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Nutrition in acute and chronic diseases

Evidence-based nutrition guidelines for cancer survivors in Europe: a call for action

European Journal of Clinical Nutrition volume 76, pages 819–826 (2022)Cite this article

Subjects

Abstract

Background/Objectives

The aims of this study were to (1) document currently available guidelines aimed at healthcare professionals and including some information on the nutritional management of cancer survivors in Europe; (2) assess the quality of these guidelines and (3) document the nutrition recommendations promoted.

Methods

Four search strategies were implemented in 2018 and updated in 2021 to locate guidelines. Papers were included if they described a European guideline or recommendation for cancer survivors that contained nutrition guidance and there were no language restrictions. Two reviewers independently assessed guideline quality using the AGREE II instrument and nutrition content was extracted and summarised.

Results

Five guidelines (of 593 documents located through the searches) met the inclusion criteria. The ESPEN guidelines were deemed to have the highest methodological quality. Limited information on nutrition was available in these guidelines with the majority of focus being on the promotion of fruit, vegetables and wholegrains and reducing fat, red meat and alcohol. Weight management was mentioned by all five guidelines. There was no detailed information available for cancer survivors or their healthcare team and no practical strategies for the implementation of recommendations.

Conclusions

There is a need for nutrition guidelines specific for cancer survivors in a European setting. Current guidelines are limited and focus on broad recommendations, while lacking in practical strategies for implementation. There is also a tendency to recommend cancer prevention guidelines be used for cancer survivors rather than developing specific guidance for this group.

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References

  1. Gatta G, Botta L, Rossi S, Aareleid T, Bielska-Lasota M, Clavel J, et al. Childhood cancer survival in Europe 1999-2007: results of EUROCARE-5-a population-based study. Lancet Oncol. 2014;15:35–47. https://doi.org/10.1016/s1470-2045(13)70548-5.

    Article  PubMed  Google Scholar 

  2. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE-5-a population-based study. Lancet Oncol. 2014;15:23–34. https://doi.org/10.1016/s1470-2045(13)70546-1.

    Article  PubMed  Google Scholar 

  3. DeSantis CE, Lin CC, Mariotto AB, Siegel RL, Stein KD, Kramer JL, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64:252–71. https://doi.org/10.3322/caac.21235.

    Article  PubMed  Google Scholar 

  4. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36:11–48. https://doi.org/10.1016/j.clnu.2016.07.015.

    Article  PubMed  Google Scholar 

  5. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62:243–74. https://doi.org/10.3322/caac.21142.

    Article  PubMed  Google Scholar 

  6. Schwedhelm C, Boeing H, Hoffmann G, Aleksandrova K, Schwingshackl L. Effect of diet on mortality and cancer recurrence among cancer survivors: a systematic review and meta-analysis of cohort studies. Nutr Rev. 2016;74:737–48. https://doi.org/10.1093/nutrit/nuw045.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Jones LW, Demark-Wahnefried W. Diet, exercise, and complementary therapies after primary treatment for cancer. Lancet Oncol. 2006;7:1017–26. https://doi.org/10.1016/s1470-2045(06)70976-7.

    Article  PubMed  Google Scholar 

  8. Pekmezi DW, Demark-Wahnefried W. Updated evidence in support of diet and exercise interventions in cancer survivors. Acta Oncologica. 2011;50:167–78. https://doi.org/10.3109/0284186X.2010.529822.

    Article  PubMed  Google Scholar 

  9. Nechuta SJ, Caan BJ, Chen WY, Flatt SW, Lu W, Patterson RE, et al. The After Breast Cancer Pooling Project: rationale, methodology, and breast cancer survivor characteristics. Cancer Causes Control CCC. 2011;22:1319–31. https://doi.org/10.1007/s10552-011-9805-9.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Keaver L. Irish cancer patients and survivors have a positive view of the role of nutritional care in cancer management from diagnosis through survivorship. Irish J Med Sci. 2021. https://doi.org/10.1007/s11845-020-02488-w.

  11. Muscaritoli M, Molfino A, Scala F, De Lorenzo F, Christoforidi K, Manneh-Vangramberen I. European survey of 907 people with cancer about the importance of nutrition. Ann Oncol. 2017;28:v513–v4. https://doi.org/10.1093/annonc/mdx385.007.

