1. A Presentation to
the University of
Manitoba Medical
Students 2012
Stephan Esser MD
www.esserhealth.com

2. Lifestyle Medicine
and Cancer:
Basic Tenants and
Application
Stephan Esser MD
Institute of Lifestyle Medicine
Harvard, Boston, MA

6. Intro
 Who we are?
 Why we care?
 What is Lifestyle Medicine?
 Does Lifestyle affect Cancer?
 Developing tools
 Implementation

7. What this is NOT
 The end
 The complete story
 Everything you need to know to be an oncologist
 Top 10 treatment protocols

9. Lifestyle Medicine
 the application of environmental, behavioral, medical
and motivational principles to the management of
lifestyle-related health problems in a clinical setting.
 Modalities:
 Diet
 Exercise
Fingers, Feet and
 Sleep

Forks
Emotional Poise
 Reduced toxic exposures: Nicotine, Alcohol, Illicits

10. Classic Medical
Model
Surgery
Pharmaceuticals

11. Ideal
Medical Model ?
Surgery
Pharmaceuticals
Physical Modalities
Lifestyle Interventions

12. Why Cancer matters?

14. Canadian CA statistics
• Lung, prostate, breast, colorectal cancer = 50% of all new
cancer cases
• Lung cancer = quarter (27%) of all cancer deaths each year.
• Breast cancer = (28%) of new cancer cases in women.
• Prostate cancer = (27%) of new cancer cases in men.
• 2011 estimates: 40% of Canadian women and 45% of men will
develop cancer during their lifetimes.
• 1 of 4 Canadians will die from cancer

15. Women’s Cancer Death Rates Canada 2008

16. Men’s Cancer Death Rates Canada 2008

17. Mortality Statistics

18. Leading Causes of Death in US

19. Top Ten Causes of Death for Men in the United States

21. Examining Risk
• Cigarette Smoking
• Obesity • Exercise
• Stress
• Nutrition

22. Cigarette Smoking

23. Obesity

24. BMI
 Underweight < 18.5 Increased
 Normal Weight 18.5 - 24.9 Least
 Overweight 25.0 - 29.9 Increased
 Obese class I 30.0 - 34.9 High
 Obese class II 35.0 - 39.9 Very high
 Obese class III >= 40.0 Extremely high

25. Canadian Obesity

26. Obesity Trends in CA

27. US and Canadian Obesity

30. Michelangelo’s David:
12 month 20 city tour of
the US

31. Obesity and Cancer
 Association of Obesity and Cancer
Risk in Canada Am. J. Epidemiol. (2004) 159 (3): 259-268
 Excess body mass accounted for 7.7% of all cancers in
Canada
 9.7% in men and 5.9% in women.
 Inc risk of overall cancer
 Non-Hodgkin’s lymphoma, leukemia, multiple myeloma,
and cancers of the kidney, colon, rectum, breast (in
postmenopausal women), pancreas, ovary, and prostate.

32. Obesity and Cancer
A prospective study of obesity and Cancer Risk
Cancer Causes and Control 2004
 Obesity = 33% increase in cancer risk
 25% in men and 37% in women.
 Increased for
 Small Intestine (SIR = 2.8; 95% CI 1.6–4.5)
 Colon (1.3; 1.1–1.5) -Cervix uteri (1.4; 1.1–1.9),
 Gallbladder (1.6; 1.1–2.3) -Endometrium (2.9; 2.5–3.4)
 Pancreas (1.5; 1.1–1.9) -Ovary (1.2; 1.1–1.5)
 Larynx (2.1; 1.1–3.5) -Brain (1.5; 1.2–1.9
 Renal parenchyma (2.3; 1.8–2.8) -Lymphomas (1.4; 1.0–1.7)
 Bladder (1.2; 1.0–1.6)

33. Obesity and Breast CA
Obesity and breast cancer: a review of the
literature The Breast 2004
 Most Studies: overweight or obese women are at increased risk
of developing postmenopausal breast cancer
 Inc. body mass index is associated with a more advanced stage
of breast cancer at diagnosis in terms of tumour size.
 Treatment modalities surgery, radiotherapy, chemotherapy and
hormonal treatment may be adversely affected by the presence of
obesity.
 The overall and disease-free survival is worse in most but not all
studies of prognosis of obese pre- and postmenopausal women
with breast cancer.

