The equivalent of almost 4% of the total population is either living with or beyond cancer.¹ In the next 25 years, the number of Irish cancer survivors is expected to double due to demographics, earlier detection and improved treatment outcomes.¹ Cancer survivorship is now recognised as a distinct phase of the cancer journey with its own distinct health implications brought about by the cancer itself, the treatment received as well as a potentially impaired nutrition and physical status. 

Unmet needs of cancer survivors

The National Cancer Registry of Ireland (NCRI) and the Irish Cancer Society (ICS) recently published a review on the unmet needs of cancer survivors in Ireland.² This highlighted that the needs of cancer survivors have not been prioritised, with little support available for the management of treatment side-effects. 

A study included in this review, which focused on breast cancer survivors specifically, found a significant lack of nutritional information being made available during survivorship care.³ A more recent survey of Irish cancer survivors found a lack of nutrition support being provided also.⁴

On foot of this review, the ICS’s strategy for 2020-2025⁵ included ‘Living well after treatment’ as one of its five priorities, emphasising the importance of research in helping to improve the quality of life of cancer survivors by uncovering their unmet needs. Moreover, the HSE’s National Cancer Control Programme has placed significant importance on the wellbeing of survivors in its recent ‘Acute Sector Cancer Survivorship Services in the Irish Context’ report.⁶

A cancer survivor’s quality of life can be profoundly impacted by the burden of symptoms, including nutritional symptoms.⁶ Some of the most common symptoms encountered by Irish healthcare professionals working with adult survivors in the acute sector were nutritional symptoms.^2,6 It is therefore important that healthcare professionals are aware of the nutritional issues faced by cancer survivors and are familiar with the current guidelines for nutrition for this group.

Nutrition-related health issues

Survivors may become at risk of weight loss/gain, malnutrition, decreased intake of food and quality of life, should they not receive follow-up care, long-term. Therefore, doctors, nurses and dietitians should regularly monitor and manage these symptoms into survivorship.

Weight management

Weight management in those with cancer has routinely been dominated by concerns about unintentional weight loss, however, many cancer survivors can be at increased risk for weight gain. As this can be associated with an increased risk of developing cancer, maintaining a healthy weight and body composition is important in survivorship.⁷ This is reflected in the World Cancer Research Fund (WCRF) guidelines for cancer prevention.⁸

This is further endorsed by European and US bodies where survivors are recommended to aim to achieve and maintain a healthy body weight. In addition, weight loss should be modest (5-10% of total body weight).^9,10,11

Side-effects of cancer treatment

Cancer treatment can result in a variety of side-effects, which can, in turn, affect the food intake, nutrition status and quality of life of the individual.

Recent Irish data¹² has shown that these nutrition impact symptoms can persist into survivorship. In a cohort of 169 Irish cancer survivors, who were at least six months post-treatment, fatigue was still being experienced by the majority (76%). 

Other common impact symptoms were decreased energy levels (51.5%), pain (36.1%), constipation (33%), dry mouth (26%) and diarrhoea (16.6%). This is similar to findings in other countries where fatigue, difficulty sleeping and pain are commonly reported in survivors.^13,14

Risk of cardiovascular morbidity

After cancer recurrence, cardiovascular disease is the secondary cause of mortality in cancer survivors. This is a long-term complication of cancer therapies.¹⁵ The risk of cardiovascular morbidity is actually higher than that of cancer recurrence.^16,17 These morbidities include hypertension, dyslipidaemia, obesity and type 2 diabetes.^18,19

Screening is important as is the promotion of lifestyle modifications such as increasing physical activity, consuming a healthy balanced diet and maintaining a healthy weight.¹⁵ The WCRF recommendations⁸ should be promoted.

Nutrition-related behaviours

While some studies have shown that cancer survivors are more likely to adopt healthy behaviours than those without a history of cancer,^20,21 there are others that have highlighted poor fruit and vegetable intake²² as well as non-adherence to recommendations for alcohol intake^23,24 and BMI.^24,25

Compared to those without cancer, cancer survivors in the US have a higher consumption of foods containing added sugars, solid fats and alcohol, and lower intakes of fibre, calcium, vitamin D and vitamin E.²⁶

Sources of nutrition advice

Cancer survivors have consistently indicated a desire for nutrition support,^27,28,29 particularly from healthcare professionals.²⁸ Survivors currently report receiving no or conflicting nutrition advice.^27,28,29 In the absence of advice from healthcare professionals, survivors source nutrition and physical activity advice from online sources,²⁸ which are largely unregulated and often present conflicting or non-evidence-based advice.^30,31 Currently, only 10% of Irish cancer survivors report receiving nutrition advice from a dietitian.³²

Guidelines and recommendations

A UK survey of specialist nurses, clinicians, surgeons and allied health professionals showed only half were aware of diet as part of lifestyle guidelines for those who had completed cancer treatment.³³ The WCRF recommends that in the absence of survivor-specific evidence, cancer survivors, unless otherwise advised, should follow its recommendations for cancer prevention as far as possible after the acute phase of treatment (see Table 1).⁸ Similar guidelines have been promoted by the American Institute for Cancer Research. 

Unfortunately, adherence to these recommendations is poor³⁴ and baseline knowledge of general or specific risk factors is low in some populations.³⁵ Better adherence to these recommendations has been positively associated with global health status, most functioning scales and less fatigue among 1,096 colorectal cancer survivors in the Netherlands,³⁶ with improvements in health-related quality of life also being observed in older female cancer survivors from the Iowa Women’s Health Study³⁷ and Chinese breast cancer survivors.³⁸ Greater adherence has also been associated with improved survival in those with colorectal cancer.³⁹

A global survey of breast cancer survivors⁴⁰ found the main barriers to healthy eating to be:

• Fatigue (reported by 72.1% of respondents)
• Stress, depression or reduced mental function (69.5%); 
• Changes in taste preference during or after cancer treatment (48.6%)
• Craving unhealthy food (42.5%)
• Loss of appetite (31.4%)
• Healthy food costing too much (30.5%)
• Lack of time to prepare healthy foods (34.3%). 

Fatigue was also the main barrier to being physically active. To support positive behaviour changes we need to consider these barriers moving forward. 

Looking to the future 

There is a need for further research into the nutrition specific needs of cancer survivors, as well as the impact of diet on longer-term cancer recurrence and survival. This will help inform the development of more specific guidelines and practices for cancer survivors. There is also a need to determine how best to integrate nutrition into survivorship care. Survivors have a desire for individualised and specific advice relating to their nutritional problems.²⁸ Providing individualised nutritional advice could improve dietary intake and potentially prevent weight loss or weight gain, as well as vitamin and mineral deficiencies.

Conclusion

Monitoring weight and nutrition-related impact symptoms and signposting to nutrition resources, such as the WCRF guidelines or Breakthrough Cancer Research cookbooks (eg. Eating Healthy for Cancer Survivors⁴¹), and referring to a dietitian where appropriate, could make a big impact to the health and health-related quality of life of cancer survivors.

References

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