THE MICHIGAN SYMPOSIUM FOR INTEGRATIVE ONCOLOGY
Amway Grand Plaza Hotel, Grand Rapids, Michigan
September 23, 2005
Report by Holly Kiger, RN, MN
INTEGRATING NUTRITIONAL THERAPY INTO CANCER CARE
Speaker: Kim Dalzell, PhD, RD, LD
Director, Holistic Nutrition Services, Cancer Resource Center
President, NutriQuest, Inc.
Author, Challenge Cancer and Win
(Nutritional plans for 16 different cancers)
Dr. Dalzell began by discussing the Segregated Model of Cancer care where radiation, surgical and medical oncology are often separated from complementary and alternative medicine/therapy. She talked about patients feeling like they need to choose their complementary therapy all on their own, without medical consultations.
They feel like they’re left in the dark, and/or are told to stay away from complementary care. This often leads to self-prescriptions of nutritional care. Over 50% have never talked to a dietitian, but instead rely on family, friends, health food stores, magazines, etc.
55% took one or more dietary supplements according to the Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994 Cancer 91(5) 1040-5, Mar 2001
She cites a survey of 978 early stage breast & cervical cancer patients. 57% wanted nutritional guidance at time of diagnosis or sometime thereafter, yet few reported ever having received recommendations from their MDs. 75% preferred a CAM referral from their physician and 2/3 felt that CAM care providers should be encouraged by their medical providers.
85% felt that CAM care should be offered at the cancer center as part of their oncology treatment. (Cancer 88:3674-84, Feb 2000 & Cancer Practice 6(3): 176 May 1988)
Dr. Dalzell then discussed a very interesting study from the University of Toronto that surveyed the views of 200 ovarian cancer survivors on its cause, prevention and recurrence.
Women reported their perceived main causes as stress (65%), diet (39%), genes (36%), environment (33%) and hormones (30%). They credited the following for their lack of recurrence: Positive attitude (83%), close medical follow-up (82%), healthy lifestyle (69%), prayer (68%), stress reduction (66%), diet (63%) and exercise (59%) (Medscape Women‘s Health 6(5):5, Oct 2001)
Another study at the University of Toronto surveyed 378 women 2 years after a diagnosis of breast cancer. These women answered the “What caused your cancer?” as stress (42%), genes (26%), environment (26%), hormones (24%), don't know (27%), diet (16%) and breast trauma (3%) (Psych Oncology 10(2):179-83 Mar-Apr 2001).
When asked, “Why do you think you are cancer free?” responses were very interesting. Only 3.9% credited Tamoxifen for their lack of recurrence. Other responses were positive attitude (40%), exercise (39%). stress reduction (28%), prayer (26%), and CAM therapies (11%).
She then discussed nutrition-related concerns during and after treatment. These include maintaining optimal weight, minimalizing side effects of treatments, creating an optimal diet plan for immune system support, quality of life, and Integrating ‘eating right’ into family life.
She sees a very important role for the registered dietitian/nutritionist in cancer care. Important activities include screening for malnutrition and recommending nutritional support, providing natural therapy suggestions for treatment-specific side effects, educating patients on drug-nutrient interactions, providing individualized dietary counseling specific to diagnosis and other health issues, and educating patients about alternative nutritional therapies, including dietary supplements and accessory nutrients.
She discussed the common problems of inadequate food intake including a compromised immune function from anorexia, metabolic abnormalities, fatigue and GI dysfunction. She listed the many tools available to assess nutrition including the following Malnutrition Assessment Tools:
· Calculate energy/protein requirements
· Evaluate nutrition intake via diet history and recall
· BMI=weight/height
· Laboratory assay review (albumin, transferring)
· Subjective Global Assessment (SGA)
· Bioelectrical Impedance Assessment (BIA) (good for long term analysis to make sure they’re not losing muscle instead of fat)
Dr. Dalzell then presented the nutrition support continuum which includes nutrient dense foods and drinks (such as peanut butter and bananas), appetite stimulants, enteral feeding (for neck cancers when the GI tract is disrupted for long periods), and parenteral feedings.
She emphasized the importance of nutritional support for survival by citing studies showing that 40% of cancer patients die from malnutrition-related causes. Nutrition support has been shown to reduce complication rates of surgery by 33%.
