e-session 463

Obesity and cancer

Expert: Dr Antonio Di Meglio, Gustave Roussy Institute, Villejuif, France

Discussant: Dr Ines Vaz Luis, Gustave Roussy Institute, Villejuif, France

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e-ESO sessions // December 6, 2018

Expert: Antonio Di Meglio, MD

Medical Oncologist
Obesity and Cancer Breast Cancer Survivorship Research Group
Institut Gustave Roussy
Villejuif, France

antonio.di-meglio@gustaveroussy.fr

Discussant: Ines Vaz-Luis, MD, PhD

Medical Oncologist
Institut Gustave Roussy

2
 Outline and learning objectives

1. Provide an overview of obesity: definitions and prevalence

2. Describe the impact and prevalence of the obesity epidemic in cancer
3. Review what we know about the link Obesity-Cancer
4. Understand the implications of weight gain after cancer diagnosis and treatment
5. Discuss strategies for weight loss in cancer patients: lifestyle interventions
6. Have an overview of the ASCO Obesity Initiative

3
 1. Obesity: Definition and Prevalence

Overweight and obesity

- “Abnormal or excessive fat accumulation that presents a risk to health”
- Obesity itself has also recently been categorized as a disease-state by the American Medical Association

Body mass index (BMI)

- defined as a person's weight in kilograms divided by the square of his height in meters (kg/m2)
- a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults
- may over/underestimate adiposity, but represents a reliable and handy measure
- sometimes complemented with waist circumference

Category BMI (kg/m2)

Underweight Below 18.5
Normal weight 18.5-24.9
Overweight 25.0-29.9
Obese
Obesity class I 30.0-34.9
Obesity class II 35.0-39.9
Obesity class III Above 40.0
4
http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
 1. Obesity: Definition and Prevalence

Obesity rates have reached epidemic levels in the United States

- There has been a dramatic increase in the rates of obesity across US from 1985-2010
- In 2016 more than 1.9 billion adults worldwide, 18 years and older, were at least overweight // of these over 650 million were obese

Trends in Obesity Prevalence (%), Adults 18 and Older, US (1985-2010)

http://www.cdc.gov/obesity/data/trends.html
Multifactorial causes of increased prevalence of obesity worldwide
- Changes in dietary habits: rising consumption of sugar-sweetened beverages, increase in portion sizes
- Decline in physical activity, partly due to automation
- Increased adoption of «Western lifestyles» 5
 2. Impact and prevalence of the obesity epidemic in cancer

Attributable risk percent of cancers Quickly overtaking tobacco as the leading preventable cause of cancer
4% of all cancers in men (38,000 cancers/year)
due to obesity:
7% of all cancers in women (50,500 cancers/year)

If the prevalence of obesity continues to

Estimated 500,000 excess cancer cases in the US due to obesity
grow at the same rate over the next 20 years:

If every person in the US decreased BMI 73,000-127,000 fewer cancers based on current rates of obesity
by 1 unit (about 2.2 lbs) there would be: 573,000-627,000 fewer cancers based on increasing rates of obesity

Polednak, Cancer Detection and Prevention 2008;

Wang I, Lancet 2011;
Obesity and cancer, ASCO 2014
6
 2. Impact and prevalence of the obesity epidemic in cancer

Prevalence of obesity at diagnosis in breast cancer patients across studies

% Of obesity % Of obesity
40% 40,0
35% 35,0
30% 37%
31% 33% 30% 30,0

20,9
20,3
25%

19,2
25,0 Diagnosis
20% 26%
23% 23% 21% 20,0 Year 1
15% 15,0
10% 17% 16% Year 2
10,0
5% 5,0
0% 0,0

Data from the French national CANTO cohort:

5098 patients with early breast cancer
Diagnosed from 2012-2014

Di Meglio A, ESMO Congress 2018

7
 3. The link Obesity-Cancer

Biological
substrate of
cancer in
the obese
Obesity and Obesity as a
financial risk factor
burden for cancer

The link
Obesity as
Impact on Obesity-Cancer prognostic
quality of
factor for
life
cancer

