Healthy lifestyles enable survivors to enjoy living instead of fear dying

Survivors of cancer have been given a unique wake-up call to become mindful of their lifestyle habits and make necessary changes.

However, after having endured the physical and psychological effects of cancer and its various treatments, survivors often are fatigued, anxious and depressed and may lack the motivation to change.

Taking the first steps toward lifestyle management can empower cancer survivors to overcome this resistance, according to Dean Ornish, MD, clinical professor of medicine at University of California, San Francisco and founder of Ornish Lifestyle Medicine.

“When you change your lifestyle in all these different ways, you often feel so much better so quickly,” Ornish, who has developed a 9-week lifestyle intervention program that is covered by Medicare and many insurance companies, said in an interview with Healio. “It often reframes the reason for making those changes — from fear of dying to joy of living.”

Clinicians who counsel cancer survivors on their lifestyle habits should consider the hardships these survivors have overcome and address their concerns with compassion and patience. The most important aspect of this lifestyle conversation is that it actually occurs.

Lack of discussion

“Clinicians don’t know how to talk about it,” Kathryn H. Schmitz, PhD, MPH, professor of population sciences at Penn State University, said in an interview with Healio. “There are now over 600 randomized controlled trials documenting the benefit of exercise during and after cancer treatment. Yet the literature tells us that about 9% of nurses talk to their patients about exercise, and surveys tell us that about 20% of oncologists have this conversation. Clearly, we have some room to grow.”

Schmitz said one reason oncologists might be reluctant to discuss lifestyle changes with cancer survivors and patients is the belief that there is not a sufficient evidence base to support these modifications.

That is simply not the case, she said.

“It’s a very interesting situation. Where else in the world of medicine is there such a robust evidence base combined with such a lack of implementation?” Schmitz said. “The Z0011 trial [Giuliano et al.] changed surgical practice in terms of doing sentinel lymph node biopsies in breast cancer. That was one trial. We have more than 600.”

Ornish has conducted extensive trials demonstrating the benefits of lifestyle changes for patients and survivors of various chronic diseases.

“For the past 43 years, we have conducted randomized controlled clinical trials and demonstration projects showing that simple lifestyle changes can slow, stop or even reverse the progression of many common chronic diseases, including heart disease, type 2 diabetes, early-stage prostate cancer and probably, by extension, early-stage breast cancer,” Ornish said. “These changes have been shown in our studies to lengthen telomeres and change gene expression, particularly downregulating the RAS oncogenes that promote prostate cancer, breast cancer and colon cancer.”

Clinicians also should weigh evidence of the efficacy of lifestyle interventions against the preponderance of evidence supporting their safety, according to Lorenzo Cohen, PhD, Richard E. Haynes distinguished professor in clinical cancer prevention and director of the integrative medicine program at The University of Texas MD Anderson Cancer Center.

“A randomized controlled trial exists for determining efficacy, but is just as important in ensuring safety. We don’t want to expose patients to things that could cause them harm, which is the case for most cancer medicines, if it isn’t counterbalanced by efficacy,” Cohen said in an interview with Healio. “When it comes to diet and exercise and lifestyle, the evidence is just overwhelming from epidemiological studies, animal studies and mechanism studies. There is zero evidence that eating more of a plant-centered diet could ever cause anyone any harm, nor could exercise or healthy sleep. We’re not going to harm someone by getting them to meditate 30 minutes a day.”

Cohen speculated that, on some level, clinicians might not be comfortable recommending healthy lifestyle habits to patients that they themselves do not follow.

“Theoretically, (physicians) lead slightly healthier lives than the general U.S. population, but they’re not getting the right amount of sleep, they’re overstressed and they’re eating on the fly; they’re not leading what I would call a cancer prevention lifestyle,” he said. “It’s like back in the 1950s, when the doctor would tell the patient with lung cancer, ‘You’ve got to quit smoking,’ although they were smoking themselves. How can we tell patients to exercise, manage stress or eat more fruits and vegetables if we’re not doing that?”

Increased awareness

Schmitz has been at the forefront of developing evidence-based clinical guidelines for exercise for patients living with and beyond cancer. She said the benefits of exercise for cancer survivors are not yet common knowledge as they are for other conditions, such as heart disease. However, she added that the connection between exercise and heart health has not always been fully understood.