34. Obesity and Colon CA
Obesity and colon and rectal cancer risk:
a meta-analysis of prospective studies
Am J Clin Nutr September 2007 vol. 86 no. 3
 5-unit increase in BMI was related to an increased risk of colon
cancer in both men (RR: 1.30; 95% CI: 1.25, 1.35) and women
(RR: 1.12; 95% CI: 1.07, 1.18)
 BMI was positively associated with rectal cancer in men (RR:
1.12; 95% CI: 1.09, 1.16) but not in women
 Colon cancer risk increased with increasing waist
circumference (per 10-cm increase) in both men (RR: 1.33; 95%
CI: 1.19, 1.49) and women

35. Obesity and Colon CA
BMI and waist circumference as predictors of lifetime colon
cancer risk in Framingham Study adults International Journal of Obesity (2004)
 BMI 30 = 50% increased risk of colon cancer among middle-
aged (30–54 y) and a 2.4-fold increased risk (95% CI: 1.5–3.9)
among older (55–79 y) adults.
 Larger waist size (99.1 cm (39 in) and 101.6 cm (40 in) for
women and men, respectively) was associated with a two-fold
increased risk of colon cancer
 A larger waist had a particularly adverse effect among sedentary
subjects (relative risk (RR)=4.4 for middle-aged adults; RR=3.0
for older adults).

36. Obesity and Prostate CA
Body Mass Index and Risk of Prostate
Cancer in U.S. Health Professionals
Journal of the National Cancer Institute 2003
 Risk of prostate cancer in men with a higher BMI (≥30 kg/
m2) was lower than that in men with a lower BMI (23–24.9
kg/m2) but only if they were younger (<60 years old)
(relative risk = 0.52, 95% confidence interval = 0.33 to
0.83; Ptrend<.001) or had a family history of prostate cancer
(relative risk = 0.74, 95% confidence interval = 0.45 to
1.19; Ptrend = .01).

37. Obesity and Prostate CA
Impact of obesity on prostate cancer recurrence
after radical prostatectomy: Data from
CaPSURE Urology 2005
 After adjusting for risk group, ethnicity, age, and comorbidities, a
significant association was found between an increasing BMI
and disease recurrence (P = 0.028). Very obese patients (BMI 35
kg/m2 or more) were 1.69 times more likely to have recurrence
relative to men of normal weight (BMI less than 25.0 kg/m2; 95%
confidence interval [CI] 1.01 to 2.84). An increasing PSA level (P
<0.0001) and Gleason grade (P <0.0001) were also associated
with recurrence. Ethnicity was not significantly associated with
either BMI or PSA recurrence (P = 0.685 and P = 0.068,
respectively).

38. Nutrition

39. Nutrition
Does what we eat really matter to
cancer risk, progression or
recurrence?

40. Dietary factors account for
about 30% of all cancer risk

41. Nutrition
 Fruits and Vegetables are Protective
 Animal Products increase risk

42. Nutrition and Breast CA
Meat consumption and risk of breast cancer
in the UK Women's Cohort Study British
Journal of Cancer (2007)
 Between 1995 and 1998 a cohort of 35 372 women was recruited, aged between 35 and
69 years with a wide range of dietary intakes, assessed by a 217-item food frequency
questionnaire.
 High consumption of total meat compared with none was associated with
premenopausal breast cancer, HR=1.20 (95% CI: 0.86-1.68), and high non-processed
meat intake compared with none, HR=1.20 (95% CI: 0.86-1.68). Larger effect sizes
were found in postmenopausal women for all meat types, with significant associations
with total, processed and red meat consumption. Processed meat showed the
strongest HR=1.64 (95% CI: 1.14-2.37) for high consumption compared with none.
 Women, both pre- and postmenopausal, who consumed the
most meat had the highest risk of breast cancer.

