American Cancer Society nutrition and physical activity guideline for cancer survivors

Cheryl L. Rock; Cynthia A. Thomson; Kristen R. Sullivan; Carol L. Howe; Lawrence H. Kushi; Bette J. Caan; Marian L. Neuhouser; Elisa V. Bandera; Ying Wang; Kimberly Robien; Karen M. Basen-Engquist; Justin C. Brown; Kerry S. Courneya; Tracy E. Crane; David O. Garcia; Barbara L. Grant; Kathryn K. Hamilton; Sheri J. Hartman; Stacey A. Kenfield; Maria Elena Martinez; Jeffrey A. Meyerhardt; Larissa Nekhlyudov; Linda Overholser; Alpa V. Patel; Bernardine M. Pinto; Mary E. Platek; Erika Rees-Punia; Colleen K. Spees; Susan M. Gapstur; Marjorie L. McCullough

doi:10.3322/caac.21719

American Cancer Society nutrition and physical activity guideline for cancer survivors

Cheryl L. Rock, Cynthia A. Thomson, Kristen R. Sullivan, Carol L. Howe, Lawrence H. Kushi, Bette J. Caan, Marian L. Neuhouser, Elisa V. Bandera, Ying Wang, Kimberly Robien, Karen M. Basen-Engquist, Justin C. Brown, Kerry S. Courneya, Tracy E. Crane, David O. Garcia, Barbara L. Grant, Kathryn K. Hamilton, Sheri J. Hartman, Stacey A. Kenfield, Maria Elena MartinezJeffrey A. Meyerhardt, Larissa Nekhlyudov, Linda Overholser, Alpa V. Patel, Bernardine M. Pinto, Mary E. Platek, Erika Rees-Punia, Colleen K. Spees, Susan M. Gapstur, Marjorie L. McCullough

Research output: Contribution to journal › Review article › peer-review

128 Scopus citations

Abstract

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

Original language	English (US)
Pages (from-to)	230-262
Number of pages	33
Journal	CA Cancer Journal for Clinicians
Volume	72
Issue number	3
DOIs	https://doi.org/10.3322/caac.21719
State	Published - May 1 2022

Keywords

alcohol
cancer survivors
dietary patterns
nutrition
obesity
physical activity

ASJC Scopus subject areas

Hematology
Oncology

Access to Document

10.3322/caac.21719

Cite this

Rock, C. L., Thomson, C. A., Sullivan, K. R., Howe, C. L., Kushi, L. H., Caan, B. J., Neuhouser, M. L., Bandera, E. V., Wang, Y., Robien, K., Basen-Engquist, K. M., Brown, J. C., Courneya, K. S., Crane, T. E., Garcia, D. O., Grant, B. L., Hamilton, K. K., Hartman, S. J., Kenfield, S. A., ... McCullough, M. L. (2022). American Cancer Society nutrition and physical activity guideline for cancer survivors. CA Cancer Journal for Clinicians, 72(3), 230-262. https://doi.org/10.3322/caac.21719

Rock, CL, Thomson, CA, Sullivan, KR, Howe, CL, Kushi, LH, Caan, BJ, Neuhouser, ML, Bandera, EV, Wang, Y, Robien, K, Basen-Engquist, KM, Brown, JC, Courneya, KS, Crane, TE, Garcia, DO, Grant, BL, Hamilton, KK, Hartman, SJ, Kenfield, SA, Martinez, ME, Meyerhardt, JA, Nekhlyudov, L, Overholser, L, Patel, AV, Pinto, BM, Platek, ME, Rees-Punia, E, Spees, CK, Gapstur, SM & McCullough, ML 2022, 'American Cancer Society nutrition and physical activity guideline for cancer survivors', CA Cancer Journal for Clinicians, vol. 72, no. 3, pp. 230-262. https://doi.org/10.3322/caac.21719

