CUP-Global-breast-report-0924

Diet, nutrition, physical activity and body
weight for people living with and beyond

breast cancer
The latest evidence, our guidance for patients, carers and
health professionals, and recommendations for future research
Table of contents
Introduction 3
World Cancer Research Fund Network 4
Global Cancer Update Programme 5
Executive Summary 8
Background 12
Incidence and survival from breast cancer 12
Our previous work and recommendations 13
About this report 14
Using evidence to develop guidance and recommendations 16
Summary of steps taken 16
Gathering evidence through systematic reviews carried out by CUP Global team at
Imperial College London (step 1) 17
Evidence judged by the CUP Global panel (step 2) 20
Recommendations for future research (step 3) 22
Development of guidance and recommendations with input from panel, cancer survivors
expert committee and users (step 4) 28
Our recommendations and guidance for those living with and beyond breast cancer 30
Our existing WCRF/AICR recommendations for cancer prevention 30
Physical activity 31
Dietary fibre 33
Soy foods 34
Body weight 35
Vitamin D supplements 36
Acknowledgments 37
References 40
Appendices 42
Appendix 1: WCRF/AICR Cancer Prevention Recommendations 42
Appendix 2: Selection of forest plots illustrating findings from systematic reviews 43
Appendix 3: Summary of grading criteria 47
Appendix 4: Summary of panel conclusions 48
Appendix 5: User input 49
Citation: World Cancer Research Fund International. Diet, nutrition, physical activity and body weight for people living
with and beyond breast cancer. The latest evidence, our guidance for patients, carers and health professionals, and
recommendations for future research. 2024. Available at: https://www.wcrf.org/diet-activity-and-cancer/global-cancer-
update-programme/cancer-survivors/
2 Diet, nutrition, physical activity and body weight for people living with and beyond breast cancer
Introduction
This report:
Outlines the prevalence of breast cancer and the growing population of people

surviving breast cancer
Describes how we are developing guidance and recommendations in the Global


Cancer Update Programme, including how we have incorporated input from
health professionals and patients
Reports the current evidence relating to the impact of diet, nutrition, physical

activity and body weight on outcomes after a breast cancer diagnosis
Reports the Global Cancer Update Programme expert panel judgements on the

evidence in those living with and beyond breast cancer
Discusses research gaps and recommendations for future research


Presents guidance and makes recommendations for those living with and beyond

breast cancer
This report focuses on those living with and beyond breast cancer, we have produced an
accompanying report with guidance for those living with and beyond colorectal cancer.
World Cancer Research Fund network
OUR VISION
Our vision is a world where no one develops a preventable cancer, and people living with
and beyond cancer are enabled to live longer, healthier lives.
OUR MISSION
We champion the latest and most authoritative scientific research from around the world on
cancer prevention and survival through diet, weight and physical activity, so that we can
help people make informed lifestyle choices to reduce their cancer risk.
OUR NETWORK
As an international network of charities, we’ve been funding life-saving research into cancer
prevention and survival, influencing global healthcare policy, and educating the public since
1982. WCRF Network comprises: American Institute for Cancer Research (AICR) in the US,
Wereld Kanker Onderzoek Fonds (WKOF) in the Netherlands, World Cancer Research Fund
(WCRF) in the UK and a presence in Asia with a science ambassador based in Hong Kong.
Together, we help people worldwide live longer, healthier lives, free from the devastating
effects of cancer.
Global Cancer Update Programme
The Global Cancer Update Programme (CUP Global) analyses global research on how diet,
nutrition, physical activity and body weight affect cancer risk and survival. It is produced by
World Cancer Research Fund International (WCRF International) in partnership with American
Institute for Cancer Research (AICR), World Cancer Research Fund in the UK (WCRF) and
Wereld Kanker Onderzoek Fonds (WKOF) in the Netherlands.
This report is from WCRF International’s CUP Global - the world’s largest source of scientific
research on cancer prevention and survivorship focused upon analysing the evidence related to
diet, nutrition, physical activity and body weight. The research in this report builds on the 2014
(updated 2018) report Diet, nutrition, physical activity and breast cancer survivors which was
published as part of the Third Expert Report produced by WCRF/ AICR titled Diet, Nutrition,
Physical Activity and Cancer: a Global Perspective [1].
Many world-renowned experts contribute to CUP Global. An expert panel evaluates the strength
of the evidence from systematic reviews, develops guidance and recommendations, makes
recommendations for future research and provides input on the direction of the work. Topic-
specific expertise for key areas of work is provided via expert committees; of particular relevance
to the current report is the cancer survivors expert committee. Additional expertise is provided
via formal observers to the panel, representing key organisations in the field (World Health
Organization, International Agency for Research on Cancer, National Cancer Institute
and Union for International Cancer Control). See page 37 for a full list of contributors to the work
in this report.
Key aims of CUP Global
The transition period in 2020/21 enabled WCRF International to develop 7 key aims for
the new programme of research under the new name of the Global Cancer Update Programme
(CUP Global):
Development of population or disease-specific guidance and recommendations –

for specific stages of life (eg children, young adults, older adults), specific
populations (eg childhood and adult cancer survivors) and specific cancer
subtypes (eg ER, PR positive and triple-negative breast cancer, Lynch syndrome,
cancers with a genetic component vs sporadic).
Clarification of existing knowledge to develop greater understanding of cancer

prevention and survivorship – eg the role and impact of specific dietary patterns,
the biological mechanisms that cause or prevent cancer.
Efficient and targeted approaches and keeping the evidence current –

eg through the application of automated approaches and analytical tools, and
the use of a dedicated scanning exercise and data prioritisation (including rapid
reviews) to target or trigger an evidence update.
Collaborations and input from experts and external stakeholders – utilising

experts from across the world, as well as continuing to work in collaboration
with the research team at Imperial College London.
Varied and targeted outputs – to enable greater reach and scope within
the scientific community (through academic papers), as well as targeted
communications for other audiences (including dissemination events).
Globally representative research – most epidemiological studies are conducted

in high-income countries, such as those in Europe, the US and Australia, with
limited or no data from other countries, especially low- and middle-income
countries. Cancer incidence and prevalence vary considerably according to
geographical region, making the case for future CUP Global studies to address
the limited data from low- and middle-income countries.
Strong public involvement – we recognise the importance of user involvement

at all stages of the work, from identifying research priorities, promoting
involvement in funded research and selecting successful research funding
applications, to making recommendations and disseminating findings.
Areas of research focus in CUP Global
The current work is organised into 4 areas: cancer incidence, cancer survivors, cancer mechanisms
and obesity. The mechanisms work supports the cancer incidence and survivors work through
developing a clearer understanding of the biological processes that underpin associations
between diet, nutrition, physical activity, body weight and cancer. This current report is part of
the cancer survivors work area, with the systematic reviews conducted by the CUP Global team
at Imperial College London.
Overview of the Global Cancer Update Programme

Mechanisms research feeds into cancer incidence and survivors work
CANCER CANCER CANCER OBESITY

SURVIVORS MECHANISMS
Data prioritisation/ Data Molecular Literature

scanning exercise prioritisation/ epidemiology scanning of
for updating scanning exercise obesity risk
Biomarker data
systematic reviews for updating factors in early
systematic reviews Genetics and life into adulthood
Cancer subtypes
omics
Colorectal cancer Dietary and
survivors Animal studies lifestyle patterns
COLLABORATION Childhood cancer Expansion into
PROJECTS: survivors novel areas
 L ifecourse exposures
and cancer (colorectal, Prostate cancer
breast and prostate survivors COLLABORATION WORK PRIMARILY
cancer) WITH INTERNATIONAL UNDERTAKEN BY WCRF
 D ietary patterns AGENCY FOR RESEARCH INTERNATIONAL,
and breast cancer ON CANCER ALONGSIDE EXTERNAL
 D ietary patterns and RAPID REVIEWS
colorectal cancer
IMPERIAL COLLEGE LONDON CUP GLOBAL TEAM

(overseeing or undertaking work)
Executive summary
Background Aims of this report
Breast cancer is the most common cancer in This report summarises the latest research
women and the second most common cancer on diet, nutrition, physical activity and body
overall, accounting for 1 in 9 (11.6%) new weight for people living with and beyond breast
cancer cases worldwide in 2022. At the same cancer. It also presents guidance for patients
time, progress in early detection and treatment and recommendations for future research. This
has significantly increased the number of years information can be used to develop materials for
lived after a diagnosis. Survival rates differ those responsible for the care of patients and
between countries, but worldwide there are patients themselves. We intend for this work
an estimated 7.8 million women who have to supplement our existing Cancer Prevention
survived at least 5 years after a diagnosis of Recommendations. Whilst we recommend that
breast cancer. There is increasing demand for people living with and beyond cancer follow
reliable, evidence-based guidance on diet and these as much as they can, they were not
physical activity from health professionals and specifically developed for this group. Our new
people living with and beyond cancer. guidance adds to these recommendations by
highlighting specific behaviours which evidence
This report is from World Cancer Research suggests may be beneficial for people living
Fund International’s Global Cancer Update with and beyond breast cancer.
Programme (CUP Global) - the world’s
largest source of scientific research on cancer The evidence underpinning this report
prevention and survivorship through diet,
nutrition, physical activity and body weight. The Global Cancer Update Programme
The research in this report builds on the 2014 research team at Imperial College London
(updated 2018) report Diet, nutrition, physical carried out a comprehensive analysis
activity and breast cancer survivors which was investigating the extent to which certain
published as part of the Third Expert Report modifiable risk factors impact mortality
produced by WCRF/ AICR on Diet, Nutrition, (cancer-specific and all-cause), risk of cancer
Physical Activity and Cancer: a Global recurrence and health-related quality of life in
Perspective. At that time, research on cancer women after a breast cancer diagnosis. Four
survival was limited, but there was enough systematic reviews were carried out. Review
evidence to conclude that people living with 1 analysed data from 108 studies on diet and
and beyond cancer should follow our Cancer breast cancer outcomes and there were 2
Prevention Recommendations. These outline reviews on physical activity (the first included
an integrated pattern of behaviours that 20 studies on breast cancer outcomes and the
the evidence consistently shows is linked to second included 79 studies on health-related
reduced cancer risk. quality of life outcomes). The fourth review
focused on body weight and breast cancer
The increasing recognition of the importance outcomes and included 225 studies.
of diet, nutrition, physical activity and body
weight in cancer survival provides the rationale
for the current work.
An independent panel of experts graded the Recommendations for future research
strength of the evidence from each review
using WCRF International's pre-determined WCRF International, our panel of experts
criteria to give a final evidence judgement for and the cancer survivors expert committee
each exposure. are continually discussing how the evidence
base within survivorship research can be
The panel judged the strength of much of strengthened. We have agreed upon several
the evidence as 'limited' which hampered key areas:
the expert panel's ability to develop
 ell-designed clinical trials and
W
recommendations. Despite this, we consider it
prospective cohorts are needed. These
important that people living with and beyond
studies should account for differences in
cancer can access reliable information based
cancer sub-types, treatment types and
on the latest evidence that has been judged by
other patient characteristics.
our expert panel. The recommendations and
guidance described here have been developed
 tudies should aim to use the most
S
using a robust and transparent process,
accurate methods possible for assessing
incorporating input from expert clinicians and
diet, nutrition, physical activity and body
scientists, along with user input from health
weight within populations living with
professionals and patients.
and beyond cancer. They should include
As an evidence-based organisation, we have more accurate reporting of the timing of
used the best available evidence to develop exposures.
this process and produce practical guidance
on diet, physical activity and body weight for  ovel methods for understanding the
N
people living with and beyond breast cancer. biological processes and mechanisms that
underpin the associations we find in our
cancer survivorship research are much
needed.
 esearch should aim to study more diverse

