Dietary Factors and Breast Cancer Prognosis among Breast Cancer Survivors: A Systematic Review and Meta-Analysis of Cohort Studies

The effects of lifestyle and behavioural interventions on cancer recurrence, overall survival and quality of life in breast cancer survivors: A systematic review and network meta-analysis

Lifestyle/behavioural interventions may improve breast cancer outcomes and quality of life (QoL); however, uncertainty remains about the most effective interventions due to limited evidence. This study aimed to assess and compare the effects of lifestyle/behavioural interventions on cancer recurrence, survival and QoL in breast cancer survivors. Electronic databases including Medline, EMBASE, PsycINFO, CINAHL and EBM Reviews were searched for relevant literature. Randomized controlled trials (RCTs) and quasi-RCTs comparing a lifestyle/behavioural intervention with a control condition in breast cancer survivors were included. Outcomes included cancer recurrence, overall survival and QoL. A network meta-analysis synthesized intervention effect. Studies not included in the analysis were reported narratively. Of 6251 identified articles, 38 studies met the selection criteria. Limited evidence exists on the impacts of lifestyle/behavioural interventions on breast cancer recurrence/survival. Exercise was identified as the most effective intervention in improving overall survival (HR 0.50, 95 % CI 0.36, 0.68). Lifestyle/behavioural interventions may improve QoL; psychosocial interventions (SMD 1.28, 95 % CI 0.80, 1.77) and aerobic-resistance exercise (SMD 0.33, 95 % CI -0.03, 0.69) were the most effective interventions to enhance QoL. This review highlights potential post-breast cancer benefits from lifestyle/behavioural interventions, notably exercise and psychosocial support for QoL and exercise for overall survival. Thus, encouraging active lifestyle, stress management and coping skills programs during and after cancer treatment may enhance physical wellbeing and QoL. However, the findings should be interpreted with caution due to the small number and sample sizes of studies. Future longer-term RCTs are required for conclusive recommendations.

Association between dietary carotenoid intake and breast cancer risk: a case-control study among Korean women

The association between dietary carotenoids and breast cancer (BC) risks were inconsistent. Therefore, this study investigated the association between dietary carotenoid and BC risks among Korean women. We recruited participants from the National Cancer Centre of Korea. Odds ratios and 95% confidence intervals were calculated with a logistic regression model. There was an inverse association between dietary carotenoid subclasses and BC risks; in particular, a higher intake of β-carotene and lutein/zeaxanthin was associated with reduced BC risks. After subgroup analysis with estrogen receptor (ER)/progesterone receptor (PR) status, there was similar trend among ER-/PR- women. We further investigated which foods contribute to the carotenoid intake. A higher intake of radish leaves, kale, and bracken was associated with lowered BC risks. Accordingly, dietary carotenoid, particularly β-carotene and lutein/zeaxanthin, appears to be associated with a lower risk of BC among Korean women.

Review of Nutrition Guidelines and Evidence on Diet and Survival Outcomes for Cancer Survivors: Call for Integrating Nutrition into Oncology Care

Several organizations have published nutrition guidelines for cancer survivors during and after treatment. This review compared nutrition guidelines for cancer survivors published in the United States for the topics that are covered in the guidelines and evaluated the evidence that these guidelines are based upon. A team of researchers, patient stakeholders, and healthcare providers collectively identified 5 nutrition guidelines for cancer survivors in the United States: the 2022 American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors, the 2018 American Institute for Cancer Research Cancer Nutrition Guide, the 2022 National Cancer Institute Physician Data Query and Eating Hints, the 2024 National Comprehensive Cancer Network Guidelines for Cancer Survivors, and the 2020 American Society for Clinical Oncology Guidelines. The 5 guidelines cover a comprehensive list of nutrition topics but overall promote to follow those recommendations for cancer prevention. This review also evaluated the current evidence from meta-analyses on dietary patterns and intakes of foods and nutrients in relation to survival outcomes among cancer survivors. Although the evidence on dietary patterns is strong, the evidence on most dietary factors is still limited and the current research was primarily conducted among breast and colorectal cancer survivors. Although nutrition recommendations are available for cancer survivors, practical strategies need to be implemented to integrate nutrition into oncology care and help cancer survivors follow these recommendations. Further research is warranted to provide additional evidence on the role of nutrition in the health outcomes of cancer survivors and guide the development of evidence-based nutrition recommendations. The protocol is registered in PROSPERO: CRD42023429240.

