Clinical Insights: May 2016

Tuesday, May 24, 2016

Release Date: May 25, 2016
Expiration Date: May 25, 2017


This activity is provided free of charge.

STATEMENT OF NEED

This CE article is designed to serve as an update on cancer detection and prevention and to facilitate clinical awareness of current and new research regarding state-of-the-art care for those with or at risk for cancer.

TARGET AUDIENCE

Advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients may articipate in this CE activity.
 

EDUCATIONAL OBJECTIVES

Upon completion, participants should be able to:

  • Describe new preventive options and treatments for patients with cancer
  • Identify options for individualizing the treatment for patients with  cancer
  • Assess new evidence to facilitate survivorship and supportive care for patientswith cancer

ACCREDITATION/CREDIT DESIGNATION STATEMENT

Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing,Provider #16669 for 1.0 Contact Hour.
 

DISCLOSURES/RESOLUTION OF COI

It is the policy of Physicians’ Education Resource®, LLC (PER®) to ensure the fair balance, independence, objectivity, and scientific objectivity in all of our CE activities. Everyone who is in a position to control the content of an educational activity is required to disclose all relevant financial relationships with any commercial interest as part of the activity planning process. PER® has implemented mechanisms to identify and resolve all conflicts of interest prior to release of this activity.The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial interests pertaining to this activity.

METHOD OF PARTICIPATION

  1. Read the articles in this section in its entirety.
  2. Go to www.gotoper.com/go/ONN16May
  3. Complete and submit the CE posttest and activity evaluation.
  4. Print your Certificate of Credit.

OFF-LABEL DISCLOSURE/DISCLAIMER

This CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CE activity is for continuing medical nursing purposes only and is not meant to substitute for the independent medical judgment of a nurse or other healthcare provider relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual authors and do not reflect those of PER®.

Prostate Cancer

ADT Increases Risk for Depression in Elderly Men With Localized Prostate Cancer

Lauren M. Green

Although androgen deprivation therapy (ADT) has a survival benefit for patients with high-risk and locally advanced prostate cancer, it is associated with substantial safety concerns, and mixed data exist regarding whether ADT causes clinically significant depression. A new population-based study published online April 11, 2016, in the Journal of Clinical Oncology sought to explore this possible association.

Using the Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database from 1992 to 2006, researchers identified a total of 78,552 men aged ≥65 years with stage I-III prostate cancer, of whom 33,882 (43%) received ADT within 6 months of diagnosis.

The association between pharmacologic ADT and a diagnosis of depression (primary endpoint) or receipt of psychiatric treatment (secondary endpoint) was analyzed using Cox proportional hazards regression.

The analysis demonstrated significantly increased risks for depression (23%) and inpatient psychiatric treatment (29%) among patients receiving ADT, and a nonsignificant 7% increased risk of outpatient psychiatric treatment. All three of these parameters demonstrated a significantly increased risk with duration of ADT: the risk of depressionrose from 12% with ≤6 months of treatment, to 26% with 7 to 11 months of treatment, to 37% with ≥12 months of treatment.

These findings add to accumulating evidence around the major adverse event profile associated with ADT, and the risk of psychiatric illness should be noted as a potential side effect when discussing ADT with patients. The possible adverse event should also be factored in when weighing the benefits and harms of ADT use in older men with intermediate-risk disease.

One study limitation noted by the researchers is that use of Medicare SEER data limited the scope to men aged ≥65 years at diagnosis, and thus, the results may not be applicable to younger men. Additionally, the relationship between depression and ADT treatment may be confounded by the fact that patients were older and had more comorbidity.