@article{47ed66af60cb414b97c999c12497c14a,

title = "American Cancer Society nutrition and physical activity guideline for cancer survivors",

abstract = "The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.",

keywords = "alcohol, cancer survivors, dietary patterns, nutrition, obesity, physical activity",

author = "Rock, {Cheryl L.} and Thomson, {Cynthia A.} and Sullivan, {Kristen R.} and Howe, {Carol L.} and Kushi, {Lawrence H.} and Caan, {Bette J.} and Neuhouser, {Marian L.} and Bandera, {Elisa V.} and Ying Wang and Kimberly Robien and Basen-Engquist, {Karen M.} and Brown, {Justin C.} and Courneya, {Kerry S.} and Crane, {Tracy E.} and Garcia, {David O.} and Grant, {Barbara L.} and Hamilton, {Kathryn K.} and Hartman, {Sheri J.} and Kenfield, {Stacey A.} and Martinez, {Maria Elena} and Meyerhardt, {Jeffrey A.} and Larissa Nekhlyudov and Linda Overholser and Patel, {Alpa V.} and Pinto, {Bernardine M.} and Platek, {Mary E.} and Erika Rees-Punia and Spees, {Colleen K.} and Gapstur, {Susan M.} and McCullough, {Marjorie L.}",

note = "Funding Information: Cynthia A. Thomson reports honoraria from and Cancer Support Community and is a member of the Colorectal Cancer Alliance Scientific Advisory Board outside the submitted work. Kristen R. Sullivan reports salary support from a Centers for Disease and Control and Prevention's Center for State, Tribal, Local, and Territorial Support grant outside the submitted work. Carol L. Howe was supported by the American Cancer Society as an independent contractor during the conduct of the study. Lawrence H. Kushi reports grants from the National Cancer Institute; travel support from the Cancer Prevention Research Institute of Texas and the International Agency for Research on Cancer; and Advisory Board service at the National Cancer Institute, all outside the submitted work. Marian L. Neuhouser reports honoraria for her work as Associate editor for (honoraria) and for serving on the internal advisory committee for NIH/NCI funded partnership grant between Fred Hutch and New Mexico State University to increase the capacity for cancer research at NMSU. Karen M. Basen‐Engquist reports grants from the National Cancer Institute and the Cancer Prevention and Research of Texas; honoraria from the National Cancer Institute, the Gynecologic Oncology Group, the University of Kentucky, and the Yale University Transdisciplinary Research on Energetics and Cancer (TREC) training program; travel support from the National Cancer Policy Forum; the National Academies of Science, Engineering, and Medicine; and the Yale University TREC training program; participation on an independent safety monitoring board at Boston University; and service as president elect (2017‐2019) and president (2019‐2021) of the American Society of Preventive Oncology, all outside the submitted work. Justin C. Brown reports grants from the National Institutes of Health and grants and personal fees from the American Institute for Cancer Research outside the submitted work. Barbara L. Grant reports royalties from the Academy of Nutrition and Dietetics for a book chapter on oncology nutrition and service as a liaison representative from the Academy of Nutrition and Dietetics to the American College of Surgeons Commission on Cancer outside the submitted work. Sheri J. Hartman reports grants from the National Cancer Institute/National Institutes of Health and is chair of a Data Safety Monitoring Board outside the submitted work. She chairs a grant‐based DSMB for a study at the University of Wisconsin and Northwestern University. It is not an institutional‐based DSMB. Stacey A. Kenfield reports grants from the National Cancer Institute/National Institutes of Health outside the submitted work. Jeffrey A. Meyerhardt reports institutional research funding from Boston Biomedical; personal fees from Merck Pharmaceuticals and COTA Healthcare; and service on a grant review panel for the National Comprehensive Cancer funded by Taiho Pharmaceutical, all outside the submitted work. Linda Overholser reports grants from the Centers for Disease Control and Prevention and the National Cancer Institute as a coinvestigator in the Cancer Prevention and Control Research Network; royalties from Springer Publishing; and is a member of the National Comprehensive Cancer Network Survivorship Guidelines Panel, all outside the submitted work. Bernardine M. Pinto reports institutional funding from the National Cancer Institute/National Institutes of Health during the conduct of the study and grants or contracts from the Greenville Health System Health Sciences Center to her institution outside the submitted work. Mary E. Platek reports honoraria for providing an American Society for Parenteral and Enteral Nutrition webinar and from the Dartmouth Norris Cotton Center outside the submitted work. The sources of the honoraria are the organizations listed—ASPEN and the Dartmouth Norris Cotton Cancer Center. Susan M. Gapstur reports grants from the National Cancer Institute/National Institutes of Health outside the submitted work. Marjorie