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## Complete Summary

#### GUIDELINE TITLE

Nutrition and physical activity during and after cancer treatment: An
American Cancer Society guide for informed choices.

#### BIBLIOGRAPHIC SOURCE(S)

Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B,
McTiernan A, Rock CL, Thompson C, Gansler T, Andrews KS, The 2006
Nutrition, Physical Activity and Cancer Survivorship Advisory Committee,
American Cancer Society. Nutrition and physical activity during and
after cancer treatment: an American Cancer Society guide for informed
choices. CA Cancer J Clin 2006 Nov-Dec;56(6):323-53. \[244 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17135691)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Brown JK, Byers T, Doyle C,
et al. Nutrition and physical activity during and after cancer
treatment: an American Cancer Society guide for informed choices. CA
Cancer J Clin 2003;53:268--291.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cancer, including:

-   Breast cancer

-   Colorectal cancer

-   Hematological cancer

-   Lung cancer

-   Prostate cancer

-   Upper gastrointestinal cancer

-   Head and neck cancer

#### GUIDELINE CATEGORY

Counseling\
Management\
Prevention\
Rehabilitation\
Risk Assessment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery\
Family Practice\
Gastroenterology\
Geriatrics\
Hematology\
Internal Medicine\
Nursing\
Nutrition\
Obstetrics and Gynecology\
Oncology\
Physical Medicine and Rehabilitation\
Pulmonary Medicine\
Thoracic Surgery\
Urology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Health Plans\
Hospitals\
Managed Care Organizations\
Nurses\
Patients\
Physical Therapists\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To present health care providers with the best possible information from
which to help cancer survivors and their families make informed choices
related to nutrition and physical activity

#### TARGET POPULATION

Cancer survivors

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Nutrition and physical activity-related lifestyle modifications for
    cancer survivors:

    -   Maintenance of healthy body weight

    -   Nutrition and food choices

        -   Balancing fat, protein and carbohydrate intake

        -   Increasing consumption of vegetables and fruits

        -   Moderation of alcohol intake

        -   Food safety

        -   Dietary supplements

    -   Increasing physical activity

#### MAJOR OUTCOMES CONSIDERED

-   Treatment outcomes

-   Quality of life

-   Survival

-   Risk of and mortality from cardiovascular and other chronic diseases

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

To synthesize evidence-based research, the American Cancer Society
convened a group of experts in nutrition, physical activity, and cancer
to evaluate the scientific evidence and best clinical practices related
to nutrition and physical activity after the diagnosis of cancer.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The continuum of cancer survivorship includes treatment, recovery,
living after recovery, and, for some, living with advanced cancer.
Survivors in each of these phases have different needs and challenges
with respect to nutrition and physical activity. Both the
characteristics of the cancer and therapeutic methods influence these
needs.

**[Cancer and Cancer Treatment]{.underline}**

**Nutrition During Cancer Treatment**

Substantial weight loss and poor nutritional status have been documented
in more than 50% of patients at the time of diagnosis, although the
prevalence of malnutrition and weight loss varies widely across cancer
types. Maintaining energy balance or preventing weight loss is therefore
vital for survivors at risk for unintentional weight loss, such as those
who are already malnourished or those who receive directed treatment to
the gastrointestinal tract.

Nutritional screening and assessment for survivors should begin while
treatment is being planned and should focus on both the current
nutritional status and anticipated symptoms related to treatment that
could affect nutritional status.

Commonly experienced symptoms of cancer and side effects of treatment
that may impact nutritional status include changes in taste or smell,
loss of appetite, nausea, vomiting, changes in bowel habits, weight
change, loss of lean mass and sarcopenia, pain, and fatigue. If these
occur, usual food choices and eating patterns may need to be temporarily
adjusted to optimize intake and meet nutritional needs.

During active cancer treatment, the overall goals of nutritional care
for survivors should be to prevent or reverse nutrient deficiencies, to
preserve lean body mass, to minimize nutrition-related side effects
(such as decreased appetite, nausea, taste changes, or bowel changes),
and to maximize quality of life.

Suggestions for finding an oncology nutrition expert to provide dietary
counseling are provided in the Table below.

**Table. Suggestions for Helping Survivors Locate Specialized Dietary
Counseling**

+-----------------------------------------------------------------------+
| -   Survivors should ask their oncologist for a referral to see a     |
|     registered dietitian.                                             |
|                                                                       |
| -   If a dietitian does not work in the clinic or medical center      |
|     where they receive their cancer treatment and care, an            |
|     appointment with a dietitian associated with their primary care   |
|     clinic can be arranged.                                           |
|                                                                       |
| -   Survivors and providers can also consult the American Dietetic    |
|     Association\'s website                                            |
|     \[[www.eatright.org](http://www.eatright.org/)\], using the       |
|     \"Find a Nutrition Professional\" feature and putting \"Oncology  |
|     Nutrition\" in the expertise/specialty tab, or call the American  |
|     Dietetic Association at 1-800-366-1655 to identify a dietitian in |
|     their area.                                                       |
+-----------------------------------------------------------------------+

Providing short-term individualized nutritional support can improve
appetite and dietary intake and decrease the toxicities associated with
cancer treatments. Examples of individualized nutritional therapies
include the following:

-   For survivors experiencing a reduced appetite, consuming smaller,
    more frequent meals without liquids can help to increase food
    intake.

