Feature

Book examines lifestyle factors that may reduce cancer risk, extend survival

Lorenzo Cohen, PhD
Lorenzo Cohen

A new book explores how six lifestyle factors may help reduce cancer risk, improve quality of life and prolong survival for individuals with cancer.

The book — Anticancer Living: Transform Your Life and Health with the Mix of Six — is intended to serve as a guide to wellness based on the latest scientific findings and clinical trials.

The authors — Lorenzo Cohen, PhD, director of the integrative medicine program at The University of Texas MD Anderson Cancer Center, and his wife, Alison Jefferies, MEd — address social and emotional support, stress management, sleep improvement, exercise, diet and minimization of exposure to environmental toxins.

HemOnc Today spoke with Cohen about the importance of each of these factors for individuals who are undergoing cancer treatment or entering the cancer survivorship phase.

Question: Why are these factors important to patients already diagnosed with cancer?

Answer: We know that most cancers are associated with lifestyle factors, or that lifestyle factors influence outcomes after a diagnosis. However, once someone has a diagnosis, it does no good to focus on blame and shame, as we often will never know the actual cause of someone’s cancer. The key, in addition to conventional treatments, is to have patients actively engaged to improve their outcomes. The data are pretty clear that lifestyle factors will improve aspects of quality of life, but likely even length of life.

Q: How should clinicians talk with their patients about these factors?

A: This is not being discussed as part of the standard of care, and the challenge is twofold. First, the comfort with the level of evidence — which I see as an excuse to not get into these topics — prevents physicians from discussing these factors with their patients. The oncologist needs to start the conversation. The second issue is that lifestyle assessment and counseling — although linked with multiple diseases — is not part of medical education. This means our health care professionals are not equipped to have these conversations. Yet, progress in some areas is being made.

Distress, across many academic centers, is being seen as the sixth vital sign. Exploring how a patient is doing emotionally and directing them to the right resources if they are struggling is imperative. Moreover, a patient who is overweight needs to be counseled that getting to a healthier weight likely will lead to improved outcomes. Exploring why the patient is overweight opens the door to diet and exercise. The American Institute for Cancer Research and American Cancer Society have guidelines for healthy weight, diet and exercise for cancer prevention, as well as decreasing the probability of cancer recurrence and improving outcomes. In addition, someone of normal weight who is not following the diet and exercise guidelines should be counseled in this area and provided the necessary support to change their lifestyle. Similarly, probing patients about sleep is a critical factor and something that we know is disrupted by chemotherapy and other treatments. Lack of sleep impacts people at a biological level, and evidence shows it will have an influence on treatment-related outcomes.

Data show that individuals who have the most diverse microbiome respond better to immunotherapy. We know that consuming a high-fiber diet, a variety of whole fruits, vegetables, whole grains and a judicious amount of fermented foods will lead to a more diverse microbiome. Patients who remain physically active throughout treatment and into survivorship tend to do better on all fronts.

Physicians need to educate patients that these lifestyle factors are important to assess and try to improve throughout treatment and into survivorship. Along with the recommendations of what a patient should be doing, physicians should explain why patients should make these changes.

Q: Why are these topics important during cancer survivorship?

A: There is both positive and negative synergy between these lifestyle factors. For example, trying to lose weight by simply eating less and exercising more but ignoring the stress in a person’s life likely will be unsuccessful and not sustainable. Therefore, for success at behavior change, it is ideal to engage in all areas.

Q: How can clinicians incorporate these factors into survivorship care plans to reduce risk for recurrence and increase likelihood of long-term survival?

A: It starts with assessment. Members of the clinical community should find out where the patient is in their life in each area and then develop an individualized plan to help the patient move forward and achieve optimal health and well-being.

Q: What prompted you to write this book , and w here did you derive the evidence cited?

A: The University of Texas MD Anderson Cancer Center has a clinic and ongoing clinical trials examining comprehensive lifestyle change. We wanted to create a book that presented the evidence for the multiple lifestyle factors in one place and make the case for why the multipronged approach is an important area of focus. We also wanted to write a book that would be accessible to the lay public and would include the recommendations and key prescriptive strategies for how to get started. We are honored to have Viking as a publisher. The company was open-minded enough to allow us to publish a 70-page reference section with more than 1,000 citations derived from top scientific journals. We also included a number of different appendices to guide patients with step-by-step recommendations. We wanted to ensure that we presented the strong evidence base so patients could share this information with their physicians. In turn, we wanted to write a book that physicians could read and see the evidence on — for example — diet impacting immune function or inflammation and immunotherapy outcomes, and how stress and exercise modulate key cancer hallmarks. This book brings together all of this information for the health care professional as well as the lay public.

Q: Why is each of the six pillars outlined in the book so important?