 Nurse Perspective  
 
Frank delaRama Frank delaRama, RN, MSN, AOCNS
Clinical Nurse Specialist Oncology Genomics
Prostate Cancer Nurse Navigator
Palo Alto Medical Foundation
Palo Alto, CA
“Possible side effects may include …” In oncology nursing practice, we probably have uttered these five words several times daily in our interactions with cancer patients and their families. Teaching our patients about what to expect is one of our most valuable roles in nursing. With some treatments, the side effects can be quantitatively measured, for example, blood counts and vital signs. Other side effects can be found with physical assessment, such as skin rashes or mouth sores.

Some treatments, such as androgen deprivation therapy (ADT), have adverse effects that can be difficult to measure and have wide variations from patient to patient. In their principles of ADT, the NCCN outlines what we should be monitoring for in our patients undergoing hormone therapy: 

“ADT has a variety of adverse side effects, including hot flashes, loss of libido and erectile dysfunction, shrinkage of penis and testicles, loss of muscle mass and strength, fatigue, depression, hair loss, osteoporosis, greater incidence of clinical fractures, obesity, insulin resistance, alterations in lipids, and greater riskfor diabetes and cardiovascular disease”
(www.nccn.org/professionals).

Reading that one sentence is pretty intimidating! If given a choice, I would like to avoid that treatment if I can. Unfortunately, for most of our cancer patients, they do not have the luxury of that choice, but must undergo ADT as part of a treatment plan prescribed to them. Given the very personal nature of these side effects, including depression, loss of libido, and erectile dysfunction, it can be difficult to complete a nursing assessment in this arena. Patients can be hesitant to share this information, and nurses and other healthcare providers may even avoid the subject to some degree.

Knowing that research is beginning to make some concrete connections between specific cancer treatments and the risk for depression, nurses can begin to systematically address these potentially underassessed adverse effects. The intervention could be as simple as privately asking a few questions, allowing ample time to actively listen and provide counsel and support. Since most men on ADT are regularly coming into our clinics every few months for PSA checks or ADT injections, nurses have the opportunity to regularly monitor these men. Just ask them.

Hematologic Malignancies

Intervention Eases Parent Burden When Child Has HSCT

Lauren M. Green

An intervention specifically aimed at reducing the trauma and anxiety that often come with parenting a child undergoing hematopoietic stem cell transplant (HSCT) proved especially helpful for parents during the time of the actual transplant and subsequent hospitalization, according to findings of a randomized clinical trial published in the Journal of Consulting and Clinical Psychology.

The parent social-cognitive intervention program (P-SCIP) also proved more beneficial in subgroups of caregivers who came into the HSCT process with already elevated depression and anxiety, as well as among those whose children experienced graft-versus-host disease (GVHD).

Between 2008 and 2013, 218 biological or foster parents of transplant recipients under age 19 were randomized to receive P-SCIP (n = 110) or best practice psychosocial care ([BPC] n=108). P-SCIP involved five, 60-minute, in-person sessions over a 2-to-3-week period following the transplant in which parents viewed an interactive CD-ROM and were given guidance on relaxation techniques, such as deep breathing and guided imagery relaxation. Topics covered included:

• Worries about your child
• Coping with solvable concerns involving a stem cell transplant
• Coping with unchangeable problems
• Communication
• Importance of expressing feelings and needs

The BPC control used for comparison had 4 components: a 1-hour video guide to a child’s stem cell transplant; a pamphlet covering common caregiver issues; an offer of 5 hours of respite care; and walkie-talkies to communicate with the child when the parent was not in the room.

A majority of caregivers in the P-SCIP group attended at least 3 of the 5 sessions where the intervention was offered. Participants were asked to complete an in-person survey within 1 month of their child receiving the transplant and to complete follow-up surveys at 1 month and phone or mail surveys at 6 months and 1 year. The surveys employed validated measures of depressive symptoms, anxiety, traumatic distress, and positive well-being.

Both P-SCIP and BPC were generally rated highly by participants. P-SCIP provided immediate relief of depression, anxiety, and traumatic distress compared with the BPC controls. “Such immediate relief as provided through this intervention is important, as it spares caregivers additional stress and trauma during a universally stressful life experience,” explained lead author Sharon L. Manne, PhD, associate director for Cancer Prevention, Control, and Population at the Rutgers Cancer Institute.

