Nutrition in Advanced Cancer
Drug-Nutrient Interactions
Guidelines for Healthy Eating
        The Food Guide Pyramid
        Cancer prevention guidelines
Survivorship and Prevention of Second Cancers
        Lung cancer
        Prostate cancer
        Breast cancer
        Colon cancer
        Esophageal and gastric cancer

Nutrition in Advanced Cancer

Advanced cancer is often associated with cachexia.[1-4] Individuals diagnosed with cancer may develop new, or worsening, nutrition-related side effects as cancer becomes more advanced. The most prevalent symptoms in this population are the following:[1-3]

• Weight loss.
• Early satiety.
• Bloating.
• Anorexia.
• Constipation.
• Xerostomia.
• Taste changes.
• Nausea.
• Vomiting.
• Dysphagia.

As defined by the World Health Organization, palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. The goal of palliative care is to give relief of symptoms that are bothersome to the patient. Although some of the symptoms listed above can be effectively treated, anorexia, though common, is a symptom that is often not noted as problematic for most terminally ill patients but is distressing to most family members; this distress may vary according to cultural factors. Several studies have demonstrated that terminally ill patients lack hunger, and of those who did experience hunger, the symptom was relieved with small amounts of oral intake.[5]

Decreased intake, especially of solid foods, is common as death becomes imminent. Individuals usually prefer and tolerate soft-moist foods and refreshing liquids (full and clear liquids). Those who have increased difficulty swallowing have less incidence of aspiration with thick liquids than with thin liquids.

Dietary restriction is not usually necessary, as intake of prohibited foods (e.g., sweets in the diabetic patient) is insufficient to be of concern.[6] As always, food should continue to be treated and viewed as a source of enjoyment and pleasure. Eating should not just be about calories, protein, and other macronutrient and micronutrient needs.

Diet restrictions are sometimes appropriate, however.[6,7] For example, people with pancreatic cancer, gynecologic cancer, abdominal carcinomatosis, pelvic masses, or retroperitoneal lymph node masses may have bowel obstruction less frequently when adhering to a prophylactic soft diet (i.e., no raw fruits and vegetables, no nuts, no skins, no seeds). Any restriction should be considered in terms of quality of life and the patient’s wishes.

Decisions regarding nutritional support should be made with the following considerations:

• Will quality of life be improved?
• Do the potential benefits outweigh the risks/costs?
• Is there an advanced directive?
• What are the wishes and needs of the family?

The benefit of home parenteral nutrition in patients with advanced cancer is often debated, and evidence-based data regarding its use are lacking. For patients who still have good quality of life but also have mechanical or physiologic barriers to achieving adequate nourishment and hydration orally (e.g., head and neck cancer), prolonged survival may be achieved with the use of enteral or parenteral nutrition.[5] In a qualitative study, 13 patients and 11 family members perceived some benefits with home parenteral nutrition.[8] The most salient positive feature of home parenteral nutrition was a sense of relief and security that nutritional needs were met. In this study, patients were also able to take oral nutrition, and the administration of total parenteral nutrition was often described as a complement to the patients' oral intake. This contradicts the traditional indication for TPN, i.e., that its use be reserved for times when nourishment via the gastrointestinal tract is not possible. Patients in this study also had regular visits by home health care providers, which could have had a positive impact on their physical, social, and psychological well-being.

Although most patients with advanced cancer will not benefit from artificial nutrition, for someone who still has good quality of life but also has mechanical or physiologic barriers to achieving adequate nourishment and hydration orally (e.g., head and neck cancer), prolonged survival can be achieved with the use of enteral or parenteral nutrition.[5]

All people with cancer and their caregivers have the right to make informed decisions. The healthcare team, with guidance from the registered dietitian, should inform patients and their caregivers about the pros and cons of using nutritional support in advanced disease. Despite the lack of proven benefit, artificial nutrition at the end of life will remain a sensitive topic for some patients and families.[5] In most cases, the cons outweigh the pros. The following is a list of the pros and cons of using nutritional support in advanced disease:[6,7,9]

Pros and Cons of Enteral Nutritional Support

• Pros:
  • May improve alertness.
  • May provide comfort to the family.
  • May decrease nausea.
  • May decrease hopelessness and fears of abandonment.



