Linking Diet to Cancer Prevention, Treatment and Survivorship

EDITOR’S NOTE: In honor of National Women Physician Day on Feb. 3, Moffitt Cancer Center’s Women in Oncology group is highlighting the ways women physicians and researchers are contributing to the prevention and cure of cancer.

When Sylvia Crowder, Ph.D., was in high school, her world was shattered. Her beloved grandmother was diagnosed with lymphoma. A teen searching for a way to help, Crowder turned to the internet.

Weeding through information on prognoses and treatments, she found something she could understand, something she could use. She discovered the role nutrition and diet can play in not only preventing cancer but also improving quality of life during treatment and survivorship outcomes.

That internet search inspired Crowder to go on to study dietetics and led her to work as an inpatient registered dietitian at the same hospital where her grandmother was treated in Champaign, Illinois. Despite the full circle moment, she was discouraged by the increasing list of unanswered questions about diet and cancer. So she returned to school for her doctorate in nutrition and found her way to Moffitt Cancer Center’s Health Outcomes and Behavior Department.

This is a newer yet quickly emerging area of cancer research, and Moffitt has put together a comprehensive team dedicated to investigating ways lifestyle behaviors such as diet, nutrition and exercise play a role along the cancer care continuum. The Population Engagement and Research Laboratory, or PEARL, opened in April 2023 and includes a research kitchen and dining area for these studies. This reflects Moffitt’s vision to elevate metabolism as another element of cancer care and help translate basic research into something tangible for patients.

“The unique thing about diet is it is something a patient can, for the most part, control,” Crowder said. “They don’t have a say in what type of cancer they’re diagnosed with, when they have cancer treatment scheduled and a lot of things revolving around their care. But when it comes to diet, it is the one thing they can choose: what to eat, when to eat and how much.”

Diet During and After Treatment

Most diet research has focused on foods and dietary patterns that are associated with cancer prevention or increased cancer risk. Diet research on active cancer patients and survivors is still a new field. The first randomized trial investigating diet in active cancer patients took place in 2002.

Although researchers haven’t been able to definitively say certain foods can help prevent cancer from returning, there are promising theories that certain food properties and nutrients do play a role in cancer metastases and recurrences. To help fill in the gaps, Moffitt researchers have trials underway to study how certain foods and dietary counseling can affect treatment, quality of life and cancer outcomes.

The Mediterranean diet is high in whole grains, fruits, vegetables, fish, nuts and healthy oils.

Crowder is leading a small pilot study funded by a Miles for Moffitt grant that is providing meals following the Mediterranean diet to patients with head and neck cancers. The diet is high in whole grains, fruits, vegetables, fish, nuts and healthy oils.

“The thought is that a plant-based diet is very anti-inflammatory, and we know there’s a lot of cell damage and cell inflammation that occurs as a result of cancer treatment,” Crowder said. “The idea is if we’re able to provide these foods that have anti-inflammatory properties, perhaps we can reduce the inflammation and cell damage that occurs to these patients, so they don’t have as much symptom burden later on.”

Patients on the trial are provided meals for seven weeks of active treatment, combined with weekly dietary coaching. Researchers are measuring their symptom trajectory, body composition and perceived quality of life compared to patients receiving only standard healthy diet educational materials.

Crowder is waiting on funding to begin a similar trial in patients with breast cancer. The patients would be provided meals that are mostly plant based, low in sodium and limited in unhealthy fats. The goal is to see whether the diet helps prevent neurological cognitive declines, also known as chemo brain, often experienced by patients undergoing large amounts of chemotherapy. Crowder is co-leading the trial with Heather Jim, Ph.D.

As part of a team science project with Doratha A. Byrd, Ph.D., Crowder has submitted for funding for a trial investigating whether fermented foods can change the gut microbiome to improve treatment response for patients with rectal cancer. Since these patients cannot eat a lot of fiber, fermented foods could be a good probiotic option to help boost the immune system without impacting digestion.

Crowder also has a National Cancer Institute-funded cross-sectional study that is gauging physical activity and diet preferences of 120 adolescent and young adult cancer survivors ages 19 to 29. The goal is to create interventions for this unique patient population.

The importance of this research is to find ways to improve quality of life during and after treatment. “Patients want to be sure that if they’re alive, they want to be able to enjoy life,” Crowder said. “They want to partake in activities they did pre-cancer diagnosis. It might be a very new normal, but they want to be able to accept this new normal they have.”

Implementing Nutrition Programs

There is little doubt nutrition and dietary counseling reduces malnutrition and improves quality of life in patients with cancer. However, the strategies are not routinely practiced in health care across the country. Kea Turner, Ph.D., focuses her research on cancer care delivery, specifically how to best implement supportive care, such as nutrition counseling, into standard health care practices.

