral density, instrumental in this tumour stasis or whether the combina- muscle strength and walking distance, all potential risk tion was essential. Also, it is uncertain how much additional benefit was derived from a controlled diet, as it has beenreported that people with diets rich in fruit and vegetables,particularly vegetarians, have serum salicylate equivalent to a dose of 80 mg a day d more than enough to inhibit the COX Mood status, depression and anxiety are commonly under- pathway . Whether diet alone, salicylates alone, or diagnosed in up to 50% of patients with cancer Cohort a combination of both is the optimal approach remains studies have suggested that depressed patients with lung unanswered For this reason, a double-blind randomised and breast cancer have reduced survival compared with multicentre controlled trial is underway under the registra- patients who are psychologically healthy . A number of tion of the National Cancer Research Network (NCRN) using prospective exercise intervention studies among patients a combination of sodium salicylate, diet and supplements in receiving therapies ranging from chemotherapy, radiother- patients with indolent or relapsing prostate cancer. The apy and hormone therapies have shown reduced levels of primary end point, PSA kinetics, is powered to detect depression, anxiety and improved quality of life .
a difference between both the control and intervention In women with breast cancer, continuing exercise into the arms, as well as all patients before and after trial entry follow-up period has been shown to improve mood,happiness, self-esteem and energy .
Lifestyle Improving Well-being Duringand After Cancer Treatment There is a wealth of information linking good nutritional Constipation caused by immobility, opiate analgesics or and exercise interventions with improved tolerability and anti-emetics during chemotherapy remains a significant quality of life during cancer therapy The most reliable patient concern. Exercise increases bowel transit time and data in this area have addressed the benefits of fatigue, ameliorates constipation and its associated abdominal thromboembolism, body composition, psychological well- Fatigue, reported to be the most common side-effect in Previously, data on associations between dietary factors 65e90% of patients receiving chemotherapy and in 80e90% and survival from breast cancer have been derived from follow-up and caseecontrol studies . The largest of who continued to smoke it was 32 (confidence interval these is the Nurse’s Health Study in which women with 12e69) A further study in patients with lung cancer breast cancer completed a dietary questionnaire 1 year showed that the chance of survival from the primary disease after radical therapy. Women following their description of was double if smoking ceased compared with 40% in patients a prudent diet (high fruit, vegetable and fibre; low fat and salt) had a statistically significant lower overall mortalityrate compared to those with a typical Western diet. Thespecific breast cancer mortality overall was not, however, different, except in the comparison of the upper quartile of Understanding the interaction between lifestyle and cancer the prudent diet with the upper quartile of the Western is complicated by the caveat that health-seeking enthusi- diet and then only in a node-positive subgroup asts often follow a range of behaviours from exercise to A subgroup analysis of 4288 patients within the National dietary manipulation, smoking cessation, reduction in body Surgical Adjuvant Breast and Bowel Project (NSABP) trial size, supplements and analgesic intake, confounding the between 1989 and 1994 showed that very underweight published data . Many of the underlying mecha- (body mass index ! 19) and obese (body mass index O 35) nisms of benefit or risk remain unproven, but emerging colon cancer patients had worse overall survival than evidence is suggesting an interesting causal relationship normal weight patients. This was due to a greater risk of cancer recurrence as well as non-cancer deaths Similar findings were shown in a retrospective analysis of1069 men with prostate cancer treated at the Cedars-Sinai Medical Center Los Angeles between 1994 and 2002; obesemen had a higher risk of early disease recurrence Antioxidants are thought to wield their anticancer properties A cohort study of 526 cases of colorectal carcinoma by directly or indirectly counterbalancing the superoxide showed a 31% reduction in cancer deaths for the physically free radicals produced from our diet or other environmental active compared with the physically inactive across all stages factors Although patients with established cancer The benefit was greatest for stage II and III disease, with have already sustained DNA damage in order to mutate from a hazard ratio for colorectal cancer-specific survival of 0.49 benign to malignant cells, avoiding further DNA insult may (adjusting for age, sex, and stage) in this subgroup. A similar avoid further mutation of indolent malignant or pre- finding was shown in the CALBG 89803 study in which 816 malignant cells into more aggressive phenotypes .
patients completed detailed lifestyle questionnaires during Otherwise known as free radical scavengers, they are found and after adjuvant chemotherapy for stage III colon cancer.
in a wide variety of dietary sources .
