A very good morning to everyone. I am here today to share about the health background of cancer survivors in Malaysia.

Before I begin, I wanted to highlight exactly what I wish everyone can take away from this presentation. First and most important, what are the lifestyle behaviors of cancer survivors after cancer diagnosis (where they are)? Second, what is the future recommendation? Introduction Cancer is one of the top ten leading causes of death worldwide. While it is ranked second in the developed countries, it is among the three leading causes of death in the developing countries. If the current trend continues, the number of deaths from cancer is projected to double by the year 2030 with higher rates occurring in both middle and low income countries. In 2008, 11.2% of deaths registered in Ministry of Health Malaysia hospitals were attributed to cancer, making it the third leading cause of death in Malaysia. The most common cancer diagnosed were breast (16.5%), colorectal (13.2%), lung (9.4%) and cervical (4.9%). While breast cancer was the most common cancer diagnosed among women, colorectal cancer was most prevalent among men. Cancer is a preventable disease that is largely determined by environmental rather than genetic factors. About 35% of all deaths from cancer worldwide are attributed to preventable risk factors with smoking alone contributed to 21% of cancer deaths. Alcohol use, low intakes of fruits and vegetables, physical inactivity, overweight and obesity are estimated to have caused another 14% of deaths from cancer. In Malaysia, smoking, overweight and obesity have been estimated as major risk factors for cancer deaths The Womens Healthy eating and living Study (WHEL) showed that breast cancer survivors tend to increase fruit and vegetable and decrease fat intake since diagnosis. The Health, Eating, Activity and Lifestyle (HEAL) Study is a population based prospective cohort study showed that women with breast cancer were significantly less physically active within their first year after breast cancer diagnosis than they were 1 year before breast cancer diagnosis. This study further reported that about half of the breast cancer survivors, consisting mainly of lean and overweight women, returned to pre-diagnosis physical activity levels after 3 years. Information on lifestyle behaviours is limited to data from developed countries. Since there are differences in the epidemiology of cancer and lifestyle patterns between Asian and Western regions, there may also be differences in the dietary intake and lifestyle pattern after cancer diagnosis. However, such information in Malaysia remains unknown. As I mention in previous slide, it is projected that the number of deaths with cancer will double after 20years. With increasing world population and exposure to cancer, preventive efforts could be a challenge to health professionals and policy makers. As more people with cancer survive longer due to advances in medical technology, they are also at risk of cancer recurrence and chronic diseases. Therefore, knowledge on health and nutrition of cancer survivors is important as this information could give insights for the planning and development of strategies to reduce cancer risk and improve cancer survival. As such information is lacking in Malaysia, this presentation aimed to describe health and nutrition of cancer survivors in Malaysia. This study was conducted in eight general hospitals and four breast cancer support groups in seven states of Peninsular Malaysia. A total of 457 women with cancers of the breast, colorectal, cervix, ovarian and stomach voluntarily participated in this study.

