Living well, with and beyond cancer: The evidence - Home : London Cancer … · 2014-11-24 · Living well, with and beyond cancer: ... cessation intervention in head and neck cancer

Living well, with and beyond cancer: The evidence 25 September 2014

Welcome and introduction

The Royal Marsden

What should you eat after cancer treatment? 3

What should you eat after cancer treatment?

Clare Shaw PhD RD

The Royal Marsden What should you eat after cancer treatment? 4

Overview

– What happens to nutritional status and food intake during cancer treatment?

– Nutritional issues after cancer treatment?

– What is the ideal diet?

– Does diet make a difference to the risk of cancer recurring?

– What about ‘Superfoods’?

– Summary


What happens to nutrition during cancer treatment?

– Rates of malnutrition are higher in people with cancer

– Malnutrition can occur due to

– Reduced food intake

– Metabolic changes due to cancer

– Side effects of treatment

– Importance of addressing nutrition

to provide optimal care (NICE guidance, CQC, British Dietetic Association)


Nutritional status

– 1000 patients nutritionally screened, all diagnoses

– 40% had lost more than 10% of body weight

– 34% identified as severely malnourished

– Poor nutritional status associated with upper Gastro Intestinal cancers, advanced disease and poor performance status

– Bozzetti (2009) Supportive Care in Cancer


Royal Marsden

Nutritional status of inpatients, 2012-13

128 patients

Category Count (percentage) of patients within each category

PG-SGA RMNST MST

Well nourished 36 (29) 25 (20) [score: 0 - 4]

61 (48) [score: 0 - 1]

Moderately nourished 63 (50) 33 (26) [score: 5 - 9]

-

Malnourished - - 65 (52) [score: 2+]

Severely malnourished 27 (21) 68 (54) [score: 10+]

-

71% of patients at medium or high risk of malnutrition


1 Mouth sores

7 Smells bother me

9 Problems swallowing

11 Diarrhoea

11 Vomiting

14 Constipation

17 Dry mouth

18 Nausea

20 Taste changes

23 Pain

27 Early satiety

38 No appetite

Percentage (%) Symptom

Khalid et al, 2007 • Subjective Global Assessment • 151 new patients (Lung and GI)

Symptoms – increase risk of weight loss


What about weight gain?

– Some people may gain weight during chemotherapy

– 98 women with breast cancer in USA (Sheppard et al, 2013)

– 62% maintained weight

– 29% gained weight (more than 5% of their baseline weight)

– 9% lost more than 5% of pre treatment weight

– 98 women with breast cancer in China (Wang et al, 2014)

– Weight changes from – 11 kg to + 9 kg

– 67% gained more than 1 kg

– 4561 women with breast cancer (Chen et al, 2011)

– 61% gained weight 18 months after treatment for breast cancer


It is not only breast cancer patients

– Prostate cancer patients undergoing chemotherapy (Joly et al, 2010)

– 50% gained weight

– Prostate cancer patients on Androgen-deprivation therapy (ADT) (Kim et al, 2011)

– 132 men, 92 (70%) gained weight and 40 (30%) either lost or maintained a stable weight

– Weight gain after a diagnosis of prostate cancer is associated with an increased rate of prostate cancer specific mortality (Bonn et al, 2014)


What to eat during cancer treatment?

– Good balanced diet providing all the required nutrients

– Balance of protein, fat and carbohydrate and total energy may change depending on requirements

– Weight loss

– Weight gain


Recommendations after cancer treatment

The Royal Marsden What should you eat after cancer treatment? 13 Make a Change, Live Well 13

World Cancer Research Fund UK Recommendations

1. Be as lean as possible without becoming underweight

2. Be physically active for at least 30minutes every day

3. Avoid sugary drinks and limit the consumption of high calorie foods

4. Eat more of a variety of vegetables, fruits, whole grains and pulses

5. Limit intake of red meat and avoid processed meat

6. Limit alcoholic drinks to 2 a day for men and 1 a day for women

7. Limit consumption of salty foods

8. Do not use nutritional supplements to protect against cancer

9. After treatment, cancer survivors should follow the recommendations for cancer prevention

The Royal Marsden What should you eat after cancer treatment? 14 Make a Change, Live Well 14

Aim to be a healthy weight

– Aim for a healthy weight for your height

– BMI 20 – 25 kg/m2

– Aim for a healthy waist measurement

– Less than 31 ½ inches/80cm for women

– Less than 37 inches/94cm

for men


www.wcrf-uk.org

The Royal Marsden


Is this the right diet for everyone?

