Nutritional and Exercise Influences On Lung Cancer

Miles Hassell MD

Department of Integrative Medicine

Providence Cancer Center

Providence Cancer CenterIntegrative Medicine Team

Miles Hassell,MD

Ken Weizer, ND

Loch Chandler, ND, MSOM, L.Ac.

Cindy Reuter, ND, MSOM, L.Ac., RD

Mary Malinski, RN, LMT

Steph Russell, LMT Tony Borcich, LMT

Laurie Biegler Katie Malone

Westside:Zidell Center for Integrative Medicine

at St. Vincent Medical Center

9135 SW Barnes Rd, Suite 161

503-216-0246

Eastside:Stuvland Center for Integrative Medicine

at Providence Portland Medical Center

503-215-3219

Integrative Medicine Clinics

Activities at Providence Department of Integrative Medicine

• Available Services:– Naturopathy– Acupuncture– Massage therapy– Nutrition consultation

• Free group classes: Cancer, Nutrition and Exercise• Wellness after Breast Cancer• Reducing Cancer Treatment Side Effects• Research: Inpatient massage, reducing radiation

injury

Overview

• Nutrition and lung cancer• Exercise and lung cancer• Nutritional supplements and lung cancer• Acupuncture• Massage

Diet and Cancer

• Lyon Heart: RCT, deLorgeril Arch Int Med 1998;158:1181-87

• Greek Epic: Observational, Trichopoulou et al. NEJM 2003;348:2599-608

– Both: 60-70% reduction in cancer deaths over 4 years with Mediterranean diet

– Diet and exercise each associated with mortality benefit

Cancer, Diet, Exercise

• 5 or more servings of F + V daily and walking 30 min 6d/week associated with 46% better survival in breast ca n=1490, Pierce J Clin Oncol 2007;25:2345-2351

• In women with breast cancer, risk of dying is 50% lower in those who exercise over 3 hrs/week of brisk walking Observational. Nurses Health Study n=2987 Holmes JAMA 2005;293:2479-2486

Do Diet & Exercise Affect Cancer Outcomes?

• Stage III Colon Ca treated with surgery +chemo: Western diet with more meat, fat refined grains, dessert associated about 3X risk of recurrence and death – Compared to diet high in fruit, vegetables,

poultry, fish Meyerhardt JAMA 2007;298:754-64

– Survival benefit with exercise Meyerhardt J Clin Oncol 2006;24:3527-3534

Mediterranean Diet and Lung Cancer

• Mediterranean diet appears protective against lung cancer in smokers Migrant studies, France. Darmon Pub Health Nutr 2001;4:163-72

• Mediterranean diet pattern associated with about 40% reduction in lung cancer incidence – Prevention particularly associated with carrots,

tomatoes, white meat, sage, exclusive use of olive oil. Case-control Italy. Fortes Nutr and Cancer 2003;46:30-7

Characteristics of an ‘ideal’ traditional Mediterranean Diet

• Vegetables, fruit, whole grains, beans, legumes.• Olive oil, herbs, nuts as main vegetable fats• Fish, preferably wild fatty fish: salmon, tuna,

herring, trout, mackerel• Cheese and yoghurt main sources of dairy• Small amounts of other animal proteins• Minimize hydrogenated oils (including most

commercially prepared foods), other vegetable oils• Moderate alcohol OK, and EXERCISE!

