Chapter 10Chapter 10

Cancer: Nutrition Prevention and Treatment

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What Is Cancer?What Is Cancer?

Cancer is the uncontrolled growth of abnormal Cancer is the uncontrolled growth of abnormal cells that form a mass of tissue known as a cells that form a mass of tissue known as a tumortumor

A malignant tumor impairs body function and A malignant tumor impairs body function and takes nourishment away from normal tissuetakes nourishment away from normal tissue

OncologOncology is the study of cancer; an oncologist is a y is the study of cancer; an oncologist is a medical doctor who specializes in the treatment of medical doctor who specializes in the treatment of cancercancer

Most cancer research is epidemiologicMost cancer research is epidemiologic——based on based on observed associations in given populations, rather observed associations in given populations, rather than cause-and-effect researchthan cause-and-effect research

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Physiologic Precursors of CancerPhysiologic Precursors of Cancer

Chronic inflammation as induced by obesity, diet, Chronic inflammation as induced by obesity, diet, inactivityinactivity

Free radicals inducing chromosomal changes (DNA)Free radicals inducing chromosomal changes (DNA) Angiogenesis (the creation of blood vessels)Angiogenesis (the creation of blood vessels) Hyperinsulinemia promoting insulin-like growth Hyperinsulinemia promoting insulin-like growth

factor; insulin resistance and hyperinsulinemia found factor; insulin resistance and hyperinsulinemia found with:with: Gynecologic cancersGynecologic cancers Digestive tract cancersDigestive tract cancers Bladder and prostatic cancersBladder and prostatic cancers LeukemiaLeukemia Non-Hodgkin’s lymphoma Non-Hodgkin’s lymphoma (Pisani, 2008; Pischon et al., 2008; Renehan et al., (Pisani, 2008; Pischon et al., 2008; Renehan et al.,

2008; Suba and Ujpal, 2006)2008; Suba and Ujpal, 2006)

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EtiologyEtiology

GeneticsGenetics——associated with correlates of associated with correlates of the metabolic syndromethe metabolic syndrome

Associated with: Associated with: High intake of saturated fat, polyunsaturated High intake of saturated fat, polyunsaturated

fat Excess CHO (sugar), low fiberfat Excess CHO (sugar), low fiber Low intake of plant-based foods/antioxidantsLow intake of plant-based foods/antioxidants Excess salt Excess salt Low intake omega-3 fatty acids (fatty fish)Low intake omega-3 fatty acids (fatty fish) Possible excess iron intakePossible excess iron intake (high iron levels(high iron levels

associated inflammation)associated inflammation) Low vitamin D statusLow vitamin D status

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Non-Diet Risk FactorsNon-Diet Risk Factors

Associated with low level of physical activityAssociated with low level of physical activity Smoking/chewing tobaccoSmoking/chewing tobacco Alcohol intake, especially excessive Alcohol intake, especially excessive Exposure to UV lightExposure to UV light Exposure to carcinogens in the environmentExposure to carcinogens in the environment

Particles and chemicals in the airParticles and chemicals in the air Nitrates in processed meats Nitrates in processed meats Inorganic arsenic in water suppliesInorganic arsenic in water supplies

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American Institute for American Institute for Cancer ResearchCancer Research

30% to 40% reduction in cancer risk with30% to 40% reduction in cancer risk with—— Diet rich in a variety of plant-based foods, Diet rich in a variety of plant-based foods,

especially fruits and vegetables; especially fruits and vegetables; magnesium-rich foods (“beans and magnesium-rich foods (“beans and greens”) lower inflammation; flavanoids greens”) lower inflammation; flavanoids (phytochemicals) associated with reduced (phytochemicals) associated with reduced risk risk

Maintenance of a healthy weight and Maintenance of a healthy weight and physical activityphysical activity

Alcohol consumed in moderationAlcohol consumed in moderation

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American Institute for American Institute for Cancer Research (continued)Cancer Research (continued)

Diet low in fat (i.e., saturated and Diet low in fat (i.e., saturated and polyunsaturated fats) and saltpolyunsaturated fats) and salt Monounsaturated and omega-3 fats have Monounsaturated and omega-3 fats have

neutral/ protective effectneutral/ protective effect Foods prepared and stored safelyFoods prepared and stored safely No tobacco in any formNo tobacco in any form

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Other Preventive MeasuresOther Preventive Measures

Emphasize nuts as a natural source of Emphasize nuts as a natural source of monounsaturated fats and vitamin E monounsaturated fats and vitamin E

Use aluminum foil under meat on the Use aluminum foil under meat on the barbecue grill. Avoid exposing the meat to barbecue grill. Avoid exposing the meat to the smoke of meat drippings on hot coals the smoke of meat drippings on hot coals (to avoid production of nitrosamines)(to avoid production of nitrosamines)

