Issues in Nutrition, Weight, and Cancer - An Overview for Clinicians
Issues in Nutrition, Weight, and Cancer - An Overview for Clinicians
US Oncology Review 2005
Published: October 2008
Published: October 2008
Reference Section 1 a report by Faith Ottery, MD, PhD, FACN Member, Editorial Board, Association of Community Cancer Centers (ACCC) With the successes in cancer diagnosis and treatment accomplished over the past 70 years, there is a growing population of cancer survivors. Quality of survivorship is as important as the duration of survivorship - whether one is addressing acute (e.g. having enough energy to go out and get the morning paper), intermediate (e.g. getting back to work or usual activity), or chronic time frames (e.g. chronic sequelae of body composition loss and fatigue years after completion of therapy as in lymphoma).
It is postulated that patients who maintain better nutritional status and body composition during and after primary therapy, are better and more willing candidates for therapy should the cancer recur.
Significant increases or decreases in a patient-s weight and body composition are undesirable for anyone going through cancer treatment.This understanding allows a consistent and integrated philosophical approach to cancer care, whether one is addressing a post- menopausal woman with breast cancer at risk for significant weight gain and associated adverse oncologic outcomes, or patients with cancers associated with progressive weight loss and cachexia.
A multimodality approach that combines nutrition, physical activity (aerobic and resistance exercises), and pharmacologic intervention as necessary is a cornerstone for addressing appropriate body composition and metabolic balance. This integrated approach is important from time of diagnosis through treatment and in long-term survival.
This article is part of the -food for thought- as the Association of Community Cancer Centers (ACCC) celebrates its 30th anniversary, and clearly supports the mission statement and vision that form the foundation of the association - to preserve and protect the entire continuum of quality cancer care. Since the ACCC-s inception, the association has set standards of integrated quality oncology care.
Physical Activity and Survivorship -Life is a metabolic dance between anabolic and catabolic processes. 1 Optimal cancer rehabilitation techniques should focus both on the reduction of unnecessary catabolism (such as unnecessary activity restrictions or corticosteroids) and support of anabolism to optimize daily functioning and quality of survivorship.
Family members and clinicians frequently advise patients to rest and to reduce the amount and intensity of their activities.1 These recommendations, however, may exacerbate the fatigue that affects the survivor. Interestingly, living alone may contribute to improved functionality and continued independence, while physical inactivity contributes to disuse muscle atrophy, which in turn may contribute to loss of cardiorespiratory fitness and to fatigue.
Catabolic losses of weight that occur as the result of cytokine-mediated changes in metabolism or chronic use of corticosteroids also contribute significantly to loss of muscle mass during cancer treatment. The combined losses of weight and lean tissue may be synergistic and if not reversed with cancer rehabilitation may progress over time.
Musculoskeletal structure and function are dependent on physical activity with an appropriate nutritional and hormonal milieu supporting anabolism. In healthy volunteers, complete bed rest for as short as a week is associated with a 1% to 4% loss of muscle mass,2 -4 which can be exacerbated by fever, corticosteroids, and proinflammatory cytokines.
Accelerated loss of bone mineral density (BMD), with ensuing complications of pain and risk for compression and other pathological or traumatic fractures, becomes more important with increased survivorship. Inactivity, combined with direct complications of chemotherapy and changes in the survivor-s hormonal milieu (e.g. orchiectomy, contraindications to hormone replacement therapy, or corticosteroid use) all contribute to risk for progressive bone demineralization and osteoporosis. Resistance exercise is an important therapeutic intervention for preventing or reversing loss of muscle mass and bone density and their complications.5-11 Issues in Nutrition, Weight, and Cancer - An Overview for Clinicians Faith D Ottery, MD, PhD, FACN, is a member of the Association of Community Cancer Centers (ACCC) editorial board. She is Director of Medical Affairs in Oncology, HIV, and Geriatrics for Savient Pharmaceuticals, Inc, is the founding president of the Society for Nutritional Oncology Adjuvant Therapy (NOAT), and current Chair of the Rehabilitation Committee of the Multinational Association of Supportive Care in Cancer (MASCC).