-   For survivors who cannot meet their nutritional needs through foods
    alone, fortified and commercially-prepared or homemade
    nutrient-dense beverages or foods may improve the intake of energy
    and nutrients.

-   For survivors who are unable to meet their nutritional needs through
    these measures, other means of short-term nutritional support may be
    needed, such as pharmacotherapy, enteral nutrition via tube feeding,
    or intravenous parenteral nutrition.

The use of dietary supplements such as vitamins, minerals, and herbal
preparations during cancer treatment remains controversial.

At the present time, most cancer experts advise against taking higher
doses of supplements with antioxidant activity during treatment because
antioxidants could prevent the cellular oxidative damage to cancer cells
that is required for treatments such as radiotherapy and chemotherapy to
be effective. In contrast, others have noted that the possible harm from
antioxidants is only hypothetical and that there may be a net benefit to
help protect normal cells from the collateral damage associated with
these therapies. Whether antioxidants or any other dietary supplements
specifically are beneficial or harmful is a critical question without a
clear scientific answer at this time.

Given this uncertainty, until more evidence is available that suggests
more benefit than harm, it is prudent for cancer survivors receiving
chemotherapy or radiation therapy to avoid exceeding more than 100% of
the daily value for antioxidant- type vitamins such as vitamins C and E
during the treatment phase.

**Exercise During Cancer Treatment**

Despite methodologic limitations and small sample sizes, existing
evidence strongly suggests that exercise is not only safe and feasible
during cancer treatment, but that it can also improve physical
functioning and some aspects of quality of life.

The decision regarding how to maintain or when to initiate physical
activity should be individualized to the survivor\'s condition and
personal preferences. In some circumstances, a training program to
improve cardiopulmonary fitness before cancer treatments might aid
recovery, although adequate research has not been done in this area.

Persons receiving chemotherapy and radiation therapy who are already on
an exercise program may need temporarily to exercise at a lower
intensity and progress at a slower pace, but the principal goal should
be to maintain activity as much as possible. For those who were
sedentary before diagnosis, low-intensity activities such as stretching
and brief, slow walks should be adopted and slowly advanced. For older
persons and those with bone disease or significant impairments such as
arthritis or peripheral neuropathy, careful attention should be given to
balance and safety to reduce the risk for falls and injuries. The
presence of a caregiver or exercise professional during exercise
sessions can be helpful. If the disease or treatment necessitates
periods of bed rest, then reduced fitness and strength, as well as loss
of lean body mass, can be expected. Physical therapy during bed rest is
therefore advisable to maintain strength and range of motion and to help
to counteract the fatigue and depression that are often experienced
under those circumstances. Some clinicians advise some survivors to wait
to determine their physical response to chemotherapy before beginning an
exercise program.

**Recovery**

After cancer therapy has been completed, the next phase of cancer
survival is recovery. In this phase, many survivors\' symptoms and side
effects of treatment that impact nutritional and physical well-being
begin to diminish and resolve.

Survivors require ongoing nutritional assessment and guidance in this
phase of survival. For those who emerge from treatment underweight or
who have compromised nutritional status, continued supportive care,
including dietary counseling and pharmacotherapy (e.g., drugs to relieve
symptoms and stimulate appetite), is helpful in the recovery process.
After treatment, a program of regular physical activity is essential to
aid in the process of recovery and improve fitness.

**Living After Recovery**

During this phase, setting and achieving lifelong goals for an
appropriate weight, a physically active lifestyle, and a healthy diet
are important to promote overall health, quality of life, and longevity.
The American Cancer Society (ACS) has established nutrition and physical
activity guidelines for the prevention of cancer (see Table below).

**Table. American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Prevention**

+-----------------------------------------------------------------------+
| Maintain a healthy weight throughout life.                            |
|                                                                       |
| -   Balance caloric intake with physical activity.                    |
|                                                                       |
| -   Avoid excessive weight gain throughout the lifecycle.             |
|                                                                       |
| -   Achieve and maintain a healthy weight if currently overweight or  |
|     obese.                                                            |
|                                                                       |
| Adopt a physically active lifestyle.                                  |
|                                                                       |
| -   Adults: engage in at least 30 minutes of moderate-to-vigorous     |
|     physical activity, above usual activities, on 5 or more days of   |
|     the week. Forty-five to 60 minutes of intentional physical        |
|     activity are preferable.                                          |
|                                                                       |
| -   Children and adolescents: engage in at least 60 minutes per day   |
|     of moderate-to-vigorous physical activity at least 5 days per     |
|     week.                                                             |
|                                                                       |
| Consume a healthy diet, with an emphasis on plant sources.            |
|                                                                       |
| -   Choose foods and beverages in amounts that help achieve and       |
|     maintain a healthy weight.                                        |
|                                                                       |
| -   Eat five or more servings of a variety of vegetables and fruits   |
|     each day.                                                         |
|                                                                       |
| -   Choose whole grains in preference to processed \[refined\]        |
|     grains.                                                           |
|                                                                       |
| -   Limit consumption of processed and red meats.                     |
|                                                                       |
| If you drink alcoholic beverages, limit consumption.                  |
|                                                                       |
| -   Drink no more than one drink per day for women or two per day for |
|     men.                                                              |
+-----------------------------------------------------------------------+

