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Cancer Supportive and Survivorship Care Improving Quality of Life Logo

Healthy Lifestyles
Ernest H. Rosenbaum, MD, Patricia Fobair, LMSW, MPh, and David Spiegel, MD

Factors Influencing Lifestyles
Comorbidities of Obesity, Diabetes and Cardiovascular Disease
Problems in the Workplace and Disability

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A cure does not mark the end of the healing process. Sometimes, it's a difficult transition from the state of illness to one of wellbeing. The goal is to resume as normal a life as possible, but there are major changes following the crisis of a cancer diagnosis and treatment. There are physical, psychological, and social problems that may come to light or persist following the completion of cancer treatment. 

To promote better health and reduce the risk of premature morbidity and mortality, survivors need to improve both the physical and emotional quality of life. Thus it is necessary that survivors acquire and adopt lifestyle changes to help reduce the risk of future morbidity. Unfortunately, with aging new risk factors are constantly evolving requiring new solutions, constant vigilance, and care.

Functional status deteriorates during cancer therapy but usually recovers post-therapy with time. Older cancer patients who have one co-morbidity have twice the risk of experiencing functional debility; with two co-morbidities the risk increases five fold. Some of the problems survivors face post-surgery, chemotherapy and radiation therapy include a decrease in immune functioning, cardiopulmonary toxicity and, in many cases, weight gain.

The diagnosis of cancer not only poses a challenge for survivors, but also necessitates many changes in lifestyle for both the patient and family thus the need to implement preventive, healthy activities including psychosocial support, healthy diet, exercise, sun protection, osteoporosis prevention, smoking cessation, and alcohol abstinence.

Factors Influencing Lifestyles
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Physicians and nurse specialists are best situated to recommend the screening and preventative medicine programs that will promote a better quality of life for post-therapy cancer patients. Survivors frequently adopt behavioral changes, although men with less education, over age 65, and urban occupants make fewer behavior changes.

Improving lifestyles may reduce co-morbid health risks and can help reduce therapy side effects. By controlling their weight with a diet low in saturated fats and high in fruits, vegetables, and whole grains, and implementing exercise activities, survivors can promote longevity. Exercise also promotes positive psychological and emotional wellbeing and quality of life.

Survivors Lifestyle Habits
Survivors frequently adopt better lifestyle habits believing they will improve their longevity and survival. They exercise, eat a prudent-type diet, don't smoke, limit their alcohol consumption, reduce excess sun exposure and initiate osteoporosis prevention programs.

Diet for Survivors
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Post cancer diagnosis diet modifications are common in 30-60% of survivors. These changes generally include decreased consumption of red meat, saturated fat, and trans-fats, and increased consumption of fruits, vegetables and whole grains. Decreased calorie intake and increased exercise are important for weight control, longevity and survival.

In particular, survivors need to acknowledge lifestyle dangers and changes due to obesity. Obesity increases the risk for diabetes, cardiovascular disease and co-morbidities for breast (postmenopausal), prostate, colon, endometrial, kidney, and esophageal cancers. Survivors need to work towards the goal of a body mass index (BMI) (weight[Kg]/height meters squared) of less than 26 to avoid obesity.

The Prudent-type Diet
Eat a well balanced diet
A low fat diet (<20-25% fat calories). Limit saturated fats to 8% of calories.
Decrease animal fats and processed meats
Increase fish intake
Use low-fat dairy foods
A high fiber diet (30-35 g/day). Increase whole grain foods (bread and cereals)
Eat a variety of 8-10 portions of fruits and vegetables/day
Increase cruciferous vegetables
Limit salt-cured, smoked and nitrate cured foods
Limit fried and barbecued foods
Limit alcohol to 1-2/day

For a weight loss diet, exercise is vital. Aerobic exercise is the most effective, although not essential for weight loss. Aerobic exercise is exercise that rhythmically uses the large muscles of the legs and arms to elevate the heart rate within a certain range. Examples are brisk walking, jogging, swimming, bicycling, gardening, dancing, playing actively with children, and sexual activity.

Exercise is correlated with improved quality of life, improved physical functioning (oxygen capacity, improved strength, flexibility and general health), blood pressure, heart rate and circulating hormone level control - thus exercise has many benefits for survivors and longevity.

Preexisting co-morbidities (arthritis, CVD (cardiovascular disease), COPD (chronic obstructive pulmonary disease)) may limit physical and social functioning. For survivors with these conditions, alternate exercise programs such as Tai Chi, Chi Gong and Yoga will help promote muscle strength, flexibility, coordination, balance and body function.

Co-morbidities of Obesity, Diabetes and Cardiovascular Disease
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A recent report from The Journal of the National Cancer Institute, (February 15, 2006) reviewed the percentages of adults at healthy weight, overweight, and obesity from 1971 to 2002. It was noted that 20-30% of cancers in the United States are associated with obesity and lack of exercise. During the study period, ten percent of the population lost weight, but the majority of people gained weight, becoming overweight or obese.

Obesity is a major co-morbidity for breast (postmenopausal), prostate, colon, kidney, esophagus (adenocarcinoma) and endometrial cancers. The proportion of newly diagnosed obese cancer patients is increasing, as is the number of patients who gain weight during and post cancer therapy.

Obesity is also associated with cancer recurrence (breast and prostate), cardiovascular disease, and reduced quality of life. Thus weight control through diet and exercise is crucial for healthy survivorship.

