By Wendy Haaf
Find out what to do after treatment
Once you’re on the other side of a cancer treatment, how do you go about living as long and healthy a life as possible, both physically and emotionally? Since an estimated two in five Canadians will develop some form of the disease in their lifetimes and 63 per cent of all survivors—regardless of cancer type and grade—will live at least five years after diagnosis, that’s a question many of us will eventually face.
Thankfully, researchers have been working on finding answers, and a growing body of evidence suggests that the everyday choices people make after finishing chemotherapy and radiation treatment have the power to increase both longevity and the quality of life after cancer and may even help reduce the odds of encountering the disease again.
“There’s a lot people can do to improve their physical and psychological health,” says Dr. Gary Rodin, a professor of psychiatry at the University of Toronto and head of supportive care at Princess Margaret Hospital.
Dealing With Depression
“It’s completely normal to get depressed when you’re diagnosed, and there’s nothing harmful about that,” says Janine Giese-Davis, a researcher and adjunct associate professor in the department of psychology at the University of Calgary and the Tom Baker Cancer Centre’s Division of Psychosocial Oncology. “What’s harmful is if it becomes a chronic pattern, so that six months or a year later, you’re still at the same level of depression or even higher.
The evidence now for a link between depression and reduced survival is pretty strong—and increasing.” (Needless to say, depression also substantially diminishes quality of life.) For instance, the authors of a 2009 analysis of 25 studies found the premature mortality rate among cancer survivors who’d been diagnosed with depression was up to 39 per cent higher than in their nondepressed counterparts.
There are undoubtedly multiple factors behind this phenomenon, including that depression is known to impair the immune system’s disease fighting capabilities and reduce a person’s ability to consistently stick to the kind of healthy lifestyle that can mitigate the increased risk for other chronic diseases (such as heart disease and osteoporosis) that go hand-in-hand with a history of cancer.
While treating depression is worthwhile for the latter reason alone, there’s also some preliminary evidence that this also may improve the odds of long-term survival. Giese-Davis cites a study she authored, involving women with stage four (the most advanced stage) metastatic breast cancer. “Decreasing their depression levels in the first year after diagnosis predicted them living longer,” she says.
Interestingly, the specific strategies women used to tackle their depression— which ranged from participating in group psychotherapy to joining recreational groups—wasn’t important. “All that mattered is that they decreased that depression level,” Giese- Davis says. “I think that’s even more hopeful—that you don’t have to be the type of person who goes to psychotherapy; you can be the type of person who exercises or volunteers.” She adds that most practitioners would recommend a combination of medication and some form of therapy for moderate to severe depression. “Antidepressants help you put a floor under yourself and get enough energy to do the work to get you back into feeling some hope about your life.”
Living with the possibility of a cancer recurrence could leave the calmest, most unflappable person struggling with anxiety. “I think most people who’ve been diagnosed with cancer live between being on the edge of fear that the cancer will return and wanting to make the best of the time they have,” Giese- Davis says.
“And just as there are many ways to improve depression levels, there are similarly numerous ways to improve anxiety levels.” Such strategies include learning relaxation techniques and expressing your fears in a safe environment, she says, adding that often means talking to someone other than the people closest to you, who typically are grappling with their own fears and their worries for you.
“Expressing how you feel—fearful, sad, angry, or whatever—really goes a long way to diminishing depression and anxiety,” Giese-Davis says. And as counterintuitive as it may sound, confronting your fears directly and even delving into them more deeply, albeit in the right way, can also be beneficial. While at Stanford University in California, Giese-Davis was involved in a study for which women with metastatic breast cancer examined their worst fears. “We had them talk about exactly what their fears were about and what they imagined,” she says. Once participants had pinpointed the things that caused them the most anxiety, they actively took steps to prevent that worst-case scenario. For example, if the thought of friends and family having to provide personal care in the event that you lost your independence was what you found most disturbing, you might start saving money so you could hire a caregiver if necessary. “The remarkable thing was, instead of depressing people, it often released them back into their lives,” Giese- Davis says.
Something many people do naturally in the aftermath of a cancer diagnosis can also be a stepping stone to reducing anxiety. “Some people begin to think about how they’re spending their lives, what sort of work they want to do, their relationships, what’s really valuable to them,” Princess Margaret Hospital’s Dr. Rodin says. “Maybe they haven’t been spending as much time with their families as they might have wanted, and they realize that might be more important than all of the other things they were doing.”
Finding ways to channel your time and energy into the things that mean the most to you doesn’t just make you happier and more engaged, it may also wrestle your anxiety down to more manageable levels. “Whether it’s making some kind of legacy for your grandkids, making quilts, joining local politics, or volunteering for cancer research projects, when you’re doing something meaningful, it’s hard to be anxious,” Giese-Davis says.