Although it may seem reasonable to assume that following these
guidelines would also favorably affect cancer recurrence or survival
rates, few data are available to directly support this assumption. In
some instances, there is evidence for such a link, as with obesity and
breast cancer recurrence, but in many instances the evidence linking
food choices and physical activity to cancer recurrence and survival is
limited or unclear. Although the scientific evidence for advice on
nutrition and physical activity after cancer is much less certain than
for cancer prevention, it is likely that following the ACS Guidelines on
diet, nutrition, and cancer prevention may be helpful for reducing the
risk of developing second cancers. It is also important to realize that,
because persons who have been diagnosed with cancer may be at increased
risk for other cancers and for cardiovascular disease, diabetes, and
osteoporosis, the guidelines established to prevent those diseases are
especially important for cancer survivors.

Convincing data exist that obesity is associated with breast cancer
recurrence, and evidence on obesity and prognosis is also accumulating
for other cancers. Therefore, achieving and maintaining a healthy
weight, as well as consuming a nutrient-rich diet and maintaining a
physically active lifestyle, are important to improve overall health and
well-being and survival.

An increasing number of studies have examined exercise during recovery
and long-term survival after cancer treatment. Exercise has been shown
to improve cardiovascular fitness, muscle strength, body composition,
fatigue, anxiety, depression, self-esteem, happiness, and several
components of quality of life (physical, functional, and emotional) in
cancer survivors. Although preliminary, these data suggest that physical
activity may be important for reducing the risk of recurrence and
extending survival for some cancer survivors.

**Living with Advanced Cancer**

Although some persons are cured or experience cancer as a controllable
chronic disease, others live with advanced cancer. For these persons, a
healthy diet and physical activity are important factors in establishing
and maintaining a sense of well-being and enhancing quality of life.
Although advanced cancer may be accompanied by substantial weight loss,
it is not inevitable that persons with cancer lose weight or experience
malnutrition. Many persons with advanced cancer may need to adapt food
choices and eating patterns to meet nutritional needs and to manage
symptoms and adverse effects such as pain, constipation, and loss of
appetite. For persons with poor appetite, weight loss, or both,
convincing evidence exists that some medications (e.g., megestrol
acetate) enhance appetite.

Furthermore, using nonsteroidal anti-inflammatory drugs or omega-3 fatty
acid oral supplements may stabilize or improve nutritional status, body
weight, and functional status.

Additional nutritional support such as nutrient-dense beverages can be
provided for those who cannot eat enough solid food to maintain energy
intake. The use of tube feedings and total parenteral nutrition should
be individualized with clear recognition of the associated risks for
complications.

The evidence of benefit from exercise for advanced cancer survivors is
insufficient to make specific recommendations. Recommendations for
nutrition and physical activity for persons who are living with advanced
cancer are best made based on individual needs and abilities.

**[Selected Issues in Nutritional and Physical Activity for Cancer
Survivors]{.underline}**

**Body Weight**

Throughout the cancer continuum, individuals should strive to achieve
and maintain a healthy weight. Some cancer survivors can be malnourished
and underweight at diagnosis or as a result of aggressive cancer
treatments. For these persons, further loss of weight can impair their
quality of life, interfere with completion of treatment, delay healing,
and increase risk of complications. In survivors with these
difficulties, dietary intake and factors affecting energy expenditure
should be carefully assessed. For those at risk for unintentional weight
loss, multifaceted interventions should focus on increasing food intake
to achieve a positive energy balance and therefore increase weight.
Physical activity may be useful to the underweight survivor when
tailored to provide stress reduction and to increase strength, but high
levels of physical activity make weight gain more difficult.

For cancer survivors who are overweight or obese, modest weight loss
(i.e., a maximum of 2 pounds per week) can be encouraged during
treatment, as long as the treating oncologists approve, weight loss is
monitored closely, and weight loss does not interfere with treatment.
Safe weight loss should be achieved through a well-balanced diet that is
reduced in energy density and increased physical activity tailored to
the specific needs of the person being treated. After cancer treatment,
weight gain or loss should be managed with a combination of dietary and
physical activity strategies. For some who need to gain weight, this
means increasing energy intake (food intake) to exceed energy expended,
and for others who need to lose weight, this means increasing energy
expenditure (via increased physical activity) to exceed energy intake.
Emerging evidence suggests that reducing the energy density of the diet
by emphasizing low-energy density foods (e.g., water- and fiber-rich
vegetables, fruits, and soups; cooked whole grains) and limiting intake
of fat and sugars promotes healthy weight control. The mechanism by
which this strategy may be useful is that food volume is not reduced,
which may help to avoid hunger and feelings of deprivation. Limiting
portion sizes of energy dense foods is an important accompanying
strategy. Increased physical activity is also an important element to
prevent weight gain, promote weight loss, and most important, to promote
maintenance of weight loss in patients who are overweight or obese. For
those who need to lose weight, even if ideal weight reduction is not
achieved, it is likely that any weight loss achieved by physical
activity and healthful eating is beneficial, with weight losses of 5% to
10% still likely to have significant health benefits.

