Dr. Maura Harrigan, Nutritional Advice for Cancer Survivors
September 12, 2010

Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Dr. Francine Foss.  I am Bruce Barber.  Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Foss is a Professor of Medical Oncology and Dermatology specializing in the treatment of lymphomas.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1888-234-4YCC.  This evening I will be sitting in for Ed and Francine and I am joined by Maura Harrigan.  Maura is a nutritionist for the Connecticut Challenge Survivorship Clinic and she joins me to talk about the role that nutrition plays in the prevention and treatment of cancer.

Barber
Maura, how did you become interested in nutrition?  I would imagine that you started with a background in nutrition and then moved into survivorship, but let's not get ahead of ourselves.  Let's find out how you got interested in the general topic of nutrition.

Harrigan
I would have to credit my parents for that, and being raised in a very health conscious home.  Both of my parents are very athletic and good minded with food.  So it was a natural fit for me, and then in terms of cancer that was a bit of a turn in the road where one of my sisters developed breast cancer and passed away at a young age, so that kind of drew me to the field.

Barber
And now you are in the Survivorship Clinic at Yale.  How did that come about?

Harrigan
The clinic came into existence because it was started by cancer survivors who recognized the need for this service.  Cancer patient's are treated exceedingly well and tended to almost on a daily basis during their active treatment, but then once active treatment stops, cancer survivors describe that as falling off a cliff.  So, the group of cancer survivors from the Connecticut Challenge raised the money and started this clinic, they said we need this, and that is how clinic came into existence. I was contacted because in my private practice I focus on wellness, and it was just a natural fit.

Barber
We are told so much about this issue of wellness, but it is so hard to put into practice.  I would imagine that once you have survived cancer treatment, all of a sudden are looking at it with a new set of eyes.

Harrigan
That is so true, and that is one of the most rewarding parts of working in this field with cancer survivors because they come through such an ordeal and it changes their perspective on their life, on health, and how they approach self care.  They come to me very open and wanting to make a change.  It is to me one of those teachable moments and you can make targeted changes and see the benefit, and they do truly benefit.  So it is very rewarding.

Barber
I remember a conversation I had one time with Channel 8 meteorologist Dr. Mel who is a multiple

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myeloma survivor, and this was actually fairly soon after his diagnosis and he had begun treatment, and he said something very interesting and very powerful to me. I asked, Mel, how are you doing?  And he said, "You know what, I wake up every morning and I treat every day as a gift."  And that was amazing to me.  Do you find that in the Survivorship Clinic?

Harrigan
I am inspired by the people that come through the clinic, the survivors.  The landscape changes for them and they do come in with a different outlook on life and they have their priorities in order and they are looking to establish what we term in the clinic, 'the new normal'.  They are reevaluating their lives, their lifestyles, their habits, and their exercise, and their nutrition because they fought hard to get well, and now they come to the clinic and we help them, we give them tools to help them stay well and have a road map going forward in wellness.

Barber
How different is the conversation you are having with the cancer survivor about nutrition from someone who is not dealing with that?

Harrigan
Definitely the motivation of the person. The cancer survivor, as I said, comes in open and motivated for change and from a caregiver's standpoint, that is very powerful.  It is actually quite easy to work with them.

Barber
Does it vary based on what you have been treated for or are there basic tenets that all cancer survivor should be following?

Harrigan
There are basic tenets, what's different is where the person is at and how you help them get to that.  The basic tenets from the nutrition standpoint, is that we look at a visual, as you imagine your dinner plate you want two-thirds of your dinner plate to be filled with foods from plant resources.  It is an interesting visual and then the meat on the plate is a condiment.  That is a good visual to work with and using that as a starting point, then you start getting to how do I get there, and two-thirds plant based means lots of whole grains, fruits, vegetables, and right there that is often a stumbling block for a lot of people.

Barber
I think this is true for all of us, food is something that we often use to relieve stress, and I cannot think of anything more stressful than dealing with cancer.  So you obviously have got someone who is motivated to do well, but you are potentially faced with taking away 'comfort food'.  Taking away that coping mechanism in a way, or changing it.

Harrigan
I am all for comfort foods, and I work around those.  We work with comfort foods and we build around them, because it is true, you cannot take away the emotional component of eating because that is so important.  Chocolate to me is a food group.

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Barber
Me too.

Harrigan
And how someone takes their first morning cup of coffee is sacred.  There are certain things you do not change.  What I try to do is target changes. When I sit and talk with people, I identify areas in their eating that may be most problematic, and we focus on those and work to build and establish some good healthy habits and not forsaking all the fun parts.