• “The most promising data in the area of nutrition and positive health outcomes relates to dietary patterns, not nutritional supplements”

• “…the relative presence of some foods and the absence of other foods are more important than the level of individual nutrients consumed…” Lichenstein JAMA 2005;294:351-8

Vegetables, Fruits and Lung Cancer

• Historically, high vegetable intake associated with 20-70% lower risk of lung cancer, even in smokers. Axelsson Nutr Ca 2002;44:145-151

• In smokers, 20% lower risk of lung cancer with each 100g/d vegetables

• 10% lower risk with each 100g/d of fruit in smokers and nonsmokers EPIC Int J Cancer 2007:121:1103-

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Fruit, Vegetables and Lung Cancer Survival

• High consumption of F and V associated with improved survival in lung ca Skuladottir Lung Cancer 2006;51:267-73

– Potatoes associated with worse survival• Carotenes are compounds most commonly

associated with reduced lung cancer incidence and mortality Ito J Epid 2005;15:S140-49

• Found in carrots, green and yellow vegetables, many fruits. Carrots seem particularly protective

• Beta Carotene supplements appear harmful, at least at 20mg +/day. Albanes Am J Clin Nutr 1999;69s:1345S-50S

Vegetables and lung cancer• Lycopene from tomatoes may have similar

benefit Holick Am J Epid 2002 156:536-47 Ito J Epid 2005;15:S140-49

• Cabbage family foods protective against many cancer, including lung. Spitz. Cancer Epid Bio & Prev 2000;9:1017-20

• Wide variety may be most important ‘rule’ Wright Cancer Causes Control 2003;14:85-96

• Dried combination vegetable supplement appears to improve survival in NSCLC. Sun Selected Vegetables Sun et al. Nutr & Ca 2001;39:85-95

‘Good’ Fats and Lung Cancer

• Fish and shellfish (omega-3 fats) associated with lower risk. No benefit from dried, salted fish. Smoked? Takezaki. Nutr Ca 2003;45:160-

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• ‘Exclusive’ use of olive oil associated with 33% lower risk. And sage! Fortes. Nutr Ca 2003;46:30-37

• Oleic acid (olive or carp oil) inhibits growth and metastases of lung cancer cells in mice Lewis lung ca. Kimura J Nutr 2002;132:2069-2075

Meat, Dairy and Lung Cancer

• Cheese may have slight protective effect Brennan Cancer Causes Control 2000;11:49-58 Kreuzer Int J Cancer 2002;100:706-713

• Yoghurt, kefir, other cultured dairy may be preferable to milk.

• Milk may be associated with significantly more lung cancer in some populations. Axelsson Nutr Ca 2002;44;145-51 Nyberg Int J Cancer 1998;78:430-36

• High meat, esp. processed, generally associated with more lung cancer, keep < 750g/week uncooked weight AICR 2007

Exercise and lung cancer

• Higher level of physical activity associated with up to 20-30% less lung cancer in some studies, for both smokers and non-smokers. Mao Am J Epid 2003;158:564-575

• Some studies show no benefit Bak Int J Ca 2005;116:439-

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• Recommendations: as high as 6-8 hours/week. Lee Int J Epid 1999;28:620-25

Minimize simple sugars

• Reducing nutrient-poor calories (sugars, juices and sweet drinks, refined flour) means eating more nutrient-rich food.

• High sucrose (table sugar) intake associated with more lung cancer in one study. DeStefani Nutr Ca 1998;31:132-7

• Cancer patients, including lung cancer, seem to have insulin resistance Euglycemic clamp Yoshikawa Nutrition 2001;17:590-3

Green and black tea

• Inhibit the growth of many cancers, reduces cardiovascular risk in some studies.

• Chemoprotective in some genetic populations exposed to oxidant stress Bonner

Mutation Research 2005;582:53-60

• Suppresses growth of some lung cancer cells. Suganuma Cancer Research 1999;59:44-7, Lu, G Clin Ca Research 2008;14:4981-88

Tea and Lung Cancer

• Many epidemiogical studies show no association between green tea and lung cancer risk Li, Q. British J Ca 2008;99:1179-84

• Benefit more likely among never-smokers Arts, IC. J Nutr 2008;138:1561S-1566S

Lung Cancer and Nutritional Supplements

• Use of vitamins and minerals may be associated with better survival in SCLC Mayo 1.8 vs 1.3 y, 37% lower death rate Jatoi Nutr and Cancer 2005;51:7-12

• Is vitamin/mineral use a marker for other beneficial habits?

