A Presentation tothe University ofManitoba Medical Students 2012 Stephan Esser MD www.esserhealth.com
Lifestyle Medicine and Cancer:Basic Tenants and Application Stephan Esser MD Institute of Lifestyle Medicine Harvard, Boston, MA
Intro Who we are? Why we care? What is Lifestyle Medicine? Does Lifestyle affect Cancer? Developing tools Implementation
What this is NOT The end The complete story Everything you need to know to be an oncologist Top 10 treatment protocols
Lifestyle Medicine the application of environmental, behavioral, medical and motivational principles to the management of lifestyle-related health problems in a clinical setting. Modalities: Diet Exercise Fingers, Feet and Sleep Forks Emotional Poise Reduced toxic exposures: Nicotine, Alcohol, Illicits
Canadian CA statistics• Lung, prostate, breast, colorectal cancer = 50% of all new cancer cases• Lung cancer = quarter (27%) of all cancer deaths each year.• Breast cancer = (28%) of new cancer cases in women.• Prostate cancer = (27%) of new cancer cases in men.• 2011 estimates: 40% of Canadian women and 45% of men will develop cancer during their lifetimes. • 1 of 4 Canadians will die from cancer
BMI Underweight < 18.5 Increased Normal Weight 18.5 - 24.9 Least Overweight 25.0 - 29.9 Increased Obese class I 30.0 - 34.9 High Obese class II 35.0 - 39.9 Very high Obese class III >= 40.0 Extremely high
Michelangelo’s David:12 month 20 city tour of the US
Obesity and Cancer Association of Obesity and Cancer Risk in Canada Am. J. Epidemiol. (2004) 159 (3): 259-268 Excess body mass accounted for 7.7% of all cancers in Canada 9.7% in men and 5.9% in women. Inc risk of overall cancer Non-Hodgkin’s lymphoma, leukemia, multiple myeloma, and cancers of the kidney, colon, rectum, breast (in postmenopausal women), pancreas, ovary, and prostate.
Obesity and Cancer A prospective study of obesity and Cancer Risk Cancer Causes and Control 2004 Obesity = 33% increase in cancer risk 25% in men and 37% in women. Increased for Small Intestine (SIR = 2.8; 95% CI 1.6–4.5) Colon (1.3; 1.1–1.5) -Cervix uteri (1.4; 1.1–1.9), Gallbladder (1.6; 1.1–2.3) -Endometrium (2.9; 2.5–3.4) Pancreas (1.5; 1.1–1.9) -Ovary (1.2; 1.1–1.5) Larynx (2.1; 1.1–3.5) -Brain (1.5; 1.2–1.9 Renal parenchyma (2.3; 1.8–2.8) -Lymphomas (1.4; 1.0–1.7) Bladder (1.2; 1.0–1.6)
Obesity and Breast CA Obesity and breast cancer: a review of the literature The Breast 2004 Most Studies: overweight or obese women are at increased risk of developing postmenopausal breast cancer Inc. body mass index is associated with a more advanced stage of breast cancer at diagnosis in terms of tumour size. Treatment modalities surgery, radiotherapy, chemotherapy and hormonal treatment may be adversely affected by the presence of obesity. The overall and disease-free survival is worse in most but not all studies of prognosis of obese pre- and postmenopausal women with breast cancer.
Obesity and Colon CAObesity and colon and rectal cancer risk: a meta-analysis of prospective studies Am J Clin Nutr September 2007 vol. 86 no. 3 5-unit increase in BMI was related to an increased risk of colon cancer in both men (RR: 1.30; 95% CI: 1.25, 1.35) and women (RR: 1.12; 95% CI: 1.07, 1.18) BMI was positively associated with rectal cancer in men (RR: 1.12; 95% CI: 1.09, 1.16) but not in women Colon cancer risk increased with increasing waist circumference (per 10-cm increase) in both men (RR: 1.33; 95% CI: 1.19, 1.49) and women
Obesity and Colon CABMI and waist circumference as predictors of lifetime colon cancer risk in Framingham Study adults International Journal of Obesity (2004) BMI 30 = 50% increased risk of colon cancer among middle- aged (30–54 y) and a 2.4-fold increased risk (95% CI: 1.5–3.9) among older (55–79 y) adults. Larger waist size (99.1 cm (39 in) and 101.6 cm (40 in) for women and men, respectively) was associated with a two-fold increased risk of colon cancer A larger waist had a particularly adverse effect among sedentary subjects (relative risk (RR)=4.4 for middle-aged adults; RR=3.0 for older adults).