Include supplement of vitamin D to reduce Include supplement of vitamin D to reduce risk of colorectal and skin cancer and other risk of colorectal and skin cancer and other formsforms

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Bladder CancerBladder Cancer

(Fourth leading type for men in U.S.(Fourth leading type for men in U.S.——ninthninthworldwide)worldwide) Associated with cigarette smoking and chronic UTIs Associated with cigarette smoking and chronic UTIs

(Murta-Nascimento et al., 2007)(Murta-Nascimento et al., 2007)

Associated with obesity Associated with obesity (Koebnick et al., 2008)(Koebnick et al., 2008)

To lower risk with diet:To lower risk with diet: Increase intake of fruits and vegetablesIncrease intake of fruits and vegetables Increase intake of B vitamins and retinolIncrease intake of B vitamins and retinol——dark-green leafy dark-green leafy

and deep orange color and deep orange color (Garcia-Closas et al., 2007)(Garcia-Closas et al., 2007)

Increase cruciferous vegetables—broccoli, cauliflower, Increase cruciferous vegetables—broccoli, cauliflower, Brussels sprouts, cabbage Brussels sprouts, cabbage (Zhao et al., 2007)(Zhao et al., 2007)

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Breast Cancer Breast Cancer

(Second leading cause of cancer death among women in the(Second leading cause of cancer death among women in theU.S.)U.S.) Central obesity associatedCentral obesity associated (Tehard and Clavel-Chapelon, 2006)(Tehard and Clavel-Chapelon, 2006)

To lower risk:To lower risk: Normalize hyperinsulinemiaNormalize hyperinsulinemia (Goodwin et al., 2008);(Goodwin et al., 2008); follow TLC diet follow TLC diet

and increased exercise, especially for overweight womenand increased exercise, especially for overweight women(Bardia et al., 2006)(Bardia et al., 2006)

Avoid excess fat—saturated, in particularAvoid excess fat—saturated, in particular (Thiebaut et al., 2007);(Thiebaut et al., 2007); emphasize monounsaturated fat—olive oilemphasize monounsaturated fat—olive oil (Menendez et al., 2007) (Menendez et al., 2007) and and fatty fishfatty fish (Sun et al., 2005; Yee et al., 2005)(Sun et al., 2005; Yee et al., 2005)

Increase fruits and vegetables, especially folate sourcesIncrease fruits and vegetables, especially folate sources (Ericson (Ericson et al., 2007; Fung et al., 2005)et al., 2007; Fung et al., 2005)

Avoid alcohol, or if included in moderation, increase intake ofAvoid alcohol, or if included in moderation, increase intake offolate to help offset riskfolate to help offset risk (Stolzenberg-Solomon et al., 2006; Tjonneland et al., (Stolzenberg-Solomon et al., 2006; Tjonneland et al., 2006)2006)

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Colorectal Cancer Colorectal Cancer

(Major cause of death and illness in adults(Major cause of death and illness in adultsOver age 50)Over age 50) Hyperinsulinemia associated, along with central obesity, Hyperinsulinemia associated, along with central obesity,

excess alcohol, smoking, and low intake of folate and the excess alcohol, smoking, and low intake of folate and the

amino acid methionineamino acid methionine (Campos et al., 2005; Kim et al., 2007)(Campos et al., 2005; Kim et al., 2007)

All individuals on insulin therapy for type 2 diabetes should All individuals on insulin therapy for type 2 diabetes should

be screened initially and every 5 yearsbe screened initially and every 5 years (Berster and Goke, 2008)(Berster and Goke, 2008)

To lower risk:To lower risk: Follow TLC diet to reduce reliance on insulin use/productionFollow TLC diet to reduce reliance on insulin use/production Limit salt intakeLimit salt intake (Marques-Vidal et al., 2006)(Marques-Vidal et al., 2006)

Include vitamin D supplementation; 1000 IU associated withInclude vitamin D supplementation; 1000 IU associated with50% reduced risk50% reduced risk (Grant et al., 2007)(Grant et al., 2007)

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Endometrial and Ovarian CancerEndometrial and Ovarian Cancer

Obesity and hyperinsulinemia linked along Obesity and hyperinsulinemia linked along with inflammation and excess estrogen with inflammation and excess estrogen levels levels (Goswami et al., 2007; Gunter et al., 2008)(Goswami et al., 2007; Gunter et al., 2008)

To reduce risk:To reduce risk: Increase folate intake Increase folate intake (Xu et al., 2007)(Xu et al., 2007)

Increase carotenoids Increase carotenoids (Czeczuga-Semeniuk and Wolczynski, 2005)(Czeczuga-Semeniuk and Wolczynski, 2005)