Increased physical activity was associated with improveddisease-free and overall survival. In practical terms, this equated to a 35% improvement in disease-free survival forindividuals in the highest quintile of regular physical activity Lycopene and beta-carotene are naturally occurring pig- ments. As well as inducing antioxidant enzymes, there is The most convincing data have been derived from a recent growing evidence related to cell differentiation and pro- prospective trial that randomised 2437 postmenopausal liferation independent of this mechanism of action .
women with early breast cancer to receive nutritional and Lycopene, predominant in tomatoes, has been shown to lifestyle counselling, or not, as part of routine follow-up. The have a protective benefit on prostate cancer risk among US dietary intervention included eight biweekly individual health professionals . For men with established cancer, counselling sessions. Dietary fat intake reduction was two small non-randomised studies looked at lycopene and significantly greater in the dietary group. After 60 months tomato sauce intake and showed decreased PSA progression of follow-up, the breast cancer relapse rate was significantly . Beta-carotene, found in carrots and green leafy lower in the intervention group (P ¼ 0.03). This difference vegetables, has also shown in vitro reduction of pro- was even greater in the oestrogen receptor-negative sub- liferation in prostate cancer cell lines . However, trials group (P ¼ 0.018). There was a statistically significant of supplemented beta-carotene in patients at high risk of improvement in overall survival in the intervention arm, lung cancer showed an elevated risk of lung and prostate although this was only statistically significant for specific cancer . Another large chemo-prevention study com- breast cancer recurrence in oestrogen receptor-negative bined beta-carotene with retinol and showed a lower risk of prostate cancer in those with pre-intervention low plasma Continuing to smoke after a diagnosis of cancer has been levels of beta-carotene; those with high levels had a higher shown to increase the risk of further neoplasms, increase complications in surgery, radiation and chemotherapy,impair appetite and nutrition and reduce survival In a retrospective study of 540 patients with histologicallyconfirmed small cell lung cancer, those who stopped smoking Non-oestrogenic phytochemicals, or polyphenols, include at the time of diagnosis had a relative risk of a second lung the phenolic acids, namely benzoic acid (hydroxybenzoic cancer of 11 (confidence interval 4.4e23), whereas, in those acid, gallic acid) and cinnamic acid (caffeic and quinic acid), LIFESTYLE DURING AND AFTER CANCER TREATMENT together with the non-oestrogenic flavanoids, including of prostate and breast cancer, but in these surveys a high anthocyanidins, the flavanols (catechins and proanthocya- dairy intake was associated with a high fat intake .
nidins), lignans and stilbens. These phytochemicals do not Excessive dietary calcium reduces vitamin D, which has act via a hormonal route, but have been shown to have some shown anti-proliferative benefits that in theory are lost direct antioxidative, anti-proliferative activities . Kaemp- ferol, found in teas, broccoli and kale, has particularly beenshown to reduce the risk of ovary and breast cancer withinthe ongoing Nurses’ Health Study. These and other phyto- chemicals are also commonly found in flaxseed, linseeds, Phytoestrogens include flavones, isoflavones and flavanones, nuts, cruciferous vegetables (e.g. cabbage, kale, broccoli), which are derived in the human diet mainly from soy beans prunes, brightly coloured vegetables, fruits and grains.
and legumes, including peas, lentils and beans Dietary Antioxidants can be found in less obvious sources such as intake could potentially create a more favourable hormonal coffee and chocolate apples used for cider, and the milieu for prostate cancer by inhibiting 5-alpha-reductase, tannin component of red wine The Food and Drug the enzyme responsible for converting testosterone to the Administration has published league tables relating to more active metabolite dihydrotestosterone . The a food’s ability to induce these defence enzymes, known as benefits or risks of phytoestrogenic supplements on breast their oxygen radical absorbance capacity .