Nutrition support has been shown to improve survival rates, without affecting tumor growth. (Nutrition 6S-7S, 10S, 1990; Nutr Hosp 14:43S-52S, 1999; & Crit Rev Oncol Hematol 34: 137-68, 2000)
She cited a study to look at the questions of whether dietary counseling reduced side effects and enhanced quality of life (QoL) for cancer patients.
This study of 111 patients showed that 90% maintained better QoL with dietary counseling, and used fewer anti emetic and anti-diarrhea medications. (J Clin Oncol 1:23(7)1431-8, 2005)
She listed the following as natural therapies for side effects of cancer treatments:
Cachexia (the wasting away of the cancer patient’s body)- fish oil
Constipation – flax, cascara sagrada
Diarrhea- chamomile, pectin
Maldigestion – probiotics, digestive enzymes, food intolerance testing
Mouth sores – Vitamin E, L-glutamine
Nausea – Ginger, sea-bands
Taste alterations – Zinc, lemon wedges
Dr. Dalzell then discussed cancer patients’ use of antioxidants (A/O). Research shows that 25-80% of cancer patients use nutritional supplements containing A/O (vitamin E, A, etc.) to enhance treatment, alleviate side effects or maintain/enhance well being. (JAMA 280:1569-75, 1998 & JAMA 98:285-92, 1998)
She said that it is a mistake when we try to give a simplistic answer to this complex issue. It’s much better to say,”It’s a good question. We don’t have the answers yet”. Proponents can point to studies in animals.
On the other hand, we know that you can't really apply these studies in humans. In fact, there’s some indication that some A/Os decrease the effectiveness of cancer treatments. In September 2005 research released from Memorial Sloan Kettering recommended that the use of antioxidant supplements should be avoided because of studies showing chemotherapy-A/O interactions.
They stated their concerns that reduction of a few percentage points in efficacy of chemotherapy may lead to hundreds of deaths each year.
However, monitoring of O/A during treatment shows that A/O capacity decreases as treatment progresses, and A/O capacity lowers significantly during the intensive phase of treatment.
The good news is that dietary intake of A/O has been shown to decrease the incidence of this toxicity. (Amer J Clin Nutr 79:1029-36, 2004 & Pediatr Blood Cancer 44:378-85, 2004)
Therefore, she encouraged eating the following foods high in antioxidants, in consultation with a nutritional expert:
· Nuts: brazil nuts, almonds, sesame seeds
· Fruits: blackberries, blueberries, cherries, oranges, plums, strawberries, raisins, raspberries, red grapes, tomatoes
· Vegetables: beets, broccoli/sprouts, Brussels sprouts, cabbage, cauliflower, collards, corn, garlic, onion, red peppers, spinach
Finally Dr. Dalzell recommended that patients evaluate alternative nutritional therapies by asking the following questions: Does it sound too good to be true? What is the source of the information? Will this therapy create safety concerns? How have the benefits been demonstrated?
Kristi Tuck: Movement & Exercise for Cancer Patients
The Michigan Symposium for Integrative Oncology
Amway Grand Plaza Hotel, Grand Rapids, Michigan
September 23, 2005
Report by Holly Kiger, RN, MN
MOVEMENT THERAPY AND EXERCISE PROGRAMS FOR CANCER PATIENTS
Panel: Kristi Tuck, Michigan Athletic Club, Cancer WellFit® Program; Rick Powell, Heart Yoga Center; Mark Eastburg, Ph.D., Lacks Cancer Center
Dr. Eastburg gave an overview of the cancer and exercise research literature. Approximately 50 studies have been done on exercise in cancer survivors, including several important review articles. Studies have consistently demonstrated the following:
· Physical exercise has a positive effect on QOL after cancer diagnosis. (Courneya & Friedenreich, 1999)
· Overall the reviewed studies showed some promising effects…during and after cancer treatment. (Oldervoll et al, 2004)
· Evidence underlies the preliminary positive physiological and psychological benefits from exercise when undertaken during or after traditional cancer treatment. (Galvao and Netwon, 2005)
· There is preliminary evidence that exercise interventions for cancer patients can lead to moderate increases in physical function and are not associated with increased symptoms of fatigue. (Stevinson et al; 2004)
Nature of the Research on Cancer on Exercise
Research on cancer and exercise has been studied in many types of cancer including breast, prostate, lung, acute leukemia, and lymphomas. Many types of exercise have been studied including cycle ergometer, walking, resistance training, and stretching.