A: We came up with these six pillars of health based on the evidence for cancer prevention and control, along with evidence from research that supports successful behavior change. Most guidelines focus primarily on diet and exercise, alone or combined, but this is somewhat of a reductionist view and misses key factors that support sustainable behavior change. Our first three pillars have often been ignored, yet they are foundational.

Love and support, stress and sleep habits have been independently documented to affect our physiology, biology and the tumor microenvironment, as well as influence cancer outcomes. These three pillars are interrelated and influence success in the area of diet and physical activity. For example, someone who is sleep deprived tends to make poor food choices, and their metabolism is modified. They also tend to be in a bad mood and less likely to exercise, and relationships are disrupted. Seven to 8 hours of sleep per night is recommended. Sleep hygiene is imperative. For individuals who are struggling with getting the recommended amount of sleep per night, screen time has been acknowledged as a disruptor. At a minimum of 30 minutes before bed, people should shut down the laptop, television and phone, and use something such as diaphragmatic breathing to move into a calmer state.

This all starts with social support. We are social beings who live in communities that support us and allow us to be successful or can sabotage us. Receiving and giving support are both beneficial. We start in the book by encouraging people to have a support network established to help them be successful in the other five areas. Independent of this indirect effect of social support, research shows that social support has an effect on a number of different cancer hallmarks, including inflammation and angiogenesis. Studies show that people who report the highest level of support are the ones who support others and give of themselves. These individuals have the lowest level of the stress hormone norepinephrine in the tumor microenvironment. So, again, starting here is key for success and to actually impact tumor biology.

We also know that chronic stress modifies tumor biology, decreases the beneficial effects of healthy food, modifies our food choices, disrupts sleep and our relationships, and decreases our ability and interest to engage in exercise. Unmanaged chronic stress leads to a tumor microenvironment that is more hospitable for cancer growth and can sabotage all of our healthy intentions. Mind-body practices such as yoga, meditation and tai chi or qigong, as well as deep diaphragmatic breathing, decrease stress hormones, improve immune function and decrease inflammation. Engaging in a mind-body practice for 10 to 20 minutes per day improves quality of life and decreases sympathetic nervous system activation. The key is to try to foster a sense of calm and allow that to expand throughout the day.

This leads to the area of exercise and diet. Exercise should be prescribed in the same way that chemotherapy is prescribed. Exercise influences all of the biological pathways that we are trying to target with conventional cancer treatments. It improves immune function, decreases inflammation, decreases stress hormones and decreases inflammatory gene expression profiles. The benefits of exercise literally get into the nucleus of every single cell in the body. We also know that individuals who remain physically active during treatment are able to not only combat fatigue, but also improve sleep outcomes, and there is evidence showing they respond better to treatment. It is recommended that people get 30 to 45 minutes per day of moderate to vigorous physical activity, 5 to 6 days per week. In addition, it is important to sit less. There is a clear link between excess sedentary behavior, independent of activity levels, and worse outcomes among patients with cancer. Sitting less and standing more is important.

As for diet, very exciting data are showing how incredibly important it is to have a diverse and healthy microbiome, and diet is the key factor that influences our microbiome. People should be encouraged to eat a primarily whole-food, plant-centered diet that is low in overall glycemic load. This essentially means low in added sugars and refined carbohydrates. Following this basic diet will without a doubt improve the microbiome because more soluble fiber is being consumed. We know that red meat and processed meats are associated with a number of different cancers. Decreasing the amount of animal protein that someone is consuming and increasing plant-based proteins is important. This does not mean that a person must become a vegetarian, but that consuming more whole foods from the plant world than processed food is key.

The sixth area is to decrease exposure to environmental toxins. Approach personal care products that may contain carcinogens or endocrine disruptors using the precautionary principle. Avoid toxins that can increase a person’s risk for cancer and other illnesses, such as asbestos, styrene — found in Styrofoam — formaldehyde and tetrachloroethylene (ie, perchloroethylene or “dry cleaning fluid”) to name a few.

Q: How can all of these factors combined benefit someone who is undergoing cancer treatment or entering the survivorship phase?

A: Each of these factors independently, and more so synergistically, will lead to improved quality of life and decreased symptoms while someone is undergoing treatment. For many, we understand the mechanisms whereby these factors also should influence longevity. At a minimum, patients are going to feel better and go through treatment better and, we hope, improve their length of life, as well. – by Jennifer Southall

Reference:

Cohen L and Jefferies A. Anticancer Living: Transform Your Life and Health with the Mix of Six. New York: Viking, 2018.

For more information:

Lorenzo Cohen, PhD, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030; email: lcohen@mdanderson.org.

Disclosure: Cohen reports no relevant financial disclosures.