cancer remain controversial, although this issue may besolved by an ongoing national NCRN DietCompLfy study, which is correlating the risks of breast cancer relapse withlevels of phytoestrogenic intake Manganese, copper and zinc are dietary trace elements,classified as antioxidants because they are essential for theproduction of superoxide dismutase (SOD) and selenium is essential for glutathione peroxidase . Together with catalase these form enzymic defence against carcinogenicoxygen reduction metabolites It has been postulated Vitamin A is a fat-soluble essential vitamin found in fish and that intensive farming food techniques and food processing dairy food in the preformed isoform retinol. It can also be may reduce these trace metals in our diet . There is ingested in fruits and vegetables that contain carotenoid evidence of an increased risk of carcinogenesis in the provitamins such as beta-carotene. Prostate cell line data presence of copper, manganese or zinc deficiencies, have shown increased apoptosis and reduced proliferation particularly under conditions of high carcinogenic attack when exposed to synthetic retinoids such as fenretinide . Likewise, in genetically susceptible mice, fenretinide in many food sources and tends to accumulate more in the reduced the incidence of prostate cancer by 49% .
prostate. One in vitro study suggested that this may offer However, in a subsequent prospective study involving 10 some protection against prostate cancer cell growth 472 US men, no reduction in prostate cancer incidence has However, in the Health Professional Follow-up Study, men yet been shown, although there have only been 93 events in who took supplemental zinc of more than 100 mg/day or for long durations were more than twice as likely to developadvanced prostate cancer compared with controls Human prostate cell lines have shown growth inhibitionwith selenium. This double-blind trial evaluated the Vitamin C has been shown to prevent the inhibition of gap- benefits of dietary selenium. The primary end point, non- junction intercellular communication (GJIC) induced by melanoma skin cancer, was not statistically significantly toxic products such as hydrogen peroxide. The inhibition of reduced, but the incidence of prostate cancer was GJIC is related to carcinogenesis and tumour promotion significantly reduced . Several large ongoing prostate . Vitamin C is involved in the mechanism that enables prevention studies, including the SELECT study, are DNA to ‘sense’ free radicals by integrating with the iron imbedded in DNA, thereby facilitating DNA repair. It istherefore an important factor in immune surveillanceagainst cancer, as according to estimates, each cell in the body can be expected to suffer about 100 000 DNA- Four prospective cohort studies relating to calcium and prostate cancer have been published Two studies witha mean calcium intake of between 1330 and 1840 mg/day showed no associated risk. Two others, one involving 86 404men in the Cancer Prevention II (CPII) nutrition cohort, Vitamin D is converted to the active metabolite calciferol in with a mean intake of O2000 mg/day from food and the kidney. Calciferol exposed to cancer cell lines reduces supplements, showed a significantly higher risk of prostate proliferation, promotes differentiation, inhibits invasion cancer . Five of nine further questionnaire surveys and loss of adhesion and promotes apoptosis associated a high intake of dairy food with an increased risk . It has also be shown to interact with the androgen signalling pathway in vivo, inhibiting angiogenesis a 63% reduction in prostate cancer, although this was not Clinical studies of calcitriol can dangerously increase serum calcium, but vitamin D analogues have been developed Fat intake, of course, is not all bad; evidence from without this risk and are being investigated in an ongoing two large prospective studies and a smaller caseecontrol study suggests a protective effect of oilyfish intake on cancer incidence and mortality . A unique nutritional component of fish is the long-chain marineomega-3 fatty acids. Cell line xenografts and small human Vitamin E in its eight naturally occurring tocopherol isoforms studies have suggested that marine omega-3 fatty acids or has been linked to a reduction in prostate cancer risk the ratio of marine omega-3: omega-6 fatty acids can The Alpha-Tocopherol Beta-Carotene Cancer Prevention modulate the COX-2 pathway, a potential route for prostate Study Trial (ATBC) involving 29 133 male smokers reported a statistically significant reduction in prostate cancer in-cidence and mortality, although the primary end point oflung cancer was higher . In the Health Professional Follow-up Study, vitamin E intake was also associated with The over-expression of COX-2 correlates with a more a decreased risk of prostate cancer in smokers, but not aggressive phenotype and resistance to hormonal therapies.
