Tammy Ward RD, CSO, LD

American Cancer Society statistics reveal the five-year survival rate for breast cancer has risen from 75% to 90% between 1975 and 2017 (1). This improvement is due, in part, to decades of research and improved treatment modalities, but also increased awareness of prevention through early detection. Breast cancer (BC) survivors frequently ponder the double-edged sword of improved survival rates which contrast with the potential risk of recurrence and/or lingering adverse health effects of their treatment.

Breast cancer patients who are overweight/obese at the time of diagnosis are at increased risk of poor outcomes, disease recurrence, and all cause and breast-cancer specific mortality (2). Obesity may also adversely impact quality of life (QOL) and increases the risk of long-term co-morbidities such as type 2 diabetes and cardiovascular disease (CVD) (3). Although research to support this issue is inconclusive, some breast cancer survivors report additional weight gain during maintenance endocrine therapy. Mechanistic etiology regarding this weight gain phenomenon is multi-varied and not the focus of this article, but data does support that weight loss may counter some of these co-morbid concerns.

The good news, the weight loss New Year’s Resolution for BC survivors, comes via published, peer-reviewed studies looking at a variety of interventions showing significantly positive results in the primary outcome of weight loss. It is well established that weight loss improves metabolic pathways thereby reducing the risk of co-morbidities (diabetes and CVD) and improves overall QOL. (4) The more successful interventions offer significant support and incorporate lifestyle modalities to complement diet and exercise components.

One such study is the Lifestyle, Exercise and Nutrition (LEAN) study (5). LEAN is a randomized controlled trial of a 6-month weight loss intervention for overweight and obese BC survivors which demonstrated successful short term weight loss. 100 women were evenly randomized to two intervention arms: in-person and telephone weight loss counseling, and a third arm consisting of usual care (UC) with no counseling. The intervention curriculum, adapted from the Diabetes Prevention Program, AICR, ACS, and the NCI, consisted of a total of 11 counseling sessions with the study dietitian over a 6-month period. In addition to diet counseling, participants were encouraged to increase physical activity, eat a mostly plant-based diet, practice mindful eating, and participate in behavioral therapy. Outcomes measured included diet compliance, physical activity, body composition, and serum markers of inflammation. Results revealed an average of 6% weight loss in both intervention groups and 2.4% in the UC groups. There was a 30% significant reduction in measure of inflammatory markers seen in the intervention groups compared with a 1% reduction in the UC group.

A follow-up of the LEAN study looked at long-term weight loss maintenance in this same grouping of women. Review of electronic health records over an eight-year period revealed that both intervention arms and UC arm maintained their weight loss over time and had additional modest weight loss during this long term follow up period (6).

A smaller 24-week longitudinal pilot study (n=22) also utilized a variety of concurrent interventions (caloric reduction, healthy eating principles, mindful eating/exercise/cooking) to measure the outcome of weight loss in African American women following treatment for BC (7). Results indicated weight change was significant in patients with stage 1 BC vs stage 2 or 3 BC and in women who had higher mindfulness scores prior to beginning the intervention. Although the small sample size indicates need for larger study size, the results indicate that adding mindful eating practices to a weight loss regimen can better mitigate behavioral change for weight loss maintenance over time.

A cursory literature search reveals a growing number of peer-reviewed randomized trials spanning short-term (months) to long-term (19+ years) showing various positive results regarding weight loss/maintenance, reduced incidence of recurrence, and decreased risk of developing CVD and type 2 diabetes. These include The Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial (8), long-term follow-up of the Women’s Health Initiative (WHI) randomized trial (9), and the Women’s Healthy Eating and Living (WHEL) randomized trial (10). Our University of Cincinnati Cancer Center’s Survivorship and Supportive Services team is positioned to help provide education regarding nutrition and lifestyle modalities to assist our breast cancer survivors on their healthy weight loss journey. This is indeed good news for those New Year’s Resolutions!

