“Be kind to yourself,” advises Ann Gaffney, founder of Cook for Your Life, a recipe and nutrition website for cancer survivors, and author of a cookbook by the same name. She’s had cancer three times, most recently bladder cancer in 2019. The website, now run by the Fred Hutchinson Cancer Center in Seattle, offers delicious recipes that follow professional guidelines for people with cancer, including those currently in treatment and survivors.
The site also provides guidance, tips and recipes to help manage some of the side effects of treatment, such as loss of appetite, fatigue and taste changes. “When people are going into treatment, it’s way too much for them to make big changes in how they eat,” she says. “Now is not the time to make radical changes to your diet. I tend to recommend that they wait until they are through with treatment and have the energy to make the changes they want.”
Gaffney does, however, advise people undergoing treatment to pay close attention to how they feel and adjust their diets so they can continue eating as well as possible. When side effects make you feel like just not eating, she says, “make changes as quickly as possible so you get organized, keep eating and get some enjoyment out of your food.” If you know you’ll feel exhausted the day after chemo, for example, make sure you have a soup you like in the freezer, ready to be microwaved. Mouth sores? A cool refreshing smoothie can ease the pain while providing fiber, protein and vitamins.
It can be daunting to navigate your way through cancer treatment and its obstacles to eating right, but you don’t have to do it alone. The first step is to work with your treatment team to address any side effects that are distressing.
Working with a registered dietitian (RD), sometimes referred to as a registered dietitian nutritionist (RDN), can be particularly effective. The gold standard is an oncology nutritionist, a registered dietitian who has undergone additional training to be certified to work with cancer patients. A dietitian who has this training is designated as certified specialist in oncology nutrition and have the initials CSO after their name.
But the truth is, many people in treatment get no nutrition help at all. In a 2020 survey of 215 outpatient cancer care centers, led by the Oncology Dietetic Practice Group of the Academy of Nutrition and Dietetics, researchers found that for every RDN, there are 2,300 cancer patients in treatment. RDNs typically counsel between seven and 11 patients per day. Most of the cancer centers (77%) surveyed don’t even bill for nutrition services because the services are not covered by Medicare or most private insurers.
“One problem I see is that some people are slow to act, to ask for help with side effects,” says Karen Collins, RDN, a nutrition adviser for the American Institute for Cancer Research. “Most people have had vomiting in their life or constipation or diarrhea, so they are used to addressing it with short-term things we use for flu, like 7 Up or Jell-O,” she says. “But in cancer treatment, these symptoms can last much longer and be more severe. And the longer they go, the harder it is to get caught back up. That’s why you want to really be right on it. Let your health care provider know so these things can be addressed quickly. A dietitian can help you adjust your diet so you get the nutrients you need. Don’t wait for weeks.”
“A 2017 evidence-based study that included 22 medical oncology centers showed that more than half of patients at the very first oncology appointment were found to have nutritional impairment that could lead to malnourishment,” says Johns Hopkins oncology nutritionist Mary-Eve Brown, RD, CSO. (Malnourishment, or malnutrition, is a condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function.) There are many possible causes, including the cancer itself as well as side effects of treatment, which is why Brown starts her nutrition plan for new patients with a nutrition assessment and then develops an individual nutrition care plan.
“If someone is able to eat well but is still losing weight, we’ll explore how to add calories and protein,” she explains. If lab results show problems with hydration, which can affect kidney function, she’ll focus on getting enough fluids. If someone has mouth sores, then baking soda and salt can help, as can soothing drinks like smoothies. If diarrhea is the problem, she’ll start with a low-fiber, low-fat, low-sugar, low-spice diet—foods like peanut butter crackers and hard-boiled eggs. As her patients are better able to manage treatment-related eating problems, she helps them gradually move toward a sustainable healthy plant-based diet that will improve their survival odds. “Every patient is different,” she says. “We’ll match the diet to the person’s food choices.” (For more tips, see the slideshow, “Don’t Let Cancer Stop You From Eating Well.”)
Some treatment protocols, such as hormonal therapy, can lead to the opposite of malnutrition-caused weight loss: weight gain. “We know that weight gain in men with prostate cancer and women with breast cancer is not favorable—it’s associated with poorer outcomes,” says University of Alabama cancer prevention and control expert Wendy Demark-Wahnefried, PhD, RD. During treatment, she notes, a patient may want to focus on preventing weight gain rather than on losing weight, “and that is where a nutritionist can be helpful.” There is no evidence at present that losing weight during the first six months after a cancer diagnosis has any benefit, she notes, although over the long term, weight is a risk factor for recurrence. After treatment is over, a patient may want to focus on lifestyle changes that will help with weight loss (See “Managing Cancer-Related Weight Gain.”)
“Patients come to us very motivated but overwhelmed,” says Lizbeth Gold, RDN, a dietitian at the Block Center for Integrative Cancer Treatment in Chicago. She gently guides patients toward a plant-based diet that can “put the body in the optimal state to make it inhospitable to cancer.” She emphasizes a vegan diet that can include seafood if desired. Recommendations are tailored to the individual. For breast cancer survivors in remission, for example, she may emphasize cruciferous vegetables, such as broccoli, which contain compounds that may help prevent cell proliferation associated with cancer recurrence. She helps patients find recipes they feel comfortable with. “We’re always flexible,” she says. “I never want anyone to feel stressed out about their diet.”