overall . The serum-based CPII nutrition cohort study In vitro, inhibitors of COX-2, such as NSAIDs, have been shown showed an inverse correlation between plasma vitamin E to induce apoptosis, inhibit proliferation, impair adhesion levels and prostate cancer, again mainly among smokers and and signal angiogenesis in prostate cancer cell lines and mostly the gamma-tocopherol isoform mainly found in the xenographs . Ongoing national studies are generally diet rather than in over the counter supplements . In concentrating on pure COX-2 inhibitors, which are thought to a further trial involving 39 876 patients with diabetes or avoid the unwanted gastrointestinal COX-1 effects while cardiovascular disease, alpha-tocopherol showed no re- amplifying the COX-2 effects. The benefits of salicylates in duction in cancer, and the incidence of heart disease was tablet form or those found naturally within the diet have not, slightly worse Likewise, in the ATBC study, cerebral however, been established and concerns have arisen with haemorrhage risk was also higher in smokers with hyperten- some pure COX-2 inhibitors. First, the reduction in gastroin- sion who took alpha-tocopherol. The ongoing National testinal side-effects of pure COX-2 inhibitors has not been as Cancer Institute-sponsored double-blind randomised SELECT strong as expected when tested clinically . Second, study comparing selenium and vitamin E supplementation prospective studies, including a COCHRANE meta-analysis, against placebo will provide data on completion in 2013.
have shown a reduced incidence of malignancy associatedwith aspirin rather than other more selective NSAIDs . Third, the only prospective randomised clinicalstudies in oncology published to date showing a protective One probable mechanism of benefit for lifestyle changes benefit against recurrent bowel cancer used aspirin .
during cancer relates to a reduction in body fat constitution: Finally, the cardiac and renal safety of some third generation associations of adiposity and outcome after cancer treat- NSAIDs has more recently been put in doubt As ment have been observed for colorectal cancer , but mentioned above, people with diets rich in fruit and also for breast and prostate cancer, with the vegetables, particularly vegetarians, have serum salicylate improvement in survival being a result of decreased cancer- equivalent to a dose of 80 mg/day e more than enough to and non-cancer-related weight loss The mechanism initiate COX’s conversion of arachidonic acid to prostaglan- of risk of being overweight for breast and endometrial cancer dins . Also, these patients have a lower incidence of may lie in their higher oestradiol levels, which have been adverse gastrointestinal symptoms. A measure of COX-2 reported to reduce after weight reduction programmes inhibition in further dietary intervention studies would be Diet may also influence hormone production and metabolism by a direct action and not via obesity . Animalresearch and caseecontrol studies have shown that diets low in fat and high in fibre are associated with a highexcretion of oestrogen in the urine Theories of the mechanisms of benefit include alterations Statins, by chemically reducing fat absorption, may also in prostaglandin levels/ratios and positive effects on the have a preventive role over and above their ability to immune system For colon cancer, exercise may reduce cholesterol. Lovastatin and simvastatin have been help by increasing the bowel transit time, reducing the shown to trigger apoptosis in cancer cell lines Five time that potentially carcinogenic substances are in randomised trials have shown fewer colon and breast contact with the bowel wall . Exercise and diet also cancers and melanomas in long-term users of statins help to control the body’s levels of serum lipids and compared with controls The data for prostate cancer, cholesterol; high levels have been particularly associated however, are inconclusive, as two other large clinical with a greater risk of advanced disease . However, cohort studies did not show a reduced risk with statin the most compelling emerging evidence lies in the idea intake. A further cohort study of 16 976 subjects showed that physical activity might exert its beneficial effect via LIFESTYLE DURING AND AFTER CANCER TREATMENT insulin-like growth factors (IGF) . A number of between 1990 and 1994, in which they had previously cohort studies have shown an increased risk of cancer, shown a prognostic benefit of physical activity. This and particularly colorectal, with higher levels of IGF-1 and another large prospective cohort study from Melbourne, C-peptide. An inverse relationship with insulin-like growth Australia, reported statistically lower levels of IGF-1 and factor binding protein 3 (IGFBP-3) levels has also higher IGFBP-3 in those physically active before diagnosis been shown, although this effect has not been confirmed in and these collated with disease-specific survival and overall all studies . The benefits of lowering IGF-1 may be linked to its central role in growth regulation processes.