Obesity and Prostate CA Body Mass Index and Risk of Prostate Cancer in U.S. Health Professionals Journal of the National Cancer Institute 2003 Risk of prostate cancer in men with a higher BMI (≥30 kg/ m2) was lower than that in men with a lower BMI (23–24.9 kg/m2) but only if they were younger (<60 years old) (relative risk = 0.52, 95% confidence interval = 0.33 to 0.83; Ptrend<.001) or had a family history of prostate cancer (relative risk = 0.74, 95% confidence interval = 0.45 to 1.19; Ptrend = .01).
Obesity and Prostate CA Impact of obesity on prostate cancer recurrence after radical prostatectomy: Data from CaPSURE Urology 2005 After adjusting for risk group, ethnicity, age, and comorbidities, a significant association was found between an increasing BMI and disease recurrence (P = 0.028). Very obese patients (BMI 35 kg/m2 or more) were 1.69 times more likely to have recurrence relative to men of normal weight (BMI less than 25.0 kg/m2; 95% confidence interval [CI] 1.01 to 2.84). An increasing PSA level (P <0.0001) and Gleason grade (P <0.0001) were also associated with recurrence. Ethnicity was not significantly associated with either BMI or PSA recurrence (P = 0.685 and P = 0.068, respectively).
NutritionDoes what we eat really matter to cancer risk, progression or recurrence?
Dietary factors account forabout 30% of all cancer risk
Nutrition Fruits and Vegetables are Protective Animal Products increase risk
Nutrition and Breast CAMeat consumption and risk of breast cancer in the UK Womens Cohort Study British Journal of Cancer (2007) Between 1995 and 1998 a cohort of 35 372 women was recruited, aged between 35 and 69 years with a wide range of dietary intakes, assessed by a 217-item food frequency questionnaire. High consumption of total meat compared with none was associated with premenopausal breast cancer, HR=1.20 (95% CI: 0.86-1.68), and high non-processed meat intake compared with none, HR=1.20 (95% CI: 0.86-1.68). Larger effect sizes were found in postmenopausal women for all meat types, with significant associations with total, processed and red meat consumption. Processed meat showed the strongest HR=1.64 (95% CI: 1.14-2.37) for high consumption compared with none. Women, both pre- and postmenopausal, who consumed the most meat had the highest risk of breast cancer.
Nutrition and Breast CA Well-Done Meat Intake and the Risk of Breast Cancer JNCI J Natl Cancer Inst (1998) 90 (22): 1724-1729. Adjusted nested, case-control study of 41 836 cohort members of the Iowa Womens Health Study Women who consumed bacon, beef steak or hamburger consistently very well done had a 4.62 times higher risk (95% CI = 1.36-15.70) than that of women who consumed the meats rare or medium done. Conclusions: Consumption of heterocyclic amines well-done meats and, thus, exposures to (or other compounds) formed during high-temperature cooking may play an important role in the risk of breast cancer.
Nutrition and Breast CA Dietary fat and breast cancer risk revisited: a meta-analysis of the published literature British Journal of Cancer (2003) The summary relative risk, comparing the highest and lowest levels of intake of total fat, was 1.13 (95% CI: 1.03-1.25). Cohort studies (N=14) had a summary relative risk of 1.11 (95% CI: 0.99-1.25) and case-control studies (N=31) had a relative risk of 1.14 (95% CI 0.99-1.32). Significant summary relative risks were also found for saturated fat (RR, 1.19; 95% CI: 1.06-1.35) and meat intake (RR, 1.17; 95% CI 1.06-1.29). Combined estimates of risk for total and saturated fat intake, and for meat intake, all indicate an association between higher intakes and an increased risk of breast cancer. Case-control and cohort studies gave similar results.
Nutrition and Colorectal CAMeat, Fish, and Colorectal Cancer Risk: The European Prospective Investigation into Cancer and Nutrition JNCI J Natl Cancer Inst (15 June 2005) 97 (12): 906-916. Our data confirm that colorectal cancer risk is positively associated with high consumption of red and processed meat and support an inverse association with fish intake.