43. Nutrition and Breast CA
Well-Done Meat Intake and the Risk of Breast
Cancer
JNCI J Natl Cancer Inst (1998) 90 (22): 1724-1729.
 Adjusted nested, case-control study of 41 836 cohort members of
the Iowa Women's Health Study
 Women who consumed bacon, beef steak or hamburger
consistently very well done had a 4.62 times higher risk (95% CI
= 1.36-15.70) than that of women who consumed the meats rare
or medium done.
 Conclusions: Consumption of heterocyclic amines well-done
meats and, thus, exposures to (or other compounds) formed
during high-temperature cooking may play an important role in
the risk of breast cancer.

44. Nutrition and Breast CA
Dietary fat and breast cancer risk revisited: a
meta-analysis of the published literature British
Journal of Cancer (2003)
 The summary relative risk, comparing the highest and lowest levels
of intake of total fat, was 1.13 (95% CI: 1.03-1.25). Cohort studies
(N=14) had a summary relative risk of 1.11 (95% CI: 0.99-1.25) and
case-control studies (N=31) had a relative risk of 1.14 (95% CI
0.99-1.32). Significant summary relative risks were also found for
saturated fat (RR, 1.19; 95% CI: 1.06-1.35) and meat intake (RR,
1.17; 95% CI 1.06-1.29). Combined estimates of risk for total and
saturated fat intake, and for meat intake, all indicate an
association between higher intakes and an increased
risk of breast cancer. Case-control and cohort studies gave
similar results.

45. Nutrition and Colorectal CA
Meat, Fish, and Colorectal Cancer Risk: The European
Prospective Investigation into Cancer and Nutrition
JNCI J Natl Cancer Inst (15 June 2005) 97 (12): 906-916.
 Our data confirm that colorectal cancer risk is
positively associated with high consumption of red
and processed meat and support an inverse association
with fish intake.

46. Nutrition and Colorectal CA
Systematic Review of the Prospective
Cohort Studies on Meat Consumption
and Colorectal Cancer Risk Cancer Epidemiol Biomarkers Prev
May 2001 10; 439
 Thirteen studies were eligible for inclusion in the meta-analysis
 Pooled results indicate that a daily increase of 100 g of all meat or red meat
is associated with a significant 12-17% increased risk of colorectal cancer.
 significant 49% increased risk was found for a daily increase of 25 g of
processed meat.

47. Nutrition and Colorectal CA
Meat consumption and colorectal cancer risk:
Dose-response meta-analysis of
epidemiological studies
International Journal of Cancer 2002
 Average RRs and 95% confidence intervals (CI) for the highest
quantile of consumption of red meat were 1.35 (CI: 1.21-1.51) and of
processed meat, 1.31 (CI: 1.13-1.51). The RRs estimated by log-
linear dose-response analysis were 1.24 (CI: 1.08-1.41) for an
increase of 120 g/day of red meat and 1.36 (CI: 1.15-1.61) for 30
g/day of processed meat. The risk fraction attributable to current
levels of red meat intake was in the range of 10-25% in regions where
red meat intake is high. If average red meat intake is reduced to
70 g/week in these regions, colorectal cancer risk would
hypothetically decrease by 7-24%

48. Nutrition and Stomach CA
Meat Intake and Risk of Stomach and Esophageal
Adenocarcinoma Within the European
Prospective Investigation Into Cancer and
Nutrition (EPIC)
JNCL 2006
 Total, red, and processed meat intakes were
associated with an increased risk of gastric
noncardia cancer, especially in H. pylori
antibody-positive subjects, but not with cardia
gastric cancer.

49. Nutrition and Pancreatic CA
Meat and Fat Intake as Risk Factors for Pancreatic
Cancer: The Multiethnic Cohort Study
JNCL 2005
 The strongest association was with processed meat; those in the fifth quintile
of daily intake (g/1000 kcal) had a 68% increased risk compared with those
in the lowest quintile (relative risk = 1.68, 95% confidence interval = 1.35 to
2.07; Ptrend<.01).
 Intakes of pork and of total red meat were both associated with 50%
increases in risk, comparing the highest with the lowest quintiles (both
Ptrend<.01).
 Intake of total and saturated fat from meat was associated with statistically
significant increases in pancreatic cancer risk but that from dairy products
was not.

