Nutrition and Exercise Guide After Cancer Treatment

Cancer occurs disproportionately worldwide because it is affected by factors such as race, ethnicity, socioeconomic status, and geographic location. However, in Türkiye, the US, and other developed countries it is the second leading cause of death. Nevertheless, US statistics over the last 30 years show approximately a 32% decline in the number of people dying from cancer. 2020 Global Cancer Statistics show that, worldwide, the number of people living after completing cancer treatment has exceeded 50 million.

Factors That Improve Cancer Treatment Outcomes

A number of factors have effects that help people survive cancer;

• An aging population
• Recent developments in cancer screening offering the opportunity for early diagnosis and treatment
• Immunotherapies and the development of other more effective, targeted treatment options

Factors such as smoking and obesity that increase cancer risk also affect cancer mortality. Evidence from observational and laboratory studies suggests that modifiable factors such as physical activity, diet, and alcohol consumption may also affect cancer recurrence and overall survival.

Data from observational studies indicate, for example, that men diagnosed with prostate cancer account for 27% of new cancer cases and women diagnosed with breast cancer for 31%. Both cancer types have high 5-year survival rates. Recent attention has therefore focused on the relationship of modifiable factors to recurrence and survival in common cancers with high survival rates. Such research is limited for less common cancers with lower survival rates.

A Guide to Living for Cancer Patients

The American Cancer Society (AKD) prepares guides for people undergoing or having completed cancer treatment, their families, and healthcare providers:

• The first guide, published in 2006, was prepared for the same purpose using the scientific knowledge available at the time.
• A second guide was published in 2012, with broader scientific evidence and more specific recommendations focused on cancer types.
• Unlike its predecessors, this newly published third guide includes evidence-based, cancer-specific recommendations aimed at reducing cancer recurrence and improving survival and covering anthropometric parameters, physical activity, diet, and alcohol consumption.

Many people undergoing or having survived cancer treatment face environmental, social, and structural barriers to following nutrition and exercise recommendations. A major barrier is inequality in care during treatment: insecurity in the food market, access to healthy food, and inability to be physically active. Many such problems also disproportionately affect people of different racial and ethnic backgrounds.

The new AKD guide includes recommendations serving as a nutrition and physical activity guide for cancer prevention, people receiving cancer treatment, and cancer survivors. It is based on scientific evidence addressing multiple cancer-related health outcomes, including anxiety, depression, fatigue, healthy quality of life, lymphedema, bone health, and sleep.

General Nutrition and Exercise Recommendations

Reaching and maintaining a healthy weight is important because it may improve treatment tolerance. Cancer patients therefore need to pay attention to nutrition and physical activity during prolonged treatment. Likewise, cancer survivors should consult health professionals about nutrition after treatment. Studies provide evidence that a physically active lifestyle, a healthy diet, and avoiding obesity improve long-term survival after cancer treatment. Reviews of nutrition and exercise have identified relationships between adiposity, physical activity, diet, and alcohol and the rates of recurrence and death among cancer survivors.

• Related topic: How does obesity cause cancer?

It is important to emphasize that cancer survivors are at risk of cardiovascular disease (KVH), diabetes, osteoporosis, and other chronic conditions. It should also be remembered that some cancer treatments increase the risk of chronic diseases.

Major organizations such as the Academy of Nutrition and Dietetics and the European Society for Enteral and Parenteral Nutrition have published guides containing nutrition and exercise plans recommended during or immediately after cancer treatment.

Neoadjuvant and adjuvant treatment are among the outpatient settings addressed by the following recommendations for optimal care;

• People at risk of malnutrition should be assessed by a dietitian and receive an individualized nutrition plan. The program should be part of a multidisciplinary care plan and reviewed regularly.
• Tumor-related or other adverse symptoms affecting nutrition should be identified and managed.
• Oral nutritional supplementation if daily protein intake is less than 1 g per unit of the person’s body weight.
• If malnutrition persists, feeding through an enteral nutrition tube may be started. If this is contraindicated, parenteral nutrition support may be considered.

