Earlier diagnosis and more effective treatments mean that the estimated number of cancer survivors in the United Kingdom is expected to reach 4 million by 2030. However, there is an increasing realisation that excess body fatness (EBF) is likely to influence the quality of cancer survivorship and disease-free survival. For decades, the discussion of weight management in patients with cancer has been dominated by concerns about unintentional weight loss, low body weight and interventions to increase weight, often re-enforced by the existence of the obesity paradox, which indicates that high body weight is associated with survival benefits for some types of cancer. However, observational evidence provides strong grounds for testing the hypothesis that interventions for promoting intentional loss of body fat and maintaining skeletal muscle in overweight and obese cancer survivors would bring important health benefits in terms of survival outcomes and long-term impact on treatment-related side effects. In this paper, we outline the need for studies to improve our understanding of the health benefits of weight-loss interventions, such as hypocaloric healthy-eating plans combined with physical activity. In particular, complex intervention trials that are pragmatically designed are urgently needed to develop effective, clinically practical, evidence-based strategies for reducing EBF and optimising body composition in people living with and beyond common cancers.
Subscribe to Journal
Get full journal access for 1 year
only $4.96 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
“DCCPS: OCS: About Cancer Survivorship Research: Survivorship Definitions”. (Office of Cancer Survivorship of the US National Cancer Institute, 2006).
Macmillan cancer Support. Cancer cash crisis—counting the cost of care beyond treatment. https://www.macmillan.org.uk/documents/campaigns/cancercashcrisisreport-macmillandecember2015.pdf (2015).
Maddams, J., Utley, M. & Møller, H. Projections of cancer prevalence in the United Kingdom, 2010–2040. Br. J. Cancer 107, 1195–1202 (2012).
Allemani, C. & Coleman, M. P. Public health surveillance of cancer survival in the United States and worldwide: The contribution of the CONCORD programme. Cancer 123, 4977–4981 (2017).
World Health Organisation. Obesity and Overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (WHO, 2018).
International Agency for Research on Cancer. Absence of Excess Body Fatness. http://publications.iarc.fr/Book-And-Report-Series/Iarc-Handbooks-Of-Cancer-Prevention/Absence-Of-Excess-Body-Fatness-2018 (IARC, 2018).
Hopkins, B. D., Goncalves, M. D. & Cantley, L. C. Obesity and cancer mechanisms: cancer metabolism. J. Clin. Oncol. 34, 4277–4283 (2016).
Quail, D. F. & Dannenberg, A. J. The obese adipose tissue microenvironment in cancer development and progression. Nat. Rev. Endocrinol. Mar. 15, 139–154 (2019).
Pietrocola, F., Pol, J., Vacchelli, E., Rao, S., Enot, D. P., Baracco, E. E. et al. Caloric restriction mimetics enhance anticancer immunosurveillance. Cancer Cell 30, 147–160 (2016).
World Cancer Research Fund. Cancer survivors: evidence on survivors of breast and other cancers. https://www.wcrf.org/dietandcancer/cancer-survivors (2018).
Arends, J., Bachmann, P., Baracos, V., Barthelemey, N., Bertz, H., Bozzetti, F. et al. ESPEN guidelines on nutrition in cancer patients. Clin. Nutr. 36, 11–48 (2017).
El-Shami, K., Oeffinger, K. C., Erb, N. L., Willis, A., Bretsch, J. K., Pratt-Chapman, M. L. et al. American cancer society colorectal cancer survivorship care guidelines. CA: Cancer J. Clin. 65, 428–455 (2015).
Anderson, A. S., Caswell, S., Wells, M. & Steele, R. J. Obesity and lifestyle advice in colorectal cancer survivors—how well are clinicians prepared? Colorectal Dis. 15, 949–957 (2013).
Koutoukidis, D. A., Lopes, S., Fisher, A., Williams, K., Croker, H. & Beeken, R. J. Lifestyle advice to cancer survivors: a qualitative study on the perspectives of health professionals. BMJ Open 8, e020313 (2018).