The main stimulus for IGF-1 production comes from growth hormone. This stimulatory effect of growth hormone ismodulated by insulin, which increases growth hormone Dietary or inhaled chemicals, such as polycyclic aromatic receptor levels and in turn IGF-1 . Early studies hydrocarbons and aromatic amines, found in super-heated have shown that after binding to its receptors, which are processed or fried foods, are converted to products that found on normal colonic mucosal cells as well as colon can directly or indirectly oxidise water or oxygen into short- cancer cells, IGF-1 can stimulate cell proliferation, inhibit lived, but highly energetic, free radicals. These cause apoptosis and promote angiogenesis . In the double or single DNA strand breaks, allowing cancer- circulation, as over 90% of IGF-1 is bound to IGFBP-3, promoting genes to escape from the influence of their binding inhibits the action of IGF-1 by limiting the suppressor gene guardians . Numerous environmental availability of free hormone. The most convincing clinical studies have linked carcinogens to cancers and the USA evidence comes from a cohort study of 41 528 people aged Food and Drug Administration regularly publishes lists of between 27 and 75 years with colorectal cancer, recruited foods containing high levels of acrylamides and other Table 1 e Tips to encourage healthy eating in cancer patients Avoid processed fatty foods, cream, and fried foods. Check serum cholesterol and discuss taking astatin if elevated.
Use meat for its taste, preferably not more than once a day. Excess fat should be removed and themeat gently grilled rather than fried to further reduce the fat content and avoid burning. If extra oilneeds to be used in cooking, use olive oil rather than animal fat.
All fresh fish, but particularly the oily varieties such as mackerel and sardines. Fresh water fish suchas trout have the advantage of avoiding the potential heavy metal contamination of tuna and swordfish, which some suggest should not be eaten more than twice a week.
Try to avoid heavily processed foods, which often contain high concentrations of fat, salt, sugar and food additives. Reducing the amount of time that vegetables are cooked should maintain the flavour.
Wash salads and vegetables thoroughly to avoid pesticides and airborne chemicals, which may havesettled on them. Organic foods reduce the pesticide exposure further. Avoid excessive amounts offoods containing high levels of aromatic hydrocarbons and acrylamides, such as smoked food or thoseassociated with high temperature cooking processes such as deep fried foods, crisps, chips,barbecued, and heavily fried meats.
Brazil nuts, sardines, prawns; 60e75 mg/day; no more than 200 mg/day.
Unless prescribed for other reasons, avoid supplements that give more than 1500 mg of calcium and11 mg zinc per day.
Fresh fruit, raw and calciferous vegetables, grains, oily fish, nuts and salads. Unless you havediarrhoea, try to increase the amount of ripe fruit you eat each day, ideally by eating the whole fruit.
Freshly squeezed fruit juices are recommended.
Onions, leeks, broccoli, blueberries, red wine, tea, apricots, pomegranates, chocolate, coffee,blueberries, kiwis, plums, cherries, ripe fruits, parsley, celery, tomatoes, mint, citrus fruit.
Soybeans and other legumes, including peas, lentils, pinto (baked beans) and other beans and nuts(supplements not recommended).
Skin of colourful foods such as cherries, strawberries, tannins (red wine), blackcurrant, blackberries,dates, cranberries, red grapes, white button mushrooms.
Flaxseed, linseeds, hemp nuts, grains.
Tomatoes, tomato sauce, chilli, carrots, green vegetables and dark green salads.
Table 2 e Summary of major lifestyle studies after cancer Intensive dietary counselling or not.
serum fat levels and relapse-freesurvival.
Retrospective analysis of prospective studies cancer in the low fat intake cohort.
very high BMI O 35 had worserecurrence rates and overallsurvival.
