6 Factors That Could Prevent Cancer and Improve Treatment Outcomes

Illustration courtesy of Violeta Noy

6 Factors That Could Prevent Cancer and Improve Treatment Outcomes

6 Factors That Could Prevent Cancer and Improve Treatment Outcomes

“The irony of getting cancer after studying and coauthoring a book on anticancer living was not lost on me,” says Lorenzo Cohen, the Richard E. Hayes Distinguished Professor in Clinical Cancer Prevention and the director of the Integrative Medicine Program at the University of Texas MD Anderson Cancer Center. With his wife, Alison Jefferies (who has a master’s in educational psychology), Cohen wrote a book (Anticancer Living) about six lifestyle changes that they’ve linked to cancer prevention and better outcomes during and post-treatment.

The six pillars, or the Mix of Six as they call them, are: love and support, stress management, sleep, physical activity, diet, and avoiding environmental toxins. Together, these factors have a powerful synergistic effect on the mind and body, the couple explain. And while Cohen believed this before his own diagnosis, the way he thinks of the body’s ability to heal and the value he places on really taking care of yourself are profoundly different today.

A Q&A with Lorenzo Cohen, PhD, and Alison Jefferies, MEd

What is the Mix of Six?

Cohen: Often, after finishing cancer treatment, doctors will say, “There is nothing you need to do; we will simply scan you on a regular basis.” But based on the overwhelming amount of evidence that links lifestyle to cancer prevention and control, this lack of advice and guidance is, to me, medically unethical. Harnessing the power of lifestyle change needs to start at the time of diagnosis.

In our book, Anticancer Living, we discuss the six factors that make up what we call the Mix of Six. Patients can live by these six lifestyle factors to create a body that is inhospitable to cancer. Grounded in my own research as well as the latest scientific studies, the Mix of Six is a great tenet to live by whether you’re in the midst of battling cancer, are a caregiver, or are trying to reduce the likelihood of ever developing cancer.

Many people continue to view cancer as a disease that can strike anyone at any time. Just random bad luck. Or they consider cancer to be a genetic disease—a predisposition inherited from our parents. What often accompanies this belief in randomness or predestination is a feeling that we have no control over cancer. That once diagnosed, there is little we can do to alter the course of fate. But that’s simply not true. In fact, “random” bad luck accounts for the minority of cancers, and inherited gene mutations account for only between 5 to 10 percent of cancers. Cancer does not grow in isolation. It develops within an environment we help create with the things we eat day after day, our stress levels, our physical activity, our support network, the quality of our sleep, and our exposure to environmental toxins.

The Mix of Six is:

  • Love and support

  • Stress management

  • Sleep

  • Exercise

  • Diet

  • Environmental exposures

The Mix of Six influences cancer risk and survival after a cancer diagnosis. And importantly, each of the six affects multiple key biological processes linked with cancer growth in our bodies—what are called the cancer hallmarks.

That said, as powerful as we know lifestyle factors are in preventing cancer and improving outcomes for those with cancer, we need to avoid guilt, blame, or shame about what may have caused a cancer. We may never know the root cause of an individual cancer, and in many respects, the source of the disease is secondary to the path of recovery. We need to start where we are today and move forward in a healthy, hopeful, and positive way.

Is it critical to do address all six together or can you focus on one at a time?

Jefferies: The beauty of the Mix of Six is that you can work on multiple areas at once or one area at a time. This is a method that is made to work with you, where you are, and what is best for you. You are the best expert on you. The smallest shifts in lifestyle can add up to big changes. And success in one area can lead to success in the other areas.

For example, if you try to modify your diet but have not worked on possible sleep issues, it can make it more challenging to successfully modify your diet. Sleep deprivation changes how we metabolize food and influences food cravings. Reducing stress levels—with meditation, yoga, or other techniques—will lead to more restful sleep and even better relationships. Sleeping well, eating well, and exercising are all interrelated: Each reinforces the others.

Another example is that stress decreases the benefits of healthy eating. A study found that stress negated the effects of eating a healthy meal, so if you are trying to improve the quality of your diet, it might not make much of a difference if you’re not also managing your stress. Stress can sabotage our healthy intentions. Ignoring this factor and just jumping in with making diet and exercise changes will make achieving success more challenging. We also now know that our efforts at self-care and lifestyle changes are related more to social support than to will-power or self-discipline.

The positive synergistic effect we see in improving behavior change is also manifested at a cellular level. The more behaviors that are changed, the lower our levels of inflammation will be and the stronger our immune system will become. Combined, this can result in an overall reduction in the activation of certain cancer hallmarks. Importantly, there is some research that suggested that when a healthy diet was combined with physical activity, the risk of dying from breast cancer was reduced by half, compared with the women in the study who only modified either by eating fruits and vegetables or by exercising or who did not change either behavior.