Impact on
Risk of
treatment
second
delivery cancers
and toxicity

8
 3. The link Obesity-Cancer

Biological
The link substrate of
cancer in the
Obesity-Cancer obese

9
Obesity, lifestyle factors, and cancer:
underlying biological mechanisms

10

Adapted from: Goodwin PJ, Annu Rev Med, 2015

 Obesity, lifestyle factors, and cancer:
underlying biological mechanisms
Reduced threshold for age at onset and incidence
of chronic disease in physically inactive and obese individuals

Individuals doing recommended amount of physical activity

Sedentary (inactive) lifestyle
Inactive and obese individuals
Individuals that exercise chronically

Threshold for incidence of chronic diseases 11

Adapted from Handschin C, Nature 2008
 3. The link Obesity-Cancer

The link Obesity as a

risk factor for
Obesity-Cancer cancer

12
 Obesity as a risk factor in cancer
Multiple studies found strong evidence supporting the association between obesity and cancers,
although the strength of the association and the types of cancers vary somewhat across studies
- Positive association of increasing BMI with cancers
occurring in a wide range of sites.

- Strong positive associations between BMI and

endometrial cancer (RR: 1.48),
esophageal adenocarcinoma (RR: 1.45)
postmenopausal breast (RR: 1.11)
kidney cancer (RR: 1.20);
- Significant inverse associations between BMI and
oral cavity (RR: 0.93),
lung (RR: 0.91),
premenopausal breast (RR: 0.95),
localized prostate (RR: 0.97)

- A male-specific association
colorectal cancer (p = 0.023),
- A female-specific association
brain (p = 0.025) 13
kidney (p = 0.035). Adapted from: Fang X, IJC 2018
 Obesity as a risk factor in cancer

a. Non-linear relationship between b. Positive relationship between c. Inverse relationship between

increasing BMI and overall risk of cancer increasing BMI and risk of specific cancers increasing BMI and risk of specific cancers
Adapted from: Fang X, IJC 2018
- Association of increasing BMI and risk of breast cancer is unique in cancer epidemiology
- Crossover effect:
- risk reduction before
- risk increase after menopause

- Recent pooled individual-level data analysis of 758,592 women / Data from 19 prospective cohort studies (1963-2013)
- Inverse association between increasing BMI and decreased risk of breast cancer 14
- Universal and across strata of other risk factors and cancer subtypes Adapted from: Schoemaker MJ, JAMA Oncology 2018
 3. The link Obesity-Cancer

Obesity as
The link prognostic
factor for
Obesity-Cancer cancer

15
 Obesity as a prognostic factor in cancer

- Data linking obesity to poor outcomes is strongest in breast, colorectal, and prostate cancer
- Emerging data suggest that obesity might be a prognostic factor also in other malignancies, including childhood leukemia

Breast Cancer Mortality Total Mortality

vs. Normal weight
RR (95% CI) RR (95% CI)
Annals of Oncology, 2014
Overweight 1.11 (1.06-1.17) 1.07 (1.02-1.12)
Obese 1.35 (1.24-1.47) 1.41 (1.29-1.53)
- Meta-analysis of 82 studies
Total Mortality Total Mortality
- 200,000+ patients with breast cancer vs. Normal weight Premenopausal Postmenopausal
- Increased mortality in overweight and obese women RR (95% CI) RR (95% CI)
vs. normal weight, regardless of menopausal status Obese 1.75 (1.26-2.41) 1.34 (1.18-1.53)

ER/PgR + ER/PgR –
Obese vs. normal weight
HR (95% CI) HR (95% CI)
BCRT, 2012 Total Mortality 1.31 (1.17–1.46) 1.18 (1.06–1.31)
- Meta-analysis of 21 studies Breast Cancer Mortality 1.36 (1.20-1.54) 1.46 (0.98-2.19)
- HR+ and HR- cancers
- No evidence of a significant interaction with HR status Significant and consistent relationship between obesity and
poor outcomes in women with early stage breast cancer
16
 Obesity as a prognostic factor in cancer

- Mixed data regarding the relationship between BMI and colon cancer outcomes

Cumulative incidence of colon cancer

recurrence or second primary cancers adjHRs (95% CI) Total mortality Colon cancer deaths Non-colon cancer
Vs. normal (1697 events) (1159 events) deaths (538 events)
P<.05
Underweight 1.49 (1.17-1.91) 1.22 (0.89-1.67) 2.23 (1.50-3.31)
Overweight 1.02 (0.91-1.14) 1.12 (0.98-1.28) 0.84 (0.68-1.02)
Obese 1.11 (0.96-1.28) 1.08 (0.90-1.30) 1.23 (0.95-1.58)
Very obese 1.28 (1.04-1.57) 1.36 (1.06-1.73) 1.25 (0.84-1.87)

