Food choices can help prevent cancer and, when cancer has been diagnosed, nutrition can improve survival. These links between diet and cancer are nothing short of dramatic. And now you can learn how certain dietary patterns help people diagnosed with cancer live longer, healthier lives.

1. Foods and Cancer
Neal D. Barnard, MD
Adjunct Associate Professor of Medicine
George Washington University School of Medicine
President, Physicians Committee for Responsible Medicine
Washington, DC

2. (per 100,000 women, 45-69 yrs)
Breast Cancer Incidence
Association of Dietary Fat & Breast Cancer
250
r=0.76
USA
Canada
200
UK
Italy
Israel
150
Australia
Romania
50
0
600
France Germany
Denmark
New Zealand
Sweden
Norway
Finland
Yugoslavia
100
Switzerland
Spain
Hong Kong
Poland
Hungary
Japan
900
1200
Per Capita Fat Availability
(kcal)
from Prentice, et al.
1500
JNCI 1988

3. Western Diets and Breast Cancer in China
The Shanghai Breast Cancer Study
The “meat-sweet” pattern:
meat dessert
fish
bread
candy milk
30% percent increased breast cancer risk
Cui X. Dietary Patterns and Breast Cancer Risk in the Shanghai Breast
Cancer Study. Cancer Epidemiol Biomarkers Prev. 2007;16(7):1443-1448.

4. Excess body fat
Increased
estrogen
activity
Cancer promotion

5. Excess body fat
High-fat / low-fiber diet
Increased
estrogen
activity
Cancer promotion

9. Women’s Health Initiative
48,835 participants, aged 50-79
Diet: 20% fat, ↑ vegetables, fruits, and grains
Fat intake fell from 38% at baseline…
to 24% at 1 year, and to 29% at 6 years.
Prentice RI. JAMA. 2006;295:629-642.

10. Women’s Health Initiative
After 8.1 years:
Overall breast cancer risk ↓9% (not significant).
Progesterone-receptor-negative tumor risk ↓24%.
Prentice RI. JAMA. 2006;295:629-642.

11. Fat Content
(Percentage of Calories from Fat)
Leanest beef
29%
Skinless chicken breast
23%
Sea trout
32%
White tuna
16%
Broccoli
8%
Beans
4%
Rice
1–5%

12. Diet and Breast Cancer Survival

13. Women in Japan
Less likely to develop breast cancer,
compared with women in U.S.
More likely to survive cancer, if it develops.
Wynder EL, et al. A comparison of survival rates between American and
Japanese patients with breast cancer. Surg Gynecol Obstet 1963;117:196-200.

14. Body Weight and Breast Cancer Survival
Risk of recurrence or decreased survival:
26 studies: higher weight increases risk
8 studies: no increased risk
Overall, a high BMI increased 5-year mortality
by 91%.
Included studies published 1990 – 2001.
Chlebowski RT. J Clin Oncol 2002;20:1128-43.

15. Body Weight and Breast Cancer Survival
Shanghai, China, 2006
1,455 women with breast cancer, aged 25-64
BMI
< 23.00
23.00-24.99
≥ 25.00
5-year survival
86.5%
83.8%
80.1% (P = 0.02)
Tao MH. Association of overweight with breast cancer survival. Am J
Epidemiol 2006;163:101-107.

16. Women’s Intervention Nutrition Study
(WINS)
2,437 women with breast cancer
Ages: 48-79, all postmenopausal
Reduced fat (15% of energy) diet vs control

17. WINS
Diet and Cancer Recurrence
All cancers
↓ 24%
Estrogen receptor -
↓ 42%
Estrogen receptor +
↓ 15%

18. WINS Study
35
Body Mass Index and Relapse (%)
30
25
Intervention
Control
20
% relapse
16.2%
15
10
12.8%
9.8%
10.2%
11.1%
8.9%
5
0
<25
25-30
>30
Body Mass Index
Women previously treated for breast cancer,
N = 957 intervention, 1424 control
Chlebowski RT, et al. JNCI 2006;98:1767-76.