Her research focuses on the complex interplay of nutrition and exercise that forms the basis of many of the seminal publications in the field of nutritional oncology.
References:
1. Winningham M, "Strategies for managing cancer-related fatigue syndrome: A rehabilitation approach", Cancer (2001), 92: pp.
988-997.
2. Shangraw R E, Stuart C A, Prince M J, et al.,"Insulin responsiveness of protein metabolism in vivo following bedrest in humans", Am. J. Physiol. October 1988; 255 (4 Pt 1): pp. E548-558.
3. Stuart C A, Shangraw R E, Prince M J, et al., "Bed-rest-induced insulin resistance occurs primarily in muscle", Metab. (1988), 37: pp. 802-806.
4. Stuart C A, Shangraw R E, Peters E J, et al., "Effect of dietary protein on bed-rest-related changes in whole-body-protein synthesis", Am. J. Clin. Nutr. (1990), 52: pp. 509-514.
5. Braith R W, Magyari P M, Fulton M N, et al., "Resistance exercise training and alendronate reverse glucocorticoid-induced osteoporosis in heart transplant recipients", J. Heart Lung Trans. (2003), 22: pp. 1,082-1,090.
6. Fiechtner J J, "Hip fracture prevention. Drug therapies and lifestyle modifications that can reduce risk", Postgrad. Med. (2003), 114: pp. 22-28, 32.
7. Mitchell M J, Baz M A, Fulton M N, et al., "Resistance training prevents vertebral osteoporosis in lung transplant recipients", Transplantation (2003), 76: pp. 557-562.
8. Winett R A and Carpinelli R N,"Potential health-related benefits of resistance training", Prev. Med. (2001), 33: pp. 503-513.
9. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy,"Osteoporosis prevention, diagnosis, and therapy", JAMA (2001), 285: pp. 785-795.
10. Kerr D, Ackland T, Maslen B, et al., "Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women", J. Bone Miner. Res. (2001), 16: pp. 175-181.
11. Hurley B F and Roth S M,"Strength training in the elderly: effects on risk factors for age-related diseases", Sports Med. (2000), 30: pp. 249-268.
12. Winningham M L, "Effects of a bicycle ergometry program on functional capacity and feelings of control with breast cancer", Unpublished doctoral dissertation,The Ohio State University, Columbus, Ohio. 1983.
13. Courneya K S and Friedenriech C M,"Relationship between exercise during treatment and current quality of life among survivors of breast cancer", J. Psychosoc. Oncol. (1997), 15: pp. 35-57.
14. Nelson J P, "Perceived health, self-esteem, health habits, and perceived benefits and barriers to exercise in women who have and who have not experienced stage I breast cancer", Oncol. Nurs. Forum. (1991), 18: pp. 1,191-1,197.
15. Schwartz A L, Mori M, Gao R, et al.,"Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy", Med Sci. Sports Exerc. (2001), 33: pp. 718-723.
16. Koldern G G, Strauman T J,Ward A, et al., "A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits", Psycho-Oncol. (2002), 11: pp. 447-456.
17. Fairey A S, Courneya K S, Field C J, et al.,"Effects of exercise training on fasting insulin, insulin resistance, insulin-like growth factors, and insulin-like growth factor binding proteins in postmenopausal breast cancer survivors: A randomized controlled trial", Cancer Epidemiol. Biomarker Prev. (2003), 12: pp. 721-727.
18. Dimeo F, Bertz H, Finke J, et al., "An aerobic exercise program for patients with hematological malignancies after bone marrow transplantation", Bone Marrow Transplantation. (1996), 18: pp. 1,157-1,160.