L. McCullough reports consulting fees paid to her institution for service on the Cancer Advisory Group to Tufts University and the “Tools to be fit” colorectal cancer survivor study for R01 grants. All remaining authors report no conflicts of interest. DISCLOSURES: Today's Dietitian Journal of Nutrition Funding Information: Cancer survivors can benefit from diet and physical activity assessment and counseling across the continuum of survivorship, from diagnosis and treatment through long-term health and survival postdiagnosis. Table 1 summarizes general recommendations that are supported by current scientific evidence. Nutritional counseling can help to manage treatment-related side effects, such as nausea, vomiting, and appetite loss, and thus prevent nutrient inadequacies and loss of muscle mass caused by these side effects. Many cancer survivors are able to exercise before, during, and after treatments, although some short-term restrictions may apply after major surgery or stem cell transplantation. Physical activity during and after treatment can improve anxiety, depressive symptoms, fatigue, physical functioning and health-related quality of life. The American College of Sports Medicine provides guidance on specific doses of aerobic and resistance training that could improve these common cancer-related health outcomes.14 Individual physical activity recommendations may need to be adapted in consideration of patient health and treatment-related symptoms and side effects because of potential impacts on exercise tolerance and safety. The ultimate aim is to achieve the current physical activity recommendations for health (150-300 minutes per week of moderate-intensity or 75-150 minutes per week of vigorous-intensity physical activity, and muscle-strengthening activities on 2 or more days a week). There is insufficient evidence for an association between alcohol intake and overall and cancer-specific mortality across all cancer types to warrant a general recommendation that is specific for cancer survivors. However, there are some types of cancer for which this association has been observed. Also, alcohol intake is an established cause of several types of cancer, so the avoidance of alcohol consumption is among the recommendations for cancer prevention and thus is relevant to reduce risk for a new cancer in cancer survivors. The ACS guideline for diet and physical activity for cancer prevention recommendations are listed in Table 2. The summary of evidence for adiposity, physical activity, diet, and alcohol after diagnosis for specific cancer types is presented in Table 3. In summarizing the findings, only systematic reviews that met the guideline methodology for inclusion and that identified a significant association are listed. Importantly, the table calls attention to the lack of quality systematic reviews for many cancers, suggesting additional research is needed to advance recommendations going forward. Abbreviations: ADT, androgen-deprivation therapy; AHEI, Alternative Healthy Eating Index; BMI, body mass index; DASH, Dietary Approaches to Stop Hypertension. The information included in this table reflects postdiagnosis exposures (not prediagnosis) given that after diagnosis is a time period wherein related health behaviors are actionable. No evidence regarding testicular cancers was available for inclusion. Blank cells indicate insufficient evidence supporting an association with the identified exposure and the specific cancer. Absence of evidence of an association is not evidence of no association. Obesity is defined as a BMI ?30 kg/m2. Cancer is the second leading cause of death in the United States, disproportionately affecting racial, ethnic, socioeconomic, and geographic subgroups.1 Over the past 30 years, there has been a decline in the overall cancer death rate of approximately 32%,1 and cancer survivorship has increased over this same period, with 16.9 million survivors in the United States as of January 2019.2 The absolute number of cancer survivors continues to increase due to several factors, including the aging of the US population.3 In addition, temporal changes in behavioral patterns and other factors that influence risk for cancer, including smoking and obesity, affect cancer incidence and mortality.4 Changes in screening practices have generally resulted in earlier cancer detection and treatment. For some types of cancer, improvements in treatment protocols and advancements in treatment as well as the use of targeted therapies and immunotherapies have dramatically increased survival rates. The overall 5-year relative survival rate for all cancers combined is now 68%, although there is notable variability across racial groups and types of cancer.1 Evidence from laboratory and observational studies, although more limited than that for the development of cancer, suggests that modifiable risk factors, such as adiposity, physical activity, diet, and alcohol intake, may affect risk for recurrence and overall survival after diagnosis. The population of cancer survivors in which observational