These psychological benefits seen during the time of the actual HSCT, when caregivers were experiencing the most distress, were not observed at the 6-month and 1-year assessments, however. This finding may reflect the fact that distress declines as the child recovers after the procedure, the researchers hypothesized.

Among the cognitive and social aspects which improved more in the intervention arm were acceptance, humor, and problem-solving; no effect was seen in the areas of positive reappraisal, seeking emotional support, or fear appraisals, compared with the usual care group.

Notably, longer-term benefits of the P-SCIP were seen in parents who reported more anxiety to begin with and in those whose children experienced more adverse medical effects from HSCT (eg, GVHD). Therefore, screening caregivers to target interventions at these specific subgroups may be beneficial.

One limitation of the study cited by the authors is a “relatively high dropout rate,” with 19% of caregivers in the P-SCIP arm not attending any or only 1 of the 5 sessions, a finding they said may be attributable, in part, to caregivers not wanting to leave their child’s bedside.

“If this intervention is carried into the clinical setting, methods of improving intervention attendance might be considered. Utilizing phone- or web-based contact that would allow the parent to remain in the room with the child during hospitalization might enable caregivers to more easily access the intervention.”

Reference
Manne S, Mee L, Bartell A, Sands S, Kashy DA. A randomized clinical trial of a parent-focused social-cognitive processing intervention for caregivers of children undergoing hematopoetic stem cell transplantation. J Consult Clin Psychol. 2016;84(5):389-401.

 Nurse Perspective  

Melissa Baker

Melissa Baker, RN, MSN, OCN, APN-C
Adult Blood & Marrow Stem Cell Transplantation Program
John Theurer Cancer Center
Hackensack, NJ
There has been limited research examining interventions for parents of children undergoing stem cell transplantation (SCT), and no empirically-proven method has been identified to reduce distress levels. Although SCT is a potentially curative procedure, it is also a high-risk procedure that invokes significant physical and emotional hardships for both the child undergoing transplant and the caregiver.

Learning to predict and screen parents at highest risk for difficulties and develop interventions to improve parental coping and adjustment through the SCT trajectory is necessary. Findings from this study suggest that parents with children undergoing SCT experience moderate elevations in distress at the time of transplant admission but that this distress decreases over time. However, distress during the acute period of transplant hospitalization, even if transient, may predict later disturbances in quality of life and provide an important mechanism for identification of individuals at risk for later impairment.

This may be especially important in those who experience late infections or impairments secondary to chronic graft versus host disease. Further efforts to better understand the psychosocial cognitive processing of parents with children undergoing SCT are vital to providing optimal support for families during the transplant course.

Effective nurse–patient communication is of paramount importance for the successful outcome of individuals undergoing SCT. Therefore, it is essential to identify familial interventions that aim to improve communication and decrease parental anxiety and depression.

Melanoma

Ipilimumab/Nivolumab Combination Shows Survival Benefit in Advanced Melanoma

Wayne Kuznar

Combining ipilimumab and nivolumab showed a 42% improvement in overall survival (OS) compared with ipilimumab monotherapy for patients with advanced melanoma in a 2-year assessment of the phase II CheckMate-069 trial, announced Michael Postow, MD, at the 2016 AACR Annual Meeting. Abstract CT002

These results extend the enthusiasm for combination immunotherapy owing to complementary and non-redundant mechanisms of action between anti-CTLA-4 ipilimumab and anti-PD-1 therapy nivolumab, said Postow, of the Melanoma-Sarcoma Oncology Service at Memorial Sloan Kettering Cancer Center.

The 2-year OS rate with the combination was 69% compared with 53% for ipilimumab alone, for patients with BRAF wild-type melanoma. The median OS among patients was not reached with the combination regimen and was 24.8 months with ipilimumab monotherapy.