This reinforces that the Mix of Six is most effective when applied synergistically and not solely as a particular diet, or a particular exercise, or a particular mind-body practice. Lifestyle changes have the greatest impact when implemented simultaneously.

Does one factor hold more weight than the others?

Jefferies: Yes! Love and support are the most critical. And the reason is simple—without substantial support, it is very hard to make sustainable changes. We often say, “Tomorrow is the day I am going to start working out or start my new diet,” and by lunch we’re celebrating a birthday, or meeting friends for drinks after work, or feeling too tired to go to the gym, etc. This leads to feeling defeated. To negate these feelings, start by finding your support team. Begin putting what you need in place to make sustainable changes that are best for your body, mind, and spirit. You might consider:

  • Finding a friend to take a meditation class with

  • Arranging to meet a colleague for a walking meeting

  • Planning a week of menus with a friend and bringing the leftovers to work for lunch

  • Having a fellow parent help with your child’s schedule and driving needs

Love and support have a direct effect on our health and well-being. Individuals who experience chronic loneliness or social isolation experience higher rates of premature death and have a decreased life expectancy after a cancer diagnosis.

Cohen: Once a support network is in place, we can begin to change our mind-set about life and our life’s purpose. The majority of patients from our lifestyle research and the long-term cancer survivors we interviewed for our book saw this mental change as the most critical component of their new way of life, more than diet or exercise. For many, healing the body became the sole focus and purpose of every daily lifestyle choice, but it began with an important mental shift that helped them recognize that their daily choices had a real and measurable impact on their health and quality of life. Once your social support network is in place and you are managing your stress better, then the other areas are much easier to tackle.

How do you put together a support team?

Jefferies: No one person can provide everything. We need different people and resources for the different levels and kinds of support in our life. This does not mean you need a huge support team. Sometimes, just a few really good friends, a work colleague or two, and a couple of fellow parents are all it takes to help you meet your needs and goals. Support can fall into five broad categories:

  1. Practical support:

    People who support you in practical, tangible ways. People you can count on during difficult times to drive you to appointments, organize care rotations, help with meal planning and prep, etc.

  2. Informational support:

    People you can get informed advice from and talk through options and decisions with. People whose opinions you trust and who you know have your best interest at heart.

  3. Motivational support:

    People who support your worth in this world, see the importance of the changes you are trying to make, and help keep you motivated. For those with cancer, these are the people who remind you of your qualities as a whole person—not just as a patient.

  4. Community support:

    Group connections and social integration provide both a sense of belonging and the ability to assist others, which reinforces your own value in the world.

  5. Emotional support:

    People with whom you can share your deepest troubles and joys and who can offer unconditional love.

Think about the different types of support as pillars that will help keep you level as you move forward. Ask yourself: Which pillars of support feel less stable? Where do you have enough, and where might you welcome some more assistance? For those who are feeling socially isolated, there are many ways to develop your social support team and get connected. This can be done both in the home and by engaging with others. Consider joining a support group, volunteering for an online organization, or starting a hobby that connects you with others.

What are your favorite ways to reduce stress?

Jefferies: The best mind-body practice for you is the one you will do every day. You are the best person to figure out what is best for you. We have explored many mind-body practices within our own family. Two that were particularly effective for us were a guided meditation before school and family yoga.

Lorenzo and I love to practice yoga—so much so that Lorenzo recently completed a two-hundred-hour yoga teacher certification. Yoga is powerful because it is a quintessential mind-body practice that, if done properly, includes body (postures—asana), breath (pranayama), and mind (meditation) all coming from a place of mindfulness. Engaging in a daily mind-body practice for as little as ten minutes has demonstrated beneficial changes down to the cellular level. Of course, practicing for more than ten minutes is likely better, but we don’t want lack of time to be an excuse or a barrier for anyone.

There is evidence that the following practices are useful for managing stress and decreasing harmful stress hormones that drive cancer progression. They also turn on genes that improve our health and turn off genes that are associated with illness and vulnerability to cancer:

  1. Cognitive behavioral therapy

  2. Meditation

  3. Deep diaphragmatic breathing

  4. Tai Chi and Qigong

  5. Yoga

  6. Being in nature

How to get started: Email a group of friends or coworkers and ask if anyone would like to join you for a six-week class to learn yoga or Tai Chi, or Qigong, etc., or engage your partner/children/roommate and commit to ten days of a daily eleven-minute meditation.

What about sleep—do some people need more than others?

Jefferies: Generally, all adults need between seven and nine hours of sleep per night. Certainly, no less than six and a half, as this affects multiple biological processes. Sleep deprivation can also contribute to worse outcomes for those with a cancer diagnosis.

