Updated evidence in support of diet and exercise interventions in cancer survivors

Figures & data

Table I. Compiled guidelines: American Cancer Society 2006 Guidelines on Nutrition and Physical Activity for Cancer Prevention, the World Cancer Research Fund/American Institute for Cancer Research Recommendations for the Prevention of Cancer, 2007, and the American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors (2010).

American Cancer Society	World Cancer Research Fund/ American Institute for Cancer Research	American College of Sports Medicine
Maintain a healthy weight throughout life	Be as lean as possible within the normal range of body weight
• Balance caloric intake with physical activity	• Ensure that body weight through childhood and adolescent growth projects toward the lower end (<22.9) of the normal BMI range at age 21
• Avoid excessive weight gain throughout the lifecycle	• Maintain body weight within the normal range from age 21
• Achieve and maintain a healthy weight if currently overweight or obese	• Avoid weight gain and increases in waist circumference throughout adulthood
Adopt a physically active lifestyle.	Be physically active as part of everyday life	Avoid inactivity
• Adults: engage in at least 30 minutes of moderate-to-vigorous physical activity, above usual activities, on five or more days of the week (45–60 minutes of intentional physical activity are preferable).	• Be moderately physically active, equivalent to brisk walking, for at least 30 minutes each day	• Return to normal activities as quickly as possible after surgery. Continue normal daily activities and exercise as much as possible during/after nonsurgical treatments. Individuals with known metastatic bone disease and cardiac conditions may require modifications and greater supervision for safety.
• Children and adolescents: engage in at least 60 minutes/day of moderate-to-vigorous physical activity at least five days per week. Limit screen time (TV, computer, games) to no more than two hours per day.	• As fitness improves, aim for 60 minutes or more of moderate, or for 30 minutes or more of vigorous, physical activity every day	• Aerobic, resistance training and flexibility exercise recommendations are the same as age-appropriate physical activity guidelines for Americans
	• Limit sedentary habits such as watching television
Consume a healthy diet, with an emphasis on plant sources	Limit consumption of energy-dense foods; avoid sugary drinks
• Choose foods and beverages in amounts that achieve and maintain a healthy weight.	• Consume energy-dense foods sparingly
• Eat five or more servings of a variety of vegetables and fruits each day.	• Avoid sugary drinks
• Choose whole grains in preference to processed (refined) grains.	• Consume fast foods sparingly, if at all
• Limit consumption of processed and red meats.
	Eat mostly foods of plant origin
	• Eat at least five portions/servings (at least 400 g or 14 oz) of a variety of non-starchy vegetables and of fruits every day
	• Eat relatively unprocessed cereals (grains) and/or pulses (legumes) with every meal
	• Limit refined starchy foods
	• People who consume starchy roots or tubers as staples also to ensure intake of sufficient non-starchy vegetables, fruits, and pulses (legumes)
	Limit intake of red meat and avoid processed meat
	• People who eat red meat to consume less than 500 g (18 oz) a week, very little if any to be processed
	Limit consumption of salt; avoid moldy cereals (grains) or pulses (legumes)
	• Avoid salt-preserved, salted, or salty foods; preserve foods without using salt
	• Limit consumption of processed foods with added salt to ensure an intake of less than 6 g (2.4 g sodium) a day
	• Do not eat moldy cereals (grains) or pulses (legumes)

Table II. Randomized Controlled Trials (RCTs) of lifestyle interventions for cancer survivors.