In the overall study population, the 2-year OS rate was 64% with the combination compared with54% for ipilimumab alone. The median OS at 2 years in patients randomized to either the combination or monotherapy has not been reached.

Findings from the CheckMate-069 study add to results from the phase III CheckMate-067 study, which showed improvements in progression-free survival (PFS) and objective response rates (ORR). The FDA granted an accelerated approval to the combination for BRAF wild-type tumors in October 2015 and for those with BRAF mutations in January 2016.

In the phase II study, treatment-naïve patients (n =142) with unresectable stage III or metastatic stage IV melanoma were randomized in a 2:1 ratio to either 3 mg/kg of ipilimumab in combination with 1 mg/kg of nivolumab (n = 95) or placebo (n = 47) once every 3 weeks for 4 doses. This was followed by nivolumab at the same dose or placebo every 2 weeks until disease progression
or unacceptable toxicity.

As reported previously, with 11 months of follow-up, the ORR in the BRAF wild-type group (the primary endpoint) was 61% in the combination arm compared with 11% in the ipilimumab monotherapy arm (N Engl J Med; 2015; 372(21):2006-2017). The results were similar among all randomized patients, which included patients with BRAF-mutant melanoma.

With 2-year follow-up, among all patients randomized to combination treatment, the median tumor burden by RECIST v1.1 decreased by 70%, whereas the median tumor burden among all patients randomized to ipilimumab increased by a median of 5%. The median duration of response was not reached in either arm. Eighty percent of responses to the combination (45 of 56) and ipilimumab monotherapy (4 of 5) were ongoing at the 2-year follow-up.

“The majority of these responses happened early, at the time of the first scan,” said Postow. “The median time to response was 2.8 months in the combination arm and 2.7 months for ipilimumab alone.” Twenty-nine of 45 patients (64%) who discontinued combination treatment remain in response.

Median PFS at 2 years in the BRAF wild-type population was not reached in the combination arm and was 4.4 months in patients randomized to ipilimumab alone, for a hazard ratio of 0.35 in favor of the combination.

“This reflects a statistically significant difference in the reduction of progression or death in favor of the combination over ipilimumab monotherapy,” he said.

The 2-year PFS rate with combination treatment in BRAF wild-type tumors was 54% compared with 11% with ipilimumab alone. Similar PFS rates were observed in the all-randomized population. The combination of ipilimumab and nivolumab resulted in a median PFS that still has not been reached at the 2-year follow-up. With ipilimumab monotherapy, the median PFS was 3 months. “This reflects a 64% reduction in the hazard of progression or death in this all-randomized patient population, whichis very impressive and statistically significant,” Postow said.

Overall, 35% of patients in the combination arm and 70% in the monotherapy arm received any subsequent therapy. Altogether, 64% of patients randomized to ipilimumab crossed over to receiveany systemic therapy at the time of progression.

Eighteen percent of patients in the combination group received subsequent anti-PD-1 therapy at progression compared with 62% in the ipilimumab monotherapy arm. The median time to initiation of the subsequent therapy was not reached in the combination arm and was 6.1 months in the ipilimumab-alone arm.

When assessing efficacy of combination immunotherapy by PD-L1 status, there was nodifference in the ORR at the 1-month data cutoff and no difference in PFS or OS at 2 years between patients who were defined as PD-L1-positive versus those defined as PD-L1-negative.

Treatment-related adverse events were consistent with the initial reports, with higher rates of gastrointestinal and hepatic adverse events of any grade with the combination compared with monotherapy.

Grade 3/4 treatment-related AEs occurred in 54% of patients treated with the combination regimen versus 20% with ipilimumab alone. AEs led to discontinuation in 37% of patients treated with the combination regimen compared with 9% for ipilimumab alone.

