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Cancer Survivorship Steven Duffy, MD Bon Secours Cancer Institute St. Mary’s Hospital Richmond, VA “People are living longer after a cancer diagnosis. Cancer survivors often face physical, emotional, social, and financial challenges as a result of their diagnosis and treatment. As the number of cancer survivors grows, CDC is working with partner organizations to help survivors, along with the people in their lives, throughout their cancer experience.” -cdc.org According to the American Cancer Society, there are now more than 14.5 million cancer survivors in the United States. That number is expected to grow to nearly 19 million by 2024. What is a cancer survivor? “An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her lives.” -NCCN (National Comprehensive Cancer Network) Overview I have 15 minutes. Buckle up! Definition of cancer survivorship. Broad view of what it entails. It’s all important, it’s all skimmed over by many. Focus on lifestyle. When to focus on survivorship: Most guidelines (including NCCN) focus on survivorship after completion of cancer treatment and when the survivor is in clinical remission Treatment Overview Neoadjuvant Definitive Tx Adjuvant Palliative Standards for survivorship care Prevention of new and recurrent cancers. Surveillance for cancer spread, recurrence, or second cancers. Assessment of late psychosocial and physical effects. Intervention for consequences of cancer treatment (medical problems, symptoms, psychologic distress, financial and social concerns). Coordination of care between primary care providers and specialists to ensure that all of the survivor’s needs are met. When cancer treatment finishes National Cancer Institute (cancer.gov) to patients: “A new normal” physical and emotional (coping with fear of cancer coming back) Focus on things you can control being involved in your health care, keeping your appointments making changes in your lifestyle no one can control every thought, some say that they try not to dwell on the fearful ones Follow-up care the survivorship care plan (stay tuned) Surveying Patients (NCCN) Cardiac toxicity (symptoms, anthracycline and targeted chemotherapy, radiation) Anxiety and depression Cognitive function Fatigue Pain Sexual dysfunction Sleep disorder Healthy lifestyle Immunizations and infections Healthy Lifestyle Survivors should be encouraged to achieve and maintain a healthy lifestyle with attention to weight management, physical activity, and healthy dietary habits. Healthy lifestyle habits have been associated with improved overall healthy and quality of life. For some cancers, a healthy lifestyle has been associated with a reduced risk of recurrence and death. Maintain a healthy diet high in fruits, vegetables, and whole grains and low in red and processed meats, sugars, and fats in order to promote weight control and avoid obesity. Healthy Lifestyle Minimize alcohol. Avoid tobacco products. Practice sun safety. Age appropriate health screening. Follow with primary care physician regularly. Routine use of dietary supplements is not recommended for the purpose of cancer control. Diet “Diet and nutrition are estimated to account for approximately 30% of all cancers in developed countries and 20% in developing countries.”1 Two important points: Disease of the affluent. Prevention of nihilism. We are taught the molecular basis of carcinogenesis. “Multiple hit” hypothesis, tumor suppressors, protooncogenes, etc. Can we have an impact on this? 1American Cancer Society. Global Cancer Facts and Figures 2nd Edition [report on the internet]. Atlanta (GA): American Cancer Society; 2011. Diet So, what’s the optimal diet? Many studies on this subject. No perfect study. Many different answers. Diet Huang et al. Cardiovascular disease mortality and cancer incidence in vegetarians: A Meta-Analysis and Systematic Review. Annals of Nutrition and Metabolism. 2012. Review of studies from UK, Germany, USA, the Netherlands, and Japan. 124,706 participants in the analysis All cause mortality 9% lower in vegetarians 29% lower mortality from ischemic heart disease 16% lower mortality from circulatory disease 12% lower mortality from cerebrovascular disease 18% lower incidence of cancer There is no differentiation in the type of “vegetarian”. Diet So, what about cancer rates among different types of vegetarians. Hard to drill down because of study limitations and small numbers of patients. Tantamango-Bartley et al. Cancer Epidemiology Biomarkers and Prevention. 2013 February. Study out of Loma Linda University looking at the 7th Day Adventist population. Seventh-day Adventists are encouraged to eat a well balanced vegetarian diet. Diet Different kinds of vegetarian: Vegans ate red meat, poultry, fish, eggs, and dairy <1 per month Lacto-ovo-vegetarians ate red meat, poultry, and fish <1 per month, and eggs and dairy ≥1 per month Pesco-vegetarians consumed red meat and poultry <1 per month, and fish ≥1 per month; Semi-vegetarians ate red meat, poultry, fish 1 per month to 1 per week, and eggs or dairy at any level Non-vegetarians, red meat, poultry, fish >1 per week, and eggs or dairy at any level. Diet 69,120 participants in the Adventist Health Study-2 2,939 cancer cases were identified The rate of cancer was statistically significantly lower in vegetarians vs non-vegetarians (8%). Overall those following vegan diet had a 16% lower incidence of cancer. Those following vegan diet had a 34% reduction in the rate of female specific cancers. Diet Animal Protein and Cancer (The China Study) Began with research on Aflatoxin contamination of peanuts and childhood rates of liver cancer in the Philippines. Liver cancer became disease of affluent – those who could afford to eat meat. This lead to animal experiments confirming these findings. Diet There is too much focus on: Medication Good where there’s data, but if there is no medication, it doesn’t mean there is nothing else to do. Genetic destiny Where is there consensus? A plant based diet and eating animal products in moderation. MD Anderson, NCCN, ASCO, NCI, ACS Diet Is it best to avoid all animal protein and adapt WFPB diet? Some studies show benefit, but not all do. Processed food is bad. Is benefit due inherent avoidance? Candy? Can a WFPB diet cure cancer? No. Can it make you cancer proof? No. Can it improve quality of life, make you healthier and decrease the chance of developing cancer or having it return after treatment? Overview Definition of cancer survivorship. Broad view of what it entails. It’s all important, it’s all skimmed over by many. Focus on impact of lifestyle. Survivorship Resources National Coalition for Cancer Survivorship (NCCS) American Association for Cancer Research (AACR) American Cancer Society American Institute for Cancer Research (AICR) American Society of Clinical Oncology (ASCO) Cancer Care Center for Disease Control and Prevention (CDC) Leukemia & Lymphoma Society LIVESTRONG National Cancer Institute (NCI) National Comprehensive Cancer Network (NCCN) MedlinePlus Thank You!