New Cancer Survivor Guidelines to Answer Questions of “What Now?”

The American Cancer Society has published updated cancer survivor guidelines covering lifestyle choices in different stages of a cancer journey. “Cancer survivor” is a term applied to anyone who has been diagnosed with cancer, from the moment of diagnosis through the rest of their life, regardless of where they are in the course of this disease.

This group of people living with and beyond cancer is increasing in number and diversity of needs.

• In 2022, 1.9 million new cases of cancer are expected to be diagnosed.
• In the U.S. today, numbering close to 17 million, cancer survivors represent 1 in 20 people. Increased success in diagnosing many cancers at an earlier stage combined with improvements in treatment mean that there are more people living with and beyond cancer than ever before.
• This group includes a wide range of people with vastly different needs. They come into a cancer diagnosis already differing in overall health and fitness, and in family and community support. Some come in with healthy eating and physical activity habits and access to healthy food. Others, due to their own choice or to social disparities or effects of their cancer, do not.

When you add in the family and friends of those with cancer, and the healthcare providers who work with them, this guideline is trying to address big questions that apply in different ways to many people.

The New Cancer Survivor Guidelines

Who Are These For?

The American Cancer Society (ACS) guideline publication identifies its intended audience as:

• Health care providers caring for cancer survivors
• Cancer survivors and their families
• Professionals in health policy, media and community programs who communicate about or develop programs for cancer survivors

How Were the Guidelines Developed?

A panel of recognized experts in nutrition, physical activity, and cancer — including researchers and those in active clinical care — worked together. They evaluated and synthesized current scientific evidence and best clinical practices related to nutrition and physical activity after the diagnosis of cancer.

• Evidence includes published systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published over the past decade.
• Recommendations and evidence reviews from large cancer care organizations and other expert bodies were also considered.
• Observations from current practice and reports about barriers to healthy lifestyles and behaviors change are reflected here, too.

Specific objectives of these cancer survivor guidelines are improved outcomes of the current cancer (fewer deaths and reduced risk of recurrence) and reduced risk of a new cancer.

What’s New in These Cancer Survivor Guidelines

The stated purpose of these guidelines is: “To provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and increasing time to new disease and cancer-specific and overall mortality.”

1) Increased Attention to Separating Priorities During and After Cancer Treatment, and Need to Consider Long-term Health Consequences of Cancer

The first thing you notice in comparing these guidelines and the previous edition (published in 2012) is the separation of steps to address needs of people during cancer treatment, and even from the moment of diagnosis before cancer starts, from longer-term concerns.

• Long-term health: As people live longer after cancer, research is showing the need to address long-term health concerns, including late effects of cancer or its treatment that some people experience. The guidelines note, “There is growing evidence that being physically active, consuming foods that reflect a healthy dietary pattern, and avoiding obesity after completion of cancer treatment improves long-term survival.”  —  Cancer survivors are at risk of other chronic diseases (CVD, diabetes, osteoporosis), and in some cases may be at heightened risk. Survivors of childhood and adolescent cancers, for example, may be at increased risk of CVD and second cancers compared to people who don’t have a history of cancer. Therefore, choices that support healthy eating, physical activity, and body composition are important elements of supporting long-term health after cancer.
• Immediate health concerns: It’s helpful for people, overwhelmed by all they must deal with in this diagnosis and treatment, to be able to set priorities for what are the most important steps right now. Yes, it’s possible that addressing long-term health sooner rather than later may be helpful. But research provides a convincing case for prioritizing meeting nutritional needs and maintaining lean muscle mass during treatment to improve outcomes. So if effects of cancer or its treatment mean that longer-term health goals need to take a backseat for some people, these guidelines provide a framework for doing that.

2) Even stronger emphasis on proactive attention to nutrition

The text of the document providing the previous edition of these guidelines highlighted the problems of nutritional inadequacy that can occur before and during cancer treatment, and the importance of nutritional assessment as soon after diagnosis as possible. But the new cancer survivor guidelines put that recommendation front and center at the top of the list. The current text discusses specifics such as use of a validated malnutrition screening tool on an ongoing basis to identify people who should see a registered dietitian nutritionist (RDN). An RDN would then provide personalized nutrition assessment and counseling.