Lorenzo Cohen, PhD
Lorenzo Cohen

A new book explores how six lifestyle factors may help reduce cancer risk, improve quality of life and prolong survival for individuals with cancer.

The book — Anticancer Living: Transform Your Life and Health with the Mix of Six — is intended to serve as a guide to wellness based on the latest scientific findings and clinical trials.

The authors — Lorenzo Cohen, PhD, director of the integrative medicine program at The University of Texas MD Anderson Cancer Center, and his wife, Alison Jefferies, MEd — address social and emotional support, stress management, sleep improvement, exercise, diet and minimization of exposure to environmental toxins.

HemOnc Today spoke with Cohen about the importance of each of these factors for individuals who are undergoing cancer treatment or entering the cancer survivorship phase.

Question: Why are these factors important to patients already diagnosed with cancer?

Answer: We know that most cancers are associated with lifestyle factors, or that lifestyle factors influence outcomes after a diagnosis. However, once someone has a diagnosis, it does no good to focus on blame and shame, as we often will never know the actual cause of someone’s cancer. The key, in addition to conventional treatments, is to have patients actively engaged to improve their outcomes. The data are pretty clear that lifestyle factors will improve aspects of quality of life, but likely even length of life.

Q: How should clinicians talk with their patients about these factors?

A: This is not being discussed as part of the standard of care, and the challenge is twofold. First, the comfort with the level of evidence — which I see as an excuse to not get into these topics — prevents physicians from discussing these factors with their patients. The oncologist needs to start the conversation. The second issue is that lifestyle assessment and counseling — although linked with multiple diseases — is not part of medical education. This means our health care professionals are not equipped to have these conversations. Yet, progress in some areas is being made.

Distress, across many academic centers, is being seen as the sixth vital sign. Exploring how a patient is doing emotionally and directing them to the right resources if they are struggling is imperative. Moreover, a patient who is overweight needs to be counseled that getting to a healthier weight likely will lead to improved outcomes. Exploring why the patient is overweight opens the door to diet and exercise. The American Institute for Cancer Research and American Cancer Society have guidelines for healthy weight, diet and exercise for cancer prevention, as well as decreasing the probability of cancer recurrence and improving outcomes. In addition, someone of normal weight who is not following the diet and exercise guidelines should be counseled in this area and provided the necessary support to change their lifestyle. Similarly, probing patients about sleep is a critical factor and something that we know is disrupted by chemotherapy and other treatments. Lack of sleep impacts people at a biological level, and evidence shows it will have an influence on treatment-related outcomes.

PAGE BREAK

Data show that individuals who have the most diverse microbiome respond better to immunotherapy. We know that consuming a high-fiber diet, a variety of whole fruits, vegetables, whole grains and a judicious amount of fermented foods will lead to a more diverse microbiome. Patients who remain physically active throughout treatment and into survivorship tend to do better on all fronts.

Physicians need to educate patients that these lifestyle factors are important to assess and try to improve throughout treatment and into survivorship. Along with the recommendations of what a patient should be doing, physicians should explain why patients should make these changes.

Q: Why are these topics important during cancer survivorship?

A: There is both positive and negative synergy between these lifestyle factors. For example, trying to lose weight by simply eating less and exercising more but ignoring the stress in a person’s life likely will be unsuccessful and not sustainable. Therefore, for success at behavior change, it is ideal to engage in all areas.

Q: How can clinicians incorporate these factors into survivorship care plans to reduce risk for recurrence and increase likelihood of long-term survival?

A: It starts with assessment. Members of the clinical community should find out where the patient is in their life in each area and then develop an individualized plan to help the patient move forward and achieve optimal health and well-being.

Q: What prompted you to write this book , and w here did you derive the evidence cited?

A: The University of Texas MD Anderson Cancer Center has a clinic and ongoing clinical trials examining comprehensive lifestyle change. We wanted to create a book that presented the evidence for the multiple lifestyle factors in one place and make the case for why the multipronged approach is an important area of focus. We also wanted to write a book that would be accessible to the lay public and would include the recommendations and key prescriptive strategies for how to get started. We are honored to have Viking as a publisher. The company was open-minded enough to allow us to publish a 70-page reference section with more than 1,000 citations derived from top scientific journals. We also included a number of different appendices to guide patients with step-by-step recommendations. We wanted to ensure that we presented the strong evidence base so patients could share this information with their physicians. In turn, we wanted to write a book that physicians could read and see the evidence on — for example — diet impacting immune function or inflammation and immunotherapy outcomes, and how stress and exercise modulate key cancer hallmarks. This book brings together all of this information for the health care professional as well as the lay public.

PAGE BREAK

Q: Why is each of the six pillars outlined in the book so important?