 Nurse Perspective  
 
Kathleen Madden, RN, MSN, FNP-BC, AOCNP, AHNP Kathleen Madden, RN, MSN, FNP-BC, AOCNP, AHNP
Nurse Practitioner
Laura and Isaac Perlmutter Cancer Center
NYU Langone Medical Center
New York, NY 
Recent updates from the annual AACR meeting provided some exciting data regarding increased overall survival (OS) for patients receiving a combination ipilimumab and nivolumab regimen. The 2-year OS data from the phase II CheckMate-069 trial revealed a 69% OS in patients who received the combination versus 53% with ipilimumab alone in BRAF wild-type patients.

FDA approval for use of combination therapy in BRAF-mutant patients occurred in October 2015, and expanded in January 2016 to include BRAF wild-type patients. The ipilimumab/nivolumab regimen upregulates the immune system’s recognition and response by a multimodal release on the breaking mechanisms of T cells. Anti-CTLA-4 increases the number of T cells and anti-PD-1 enhances their efficiency and ability to work directly on the tumor environment. This upregulation can result in a robust and rapid onset of immune-related adverse events (IRAEs). On study, grade 3/4 IRAEs occurred in 54% of patients treated with combination therapy versus 20% treated with ipilimumab alone.

Oncology nurses are often the front line for triaging symptoms and initiating management of toxicities. It is prudent for oncology nurses to remain vigilant in understanding that any organ system can be affected by this combination of immunotherapy. On study, the most common treatment IRAEs reported were GI and hepatic in nature. GI disturbances tend to be clinically evident with symptoms of nausea, anorexia, and diarrhea, whereas hepatic changes entail elevated transaminases, fever, abdominal pain, nausea, and anorexia.

The ipilimumab/nivolumab regimen can also rapidly impact the endocrine, nervous, respiratory, dermatologic, and genitourinary systems. Since IRAEs can occur earlier with greater intensity, having a lower threshold for in-person evaluations and initiating toxicity management should be considered. Patients must be educated to report symptoms at the onset and not to delay due to the quicker progression and severity in IRAEs with combination therapy.

Breast Cancer

Genetic Variants May Predict Risk for Breast Cancer After Chest Radiation

Lauren M. Green

Chest radiation to treat a pediatric cancer is a well-known risk factor for gettingbreast cancer in adulthood, and research has now unearthed two specific genetic variants that may help to identify those survivors who are most at risk.

“This is the first study that provides evidence that germline genetics outside the context ofhigh-risk syndromes can modify the risk for breast cancer in childhood cancer survivors treated with chest radiation therapy,” said Lindsay M.Morton, PhD, reporting the study results at the 2016 AACR Annual Meeting held April 16-20 in New Orleans. Abstract 2691

“In addition, for patients who have already been treated, the results could be used to identifythe survivors who have the highest risks of developing breast cancer and therefore might benefit the most from screening.”

The specific variants were found to increase breast cancer risk only in women who received 10 or more Gy of chest radiotherapy, reported Morton, a senior investigator with the National Cancer Institute’s Radiation Epidemiology Branch. A variant at position q41 on chromosome1 was associated with nearly a 2-fold increase in risk, Morton said, and one at position q23 on chromosome 11 was associated with a nearly 3-fold increased risk for each copy of the risk alleles. These variants did not increase breast cancer risk in survivors who had not received radiotherapy to the chest as part of their cancer treatment, however.

Morton said the findings, if elucidated and confirmed in subsequent studies, have the potential to impact cancer and survivorship care for the nation’s growing number of childhood cancer survivors—currently estimated to number 420,000—particularly the women among them.

The researchers conducted genomic DNA analyses of more than 3400 blood or saliva samples drawn from 2 large groups of childhood cancer survivors who had been followed for a median 25 years: the Childhood Cancer Survivor Study, which includes children diagnosed with cancer between 1970 and 1986, and the St. Jude Lifetime Cohort, which includes children diagnosed between 1962 and 2001.

