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Cancer Survivor Project
“Be as lean as possible without becoming underweight”
Jenifer Tharani
November 12, 2014
Cancer survivors are defined as patients who have either completed initial anti-cancer
treatment and have entered the remission or who are suffering from advanced stage of cancer9.
The increase in number of new early detection techniques as well as treatment options has now
made it possible for cancer patients to live a longer life. In addition, the number of cancer
survivors is also rising gradually so that 1 in 25 cancer patients will fit the ‘cancer survivors’
category14. Approximately, 70% of Americans who are diagnosed with cancer are now able to
survive beyond the 5-year mark14. Therefore, it is extremely critical for them to live a healthy
lifestyle, which will decrease their risk of mortality and cancer events (cancer recurrence,
second primary cancers) as well as other chronic diseases such as diabetes and cardiovascular
diseases. This will in turn, enhance their quality of life. In order to lead them towards a healthy
lifestyle, the American Institute for Cancer Research (AICR) have released eight lifestyle
guidelines, associated with weight management, diet and physical activity17.
One of these recommendations is “Be as lean as possible without becoming
underweight”17 suggesting the significance of healthy weight maintenance in a cancer survivor’s
life. Body mass index (BMI) is used to categorize people under various categories namely
Underweight (BMI<18kg/m2), Normal (BMI-18.5 to 24.9kg/m2), Overweight (BMI-25 to
29.9kg/m2), Obese (BMI- 30 to 34.9kg/m2) and Extremely Obese (BMI>40kg/m2) 11. It is
estimated that more than one-third which is approximately 34.9% or 78.6 million of U.S. adults
are obese12. The AICR weight management guideline is based on large amount of scientific
evidence that suggests the adverse relationship between obesity and increased risk of
inflammation, diabetes and cancer events among cancer patients 2,6,8,13,15,18. Obesity also
increases the risk of mortality from non-cancer risk factors such as dyslipidemia, respiratory
problems, hypertension, cardiovascular disease and stroke11. Research has shown that cancer
patients with these pre-existing non-cancer conditions have a predisposition to tumor recurrence
even after undergoing treatment7. Therefore, it is extremely important to alert cancer survivors
about the value of maintaining healthy weight (normal BMI) during survivorship without
becoming underweight, overweight or obese.
Mechanisms associated with obesity and its harmful effects involve factors such as
increased levels of insulin, insulin like growth factor 1 (IGF-1), adipokines like leptin hormone
and pro-inflammatory cytokines such as IL-6, TNF- and retinol binding protein (RBP). These
elements trigger several molecular signaling pathways that facilitate tumor progression, survival
and metastasis by increasing angiogenesis and levels of bioavailable IGF-12. These obesityrelated factors may also contribute towards increased resistance of tumor cells against anticancer treatments suppressing their positive effect. One study showed that breast cancer
tumors expressed higher levels of IGF-1 receptors. Since, insulin and IGF-1 levels may be high
among overweight and obese postmenopausal women, this may certainly contribute towards
sustained tumor growth increasing cancer relapse among breast cancer survivors2.
Few studies have also shown that underweight women suffering from breast cancer are
also at an increased risk of poor survival after treatment10. This may be due to increased
release of cortisol hormone as a result of protein calorie malnutrition, which in turn results in
increased energy expenditure and affects hematopoiesis. In addition, immune system is also
weakened due to impaired cytokine response, which makes body more prone to infections4.
WINS study1 indicated that its essential to lose weight for overweight or obese women
in addition to reducing calories from dietary fat, by maintaining energy balance to result in better
survival. It is critical that patient’s weight management strategies are based on the type of
cancer, treatment and the phase in survival13. This is because breast cancer patients were
either overweight or obese at the time of diagnosis and gained weight as a result of
treatment3,15, whereas patients suffering from head, neck, and esophageal cancers may be
underweight at the time diagnosis or lost weight during survival phase.