The US National Comprehensive Cancer Network (UKKA) and the American Society of Clinical Oncology (ASCO) have also recently offered nutrition and exercise recommendations for cancer survivors and clinicians;

• Ensure adequate macronutrient and micronutrient content from both animal and plant sources
• Be cautious about excessive or inappropriate use of nutritional supplements during or after cancer treatment
• Follow food safety procedures to prevent foodborne illness
• Be as physically active as possible

The report “A Global Perspective in 2018” on these issues concluded that following all these recommendations is not harmful unless a person’s doctor advises otherwise. They generally include maintaining a healthy weight, physical activity, healthy eating, and avoiding alcohol. The AKD guide also emphasizes a dietary pattern rich in a variety of plant foods, including vegetables, fruit, whole grains, and legumes, while limiting red and processed meat, refined grains, and sugary drinks.

People with high physical activity levels before diagnosis were found to have an 18% lower risk of breast cancer. High activity after diagnosis has been associated with reductions in breast, colorectal, and prostate cancer. Data are limited for other cancer types (kidney, lung, esophageal cancer, Hodgkin lymphoma, childhood cancers, and malignant glioma).

Exercise Recommendations

As noted earlier, evidence suggests that exercise during cancer treatment helps manage various aspects of quality of life. Although benefits for managing anxiety, depression, and lymphedema have been demonstrated depending on cancer type and treatment, further studies are needed to provide evidence for managing other side effects.

Recommendations for physical activity in this context include aerobic exercise, resistance exercise, or both. Exercise during treatment will also improve treatment tolerance. It is important for cancer patients to obtain medical support for an appropriate exercise program. Such support enables safe and effective fitness programs tailored to problems associated with particular cancers or treatments, such as breast cancer-related lymphedema.

Nutrition Recommendations

Inadequate nutrition because of a cancer diagnosis and the side effects of subsequent treatment is common and often adversely affects the clinical course. A plan developed with a dietitian responsible for cancer-related nutrition will help manage this situation. The nutrition plan generally includes screening, a nutrition-focused physical assessment, medical nutrition therapy interventions, and ongoing monitoring.

Cancer-Specific Nutrition and Exercise Recommendations

Breast Cancer

Breast cancer is the most common cancer among women in the United States and the second leading cause of cancer-related death. For 2022, 287,850 women are expected to be diagnosed with breast cancer, and 43,250 people are expected to die from it.

Evidence indicates better survival among women with breast cancer who are physically active and consume fiber-rich, soy-containing, and low-fat foods. Studies in women with breast cancer have also shown that obesity (Body Mass Index (VKİ) ≥30 kg/m²) before diagnosis, during treatment, and afterward increases recurrence, poor prognosis, and mortality rates.

Breast Cancer and Nutrition

Studies have shown that women with breast cancer and VKİ ≥30 kg/m² have higher recurrence and mortality rates than those with VKİ 18.5 – 24.9 kg/m² . Another study, however, compared deaths after diagnosis among women with breast cancer and VKİ ≥25 kg/m² and found no significant result. Nevertheless, obesity was reported to be associated with increased mortality only among breast cancer survivors treated with siklofosfamid, doksorubin, and 5-florourasil.

However, no relationship is yet understood for the effects of measures such as fat distribution (waist-to-hip ratio and waist circumference) and body composition (body fat and muscle percentage and fat mass index) in women with breast cancer. Although adult weight gain is associated with breast cancer risk, whether weight gain before diagnosis has such a relationship is not fully understood, despite some studies supporting it. Evidence for intentional weight loss after diagnosis is also limited. For example, a review after recovery from estrogen receptor-positive (ER+) breast cancer observed 24% more recurrence among those who gained weight and reduced recurrence risk with weight loss. In contrast, some studies report that losing weight increases mortality after breast cancer treatment.

Breast Cancer and Exercise

According to the ACSM (American College of Sports Medicine) report published in 2019, physical activity assessed before diagnosis reduces breast cancer-specific and all-cause mortality risk. A more recent meta-analysis by Friedenreich and colleagues supports this result. In that study, physical activity reduced all-cause mortality independently of VKİ in postmenopausal breast cancer patients, but not in premenopausal patients. Evidence also supports an inverse dose-response relationship between physical activity and breast cancer-specific and all-cause mortality. Following a moderate or more intensive exercise program in particular further reduces these risks.

However, more intensive physical activity was targeted to increase effectiveness, and both recreational activity (such as walking or running) and total activity (recreation, transport, work, and home) were associated with lower breast cancer-specific and all-cause mortality, regardless of dose.

