Nutrition plays an important role throughout the continuum of lung cancer. It is well documented that the best protection from lung cancer is to avoid smoking, but it is also protective to eat a diet rich in fruits and vegetables. Studies suggest that smokers who took high amounts of beta-carotene and vitamin A supplements had an increased incidence of lung cancer and increased mortality rates, whereas beta-carotene from a healthy diet of fruits and vegetables had a protective effect against lung disease.1 There is also strong evidence that consuming arsenic in drinking water increases lung cancer risk. Beyond that, there is some evidence that the consumption of red meats, processed meats, and alcoholic drinks may also increase the incidence of lung cancer. On the other hand, consuming foods rich in vitamin C may reduce the incidence of lung cancer in current smokers, whereas foods rich in isoflavones may reduce the risk for never-smokers.2 There is still research to be done, but these are important factors to take into consideration when counseling patients who are at high risk for lung cancer or part of a lung cancer screening program.
Unlike malignancies such as colon or breast cancer, in which nutritional factors can modify risk and alter prognosis, there are no data to suggest that nutritional factors will have an effect on lung cancer outcomes. To date, there is no one supplement, food, or diet that will cure lung cancer. However, obesity and cachexia can affect treatment and survival rates of patients with lung cancer in an inverse manner. Cancer cachexia is defined as weight loss greater than 5%, or weight loss greater than 2% in patients who already exhibit depletion in body mass index (BMI) or skeletal muscle mass.3 Unfortunately, cachexia is frequently present at the time of diagnosis of non–small-cell lung cancer (NSCLC) and has been associated with lower survival rates. On the other hand, obesity with a BMI greater than 25 has a protective effect on the development of lung cancer, particularly in current or former smokers.4
Cancer cachexia syndrome is characterized by anorexia, weight loss, fatigue, impaired immune function, and poor performance status that are not improved with forced caloric intake. This can affect up to 80% of patients with NSCLC, making it difficult to treat with anticancer therapies, which can cause toxicities such as dysgeusia, nausea, or mucositis. In patients with NSCLC treated with immunotherapy, cancer cachexia is associated with lower response rates and disease stabilization rates.5 Approximately 22% of the deaths in lung cancer patients can be associated with cachexia, so it is imperative to educate providers and patients about the need for a well-balanced nutrition plan.6 It is recommended that patients with lung cancer eat multiple small meals throughout the day, choosing foods that are rich in proteins and vitamins. Patients dietary plans should be customized to their current eating habits, comorbid conditions, regional differences, and individual backgrounds. It is also important to encourage patients to try novel foods and to improve the visual appearance of a meal on the plate by using brightly colored foods that will stimulate their appetite. Following these guidelines will avoid overindulgence that can lead to nausea, heartburn, or gastrointestinal distress, which can be exacerbated by cancer therapies.
When managing treatment-related side effects, alterations in diet must be considered. In patients who experience nausea and vomiting, a bland diet and clear liquids are recommended. A bland diet includes foods such as pasta, oatmeal, whole wheat bread, broth, eggs, and rice. Sticking to small meals, if possible, throughout the day or consuming ginger has also been shown to improve nausea symptoms. Two studies with adults who took ginger at various dosages in combination with prescribed antinausea medications 3 days prior to starting chemotherapy showed reduced severity of nausea.7,8 The use of ginger as a monotherapy did not reduce the incidence or severity of nausea. Patients who develop diarrhea should remember to adequately hydrate throughout the day with water, Pedialyte, or Gatorade along with consuming a bland diet. Avoid caffeine, fatty or greasy foods, and lactose-containing products that may exacerbate symptoms. Conversely, for constipation, naturally occurring laxatives such as prunes, prune juice, chia/flax seeds, or apples may be helpful before taking over-the-counter stool softeners.
