A Home-based Lifestyle Intervention for Optimizing Surgical Outcomes Among Urinary Bladder Cancer Patients

Urinary bladder cancer is the fourth leading cancer in men in the US, leading to 18,000 deaths among men and women annually.1 The survival rate is 69% for localized disease, 36% for regional disease, and only 5% for metastatic disease.2 Bladder cancer patients often present with non-muscle invasive bladder cancer (NMIBC) and are treated with chemotherapy or immunotherapy delivered locally in the bladder. Patients with muscle- invasive bladder cancer or intravesical therapy-refractory disease undergo cystectomy. Weight loss, frailty, sarcopenia, and malnutrition are commonplace among urinary bladder cancer patients, all being associated with treatment-related complications including susceptibility to infection, poor prognosis and quality of life.3 Medical nutrition therapy is indicated in this population that generally has poor diet quality4-7 to achieve or maintain a healthy body weight, preserve lean body mass, minimize nutrition-related side effects, and maximize quality of life.8-10 Yet, only a handful of dietary interventions have been conducted among urinary bladder cancer patients, and no studies of diet intervention coupled with exercise prescription, with the goal of improving treatment outcomes in this population. Pre- and postoperative nutrition support has been linked to reduced hospital length of stay,11 and lower postoperative complications like infection. Immunonutrition interventions, which comprise of supplements or food/drinks high in vitamin A, fish oil or omega-3 fatty acids, and specific amino acids like arginine, have also been shown to lower postoperative complications in cystectomy patients and other cancer populations.12-15 In patients receiving chemotherapy or radiation, immunonutrition also appears to reduce mucositis and weight loss.16 Furthermore, resistance exercise promotes maintenance or increase in muscle mass, particularly among individuals with sarcopenia.17

Little is known about the trajectory of dietary intake after bladder cancer diagnosis, and the specific nutritional needs of this population in diverse settings where health disparities exist, such as among rural or socio- economically disadvantaged patients.18 There is also a critical need to develop and test interventions that are simple, scalable, durable, and cost-effective,4, 19 and that address food insecurity.20 Given these major research gaps, we will implement a novel, peri-operative lifestyle intervention rooted in Social Cognitive Theory (SCT)21, 22 that uses food/ingredient, menu and recipe provision coupled with resistance exercise recommendations and tools provided in the "Boost Box", mailed to participants over 12-weeks. The intervention builds self-efficacy and behavioral capability in preparing meals to support nutrition goals and addresses social determinants of health in underserved populations by tackling food insecurity.23 Community partnerships will build the foundation for scaling up lifestyle intervention for cancer patients in Utah. Expanding the availability of evidence-based options for nutrition and physical activity counseling for cancer patients and survivors has been identified as a major need.24 Our proposed study is multidisciplinary and community-focused by partnering with the University of Utah Center for Community Nutrition and their established partners (e.g., Waste Less Solutions, Wasatch Community Gardens, Food Recovery Network, Utah Food Bank, Dairy West, and commercial grocers like Smiths and Harmons) to roll out the intervention in the community. Indeed, community and home-based lifestyle interventions improve physical functioning and clinical outcomes among cancer survivors and are cost-effective.25, 26 Delivering diet and physical activity education using a home-based 'Blue Apron' type approach in partnership with the community is highly novel.

Urinary bladder cancer is the fourth leading cancer in men in the US and accounts for over 18,000 deaths among both men and women annually.1 About three quarters of bladder cancer patients present with non- muscle invasive bladder cancer and are treated with chemotherapy or immunotherapy delivered locally in the bladder, or cystectomy alone in intravesical-refractory or extensive disease. Muscle-invasive bladder cancer treatment includes neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy. Cisplatin- ineligible patients proceed with cystectomy and those who are too sick or frail for cystectomy receive chemotherapy followed by local radiation. Weight loss is a common occurrence post-radical cystectomy, and is associated with malnutrition3 and poor overall survival.34 Moreover, up to 70% of bladder cancer patients, particularly those with frailty, present with sarcopenia, a condition of reduced skeletal muscle mass and function that is an independent poor prognostic factor35 linked to medical complications and quality of life.36 In all, this population has a 60% complication rate by 90-days,37 from urinary tract infections to bowel obstruction.

Nutrition is a vital component of chemotherapy tolerability and preparation for and recovery after cystectomy38 to prevent or resolve nutrient deficiencies, achieve or maintain a healthy body weight, preserve lean body mass, minimize nutrition-related side effects, and maximize quality of life.4, 8-10, 39 Diet quality is generally poor among adult cancer survivors in the United States.4 Bladder cancer is especially prevalent in developed countries with Western style dietary patterns and high levels of obesity,2, 40 with significant socioeconomic and geographic disparities observed.18, 41 Indeed, rural compared with urban residence is associated with elevated cancer-specific and other cause mortality among bladder cancer survivors.41 In addition, improvement in diet quality among cancer survivors undergoing dietary intervention has been found to be smaller in rural than urban patients. Yet, despite the biologically plausible role of diet in the etiology of bladder cancer, and the potent effects of treatment on nutritional status and weight loss in this population, remarkably few studies have evaluated either pre- or post-diagnosis diet in association with outcomes after bladder cancer diagnosis, nor implemented dietary intervention among bladder cancer patients to optimize their treatment outcomes.42

We will address this immense research gap by testing a randomized, controlled diet and physical activity trial designed to address barriers to participation in lifestyle intervention among 16 urinary bladder cancer patients (50% rural; 50% no college education). Baseline and post-surgical recovery nutritional status will be evaluated with patient-generated subjective global assessment (PG-SGA).43, 44 Diet will be assessed with 3-day food record during the first 6-months post-diagnosis. In the intervention arm, patients will be mailed a "Boost Box" weekly for 6-weeks before and 6-weeks after surgery, prepared by our community partners, containing food ingredients. We will work with the University of Utah Center for Community Nutrition to mail curriculum boxes with a menu and recipes for a high protein, immunonutrition-tailored diet (i.e., arginine, vitamin A, and omega-3 rich foods/beverages), and resistance bands (Theraband) with strength training guidelines.3,