Authors	Sample	Design	Intervention	Frequency/intensity/duration	Results
Diet-Related RCTs
Aronson et al. 2010 [12]	18 men diagnosed with prostate cancer within the past two years and on active surveillance. Mean age = 64. 67% Caucasian and 33% African American.	Evenly randomized to a low fat diet and a Western diet.	Feeding study with the low fat diet defined as <15% of total energy from fat and the Western diet defined ∼40% of energy coming from fat.	4-weeks	No differences noted between study arms in PSA, serum lipids or IGF-1/-2 or binding protein change scores. LNCaP cells exposed to sera of men on the low fat diet grew significantly less rapidly (p=0.03) than cells exposed to sera of men assigned to the Western diet.
Demark-Wahnefried et al. 2008 [13]	161 men with operable prostate cancer scheduled for prostatectomy. Age range 36–73 (M = 59.2). 70% Caucasian, 26% African American, 4% Other.	Phase II trial testing the comparative effects of flaxseed supplementation +/− a low fat diet. Controls continued usual diet.	Flaxseed arms received 30 grams/day of ground flaxseed. Low fat arms received instruction on diet of <20% of kcal from fat. Fat gram budgets given and men recorded fat grams.	Upon randomization men received appropriate instruction and supplies. Weekly telephone calls fielded questions/problems and reviewed dietary intakes. Urine analyzed for presence of lignans to confirm flaxseed consumption. Mean study period was 30 days.	Proliferation rates were significantly lower (p<0.002) among men assigned to the flaxseed arms. Median Ki-67 positive cells/total nuclei ratios (x100) were 1.66 (flaxseed alone) and 1.50 (flaxseed + low fat) vs. 3.23 (control) and 2.56 (low fat). Men assigned to the low fat arms experienced significant decreases in serum cholesterol (p=0.048). Intention to treat analysis with 7.5% attrition.
Djuric, et al. 2009 [14]	24 African American breast cancer (Stages I–IIIA) survivors. BMI 30–45. Mean age = 55.	Feasibility study of diet counseling vs. diet + spirituality counseling.	Weight loss intervention based on Weight Watchers approach. Diet-spirituality counseling based on 12-step approach.	Weekly sessions for the 1^st three months, biweekly sessions 3–6 months and monthly sessions for remainder of 18 month program.	Significantly greater improvements in vegetable consumption (p=0.013) and spirituality (p=0.024) in the Diet + Spirituality arm, but no arm differences in other dietary parameters, or body weight status. 8% attrition.
Parsons et al. 2008 [15]	43 Prostate cancer survivors on active surveillance. Mean age = 64. 88% Caucasian.	Telephone counseling vs. standardized written materials.	Experimental arm counseled to consume at least seven servings of vegetables/day (two cruciferous, two tomato products and three others), two servings/day of whole grains and one serving/day of beans/legumes.	Theory based, telephone counseling based intervention comprised of 13 (25–50 minute) sessions scheduled over a 6-month period.	Change in mean levels of PSA were +2.28 in the experimental arm vs. −0.06 among controls (p=0.29). Men in the experimental arm consumed significantly more vegetables and had significantly higher serum levels of carotenoids. 2% attrition.
Physical Activity RCTs
Adamsen et al. 2009 [31]	269 patients with mixed cancers (73% female) undergoing chemotherapy. No brain or bone metastases. Mean age = 47. Median days since diagnosis = 84.	Supervised exercise + massage vs. usual care control.	Supervised exercise involving high intensity cardiovascular and resistance training, relaxation and body awareness training, and massage vs. usual care.	Nine hours weekly for six weeks including resistance training 45 minutes/3x week (goal=3 continuous series of 5–8 repetitions (rep.) at 70–100% of the one rep. maximum test) and cardiovascular exercise 15 minutes/3x week (85–95% of maximum heart rate).	At six weeks, the intervention had significantly reduced fatigue and improved vitality, aerobic capacity, muscular strength, physical and functional activity, and emotional well-being, but not quality of life. 13% attrition.
Allgayer et al. 2008 [28]	48 colorectal cancer patients following primary therapy. Mean age = 59.	Moderate vs. high intensity exercise	Hospital based exercise programs.	Two weeks of exercise for 30–40 minutes/day at moderate intensity (0.3–0.4 X maximal exercise capacity) vs. high intensity (0.5–0.6 X maximal exercise capacity).	Short term moderate intensity exercise significantly reduced (29%) urinary 8-oxo-dG excretion levels, suggesting decreased oxidative DNA damage. High intensity exercise resulted in a non-significant increase (42%). 10% attrition.
Carson et al. 2009 [19]	37 disease-free breast cancer (Stage IA–IIB) survivors experiencing hot flashes Mean age = 54.4. Mean years since diagnosis = 4.9. 81% White, 19% African American.	Yoga vs. wait-list control.	Gentle yoga poses, meditation, breathing exercises.	Eight weekly, 120 minute yoga classes.	Significantly greater post-treatment increases in vigor and reductions in joint pain, fatigue, sleep disturbance, symptom-related bother, and hot-flash frequency and severity for yoga group. 19% attrition.
Fillion et al. 2008 [23]	87 French breast cancer (Stages 0–III) survivors who recently completed radiotherapy. Mean age = 52.5	Walking and psychosocial management vs. usual care control	Supervised walking training (one hour) and psycho-educational fatigue management sessions (1.5 hours).	Four weekly, 2.5-hour group meetings and 5–15 minute telephone booster sessions, with individualized goals for frequency and intensity.	Intervention arm showed significantly greater improvements in energy level, and reductions in fatigue and emotional distress three months post-intervention, relative to controls. 7% attrition.
