Landmark cancer prevention report puts forth a blueprint to reduce the risk of cancers

The American Institute for Cancer Research (AICR) and the World Cancer Research Fund (WCRF) recently issued an evidence-based blueprint for healthy living that could prevent nearly half of all cancer cases.

This is the 3^rd report in the series of expert reports Diet, Nutrition, Physical Activity, and Cancer: A Global Perspective, and updates the two previous comprehensive reports, which were published in 1997 and 2007.

The report has distilled evidence of 30 years of research into 10 recommendations that could help prevent cancer by lifestyle modification. The report is based on a review of data from 51 million people, including 3.5 million cancer cases in 17 cancers.

The evidence shows that a modification in your diet, staying physically active, having a healthy body weight and other health-related choices can prevent 12 cancer diagnoses. These include breast, colorectal, pancreatic, endometrial, ovarian, prostate, liver, gallbladder, kidney, bladder, stomach and esophageal cancers.

In 2012, an estimated 14.1 million new cases of cancer occurred worldwide, with nearly 1 in 6 deaths due to cancer.

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“The evidence is clear that making changes to diet and exercise and maintaining a healthy weight cuts cancer risks, regardless of age. The message may not be glamorous, but these changes can save your life,” said Kelly Browning, Chief Executive Officer of AICR.

The ten recommendations are:

1) Maintaining a healthy weight is the most important thing you can do to reduce your risk of cancer. Aim to be in the lower end healthy Body Mass Index (BMI) range.

2) Be physically active-incorporate physical activity as a part of your daily life. Walk more and sit less, for maximum health benefits, aim for 150 minutes of moderate, or 75 minutes of vigorous, physical activity a week.

3) Eat a diet rich in vegetables, fruits, whole grains, and beans. AICR recommends a plant-based diet that forms at least two-thirds of your plate.

4) Limit the intake of fast food. There is strong evidence that consuming "fast-foods" and a "Western-type" diet are causes of weight gain, overweight and obesity, which are linked to 12 cancers. Glycemic load also increases the risk for endometrial cancer.

5) Limit red meat and avoiding processed meat - red meat includes beef, pork and lamb and processed meat includes ham, bacon, salami, hot dogs, sausages.

6) Limit consumption of sugar-sweetened beverages- Whenever you feel thirsty drink water or unsweetened beverages.

7) Limit alcohol consumption- alcohol in any form is a potent carcinogen. It's linked to 6 different cancers. The best advice for those concerned about cancer is not to drink.

8) Do not take the supplement for cancer prevention-Aim to obtain nutrition from diet instead of popping the supplements. The panel doesn’t discourage the use of multivitamins or specific supplements for those sub-sections of the population who stand to benefit from them, such as women of childbearing age and the elderly. But, dietary supplements will not avoid cancer.

9) Mothers, please breastfeed your baby- There is a strong evidence that breastfeeding your baby protects against breast cancer later in life.

10) If you are already diagnosed with cancer, you should follow the nutritional advice from an appropriately trained professional. For breast cancer survivors, there is persuasive evidence that nutritional factors and physical activity reliably predict important outcomes from breast cancer.

The report emphasizes the need for knowledge about the link between lifestyle and cancer. In a 2017 AICR Cancer Risk Awareness Survey more than 50% of the population who responded was not aware of the link between obesity and cancer.

The report provides robust evidence for healthcare professionals and government officials to advise the patients about healthy eating and making policies that make healthy eating more affordable.  

AICR today launched Cancer Health Check – an easy-to-use tool, which shows how your lifestyle stacks up against known cancer risks and outlines the changes you can make to follow AICR’s evidence-based Cancer Prevention Recommendations.

ACIR News Release

Cancer Health Check – an easy-to-use tool

Diet, Nutrition, Physical Activity, and Cancer: A Global Perspective, the Second Expert Report

Ob/Gyn Updated Facebook page

Here is a video about AICR 10 recommendations for cancer prevention.