Phytonutrients and outcomes following breast cancer: a systematic review and meta-analysis of observational studies

BACKGROUND

Phytonutrient intakes may improve outcomes following breast cancer, but the impact of postdiagnosis introduction vs established prediagnostic exposure as well as optimum doses has not been established. Evidence from observational studies for key exposures was evaluated, including dosage and intake time frames.

METHODS

MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and the ISRCTN registry were searched for prospective and retrospective observational studies investigating the impact of soybean, lignans, cruciferous (cabbage-family) vegetables, green tea, or their phytonutrients on breast cancer survival outcomes. A random-effects model was used to calculate summary hazard ratios (HRs) and 95% confidence intervals (CIs). Nonlinear dose-response analyses were conducted using restricted cubic splines.

RESULTS

Thirty-two articles were included. Soy isoflavones were associated with a 26% reduced risk of recurrence (HR = 0.74, 95% CI = 0.60 to 0.92), particularly among postmenopausal (HR = 0.72, 95% CI = 0.55 to 0.94) and estrogen receptor-positive survivors (HR = 0.82, 95% CI = 0.70 to 0.97), with the greatest risk reduction at 60 mg/day. In mortality outcomes, the reduction was mostly at 20 to 40 mg/day. Soy protein and products were inversely associated with cancer-specific mortality for estrogen receptor-positive disease (HR = 0.75, 95% CI = 0.60 to 0.92). An inverse association was observed for serum or plasma enterolactone, measured prediagnosis and early postdiagnosis, with cancer-specific mortality (HR = 0.72, 95% CI = 0.58 to 0.90) and all-cause mortality (HR = 0.69, 95% CI = 0.57 to 0.83). No effects were observed for cruciferous vegetables. There was a 44% reduced risk of recurrence with prediagnostic green tea for stage I and II breast cancer (HR = 0.56, 95% CI = 0.38 to 0.83).

CONCLUSIONS

Soy, enterolactone, and green tea demonstrated significant risk reductions in outcomes following breast cancer. Evidence is needed regarding the impact of postdiagnostic introduction or substantial increase of these exposures.

Association between nutritional status assessed by a digital self-administered tool (R+ dietitian) and clinicopathologic factors in cancer patients: A comprehensive analysis

Objective

Malnutrition is prevalent among cancer patients, smartphone-based self-administered nutritional assessment tools offer a promising solution for effective nutritional screening. This study aims to retrospectively analyze the relationships between nutritional status evaluated by the digital tool (R+ Dietitian) and clinicopathologic factors of cancer patients.

Methods

Cancer patients who met the inclusion criteria were divided into two subgroups based on age, Nutritional Risk Screening-2002, Patient-Generated Subjective Global Assessment Short Form, body mass index, and hospital stays for comparison. Correlation and regression analysis were used to comprehensively assess the relationship between nutritional status and clinicopathologic factors.

Findings

A total of 535 hospitalized cancer patients (58.32 ± 11.24 years old) were recruited. Patients identified with nutritional risk assessed by R+ Dietitian were significantly older, had lower body weight, lower body mass index, greater weight loss, and longer hospital stays (all of above, P < 0.01). Multiple logistic regression analysis indicated that serum prealbumin concentration (odds ratio: 0.992, 95% confidence interval: 0.987-0.997, P = 0.001), weight loss (odds ratio: 7.309, 95% confidence interval: 4.026-13.270, P < 0.001), and body mass index < 18.5 (odds ratio: 5.882, 95% confidence interval: 2.695-12.821, P < 0.001) predicted nutritional risk indicated by Nutritional Risk Screening-2002 score ≥3. Hemoglobin concentration (odds ratio: 0.983, 95% confidence interval: 0.970-0.996, P = 0.011), weight (odds ratio: 1.111, 95% confidence interval: 1.056-1.169, P < 0.001), weight loss (odds ratio: 7.502, 95% confidence interval: 4.394-12.810, P < 0.001), body mass index (odds ratio: 0.661, 95% confidence interval: 0.564-0.775, P < 0.001), and energy intake (odds ratio: 0.996, 95% confidence interval: 0.995-0.997, P < 0.001) predicted nutritional risk indicated by Patient-Generated Subjective Global Assessment Short Form score ≥4. Multiple linear regression analysis revealed that Patient-Generated Subjective Global Assessment Short Form scores ≥3 (b = 2.032, P = 0.008) were significantly associated with longer hospital stays.

