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40 Years of Progress:  Empowering Cancer Prevention and Survivorship

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This year marks the 40th anniversary of the American Institute for Cancer Research (AICR) and I am proud to be a part of their legacy and mission for 38 of those 40 years. In all these years, I have always seen AICR devoted to its mission of funding cutting-edge research that can move the needle forward in reducing the burden of cancer. As research about diet, physical activity and weight/body composition after a cancer diagnosis has grown, education and support in that area has expanded as well. But back in 1982, talking about how you could reduce risk of cancer seemed like a “fringe” idea for many health professionals. Yes, it was over 10 years since the U.S. Congress had officially declared (and funded) a “War on Cancer.” But most of the research related to cancer was focused on treatment.

Do you remember the introduction to each of the Star Wars movies: “A long time ago in a galaxy far, far away. . . ?” That’s sometimes how it feels when I look back at the earliest days of my work with AICR.

We have taken some giant steps in moving forward on understanding the role of lifestyle in cancer prevention and survivorship.

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Accomplishments in talking about cancer risk: Magnified in context

AICR began before the founding of the World Wide Web. Health-care providers and journalists had to work hard to search out scientific evidence and try to evaluate it, and lack of information was a major barrier. Today, people face a different kind of challenge. Information about diet and cancer is everywhere. An important role for AICR is in helping people know what advice is actually sound.

In 1981, a landmark report commissioned by Congress shocked a lot of people. Smoking was already recognized as a risk factor. But highlighting diet as an important influence was groundbreaking in the larger health-care and scientific community, as well as for the public. In 1983, AICR took a giant step forward by publishing four Dietary Guidelines to Lower Cancer Risk.

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Over the decades since then, we’ve gone from health-care professionals and the public questioning whether the concept of being able to reduce cancer risk was really based on sound science, to having the goal of risk reduction included in multiple major health guidelines.

Three big changes in how we talk about cancer risk

  • Quality and quantity of research on which the AICR Cancer Prevention Recommendations are based

Early on, many people believed that cancer risk was largely inherited. And initially, a lot of the available human research involved people in studies (like cross-sectional and case-control studies) in which results can be easily influenced by other factors. For example, people have trouble accurately recalling what they ate years ago, and people with certain eating habits may have other things in common that protect against or increase cancer risk.

However, even then, the puzzle pieces fit together when evidence from that research was supported by laboratory studies showing potential mechanisms through which diet could influence cancer.

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Today, AICR’s Cancer Prevention Recommendations are based on stronger evidence than ever before.

  • Large prospective cohort studies that follow people for years provide important evidence for a disease like cancer that tends to develop over many years. And statistical techniques now allow pooling of study results analyzing the results of all studies that meet certain criteria to see what overall research shows.
  • Biomarkers of what people eat, how food is processed and the body environment (like inflammatory markers) add important evidence.
  • The Continuous Update Project reports, a collaboration of AICR and the World Cancer Research Fund (WCRF) provided groundbreaking quality of evidence beginning in 2008. This international effort gathers and maintains a database of all relevant research, and an internationally renowned expert panel reviews it for key findings strong enough to be included in the Recommendations. These CUP reports are recognized around the world as the gold standard in research review and analysis.
  • What we talk about in cancer risk and survivorship

As the quality of evidence has improved, some of the Recommendations have remained consistent (and even become stronger), while additional Recommendations have been added.

  • Overall dietary pattern has more impact than single nutrients or phytochemicals. Early evidence focused on dietary fiber and antioxidant nutrients like beta-carotene and vitamins C and E. Then research uncovered more about how thousands of natural compounds in vegetables, whole grains and other plant foods could offer a variety of protective effects, including influence on gene expression and cell signaling.
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Initially, scientists thought that supplying protective nutrients in supplements—sometimes in extra-high amounts hoping for additional protection—might be a solution. But those studies largely did not show much benefit, and sometimes the high-dose studies caused harm. A wide range of nutrients and compounds contribute to eating habits that protect against cancer. But rather than keeping a tally of all these compounds, research now shows an overall type of eating pattern is most strongly linked to lower risk.

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AICR’s educational materials, recipes and tools focus on how to achieve this pattern: The New American Plate.

  • Weight, weight gain and physical activity have become important—and increasingly complex—pieces of the puzzle. Excess body fat and weight gain are now clearly identified as important influences on cancer. Greater adiposity leads to increased risk of at least 12 cancers. Amid growing rates of obesity, people today live in an environment of food choices and sedentary lifestyles that promote weight gain. Healthy choices have to encompass more than meeting nutritional needs and also support a healthy weight.