Nutrition support should be a standard of care for people in treatment, argues MD Anderson Cancer Center professor Lorenzo Cohen, PhD. “We have specialists trying to figure out the right surgical or chemo treatments for people with cancer—we need to take the dietary component as seriously,” he says. “We need professionals working with patients. We need to take the burden to navigate eating well during treatment off the patient and put it where it belongs: in a formal profession.” Insurance often does not pay for these services, he admits, but he advocates for changes that would require insurers to do so.
While it would be ideal if everyone diagnosed with cancer could work with a nutritionist trained in oncology and have that work be covered by health insurance, that is far from the reality. To help fill that gap, researchers are working to design online support systems. Amplify, which stands for “aim, plan and act on lifestyles,” is one such program being studied. It combines diet and exercise interventions for cancer survivors based on the latest guidelines. About 300 cancer survivors are currently enrolled in the Amplify clinical trial, with a goal of recruiting several hundred more by the spring of 2023. The study is open to anyone ages 50 and older in the continental United States who had breast, prostate, colorectal, endometrial, ovarian, renal or thyroid cancers, multiple myeloma or non-Hodgkin lymphoma. (To learn more about the study, go to amplifymyhealth.org.) “We lead people through a gradual change in lifestyle,” says Demark-Wahnefried, who is leading the study. “That’s really important. If you change your diet for two weeks and go back because you’re frustrated, that won’t help you. This online program helps people find out what they are willing to change and help them.”
It’s important to become your own advocate and seek help to make the lifestyle changes that can support a healthy recovery. That was the experience of Glenn Sabin, author of n of 1, who was diagnosed with the blood cancer chronic lymphocytic leukemia in 1991. He researched the healthiest diet for himself while working with hematologists who kept a close watch on his cancer. “I eat a very plant-based diet, no processed foods, no added sugars,” he says. “The only animal protein I eat is cold-water fish, such as salmon, halibut, cod, sardines. I eat a great colorful rainbow of foods. I’m not a big drinker either—maybe four beers a year.” He also does intermittent fasting, eating over a seven-hour window during the day.
Sabin, who consults with cancer patients—helping them do research, avoid misinformation and find resources to help them make lifestyle changes—is optimistic for the future of nutrition in cancer management. “What I started doing 30 years ago is becoming mainstream today,” he says. “That is gratifying.” His advice? “Take your time. If you’re drinking a lot of sugar-laden beverages, start drinking more water, less soda. Consume less meat and eat more plants and whole foods. Don’t try to do it all at once. You can pivot over time. We are seeing growing evidence that these lifestyle factors may mitigate various treatment side effects, and positively modulate treatment efficacy and survival. In the end, eating a sensible diet, moving your body, staying hydrated and paying attention to sleep have no side effects other than a stronger immune system, more resilience, less morbidity from other diseases and a better quality of life.”
For Julie Murkette of central Massachusetts, who has metastatic breast cancer, adjusting to intermittent fasting, as she did as a participant in a study, has been relatively easy. Changing when she ate wasn’t too hard, although it was a challenge not eating breakfast with her husband. “My husband, the first thing when he gets up, he wants to eat,” she says. They adjusted. For her, breakfast is usually Greek yogurt mixed with granola and a teaspoon of honey. “Morning isn’t that difficult but sitting around watching TV [at night] and not snacking was tricky.” It’s now a habit, though—and one she likes. “I don’t wake up starving, which I used to do, and waiting to eat until 11 or even noon is fine now,” she says.
In December, she got good news. “I don’t know if it’s the meds working, or a combination of meds, exercise and intermittent fasting (all of which I continue to do), but as of December 1, 2022, I am NED (no evidence of disease). Even my oncologist was a bit taken aback by the results.” While she doesn’t know what role the lifestyle changes may be playing in her new NED status, but she’s definitely feeling good these days. “There’s a tendency not to overeat over the course of the day,” she says, “and I’m in the best shape I’ve been in for 20 years.”
For Brad McDearman, 60, of Baltimore, who was diagnosed with metastatic colorectal cancer in 2018, working with Johns Hopkins oncology nutritionist Mary-Eve Brown, RD, CSO, has been a slow evolution toward a healthier diet. Now, McDearman, who still undergoes regular chemotherapy to keep his metastatic cancer under control, eats a robust healthy diet. “I’ve gotten red meat out, and no processed meats,” he says. “I learned that even ‘fresh oven-baked turkey’ from the deli is just processed turkey. So I avoid it. Now I just make my own turkey, cut it up and freeze it. I eat lots of salads, nuts and berries. I learned there are ways to make pizza at home that taste good and are pretty healthy.”
McDearman has also kept up his active lifestyle. His chemo is on a three-week schedule, so after treatment on Tuesdays, he’s pretty knocked out through the weekend. So the weekend before, he’ll prep meals such as fish or chicken with rice and green beans and make sure he has plenty of protein shakes and cereals on hand. By the following weekend, he’ll be cooking again and eating his healthiest diet. “By Monday, I’m back on my bike and kayaking,” he adds.
For cancer prevention expert Lorenzo Cohen, PhD, a healthy diet is one of the foundations of an anticancer lifestyle, whether you want to avoid getting cancer in the first place, reduce the burdens of treatment, reduce the risk of recurrence, protect against a second cancer or strengthen your chances of becoming the healthiest longtime survivor you can be. “Diet is only one component of healthy living,” he says. “Exercise, stress management and mental health are all important. So is getting a good night’s sleep. It’s all part of anticancer living. The evidence is there. We need to have medical support for lifestyle change. Now it needs to be part of the standard of care.”