References:

1.  https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf

2. Chan, D. S. et al. Body mass index and survival in women with breast cancer systematic

literature review and meta-analysis of 82 follow-up studies. Ann. Oncol. 25, 1901–1914 (2014).

3. Sheng JY, Sharma D, Jerome G, Santa-Maria CA. Obese Breast Cancer Patients and Survivors: Management Considerations. Oncology (Williston Park). 2018 Aug 15;32(8):410-7. PMID: 30153321.

4. Demark-Wahnefried W, Platz EA, Ligibel JA, Blair CK, Courneya KS, Meyerhardt JA, Ganz PA, Rock CL, Schmitz KH, Wadden T, Philip EJ, Wolfe B, Gapstur SM, Ballard-Barbash R, McTiernan A, Minasian L, Nebeling L, Goodwin PJ. The role of obesity in cancer survival and recurrence. Cancer Epidemiol Biomarkers Prev. 2012 Aug;21(8):1244-59. doi: 10.1158/1055-9965.EPI-12-0485. Epub 2012 Jun 13. PMID: 22695735; PMCID: PMC3415558.

5. Harrigan M, Cartmel B, Loftfield E, Sanft T, Chagpar AB, Zhou Y, Playdon M, Li F, Irwin ML. Randomized Trial Comparing Telephone Versus In-Person Weight Loss Counseling on Body Composition and Circulating Biomarkers in Women Treated for Breast Cancer: The Lifestyle, Exercise, and Nutrition (LEAN) Study. J Clin Oncol. 2016 Mar 1;34(7):669-76. doi: 10.1200/JCO.2015.61.6375. Epub 2015 Nov 23. PMID: 26598750; PMCID: PMC4872022.

6.  Lisevick A, Cartmel B, Harrigan M, Li F, Sanft T, Fogarasi M, Irwin ML, Ferrucci LM. Effect of the Lifestyle, Exercise, and Nutrition (LEAN) Study on Long-Term Weight Loss Maintenance in Women with Breast Cancer. Nutrients. 2021 Sep 18;13(9):3265. doi: 10.3390/nu13093265. PMID: 34579142; PMCID: PMC8469752.

7. Chung S, Zhu S, Friedmann E, Kelleher C, Kozlovsky A, Macfarlane KW, Tkaczuk KH, Ryan AS, Griffith KA. Weight loss with mindful eating in African American women following treatment for breast cancer: a longitudinal study. Support Care Cancer. 2016 Apr;24(4):1875-81. doi: 10.1007/s00520-015-2984-2. Epub 2015 Oct 13. PMID: 26463645; PMCID: PMC4909150.

8.  Rock CL, Byers TE, Colditz GA, Demark-Wahnefried W, Ganz PA, Wolin KY, Elias A, Krontiras H, Liu J, Naughton M, Pakiz B, Parker BA, Sedjo RL, Wyatt H; Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial Group. Reducing breast cancer recurrence with weight loss, a vanguard trial: The Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial. Contemp Clin Trials. 2013 Mar;34(2):282-95. doi: 10.1016/j.cct.2012.12.003. Epub 2012 Dec 22. PMID: 23266440; PMCID: PMC3593786.

9. Chlebowski RT, Aragaki AK, Anderson GL, Pan K, Neuhouser ML, Manson JE, Thomson CA, Mossavar-Rahmani Y, Lane DS, Johnson KC, Wactawski-Wende J, Snetselaar L, Rohan TE, Luo J, Barac A, Prentice RL; Women’s Health Initiative. Dietary Modification and Breast Cancer Mortality: Long-Term Follow-Up of the Women's Health Initiative Randomized Trial. J Clin Oncol. 2020 May 1;38(13):1419-1428. doi: 10.1200/JCO.19.00435. Epub 2020 Feb 7. PMID: 32031879; PMCID: PMC7193750.

10.  Pierce, J. P. et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women's

Healthy Eating and Living (WHEL) randomized trial. JAMA 298, 289–298 (2007).