Physical activity after diagnosis reduces breast cancer-specific and all-cause mortality risk in premenopausal and postmenopausal women.

In a study by Spei and colleagues of recreational exercise and mortality, breast cancer survivors following an intensive exercise program had 40% lower breast cancer mortality and 42% lower all-cause mortality than those following a less intensive program.

A study by Morishita and colleagues also showed that physical activity interventions (aerobic, resistance, or combined) reduced all-cause mortality risk by 24% and recurrence risk by 48%.

A study reviewing multiple research findings examined physical activity and mortality among breast cancer survivors. Overall, there was an inverse dose-response relationship between activity after diagnosis and mortality. Activity up to approximately 10 metabolic equivalent (MET) hours per week was associated with sharp reductions in cancer-related and all-cause mortality risk. This activity level included guidelines recommending 150 minutes of moderate-intensity or 75 minutes of vigorous exercise weekly. The study supports following exercise guidelines, which reduced breast cancer mortality risk by 21% and all-cause mortality by 28%, respectively. It also recommended that activity volume and intensity in breast cancer patients exceed current advice (150 minutes of moderate-to-vigorous activity weekly), with moderate activity increased to 300 minutes weekly.

In another meta-analysis, Wang and colleagues reported that exercising even in small amounts may reduce mortality risk compared with not exercising.

Most importantly, 2 studies conducted by Lee and colleagues reported that reducing physical activity between the periods before and after diagnosis increased all-cause mortality risk by 236%.

Overall, recreational and total activity before and after diagnosis were found to provide sustained protection against cancer-specific and all-cause deaths. However, there is no general conclusion for activity in areas such as home, transport, and work because these have not been examined separately. Clear recommendations also cannot be made about which activity domains contribute to the dose identified in dose-response analyses of 10 MET hours weekly (approximately 3 hours of walking).

There are also studies on the health effects of a sedentary lifestyle. Swain and colleagues found no significant relationship between sedentary time after diagnosis and all-cause mortality in cancer survivors. The team emphasized the need for more observational and interventional research to determine whether sedentary time increases breast cancer-specific and all-cause mortality risk and is a potential intervention target for survivors.

As many of these reviews note, mechanisms underlying the protective effects of activity on breast cancer mortality may include reduced estrogen and androgen action, effects on insulin and insulin-related factors, and reduced inflammation. Activity may affect these pathways directly or indirectly through weight reduction. Lower all-cause mortality may relate to other benefits of activity through reduced cardiovascular risk (for example, greater exercise capacity) and lower risks of other comorbidities.

In conclusion, all studies emphasize the importance of breast cancer survivors being as active as possible, increasing activity when possible, and particularly not reducing activity after diagnosis and treatment.

Lung Cancer

In 2022, an estimated 236,740 new lung cancer diagnoses and 130,180 deaths from this cancer are expected. Lung cancer is the second most common cancer in both men and women in the US and the leading cause of cancer death. As of 2018, there were 517,350 lung cancer survivors in the US. Although stopping smoking remains the first priority, other modifiable risk factors may also influence long-term survival.

Lung Cancer and Nutrition

The relationship between weight, VKİ, body composition, and lung cancer survival is somewhat complex. Smoking is an important disease risk factor, and smokers tend to have a lower VKİ, potentially confounding its relationship with cancer survival. Research on VKİ at diagnosis and lung cancer prognosis is limited and inconsistent.

A study of patients receiving specific chemotherapy drugs found survival advantages in patients with higher VKİ. Research examining VKİ and survival found a lower mortality risk in overweight patients with non-small cell lung cancer receiving karboplatin and paklitaksel. Higher VKİ was not associated with mortality in patients receiving sisplatin and vinorelbin, however.

In another study, Petrelli and colleagues found lower overall mortality in obese lung cancer patients than in nonobese patients.

Most studies, however, included advanced lung cancer patients in whom substantial weight loss was common, so findings should be interpreted cautiously.

Lung Cancer and Exercise

Few studies examine the relationship between activity or sedentary behavior after diagnosis and lung cancer survival.

Friedenreich and colleagues examined activity before and after diagnosis in relation to cancer-specific and overall survival and found a 24% lower mortality risk in physically active than in less active patients.

Another study observed that physical activity reduced lung cancer mortality rates by 19%.