Outcomes studied include physical characteristics (muscle strength, body weight and composition, cardiovascular capacity) symptoms (pain fatigue, nausea, diarrhea) emotional (depression anxiety, mood, anger) and overall quality of life and functional capacity.
The limitations of current research include sampling problems (heterogeneous, selection bias), intervention variability (duration, type, intensity), outcome instrument heterogeneity, assessors not blinded to treatment vs. control subjects.
Cancer Wellfit
Kristi Tuck, BS, ACSM (616-956-8003 x247)
Adam Jauregui, BS (616-956-8003 x316)
The Saint Marys ‘Cancer Wellfit Program, started at the Michigan Athletic Club (MAC) in 2001, is based on the Santa Barbara Athletic club model. Over the past four years 300+ cancer survivors have enrolled in this supervised exercise program.
The instructional format for the program includes the following:
· 10 week exercise program 2X/week with an emphasis on strength straining. A full membership to the facility is granted during the 10-week program for the participant and their support person. Cardiovascular exercise is explained in the beginning of the program and increases as the participant gains strength. One lecture on nutrition and one class session on yoga are included.
· $23,000 grant from Lance Armstrong Foundation supported the second year, and added coverage for 5 sessions for the support person.
· Most were women, and most (64%) were breast cancer patients. Ages range from 18-84, with demographics moving towards younger patients.
· Ongoing funding was obtained from St. Mary’s and the fitness center.
Results included more than 66% believed that attending a supervised exercise program was a form of support network.
The program is structured and supportive of the recovery process. Within the class format, the exercise protocols are individualized for each participant. Patients receive the benefits of a support program (sense of belonging, help through a difficult period, assigned a task and goal setting, working through discomfort, etc.) similar to the effects of group therapy (sharing thoughts on cancer, recovery process, feelings of hope and a sense of belonging). Participants are expected to attend all training sessions and participate in pre and post assessment screening
The testing protocol includes:
· Resting Heart Rate
· Resting Blood Pressure
· Harvard Step Test (stepping up and down to the beat of a metronome for three minutes with post exercise heart rate)
· Muscular Endurance (prone hover until fatigue to determine core body strength)
· Core Strength (various core strength tests to determine fitness levels)
She recommended Cancer Fitness by Anna Swartz (forward by Lance Armstrong)
September 23, 2005
Report by Holly Kiger, RN, MN
INTEGRATING NUTRITIONAL THERAPY INTO CANCER CARE
Speaker: Kim Dalzell, PhD, RD, LD
Director, Holistic Nutrition Services, Cancer Resource Center
President, NutriQuest, Inc.
Author, Challenge Cancer and Win
(Nutritional plans for 16 different cancers)
Dr. Dalzell began by discussing the Segregated Model of Cancer care where radiation, surgical and medical oncology are often separated from complementary and alternative medicine/therapy. She talked about patients feeling like they need to choose their complementary therapy all on their own, without medical consultations.
They feel like they’re left in the dark, and/or are told to stay away from complementary care. This often leads to self-prescriptions of nutritional care. Over 50% have never talked to a dietitian, but instead rely on family, friends, health food stores, magazines, etc.
55% took one or more dietary supplements according to the Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994 Cancer 91(5) 1040-5, Mar 2001
She cites a survey of 978 early stage breast & cervical cancer patients. 57% wanted nutritional guidance at time of diagnosis or sometime thereafter, yet few reported ever having received recommendations from their MDs. 75% preferred a CAM referral from their physician and 2/3 felt that CAM care providers should be encouraged by their medical providers.
85% felt that CAM care should be offered at the cancer center as part of their oncology treatment. (Cancer 88:3674-84, Feb 2000 & Cancer Practice 6(3): 176 May 1988)
Dr. Dalzell then discussed a very interesting study from the University of Toronto that surveyed the views of 200 ovarian cancer survivors on its cause, prevention and recurrence.
Women reported their perceived main causes as stress (65%), diet (39%), genes (36%), environment (33%) and hormones (30%). They credited the following for their lack of recurrence: Positive attitude (83%), close medical follow-up (82%), healthy lifestyle (69%), prayer (68%), stress reduction (66%), diet (63%) and exercise (59%) (Medscape Women‘s Health 6(5):5, Oct 2001)
Another study at the University of Toronto surveyed 378 women 2 years after a diagnosis of breast cancer. These women answered the “What caused your cancer?” as stress (42%), genes (26%), environment (26%), hormones (24%), don't know (27%), diet (16%) and breast trauma (3%) (Psych Oncology 10(2):179-83 Mar-Apr 2001).