Endocrine Society issues guidelines for management of menopausal symptoms in breast cancer survivors

Women experiencing menopausal symptoms after receiving treatment for breast cancer should be managed with life-style changes instead of hormonal therapy says the first ever set of professional guidelines issued by the Endocrine Society.

Increasing incidence of breast cancer and improved survival have led to increasing number of women survivors who have a long life ahead, while experiencing the side effects of cancer chemotherapy.  

It is estimated that there are 9.3 million breast cancer survivors worldwide, who experience menopausal symptoms or clinical manifestations of estrogen deficiency.

The comprehensive review was published August 02, 2017 in Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

Premenopausal women diagnosed with breast cancer experience abrupt onset of estrogen depletion symptoms after treatment with chemotherapy. Just like women experiencing natural menopause these women develop vulvovaginal atrophy (VVA), vasomotor symptoms (VMS), osteopenia, and osteoporosis, CVDs and psychological symptoms like sleep disorders, mood changes and depression.

These women cannot be treated with Hormonal Replacement Therapy (HRT) like their counterparts with natural menopause.

The study’s first author, Richard J. Santen, M.D., of the University of Virginia Health System in Charlottesville, VA said in a News Release by Endocrine Society “Following breast cancer, women should generally not be treated with menopausal hormone therapy but should instead focus on lifestyle modifications such as smoking cessation, weight loss, and regular physical activity.”

“Pharmacologic agents are also available to treat women with severe symptoms. The most important thing to remember is that therapy must be individualized based on each woman’s needs and goals,” he further added.

The author and his colleagues reviewed randomized controlled clinical trials (RCTs), observational studies, evidence- based guidelines, and expert opinion from professional societies to formulate the guidelines.

1) Life style modification advised for all breast cancer survivors include weight management, regular physical activity, smoking and alcohol cessation, vitamin D and calcium supplementation and eating healthy diet.

2) Sleep and other psychomotor symptoms should be treated with mind-brain-behavior or nonhormone, pharmacologic therapy.

3) Vasomotor symptoms respond well to selective serotonin /noradrenaline reuptake inhibitors and gabapentenoid agents.

4) A variety of non-hormonal treatments are available for treating osteoporosis like bisphosphonates, including zoledronic acid (Reclast) and denosumab (Prolia).

5) Treatment of VVA is a grey zone, low dose estrogen applied vaginally is absorbed in blood and although the blood levels are within normal limits, it could still potentially stimulate occult breast cancer cells. Hence, it is not generally advised, especially those on aromatase inhibitors.

6) Intravaginal DHEA and oral ospemiphene is often prescribed to relieve dyspareunia but their safety is still not established in breast cancer survivors.

7) Vaginal laser therapy is being used, but still more data is needed to document its efficacy.

8) Researchers are looking into other therapies in near future like lasofoxifene, neurokinin B inhibitors, stellate ganglion blockade, vaginal testosterone, and estetrol.

9) The most important recommendation is treatment should be individualized according to need of each patient.

Hypertensive disorders during pregnancy predisposes to future hypertension and the risk persists for more than 20 years.

Women face substantially high risk of post pregnancy hypertension in the first year after the index pregnancy and the risk persists for more than 20 years, with 14- 32% for the first decade reports the result of a nationwide register based cohort study published in July issue of BMJ.

Nearly one third of women with hypertensive disorder of pregnancy will develop hypertension within 10 years of the affected pregnancy, so blood pressure monitoring should be initiated immediately after delivery.  

What is already known:

Women who have a history of hypertensive disorders while pregnant have 2 to 4-fold increased risk of developing essential hypertension, and a subsequent CV event.

But the data about the timing of developing hypertension and the time at which the screening of these at-risk women should begin is not known.

What the study adds:

This study gives us the chronology of events: How soon the women may develop hypertension, how long the risk will persist after the affected pregnancy and when to start monitoring these women for development of hypertension.