Nutrition and Colorectal CA Systematic Review of the Prospective Cohort Studies on Meat Consumption and Colorectal Cancer Risk Cancer Epidemiol Biomarkers Prev May 2001 10; 439 Thirteen studies were eligible for inclusion in the meta-analysis Pooled results indicate that a daily increase of 100 g of all meat or red meat is associated with a significant 12-17% increased risk of colorectal cancer. significant 49% increased risk was found for a daily increase of 25 g of processed meat.
Nutrition and Colorectal CA Meat consumption and colorectal cancer risk: Dose-response meta-analysis of epidemiological studies International Journal of Cancer 2002 Average RRs and 95% confidence intervals (CI) for the highest quantile of consumption of red meat were 1.35 (CI: 1.21-1.51) and of processed meat, 1.31 (CI: 1.13-1.51). The RRs estimated by log- linear dose-response analysis were 1.24 (CI: 1.08-1.41) for an increase of 120 g/day of red meat and 1.36 (CI: 1.15-1.61) for 30 g/day of processed meat. The risk fraction attributable to current levels of red meat intake was in the range of 10-25% in regions where red meat intake is high. If average red meat intake is reduced to 70 g/week in these regions, colorectal cancer risk would hypothetically decrease by 7-24%
Nutrition and Stomach CAMeat Intake and Risk of Stomach and Esophageal Adenocarcinoma Within the European Prospective Investigation Into Cancer and Nutrition (EPIC) JNCL 2006 Total, red, and processed meat intakes were associated with an increased risk of gastric noncardia cancer, especially in H. pylori antibody-positive subjects, but not with cardia gastric cancer.
Nutrition and Pancreatic CAMeat and Fat Intake as Risk Factors for Pancreatic Cancer: The Multiethnic Cohort Study JNCL 2005 The strongest association was with processed meat; those in the fifth quintile of daily intake (g/1000 kcal) had a 68% increased risk compared with those in the lowest quintile (relative risk = 1.68, 95% confidence interval = 1.35 to 2.07; Ptrend<.01). Intakes of pork and of total red meat were both associated with 50% increases in risk, comparing the highest with the lowest quintiles (both Ptrend<.01). Intake of total and saturated fat from meat was associated with statistically significant increases in pancreatic cancer risk but that from dairy products was not.
Plant Foods and Colorectal CA Nutrition, lifestyle and colorectal cancer incidence: a prospective investigation of 10 998 vegetarians and non-vegetarians in the United Kingdom British Journal of Cancer (2004) In a cohort of 10 998 men and women, 95 incident cases of colorectal cancer were recorded after 17 years. Risk increased in association with smoking, alcohol, and white bread consumption, and decreased with frequent consumption of fruit. The relative risk in vegetarians compared with nonvegetarians was 0.85 (95% CI: 0.55-1.32).Dietary fiber and plant foods in relation to colorectal cancer mortality: The Seven Countries Study International Journal of Cancer Seven Countries Study, around 1960 12,763 men aged 40 to 59 were enrolled in 16 cohorts in 7 countries Fiber intake was inversely associated with colorectal-cancer mortality with an energy-adjusted rate ratio of 0.89 (95% confidence interval 0.80-0.97). An increase of 10 gram of daily intake of fiber was associated with a 33% lower 25-year colorectal-cancer mortality risk. Intakes of vitamin B6 [0.84 (0.71-0.99)] and alpha-tocopherol [0.94 (0.89-0.99)] were also inversely associated with risk. Consumption of plant foods and related sub-groups was not related to colorectal cancer. It appears that fiber intake best indicates the part of plant food consumption, including whole grains, that is relevant for lowering colorectal cancer risk.
Plant Foods and Gastric Cancer Plant foods and risk of gastric cancer: a case- control study in Uruguay European Journal of Cancer Prevention 2001 Total plant foods were strongly associated with a reduced risk of stomach cancer (OR 0.31, 95% CI 0.18-0.54). It is suggested that vitamins (vitamin C and carotenoids) and bioactive substances (diallyl sulfide) could be involved in the mechanisms of action of plant foods. Total antioxidant potential of fruit and vegetables and risk of gastric cancer? Gastroenterology 2002 Dietary intake of antioxidants measured as total antioxidant potential is inversely associated with risk of both cardia and distal cancer.
Plant Foods and Breast CA Estrogen Excretion Patterns and Plasma Levels in Vegetarian and Omnivorous Women NEJM 1982 Vegetarian women have increased fecal excretion of estrogen and a decreased plasma concentration of estrogen.