19. Na Y-M, Kim M-Y, Kim Y-K, et al.,"Exercise therapy effect on natural killer cell cytotoxic activity in stomach cancer patients after curative surgery", Arch. Phys. Med. Rehab. (2000), 81: pp. 777-779.
20. Mastaglia F L,"Adverse effect of drugs on muscle", Drugs (1982), 24: pp. 304-321.
21. Braith R W,Welsch M A, Mills R M, et al., "Resistance exercise prevents glucocorticoid-induced myopathy in heart transplant recipients", Med. Sci. Sports Exerc. (1998), 30: pp. 483-489.
22. Horber F F, Hoppeler H, Scheidegger J R, et al., "Impact of physical training on the ultrastructure of midthigh muscle in normal subjects and in patients treated with glucocorticoids", J. Clin. Invest. (1987), 79: pp. 1,181-1,119.
23. Fearon K C,Von Meyenfeldt M F, Moses A G, et al.,"Effect of a protein and energy dense N-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial", Gut (2003), 52: pp. 1,479-1,486.
24. May P E, Barber A, D Olimpio J T, et al.,"Reversal of cancer-related wasting using oral supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine", Am. J. Surg. (2002), 183: pp. 471-479.
25. Khan Z H, Simpson E J, Cole A T, et al.,"Oesophageal cancer and cachexia: the effect of short-term treatment with thalidomide on weight loss and lean body mass", Aliment Pharmacol.Ther. (2003), 17: pp. 677-682.
26. Von Roenn J H, Tchekmedyian S, Hoffman R, et al., "Safety of Oxandrolone in Cancer-related Weight Loss" (Poster N2 #3013) 39th ASCO meeting, Chicago, IL. May 31-June 3, 2003.
27. Tchekmedyian S, Fesen M, Price L M, et al., "On-going placebo-controlled study of oxandrolone in cancer-related weight loss (Abstract 1039, Discussed Poster Presentation)", 45th ASTRO meeting, Salt Lake City, Utah. October 19-23. In: Int. J. Radiat. Oncol. Biol. Phys. (2003), 57 (2 suppl): pp. S283-284.
28. Von Roenn J H,Tchekmedyian S, Cleary S, et al.,"State-of-the-Art in Cachexia Therapy:Anabolic Steroids", Oral Presentation,
2. Shangraw R E, Stuart C A, Prince M J, et al.,"Insulin responsiveness of protein metabolism in vivo following bedrest in humans", Am. J. Physiol. October 1988; 255 (4 Pt 1): pp. E548-558.
3. Stuart C A, Shangraw R E, Prince M J, et al., "Bed-rest-induced insulin resistance occurs primarily in muscle", Metab. (1988), 37: pp. 802-806.
4. Stuart C A, Shangraw R E, Peters E J, et al., "Effect of dietary protein on bed-rest-related changes in whole-body-protein synthesis", Am. J. Clin. Nutr. (1990), 52: pp. 509-514.
5. Braith R W, Magyari P M, Fulton M N, et al., "Resistance exercise training and alendronate reverse glucocorticoid-induced osteoporosis in heart transplant recipients", J. Heart Lung Trans. (2003), 22: pp. 1,082-1,090.
6. Fiechtner J J, "Hip fracture prevention. Drug therapies and lifestyle modifications that can reduce risk", Postgrad. Med. (2003), 114: pp. 22-28, 32.
7. Mitchell M J, Baz M A, Fulton M N, et al., "Resistance training prevents vertebral osteoporosis in lung transplant recipients", Transplantation (2003), 76: pp. 557-562.
8. Winett R A and Carpinelli R N,"Potential health-related benefits of resistance training", Prev. Med. (2001), 33: pp. 503-513.
9. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy,"Osteoporosis prevention, diagnosis, and therapy", JAMA (2001), 285: pp. 785-795.
10. Kerr D, Ackland T, Maslen B, et al., "Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women", J. Bone Miner. Res. (2001), 16: pp. 175-181.