This is consistent with the recommendations of the American Institute for Cancer Research (AICR), which say: “All cancer survivors should receive nutritional care and guidance on physical activity from trained professionals…. People who have been diagnosed with cancer should be given the opportunity, as soon as possible, to consult an appropriately trained health professional who can take each person’s circumstances into account.”

3) New note about soy foods: addressing common questions, especially from breast cancer survivors 

Evidence does not support fears of risk from the often-misunderstood isoflavone compounds these foods contain. On the other hand, while decreased risk of recurrence was statistically significant, trends for fewer deaths with higher soy food intake were not. (That can mean associations with lower mortality occurred by chance, or may reflect the variations among different studies.) It’s worth noting that evidence cuts across populations, including not only “high” intake in the US, but also in Asia where “high” intake includes frequent consumption of soy foods.)

The AICR/WCRF CUP Global report on breast cancer survivorship categorized evidence from women 12 months or more after diagnosis that soy food intake may be associated with longer overall survival and reduced risk of breast cancer recurrence as “Limited-suggestive”. That means evidence shows potential but is not strong enough for AICR to include it in recommendations. Since that analysis, additional studies continue to support this lack of harm and possibility of promoting health.

For more insights on making sense of this research, check my research review on soy and breast cancer.

4) More evidence on physical activity from the moment of diagnosis throughout treatment and beyond

Research, including controlled clinical intervention trials that include people with cancer, is growing rapidly and shows great potential for improving many aspects of survivorship.

The ACS cancer survivor guidelines stipulate:

• Evidence is sufficient for specifics in a prescription of physical activity for anxiety, depression, physical function, and lymphedema.
• But while preliminary evidence suggests physical activity may improve treatment tolerance and response, evidence is insufficient for providing people with specific recommendations on what, how much, and with what intensity is optimal.

The guidelines identify the ultimate aim as, “To achieve the current physical activity recommendations for health (150-300 minutes per week of moderate-intensity or 75-150 minutes per week of vigorous-intensity physical activity, and muscle-strengthening activities on 2 or more days a week).”

However, individual physical activity recommendations may need to be adapted to address health and treatment-related symptoms and side effects that can affect exercise tolerance and safety. This can be due to nerve damage, balance issues, anemia, limited immune system strength, or lymphedema risk. That’s why it’s important to get advice from someone trained in exercise after cancer. In this case, typical strength coaches or trainers may not fit the bill.

5) Weight and BMI… shifting emphasis to Body Composition (adipose tissue and lean muscle mass)

In large population studies, body mass index (BMI) provides an accessible way to express and study weight in relation to height. And this tends to identify people with higher or lower levels of body fat. But especially on an individual basis, there are problems with relying on BMI.

The new guidelines state, “Reliance on BMI as an indicator of adiposity, which is the most common anthropometric parameter examined in clinical and epidemiological studies, is inherently limited. This indicator does not differentiate between lean and fat tissue mass and does not provide information about the amount or location of adiposity. Body fat distribution and low skeletal muscle mass likely contribute to mortality in cancer survivors, and relevant high-quality data on these measures are limited. More research is needed to evaluate the complex interactions between body composition and cancer progression, recurrence, site-specific mortality, and all-cause mortality.”

Obesity – usually assessed based on BMI (body mass index), but also as weight gain – is strongly associated with greater risk of at least 13 different cancers. However, for the many people with overweight or obesity at the time of cancer diagnosis, research is unclear about how intentional weight loss might affect cancer outcomes.

This research is complex! Simply looking at outcomes based on whether people with cancer did or did not lose weight does not provide a good answer. It requires separating the effects of unintentional weight loss (often with loss of lean muscle) that occurs as a side effect of cancer treatment or of cancer disease progression from intentional weight loss. Weight loss — if not done in a way that results in a meaningful loss of lean body mass — offers potential benefits by reducing the influence of adiposity (especially with excess visceral fat) on inflammation and hormones. The guidelines document reviews evidence related to specific cancers, but for no cancer does it identify evidence that is strong or conclusive.