Schmitz recounted that in 1955, cardiologist Paul Dudley White, MD, at Bethesda Naval Hospital (now Walter Reed National Military Medical Center) faced scrutiny for encouraging President Dwight D. Eisenhower to get out of bed 3 weeks after Eisenhower experienced a heart attack. At that time, she said, the prevailing opinion was that heart attack survivors should rest and avoid overworking their hearts.

“Now, the average person on the street with an eighth-grade education knows that a person who has had a heart attack should be exercising to improve their heart health,” Schmitz said. “That awareness is there now, but it wasn’t always there.”

Similarly, Schmitz said she believes exercise will eventually become standard of care for cancer survivors. But first, clinicians must be educated on how to discuss exercise with their patients. Schmitz said she and her colleagues are conducting a pilot study of a U.K.-based educational program among a group of U.S.-based health care professionals.

“If these clinicians feel that this program is useful, if it helps them in having this conversation, we will work on making it a CME program in the U.S.,” she said.

Another essential piece of the puzzle will be training for exercise professionals to work with cancer survivors, according to Schmitz.

“We need to increase the proportion of the workforce in exercise who are prepared to receive these patients,” she said. “If the doctor says to the patient, ‘You need to be exercising. There’s a gym down the street; go talk to them,’ we don’t want the person at the gym to say, ‘Well, I’ve never worked with patients with cancer.’”

Schmitz said the American College of Sports Medicine is working with a U.K.-based company called CanRehab that has developed a program to train gym personnel to work with patients with cancer, and that this program will be brought to the U.S. soon.

“Hopefully, over time, we can increase the readiness of the exercise workforce to receive patients with cancer and be ready to help them,” she said.

Individual recommendations

Schmitz said when counseling patients on exercise, clinicians should consider these recommendations the same way they would consider prescribing a new medication.

“We don’t dose medication by saying, ‘go take some medicine,’ or, ‘go get some chemotherapy.’ It has to be dosed appropriately,” she said. “Exercise also needs to be dosed appropriately. I’m not going to recommend the same thing to a patient with stage III lung cancer who is actively undergoing chemotherapy that I would to a 10-year survivor of stage I breast cancer.”

Schmitz said, in general, she recommends patients who are still in active treatment do 30 minutes of aerobic exercise per week and twice-weekly strength exercises.

Schmitz has revised recommendations for those seeking to prevent cancer, such as survivors who aim to prevent secondary cancers.

“For these patients, we recommend 150 to 300 minutes a week of aerobic activity to go with the strength training,” she told Healio. “The amount of exercise that you need for the outcome of cancer prevention is greater than the amount you need for addressing symptoms.”

Healthy habits for children

Encouraging exercise among pediatric cancer survivors may be more complicated, but with the right guidance, these survivors can become motivated to practice healthy lifestyles. According to Kirsten K. Ness, PT, PhD, FAPTA, full member of the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, it is important to engage the family of a pediatric cancer survivor.

“The data indicate that young children who come from active families do well in terms of exercise,” Ness told Healio. “Kids who don’t come from active families are still fairly active when they are young, but then once they get to middle school age, they start to deteriorate, because at that point there are so many games and there is so much online time.”

Ness said cancer survivors with comorbidities should receive specialized guidance from providers who have experience in cancer care. Some comorbidities, such as peripheral neuropathy, might make it difficult to perform exercises that require patients to be stable on their feet.

“It’s not a good feeling to have signed up to play soccer and be tripping over your own feet,” Ness said. “These patients might need a little more help, someone to coach them through the experience. They should be referred to an exercise specialist, like a physical therapist, rehabilitation specialist or exercise physiologist. They need someone who can say, ‘I understand it doesn’t feel good, but we just have to teach your system to accommodate this. If you can stick with it for 11 days, it will become a habit.’”

Ness discussed a program in Denmark, called the Respect Program, which assigns peer “ambassadors” to children with cancer during treatment.

“The ambassador is a healthy classmate from their school,” she said. “When the child with cancer is admitted to the hospital, the healthy classmate is co-admitted. They do their schoolwork there with the child with cancer and they also do the same physiotherapy or exercise. It really normalizes the experience for these kids to have a healthy classmate going through the whole thing with them.”

Ness added that thanks in part to COVID-19, the benefits of telehealth can now also be applied to exercise. This technology not only enables remote tracking of a patient’s activity and fitness levels, but also facilitates an interactive experience between the patient and provider.