When asked, “Why do you think you are cancer free?” responses were very interesting. Only 3.9% credited Tamoxifen for their lack of recurrence. Other responses were positive attitude (40%), exercise (39%). stress reduction (28%), prayer (26%), and CAM therapies (11%).
She then discussed nutrition-related concerns during and after treatment. These include maintaining optimal weight, minimalizing side effects of treatments, creating an optimal diet plan for immune system support, quality of life, and Integrating ‘eating right’ into family life.
She sees a very important role for the registered dietitian/nutritionist in cancer care. Important activities include screening for malnutrition and recommending nutritional support, providing natural therapy suggestions for treatment-specific side effects, educating patients on drug-nutrient interactions, providing individualized dietary counseling specific to diagnosis and other health issues, and educating patients about alternative nutritional therapies, including dietary supplements and accessory nutrients.
She discussed the common problems of inadequate food intake including a compromised immune function from anorexia, metabolic abnormalities, fatigue and GI dysfunction. She listed the many tools available to assess nutrition including the following Malnutrition Assessment Tools:
· Calculate energy/protein requirements
· Evaluate nutrition intake via diet history and recall
· BMI=weight/height
· Laboratory assay review (albumin, transferring)
· Subjective Global Assessment (SGA)
· Bioelectrical Impedance Assessment (BIA) (good for long term analysis to make sure they’re not losing muscle instead of fat)
Dr. Dalzell then presented the nutrition support continuum which includes nutrient dense foods and drinks (such as peanut butter and bananas), appetite stimulants, enteral feeding (for neck cancers when the GI tract is disrupted for long periods), and parenteral feedings.
She emphasized the importance of nutritional support for survival by citing studies showing that 40% of cancer patients die from malnutrition-related causes. Nutrition support has been shown to reduce complication rates of surgery by 33%.
Nutrition support has been shown to improve survival rates, without affecting tumor growth. (Nutrition 6S-7S, 10S, 1990; Nutr Hosp 14:43S-52S, 1999; & Crit Rev Oncol Hematol 34: 137-68, 2000)
She cited a study to look at the questions of whether dietary counseling reduced side effects and enhanced quality of life (QoL) for cancer patients.
This study of 111 patients showed that 90% maintained better QoL with dietary counseling, and used fewer anti emetic and anti-diarrhea medications. (J Clin Oncol 1:23(7)1431-8, 2005)
She listed the following as natural therapies for side effects of cancer treatments:
Cachexia (the wasting away of the cancer patient’s body)- fish oil
Constipation – flax, cascara sagrada
Diarrhea- chamomile, pectin
Maldigestion – probiotics, digestive enzymes, food intolerance testing
Mouth sores – Vitamin E, L-glutamine
Nausea – Ginger, sea-bands
Taste alterations – Zinc, lemon wedges
Dr. Dalzell then discussed cancer patients’ use of antioxidants (A/O). Research shows that 25-80% of cancer patients use nutritional supplements containing A/O (vitamin E, A, etc.) to enhance treatment, alleviate side effects or maintain/enhance well being. (JAMA 280:1569-75, 1998 & JAMA 98:285-92, 1998)
She said that it is a mistake when we try to give a simplistic answer to this complex issue. It’s much better to say,”It’s a good question. We don’t have the answers yet”. Proponents can point to studies in animals.
On the other hand, we know that you can't really apply these studies in humans. In fact, there’s some indication that some A/Os decrease the effectiveness of cancer treatments. In September 2005 research released from Memorial Sloan Kettering recommended that the use of antioxidant supplements should be avoided because of studies showing chemotherapy-A/O interactions.
They stated their concerns that reduction of a few percentage points in efficacy of chemotherapy may lead to hundreds of deaths each year.
However, monitoring of O/A during treatment shows that A/O capacity decreases as treatment progresses, and A/O capacity lowers significantly during the intensive phase of treatment.