11. Hurley B F and Roth S M,"Strength training in the elderly: effects on risk factors for age-related diseases", Sports Med. (2000), 30: pp. 249-268.
12. Winningham M L, "Effects of a bicycle ergometry program on functional capacity and feelings of control with breast cancer", Unpublished doctoral dissertation,The Ohio State University, Columbus, Ohio. 1983.
13. Courneya K S and Friedenriech C M,"Relationship between exercise during treatment and current quality of life among survivors of breast cancer", J. Psychosoc. Oncol. (1997), 15: pp. 35-57.
14. Nelson J P, "Perceived health, self-esteem, health habits, and perceived benefits and barriers to exercise in women who have and who have not experienced stage I breast cancer", Oncol. Nurs. Forum. (1991), 18: pp. 1,191-1,197.
15. Schwartz A L, Mori M, Gao R, et al.,"Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy", Med Sci. Sports Exerc. (2001), 33: pp. 718-723.
16. Koldern G G, Strauman T J,Ward A, et al., "A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits", Psycho-Oncol. (2002), 11: pp. 447-456.
17. Fairey A S, Courneya K S, Field C J, et al.,"Effects of exercise training on fasting insulin, insulin resistance, insulin-like growth factors, and insulin-like growth factor binding proteins in postmenopausal breast cancer survivors: A randomized controlled trial", Cancer Epidemiol. Biomarker Prev. (2003), 12: pp. 721-727.
18. Dimeo F, Bertz H, Finke J, et al., "An aerobic exercise program for patients with hematological malignancies after bone marrow transplantation", Bone Marrow Transplantation. (1996), 18: pp. 1,157-1,160.
19. Na Y-M, Kim M-Y, Kim Y-K, et al.,"Exercise therapy effect on natural killer cell cytotoxic activity in stomach cancer patients after curative surgery", Arch. Phys. Med. Rehab. (2000), 81: pp. 777-779.
20. Mastaglia F L,"Adverse effect of drugs on muscle", Drugs (1982), 24: pp. 304-321.
21. Braith R W,Welsch M A, Mills R M, et al., "Resistance exercise prevents glucocorticoid-induced myopathy in heart transplant recipients", Med. Sci. Sports Exerc. (1998), 30: pp. 483-489.
22. Horber F F, Hoppeler H, Scheidegger J R, et al., "Impact of physical training on the ultrastructure of midthigh muscle in normal subjects and in patients treated with glucocorticoids", J. Clin. Invest. (1987), 79: pp. 1,181-1,119.
23. Fearon K C,Von Meyenfeldt M F, Moses A G, et al.,"Effect of a protein and energy dense N-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial", Gut (2003), 52: pp. 1,479-1,486.
24. May P E, Barber A, D Olimpio J T, et al.,"Reversal of cancer-related wasting using oral supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine", Am. J. Surg. (2002), 183: pp. 471-479.
25. Khan Z H, Simpson E J, Cole A T, et al.,"Oesophageal cancer and cachexia: the effect of short-term treatment with thalidomide on weight loss and lean body mass", Aliment Pharmacol.Ther. (2003), 17: pp. 677-682.
26. Von Roenn J H, Tchekmedyian S, Hoffman R, et al., "Safety of Oxandrolone in Cancer-related Weight Loss" (Poster N2 #3013) 39th ASCO meeting, Chicago, IL. May 31-June 3, 2003.
27. Tchekmedyian S, Fesen M, Price L M, et al., "On-going placebo-controlled study of oxandrolone in cancer-related weight loss (Abstract 1039, Discussed Poster Presentation)", 45th ASTRO meeting, Salt Lake City, Utah. October 19-23. In: Int. J. Radiat. Oncol. Biol. Phys. (2003), 57 (2 suppl): pp. S283-284.
28. Von Roenn J H,Tchekmedyian S, Cleary S, et al.,"State-of-the-Art in Cachexia Therapy:Anabolic Steroids", Oral Presentation,