The Royal Marsden


Gastrointestinal symptoms as a result of cancer treatment


Gastro-intestinal Symptom Rating Scale: 12 months (following chemo/RT/surgery Most common at 12 months (n=25) % patients

Flatulence 76%

Belching 72%

Abdominal pain 68%

Abdominal grumbling 56%

Early satiety 52%

Acid reflux 48%

Incomplete evacuation 48%

Constipation 44%

Diarrhoea 44%

Upper gastrointestinal cancer patients


GI problems following pelvic radiotherapy


Consequences of cancer treatment clinic

Profile of patients

Cancer site Prevalence in our clinic population (%)

Urology 37% prostate: 88%

Gynaecology 18% cervix: 51%

Colorectal 16% rectum: 48%

Upper GI 12% gastric: 46%

Haematology 6% multiple myeloma: 46%

Other 11%


% of patients with moderate or severe GI symptoms (n=110)

% of affected patients

0 10 20 30 40 50 60 70 80 90 100

abdo pain

bloating

flatulence

belching

borborygmi

urgency

frequency

diarrhoea

tenesmus

leakage

nausea

heartburn

rectal bleeding

steatorrhoea

noct defaecation

severe

moderate


Nutritional consequences of cancer treatment

– Weight change

– Weight loss

– Weight gain

– Gastrointestinal symptoms

– Pelvic radiotherapy

– Upper GI surgery

– Bone marrow transplantation

– Swallowing problems

– Head and neck patients

– Taste changes


Does a healthy diet make a difference to the risk of cancer returning?


Women’s Healthy Eating and Living Study (WHEL)

– Recruited women with breast cancer, on average, 23.5 months post diagnosis

– 3088 women

– Randomised

– Counselling programme to increase 5 portions vegetables and 3 portions of fruit plus 16 oz vegetable juices plus a reduction in fat intake

– Control group – written material on eating ‘5 a day’


The Women’s Healthy Eating and Living Randomized Trial

Pierce et al, 2007


Risk in women taking tamoxifen


WINS study

– 2437 women with breast cancer reduced their fat intake from 51g to 33g

– Lost on average 6lb in weight

– Follow up period of 60 months

– Measured relapse of breast cancer

Chlebowski et al, 2006)


WINS study

Oestrogen receptor positive

Oestrogen receptor negative

Chlebowski et al, 2006)


What about Superfoods?


What is a Superfood?

– Substance that is liked by the popular press!

– Claimed to have special health giving beneficial properties

– Much interest in individual foods and cancer risk


Superfoods?


Superfoods?

– Often lack the scientific evidence to support ‘ popular claims’

– Often delicious and great to include as part of a balanced diet

– Variety is perhaps the most important aspect, especially fruit and vegetables.


Summary

– Variety of nutritional issues at the end of treatment

– May be consequences of treatment

– Body weight – very important! (especially hormone dependent cancers)

– Superfoods – eat them (but don’t expect too much!)

– Healthy eating guidance for those who are eating well

Dietary advice after cancer, the reality

Ms Rebecca Shoosmith

Evidence based smoking cessation intervention in head and neck cancer

Mr Richard Oakley

Consultant Head and Neck Surgeon

Guy’s and St Thomas’ NHS Foundation Trust

Coffee Break

Please spend some time looking at the marketplace as well as ‘networking’

The evidence for exercise throughout the cancer pathway

Nicola Glover

BSc (Hons), PGCert, MCSP

The London Cancer Alliance West and South

Overview

• Definitions

• Rehabilitation and survivorship models

• Behavioural change

• Overview of the evidence – Summary by pathway point

– Specific examples

• Risk assessment and considerations

• International recommendations

• UK guidelines

• Summary


Exercise or physical activity?

• Exercise: “activity requiring physical effort, carried out to sustain or improve health and fitness”

Oxford English Dictionaries (2014)

• Physical activity: “Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure”

World Health Organization (2014)


Cancer rehabilitation

• Preventative: reducing impact of expected disabilities and improving coping strategies

• Restorative: returning person to pre-morbid levels

• Supportive: in presence of persistent disease and need for treatment, rehab is aimed at limiting functional loss and providing support

• Palliative: prevent further loss of function, measures put in place to eliminate or reduce complications and to provide symptom management

(Dietz 1980)


Physical activity and cancer control model

Peace framework, Courneya and Friedenreich (2001), from ACSM (2010)


Teachable Moment

• Something happens which means that you are open to change

• Have to recognise that change is necessary

• Have to understand that life-style behaviours are impacting on health (BeWEL programme, Anderson et al 2014)

• Have to believe you can make the change

• Self-determination and self-efficacy (Bandura 1977)