Sure, you know that a healthy diet is linked with a lower risk for several types of first-time cancers, but if you’ve already been diagnosed, you might assume that the horse is already out of the barn. In fact, accumulating evidence strongly suggests that’s not the case at all.
For one thing, following treatment, cancer survivors face higherthan- average odds of developing several chronic health problems including heart disease, Type 2 diabetes, and osteoporosis; a healthy lifestyle, including excellent nutrition, can help cut those heightened risks down to size.
“We know that maintaining a healthy weight, consuming a nutrient- rich diet, and being physically active are all going to be important to a person’s long-term health,” says Christy Brissette, a registered dietitian with the Head & Neck Centre and the ELLICSR Health, Wellness, and Cancer Survivorship Centre at Toronto’s Princess Margaret Hospital. “We’re also getting more and more evidence indicating that by managing all of these things, we might see a lower risk for recurrence of certain cancers. And in some cancers, we’re seeing a trend such that there might be a lower risk for recurrence, as well as improvements in overall survival after treatment.”
So what kinds of dietary changes could improve your long-term prognosis? If your body weight is higher than what’s considered healthy, cutting nutritionally empty calories is a good place to start. “The number one thing we can do to lower our risk for cancer is to be as lean as possible without being underweight,” Brissette explains. “Carrying extra weight, especially around the midsection, is associated with higher insulin levels and all kinds of hormone cascades that are being linked to a higher risk for certain cancers.”
Cutting back on sugary drinks and foods high in added sugars and low in fibre (i.e., many processed foods) and focusing on whole foods serves a dual purpose. First, these changes improve your chances of shrinking a spare tire, but perhaps even more importantly, this type of eating pattern helps curb blood sugar levels and, by extension, the amount of insulin the body produces in response.
Fat is another nutrient that seems to play a key role in cancer prevention. “There have been a lot of studies looking at the impact of dietary fat, mainly on breast, prostate, and ovarian and other gynecological cancers,” Brissette says, “and basically, the type of fat seems to be just as important as overall fat.” The importance of the latter is likely because fat is relatively dense in calories. As far as type of fat goes, “higher saturated fat intakes are being linked to shorter survival, and greater monounsaturated fat intakes might predict longer survival in some cancers.”
Consequently, most experts now recommend replacing saturated fats from sources such as red meats and full-fat dairy products with monounsaturated fats from things such as olive oil, nuts, and avocados. Keep in mind that portion size is still important, since these healthy fats are equally high in calories.
That theme of de-emphasizing animal sources in favour of plants is echoed in the results of other studies aimed at pinpointing the best diet for cancer survivors. “So far, what we see is that the type of diet that’s linked to a lower risk for different types of cancer in some cases also reduces the risk for recurrence,” Brissette says. “Basically, that dietary pattern is high in vegetables, fruits, whole grains, and beans and legumes, and includes leaner foods that come from animals, such as chicken and fish, while it minimizes intakes of refined grains, processed and red meats, desserts, and full-fat dairy products.”
Consequently, organizations such as the World Cancer Research Fund and the American Institute for Cancer Research recommend that “cancer survivors, or really all of us who are trying to lower our risk, allow two-thirds or more of our plates for foods that come from plants and one-third or less for foods that come from animals,” Brissette says.
The same sets of recommendations suggest limiting red meat to 18 ounces (510 grams) or less each week and, if you consume alcohol, stopping at two drinks a day for men and one for women. Happily, this type of eating plan—which encompasses both the Mediterranean and DASH diets—is also linked with a reduction in the risk for other health problems, including high blood pressure, heart disease, and stroke.
Just how dramatic a difference can this type of eating plan make? While that probably depends on the type of cancer, Brissette says, “in one study looking at dietary patterns in breast cancer survivors, those who had the highest intakes of vegetables and whole grains saw a 43 per cent reduction in overall early mortality, versus those people with the lowest intakes.”
Of course, changing eating habits developed during a lifetime can be a struggle, but there are resources to help. “Here at Princess Margaret, I’m part of a program called the ELLICSR Kitchen,” Brissette says. “I work with a wellness chef, and we deliver nutrition education and cooking classes.” Participants also get to taste the wares from the classes. Shawn Hart, 54, of Toronto, a two-time breast cancer survivor, says the program has helped her completely change the way she eats. “I grew up in an Irish family, so it was meat and potatoes, and junk food was its own food group,” she says. “I don’t like much, and the treatment narrowed my tastes even more. I can’t even tolerate the smell of some things.”