“I think part of the problem is that there aren’t a lot of studies on implementation,” Turner said. “There needs to be more research that looks at not just the importance of nutrition, but also how do we take the tools that we know help a patient to manage their malnutrition and integrate that into care delivery? And how do we do it in a way that fits with clinicians’ workflow that doesn’t impose too much burden?”

Kea Turner, Ph.D., demonstrates how dietitians can monitor patients’ nutrition with a Fitbit as part of a study. The ultimate goal is to integrate nutrition monitoring into routine care delivery.

Turner is co-leading a study with Pamela Hodul, M.D., funded by a $1.2 million grant from the Department of Defense to develop and test a remote nutrition-monitoring program that will be integrated into routine care delivery. The Support Through Remote Observation and Nutrition Guidance program will target patients with pancreatic cancer who are undergoing surgery, a population at high risk for malnutrition. Patients on the trial will meet with a dietitian biweekly after surgery for a 60-day period. They will also be given a Fitbit to log their food intake to make it easier to share information with the dietitian and be monitored in real time. The study will follow 80 patients over three years and will analyze their nutritional status, quality of life, hospital readmissions and overall survival. The study team will also collect information from participating clinicians, dietitians, patients and caregivers to assess program implementation, information that can be used to improve the program in the future.

Turner’s team is also testing the nutrition monitoring system in patients with pancreatic cancer who are undergoing chemotherapy to see if it helps with malnutrition and curbing symptoms such as bloating and nausea. The project is funded by a Career Development Award from the Pancreatic Cancer Action Network. Turner also received a Moffitt Team Science Award with Jose Pimiento, M.D., for their work studying the monitoring system in a small group of patients with gastroesophageal cancer. She is now working on expanding the study into a larger trial.

“It takes a long time to change clinical practice, but this is a problem Moffitt can solve because we have dietitians. We have the infrastructure to fix the problem,” Turner said.

Once this initial research demonstrates these programs are beneficial, the next step would be to scale the programs across health care systems, especially for those systems that don’t have in-house dietitians.

Cultural and Lifestyle Factors

Even as Moffitt researchers pioneer studies into diet during treatment, cancer prevention remains a key area of focus. Obesity is a risk factor linked to at least 13 different cancers. But when it comes to how diet and physical activity impact weight management, it’s not a one-size-fits-all answer.

Tiffany Carson, Ph.D., works in cancer prevention and focuses on how to help people make healthier choices that fit their lifestyle and cultural preferences.

“My research studies high-fiber diets to see if they lead to healthier gut microbiomes, what that looks like across different populations and how we can help different types of people achieve those dietary patterns,” Carson said.

Tiffany Carson, Ph.D., focuses her research on how to help people make healthier choices with the goal of cancer prevention.

One of Carson’s studies, called the DINING study and funded by the National Cancer Institute, is exploring the impact of different dietary patterns on the gut microbiome and how this affects risk for colorectal cancer. Participants receive either meals that follow the standard American diet or the Dietary Approaches to Stop Hypertension dietary pattern. The diet is high in fruit, vegetables and whole grains, resulting in a higher fiber diet. During the study’s seven-week period, the research team collects surveys, biospecimen samples and physical activity data to analyze how the different diets affect the gut microbiome.

“We have learned a lot over the last decade about the gut microbiome, and we know there are some bacterial groups that are overly abundant in individuals with colorectal cancer,” Carson said. “What we want to do is study behaviors and create a generally healthier gut environment that should lead to a lower risk of cancer in addition to a number of other chronic diseases that we’re learning are linked to gut bacteria as well.”

Carson’s RESET study is investigating the role stress plays in weight loss among Black women. The study will determine whether enhancing current evidence-based behavioral weight loss programs with training in stress management will lead to better weight loss outcomes for Black women with obesity and elevated stress levels.

A modified version of the RESET study, called Survivors RESET, recently launched focusing on breast cancer survivors. The goal of the study is to adapt and test the feasibility and acceptability of a stress management enhanced behavioral weight loss intervention for Black breast cancer survivors with obesity and elevated stress.

Moving the Needle Forward

While diet is a newer addition to the cancer research environment, it’s quickly becoming a bigger part of the conversation around cancer care. Moffitt researchers are working to advance the field, but there is still a lot of work to be done.

“One of the things I would love to see that we don’t currently have is more dietary pattern research,” Crowder said. “So, dependent on what type of cancer someone has, we would be able to give very specific recommendations based upon what types of dietary patterns they should consume.”

That would also mean tackling cultural and racial barriers and cancer care delivery roadblocks. Challenges include the need for more dietitians in health care systems and a way to better implement nutritional tools into standard treatment protocols.

One study at a time, Moffitt is working to identify diets and lifestyle behaviors that play a role in cancer prevention, treatment and survivorship. The goal is to discover not only customized plans and counseling for patients but also the best ways to deliver this newly established pillar of care.