**Nutrition and Food Choices**

During all phases of cancer survival, even for those with no apparent
nutritional problems, the principles outlined in the National Guideline
Clearinghouse (NGC) summary of the [American Cancer Society Guidelines
on Nutrition and Physical Activity for Cancer
Prevention](http://www.guideline.gov/summary/summary.aspx?doc_id=11880&nbr=006082)
should be regarded as the basis for a healthful diet. These guidelines
are similar to those recommended by several other organizations,
agencies, and expert panels as a reasonable basis for the dietary
prevention of other chronic diseases and cancer.

*Balancing Fat, Protein, and Carbohydrate Intake*

Protein, carbohydrate, and fat all contribute energy (calories) to the
diet, and each of these dietary constituents is available from a wide
variety of foods. Informed choices about foods that provide these
macronutrients should be based in goals of achieving variety and
nutrient adequacy. Many cancer survivors are at high risk for other
chronic diseases. Therefore, the recommended amounts and type of fat,
protein, and carbohydrate to reduce cardiovascular disease risk are also
appropriate for cancer survivors.

Currently, the recommended level of fat in the diet is 20% to 35% of
energy, with saturated fat intake limited to \<10% and trans fatty acids
limited to \<3% of total energy intake. Some studies have suggested that
omega-3 fatty acids may have specific benefits for cancer survivors,
such as ameliorating cachexia, improving quality of life, and perhaps
enhancing the effects of some forms of treatment. These findings are not
certain, however, and more research is needed. However, including foods
that are rich in omega-3 fatty acids (e.g., fish, walnuts) in the diet
should still be encouraged because it is associated with a lower risk
for cardiovascular diseases and a lower overall mortality rate, and
evidence is largely lacking for a detrimental effect.

Adequate protein intake is essential during all stages of cancer
treatment, recovery, and long-term survival. The best choices to meet
protein needs are foods that are also low in saturated fat (e.g., fish,
lean meat and poultry, eggs, nonfat and low-fat dairy products, nuts,
seeds, and legumes). An intake of 10% to 35% of energy from protein, or
at least 0.8 g/kg body weight, is recommended for the general population
and will generally meet the protein needs of adult cancer survivors.

Healthful carbohydrate sources are foods that are rich in essential
nutrients, phytochemicals, and fiber, such as vegetables, fruit, whole
grains, and legumes. These foods should provide the majority of
carbohydrate in the diet. The recommended level of carbohydrate in the
diet is 45% to 65% of energy intake for the general population.

Choosing whole grains and whole grain food products as a source of
fiber, rather than relying on fiber supplements, adds nutritional value
to the diet.

Limiting sugar consumption is recommended.

A vegan diet, which excludes all animal foods and animal products, can
meet protein needs if nuts, seeds, legumes, and cereal-grain products
are consumed in sufficient quantities, although supplemental vitamin B12
will be necessary to meet needs for that vitamin. As dietary vitamin D
in the United States comes primarily from fortified dairy foods, a vegan
diet may also need to include supplemental vitamin D if adequate
exposure to the sun or ultraviolet light is not obtained.

A vegetarian diet is consistent with the ACS Nutrition Guidelines for
the Prevention of Cancer. However, no direct evidence has determined
whether consuming a vegetarian diet has any additional benefit for the
prevention of cancer recurrence over an omnivorous diet high in
vegetables, fruits, and whole grains, and low in red meats.

*Vegetables and Fruits*

Higher intakes of vegetables and fruits have been specifically
associated with a lower incidence of cancer at several sites, including
the colorectum, stomach, lung, oral cavity, and esophagus.

The benefits of eating a variety of vegetables and fruits probably
exceed the health-promoting effects of any individual constituents in
these foods because the various vitamins, minerals, and other
phytochemicals in these whole foods act in synergy. It is reasonable to
recommend that cancer survivors adopt the general recommendations issued
by the ACS for cancer prevention to eat at least five servings of a
variety of vegetables and fruit each day.

*Alcohol*

Alcoholic drinks up to one or two drinks per day (for women and men,
respectively) can lower risk for heart disease, but higher levels do not
offer additional benefit and may increase risk not only for
complications of alcohol overuse, but also for cancer. For this reason,
it is important for the health care provider to tailor advice on alcohol
consumption to the individual cancer survivor. The cancer type and stage
of disease, treatment, risk factors for recurrence or new primary
cancers, and comorbid conditions should be considered in making
recommendations. For example, alcohol, even in the small amounts found
in mouthwashes, can be irritating to survivors with oral mucositis and
can exacerbate that condition. Therefore, it is reasonable to recommend
that alcohol intake should be avoided or limited among survivors with
mucositis and among those beginning head and neck radiotherapy or
chemotherapeutic regimens that put them at risk for mucositis.

Many studies have found a link between alcohol intake and risk for some
primary cancers, including cancers of the mouth, pharynx, larynx,
esophagus, liver, breast, and probably colon cancer. In persons who have
already received a diagnosis of cancer, alcohol intake could also affect
the risk for new primary cancers of these sites. Therefore, the degree
of risk present should be considered in recommendations regarding
individual alcohol consumption.