Markham, M. J., Wachter, K., Agarwal, N., Bertagnolli, M. M., Chang, S. M., Dale, W. et al. Clinical cancer advances 2020: annual report on progress against cancer from the American Society of Clinical Oncology. J. Clin. Oncol. 38, 10, 1081 (2020).
Cao, F., Li, F., Shi, L., Zhang, L., Ma, T. & Zhang, G. Mortality trends of colorectal cancer among overweight patients at the global and national levels. Int. J. Colorectal Dis. https://doi.org/10.1007/s00384-019-03371-6 (2019)
Chan, D. S., Vieira, A. R., Aune, D., Bandera, E. V., Greenwood, D. C., McTiernan, A. et al. Body mass index and survival in women with breast cancer-systematic literature review and meta-analysis of 82 follow-up studies. Ann. Oncol. 25, 1901–1914 (2014).
Westhoff, E., Witjes, J. A., Fleshner, N. E., Lerner, S. P., Shariat, S. F., Steineck, G. et al. Body mass index, diet-related factors, and bladder cancer prognosis: a systematic review and meta-analysis. Bladder Cancer 4, 91–112 (2018).
Cao, Y. & Ma, J. Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis. Cancer Prev. Res. 4, 486–501 (2011).
Gupta, A., Das, A., Majumder, K., Arora, N., Mayo, H. G., Singh, P. P. et al. Obesity is independently associated with increased risk of hepatocellular cancer-related mortality: a systematic review and meta-analysis. Am. J. Clin. Oncol. 41, 874–881 (2018).
Park, Y., Peterson, L. L. & Colditz, G. A. The plausibility of obesity paradox in cancer-point. Cancer Res. 78, 1898–1903 (2018).
Cespedes Feliciano, E. M., Kroenke, C. H. & Caan, B. J. The obesity paradox in cancer: how important is muscle? Annu. Rev. Nutr. 38, 357–379 (2018).
Walter, V., Jansen, L., Hoffmeister, M., Ulrich, A., Roth, W., Bläker, H. et al. Prognostic relevance of prediagnostic weight loss and overweight at diagnosis in patients with colorectal cancer. Am. J. Clin. Nutr. 104, 1110–1120 (2016).
Van Arsdale, A., Miller, D. T., Kuo, D. Y., Isani, S., Sanchez, L. & Nevadunsky, N. S. Association of obesity with survival in patients with endometrial cancer. Gynecol. Oncol. 154, 156–162 (2019).
Wang, J., Xu, H., Zhou, S., Wang, D., Zhu, L., Hou, J. et al. Body mass index and mortality in lung cancer patients: a systematic review and meta-analysis. Eur. J. Clin. Nutr. 72, 4–17 (2018).
Arem, H. & Irwin, L. Obesity and endometrial cancer survival:a systematic review. Int J. Obes. 37, 634–639 (2013).
Christensen, J. F., Simonsen, C. & Hojman, P. Exercise training in cancer control and treatment. Comprehensive Physiol. 9, 165–205 (2019).
Playdon, M. C., Bracken, M. B., Sanft, T. B., Ligibel, J. A., Harrigan, M. & Irwin, M. L. Weight gain after breast cancer diagnosis and all-cause mortality: systematic review and meta-analysis. J. Natl Cancer Inst. 107, djv275 (2015).
Otto, S. J., Korfage, I. J., Polinder, S., van der Heide, A., de Cries, E., Rietjens, J. A. C. et al. Association of change in physical activity and body weight with quality of life and mortality in colorectal cancer: a systematic review and meta-analysis. Support Care Cancer 23, 1237–1250 (2015).
Doleman, B., Mills, K., Lim, 3, Zelhart, M. & Gagliardi, G. Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis. Tech. Coloproctol. 20, 517–535 (2016).
Caan, B. J., Cespedes Feliciano, E. M. & Kroenke, C. H. The importance of body composition in explaining the overweight paradox in cancer-counterpoint. Cancer Res. 78, 1906–1912 (2018).
Parkin, E. & Renehan, A. G. Need to distinguish the term sarcopenia from risk stratification derived from muscle parameters. J. Clin. Oncol. 36, 2128–2129 (2018).