Gradual weight loss in overweight patients is beneficial for control of hypertension, lipid dysfunction and impaired physical function. The American Cancer Society recommends a healthy weight. These diseases associated with obesity, diabetes and cardiovascular disease, are responsible for an increased number of non-cancer related deaths among survivors. In survivors, fully one half of non-cancer related deaths are related to cardiovascular, diabetes, pulmonary and renal disease and non-cancer co-morbidities.

Diabetes is a common, chronic disease. It can lead to eye disease, kidney disease, and nerve damage, and is a risk factor for cardiovascular disease. Most people with diabetes are overweight and have type 2 diabetes or non-insulin dependent diabetes mellitus. Although excellent control of blood sugar levels can decrease the risk of the above complications, prevention of this type of diabetes through lifelong diet modification with weight control with exercise remains the best option for a healthy life.

Exercise plays a key role in reducing cancer risk and can be very beneficial in promoting survival and longevity. It is now well established that for breast and prostate cancers that exercise helps promote longevity and potentially disease control. The risk reduction has been confirmed in many studies, which also provides an understanding of the physiological mechanisms by which exercise effectively reduces breast and prostate cancer risk as well as fatigue, and improves quality of life.

Thus exercise helps reduce obesity and not only improves long-term health, but reduces the risk of several co-morbid conditions including disease progression, possible second primaries, obesity, osteoporosis, cardiovascular disease, diabetes, and functional physical decline. Unfortunately, males who are older and less educated adopt fewer of these necessary changes. It has been estimated that only 25% to 42% of survivors consume adequate amounts of fruits and vegetables, and that 70% of breast and prostate cancer survivors are overweight or obese.

Physical activity programs help improve cardio-respiratory fitness during and post-treatment, and at the same time helps lessen fatigue, and promotes improved vigor with better quality of life and less depression and mental distress.

Tai Chi Chuan (TCC) has been shown to not only improve health-related quality of life, balance, and self-esteem, but could contribute to prolonged longevity. TCC also promotes psychosocial support for improving health-related quality of life.

Tobacco in Survivors
The use of tobacco is diminishing. Fewer cigarettes were sold 2005 than 1951 and more places are now designated as non-smoking areas. There are now more non-smokers than smokers.

But, unfortunately, more children in the 8th grade are now smoking. Quitting rates for lung and head/neck cancer survivors is at about 40% vs. about 4% for breast cancer patients. Unfortunately younger survivors continue to smoke. Smoking has been causally related to lung, bladder, head and neck, cervix, kidney, and esophagus cancer, as well as cardiovascular disease and chronic obstructive pulmonary disease (COPD).

Cessation efforts are necessary for survivors. Five minutes of a physician's advice on how to stop smoking can be very successful.

Alcohol in Survivors
In over 100 studies, alcohol has been shown to be a small to modest cancer risk factor, where one drink a day increases the risk 8-10% and two drinks a day may increase the risk up to about 25%.

Research suggests that the effect of alcohol on breast cancer risk is greater in postmenopausal women with estrogen positive tumors. How and why is unknown, but it appears to raise estrogen levels. Alcohol increases the need for folic acid; thus 400 mcg per day is suggested for those who consume alcohol.

The majority of habitual alcohol drinkers do not eat a nutritious diet, resulting in an additional health deficit. The alcohol abstinence rate for head and neck cancer survivors is about 50%; for breast and lung cancer survivors the abstinence rate is from 8% to 16%.

Reduce Sun Exposure
Excess sun exposure can damage the skin causing premature aging and sometimes cancer. A skin protection program is vital.

Fatigue is one of the major problems during and post therapy requiring an active program for fatigue reduction. Both rest and exercise help in controlling debility and fatigue problems. In addition to treatment effects, fatigue can also be caused by emotional stress, anxiety, depression, pain, and problems sleeping, as well as hormonal problems, such as hypothyroidism (low thyroid function) or anemia due to cancer or its treatment.

Problems in the Workplace and Disability
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Unfortunately, many people do not understand that cancer is not contagious, and their fears may be transmitted and cause problems in the work area. Misconceptions and prejudices can influence how employers and coworkers treat survivors. The fear that a worker will be less productive is not proven to be correct. In a study by Met Life Insurance and Bell Telephone, a survivor's performance showed no difference in job performance versus non-survivors. In fact, survivors often worked harder to prove their worth.

One needs to look at changes directed by superiors at the job, often because of fears that responsibilities cannot be effectively accomplished. There is a social readjustment with coworkers and superiors, who may treat you differently or not promote you as merited. Keeping notes on these problems: if you're discriminated against and legal action is necessary, you will need documentation.

The American Disability Act of 1990 makes it illegal to discriminate against any qualified applicant, who is disabled, has a history of disability, or is perceived to have a disability. Thus, survivors have recourse if they have legitimate complaints (Equal Employment Opportunity Connection, 1801 L Street, NW, Washington, D.C., 20507).

A good resource is the National Coalition for Cancer Survivorship, Silver Springs, Maryland (
More information is also available in: The Institute of Medicine/National Research Council report, From Cancer Patient to Cancer Survivor, Lost in Transition, published in November 2005, and
A Cancer Survivors Almanac by Barbara Hoffman, J.D., the National Coalition for Cancer Survivorship, published in 2004
These two references also have extensive information about health insurance and employment issues for survivors.

Additional resources:

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