Weigh Pink: Weight Management and Lifestyle Strategies to Reduce Breast Cancer Risk & Risk of Recurrence
Shari Oakland Schulze, RD, CSO
Exempla Saint Joseph Hospital Comprehensive Cancer Center and Breast Center
Denver, CO
Of the 2.9 million breast cancer survivors in the United States today, many are living long, cancer-free lives. When faced with a diagnosis of breast cancer or found to be at high risk for breast cancer, women often pursue nutrition and physical activity changes to affect a risk factor they can personally control. Unfortunately, overweight status is common among female breast cancer survivors. Being overweight places them at greater risk for chronic disease such as diabetes, hypertension, cardiovascular disease, and breast cancer recurrence. Efforts are needed to promote weight control and a healthy lifestyle in this population to reduce overall risk and risk of recurrence.
The current prevalence of overweight adults in the United States is currently greater than 55%.(1) Over the years, multiple studies have attempted to look at the connection between obesity and cancer risk. Results of the Nurses’ Health Study demonstrated that women who gained 25 kg [55 lb] since age 18 and those who gained 10 kg [22 lb] since menopause were at increased risk for breast cancer.(2) Furthermore, obesity has been associated with more aggressive tumor characteristics such as larger tumor size or greater axillary nodal involvement.(3)
As a complicating factor, women who go through cancer treatment are more likely to gain weight after breast cancer diagnosis. A decline in physical activity, loss of muscle mass, use of steroids, and an increase in carbohydrate intake to help manage side effects are major contributing factors towards weight gain and worse, a form of sarcopenic obesity.(4)
Observational data demonstrate there is an increased risk of breast cancer recurrence and death in women who gain weight after diagnosis. Weight gain of more than 5 kg [11 lb] has been associated with poor breast cancer outcomes in several studies. One group studied was found to have a 15%-20% difference in outcome at 7 to 10 years after diagnosis, with women weighing more than average having the worst outcome. Women who were overweight or obese (BMI of 25 or more) had a greater risk over time of developing metastatic breast cancer. In addition, the risk of dying from breast cancer was higher for women with a BMI of 25 or above then those with a lower BMI.(5-7)
The Women’s Intervention Nutrition Study (WINS) suggests that lifestyle modifications can alter breast cancer prognosis. WINS specifically demonstrated that women participating in a low fat diet had a lower risk of cancer recurrence than women who maintained a higher fat diet.(8) The Nurses’ Health Study demonstrated reduced risk of breast cancer recurrence/death in women who participated in moderate exercise for 3-5 hours/week. Weight, diet, and physical activity recommendations for prevention of cancer and for the cancer survivor are outlined through the American Cancer Society, the National Cancer Institute, and the American Institute of Cancer Research. These recommendations can provide the foundation for diet and lifestyle changes. Women need to be educated about the appropriate diet strategies for weight loss but they also need to understand how what they eat, or do not eat, can affect their risk of recurrence.
There are many approaches to weight loss and efforts aimed at rapid weight loss or gimmicks typically result in weight regained vs. maintained long–term loss. A study in Obesity Research compared the efficacy of different weight loss regimens on body weight loss and metabolic improvement in breast cancer survivors. Forty-eight breast cancer survivors were randomly divided into four groups and were followed for one year. The group which received individualized counseling and weekly weight management meetings had the most significant losses and showed the most improvement in cholesterol levels, and had reductions in blood leptin levels.(9) For breast cancer survivors, strategies to facilitate weight loss and lifestyle changes need to be evaluated and individualized with frequent support and follow up.