Baracos, V. E. & Arribas, L. Sarcopenic obesity: hidden muscle wasting and its impact for survival and complications of cancer therapy. Ann. Oncol. 29, ii1–ii9 (2018).
Caan, B. J., Cespededs Feliciano, E. M., Prado, C. M., Alexeeff, S., Kroenke, C. H., Bradshaw, P. et al. Association of muscle and adiposity measured by computed tomography with survival in patients with nonmetastatic breast cancer. JAMA Oncol. 4, 798–804 (2018).
Slawinski, C. G. V., Barriuso, J., Guo, H. & Renehan, A. G. 2020 obesity and cancer treatment outcomes: interpreting the complex evidence clinical oncology. Clin. Oncol. 32, 591–608 (2020).
Parekh, N., Chandran, U. & Bandera, E. V. Obesity in cancer survival. Annu. Rev. Nutr. 32, 311–342 (2012).
Protani, M., Coory, M. & Martin, J. H. Effect of obesity on survival of women with breast cancer: systematic review and meta-analysis. Breast Cancer Res. Treat. 123, 627–635 (2010).
Doerstling, S. S., O’Flanagan, C. H. & Hursting, S. D. Obesity and cancer metabolism: a perspective on interacting tumor–intrinsic and extrinsic factors. Front. Oncol. 7, 216 (2017).
Doleman, B., Mills, K. T., Lim, S., Zelhart, M. D. & Gagliardi, G. Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis. Tech. Coloproctol. 20, 517–535 (2016).
Chlebowski, R. T., Blackburn, G. L., Thomson, C. A., Nixon, D. W., Shapiro, A., Hoy, M. K. et al. Dietary fat reduction and breast cancer outcome: interim efficacy results from the Women’s Intervention Nutrition Study. J. Natl Cancer Inst. 98, 1767–1776 (2006).
Rock, C. L., Pande, C., Flatt, S. W., Ying, C., Pakiz, B., Parker, B. A. et al. Favorable changes in serum estrogens and other biologic factors after weight loss in breast cancer survivors who are overweight or obese. Clin. Breast Cancer 13, 188–195 (2013).
Harrigan, M., Cartmel, B., Loftfield, E., Sanft, T., Chagpar, A. B., Zhou, Y. et al. Randomized trial comparing telephone versus in-person weight loss counseling on body composition and circulating biomarkers in women treated for breast cancer: the lifestyle, exercise, and nutrition (LEAN) study. J. Clin. Oncol. 34, 669–676 (2016).
Pakiz, B., Flatt, S. W., Bardwell, W. A., Rock, C. L. & Mills, P. J. Effects of a weight loss intervention on body mass, fitness, and inflammatory biomarkers in overweight or obese breast cancer survivors. Int. J. Behav. Med. 18, 333–341 (2011).
Ligibel, J. A., Barry, W. T., Alfano, C. M., Hershman, D. L., Irwin, M. L., Neuhouser, M. et al. The breast cancer weight loss (BWEL) trial: randomized phase III trial evaluating the role of weight loss in adjuvant treatment of overweight and obese women with early-stage breast cancer (Alliance A011401). J. Clin. Oncol. 36, TPS598–TPS598 (2018).
Rack, B., Andergassen, U., Neugebauer, J., Salmen, J., Hepp, P., Sommer, H. et al. The German SUCCESS C Study—the first european lifestyle study on breast cancer. Breast Care 5, 395–400 (2010).
Villarini, A., Pasanisi, P., Traina, A., Mano, M. P., Bonanni, B., Panico, S. et al. Lifestyle and breast cancer recurrences: the DIANA-5 trial. Tumori 98, 1–18 (2012).
Kitson, S., Ryan, N., MacKintosh, M. L., Edmondson, R., Duffy, J. M. & Crosbie, E. J. Interventions for weight reduction in obesity to improve survival in women with endometrial cancer. Cochrane Database Syst. Rev. 2, CD012513, https://doi.org/10.1002/14651858.CD012513.pub2 (2018).
Jackson, S. E., Heinrich, M., Beeken, R. J. & Wardle, J. Weight loss and mortality in overweight and obese cancer survivors: a systematic review. PloS ONE 12, e0169173 (2017).