19. Women’s Healthy Eating and Living Study
3,109 pre- and postmenopausal women
previously treated for breast cancer
7 clinical sites, enrollment 1995-2000

20. Women’s Healthy Eating and Living Study
Comparison diet (“5-a-day”):
5 servings of vegetables and fruits
(<30% fat, 20 g fiber)
Intervention diet (“8-a-day”):
5 vegetable servings, 3 fruit servings
16 oz. vegetable juice
(15-20% fat, 30 g fiber)

21. Vegetables and Fruits:
“8-a-day” vs “5-a-day”
Mean follow-up: 7.3 years
Mortality
Intervention group (“8-a-day+”)
10.1%
Comparison group (5-a-day)
10.3%
Pierce JP. JAMA 2007;858:289-98.

22. “A diet high in vegetables and fruits apparently does
nothing to prevent breast cancer from returning,
according to a seven-year U.S. government study of more
than 3,000 women.”
USAToday.com, accessed July 19, 2007

23. WHEL Study
Vegetables-Fruits and Regular Walking
1490 women in comparison group
Followed for 5-11 years
Mortality
↑ veg/fruit (7.6 servings) + ↑ activity
4.8%
↓ veg/fruit (3.4 servings) + ↑ activity
10.4%
↑ veg/fruit (7.2 servings) + ↓ activity
10.7%
↓ veg/fruit (3.1 servings) + ↓ activity
11.5%
Pierce JP. J Clin Oncol 2007;25:2345-51.

24. What about Soy Products?
Source: Wood CE. Biology of Reproduction. 2006;75:477-86.

25. Soy and Breast Cancer
Meta-analysis of 8 studies in Asians and Asian
Americans:
High soy intake: 29% ↓ risk of breast cancer.
High: 20 mg isoflavones
Low: 5 mg isoflavones
Wu AH. Br J Cancer. 2004;98:9-14.

26. Soy and Cancer Recurrence or Mortality in WHEL
1
Hazard Ratio
P for trend = 0.02
.3
3
>1
6
1.
01
-1
6.
33
1
0.
07
-1
.0
<0
.0
7
0
Isoflavone Intake (mg/d)
Caan BJ. Cancer Epidemiology, Biomarkers, & Prevention. 2011;20:854-8.

27. Soy and Survival
Soy and Cancer Recurrence or Mortality
>1
6.
33
1.
01
-1
6.
33
0.
07
-1
.0
1
0
<0
.0
7
16.3 mg isoflavones =
½ cup soymilk or
2 oz. tofu
P for trend = 0.02
Hazard Ratio
High soy intake:
54% ↓ risk.
1
Isoflavone Intake (mg/d)
Caan BJ. Cancer Epidemiology, Biomarkers, & Prevention. 2011;20:854-8.

28. Shanghai Breast Cancer Survival Study
Soy and Cancer Mortality
Hazard Ratio
1
>6
2.
68
36
.5
162
.6
8
20
.0
136
.5
0
<2
0.
01
0
Isoflavone Intake (mg/d)
Shu XO. JAMA. 2009;302:2437-43
16.3 mg isoflavones =
½ cup soymilk or
2 oz. tofu

29. After Breast Cancer Pooling Project
1. Women’s Healthy Eating &
Living Study
0.5
≥1
-9
.9
9
4.
0
9,514 breast cancer survivors
0.
0
0.0
<4
.0
3. Life After Cancer
Epidemiology Study
1.0
Hazard Ratio
2. Shanghai Breast Cancer
Survival Study
Soy and Breast Cancer Recurrence
Isoflavone Intake (mg/d)
Nechuta SJ. Am J Clin Nutr. 2012;96:123-32.

30. Kaiser Permanente
Life After Cancer Epidemiology Study
Soy Intake and Breast Cancer Recurrence
Daidzein
Genistein
1
Glycetein
1
Hazard Ratio
Hazard Ratio
Hazard Ratio
1
Genistein Intake (mcg/d)
3.
62
-8
.1
6
8.
17
-1
4.
99
15
.0
078
.5
78
3
.5
479
5.
39
>7
96
.3
9
0
03.
61
.7
7.
7
78
-1
14
49
9.
.5
60
9
-1
1,
,4
45
53
3.
.0
10
0
-9
,5
96
.5
4
>9
,5
96
.5
4
0
0.
10
-7
Daidzein Intake (mcg/d)
0
0.
10
-6
.9
7.
9
00
-2
20
22
.6
0.
1
62
2,
-2
19
,1
9.
84
82
.8
-1
3,
02
5.
87
>1
3,
02
5.
87
0
0
Glycetin Intake (mcg/d)
Guha N. Breast Cancer Research & Treatment. 2009;118:395-405.