• Cons:
  • May increase secretions.
  • Diarrhea/constipation.
  • May increase nausea.
  • Surgery with gastrostomy or jejunostomy.
  • Risk of aspiration or pneumonia.
  • Risk of infection.
  • Greater burden on caregiver.

Individuals being treated for cancer may require the use of a series of curative or supportive drugs throughout their care; they may also receive advice on the use of dietary supplements, or they may self-diagnose and self-prescribe the use of dietary supplements. Drug-nutrient interactions or dietary supplement-drug-nutrient interactions can occur and can compromise the safety and efficacy of the anticancer treatment plan. A review of antineoplastic drugs listed in various references revealed the interactions listed in Table 2.[10]

Table 3 provides information about known interactions with dietary supplements—in this case, herbs—commonly consumed by individuals with cancer. Of note, the information provided covers only known interactions; additional side effects are possible for these herbs.[11] A pharmacist or updated dietary supplement references should be consulted for more information.

Numerous studies have shown that dietary practices can either promote health or have deleterious effects.[15-17] Health agencies and disease prevention organizations used the resulting evidence to develop dietary recommendations for the public. Created for healthy individuals, these guidelines can be modified by healthcare providers to focus on specific medical conditions. Individuals diagnosed with cancer can benefit during and after treatment by following these to the best of their ability.

The United States Department of Agriculture (USDA) developed the most commonly used set of guidelines, the Dietary Guidelines for Americans,[18] to be used in conjunction with the Food Guide Pyramid. These guidelines feature recommendations that support good overall health, including fitness guidelines as well as suggestions about what to emphasize and limit in the diet. The Food Guide Pyramid depicts the five food groups: grains, vegetables, fruits, dairy, and meat and nonmeat protein (fats, oils, and sweets to be used sparingly), each accompanied by the amount of servings needed to provide adequate nutrients and calories daily.

Key recommendations in the 2005 version of Dietary Guidelines for Americans include the following:

• Consume adequate nutrients within caloric needs.



• Maintain body weight in a healthy range.



• Engage in regular physical activity.



• Consume a variety of fruits, vegetables, whole grains, and low-fat dairy products each day.



• Consume less fat, keeping trans fatty acid consumption as low as possible.



• Choose fiber-rich fruits, vegetables, and whole grains often.



• Consume less high-sodium foods and more potassium-rich foods.



• Those who choose to drink alcoholic beverages should do so sensibly and in moderation, keeping in mind that certain individuals should avoid alcohol entirely.



• Keep food safety in mind during the preparation, storing, and serving of foods.

The American Cancer Society (ACS) Guidelines for Nutrition and Cancer Prevention [19] first published in 1996 provide more detailed dietary advice with a focus on cancer prevention. These guidelines, updated in 1999, are consistent in principle with those recommended by the USDA and other organizations. The ACS guidelines form the beginning of a report that contains the most up-to-date information available on nutrition issues linked to neoplastic diseases. Included are in-depth answers on how different foods, food preparation methods, portion sizes, variety, and overall calories can reduce or increase the risk of specific cancers. These guidelines provide sound advice regarding healthy eating for cancer prevention for all individuals, including cancer survivors.[20]

The ACS guidelines include the following:

• Choose most of the foods you eat from plant sources. Consume at least five servings of fruit and vegetables daily, as well as grain products such as cereals, breads, and pasta plus beans several times daily.



• Limit your intake of high-fat foods, particularly from animal sources. This is accomplished by choosing foods low in fat and cutting back on meat consumption.



• Be physically active: achieve and maintain a healthy weight. Be at least moderately active for 30 minutes on most days of the week. Stay within a healthy weight range.



• Limit consumption of alcoholic beverages, if you drink at all.

The American Institute for Cancer Research (AICR) published a report in 1997 [21] that includes an expert scientist panel review and evaluation of more than 4,500 studies on diet and cancer. The AICR Diet and Health Guidelines for Cancer Prevention were developed from these recommendations. The AICR also maintains a Web site that includes booklets of healthy recipes that follow their dietary guidelines.[22] The AICR and ACS guidelines are similar.

