The 20th International Congress of Nutrition (ICN) hosted by the International Union of Nutritional Science (IUNS) took place on the 15th-20th September 2013, Granada, Spain. WCRF International held a 2-hour symposium on the Continuous Update Project (CUP) entitled ‘Food, Nutrition, Physical Activity and Cancer – Keeping the Evidence Current: WCRF/AICR Continuous Update Project (CUP).’ It included four presentations exploring the latest updates from the CUP.

1. The WCRF/AICR Continuous Update Project –
Systematic Reviews on Nutrition, Physical Activity
& Health Outcomes in Cancer Survivors
Anne McTiernan, MD, PhD
Fred Hutchinson Cancer Research Center,
Seattle, WA, USA
WCRF/AICR CUP Panel
ICN
September 2013

2. Recognition

World Cancer Research Fund International


American Institute for Cancer Research, USA
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Dr. Susan Higginbotham, PhD
Imperial College London
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Dr. Rachel Thompson, PhD PHNutr, Professor Martin
Wiseman, FRCP FRCPath, & colleagues
Dr. Teresa Norat, PhD & colleagues
Continuous Update Project Panel

International scientific experts

3. Why Study Cancer Survivors?
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U.S. National Cancer Institute: In cancer, a
person is considered to be a survivor from
the time of diagnosis until the end of life
~ 28 million cancer survivors worldwide
Growing evidence of associations
between nutrition, weight, physical activity
& cancer prognosis
Role of lifestyle may differ for cancer
prognosis vs. prevention, and may differ
by cancer type

4. Second Expert Report (2007)


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‘Food, Nutrition, Physical Activity, and the
Prevention of Cancer: a Global
Perspective’
Not possible to draw firm conclusions that
apply to cancer survivors specifically
Evidence was emerging but not sufficiently
developed
Panel concluded cancer survivors should
aim to follow the recommendations for
prevention of cancer

5. Rationale for Focus on Breast Cancer

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Globally, 1.38 million new breast cancer
cases diagnosed in 2008 (23% of all
cancers)
Ranks second overall (10.9% of all
cancers)
Most available data on nutrition and
cancer survivors is for breast cancer
Additional cancer sites will be studied

6. Global Health Statistics: Breast
Cancer
CA: A Cancer Journal for Clinicians 2011;61(2):69-90
WHO IARC GLOBOSCAN http://globocan.iarc.fr/factsheet.asp

7. Types of Studies

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Most studies with mortality endpoints are
observational
Greater weight placed on randomized
clinical trials vs. follow-up studies

8. Criteria for Study Inclusion

Randomised controlled trials

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≥ 50 women
≥ 6 months follow-up
Only 2 identified (both low-fat diet trials)
Prospective cohort (follow-up) studies

Primary analysis, secondary analysis or
ancillary analysis of randomized controlled
trials, or follow-up studies in breast cancer
survivors

9. Breast Cancer Survivors Included

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Pre-menopausal women
Post-menopausal women
Incident in-situ breast cancer
Incident invasive breast cancer

10. Exposures Included
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Specific foods
Micro- and macro-nutrients
Dietary patterns
Alcohol
Overweight, obesity, underweight, weight
change
Body composition
Dietary supplements
Physical activity

11. Timing of Exposures Included

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Pre-diagnosis
Immediate 12 months following
diagnosis

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Period of intensive primary therapy (surgery,
radiation, chemotherapy)
After 12 months post-diagnosis

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Patients may be receiving targeted therapy
during this period (e.g. hormonal therapy,
HER2neu, bone metastases prevention)
Data may extend 20 years or more

12. Outcomes Included


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
Total mortality
Breast cancer specific mortality
Second primary breast cancer
Other cause-specific mortality, i.e.
cardiovascular

13. Nutrients Exposures

Dietary:


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Fibre
Folate
Soy protein & isoflavones
Total fat (g/d & % calories)
Saturated fat
Dietary patterns
Alcohol

14. Other Exposures

Physical activity

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Total (work, home, commute, recreation)
Recreational only
Body fatness

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Body mass index (kg/m2)
Weight change

15. Issues Relevant to Survivor Research

Confounding effects of:

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Treatment types, efficacies, adverse effects
Stage of disease
Comorbidities
Type of cancer
Methodological:

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Determining cause of death
Determining and classifying recurrence
Screening for second primary breast cancer
Increasing length of survival