Overall, evidence linking physical activity to lung cancer survival is limited. Robust data and studies on the role of sedentary behavior in lung cancer survival are not currently available.

Upper Aerodigestive Tract Cancers

Upper aerodigestive tract cancers (UADT) include gastrointestinal [GI] cancers of the esophagus, stomach, small bowel, colon, rectum, anus, and liver, as well as gallbladder, biliary tract, pancreatic, oral cavity, and pharyngeal cancers. These account for approximately 21% of new cancer cases in the US. For 2022, 397,040 new GI cancer cases and 183,150 deaths from these cancers are estimated.

Colorectal cancer is the most common UADT cancer. Its incidence is decreasing by 2% annually among people aged 50 and older but increasing by 1.5% each year in people younger than 50. Approximately 1,5 million Americans are estimated to have a history of colorectal cancer.

Most studies of VKİ and mortality in UADT cancers have focused on esophageal, colorectal, gastric, oropharyngeal, and pancreatic cancers. In an esophageal cancer meta-analysis, Liu and Zhang reported a 3% lower all-cause mortality risk per 5-unit increase in VKİ. Another meta-analysis by Han and colleagues associated higher VKİ before or at diagnosis with 23% lower all-cause mortality. Colorectal cancer patients in the overweight range also had reduced all-cause mortality risk. Han’s team found no increased risk in overweight patients, but obesity was associated with a 22% higher mortality risk.

In a study of visceral adiposity, which may affect cancer survival, Xiao and colleagues reported increased mortality risk in colorectal cancer patients with visceral adiposity.

Upper Aerodigestive Tract Cancers and Exercise

People physically active after colorectal cancer diagnosis have a lower all-cause mortality risk after surviving the disease. Qui and colleagues reported 36% lower colorectal cancer mortality and 37% lower all-cause mortality in physically active patients.

Each 10 MET-hour weekly increase in activity after diagnosis (approximately 3 hours of brisk walking or 1.5 hours of cycling weekly) reduced all-cause mortality risk by 24%. Benefits of particular activities, such as aerobic or muscle-strengthening exercise, have not been established. Evidence on activity after diagnosis remains insufficient for other upper aerodigestive tract cancers.

Patients maintaining a sedentary lifestyle after colorectal cancer diagnosis have a high mortality risk after surviving the disease. Sedentary behavior is defined as sitting or lying down and often includes screen-based activities.

Upper Aerodigestive Tract Cancers and Nutrition

Vegetables and fruit are essential to a healthy diet. Research identifies 2 main dietary patterns followed by cancer survivors.

• Mediterranean diet: fruit, vegetables, grains, hazelnuts, legumes, and low-fat dairy products
• Western-style diet: red and processed meat, refined grains, and high-fat dairy products

It is important to follow a diet rich in whole grains, vegetables, fruit, and legumes.

• Related topic: Why Is the Mediterranean Diet the Best Diet? How Is It Followed?

Genitourinary Cancers

The genitourinary system includes the kidneys, bladder, ureters, urethra, and, in men, the prostate, penis, and testes. Estimated new US cases in 2022 are: prostate 268,490, bladder 81,180, kidney 79,000, testis 9910, ureter and other urinary organs 4010, and penis 2070. Prostate cancer is the most common cancer and the second leading cause of cancer death. It is expected to account for 11% of deaths among men in 2022.

Prostate Cancer and Nutrition

Evidence is insufficient that overweight and obesity increase mortality risk in advanced prostate cancer. Using data from 22 clinical trials at the Southwest Oncology Group, Greenlee and colleagues analyzed VKİ and cancer mortality in 14 cancer types. Unlike previous studies, these data showed lower mortality risk in overweight or obese prostate cancer patients receiving androgen deprivation therapy.

Parekh and colleagues reviewed VKİ before and after diagnosis in relation to prostate cancer survival. Obese men had significantly higher mortality risk than healthy men and also greater metastatic risk.

In contrast, neither the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) study, with approximately 4 years of average follow-up, nor the Mayo Clinic Prostatectomy Registry, with 10 years of follow-up, found a relationship between VKİ and prostate cancer-specific mortality.

Interpretation of most findings is limited by the small number of prostate cancer studies controlling for tumor pathological characteristics.

Bladder Cancer and Nutrition

Greenlee and colleagues found significantly lower mortality risk in 35 overweight bladder cancer patients treated with Bacillus Calmette-Guerin.  