A BMI ≥ 35 kg/m2 was associated with an increased risk of colon

cancer recurrence, total and colon cancer-related mortality
Dignam JJ, JNCI 2006

- In a metanalysis of 7 adjuvant chemotherapy trials for patients with stage II and III colorectal cancer (N= 25,291) treated
with fluoro-uracil based therapy within the Adjuvant Colon Cancer Endpoints (ACCENT) database:

- BMI was significantly prognostic in men for DFS (P< .0001) and OS (P < .0001), but not in women (all P > .10)
- There was a significant interaction BMI-sex for OS (Pinteraction = .0129)
Sinicrope FA, Cancer 2013
17
 Obesity as a prognostic factor in cancer

- Obesity is associated with the development of biologically adjRRs (95% CI) vs. normal Mortality
more aggressive and advanced prostate cancer Overweight 1.25 (0.87-1.80)
- A significant elevation in prostate cancer mortality was
Obese I 1.46 (0.92-2.33)
observed at higher BMI levels
Obese II 2.12 (1.08-4.15)

Gong Z, Cancer Epidemiol Biomarkers Prev 2006

Wright ME, Cancer 2007

- Obesity at diagnosis independently predicts likelihood of relapse and cure

in preteenagers and adolescents with acute lymphoblastic leukemia

- Adj HRs (95% CI) for events = 1.5 (1.1 - 2.1; P=.009) obese vs. not obese
- Adj HRs (95% CI) for relapses and = 1.5 (1.2 - 2.1; P=.013) obese vs. not obese

Log-rank P = .01
N = 1003 (obese n=95)

Butturini AM, J Clin Oncol 2007

18
 3. The link Obesity-Cancer

The link Risk of second

cancers
Obesity-Cancer

19
 Obesity and risk of second malignancies

- Together with other modifiable lifestyle factors, obesity is associated with higher risk of second primary breast cancer

ORs (95% CI) of developing N= 365 patients with ER+ breast cancer
Lifestyle factor (at diagnosis)
contralateral breast cancer N= 726 matched controls
Obesity 1.4 (1.0-2.1)
Consumption of 7+ alcohol servings/week 1.9 (1.1-3.2)
Being current smoker 2.2 (1.2-4.0) Li CI, J Clin Onc 2009

- In the French national CANTO cohort, overweight and obesity at diagnosis were associated with a higher rate of breast
cancer recurrences (local, nodal, or distant) and second cancers (N. Events 221).
% Of overweight and obesity (N=5098) Cancer recurrence rates (%)
Proportion of patients (%)

40,0
29,8
29,7
28,9

35,0
30,0 8,0
20,9

Fisher’s exact p-value .0007

20,3
19,2

25,0

5,3
20,0 6,0 adjusted OR (95% CI)
1.41 (1.05-1.91)
15,0
4,0 3,4 vs. Underweight/Normal
10,0
5,0 2,0
0,0
Overweight Obese 0,0 Di Meglio A, ESMO Congress 2018
Diagnosis Year 1 Year 2 Underweight/Normal Overweight/Obese 20
 3. The link Obesity-Cancer

Impact on
The link cancer
treatment
Obesity-Cancer delivery and
toxicity

21
 Obesity and delivery of cancer treatment:
Increased treatment toxicity and morbidity
- Delay in seeking medical care and less likelihood to participate in screening programs
Maruthur NM, Journal of General Internal Medicine 2009
Fagan H, J Obes 2011

- Reduced accuracy of diagnostics due to hemodilution of tumor biomarkers and

reduced imaging quality
Impact of obesity Chang IH, J Urol 2009
Hijazi H, Crit Rev Onc/Hem
on cancer treatment
- Technical difficulties in delivery of radiation therapy and surgical management
Choi M, Radiother Oncol 2009