Barber
How long does it take, do you find, to make real change in your life? I have heard that it takes 30 days to really make a change.

Harrigan
You are a fast worker.  I am going more with the three-month plan.

Barber
No kidding.

Harrigan
In fact, we changed at the Survivorship Clinic, we now have people come back for three visits, once a month to work with that process.  It really takes a good three months to establish a new habit, break down an old one, and build a new one.

Barber
What is your process for working with someone? Take me through that first visit.  What are you doing?  Are you finding out what they are eating now?

Harrigan
Yes, when someone comes in I do ask them if they have any pressing nutritional questions first.  And some people come in just for a quick tune up.  They have a real short list of questions that they have investigated and they want the answers.  They give me a quick review of how they are eating.  I give them my blessing and they are happy and they are off.  Some people come in really without any starting point, and they are at a loss.  At that point, I sit down and go through their day.  How they eat throughout the day, and then I get a good sense of what do we keep, what do we add, what do we take away? And also what they are able and willing to do.  It is a bit of a negotiation at times.

Barber
In a perfect world, what would you say to have for breakfast?  Keeping in mind that the cup of coffee is sacred.

Harrigan
I am so glad you even mention breakfast because often that is the biggest omission in people's days. Getting people to eat breakfast is also one of the most powerful things they can do.  As simple as a quick bowl of high-fiber cereal with milk on it, throw a handful of blueberries, you are good to go, and that makes a huge difference in people's day.  The biggest benefit I find from

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eating well for cancer survivors is that they feel better.  It gives them better energy levels and it helps manage the fatigue that is inherent from the cancer treatment.  First and foremost, that sense of well beginning, so that breakfast meal gets that feeling going right away, and then we can build upon that.

Barber
How important is it to throw in some protein to that breakfast meal, some eggs or egg whites?

Harrigan
Protein is essential and I encourage people to eat early, eat often, and always have a bit of protein at each meal and snack.  Let's take that bowl of high fiber cereal, if you put organic skim milk on, the protein in the milk is a good source.  Another alternative breakfast would be eggs or egg whites, even yogurt and fruits and granolas.  Those are quick where people can have it as they are trying to get out of the door, get on with living, we try to make things quick, easy, fast, and simple.

Barber
What if they are a person who stops at, dare I say a fast food restaurant, or some place where they are picking up something on the go.  Is there is a way to eat more healthfully when you do go to one of those establishments, or are you pretty much out of luck?

Harrigan
It is usually one of my personal tendencies to avoid anything you purchase through a drive through window.

Barber
That is good, that is good to know.

Harrigan
Often that gets people in trouble, that eating on the go and eating where you do not even get out of the car, that is often a fundamental habit that we start working on right away.

Barber
That is something that is great to take away from this though, just putting in your mind that this does not happen without some effort on your part, not only in making the decision to eat differently, but to shop for what you need and have it there and make it so you can prepare it quickly and so it works in with your schedule.

Harrigan
You are now an honorary dietitian.

Barber
Excellent.

Harrigan
That is really it, to eat well in this environment is very difficult.  If you eat what is out there and available, readily available and convenient, it is high in fat, high in salt, and high in calories.  It is very hard to manage weight and have a nutritious diet.  To eat well in this environment you do have to be very mindful and have to put thought into it and have a plan. It is as basic as getting a

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good shopping list and having the food in your home environment so that you are surrounded with good choices and you can grab these things as you head out and that is exactly the bread and butter, so to speak, of what I do in the clinic. Help people with very fundamental, basic day-to-day tools.

Barber
So I have had my healthy breakfast, my whole grain cereal with some blueberries on it, what do you have for snack? Everybody gets hungry between breakfast and lunch, what are some healthy snacks?

Harrigan
Snacks are important.  My favorite snacks are a fruit and a nut, so a handful of nuts and dried fruit is a great combination of a heart-healthy fat, a protein, and just enough carbohydrates, so it is a nice mix and gets your blood sugars stable.

Barber
We are now up to breakfast and then the healthy snack.  We are speaking with Maura Harrigan about nutrition and cancer and will get to lunch, afternoon snack, and dinner, when we come back.

Barber
Welcome back to Yale Cancer Center Answers.  I am Bruce Barber and I am joined by Maura Harrigan who is a nutritionist for the Connecticut Challenge Survivorship Clinic at Yale Cancer Center. We are talking about nutrition for cancer survivors and we got up through breakfast and mid-morning snack, let us continue our day now, what is a great lunch?