Zuniga and colleagues systematically reviewed 105 studies of modifiable risk factors, recurrence, progression, cancer-specific mortality, and all-cause mortality in non-muscle-invasive bladder cancer. Of these, 18 assessed VKİ and bladder cancer and supported the idea that overweight or obesity (VKİ ≥25 kg/m²) was associated with increased recurrence risk in non-muscle-invasive disease. Findings on VKİ and cancer-specific or all-cause mortality remain insufficient.

Two studies suggested that measuring adiposity and muscle mass with computed tomography (BT) scans may predict clinical outcomes after cystectomy better than anthropometry because both fat and skeletal muscle can be measured. VKİ alone had no relationship to sarcopenia but was associated with higher all-cause mortality risk. As researchers generally acknowledge, using a single database is a limitation of systematic reviews, including this study.

Kidney Cancer and Nutrition

In Greenlee and colleagues’ observational analysis, 35 kidney cancer patients with higher VKİ at diagnosis who received a-IFN 9 showed no relationship between baseline VKİ and mortality risk.

Xiao and colleagues’ 2016 systematic review assessed visceral adiposity and cancer survival across several cancers, including 5 renal cell carcinoma studies. In 4 of those 5 studies, either greater visceral adiposity predicted survival or lower visceral adiposity was associated with poorer survival.

Testicular Cancer and Nutrition

No systematic reviews evaluating adiposity, body weight, body composition, or weight change in relation to testicular or other male genital cancers have yet been reported.

Genitourinary Cancers and Exercise

Few studies examine activity or sedentary behavior after diagnosis in relation to genitourinary cancer survival.

Benke and colleagues examined activity in relation to prostate cancer incidence and mortality. Their study of activity after diagnosis and prostate cancer-specific mortality reported a 31% lower risk with higher activity. The activity assessed was recreational exercise.

Friedenreich and colleagues systematically reviewed 136 studies of activity before and after diagnosis in relation to cancer-specific and overall survival across all cancers. Like Benke and colleagues, they reported a 30% reduction in risk.

In 5 studies of activity and all-cause mortality, very active prostate cancer survivors had a 40% lower risk than physically inactive survivors.

For other genitourinary cancers, Friedenreich and colleagues identified only one study of activity after kidney cancer diagnosis and survival. Physically active kidney cancer survivors had 43% lower kidney cancer-specific mortality and 40% lower all-cause mortality risk.

Swain and colleagues examined sedentary behavior after diagnosis and health outcomes among survivors. One kidney cancer survivor study showed higher overall mortality with a sedentary lifestyle. A prostate cancer survivor study also reported reduced overall mortality risk in those physically active.

Gynecological Cancers

Gynecological cancer refers to any cancer arising in female reproductive organs, including the cervix, ovaries, uterus, vagina, and vulva. An estimated 115,130 new gynecological cancers are expected in the US in 2022.

Endometrial cancer, comprising most uterine corpus cancers, is the most common gynecological malignancy in the US. For 2022, 65,950 new diagnoses and 12,550 deaths are estimated.

Ovarian cancer is the most life-threatening gynecological cancer, with 29,880 diagnoses and 12,810 deaths estimated in 2022. At least half of ovarian cancers are diagnosed at advanced stages, resulting in poor prognosis and contributing to an overall 5-year survival rate of 49%.

For invasive cervical cancer, 14,100 diagnoses and approximately 4280 deaths are expected in 2022. The role of diet and activity in gynecological cancer prognosis is largely unknown.

Endometrial (Uterine) Cancer and Nutrition

Obesity is a strong risk factor for several cancers, with one of the strongest associations being endometrial cancer. However, studies of its role in endometrial cancer progression are limited.

In 2 systematic reviews, half the studies found higher mortality risk in people with higher VKİ before diagnosis, while the other half reported no result. Studies indicate that a 10% increase in VKİ among endometrial cancer survivors is associated with 9% higher mortality rates.

A recent large meta-analysis by Petrelli and colleagues of obesity and mortality found a 20% higher mortality risk in women obese at endometrial cancer diagnosis than in nonobese women. The role of weight change before and after diagnosis in survival is unknown.