The AICR guidelines include the following:

• Choose a diet rich in a variety of plant-based foods.



• Eat plenty of vegetables and fruits.



• Maintain a healthy weight and be physically active.



• Drink alcohol in moderation, if at all.



• Select foods low in fat and salt.



• Prepare and store food safely.



• Do not use tobacco in any form.

The importance of maintaining healthy eating patterns extends through the continuum of care to the prevention of secondary cancers. Although dietary recommendations do not provide specific guidelines for secondary cancer prevention, it is generally accepted that individuals posttreatment should follow cancer prevention dietary recommendations established for the general population.

Consumption of more than five servings per day of fruits and vegetables is generally associated with a reduced risk of lung cancer.[23-31] Early studies of beta-carotene supplementation in men who smoked, however, showed increased risk.[32] It is now known that more than 500 types of carotenoids—including alpha-carotene, beta-cryptoxanthin, lutein, and lycopene—are present in foods. Multiple components in fruits and vegetables, such as isothiocyanates, carotenoids, and vitamin C, may explain the reduction in lung cancer risk.

Saturated fat and intake of meat or animal fat has been associated with increased risk of advanced prostate cancer in several epidemiologic studies.[33] In one study, men given test diets high in animal fat were shown to have higher free androgen index and testosterone levels postprandially than those given a diet low in animal fat.[34] This may provide some insight into the association between prostate cancer risk and diet.

Diet and risk of prostate cancer progression was evaluated in more than 1,200 men who participated in the Health Professionals Follow-up Study. Results support the hypothesis that postdiagnostic diet can influence disease progression in men diagnosed with localized or regional prostate cancer. Preliminary results of diet assessments after prostate cancer diagnosis suggest that a diet high in tomato sauce and fish may offer meaningful protection against disease progression. These findings are consistent with other studies that have reported the potential benefits of lycopene consumption and reduced risk of developing prostate cancer. Tomato sauce is the best source of bioavailable lycopene. The association of fish intake with lower risk of prostate cancer recurrence or progression is also consistent with previous results from cancer prevention studies that reported positive benefits associated with higher fish and fish oil intake. The current results suggest that diet modifications after diagnosis may have similar beneficial effects on protecting against the risk of prostate cancer progression, as has been shown in previous studies.[35,36]

The Alpha-Tocopherol Beta-Carotene Cancer Prevention Study, a randomized trial (n = 29,133), found that daily supplementation with 50 mg of alpha-tocopherol was associated with a 41% reduction in prostate cancer mortality.[37] Daily supplementation with 20 mg of beta-carotene, however, was associated with a 23% increased incidence of prostate cancer in smokers.

Recurrence of breast cancer and its relationship to diet have been examined in prospective cohort studies.[38-40] In one study, total energy and saturated and monounsaturated fat were associated with an increased risk of recurrence, although the association with the various types of fat was weakened after adjusting for energy intake.[38] When comparing the dietary intake of breast cancer survivors in Hispanic versus non-Hispanic white women, one study found more similarities than differences.[41]

Obesity and low physical activity have each been associated with increased breast cancer risk in postmenopausal women. Higher fasting insulin levels, the result of obesity and lower physical activity, have been proposed as a potential mediator of this increase in risk.[42] To help determine the effects of physical activity on survival rates, a prospective observational review was conducted in which women diagnosed with stage I, II, or III breast cancer were followed postdiagnosis through the Nurses' Health Study. The study found that a moderate increase in physical activity was associated with reduced risk of disease recurrence and increased survival rates, with the greatest benefit occurring in women who performed the equivalent of walking 3 to 5 hours per week at an average pace.[43] Another prospective observational study using data from more than 5,000 women diagnosed with nonmetastatic breast cancer who participated in the Nurses' Health Study suggests that high body mass index (BMI) before diagnosis is associated with poorer survival rates. Higher rates of breast cancer recurrences and mortality were also observed in women with an increase in BMI of 0.5 kg/m² or more one year or more after diagnosis, particularly in premenopausal, nonsmoking women.[44] Strategies to reduce body weight by increasing physical activity and decreasing caloric intake resulting in reduced insulin levels may lead to a reduction in breast cancer risk or risk of recurrence.[42]