50. Plant Foods and Colorectal CA
Nutrition, lifestyle and colorectal cancer incidence: a prospective
investigation of 10 998 vegetarians and non-vegetarians in the United
Kingdom British Journal of Cancer (2004)
 In a cohort of 10 998 men and women, 95 incident cases of colorectal cancer were recorded after 17
years. Risk increased in association with smoking, alcohol, and white bread consumption, and
decreased with frequent consumption of fruit. The relative risk in vegetarians compared with
nonvegetarians was 0.85 (95% CI: 0.55-1.32).
Dietary fiber and plant foods in relation to colorectal cancer
mortality: The Seven Countries Study International Journal of Cancer
 Seven Countries Study, around 1960 12,763 men aged 40 to 59 were enrolled in 16 cohorts in 7 countries
 Fiber intake was inversely associated with colorectal-cancer mortality with an energy-adjusted rate ratio of
0.89 (95% confidence interval 0.80-0.97). An increase of 10 gram of daily intake of fiber was
associated with a 33% lower 25-year colorectal-cancer mortality risk. Intakes of vitamin
B6 [0.84 (0.71-0.99)] and alpha-tocopherol [0.94 (0.89-0.99)] were also inversely associated with risk.
Consumption of plant foods and related sub-groups was not related to colorectal cancer. It appears that fiber
intake best indicates the part of plant food consumption, including whole grains, that is relevant for lowering
colorectal cancer risk.

51. Plant Foods and Gastric Cancer
Plant foods and risk of gastric cancer: a case-
control study in Uruguay European Journal of Cancer Prevention 2001
 Total plant foods were strongly associated with a reduced risk of stomach
cancer (OR 0.31, 95% CI 0.18-0.54). It is suggested that vitamins (vitamin C
and carotenoids) and bioactive substances (diallyl sulfide) could be involved
in the mechanisms of action of plant foods.
Total antioxidant potential of fruit and vegetables
and risk of gastric cancer? Gastroenterology 2002
Dietary intake of antioxidants measured as total antioxidant
potential is inversely associated with risk of both cardia and
distal cancer.

52. Plant Foods and Breast CA
Estrogen Excretion Patterns and Plasma Levels in
Vegetarian and Omnivorous Women NEJM 1982
 Vegetarian women have increased fecal
excretion of estrogen and a decreased plasma
concentration of estrogen.

53. Plant Foods and Prostate CA
-93 volunteers with serum PSA 4 to 10 ng/ml
and cancer Gleason scores less than 7
-Ornish, plant based nutrition
-PSA decr. by 4% in the experimental group but
increased 6% in the control group
-LNCaP prostate cancer cells were inhibited
almost 8 times more by serum from the
experimental than from the control group (70%
vs 9%, p < 0.001

54. Exercise

55. What’s Recommended
Public Health Agency of Canada
 Aerobic Exercise
 150 min/wk
 Strength Training
 2 days per week

58. Exercise and Breast CA
Physical Exercise and Reduced Risk of Breast
Cancer in Young Women J Natl Cancer Inst
 Case-control design with 545 women (aged 40 and younger at
diagnosis) who had been newly diagnosed with in situ or invasive
breast
 The odds ratio (OR) of breast cancer among women who, on
average, spent 3.8 or more hours per week participating in physical
exercise activities was 0.42 (95%confidence limits [CLs] = 0.27, 0.64)
relative to inactive women. The effect was stronger among women
who had had a full-term pregnancy. Comparing most active (>3.8
hours/wk of exercise) women to inactive women, the ORs were 0.28
(95% CL = 0.16, 0.50) for parous and 0.73 (95% CL = 038, 1.41) for
nulliparous women.