    Article  Google Scholar 

  12. Beeken RJ, Williams K, Wardle J, Croker H. “What about diet?” A qualitative study of cancer survivors’ views on diet and cancer and their sources of information. Eur J Cancer Care. 2016;25:774–83. https://doi.org/10.1111/ecc.12529.

    Article  CAS  Google Scholar 

  13. Zhang FF, Liu S, John EM, Must A, Demark-Wahnefried W. Diet quality of cancer survivors and noncancer individuals: results from a national survey. Cancer. 2015;121:4212–21. https://doi.org/10.1002/cncr.29488.

    Article  CAS  PubMed  Google Scholar 

  14. Grimmett C, Bridgewater J, Steptoe A, Wardle J. Lifestyle and quality of life in colorectal cancer survivors. Qual life Res. 2011;20:1237–45. https://doi.org/10.1007/s11136-011-9855-1.

    Article  PubMed  Google Scholar 

  15. Smith WA, Nolan VG, Robison LL, Hudson MM, Ness KK. Physical activity among cancer survivors and those with no history of cancer- a report from the National Health and Nutrition Examination Survey 2003-2006. Am J Transl Res. 2011;3:342–50.

    PubMed  PubMed Central  Google Scholar 

  16. Williams K, Steptoe A, Wardle J. Is a cancer diagnosis a trigger for health behaviour change? Findings from a prospective, population-based study. Br J Cancer. 2013;108:2407–12. https://doi.org/10.1038/bjc.2013.254.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Grimmett C, Wardle J, Steptoe A. Health behaviours in older cancer survivors in the English Longitudinal Study of Ageing. Eur J Cancer. 2009;45:2180–6. https://doi.org/10.1016/j.ejca.2009.02.024.

    Article  PubMed  Google Scholar 

  18. Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26:2198–204. https://doi.org/10.1200/jco.2007.14.6217.

    Article  PubMed  Google Scholar 

  19. Koutoukidis DA, Beeken RJ, Lopes S, Knobf MT, Lanceley A. Attitudes, challenges and needs about diet and physical activity in endometrial cancer survivors: a qualitative study. Eur J Cancer Care. 2017;26. https://doi.org/10.1111/ecc.12531.

  20. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10:38–43.

    PubMed  PubMed Central  Google Scholar 

  21. Schmidt K, Ernst E. Assessing websites on complementary and alternative medicine for cancer. Ann Oncol. 2004;15:733–42. https://doi.org/10.1093/annonc/mdh174.

    Article  CAS  PubMed  Google Scholar 

  22. Hestevik CH, Molin M, Debesay J, Bergland A, Bye A. Healthcare professionals’ experiences of providing individualized nutritional care for Older People in hospital and home care: a qualitative study. BMC Geriatrics. 2019;19:317 https://doi.org/10.1186/s12877-019-1339-0.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Murphy JL, Munir F, Davey F, Miller L, Cutress R, White R, et al. The provision of nutritional advice and care for cancer patients: a UK national survey of healthcare professionals. Support Care Cancer. 2020. https://doi.org/10.1007/s00520-020-05736-y.

  24. Keaver L, Connolly P, Richmond J. Providing nutrition advice in the oncology setting: a survey of current practice, awareness of guidelines and training needs of Irish healthcare professionals in three hospitals. Eur J Cancer Care. 2021:e13405. https://doi.org/10.1111/ecc.13405.

  25. Murad MH, Wang Z. Guidelines for reporting meta-epidemiological methodology research. Evid Based Med. 2017;22:139 https://doi.org/10.1136/ebmed-2017-110713.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Can Med Assoc J. 2010;182:E839–E42. https://doi.org/10.1503/cmaj.090449.

    Article  Google Scholar 

  27. Barriocanal AM, López A, Monreal M, Montané E. Quality assessment of peripheral artery disease clinical guidelines. J Vasc Surg. 2016;63:1091–8. https://doi.org/10.1016/j.jvs.2015.12.040.

    Article  PubMed  Google Scholar 

  28. Madera Anaya MV, Franco JV, Merchán-Galvis ÁM, Gallardo CR, Bonfill Cosp X. Quality assessment of clinical practice guidelines on treatments for oral cancer. Cancer Treat Rev. 2018;65:47–53. https://doi.org/10.1016/j.ctrv.2018.03.001.