The study identified 482972 women through Danish civil registration system, of these 23235 (4.8%) women developed hypertensive disorder of pregnancy and 16611 developed hypertension during follow-up.

In a cohort of more than one million women delivering in Denmark from 1978-2012, the investigators formed two cohorts and followed them for estimation of cumulative incidence of post-pregnancy hypertension and the other cohort for the estimation of hazard ratios for post-pregnancy hypertension.

Women with chronic hypertension were excluded from the study.

In women who had normotensive first pregnancy in 20s, 30s, or 40s, the cumulative incidences of hypertension in the first 10 years after delivery were 4.0%, 5.7%, and 11.3%, respectively, whereas in women with hypertensive disorder the corresponding incidence were 13.7%, 20.3%, and 32.4%, respectively.

In women with history of hypertensive disorder in most recent pregnancy, the rates of developing hypertension were 12-fold to 25-fold higher in the first-year after delivery and up to 10-fold higher in the coming 10 years.

Women face 2 fold increase risk of developing hypertension, that lasts for the next 20 years, if they have a previous history of hypertensive disorder in pregnancy as compared to women who had normal blood pressure while pregnant.

Why this study is important:

Large cohort, elimination of selection and recall bias.

Data adjusted for age, parity, smoking status, diabetes and BMI.

Immediate post-partum period is very important: The risk of developing hypertension is highest shortly after an affected pregnancy but persists for more than 20 years.

The higher risk of hypertension in a decade after the affected pregnancy also indicates that the etiopathological process causing hypertension in later life, are already at play during the affected pregnancy.

A hypertensive disorder of pregnancy in the second pregnancy was more strongly associated with later hypertension than a hypertensive disorder of pregnancy in the first pregnancy.

Initiation of regular blood pressure assessments should begin soon after a pregnancy complicated by a hypertensive disorder of pregnancy for prompt identification of hypertension in these women.

What is needed in the future:

An algorithm to identify those at greatest risk (the subgroup most likely to benefit from screening) is urgently needed; identification of biomarkers that predict which women will develop hypertension after an affected pregnancy would be very useful.

Quantification of cardiovascular events that can be prevented by early identification of these at-risk women is also needed.

More randomized control trials to form policies on clinical follow up of such women.

Gestational Diabetes Mellitus Revisited

Gestational Diabetes Mellitus Revisited 

Today is world diabetes day. The International Diabetes Federation has released new data in support of its campaign against Diabetes quoting that “1 in 7 births is affected by gestational diabetes” and “One quarter of all births are affected by high blood glucose during pregnancy in South-East Asia.”

 This article is based on The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care.

• The International Diabetes Federation (IDF) estimates that one in six live births (16.8%) are to women with some form of hyperglycemia in pregnancy.

• While 16% of these cases may be due to diabetes in pregnancy (either preexisting diabetes—type 1 or type 2—which antedates pregnancy or is first identified during testing in the index pregnancy), the majority (84%) is due to gestational diabetes mellitus (GDM).

• The definition of GDM is still evolving.

• Hyperglycemia first detected at any time during pregnancy should be classified either as diabetes mellitus in pregnancy (DIP) or GDM.

• When the level of hyperglycemia first detected by testing at any time during the course of pregnancy meets the criteria for diagnosis of diabetes in the nonpregnant state, the condition is called DIP. Those criteria are:

      1) Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL); and/or

      2) 2-hour plasma glucose ≥11.1 mmol/L (200 mg/dL) following a 75-g oral glucose load; or

      3)Random plasma glucose ≥11.1 mmol/L (200 mg/dL) in the presence of diabetes   symptoms.

• DIP may either have been pre-existing diabetes (type 1 or type 2) antedating pregnancy, or diabetes first diagnosed during pregnanc.

