Download Breast Cancer

Obesity and Breast Cancer:
An Ever Growing Problem
Presented By:
Dr. Jaixin Niu
Dr. Adam Kerievsky
Brenda Keith RN MSN OCN
Amy Malensek RN OCN CBCN
Sara Kiser MS ND
Obesity and Breast Cancer:
A Medical Oncologist’s Perspective
Presented By:
Dr. Jiaxin Niu
© 2015 Rising Tide
Obesity and Breast Cancer
Obesity: Body Mass Index (BMI) of 30 or higher
Obesity itself was recognized as a disease by
the American Medical Association in 2013
© 2015 Rising Tide
Prevalence of Obesity
USA: 32% of men, 34% women
Western Europe: 21% in both Sexes
Southeast Asia: 8% men, 5% Women
Lancet, 2014
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Obesity Predicted to
Top 60% in 13 States by 2030

Source: Trust for America's Health and the Robert Wood Johnson Foundation
© 2015 Rising Tide
2013 POLL:
RISKS OF OBESITY
7% of People surveyed mentioned cancer !!!
© 2015 Rising Tide
Obesity Increases Cancer Risk
Obesity may account for roughly 10% of colorectal
cancers, and 25-40% of kidney, esophageal and
endometrial cancers
As many as 80, 000 cancer diagnoses each year are
attributed to Obesity.
Obesity will overtake tobacco as the leading
preventable cause of cancer.
© 2015 Rising Tide
OBESITY AND BREAST CANCER
1. Obesity is a risk factor for breast cancer
2. Diagnostic and therapeutic challenges
3. Obesity is a poor prognostic factor
© 2015 Rising Tide
Breast Cancer
Approximately 63, 000 new cases of carcinoma in situ (CIS) will be diagnosed
Siegel R, Ma J, Zou Z, et al: Cancer statistics, 2014. CA Cancer J Clin 64:9-29, 2014
© 2015 Rising Tide
Your Breast Cancer Risk
• 1 in 8 women (12.4%) born in the US will develop
breast cancer at some time during their lifetime
• ~ 3 million breast cancer survivors at this time
Howlader N, et al SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations), 2012.
© 2015 Rising Tide
Nurses’ Health Study:
Obesity Increases Breast Cancer Risk
87143 female nurses aged 30-55 years followed up to 26
years (1976-2002), 4393 developed breast cancer
>10 Kg since age 18, 20% postmenopausal nonhormone users
>25 Kg since age 18, 100% postmenopausal non-hormone
users
Eliassen et al. JAMA 2006; 296: 193
© 2015 Rising Tide
Nurses’ Health Study:
Obesity Increases Breast Cancer Risk
87143 female nurses aged 30-55 years followed up to 26
years (1976-2002), 4393 developed breast cancer
15% of breast cancer is attributable to weight gain of 2.0 kg
or more since age 18 years
Obesity + Hormonal replacement, they account for 1/3
breast cancer cases
Eliassen et al. JAMA 2006; 296: 193
© 2015 Rising Tide
Nurses’ Health Study: Obesity
Increases Breast Cancer Risk
87143 female nurses aged 30-55 years followed up to 26
years (1976-2002), 4393 developed breast cancer
Non-hormone users, sustained weight loss of at least 10 Kg
after menopause resulted in a 57% reduction in breast
cancer risk
Eliassen et al. JAMA 2006; 296: 193
© 2015 Rising Tide
Obesity Increases
Breast Cancer Risk
Sinicrope, FA, Dannenberg AJ. JCO 2010
© 2015 Rising Tide
Obesity: Advanced Stage
Upon Diagnosis
a. Larger Tumor
b. Higher Grade
c. HR-Negative Tumor
d. More Positive LNs
Breast Cancer Res Treat. 2008 Sep;111(2):329-42.
Breast Cancer Res Treat. 2010 Aug;122(3):823-33.
J Clin Oncol. 2011 Jan 1;29(1):25-31.
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Wound healing
Lymphedema
Radiation planning
Delivery of systemic therapy
Breast Cancer Res Treat. 2008 Sep;111(2):329-42.
