Exercise, Diet, and Weight Management During Cancer Treatment Guideline

An interview with Dr. Jennifer Ligibel from Dana Farber Cancer Institute in Boston, MA and Dr. Catherine Alfano from Northwell Health Cancer Institute and Feinstein Institutes for Medical Research in New York, NY, co-chairs on "Exercise, Diet and Weight Management During Cancer Treatment: ASCO Guideline." This guideline addresses recommendations for exercise, diet, and weight management for adult patients undergoing active cancer treatment, highlighting where there is evidence to recommend interventions, and where future research is needed. Read the full guideline at www.asco.org/supportive-care-guidelines.

TRANSCRIPT

Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one at asco.org/podcasts.

My name is Brittany Harvey, and today I'm interviewing Dr. Jennifer Ligibel from Dana Farber Cancer Institute in Boston, Massachusetts, and Dr. Catherine Alfano from Northwell Health Cancer Institute, and Feinstein Institutes for Medical Research in New York, New York, co-chairs on 'Exercise, Diet and Weight Management During Cancer Treatment: ASCO Guideline'.

Thank you for being here, Dr. Ligibel and Dr. Alfano.

Dr. Jennifer Ligibel: Thanks for having us.

Brittany Harvey: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline.

The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Ligibel, do you have any relevant disclosures that are directly related to this guideline topic?

Dr. Jennifer Ligibel: I have no personal conflicts with this guideline.

Brittany Harvey: Thank you. Dr. Alfano, do you have any relevant disclosures that are directly related to this guideline topic?

Dr. Catherine Alfano: I have no conflicts.

Brittany Harvey: Thank you. Then, getting into the content of this guideline. Dr. Ligibel, can you start us off with an overview of the scope of this guideline?

Dr. Jennifer Ligibel: Sure. So, this guideline was developed to provide recommendations around exercise, diet, and weight management for patients undergoing active cancer treatment. We defined active cancer treatment as either the perioperative period or the period of time in which patients were receiving chemotherapy and/or radiation.

This guideline specifically focuses on adult cancer patients and largely focuses on individuals undergoing treatment for curative intent. There were a number of reasons why we thought it was important to develop a guideline specifically for patients who were undergoing cancer treatment.

There are a number of other guidelines that talk about the role of these types of lifestyle factors in preventing cancer, and also information widely available about the potential benefits of exercising more, consuming certain types of diets, or losing weight after cancer treatment is finished. But there's much less information about the feasibility and potential benefits and safety of increasing your exercise, changing your diet, or losing weight during cancer treatment.

This is the time when oncology providers are primarily working with patients in a time when patients have a lot of questions about what they should be eating and what they should be doing. So, this guideline was developed to specifically try to provide guidance during treatment.

Brittany Harvey: Yes, definitely an area in which guidance is very much needed. So, then Dr. Alfano, I'd like to next review the key recommendations of this guideline, starting with what are the recommendations regarding exercise during cancer treatment?

Dr. Catherine Alfano: For exercise, the expert panel felt that the evidence was very strong. And so, oncology providers should recommend aerobic and resistance exercise during active treatment with curative intent because it can mitigate the side effects of cancer treatments.

So, exercise has been shown during active cancer treatment to reduce fatigue, to either improve or preserve a patient's cardiorespiratory fitness, their physical functioning, their strength outcomes, and in some kinds of patients exercise has been shown to improve quality of life and reduce anxiety and depression.

The evidence is not sufficient to recommend exercise specifically for improving cancer control outcomes yet. This is a source of ongoing study, but we felt that the evidence was strong enough that oncology providers should recommend aerobic and resistance exercise, and it should become the standard of care for all cancer patients.

The second recommendation regarding exercise is that oncology providers may recommend pre-operative exercise for patients specifically undergoing surgery for lung cancer. So, this can be called prehab or pre-habilitation exercise. And this exercise has been shown to reduce outcomes like the length of hospital stay and postoperative complications.

Brittany Harvey: Excellent. Thank you for reviewing those recommendations and the level of evidence behind them. So, then, Dr. Ligibel, what did the panel recommend regarding particular dietary patterns or foods for patients during cancer treatment?

Dr. Jennifer Ligibel: One of the things that we recognized as a panel as we reviewed the evidence that shaped these guidelines was that there was much less evidence for both dietary factors and whether that was specific dietary patterns or some specific foods, as well as weight management, how those types of changes during treatment, affected outcomes, or even the feasibility of changing your diet or losing weight during cancer treatment. We, for this guideline, really relied on randomized trials to help shape our guidance, and we realized very quickly that there were few randomized trials testing dietary change or weight management during cancer treatment.

So, as a panel, we debated for a long time about what we should say in this setting. We did find that there were a few randomized trials that specifically looked at neutropenic diets. We defined that as diets that omitted fresh fruits and vegetables for patients who had undergone treatment for hematologic malignancies, and in particular bone marrow transplants.

