Counseling for Risk Reduction After Diagnosis of Breast Cancer

By Mary L. Hardy, MD

When a diagnosis of breast cancer is made, both the patient and the physician struggle with the impact of this bad news. They immediately focus on initiating definitive therapy, usually with conventional treatments. However, one of the strengths of complementary/alternative/integrative medicine is promotion of the patients’ maximal health and wellness—no matter what the presenting condition of the patient.

This month, we are focusing on the recent work of a research team at Duke University with an interest in nutrition and breast cancer survival.1,2 Healthy diet may seem to be the last issue needing attention when dealing with a life-threatening illness, but soon after the diagnosis may be a critical time to focus on health promotion and risk factor modification. The most common question I am asked by my breast cancer patients even before the completion of therapy is: What can I do myself to prevent this from coming back? Evidence suggests that a healthy diet, maintaining normal weight, and increasing exercise may be exactly what the patient needs and the doctor should order.

Breast cancer, the most common cancer in women, accounts for 32% of the cases of cancer reported in 2003. However, since more women are reaching the five-year survival mark (86% in 2002), we need to pay attention to disease prevention in the survivors.3 Physicians should address strategies for secondary cancer prevention as well as risk factor modification for other common illnesses such as heart disease or osteoporosis.

A recent review by Rock and Demark-Wahnefried focused on the role of nutrition in breast cancer survivors.1 Based on the evidence cited in this review and the other references listed here, we can give our breast cancer patients advice that should decrease their risk of heart disease or cancer recurrence and may increase their survival. Let’s look at the specifics.

Weight gain, a risk factor for both breast cancer and heart disease, is very common in premenopausal breast cancer patients receiving chemotherapy. In fact, weight gain after diagnosis may adversely effect disease-free survival. Women who gained an average of 6 kg were 1.5 times more likely to have a recurrence than women who did not gain weight and these women were 1.6 times more likely to die of their breast cancer.4 Observations made by the research team at Duke University suggest that this weight gain, while a modest 2.1 kg on average for their chemotherapy patients, was the result of the loss of lean body mass.5 This is significant because loss of lean body mass decreases women’s resting energy expenditure, making it easier to continue to gain weight. Further they noted that over the year of the study there was no increase in resting energy rate or food intake, which could account for this weight gain. They did, however, find a significant decrease in physical activity in the chemotherapy-treated patients. This study recommends that breast cancer survivors be advised to exercise regularly and include weight training, especially of the lower extremities, to increase lean body mass and to limit weight gain after treatment.

Dietary choices that limit weight gain and favor foods with a demonstrated benefit on survival after breast cancer should be stressed. According to Demark-Wahnefried’s review, decreasing dietary fat and increasing fruit and vegetable consumption showed an inverse relationship with survival.1 Fruits and vegetables may displace more calorie dense foods and are great sources of vitamins and other phytonutrients like flavonoids, lignans, and fiber. Most studies showed an inverse relationship between fruit and vegetable consumption and survival following breast cancer. Patients should be encouraged to eat a variety of foods, but preliminary data suggest that some foods— such as green tea (for the epicatechins) and cruciferous vegetables including broccoli and watercress (for the isothyiocyanates)—could be of particular benefit to breast cancer patients.

Alcohol is more controversial, showing some benefit for heart disease but not for breast cancer survival.6 In general, women recovering from breast cancer should be discouraged from drinking alcohol regularly and use those calories for more healthful choices.

In case you’re not convinced that we need to do this, note that most of 531 breast cancer patients were not recommended to make healthy lifestyle changes by their physicians (increased fruits and vegetables: 17% recommended; decreased fat intake: 29% recommended; exercise: 34% recommended). This group needed to hear these messages; only 50% of them were exercising regularly and less than half of them were eating five or more servings of fruits and vegetables a day. Compliance with a low-fat diet was better, with 78% reporting that they ate less than 30% of their calories from fat. They reported an interest in hearing these healthy messages within the first six months of their diagnosis and appeared receptive to lifestyle change.2

Current studies are under way to test the effect of these interventions on survival, but when you see breast cancer patients or those at high risk for breast cancer, take advantage of a "teachable moment." Counsel them to adopt habits that decrease their risk of breast cancer and other diseases like heart disease. To be successful, be specific with your patients about what to do. Suggest five or more servings of a variety of fruits and vegetables; a low-fat diet (no more than 30% calories from fat); no weight gain during or after treatment; exercise for at least 30 minutes most days and include weight or resistance training in the exercise regime to preserve or increase lean body mass. Ask about these behaviors during follow-up visits and problem-solve the difficulties patients can anticipate in putting these ideas into practice. These suggestions can give patients struggling with feelings of loss of control and disempowerment proactive behaviors that allow them to take charge of at least this part of their health care program. In fact, this may the best time to talk about health promotion—it’s hopeful and helpful.

Dr. Hardy, Medical Director, Cedars-Sinai Integrative Medicine Medical Group, Los Angeles, CA, is on the Editorial Advisory Board of Alternative Therapies in Women’s Health.

References

1. Rock CL, Demark-Wahnefried W. Nutrition and survival after the diagnosis of breast cancer: A review of the evidence. J Clin Oncol 2002;15:3302-3316.

2. Demark-Wahnefried W, et al. Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinoma. Cancer 2000;88:674-684.

3. American Cancer Society. Cancer Statistics 2003: A presentation from the American Cancer Society.

4. Camoriano JK, et al. Weight change in women treated with adjuvant therapy or observed following mastectomy for node-positive breast cancer. J Clin Oncol 1990;8:1327-1334.

5. Demark-Wahnefried W, et al. Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy. J Clin Oncol 2001;19: 2367-2369.

6. Bradlow HL, Sepkovic DW. Diet and breast cancer. Ann NY Acad Sci 2002;963:247-267.