Plant Foods and Prostate CA -93 volunteers with serum PSA 4 to 10 ng/ml and cancer Gleason scores less than 7 -Ornish, plant based nutrition -PSA decr. by 4% in the experimental group but increased 6% in the control group -LNCaP prostate cancer cells were inhibited almost 8 times more by serum from the experimental than from the control group (70% vs 9%, p < 0.001
What’s Recommended Public Health Agency of Canada Aerobic Exercise 150 min/wk Strength Training 2 days per week
Exercise and Breast CA Physical Exercise and Reduced Risk of Breast Cancer in Young Women J Natl Cancer Inst Case-control design with 545 women (aged 40 and younger at diagnosis) who had been newly diagnosed with in situ or invasive breast The odds ratio (OR) of breast cancer among women who, on average, spent 3.8 or more hours per week participating in physical exercise activities was 0.42 (95%confidence limits [CLs] = 0.27, 0.64) relative to inactive women. The effect was stronger among women who had had a full-term pregnancy. Comparing most active (>3.8 hours/wk of exercise) women to inactive women, the ORs were 0.28 (95% CL = 0.16, 0.50) for parous and 0.73 (95% CL = 038, 1.41) for nulliparous women.
Exercise and Breast CAPhysical Activity and the Risk of Breast Cancer N Engl J Med 1997 Cohort study of 25,624 women. Greater leisure-time activity was associated with a reduced risk of breast cancer, after adjustments for age, body-mass index (the weight in kilograms divided by the square of the height in meters), height, parity, and county of residence (relative risk, 0.63; 95 percent confidence interval, 0.42 to 0.95), among women who exercised regularly, as compared with sedentary women (P for trend = 0.04). In stratified analyses the risk of breast cancer was lowest in lean women (body- mass index, <22.8) who exercised at least four hours per week (relative risk, 0.28; 95 percent confidence interval, 0.11 to 0.70). The risk was also reduced with higher levels of activity at work, and again there was a more pronounced effect among premenopausal than postmenopausal women.
Exercise and Breast CA Lifetime Recreational Exercise Activity and Breast Cancer Risk Among Black Women and White Women NCI J Natl Cancer Inst 2006 Among all women, decreased breast cancer risk was associated with increased levels of lifetime exercise activity (e.g., average MET-hours per week per year, Ptrend = .002). Exercise level above median level for active control subjects was associated with an approximately 20% lower risk of breast cancer, compared with that for inactivity (for 6.7-15.1 MET-hours/week/year, odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.71 to 0.93; for 15.2 MET-hours/week/year, OR = 0.80, 95% CI = 0.70 to 0.92). The inverse associations did not differ between black and white women (for MET-hours/week/year, Ptrend = .003 and Ptrend = .09, respectively; homogeneity of trends P = .16).
Exercise and Breast CARecreational Physical Activity and the Risk of Breast Cancer in Postmenopausal Women JAMA. 2003 An increasing total current physical activity score was associated with a reduced risk for breast cancer (P = .03 for trend). Women who engaged in the equivalent of 1.25 to 2.5 hours per week of brisk walking had an 18% decreased risk of breast cancer (RR, 0.82; 95% CI, 0.68-0.97) compared with inactive women. Slightly greater reduction in risk was observed for women who engaged in the equivalent of 10 hours or more per week of brisk walking.
Exercise and Breast CAEffects of exercise on breast cancer patients and survivors: a systematic review and meta- analysis CMAJ 2006 Exercise improves: quality of life cardiorespiratory fitness physical functioning fatigue
Exercise and Colon CAPhysical Activity, Obesity, and Risk for Colon Cancer and Adenoma in Men AIM 1995 Physical activity was inversely associated with risk for colon cancer (high compared with low quintiles of average energy expenditure from leisure-time activities: relative risk, 0.53 [95% CI, 0.32 to 0.88], P for trend = 0.03) after adjustment for age; history of colorectal polyp; previous endoscopy; parental history of colorectal cancer; smoking; body mass; use of aspirin; and intake of red meat, dietary fiber, folate, and alcohol. Body mass index was directly associated with risk for colon cancer independently of physical activity level. Waist circumference and waist-to-hip ratio were strong risk factors for colon cancer (waist-to-hip ratio ? 0.99 compared with waist-to-hip ratio < 0.90: multivariate relative risk, 3.41 [CI, 1.52 to 7.66], P for trend = 0.01; waist circumference ? 43 inches compared with waist circumference < 35 inches: relative risk, 2.56 [CI, 1.33 to 4.96], P for trend < 0.001). These associations persisted even after adjustment for body mass and physical activity.
