Obesity and Cancer Survivorship Where are we in Providing Care Cynthia T homson PhD RD Mary Koithan PhD RN CNSBC Objectives This webinar will help you Describe the relationship between obesity weight gain and cancer risk and survival ID: 764914
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Obesity and Cancer Survivorship: Where are we in Providing Care? Cynthia T homson, PhD, RD Mary Koithan , PhD, RN, CNS-BC
Objectives This webinar will help you: Describe the relationship between obesity, weight gain and cancer risk and survival. Better understand the biological and psychosocial influences contributing to obesity Efforts for multidisciplinary cancer survivorship care to reduce the burden of obesity in cancer survivors.
2000 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Factors Associated with Obesity Independent of prior cancer diagnosis: Age Race/ethnicity SESFood and activity environmentStress and eating response*
Stress and Obesity
Obesity Defined: Is BMI Enough? Weight (pounds) 23 22 21 19 18 17 16 15 15 25 24 22 21 20 19 18 17 16 27 26 24 2321201918 1729272624232220191831 29282624232221203331292726242322213533 31292726242322 37 3533312927262423 3937343230292726244138363432302927264340383634323028 2745424037353331302847444139373533 3129494643403836343230 51 4845424037353332534946444139373533 55514845434038363457 53504744423937355955 52494643413937 635955524846434140666258 5552494644 41 7066625855524946 44747065615855524946 78 7369656157545149 120 130 140150 160170180 190 200210 220320340360 240250 260 230270280 29038030040064 Height (inches)6260706866727476
Metabolic State Correlates with Body Shape
Adiposity and Insulin R esistance
Annual Reviews Obesity and Chronic I nflammation
Fat Cell-Adipocyte and Inflammation Lee et al, Curr Opin Clin Nutr Metab Care. 2010 13(4): 371-376 Adipocyte stromal cells have high angiogenic potential and as such may contribute to cancer progression
Obesity-Associated Biomarkers of Cancer Risk and Recurrence Biomarker Role Insulin Growth-promotion/ cell division, anti-apoptoticIGF-1 and IGF-BP-1Increased cell migration, prolonged elevated insulin, potentiates growth factorsC-reactive protein (CRP)Inflammation, may correlate with estradiolInterleukin 6Inflammation, growth and differentiation of malignant cells Tumor necrosis factor alphaInflammation, associated with insulin resistanceSerum amyloid A (SAA)Low-grade chronic inflammation; assoc with reduced survival in breast cancer
Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosisCoronary heart disease Diabetes Dyslipidemia Hypertension Gynecologic abnormalities abnormal mensesinfertilitypolycystic ovarian syndromeOsteoarthritisGallbladder diseaseCancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate Phlebitisvenous stasisGoutMedical Complications of Obesity Idiopathic intracranial hypertension Stroke Cataracts Severe pancreatitis Slide source: www.obesityonline.org
Psychological Effects of Obesity Eating dysregulation: Craving cycle Increase in stress Body image MobilityDepressionFatigueOverall effects on quality of life
Obesity and Cancer Obesity is associated with risk for: post-menopausal breast endometrial/uterine pancreaticcolorectalgallbladder esophageal
Obesity and Cancer Survival In the survival setting associations are less consistent Treatment efficacy; treatments employed; Recalcitrant disease Most studies in breast cancer Weight gain during therapy in those with normal BMI –greater risk?Metabolic co-morbidities are highly relevantParekh, Chandran and Bandera, 2012
Survival Varies by Race and Obesity
Framework for the combined influence of race and obesity on cancer survivorship. Schmitz K H et al. JNCI J Natl Cancer Inst 2013;105:1344-1354 © The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
Cancer Therapies: Surgery, Radiation, Chemotherapy, Hormone suppression Increased adiposity Loss of lean mass Inflammatory and/or abnormal metabolicresponse Fatigue, and/orreduced mobility InterventionsDietPhysical activitySleep hygieneAnti-inflammatory drugsWeight control
Evidence in Support of Theoretical Models Limited intervention studies; most in breast cancer survivors Survivors report change in diet; trials suggest that behaviors can be modified after diagnosis Few assessed cancer endpoints; most evaluate intermediate biomarkers of disease risk
Low CHO versus Low Fat Weight Loss Diets 50 overweight breast cancer survivors on tamoxifen or aromatase inhibitors Randomized, 2-arm trialFace-to-face counseling with a dietitian weekly x 4 weeks, then monthly for 5 monthsBaseline, 3 and 6 month measures of: Anthropometrics, body composition Metabolic indices Inflammation (CRP, IL-6)Thomson, et al. Nutr & Cancer, 2010