• When hyperglycemia detected during routine testing in pregnancy (generally between 24 and 28 weeks) does not meet the criteria of DIP it is called GDM.

            To address the global burden of GDM, FIGO recommendations:

• Universal testing-- All pregnant women should be tested for hyperglycemia during pregnancy using a one-step procedure and FIGO encourages all countries and its member associations to adapt and promote strategies to ensure this.

• As per the recommendation of the IADPSG (2010) and WHO (2013), the diagnosis of GDM is made using a single-step 75-g OGTT when one or more of the following results are recorded during routine testing specifically between weeks 24 and 28 of pregnancy or at any other time during the course of pregnancy:

     1)Fasting plasma glucose 5.1−6.9 mmol/L (92−125 mg/dL);

     2)1-hour post 75-g oral glucose load ≥10 mmol/L (180 mg/dL);

     3)2-hour post 75-g oral glucose load 8.5–11.0 mmol/L(153−199 mg/dL)

• Asian Indians are considered to be at the highest risk of gestational diabetes. Based on studies from India and keeping in mind the already high burden and rising prevalence of diabetes and the realities of resource constraints within the health system in India, as well as the high rate of deliveries (27 million each year), the Diabetes in Pregnancy Study Group in India (DIPSI) developed the following guideline for diagnosis of GDM in the community. This guideline has been endorsed by the Ministry of Health, Government of India, the Federation of Obstetrics and Gynecological Societies of India (FOGSI), and the Association of Physicians of India (API)
• For Asian Indians Testing for GDM is recommended twice during prenatal care. The first testing should be done during first prenatal contact as early as possible in pregnancy. The second testing should be done ideally during 24−28 weeks of pregnancy if the first test is negative. If women present beyond 28 weeks of pregnancy, only one test is to be done at the first point of contact.

• The management of GDM should be in accordance with available national resources and infrastructure even if the specific diagnostic and treatment protocols are not supported by high-quality evidence, as this is preferable to no care at all.

• Life style modification is the corner stone in management of DIP and GDM.

• Nutritional therapy includes an individualized food plan to optimize glycemic control. Medical nutritional therapy in pregnancy can be described as “a carbohydrate-controlled meal plan that promotes adequate nutrition with appropriate weight gain, normoglycemia, and the absence of ketosis.

• Daily energy intake of approximately 2050 calories (minimum of 175 g carbohydrates/day) in all BMI categories in women with GDM was reported to reduce weight gain, maintain euglycemia, avoid ketonuria, and achieve average birth weights of 3542 g.

• Oral antidiabetic agents  Insulin, glyburide, and metformin are safe and effective therapies for GDM  during the second and third trimesters, and may be initiated as first-line treatment after failing to achieve glucose control with lifestyle modification. Among OADs, metformin may be a better choice than glyburide.

• Insulin should be considered as the first-line treatment in women with GDM who  are at high risk of failing on OAD therapy, including some of the following factors

       • Diagnosis of diabetes <20 weeks of gestation

             • Need for pharmacologic therapy >30 weeks

       • Fasting plasma glucose levels >110 mg/dL

       • 1-hour postprandial glucose >140 mg/dL

       • Pregnancy weight gain >12 kg

• The postpartum period is crucial, not only in terms of addressing the immediate perinatal problems, but also in the long term for establishing the basis for early preventive health for both mother and child, who are at a heightened risk for future obesity, metabolic syndrome, diabetes, hypertension, and cardiovascular disorders.

• Progression to diabetes is more common in women with a history of GDM compared with those without a GDM history. 
• Both “intensive lifestyle” and metformin have been shown to be highly effective in delaying or preventing diabetes in women with IGT and a history of GDM.

• The current EBCOG proposal is to screen women with a history of GDM at 6−12 weeks postpartum using the 2-hour 75-g OGTT with nonpregnancy diagnostic criteria. Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years.

     References:

• http://www.ijgo.org/article/S0020-7292%2815%2930033-3/pdf

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