Breast Cancer Res Treat. 2010 Aug;122(3):823-33.
J Clin Oncol. 2011 Jan 1;29(1):25-31.
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Timing of Chemotherapy
Meta-analysis of 15,327 patients : initiation of
Each 4-week delay: 8% in recurrence
Adjuvant chemotherapy
HR- patients: initiation of Adjuvant chemotherapy
< 20 days vs 21-86 days: 60% vs 34% 10-year DFS
Biagi JJ, et al. J Clin Oncol 29: 111s, 2011
Colleoni M, et al. J Clin Oncol 18: 584-590, 2000
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Dosing of Chemotherapy
Compelling evidence that reduction from standard dose and
dose-intensity may compromise OS
Many oncologists use ideal body weight to calculate BSA or to
CAP BSA at 2.0 m2
Up to 40% of obese patients were undertreated
Biagi JJ, et al. J Clin Oncol 29: 111s, 2011
Colleoni M, et al. J Clin Oncol 18: 584-590, 2000
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Dosing of Chemotherapy
Pharmacokinetics of some but not all drugs may be altered in obese patients!
Griffs, JJ, et al. J Clin Oncol 30 2012
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Efficacy of Chemotherapy
Over 1100 Patients receiving neoadjuvant chemotherapy
(1990-2004, using actual weight at MDACC)
Overweight
40% to achieve pCR (pathological complete remission)
Obese Patients
Litton, J, et al. J Clin Oncol 26 2008
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Compliance of Hormonal Therapy
AIs (anastrozole, letrozole and exemestane) have similar benefits and toxicities
Myalgia & Arthralgia in up to 60% patients
Median time to discontinuation is 6 months
Discontinuation Rate 30-50%, 75% due to musculoskeletal toxicities
Henry, NL, et al. J Clin Oncol 30 2012
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Risk Factors for AI-induced Arthralgia
Previous HRT or young age
Previous chemotherapy, in particular, Taxane
Obesity
Henry, NL, et al. J Clin Oncol 30 2012
© 2015 Rising Tide
Obesity: Therapeutic Challenges
Efficacy of Hormonal Therapy
ATAC (Arimidex, TAM, Alone or in Combination)
Hazard plots for anastrozole versus tamoxifen by body mass index (BMI) group
Sestak I et al. JCO 2010;28:3411-3415
© 2015 Rising Tide
Obesity: Worse Outcome
ATAC (Arimidex, TAM, Alone or in Combination)
All breast cancer recurrences according to body mass index (BMI) group
Sestak I et al. JCO 2010;28:3411-3415
© 2015 Rising Tide
Obesity:
After Diagnosis
~ 60% of patients gained weight after adjuvant or neoadjuvant
chemotherapy with average weight gain 6-10 Ibs
The effect of adjuvant hormonal therapy is controversial
~ 50% breast cancer survivors are overweight or obese
Clin Oncol (R Coll Radiol). 2002 Feb;14(1):64-7. Clinical Nutrition 29 (2010) 187–191
© 2015 Rising Tide
Obesity: Worse Prognosis
Danish Breast Cancer Cooperative Group
Dataset of 53816 patients
18967 patients (35%): BMI data available
30 years of follow-up: 1977-2006
Marianne Ewertz, Maj-Britt Jensen, KatrínA´ . Gunnarsdo´ttir, Inger Højris, Erik H. Jakobsen
© 2015 Rising Tide
Obesity: Worse Prognosis
Cumulative incidence of recurrence in relation to body mass index (BMI)
Marianne Ewertz, Maj-Britt Jensen, KatrínA´ . Gunnarsdo´ttir, Inger Højris, Erik H. Jakobsen
© 2015 Rising Tide
Obesity: Worse Prognosis
BMI and Breast Cancer Survival
82 Studies: ~ 213, 000 breast cancer survivors with
41,500 deaths (23,200 breast cancer-specific death)
BMI >30, increases total mortality 40% (75% for
premenopausal, 35% for postmenopausal)
Chan DSM, et al. Annals of Oncology June, 2014
© 2015 Rising Tide
OBESITY AND BREAST CANCER
1. Obesity is a risk factor for breast cancer
2. Diagnostic and therapeutic challenges
3. Obesity is a poor prognostic factor
© 2015 Rising Tide
10/1/2014
Education and Awareness
Clinical Guidance
Research Promotion
© 2015 Rising Tide
Obesity and Breast Cancer:
How to Assess Your Patient
Presented By:
Amy Malensek RN OCN CBCN
© 2015 Rising Tide
Assessment Barriers
• Barriers to assessing patients with obesity
• How to approach patients with obesity
• Different assessment styles and goals based
on the timeline of your patient’s treatment
plan
© 2015 Rising Tide
Barriers
• Knowledge base
– Being comfortable with knowledge that you have
regarding the disease process and treatment plan
• Personal comfort zone
– Being comfortable with asking the right questions
at the right time
– Knowing how and when to begin those difficult
conversations
© 2015 Rising Tide
Physical Assessment
• Head to toe: remember side effects of disease,
as well as treatment
• Assessment will have a different focus
depending on the stage of treatment
• Before Treatment
• During Treatment
• After Treatment
© 2015 Rising Tide
Mobility
• Are they able to move around with ease?
