Teaching pack: Diet, Exercise & Lifestyle

Obesity, alcohol and inactivity are established causes; diet quality, fibre and the gut microbiome shape immunotherapy response; structured exercise improved survival in a randomised colon cancer trial (CHALLENGE, 2025); fasting-mimicking and ketogenic diets, GLP-1 agonists, vitamin D and aspirin are under test. Cachexia and malnutrition during treatment are treatable and under-treated. The evidence ranges from strong to hype, and this front keeps the two apart.

• Alcohol reduction, pricing and cancer warning labels: Alcohol causes at least seven cancers and there is no safe threshold. Price, availability and cancer warning labels are the tools that work; most people still do not know alcohol causes cancer.
• American ginseng for cancer-related fatigue: In a randomised placebo-controlled trial of 364 people, eight weeks of Wisconsin American ginseng modestly improved cancer-related fatigue, mainly in those still on treatment. The 2024 fatigue guideline says it may be offered during treatment; quality of the product matters.
• Aspirin for cancer prevention and adjuvant therapy: Daily low-dose aspirin lowers bowel cancer risk in people with Lynch syndrome and appears to cut recurrence in bowel cancers with a particular mutation. In healthy older people it caused more harm than good.
• Bariatric surgery and cancer incidence: People with severe obesity who have weight-loss surgery develop about a third fewer cancers over the following decade, especially womb and other hormone-related cancers, than similar people who do not.
• Cachexia pharmacotherapy: GDF-15 blockade, anamorelin, olanzapine: Cachexia pharmacotherapy covers three drug approaches to cancer wasting: ponsegromab, an antibody that blocks the appetite-suppressing hormone GDF-15 and is in phase 3; anamorelin, a ghrelin mimic approved only in Japan; and low-dose olanzapine, a generic tablet available everywhere that ASCO added to guidance in 2024. None has yet been shown to improve physical function.
• Cachexia-directed therapy (GDF-15 blockade): Cachexia-directed therapy treats cancer wasting by blocking GDF-15, a hormone that rises in advanced cancer and acts on the brainstem to suppress appetite. Pfizer's antibody ponsegromab improved weight in a phase 2 trial and is in phase 2/3 in pancreatic cancer cachexia; whether weight gain translates into function is the open question.
• Chronotherapy: timing treatment to the body clock: Giving the same drug at a different time of day, because the body clock changes how much damage it does and how well the immune system responds.
• Coffee and tea intake: Coffee does not cause cancer: IARC downgraded it in 2016, and cohort studies link two to three cups a day with lower rates of liver and womb cancer. Drinks of any kind served above 65 C are classed as a probable cause of oesophageal cancer, so the temperature, not the coffee, is the risk.
• CT body composition and sarcopenia measurement: The staging CT scan every cancer patient already has can be measured for muscle and fat at the level of the third lumbar vertebra; low muscle predicts chemotherapy toxicity and shorter survival across cancers, and software now does the measuring automatically.
• Curcumin and turmeric: Curcumin, the yellow pigment in turmeric, kills cancer cells in a dish and is one of the most studied supplements, but it is barely absorbed from the gut and no randomised trial has shown it treats cancer in people. Cooking with turmeric is fine; high-dose capsules can interact with chemotherapy and blood thinners.

• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · The causes are established (historic)
• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · The intervention trials that disappointed, and taught (historic)
• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · Exercise becomes a treatment (current)
• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · Nutrition care as a standard of care (current)
• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · The microbiome and immunotherapy (emerging)
• Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment · Metabolic interventions under randomised test (emerging)

• ALASCCA (phase 3, n=626): Time to recurrence at 3 years, group A (PIK3CA exon 9/20): 7.7% vs 14.1%, HR 0.49
• CHALLENGE (CCTG CO.21) (phase 3, n=889): Disease-free survival at 5 years: 80.3% vs 73.9%, HR 0.72
• BWEL (Breast Cancer Weight Loss, Alliance A011401) (phase 3, n=3,181): Invasive disease-free survival: Event-driven primary analysis not yet published; ClinicalTrials.gov lists primary completion in 2030. Only weight and quality-of-life secondary analyses have been reported (2025-2026).
• PREHAB: multimodal prehabilitation before colorectal cancer surgery (phase 3, n=251): Severe postoperative complications (Comprehensive Complication Index > 20): 17.1% vs 29.7%
• ROMANA 1 and ROMANA 2 (phase 3, n=979): Change in lean body mass over 12 weeks (ROMANA 1): 0.99 kg vs -0.47 kg
• CAPP2 (phase 3, n=861): Colorectal cancer over a mean of 10 years of follow-up (intention to treat): 9% vs 13%, HR 0.65

1. What is exercise oncology and is there real evidence?
   Answer

   Structured exercise during and after treatment; the CHALLENGE trial (2025) randomised colon cancer survivors and showed improved disease-free and overall survival, the first level-1 evidence, plus less fatigue and neuropathy.

• CHALLENGE trial (NEJM 2025): https://www.nejm.org/doi/full/10.1056/NEJMoa2502760