In conclusion, adherence to 6 or 7 AICR guidelines is found to be associated with
approximately a range of 15-60% reduction in risk of breast cancer5.
References
1. Blackburn GL, Wang KA. Dietary fat reduction and breast cancer outcome: results from
the Women’s Intervention Nutrition Study (WINS). J Natl Cancer Inst. 2006 Dec 20;
98(24):1767-76.
2. Champ CE, Volek JS, Siglin J, Jin L, Simone NL. Weight Gain, Metabolic Syndrome,
and Breast Cancer Recurrence: Are Dietary Recommendations Supported by the Data?
International Journal of Breast Cancer. 2012.
3. Chlebowski RT, Aiello E, McTiernan A. Weight Loss in Breast Cancer Patient
Management. Journal of Clinical Oncology. 2002; 20(4):1128-1143.
4. Catsburg C, Miller AB and Rohan TE. Adherence to cancer prevention guidelines and
risk of breast cancer. Int. J. Cancer. 2014; 135:2444–2452
5. Cunningham-Rundles S, McNeeley DF, Moon A. Mechanisms of nutrient modulation of
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receive adjuvant chemotherapy for colon cancer. J Natl Cancer Inst. 2006 Nov
15;98(22):1647-54.
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treatment: An American Cancer Society guide for informed choices. CA Cancer J Clin.
2006 Nov-Dec;56(6):323-53.
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obesity as a common risk factor. Diabetes Obes Metab. 2014 Feb;16(2):97-110. doi:
10.1111/dom.12124. Epub 2013 Jun 12.
9. Ganz PA, Yip CH, Gralow JR, et al. Supportive care after curative treatment for breast
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Breast. 2013 Oct;22(5):606-15. doi: 10.1016/j.breast.2013.07.049. Epub 2013 Sep 3.
10. Moon HG, Han W, Noli ADY. Underweight and Breast Cancer Recurrence and Death: A
Report From the Korean Breast Cancer Society. J Clin Oncol. 2009 Dec 10;27(35):5899905. doi: 10.1200/JCO.2009.22.4436. Epub 2009 Oct 5.
11. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and
Treatment of Obesity in Adults (US). Clinical Guidelines on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda
(MD): National Heart, Lung, and Blood Institute; 1998.
http://www.ncbi.nlm.nih.gov/books/NBK2003/. Accessed on 11/04/2014
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the United States, 2011-2012. JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732.
13. Pakiz B, Flatt SW, Bardwell WA, Rock CL, Mills PJ. Effects of a Weight Loss
Intervention on Body Mass, Fitness, and Inflammatory Biomarkers in Overweight or
Obese Breast Cancer Survivors. Int J Behav Med. 2011 Dec;18(4):333-41. doi:
10.1007/s12529-010-9079-8.
14. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and Physical Activity
Guidelines for Cancer Survivors. CA Cancer J Clin 2012; 62:242-274.
15. Sinicrope F, Foster N, Sargent D, O'Connell M, Rankin C. Obesity Is an Independent
Prognostic Variable in Colon Cancer Survivors. Clin Cancer Res. 2010 Mar
15;16(6):1884-93. doi: 10.1158/1078-0432.CCR-09-2636. Epub 2010 Mar 9.
16. Voskuil DW, van Nes JG, Junggeburt JM, van de Velde CJ, van Leeuwen FE, de Haes
JC. Maintenance of physical activity and body weight in relation to subsequent quality of
life in postmenopausal breast cancer patients. Annals of Oncology. 2010; 21(10):2094101.
17. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition,
Physical Activity, and the Prevention of Cancer: a Global Perspective. AICR, 2007.
http://www.aicr.org/assets/docs/pdf/reports/Second_Expert_Report.pdf. Accessed on
10/20/2014
18. Zeng H, Lazarova DL. Obesity-related colon cancer: Dietary factors and their
mechanisms of anticancer action. Clin Exp Pharmacol Physiol. 2012 Feb;39(2):161-7.
doi: 10.1111/j.1440-1681.2011.05518.x.