Harrigan
A great lunch first off is one where you can incorporate a bit of an outside walk, so that you get in some exercise and again that is what we encourage at the clinic.  There is also a physical therapist

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who talks about the exercise component.  But lunch time is a great time to remove yourself from the work environment or your home environment where you can get outside, take a nice walk and incorporate that into your lunch routine.  I do promote brown-bagging lunch, again, it is cost effective and you have more control over what you are eating and keeping it simple, whole grain breads, simple sandwiches, working in tuna fish, even peanut butter, and really keep it simple. We want to limit red meat to about once a month.  That is often bad news for a lot of people, and to avoid processed meats.  Lunch time can be tricky for people in terms of luncheon meets, which is really a food group that we strongly encourage to be avoided.

Barber
Your guest dietician likes chicken breast, is that a good one?

Harrigan
Excellent choice.

Barber
I am glad to hear that; a little mustard on whole wheat bread.  Is there a difference in whole wheat breads?

Harrigan
There is a difference in the amount of fiber, and the more fiber the better. The way you find that out is when you are purchasing bread look on the food label and look where the grams for fiber are listed and 3 g or more is considered a high-fiber food.

Barber
Per serving?

Harrigan
Per serving, yes, those numbers are listed per serving and that applies to cereals also.

Barber
Now, how about a mid-afternoon snack?

Harrigan
Well, I did want to add some vegetables and fruits at lunch.

Barber
Okay, let's not jump to snack before we finish our lunch.  That is a good point.

Harrigan
We are trying to work in fruits and vegetables here.

Barber
Okay, good.

Harrigan
A nice way to work in vegetable is tomato juice. It is good to always add fruits to lunch, lettuce and tomato to the sandwich, so that about covers lunch.

Barber
Not to continue to toot my own horn, if you will, but I have been trying to work in more fruits and

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vegetable and I have found that just taking those carrots and even cutting them up a little more and adding a little pepper on them to give them a little flavor, is great.

Harrigan
That is an excellent suggestion.

Barber
Let's move on to the mid afternoon snack now.

Harrigan
We could use those carrots that you just described.

Barber
If I could hold off at lunch and save them for the snack.

Harrigan
That afternoon snack seems to me to be essential because it is a natural low energy time for people and if you skip that snack, you set yourself up, particularly for survivors, for worsening fatigue in the afternoon and also setting the stage for overeating at dinner.  That late afternoon snack is essential.  I like vegetables, hummus, cheeses, even cheeses that you buy in the store, the Laughing Cow Wedges, things that are portable, throw it in your briefcase, in you purse, you can carry those with you and the cut-up vegetables that you described.  Those are excellent suggestions.

Barber
And then dinner.  A lot of times in our culture people go for that big dinner, before we are going to go to bed, and that is generally advised against.

Harrigan
That is true.  Eating early and often through the day enables you to eat less at night because you are not under fueling during the day, so that you are at this deficit where your body is just saying "I am so hungry, please feed me," and the largest meal of your day in the evening is a recipe for weight gain and that is one of the goals in cancer survivorship, weight maintenance and preventing weight gain.  Fueling early and often is key. There is an old adage, eat breakfast like a king, lunch like prince, and dinner like a pauper and that still holds true.  By having those important snacks during the day, the goal is to have dinner be your smallest meal and that is often a big reversal for people.

Barber
How soon before bed do you want to make sure you have not had anything to eat? Is there a period of time where you want to make sure you have not had anything to eat by a certain time?

Harrigan
Yes, I often negotiate that with people.  At least an hour, ideally 2 or 3, but it depends and many cancer survivors do suffer from gastric reflux.  That is an important management tool, not to eat close to lying down, before bedtime.  There I would like to see 3 hours where they are not consuming foods and that lessens the symptoms of reflux at night.

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Barber
How about alcohol? What you are telling cancer survivors who maybe love to have that glass of wine with dinner, or beer when they get home?

Harrigan
Well the benefits of alcohol have been shown for cardiovascular health, not necessarily for cancer prevention, but cancer survivors do need to be concerned about their cardiovascular health.  So the alcohol does play a protective role there, but it is the amount.  Moderate drinking is one drink a day for women and two for men, and also that alcohol is the same whether it is a 5 ounce glass of wine, a 12 ounce bottle of bear, or a shot of good scotch, that alcohol content is all the same.

Barber
We have already mentioned fast food as being something to avoid.  Are there other types of foods that I might even find in the supermarket, that if I am a cancer survivor, I really want to stay away from?