R
populations.
By highlighting gaps in the evidence base,

current research enables us to look to the
future with insights on where further (high
quality) research is needed. Observational
studies can also help to identify promising
exposures for testing in randomised-controlled
trials. This allows us to develop new areas
of investigation, with the aim of future new
findings being used to develop specific
recommendations for this group and to
further confirm the benefits of following our
recommendations and guidance.
Recommendations and guidance
for people living with and beyond
breast cancer
The below recommendations and guidance
have been developed using the best available
evidence and consultation with experts in the
field and individuals living with and beyond
breast cancer.
Evidence comes from the 4 systematic reviews

described in the full report, along with previous
evidence reviewed for the Third Expert Report Please note: We recommend that
which led to the development of WCRF/AICR’s individuals living with and beyond
Cancer Prevention Recommendations. cancer speak to their healthcare team
before making any changes related
to diet, nutrition, physical activity
or body weight. Any healthcare
professionals using this guidance
should consider where a patient is in
their cancer journey and interpret the
guidance appropriately to suit each
person’s individual needs.
Summary of our recommendations and guidance for for those living with
and beyond breast cancer
EVIDENCE RECOMMENDATIONS/GUIDANCE
OUR
General guidance
CANCER PREVENTION
RECOMMENDATIONS
WCRF/AICR’s recommendations
for cancer prevention
Nutritional factors and physical activity appear We suggest that people consider
to predict outcomes in people living with beyond following as many of WCRF/AICR’s
cancer, but there is insufficient evidence that cancer prevention recommendations
changing these improves outcomes. as they are able to.
New specific recommendation on
physical activity
Physical activity
Increasing physical activity improves health-related We recommend that people are
quality of life after a diagnosis of breast cancer. People physically active. However, physical
who are more physically active have better health activity should be increased under
outcomes, but it is uncertain whether increasing the supervision of health care
physical activity will improve health outcomes. professionals.
New specific guidance on diet and
body weight
Diet
Dietary fibre
People who eat more dietary fibre have better health We suggest that people consider
outcomes after a diagnosis of breast cancer. But it is increasing their dietary fibre intake.
uncertain that increasing dietary fibre improves these
outcomes.
Soy
There is limited evidence suggesting that people The current evidence does not support
who eat more soy foods have better health outcomes guidance to consume more soy foods
after a diagnosis of breast cancer. There have (or to introduce soy foods if these are
previously been concerns over soy foods increasing not currently part of the diet) after a
the risk of developing breast cancer, but systematic diagnosis of breast cancer, but for
reviews show no consistent evidence of a link those who already consume them,
between soy foods and breast cancer risk.
there is no need to stop.
Vitamin D
This review found limited evidence suggesting that
those with higher vitamin D status have better health
outcomes after a diagnosis of breast cancer, but We are not making specific guidance
there was no evidence of any benefit from vitamin D about vitamin D supplements to
supplements. improve outcomes after a breast
cancer diagnosis.
Body weight
Those with body weight in the ‘healthy range’ after
a diagnosis of breast cancer have the best health We suggest that people who are not
outcomes. But it is uncertain that deliberate weight underweight aim to avoid gaining
loss by people with overweight or obesity improves weight during and after treatment.
these outcomes.
Recommendations are based on strong evidence.

Guidance is based on evidence graded as ‘limited suggestive’. Limitations in the evidence meant that the panel could not
be confident that associations were causal, so we cannot be sure that changing the exposures would change the outcomes.
Despite the limitations in the evidence, this represents the best advice based on the current evidence and expert opinion.
Outcomes are health outcomes (including all-cause mortality and cancer outcomes) and health-related quality of life.
Background
Incidence and survival from breast cancer
The global burden of cancer is increasing due to a growing and aging population alongside
increases in risk factors, most notably obesity; other contributing risk factors include smoking,
physical inactivity and unhealthy dietary patterns [2]. In recent decades, progress in the early
detection and treatment of cancer has led to a dramatic increase in the number of people
living with and beyond cancer (LWBC). In addition, therapeutic control of tumour growth and
progression in patients with recurrent disease has led to a diagnosis becoming a prolonged chronic
condition with a long lifespan and acceptable quality of life. Within this report, we define this
group as all people who have been diagnosed with cancer, including before, during and after
treatment [3].
Breast cancer is the most common cancer in women and the second most common type of cancer
overall, accounting for 1 in 9 (11.6%) new cancer cases worldwide in 2022 [4]. Survival rates
differ between countries, but worldwide there are an estimated 7.8 million women who have
survived at least five years after a diagnosis of breast cancer [5].
It is essential that the long-term health needs of people LWBC, beyond those directly related
to their cancer, be considered. Cancer prevention is a crucial component of the World Health
Organization’s (WHO) global target of a 25% reduction in deaths from cancer and other non-
communicable diseases (NCDs) in people aged 30 to 69 by 2025 [6]. However, achieving this
target (referred to as 25 x 25) requires the deployment of more effective health systems to
improve survival, alongside more effective prevention [7].
Research has historically focused on understanding exposures influencing cancer development.

Despite growing numbers of people LWBC, until recently there has been relatively little available
research focused on diet, nutrition, physical activity and body weight as levers for improving
post-diagnostic survival and quality of life. Although there has been a substantial growth in
research, the increase in people LWBC has resulted in greater demand for reliable, evidence-
based guidance for health professionals and people LWBC concerning diet, physical activity and
body weight. Our work with researchers, health professionals and patients has also highlighted
the need for more tailored advice for people LWBC. Numerous studies have explored the views
of people LWBC about their needs, preferences and experiences of accessing dietary information
(including weight-related information). Studies commonly show a preference for receiving
information directly from health-professionals, however, people also report that information can
be too generic and sometimes conflicting [8].
Our current report aims to help fill this gap by providing information based on the latest available
research.
Our previous work and recommendations
WCRF/AICR previously produced a set of Cancer Prevention Recommendations (see Appendix

1), based on evidence judgements made by a panel of independent experts and published in
2018 as part of The Third Expert Report Diet, Nutrition, Physical Activity and Cancer: a Global
Perspective [9]. The panel concluded that following these recommendations would ‘convincingly
or probably’ contribute to reducing cancer risk. These recommendations were based on evidence
for reducing the risk of developing cancer and did not specifically focus on studies including
patients following a cancer diagnosis.
The first report on cancer survivors was published in 2014; this examined literature linking diet,
nutrition, physical activity and body weight to survival and occurrence of new primary cancers in
people living with and beyond breast cancer [1]. At the time, the panel was unable to draw firm
conclusions on the effect of diet, nutrition, physical activity or body weight upon outcomes in this
group. The lack of evidence was especially apparent in relation to the reduction of mortality (from
breast cancer or any other cause) or risk of developing second primary breast cancer. However,
the panel agreed that the conclusions underpinning the Cancer Prevention Recommendations
were also likely to be relevant for people LWBC and recommended that, as far as possible, they
should aim to follow these recommendations once acute treatment had finished. In addition,
the panel judged that following these recommendations was unlikely to be harmful to people
LWBC who have completed treatment. However, the evidence was inadequate to make specific
recommendations for this group with confidence. The current work builds upon this and signals
an increasing focus for the WCRF Network in the cancer survivorship area.
About this report
Purpose of the report
This report brings together the findings from a series of new systematic reviews along
with interpretation of the evidence by our panel of experts. This has been used to develop
recommendations and guidance. The systematic reviews, carried out by the CUP Global team at
Imperial College London, examine how diet, nutrition, physical activity and body weight affect
survival and recurrence after a breast cancer diagnosis [10-13]. A further review examined how
physical activity affects health-related quality of life for women living with and beyond breast
cancer [14].
As the evidence base for people LWBC continues to develop, we hope to expand our guidance
to include information for different cancer types. Further to this, as the evidence base improves
in quality, we hope to develop cancer survival recommendations to accompany those we have for
cancer prevention.
Who the report is for

The information included in this report is aimed at those with an interest in improving the survival
and quality of life of people living with and beyond breast cancer. This group includes:
 ealthcare professionals involved in the clinical and supportive care of people living with and
H
beyond breast cancer at various stages of their cancer journey. This could be: oncologists;
surgeons; cancer nurse specialists; nurse practitioners; dietitians; physiotherapists; other
medical professionals; pharmacists; nutritionists and nutritional therapists; and any other
relevant healthcare professionals.
 Civil society, patient and charitable organisations (eg cancer charities).

 Researchers working in the areas of diet, nutrition, physical activity, body weight and cancer.

