Nutrition and Cancer Survivorship
Introduction: In Ireland, there are more than 200,000 people who are living with or beyond cancer. This is equivalent to nearly 4% of the total population (Mullen & Hanan, 2019). In the next 25 years, the number of Irish cancer survivors is expected to double due to demographics, earlier detection, and improved treatment outcomes (Mullen et al., 2020). Cancer survivorship is now recognised as a distinct phase of the cancer journey with its own distinct health implications brought about by the cancer itself, the treatment received as well as a potentially impaired nutrition and physical status, these are discussed below.
National reviews and strategies
The National Cancer Registry of Ireland and the Irish Cancer Society recently published a review titled; ‘The Unmet Needs of Cancer Survivors in Ireland’ (O’ Connor et al., 2019). It highlights that the needs of cancer survivors have not been prioritised, with little support available for the management of treatment side-effects. A study included in this review, which focused on breast cancer survivors specifically, found a significant lack of nutritional information being made available during survivorship care (Power & Hegarty, 2010). A more recent survey of Irish cancer survivors found a lack of nutrition support being provided also (O’Sullivan et al., 2020).
Following the review, the Irish Cancer Society’s strategy for 2020-2025 includes ‘Living Well After Treatment’ as one of its five priorities, emphasising the importance of research in helping to improve the quality of life of cancer survivors by uncovering their unmet needs. Moreover, the HSE’s National Cancer Control Programme has placed significant importance on the wellbeing of survivors in its recent ‘National Cancer Survivorship Needs Assessment’ report (Hegarty et al., 2018). A cancer survivor’s quality of life can be profoundly impacted by the burden of symptoms including nutritional symptoms (Hegarty et al., 2018). One of the most common symptoms encountered by Irish healthcare professionals working with adult survivors in the acute sector were nutritional symptoms (Hegarty et al., 2018; Mullen & Hanan, 2019). It is therefore important that healthcare professionals are aware of the nutritional issues faced by cancer survivors and are familiar with the current guidelines for nutrition for this group.
Nutrition-related issues
Survivors may become at risk of weight loss/gain, malnutrition, decreased intake of food and quality of life, should they not receive follow-up care long-term. Therefore, doctors, nurses and dietitians should regularly monitor and manage these symptoms into survivorship (Crowder et al., 2018).
Weight
Weight management in those with cancer has routinely been dominated by concerns about unintentional weight loss, however, many cancer survivors can be at increased risk for weight gain. As this can be associated with an increased risk of developing cancer, maintaining a healthy weight and body composition is important in survivorship (Reeves et al., 2014). This is reflected in the World Cancer Research Fund guidelines for cancer prevention (Table 1). This is further endorsed by European and American bodies where survivors are recommended to aim to achieve and maintain a healthy body weight and that weight loss should be modest (5-10% of total body weight) (El-Shami et al., 2015; Arends et al., 2017, WCRF/AICR 2018).
Residual impact symptoms
Cancer treatment can result in a variety of side effects. These side effects can, in turn, affect the food intake, nutrition status and quality of life of the individual.
Recent Irish data (O’Callaghan et al., 2021) has shown that these impact symptoms can persist into survivorship. In this cohort of 169 Irish cancer survivors, who were at least six months post-treatment. Fatigue was still being experienced by the majority (76%). Other common impact symptoms were decreased energy levels (51.5%); pain (36.1%); constipation (33%); dry mouth (26%) and diarrhoea (16.6%). This is similar to findings in other countries where, fatigue, difficulty sleeping and pain are commonly reported in survivors (Strollo et al., 2020; Bower 2008).
Cardiovascular disease
After cancer recurrence, cardiovascular disease is the secondary cause of mortality in cancer survivors. This is a long-term complication of cancer therapies (Okwuosa et al., 2017). The risk of cardiovascular morbidity is actually higher than that of cancer recurrence (Schultz et al., 2003; Oeffinger et al., 2006). These morbidities include hypertension, dyslipidaemia, obesity and type 2 diabetes (Schultz et al., 2003; Oeffinger et al., 2006). Screening is important as is the promotion of lifestyle modifications such as increasing physical activity, consuming a healthy balanced diet and maintaining a healthy weight (Okwuosa et al., 2017). The WCRF recommendations in Table 1 should be promoted.