• Are they having difficulty with ADLs
• Is it related to Pain or Neuropathy,
Or Both
© 2015 Rising Tide
Appetite
• Decreased or Increased
• Have their taste sensations changed
• Are they having
Nausea/Diarrhea/Constipation
© 2015 Rising Tide
Psychosocial Assessment
• Understanding that all patients will have
psychosocial needs
•
•
•
•
Fatigue
Irritability
Anxiety
Depression (more than 47% of breast cancer patients
report suffering from some level of depression)
© 2015 Rising Tide
Other Barriers
• Do they have underlying metabolic disorders
– Thyroid
– Hormonal imbalances
– Other Genetic disorders
© 2015 Rising Tide
Other Barriers
• Are they afraid to talk to you…..
• Are you afraid to talk to them
© 2015 Rising Tide
How Can I Improve
• Understanding your personal barriers will
allow you to become more open to your
patient’s needs
• Practice your communication and assessment
skills
© 2015 Rising Tide
Conclusion
• Gaining a new understanding into the patient
perspective will allow for you to better
understand the needs of your patient
• Active listening and careful observation will
give you a much clearer picture of what your
patient is experiencing
• Realizing the stigma that has been placed on
patients with obesity can improve the patient
experience
© 2015 Rising Tide
Clinical Challenges of Obesity &
Breast Cancer
Presented By:
Brenda Keith RN MSN AOCNS
Physical Challenges
•
•
•
•
Challenges in screening and diagnosis
Surgical complications
Implications for treatment
Survivorship issues
PHYSICIAL: Challenges in Screening
and Diagnosis
• Women may delay or avoid screening
–
–
–
–
–
Embarrassment
Pain
Inadequate equipment
Negative provider attitudes
Unsolicited weight-loss advice and routine weighing
• Provider barriers
– Difficulty doing exams
– Inadequate equipment and education
– Challenges overcoming patient barriers and refusal
Ferrante, et al. (2010) Family Physicians' Barriers to Cancer Screening in Extremely Obese Patients
Challenges of Imaging Studies
Miller, J. (2005). Imaging and obese patients. From Radiology Rounds: A newsletter for referring physicians, Massachusetts General
Hopsital, Department of Radiology. Retrieved March 20, 2015, from
http://www.mghradrounds.org/index.php?src=gendocs&link=2005_july
PHYSICAL: Surgical complications
• Complications after breast reconstruction
– Wound complications
– VTE
– Pneumonia
– Implant and flap failure
Fischer, J., et al. (2013). Impact of obesity on outcomes in breast reconstruction: Analysis of 15,937 patients from the ACS-NSQIP
datasets. Journal of the American College of Surgeons, 217(4), 656-664.
PHYSICAL: Treatment complications
• Radiation
– Radiation pneumonitis
– Fibrosis
– Poorer cosmetic outcome
– Ipsilateral arm edema
Iyengar, et al. (2013). Obesity, Inflammation and Cancer. In A. Dannenberg & N. Berger (eds.) Obesity, Inflammation and Cancer.