Critical biological processes happen while we sleep. Sleep deprivation can lead to the activation of certain cancer hallmarks such as increased inflammation, shorter telomeres (a reflection of our biological age), and suppressed immune function. Sleep is now being viewed by the medical world as being so essential for the successful blocking of free radical damage and for cellular repair that some scientists have even begun classifying sleep disruption, especially long-term shift work, as a “probable” carcinogen.

To what extent can physical activity reduce the chances of developing cancer, improve treatment outcomes, or enhance health post-treatment?

Cohen: Exercise, physical activity, and simply moving more is something we should all do daily. It is critical to also limit sedentary behavior, since long hours of sitting and a lack of exercise can pose health risks equivalent to those from smoking or obesity.

Physical activity downregulates, or turns off, genes that promote tumor growth and upregulates, or turns on, genes that help prevent tumor growth. This includes genes that control inflammation, immune function, angiogenesis (the formation of new blood vessels to feed the cancer), and all the processes that we call the cancer hallmarks—key biological processes that are necessary for a cancer to form and thrive in our body. We now know that people who are more physically active have a lower risk of developing a number of cancers including breast, colon, prostate, kidney, endometrial, ovarian, pancreatic, lung, and gastroesophageal. We also know that physical activity after a cancer diagnosis is associated with lower probability of recurrence of disease, increased survival time, and better quality of life. Exercise is a treatment for combating cancer-related fatigue, a condition for which there are few conventional medications. There is also evidence to suggest that exercise can help slow the aging process, treatment-related cognitive decline and sleep problems, and other cancer-related issues.

What environmental toxins should we be aware of? What steps can we take to reduce our exposure?

Jefferies: It is easy to feel as if you need a PhD in chemistry to know and understand the risks associated with all the chemicals that we are exposed to on a daily basis. We recommend adopting a precautionary principle—until a chemical is found to be harmless, try not to use it. The vast majority of chemicals in circulation have not undergone rigorous scientific testing, so it’s best to assume that most of these chemicals will not support our body’s health. It is also important to remember that there has been little to no testing on the mix of chemicals we are exposed to daily, and what it does to our bodies and our environment.

Two types of chemicals to avoid and/or limit are carcinogens and endocrine disruptors. Carcinogens are substances that cause cancer through DNA damage. Endocrine disruptors are a class of compounds that interfere with hormone production and metabolism in ways that may—especially over the long term—create biological conditions that make us more susceptible to cancer and other diseases. Endocrine disruptors can be found in our food, our environment, and in the products that we put on our bodies. We provide a comprehensive list of common carcinogens and endocrine disruptors in the book, but a few common substances to try to avoid are:


  • Alcohol:

    We are sorry to be the bearers of bad news! Alcohol is listed by the National Toxicology Program as a known human carcinogen. The more someone drinks, the higher their risk of developing a number of different cancers.

  • Formaldehyde:

    This naturally occurring substance becomes carcinogenic in high doses and can be found in carpets, wood flooring, hair-straightening products, fingernail polish, paints and varnishes, and household cleaning products.

  • Asbestos:

    Despite the direct link between asbestos and lung cancer—among other scientifically established diseases—and the fact that it’s banned in more than fifty other countries, it is still legal and used in the United States. You can still find asbestos in roofing and vinyl materials, brake pads, and other auto parts, such as clutches. It was even recently detected in crayons.

  • Sun exposure:

    Excessive sun exposure is the primary cause of melanoma and nonmelanoma skin cancers.

  • Vinyl chloride:

    This is used to make polyvinyl chloride (PVC), which is used to make an array of plastic products including pipe, wire, and cable coatings and packaging materials. It’s used in many household products, such as shower curtains. Vinyl chloride is also produced as a combustion product in tobacco smoke. Exposure to airborne PVC affects the nervous system, and long-term exposure can lead to liver damage.

Endocrine disruptors:

  • Bisphenol A (BPA):

    This compound can be found in food and beverage containers— and in people, including babies in the womb. In 2015, California took the step of listing BPA as a female reproductive toxicant.

  • Phthalates:

    These compounds make plastics more flexible and are used in PVC plastics, solvents, vinyl flooring, adhesives, and detergents. They are endocrine disruptors and have been linked to diabetes, obesity, and reproductive and thyroid problems.

  • Polybrominated diethyl ethers:

    These are flame-retardants that are used in building materials, furniture, clothes, electronics, plastics, tiles, and foams. They have been connected to an assortment of health problems, including the disruption of thyroid function, learning impairment, delayed puberty onset, and fetal malformations.

  • Perfluorinated compounds (PFC):

    Perfluorinated chemicals are nonstick, waterproof, and grease-resistant and are used in cookware, weatherproof outerwear, and food packaging. They have recently been found in the drinking water in twenty-seven states. Research into the impact of PFCs on human health are ongoing, but animal and human studies have shown effects on developing fetuses and young children, decreased fertility, increased cholesterol, immune system effects, and increased cancer risk.