*Food Safety*

During any immunosuppressive cancer treatment, survivors should take
extra precautions to prevent infection, and they should be particularly
careful to avoid eating foods that may contain unsafe levels of
pathogenic microorganisms. Because chemotherapy can impair the immune
response, raw vegetables and fruits may increase the risk for infection
in some patients during immune-suppression treatment (i.e., some
chemotherapies and radiotherapies) as a result of bacteria on these
foods. By following safe food practices, cancer survivors and their
caregivers can reduce the risk of food-borne illness. Refer to the
general guidelines for food safety as shown in the Table below.

**Table. General Guidelines for Food Safety**

+-----------------------------------------------------------------------+
| -   Wash hands thoroughly before eating.                              |
|                                                                       |
| -   Keep all aspects of food preparation clean, including washing     |
|     hands before food preparation and washing fruits and vegetables   |
|     thoroughly.                                                       |
|                                                                       |
| -   Use special care in handling raw meats, fish, poultry, and eggs.  |
|                                                                       |
| -   Thoroughly clean all utensils, countertops, cutting boards, and   |
|     sponges that have contacted raw meat; keep raw meats and          |
|     ready-to-eat foods separate.                                      |
|                                                                       |
| -   Cook to proper temperatures; meat, poultry, and seafood should be |
|     thoroughly cooked, and beverages (milk and juices) should be      |
|     pasteurized.                                                      |
|                                                                       |
| -   Store foods promptly at low temperatures to minimize bacterial    |
|     growth (below 40 degrees F).                                      |
|                                                                       |
| -   When eating in restaurants, avoid foods that may have potential   |
|     bacterial contamination such as salad bars, sushi, raw or         |
|     undercooked meat, fish, shellfish, poultry, and eggs.             |
|                                                                       |
| -   If there is any question or concern about water purity (e.g.,     |
|     well water), it can be checked for bacterial content by           |
|     contacting local public health departments.                       |
+-----------------------------------------------------------------------+

*Dietary Supplements*

During and after cancer treatment, there is a probable benefit of taking
a standard multiple vitamin and mineral supplement that contains
approximately 100% of the Daily Value because during these times, it may
be difficult to eat a diet with adequate amounts of these
micronutrients. In contrast, the use of very large doses of vitamins,
minerals, and other dietary supplements is not recommended. There is
reason for caution in taking high-dose supplements.

There are, however, some indications for lower-dose nutrient
supplementation by cancer patients and survivors. These include the
following:

-   Biochemically demonstrated nutrient deficiency (e.g., low plasma
    vitamin D levels, B12 deficiency) where dietary approaches have been
    inadequate.

-   Nutrient intakes persistently below recommended intake levels.

-   To meet public health recommended levels of intake (i.e., calcium or
    vitamin D supplementation for bone health, folate among women of
    child-bearing age planning pregnancy) *if* not contraindicated due
    to cancer therapy.

-   Known health sequelae related to cancer therapy (i.e., bone loss
    requiring calcium and/or vitamin D supplementation).

Open dialogue between patients and health care providers should occur
regarding dietary supplementation to assure there is no contraindication
in relation to the prescribed cancer therapy or for longer-term health
effects. In turn, health care providers should make an effort not only
to provide time to review dietary supplement decisions with patients,
but also to stay abreast of recent research in this area, particularly
related to potential drug interactions. It is most prudent to encourage
cancer survivors to obtain the potentially beneficial compounds from
food. A daily multivitamin supplement in amounts equivalent to 100% of
the Daily Value is a good choice for anyone who, for whatever reasons,
cannot eat a healthful diet, but the need for vitamin and mineral
supplements in higher doses should be assessed and discussed on an
individual basis.

**Physical Activity Issues for Cancer Survivors**

Studies have shown that exercise programs can reduce anxiety and
depression, improve mood, boost self-esteem, and reduce symptoms of
fatigue. In general, physical activity is likely to be beneficial for
most cancer survivors who have completed their primary treatments.

Although some cancer survivors can adopt an exercise program
independently, many will benefit from referral to an exercise
specialist. Survivors should seek individuals who have been certified by
an exercise-related professional organization, such as the American
College of Sports Medicine. A physical therapist is the appropriate
resource for survivors with injuries, pain, or specific postsurgical
issues such as lymphedema or amputation. Exercise physiologists receive
college training and are certified by various professional organizations
to develop individualized exercise programs. Personal trainers are also
popular choices for persons who want to increase their fitness and
activity levels. Recommendations on the type, frequency, duration, and
intensity of exercise should be individualized to the survivor\'s age,
previous fitness activities, type of cancer, stage of treatment, type of
therapy, and comorbid conditions. The Table below contains some
suggested ways to increase physical activity.