 Policymakers in public health settings.

 eople living with and beyond cancer. We will be developing resources specifically for patients
P
and their families, but these reports can be accessed by anyone wanting to read more about
the science underpinning the recommendations and guidance.
This report aims to inform:
 he development of appropriate public-facing outputs and resources for people living with and
T
beyond breast cancer including patients who have completed the acute phase of their cancer
treatment.
 he development of resources for healthcare professionals working with patients living with
T
and beyond breast cancer.
 ow the quality and interpretation of future research can be improved to make it more relevant
H
to the specific considerations of people LWBC.
 olicymakers about the strength and limitations of current evidence on diet, nutrition, physical
P
activity and body weight and key outcomes within this group.
Approach
WCRF International’s Global Cancer Update Programme (CUP Global) has a robust process
for reviewing and interpreting evidence to ensure that our recommendations and guidance
are supported by the best available research. Recommendations for the public are generally
developed from evidence judged as ‘strong’ by the independent expert panel. The literature
on how diet, nutrition, physical activity and body weight influence long-term health for people
LWBC is, despite growth in recent years, in its infancy compared with that for cancer incidence.
Researching the modifiable behaviours that might influence health-related outcomes among those
LWBC is also highly complex.
The term ‘cancer survivor’ (or ‘living with and beyond cancer’ (LWBC)) covers a wide variety of
circumstances beginning at diagnosis through cancer treatment to the end of life. In this report,
the term ‘living with and beyond cancer’ (LWBC) will be used. The definition LWBC here does not
include people living with a diagnosis of benign tumour or conditions defined as premalignant,
such as premalignant breast lesions. Using a single term to cover people LWBC to encompass
all of these stages cannot do justice to the heterogenous, complex and emotional reality of living
with cancer. Each stage of survivorship has its own particular characteristics, and the impact of
interventions or exposures, including those related to diet, nutrition, physical activity and body
weight, can vary considerably. The experience of LWBC also varies depending upon the site-
specific cancer diagnosed. That is why, when it comes to survival-related information, we are
producing guidance for individual cancers rather than cancer overall.
Despite the challenges, it is important that people LWBC can access sound information. Therefore,
along with recommendations for how future research can address these challenges, it is important
to maximise how the currently available evidence is used. The processes developed in CUP Global,
and described in this report, utilise the evidence as it currently stands through a robust transparent
process, incorporating input from expert clinicians and scientists, along with user input from health
professionals and patients. This enables us to provide people LWBC with information based on
the best available evidence while taking into account its limitations.
Using evidence to develop guidance
and recommendations
Summary of steps taken
1 2 3 4
DEVELOPMENT OF
GATHERING EVIDENCE RECOMMENDATIONS GUIDANCE AND
EVIDENCE THROUGH JUDGED FOR FUTURE RECOMMENDATIONS
SYSTEMATIC REVIEWS BY THE CUP RESEARCH WITH INPUT FROM
CARRIED OUT BY CUP GLOBAL PANEL PANEL, CANCER
GLOBAL TEAM AT SURVIVORS EXPERT
IMPERIAL COLLEGE COMMITTEE AND USERS
LONDON TEAM
RECOMMENDATIONS- typically developed using strong evidence

GUIDANCE- developed using less strong evidence with input from expert clinicians,
scientists and patients and their healthcare providers
Factors considered
 Is there potential patient benefit? (on cancer or other outcomes)
 Is there evidence of harm in this population?
 Are there specific population groups (eg age, sex, race and ethnicity, other

socio-demographic characteristics) or clinical populations (eg cancer subtype, treatment)
which need to be considered?
Taking into account the broader context, is there possible harm/ benefit for other health

outcomes or any environmental considerations?
 Does the current research allow for a degree of confidence?
 What is the likely impact of a recommendation/ guidance?
What we mean by ‘guidance’ and 'recommendations'

Guidance in this report refers to statements developed with input from experts (scientists, health
professionals and patients). This differs from clinical guidelines and our recommendations - which
we developed based around a strong evidence base. The current guidance is a way of providing
information for healthcare professionals and patients in areas where the evidence is less strong
based on the judgement criteria. However, it is noteworthy that a substantial body of evidence
was reviewed by the panel to be able to develop this guidance.
STEP 1
Gathering evidence through systematic reviews carried out by
CUP Global team at Imperial College London
Four systematic reviews were carried out by the CUP Global team at Imperial College London:
3 reviews examined the effect of post-diagnosis diet, physical activity and body weight on all-
cause mortality, breast and non-breast cancer-specific mortality, breast cancer recurrence and
second primary cancers (referred to here as ‘health outcomes’). A further review examined the
effect of physical activity on health-related quality of life outcomes.
The results from each review are summarised below; these are supported by a selection of forest
plots to illustrate the results, see Appendix 2, please refer to the papers to access all of the
results and forest plots.
Reviews on health outcomes
Published papers available here:

https://onlinelibrary.wiley.com/toc/10970215/2023/152/4
These studies focused on mortality and recurrence outcomes.
The protocol was developed by the research team at Imperial College London with input from the
Protocol Expertise Group. The peer reviewed protocol is available online [15].
PubMed and Embase databases were searched from inception to 31st October 2021. Relevant
exposures were any type of post-diagnosis physical activity, diet (food, food components,
nutrients, dietary patterns, supplements) and adiposity1 (body mass index (BMI), waist
circumference, waist-to-hip ratio, changes in weight or BMI). Randomised controlled trials (RCTs)
and observational longitudinal studies (or pooled analyses of individual data of these studies)
were included if they reported outcome data on all-cause mortality, breast and non-breast cancer-
specific mortality, breast cancer recurrence and/or second primary cancers. Most studies reported
all-cause mortality, breast cancer-specific mortality and/ or breast cancer recurrence, with more
limited data available for second primary cancers, non-breast cancer-specific mortality and
cardiovascular mortality.
1The term ‘body weight’ is used in this report hereafter as a simpler term for adiposity; it includes body mass index,
waist circumference, waist-to-hip ratio
Physical activity findings
A total of 23 studies were included in the review (20 observational studies and follow ups from
3 RCTs). These comprised more than 39,000 women with breast cancer, of whom approximately
5,000 died, including 2,000 who died from breast cancer.
Most studies looked at the effect of recreational physical activity such as aerobics, walking and
running, with limited data on other types of activity. Higher levels of recreational physical activity
were associated with a lower risk of all-cause mortality and breast cancer-specific mortality.
Diet findings
A total of 108 studies were included in the review (104 observational studies and 4 RCTs).
These comprised more than 151,000 women with breast cancer, of whom 14,900 died, including
5,900 who died of breast cancer.
Higher intake of soy foods was associated with lower all-cause mortality, breast cancer-specific
mortality and breast cancer recurrence; higher intake of dietary fibre was associated with lower
all-cause mortality only. Following certain healthier dietary and lifestyle patterns was associated
with lower all-cause mortality. Higher vitamin D status (measured by serum 25-hydroxyvitamin D,
25(OH)D) was associated with lower all-cause mortality and breast cancer-specific mortality.
The results were not conclusive for other dietary exposures, including fruit and vegetables;
wholegrains; meat, fish and eggs; milk and dairy products; carbohydrate, protein and fat; alcohol;
dietary supplements. Few studies were found which reported the effect of dietary change –
making it difficult to draw any conclusions from their results.
Body weight-related findings
A total of 226 studies were included in the review (225 observational studies and one RCT). These
comprised more than 456,000 women with breast cancer, 36,000 of whom died, including 21,000
who died from breast cancer.
In general, greater BMI, waist circumference and waist-to-hip ratio were associated with a higher
risk of adverse health outcomes. Few studies were found which reported the effect of BMI change
or weight change – making it difficult to draw any conclusions from their results.
Review on health-related quality of life
Published paper available here:

https://doi.org/10.1093/jncics/pkac072
The peer reviewed protocol is available online [16]. PubMed and CENTRAL databases were
searched from inception to 31st August 2019. Studies were included if they reported RCTs of
exercise and physical activity interventions before, after or during primary treatment. Primary
treatment included surgical treatment and/or (neo)adjuvant therapy (eg chemotherapy,
radiotherapy and/or hormonal therapy) in the acute phase only, the extended use of hormonal
therapy was excluded. Relevant outcomes were health-related quality of life (overall and its main
functional domains - physical, emotional, mental) measured using validated tools.
Findings
The review included approximately 14,500 women taking part in 79 trials (reported in 92
publications), mainly in North America and Europe. The results from most of these trials (59 out
of 92 publications) could be meta-analysed. Overall, the results showed that physical activity
improved health-related quality of life. This was seen for global quality of life and specific quality
of life domains (including physical and emotional functioning). The evidence was less clear on how
frequency and amount of physical activity made a difference to health-related quality of life. There
was some evidence that physical activity had a greater effect on health-related quality of life
when it was started after treatment had ended compared with during it.
STEP 2
Evidence judged by the CUP Global panel
An independent panel of experts, convened by WCRF international, graded the strength of the
evidence described above using pre-defined grading criteria (shown in Appendix 3 and [1]).
WCRF International’s grading criteria are designed to judge, for observational studies, whether
an association is causally linked to a particular health outcome, or, for RCTs, whether a specific
intervention affects the risk of developing specific health outcomes. The panel considered several
factors when judging the evidence, including: the amount of evidence; the consistency, magnitude
and precision of the summary estimates; whether there was a dose-response relationship; study
design and risk of bias; generalisability; the presence of biological plausibility and mechanisms.
The evidence levels used within the grading criteria were 'strong’ (either ‘convincing’ or 'probable')
or ‘limited’ (either ‘suggestive’ or ‘no conclusion’), with an additional ‘strong’ grading of ‘substantial
effect on risk unlikely’ where there is strong evidence that the exposure does not affect the risk of
an outcome.
Summary of panel judgements of evidence
The panel made the following judgements based on the evidence from the systematic reviews in
relation to medical outcomes and health-related quality of life in people living with and beyond
breast cancer (see Appendix 4 for a summary of the evidence judgements).
Physical activity
 There was strong evidence (probable causality) that interventions for increasing physical

activity result in improved health-related quality of life.
 There was insufficient evidence to draw conclusions on specific domains of quality of life