At Exempla Saint Joseph Hospital Comprehensive Cancer Center and Breast Care Center in Denver, Colorado, a program was initiated to address the unique needs of the women with or at high risk for breast cancer. Part support group and part weight management group, the program aptly named Weigh Pink, provides women the opportunity to have education regarding long-term weight loss efforts and prevention of recurrence strategies while having accountability and support from other women who understand the unique issues that breast cancer survivors’ face. The group is open to breast cancer survivors and those at high risk for breast cancer of all ages. Most women are between the ages of 35 and 75. Each week, the women weigh in and discuss challenges they are facing in adhering to diet and physical activity guidelines. Goals are designed individually to address each person’s concerns and challenges. The ability to focus on building inner and outer strength with the development of lifelong lifestyle changes can create a powerful bond that motivates and supports the women in the group. Success is measured not only by pounds lost but by healthy habits gained. Most women find they have more energy and strength to do everyday tasks. They feel better, clothes fit better, and they find a stronger sense-of-self outside their diagnosis.
The Weigh Pink program receives referrals from the Breast Care Center, the high risk breast cancer clinic, and from the medical oncologists in the cancer center. To reduce barriers to participation, there is currently no cost to join the program. Women will frequently attend consistently for eight to ten weeks and then attendance becomes more sporadic. Weekly emails with education and motivation support as well as available phone consultations continue to support weight loss efforts.
It is imperative that physicians caring for patients at risk for breast cancer or with a diagnosis of breast cancer support and encourage efforts to improve diet and lifestyle beyond the office handout. Likewise, this is an opportunity for comprehensive breast centers to focus on diet and lifestyle changes. Connecting patients with the appropriate resources such as nutrition counseling from a Registered Dietitian who is a specialist in oncology nutrition (CSO-Certified Specialist in Oncology Nutrition) can greatly assist patients in making changes that can affect their risk of cancer and overall health. To find a Registered Dietitian in your area, go to http://www.oncologynutrition.org. Developing programs similar to Weigh Pink can be an additional strategy to improve a patient’s outcome and quality of life.
Shari Oakland Schulze, RD, CSO can be reached at shari.oakland@sclhs.net
- http://win.niddk.nih.gov/statistics. (last accessed 4/2014).
- Eliassen A, Colditz G, Rosner B, et al. Adult weight change and risk of post-menopausal breast cancer. JAMA. 2006; July 12; 296(2):193-201.
- Carmichael AR, Bates T. Obesity and breast cancer: a review of the literature. Breast. 2004 April;13(2):85-92.
- Demack-Wahnefried W, Winer E, Rimer B. Why women gain weight with adjuvent chemotherapy for breast cancer. J Clin Oncol. 1993; 2; 7; 1418-1429.
- Chlebowski R, Weiner J, Reynolds R, et al. Long-term survival following relapse after 5FU but not CMF chemotherapy. Breast Cancer Res Treat. 1986; 7: 23-29.
- Camoriano J, Loprinzi C, Ingle J, et al. Weight change in women treated with adjuvent therapy or observed following mastectomy for node-positive breast cancer. J Clin Oncol. 1990;8:1327-1334.
- Bonomi P, Bunting N, Fishman D, et al: Weight gain during adjuvent chemotherapy or hormono-chemotherapy for stage II breast cancer in relation to disease free survival. Breast Cancer Res Treat. 1984;4:339 (abst 17)
- Blackburn GL, Wang KA. Dietary fat reduction and breast cancer outcome: results from the Women's Intervention Nutrition Study (WINS). Am J Clin Nutr. 2007 Sept;86(3):5 878-81.
- Jen KL, Djuric Z, Dilaura NM, et al. Improvement of metabolism among obese breast cancer survivors in differing weight loss regimes. Obes Res. 2004 Feb;12(2):306-12.
Synopsis: Conference Ticklers
Saturday March 14th during the ASBD/NCBC Clinical Track
How should clinicians use genomic analysis (Oncotype, Mammaprint, PAM50, next generation sequencing, etc.) to make treatment decisions in 2015? –Hope, Hype, and Reality.