This study was registered with The National Medical Research Register (NMRR) and approved by The Ethical Committee of Medical Research, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia and The Medical Research Ethics Committee (MREC), Ministry of Health Malaysia. All cancer patients were interviewed and measured by trained enumerators using a pre-tested questionnaire. The questionnaire consisted of five sections: Sociodemographic characteristics and cancer history, anthropometric measurements, dietary intake, physical activity and complementary and alternative medicine practices. For socio-demographic characteristics, most of the subjects were Malay, married, had had completed secondary education unemployed. Majority (86.2%) of the subjects were breast cancer survivors and were diagnosed with cancer at Stage I (47.5%) and Stage II (42.7%) More than half of subjects were overweight and obese and about 25% had waist circumference more than 80 cm where at increase risk of metabolic complications while approximately 41% of the women had more than 88 cm which at substantial risk of metabolic complications. In other words, many of these subjects were not only overweight but were also at risk of having abdominal obesity. These conditions will put them at greater risk of developing cardiovascular diseases, diabetes and cancer recurrence. Most cancers cause weight loss, changes in appetite and dietary intake and reduced physical activity. However, weight gain is a common observation among breast cancer survivors. In this study, weight changes among breast cancer survivors were identified at 3 time periods which were from a year preceding diagnosis to time of diagnosis, from a year preceding diagnosis to study entry and from time of diagnosis to study entry. Women had significantly gained weight both at from a year preceding diagnosis to study entry and from time of diagnosis to study entry, but had significant weight loss from a year preceding diagnosis to time of diagnosis. One plausible explanation for this weight loss is that the breast cancer disease process itself causes the weight loss. What I would like to highlight here is weight at a year preceding breast cancer diagnosis is considered as stable weight, women should returned to their weight at a year preceding breast cancer diagnosis at study entry, however, these women tend to have weight gain. Weight gain is a concern for women after breast cancer diagnosis as excessive weight gain may put breast cancer survivors at greater risk for future obesity-related morbidity, cancer recurrence and mortality. Weight gain amounting to 3-4 kg after breast cancer diagnosis was observed in this study. These findings are in line with the findings from Western populations, which reported that women are more likely to experience weight gain after breast cancer diagnosis. For percentage of energy from carbohydrate, nearly half of the subjects get energy from carbohydrate and fat within the recommended range. However, half of them had energy intake from protein more than the recommended range. Although, adequate protein intake is essential for survival, longer survival was not observed in women eating more meat as protein source.

The number of servings for all food groups, except for meat/fish/poultry/legumes was less than the recommended servings. The daily intake of fruits and vegetables among women in the present study is similar to the findings of the Malaysian Adult Nutrition Survey, which reported that about 75.5% of Malaysian women aged 18 to 59 years did not meet the dietary guideline for fruit and vegetable intakes. ). Although there are no studies to date that confirm which compounds in fruits and vegetables are most protective against cancer, cancer patients and survivors are encouraged to consume five or more servings of a variety of coloured fruits and vegetables daily for health benefits. Therefore, there is interest in the development of strategies to increase fruit and vegetables consumption, in the general population or high risk groups, as well as cancer patients or survivors in Malaysia. Most of the subjects in the present study had moderate and high physical activity level. The physical activity patterns in the present study were consistent with those reported by Bellizzi et al., 2005, in that cancer survivors were more active than non-cancer controls. Cancer survivors are more likely to adopt a healthier lifestyle, which could explain why most of the women in the present study had at least a moderate intensity physical activity. The use of complementary and alternative medicine is increasingly prevalent among cancer patients. The finding showed that slightly less than half of the subjects reported the use of CAM as complementary to conventional treatment. The study finding in this study is similar to the prevalence reported in other studies, in that about 35.9% reported in 14 European countries, 56% in Singapore, 45% in Japan, 35% in Iran and 50% in Malaysia. Previous studies reported that there are various types of CAM therapies commonly used by cancer patients. The therapies include herbal remedies, dietary supplements, homeopathy, spiritual therapies, and massage. Similarly, this study also found that dietary supplements such as vitamin and spiritual activities were the most common types of CAM therapies used by cancer survivors in Malaysia. Cancer patients may have their own reasons to use CAM therapies. In this study, the main reasons for CAM use among cancer patients were to increase bodys ability to perform daily activities, enhance immune functions and improve physical and emotional well-being. In Malaysia, the incidence of cancer is on the rise but with effective treatment and care, many cancer patients have better survivorship. The study finding has highlighted that diet, physical activity and other lifestyle factors should be the focus of the strategies as these lifestyle factors are linked to cancer. The strategies should assist or motivate cancer survivors to adopt a healthy lifestyle through appropriate diet such as increase fruit and vegetable intake, maintain high to moderate physical activity which will help to maintain a healthy body weight and to improve overall quality of life after cancer diagnosis. Cancer patients may use CAM together with conventional medicine. As CAM may have the potential to be directly or indirectly harmful to the users, cancer patients should be knowledgeable on CAM and discuss their CAM use with health professionals to prevent possible adverse effects of these therapies. There is also a need to provide health

professionals and the general public particularly cancer patients with guidelines on safe use of CAM. Thank you for your attention and now I am pleased to answer to any questions you may have.