The use of soy foods in breast cancer survivors has led to significant research in this area. Several studies suggest soy consumption may reduce breast cancer risk and improve survival; however, the estrogenic effects of isoflavones naturally found in soy products have led to controversy among health professional over the use of soy by breast cancer patients, especially those with estrogen receptor–positive tumors. Research on genistein and daidzein, the two main isoflavones in soy, has shown that these phytochemicals may bind to estrogen receptors and decrease the plasma estrogen levels in women, thus acting in a preventive manner.[45] Animal studies, however, have found that genistein inhibited the efficacy of tamoxifen, a drug used to block the body’s circulating estrogen.[46] One study [47] reviewed the relevant literature and found no convincing data to support the claim that soy is protective against breast cancer or that soy is harmful for women with a history of, or at high risk for, breast cancer. A follow-up study using data collected from a large cohort of breast cancer patients as part of the Shanghai Breast Cancer Study also concluded that soyfoods do not have an adverse effect on breast cancer survival.[48]

Researchers from these studies concluded that soyfoods, as part of a healthy diet and in moderate amounts, are safe to consume; however, there is not enough evidence to recommend that breast cancer patients begin to consume soy specifically to prevent the occurrence of a secondary tumor and enhance survival.[45] Adding soy to the diet after a diagnosis of breast cancer has not been shown to be protective against recurrences. Likewise, the consumption of concentrated isolated isoflavone supplements in the form of powders or pills has not shown effects consistent with breast cancer risk reduction and is not recommended.[47,49] As more research is conducted on the biological mechanisms relating to soy isoflavone intake, scientists may clarify the optimal exposure, duration, and timing of intake. Recommendations for the inclusion of soy in the diets of breast cancer survivors should be based on all available (and the most current) evidence.[50]

In a prospective study, breast cancer recurrence and mortality were strongly associated with beer consumption.[39] There appears to be an association between the consumption of two or more alcoholic drinks per day and an increased risk of breast cancer.[51] Dietary folate may attenuate the risks of postmenopausal breast cancer associated with family history, but only if alcohol use is avoided or minimized. In a study of 33,552 postmenopausal women aged 55 to 69 years, women with a family history of breast cancer who did not drink alcohol and who had adequate amounts of dietary folate demonstrated rates of breast cancer similar to those in women with no family history.[52]

Dietary fiber intake and its relationship to reduced cancer risk is more complex than once thought.[53] Supplementation studies of wheat bran fiber did not show an effect on the recurrence of adenomas, but the duration of supplementation (36–48 weeks) may not have been long enough.[53] In other words, the benefits from whole grains may only be seen on long-term intake. For example, the Iowa Women’s Health Study found that dietary fiber from all sources was associated with a 20% reduced risk of colon cancer.[54] Supplementation with 13.5 g of wheat fiber per day reduced the fecal concentration of bile acids by 52% and reduced the concentration of deoxycholic acid by 48%.[55] It is also known that dietary fiber decreases gastrointestinal transit time, thereby decreasing the time during which toxins persist in the gut.[56]

A population-based case-control study in Sweden found that intake of cereal fiber was associated with a 77% reduction in risk of gastric cardia cancer (relative risk = 0.3; 95% confidence interval, 0.2–0.5).[57] Wheat fiber may be a scavenger of nitrites under acidic conditions.[58]

Another case control study found that high antioxidant intake (total median intake of vitamin C [88 mg/day], alpha-tocopherol [6.8 μg/day], and beta-carotene [5 mg/day]) was associated with a 50% reduced risk of adenocarcinoma and a 40% reduced risk of squamous cell carcinoma of the esophagus, but risk of gastric cardia adenocarcinoma was not reduced.[59] Beta-carotene and total antioxidants were associated with a reduced risk of adenocarcinoma of the esophagus when reflux symptoms were present. Recall bias likely was a factor in this study, but the diverging effects antioxidants appear to have on histologic types of esophageal cancer suggest that the patterns of intake have been fairly consistent.

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