Conclusions

The nutritional risks assessed by R+ Dietitian accurately reflected the characteristics of malnutrition in cancer patients and predicted hospital stay and cost, indicating the applicability of R+ Dietitian to improving the efficiency of nutritional management for cancer patients.

Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Dietary intake of total vegetable, fruit, cereal, soluble and insoluble fiber and risk of all-cause, cardiovascular, and cancer mortality: systematic review and dose-response meta-analysis of prospective cohort studies

Objectives

To conduct a systematic review and meta-analysis of prospective cohort studies to investigate the association between total, vegetable, fruit, cereal, soluble and insoluble fiber intake and risk of all causes, cardiovascular disease (CVD), and cancer mortality and quantitatively assess the dose-response relation.

Methods

Eligible studies were identified by searching PubMed, Embase and Web of science before August 2023. Random effects models were used to calculate summary relative risk (RR) and 95% confidence intervals (CI) and restricted cubic splines to model the linear/non-linear association.

Results

The summary RR for all-cause, CVD and cancer mortality of dietary fiber was 0.90 (95% CI: 0.86,0.93), 0.87 (0.84,0.91), 0.91 (0.88,0.93), respectively. Significant association was observed for all-cause and CVD mortality with fruit, vegetable cereal and soluble fiber intake and cancer mortality with cereal fiber intake. No significant association was found for insoluble fiber, vegetable or fruit fiber intake and cancer mortality. Dose-response analysis showed a significant non-linear relation of dietary fiber intake with all-cause mortality, and linear relation for others.

Conclusions

Higher dietary fiber including different type and food sources of fiber intake were associated with lower risk of mortality. Our findings provide more comprehensive evidence on dietary fiber intake with mortality.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier: CRD42022338837.

Association of dietary total antioxidant capacity and its distribution across three meals with all-cause, cancer, and non-cancer mortality among cancer survivors: the US National Health and Nutrition Examination Survey, 1999-2018

The effect of the antioxidant capacity of diet and its distribution across three meals on mortality risk among cancer patients remains unexplored. We aimed to prospectively investigate the association of dietary total antioxidant capacity (DAC) and its distribution across three meals with all-cause, cancer, and noncancer mortality among cancer survivors. We included 5,009 patients with cancer from the National Health and Nutrition Examination Survey conducted between 1999 and 2018. The adjusted hazard ratio (aHR) was estimated using the survey-weighted Cox proportional hazards model. During a median follow-up of 7.9 years, 1811 deaths, including 575 cancer-related deaths, were recorded. Among cancer survivors, compared with participants in the lowest quartile of total DAC from three meals, those in the highest quartile had a 24% decreased risk of noncancer mortality (aHR = 0.76, 95% confidence interval [CI]: 0.60-0.92), but not of all-cause and cancer mortality (each p trend >0.1). However, this association became insignificant for total DAC after excluding dinner DAC. In addition, higher dinner DAC rather than breakfast or lunch DAC was associated with a 21% lower risk of all-cause mortality (aHR = 0.79, 95% CI: 0.65-0.98) and 28% lower risk of noncancer mortality (aHR = 0.72, 95% CI: 0.57-0.90). Similar associations were found for ΔDAC (dinner DAC - breakfast DAC) with noncancer mortality (aHR = 0.56, 95% CI: 0.38-0.83), but DAC was not associated with cancer mortality (p trend >0.3). Among cancer survivors, total DAC from three meals was associated with reduced noncancer mortality, with the primary effect attributable to increased DAC intake from dinner. Our findings emphasize that DAC consumption from dinner should be advocated to reduce mortality risk in cancer survivors.

Dietary Fats and All-cause and Breast Cancer-specific Mortality among Women with Breast Cancer: The Western New York Exposures and Breast Cancer Study

BACKGROUND

Study results of prediagnostic dietary fat intake and breast cancer mortality have been inconclusive. While dietary fat subtypes [saturated (SFA), polyunsaturated (PUFA), and monounsaturated (MUFA) fatty acids] may have different biological effects, there is little evidence regarding the association of dietary fat and fat subtype intake with mortality after breast cancer diagnosis.

METHODS

Women with incident, pathologically confirmed invasive breast cancer and complete dietary data (n = 793) were followed in a population-based study, the Western New York Exposures and Breast Cancer study. Usual intake before diagnosis of total fat and subtypes were estimated from a food frequency questionnaire completed at baseline. HRs and 95% confidence intervals (CI) for all-cause and breast cancer-specific mortality were estimated with Cox proportional hazards models. Interactions by menopausal status, estrogen receptor (ER) status, and tumor stage were examined.