Percent of Breast Cancer Survivors with Metabolic Syndrome Before and After Weight Loss Thomson CA, J Women’s Health, 2009
Obesity-associated Co-Morbidities may Influence Cancer Survival Women’s Healthy Eating and Living Study 3055 women treated for breast cancer CVD, hypertension not associated with breast cancer events or mortality after breast cancer Diabetes associated with a 2-fold greater risk for breast cancer event and 2.5-fold higher risk for mortalityCombined co-morbidities: CVD, HTN, DM increased mortality risk 2-foldRecent analysis in 636 ovarian cancer survivors showed DM increased mortality 84% WHEL Research Group; Breast Ca Res Treatment 2010; WHI ms #2080
Weight Control Studies in the Survivor Population African American W omens’ study –improved QOLPrimary outcomes:Chronic and late effectsWeight changeImproved function Quality of LifeReduced metabolic abnormalitiesLombardi study in African American Women: Sheppard and Adams-Campbellhttp://www.youtube.com/watch?v=_l9xoqAUE-I&feature=player_embedded
ENERGY Trial Weight loss in breast cancer survivors (N=693) Daily activity, eating behaviors Outcome: breast cancer recurrence and disease-free survival Pilot data from 220 women demonstrated ≥5% weight loss decreased leptin, insulin, estrone, estradiolRock et al, Clin Breast Cancer, 2013; Rock et al., Contemp Clin Trials, 2013
Summary: Interventions for Weight Control Post-Diagnosis No evidence of survival benefit demonstrated to date Trials underway: ENERGY, LEAN, etcWeight loss diets will “correct” metabolic and inflammatory abnormalitiesTrails with: RD counseling, Weight Watchers, Curves, etcMay reduce risk co-morbidities associated with poorer prognosisDiet-induced weight loss reduces lean mass and bone;Physical activity, including strength training, should be considered in weight loss plansMust address whole person
Role of Healthcare Providers ACS Guidelines, 2011 Promote weight control Plant-rich diet Physical activity > 30 minutes dailyLimit alcoholAvoid energy-dense foods; sweetened beveragesLifestyle modification counseling and supportTailored to individual patient, prognosis and time-course of diseaseRobien, Demark-Wahnefried and Rock, JAND, 2011
The Anti- inflammatory/ Mediterranean Diet
Limited Evidence, but Biological Support Low Glycemic Diet Low Glycemic Index Lentils Black beansCashewsSweet potatoMacaroniModerate Glycemic Index Brown riceQuick oatsBran muffinPineappleRaisinsApricotsHigh Glycemic IndexWhite BreadBaked potatoCorn FlakesWatermelon
Exercise and Movement Yoga Tai Chi Walking
Mind-body Stress Reduction Mindfulness Meditation Breathing
Restorative Sleep
Integrative Approaches to Weight Loss
Lifestyle/Behavioral Change
5 Stages of Change
Experiential 10 Processes of Change
Behavioral 10 Processes of Change
Provision of Care Multidisciplinary – healthcare professionals and community-based providers Beyond cancer survivorship clinics Move from cancer care centers to primary care settings
Resources: NCI TRECs Translational Research Energetics and Cancer Fred Hutchinson Cancer Research Center Harvard: biological mechanisms linking obesity and cancer throughout the lifespan and at multiple levels, and translating this knowledge into actionable behavioral interventions targeting children, minorities, and cancer survivors. University California, San Diego: mechanisms linking obesity with breast cancer risk and conducts studies investigating obesity and lifestyle factors related to insulin resistance and inflammation using mouse models, clinical trials, and wireless and networked technologies in the community.University of Pennsylvania: the association between energy balance and breast cancer recurrence and persistent adverse treatments effects and explores the impact of exercise and weight control interventions in cancer survivors through cost effectiveness analysis.Washington University in St. Louis: multilevel and multigenerational approaches to investigate mechanisms by which preconception diet, nutrition and built environment policies impact inactivity and how physical activity and energy balance influence body weight and carcinogenesis across the lifespan.
Resources: Diet, Obesity and Cancer Academy of Nutrition and Dietetics – Oncology Dietetics Practice group: www.oncologynutrition.orgAmerican Cancer Society Guide: www.cancer.orgAmerican Institute for Cancer research: www. AICR.orgCenter for Disease Control and Prevention http://www.cdc.gov/cancer/survivorship/Marian M and Roberts S. Clinical Nutrition for Oncology Patients, Jones & Bartlett, 2010The University of Arizona College of Nursing’s Community Cancer Connections Projects @ www.linkin.nursing.arizona.edu
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