(eg physical or emotional functioning or well-being) that may benefit from physical activity,
or the types and doses of activity required for improving quality of life.
 igher levels of recreational physical activity after diagnosis were associated with a
H
lower risk of death overall and from breast cancer. The evidence was judged as limited
(suggestive) because the panel could not be sure of the direction of these associations.
Diet
 There was limited (suggestive) evidence that higher consumption of soy foods (isoflavones

and soy protein) reduces the risk of all-cause mortality, breast cancer mortality and breast
cancer recurrence.
 here was limited (suggestive) evidence that higher consumption of dietary fibre reduces
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the risk of all-cause mortality.
 here was limited (suggestive) evidence that greater serum vitamin D [25(OH)D] reduces
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the risk of all-cause mortality and breast cancer mortality. Relevant here is that the evidence
for vitamin D supplements impacting all-cause mortality, breast cancer mortality and breast
cancer recurrence was limited (no conclusion).
 T
here was limited (suggestive) evidence that following certain healthy dietary and lifestyle
patterns reduces the risk of all-cause mortality and other causes of death.
Body weight
 There was strong evidence (probable) that greater body weight (measured by body mass

index, waist circumference, waist-to-hip ratio) increases the risk of all-cause mortality and
breast cancer specific mortality, and that higher body mass index also increases the risk of a
second primary breast cancer.
 here was limited (suggestive) evidence that greater body weight (measured by body mass
T
index, waist circumference, waist-to-hip ratio) increases the risk of breast cancer recurrence,
and that increased body mass index also increases the risk of non-breast cancer specific
mortality and cardiovascular disease mortality.
STEP
Recommendations for future research
3
The work of the CUP Global panel in judging the evidence from these reviews highlighted a number
of limitations that should be addressed in future research. In particular, it was agreed that there
is a need not just for more research but also improved methodologies, so that future research can
address these limitations. In other words, more of the same types of data or studies are unlikely to
strengthen our understanding of the influence of modifiable behaviours related to diet, nutrition,
physical activity and body weight on outcomes for people LWBC. Improved research would allow
for stronger evidence conclusions, which could then be turned into information for the public. This
work will help the WCRF Network to support those LWBC to live healthier and longer lives.
In addition, research that can more clearly define the potential health and economic benefits from
intervening to improve diet, nutrition, physical activity and body weight in those LWBC may help to
achieve greater buy-in from key decision makers.
It is also important that health professionals, researchers, policy makers and other relevant
stakeholders are aware of the limitations of current research when offering advice or making
decisions that may impact the long-term health of those LWBC.
The key issues that future research should aim to address include:
 C
onducting well-designed clinical trials and prospective cohorts that account for differences
in cancer sub-types (eg ER+ vs ER- breast cancer), timing and types of treatment (eg surgery,
medication), and other patient characteristics (eg co-morbidities, age, race, ethnicity). These
factors should be accurately reported.
 sing more accurate methods to assess ‘usual’ pre-diagnosis dietary intake, physical activity
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and body weight, with more accurate reporting of the timing of exposures, and accurate
measurement of potential confounding factors.
 roviding further information on the biological pathways that may explain the relationships
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between diet, nutrition, physical activity, body weight and cancer/non-cancer outcomes.
Increasing diversity and inclusivity of study populations and accurate characterisation of samples.

The above key issues are outlined in more detail in the table below, along with potential
solutions. While many of these issues are generally applicable to research on diet, nutrition,
physical activity and body weight involving those LWBC, where there are specific considerations
for breast cancer these are noted.
It is also important to note that despite limitations, observational studies can help to
identify promising exposures for testing in more robust study designs (eg appropriately
conducted RCTs).
Research recommendations
RESEARCH CONSIDERATION Reverse causation

ISSUES AND POTENTIAL SOLUTIONS
The observational design of many studies on diet, physical activity and body weight makes it
difficult to exclude the possibility of reverse causation. The disease and treatments received
may affect a patient’s dietary choices and ability to do physical activity, while their dietary
and physical activity choices may also affect disease outcomes. Reverse causality is also a
particular issue when interpreting associations between body weight and survival outcomes,
and it is challenging to disentangle intentional and unintentional weight loss. This is an
inherent problem for observational studies in cancer survivorship populations.
Future research could attempt to address this through:

 ell-conducted intervention studies where the impact of specific diet, physical activity
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and/or weight management interventions on survival or other outcomes is the primary
research question. However, such studies can be costly and challenging to conduct.
 ore accurate reporting of the timing of exposures in studies (eg before, during and/or
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after treatment) and/or analyses of existing studies that account for treatment timing.
 easuring body weight both pre- and post-diagnosis will enable better exploration of
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these associations. Collecting and reporting pre-diagnosis body weight data is challenging
but is possible in cohort studies. However, depending on the type of cancer and treatment
pathway, this may introduce bias.
 ethods for better understanding the impact of treatment on modifiable risk factors
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as well as outcomes should be considered. This includes how treatment might result
in changes in diet, physical activity levels and body weight, as well as quality of life,
morbidity and mortality.
 tage of disease at diagnosis has a clear impact on outcomes, for example, whether the
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cancer is metastatic or has already impacted health (eg cachexia), by impacting behaviour
and affecting treatment options and effectiveness. Future studies need to develop better
ways of collecting stage data and including it within analysis.
RESEARCH CONSIDERATION Residual confounding
It is rarely possible to control for all factors that may affect the outcome of interest in cohort
studies. Treatment-related factors may interact with behaviours (eg by changing the way
that a person eats or the energy they have for recreational exercise) and make interpretation
complicated. In addition, the presence of other co-morbidities among people with cancer, such
as cardiovascular disease or type 2 diabetes, may also impact exposures
and outcomes of interest.
Future research should consider how to better account for confounding factors.
Suggestions for how future research could attempt to address this include:
 ccurate reporting of disease state, presentation of disease, disease stage, treatment
A
factors (treatment mode, completion, dose) and any co-morbidities.
 Accurate reporting and appropriate adjustment for confounders, including information on

timing of confounders in relation to exposure and outcome of interest.
 Studies often use recalled data – this can introduce bias – novel ways of more accurately

recording such data could be considered.
 The use of longitudinal data has the potential to overcome some of the limitations of

current studies.
 Consideration of the impact of other factors on outcomes, including patient genetic cancer

risk, as well as broader social determinants of health (eg socio-economic status, race and
ethnicity).
 Consideration of whether some confounders also act as effect modifiers.

 Appropriate sample sizes to offer sufficient study power to account for confounders.

Breast cancer specific considerations:

Better reporting within studies of breast cancer survivors would aid interpretation of studies,
including specific information on:
- Biological subtype of tumour

- Treatment-induced menopause
-
Type of treatment including hormonal therapy
-
Invasive vs non-invasive breast cancer
RESEARCH CONSIDERATION Time-varying impacts

There is a growing body of evidence demonstrating that the impact of a risk factor upon a
health outcome changes over time and across the lifecourse. Considering this in future studies
will allow for better understanding of potentially dynamic associations.
Repeated dietary, nutritional, physical activity or body weight assessments can account for
changes in the exposure over time or changes in behaviour after diagnosis (eg cutting out
unhealthy foods). This is important because a single measure post-diagnosis is unlikely to
accurately capture ‘usual’ behaviour pre-diagnosis.
RESEARCH CONSIDERATION Indirect effects
Some risk factors, such as body weight, may adversely affect outcomes by limiting the
treatment options available to a patient. They may also alter the efficacy of treatment. For
instance, breast cancer patients living with obesity experience more complications related to
surgery, radiation and chemotherapy, resulting in worse outcomes.
One solution to overcome this may be to conduct trials in patients where more in-depth
and repeated information on these factors is available. For example, there is potential to look
at computed tomography (CT) derived body composition measurements in studies of
metastatic cancer where patients have regular CTs.
RESEARCH CONSIDERATION More accurate data on diet, nutrition, physical activity and body weight
Despite there now being large amounts of data collected related to cancer survival, the
quality of published research in this area does not allow for strong conclusions to be drawn.
Future studies should consider improving the quality and accuracy of the patient data they
collect. Best practice and quality assurance within the research field could be considered.
For example:
 Ensuring that validated questionnaires (eg food frequency questionnaires) are used to

collect dietary components. Dietary components also need to be appropriately defined to
avoid misclassification. The development of online data collection software enables data to
be collected more easily in large samples and should be considered.
 O
bjective measures of physical activity (eg accelerometery) should be considered to
better capture the amount, intensity and type of activity, and any changes in patterns of
activity over time.
 Most studies use BMI as a measure of adiposity, but this does not distinguish between lean

body mass and fat mass and does not provide information about fat distribution. Future
studies should consider collecting more detailed information on this in addition to BMI.
RESEARCH CONSIDERATION Study cohorts specific to cancer survivorship

Existing data are largely from cohorts not specifically designed to look at cancer survivorship
but rather incidence. The level of information about exposures and other details of
participants may therefore be insufficient to fully assess the impact of modifiable risk factors
upon survivor-specific outcomes.
There are also different patterns of cancer recurrence based on the type of cancer (the
‘natural history’ of the disease) that can affect study outcomes. This should be considered in
the study design.
Initiatives for establishing cancer survivor cohorts, to increase size and study power, have
been discussed and some are currently underway. Given the increasing size of survivor
populations – the inclusion of people LWBC in studies should be seen as a priority.
RESEARCH CONSIDERATION Increased diversity and inclusivity within research
Research should aim to study more diverse populations as published research currently tends
to focus on populations from countries in Europe, North America and China.
More inclusive and representative study populations are needed, including greater diversity in
terms of geography, race and ethnicity, socio-economic status and other factors known to
impact long-term health and life expectancy.
There is also a growing body of evidence that diverse research teams are better able to
understand and overcome challenges within their work. Research organisations should
consider the diversity of their research teams – and seek out diverse ways of thinking about
research focused upon cancer survivorship.
RESEARCH CONSIDERATION More accurate characterisations of study populations
Cancer patients represent a diverse group of individuals. Study populations should be well-
characterised. This will help to improve the quality of the available data and the accuracy of
study outcomes. Studies should better define and report on their study populations, including:
 Cancer sub-types
 otential influence of disease-specific factors, such as treatment type, stage
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(eg metastatic vs early-stage), time since diagnosis
 ocio-demographic determinants (eg age, sex, race and ethnicity, socio-economic factors,
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menopausal status).
RESEARCH CONSIDERATION Improved understanding of underlying mechanisms
Increased knowledge of the potential biological pathways underpinning the associations

between exposures and outcomes seen in epidemiological studies would improve our
understanding of causality. This is an active area of work within CUP Global.
For example, there are multiple mechanisms that underpin the associations between
physical activity and cancer progression. These include the role of sex hormones, metabolic
dysregulation, inflammation, immune function, oxidative stress and genetic mutations. It
remains unclear if physical activity influences these pathways independently or if it exerts its
action via reductions in adipose tissue.
Breast cancer specific considerations:

Weight gain during and after breast cancer treatment is common. Changes in body
composition, such as increased fat mass or lean tissue atrophy, can increase the risk of
co-morbidities, such as cardiovascular disease or type 2 diabetes, which consequently may
influence survival.
RESEARCH CONSIDERATION More multi-disciplinary research collaborations

There is a clear need for more collaboration between specialists so that expertise on cancer,
diet, nutrition, physical activity and body weight can be brought together more effectively. As
our understanding of biological mechanisms increases and becomes more complex – research
teams will likely benefit from the inclusions of experts in this field.
Multidisciplinary teams and projects would help to address some of the key issues with the
current research discussed here.
STEP 4
Development of guidance and recommendations with input
from the panel, cancer survivors expert committee and users
WCRF International worked with the CUP Global panel and cancer survivors expert committee
in 2023 to develop a process for producing guidance. The guidance presented in this document is
based on evidence judged by the panel to be at least ‘limited suggestive’. Oncology experts from
the panel and expert committee provided direction on which evidence gradings were suitable for
developing into guidance.
User input
Input from individuals living with and beyond breast cancer
When developing this report, we recognised the importance of getting input from those who would
be directly using the public-facing information produced from it. This included those living with
and beyond breast cancer and the health professionals who will be communicating and relaying
the guidance to them. Involving direct users in the development of the guidance is important for
enhancing patient care as it allows them to identify patient-focused issues and ensures it most
closely matches their lived experience.
We recruited 8 people living with and beyond breast cancer to contribute, interviewees were
identified using People in Research (NIHR) and Breast Cancer Now. Some of the interviewees had
previous experience in reviewing patient materials through their work with other organisations,
though for others, this was their first time doing such a review. Before the interview, each
participant was sent a draft example of patient facing material which was intended to communicate
our guidance. The interviewees were asked 2 sets of questions: one set on their experiences of
accessing advice on health information (specifically around diet and physical activity) since their
diagnosis, and the other more specifically on our guidance. Their feedback was used to develop
the guidance within this report and will be used further by the WCRF Network when developing
public-facing outputs based on this guidance.
They also gave feedback on the layout, highlighting
the need for a clearer structure with greater use of
bullet points. Multiple interviewees stressed the
need for accessible and conversational language
which was direct but also empowered the reader
to take control of potential changes in behaviour.
Several interviewees also suggested including
examples of how others have incorporated the
guidance into their lives and that these case studies
should come from a range of backgrounds to bring
the guidance to life and ensure inclusiveness.
Appendix 5 summarises their feedback and outlines
how it has been incorporated into the guidance.
Input from health professionals:
In our ongoing conversations with healthcare professionals, it is clear that there is an unmet
need for cancer-specific information about what those LWBC can do to improve their health and
potentially outcomes. With this in mind, we sought input from healthcare professionals – firstly,
about the need for our new guidance and, secondly, how they might use it.
We received feedback from clinical cancer nurse specialists and cancer dieticians, both in the
UK and US, on a draft example of the information that we could provide them to support their
conversations with patients LWBC. As a result of their feedback, the document was restructured
for clarity. They further highlighted the importance of the “strong” evidence gradings on health-
related quality of life and physical activity, and wanted to ensure that this was addressed
separately from the rest of the guidance. They also noted that stronger evidence should come
before limited evidence in information for the public.
Based on suggestions from the healthcare professionals reviewing the document, the wording
around the recommendations/guidance for soy foods was revised. This ensured that patients
would fully understand that soy consumed should be high in isoflavones and minimally processed.
Clarity was added to the explanation of soy foods, as well as the need to choose unsweetened,
fortified soya-based dairy alternatives.
Within our conversations with individuals LWBC and healthcare professionals it was noted that
it would be useful to link to information that was already available. Therefore, references to other
organisations, where possible, were included – for example, the WHO recommendations on the
amount of physical activity required to confer a health benefit.
The reviewers, especially those not based in the UK, provided feedback on the need for language
to be inclusive and have a consideration of global audiences. We will carefully consider this when
we are developing public-facing outputs based on the current guidance.
Our recommendations and guidance for those living
with and beyond breast cancer
Current evidence, as well as our recommendations and guidance for those living with and beyond
breast cancer are provided below, these reflect the strength of the scientific evidence and expert
opinion. Additional information on specific considerations for interpreting the recommendations
and guidance statements is also provided. It is important that changes to diet, nutrition, physical
activity and body weight are discussed with a healthcare professional, as appropriate.
Much of the evidence on which the guidance in this report is based comes from observational
studies rather than intervention studies. This means that any associations found cannot
confidently be assumed to be causal, for instance because of confounding or reverse causation.
So, even if people who are found to experience a particular diet, physical activity or body weight
exposure have better outcomes, if the exposure is not causal, then changing it cannot be assumed
to change the outcome. This problem is a main reason why the evidence is regarded as weak and
this guidance is less secure than our firm recommendations. Nevertheless it represents the best
advice, based on current evidence and expert opinion.
In developing the guidance, we include a description of the association between the exposure
(eg diet) and health outcomes, followed by a brief outline of our guidance. For each guidance
statement, we have provided a supporting summary statement of the evidence grading.
These recommendations and guidance are based on the evidence described in this
report; there is evidence for health-related quality of life, with other outcomes referred
to collectively as ‘health outcomes’. See steps 1 and 2 for information about the specific
health outcomes.
Our existing WCRF/AICR recommendations for cancer prevention

WCRF/AICR have previously developed a set of 10 cancer prevention recommendations, these
include following a healthy diet, being physically active and maintaining a healthy body weight.
These are based on decades of research and many studies have now shown that following them
reduces the risk of developing cancer, as well as reducing the risk of other chronic diseases [9].
One of these recommendations is that people LWBC follow the cancer prevention
recommendations as much as possible (see Appendix 1). This recommendation was made by
the expert panel, as part of the Third Expert Report, based on the best available evidence at the
time. The panel made this recommendation with caution because, although nutritional factors and
physical activity appear to predict outcomes in people LWBC, there was insufficient evidence that
changing these improves outcomes for this group.
Guidance statement:
People who follow WCRF/AICR’s Cancer Prevention Recommendations are predicted to
have better outcomes after a breast cancer diagnosis.
We suggest that people consider following as many of these recommendations as they
are able to.
The findings from the reviews described in this report (that healthy dietary and lifestyle patterns
are associated with a lower risk of all-cause and non-breast cancer mortality) are consistent with
this guidance.
In addition to this general guidance, we have used the more recent evidence from the current
reviews to develop guidance and a recommendation specifically for people living with and beyond
breast cancer. These are outlined below.
Physical activity
There is strong evidence that increasing physical activity after a diagnosis of breast cancer
improves health-related quality of life. It was not possible to assess which types of physical
activity were most beneficial or whether there was an optimal amount of physical activity for
quality of life. However, there is little evidence that physical activity would cause increased harm
in this group compared with the general population (eg injury from physical activity).
There is also limited evidence suggesting that higher levels of recreational physical activity might
improve health outcomes.
Recommendation:
Increasing physical activity improves health-related quality of life after a diagnosis of
breast cancer.
People who are more physically active have better health outcomes after a diagnosis of
breast cancer, but it is uncertain whether increasing physical activity will improve these
outcomes
We recommend that people are physically active. However, physical activity should be
increased under the supervision of health care professionals.
There are numerous wider benefits of regular physical activity [17], including:
 educing the risk of developing other

R
conditions, such as cardiovascular disease
and type 2 diabetes
 Helping maintain a healthy body weight
 Reducing the risk of depression and anxiety
 R
educing the risk of falls, as well as hip and
vertebral fractures, in older adults
 Helping improve sleep and cognitive health
 Helping keep joints and muscles healthy
Additional information:
International guidelines on physical activity from the World Health Organization (WHO)
[17] recommend that adults (aged 19 to 64 years):
 Should do at least 150–300 minutes of moderate-intensity aerobic physical activity, or

at least 75–150 minutes of vigorous-intensity aerobic physical activity (or an equivalent
combination of these) throughout the week.
 Should also do muscle-strengthening activities (at moderate or greater intensity) that

involve all major muscle groups on two or more days a week, as these provide additional
health benefits.
 ay do more than 300 minutes of moderate-intensity aerobic physical activity or

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more than 150 minutes of vigorous-intensity aerobic physical activity (or an equivalent
combination of these) throughout the week for additional health benefits.
 Should limit the amount of time spent being sedentary. Replacing sedentary time with

physical activity of any intensity (including light intensity) provides health benefits.
For adults aged 65 years and above, WHO additionally recommends:
 oing varied multicomponent physical activity that emphasises functional balance and
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strength training at moderate or greater intensity, on 3 or more days a week, to enhance
functional capacity and to prevent falls.
Please note that these general physical activity guidelines may not be applicable to all people.
Dietary fibre
There is limited evidence suggesting that higher consumption of dietary fibre might improve
health outcomes.
Guidance statement:
People who eat more dietary fibre have better health outcomes after a diagnosis of
breast cancer.
While it is uncertain that increasing dietary fibre improves these outcomes, we suggest
that people consider increasing their dietary fibre intake.
Foods containing dietary fibre:
 Vegetables