16. Literature search
(New search for CUP)
19831 unique records identified in Pubmed
and Embase until 30th June 2012 and 18
articles found in handsearch
897 full-text articles retrieved and
assessed for inclusion
319 articles on survival and health events
in women with breast cancer
18952 records excluded on the basis of
title and abstract
578 articles excluded for not fulfilling the
inclusion criteria
85 no original data
278 did not report on the associations of
interest
30 abstract/commentary
9 meta-analyses
94 irrelevant study design
33 follow-up less than 6 months
49 study smaller than 50 women
106 articles excluded on health events
other than death or second primary
cancer in women with breast cancer
213 articles have mortality or any second
primary cancer as study endpoints

17. Example: Alcohol
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Alcohol use associated with increased risk
of breast cancer development
Unclear if use associated with survival
Most data from pre-diagnosis or beyond
12-months post-diagnosis
Data from self-report only
Little information on specific alcohol types
Little information on cancer treatments
Major cultural/geographic variation in use

18. Summary: Alcohol
Total mortality
Breast cancer
mortality
Second primary/
contralateral
breast cancer
N deaths
RR (95%CI)
N deaths
N
events
Before
diagnosis:
High vs. Low
2650
0.93 (0.82-1.06)
Before :
Per 1
drink/week
2676
After
diagnosis:
High vs. Low
3827
After
diagnosis:
Per 10g/d
3779
1.00 (0.99-1.00)
0.89 (0.72-1.09)
0.98 (0.93-1.03)
1329
RR (95%CI)
-
-
1.00 (0.97-1.02)
-
-
403
1.22 (0.88-1.69)
2347
1.19 (0.96-1.47)
403
1.06 (0.79-1.42)
2347
1.01 (0.99-1.03)
1296
1.18 (0.81-1.72)
RR (95%CI)

19. Example: Body Mass Index (BMI)
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Increased BMI associated with risk for
postmenopausal breast cancer, but not for
premenopausal breast cancer
Measured or self-reported height & weight
Data from clinical series, trials, &
epidemiological studies
Most data from 12-month period after
diagnosis, and from before diagnosis

20. Summary: Before diagnosis- BMI
summary
Second primary
Total mortality
Breast cancer mortality
breast cancer
N
deaths
RR (95%CI)
1.41 (1.29-1.54)
N
deaths
High vs. Low
8318
9854
Underweight vs.
normal weight
4944
1.10 (0.92-1.31)
4479
Per 5 kg/m2
6261
1.17 (1.13-1.21)
Premenopause
644
Postmenopause
1103
RR (95%CI)
1.34 (1.23-1.46)
N
events
RR (95%CI)
701
1.43 (0.87-2.34)
1.02 (0.85-1.21)
-
-
6600
1.17 (1.11-1.24)
701
1.21 (1.04-1.40)
1.25 (1.10-1.43)
1350
1.06 (0.85-1.32)
-
-
1.16 (1.01-1.34)
2866
1.15 (1.05-1.25)
-
-

21. Summary: Around diagnosis- BMI
summarymortality Second primary
1
Total mortality
Breast cancer
breast cancer
N
deaths
RR (95%CI)
N
deaths
High vs. Low
BMI
16925
Premenopause
4604
1.28 (1.16-1.42)
586
Postmenopause
4614
1.13 (1.03-1.23)
Underweight vs.
normal weight
2598
Per 5 kg/m2
5875
1.27 (1.16-1.38)
10063
RR (95%CI)
1.36 (1.23-1.50)
N
events
RR (95%CI)
3478
1.30 (1.14-1.48)
0.96 (0.45-2.06)
-
-
1067
1.57 (1.31-1.89)
-
-
1.23 (0.93-1.63)
1455
1.52 (1.26-1.84)
-
-
1.11 (1.06-1.17)
1918
1.18 (1.11-1.25)
3186
1.13 (1.06-1.21)

22. Summary: After diagnosis – BMI
summary
Second primary
Total mortality
Breast cancer mortality
breast cancer
N
deaths
RR (95%CI)
High vs. Low
2289
1.21 (1.06-1.38)
Underweight vs.
normal weight
1361
1.29 (1.02-1.63)
Per 5 kg/m2
1703
1.08 (1.01-1.15)
4, 0%, p=0.52
N
deaths
RR (95%CI)
2 studies
Both  risk, 1 significant
N
events
RR (95%CI)
No studies

23. Global Implications

25. Global Prevalence of Overweight & Obesity in Women

27. Future considerations

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Newly developed criteria specific for
cancer survivors for judging evidence
Recommendations for breast cancer
survivors
To reduce mortality, prevent further
primary cancers, and other diseases

28. Summary
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Growing literature on nutrition, related
factors, & breast cancer survival
Time of exposure is dynamic
Various outcomes are important to study
Data are sufficient for meta-analyses for
several variables
Systematic literature review identifies
patterns of associations for nutrientrelated factors & breast cancer survival