- Higher rates of thromboembolism in individuals receiving chemotherapy

Khorana AA, J Clin Oncol 2006

- Among 2258 patients who underwent major abdominal cancer surgery, higher BMI was associated with higher rates of post-surgical
complications and wound infections
Underweight Normal weight Overweight Obese I Obese II Obese III
Outcome p (ANOVA)
(n=55) (n=819) (n=811) (n=357) (n=137) (n=79)
Morbidity rate 21.8 23.1 26.0 29.1 29.9 32.9 0.11
Complications 9.1 13.1 14.2 16.8 18.2 25.3 0.023
Wound infections 7.3 10.0 12.5 16.5 13.1 19.0 0.0084 22
Mullen T, Ann Surg Oncol 2008
 3. The link Obesity-Cancer

The link Impact on

quality of life
Obesity-Cancer

23
 Obesity and Quality of life of cancer patients

- Obesity and unfavourable energy balance can adversely impact several physical and psychological outcomes, including:
- Poor physical functioning
- Reduced capacity for physical activity
- Dimished sexual functioning
- Fatigue
Kolotkin RL, Surg Obes Relat Dis 2009
- Dyspnea
Martinelli LM, Clinics 2008
- Poor body image

- The Women’s Healthy Eating and Living (WHEL) Study found that obesity was
significantly associated with
- Worse physical functioning in all study participants (p=.001)
- Worse physical health, vitality, pain, and overall health-related QoL
in white study participants (all p=.001)

- N=3013 women with stage I-III breast cancer

Paxton RJ, Cancer 2012

24
 3. The link Obesity-Cancer

The link Obesity and

financial
Obesity-Cancer burden

25
 Obesity and financial toxicity

- In a recent analysis of costs and admission rates in relation to BMI at recruitment among over 1 million women in the UK NHS:
- Increasing BMI at diagnosis was associated with higher hospital admission rates and care costs
- Overweight and obesity were associated with increased hospital costs for most diagnostic categories, including neoplasms

Hospital admission rate Hospital care costs

BMI (Kg/m2)
(99% CI), woman-yrs (99% CI) per year
20.0 to ≤ 22.5 321/1000 (316–326) ￡567 (556–577)
40.0 or higher 530/1000 (511–549) ￡1220 (1170–1270)
26 Kent S, Lancet Public Health 2017
 4. Weight gain among cancer patients

- Many cancer survivors experience weight gain after cancer diagnosis, particularly:
- in individuals treated with chemotherapy, (especially if it includes steroid)
- when chemotherapy results in premature menopause for a previously premenopausal woman
- women treated with chemotherapy gain 2-5 kg and up to 10 Kg of weight in the first 1-2 years after breast cancer diagnosis
Reddy SM, Br J Cancer 2013
Caan BJ, CEBP 2012
- Change in body composition and «sarcopenic obesity» (loss of muscle mass and concomitant gain of adipose tissue):
- common in individuals receiving chemotherapy
- can be seen in patients receiving androgen deprivation therapy for prostate cancer
Timilshina N, Cancer 2012
At 2 years post-diagnosis
Patient and treatment characteristics
% pts gaining Mean n.
At diagnosis of breast cancer adjOR (95% CI)
≥5% weight Kg gained
Total - 24.0 +6.6 -
Age at diagnosis <50 years 35.5 +7.1 1.98 (1.28-3.06)
≥50 and <65 years 23.6 +6.3 1.95 (1.45-2.64) Data from the French national CANTO cohort:
≥65 years 11.3 +5.9 Ref. 5800 patients with early breast cancer
Receipt of CT Yes 29.0 +6.9 1.62 (1.29-2.04) Diagnosed from 2012-2014
No 18.1 +6.2 Ref.
Receipt of ET Yes 23.8 +6.6 1.29 (0.99-1.67) Di Meglio A, ESMO Congress 2018
No 24.7 +6.5 Ref.
PA exposure < 10 MET-hrs/week 25.5 +6.9 1.24 (1.01-1.52)
≥ 10 MET-hrs/week 22.0 +6.3 Ref.
Weight gain at year 1 For each 1-Kg gained - - 1.56 (1.50-1.62)
For each 6-Kg gained - - 14.41 (11.39-18.07) 27
 4. Weight gain among cancer patients

- Weight gain after breast cacer may be associated with risk of recurrence but studies have reported inconsistent results