studies (and, to a lesser extent, intervention studies) have been conducted reflects both incidence and survival rates. For example, prostate cancer accounts for 27% of new cancer cases in men, whereas breast cancer accounts for 31% of new cases in women, and the 5-year relative survival rates are among the highest for these cancers (98% for prostate cancer, 90% for breast cancer).1 Colorectal cancer (CRC) accounts for 8% of new cases in both men and women and is associated with a 5-year relative survival rate of 65%.1 Therefore, substantially more investigations of the link between modifiable risk factors and recurrence risk and survival have been conducted for the more common cancers with higher survival rates. In contrast, evidence is much more limited for cancers that are less common and/or have lower survival rates. This is the third American Cancer Society (ACS) guideline with recommendations for relevant diet and physical activity factors for cancer survivors to be released. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing ACS programs, additional ACS electronic and printed documents written with simpler terminology to be widely comprehensible by cancer survivors and their families, health policy, and the media. The first report,5 published in 2006, was presented as a guide for informed choices with the aim of guiding patients and their health care providers in the interpretation of the scientific evidence available at that time. The second ACS guideline,6 published in 2012, provided more specific recommendations across cancer types and was a review of scientific literature based on a larger body of evidence. This ACS guideline differs from earlier versions. The purpose is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and increasing time to new disease and cancer-specific and overall mortality. The body of evidence on the relationship between modifiable risk factors and postdiagnosis recurrence and survival has increased substantially since the last version, especially in the form of systematic literature reviews and meta-analyses, which can add comprehensive evidence with a lower risk of bias than previous evidence syntheses. In addition, high-quality, systematic literature reviews and meta-analyses have been conducted by recognized scientific and advisory groups, and their recommendations are considered and presented in this report, which reduces redundancy and promotes a unified message for patients and health care providers. Notably, the focus of the evidence presented in this version of the ACS guideline is on reducing risk of recurrence and mortality and increasing disease-free survival for survivors of cancers for which evidence is available based on the systematic review described below. Evidence for intermediate outcomes from observational and intervention studies, such as biomarkers or potential mediators of cancer recurrence or progression, are not addressed in this report. This report also includes information of relevance for cancer survivors, their families, and health care providers that was not subject to systematic review. Recommendations for nutrition and physical activity during active cancer treatment, informed by current practice and reviews of other expert bodies, are presented in the guideline. Other topical issues include the relationship between health-related behaviors and comorbidities, long-term sequelae, and patient-reported outcomes (PROs), with attention to enabling survivors' ability to adhere to recommendations. Information on clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis are also provided. Although understanding how to help survivors make sustainable behavior change is critically important in operationalizing this guideline, a thorough discussion of evidence for specific interventions and strategies to support nutrition and physical activity behavior change in cancer survivors is beyond the scope of this review. The reader is referred to other reviews on this topic.7,8 Supporting Table 1 provides a list of available nutrition and physical activity resources from national organizations for cancer survivors. Many cancer survivors face environmental, social, and structural barriers that impact their ability to adhere to nutrition and physical activity recommendations. These include disparities in cancer care, food insecurity, targeted marketing, and lack of access to healthy food and opportunities to be physically active. Many of these issues disproportionately impact people from diverse racial and ethnic backgrounds. We recognize that policies, systems, and environmental approaches are necessary to support behavior change and allow many survivors to adhere to nutrition and physical activity recommendations. Although some community and policy approaches to meet survivors' needs are discussed, a full systematic review of these approaches was not included in this guideline. Publisher Copyright: {\textcopyright} 2022 The Authors. CA: A Cancer Journal for Clinicians published by Wiley Periodicals LLC on behalf of American Cancer Society.",