Ovarian Cancer and Nutrition

The relationship between VKİ and ovarian cancer survival is not fully understood. Greenlee and colleagues reported poorer survival with higher VKİ, but the sample was relatively small (n = 241) and results were not statistically significant. Petrelli and colleagues found no survival difference between obese and nonobese women.

Gynecological Cancers and Exercise

When the AKD recommendation report was written, there were no systematic reviews or meta-analyses of activity or sedentary behavior in the prognosis of endometrial, ovarian, or other gynecological cancers.

A meta-analysis by Friedenreich and colleagues found a 33% lower mortality risk in women physically active after diagnosis than in less active women. No reviews or meta-analyses of sedentary behavior in gynecological cancer prognosis are yet available.

Hematological Cancers

Hematological cancers arise in bone marrow and lymphatic system cells. The 3 main types are leukemia, lymphoma, and multiple myeloma. In 2022, 184,130 new US cases are expected, representing 9.6% of new cancers. Survival in hematopoietic and lymphoid cancers has improved over recent decades; for example, chronic myeloid leukemia 5-year survival increased from 22% in the mid-1970s to 71% for people diagnosed from 2011 to 2017.

However, substantial racial and ethnic differences in incidence and survival also exist for patients with hematological cancers.

Knowledge of the origins and risk factors of these cancers is limited. The link between ionizing radiation and leukemia is well known. Smoking is also a known leukemia risk factor. Recent evidence suggests that lower fruit and vegetable consumption may increase non-Hodgkin lymphoma risk.

Studies of modifiable risk factors in the prognosis of hematological cancers are also limited. In studies covering several cancers, hematological cancer patients represented only a small proportion of all patients analyzed.

Hematological Cancers and Nutrition

Greenlee and colleagues found no significant relationship between VKİ at cancer diagnosis and disease progression in acute myeloid leukemia or non-Hodgkin lymphoma.

Hematological Cancers and Exercise

Fredenreich and colleagues reported a protective effect of activity before diagnosis in their research on activity and mortality in hematological cancer patients. Activity after diagnosis was not significantly associated with mortality.

Nutrition and Exercise for Childhood Cancer

In 2022, 10,470 US children younger than 15 and 5480 adolescents aged 15-19 are expected to receive a cancer diagnosis. Nutrition recommendations for children receiving treatment aim to maintain normal growth and development during and after treatment. Close work with dietitians and physiotherapists is needed to tailor diet and activity to the child’s particular needs.

Treatment of childhood cancers has advanced substantially over the last 50 years, greatly improving long-term survival. Overall 5-year survival is 85% in children younger than 15 and 86% in adolescents. More than 400,000 survivors diagnosed during childhood or adolescence now live in the United States.

Childhood cancer survivors tend to develop chronic conditions earlier than people without a cancer history. Maintaining a healthy weight, making healthy dietary choices, and being regularly active to prevent these conditions are therefore particularly important.

Summary of Recommendations and Evidence for Cancer Survivors

Cancer survivors can benefit from dietary and activity counseling after diagnosis and treatment. The following table summarizes recommendations supported by current scientific evidence.

Table 1:  Diet and Activity Guide for Cancer Survivors, American Cancer Society, 2022

Nutrition counseling can help manage treatment-related nausea, vomiting, and appetite loss, preventing the resulting nutrient deficiencies and muscle loss.

Although short-term restrictions may apply after major surgery or stem cell transplantation, most survivors can exercise before, during, and after treatment. Activity during and after treatment may improve anxiety, depressive symptoms, fatigue, physical function, and health-related quality of life. The American Institute of Sports Medicine provides guidance on specific doses of aerobic and resistance training that may improve these common cancer-related outcomes.

Exercise may need individual adaptation for tolerance, safety, treatment symptoms, and side effects. The ultimate goal is to reach current recommendations: 150-300 minutes of moderate or 75-150 minutes of vigorous activity weekly, plus muscle strengthening on 2 or more days weekly.

Evidence is insufficient for a general recommendation on alcohol use. Some cancers, however, show increased mortality with alcohol use. Avoiding alcohol is therefore a cancer prevention recommendation and is associated with reduced risk of a new cancer in survivors.

The American Cancer Society’s dietary and activity recommendations for cancer prevention are summarized below.

Table 2: American Cancer Society Diet and Physical Activity Guide for Cancer Prevention Recommendations

Table 3 summarizes evidence on adiposity, activity, diet, and alcohol after diagnosis for specific cancers. It highlights the lack of high-quality research for many cancers and suggests further research is needed to improve future recommendations.