59. Exercise and Breast CA
Physical Activity and the Risk of Breast Cancer
N Engl J Med 1997
 Cohort study of 25,624 women.
 Greater leisure-time activity was associated with a reduced risk of breast cancer, after
adjustments for age, body-mass index (the weight in kilograms divided by the square of
the height in meters), height, parity, and county of residence (relative risk, 0.63; 95
percent confidence interval, 0.42 to 0.95), among women who exercised regularly, as
compared with sedentary women (P for trend = 0.04).
 In stratified analyses the risk of breast cancer was lowest in lean women (body-
mass index, <22.8) who exercised at least four hours per week (relative risk, 0.28;
95 percent confidence interval, 0.11 to 0.70). The risk was also reduced with higher
levels of activity at work, and again there was a more pronounced effect among
premenopausal than postmenopausal women.

60. Exercise and Breast CA
Lifetime Recreational Exercise Activity and Breast
Cancer Risk Among Black Women and White
Women NCI J Natl Cancer Inst 2006
 Among all women, decreased breast cancer risk was associated with
increased levels of lifetime exercise activity (e.g., average MET-hours per
week per year, Ptrend = .002).
 Exercise level above median level for active control subjects was associated
with an approximately 20% lower risk of breast cancer, compared with that
for inactivity (for 6.7-15.1 MET-hours/week/year, odds ratio [OR] = 0.82,
95% confidence interval [CI] = 0.71 to 0.93; for 15.2 MET-hours/week/year,
OR = 0.80, 95% CI = 0.70 to 0.92).
 The inverse associations did not differ between black and white women
(for MET-hours/week/year, Ptrend = .003 and Ptrend = .09, respectively;
homogeneity of trends P = .16).

61. Exercise and Breast CA
Recreational Physical Activity and the Risk of
Breast Cancer in Postmenopausal Women
JAMA. 2003
 An increasing total current physical activity score was associated
with a reduced risk for breast cancer (P = .03 for trend).
 Women who engaged in the equivalent of 1.25 to 2.5 hours per
week of brisk walking had an 18% decreased risk of breast
cancer (RR, 0.82; 95% CI, 0.68-0.97) compared with inactive
women.
 Slightly greater reduction in risk was observed for women who
engaged in the equivalent of 10 hours or more per week of brisk
walking.

62. Exercise and Breast CA
Effects of exercise on breast cancer patients and
survivors: a systematic review and meta-
analysis CMAJ 2006
 Exercise improves:
 quality of life
 cardiorespiratory fitness
 physical functioning
 fatigue

63. Exercise and Colon CA
Physical Activity, Obesity, and Risk for Colon Cancer
and Adenoma in Men AIM 1995
 Physical activity was inversely associated with risk for colon cancer (high
compared with low quintiles of average energy expenditure from leisure-time
activities: relative risk, 0.53 [95% CI, 0.32 to 0.88], P for trend = 0.03) after
adjustment for age; history of colorectal polyp; previous endoscopy; parental
history of colorectal cancer; smoking; body mass; use of aspirin; and intake of red
meat, dietary fiber, folate, and alcohol.
 Body mass index was directly associated with risk for colon cancer
independently of physical activity level. Waist circumference and waist-to-hip
ratio were strong risk factors for colon cancer (waist-to-hip ratio ? 0.99 compared
with waist-to-hip ratio < 0.90: multivariate relative risk, 3.41 [CI, 1.52 to 7.66], P
for trend = 0.01; waist circumference ? 43 inches compared with waist
circumference < 35 inches: relative risk, 2.56 [CI, 1.33 to 4.96], P for trend <
0.001). These associations persisted even after adjustment for body mass and
physical activity.