year = "2022",

month = may,

day = "1",

doi = "10.3322/caac.21719",

language = "English (US)",

volume = "72",

pages = "230--262",

journal = "CA Cancer Journal for Clinicians",

issn = "0007-9235",

publisher = "Wiley-Blackwell",

number = "3",

}

TY - JOUR

T1 - American Cancer Society nutrition and physical activity guideline for cancer survivors

AU - Rock, Cheryl L.

AU - Thomson, Cynthia A.

AU - Sullivan, Kristen R.

AU - Howe, Carol L.

AU - Kushi, Lawrence H.

AU - Caan, Bette J.

AU - Neuhouser, Marian L.

AU - Bandera, Elisa V.

AU - Wang, Ying

AU - Robien, Kimberly

AU - Basen-Engquist, Karen M.

AU - Brown, Justin C.

AU - Courneya, Kerry S.

AU - Crane, Tracy E.

AU - Garcia, David O.

AU - Grant, Barbara L.

AU - Hamilton, Kathryn K.

AU - Hartman, Sheri J.

AU - Kenfield, Stacey A.

AU - Martinez, Maria Elena

AU - Meyerhardt, Jeffrey A.

AU - Nekhlyudov, Larissa

AU - Overholser, Linda

AU - Patel, Alpa V.

AU - Pinto, Bernardine M.

AU - Platek, Mary E.

AU - Rees-Punia, Erika

AU - Spees, Colleen K.

AU - Gapstur, Susan M.

AU - McCullough, Marjorie L.