RESULTS

Median follow-up time was 18.75 years; 327 (41.2%) participants had died. Compared with lower intake, greater intake of total fat (HR, 1.05; 95% CI, 0.65-1.70), SFA (1.31; 0.82-2.10), MUFA (0.99; 0.61-1.60), and PUFA (0.99; 0.56-1.75) was not associated with breast cancer-specific mortality. There was also no association with all-cause mortality. Results did not vary by menopausal status, ER status, or tumor stage.

CONCLUSIONS

Prediagnostic intake of dietary fat and fat subtypes was not associated with either all-cause or breast cancer mortality in a population-based cohort of breast cancer survivors.

IMPACT

Understanding factors affecting survival among women diagnosed with breast cancer is critically important. Dietary fat intake prior to diagnosis may not impact that survival.

Adherence to Cancer Prevention Lifestyle Recommendations Before, During, and 2 Years After Treatment for High-risk Breast Cancer

Importance

The American Institute for Cancer Research and American Cancer Society regularly publish modifiable lifestyle recommendations for cancer prevention. Whether these recommendations have an impact on high-risk breast cancer survival remains unknown.

Objective

To investigate whether adherence to cancer prevention recommendations before, during, and 1 and 2 years after breast cancer treatment was associated with disease recurrence or mortality.

Design, Setting, and Participants

The Diet, Exercise, Lifestyles, and Cancer Prognosis Study (DELCaP) was a prospective, observational cohort study designed to assess lifestyles before diagnosis, during treatment, and at 1 and 2 years after treatment completion, implemented ancillary to the Southwest Oncology Group (SWOG) S0221 trial, a multicenter trial that compared chemotherapy regimens in breast cancer. Participants were chemotherapy-naive patients with pathologic stage I to III high-risk breast cancer, defined as node-positive disease with hormone receptor-negative tumors larger than 1 cm or any tumor larger than 2 cm. Patients with poor performance status and comorbidities were excluded from S0221. The study was conducted from January 1, 2005, to December 31, 2010; mean (SD) follow-up time for those not experiencing an event was 7.7 (2.1) years through December 31, 2018. The analyses reported herein were performed from March 2022 to January 2023.

Exposure

An aggregated lifestyle index score comprising data from 4 time points and 7 lifestyles, including (1) physical activity, (2) body mass index, (3) fruit and vegetable consumption, (4) red and processed meat intake, (5) sugar-sweetened beverage consumption, (6) alcohol consumption, and (7) smoking. Higher scores indicated healthier lifestyle.

Main Outcomes and Measures

Disease recurrence and all-cause mortality.

Results

A total of 1340 women (mean [SD] age, 51.3 [9.9] years) completed the baseline questionnaire. Most patients were diagnosed with hormone-receptor positive breast cancer (873 [65.3%]) and completed some education beyond high school (954 [71.2%]). In time-dependent multivariable analyses, patients with highest vs lowest lifestyle index scores experienced a 37.0% reduction in disease recurrence (hazard ratio, 0.63; 95% CI, 0.48-0.82) and a 58.0% reduction in mortality (hazard ratio, 0.42; 95% CI, 0.30-0.59).

Conclusions and Relevance

In this observational study of patients with high-risk breast cancer, strongest collective adherence to cancer prevention lifestyle recommendations was associated with significant reductions in disease recurrence and mortality. Education and implementation strategies to help patients adhere to cancer prevention recommendations throughout the cancer care continuum may be warranted in breast cancer.

Prevalence and Relevance of Vitamin D Deficiency in Newly Diagnosed Breast Cancer Patients: A Pilot Study

(1) Background: Vitamin D plays an important role in many types of cancer. It was the aim of this study to analyze serum 25-hydroxyvitamin D (25(OH)D) levels in newly diagnosed breast cancer patients, and the association with prognostic and lifestyle factors. (2) Methods: 110 non-metastatic breast cancer patients were included in the prospective observational “BEGYN” study at Saarland University Medical Center between September 2019 and January 2021. At the initiation visit, serum 25(OH)D levels were measured. Clinicopathological data on prognosis, nutrition, and lifestyle were extracted from data files and obtained using a questionnaire. (3) Results: Median serum 25(OH)D in breast cancer patients was 24 ng/mL (range 5–65 ng/mL), with 64.8% of patients being vitamin D deficient. 25(OH)D was higher among patients that reported the use of vitamin D supplements (43 ng/mL versus 22 ng/mL; p < 0.001), and in summer compared to other seasons (p = 0.03). Patients with moderate vitamin D deficiency were less likely to have triple negative breast cancer (p = 0.047). (4) Conclusions: Routinely measured vitamin D deficiency is common in breast cancer patients and needs to be detected and treated. However, our results do not support the hypothesis that vitamin D deficiency may be a main prognostic factor for breast cancer.