• Transtheoretical model (Prochaska 1977)

– Pre-contemplation

– Contemplation

– Preparation

– Action

– Maintenance


Evidence for exercise during treatment

• Safe and feasible

• Improves physical function (17 RCTs), fatigue(15 RCTs) and quality of life (10 RCTs)

• May increase the completion of chemotherapy

• Reduces on-treat side effects e.g. pain, nausea

• Improves multiple post-treatment effects – Bone health

– Muscle strength

• Reduces length of stay

• Increases immune function

• Increases strength and lung function Baumann et all (2010), Schmitz et al (2010), Macmillan, Spence et al (2009), Grimmet (2011), Speck (2010), Dimeo (1997)


An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis (Speck et al 2010)

• 66 studies with high internal validity

• Physical activity

• Aerobic fitness and upper and lower limb stranght

• % body fat

• Functional quality of life

• Mood, anxiety, self-esteem

• Only 5 adverse incidents attributable to exercise

• Recurrent themes of fear of harm, specifically around exercise towards end of treatment, with lymphoedema (risk) and with neutropaenia

• On-going advice to ‘take it easy’


Post-treatment

• Significant improvements in VO2 Max, upper and lower body strength, resting heart rate (breast)

• Higher levels of physical activity = ↑ QoL, physical functioning and fatigue (CRC)

• Systematic reviews show positive effects on muscular fitness, physical functioning, fatigue and HR QoL (prost)

• RCT of 121 people having RT +/- ADT showed aerobic improved fatigue and fitness and resistance training showed fatigue, QoL, aerobic fitness, strength (prost)

• Progressive resistance training reduces lymphoedema recurrence

• Reduced fatigue (14 RCTs) Macmillan, Spence et al (2009)ACSM (2010), Baumann et al (2010) Dimeo (1997, 2008), Buffart et al (2013)


Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions (Buffart et al 2013)

• Widespread, consistent evidence that exercise is safe and sedentary lifestyle should be avoided

• Should be working at 80% 1-RM and 50-80% HR max

• Aerobic exercise improves VO2 max and prevents fat gain

• Resistance training improves lower and upper body strength and adds lean mass

• Both alter body composition, but not weight

• Both alter psychosocial outcomes


Limitations to research

• Most gold standard evidence remains within breast, colorectal, prostate and SCT

• Dose remains unclear – How much?

– How often?

– What?

– When?


Risk assessment

• Increasing co-morbidities

• Bone mets?

• Lymphoedema?

• Tumour specific limitations?

• Use of assessment tools, such as PAR-Q+ Warburton et al (2011), Burr et al (2012)

• Do we know what ‘safe’ is?


Secondary prevention and reduced all-cause mortality and morbity • Meta-analysis including more than 12,000 survivors

– Post-diagnosis physical activity associated with a 24% lower cancer recurrence and 34% lower breast cancer mortality and a 41% lower all cause mortality

• ↓ cancer recurrence, colorectal mortality and all cause mortality (Anderson et al 2014)

• In women, 50% all cause mortality reduction with >9MET/h/wk (Mayerhardt et al 2006 in Grimmett 2011)

• Post-SCT, reduced serious infections, increased recovery and faster discharge


LUNGEVITY (Jones et al 2010)

• Single centre RCT with 4 arms

• Aerobic training

• Resistance training

• Combination

• Attention control

• Multiple analysis

• VO2 max

• PRQoL (FACT-L and depression scale))

• FEV1 and Cardiac output

• Hb concentration

• Muscle Fibre distribution

• Adults

• 6 months post surgery

• Karnofsky of at least 70%

• Regular exercise (> 5/7, >30 mins)


International Recommendations

“Existing evidence strongly suggests that exercise is not only safe and feasible during cancer treatment, that…it can improve physical function, fatigue, and multiple aspects of quality of life”

American Cancer Society (2012)

“…both aerobic and resistance exercise [should] be prescribed, unless specific problems dictate otherwise.”

Australian Association of exercise and sport science (2009)

“…cancer survivors should follow the 2008 Physical Activity Guidelines for Americans…the advise to “avoid inactivity”…is likely helpful.”

American College of Sports Medicine (2010)

“An overall volume of 150 mins of moderate-intensity exercise, or 75 mins vigorous-intensity exercise of an equivalent combination. Guidelines for strength training is to perform two or three weekly sessions that include exercise for major muscle groups. Flexibility guidelines are to stretch major muscle groups and tendons on days that other exercise are performed.”