Springer: New York.
Psychosocial Implications
• Bias, stigma and discrimination due to weight
– Bias or stigma: negative weight-related attitudes
toward an overweight or obese individual
– Discrimination: Unequal, unfair treatment of
people because of their weight
• Perception about causes of obesity
• Consequences
– Personal and social well-being
– Emotional health
Puhl, R. Understanding the Stigma of Obesity and its Consequences. Obesity Action Coalition.
Psychosocial Implications
• Considerable social consequences associated
with obesity
• The language used to discuss obesity can
either promote or reduce weight bias and
stigmatization
Puhl, R. (2014). Language and Obesity: Putting the person before the disease. Medscape. July 24, 2014.
Psychosocial Implications
• Weight bias in health care
– Perceptions of obesity among HCPs
– Reactions of patients to weight discrimination
Nadglowski, J. (2014). Understanding Obesity: Weight stigma and its consequences. Obesity Action Coalition.
http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000003266/Nadglowski%20-%20Key%20Note.pdf
Psychosocial Implications
• Patients may feel overwhelmed by cancer
diagnosis
• Additional burden of talking about their
weight
Lawrence, L. (2014). Cancer Care Faces a Growing Crisis: Obesity. ASCO Connection, September 2014, 16-23.
Psychosocial Implications
• Role of HCP in addressing weight bias and
stigma of obesity
• Addressing weight loss may be a new area of
discussion
– Discussing obesity may be uncomfortable for
healthcare providers
Lawrence, L. (2014). Cancer Care Faces a Growing Crisis: Obesity. ASCO Connection, September 2014, 16-23.
• Clinicians lack knowledge and critical skills in
assessment and management of obesity
– Providers often do not counsel patients about
weight
– If providers do counsel patients about weight,
they often do not discuss specific
recommendations for behavior change
– Reasons for inadequate counseling
• Lack of training and competency in obesity
management
Jay, M., et al. 2010; Kraschnewski, M., et al. 2013; Huang, J., et al. 2004; Jay, M., et al. 2008
Addressing Obesity in the Clinic
Society of Gynecologic Oncology
Addressing Obesity in the Clinic
• Ask permission to discuss weight
• Acknowledge that obesity is a disease with
multiple causes
– Culture
– Environment
– Genetics
• Understand that patients may feel blame,
shame, and guilt about their weight
Vallis, M., et al. 2013; Via, M. & Mechanick, J. 2014; Dalle, G., et al. 2013; Ahmed, S., et al. 2002
Summary
• Ways to reduce weight stigma
– Approach patients with sensitivity
– Recognize complex etiology of obesity
– Avoid stereotyping
– Emphasize behavior changes
– Offer concrete advice
– Acknowledge difficulty of lifestyle changes
– Create a supportive healthcare environment
O’Reilly, K. (2013). Confronting bias against obese patients. . From American Medical News. Retrieved Mach 20, 2015 from
http://www.amednews.com/article/20130902/profession/130909988/4/
Obesity and Breast Cancer:
Supplement Usage and
Contraindications
Presented By:
Dr. Adam Kerievsky
© 2015 Rising Tide
Objectives
• Introduction
• Regulation of Weight-Loss Dietary
Supplements
• Three common ingredients in weight loss
supplements
• Safety considerations
• Drug-Herb interactions
© 2015 Rising Tide
Introduction
• Americans spend roughly $2 billion a year on
weight-loss dietary supplements [2]
• Weight-loss is one of the top 20 reasons why
people take dietary supplements.[3]
© 2015 Rising Tide
Dietary supplements promoted for
weight loss
• Manufacturers market these
products with various claims:
–Reduce macronutrient absorption
–Reduce appetite
–Reduce body fat, and weight
–Increase metabolism and
thermogenesis.
© 2015 Rising Tide
Use of nonprescription dietary supplements for weight loss is
common among Americans.