Irwin et al. 2009a and 2009b [17,18]	75 sedentary post-menopausal breast cancer (Stages 0–III) survivors. Completed adjuvant treatment > six months before study. Mean age = 56. Mean years since diagnosis = 3.3. 84% Non-Hispanic White.	Exercise vs. usual care control.	Supervised gym- and home-based aerobic exercise.	Goal = 150 minutes/week of moderate-intensity exercise (60–80% of predicted maximal heart rate) for six months.	Significantly greater post-treatment improvements in exercise, % body fat and lean mass for intervention group. Intervention arm experienced stable bone mineral density and decreased insulin, and IGF-1, and increased IGFBP-3, unlike control group. 9% attrition.
Ligibel et al. 2008, 2009 [25,26]	101 sedentary, overweight breast cancer (Stage I–III) survivors who completed chemotherapy and/or radiation therapy three months before study. Mean age = 53. Mean months since diagnosis = 21.2 (intervention arm) and 28.6 (control arm).	Exercise vs. usual care control	Supervised strength training and home-based aerobic training	16 week moderate intensity program with 50 minutes, 2x/week strength training and 90 minutes/week of aerobic exercise.	Significant post-treatment decreases in insulin levels and hip circumference for exercise group (not control group). No significant changes in total or high molecular weight adiponectin, or leptin for either arm. 18% attrition.
May et al. 2008, 2009 [29,30]	147 mixed cancer survivors. Medical treatment completed > three months. Mean age = 48.8.	Physical Training (PT) + cognitive-behavioral therapy (CBT) vs. PT alone.	Supervised PT with individual aerobic and resistance exercise sessions and group sports.	PT 2x/week for 12 weeks with 30 minutes aerobic bicycle training at intensity of HRrest +70% to 80% of (HR peak –HR rest); 30 minutes strength training at intensity of 50–60% of one-repetition maximum; 60 minutes group sports.	Improved physical activity and quality of life found post-intervention and also at three- and nine-months post-intervention for both arms (p < 0.001). 17% attrition.
Pinto et al. 2008 [24]	86 sedentary, post-treatment breast cancer (Stages 0–II) survivors. Mean age = 53.14. Mean years since diagnosis = 2. 95% White.	Exercise vs. attention control	In-person exercise instruction, self monitoring with logs and pedometers, motivation-matched telephone counseling, tip sheets.	12 weekly phone calls. Goal = moderate intensity exercise (55–65% maximum heart rate) 30 minutes/day, five days/week.	Significantly greater improvements in minutes/week of moderate intensity physical activity, fitness, and reduced fatigue post-treatment for intervention group. Gains were maintained at nine months follow-up. 8% attrition.
Rogers et al. 2009a, 2009b [21,22]	41 sedentary breast cancer (Stages I–III) survivors receiving hormone therapy. Mean age = 53. 93% White.	Exercise vs. usual care control.	Theory-based physical activity behavior change intervention including group discussions with a psychologist, and individual exercise and counseling sessions with an exercise specialist.	12 week program with six group sessions and 15 individual sessions. Goal = 150 minutes/ week of moderate intensity activity.	Significantly greater improvements in minutes/week of moderate intensity or greater physical activity, and strength, and reduced central adiposity and lower extremity joint dysfunction at three months post-intervention for the intervention arm. 7% attrition.
Schmitz et al. 2009 [27]	141 breast-cancer (Stages I–III) survivors with stable lymphedema of the arm. Mean age = 57. Mean months since cancer diagnosis = 79 (intervention) and 88 (control). White (58%) African American (38%).	Progressive weight lifting vs. wait-list control.	Progressive weight lifting program with 1-year membership at a community fitness center.	90 minute supervised group sessions 2x/week for first 13 weeks, then 2x/week unsupervised exercise at a self-directed intensity for 39 weeks. Exercises performed with compression garment.	Greater reductions in self-reported severity of lymphedema symptoms and exacerbations, and improvements in upper- and lower-body strength in weight lifting group (p-values<0.05). No significant effect on limb-swelling. 8% attrition.
Speck et al. 2009 [16]	234 breast cancer (Stages 0–III) survivors (112 with lymphedema). Currently cancer-free. Mean age = 56.5. Diagnosis > one year before study entry. Primarily White.	Progressive strength training vs. wait-list control.	Progressive strength training.	13 weeks of supervised instruction (90 minutes, 2x per week) then unsupervised strength training at a self-directed intensity to one year.	Significantly greater post-treatment improvements in strength (bench and leg press) and quality of life (perceived appearance, health, physical strength, sexuality, relationship, social functioning) for intervention group. 7.7% attrition.