US Department of Health and Human Services (2008)


UK Recommendations

• “Unless advised otherwise, cancer survivorship should follow the health-related physical activity guidelines for the general UK population”

British Association of Sport and Exercise Sciences (2011)

• “Cancer survivors should be advised to gradually build up to the health-related physical activity guidelines for the general population.”

Macmillan

• “At least 150 minutes of moderate-intensity aerobic activity…and muscle strengthening activities on two or more days…or 75 mins of vigorous-intensity aerobic activity…and muscle-strengthening activity on two or more days a week”

www.nhs.uk physical activity guidelines for adults (2014)

http://www.nhs.uk/


Conclusions

• Evidence is overwhelming suggestive that exercise at high intensities is safe throughout the cancer pathway

• Risk assessment is important

• Referral to cancer trained exercise specialists is sometimes useful

• Consider referral to oncology specialist physios for those with complex presentations/multiple morbidities and/or higher risk factors for exercise


Take home message

Avoid a sedentary lifestyle. Some exercise is better than none, and more is better than less, at least up

to recommended amounts.

Supporting Return to Work following Cancer Treatment

Theresa Wiseman Lead for Health Service Research,

The Royal Marsden Amrit Sangha Research Assistant, The Royal Marsden


Background

• It is estimated that there are approximately 700,000 people of working age with cancer in the UK (Maddams et

al. 2009). - This figure is increasing in line with people working later in life. - People with cancer are 1.37 times more likely to be unemployed than those without (de Boer et al. 2009).


Background

• Work serves a range of functions reducing or avoiding: - social isolation - boredom - loss of self-esteem - financial hardship

• It is also a way of enabling people to regain normality, self-concept and identity. (Amir et al. 2008, Spelton et al. 2002 & Frazier et al. 2009)


Background

• Between 20-30% of people report impairments in ability

to work after cancer (Taskila et al. 2007).

• Many who do return to work report:

- a loss of self-confidence

- difficulty coping with symptoms at work

- feeling less able to do their jobs

- deteriorating career prospects (Lee et al. 2008, Main et al. 2005 & Bennett et al. 2009)


Research Groups

• There is a growing number of multi-disciplinary research

groups focused on cancer and work.

• CCAT- 12 researchers including Prof Mary Wells, Dr

Diana Greenfield & Dr Theresa Wiseman

• CanWork (UK)- 13 researchers including Theresa

Wiseman

• CANWON Network (Europe)- connects 28 researchers

from 18 EU countries

• Work Foundation

• Vocational Rehabilitation- Dr Gail Eva


CANWON

• CANWON Network (Europe): 4 work streams

1. Prognostic factors of work participation in cancer

survivors

2. Work-related costs of survivorship

3. Role of employers

4. Development and evaluation of innovative,

interdisciplinary interventions


CANWON

• 1. Prognostic Factors

What we know: • Fatigue, Depression

• Cognitive functioning, Work ability

• Diagnosis and Treatment

What we need to explore:

• Gender issues

• Social security systems and legislation

• Cultural differences

• Validated and reliable instruments

• Harmonisation of new quantitative data collection


CANWON

• 2. Work-related Costs

What we need to explore:

– Economic consequences of decreased work participation: unemployment, unpaid sick leave, reduced productivity and income losses, early retirement.

– Effect of social policies and macro-economic situation

• What we will aim do: – Assess transitions from employment to unemployment, sick

leave, lower income and reduced productivity

– Calculate the cost of all detrimental effects of cancer upon the occupational status


CANWON

• 3. Employer

What we need to explore more: – Accommodating role of employers and line managers

– Discrimination

– Social security systems and legislation

• What we will do: • Study communication on work participation matters

• Assess workplace factors such as workplace accommodations (such as change of work times, adaptations of physical workplace and travel arrangements).

• Discrimination of cancer survivors in work participation

• Social policies and the role of the employer


CANWON

4.Interventions

• What we know:

– Return to work of cancer patients needs to be supported

• What we will do: – Establish a theoretical model

– Development new multidisciplinary interventions, adapted to identified prognostic factors and social legislation and role of employer

– Use knowledge of earlier and running interventions

– Evaluate cost-effectiveness of these new interventions in controlled trials and field studies


REJOIN study

NIHR Post-Doc Fellowship - Dr Gail Eva

- Priority to provide services to support patients’ to return to work.

- Very little research which assesses the effectiveness of vocational rehabilitation.

- Study aims to determine the feasibility of a RCT to evaluate a cancer-specific vocational rehabilitation intervention (the REJOIN intervention) in terms of its clinical and cost effectiveness.