64. Exercise and Colon CA
Impact of Physical Activity on Cancer Recurrence and Survival in
Patients With Stage III Colon Cancer: Findings From CALGB
89803 American Society of Clinical Oncology 2006
 Compared with patients engaged in less than three metabolic equivalent task
(MET) -hours per week of physical activity, the adjusted hazard ratio for disease-
free survival was 0.51 (95% CI, 0.26 to 0.97) for 18 to 26.9 MET-hours per week
and 0.55 (95% CI, 0.33 to 0.91) for 27 or more MET-hours per week. The
adjusted P for trend was .01.
 Postdiagnosis activity was associated with similar improvements in recurrence-
free survival (P for trend = .03) and overall survival (P for trend = .01). The
benefit associated with physical activity was not significantly modified by sex,
body mass index, number of positive lymph nodes, age, baseline performance
status, or chemotherapy received. Moreover, the benefit remained unchanged
even after excluding participants who developed cancer recurrence or died within
6 months of activity assessment.

65. Stress

66. Stress and Breast CA
Self-reported stress and risk of breast cancer
Cancer 1996
 258 breast cancer patients and 614 randomly selected population-based controls with same
number of stressful life events in the five years prior to diagnosis
 The results of this retrospective study do not suggest any important
associations between stressful life events and breast cancer risk.
Job Stress and Breast Cancer Risk The Nurses’ Health Study
 Adjusted for age, reproductive history, and other breast cancer risk factors, the multivariate relative risks of breast
cancer, in comparison with women who worked in low-strain jobs, were 0.83 (95% confidence
interval (CI): 0.69, 0.99) for women in active jobs, 0.87 (95% CI: 0.73, 1.04) for women in
high-strain jobs, and 0.90 (95% CI: 0.76, 1.06) for women in passive jobs. Findings from this
study indicate that job stress is not related to any increase in breast cancer risk.

67. Stress and Breast Cancer
Increased Breast Cancer Risk among Women Who
Work Predominantly at Night
Epidemiology 2001
 The odds ratio for breast cancer among women who
worked at night at least half of a year was 1.5 (95%
confidence interval, 1.2 to 1.7), and there was a
tendency to increasing odds ratio by increasing
duration of nighttime employment.

68. Stress and Breast Cancer
Stress, depression, the immune system, and
cancer Lancet Oncology 2004
 The consecutive stages of the multistep immune reactions are
either inhibited or enhanced as a result of previous or parallel
stress experiences, depending on the type and intensity of the
stressor and on the animal species, strain, sex, or age. In general,
both stressors and depression are associated with the decreased
cytotoxic T-cell and natural-killer-cell activities that affect
processes such as immune surveillance of tumours, and with the
events that modulate development and accumulation of somatic
mutations and genomic instability. A better understanding of the
bidirectional communication between the neuroendocrine and
immune systems could contribute to new clinical and treatment
strategies.

69. “Inflammation is a critical component of tumor
progression. It is now becoming clear that the tumor
microenvironment, which is largely orchestrated by
inflammatory cells, is an indispensable part of the
neoplastic process.”

71. What we know
 Cancer is a major cause of morbidity and mortality in
Canada
 Lifestyle factors are strongly associated

72. What next?
How do we apply the knowledge
to clinical practice?

73. 1 things 1
st st
 Learn both modifiable and non-modifiable risks
 Learn about your patients
 Recognize opportunities
 Lead by example

74. Breast Cancer

75. Breast Cancer Risk

76. 1 things 1
st st
 Learn both modifiable and non-modifiable risks
 Learn about your patients
 Who are they, what is important to them, what do they enjoy etc
 Recognize opportunities
 Lead by example

77. Trans-theoretical Model of Change
(Prochaska and DiClemente)
1: Pre-contemplation
2: Contemplation
3: Preparation/planning
4: Action
5: Maintenance
6: Permanent Maintenance (Termination)

78. Setting Goals
Specific
Measureable
Achievable
Realistic
Timely

79. Conclusion
 Cancer is a major cause of death and disability
 Lifestyle factors are common modifiable risk factors
 Modifications may provide significant benefit
 Tools to promote healthy change exist
 You are the most trusted health care resource
 Together we can make a differnce

80. Thank you!
Stephan Esser MD
Institute of Lifestyle Medicine
Harvard, Boston, MA

81. ?’s
Stephan Esser MD
Institute of Lifestyle Medicine
Harvard, Boston, MA

82. Thank you!
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