Those studies were designed to look at whether those types of diets reduce the risk of infection. We did not see evidence that omitting fruits and vegetables during cancer treatment for those malignancies, reduced infection, and so the group provided a recommendation that neutropenic diets not be recommended for patients during cancer treatment, but we were unable to provide specific guidance regarding other dietary factors or the incorporation of specific foods during cancer treatment.

As a group, we recognize the importance of a healthy diet for general health. But given that we were really looking at randomized trials of the effects of changing someone's diet during treatment, we ultimately did not make a recommendation for a particular diet during cancer treatment, but really called for more research with well-designed clinical trials to test the impact of things like plant-based diets, intermittent fasting, other types of diets for which there may be interesting preclinical evidence, but very little information in people about the benefits or even the safety of these types of diets during cancer treatment.

Brittany Harvey: Understood, I appreciate you outlining the nuance of that recommendation, and also the areas for future research, which we can get into a little bit more in a little bit. So then, in the last category of recommendations, Dr. Alfano, what does the guideline state regarding interventions to promote intentional weight loss or avoidance of weight gain during cancer treatment?

Dr. Catherine Alfano: So, when our panel reviewed the evidence for weight loss or the avoidance of weight gain during cancer treatment, unfortunately, we decided that ultimately, there's insufficient evidence right now to recommend either for or against intentional weight loss or the prevention of weight gain during active treatment to improve outcomes related to the quality of life or things like treatment toxicities, or ultimately cancer control outcomes.

Brittany Harvey: Thank you, Dr. Alfano, for that recommendation, as well. So, Dr. Ligibel, in your view, what is the importance of this guideline? And how will it impact both clinicians and patients?

Dr. Jennifer Ligibel: This guideline is really the first large-scale effort to pull together all of the data from randomized trials about the effects of changing your lifestyle, exercising more, in particular, changing your diet, changing your weight during cancer treatment.

I think that as a panel, we found very clear and consistent evidence as Dr. Alfano outlined, that exercise has concrete benefits for patients during cancer treatment. I think that this is really an important call to action, both for providers in speaking about these topics to their patients, but also for payers. And as we think about our healthcare system, about how we're going to support patients in becoming more active in a safe way during their cancer treatment.

I think that it's very important that we recognize that encouraging physical activity is not just telling people that they should go out and do it. We really need to think about how we support patients in making these types of lifestyle changes in a sustained way.

So, I think that this guideline really provides clear evidence that exercise is important. It also provides clear evidence that we need more research in other areas. Patients are asking their oncology providers every day, what they should be eating, whether they should be thinking about losing weight, and we really don't have clear evidence to guide these conversations at this point.

I do think it's important to recognize that as a panel, we all felt very strongly that this guideline should not be interpreted as saying that a healthy diet or maintaining a healthy weight during treatment wasn't important. But we were really struck by the dearth of high-level evidence to be able to help our patients make informed choices and I think that's something that, from this guideline, we really need to come up with a plan be better able to ask the question that comes up in the clinic every day of, 'Doctor, what should I eat?'

Brittany Harvey: Those are excellent points. I appreciate the panel looking critically at the evidence that's actually out there to try and determine recommendations. So then, Dr. Ligibel just mentioned a few areas in which more research is needed. So, Dr. Alfano, what are the outstanding questions regarding optimal diet, weight management, and exercise during active cancer treatment?

Dr. Catherine Alfano: Being treated for cancer makes many patients feel like they have no control over their health and that causes them enormous anxiety. Patients are really looking for things that they can do to take the reins of control back over their health to improve their long-term health and well-being during treatment.

I want to underscore the importance of the oncology team in helping patients improve their exercise. Research has shown that 50% of patients undergoing cancer treatment are not getting enough exercise. Patients want to receive guidance about exercise from their oncology team. And importantly, patients whose oncology clinicians discuss exercise with them are more likely to make these healthy behavior changes.

So, it really underscores the importance of the oncology team in helping patients to access these important components of their health that they're asking for. The appropriate referral for exercise in patients undergoing treatment for cancer can really depend on several factors such as comorbidities, treatment toxicities, and the patient's pre-existing physical activity level. For example, many patients can safely perform unsupervised exercise, but others may need supervised cancer-specific exercise because they've got problems that they need to deal with clinically supervised exercise or to participate in a formal cancer rehabilitation program prior to undertaking exercise on their own.

I want to highlight for everyone that there are national efforts that are focusing on building referral algorithms and clinical decision support tools to help point to the most safe, feasible, and effective intervention for a given patient.

Brittany Harvey: Excellent. Well, thank you both so much for outlining the recommendations here and describing the nuance that the expert panel went through. It was certainly a large effort that you've helped lead. And so, I want to thank you so much for your work on these guidelines, and for your time today, Dr. Ligibel and Dr. Alfano.

Dr. Jennifer Ligibel: Thanks for having us.

Dr. Catherine Alfano: Thank you.

Brittany Harvey: Thank you to all of our listeners for tuning in to the ASCO guidelines podcast series. To read the full guideline go to www.asco.org/supportive-care-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.