Table 3: Evidence for Factors That May Be Effective by Cancer Type

Late Effects and Patient-Reported Outcomes

Problems Affecting Exercise and the Nutrition Guide    

Adopting healthy dietary and activity behaviors may benefit treatment-related symptoms and quality of life. Exercise, for example, may improve quality of life and symptoms such as fatigue. Structured exercise programs may improve cardiovascular fitness after cancer treatment.                       

Some studies specifically confirm that adherence to the previous AKD diet and activity guide may improve health-related quality of life and reduce metabolic syndrome risk after cancer treatment. Metabolic syndrome also increases risks of comorbidities such as diabetes and KVH, which remain leading causes of morbidity and mortality among US cancer survivors. 

Counseling to Improve Health After Completing Cancer Treatment and Surviving Cancer

In meeting current healthy-behavior recommendations, people with a cancer history are not required to follow nutrition and exercise guidance more than peers without that history. There may be gaps in assessment and counseling on nutrition, alcohol, and activity after cancer treatment.     

Counselors should tailor communication and strategies to individual health literacy and numeracy to improve access to information. Literacy may be affected by age, education, cognitive ability, and language. Older people, for example, may have more limited health literacy than younger people.

Late and Long-Term Effects May Hinder Adherence to the Guide

Adherence to the AKD guide may be inadequate after cancer treatment. A breast cancer survivor study found only moderate adherence.

Poor adherence to nutrition and activity recommendations has various causes, including sociodemographic factors, time, and access to resources. Late and long-term cancer effects may also hinder healthy behavior. One study found these treatment effects could overshadow other barriers. Functional impairments such as peripheral neuropathy, avascular necrosis sequelae, cardiomyopathy, partial limb amputations, or lymphedema may pose risks for particular activities.

The Role of Patient-Reported Outcomes

Cancer and its treatment have many late and long-term effects. An individualized approach is needed to adopt healthy diet and activity behaviors and assess possible barriers. Patient-reported outcomes offer a systematic way to do this in clinical practice and can help assess interventions intended to improve long-term cancer outcomes. Prehabilitation, a prospective approach in cancer care using baseline assessments to guide outcome-improving interventions, provides an example.

Although cancer treatment has traditionally focused on short-term outcomes, a recent systematic review identified the potential and limitations of existing prehabilitation programs for long-term survival outcomes. Combined with rehabilitation after treatment, prehabilitation may more effectively reduce morbidity and adverse clinical outcomes. Many studies have excluded people with comorbidities. The substantial prevalence and variety of these conditions in cancer patients further emphasize the need for individualized care.     

Organizations such as the American Heart Association have published guidance on cardio-oncology rehabilitation to improve cancer outcomes, recognizing cardiovascular disease both as an important late treatment effect and a common comorbidity.

People who have completed cancer treatment and survived cancer experience multiple symptoms, a key modifiable barrier to healthy behavior. Many persist after treatment for 10 years or more. Among people completing chemotherapy, for example, pain and fatigue severity was 6 on a scale from zero to 10. These symptoms continue for a year after diagnosis, making this transition a possible opportunity for intervention. Persistent pain and peripheral neuropathy have been documented elsewhere. More than 60% of breast cancer survivors had fatigue and sleep problems, and 67% of cancer survivors reported depressive symptoms. Between 2010 and 2013, 2.5 million US cancer survivors took medication for depression, anxiety, or both. Recognizing symptoms as barriers, approaches are needed that manage symptoms while encouraging healthy behaviors to optimize long-term outcomes.

What Health Inequalities Occur During and After Cancer Treatment?

Cancer survivors face physical, emotional, psychosocial, and financial difficulties resulting from diagnosis and treatment. Although everyone faces challenges, some groups are disproportionately affected. Black and American Indian populations in rural areas, for example, experience greater poverty and racism and often lack access to healthcare.

Hispanic people have the lowest prevalence of health insurance of any racial and/or ethnic group. Inequalities in access remain a major US public health issue. Research on cancer health disparities among survivors has largely focused on racial, ethnic, and rural populations. It is expanding to inequalities by age, sexual orientation, gender identity, social determinants (such as care access, language, health literacy, and education), socioeconomic status, environment, and geography. This inclusive approach emphasizes equitable access to health for everyone.