Demark-Wahnefried, W., Schmitz, K. H., Alfano, C. M., Bail, J. R., Goodwin, P. J., Thomson, C. A. et al. Weight management and physical activity throughout the cancer care continuum. CA Cancer J. Clin. 68, 64–89 (2018).
Renehan, A. G., Alam, N. N. & Sperrin, M. Interaction between co-morbidities and cancer survival. Eur. J. Epidemiol. 34, 1103–1105 (2019).
Martin, L. P., Senesse, I., Gioulbasanis, I., Antoun, S., Bozzetti, F., Deans, C. et al. Diagnostic criteria for the classification of cancer-associated weight loss. J. Clin. Oncol. 33, 90–99 (2015).
Vance, V., Mourtzakis, M., McCargar, L. & Hanning, R. Weight gain in breast cancer survivors: prevalence, pattern and health consequences. Obes. Rev. 12, 282–294 (2011).
Makari-Judson, G., Braun, B., Jerry, D. J. & Mertens, W. C. Weight gain following breast cancer diagnosis: implication and proposed mechanisms. World J. Clin. Oncol. 5, 272–282 (2014).
Gandhi, A., Copson, E., Eccles, D., Durcan, L., Howell, A., Morris, J. et al. Predictors of weight gain in a cohort of premenopausal early breast cancer patients receiving chemotherapy. Breast 45, 1–6 (2019).
Sepulveda, A. R., Hamilton, S. R., Allegra, C. J., Grody, W., Cushman-Vokoun, A. M., Funkhouser, W. K. et al. Molecular biomarkers for the evaluation of colorectal cancer: guideline from the American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology, and the American Society of Clinical Oncology. J. Clin. Oncol. 35, 1453–1486 (2017).
Williamson, P. R., Altman, D. G., Bagley, H., Barnes, K. L., Blazeby, J. M., Brookes, S. T. et al. The COMET handbook: version 1.0. Trials 18, 280 (2017).
Rosenbaum, M., Agurs-Collins, T., Bray, M. S., Hall, K. D., Hopkins, M., Laughlin, M. et al. Accumulating data to optimally predict obesity treatment (ADOPT): recommendations from the biological domain. Obesity 26, S25–S34 (2018).
Ballard-Barbash, R., Hunsberger, S., Alciati, M. H., Blair, S. N., Godwin, P. J., McTiernan, A. et al. Physical activity, weight control, and breast cancer risk and survival: clinical trial rationale and design considerations. J. Natl Cancer Inst. 101, 630–643 (2009).
Chaput, J. P., Klingenberg, L., Rosenkilde, M., Gilbert, J. A., Tremblay, A. & Sjödin, A. Physical activity plays an important role in body weight regulation. J. Obes. pii: 360257. https://doi.org/10.1155/2011/360257 (2011).
Ostendorf, D. M., Caldwell, A. E., Creasy, S. A., Pan, Z., Lyden, K., Bergouignan, A. et al. Physical activity energy expenditure and total daily energy expenditure in successful weight loss maintainers. Obesity 27, 496–504 (2019).
Poggiogalle, E., Migliaccio, S., Lenzi, A. & Donini, L. M. Treatment of body composition changes in obese and overweight older adults: insight into the phenotype of sarcopenic obesity. Endocrine 47, 699–716 (2014).
Caan, B. J., Cespedes Feliciano, E. M., Prado, C. M., Alexeeff, S., Kroenke, C. H., Bradhsaw, P. et al. Association of muscle and adiposity measured by computed tomography with survival in patients with nonmetastatic breast cancer. JAMA Oncol. 4, 798–804 (2018).
Stiegler, P. & Cunliffe, A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss. Sports Med. 36, 239–262 (2006).
Friedenreich, C. M., Stone, C. R., Cheung, W. Y., Hayes, S. C. Physical activity and mortality in cancer survivors: a systematic review and meta-analysis. JNCI Cancer Spectr. 4, pkz080 (2019).
Campbell, K. L., Winters-Stone, K. M., Wiskemann, J., May, A. M., Schwartz, A. L., Courneya, K. S. et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med. Sci. Sports Exerc 51, 2375–2390 (2019).