Avoid excess coffee intake Avoid excess coffee intake (Silvera et al., 2007)(Silvera et al., 2007)

Avoid acrylamide—found in starchy foods Avoid acrylamide—found in starchy foods prepared at high temperatures (i.e., fried prepared at high temperatures (i.e., fried foods) foods) (Hogervorst et al., 2007)(Hogervorst et al., 2007)

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Esophageal Cancer: On the RiseEsophageal Cancer: On the Rise

Precursor: Barrett’s esophagus (premalignant lesion Precursor: Barrett’s esophagus (premalignant lesion and strictures of the lower esophageal section related and strictures of the lower esophageal section related to ulceration and reflux). Zinc deficiency may to ulceration and reflux). Zinc deficiency may contribute contribute (Guy et al., 2007)(Guy et al., 2007)

Obesity and high sugar intake implicatedObesity and high sugar intake implicated (Thompson et al., (Thompson et al., 2008)2008)

To lower risk:To lower risk: Increase intake of omega-3 fats—fatty fish or supplementsIncrease intake of omega-3 fats—fatty fish or supplements

(Mehta et al., 2008)(Mehta et al., 2008)

Avoid alcohol and smokingAvoid alcohol and smoking (La Vechhia et al., 2008)(La Vechhia et al., 2008)

Slow down pace of eating and decrease saltSlow down pace of eating and decrease salt (Yang et al., 2005)— (Yang et al., 2005)—

may be due, in part, to increased saliva production withmay be due, in part, to increased saliva production withincreased chewingincreased chewing

Include antioxidant sources—vitamins C, EInclude antioxidant sources—vitamins C, E (Dong et al., 2008)(Dong et al., 2008)

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Lung Cancer: Lung Cancer: Part Environmental, Part DietPart Environmental, Part Diet

To minimize risk:To minimize risk: Increase intake of magnesium to promote DNA Increase intake of magnesium to promote DNA

repair capacity repair capacity (Mahabir et al., 2008)(Mahabir et al., 2008)

Increase intake of cruciferous Increase intake of cruciferous vegetables—may be due to magnesium vegetables—may be due to magnesium content or other phytochemicals content or other phytochemicals (Wang et al., 2004)(Wang et al., 2004)

Increase omega-3 and reduce omega-6 fatty Increase omega-3 and reduce omega-6 fatty acids acids (Xia et al., 2005)(Xia et al., 2005)

Increase fruits Increase fruits (Kubik et al., 2008)(Kubik et al., 2008)

Increase dietary intake of boron Increase dietary intake of boron (Mahabir et al., 2008) (Mahabir et al., 2008) andand

copper, zinc, iron copper, zinc, iron (Mahabir et al., 2007)(Mahabir et al., 2007)

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Prostate CancerProstate Cancer

(Most common form and leading cause of death(Most common form and leading cause of deathamong men in the U.S.)among men in the U.S.) Screened with PSA levelsScreened with PSA levels High risk factors include African heritage, family hx, low High risk factors include African heritage, family hx, low

intake of tomato products, smoking, taller height, high BMI, intake of tomato products, smoking, taller height, high BMI,

low physical activitylow physical activity (Giovannucci et al., 2007); (Giovannucci et al., 2007); male breast cancer male breast cancer

linkedlinked (Lee and Jones, 2008)(Lee and Jones, 2008)

To reduce risk:To reduce risk: Follow TLC diet to lower insulin levels Follow TLC diet to lower insulin levels Vitamin E—nutsVitamin E—nuts (Wright et al., 2007)(Wright et al., 2007)

Supplement with vitamin D Supplement with vitamin D Increase tomato product intakeIncrease tomato product intake Increase zinc intakeIncrease zinc intake (van Wijngaarden et al., 2007)(van Wijngaarden et al., 2007)

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Thyroid CancerThyroid Cancer

Increased risk among persons living near Increased risk among persons living near or downwind (Europe) of 1986 Chernobyl or downwind (Europe) of 1986 Chernobyl nuclear power plant accident in Russia nuclear power plant accident in Russia and Ukraine regionand Ukraine region Such individuals (especially the children) Such individuals (especially the children)

should receive lifetime screening due to high should receive lifetime screening due to high rate of secondary cancers such as leukemia rate of secondary cancers such as leukemia (Kumagai et al., 2007 ; Balanov, 2007)(Kumagai et al., 2007 ; Balanov, 2007)

Such individuals should avoid iodine deficiency Such individuals should avoid iodine deficiency with iodine supplementation to reduce risk of with iodine supplementation to reduce risk of thyroid cancer, leukemia, and breast cancerthyroid cancer, leukemia, and breast cancer

(Kesminiene and Cardis, 2007) (Kesminiene and Cardis, 2007)

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Impact of Cancer on Food ChoicesImpact of Cancer on Food Choices