J Am Diet Assoc. 2007 Mar;107(3):441-7.[5]
• Adults aged > or =18 years (n=9,403)
completed a cross-sectional populationbased telephone survey of health
behaviors.
© 2015 Rising Tide
Study Details:
• Approximately 15.2% of U.S. adults have used
a weight-loss dietary supplement at some
point in their lives, with more women
reporting use (20.6%) than men (9.7%),
highest use was among women aged 18 to 34
years (16.7%)
© 2015 Rising Tide
Dietary supplements for body-weight reduction: a systematic
review.
Am J Clin Nutr 2004;79:529-36.
• The objective of the study was to assess
the evidence on the effectiveness of
dietary supplements in reducing body
weight.
• Five systematic reviews and metaanalyses and 25 additional trials were
included and reviewed.
© 2015 Rising Tide
Study Details:
• The reviewed studies provide some
encouraging data but no evidence beyond a
reasonable doubt that any specific dietary
supplement is effective for reducing body
weight.
© 2015 Rising Tide
Regulation of Weight-Loss Dietary
Supplements
• Unlike drugs, dietary supplements do not
require premarket review or approval by the
FDA.
© 2015 Rising Tide
Tainted products
• FDA has discovered hundreds of "dietary
supplements" containing drugs or other
chemicals, particularly in products for
weight loss.
• The "extra ingredients" generally aren't
listed on the label, but could cause serious
side effects or interact in dangerous ways
with medicines or other supplements.
© 2015 Rising Tide
Tainted Products
• FDA has found weight-loss products tainted
with prescription drug ingredients such as:
– Sibutramine
– Fluoxetine
– Triamterene
© 2015 Rising Tide
Common Ingredients in Weight-Loss
Dietary Supplements
• Caffeine (as added caffeine or from guarana,
kola nut, yerba mate, or other herbs)
– Evidence of Safety
– Evidence of Efficacy
– Proposed Mechanism of Action
© 2015 Rising Tide
Common Ingredients in Weight-Loss
Dietary Supplements
• Green coffee bean extract (Coffea aribica,
Coffea canephora, Coffea robusta
– Evidence of Safety
– Evidence of Efficacy
– Proposed Mechanism of Action
Marketer Who Promoted a Green Coffee Bean WeightLoss Supplement Agrees to Settle FTC Charges
• The FTC charged that Duncan and his
companies, Pure Health LLC and Genesis
Today, Inc., deceptively claimed that the
supplement could cause consumers to lose 17
pounds and 16 percent of their body fat in just
12 weeks without diet or exercise, and that
the claim was backed up by a clinical study.
[10]
© 2015 Rising Tide
Marketer Who Promoted a Green Coffee Bean Weight-Loss
Supplement Agrees to Settle FTC Charges
• Lindsey Duncan and the companies he controlled agreed to
settle Federal Trade Commission charges that they
deceptively touted the supposed weight-loss benefits of
green coffee bean extract through a campaign that
included appearances on The Dr. Oz Show, The View, and
other television programs.
• After appearing on Dr. Oz, Duncan and his companies sold
tens of millions of dollars’ worth of the extract, according
to the FTC.
• Under the FTC settlement, the defendants are barred from
making deceptive claims about the health benefits or
efficacy of any dietary supplement or drug product, and will
pay $9 million dollars.[10]
© 2015 Rising Tide
Common Ingredients in Weight-Loss
Dietary Supplements
• Green tea (Camellia sinensis) and green tea
extract
– Evidence of Safety
– Evidence of Efficacy
– Proposed Mechanism of Action
© 2015 Rising Tide
Potential Mechanisms for Interactions
with pharmaceuticals
• Combined use of Herbs with Pharmaceuticals may
increase or decrease the effects of either substance,
leading potentially to greater toxicity or treatment
failure.
• Most known drug interactions are due to changes in
metabolic routes related to altered expression or
functionality of cytochrome P450 (CYP) isoenzymes,
responsible for activating or inactivating many drugs.