For those who experience weight loss or anorexia, drinking nutritional supplements that are high in protein, or adding healthy fats such as avocado or nut butters, can increase caloric intake. Mucositis, an inflammation of the buccal mucosa, including mouth sores, can make it difficult to maintain proper nutrition during cancer treatment. Avoiding foods containing alcohols, vinegars, or spices is necessary to circumvent pain. Drinking through a straw helps avoid mouth sores, and eating soft, easily digestible foods such as applesauce, eggs, or yogurt will help to maintain adequate caloric intake.
The standard dietary recommendations for patients with lung cancer correlate directly with the guidelines put forth by the Department of Health & Human Services (HHS) that includes consuming a wide variety of vitamin-dense fruits, vegetables, and legumes. The HHS recommends consuming low-fat dairy, protein-rich foods such as lean meats/poultry, as well as healthy oils such as extra virgin olive oil or coconut oil, or those that naturally occur in foods such as nuts and avocados. Foods to limit include salt—no more than 2300 mg of sodium per day unless otherwise instructed by a physician. Saturated fats and trans fats such as butter or whole milk and added sugars should also be minimized.
There is much debate and controversy about dietary sugar intake and its link to lung cancer. Recently, a study published in Nature Communications suggested that squamous-cell carcinoma of the lung is uniquely addicted to high sugar consumption. However, further research is needed to determine whether dietary modifications will have an impact on outcome.9 All carbohydrates are broken down into glucose in the cells to fuel the body, and as a result they fuel the cancer cells as well. However, avoiding all dietary intake of carbohydrates or sugars will not “starve” the cancer because other nutrients in the body are also broken down into glucose for energy. It is important to avoid a high-sugar diet for many health reasons, and also to remember moderation is the key to maintaining a healthy balance.
Food preparation is important to reduce the risk of infections when patients are undergoing treatment for lung cancer. Be sure to thoroughly wash your hands prior to handling food. Be sure to use special care when handling raw meats or fish and immediately wash anything that has touched raw meat. Thoroughly wash vegetables and fruit before consumption, and be sure to avoid foods that may have an increased risk of bacterial contaminants, such as sushi or salad bars. If you plan to store food, do so at temperatures below 40°F to avoid bacterial overgrowth.
Nutrition is an essential part of the treatment of any lung cancer patient. Eating a well-balanced diet before, during, and after treatment can improve strength, time to recovery, and avoid side effects. But it is important to remember that no one diet fits all. Each patient’s nutritional needs, treatment plan, and activity level are unique, making it important to discuss the goals of nutrition at each step of the journey.
- Cranganu A, Camporeale J. Nutrition aspects of lung cancer. Nutr Clin Pract. 2009;24:688-700.
- World Cancer Research Fund. Diet, nutrition and physical activity and lung cancer. www.wcrf.org/sites/default/files/Lung-cancer-report.pdf. Revised 2018.
- Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12:489-495.
- Lau S, Gannavarapu BS, Carter K, et al. Impact of socioeconomic status on pretreatment cachexia and survival in non-small cell lung cancer. J Clin Oncol. 2017;35(suppl):31S. Abstract 101.
- Ageleki S, Rounis K, Papadakiet C, et al. Cancer cachexia, sarcopenia and hand-GRIP strength (HGS) in the prediction of outcome in patients with metastatic non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs): a prospective, observational study. J Clin Oncol. 2019;37(suppl). Abstract 9909.
- Zhu R, Liu Z, Jiao R, et al. Updates on the pathogenesis of advanced lung cancer-induced cachexia. Thorac Cancer. 2019;10:8-16.
- Marx WM, Teleni L, McCarthy AL, et al. Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review. Nutr Rev. 2013;71:245-254.
- Ryan JL, Heckler CE, Roscoe JA, et al. Ginger (Zingiber officinale) reduces acute chemotherapy-induced nausea: a URCC CCOP study of 576 patients. Support Care Cancer. 2012;20:1479-1489.
- Goodwin J, Neugent ML, Lee SY, et al. The distinct metabolic phenotype of lung squamous cell carcinoma defines selective vulnerability to glycolic inhibition. Nat Commun. 2017;8:15503.