Of the 207 breast cancer cases diagnosed across the two cohorts, the majority (65%) had Hodgkin lymphoma as their first primary childhood cancer, 10% had leukemia, and the remaining had a mix of other childhood cancer types.

Investigators compared the genotypes for survivors who developed breast cancer against those who did not. “About two-thirds of the cases had at least 10 Gy of radiation to their breasts during the course of their childhood cancer radiotherapy,” Morton noted. She added that the median age of breast cancer diagnosis in the population was 39. “These are breast cancer cases that are being seen at a much younger age than you would see in the general population.”

Morton explained the mechanisms behind the two single nucleotide polymorphisms (SNPs, or “snips”) found to be implicated in increasing breast cancer risk in the ≥10-Gy group. The chromosome 1 marker, PROX1, is involved inembryonic development, cellular proliferation,and migration, and alterations are present in about 13% of breast tumor cells, Morton said. The chromosome 11 marker, TAGLN, is involved in cellular migration and is overexpressed in breast tumors compared with normal breast tissue.

“Our top association was for a marker on chromosome 1q41 … there was a very significant difference in the genotype distribution at this particular location among the childhood cancer survivors who developed breast cancer compared with those who did not,” said Morton. “The relative risk for developing breast cancer was nearly 2-fold for each copy of the risk allele … but there was no effect on risk among childhood cancer survivors who had not received chest radiotherapy.”

Similar results were seen for the marker on chromosome 11q23, Morton noted, but “unlike the chromosome 1 snip, which was a relatively common one, the chromosome 11 snip was a relative rare marker,” only present in 2% to 3% of controls. This snip conferred about a 2.6-fold increased risk for breast cancer, again restricted to those childhood cancer survivors who had received at least 10 Gy of radiation to the breast, Morton continued.

Morton cautioned that, because they were generated in a “discovery” study, these early findings will require replication before evaluation in the clinic. Among the unanswered questions, she said, is the relationship between the genotypeand the risk from the lower radiation levels patients are typically treated with today.

Other factors to consider include the effect of the child’s age at treatment and whether an individual’sbreast cancer molecular subtype affects the level of increased risk.

“Once all of this work is done—the laboratory studies and additional replication—we think that these studies have tremendous potential for the future,” concluded Morton. “There is the possibility that understanding genetic susceptibility could impact frontline therapy decisions. It may alter the risk-and-benefit calculation for receipt of radiotherapy for a childhood cancer patient who is being diagnosed today.

“For the many survivors who are already out there, these data also could impact the screening recommendations.”

Nightly Fasting Found Beneficial to Reduce Breast Cancer Recurrence

Lauren M. Green

A study of more than 2400 women with early-stage breast cancer has found that those who fasted 13 hours or more at night reduced their risk of breast cancer recurrence, findings that suggest prolonging the nightly fasting interval may offer a relatively safe nonpharmacologic way for women with early breast cancer to lower their risk of disease recurrence.

Nightly fasting less than 13 hours was not significantly associated with a higher risk of breast cancer mortality, however. The patient cohort for this study was drawn from participants in the Women’s Healthy Eating and Living (WHEL) study conducted between 1995 and 2007.

This randomized, controlled trial involved 3088 women with early-stage invasive breast cancer and evaluated whether a low-fat diet focused on vegetables, fruit, and fiber reduced breast cancer recurrence risk and mortality.

The present study looked at invasive breast cancer recurrence and new primary breast tumors during an average of 7.3 years of follow-up and death from breast cancer or any cause during an average 11.4 years of surveillance.

Data were gathered from the participants’ telephone self-reports of their recall of their dietary patterns over the previous 24 hours, taken at baseline, year 1, and year 4. 

Participants were aged a median 52.4 years. They reported a mean fasting duration of 12.5 hours per night and 4.4 eating episodes, defined as the number of times per day that they consumed ≥25 kcal at a single time point. Approximately 33% of participants reported eating episodes after 8 pm.