• CYP3A4/5 is perhaps most important as it is involved in
metabolizing almost half of all conventional
medications. CYP2D6 and CYP2C9 rank second and
third, respectively, in the number of drugs affected.[12]
© 2015 Rising Tide
Variable inhibitory effect of different brands of
commercial herbal supplements on human CYP3A4
• Among the supplements tested, Green Tea Extract
produced the most pronounced inhibition of CYP3A4,
which ranged from 5.6% by Nature's Resource to 89.9% by
Natrol Green Tea Extract (GTE) product.
• This study suggests that GTE use may cause significant
interactions with drugs metabolized by CYP3A4.
• However, the effect on CYP3A4 varied among different
brands of GTE, possibly due to variations in their content
of the herbal product's active ingredients. [13]
• Botanicals pose the highest risk for interactions and thus
require the most vigilance.
© 2015 Rising Tide
Figure 1. Approach to patients taking a particular herbal product
Scenario 1
Is the patient currently
receiving cytotoxic,
targeted, or
immunotherapy?
No
Yes
High risk for drug-herb
interaction. Discuss risk
with patient. Where
appropriate, suggest nonherbal alternative for side
effect mitigation, immune
function support, and/or
improving quality of life
Scenario 2
Scenario 3
Is the patient
currently on
hormonal or
androgen
deprivation
therapy?
Is the patient
currently off
chemotherapy or
on a drug
holiday?
Yes
Similar to Scenario 1.
High risk for drugherb interaction.
Discuss risk with
patient. Where
appropriate, suggest
non-herbal options.
No
Scenario 4
No
Yes
If they not taking other medications
with a narrow therapeutic index/ high
risk for adverse effects (e.g.
methadone, warfarin,
benzodiazepines), consider allowing
them to take herbal products during the
drug holiday. Recommend that they
discontinue herbal products at least 7
days prior to returning for re-evaluation
to allow a sufficient wash out period
should they need to resume anti-cancer
therapy at their follow up visit. If the
patient is on medications that may pose
a risk, recommend non-herbal options
and discuss the relative risks.
© 2015 Rising Tide
Has the patient completed
therapy or does not need
therapy at this time?
Yes
Similar to Scenario 3, as long as
the patient is not on other
medications that may pose a
risk, consider allowing use of
herbal products. If the patient
has a hormone-sensitive cancer,
advise against the use of any
herbs with estrogenic potential.
Websites
•
•
•
•
•
Epocrates.com
Naturaldatabase.com
Pubmed.org-search for the herb AND CYP450
micromedexsolutions.com
Consumerlab.com
© 2015 Rising Tide
Conclusion
Obesity and Breast Cancer:
Nutrition
Presented By:
Sarah Kiser MS RD
Background
• Overweight, poor diet, and physical inactivity:
– Increase risk and recurrence
– Associated with poorer prognosis
• Many breast cancer survivors are overweight at
time of diagnosis and gain weight during
treatment
• Increased risk for other chronic diseases
− Heart disease
− Diabetes
− High blood pressure
Thomson CA. Nutr Clin Pract. 2012;27:636-650.
Nutrition Assessment
• Assessment
– Weight history
– Diet history and food
preferences
– Bioelectrical impedance
analysis (BIA)
– Energy needs
– Waist circumference
– Physical activity
Nutrition Assessment
• BMI = body mass index; kg/m2
• BMR = basal metabolic rate; the amount of
energy expended while at rest
Metabolic Health
• Fasting insulin
• HOMA-IR
• Fasting glucose
• Aerobic fitness
• Triglycerides
• Blood pressure
• Edmonton Obesity Staging System –
independently predicted increased mortality
even after adjustment for adiposity
Padwal RS, Pajewski NM, Allison DB, Sharma AM. CMAJ. 2011;183(14):E1059-E1066.
Gunter MJ, Xie X, Xue X, et al. Cancer Res. 2015;75(2):270-274.