- Older studies reported that women with breast cancer who were overweight or gained weight after diagnosis were at
greater risk for breast cancer recurrence and death compared with lighter women (Chlebowski RE, J Clin Onc 2002)

- Results of 2 larger studies addressing this question have reported conflicting results:

Life After Cancer Epidemiology (LACE) Study +

Nurses’ Health Study
Kroenke C, J Clin Oncol 2005 // n=5204 Women’s Healthy Eating and Living (WHEL) Study
Caan BJ, BCRT 2006 // n=3215

vs. women maintaining their weight vs. women maintaining their weight
Gain 0.5-2.0 Kg/m2 – median gain 6.0 lb Moderate weight gain 5-10%
RR of breast-cancer death 1.35 (0.93-1.95) HR of breast cancer recurrence 0.8 (0.6-1.1)

Gain >2.0 Kg/m2 – median gain 17.0 lb Large weight gain >10%
RR of breast-cancer death 1.64 (1.07-2.51) HR of breast cancer recurrence 0.9 (0.7-1.2)

Similar findings for breast cancer recurrence Impact of weight gain on overall survival or
and all-cause mortality risk of other cancers not addressed
28
 Weight changes, physical and psychosocial patient reported outcomes (PRO)

Among 993 obese breast cancer patients in the CANTO cohort, weight gain occurring between cancer diagnosis and
completion of primary treatment was associated with highest prevalence of impaired and deteriorated PROs
Weight Gain Stable Weight Weight Loss
60,0
55,0

44,3
42,5

50,0
39,5

45,0 ORs for severe dysfunctions or symptoms post-treatment vs weight gain

32,8
40,0 Domain/Scale Stable Weight - 67.3% Weight Loss - 18.6%

29,8
35,0
27,0

26,2

Global Health 0.82 (0.49-1.36) 0.45 (0.24-0.86)

24,6

23,8
22,6

30,0

19,2
Physical Function 0.45 (0.24-0.83) 0.37 (0.17-0.79)
17,7

25,0

16,6
15,2
20,0 Role Function 0.64 (0.37-1.13) 0.48 (0.23-0.99)

10,1
15,0 Pain 0.55 (0.33-0.92) 0.34 (0.18-0.65)
10,0
5,0 Dyspnea 0.45 (0.25-0.80) 0.21 (0.09-0.48)
0,0
Global Health Physical Role Function Pain Dyspnea
Function

Weight Gain Stable Weight Weight Loss

38,0

45,0 36,9
ORs for deterioration (decrease of ≥10 points on EORTC QLQ) vs weight gain
32,8

40,0
Domain/Scale Stable Weight (67.3%) Weight Loss (18.6%)
28,4
27,8

35,0 27,7
26,2

26,0
22,6

30,0 Physical Function 0.67 (0.42-1.04) 0.57 (0.32-0.99)

17,7

25,0
16,6

Dyspnea 0.67 (0.42-1.08) 0.34 (0.19-0.62)

20,0
10,1

15,0 Appetite Loss 1.29 (0.64-2.60) 2.04 (0.93-4.49)

9,4
6,2
5,1

10,0 Body Image 0.79 (0.49-1.29) 0.53 (0.29-0.97)

5,0 Breast Symptoms 0.82 (0.50-1.36) 0.56 (0.30-1.02)
0,0
Physical Dyspnea Appetite Body Breast
Function Loss Image Symptoms 29 Di Meglio A, ESMO Congress 2018
 5. Strategies to promote weight loss and/or prevent weight gain in cancer survivors

- A number of small-to-moderate sized studies have looked at the feasibility and benefits of lifestyle and weight loss interventions
- Calorie restriction, increased physical activity and behavioral counselling are the cornerstones of weight management and should be
recommended as the primary means of achieving weight loss
- Lifestyle change produces weight loss of 5-7% of body weight: weight loss of this magnitude reduces the incidence of other diseases
(diabetes and cardiovascular)
Guide to selecting weight loss treatment

* * *

* * *

*always indicated regardless of comorbidities

Weight loss:
-use of lifestyle therapy to lose weight recommended if BMI 25-29.9 kg/m2 and 2+ comorbidities
-pharmacotherapy should be considered only if a patient has not lost 1 pound/week after 6 months
Weight gain:
-prevention of weight gain with lifestyle therapy is indicated in any patient with BMI ≥ 25 kg/m2 30
 5. Weight loss and lifestyle interventions