However, after being gradually introduced to unfamiliar ingredients such as herbs and to template-type recipes that allow her to switch a loathed vegetable for one she likes, Hart has incorporated a host of healthy foods such as kale into her diet. Having once disliked berries due to their texture, she now incorporates them into foods such as smoothies. “My mom is amazed at what I’m eating,” she says. “I think each time I do something good for myself, I feel like I have a little bit of control over the cancer coming back. My wellness chef and dietitian are just as important to me as my doctors.”
Even if you’re not a patient of the Princess Margaret, or live outside of Toronto, you can access some of ELLICSR’s resources. “We have a big show once a month that we stream live on the Internet, so people can tune in and ask us questions, and we have a huge library of 500 recipes on our website [ellicsr.ca],” Brissette says. “We also have a YouTube channel where we post oneto two-minute videos on nutrition skills such as how to manage taste changes from treatment,” she says; other videos on the channel focus on basic kitchen tips. (Brissette is also one of the consulting dietitians for a magazine called Nourish— nourishonline.ca— which offers evidencebacked nutrition information and practical tips specifically for cancer survivors.)
Staying or Becoming Physically Active
About 20 years ago, the evidence that physical activity could improve quality of life and reduce symptoms such as fatigue began rolling in, followed by research pointing towards physical activity as a powerful tool for dealing with the mental and emotional challenges a cancer diagnosis often brings. Catherine Sabiston, the Canada Research Chair in Physical Activity and Mental Health and an associate professor of kinesiology and physical education at the University of Toronto, is involved in one of the latest of such studies, now currently under way.
She sums up the findings of the research that’s been done to date this way: “We see consistently, both cross-sectionally and over time, that physical activity helps to reduce symptoms of depression, reduces stress, reduces anxiety, and improves overall emotional wellbeing.” As evidence for the benefits of exercise grew stronger, scientists began to look into the question of how physical activity might affect longevity and the likelihood of cancer recurrence.
A landmark study of breast cancer survivors released in 2005 was the first to find that “physical activity in survivorship was linked with reduced risk for recurrence and lower premature mortality rates,” with roughly 30 per cent drops in each of these measures, says Jeff Vallance, a Tier 2 Canada Research Chair in Health Promotion and Chronic Disease Management and a health solutions population investigator at Athabasca University in Alberta. “Three to five hours a week of moderate intensity walking had the greatest benefit,” he adds.
Now, after 10 years and roughly as many studies, research has shown fairly consistent associations between physical activity and reductions in premature mortality and cancer recurrence, he says. And perhaps the best news of all to emerge from all this research is that people can reap the benefits even if they’ve never exercised. “Some of our colleagues have done work that shows that change in physical activity at any point following a cancer diagnosis is important,” Sabiston says. “It’s as if starting today helps you regardless.” Sabiston also emphasizes that simply choosing an activity you enjoy and moving more today than you did yesterday is more crucial than the specific type of exercise or aiming for a particular amount of activity per week.
For one thing, she says, “light activity is beneficial for a number of mental health facets.” Light activity also reduces sedentary time, which is emerging as a potential cancer risk factor. Doing something you enjoy improves the chances that you’ll continue to be active on a consistent basis and perhaps even slowly increase the amount and intensity of activity. “The problem is that 85 per cent of women are not active enough,” Sabiston says.
However, there is one research tested tool that has been shown to help increase activity after a breast cancer diagnosis. “We looked at the effect of specific physical activity print materials on activity behaviour in a large group of breast cancer survivors,” Vallance says. The nearly 400 women were randomized to various groups: some received the print materials alone, others were given a pedometer, a third group got both, and the rest received neither. Even just the print materials increased self-reported physical activity (though not steps walked weekly) by 30 minutes, compared with the no-intervention group. Better yet, Vallance says, “when we combined the print materials with the pedometer, we were looking at about 80 to 90 more minutes per week of physical activity.”
To make these materials widely available to the public, Vallance and a co-author, Kerry Courneya, turned them into a 90-page interactive workbook called Fight Breast Cancer With Exercise (Lone Pine Publishing, 2014; an electronic version is available through iTunes).
Sabiston and her colleagues, too, have launched a resource they’re hoping will help female cancer survivors become more active. “Something women in particular tell us is that they need social support— the general idea is that if someone would just show up and drag me out of the house, I would exercise,” she says. In response, “we developed a system that helps women who have had cancer find an exercise partner,” she says.
To use the free online tool, called ActiveMatch, a woman goes to the activematch.ca website and creates a profile, answering questions about physical activity and what she’s looking for in an exercise partner. “The system finds matches based on algorithms that we’ve developed, but women can also override that and find their own exercise partners,” Sabiston says. “We’re testing that now to see if lack of social support is in fact one of these limiting factors around exercise,” she adds, “and whether helping people find partners is a good solution to the problem of lack of adequate exercise.”