**Suggested Ways to Increase Physical Activity**

+-----------------------------------------------------------------------+
| -   Use stairs rather than an elevator.                               |
|                                                                       |
| -   If you can, walk or bike to your destination.                     |
|                                                                       |
| -   Exercise with your family, friends, and coworkers.                |
|                                                                       |
| -   Take an exercise break to stretch or take a short walk.           |
|                                                                       |
| -   Walk to visit nearby friends or coworkers instead of sending an   |
|     e-mail.                                                           |
|                                                                       |
| -   Plan active vacations rather than only driving trips.             |
|                                                                       |
| -   Wear a pedometer every day and increase your daily steps.         |
|                                                                       |
| -   Use a stationary bicycle or treadmill while watching TV.          |
+-----------------------------------------------------------------------+

Particular issues for cancer survivors may affect their ability to
exercise. Effects of treatment may also promote the risk for
exercise-related injuries and adverse effects. Specific precautions
should be heeded:

-   Survivors with severe anemia should delay exercise, other than
    activities of daily living, until the anemia is improved.

-   Survivors with compromised immune function should avoid public gyms
    and other public places until their white blood cell counts return
    to safe levels. Survivors who have completed a bone marrow
    transplant are usually advised to avoid such exposures for 1 year
    after transplantation.

-   Survivors suffering from severe fatigue from their therapy may not
    feel up to an exercise program, so they may be encouraged to do 10
    minutes of stretching exercises daily.

-   Survivors undergoing radiation should avoid chlorine exposure to
    irradiated skin (e.g., from swimming pools).

-   Survivors with indwelling catheters should avoid water or other
    microbial exposures that may result in infections, as well as
    resistance training of muscles in the area of the catheter to avoid
    dislodgment.

-   Survivors with significant peripheral neuropathies or ataxia may
    have a reduced ability to use the affected limbs because of weakness
    or loss of balance. They may do better with a stationary reclining
    bicycle, for example, than walking on a treadmill.

For the general population, the ACS recommends at least 30 to 60 minutes
of moderate to vigorous physical activity at least 5 days per week to
reduce the risk for cancer, cardiovascular disease, and diabetes. These
levels of activity have not been studied systematically in cancer
survivors, but aside from specific circumstances related to treatment or
other cancer-specific conditions such as outlined above, there is no
reason to think that these recommendations would not also be beneficial
for cancer survivors. Therefore, although daily and regular activity may
be preferred and may be a goal, any steps that are taken to move from a
sedentary to an active lifestyle should be encouraged. If an individual
has been completely sedentary, encouragement to take short walks may be
appropriate. If someone already exercises three times a week,
encouragement to increase this to five times a week may be appropriate.
For survivors wanting maximum benefit, the message should be that the
health benefits of exercise are generally linear, with increasing health
benefit with a higher volume of physical activity. Caution should be
noted that extremely high levels of exercise might increase the risk for
infections, and the risk of exercise-related injuries should also be
minimized.

**[Nutrition and Physical Activity by Selected Cancer
Sites]{.underline}**

**Breast Cancer**

Nutrition and physical activity recommendations to reduce the risks for
primary breast cancer and heart disease are especially important for
breast cancer survivors. Diets should emphasize vegetables and fruits,
low amounts of saturated fats, and sufficient dietary fiber. If soy
foods are consumed, intakes should be kept in moderation, and
concentrated sources of isoflavones should be avoided. Most importantly,
breast cancer survivors should strive to achieve and maintain a healthy
weight through appropriate diet and regular physical activity. In
addition, regular physical activity should be maintained regardless of
any weight concerns.

**Colorectal Cancer**

Colorectal cancer survivors should be advised to maintain a healthy
weight, eat a well-balanced diet consistent with guidelines for cancer
and heart disease prevention, and participate in regular physical
activity. Colorectal cancer survivors with chronic bowel problems or
surgery that affects normal nutrient absorption should be referred to a
registered dietitian to modify their diets to accommodate these changes
and maintain optimal health.

**Hematologic Cancers and Cancers Treated with Bone Marrow
Transplantation or Hematopoietic Stem Cell Transplantation**

As an infection prevention strategy, low-microbial diets are often
prescribed for transplant recipients. A low-microbial or low-bacteria
diet is primarily a cooked-food diet because the major limitation
imposed is on fresh or uncooked food items. Because many food
restrictions are imposed with this strategy, the nutrient adequacy of
actual food intake of patients who are prescribed the low-microbial diet
should be monitored. Prevention of malnutrition and correction of energy
and nutrient inadequacies has been incorporated into the standardized
posttransplant treatment at most transplant centers. In a recent review
of the evidence relating to the relative effectiveness of enteral
nutrition versus parenteral nutrition support, the issue could not be
evaluated due to lack of evaluable data. Recent trends include
prescribing less parenteral nutrition support and more enteral nutrition
support, which could reduce risk of medical complications and control
costs.

**Lung Cancer**

During treatment and the immediate recovery period, lung cancer
survivors may benefit from eating foods that are energy-dense and are
easy to swallow. Small, frequent meals may be easier to manage than
three large meals per day. Medications, omega-3 fatty acid supplements,
and nutritional support via energy-dense dietary supplements or enteral
nutrition may be helpful for those experiencing weight loss. If nutrient
deficiencies are present or survivors cannot eat enough to adequately
meet micronutrient needs, a multivitamin--mineral supplement is
advisable, either in pill or liquid form. The potential role of physical
activity in improving outcomes in lung cancer survivors has not been
characterized.

Recommendations for nutrition and physical activity for persons who are
living with lung cancer are best made based on individual needs.
Striving toward a healthy weight by adjusting food intake and physical
activity is a reasonable goal, as is ensuring that nutritional needs are
met with a well-balanced diet and a multivitamin--mineral supplement, if
needed to achieve adequate levels of intake.