A: We came up with these six pillars of health based on the evidence for cancer prevention and control, along with evidence from research that supports successful behavior change. Most guidelines focus primarily on diet and exercise, alone or combined, but this is somewhat of a reductionist view and misses key factors that support sustainable behavior change. Our first three pillars have often been ignored, yet they are foundational.

Love and support, stress and sleep habits have been independently documented to affect our physiology, biology and the tumor microenvironment, as well as influence cancer outcomes. These three pillars are interrelated and influence success in the area of diet and physical activity. For example, someone who is sleep deprived tends to make poor food choices, and their metabolism is modified. They also tend to be in a bad mood and less likely to exercise, and relationships are disrupted. Seven to 8 hours of sleep per night is recommended. Sleep hygiene is imperative. For individuals who are struggling with getting the recommended amount of sleep per night, screen time has been acknowledged as a disruptor. At a minimum of 30 minutes before bed, people should shut down the laptop, television and phone, and use something such as diaphragmatic breathing to move into a calmer state.

This all starts with social support. We are social beings who live in communities that support us and allow us to be successful or can sabotage us. Receiving and giving support are both beneficial. We start in the book by encouraging people to have a support network established to help them be successful in the other five areas. Independent of this indirect effect of social support, research shows that social support has an effect on a number of different cancer hallmarks, including inflammation and angiogenesis. Studies show that people who report the highest level of support are the ones who support others and give of themselves. These individuals have the lowest level of the stress hormone norepinephrine in the tumor microenvironment. So, again, starting here is key for success and to actually impact tumor biology.

We also know that chronic stress modifies tumor biology, decreases the beneficial effects of healthy food, modifies our food choices, disrupts sleep and our relationships, and decreases our ability and interest to engage in exercise. Unmanaged chronic stress leads to a tumor microenvironment that is more hospitable for cancer growth and can sabotage all of our healthy intentions. Mind-body practices such as yoga, meditation and tai chi or qigong, as well as deep diaphragmatic breathing, decrease stress hormones, improve immune function and decrease inflammation. Engaging in a mind-body practice for 10 to 20 minutes per day improves quality of life and decreases sympathetic nervous system activation. The key is to try to foster a sense of calm and allow that to expand throughout the day.

PAGE BREAK

This leads to the area of exercise and diet. Exercise should be prescribed in the same way that chemotherapy is prescribed. Exercise influences all of the biological pathways that we are trying to target with conventional cancer treatments. It improves immune function, decreases inflammation, decreases stress hormones and decreases inflammatory gene expression profiles. The benefits of exercise literally get into the nucleus of every single cell in the body. We also know that individuals who remain physically active during treatment are able to not only combat fatigue, but also improve sleep outcomes, and there is evidence showing they respond better to treatment. It is recommended that people get 30 to 45 minutes per day of moderate to vigorous physical activity, 5 to 6 days per week. In addition, it is important to sit less. There is a clear link between excess sedentary behavior, independent of activity levels, and worse outcomes among patients with cancer. Sitting less and standing more is important.

As for diet, very exciting data are showing how incredibly important it is to have a diverse and healthy microbiome, and diet is the key factor that influences our microbiome. People should be encouraged to eat a primarily whole-food, plant-centered diet that is low in overall glycemic load. This essentially means low in added sugars and refined carbohydrates. Following this basic diet will without a doubt improve the microbiome because more soluble fiber is being consumed. We know that red meat and processed meats are associated with a number of different cancers. Decreasing the amount of animal protein that someone is consuming and increasing plant-based proteins is important. This does not mean that a person must become a vegetarian, but that consuming more whole foods from the plant world than processed food is key.

The sixth area is to decrease exposure to environmental toxins. Approach personal care products that may contain carcinogens or endocrine disruptors using the precautionary principle. Avoid toxins that can increase a person’s risk for cancer and other illnesses, such as asbestos, styrene — found in Styrofoam — formaldehyde and tetrachloroethylene (ie, perchloroethylene or “dry cleaning fluid”) to name a few.

Q: How can all of these factors combined benefit someone who is undergoing cancer treatment or entering the survivorship phase?

A: Each of these factors independently, and more so synergistically, will lead to improved quality of life and decreased symptoms while someone is undergoing treatment. For many, we understand the mechanisms whereby these factors also should influence longevity. At a minimum, patients are going to feel better and go through treatment better and, we hope, improve their length of life, as well. – by Jennifer Southall

PAGE BREAK

Reference:

Cohen L and Jefferies A. Anticancer Living: Transform Your Life and Health with the Mix of Six. New York: Viking, 2018.

For more information:

Lorenzo Cohen, PhD, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030; email: lcohen@mdanderson.org.

Disclosure: Cohen reports no relevant financial disclosures.