Return to Work - Perspectives from the workplace

Dr Theresa Wiseman

• Grounded theory study

• Interviewing people returning to work and managers

facilitating return to work

• 17 participants, 12 RTW, 5 managers

Within ORGANISATION

Within MANAGER

Within SELF


Wells et al. 2013

- Conducted a systematic review and meta-synthesis of

the qualitative literature on employment and cancer.

- Individuals experiences of “return to work” were

strongly influenced by 4 key factors.


Model

Wells et al. 2013


1. Self-identity

• Re-establish a sense of their former selves.

- Maintain their identity as a reliable and useful employee.

- Opportunity for growth and self-development.

- A way of confronting and re-adjusting to their altered bodies.

- However some felt that others saw them differently, which fuelled their own negative self-perceptions.


2. Meaning and significance of work

• Work viewed as providing a structure to everyday life and being a source of social interaction.

• The disruption or loss of this structure could threaten survivor’s well-being causing: – financial burden

– dislocation from normal life

– loss of the self-esteem and social interactions gained through working life


2. Meaning and significance of work

• For many the “old normality” was rarely achieved.

• Negative work experiences appeared to be heavily influenced by colleagues or managers perceived attitudes and behaviours.

• The importance of work diminished in relation to family and personal pursuits.

• Survivors with fears of recurrence felt frustrated about spending their time working, rather than pursuing other goals.


3. Family and financial context

• Cost associated with cancer pushed some survivors into remaining in particular work roles.

• Some choose to go back to protect their position at work or provide for lifestyle aspirations.

• Attitudes towards benefits systems were mixed: – some reporting systems fair, accessible and easy to negotiate

– others reporting insensitive treatment, protracted claims and administrative errors


3. Family and financial context (2)

• Attitudes of family members could sometimes have a negative effect on self-confidence. Which could be seen as:

- overly supportive or protective - disapproving of return to work - suggesting that survivors should expect exactly the same conditions as before


4. Work environment - relationships and performance • Positive experiences of returning to working were

dependent on:

- good organisational & work related support - and/or interpersonal support

• Successfully returning to work depended on:

- the kind of job e.g. manual or professional - the physical and emotional demands of the role - the size of the organisation


4. Work environment - relationships and performance • Adjustments in the workplace such as:

- modifications to the workplace - working hours - duties - accommodation of hospital appointments - load alleviation - provision of assistance and changes in personnel


4. Work environment - relationships and performance • Healthcare professionals frequently failed to meet the

needs of survivors.

• Some felt they were “bothering” their doctor or simply did not know what to ask.

• Many organisations lacked HR personnel specific to dealing with survivors.

• Occupational health wellness programmes were seen as beneficial but were usually only available in larger organisations.


Responses and strategies

• Survivors appeared to use 4 strategies to help them integrate into work after cancer: 1. Communication and negotiation with employers 2. Acknowledging and accepting changed capabilities 3. Managing symptoms and rebuilding confidence 4. “Working Smarter”



1. Communication and negotiation with employers - Some survivors were reluctant to disclose their cancer diagnosis with employers. Whilst others believed in open communication.

2. Acknowledging and accepting changed capabilities - Successful self-management of symptoms and utilisation of supportive resources.

- Some felt frustrated which led to feeling overwhelmed as they struggled to manage symptom and work demands



• 3. Managing symptoms and rebuilding confidence

Important in rebuilding self-confidence and feelings of reliability at work. Strategies for managing fatigue and cognitive problems included: - checking work with colleagues - keeping more detailed records - reducing self-expectations.



4. “Working Smarter”

- pacing themselves/resting at work

- taking days off when necessary - managing time - giving themselves flexibility - concentrating on tasks that best utilised their strengths


Points to consider

- Returning to work is rarely seen as an end in itself.

- Need to acknowledge individuals sense of identity as well as the meaning and significance of work.

- Urgent need to develop new strategies or policies.

- Initiatives should focus on supporting “work-related goals” rather than assuming the desirability of return to work.


Future role

- Clinical team managing the patient can have a key influence on the likelihood of patients returning to work (Pryce et al. 2007).

- Need to implement support into clinical practice.

- Front line oncology staff need to be open to dialogue around returning to work.

- Nurses can play a key role in signposting to further advice and support.


Further work

• Further longitudinal research is also needed: - on the experiences of individuals over time - the perspectives of under-researched groups - those who are self-employed or do not return to work - people with advanced disease - family members - employers


Thank you [email protected]

Documents

Living well, with and beyond cancer: The evidence - Home : London Cancer … · 2014-11-24 · Living well, with and beyond cancer: ... cessation intervention in head and neck cancer