**Prostate Cancer**

Men in whom prostate cancer has been diagnosed should consume diets that
are rich in vegetables and fruit and low in saturated fat and pursue a
physically active lifestyle. Based on studies of prostate cancer
incidence, it may also be prudent to consume diets that are moderate in
calcium and low in dairy intake, although such dietary suggestions need
to be considered in the context of increased risk of fractures from
antiandrogen therapy and physical activity patterns. Although the
evidence relating these recommendations to prostate cancer recurrence is
limited, there are likely substantial other benefits, most prominently
decreasing cardiovascular disease risk, which is the major cause of
death in prostate cancer survivors.

**Upper Gastrointestinal and Head and Neck Cancers**

In the absence of more definitive information, survivors of head and
neck and upper gastrointestinal cancers should strive to follow the ACS
Nutrition and Physical Activity Guidelines for the Prevention of Cancer.
High intakes of vegetables and fiber have been shown to be beneficial.
Because food intake can be compromised due to the effects of disease or
therapy, consultation with a registered dietitian for individualized
recommendations is recommended.

**Common Questions About Diet, Physical Activity, and Cancer
Survivorship**

Cancer survivors often request information and advice from their
healthcare providers about food choices, physical activity, and dietary
supplement use to improve their quality of life and survival. Health
professionals who counsel patients should emphasize that no one study
provides the last word on any subject, and that individual news reports
may overemphasize what seem to be contradictory or conflicting results
because they seem to be new, different, or challenge conventional
wisdom.

The best advice about diet and physical activity is that it is rarely
advisable to change diet or activity levels based on a single study or
news report. See the original guideline document for questions and
answers that address common concerns of cancer survivors regarding diet
and physical activity. The following questions are addressed:

-   Does alcohol increase the risk of cancer recurrence?

-   Should alcohol be avoided during cancer treatment?

-   What do antioxidants have to do with cancer?

-   Is it safe to take antioxidant supplements during cancer treatment?

-   Will eating less total fat lower risk of cancer recurrence or
    improve survival?

-   Do different types of fat influence cancer incidence and survival?

-   Can dietary fiber prevent cancer or improve cancer survival?

-   Are there special food safety precautions for individuals undergoing
    cancer treatment?

-   Should I avoid meats?

-   Does being overweight increase risk of cancer recurrence and second
    primary cancers?

-   Are foods labeled organic recommended for cancer survivors?

-   Should I exercise during cancer treatment and recovery?

-   Are there special precautions survivors should consider?

-   Can regular exercise reduce the risk of cancer recurrence?

-   What are phytochemicals, and do they reduce cancer risk?

-   Is including soy-based foods in the diet recommended for cancer
    survivors?

-   Does sugar \"feed\" cancer?

-   Would survivors benefit from using vitamin and mineral supplements?

-   Can nutritional supplements lower cancer incidence or risk of
    recurrence?

-   Will eating vegetables and fruits lower risk of cancer recurrence?

-   Is there a difference in the nutritional value of fresh, frozen, and
    canned vegetables and fruits?

-   Does cooking affect the nutritional value of vegetables?

-   Should I be juicing my vegetables and fruits?

-   Do vegetarian diets reduce risk of cancer recurrence?

-   How much water and other fluids should I drink?

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is not specifically stated for each recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate nutrition and physical activity during and after cancer
    treatment

-   For long-term cancer survivors, an appropriate weight, a healthful
    diet, and a physically active lifestyle may improve response to
    treatment, quality of life, and survival; and prevent recurrence,
    second primary cancers, and other chronic diseases.

#### POTENTIAL HARMS

-   Particular issues for cancer survivors may affect their ability to
    exercise. Effects of treatment may also promote the risk for
    exercise-related injuries and adverse effects.

-   Caution should be noted that extremely high levels of exercise might
    increase the risk for infections, and the risk of exercise-related
    injuries should also be minimized.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The underlying premise in creating this report is that, even when
    the scientific evidence is incomplete, reasonable conclusions can be
    made on several issues that can guide choices about body weight,
    foods, physical activity, and nutritional supplement use.

-   It is important for both health care providers and cancer survivors
    to consider the nutritional and physical activity issues discussed
    in this report within the context of the individual survivor\'s
    overall medical and health situation. This report is not intended to
    imply that nutrition and physical activity are more important than
    other clinical or self-care approaches. For example, although we
    present nutritional suggestions for persons with nausea or fatigue,
    we recognize that other medical interventions may be more important
    in controlling these symptoms. In writing these suggestions, we have
    assumed that survivors are receiving appropriate medical and
    supportive care and are seeking information on self-care strategies
    to provide further relief of symptoms and to enhance health and
    improve the quality of their lives.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B,
McTiernan A, Rock CL, Thompson C, Gansler T, Andrews KS, The 2006
Nutrition, Physical Activity and Cancer Survivorship Advisory Committee,
American Cancer Society. Nutrition and physical activity during and
after cancer treatment: an American Cancer Society guide for informed
choices. CA Cancer J Clin 2006 Nov-Dec;56(6):323-53. \[244 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17135691)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2006 Nov)