Harvie, M., Wright, C., Pegington, M., McMullan, D., Mitchell, E., Martin, B., Cutler, R. G. et al. The effect of intermittent energy and carbohydrate restriction v. daily energy restriction on weight loss and metabolic disease risk markers in overweight women. Br. J. Nutr. 110, 1534–1547 (2013).
Lean, M. E., Leslie, W. S., Barnes, A. C., Brosnahan, N., Thom, G., McCombie, L. et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 391, 541–551 (2018).
Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A. et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N. Engl. J. Med. 346, 393–403 (2002).
Hoedjes, M., van Stralen, M. M., Joe, S. T. A., Rookus, M., van Leeuwen, F., Michie, S. et al. Toward the optimal strategy for sustained weight loss in overweight cancer survivors: a systematic review of the literature. J. Cancer Surviv. 11, 360–385 (2017).
Sandu, M. R., Beynon, R., Richmond, R., Ferreira, S. L. S., Hackshaw-McGeagh, L., Smith, G. D. et al. Two-step randomisation: applying the results of small feasibility studies of interventions to large-scale Mendelian randomisation studies to robustly infer causal effects on clinical endpoints. Preprint at https://doi.org/10.20944/preprints201910.0276.v1 (2019).
Beynon, R., Richmond, R. C., Santos Ferreira, D. L., Ness, A. R., May, M., Davey, G. D. et al. The ProtecT Study Group. The PRACTICAL consortium. Investigating the effects of lycopene and green tea on the metabolome of men at risk of prostate cancer: the ProDiet randomised controlled trial. Int. J. Cancer https://doi.org/10.1002/ijc.31929 (2018).
The authors thank Ms Jill Hampton, Mrs Mary Burke for the paper coordination and preparation and Ms Fiona Davies for organisation of meetings and discussion sessions.
the UK NIHR Cancer and Nutrition Collaboration (Population Health Stream)
Annie Anderson14, Rebecca Beeken15, Janet Cade16, Amanda Cross17, Angela King18, Richard Martin19, Giota Mitrou20, Elio Riboli21, John Saxton22, Andrew Renehan23
Ethics approval and consent to participate
Consent to publish
R.M.M. reports grants from CRUK, during the conduct of the study. J.C. reports that she is the director of Dietary Assessment Ltd. E.R.C. reports other from SECA, personal fees from Roche, personal fees from Lilly, personal fees from Pfizer, personal fees from Novartis, personal fees from Astra-Zeneca and personal fees from Nanostring, outside the submitted work. C.S. reports personal fees from Boehringer Ingelheim, personal fees from Eli Lilley and Company and personal fees from Chugai, outside the submitted work. The remaining authors declare no competing interests.
This work was supported by the NIHR Cancer and Nutrition Collaboration. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care Funding. R.M.M. is supported by a Cancer Research UK programme grant (C18281/A19169) and by the National Institute for Health Research (NIHR) Bristol Biomedical Research Centre. The National Institute for Health Research (NIHR) Bristol Biomedical Research Centre is funded by the National Institute for Health Research and is a partnership between University Hospitals Bristol NHS Trust and the University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. A.G.R. is supported by the Manchester NIHR Biomedical Research Centre (IS-BRC-1215-20007). C.S. is partly funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London.
Note This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The Population Health Stream exists to promote research on key nutrition-related factors in the primary and secondary prevention of cancer. These are; diet and nutrition, alcohol, physical activity and obesity. In calling for more research, the group is addressing an urgent need for more effective cancer prevention strategies and interventions. We do not assign any judgement or stigma to any groups or individuals on the basis of their lifestyle.
Members of the UK NIHR Cancer and Nutrition Collaboration (Population Health Stream) are listed above Acknowledgements.
These members were involved in work stream discussions but were not involved with the drafting of the publication: Rebecca Beeken, Giota Mitrou.
About this article
Cite this article
Anderson, A.S., Martin, R.M., Renehan, A.G. et al. Cancer survivorship, excess body fatness and weight-loss intervention—where are we in 2020?. Br J Cancer 124, 1057–1065 (2021). https://doi.org/10.1038/s41416-020-01155-2