N1 - Funding Information: Cynthia A. Thomson reports honoraria from and Cancer Support Community and is a member of the Colorectal Cancer Alliance Scientific Advisory Board outside the submitted work. Kristen R. Sullivan reports salary support from a Centers for Disease and Control and Prevention's Center for State, Tribal, Local, and Territorial Support grant outside the submitted work. Carol L. Howe was supported by the American Cancer Society as an independent contractor during the conduct of the study. Lawrence H. Kushi reports grants from the National Cancer Institute; travel support from the Cancer Prevention Research Institute of Texas and the International Agency for Research on Cancer; and Advisory Board service at the National Cancer Institute, all outside the submitted work. Marian L. Neuhouser reports honoraria for her work as Associate editor for (honoraria) and for serving on the internal advisory committee for NIH/NCI funded partnership grant between Fred Hutch and New Mexico State University to increase the capacity for cancer research at NMSU. Karen M. Basen‐Engquist reports grants from the National Cancer Institute and the Cancer Prevention and Research of Texas; honoraria from the National Cancer Institute, the Gynecologic Oncology Group, the University of Kentucky, and the Yale University Transdisciplinary Research on Energetics and Cancer (TREC) training program; travel support from the National Cancer Policy Forum; the National Academies of Science, Engineering, and Medicine; and the Yale University TREC training program; participation on an independent safety monitoring board at Boston University; and service as president elect (2017‐2019) and president (2019‐2021) of the American Society of Preventive Oncology, all outside the submitted work. Justin C. Brown reports grants from the National Institutes of Health and grants and personal fees from the American Institute for Cancer Research outside the submitted work. Barbara L. Grant reports royalties from the Academy of Nutrition and Dietetics for a book chapter on oncology nutrition and service as a liaison representative from the Academy of Nutrition and Dietetics to the American College of Surgeons Commission on Cancer outside the submitted work. Sheri J. Hartman reports grants from the National Cancer Institute/National Institutes of Health and is chair of a Data Safety Monitoring Board outside the submitted work. She chairs a grant‐based DSMB for a study at the University of Wisconsin and Northwestern University. It is not an institutional‐based DSMB. Stacey A. Kenfield reports grants from the National Cancer Institute/National Institutes of Health outside the submitted work. Jeffrey A. Meyerhardt reports institutional research funding from Boston Biomedical; personal fees from Merck Pharmaceuticals and COTA Healthcare; and service on a grant review panel for the National Comprehensive Cancer funded by Taiho Pharmaceutical, all outside the submitted work. Linda Overholser reports grants from the Centers for Disease Control and Prevention and the National Cancer Institute as a coinvestigator in the Cancer Prevention and Control Research Network; royalties from Springer Publishing; and is a member of the National Comprehensive Cancer Network Survivorship Guidelines Panel, all outside the submitted work. Bernardine M. Pinto reports institutional funding from the National Cancer Institute/National Institutes of Health during the conduct of the study and grants or contracts from the Greenville Health System Health Sciences Center to her institution outside the submitted work. Mary E. Platek reports honoraria for providing an American Society for Parenteral and Enteral Nutrition webinar and from the Dartmouth Norris Cotton Center outside the submitted work. The sources of the honoraria are the organizations listed—ASPEN and the Dartmouth Norris Cotton Cancer Center. Susan M. Gapstur reports grants from the National Cancer Institute/National Institutes of Health outside the submitted work. Marjorie L. McCullough reports consulting fees paid to her institution for service on the Cancer Advisory Group to Tufts University and the “Tools to be fit” colorectal cancer survivor study for R01 grants. All remaining authors report no conflicts of interest. DISCLOSURES: Today's Dietitian Journal of Nutrition Funding Information: Cancer survivors can benefit from diet and physical activity assessment and counseling across the continuum of survivorship, from diagnosis and treatment through long-term health and survival postdiagnosis. Table 1 summarizes general recommendations that are supported by current scientific evidence. Nutritional counseling can help to manage treatment-related side effects, such as nausea, vomiting, and appetite loss, and thus prevent nutrient inadequacies and loss of muscle mass caused by these side effects. Many cancer survivors are able to exercise before, during, and after treatments, although some short-term restrictions may apply after major surgery or stem cell transplantation. Physical activity during and after treatment can improve anxiety, depressive symptoms, fatigue, physical functioning and health-related quality of life. The American College of Sports Medicine provides guidance on specific doses of aerobic and resistance training that could improve these common cancer-related health outcomes.14 Individual physical activity recommendations may need to be adapted in consideration of patient health and treatment-related symptoms and side effects because of potential impacts on exercise tolerance and safety. The ultimate aim is to achieve the current physical activity recommendations for health (150-300 minutes per week of moderate-intensity or 75-150 minutes per week of vigorous-intensity physical activity, and muscle-strengthening activities on 2 or more days a week). There is insufficient evidence for an association between alcohol intake and overall and cancer-specific mortality across all cancer types to warrant a general recommendation that is specific for cancer survivors. However, there are some types of cancer for which this association has been observed. Also, alcohol intake is an established cause of several types of cancer, so the avoidance of alcohol consumption is among the recommendations for cancer prevention and thus is relevant to reduce risk for a new cancer in cancer survivors. The ACS guideline for diet and physical activity for cancer prevention recommendations are listed in Table 2. The summary of evidence for adiposity, physical activity, diet, and alcohol after diagnosis for specific cancer types is presented in Table 3. In summarizing the findings, only systematic reviews that met the guideline methodology for inclusion and that identified a significant association are listed. Importantly, the table calls attention to the lack of quality systematic reviews for many cancers, suggesting additional research is needed to advance recommendations going forward. Abbreviations: ADT, androgen-deprivation therapy; AHEI, Alternative Healthy Eating Index; BMI, body mass index; DASH, Dietary Approaches to Stop Hypertension. The information included in this table reflects postdiagnosis exposures (not prediagnosis) given that after diagnosis is a time period wherein related health behaviors are actionable. No evidence regarding testicular cancers was available for inclusion. Blank cells indicate insufficient evidence supporting an association with the identified exposure