    Article  PubMed  Google Scholar 

  29. Barnadas A, Algara M, Cordoba O, Casas A, Gonzalez M, Marzo M, et al. Recommendations for the follow-up care of female breast cancer survivors: a guideline of the Spanish Society of Medical Oncology (SEOM), Spanish Society of General Medicine (SEMERGEN), Spanish Society for Family and Community Medicine (SEMFYC), Spanish Society for General and Family Physicians (SEMG), Spanish Society of Obstetrics and Gynecology (SEGO), Spanish Society of Radiation Oncology (SEOR), Spanish Society of Senology and Breast Pathology (SESPM), and Spanish Society of Cardiology (SEC). Clin Transl Oncol. 2018;20:687–94. https://doi.org/10.1007/s12094-017-1801-4.

    Article  CAS  PubMed  Google Scholar 

  30. de las Peñas R, Majem M, Perez-Altozano J, Virizuela JA, Cancer E, Diz P, et al. SEOM clinical guidelines on nutrition in cancer patients (2018). Clin Transl Oncol. 2019;21:87–93. https://doi.org/10.1007/s12094-018-02009-3.

    Article  PubMed  Google Scholar 

  31. World Cancer Research Fund/American Institute for Cancer Research. Diet, nutrition, physical activity and cancer: a global perspective. Continuous Update Project Expert Report. 2018. https://www.wcrf.org/dietandcancer.

  32. Arends J, Bertz H, Bischoff SC, Fietkau R, Herrmann HJ, Holm E, et al. S3-Leitline der Deutschen Gesellschaft für Ernährungsmedizin e. V. (DGEM) in Kooperation mit der Deutschen Gesellschaft für Hämatologie und Onkologie e. V. (DGHO), der Arbeitsgemeinschaft „Supportive Maßnahmen in der Onkologie, Rehabilitation und Sozialmedizin“ der Deutschen Krebsgesellschaft (ASORS) und der Österreichischen Arbeitsgemeinschaft für klinische Ernährung (AKE). Aktuelle Ernährungsmedizin. 2015;40:e1–e74.

    Article  Google Scholar 

  33. Molino C, Leite-Santos NC, Gabriel FC, Wainberg SK, Vasconcelos LP, Mantovani-Silva RA, et al. Factors associated with high-quality guidelines for the pharmacologic management of chronic diseases in primary care: a systematic review. JAMA Intern Med. 2019;179:553–60. https://doi.org/10.1001/jamainternmed.2018.7529.

    Article  PubMed  Google Scholar 

  34. Gillespie BM, Bull C, Walker R, Lin F, Roberts S, Chaboyer W. Quality appraisal of clinical guidelines for surgical site infection prevention: a systematic review. Plos One. 2018;13:e0203354 https://doi.org/10.1371/journal.pone.0203354.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Pavenski K, Stanworth S, Fung M, Wood EM, Pink J, Murphy MF, et al. Quality of evidence-based guidelines for transfusion of red blood cells and plasma: a systematic review. Transfus Med Rev. 2018. https://doi.org/10.1016/j.tmrv.2018.05.004.

  36. Zhao Y, Lu H, Zang Y, Li X. A systematic review of clinical practice guidelines on uncomplicated birth. BJOG: Int J Obstet Gynaecol. 2020;127:789–97. https://doi.org/10.1111/1471-0528.16073.

    Article  CAS  Google Scholar 

  37. Rauh S, Antonuzzo A, Bossi P, Eckert R, Fallon M, Fröbe A, et al. Nutrition in patients with cancer: a new area for medical oncologists? A practising oncologist’s interdisciplinary position paper. ESMO Open. 2018;3:e000345 https://doi.org/10.1136/esmoopen-2018-000345.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Devries S. A global deficiency of nutrition education in physician training: the low hanging fruit in medicine remains on the vine. Lancet Planet Health. 2019;3:e371–e2. https://doi.org/10.1016/S2542-5196(19)30173-1.

    Article  PubMed  Google Scholar 

  39. Downer S, Berkowitz SA, Harlan TS, Olstad DL, Mozaffarian D. Food is medicine: actions to integrate food and nutrition into healthcare. BMJ. 2020;369:m2482 https://doi.org/10.1136/bmj.m2482.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Wolfson JA, Ramsing R, Richardson CR, Palmer A. Barriers to healthy food access: associations with household income and cooking behavior. Preventive Med Rep. 2019;13:298–305. https://doi.org/10.1016/j.pmedr.2019.01.023.

