Chapter 10

1. Chapter 10 Cancer: Nutrition Prevention and Treatment

2. What Is Cancer? Cancer is the uncontrolled growth of abnormal cells that form a mass of tissue known as a tumor A malignant tumor impairs body function and takes nourishment away from normal tissue Oncology is the study of cancer; an oncologist is a medical doctor who specializes in the treatment of cancer Most cancer research is epidemiologic—based on observed associations in given populations, rather than cause-and-effect research

3. Physiologic Precursors of Cancer Chronic inflammation as induced by obesity, diet, inactivity Free radicals inducing chromosomal changes (DNA) Angiogenesis (the creation of blood vessels) Hyperinsulinemia promoting insulin-like growth factor; insulin resistance and hyperinsulinemia found with: Gynecologic cancers Digestive tract cancers Bladder and prostatic cancers Leukemia Non-Hodgkin’s lymphoma (Pisani, 2008; Pischon et al., 2008; Renehan et al., 2008; Suba and Ujpal, 2006)

4. Etiology Genetics—associated with correlates of the metabolic syndrome Associated with: High intake of saturated fat, polyunsaturated fat Excess CHO (sugar), low fiber Low intake of plant-based foods/antioxidants Excess salt Low intake omega-3 fatty acids (fatty fish) Possible excess iron intake(high iron levelsassociated inflammation) Low vitamin D status

5. Non-Diet Risk Factors Associated with low level of physical activity Smoking/chewing tobacco Alcohol intake, especially excessive Exposure to UV light Exposure to carcinogens in the environment Particles and chemicals in the air Nitrates in processed meats Inorganic arsenic in water supplies

6. American Institute for Cancer Research 30% to 40% reduction in cancer risk with— Diet rich in a variety of plant-based foods, especially fruits and vegetables; magnesium-rich foods (“beans and greens”) lower inflammation; flavanoids (phytochemicals) associated with reduced risk Maintenance of a healthy weight and physical activity Alcohol consumed in moderation

7. American Institute for Cancer Research (continued) Diet low in fat (i.e., saturated and polyunsaturated fats) and salt Monounsaturated and omega-3 fats have neutral/ protective effect Foods prepared and stored safely No tobacco in any form

8. Other Preventive Measures Emphasize nuts as a natural source of monounsaturated fats and vitamin E Use aluminum foil under meat on the barbecue grill. Avoid exposing the meat to the smoke of meat drippings on hot coals (to avoid production of nitrosamines) Include supplement of vitamin D to reduce risk of colorectal and skin cancer and other forms

9. Bladder Cancer (Fourth leading type for men in U.S.—ninth worldwide) Associated with cigarette smoking and chronic UTIs (Murta-Nascimento et al., 2007) Associated with obesity (Koebnick et al., 2008) To lower risk with diet: Increase intake of fruits and vegetables Increase intake of B vitamins and retinol—dark-green leafy and deep orange color (Garcia-Closas et al., 2007) Increase cruciferous vegetables—broccoli, cauliflower, Brussels sprouts, cabbage (Zhao et al., 2007)

10. Breast Cancer (Second leading cause of cancer death among women in the U.S.) Central obesity associated(Tehard and Clavel-Chapelon, 2006) To lower risk: Normalize hyperinsulinemia(Goodwin et al., 2008);follow TLC diet and increased exercise, especially for overweight women(Bardia et al., 2006) Avoid excess fat—saturated, in particular(Thiebaut et al., 2007);emphasize monounsaturated fat—olive oil(Menendez et al., 2007) and fatty fish(Sun et al., 2005; Yee et al., 2005) Increase fruits and vegetables, especially folate sources(Ericson et al., 2007; Fung et al., 2005) Avoid alcohol, or if included in moderation, increase intake offolate to help offset risk(Stolzenberg-Solomon et al., 2006; Tjonneland et al., 2006)

11. Colorectal Cancer (Major cause of death and illness in adults Over age 50) Hyperinsulinemia associated, along with central obesity, excess alcohol, smoking, and low intake of folate and the amino acid methionine(Campos et al., 2005; Kim et al., 2007) All individuals on insulin therapy for type 2 diabetes should be screened initially and every 5 years(Berster and Goke, 2008) To lower risk: Follow TLC diet to reduce reliance on insulin use/production Limit salt intake(Marques-Vidal et al., 2006) Include vitamin D supplementation; 1000 IU associated with50% reduced risk(Grant et al., 2007)

12. Endometrial and Ovarian Cancer Obesity and hyperinsulinemia linked along with inflammation and excess estrogen levels (Goswami et al., 2007; Gunter et al., 2008) To reduce risk: Increase folate intake (Xu et al., 2007) Increase carotenoids (Czeczuga-Semeniuk and Wolczynski, 2005) Avoid excess coffee intake (Silvera et al., 2007) Avoid acrylamide—found in starchy foods prepared at high temperatures (i.e., fried foods) (Hogervorst et al., 2007)