Exercise and Colon CAImpact of Physical Activity on Cancer Recurrence and Survival in Patients With Stage III Colon Cancer: Findings From CALGB 89803 American Society of Clinical Oncology 2006 Compared with patients engaged in less than three metabolic equivalent task (MET) -hours per week of physical activity, the adjusted hazard ratio for disease- free survival was 0.51 (95% CI, 0.26 to 0.97) for 18 to 26.9 MET-hours per week and 0.55 (95% CI, 0.33 to 0.91) for 27 or more MET-hours per week. The adjusted P for trend was .01. Postdiagnosis activity was associated with similar improvements in recurrence- free survival (P for trend = .03) and overall survival (P for trend = .01). The benefit associated with physical activity was not significantly modified by sex, body mass index, number of positive lymph nodes, age, baseline performance status, or chemotherapy received. Moreover, the benefit remained unchanged even after excluding participants who developed cancer recurrence or died within 6 months of activity assessment.
Stress and Breast CA Self-reported stress and risk of breast cancer Cancer 1996 258 breast cancer patients and 614 randomly selected population-based controls with same number of stressful life events in the five years prior to diagnosis The results of this retrospective study do not suggest any important associations between stressful life events and breast cancer risk. Job Stress and Breast Cancer Risk The Nurses’ Health Study Adjusted for age, reproductive history, and other breast cancer risk factors, the multivariate relative risks of breast cancer, in comparison with women who worked in low-strain jobs, were 0.83 (95% confidence interval (CI): 0.69, 0.99) for women in active jobs, 0.87 (95% CI: 0.73, 1.04) for women in high-strain jobs, and 0.90 (95% CI: 0.76, 1.06) for women in passive jobs. Findings from this study indicate that job stress is not related to any increase in breast cancer risk.
Stress and Breast Cancer Increased Breast Cancer Risk among Women Who Work Predominantly at Night Epidemiology 2001 The odds ratio for breast cancer among women who worked at night at least half of a year was 1.5 (95% confidence interval, 1.2 to 1.7), and there was a tendency to increasing odds ratio by increasing duration of nighttime employment.
Stress and Breast Cancer Stress, depression, the immune system, and cancer Lancet Oncology 2004 The consecutive stages of the multistep immune reactions are either inhibited or enhanced as a result of previous or parallel stress experiences, depending on the type and intensity of the stressor and on the animal species, strain, sex, or age. In general, both stressors and depression are associated with the decreased cytotoxic T-cell and natural-killer-cell activities that affect processes such as immune surveillance of tumours, and with the events that modulate development and accumulation of somatic mutations and genomic instability. A better understanding of the bidirectional communication between the neuroendocrine and immune systems could contribute to new clinical and treatment strategies.
“Inflammation is a critical component of tumorprogression. It is now becoming clear that the tumormicroenvironment, which is largely orchestrated by inflammatory cells, is an indispensable part of the neoplastic process.”
What we know Cancer is a major cause of morbidity and mortality in Canada Lifestyle factors are strongly associated
What next?How do we apply the knowledge to clinical practice?
1 things 1 st st Learn both modifiable and non-modifiable risks Learn about your patients Recognize opportunities Lead by example
1 things 1 st st Learn both modifiable and non-modifiable risks Learn about your patients Who are they, what is important to them, what do they enjoy etc Recognize opportunities Lead by example
Trans-theoretical Model of Change (Prochaska and DiClemente) 1: Pre-contemplation 2: Contemplation 3: Preparation/planning 4: Action 5: Maintenance 6: Permanent Maintenance (Termination)
Conclusion Cancer is a major cause of death and disability Lifestyle factors are common modifiable risk factors Modifications may provide significant benefit Tools to promote healthy change exist You are the most trusted health care resource Together we can make a differnce
Thank you! Stephan Esser MD Institute of Lifestyle Medicine Harvard, Boston, MA
?’s Stephan Esser MD Institute of Lifestyle Medicine Harvard, Boston, MA
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