Health & Fitness

Living well after cancer

Cancer survivor and TV personality Joan Lunden talks to participants at the start of the Dempsey Challenge Positive Tracks 10K run in October.
Cancer survivor and TV personality Joan Lunden talks to participants at the start of the Dempsey Challenge Positive Tracks 10K run in October. TNS

Cancer patients used to be told to go home and take care of themselves without too many specifics for life after treatment. Now, as soon as they’re feeling strong enough, they’re advised to mind their lifestyle: lace up their sneakers, eat healthy, watch their weight and avoid tobacco and excess alcohol.

Roughly a third of cancers are considered preventable and the lifestyle recommended to help avoid them is the focus of ongoing research to help cancer survivors live healthier and, perhaps, longer.

Healthy behaviors may be especially important for someone who has had cancer. “They can not only be potentially helpful in preventing cancer from being there in the first place, but … they may be powerful tools in preventing recurrence,” said Jennifer Ligibel, a senior physician at Dana-Farber Cancer Institute in Boston. “We’re hoping that these types of things can improve survival rates in people who’ve had early cancers.”

Cancer survivors often need a tailored lifestyle program because side effects from their treatments can make it harder for them even to put on their shoes and go outside, Ligibel said.

About 14.5 million Americans are living with a history of cancer, and those ranks are expected to reach 19 million by 2024, according to the American Cancer Society. More than two-thirds of U.S. cancer survivors live five years beyond diagnosis, up from half in the 1970s and a third in the 1950s.

“We’re getting better at catching it earlier and treating it,” said Kathryn H. Schmitz, director of the exercise medicine unit at the University of Pennsylvania’s Perelman School of Medicine.

While advances in battling cancer have grabbed the spotlight, post-treatment life has gotten much less attention, as detailed more than a decade ago in an Institute of Medicine report called “From Cancer Patient to Cancer Survivor: Lost in Transition.” A patient who turns into a survivor faces many challenges: physical and psychological effects of treatment, including fatigue, numbness, pain and anxiety; and additional disease. Some effects can appear months or years later.

Survivors also live with the possibility of a recurrence or of developing a different form of cancer. Nearly 1 in 5 cancers are a second diagnosis, according to the National Cancer Institute.

Weight loss, exercise are key

A healthy lifestyle can help survivors feel better and cope with the changes that cancer brings.

“Cancer forever changes an individual — not because of the cancer itself; usually, it’s because of the treatment,” Schmitz said.

Fatigue is the most common side effect of many cancer therapies, and some fatigue can persist for months or even years, according to the National Cancer Institute. More than 100 studies have shown that survivors who participate in exercise programs reduce their fatigue levels, said Ligibel, who is also an assistant professor at Harvard Medical School.

Weight loss and exercise improve quality of life and the functioning of the body for cancer survivors, she said.

Studies suggest that exercise may help cognitive functioning in cancer survivors. After treatment some can feel a general mental fog in attention, thinking or short-term memory.

People with early forms of many cancers, including breast and prostate, may have a higher risk of dying of heart disease or other disorders than of cancer, Ligibel said. Cancer and heart disease share many risk factors, such as obesity and inactivity. Cancer treatments can also cause people to gain weight and become less active, increasing the risk of heart disease and diabetes. Finally, some cancer treatments can have a direct adverse impact on the heart. For all of these reasons, physical activity and nutrition are very important for survivors.

“I think sometimes we get lost in the fact that someone has had cancer and forget about their competing risks,” she said.

Calorie balance

Being fit and eating well may help bolster energy levels and address some of the metabolic and biological factors in survivors that can create conditions for developing cancer and other diseases down the road, said Linda Nebeling, deputy associate director of behavioral research at the National Cancer Institute.

Over the past five years, research has increasingly focused on energy balance, a concept linking exercise, diet and weight: Calories eaten should be balanced by calories burned in exercise, thereby avoiding turning extra calories into excess weight.

Large studies have shown a relationship between energy balance and risk of cancer recurrence and death in people who have had breast, prostate, colon and perhaps other cancers, Ligibel wrote in a review article in the Journal of Clinical Oncology. Although cause and effect has not been established, data reveal that obesity is linked to an increased risk of breast cancer recurrence and breast-cancer-related death in women diagnosed with early-stage breast cancer, Ligibel said. Obesity has also been linked to recurrences of colon and rectal cancers.

Ligibel said that people who are more physically active after a diagnosis of breast, colon or prostate cancer appear to have a lower risk of recurrence than inactive survivors of those cancers.

Regarding diet, there is no “magic food” that promotes survival, said Cheryl Rock, a professor of family medicine and public health at the University of California at San Diego School of Medicine. Many researchers examine patterns of eating because foods and nutrients are not consumed in a vacuum. Dietary patterns that stress red and processed meat and fat may be linked to an increased risk of colon cancer recurrence. Experts see promise for survivors in a diet rich in fruits, vegetables and whole grains, with low-fat dairy products — a pattern that may aid survival and avoid recurrence as well as keep at bay conditions such as heart disease and diabetes, she said.

Links or relationships have been seen between lifestyle factors and the risk of cancer recurrence, but more-direct evidence, from trials that actually test whether such things as exercising and losing weight reduce the risk of death after cancer diagnoses, is not yet available. Major survivorship studies are under way in such areas as colon cancer and exercise, breast cancer and weight loss, and ovarian cancer and lifestyle interventions.