• Previous studies have shown null or adverse effects of beta carotene, vitamin E, homocysteine treatment despite promising epidemiological associations

Lung Cancer and Nutritional Supplements

• 10 year study studying MVI, C, E, folate and lung cancer risk– No supplement associated with reduced risk– Vitamin E associated with 5% increased risk

with every 100 mg/d increased dose n= 77,721 Am J Resp Crit Care Med 2008;177:524-30

– Supplemental beta carotene associated with increased lung cancer risk in previous studies

Lung Cancer and Selenium

• Rx: Selenium 200mcg qd vs. placebo. Brewers yeast

source. 4.5 yy Rx, 6.4 y follow up, n=1312, avg. age 63yo. Clark. JAMA 1996;276:1957-63 British J. Urology 1998;81:730-34

– 50% reduction in cancer deaths, 37% lower incidence. Less lung, colorectal, prostate ca.

• Benefit for lung cancer in those with low serum selenium. Reid Ca Epid Biomarkers Prev 2002;11:1285-91 Recent review Navarro Cancer Causes Control 2007;18:7-27

• Improved radiosensitivity in vitro Shim Oncol Reports 2007;17:209-16

• Selenium in: garlic, onions, whole grains, Brazil nuts (4/d aprox 200mcg), nutritional (Brewer’s) yeast

Melatonin?• Used in cancer therapy since 1970’s• Appears to improve survival when used

with many chemotherapy drugs Lissoni Pathologie Biologie 2007;55:201-4

• Seems to improve outcomes in advanced cancers, including NSCL Lissoni J Pineal Res 2003;35:12-15

• May improve performance status, sleep.• 10-20 mg in evening is a reasonable dose in

patients with cancer. Vijayalaxmi. J Clin Onc 2002;20:2575-2601

Lung Cancer and Vitamin D

• Higher vitamin D intake and summer surgery associated with lower recurrence and better survival in early-stage NSCLC Zhou Cancer Epidemil Biomarkers Prev 2005;14:2303-9; CEBP 2006;15:2239-45

• More solar UVB exposure, less cancers, including lung cancer Grant, WB. J Steroid Biochem Mol Biol 2007;103:668-74

• Higher 25-OH vit D levels asociated with better survival in stage IB-IIB NSCLC Zhou, W. J Clin Oncol 2007;25:479-85

Cancer Cachexia Cocktail

• Whole food high-good-fat diet, emphasize protein

• Daily exercise as tolerated• Vit D supplement to high-normal level• Fish oil 1-2 TBSP/d• Glutamine 1 TBSP/d• Melatonin 10-20 mg/d

Other Integrative Medicine Interventions To Consider For Your Cancer Patient

Acupuncture and Cancer Patients

• Probably effective for – Chemotherapy-induced nausea and vomiting– Chronic pain– Chemotherapy-related neutropenia– Fatigue– Radiation induced xerostomia Lu, W. Hem Onc Clin North

Amer 2008;doi:10.1016/j.hoc.2008.04.005

Massage for Cancer Patients

• 1290 patients with cancer, out- and in-patient In: 74% Out 26%

• Standard (Swedish), light touch, and foot

massage

• Pre- and post-massage scores collected for

pain, fatigue, stress/anxiety, nausea, depression

• Approximately 50% reduction in each

symptom score Cassileth J Pain Symptom Manage 2004;28:244-49

Summary• Consider the vigor with which you address the

nutrition and exercise components of cancer treatment

• Diet and (outdoor?) exercise are likely to improve the outcome in lung cancer patients – Idealized Mediterranean diet, high dose vitamin D and

melatonin, exercise prescription may have a survival benefit

– These measures reduce heart disease, diabetes, stroke and dementia in almost everybody!

• Other integrative medicine modalities may improve quality of life for your cancer patient