The good news is that dietary intake of A/O has been shown to decrease the incidence of this toxicity. (Amer J Clin Nutr 79:1029-36, 2004 & Pediatr Blood Cancer 44:378-85, 2004)
Therefore, she encouraged eating the following foods high in antioxidants, in consultation with a nutritional expert:
· Nuts: brazil nuts, almonds, sesame seeds
· Fruits: blackberries, blueberries, cherries, oranges, plums, strawberries, raisins, raspberries, red grapes, tomatoes
· Vegetables: beets, broccoli/sprouts, Brussels sprouts, cabbage, cauliflower, collards, corn, garlic, onion, red peppers, spinach
Finally Dr. Dalzell recommended that patients evaluate alternative nutritional therapies by asking the following questions: Does it sound too good to be true? What is the source of the information? Will this therapy create safety concerns? How have the benefits been demonstrated?
Kristi Tuck: Movement & Exercise for Cancer Patients
The Michigan Symposium for Integrative Oncology
Amway Grand Plaza Hotel, Grand Rapids, Michigan
September 23, 2005
Report by Holly Kiger, RN, MN
MOVEMENT THERAPY AND EXERCISE PROGRAMS FOR CANCER PATIENTS
Panel: Kristi Tuck, Michigan Athletic Club, Cancer WellFit® Program; Rick Powell, Heart Yoga Center; Mark Eastburg, Ph.D., Lacks Cancer Center
Dr. Eastburg gave an overview of the cancer and exercise research literature. Approximately 50 studies have been done on exercise in cancer survivors, including several important review articles. Studies have consistently demonstrated the following:
· Physical exercise has a positive effect on QOL after cancer diagnosis. (Courneya & Friedenreich, 1999)
· Overall the reviewed studies showed some promising effects…during and after cancer treatment. (Oldervoll et al, 2004)
· Evidence underlies the preliminary positive physiological and psychological benefits from exercise when undertaken during or after traditional cancer treatment. (Galvao and Netwon, 2005)
· There is preliminary evidence that exercise interventions for cancer patients can lead to moderate increases in physical function and are not associated with increased symptoms of fatigue. (Stevinson et al; 2004)
Nature of the Research on Cancer on Exercise
Research on cancer and exercise has been studied in many types of cancer including breast, prostate, lung, acute leukemia, and lymphomas. Many types of exercise have been studied including cycle ergometer, walking, resistance training, and stretching.
Outcomes studied include physical characteristics (muscle strength, body weight and composition, cardiovascular capacity) symptoms (pain fatigue, nausea, diarrhea) emotional (depression anxiety, mood, anger) and overall quality of life and functional capacity.
The limitations of current research include sampling problems (heterogeneous, selection bias), intervention variability (duration, type, intensity), outcome instrument heterogeneity, assessors not blinded to treatment vs. control subjects.
Cancer Wellfit
Kristi Tuck, BS, ACSM (616-956-8003 x247)
Adam Jauregui, BS (616-956-8003 x316)
The Saint Marys ‘Cancer Wellfit Program, started at the Michigan Athletic Club (MAC) in 2001, is based on the Santa Barbara Athletic club model. Over the past four years 300+ cancer survivors have enrolled in this supervised exercise program.
The instructional format for the program includes the following:
· 10 week exercise program 2X/week with an emphasis on strength straining. A full membership to the facility is granted during the 10-week program for the participant and their support person. Cardiovascular exercise is explained in the beginning of the program and increases as the participant gains strength. One lecture on nutrition and one class session on yoga are included.
· $23,000 grant from Lance Armstrong Foundation supported the second year, and added coverage for 5 sessions for the support person.
· Most were women, and most (64%) were breast cancer patients. Ages range from 18-84, with demographics moving towards younger patients.
· Ongoing funding was obtained from St. Mary’s and the fitness center.
Results included more than 66% believed that attending a supervised exercise program was a form of support network.
The program is structured and supportive of the recovery process. Within the class format, the exercise protocols are individualized for each participant. Patients receive the benefits of a support program (sense of belonging, help through a difficult period, assigned a task and goal setting, working through discomfort, etc.) similar to the effects of group therapy (sharing thoughts on cancer, recovery process, feelings of hope and a sense of belonging). Participants are expected to attend all training sessions and participate in pre and post assessment screening
The testing protocol includes:
· Resting Heart Rate
· Resting Blood Pressure
· Harvard Step Test (stepping up and down to the beat of a metronome for three minutes with post exercise heart rate)
· Muscular Endurance (prone hover until fatigue to determine core body strength)
· Core Strength (various core strength tests to determine fitness levels)
She recommended Cancer Fitness by Anna Swartz (forward by Lance Armstrong)