Links between lifestyle, cancer survival

The focus on survivor lifestyle takes a page from heart disease. Cardiac patients were once prescribed bed rest. President Dwight D. Eisenhower toppled that notion in the 1950s after he suffered a heart attack in office. With his doctors’ encouragement, he continued to work and returned to his favorite activities of walking, golfing and fishing. Today, getting heart patients moving as soon as possible is standard cardiac rehabilitation.

Researchers hope to develop similar care standards for cancer survivors, but more work is needed. “You can’t change policy without evidence-based research,” Nebeling said.

As research continues, many survivors fail to incorporate lifestyle changes into their daily routines, often for financial reasons.

Schmitz conducts research trials of exercise interventions for breast cancer survivors. She was lead author of a study published in 2012 that followed 600 survivors for six years to assess needs and benefits of physical therapy and rehab exercise. At six years post treatment, more than 60 percent had at least one symptom that could have been helped by a physical intervention.

Schmitz has been angered to find that many in her studies had developed disabilities because the circumstances they returned to after treatment were ignored. The women had jobs — as child-care workers, nursing aides and cleaners, for example, that required much physical labor. Without adequate physical and occupational therapy, they returned to work and developed such severe upper-body difficulties that they became disabled.

Unlike many other countries, the United States lacks consistency in assessing cancer survivors’ needs and in funding rehabilitation, nutrition counseling and ongoing care. Ligibel said that survivors need an infrastructure that takes them from finishing treatment and being fatigued to a program of being more active and getting help with nutrition. It’s “hard for people to make these changes on their own,” she said.

Research into the possible links between lifestyle and cancer survival may help raise the profile of cancer rehabilitation. “Hopefully that will lead to better development of infrastructure and third-party payment to help people actually do these things,” she said.

Enormous strides have been made in keeping cancer patients alive, and lifestyle may help many rebuild survivors’ quality of life. “It is no longer enough to say, ‘Well, you’re alive,’ ” Schmitz said.

And celebrities such as television journalist and author Joan Lunden, a breast cancer survivor, are doing a lot to raise awareness of survivor issues. Lunden has written a book about her cancer journey, called Had I Known: A Memoir of Survival (Harper).

Ligibel said there is no doubt that many survivors are not living the way they want to. “I think our goal now is to give people the lives back they had before their diagnosis,” she said. “So we have to help them not only to live longer but also to live better than they are now.”

CANCER SURVIVAL TIPS

A diagnosis of cancer is shocking news, but it can create a teachable moment for the patient. “Think about what changes do I need to make to improve my chances of survival and to improve my overall well-being and my ability to cope with my disease,” suggests Kevin Stein, director of the American Cancer Society’s behavioral research center.

Cancer patients first go through a period where rest is critical: the intensive phase of treatment such as surgery or chemotherapy. At this time, it’s important to follow the advice of your oncologist and other providers of medical care, said Linda Nebeling, deputy associate director of the behavioral research program at the National Cancer Institute.

The changes that survivors need to make after treatment are mostly the common-sense steps for good health that are suggested for a variety of conditions. Many groups offer diet and exercise recommendations similar to the following, from the American Cancer Society’s “Lifestyle Changes That Make a Difference,” a guide for patients, and “Nutrition and Physical Activity Guidelines for Cancer Survivors.”

▪ Get to and stay at a healthy weight.

The ACS recommends limiting high-calorie foods and drinks and getting more active. Aim to get your BMI in a healthy range.

▪  Be active on a regular basis.

Return to normal activities as soon as your doctor says it’s okay, and exercise at least 150 minutes a week. Include at least two days of strength training. Check with your doctor before beginning any program.

The exercise that helps cancer survivors doesn’t require them to become marathon runners, Nebeling says. Experts recommend starting slowly with controlled exercise such as riding a stationary bike and using hand weights, gradually building up to more cardiovascular-related gym activities. “We’re training you so you don’t waste and lose muscle mass,” Nebeling said. Exercise helps maintain muscle strength and capacity for balance. It reduces fatigue and keeps energy levels up “so that your body stays healthy,” she said.

▪  Eat a variety of foods.

Aim for 2 1/2 cups or more of fruits and vegetables daily. Choose whole grains. Limit red and processed meat.

Cancer survivors should enjoy what they eat and cook with foods from their local markets, said Cheryl Rock, a professor of family medicine and public health at the University of California at San Diego School of Medicine.

Healthy food can be tasty, she said. Ingredients provide zip: Instead of pepperoni on a pizza, use sun-dried tomatoes for added flavor. Instead of croutons on a salad, try roasted walnuts for crunchy satisfaction. Slivered almonds or mustard perk up fish.

Survivors can also eat healthier by adding ingredients to their regular diets: fruit on cereal or veggies added to the pasta that you order out.

▪  Limit alcohol consumption.

▪  Find a local program.

“Livestrong at the YMCA,” a 12-week program for cancer survivors, is offered at little or no cost in more than 450 communities across the country. Certified instructors teach cardiovascular, strength training and flexibility exercises that suit an individual’s preferences and needs and that help the survivor find exercises to continue doing after the program is completed. The American Cancer Society (800-ACS-2345) has a database of local programs.

For more information:

National Cancer Institute, cancercontrol.cancer.gov/ocs.

American Cancer Society, cancer.org/treatment.

American Institute for Cancer Research, aicr.org/patients-survivors/aicrs-guidelines-for-cancer.html

Livestrong, livestrong.org.

National Coalition for Cancer Survivorship, canceradvocacy.org.

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