    Article  Google Scholar 

  41. Bagley HJ, Short H, Harman NL, Hickey HR, Gamble CL, Woolfall K, et al. A patient and public involvement (PPI) toolkit for meaningful and flexible involvement in clinical trials – a work in progress. Res Involv Engagem. 2016;2:15 https://doi.org/10.1186/s40900-016-0029-8.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Kwan ML, Weltzien E, Kushi LH, Castillo A, Slattery ML, Caan BJ. Dietary patterns and breast cancer recurrence and survival among women with early-stage breast cancer. J Clin Oncol. 2009;27:919–26. https://doi.org/10.1200/JCO.2008.19.4035.

    Article  PubMed  Google Scholar 

  43. Kroenke CH, Fung TT, Hu FB, Holmes MD. Dietary patterns and survival after breast cancer diagnosis. J Clin Oncol. 2005;23:9295–303. https://doi.org/10.1200/jco.2005.02.0198.

    Article  PubMed  Google Scholar 

  44. Pierce JP, Natarajan L, Caan BJ, Parker BA, Greenberg ER, Flatt SW, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women’s Healthy Eating and Living (WHEL) randomized trial. JAMA. 2007;298:289–98. https://doi.org/10.1001/jama.298.3.289.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Meyerhardt JA, Niedzwiecki D, Hollis D, Saltz LB, Hu FB, Mayer RJ, et al. Association of dietary patterns with cancer recurrence and survival in patients with stage III colon cancer. JAMA. 2007;298:754–64. https://doi.org/10.1001/jama.298.7.754.

    Article  CAS  PubMed  Google Scholar 

  46. World Health Organisation. Healthy diets. World Health Organisation. 2020. https://www.who.int/news-room/fact-sheets/detail/healthy-diet. Accessed 06 Sept 2021.

  47. Siegel EM, Ulrich CM, Poole EM, Holmes RS, Jacobsen PB, Shibata D. The effects of obesity and obesity-related conditions on colorectal cancer prognosis. Cancer Control J Moffitt Cancer Cent. 2010;17:52–7. https://doi.org/10.1177/107327481001700107.

    Article  Google Scholar 

  48. Meyerhardt JA. Beyond standard adjuvant therapy for colon cancer: role of nonstandard interventions. Semin Oncol. 2011;38:533–41. https://doi.org/10.1053/j.seminoncol.2011.05.007.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Golabek T, Bukowczan J, Chłosta P, Powroźnik J, Dobruch J, Borówka A. Obesity and prostate cancer incidence and mortality: a systematic review of prospective cohort studies. Urologia Internationalis. 2014;92:7–14. https://doi.org/10.1159/000351325.

    Article  CAS  PubMed  Google Scholar 

  50. Allott EH, Masko EM, Freedland SJ. Obesity and prostate cancer: weighing the evidence. Eur Urol. 2013;63:800–9. https://doi.org/10.1016/j.eururo.2012.11.013.

    Article  CAS  PubMed  Google Scholar 

  51. Bassett JK, Severi G, Baglietto L, MacInnis RJ, Hoang HN, Hopper JL, et al. Weight change and prostate cancer incidence and mortality. Int J Cancer. 2012;131:1711–9. https://doi.org/10.1002/ijc.27414.

    Article  CAS  PubMed  Google Scholar 

  52. Vance V, Mourtzakis M, McCargar L, Hanning R. Weight gain in breast cancer survivors: prevalence, pattern and health consequences. Obes Rev. 2011;12:282–94. https://doi.org/10.1111/j.1467-789X.2010.00805.x.

    Article  CAS  PubMed  Google Scholar 

  53. Caan BJ, Kwan ML, Shu XO, Pierce JP, Patterson RE, Nechuta SJ, et al. Weight change and survival after breast cancer in the after breast cancer pooling project. Cancer epidemiology, biomarkers & prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive. Oncology. 2012;21:1260–71. https://doi.org/10.1158/1055-9965.EPI-12-0306.

