The Impact of Nutrition and Exercise on Cancer Outcomes

Lifestyle and survivorship researchers at Sylvester Comprehensive Cancer Center, part of the University of Miami Miller School of Medicine, have launched several key studies to examine the impacts of nutrition and exercise on cancer therapy and outcomes.

Tracy E. Crane, Ph.D., RDN, co-lead of the Cancer Control Program and director of lifestyle medicine, prevention and digital health at Sylvester, is investigating ways to integrate lifestyle medicine into clinical practice so every patient receives nutrition and exercise support as part of their cancer care. Dr. Crane and her team utilize digital health and technology solutions developed in her lab to achieve this goal.

“Many people do not realize the depth of Sylvester’s resources in lifestyle medicine,” Dr. Crane said. “The research and clinical sides create a cyclical process where research is conducted, findings are discovered and new treatment protocols are then integrated into the clinic.”

Exercise and Nutrition Interventions During Chemotherapy

With this cyclical process in mind, Dr. Crane, principal investigator (PI), and Matthew Schlumbrecht, M.D., co-investigator, are leading efforts for Sylvester’s key role in the National Cancer Institute (NCI)-funded Exercise and Nutrition Interventions to Improve Cancer Treatment-related Outcomes (ENICTO) in Cancer Survivors consortium. Sylvester is co-leading one of the consortium’s four trials and the cancer center’s researchers’ participation offers Sylvester a national presence.

Dr. Crane is steering the consortium’s diet and nutrition working group. Frank J. Penedo, Ph.D., Sylvester’s associate director for Cancer Survivorship and Translational Behavioral Sciences, leads the patient-reported outcomes working group.

For the ENICTO consortium trial, Dr. Crane works alongside Yale University researchers on the Trial of Exercise and Lifestyle in Women With Ovarian Cancer (TEAL). Currently recruiting patients, the TEAL study examines ovarian cancer patients who are starting chemotherapy. The trial aims to determine whether a rigorous, prescribed diet and exercise intervention improves treatment outcomes for ovarian cancer, the most common cause of gynecological cancer death among U.S. women.

“We are the only site in the consortium also offering the trial in Spanish and have culturally adapted and tailored the intervention to meet the needs of our South Florida population,” Dr. Crane said.

Ovarian cancer patients have lower-than-desired rates of completion for their chemotherapy regimens, according to Dr. Schlumbrecht, medical co-director of the Cancer Survivorship Program and co-lead of the Gynecologic Oncology Site Disease Group at Sylvester.

“We’re hypothesizing that women randomized to the intervention will see improved levels of chemotherapy completion rates,” Dr. Schlumbrecht said. “That’s important because studies also show that women who complete chemotherapy treatment for ovarian cancer on time have better outcomes.”

TEAL started on the heels of the Lifestyle Intervention for Ovarian Cancer Enhanced Survival (LIVES) trial, which Dr. Crane co-leads.

“When completed, LIVES will be the largest behavior-based lifestyle intervention trial conducted among ovarian cancer survivors,” Dr. Crane said. “We published the baseline paper this year and will soon publish our findings on how the diet and exercise intervention impacted progression-free survival in ovarian cancer.”

Food and Exercise for Lymphoma Patients

Dr. Crane and Craig Moskowitz, M.D., joined Sylvester colleagues to launch the Lifestyle Intervention of Food and Exercise for Lymphoma Survivors (LIFE-L) study. This V Foundation for Cancer Research-funded study is enrolling patients who speak English and/or Spanish. LIFE-L also evaluates nutrition and exercise but is more nuanced.

“The LIFE-L study is among the first to test a lifestyle intervention during treatment for lymphoma,” said Dr. Moskowitz, physician-in-chief at Sylvester, whose research focuses on improving outcomes for patients with poor risk Hodgkin lymphoma and diffuse large B-cell lymphoma. “Diet during treatment has not been well studied in lymphoma patients.”

Researchers are evaluating a Mediterranean diet and physical activity intervention to improve treatment completion rates among patients starting chemotherapy for lymphomas. According to Dr. Crane, they’re also looking at the diet’s impact on fatigue.

Past studies suggest lower levels of fatigue and even better sleep when cancer patients follow a Mediterranean diet. According to Dr. Crane, studies have found similar results with the Mediterranean diet’s impact on chronic health conditions like cardiovascular disease.

“We think it’s likely due to the higher levels of vegetables and plant-based intake but also because of its more specific focus on healthy fats,” Dr. Crane said.