Nutrition related behaviours of survivors
While some studies have shown that cancer survivors are more likely to adopt healthy behaviours than those without a history of cancer (Park et al., 2015; Oh et al., 2013), there are many studies that have highlighted poor fruit and vegetable intakes (Kanera et al., 2016) as well as non-adherence to recommendations for alcohol intake (Iyer et al,2016; Underwood et al., 2009 Cortés-Ibáñez et al., 2020); and Body Mass Index (BMI) (Underwood et al., 2009; Cortes). Compared to those without cancer, cancer survivors in the USA have a higher consumption of foods containing added sugars, solid fats and alcohol and lower intakes of fibre, calcium, vitamin D and vitamin E (Zhang et al., 2015).
Nutrition advice
Survivors have consistently indicated a desire for nutrition support (Hardcastle et al., 2017; Matsell et al., 2020.; Puller and Jackson 2012), particularly from healthcare professionals (Matsell et al.,2020). Survivors currently report receiving no or conflicting nutrition advice (Hardcastle et al., 2017; Matsell et al.; Puller and Jackson 2012). In the absence of advice from healthcare professionals, survivors source nutrition and physical activity advice from online sources (Keaver et al., 2020; Matsell et al., 2020), which are largely unregulated and often present conflicting or non-evidence-based advice (Keaver et al., 2019). Currently only 11% of Irish cancer survivors report receiving nutrition advice from a dietitian (O’Callaghan et al., 2021).
Current guidelines and recommendations
A UK survey of specialist nurses, clinicians, surgeons and allied health professionals showed only half were aware of diet as part of lifestyle guidelines for those who had completed treatment (Murphy et al., 2021).
The World Cancer Research Fund recommends that in the absence of survivor specific evidence, cancer survivors should follow their guidelines for cancer prevention. These have been outlined in Table 1 below. Similar guidelines have been promoted by the American Institute for Cancer Research.
Unfortunately, adherence to these recommendations is poor (Winkels 2016) and baseline knowledge of general or specific risk factors is low in some populations (Anderson, 2015)
Better adherence to these recommendations has been positively associated with global health status, most functioning scales and less fatigue among 1096 colorectal cancer survivors in the Netherlands (van Veen et al., 2019), with improvements in health-related quality of life also being observed in elderly female cancer survivors from the Iowa Women’s Health Study (Inoue-Choi et al., 2013) and Chinese breast cancer survivors (Yei et al., 2018). Greater adherence has also been associated with improved survival in those with colorectal cancer (Song et al., 2021).
Results from a global survey of breast cancer survivors (Keaver et al., 2020) reported that fatigue (reported by 72.1% of respondents); followed by stress, depression or reduced mental function (69.5%); changes in taste preference during or after cancer treatment (48.6%); craving unhealthy food (42.5%); loss of appetite (31.4%); healthy food costing too much (30.5%); and lack of time to prepare healthy foods (34.3%) as the main barriers to healthy eating. Fatigue was also the main barrier to being physically active. To support positive behaviour changes we need to consider these barriers moving forward.
Future
There is a need for research into the nutrition specific needs of cancer survivors as well as the impact of diet on longer term cancer recurrence and survival. This will help inform the development of more specific guidelines and practices for cancer survivors. There is also a need to determine how best to integrate nutrition into survivorship care. Survivors have a desire for individualised and specific advice relating to their nutritional problems (Matsell et al., 2020). Providing individualized nutritional advice could improve dietary intake and potentially prevent weight loss or weight gain, as well as vitamin and mineral deficiencies.
So, what can you do? Monitoring weight and nutrition related impact symptoms and signposting to nutrition resources such as the WCRF guidelines or breakthrough cancer research cookbooks https:// breakthroughcancerresearch.ie/ cancer-diet/for specific impact symptoms and healthy eating and referring to a dietitian where appropriate could make a big impact to the health and health related quality of life of cancer survivors.
References available on request
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