From the “patient page” about these guidelines:  “During cancer treatment, focus on maintaining (or even increasing) muscle mass through diet and physical activity. After treatment, survivors with overweight or obesity may consider trying to lose weight to improve their overall health, reduce the chances of getting another cancer, and possibly reduce their risk of recurrence and improve survival for some cancer types.”

Since obesity is strongly linked to increased risk of cancer, the long-term recommendation to follow prevention guidelines includes, “Achieve and maintain a healthy body weight throughout life…. Keep body weight within the healthy range and avoid weight gain in adult life.” When appropriate to focus on protecting long-term health, which includes risk of type 2 diabetes and cardiovascular disease, recommendations from organizations like the American Society of Clinical Oncology endorse including conversations about weight management as part of helping people lead healthier lives after a cancer diagnosis.

6) More caution about alcohol

Research continues to grow about the increase in cancer risk linked to excess alcohol consumption.  And for some cancers (like breast cancer) there’s a link even to alcohol consumption that falls within the current definition of moderation. At the same time, evidence from more carefully designed research on alcohol and cardiovascular disease is showing a less clear-cut picture of benefits.

The new ACS guidelines say, “There is insufficient evidence for an association between alcohol intake and overall and cancer-specific mortality across all cancer types to warrant a general recommendation that is specific for cancer survivors. However, there are some types of cancer for which this association has been observed. Also, alcohol intake is an established cause of several types of cancer, so the avoidance of alcohol consumption is among the recommendations for cancer prevention and thus is relevant to reduce risk for a new cancer in cancer survivors.”

For more on alcohol and cancer risk — not necessarily cancer outcomes — you can check a summary from the AICR recommendations and expert report.

7) What hasn’t changed: Barriers to meeting guidelines continue

Disparities in access to healthy food and safe places for activity and access to professional guidance, both for meeting immediate eating and physical activity advice and for risk of late effects of cancer treatment and long-term health continue. As evidence grows supporting the potential for better outcomes through nutrition and physical activity, if advice about how to do it and living conditions that make advice attainable are out of reach, those benefits won’t be attained.

Barrers occur in multiple forms:

• Access to the individualized guidance recommended to help people identify and implement new behaviors. The guidelines highlight a survey published in the Journal of Oncology. Among cancer center RDNs in the survey, the patient load per dietitian was nearly 20 times the number recommended for people with cancer to receive evidence-based care that can improve quality-of-life and nutrition outcomes.
• Access to healthy food and safe places to be physically active once they know the choices helpful for them

The Challenge of providing guidance to “Cancer Survivors”

Cancer treatments are individualized. So are needs after cancer. Cancer treatment doesn’t just differ between major organs (colorectal cancer vs. breast cancer). It now hones in on unique characteristics of specifics of a cancer. Likewise, when talking to people who have had a diagnosis of cancer, there are layers of differences in type and stage of cancer, type of treatment and side effects experienced, and other health conditions that may be present.

At the 2021 AICR Research Conference, Neil Iyengar, MD, (researcher and medical oncologist at Memorial Sloan Kettering) predicted in his presentation that we are moving toward “precision nutrition,” in which choices for diet, physical activity and weight maintenance or change may someday be geared to match different cancer or treatment types. For now, however, this remains a theoretical potential. Before we promote tentative findings prematurely, we must remember that there are still many potential consequences of such strategies of which we are currently unaware.

Dietitians around the country are developing innovative, hands-on programs for cancer survivors with realistic healthy eating tips. With adequate financial support from a cancer center or other source, these can be available free of charge to cancer survivors and their families. Habit change isn’t easy for anyone, and people living with and beyond cancer often face extra challenges. Dietitians working one-on-one and in groups can help people create a “new normal” lifestyle.

Right now, referring to these ACS cancer survivor guidelines and evidence-based summaries from organizations like AICR provide as good a map as we have for navigating the twists, turns, and unexpected detours on the path of life with and beyond cancer.

Whether you are a health professional, a person with cancer, or someone who cares about someone with cancer, make sure to check the Resources below.