In patients with early stage breast cancer, there is evidence that tumor gene expression (genomic) analysis may be both prognostic (indicating relative risk of cancer recurrence) and predictive (indicating relative benefit of various types of treatment, such as adjuvant endocrine therapy and/or chemotherapy). What is the status of these assays in 2015, and will the proportion of patients for whom their results play a role in determining treatment likely increase over the next few years? In patients with advanced breast cancer, more intensive genomic analysis such as next generation sequencing of entire genome has been suggested as a way to identify novel targets and treatments for small patient subsets and individual patients. Is this ‘ready for prime time’, or still just a research tool? The session on “How should clinicians use genomic analysis (Oncotype, Mammaprint, PAM50, next generation sequencing, etc.) to make treatment decisions in 2015? –Hope, Hype, and Reality” will address these issues, particularly for hormone receptor positive breast cancer.
Aditya Bardia, MD, MPH
Attending Physician, Massachusetts General Hospital Cancer Center,
Harvard Medical School
Boston, MA
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Monday March 16th ASBD/NCBC Clinical Track
Attending to Gender: Innovating Meaningful Interactions for Survivors, Partners, and Staff
Patient’s families and health care professionals are all impacted by sex and gender. Sex and gender have become invisible and extremely influential screens that we all look through, but may not see. Acute stress has been shown to increase gender differences that can lead to increased vulnerabilities, frustration and isolation. Within the context of serious illness, gender inclinations are activated but may not be understood or appreciated for the significant benefit that is inherent in such every day interactions. Across the gender continuum, there are opportunities for mutual understanding, creative problem-solving and emotional growth. The speaker will outline barriers and practical ways to use gender inclinations to promote teamwork, trust, understanding and emotional growth.
Monday March 16th Plenary Afternoon
Distress Management: Something for Everyone while Meeting the New Accreditation Standards
As of January 2015, psychosocial distress screening is an accreditation standard for both the American College of Surgeons (Commission on Cancer) and the American Society of Clinical Oncology. Although the new standards may initially seem like an added burden, there are a number of benefits to patients, physicians, nurses and institutions relating to quality care, safety, efficiencies, resource deployment and competitiveness in the market place. The speaker will outline the specific requirements of the new standards, offer strategies to meet or exceed the new standards and identify significant secondary benefits of distress screening. Finally, the experiences of a number of large and small cancer programs will be used to demonstrate effective implementation strategies.
Matthew J. Loscalzo, L.C.S.W.
Liliane Elkins Professor in Supportive Care Programs
Administrative Director, Sheri & Les Biller Patient and Family Resource Center
Executive Director, Department of Supportive Care Medicine
Professor, Department of Population Sciences
City of Hope
Duarte, CA
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Sunday March 15 Plenary Afternoon
Reclaiming Sexual Health for Breast Cancer Survivors: A New Internet Toolkit
Despite many surveys defining the causes, prevalence, and types of sexual problems that women experience with breast cancer treatment, most women still do not get timely and accurate information on preventing or overcoming sexual problems. A web site, Tendrils: Sexual Renewal and Motherhood after Cancer provides site- and treatment-specific information about why sexual problems occur, guidance on finding expert medical help, and practical, cognitive-behavioral self-help exercises to address sexual problems. Videotaped interviews with women of a variety of ages and ethnicity are included, as are video vignettes with actors illustrating common dilemmas and communication strategies. For women with breast cancer, sections on understanding and coping with loss of sexual desire or vaginal dryness and pain are particularly relevant. A recent efficacy study published in the Journal of the National Comprehensive Cancer Network with 58 women who had finished active cancer treatment (other than ongoing hormonal therapy), suggests that using Tendrils for 12 weeks can improve women’s sexual function and satisfaction, but that three sessions of supplemental coaching enhanced outcomes compared to using the web site only on a self-help basis. We are currently using the web site as part of an intervention to prevent sexual dysfunction in women just starting adjuvant therapy with aromatase inhibitors, along with providing nonhormonal vaginal moisturizers and lubricants, a vaginal dilator, and phone coaching sessions. Tendrils is being updated both in content and format in preparation to making it available to the public.
Leslie R. Schover, PhD
Department of Behavioral Science, University of Texas MD Anderson Cancer Center