Nutrition Intervention
• Intervention
– Education and counseling
– Diet modification
– Physical activity
Diet Modification
• National Weight Control Registry
–
–
–
–
78% eat breakfast daily
75% weigh themselves at least once a week
62% watch less than 10 hours of TV per week
90% exercise about 1 hour per day
• Macronutrient composition not as important as
negative calorie balance
• Meal replacements may be useful tool
• Food and activity tracking
http://nwcr.ws/default.htm
Diet Modification
• Energy needs
– Indirect calorimetry
• Metabolic cart
• Handheld calorimeters
– Estimated BMR equations
• Mifflin-St. Jeor formula
– Men: BMR = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y)
+5
– Women: 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) –
161
Mifflin MD, St Jeor ST, Hill LA, et al. Am J Clin Nutr. 1990;51(2):241-247.
Frankenfield DF, Roth-Yousey L, Compher C, et al. J Acad Nutr Diet. 2005;105(5):775-789.
Diet Modification
• American Institute for Cancer Research (AICR)
guidelines
– Avoid sugary beverages
– Limit consumption of energy-dense foods
(particularly processed foods high in sugar, high in
sodium, low in fiber, and high in fat)
– Eat a variety of vegetables, fruits, whole grains,
and legumes
http://www.aicr.org
Diet Modification
• AICR guidelines
– Limit consumption of red meat to <18 oz/wk and
avoid processed meats
– Limit alcoholic drinks to two for men and one for
women daily
– Be as lean as possible without becoming underweight
– Be physically active for at least 30 minutes every day
– Do not rely on supplements to protect against cancer
http://www.aicr.org
Physical Activity
• 2008 Physical Activity Guidelines for
Americans
– Avoid inactivity
– Achieve at least 150 minutes of moderate
intensity PA or 75 minutes of vigorous activity PA
per week or a combination
• At least 3 days per week
• At least 10 minute bouts
– Muscle strengthening 2x/week – at least one set
for 8-12 muscle groups
Physical Activity
• PA for weight maintenance
– 150-200 minutes per week to prevent a weight
gain of <3% in most adults
• PA for weight loss
– <150 minutes/week – minimal weight loss
– 150-225 minutes/week – moderate weight loss (23 kg)  30-45 minutes on 5 days per week
– 225-420 minutes/week – significant weight loss
(5-7.5 kg)  30-60 minutes per day
American College of Sports Medicine. Medicine and Science in Sport and Exercise. 2009;41(2):459-471.
Dietary factors
– ↑ risk
• Alcohol – even low to moderate intake
– Women’s Health Initiative (WHI)
» 1 alcoholic drink daily associated with 82% greater risk for
breast cancer
» Follow-up analysis – ER+ disease associated with alcohol
intake
– LACE cohort
» Alcohol intake at >3 drinks/week increased recurrence
risk by 35%, particularly in postmenopausal and
overweight/obese women
– Recommendation: <1 drink/day
Thomson CA. Nutr Clin Pract. 2012;27:636-650.
Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431.
Dietary Factors
– ↑ risk
• Dietary fat
– Women’s Intervention Nutrition Study (WINS)
» Low-fat diet group: 24% lower risk of relapse than control
group after 5 years of follow-up
» Had only modest weight loss – 2.7 kg less than control
group at 5 years
– Another epidemiological analysis showed that higher intake of
butter, margarine, and lard was associated with 30% higher
risk for recurrent disease
Thomson CA. Nutr Clin Pract. 2012;27:636-650.
Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431.
Chlebowski RT, Blackburn GL, Thomson CA, et al. J Natl Cancer Inst. 2006;98(24):1768-76.
Blackburn GL, Wang KA. Am J Clin Nutr. 2007;86(suppl):878S-81S.
Dietary Factors
– ↓ risk
• Vegetables and fruits
– Dietary fiber can modify estrogen concentration
– Women’s Healthy Eating and Living (WHEL) study
» Women who ate at least 5 servings of fruits and
vegetables per day, along with exercise equivalent to
walking 30 minutes 6 days/week had 50% reduced risk of
recurrence regardless of weight loss
Thomson CA. Nutr Clin Pract. 2012;27:636-650.
Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431.
Pierce JP, Stefanick ML, Flatt SW, et al. JCO. 2007;25(17): 2345-2351.
Summary
• Lifestyle modification even with modest
weight loss can attenuate risk
• Overall diet quality matters
• Be available as support system and encourage
small changes