    Article  Google Scholar 

  54. Nichols HB, Trentham-Dietz A, Egan KM, Titus-Ernstoff L, Holmes MD, Bersch AJ, et al. Body mass index before and after breast cancer diagnosis: associations with all-cause, breast cancer, and cardiovascular disease mortality. Cancer Epidemiol Biomark Prev. 2009;18:1403–9. https://doi.org/10.1158/1055-9965.Epi-08-1094.

    Article  Google Scholar 

  55. Petrelli F, Cortellini A, Indini A, Tomasello G, Ghidini M, Nigro O, et al. Association of obesity with survival outcomes in patients with cancer: a systematic review and meta-analysis. JAMA Netw Open. 2021;4:e213520–e. https://doi.org/10.1001/jamanetworkopen.2021.3520.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Makari-Judson G, Braun B, Jerry DJ, Mertens WC. Weight gain following breast cancer diagnosis: Implication and proposed mechanisms. World J Clin Oncol. 2014;5:272–82. https://doi.org/10.5306/wjco.v5.i3.272.

    Article  PubMed  PubMed Central  Google Scholar 

  57. van den Berg MMGA, Winkels RM, de Kruif JTCM, van Laarhoven HWM, Visser M, de Vries JHM, et al. Weight change during chemotherapy in breast cancer patients: a meta-analysis. BMC Cancer. 2017;17:259 https://doi.org/10.1186/s12885-017-3242-4.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Tsai S. Importance of lean body mass in the oncologic patient. Nutr Clin Pr. 2012;27:593–8. https://doi.org/10.1177/0884533612457949.

    Article  Google Scholar 

  59. Thibault R, Cano N, Pichard C. Quantification of lean tissue losses during cancer and HIV infection/AIDS. Curr Opin Clin Nutr Metab Care. 2011;14:261–7. https://doi.org/10.1097/MCO.0b013e3283455d60.

    Article  PubMed  Google Scholar 

  60. Villaseñor A, Ballard-Barbash R, Baumgartner K, Baumgartner R, Bernstein L, McTiernan A, et al. Prevalence and prognostic effect of sarcopenia in breast cancer survivors: the HEAL Study. J Cancer Survivorship. 2012;6:398–406. https://doi.org/10.1007/s11764-012-0234-x.

    Article  Google Scholar 

  61. Sunga AY, Eberl MM, Oeffinger KC, Hudson MM, Mahoney MC. Care of cancer survivors. Am Fam Phys. 2005;71:699–706.

    Google Scholar 

  62. Ewertz M, Jensen AB. Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol. 2011;50:187–93. https://doi.org/10.3109/0284186x.2010.533190.

    Article  PubMed  Google Scholar 

  63. Albreht T, Kiasuwa, R, Van den Bulcke, M, editors. European guide on quality improvement in comprehensive cancer control. Ljubljana: National Institute of Public Health; 2017.

  64. Mullen L and Hanon T. National cancer survivorship needs assessment: living with and beyond cancer in Ireland. National Cancer Control Programme: Dublin; 2019.

  65. Atkins D, Briss PA, Eccles M, Flottorp S, Guyatt GH, Harbour RT, et al. Systems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system. BMC Health Serv Res. 2005;5:25 https://doi.org/10.1186/1472-6963-5-25.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Health and Nutritional Science, Institute of Technology Sligo, Sligo, F91 YW50, Ireland

    Laura Keaver, Christine Houlihan & Niamh O’Callaghan

  2. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, 02111, USA

    Laura Keaver, Xinge Ding & Fang Fang Zhang

  3. Hirsh Health Sciences Library, Tufts University, Boston, MA, 02111, USA

    Amy E. LaVertu

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  1. Laura Keaver
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Contributions

LK was responsible for designing the review protocol, conducting the searches, screening potentially eligible studies, extracting and analysing data, interpreting results, and writing the paper. AELV assisted with designing and conducting the database search strategies. CH contributed to data searching, data extraction and provided feedback on the report. NOC contributed to data analysis and provided feedback on the final report. XD and FFZ provided feedback on the report.

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Correspondence to Laura Keaver.

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Keaver, L., Houlihan, C., O’Callaghan, N. et al. Evidence-based nutrition guidelines for cancer survivors in Europe: a call for action. Eur J Clin Nutr 76, 819–826 (2022). https://doi.org/10.1038/s41430-021-01036-8

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