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      Cancer survivorship, excess body fatness and weight-loss intervention—where are we in 2020?

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          Abstract

          Earlier diagnosis and more effective treatments mean that the estimated number of cancer survivors in the United Kingdom is expected to reach 4 million by 2030. However, there is an increasing realisation that excess body fatness (EBF) is likely to influence the quality of cancer survivorship and disease-free survival. For decades, the discussion of weight management in patients with cancer has been dominated by concerns about unintentional weight loss, low body weight and interventions to increase weight, often re-enforced by the existence of the obesity paradox, which indicates that high body weight is associated with survival benefits for some types of cancer. However, observational evidence provides strong grounds for testing the hypothesis that interventions for promoting intentional loss of body fat and maintaining skeletal muscle in overweight and obese cancer survivors would bring important health benefits in terms of survival outcomes and long-term impact on treatment-related side effects. In this paper, we outline the need for studies to improve our understanding of the health benefits of weight-loss interventions, such as hypocaloric healthy-eating plans combined with physical activity. In particular, complex intervention trials that are pragmatically designed are urgently needed to develop effective, clinically practical, evidence-based strategies for reducing EBF and optimising body composition in people living with and beyond common cancers.

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          Most cited references58

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          Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.

          Type 2 diabetes affects approximately 8 percent of adults in the United States. Some risk factors--elevated plasma glucose concentrations in the fasting state and after an oral glucose load, overweight, and a sedentary lifestyle--are potentially reversible. We hypothesized that modifying these factors with a lifestyle-intervention program or the administration of metformin would prevent or delay the development of diabetes. We randomly assigned 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations to placebo, metformin (850 mg twice daily), or a lifestyle-modification program with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week. The mean age of the participants was 51 years, and the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 34.0; 68 percent were women, and 45 percent were members of minority groups. The average follow-up was 2.8 years. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58 percent (95 percent confidence interval, 48 to 66 percent) and metformin by 31 percent (95 percent confidence interval, 17 to 43 percent), as compared with placebo; the lifestyle intervention was significantly more effective than metformin. To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program, and 13.9 would have to receive metformin. Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.
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            Exercise Guidelines for Cancer Survivors

            The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.
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              ESPEN guidelines on nutrition in cancer patients

              Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.
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                Author and article information

                Contributors
                a.s.anderson@dundee.ac.uk
                Journal
                Br J Cancer
                Br J Cancer
                British Journal of Cancer
                Nature Publishing Group UK (London )
                0007-0920
                1532-1827
                25 November 2020
                16 March 2021
                : 124
                : 6
                : 1057-1065
                Affiliations
                [1 ]GRID grid.416266.1, ISNI 0000 0000 9009 9462, Centre for Research into Cancer Prevention and Screening, Division of Population Health & Genomics, , University of Dundee Ninewells Hospital and Medical School, ; Dundee, DD1 9SY UK
                [2 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, Bristol Medical School: Population Health Sciences, , University of Bristol, ; Canynge Hall, Bristol, BS8 2PS UK
                [3 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, MRC Integrative Epidemiology Unit, , University of Bristol, ; Oakfield House, Bristol, BS8 2BN UK
                [4 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, University Hospitals Bristol NHS Foundation Trust National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, ; Bristol, UK
                [5 ]GRID grid.5379.8, ISNI 0000000121662407, The Christie NHS Foundation Trust, Manchester Cancer Research Centre, NIHR Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, , University of Manchester, ; Wilmslow Road, Manchester, M20 4BX UK
                [6 ]GRID grid.9909.9, ISNI 0000 0004 1936 8403, Nutritional Epidemiology Group, School of Food Science and Nutrition, G11, Stead House, , University of Leeds, ; Leeds, LS2 9JT UK
                [7 ]Wessex Genomic Medicine Centre, Cancer Sciences Academic Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
                [8 ]GRID grid.7445.2, ISNI 0000 0001 2113 8111, Department of Epidemiology and Biostatistics, , School of Public Health, Imperial College London, ; Norfolk Place, London, W2 1PG UK
                [9 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, School of Health Sciences, , University of Southampton, ; Southampton, SO17 1BJ UK
                [10 ]GRID grid.418998.5, ISNI 0000 0004 0488 2696, Department of Health and Nutritional Science, , Institute of Technology Sligo, ; Sligo, F91 YW50 Ireland
                [11 ]GRID grid.123047.3, ISNI 0000000103590315, NIHR Cancer and Nutrition Collaboration, Level E and Pathology Block (mailpoint 123), , Southampton General Hospital, ; Tremona Road, Southampton, SO 16 6YD UK
                [12 ]GRID grid.18886.3f, ISNI 0000 0001 1271 4623, Biomedical Research Centre at The Royal Marsden and the Institute of Cancer Research, ; Fulham Road, London, SW3 6JJ UK
                [13 ]GRID grid.42629.3b, ISNI 0000000121965555, Department of Sport, Exercise & Rehabilitation, Faculty of Health and Life Sciences, , Northumbria University, ; Northumberland Building, Newcastle upon Tyne, NE1 8ST UK
                [14 ]GRID grid.8241.f, ISNI 0000 0004 0397 2876, Public Health Nutrition, Centre for Research into Cancer Prevention and Screening, , University of Dundee, ; Dundee, UK
                [15 ]GRID grid.9909.9, ISNI 0000 0004 1936 8403, Yorkshire Cancer Research University Academic Fellow, University of Leeds, ; Leeds, UK
                [16 ]GRID grid.9909.9, ISNI 0000 0004 1936 8403, Nutritional Epidemiology and Public Health, , University of Leeds, ; Leeds, UK
                [17 ]GRID grid.7445.2, ISNI 0000 0001 2113 8111, Cancer Epidemiology, , Imperial College London, ; London, UK
                [18 ]Public Representative, NIHR Cancer and Nutrition Collaboration, Southampton, UK
                [19 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, Clinical Epidemiology, , University of Bristol, ; Bristol, BRC UK
                [20 ]Research Funding & Science External Relations, WCRF, London, UK
                [21 ]GRID grid.7445.2, ISNI 0000 0001 2113 8111, Cancer Epidemiology and Prevention, , Imperial College London, ; London, UK
                [22 ]GRID grid.42629.3b, ISNI 0000000121965555, Clinical Exercise Physiology, , Northumbria University, ; Newcastle, UK
                [23 ]GRID grid.5379.8, ISNI 0000000121662407, Cancer Studies and Surgery, , University of Manchester; Honorary Consultant Colorectal Surgeon, ; Manchester, UK
                Author information
                http://orcid.org/0000-0002-7992-7719
                http://orcid.org/0000-0001-8994-4056
                http://orcid.org/0000-0003-4169-9391
                http://orcid.org/0000-0003-1945-9455
                Article
                1155
                10.1038/s41416-020-01155-2
                7961062
                33235316
                07e89356-d492-473d-a013-eac846e82cea
                © Cancer Research UK 2020

                Note This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).

                History
                : 28 April 2020
                : 24 September 2020
                : 22 October 2020
                Categories
                Perspective
                Custom metadata
                © Cancer Research UK 2021

                Oncology & Radiotherapy
                risk factors,cancer prevention,weight management
                Oncology & Radiotherapy
                risk factors, cancer prevention, weight management

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