13. Esophageal Cancer: On the Rise Precursor: Barrett’s esophagus (premalignant lesion and strictures of the lower esophageal section related to ulceration and reflux). Zinc deficiency may contribute (Guy et al., 2007) Obesity and high sugar intake implicated (Thompson et al., 2008) To lower risk: Increase intake of omega-3 fats—fatty fish or supplements(Mehta et al., 2008) Avoid alcohol and smoking(La Vechhia et al., 2008) Slow down pace of eating and decrease salt (Yang et al., 2005)—may be due, in part, to increased saliva production withincreased chewing Include antioxidant sources—vitamins C, E(Dong et al., 2008)

14. Lung Cancer: Part Environmental, Part Diet To minimize risk: Increase intake of magnesium to promote DNA repair capacity (Mahabir et al., 2008) Increase intake of cruciferous vegetables—may be due to magnesium content or other phytochemicals (Wang et al., 2004) Increase omega-3 and reduce omega-6 fatty acids (Xia et al., 2005) Increase fruits (Kubik et al., 2008) Increase dietary intake of boron (Mahabir et al., 2008) andcopper, zinc, iron (Mahabir et al., 2007)

15. Prostate Cancer (Most common form and leading cause of death among men in the U.S.) Screened with PSA levels High risk factors include African heritage, family hx, low intake of tomato products, smoking, taller height, high BMI, low physical activity(Giovannucci et al., 2007); male breast cancer linked(Lee and Jones, 2008) To reduce risk: Follow TLC diet to lower insulin levels Vitamin E—nuts(Wright et al., 2007) Supplement with vitamin D Increase tomato product intake Increase zinc intake(van Wijngaarden et al., 2007)

16. Thyroid Cancer Increased risk among persons living near or downwind (Europe) of 1986 Chernobyl nuclear power plant accident in Russia and Ukraine region Such individuals (especially the children) should receive lifetime screening due to high rate of secondary cancers such as leukemia (Kumagai et al., 2007 ; Balanov, 2007) Such individuals should avoid iodine deficiency with iodine supplementation to reduce risk of thyroid cancer, leukemia, and breast cancer (Kesminiene and Cardis, 2007)

17. Impact of Cancer on Food Choices Taste changes (dysgeusia): Reduced threshold for bitter tastes (meat aversion is common) Increased threshold for sweetness (high-sugar foods more acceptable) Increased threshold for salt and sour flavors

18. Effect of Cancer and Treatmenton Nutritional Status Altered metabolism with hypermetabolic state Requires some form of nutrition support (enteral or parenteral) Nausea and vomiting from chemotherapy or toxins generated from cancer cells Dysphagia (impaired swallowing), dry mouth (with greatly increased risk of dental decay), and sore mouth/esophagitis from radiation or surgery of the neck area Diarrhea from radiation or surgery in the abdominal area. If villi are damaged, digestive enzymes are diminished and diarrhea occurs Low-lactose milk products or alternatives advised

19. Nutrition Goals for Cancer Treatment Maintain body weight—sweet foods may be best accepted Include adequate protein for goal of normal albumin Alternatives to meat: Eggs Cheese/yogurt/milkshakes Peanut butter or nuts Bean-based soups Ensure adequate fluid intake

20. Other Nutrition Goals Replace minerals/electrolytes lost from vomiting/diarrhea Use commercial products Include bean-based soups (potassium, magnesium, and sodium) Citrus fruits (potassium) Other soups (sodium) Whole grains (magnesium and potassium) Maintain as good a nutritional status as possible with a variety of foods or reliance on commercial liquid supplements

21. Monitor Altered Nutritional Needs for Cancer Survivors Increased risk for CVD and diabetes due to weight gain, osteoporosis with estrogen/androgen deficiency, secondary tumors DXA scans to r/o osteoporosis Promote increased exercise for bone health, weight goals Promote MyPyramid/Dietary Guidelines for CA prevention With gastric surgery, pellagra may develop Monitor s/s: dermatitis, diarrhea, delirium/dementia,possible neurologic changes and prevent/tx with vitamin B3 Intestinal resections increase risk for variety of nutrient deficiencies

22. With Cancer Remission for Prevention of Recurrence Promote lifelong positive nutrition behaviors Encourage high-fiber diet and emphasis on monounsaturated fats Encourage moderate kilocalorie intake to manage weight and avoidance of excess salt Encourage high-quality diet per the MyPyramid Food Guidance System Promote positive lifestyle Encourage regular physical activity Encourage avoidance of excess alcohol Encourage avoidance of tobacco