PSA, prostate-specific antigen; NSABP, National Surgical Adjuvant Breast and Bowel Project; BMI, body mass index.
potential carcinogens, such as pesticides, toxic additives size, supplements and analgesic intake. Nevertheless, and chemical contaminants . Avoiding carcinogens may, despite these caveats there is now persuasive evidence therefore, have a benefit in reducing the risk of developing that a healthy lifestyle during and after cancer is associated further cancers in patients who may be more susceptible with improved physical and psychological well-being, from a pre-existing genetic signature or damage from reduced risks of treatment, enhanced self-esteem, reduced chemotherapy or radiotherapy. The latter theory is sup- risk of recurrence and improved survival. Prising the ported by data from patients surviving the Hiroshima and individual anticancer components of a healthy lifestyle will Nagasaki bombings. A comprehensive medical follow-up of require extensive further evaluation and even then they are survivors of the atomic bombings by the Radiation Effects probably multifactorial. In the meantime, an important Research Foundation showed that those who undertook theme emerging from the data is that a simple balanced regular exercise and had a higher intake of fruit and approach to lifestyle is safer than a faddy supplement- vegetables had a significantly lower risk of cancer, despite taking culture, as over-consumption of dietary supplements can be unsafe or counterproductive. Ideally, future trialdesigns should include bespoke patient analysis to identifythose individuals with subclinical deficiencies in trace elements and vitamins, which may lead to an increasedrisk or progression of cancer, especially under circum- A number of methodological limitations confound the stances of high carcinogen exposure. The levels and type of interpretation of the benefits of exercise and diet after dietary supplement for each individual will also probably a diagnosis of cancer from other risks such as smoking, body differ considerably, depending on the patient’s dietary LIFESTYLE DURING AND AFTER CANCER TREATMENT history and genetic susceptibility . As vitamin, mineral How this advice should be formally introduced into and essential fatty acid levels have not always been found clinical practice requires close work with clinicians, to reflect the true status of individual requirements patients and advocacy groups. A straightforward first step more complex tests may be required in addition to detailed is to include lifestyle advice sheets in patient information dietary questionnaires. These may include an analysis of packs after their diagnosis, supported with well-written a patient’s genetic signature measurement of serum leaflets. This policy is already adopted by our and a number metabolites that accumulate in vitamin deficiencies of UK oncology units. Nurses could be trained to direct serum lipid peroxide levels as an indicator of oxidative free patients towards the myriad of council or independent radical damage , or markers relating to the function exercise activities available locally and with the Internet, of the primary defence enzymes, catalase, glutathione accessible information is even more readily available.
Cancernet.co.uk, for example, is able to search for a range In the meantime, a logical, albeit pragmatic, approach is of activities by postcode, ranging from ballroom, line and summarised in This approach is based on the salsa dance lessons, aerobics, yoga and fitness classes, local evidence reviewed in this article, some of which is walking, swimming and cycling groups through to gyms, represented in . It essentially advises adequate sport centres, tennis and badminton courts, pilates and amounts of fresh fruits, brightly coloured berries, raw and personal trainers; information on times, contact numbers lightly cooked leafy and cruciferous vegetables, grains, and locations is provided. Even if patients do not have legumes, oily fish, nuts, dark green salads, tomatoes, and access to the Internet, information on these local activities soy products. This is complemented with advice to avoid could be printed out as necessary during the patient’s excessive unregulated over the counter supplementation, particularly calcium and zinc at high doses, saturated fat, A more comprehensive, but expensive, strategy is to grilled meats, and other foods with high carcinogen introduce structured lifestyle clinics facilitated by trained content. Advice on increasing exercise among cancer physiotherapists and nutritionists, the feasibility and cost- effectiveness of which are currently under investigation in Table 3 e Tips to encourage increased exercise activities in cancer patients Exercise should not just be a passing fad, but be incorporated into our daily lives for the rest of our lives.
During the day we have several choices, which require more or less levels of exertion. Try to take the moreactive option, such as walking instead of using the car for short journeys or getting off the bus or tube onestop earlier.