Metabolomics: Studying the White Noise

LIFE-L study researchers Melissa Lopez-Pentecost, Ph.D., M.S., RDN, a postdoctoral research fellow at Sylvester, and David Lombard, M.D., Ph.D., co-leader of the Cancer Epigenetics Program at Sylvester, are investigating body composition and metabolism in the form of metabolomics.

“Metabolomics is the study of the smallest biomolecules that result from different metabolic processes in our body. I like to refer to it as the ‘white noise’ that is often neglected and understudied,” Dr. Lopez-Pentecost said.

Metabolomics is a powerful tool that provides a snapshot of what is happening metabolically in the body due to intrinsic (genetics, age, disease, etc.) and extrinsic (environmental exposures, drugs, etc.) factors, as well as behaviors like diet and exercise.

“By incorporating metabolomics in our research studies, we can better understand how factors such as diet and exercise influence cancer outcomes, thereby paving the way for the development of more personalized and effective approaches to treat cancer patients,” Dr. Lopez-Pentecost said.

Integrating Technology into Cancer Care

Sylvester researchers launched an NCI-funded study with the NRG Oncology Group that focuses on the digital health component of Dr. Crane’s research.

“We’re delivering an automated, interactive voice response system to community-based sites in English and Spanish to monitor symptoms for patients taking oral anti-cancer medications across the country,” she said.

The system calls patients who report their symptoms by pressing a button or saying a number. Based on patient responses, the automated system refers patients to an evidence-based symptom management handbook designed to tackle reported symptoms.

Clinical trial participants receive interventions to address anxiety and depression if symptoms don’t resolve via automated symptom management.

The technology works on land lines, an intentional design feature intended to reach patients without smartphones.

“This helps to ensure the digital divide between rural and urban cancer survivors is not widened,” she said.

The NCI Community Oncology Research Program (NCORP) trial uses clinic-based randomization so some clinics will receive the automated intervention for patients and others will not.

“That allows us to compare, at the health system level, whether or not we can implement these self-management interventions successfully in community-based settings,” Dr. Crane said.  

Dr. Crane’s research uses the My Wellness Research software platform she developed with colleagues, including Grey Freylersythe, the senior manager for Dr. Crane’s lab.

“The MWR platform is an indispensable, customizable digital research solution that makes it possible for us to collect wearable and self-report data and have two-way communication with participants and more through one central location,” Freylersythe said.

Precision Intervention in Lifestyle Medicine

Dr. Crane has several other studies at various stages of progress. The recently launched, Applebaum Foundation-supported study OnPOINT examines precision risk stratification. The study aims to understand better how to take biometric wearable data from devices such as activity monitors and routinely assessed clinical measures like age and performance status to improve risk-stratifying decisions about appropriate lifestyle interventions, said Dr. Crane.

The OnPOINT study is a Sylvester-wide collaboration that examines cancer survivors after treatment. OnPOINT researchers include co-investigators Paola Rossi, M.D., M.S., clinical program director for lifestyle medicine, Jessica MacIntyre, D.N.P., ARNP, NP-C, AOCNP, executive director for Sylvester’s clinical operations, and Dr. Penedo, as well as oncology clinicians and support service personnel at Sylvester.

“Oncology is moving toward more precise interventions—getting the right intervention, at the right time, for the right individual,” Dr. Rossi said. “With OnPOINT, we’re trying to better understand the feasibility and delivery of what individual survivors need to support a healthy lifestyle. We know that they’ll benefit from exercising more and eating a healthy diet, but what each person needs to get there is different.”

These trials and multidisciplinary teams are leading the charge to improve outcomes for cancer patients across the continuum of care, according to Dr. Crane. She’s involved with two additional studies enrolling participants: FastER, which studies the effects of exercise and fasting on breast cancer, and VITALITY, which examines lifestyle interventions for older cancer survivors and their caregivers.

“Sylvester’s investment and commitment to grow lifestyle medicine has resulted in the cancer center quickly becoming a leader in this space, with numerous trials, development of a software platform and our interests across the cancer continuum from prevention to metastatic disease,” Dr. Crane said.

Tags: Cancer Control Program, cancer epigenetics, cancer survivorship, Dr. Craig Moskowitz, Dr. David Lombard, Dr. Frank Penedo, Dr. Paola Rossi, Dr. Tracy Crane, Jessica MacIntyre, nutrition, Sylvester Comprehensive Cancer Center