But research is complex, and it’s challenging to communicate results while we are still learning about the nuances. Physical activity includes not only “exercise,” but all the movement that can be included as part of daily activities. And this may be separate from the benefits of limiting sedentary time. Although large population studies show BMI (body mass index) as the way of expressing weight and height that’s linked with greater cancer risk, research is still looking at important questions of whether risk varies by the location of body fat (visceral fat deep in the abdomen versus fat in the hips and thighs, for example) and when weight gain or loss occurs.

  • Survivorship is part of the conversation more than ever before. With growing success in early diagnosis and treatment of cancer, more people today are living with and beyond a diagnosis of cancer than ever before. Intervention trials are showing remarkable success for some cancers by including physical activity early—and sometimes even before—treatment begins.

Questions about diet are complex, since priorities may shift at different stages of the cancer journey, and among people who differ in health at the time they’re diagnosed and in the specific type of cancer. During treatment, maintaining nutritional status and avoiding loss of lean muscle tissue may be of primary importance. During and after treatment, nutrition may play a role in improving quality of life, as well as cancer outcomes. And as treatments improve, concerns about reducing risk of another cancer and other chronic diseases (like heart disease or diabetes) become part of nutrition conversations, too. Following the AICR Cancer Prevention Recommendations also provide a good foundation for long-term health after cancer.

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  • How we talk about cancer risk and survivorship

In AICR’s early years, methods of communication were dramatically different.

  • Reaching people without the Internet: How did people learn about nutrition and cancer recommendations before websites, Google searches, email and social media? Since AICR began before the ability to reach people through the World Wide Web, brochures that people wrote in to request by mail were key tools. From the beginning, the AICR Newsletter has been an essential way to share practical tips and help people learn about advances in research, translated in articles that could make sense to non-scientists. And through the years, the AICR Newsletter has received multiple awards for excellence.
  • Sharing recipes without apps and websites: Then, as now, people rely on recipes to get new ideas and learn how to prepare healthful foods. The AICR Newsletter has always included recipes. But in efforts to do more, AICR has also developed cookbooks focused on putting the Recommendations into practice.
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In 1985 and 1986, one of my early projects for AICR was writing a four-volume cookbook series, An Ounce of Prevention. I still use these recipes. But these spiral-bound cookbooks with no food photography are a far cry from The New American Plate Cookbook that AICR published in 2005 and is still sold through bookstores and online. Filled with gorgeous photography, this cookbook shows how food can be healthy and as simple or exotic as you want to make it. And now it’s as easy as going to the recipe section of the AICR website to get instant access to tasty and healthy ideas.

  • The need to combat misinformation: AICR’s efforts to communicate information grounded in the best available science were challenged from the start by books, TV shows and magazine articles promoting unfounded advice. But the downside of the growth of information on the Internet is that misinformation is more widespread than ever. And many people seem unprepared to review what they find there with caution.

Still, the Internet has brought tremendous benefits by making it possible for the AICR website to provide research updates and share them. And it’s what makes it possible to provide online programs to implement the Recommendations (like AICR’s Cancer HealthCheck and Healthy10 Challenge).

What has remained the same and what lies ahead

One of my very first projects for AICR in 1984 was, Planning Meals That Lower Cancer Risk: A Reference Guide. Designed for registered dietitians and health professionals, it showed how a variety of different dietary patterns (including basic, low meat, no dairy and lacto-ovo vegetarian) could be implemented to meet the AICR Recommendations. And it included sections on how to include more whole grains and incorporate legumes in meals. The guide was so successful, that in 1990 AICR asked me to create an updated edition. If we were doing such a project today, we’d clearly need to also include a plants-only (vegan) dietary pattern. A plant-based diet (meaning plant-focused, whether or not it’s plants-only) has always been part of AICR’s message. Originally, nobody heard of that term. Today, the challenge is in translating the research about how this can be accomplished in many ways, and which are the important elements. (For example, what about processed foods in a plant-based diet?)

AICR has always focused on providing the public with direct access to accurate translation of research on nutrition and physical activity related to cancer. But people want—and need—to turn to health-care professionals for personalized advice about how research and recommendations relate to their individual circumstances. That’s why AICR has always tried to help health professionals stay updated in this area.

Looking ahead, AICR’s messages may someday be able to become more precise, perhaps addressing different genetic tendencies, stages of cancer development and stages of life.

One thing I can’t imagine changing is that people count on AICR as a source that is always based on sound science. And I know it’s an organization with a mission to which I will always be grateful for the chance to contribute.

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