If you like exercising at home, it is worth having a semi-formal programme to follow. There are many usefulgadgets available to make it more fun (exercise bikes, treadmills, rowing machines, etc). Alternatively, followan exercise video d there are many good ones available. When watching television, try to get up and walkaround for a few minutes at every break.
Use the stairs instead of the lift. If possible take a walk at lunchtime. Try desk exercises d you may look odd,but they can keep you alert, especially when you get tired or sleepy. Do not worry about the comments d peoplewill secretly admire your enthusiasm.
There is an alternative to the pub or the television. Exercise can and should be sociable and enjoyable d findsomething that is fun, otherwise you will give it up very quickly.
In addition to integrating walking into our daily routine, social walking groups are available in many areas and area good way to meet new people, view interesting scenery and exercise to a variety ofability levels. Golf is a good encouragement to walk and clubs are available throughout Britain for all levels.
Cycling socially with family or part of a daily commute, even if only once or twice a week, can be fun andeven save money. Consider buying a bike with a basket for the shopping.
Joining a gym is always a good start. Paying money every month is a good incentive to use it. Even if you areoverweight or unfit, do not worry, as so are most other people and nobody of worth will criticise your efforts.
There are numerous enjoyable ways to exercise in groups at a variety of levels. Your local sports centrewill also have many activities from five-aside football, squash, badminton, volleyball, netball, and numerousexercise aerobics classes.
Many pools offer classes to learn to swim; they often offer single sex or disabled classes.
There are numerous dance classes available in most towns, from traditional ballroom and line dancing to rockand roll or salsa.
is able to search for a range of activities by postcode, providing times, contact numbers and locations.
our unit. The rationale for these clinics is that individu- 11 Thomas R, Blades M, Williams M, Godward S. Dietary advice alised lifestyle counselling will probably elicit a response, combined with a salicylate, mineral and vitamin supplement especially as fundamental changes in the patient’s aspira- (CV247) has some tumour static properties: a phase II study.
tions and abilities will probably have occurred after their 12 Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes diagnosis and treatment. The cancer itself, surgery, or may affect the progression of prostate cancer. J Urol 2005; anticancer therapies may have caused physical disability, fatigue, weight gain and reduced esteem in body image.
13 Pantuck AJ, Leppert JT, Zomorodian N, et al. Phase II study The baselines or benchmarks patients adopt when evaluat- of pomegranate juice for men with rising PSA following surgery ing their health status, including the activities they feel or RXT for prostate cancer. Clin Cancer Res 2006;12(13): they can and cannot participate in, are currently under investigation at our clinic. The theory of health baseline 14 Madaan S, Abel PD, Chaudhary KS, et al. Cytoplasmic induction comparisons may influence a patient’s adjustment to and over-expression of cyclooxygenase-2 in human prostate cancer and lifestyle choices after a cancer diagnosis. If this cancer: implications for prevention and treatment. Int J Urol is the case, there will be scope for the development of 15 Baron JA, Cole BF, Sandler RS, et al. A randomised trial of more effective, diverse and bespoke lifestyle interventions aspirin to prevent colorectal adenomas. N Engl J Med 2003; for cancer patients at diagnosis, during treatment, and on 16 Harris RE, Namboodiri KK, Farrar WB. Nonsteroidal anti- inflammatory drugs and breast cancer. Epidemiology 1996;7:203 Acknowledgement. The authors would like to extend their 17 Sandler RS, Halabi S, Baron JA, et al. A randomised trial of gratitude to the editorial panel of Cancernet.co.uk for their aspirin to prevent colorectal adenomas in patients with provision of lifestyle guidance and information.
previous colorectal cancer. N Engl J Med 2003;348(10):883e890.
Author for correspondence: Professor R. Thomas, Cranfield 18 Blacklock CJ, Lawrence JR, Wiles D, et al. Salicylic acid in the University, Bedford and Addenbrooke’s Hospital, c/o The Primrose serum of subjects not taking aspirin. Comparison of salicylic Unit, Bedford Hospital, Bedford MK42 9DJ, UK. Tel: þ44-01223-216- acid concentrations in the serum of vegetarians, non-vegetar- ians, and patients taking low dose aspirin. J Clin Pathol 2001;54:553e555.
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