  • Parabens:

    This class of commonly used preservatives help prevent bacterial growth in cosmetics, foods, and pharmaceutical products. They are added to toothpaste, shampoo, deodorant, and other products.

  • Fragrance/parfum:

    Most of the thousands of chemicals listed as fragrances have not been tested for toxicity. Fragrances are found in everything from cosmetics and deodorants to laundry detergent, fabric softeners, and cleaning products.

  • Triclosan:

    An ingredient in many self-described antibacterial products, including hand sanitizers, deodorants, and toothpaste.

While it’s nearly impossible to completely avoid exposure to all environmental toxins, the key is to reduce your overall chemical burden using the precautionary principle. This better-safe-than-sorry approach is the only way to reduce your contact with known and suspected carcinogens in our current unregulated environment. This means that you are maintaining awareness of what you are putting on and in your body and that you are taking the steps to avoid exposing yourself unnecessarily to environmental toxins.

Do you consider radio frequency fields and cell phones to be a potential risk?

Jefferies: The connection between exposure to radio frequency radiation and cancer remains hotly debated. In 2011, the International Agency for Research on Cancer concluded that cell phone use was a possible human carcinogen. As we increase the amount of exposure we have to electromagnetic fields, we believe we’re likely to see increases in certain types of cancer, especially in people who have weakened immune systems or genetic predispositions. Because our brains are still developing through adolescence, children and teenagers could be more susceptible to radio frequency radiation.

Ways to reduce your exposure include increasing the distance between you and your phone, whether that means using a wired earbud when talking, using the speaker function, or keeping your phone away from your body, even when it’s on and you’re not using it. You can limit your cell phone use when reception is weak or when you’re on the go. EMF (electromagnetic field) emissions are strongest when your signal is weak. It is also stronger when your signal is moving from one receiver to the next.

You’ve spent most of your career conducting cancer research. How did your own cancer diagnosis and treatment impact your work?

Cohen: In 2018, on the same day Alison and I signed off on the final version of our book, Anticancer Living, I went to the doctor’s office to get a biopsy of a swollen node that I had noticed a few weeks before. They eventually determined the malignant cells were melanoma.

The irony of getting cancer after studying and coauthoring a book on anticancer living was not lost on me. As the primary risk factor for melanoma is excess sun exposure in childhood, there is not much I could have done recently about the initiation of the disease due to my multiple sunburns as a child. Yet my subsequent lifestyle choices likely influenced the establishment of the disease. Effectively managing stress in my life has been a challenge. As someone who is passionate about my work, I know that I often drove myself far beyond what was healthy for my body.

Yet as strange as it might sound, having cancer has given me the permission to take care of myself in a way that I had never done before. I now prioritize exercise and my mind-body practice on a daily basis, which is something that I did not consistently do before. I also recently completed a two-hundred-hour yoga teacher certification course. I have never felt healthier: physically, mentally, or spiritually. I feel fortunate to be in this good place.

Currently, after undergoing immunotherapy and surgery, I am now classified as cancer-free. That said, Alison and I realize that just because there is no evidence of the disease does not mean that it’s okay to go back to my life as it was before. Melanoma, like many cancers, is controlled through the immune system. In fact, it is one of the most immunogenic of all cancers, which is why the best way to control melanoma is through treatments that boost the immune system. This means that lifestyle factors such as stress, exercise, diet, social support, and sleep are all critically important, as each independently and synergistically influences immune function.

In terms of my research and what we are doing to support patients at MD Anderson Cancer Center, I am focused more than ever on trying to study and provide patients a comprehensive approach to their care. Studying the benefits of yoga or diet on their own is scientifically important, but when I was diagnosed with cancer, I didn’t just change one aspect of my life. I took stock of my Mix of Six and upped my game in each area. We need to engage in and support patients in improving all aspects of their lives to prevent cancer in the first place and, for those of us with cancer, to improve our outcomes.

Lorenzo Cohen, PhD, is the Richard E. Haynes Distinguished Professor in Clinical Cancer Prevention and the director of the Integrative Medicine Program at the University of Texas MD Anderson Cancer Center in Houston. He is a former vice-chair of the Academic Consortium for Integrative Medicine and Health and is a founding member and a past president of the Society for Integrative Oncology. Cohen has published more than 140 scientific articles and has edited two books on integrative medicine for cancer care.

Alison Jefferies, MEd, is a former president of the MD Anderson Cancer Center Faculty and Family Organization. Jefferies is an educator and received a degree in educational psychology from the University of Houston. She works closely with Lorenzo Cohen to foster health and wellness in individuals and their communities.

Cohen and Jefferies are the authors of Anticancer Living: Transform Your Life and Health with the Mix of Six. They live in Houston with their three children.

This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.