Waltman et al. 2009[20]	223 post-menopausal breast cancer survivors with bone loss who completed cancer treatment ≥ six months before study. Mean age = 58.6. 98.7% Caucasian.	Exercise + risedronate, calcium, and vitamin D vs. risedronate, calcium, and vitamin D, alone	Progressive strength/ weight training at home for first nine months and then with weight machines at local fitness center.	Exercise 30–45 minutes 2x weekly for 24 months at self-directed intensity.	No significant post-treatment improvements in bone mineral density over oral agents alone. Participants who were > 50% adherent to exercise (81 of 110) were significantly less likely to lose bone mineral density at the total hip and femoral neck. 10% attrition.
Dietary and Physical Activity RCTs
Bloom et al. 2008 [7]	404 female breast cancer (Stage 0–IV) survivors who were five years from diagnosis and cancer-free. ≤ 50 y.o. at diagnosis. 76% Euro-American, 5% African American, 7% Latina, 10% Asian, 2% other.	Multi-component intervention vs. wait list control.	Sessions included supervised 30 minute resistance exercise and yoga sessions, group walks, exercise prescription, progress reports, healthy diet handouts (on low fat cooking, eating more fruits and vegetables).	Three six-hour workshops over three months.	At post-test, intervention group was more likely than control to report increased physical activity (p=0.036) but not diet changes. 4% attrition.
Campbell et al. 2009 [8]	266 colorectal cancer survivors and 469 controls. M = 66.5 yrs.	2x2 design testing tailored print, telephone motivational interviewing or both vs. control of standardized print materials.	Intervention aimed at promoting physical activity and fruit and vegetable consumption.	The tailored print intervention consisted of four newsletters delivered over nine months; the telephone motivational interviewing consisted of 4–20 minute calls over nine months.	The combined intervention produced the greatest changes in fruit and vegetable consumption, though this effect was only consistently seen among controls, not colorectal cancer survivors. No changes in weight or physical activity were observed.
Demark-Wahnefried et al. 2008 [9]	90 newly diagnosed premenopausal women with Stage I–IIIA breast cancer scheduled for adjuvant chemotherapy. Mean age = 41.8.	Three-armed trial with calcium-rich diet (attention control) vs. exercise vs. exercise + low fat, plant-based diet.	All study arms were provided counseling and written materials on 1 200–1 500 mg of calcium/day. Exercise counseling promoted both aerobic exercise (> 30 minutes/day at least three days/week) and resistance training (exercise bands and water-filled weights in legs and lower body region). Additional diet counseling emphasized < 20% of kcal from fat and at least five daily servings of fruits and vegetables.	All study participants received written mailed materials and telephone counseling (14 sessions over the six month study period).	Targeted accrual was achieved with 8.8% drop-out. Fat and fruit and vegetable change scores differed significantly in the diet + exercise arm; though no differences in change scores were observed for physical activity. Measures of adiposity were generally lower in the study arm that received all intervention elements (diet + exercise), though the only significant difference was in extremity adiposity, i.e., 0.7% vs. 1.2% vs. 0.1%, in control vs. exercise alone vs. exercise + diet arms, respectively (p = 0.047). No differences between study arms were observed for quality of life, anxiety and depression, serum lipids, sex hormone binding globulin, insulin, proinsulin, C-reactive protein, interleukin-1B, and tumor necrosis factor receptor- II.
Morey et al. 2009 [10]	641 older, overweight, long-term (colorectal, breast, prostate) cancer survivors. Mean age = 73. Mean years since diagnosis = 9. 89% White.	Diet-exercise intervention vs. wait list control.	Theory-based, telephone counseling and mailed print material-based diet and exercise intervention, with pedometers, exercise bands, table guide for portion control, and diet/exercise logs.	12 month program with one mailing of a personally-tailored workbook and quarterly newsletters, 15 telephone sessions (lasting 15–30 minutes) and eight prompts. Goals = 15 minutes strength training every other day, 30 minutes/day endurance exercise, 7–9 servings/day fruits and vegetables, reduce fat to 10% of energy intake, 10% weight loss.	At 12 months, physical function had declined less rapidly in the intervention group (−2.15; 95% confidence interval [CI], −0.36 to −3.93), compared with the control group (−4.84; 95% CI, −3.04 to −6.63) (p = 0.03). Physical activity, dietary behaviors, and overall quality of life improved significantly in the intervention group, compared with control. Weight loss was also greater (2.06 kg for intervention vs. 0.92 kg for control, p < 0.001). 13% attrition.
von Gruenigen et al. 2008 [11]	45 overweight/obese early stage (I–II) endometrial cancer survivors. Mean age = 55. Mean years since diagnosis = 2. 98% Caucasian.	Diet-exercise intervention vs. usual care control.	Theory-based lifestyle intervention involving group and individual physical activity and nutritional counseling with behavior modification. Pedometers were provided.	Six-month program with groups meeting weekly for six weeks, bi-weekly for one month, and monthly for three months, with calls or newsletters on weeks groups did not meet. Goal = aerobic activity five days/week for 45 min or more and 5% weight loss in six months.	At 12 months, the intervention group showed greater improvements in weight (−3.5 kg vs. +1.4 kg) and physical activity than the control group (p-values<0.05). No significant group differences in intakes of energy, vitamin C, or folate. 16% attrition.