 Fruits
 holegrain foods, such as oats, brown rice, bulgur wheat, wholegrain breakfast cereals,
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wholewheat pasta and wholemeal breads
 Pulses such as chickpeas, beans and lentils
 Nuts and seeds
People who increase their fibre intake should do so gradually. In general we are referring
to natural food sources of fibre.
Soy foods
There is limited evidence suggesting that soy foods might reduce all-cause mortality, breast cancer
mortality and breast cancer recurrence after a diagnosis of breast cancer.
People may have heard that eating soy foods can increase the risk of developing breast cancer
and understandably may have concerns about eating these foods. This concern comes from the
theoretical link between dietary isoflavones (of which soy is the main dietary source) and breast
cancer. However, systematic reviews show no consistent evidence of a link 2 between soy foods
and developing breast cancer, and there was no evidence from the current work that soy foods are
harmful after diagnosis.
Therefore, although the evidence is currently insufficient to advise an increase in consumption of

soy foods, those already consuming them do not need to stop.
Guidance statement:
The evidence does not support guidance to consume more soy foods (or to introduce soy
foods if these are not currently part of the diet) after a diagnosis of breast cancer, but for
those who already consume them, there is no need to stop.
Soy (or soya) foods include:
 Edamame (green soybeans)

 Tofu
 Tempeh
 Soy beverages and other dairy alternatives
 Roasted soy nuts
If soy alternatives to dairy are consumed, it is preferable to use products that are
unsweetened and fortified with calcium and other essential nutrients, such as vitamin D
and iodine (check the product label).
2Our expert panel previously judged the evidence for soy foods/isoflavones and breast cancer risk as ‘limited no
conclusion' in the Third Expert Report (https://www.wcrf.org/wp-content/uploads/2021/02/Breast-cancer-report.pdf)
Body weight
The review showed strong associations between body weight (measured by BMI, waist
circumference and waist-to-hip ratio) and health outcomes. The panel concluded that these
were unlikely to be caused by chance or bias and therefore judged these to be ‘strong probable’.
However, there was insufficient evidence on body weight change to make any guidance about
weight loss. Therefore, a cautious approach has been taken, focusing on avoiding weight gain.
This is important since women commonly gain weight during treatment for breast cancer.
Guidance statement:
Those with body weight in the ‘healthy range’ after a diagnosis of breast cancer have the
best health outcomes. While it is uncertain that deliberate weight loss by people with
overweight or obesity improves these outcomes, we suggest that people who are not
underweight aim to avoid gaining weight during and after treatment.
Maintaining a healthy body weight can reduce the risk of the following conditions:
 Cardiovascular disease
 Type 2 diabetes
 Osteoarthritis
Underweight patients should discuss their nutritional needs with their medical team.
Vitamin D supplements
This review found limited evidence suggesting that higher vitamin D status reduces the risk of
breast cancer-specific and all-cause mortality, but there was no evidence of any benefit from
vitamin D supplements.
Therefore, we are not making specific guidance about vitamin D supplements to improve outcomes
after a breast cancer diagnosis. People should take any supplements advised by their health care
team, but should be cautious of taking over the counter vitamin D supplements if they are already
being prescribed vitamin D or calcium supplements.
Please note: We recommend that individuals living

with and beyond cancer speak to their healthcare
team before making any changes related to diet,
nutrition, physical activity or body weight. Any
healthcare professionals using this guidance should
consider where a patient is in their cancer journey
and interpret the guidance appropriately
to suit each person’s individual needs.
Acknowledgments
Global Cancer Update Programme panel (developed guidance for people living with and
beyond breast cancer)
Professor Lord John Krebs, University of Oxford, UK (Panel Chair); Professor Matty Weijenberg,
Maastricht University, NL (Panel Deputy Chair; Professor Monica Baskin, University of Pittsburgh,
US (Chair of Expert Committee on Cancer Incidence; Professor Sarah Lewis, University of Bristol,
UK (Chair of Expert Committee on Cancer Mechanisms); Professor Ellen Copson, University of
Southampton, UK (Chair of Expert Committee on Cancer Survivors); Professor Jaap Seidell,
VU University, NL (Chair of the Expert Committee on Obesity); Professor Rajiv Chowdhury, Florida
International University, US (Global Representative); Lynette Hill, UK (Public Representative)
Formal observers to the Global Cancer Update Programme panel

Dr Carolina Espina, International Agency for Research on Cancer, FR; Dr Jason Montez,
World Health Organization, CH; Professor Mathilde Touvier, French National Institute of Health
and Medical Research, FR; Shalini Jayasekar Zürn, Union for International Cancer Control, CH;
Dr Emily Tonorezos, National Cancer Institute, US
Global Cancer Update Programme cancer survivors expert committee (contributed to the
development of guidance for people living with and beyond breast cancer)
Professor Ellen Copson, University of Southampton, UK (Chair); Professor Andrew Renehan,
University of Manchester, UK (Deputy Chair); Professor Anne May, University Medical Centre
Utrecht, NL; Professor Anne Tjonneland, Danish Cancer Society Research Centre, DK;
Professor Galina Velikova, University of Leeds, UK; Professor Karen Steindorf, DKFZ and NCT,
DE; Dr Martijn Bours, Maastricht University, NL; Dr Melissa Hudson, St. Jude Children’s Research
Hospital, US; Professor Rod Skinner, Newcastle University, UK; Professor Wendy Demark-
Wahnefried, University of Alabama, US; Professor Folakemi Odedina, Mayo Clinic, US
CUP Transition panel (carried out judgement of breast cancer evidence and developed
recommendation for physical activity and quality of life for people living with and beyond
breast cancer)
Professor Alan Jackson, University of Southampton, UK; Professor Ed Giovannucci, Harvard T.H.
Chan School of Public Health, US; Professor Anne McTiernan, Fred Hutchinson Cancer Research
Center, US; Professor Ellen Kampman, Wageningen University, NL; Professor Marc Gunter, Imperial
College London, UK; Dr Kostas Tsilidis, Imperial College London, UK; Professor Steven Clinton,
Ohio State University, US; Dr Vivien Lund, UK (Public Representative)
Formal observers to CUP Transition panel
Professor Elio Riboli, Imperial College London, UK; Professor Amanda Cross, Imperial College
London, UK
Imperial College London research team (carried out the systematic literature reviews)
Dr Kostas Tsilidis (co-Principal Investigator); Dr Doris Chan (co-Principal Investigator);
Professor Amanda Cross, Dr Georgios Markozannes, Margarita Cariolou, Katia Balducci, Sonia Kiss,
Sofia Cividini, Rita Vieira, Dr Dagfinn Aune, Dr Ahmad Jayedi, Dr Eduardo Seleiro (project manager),
Lam Teng (database manager), Dr Darren C. Greenwood, University of Leeds, UK (statistical
advisor)
Previously in Imperial College London research team:

Dr Teresa Norat (previously Principal Investigator CUP), Dr Nerea Becerra-Tomás, Dr Leila Abar,
Dr Jakub Sobiecki, Neesha Nanu, Britta Talumaa, Victoria White, Dr Rui Vieira (database manager),
Christophe Stevens (database manager), Yusuf O. Anifowoshe (database manager)
Protocol Expertise Group

Professor Annie Anderson, University of Dundee, UK; Professor Steven Clinton, The Ohio State
University, US; Professor Ellen Copson, Southampton University, UK; Professor Wendy Demark-
Wahnefried, University of Alabama, US; Professor John Mathers, Newcastle University, UK;
Professor Anne McTiernan, Fred Hutchinson Cancer Research Center, US; Professor Andrew
Renehan, University of Manchester, UK; Dr Franzel van Duijnhoven, Wageningen University, NL;
Professor Galina Velikova, University of Leeds, UK; Lesley Turner (patient representative)
User involvement
Patients and health professionals providing feedback on the guidance and recommendation,
including patient representatives via Breast Cancer Now and People in Research (NIHR)
Secretariat
WCRF International: Dr Giota Mitrou, Director of Research, Policy and Innovation;

Dr Helen Croker, Assistant Director of Research and Policy, and Head of CUP Global Secretariat;
Dr Christelle Clary, Research Interpretation Manager; Sarah Kefyalew, Senior Research
Interpretation Officer; Dr Kate Allen, Science and Policy Advisor
AICR: Dr Nigel Brockton, Vice President of Research; Dr Holly Paden, Research Programs Manager
WCRF Network Executive

Marilyn Gentry, President, WCRF International; Rachael Gormley, Executive Director, WCRF
International and CEO, WCRF; Nadia Ameyah, Director, Wereld Kanker Onderzoek Fonds (WKOF)
Scientific consultants
Professor Martin Wiseman, UK; Dr Vanessa Gordon-Dseagu, UK; Kirsty Beck, UK
Other senior Network staff

Germund Daal, Head of Mission Realisation and Communications, Wereld Kanker Onderzoek Fonds
(WKOF); Vickie Gregory, Director, Network Operations, WCRF International
Other staff members have contributed previously, including:

Nicole Musuwo, Senior Research Interpretation Officer, WCRF International; Daphne Katsikioti,
Senior Research Interpretation Officer, WCRF International; Deirdre McGinley-Gieser,
Executive Vice President, AICR
References
1. W
orld Cancer Research Fund/ American Institute for Cancer Research. Continuous Update
Project Expert Report 2018. Diet, nutrition, physical activity and breast cancer survivors. 2018.
[Available from: dietandcancerreport.org].
2. G
BD 2019 Cancer Risk Factors Collaborators. The global burden of cancer attributable to risk
factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019.
The Lancet. 2022;400(10352):563-91.
3. National
Cancer Institute. NCI Dictionary of Cancer Terms. Accessed 13/07/24. [Available from:
https://www.cancer.gov/publications/dictionaries/cancer-terms].
4. B
ray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer
statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in
185 countries. CA: A Cancer Journal for Clinicians. 2024;74(3):229-63.
5. Ferlay J, Colombet M, Soerjomataram I, Parkin DM, Piñeros M, Znaor A, et al. Cancer statistics
for the year 2020: An overview. International Journal of Cancer. 2021;149(4):778-89.
6. W
HO. Global action plan for the prevention and control of noncommunicable diseases 2013-
2020. 2013. Accessed 13/07/2024.
[Available from: https://iris.who.int/bitstream/handle/10665/94384/9789241506236_eng.
pdf?sequence=1].
7. C
oleman MP. Cancer survival: global surveillance will stimulate health policy and improve
equity. The Lancet. 2014;383(9916):564-73.
8. J ohnston EA, van der Pols JC, Ekberg S. Needs, preferences, and experiences of adult cancer
survivors in accessing dietary information post-treatment: A scoping review. European Journal
of Cancer Care. 2021;30(2):e13381.
9. W
orld Cancer Research Fund/ Americal Institute for Cancer Research. Continuous Update
Project Expert Report 2018. Recommendations and public health and policy implications.
2018. [Available from: dietandcancerreport.org].
10. Tsilidis KK, Cariolou M, Becerra-Tomás N, Balducci K, Vieira R, Abar L, et al. Postdiagnosis
body fatness, recreational physical activity, dietary factors and breast cancer prognosis: Global
Cancer Update Programme (CUP Global) summary of evidence grading. International Journal
of Cancer. 2023;152(4):635-44.
11. Chan DSM, Vieira R, Abar L, Aune D, Balducci K, Cariolou M, et al. Postdiagnosis body
fatness, weight change and breast cancer prognosis: Global Cancer Update Program (CUP
global) systematic literature review and meta-analysis. International Journal of Cancer.
2023;152(4):572-99.
12. Becerra-Tomás N, Balducci K, Abar L, Aune D, Cariolou M, Greenwood DC, et al. Postdiagnosis
dietary factors, supplement use and breast cancer prognosis: Global Cancer Update
Programme (CUP Global) systematic literature review and meta-analysis. International Journal
of Cancer. 2023;152(4):616-34.
13. C
ariolou M, Abar L, Aune D, Balducci K, Becerra-Tomás N, Greenwood DC, et al. Postdiagnosis
recreational physical activity and breast cancer prognosis: Global Cancer Update Programme
(CUP Global) systematic literature review and meta-analysis. International Journal of Cancer.
2023;152(4):600-15.
14. A
une D, Markozannes G, Abar L, Balducci K, Cariolou M, Nanu N, et al. Physical Activity and
Health-Related Quality of Life in Women With Breast Cancer: A Meta-Analysis. JNCI Cancer
Spectrum. 2022;6(6):pkac072.
15. Imperial College London CUP Global Team. Continuous Update Project on diet and cancer:
Protocol for the data collection and systematic literature reviews on the role of diet, nutrition
and physical activity on outcomes after diagnosis of breast cancer., ed. Version 3, 2019.
Accessed 28/08/2024. [Available from: https://www.imperial.ac.uk/school-public-health/
epidemiology-and-biostatistics/research/cancer-and-nutritional-epidemiology/global-cancer-
update-programme/].
16. Imperial College Continuous Update Project team. Protocol for the data collection and
systematic literature reviews on the role of diet, body fatness and physical activity on health-
related quality of life after diagnosis of breast cancer. Accessed 28/08/2024. [Available from:
https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/research/
cancer-and-nutritional-epidemiology/global-cancer-update-programme/].
17. WHO. Guidelines on physical activity and sedentary behaviour. Geneva: World Health
Organization. 2020. Accessed 14/07/2024. [Available from: https://iris.who.int/bitstream/hand
le/10665/336656/9789240015128-eng.pdf?sequence=1&isAllowed=y].
Appendix 1: WCRF/ AICR Cancer Prevention
Recommendations
LIMIT CONSUMPTION LIMIT CONSUMPTION

OF RED AND OF SUGAR
PROCESSED MEAT SWEETENED DRINKS
LIMIT CONSUMPTION
OF ‘FAST FOODS’ AND LIMIT ALCOHOL
OTHER PROCESSED CONSUMPTION
FOODS HIGH IN FAT,
STARCHES OR SUGARS
EAT A DIET RICH DO NOT USE

IN WHOLEGRAINS,
VEGETABLES,
OUR SUPPLEMENTS
FOR CANCER
FRUIT AND BEANS
CANCER PREVENTION PREVENTION
RECOMMENDATIONS
Not smoking and avoiding other exposure to tobacco and
BE PHYSICALLY excess sun are also important in reducing cancer risk. FOR MOTHERS:
ACTIVE Following these Recommendations is likely to reduce BREASTFEED YOUR
intakes of salt, saturated and trans fats, which together BABY, IF YOU CAN
will help prevent other non-communicable diseases.
AFTER A CANCER
BE A
HEALTHY WEIGHT wcrf.org DIAGNOSIS: FOLLOW OUR
RECOMMENDATIONS,
IF YOU CAN
Appendix 2: Selection of forest plots illustrating
findings from systematic reviews
The below forest plots are a selection shown to illustrate the results from the reviews, please
refer to the papers to access all of the results and forest plots.
Health outcomes
Recreational physical activity after diagnosis and health outcomes
All-cause mortality
Breast cancer-specific mortality
Footnote:
Summary hazard ratio estimate (95% CI) of all-cause mortality for the highest compared to the lowest level of
recreational physical activity after diagnosis (top plot) and breast cancer-specific mortality for the highest compared
to the lowest level of recreational physical activity after diagnosis (bottom plot). Forest plot shows results from
the random effects model. Diamond represents the summary hazard ratio. Each square represents the hazard ratio
estimate of each study and the horizontal line across each square represents the 95% confidence interval (CI) of the
hazard ratio estimate. ABCPP (Beasley 2012) included data from three US cohorts that is, LACE, NHS, WHEL and
one Chinese cohort SBCSS. For the CPS-II Nutrition Cohort (Maliniak 2018), the HR estimates for the two age groups
reported were combined using fixed effects models before inclusion in the meta-analysis.
Citation: Cariolou M, Abar L, Aune D, Balducci K, Becerra-Tomás N, Greenwood DC, et al. Postdiagnosis recreational
physical activity and breast cancer prognosis: Global Cancer Update Programme (CUP Global) systematic literature
review and meta-analysis. International Journal of Cancer. 2023;152(4):600-15. (Plots B and D, taken from Figure 2)
Diet after diagnosis and health outcomes
Isoflavone intake and all-cause mortality
Dietary fibre intake and all-cause mortality
Serum 25(OH)D and all-cause mortality
Footnote:
Linear dose-response meta-analyses on isoflavone intake, dietary fibre intake, serum 25(OH)D and all-cause mortality.
Forest plots show the linear dose-response results from the inverse variance DerSimonian-Laird random-effects
models. Diamonds represent the summary relative risk (RR) estimates. Each square represents the RR estimate of
each study and the horizontal line across each square represents the 95% confidence interval (CI) of the RR estimate.
The increment units were 2 mg/day (isoflavone intake), 10 g/day (dietary fibre intake), 10 nmol/L (serum 25(OH)D).
Abbreviations: ABCPP, After Breast Cancer Pooling Project; BCFR, Breast Cancer Family Registry; CI, confidence
interval; CWLS, Collaborative Women's Longevity Study; HEAL, Health, Eating, Activity, and Lifestyle Study; MARIE,
Mammary carcinoma risk factor Investigation; NHS, Nurses' Health Study; RR, Relative risk.
Citation: Becerra-Tomás N, Balducci K, Abar L, Aune D, Cariolou M, Greenwood DC, et al. Postdiagnosis dietary factors,
supplement use and breast cancer prognosis: Global Cancer Update Programme (CUP Global) systematic literature
review and meta-analysis. International Journal of Cancer. 2023;152(4):616-34. (Plots B, D and F, taken from Figure 3)
Body mass index after diagnosis and health outcomes (all-cause mortality)
Footnote:
Linear and nonlinear dose-response meta-analyses of postdiagnosis body mass index and all-cause mortality. Forest
plot shows the linear dose-response results for postdiagnosis body mass index (BMI) and all-cause mortality from
the inverse variance DerSimonian-Laird random-effects model. Diamond represents the summary relative risk (RR)
estimate and its width as the 95% confidence interval (CI). Each square represents the RR estimate of each study and
the horizontal line across each square represents the 95% CI of the RR estimate. The increment unit was per 5 kg/
m2 . Nonlinear curve was estimated using restricted cubic spline regression with three knots at 10th, 50th and 90th
percentiles of distribution of the exposure and pooled in random-effects meta-analysis. BMI at 20 kg/m2 was selected
as reference. The table shows selected BMI values and their corresponding RR (95% CI) estimated in the nonlinear
dose-response meta-analysis.
Citation: Chan DSM, Vieira R, Abar L, Aune D, Balducci K, Cariolou M, et al. Postdiagnosis body fatness, weight change
and breast cancer prognosis: Global Cancer Update Program (CUP global) systematic literature review and meta-
analysis. International Journal of Cancer. 2023;152(4):572-99. (Figure 2)
Physical activity and health-related quality of life
Citation: Aune D, Markozannes G, Abar L, Balducci K, Cariolou M, Nanu N, et al. Physical Activity and Health-Related
Quality of Life in Women With Breast Cancer: A Meta-Analysis. JNCI Cancer Spectrum. 2022;6(6):pkac072. (Figure 5)
Appendix 3: Summary of grading criteria
EVIDENCE GRADING CRITERIA FOR EVIDENCE ON DIET, NUTRITION,
GRADES PHYSICAL ACTIVITY AND SURVIVAL FOLLOWING CANCER
Het PB Mec
Evidence of an effect from a meta-analysis of RCTs

CONVINCING NO NO DESIRABLE
or at least 2 well-designed independent RCTs
Evidence of an effect from a meta-analysis of SOME NO DESIRABLE

RCTs or 2 well-designed RCTs
STRONG
EVIDENCE OR Evidence of an effect from 1 well-designed NO NO REQUIRED
RCT and 1 well-designed cohort study
PROBABLE
OR Evidence from at least 1 well-designed NO NO REQUIRED
pooled analysis of follow-up studies
OR Evidence from at least 2 independent NO NO REQUIRED
well-designed follow-up studies
Evidence from a meta-analysis of RCTs or at least

2 well-designed RCTs but the confidence interval
SOME NO NOT REQUIRED
may include the null
OR Evidence from 1 well-designed RCT but the
confidence interval may include the null NO NO REQUIRED
OR Evidence of an effect from a pooled analysis SOME NO NOT REQUIRED
of follow-up studies
LIMITED OR Evidence from a pooled analysis of follow-up
SUGGESTIVE SOME NO REQUIRED
studies but the confidence interval may include
the null
LIMITED OR Evidence of an effect from at least 1
SUGGESTIVE NO NO REQUIRED
follow-up study
OR Evidence of an effect from at least 2 NO NO NOT REQUIRED
follow-up studies
OR Evidence from at least 2 follow-up studies
but the confidence interval may include the null SOME NO REQUIRED
Any of the following reasons:

LIMITED - - Too few studies available
NO CONCLUSION − − −
- Inconsistency of direction of effect
- Poor quality of studies
Evidence of the absence of an effect (a summary

estimate close to 1.0) from any of the following: NO − ABSENCE
a. A meta-analysis of RCTs
SUBSTANTIAL b. At least 2 well-designed independent RCTs
STRONG EFFECT ON RISK c. A well-designed pooled analysis of follow-up
EVIDENCE UNLIKELY studies
d. At least 2 well-designed follow-up studies
- Absence of a dose-response relationship
(in follow-up studies)
Note: Special upgrading factors: (a) Presence of a plausible biological gradient (‘dose response’) in the association.
Such a gradient need not be linear or even in the same direction across the different levels of exposure, so long as
this can be explained plausibly. (b) A particularly large summary effect size (a relative risk of 2.0 or more, or 0.5 or
less, depending on the unit of exposure), after appropriate control for confounders. (c) Evidence from appropriately
controlled experiments demonstrating one or more plausible and specific mechanisms. (d) All plausible known
residual confounders or biases including reverse causation would reduce a demonstrated effect, or suggest a spurious
effect when results show no effect. Special considerations important for evidence for breast cancer survivors
including the following potential confounding variables—the type of tumour, type of treatment,
amount of treatment received and the dissemination of the disease.
Abbreviations: Het, substantial unexplained heterogeneity or some unexplained heterogeneity; PB, publication bias;
Mec, strong and plausible mechanistic evidence is required, desirable but not required, not required or absent.
Appendix 4: Summary of panel conclusions
The below table summarises the evidence judgements made by the expert panel as part of our
ongoing work to examine how diet, weight and physical activity exposures affect outcomes
following a breast cancer diagnosis.
LIVING WITH AND BEYOND BREAST CANCER

(HEALTH AND HEALTH-RELATED QUALITY OF LIFE OUTCOMES)
2022
Post diagnosis diet, nutrition and physical activity for breast cancer survivors
DECREASES RISK INCREASES RISK
EXPOSURE OUTCOME EXPOSURE OUTCOME
CONVINCING
STRONG EVIDENCE
Physical activity HR quality of life1 Body fatness2 All mortality
PROBABLE interventions BC mortality
2nd BC
Healthy dietary All mortality Body fatness4 Recurrence
LIMITED−SUGGESTIVE patterns3 Non-BC mortality
Non-cancer
mortality CVD mortality
Soy foods All mortality
BC mortality
Recurrence
Dietary fibre All mortality
Vitamin D status5 All mortality

BC mortality
LIMITED
EVIDENCE
Recreational All mortality
physical activity BC mortality
Post diagnosis BMI change or weight change

LIMITED−NO CONCLUSION Low-fat diet, predefined healthy dietary and lifestyle patterns (for breast
cancer-specific mortality and cardiovascular disease death), data-driven
dietary patterns, high-fat dietary pattern, alcoholic drinks, fruit and vegetables,
cruciferous vegetables, dietary fibre (for breast cancer-specific mortality
and recurrence), wholegrains, red and processes meats, fish, eggs, milk and
dairy products, nutrients (fats, carbohydrate, animal protein, plant protein),
supplements (multivitamins, antioxidants, vitamins, carotenoids), vitamin D
(blood levels on recurrence)
STRONG SUBSTANTIAL EFFECT ON

EVIDENCE RISK UNLIKELY
Abbreviations:
HR quality of life, health-related quality of life; All mortality, all-cause mortality; BC mortality, breast cancer-specific
mortality; 2nd BC, 2nd primary breast cancer; non-BC mortality, non-breast cancer related mortality; CVD mortality,
cardiovascular disease mortality
Footnotes:
1 There was insufficient evidence to draw conclusions on specific domains of quality of life or the types and doses of
physical activity
2 BMI, waist circumference, waist-hip ratio for all-cause mortality and BC mortality; BMI for 2nd BC
3 Refers to predefined healthy dietary and lifestyle patterns
4 BMI, waist circumference, waist-hip ratio for recurrence; BMI for non-BC related mortality and CVD mortality
5 Refers to blood level
Appendix 5: User input
Feedback on accessing advice on diet, physical activity and health:
 articipants consistently mentioned a lack of reliable, evidence-based information following

P
their diagnosis.
 articipants reported that healthcare professionals were generally either too “afraid” to talk
P
about diet and lifestyle changes, not aware of the changes that could be suggested, or seemed
to lack the knowledge needed to offer such information.
 In some cases, the advice that was given by healthcare teams was not considered appropriate
or necessarily evidence-based .
 ome reported cancer charities as offering very good general support, but not enough specific
S
information about diet, physical activity and their health that was relevant to their cancer
journey and cancer sub-type.
 any participants reported that the information found on the internet or social media was
M
generally unreliable and often conflicting.
 atient forums were a popular source of support, but some participants doubted the accuracy
P
of some of the advice from other survivors.
 acebook support groups were also mentioned, although some included strong opinions from
F
survivors that were seen as potentially misleading.
 Information and advice from appropriately qualified people with their own cancer diagnosis
was one source considered relevant and trustworthy.
Feedback on the guidance:
 Guidance was considered accessible and easy to read.

 The use of clear sections and sub-titles was seen as helpful.
 The links to additional information were viewed positively.
 However, many participants said the example guidance needed to be more visual.
 uidance also needed to be more inclusive to suit lower literacy levels, but also to consider
G
different cultural and personal food preferences.
 xamples to ‘bring to life’ the guidance were needed, such as specific hints and tips, or quotes/
E
stories detailing the challenges that cancer survivors had faced to make it more personable and
actionable.
 pecific consideration of some of the challenges following a diagnosis was needed (for
S
example early-onset menopause for some breast cancer patients).
 here was a perceived need to set the guidance in the context of the potential broader health
T
and wellbeing benefits (e.g. for mental health) or health challenges (e.g. other co-morbidities;
physical impairment due to surgery or medication side effects) and also for the advice to feel
more achievable (e.g. considering cost-of-living).
 aking the guidance more ‘empowering’ by emphasising the potential benefits of making even
M
small changes to behaviour could be helpful.
World Cancer Research Fund International
Upper Ground Floor, 140 Pentonville Road, London N1 9FW
Tel: +44 (0)20 7343 4200
Email: [email protected]
x.com/wcrfint
facebook.com/WoCRF
linkedin.com/company/wcrf
wcrf.org
World Cancer Research Fund International’s Global Cancer Update Programme is a global analysis of scientific research
into the link between diet, nutrition, physical activity, weight and cancer. It is produced in partnership with American Institute
for Cancer Research, World Cancer Research Fund in the UK and Wereld Kanker Onderzoek Fonds in The Netherlands.
© 2024 World Cancer Research Fund International. All rights reserved.

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Diet, nutrition, physical activity and body

weight for people living with and beyond

Describes how we are developing guidance and recommendations in the Global

Discusses research gaps and recommendations for future research

Development of population or disease-specific guidance and recommendations –

Clarification of existing knowledge to develop greater understanding of cancer

Efficient and targeted approaches and keeping the evidence current –

Collaborations and input from experts and external stakeholders – utilising

Globally representative research – most epidemiological studies are conducted

Strong public involvement – we recognise the importance of user involvement

Overview of the Global Cancer Update Programme

CANCER CANCER CANCER OBESITY

Data prioritisation/ Data Molecular Literature

IMPERIAL COLLEGE LONDON CUP GLOBAL TEAM

 esearch should aim to study more diverse

By highlighting gaps in the evidence base,

Evidence comes from the 4 systematic reviews

Recommendations are based on strong evidence.

Research has historically focused on understanding exposures influencing cancer development.

WCRF/AICR previously produced a set of Cancer Prevention Recommendations (see Appendix

Who the report is for

 Civil society, patient and charitable organisations (eg cancer charities).

 Policymakers in public health settings.

Summary of steps taken

RECOMMENDATIONS- typically developed using strong evidence

What we mean by ‘guidance’ and 'recommendations'

Reviews on health outcomes

Published papers available here:

These studies focused on mortality and recurrence outcomes.

Review on health-related quality of life

Published paper available here:

RESEARCH CONSIDERATION Reverse causation

Future research could attempt to address this through:

Breast cancer specific considerations:

RESEARCH CONSIDERATION Time-varying impacts

ISSUES AND POTENTIAL SOLUTIONS

RESEARCH CONSIDERATION Study cohorts specific to cancer survivorship

RESEARCH CONSIDERATION More accurate characterisations of study populations

ISSUES AND POTENTIAL SOLUTIONS

Increased knowledge of the potential biological pathways underpinning the associations

Breast cancer specific considerations:

RESEARCH CONSIDERATION More multi-disciplinary research collaborations

Input from health professionals:

Our existing WCRF/AICR recommendations for cancer prevention

 educing the risk of developing other

 Helping maintain a healthy body weight

 Reducing the risk of depression and anxiety

 Helping improve sleep and cognitive health

 Helping keep joints and muscles healthy

 Should do at least 150–300 minutes of moderate-intensity aerobic physical activity, or

 Should also do muscle-strengthening activities (at moderate or greater intensity) that

 ay do more than 300 minutes of moderate-intensity aerobic physical activity or

For adults aged 65 years and above, WHO additionally recommends:

Foods containing dietary fibre:

Therefore, although the evidence is currently insufficient to advise an increase in consumption of

Soy (or soya) foods include:

 Edamame (green soybeans)

Please note: We recommend that individuals living

Formal observers to the Global Cancer Update Programme panel

Previously in Imperial College London research team:

 esearch should aim to study more diverse

 educing the risk of developing other

 ay do more than 300 minutes of moderate-intensity aerobic physical activity or

 articipants consistently mentioned a lack of reliable, evidence-based information following

 Guidance was considered accessible and easy to read.