Effects of Combined Interventions of Exercise and Diet or Exercise and Supplementation on Breast Cancer Patients: A Systematic Review

This systematic review investigated the effects of exercise interventions combined with diet and/or dietary supplement interventions on anthropometry, body composition, metabolic biomarkers, physical function, healthy lifestyles, quality of life, psychosocial variables and fatigue for women with breast cancer. A systematic search was performed in the PubMed and Web of Science databases (from inception to 1 March 2022). A review was carried out following the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines. The methodological quality and the risk of bias of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale. A total of 13 randomised controlled trial studies were included, comprising 1569 breast cancer patients. The main finding of this systematic review is that groups performing interventions combining exercise plus diet show significant improvements in cardiorespiratory fitness, muscular strength, body composition, quality of life, fatigue, anxiety, depression and sleep compared to control groups. On the other hand, the use of interventions combining exercise plus supplementation does not result in an improvement compared to groups using exercise alone or supplementation alone.

How the COVID-19 pandemic has affected eating habits and physical activity in breast cancer survivors: the DianaWeb study

Purpose

Breast cancer (BC) survivors are increasingly interested in learning about healthy lifestyles to reduce the risk of BC recurrence and mortality. The DianaWeb study, a community-based participatory research, offers BC patients a specific interactive website to help them in adopting and maintain correct lifestyles, in line with World Cancer Research Fund recommendations. However, to limit the spread of the COVID-19 pandemic, most countries introduced restrictions which, inevitably, caused sudden lifestyle changes.

The current study aimed at evaluating changes in lifestyle in BC survivors before, during, and after the first two waves of the COVID-19 pandemic.

Methods

We used data of 224 BC cancer survivors enrolled in the DianaWeb study. We evaluated the adherence to physical activity (PA) guidelines, to Mediterranean diet (MD), and WCRF recommendations, at baseline, during and after the first two waves of the COVID-19 pandemic. We estimated the association between PA, MD, and WCRF adherence with sociodemographic characteristics, years from enrolment in the DianaWeb study, and type of breast cancer.

Results

As expected, during confinement periods, we observed a significant decrease in walking activity and in the percentage of patients performing vigorous PA. In post-quarantine, total weekly energy expenditure increased significantly. BC patients participating in the DianaWeb study for more than 3 years were more likely to be more active. There were no changes in MD and WCRF adherence.

Conclusions

Our results show that the proposed interactive website was useful in achieving durable lifestyle changes, that have not been undermined either during the COVID-19 pandemic.

Implications for Cancer Survivors

Patient education is essential for guiding BC survivors toward improving their health outcomes; therefore, an interactive website like the one proposed by the DianaWeb study may be useful to improve healthy lifestyles.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-022-01294-w.

Cytotoxic Effect of the Paku Atai Merah (Angiopteris ferox Copel) Fraction on MCF-7 and HeLa Cells and its Compound Profile by GC-MS

Cancer is a condition of abnormal cell proliferation of tissue cells in the body that becomes malignant. It can attack other parts of the body and affect the normal function of the body organs. The sample used in this study was tubers of paku atai merah (Angiopteris ferox Copel), then extracted using 96% ethanol eluent to obtain a thick extract. The ethanolic extract of A. ferox was fractionated using column chromatography to get the active fraction to characterize the compound using thin-layer chromatography and gas chromatography-mass spectroscopy (GC-MS) and tested its cytotoxic effectiveness on MCF-7 and HeLa cancer cells. The results of this study were obtained from fractionation using the column chromatography method to get sub-fraction C and the results of compound characterization using GC-MS and obtained variations in the class of compounds contained in the sample: amino acids, glucosinolates, alkaloids, flavonoids, and terpenoids. Based on the cytotoxic effect test of sub-fraction C on MCF-7 cells, the results obtained moderate cytotoxic effects with an IC50 value of 61.027 µg/mL, and HeLa cells had an IC50 value of 521.03 µg/mL, which was categorized as having a weak cytotoxic effect. Based on the results obtained from this study, it can be concluded that sub-fraction C of A. ferox tubers has a cytotoxic effect on MCF-7 cells to be used as a reference for tracing pure compounds from A. ferox tuber.