Aronson WJ, Barnard RJ, Freedland SJ, Henning S, Elashoff D, Jardack PM, . Growth inhibitory effect of low fat diet on prostate cancer cells: Results of a prospective, randomized dietary intervention trial in men with prostate cancer. J Urol 2010;183:345–50.

 PubMed Web of Science ®Google Scholar

Demark-Wahnefried W, Polascik TJ, George SL, Switzer BR, Madden JF, Ruffin MT 4th, . Flaxseed supplementation (not dietary fat restriction) reduces prostate cancer proliferation rates in men presurgery. Cancer Epidemiol Biomarkers Prev 2008;17:3577–87.

 PubMed Web of Science ®Google Scholar

Djuric Z, Mirasolo J, Kimbrough L, Brown DR, Heilbrun LK, Canar L, . A pilot trial of spirituality counseling for weight loss maintenance in African American breast cancer survivors. J Natl Med Assoc 2009;101:552–64.

 PubMed Web of Science ®Google Scholar

Kellogg Parsons J, Newman VA, Mohler JL, Pierce JP, Flatt S, Marshall J. Dietary modification in patients with prostrate cancer on active surveillance: A randomized, multicentre feasibility study. Brit J Urol 2008;101:1227–31.

 Google Scholar

Adamsen L, Quist M, Andersen C, Moller T, Herrstedt J, Kronborg D, . Effect of a multimodal high intensity exercise intervention in cancer patients undergoing chemotherapy: Randomised controlled trial. BMJ 2009;339:b3410.

 PubMed Web of Science ®Google Scholar

Allgayer H, Owen RW, Nair J, Spiegelhalder B, Streit J, Reichel C, . Short-term moderate exercise programs reduce oxidative DNA damage as determined by high-performance liquid chromatography-electrospray ionization-mass spectrometry in patients with colorectal carcinoma following primary treatment. Scand J Gastroenterol 2008; 43:971–8.

 PubMed Web of Science ®Google Scholar

Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL. Yoga of Awareness program for menopausal symptoms in breast cancer survivors: Results from a randomized trial. Support Care Cancer 2009;17:1301–9.

 PubMed Web of Science ®Google Scholar

Fillion L, Gagnon P, Leblond F, Gelinas C, Savard J, Dupuis R, . A brief intervention for fatigue management in breast cancer survivors. Cancer Nurs 2008;31:145–59.

 PubMedGoogle Scholar

Irwin ML, Varma K, Alvarez-Reeves M, Cadmus L, Wiley A, Chung GG, . Randomized controlled trial of aerobic exercise on insulin and insulin-like growth factors in breast cancer survivors: The Yale Exercise and Survivorship study. Cancer Epidemiol Biomarkers Prev 2009;18:306–13.

 PubMed Web of Science ®Google Scholar

Irwin ML, Alvarez-Reeves M, Cadmus L, Mierzejewski E, Mayne ST, Yu H, . Exercise improves body fat, lean mass, and bone mass in breast cancer survivors. Obesity (Silver Spring) 2009;17:1534–41.