and the specific cancer. Absence of evidence of an association is not evidence of no association. Obesity is defined as a BMI ?30 kg/m2. Cancer is the second leading cause of death in the United States, disproportionately affecting racial, ethnic, socioeconomic, and geographic subgroups.1 Over the past 30 years, there has been a decline in the overall cancer death rate of approximately 32%,1 and cancer survivorship has increased over this same period, with 16.9 million survivors in the United States as of January 2019.2 The absolute number of cancer survivors continues to increase due to several factors, including the aging of the US population.3 In addition, temporal changes in behavioral patterns and other factors that influence risk for cancer, including smoking and obesity, affect cancer incidence and mortality.4 Changes in screening practices have generally resulted in earlier cancer detection and treatment. For some types of cancer, improvements in treatment protocols and advancements in treatment as well as the use of targeted therapies and immunotherapies have dramatically increased survival rates. The overall 5-year relative survival rate for all cancers combined is now 68%, although there is notable variability across racial groups and types of cancer.1 Evidence from laboratory and observational studies, although more limited than that for the development of cancer, suggests that modifiable risk factors, such as adiposity, physical activity, diet, and alcohol intake, may affect risk for recurrence and overall survival after diagnosis. The population of cancer survivors in which observational studies (and, to a lesser extent, intervention studies) have been conducted reflects both incidence and survival rates. For example, prostate cancer accounts for 27% of new cancer cases in men, whereas breast cancer accounts for 31% of new cases in women, and the 5-year relative survival rates are among the highest for these cancers (98% for prostate cancer, 90% for breast cancer).1 Colorectal cancer (CRC) accounts for 8% of new cases in both men and women and is associated with a 5-year relative survival rate of 65%.1 Therefore, substantially more investigations of the link between modifiable risk factors and recurrence risk and survival have been conducted for the more common cancers with higher survival rates. In contrast, evidence is much more limited for cancers that are less common and/or have lower survival rates. This is the third American Cancer Society (ACS) guideline with recommendations for relevant diet and physical activity factors for cancer survivors to be released. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing ACS programs, additional ACS electronic and printed documents written with simpler terminology to be widely comprehensible by cancer survivors and their families, health policy, and the media. The first report,5 published in 2006, was presented as a guide for informed choices with the aim of guiding patients and their health care providers in the interpretation of the scientific evidence available at that time. The second ACS guideline,6 published in 2012, provided more specific recommendations across cancer types and was a review of scientific literature based on a larger body of evidence. This ACS guideline differs from earlier versions. The purpose is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and increasing time to new disease and cancer-specific and overall mortality. The body of evidence on the relationship between modifiable risk factors and postdiagnosis recurrence and survival has increased substantially since the last version, especially in the form of systematic literature reviews and meta-analyses, which can add comprehensive evidence with a lower risk of bias than previous evidence syntheses. In addition, high-quality, systematic literature reviews and meta-analyses have been conducted by recognized scientific and advisory groups, and their recommendations are considered and presented in this report, which reduces redundancy and promotes a unified message for patients and health care providers. Notably, the focus of the evidence presented in this version of the ACS guideline is on reducing risk of recurrence and mortality and increasing disease-free survival for survivors of cancers for which evidence is available based on the systematic review described below. Evidence for intermediate outcomes from observational and intervention studies, such as biomarkers or potential mediators of cancer recurrence or progression, are not addressed in this report. This report also includes information of relevance for cancer survivors, their families, and health care providers that was not subject to systematic review. Recommendations for nutrition and physical activity during active cancer treatment, informed by current practice and reviews of other expert bodies, are presented in the guideline. Other topical issues include the relationship between health-related behaviors and comorbidities, long-term sequelae, and patient-reported outcomes (PROs), with attention to enabling survivors' ability to adhere to recommendations. Information on clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis are also provided. Although understanding how to help survivors make sustainable behavior change is critically important in operationalizing this guideline, a thorough discussion of evidence for specific interventions and strategies to support nutrition and physical activity behavior change in cancer survivors is beyond the scope of this review. The reader is referred to other reviews on this topic.7,8 Supporting Table 1 provides a list of available nutrition and physical activity resources from national organizations for cancer survivors. Many cancer survivors face environmental, social, and structural barriers that impact their ability to adhere to nutrition and physical activity recommendations. These include disparities in cancer care, food insecurity, targeted marketing, and lack of access to healthy food and opportunities to be physically active. Many of these issues disproportionately impact people from diverse racial and ethnic backgrounds. We recognize that policies, systems, and environmental approaches are necessary to support behavior change and allow many survivors to adhere to nutrition and physical activity recommendations. Although some community and policy approaches to meet survivors' needs are discussed, a full systematic review of these approaches was not included in this guideline. Publisher Copyright: © 2022 The Authors. CA: A Cancer Journal for Clinicians published by Wiley Periodicals LLC on behalf of American Cancer Society.

PY - 2022/5/1

Y1 - 2022/5/1

N2 - The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

AB - The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

KW - alcohol

KW - cancer survivors

KW - dietary patterns

KW - nutrition

KW - obesity

KW - physical activity

UR - http://www.scopus.com/inward/record.url?scp=85126314558&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85126314558&partnerID=8YFLogxK

U2 - 10.3322/caac.21719

DO - 10.3322/caac.21719

M3 - Review article

C2 - 35294043

AN - SCOPUS:85126314558

SN - 0007-9235

VL - 72

SP - 230

EP - 262

JO - CA Cancer Journal for Clinicians

JF - CA Cancer Journal for Clinicians

IS - 3

ER -

American Cancer Society nutrition and physical activity guideline for cancer survivors

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