Harrigan
Yes, look at the ingredient list and if it reads like a chemistry textbook, that is not food you want to choose.  Keeping the ingredients list short and keeping foods real and as I say, close to the ground, those are the food you want to choose, so highly processed foods are foods that you want to avoid.

Barber
How about supplements?  What are the things that cancer survivors should think about in that regard, because that seems like a dizzying ray of possibilities.

Harrigan
It is dizzying, even to me.  It is interesting, over 70% of cancer survivors take supplements just on their own and supplements are actually not recommended except for a few, and I would like to get to that. From the American Cancer Society, the World Health Organization, the message is to get your nutrients through whole foods, not supplements.  Do not rely upon supplements for your nutrients.  Now the ones that are good are calcium, of course vitamin D, because cancer survivors do need to monitor their bone health and that is one of the late effects of treatments, and omega-3 fatty acids are proving to be important, mostly because we have almost wiped it out of our food supply, so we are just replacing omega-3 back into our diet, but what is most important is, before you take any supplement, talk about it with your physician.  Particularly during active treatment, these supplements can directly interfere with the chemotherapy agents that are being used.  During active treatment, supplements are highly discouraged and then in the survivorship phase and in the clinic, it tends to be a negotiation too.  First do no harm, so I really look at peoples report of their supplement use very carefully because another aspect that people do not realize is when they take multiple formulas that they are getting duplicate versions of, let's say, Vitamin A, and that adds up pretty quickly and there are upper limits of safety, so that is one thing I look for.

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Barber
I would imagine that it is very important for a cancer survivor that the whole family be involved in this, is that something that you stress also?

Harrigan
Yes, and it depends on the role of the cancer survivor, what their role is in the family in terms of food.  If this person is the primary cook and food shopper, they may not feel up to the task because of the fatigue.  That may be something that again we negotiate with the family, saying, you know, "I used to do this, but I cannot do it anymore because my energy needs to be spent elsewhere."  It is important to evaluate where the survivor is in terms of the family and in terms of their role in food preparation and shopping. Another aspect is if there are children in the home, I often discuss with survivors their concern about their children's eating and that teaching them good nutrition habits that will help their children to avoid cancer in the future and that becomes a big focus and concern for the parents.  Often times we will focus on the children's eating and that sets the ground work for the whole family eating well.

Barber
That is really the perfect way to lead into my next question which is the role of good nutrition in cancer prevention.

Harrigan
The research is showing that at least 30% of cancers can be prevented through good nutrition and exercise and it always goes hand and hand, you cannot have one without the other.  It is a vital role in cancer prevention.

Barber
Talk a little about the research that is being done, and ongoing projects that you are involved with.

Harrigan
I am fortunate to be involved in two very exciting studies, one is called the Walk Study, which is for women who have been treated for ovarian cancer.  It is one of the first research studies for women who have been treated for ovarian cancer and it is an exercise study that looks at the effect exercise has on quality of life and also certain hormones in the blood for women who have been treated for ovarian cancer. Another study is called the Hope Study, which is for women who have been treated for breast cancer who are receiving aromatase inhibitor therapy, and those medications are very powerful, but they tend to carry some strong side effects for certain women to the point where the women do not want to take the medication anymore.  This study is aimed for those women, and again using exercise, to see if it mitigates some of the side effects of the aromatase inhibitors to help them stay on the medication and reap the benefits of the medication.

Barber
Is this all pretty new?

Harrigan
It is very new and is exciting, and the research team is thrilled to be doing this and when we contact women to participate in his study, every woman is happy to jump on board.

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Barber
Probably because they are not just gaining the benefit, but it is the knowledge also of the fact that it is benefiting future survivors.

Harrigan
Yes, that is something I hear from cancer survivors.  They want to give back to the community to help future survivors and it is very powerful.

Barber
You mentioned before, and I could just tell the way you were energized when you started to talk about the people you work with, that must be the real joy of what you do.

Harrigan
In terms of the patients, it is an honor, and as I said, cancer survivors have gone through a life changing experience and they bring to me this wisdom that I learn from every day.

Barber
Going forward, what is the most exciting thing you see on the horizon in the field of nutrition and cancer?

Harrigan
There are targeted therapies, treatment gets more and more targeted towards the specific cancer and the subtypes of cancers and that we can also target foods to address that.

Barber
Maura Harrigan is a nutritionist for the Connecticut Challenge Survivorship Clinic at Yale Cancer Center.

If you have questions or would like to share your comments, visit yalecancercenter.org where you can also subscribe to our pod cast and find written transcripts of past programs.  I am Bruce Barber and you are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.