 PubMed Web of Science ®Google Scholar

Ligibel JA, Partridge A, Giobbie-Hurder A, Golshan M, Emmons K, Winer EP. Physical activity behaviors in women with newly diagnosed ductal carcinoma-in-situ. Ann Surg Oncol 2009;16:106–12.

 PubMed Web of Science ®Google Scholar

Ligibel JA, Giobbe-Hurder A, Olenczuck D, Campbell N, Salinardi T, Winer EP, . Impact of a mixed strength and endurance exercise intervention on levels of adiponectin, high molecular weight adiponectin and leptin in breast cancer survivors. Cancer Causes Control 2009;20:1523–8.

 PubMed Web of Science ®Google Scholar

May AM, Korstjens I, van Weert E, van den Borne B, Hoekstra-Weebers JE, van der Schans CP, . Long-term effects on cancer survivors’ quality of life of physical training versus physical training combined with cognitive-behavioral therapy: Results from a randomized trial. Support Care Cancer 2009;17:653–63.

 PubMed Web of Science ®Google Scholar

May AM, van Weert E, Korstjens I, Hoekstra-Weebers JE, van der Schans CP, Zonderland ML, . Improved physical fitness of cancer survivors: A randomised controlled trial comparing physical training with physical and cognitive-behavioural training. Acta Oncol 2008;47:825–34.

 PubMed Web of Science ®Google Scholar

Pinto BM, Rabin C, Papandonatos GD, Frierson GM, Trunzo JJ, Marcus BH. Maintenance of effects of a home-based physical activity program among breast cancer survivors. Support Care Cancer 2008;16:1279–89.

 PubMed Web of Science ®Google Scholar

Rogers LQ, Hopkins-Price P, Vicari S, Pamenter R, Courneya KS, Markwell S, . A randomized trial to increase physical activity in breast cancer survivors. Med Sci Sports Exerc 2009;41:935–46.

 PubMed Web of Science ®Google Scholar

Rogers LQ, Hopkins-Price P, Vicari S, Markwell S, Pamenter R, Courneya, KS, . Physical activity and health outcomes three months after completing a physical activity behavior change intervention: Persistent and delayed effects. Cancer Epidemiol Biomarkers Prev 2009;18:1410–8.

 PubMed Web of Science ®Google Scholar

Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, . Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 2009;361: 664–73.

 PubMed Web of Science ®Google Scholar

Speck RM, Gross CR, Hormes JM, Ahmed RL, Lytle LA, Hwang WT, . Changes in the Body Image and Relationship Scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema. Breast Cancer Res Treat 2010;121:421–30.

 PubMed Web of Science ®Google Scholar

Waltman NL, Twiss JJ, Ott CD, Gross GJ, Lindsey AM, Moore TE, . The effect of weight training on bone mineral density and bone turnover in postmenopausal breast cancer survivors with bone loss: A 24-month randomized controlled trial. Osteoporos Int 2010;21:1361–9.

 PubMed Web of Science ®Google Scholar

Bloom JR, Stewart SL, D'Onofrio CN, Luce J, Banks PJ. Addressing the needs of young breast cancer survivors at the 5 year milestone: Can a short-term, low intensity intervention produce change? J Cancer Surviv 2008;2:190–204.

 PubMedGoogle Scholar

Campbell MK, Carr C, Devellis B, Switzer B, Biddle A, Amamoo MA, . A randomized trial of tailoring and motivational interviewing to promote fruit and vegetable consumption for cancer prevention and control. Ann Behav Med 2009;38:71–85.

 PubMedGoogle Scholar

Demark-Wahnefried W, Case LD, Blackwell K, Marcom PK, Kraus W, Aziz N, . Results of a diet/exercise feasibility trial to prevent adverse body composition change in breast cancer patients on adjuvant chemotherapy. Clin Breast Cancer 2008;8:70–9.

 PubMed Web of Science ®Google Scholar

Morey MC, Snyder DC, Sloane R, Cohen HJ, Peterson B, Hartman TJ, . Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: A randomized controlled trial. JAMA 2009;301:1883–91.

 PubMed Web of Science ®Google Scholar

von Gruenigen VE, Courneya KS, Gibbons HE, Kavanagh MB, Waggoner SE, Lerner E. Feasibility and effectiveness of a lifestyle intervention program in obese endometrial cancer patients: A randomized trial. Gynecol Oncol 2008;109:19–26.

 PubMed Web of Science ®Google Scholar