Comments on:

1
Comments on Food, Nutrition, Physical
Activity, and the Prevention of Cancer a Global
Perspective and the ACS recommendations for
cancer prevention Lawrence H. Kushi,
Sc.D. Associate Director, Division of
Research, Kaiser Permanente, Oakland, CA PCRM
Doctors Forum, Wednesday 7 November 2007
2
Comments onFood, Nutrition, Physical
Activity,and the Prevention of Cancera Global
Perspectiveand the ACS recommendations for
cancer prevention

• Lawrence H. Kushi, Sc.D.
• Associate Director, Division of Research,
• Kaiser Permanente, Oakland, CA
• PCRM Doctors Forum, Wednesday 7 November 2007

3
WCRF / AICR 1997 Monograph Update November 1,
2007
4
WCRF/AICR 2nd Report Process
STAGE 2
STAGE 3
STAGE 1
Peer Reviewers Review protocol and end product
developed by SLR Centers
Systematic Literature Review Centers Review
relationships between diet, physical activity,
anthropometry and cancer
Methodology Task Force Develop methodology to be
used in reviews
Panel Judgment of the evidence
Advisory Group Guidance to SLR Centers, WCRF/AICR
5
Databases searched

• Detailed searches
• Medline
• ISI Web
• Embase
• Biosis
• Ingenta
• CINAHL
• ScienceDirect

• General searches
• Medline
• Pascal, ExtraMed, Allied CompMed
• LILACs
• MedCarib
• REPIDISCA
• ETOH, Alcohol Studies
• PreMedline, OldMedline
• IMEMR
• EBM Reviews (Cochrane DSR, ACP, DARE, CCTR)

6
Major Systematic Literature Review Steps

• Protocols and Final Reports peer reviewed
• SLR follows Specification Manual
• Searches
• Include premalignant lesions
• Comprehensive database searches (multiple
  databases with detailed search terms)
• Include foreign language papers
• Abstract review and paper selection
• Data extraction new Access program
• Data cleaning, processing, and analysis
• Preparation of Report (August 2004) and
  presentation of preliminary results to the Panel
  (November 2005).
• Update searches by December 2005. Update and
  submit Final SLR August 2006.

7
Strengths of the SLR Process

• Most thorough and inclusive review on these
  topics to date
• Systematic approach across SLR Centres
• Access Program for data extraction brought some
  uniformity to data presentation
• Standardized criteria to conduct meta-analyses
• Assessment of heterogeneity
• Summary tables

8
Grading the Evidence

• Convincing, probable basis for recommendations
• Limited-suggestive not strong enough
• Limited-no conclusion
• Substantial effect on risk unlikely
• Upgrading factors

9
Grading the evidence convincing, probable

• Judgement unlikely to change over time
  (convincing)
• At least 2 independent cohort studies
  (convincing)
• At least 2 cohort or 5 case-control studies
  (probable)
• No unexplained heterogeneity
• Good quality studies that account for error
• Dose response evident
• Plausible evidence from laboratory studies

10
Grading the evidencelimited-suggestive

• At least 2 cohort or 5 case-control studies
• Some unexplained heterogeneity accepted
• Good quality studies that account for error
• Generally consistent dose response evident
• Plausible data from laboratory studies
• Studies generally sparse, poor, or confused

11
Grading the evidenceupgrade factors

• Large effect size
• Clear dose response
• Evidence from human randomised controlled trials
• Evidence for human biological pathways
• Impressive evidence from animal studies

12
Recommendations - 1

• Be as lean as possible without becoming
  underweight.
• Be physically active for at least 30 minutes each
  day.
• Avoid sugary drinks. Limit consumption of
  energy-dense foods (particularly processed foods
  high in added sugar, or low in fiber or high in
  fat).
• Eat more of a variety of vegetables, fruits,
  whole grains, and legumes such as beans.

13
Recommendations - 2

• Limit consumption of red meats (such as beef,
  pork, and lamb) and avoid processed meats.
• If consumed at all, limit consumption of
  alcoholic drinks to 2 for men and 1 for women a
  day.
• Limit consumption of salty foods and foods
  processed with salt (sodium).
• Dont use supplements to protect against cancer.

14
Special Recommendations

• Mothers to breastfeed infants to be breast fed.
  It is best for mothers to breastfeed exclusively
  for up to 6 months and then add other liquids and
  foods.
• After treatment, cancer survivors should follow
  the recommendations for cancer prevention.