31. Nutrition & Breast Cancer Survival
Summary
Reduced body fat → ↑ survival
Reduced dietary fat → ↑ survival
Vegetables & fruits + exercise → ↑ survival
Soy (~2 servings/day) → ↑ survival

32. Prostate Cancer

33. Milk and Prostate Cancer
Ganmaa D, Li X, Wang J, Qin L, Wang P, Sato A. Int J Cancer 2002:98,262-267.

34. Physicians’ Health Study (Harvard)
20,885
physicians
≥ 2.5
servings/day of
dairy products
Relative risk: 1.34 (1.04-1.71)
Chan JM. Am J Clin Nutr 2001;74:549-54.
34% increased
risk
of prostate cancer

35. Health Professionals
Follow-up Study (Harvard)
47,781 health
professionals
> 2 servings/day
of milk
83% of milk consumed was skim or lowfat
Relative risk for advanced cancer: 1.6 (95% CI, 1.2-2.1)
Giovannucci E. Cancer Res 1998;58:442-7.
60% increased
risk
of prostate cancer

36. Milk Affects Hormones
↑ IGF-I
Milk
↓ Vitamin D

37. Insulin-Like Growth Factor I
“Insulin-like” = moves sugar into cells
“Growth factor” = encourages cell proliferation

38. Milk Drinking Raises Human IGF-I
Men and women aged 55 to 85 years
Three 8-oz servings of milk for 12 weeks
Serum IGF-I levels: ↑ 10%
P<.001
Heaney RP. J Am Dietetic Asso 1999;99:1228-33.

39. Vitamin D
skin

40. Vitamin D
skin
liver

41. Vitamin D
skin
kidney
liver

42. Vitamin D
Calcium
skin
intestine
kidney
liver

43. Vitamin D
Calcium
skin
intestine
kidney
liver
prostate

44. Vitamin D
Calcium
skin
X
X
liver
kidney
intestine
X
prostate

45. Vegan Diet and Prostate Cancer
Preventive Medicine Research Institute
84 men with untreated prostate cancer, 1-year study
Control group:
PSA ↑ 6%
6 of the 43 participants required cancer treatment
Vegan group:
PSA ↓4%
No one required treatment
Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of
prostate cancer. J Urol. 2005;174:1065-1069.

46. Heterocyclic Amines

47. PhIP Structure*
* 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine)

49. Processed meats:
Bacon
Sausage
Ham
Hot dogs
Deli meats

50. Nutrition and Cancer: Mechanisms
• Low-fat diets reduce body weight
• Fiber increases hormone elimination
• Low-fat, high-fiber diets reduce hormone
effects
• Isoflavones may reduce risk.
• Avoiding meat reduces carcinogen exposure

52. Complete Nutrition
Protein
Calcium
Vitamin B12

53. Acceptability
•
•
•
•
No artificial calorie limits.
No portion sizes.
No carbohydrate-counting.
Benefits encourage adherence.

54. Acceptability
Acceptability is similar to that of other therapeutic diets.
•
•
•
•
Men and women with heart disease (1992)
Young women with dysmenorrhea (2000)
Postmenopausal overweight women (2004)
Men and women with diabetes (2008)
Barnard ND, Scherwitz L, Ornish D. J Cardiopulmonary Rehab 1992;12:423-31.
Barnard ND, Scialli AR, Bertron P, et al. J Nutr Educ 2000;32:314-9.
Barnard ND, Scialli AR, Turner-McGrievy GM, et al. J Cardiopulm Rehab
2004;24:229-35.
Barnard ND, et al. J Am Diet Assoc 2009;109:263-72.

55. Body Weight
P-value < 0.0001
Am J Health Promotion, In pre

56. Waist Circumference
P-value < 0.001
Am J Health Promotion, In pre