#### GUIDELINE DEVELOPER(S)

American Cancer Society - Disease Specific Society

#### SOURCE(S) OF FUNDING

American Cancer Society

#### GUIDELINE COMMITTEE

2006 Nutrition, Physical Activity, and Cancer Survivorship Advisory
Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Volunteer Members*: Noreen M. Aziz, MD, PhD, MPH, Senior Program
Director, Office of Cancer Survivorship, Division of Cancer Control &
Population Sciences, National Cancer Institute, NIH/DHHS, Bethesda, MD;
Abby F. Bloch, PhD, RD, FADA, Nutrition Consultant, New York, NY; Jean
K. Brown, PhD, RN, FAAN, Acting Dean and Professor in Nursing,
Nutrition, and Rehabilitation Science, University at Buffalo School of
Nursing, Buffalo, NY; Tim Byers, MD, MPH, Professor, Department of
Preventive Medicine and Biometrics; and Deputy Director, University of
Colorado Cancer Center, Aurora, CO; Bette Caan, DrPH, Senior Research
Scientist, Division of Research, Kaiser Permanente, Oakland, CA; June M.
Chan, ScD, Assistant Professor and Program Director, Genitourinary
Cancer Epidemiology and Population Science, University of California,
San Francisco, CA; Kerry S. Courneya, PhD, Professor and Canada Research
Chair in Physical Activity and Cancer, Faculty of Physical Education,
University of Alberta, Edmonton, Alberta; Wendy Demark-Wahnefried, PhD,
RD, LDN, Professor, School of Nursing and Department of Surgery, Duke
University Medical Center, Durham, NC; Brandy M. Gazo, MA, MSSW,
Research Program Coordinator, Lance Armstrong Foundation, Austin, TX;
Barbara Grant, MS, RD, Oncology Nutritionist, Saint Alphonsus Regional
Medical Center, Cancer Care Center, Boise, ID; Kathryn K. Hamilton, MA,
RD, CDN, Outpatient Oncology Dietitian, Carol G. Simon Cancer Center,
Morristown Memorial Hospital, Morristown, NJ; Carolyn Katzin, MSPH, CNS,
Certified Nutrition Specialist, Los Angeles, CA; Lawrence H. Kushi, ScD,
Associate Director for Etiology & Prevention Research, Division of
Research, Kaiser Permanente, Oakland, CA; Anne McTiernan, MD, PhD, Full
Member, Fred Hutchinson Cancer Research Center, Cancer Prevention
Research Program, Seattle, WA; Marion Morra, MA, ScD, President, Morra
Communications, Milford, CT; Margaret S. Pierce, MSN, MPH, AOCN, APRN,
BC, Assistant Professor, University of Tennessee, College of Nursing,
Knoxville, TN; Cheryl L. Rock, PhD, RD, Professor, Department of Family
and Preventive Medicine, School of Medicine, University of California,
San Diego, La Jolla, CA; Julia H. Rowland, PhD, Director, Office of
Cancer Survivorship, Division of Cancer Control and Population Sciences,
National Cancer Institute, NIH/DHHS, Bethesda, MD; Cyndi Thompson, PhD,
Assistant Professor, University of Arizona Department of Nutritional
Sciences, Tucson, AZ

*American Cancer Society Staff Members*: Terri Ades, RN, MS, AOCN,
Director of Cancer Information; Kimberly S. Andrews; Research Associate,
Cancer Control Science; Colleen Doyle, MS, RD, Director, Nutrition and
Physical Activity; Ted Gansler, MD, MBA, Director of Medical Content;
Greta Greer; Manager, Cancer Survivors Network; Sheri Knecht, RD, CNSD,
LDN, Dietitian on Call, South-Atlantic Division; Kristina Ratley, RD,
LDN, Dietitian on Call, South-Atlantic Division

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Brown JK, Byers T, Doyle C,
et al. Nutrition and physical activity during and after cancer
treatment: an American Cancer Society guide for informed choices. CA
Cancer J Clin 2003;53:268--291.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Cancer Society Web
site](http://caonline.amcancersoc.org/cgi/content/full/56/6/323).

Print copies: Available from the American Cancer Society, 250 Williams
St., Suite 600, Atlanta, GA 30303; Web site:
[www.cancer.org](http://www.cancer.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Kushi LH, Byers, T, Doyle C. Bandera EV, McCullough M, McTiernan A,
    Gansler T, Andrews KS, Thun MJ, American Cancer Society 2006
    nutrition and physical activity guidelines for cancer prevention:
    reducing the risk of cancer with healthy food choices and physical
    activity. CA Cancer J Clin 2006 Sep-Oct;56(5):254-81. Available from
    the [American Cancer Society Web
    site](http://caonline.amcancersoc.org/cgi/content/full/56/5/254).

#### PATIENT RESOURCES

The following is available:

-   Nutrition for the person with cancer during treatment: a guide for
    patients and families. Available from the [American Cancer Society
    (ACS) Web site](http://www.cancer.org/docroot/MBC/MBC_6.asp).

Also available by calling 1-800-ACS-2345.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI Institute on February 1, 2008.
The information was verified by the guideline developer on February 29,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

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<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008