“COVID has taught us all how to see each other remotely. If you were a cancer survivor and could see me right now, I could set up a room so you could see me move, and I could exercise with you and be your exercise partner,” Ness said. “I can send a stethoscope and a heart rate monitor that will hook up to the computer. One thing we’re getting out of this is we’re teaching people how to use the technology that’s available.”

Dietary recommendations

In June, the American Cancer Society updated its guideline on diet and physical activity for cancer prevention. The guideline generally recommends eating a diet rich in fruits and vegetables, whole grains and lean proteins, and cutting back on or eliminating foods high in salt, sugar or fat.

Updates to the guideline include recommendations to avoid or restrict red meat, including beef, pork, or lamb, as well as processed meats such as bacon, sausage, deli meats and hot dogs. The update also advises consumption of a “colorful variety” of vegetables and fruits, and calls for limitations on sugar-sweetened beverages, highly processed foods and refined grains.

Although alcohol consumption is discouraged, the updated guideline stipulates that women should have no more than one drink per day and men should not exceed two drinks daily. One drink would consist of 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof spirits.

According to Cohen, alcohol has been a known carcinogen for years but has been given a “hall pass” due to its social popularity.

“Before the guidelines came out, I asked one of the authors about why we have such a strong message about tobacco but not alcohol,” Cohen said. “She said they’re in debates at the moment on how to modify it to be more in line with the data.”

Ornish, whose lifestyle program recommends a whole-foods, plant-based diet rich in fruits, vegetables, whole grains, legumes and unrefined soy products, said it is important not to impose strict dietary rules on survivors or patients with cancer.

“One thing I’ve learned is that more than wanting to eat healthy, people want to feel free and in control,” he told Healio. “Nobody wants to be told, ‘Eat this. Don’t eat that.’ When I lecture, I say that goes back to the first dietary intervention, when God said, ‘Don’t eat the apple.’ That didn’t go so well.”

Instead, Ornish said he asks individuals how much they are willing to change to meet a certain goal if they are just trying to prevent chronic diseases.

“If someone says they want to lower their LDL 50 points, I will ask them how much they’re willing to change,” he said. “If they say they will eat fewer unhealthy foods, we will support that and track it. If they are willing to walk 20 minutes a day, we will support that degree of change. However, reversing the progression of many chronic diseases requires much bigger lifestyle changes.”

The ways in which foods are prepared also can increase their potential dangers to cancer survivors, according to Emily S. Tonorezos, MD, an internist and survivorship specialist at Memorial-Sloan Kettering Cancer Center.

“There is a terrific study called the Long Island Breast Cancer study, in which researchers asked women at the time of diagnosis about the foods they were eating, then followed them for 20 years,” she said. “They found a negative impact among the women who were eating smoked, grilled or barbecued meat.”

Tonorezos said it is commonly believed that the black char associated with grilling contains heterocyclic amines and other carcinogens that may contribute to gastrointestinal and esophageal cancers.

“However, the Long Island Breast Cancer Study showed that there is a negative impact among patients with breast cancer, as well,” Tonorezos said. “It’s not just stomach cancer or colon cancer that’s impacted by these foods. It’s also breast cancer, and probably others.”

Understanding addiction

The association between tobacco use and increased risk for cancer has been well known to the public for decades. The fact that some cancer survivors continue to smoke despite this knowledge is a testament to the addictive nature of tobacco.

“Nothing more clearly illustrates how addictive this drug is than a person who has survived a cancer diagnosis but continues to use tobacco,” Michael B. Steinberg, MD, MPH, professor of medicine in the division of general internal medicine at Robert Wood Johnson Medical School, director of the Tobacco Dependence Program at Rutgers University, and a HemOnc Today Editorial Board Member, told Healio. “These are not people who are stupid or naive; they’re addicted. I think it’s important for us to understand the power of addiction.”

Steinberg said he works closely with oncology colleagues at his center in helping cancer survivors and patients with cancer overcome smoking dependence.

“When I am speaking with someone who has survived any form of cancer, and they are having a tough time quitting tobacco, I make it very clear to them that they are not a bad person or a weak person because they continue to smoke,” he said. “I make it clear that we work with people every day who are very dependent on tobacco, and we see these people quit smoking every day.”

Steinberg said there are now effective, evidence-based treatments clinicians can offer patients, including behavioral interventions and pharmacotherapy with one of seven FDA-approved medications. He said when discussing smoking cessation with a cancer survivor, providers traditionally have been advised to structure the conversation around “five ‘A’s”: ask, advise, assess, assist and arrange.