Taste changes (dysgeusia):Taste changes (dysgeusia): Reduced threshold for bitter tastes Reduced threshold for bitter tastes

(meat aversion is common)(meat aversion is common) Increased threshold for sweetness Increased threshold for sweetness

(high-sugar foods more acceptable)(high-sugar foods more acceptable) Increased threshold for salt and sour flavorsIncreased threshold for salt and sour flavors

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Effect of Cancer and TreatmentEffect of Cancer and Treatmenton Nutritional Statuson Nutritional Status

Altered metabolism with hypermetabolic stateAltered metabolism with hypermetabolic state Requires some form of nutrition support (enteral or Requires some form of nutrition support (enteral or

parenteral)parenteral) Nausea and vomiting from chemotherapy or Nausea and vomiting from chemotherapy or

toxins generated from cancer cellstoxins generated from cancer cells Dysphagia (impaired swallowing), dry mouth (with Dysphagia (impaired swallowing), dry mouth (with

greatly increased risk of dental decay), and sore greatly increased risk of dental decay), and sore mouth/esophagitis from radiation or surgery of the mouth/esophagitis from radiation or surgery of the neck areaneck area

Diarrhea from radiation or surgery in the Diarrhea from radiation or surgery in the abdominal area. If villi are damaged, digestive abdominal area. If villi are damaged, digestive enzymes are diminished and diarrhea occursenzymes are diminished and diarrhea occurs Low-lactose milk products or alternatives advisedLow-lactose milk products or alternatives advised

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Nutrition Goals for Nutrition Goals for Cancer TreatmentCancer Treatment

Maintain body weightMaintain body weight——sweet foods may sweet foods may be best acceptedbe best accepted

Include adequate protein for goal of Include adequate protein for goal of normal albuminnormal albumin Alternatives to meat:Alternatives to meat:

• EggsEggs• Cheese/yogurt/milkshakesCheese/yogurt/milkshakes• Peanut butter or nutsPeanut butter or nuts• Bean-based soupsBean-based soups

Ensure adequate fluid intakeEnsure adequate fluid intake

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Other Nutrition GoalsOther Nutrition Goals

Replace minerals/electrolytes lost from Replace minerals/electrolytes lost from vomiting/diarrheavomiting/diarrhea Use commercial productsUse commercial products Include bean-based soups (potassium, Include bean-based soups (potassium,

magnesium, and sodium)magnesium, and sodium) Citrus fruits (potassium)Citrus fruits (potassium) Other soups (sodium)Other soups (sodium) Whole grains (magnesium and potassium)Whole grains (magnesium and potassium)

Maintain as good a nutritional status as Maintain as good a nutritional status as possible with a variety of foods or reliance possible with a variety of foods or reliance on commercial liquid supplementson commercial liquid supplements

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Monitor Altered Nutritional Monitor Altered Nutritional Needs for Cancer SurvivorsNeeds for Cancer Survivors

Increased risk for CVD and diabetes due to weight Increased risk for CVD and diabetes due to weight gain, osteoporosis with estrogen/androgen gain, osteoporosis with estrogen/androgen deficiency, secondary tumorsdeficiency, secondary tumors DXA scans to r/o osteoporosisDXA scans to r/o osteoporosis Promote increased exercise for bone health, weight goalsPromote increased exercise for bone health, weight goals Promote MyPyramid/Dietary Guidelines for CA preventionPromote MyPyramid/Dietary Guidelines for CA prevention

With gastric surgery, pellagra may developWith gastric surgery, pellagra may develop Monitor s/s: dermatitis, diarrhea, delirium/dementia,Monitor s/s: dermatitis, diarrhea, delirium/dementia,

possible neurologic changes and prevent/tx with vitamin Bpossible neurologic changes and prevent/tx with vitamin B33

Intestinal resections increase risk for variety of Intestinal resections increase risk for variety of nutrient deficienciesnutrient deficiencies

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With Cancer Remission With Cancer Remission for Prevention of Recurrencefor Prevention of Recurrence

Promote lifelong positive nutrition Promote lifelong positive nutrition behaviorsbehaviors Encourage high-fiber diet and emphasis on Encourage high-fiber diet and emphasis on

monounsaturated fatsmonounsaturated fats Encourage moderate kilocalorie intake to Encourage moderate kilocalorie intake to

manage weight and avoidance of excess saltmanage weight and avoidance of excess salt Encourage high-quality diet per the MyPyramid Encourage high-quality diet per the MyPyramid

Food Guidance SystemFood Guidance System Promote positive lifestylePromote positive lifestyle

Encourage regular physical activityEncourage regular physical activity Encourage avoidance of excess alcoholEncourage avoidance of excess alcohol Encourage avoidance of tobaccoEncourage avoidance of tobacco