A nightly fast of less than 13 hours was associated with a 36% higher risk of breast cancer recurrence, compared with fasting ≥13 hours per night. Additionally, each 2-hour increase in nightly fasting was associated with significantly lower hemoglobin A1C levels.

Another interesting research finding involved sleep quality: the investigators found that prolonged fasting at night was associated with longer sleep duration, a finding in line with previous research that consuming foods late at night may interfere with circadian rhythms.

The authors noted that limited data exist from previous small studies involving humans that signal a positive impact from intermittent fasting regimens on risk factors for poor breast cancer outcomes, among them, glucose regulation, inflammation, obesity, and sleep.

The researchers concluded that although the study findings “have broad and significant implications for public health, randomized trials are needed to adequately test whether prolonging the nightly fasting interval can reduce the risk of chronic disease.”

Reference
Marinac CR, Nelson SH, Breen CI, et al. Prolonged nightly fasting and breast cancer prognosis [published online before print March 31, 2016]. JAMA Oncol.

 Perspective 

Laura Newton, MA, RD Laura Newton Rutledge, MA, RD
Assistant Professor
Department of Nutrition Sciences
University of Alabama at Birmingham
Birmingham, AL
Nutrition research in cancer has primarily focused on what people eat in relation to cancer, but this article lends weight to also focus on when and how often people eat. A variety of fasting-type diets are currently being studied in relation to cancer, weight control, and other chronic diseases. In these studies, fasting is often defined as: intermittent energy restriction (IER), which involves fasting or greatly reduced (<500 calories/day) food intake intermittently, such as 2 days a week or every other day, or time-restricted feeding (TRF), which involves limiting intake of food to a set time window. Interestingly, the Marinac study found a correlation between a 13-hour fast and breast cancer recurrence while most time-controlled studies limit food intake to a 4-6 hour time window.

Obesity is a known risk factor for many types of cancer and breast cancer recurrence. For many years, nutrition advice has focused on the benefits of a plant-based diet emphasizing vegetables and fruits and including fish and nuts, along with the mantra to eat 3 meals/day with small snacks to reduce cancer risk and control weight. However, this pattern of frequent eating is abnormal from an evolutionary perspective, and recent research has shown that even skipping breakfast is not associated with weight gain.1 Focusing on the frequency and timing of meals may improve overall health and reduce the risk of some diseases,including cancer.

One rationale behind fasting reducing the risk of cancer and potentially other chronic diseases is that fasting lowers insulin and insulin-like growth factor, high levels of which have been linked to cancer. Reducing these hormones may slow cancer cell growth and development. Animal studies have shown that IER inhibits and can even reverse the growth of a variety of tumors, including neuroblastoma, ovarian, and breast cancer.2

Studies are ongoing looking at these various methods of fasting, and it is likely that there is not a one-size-fits-all approach, but rather to see what is most realistic and feasible for the individual. For some, limiting intake to a specified time window may work, while caloric restriction (<500 calories/day) a few days a week or skipping breakfast and lunch a few days a week may be more achievable for others. Personally, I have a hard time eating dinner before 7 or 8 pm but could certainly skip breakfast a few days a week (and maybe lunch, over time!).

There are still many questions that need to be answered before making widespread recommendations regarding fasting, but as the authors of this study point out, this might be a simple, nonpharmacologic way to reduce the risk of breast cancer recurrence and potentially other chronic diseases.

References
1. Dhurandhar EJ, Dawson J, Alcorn A, et al. The effectiveness of breakfast recommendations on weight loss: A randomized controlled trial. Am J Clin Nutr. 2014;100(2):507–513.
2. Lee C, Raffaghello L, Brandhorst S, et al. Fasting cycles retard growth of tumors and sensitize a range of cancer cell types to chemotherapy. Sci Transl Med. 2012;4(124):124-127.
 
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