Lifestyle Intervention Study for Adjuvant Treatment of Early breast cancer (LISA)
- The largest weight loss intervention study reported
- Breast cancer patients (n=338) receiving adjuvant letrozole
- BMI ≥ 24 kg/m2
- 2-year, telephone-based intervention vs. control
- Individualized goals:
- 10% weight loss
- calorie restriction of 500-1000 kcal/day
- 150-200 minutes of moderate-intensity physical activity/week

Individualized Lifestyle
Weight (in kg) Control group telephone based p-value
Intervention
n Mean (SD) n Mean (SD)
Baseline 167 81.2 (14.5) 171 82.7 (15.3)
To Month 6 155 -0.6 (4.1) 161 -4.3 (4.1)
Change
To Month 12 147 -0.6 (5.7) 142 -4.5 (5.4) <0.001
from
To Month 18 144 -0.8 (6.1) 135 -3.8 (5.8)
Baseline
To Month 24 131 -0.3 (5.3) 133 -3.1 (6.2)

31 Goodwin PJ, J Clin Oncol 2014

 Weight loss and lifestyle interventions

- A few pilot studies evaluated the feasibility of using cooperative clinical trials systems for the conduct of lifestyle intervention research

The Active After Cancer Trial (AACT)

- Breast and colorectal cancer survivors who were sedentary
= engaging in less than 60 minutes of recreational activity/week
- Total 121 patients enrolled through ten CALGB institutions
- 16-week telephone-based exercise intervention vs. usual care control
- Individualized goals:
- 180 min of moderate-intensity physical activity/week
- Participants allowed to choose their own form of exercise

Mean (±SD) Baseline Change over 16 weeks

Exercise Control Exercise Control
P P
(n=48) (n=51) (n=48) (n=51)
Physical Activity
44.9 ± 58.5 65.7 ± 84.1 0.12 54.5 ± 142.0 14.6 ± 117.2 0.13
(min/wk)*
MET-hrs/wk* 2.7 ± 3.6 4.0 ± 5.0 0.10 3.0 ± 8.2 1.0 ± 7.6 0.23
6-Minute Walk
1431.9 ± 309.1 1495.2 ± 246.3 0.22 186.9 ± 215.1 81.9 ± 135.2 0.006
Test (feet)
Physical Function
82.8 ± 17.8 85.8 ± 11.9 0.29 7.1 ± 11.4 2.6 ± 10.2 0.04
(EORTC QLQC-30) 32
*As measured by the 7-Day Physical Activity Recall
Ligibel JA, BCRT 2012
 Weight loss and lifestyle interventions

Lifestyle interventions in cancer populations

Calorie restriction, increased physical activity and behavioral counselling

Safe and Impactful on cancer

Feasible Beneficial outcomes ?

Better quality of life, reduced fatigue

Tested multiple times in Better cardiorespiratory fitness Unaddressed question
oncology settings Better body image Ongoing trials (BWEL)
Reduced comorbidity (heart diseases, diabetes)
Favorable change in cancer biomarkers

33
Weight loss and lifestyle interventions

Ligibel JA, NPJ Breast Cancer 2017

Breast Cancer WEight Loss Study (BWEL Study)

ClinicalTrials.gov Identifier: NCT02750826
PI: Jennifer Ligibel

Primary endpoint:
Reduction in Invasive disease free survival
34
 Do cancer survivor behave different than other individuals?

Cancer survivors are no more likely to engage in healthy behavior

compared with adults without a history of cancer

Physical activity patterns in breast cancer survivors

80%
60%
40%
20%
0%
WHI HEAL CWLS Shanghai LACE NHS
No activity Less than 3 hours/wk
WHI: Women's Health Initiative study Irwin, Canc Prev Res 2011
HEAL: Health, Eating, Activity, and Lifestyle Study Irwin, JCO 2008
CWLS: Collaborative Women's Longevity Study Holick, CEBP 2008
Population-based Shanghai Cancer Registry Chen, Canc Prev Res 2011
LACE: Life After Cancer Epidemiology study Sternfeld, CEBP 2009
NHS: Nurses’ Health Study Holmes, JAMA 2005
%
Mayer DK, Oncol Nurs Forum 2007
35
 Physical Activity recommendations in cancer survivors

• Cancer survivors should follow survivor-specific guidelines written by an expert panel convened by the American College of Sports Medicine
• The panel recommended that individuals avoid inactivity and return to normal activity as soon as possible after diagnosis or treatment.

