Lung Cancer and Diet
Dr Richard Roope, RCGP Clinical Champion for Cancer
Dr Rachel Pryke, RCGP Clinical Lead for Nutrition
Diet and prevention of lung cancer
While smoking causes 37, 200 cases of lung cancer per year in the UK, diet and nutritional status are a significant factor for both smokers and non-smokers. It is well recognised that a cluster of risk factors is linked to deprivation and that lifestyle-related issues (poor diet, smoking, excess alcohol and lack of physical activity) are contributing to increased non-communicable diseases. The World Cancer Research Fund suggests that 33% of lung cancer cases could be prevented if everyone ate their '5 a day'1. There would also appear to be a weak link with high red meat consumption - with every increment of 50 grams of red meat per day, the risk of lung cancer increases by 20%2. Public health and pricing measures have made demonstrable inroads into smoking rates3 and, whilst parallel approaches to promoting healthier diets and physical activity are evolving, more evidence is required regarding influencing diets across a population. The social determinants of malnutrition are often present long before disease processes develop, and nutritional status should form part of the general assessment of frail elderly patients, such as those isolated or recently bereaved, or have difficulties in obtaining, preparing or consuming food for whatever reason.
Diet and lung care treatment
In addition to its impact on the risk of developing cancer, nutritional status has a significant impact on the patient's journey, their response to treatments and their quality of life. The new publication 'A Practical Guide for Lung Cancer Nutritional Care'4 has been developed by a multi-disciplinary team and has the endorsement of ten key organisations, including the RCGP5. The nutritional status of the patient undergoing treatment contributes to the success of it. Malnutrition can arise from two separate processes: the disease process causing cancer cachexia, plus the side effects of treatment. Cytoxic agents may weaken the patient because of decreased appetite due to nausea, vomiting and fatigue. If malnourished then treatment doses may need to be reduced or radiotherapy to be given less often, which may mean less ability to halt the disease process. This in turn can contribute to morbidity and mortality6 with impaired immune function, performance status, muscle function, depression and fatigue.
Early nutritional screening can help identify malnutrition risk and allow early intervention with dietary advice, oral nutritional supplements (ONS) and, if required, enteral tube feeding, resulting in improved quality of life, increased survival and cost savings. For those patients that are likely to require surgery, not only does pre-operative improved nutritional status help patients cope better with their treatment, it reduces hospital length of stay, improves wound healing and infection rates and reduces re-admission rates7.
The guide recommends that patients eat energy and protein-rich meals and snacks, with a varied diet to enable their vitamin and mineral needs being met. It suggests that patients should aim for three small meals and three snacks a day, focusing on foods such as full fat milk, cream and cheese, high-energy snacks, such as biscuits, cakes, nuts, crisps and dried fruit. Milky drinks are also suggested and avoiding drinking too much fluid with meals (fluids accelerate the feeling of satiety quicker).
The guide also addresses when, and the way to introduce and establish use of ONS.
Diet after cancer treatment
As we see more patients surviving lung cancer, the issue of dietary advice after treatment is more frequently required. It is now recognised that having had one cancer is a risk for other new primary cancers. This risk can be reduced by adopting a healthy lifestyle. This will include avoiding smoking, engaging in regular exercise and maintaining a healthy diet. The latter two behaviours in turn then contribute to reaching and maintaining a healthy weight. Lifestyle factors now account for 42% of all primary cancers8 but this risk can be very positively reduced by empowering patients to recognise the areas where they get most benefit. Stopping smoking will always gain the most benefit in terms of reducing risk, but addressing nutrition, weight and physical activity will bring worthwhile additional health gains.
Further information about managing malnutrition in the community is available here.
1. World Cancer Research Fund
2. Xue XJ et al Int J Clin Exp Med 2014 Jun 15;7(6):1542-53
3. Department of Health Reducing Smoking Policy
4. Lung Cancer Nutrition
5. British Association for Parenteral and Enteral Nutrition (BAPEN), British Dietetic Association (BDA)/The Oncology Group of the BDA, British Thoracic Oncology Group (BTOG), British Oncology Pharmacy Association (BOPA), British Pharmaceutical Nutrition Group (BPNG), National Lung Cancer Forum for Nurses (NLCFN), National Nurses Nutrition Group (NNNG), Royal College of General Practitioners (RCGP), Royal College of Nursing (RCN), Royal Pharmaceutical Society (RPS)
6. Arrieta O, Ortega RMM, Vilanueva-Rodriguez G et al. Association of nutritional status and serum albumin levels with development of toxicity in patients with advance non-small cell lung cancer treated with paclitaxel-cisplatin chemotherapy: a prospective study. BMC Cancer 2010;10:50
7. Elia M (ed). The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. 2005.
8. Cancer Research UK