 ASCO issued a statement in 2020 supporting reduced disparities and improved equity in cancer care. It addressed equal access to quality care, equitable research, barriers such as workforce diversity, community partnerships and institutional discrimination, and increased awareness and action, including policy solutions. Specific recommendations included robust, sustainable, predictable funding increases for agencies and programs reducing prevention and treatment disparities; steps to ensure diverse clinical trial populations; support for a healthcare workforce reflecting its communities; and prioritization of cancer-control initiatives.

Reducing cancer disparities and achieving health justice is an overarching goal of AKD and the AKD Cancer Action Network.

The evidence-based health equity principles of AKD and the AKD Cancer Action Network have 3 headings:

1. People: Identify populations with greatest needs and use quantitative and qualitative data to prioritize research. Accepting, respecting, and valuing different people creates a collaborative environment with communities affected by health disparities.
2. Place: Address structural and social determinants of health, understand communities’ historical, social, cultural, and economic backgrounds before organizing research, events, programs, and policies affecting them, and implement sustainable community solutions.
3. Working together: Draw on volunteers’ strength by involving partners across sectors and preventing unintended consequences in communities affected by developing, evaluating, and implementing solutions.

As part of addressing social determinants of health, it is important to consider lack of money and other resources as the basis of food insecurity, defined as disruption of food intake or eating patterns. According to the US Department of Agriculture Economic Research Service, 10.5% of US households experienced food insecurity during 2019. Its prevalence is twice as high among Hispanic and Black people as among non-Hispanic White people. 34.5% of households below the poverty line also experienced it. Data among cancer survivors are scarce. Using Behavioral Risk Factor Surveillance System data, Charkhchi and colleagues showed that cancer patients were more likely to experience food insecurity than people without chronic conditions.

Although data on food insecurity in different sociodemographic groups of cancer patients are lacking, disparities may exist because income, employment, disability, and race/ethnicity affect it. Gany and colleagues found food insecurity in 41% of Latino and Black cancer patients, most with incomes below the poverty level. As a community, we must recognize food equity as a goal for all survivors to meet nutrition guidance. Efforts addressing food insecurity and strategies eliminating disparities among cancer patients and survivors should be prioritized.

This guide and the AKD cancer prevention guide recommend collaboration among researchers, clinicians, and communities at national, state, and local levels to develop and implement policies and environmental changes improving affordable, nutritious food access. Survivors’ disparities also reflect social/cultural context, food insecurity, and environment, such as neighborhood safety. Coordinated efforts, including policies addressing structural racism and barriers to healthy behavior, are therefore necessary to reduce cancer disparities and ensure equity throughout cancer care.

Community Influences

Many community and clinical influences affect nutrition and activity, with similar effects on healthy behaviors in survivors and the general population. Many cancer survivors turn to the internet for information about healthy behavior after cancer. Websites, especially social media, contain much misinformation, and reliable nutrition information is known to be difficult to find online.

Counseling Services

Most cancer survivors prefer information from their healthcare teams about diet, alcohol, weight management, and activity. Many oncology patients also cite lack of time as a barrier to providing counseling and acknowledge insufficient training and knowledge of available resources.    

Some survivors say online nutrition information is often inadequate or contradictory. Knowledge and skills training on nutrition, activity, and weight management should be included in oncology education and made part of clinical practice.

Approaches to Health Promotion for Cancer Survivors

Several approaches should be considered to promote survivors’ health.

1. Specialists should encourage education about the benefits of nutrition and exercise interventions for cancer survivors.
2. Teams caring for survivors have been advised to develop systems routinely assessing these behaviors in cancer patients and strategies for clinical use that reassess them regularly.
3. Technology may coordinate nutrition and exercise counseling. Electronic health records, for example, can support strategies such as asking patients about exercise and an algorithm for referral to an appropriate exercise level.

Such strategies may also help nutrition counseling.

Reaching Beyond the Clinic for Maximum Impact

Oncology nutrition and activity interventions should be used not only in primary care but in every possible setting, including communities.

Conclusion

With advances in health, awareness and implementation of these recommendations after completing cancer treatment are necessary to reduce recurrence risk and improve survival. Community and clinical settings can strongly influence behavior, making implementation critical.