According to those guidelines, adults aged 18 to 64 years should engage in:

at least 150 minutes per week of moderate intensity or
75 minutes per week of vigorous intensity aerobic physical activity, or
an equivalent combination

Schmitz KH, Med Sci Sports Exerc. 2010

36

Cancer as a teachable moment
«A naturally occurring life transition or health
event that have the potential to motivate
individuals to adopt risk-reducing
or health protective behaviors»
Demark-Wahnefried W, J Clin Oncol 2005
Cancer as a “Teachable moment”
- Among cancer survivors across multiple studies in multiple cancer types:
- Most seem to be interested in health-promotion programs
(mostly diet and exercise, smoking cessation)
- Preference for home-based formats
(mailed materials followed by telephone counseling)
- A substantial number reported dietary changes after diagnosis
- Factors reducing likelihood of healthy lifestyle adoption:
- male sex and older age
- lower education
- living in urban areas
- Physicians are the most powerful catalysts for promoting behavior change
- Only 20% of oncology care physicians provide assistance in this area:
Assessing obesity in cancer is an unmet need
- Competing treatment or health concerns, time constraints
- Uncertainty regarding the delivery of appropriate health-behavior
messages, impact on outcomes
- Insurance coverage and reimbursement of lifestyle interventions
37
 6. Addressing obesity in cancer patients: the ASCO Obesity Initiative

Education and Awareness

• Increase knowledge about existing evidence on the role of energy balance in cancer risk and prevention
• Integrate weight management into the oncology fellowship trainig curriculum

Clinical guidance, tools, and resources

• Develop practical recommendations based on evidence to help oncology providers address obesity

Research promotion

• Support development of robust reseatch to evaluate the benefits of weight loss in cancer survivors and
best practices to help them make behavioral changes after diagnosis
• Advocate for increased funding for research in key gap areas

Policy and Advocacy

• Advocate for policy systems change to addres societal factors contributing to obesity and improve
access to nutrition and exerise counseling services for patients with cancer
• Promote coverage of and access to obesity screening, diagnosis, and treatment services

Adapted from: American Society of Clinical Oncology Position Statement on Obesity and Cancer. Ligibel JA, J Clin Oncol 2014
38
 Implementation of weight loss and weight maintenance strategies

A practical approach to weight management in cancer patients and survivors proposed by ASCO

1. Assess
- BMI is a easily done assessment not requiring any special equipment
- BMI should be evaluated during each office visit

2. Advise
- Approach weight management in a neutral manner, including BMI as part of review of systems during visits
- Discuss exercise habits and introduce diet and weight issues
- Acknowledge the challenges and struggles that patients may face in trying to lose weight
«I’ve tried everything and just can’t lose weight»
«I’m already stressed in dealing with my cancer»
«Now it is not a good time to talk about my weight and my physical activity»

3. Refer
- Oncologists are in a unique position to optimize the «teachable moment» and help patients make healthy lifestyle choices
- Nevertheless, it is crucial to identify local resources: dietitians and nutritionists who are appropriately trained

39
 Towards an integrated model for energy balance interventional obesity research

Existing model

Proposed model

Recommendations for Obesity Clinical Trials in Cancer Survivors: American Society of Clinical Oncology Statement. 40
Ligibel JA, J Clin Oncol 2015
 Obesity and Cancer - Take Home Messages

1. Obesity has reached epidemic levels worldwide: 1/3 adults in US is categorized as obese
2. Obesity is becoming the leading preventable cause of cancer
- Prevalence of obesity among cancer patients reaches up to 40%
3. There is a strong link Obesity-Cancer
- There is compelling evidence that obesity acts as a risk and prognostic factor in cancer
- Obesity negatively impacts treatment toxicity, quality of life, and financial burden in cancer care

4. One out of four patients gain weight after cancer

5. Weight control and weight loss strategies based on lifestyle interventions
should become part of standard oncology care

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