15
(No Transcript)
16
(No Transcript)
17
Available at http//caonline.amcancersoc.org/
18
(No Transcript)
19
ACS Guidelines for Nutrition and Physical
Activity for Cancer PreventionRecommendations
for Individual Choices

• Maintain a healthy weight
• Balance caloric intake with physical activity
• Avoid excessive weight gain throughout the life
  cycle
• Achieve and maintain a healthy weight if
  currently overweight or obese
• Adopt a physically active lifestyle
• Adults engage in at least 30 minutes of
  moderate to vigorous activity, above usual
  activities, on 5 or more days of the week
• Children and adolescents engage in at least 60
  minutes per day of moderate to vigorous activity
  at least 5 days per week

20
ACS Guidelines for Nutrition and Physical
Activity for Cancer PreventionRecommendations
for Individual Choices

• Consume a healthy diet, with an emphasis on plant
  sources
• Choose foods and beverages in amounts that help
  achieve and maintain a healthy weight
• Eat five or more servings of a variety of
  vegetables and fruits each day
• Choose whole grains in preference to processed
  (refined) grains
• Limit consumption of processed and red meats
• If you drink alcoholic beverages, limit
  consumption
• Drink no more than one drink per day for women
  and two per day for men

21
ACS Guidelines for Nutrition and Physical
Activity for Cancer PreventionRecommendations
for Community Action

• Public, private and community organizations
  should work to create social and physical
  environments that support the adoption of
  healthful nutrition and physical activity
  behaviors
• Increase access to healthful foods in schools,
  worksites, and communities
• Provide safe, accessible, and enjoyable
  environments for physical activity in schools,
  and for transportation and recreation in
  communities

22
General methods for the development of public
health recommendations

• Consensus development method
• Evidence-based method

23
Consensus Development Method

• Based on opinions of a group of experts.
• Problem or question to be addressed is based on
  the interests, habits, protocols, or traditions
  of the group. Usually, this is when evidence is
  less certain, incomplete or absent.
• Guidelines may be produced without systematic
  procedures.
• Focuses on using the best available evidence,
  relying on expert opinion.

Cooper, JADA, 2003 103 S28-S33
24
Evidence-based Method

• Based on research evidence.
• Problem or question to be addressed determines
  the nature and source of evidence to be sought.
  Usually this is a question that can be answered.
• Guidelines are produced using systematic
  procedures.
• Focuses on using the best available evidence,
  including the use of randomized controlled trials.

Cooper, JADA, 2003 103 S28-S33
25
American Cancer Society Guidelines on Nutrition
and Physical Activity for Cancer Prevention, 2001

• Eat a variety of healthful foods, with an
  emphasis on plant sources.
• Eat five or more servings of a variety vegetables
  and fruits each day.
• Choose whole grains in preference to processed
  (refined) grains and sugars.
• Limit your consumption of red meats, especially
  those high in fat and processed.
• Choose foods that maintain a healthful weight.
• Adopt a physically active lifestyle.
• Maintain a healthful weight throughout your life.
• If you drink alcoholic beverages, limit
  consumption.

Byers et al., CA Cancer J Clin, 2002
26
Methods for Updating ACS Guidelines

• Topics assigned to 2-3 committee members based on
  interest and expertise
• Focus on new studies, and meta-analyses or
  systematic reviews since 2000
• Key papers or reviews prior to 2000
• Case-control, cohort, and randomized trials with
  cancer endpoints or precancerous lesions only
• Studies with at least 200 (or in some instances,
  100) cases of cancer
• Summarize findings in a brief (two-page) synopsis
  for discussion at an in-person meeting
• Follow-up writing and editing via email and
  conference calls

27
Members of the 2006 ACS Committee on Nutrition
and Physical Activity for Cancer Prevention

• Barbara Ainsworth, SDSU
• Rachel Ballard-Barbash, NCI
• Elisa Bandera, CINJ
• Abby Block, MSKCC
• Tim Byers, Univ Colorado
• June Chan, UCSF
• Ralph Coates, CDC
• Wendy Demark-Wahnefried, Duke
• Jo Freudenheim, SUNY, Buffalo
• Peter Gann, UIC
• Ed Giovannucci, Harvard
• Terry Hartman, Penn State
• Larry Kolonel, Univ Hawaii
• Larry Kushi, KPNC
• Alice Lichtenstein, Tufts
• Maria Elena Martinez, Univ Arizona
• Anne McTiernan, FHCRC

• Marion Morra, Morra Communications
• Arthur Schatzkin, NCI
• Marty Slattery, Univ Utah
• Stephanie Smith-Warner, Harvard
• Judith Wylie-Rosett, Albert Einstein
• Wei Zheng, Vanderbilt
• ACS Staff
• Terri Ades
• Kimberley Andrews
• Vilma Cokkinides
• Colleen Doyle
• Ted Gansler
• Marji McCullough
• Alicia Samuels
• David Ringer
• Robert Smith
• Michael Thun