“The U.S. Public Health Service Clinical Practice Guidelines on treating tobacco dependence outline the steps that even a brief clinical encounter for tobacco treatment should include,” Steinberg said. “A primary care provider should always ask about tobacco use. Don’t assume that somebody who has survived lung cancer or other types of cancer has quit smoking. You want to ask and to advise them to quit, assess their readiness to quit, assist them with their quit attempt and arrange for follow-up.”

Steinberg added that the CDC recently recommended a scaled-back version of this approach.

“We’re still asking about tobacco use and advising the patient to quit, but then we’re referring them for treatment resources in the community,” he said. “Those resources could be a face-to-face specialty tobacco treatment program, like our Rutgers Tobacco Dependence Program; it could be your state’s quit hotline; or it could be a website like www.smokefree.gov, which is funded through the NIH.”

Sleep, stress, support

For cancer survivors, maintaining optimal health also involves getting sufficient sleep, controlling stress, and having a loving and supportive network of friends and family. According to Cohen, insufficient sleep has been shown to affect cancer hallmarks.

“Sleep restriction and sleep loss decreases cell-mediated immunity and increases inflammation, which are two things we don’t want when you have cancer on board,” he said.

Additionally, lack of sleep has been associated with a change in metabolism, such that the same meal consumed on a lack of sleep can cause higher spikes in glucose and insulin, Cohen said.

“There is a slower return to baseline, and a higher probability that the energy from the food is going to be stored as fat,” Cohen said. “So, there’s a direct association between sleep deprivation and excess weight.”

Cohen pointed to evidence showing that people who sleep 6.5 hours or less a night have increased all-cause mortality.

“You can line up almost any disease, and it will be linked with restricted sleep,” Cohen said. “There are individual differences; there may be a person who says, ‘Oh, but I function well.’ Yes, you might as an individual, but population-based studies make it clear that it’s linked to shortened life span.”

Stress is another factor that clinicians may not feel comfortable discussing with patients. Cohen and his colleagues at MD Anderson developed a program called Changing the Culture, through which he interviewed faculty members about discussing stress with patients.

“What we found is that they said, ‘How are we supposed to manage a patient’s stress when we are overworked and overstressed ourselves?’” Cohen said.

After Cohen and a colleague presented detailed data on the relationship between stress and cancer, they began to understand the value of working with patients and survivors to reduce stress.

“They were flabbergasted,” he said. “They had no idea that stress hormones can cause changes in the tumor microenvironment, making it essentially more hospitable to cancer growth. How that changed their behavior, I don’t know, but they became believers.”

Ornish said another important piece of the puzzle is having a close and reliable support system of family and friends. He said the support groups his programs offer provide more than just healthy diet and exercise advice — they seek to build community.

“It’s about creating a safe place where people can connect and talk in an authentic way, without fear, about what is really going on in their lives, and not be judged or criticized,” he said.

Social media, with its idealized versions of people’s lives, cannot replicate this kind of community or support, he said.

“When you grew up in a neighborhood 50 years ago, and your extended family lived nearby, people really got to know each other,” Ornish said. “They watched you grow up; they remember you getting into trouble. They know your kids and they’re there for you. There’s something primal about being seen in all of your humanity. That kind of authenticity is powerful in terms of healing.”

For more information:

Lorenzo Cohen, PhD, can be reached at: lcohen@mdanderson.org.

Kirsten K. Ness, PT, PhD, FAPTA, can be reached at: kiri.ness@stjude.org.

Dean Ornish, MD, can be reached at: dean.ornish@pmri.org and www.ornish.com.

Kathryn H. Schmitz, PhD, MPH, can be reached at: kschmitz@phs.psu.edu.

Michael B. Steinberg, MD, MPH, can be reached at: steinbmb@rwjms.rutgers.edu.

Emily S. Tonorezos, MD, can be reached at: tonoreze@mskcc.org.

References:

• Gammon MD, et al. Breast Cancer Res Treat. 2002;doi:10.1023/a:1016387020854.
• Giuliano AE, et al. JAMA. 2017;doi:10.1001/jama.2017.11470.
• Ligibel JA, et al. J Oncol Pract. 2019;doi:10.1200.JOP.19.00124.
• Rock CL, et al. CA Cancer J Clin. 2020;doi:10.3322/caac.21591.
• Schmitz KH, et al. CA Cancer J Clin. 2019;doi:10.3322/caac.21579.