Breast Cancer, Diet, Exercise, and Treatment Cost

Breast Cancer, Diet, Exercise, and Treatment Cost

Michael A. Thompson, MD, PhD

@mtmdphd
Nov 14, 2011

After the ASCO Integrated Media and Technology Committee meeting I was delayed at Reagan National Airport with poor Wi-Fi access. I resorted to reading a physical (yes, paper!) journal (Oncology. Oct 2011, Volume 25, Number 11). I was struck by two seemingly unrelated manuscripts (and commentary).

Goals and Costs of Cancer Therapy
The first article was by fellow ASCO member and blogger L. Michael Glodé, MD: “Oncology Perspectives: Is Cancer the Answer?” Some of his main points were that humans are not immortal, cancer care is expensive, early palliative care appears to have a survival benefit (at least in some cancers), and we should consider all treatment options including non-pharmacological interventions.

Obesity, Diet, Exercise, and Breast Cancer
The other article was “Obesity and Breast Cancer” by Jennifer Ligibel, MD. Commentary articles followed that manuscript. I was aware of data suggesting that obesity and related medications or biomarkers such as metformin, insulin level, metabolic syndrome, diabetes, etc., were related to breast cancer risk or recurrence. However, I admit I was unaware of the depth and number of studies evaluating this. I was also unaware of some holes in our information, i.e. “…no studies examining the impact of purposeful weight loss on breast cancer prognosis.” Please read the full manuscript and accompanying commentaries. I was struck by the consistency of hazard ratio (HR) risk reduction from various interventions including diet and exercise (often intensive and individualized, not just an offhanded statement to eat more veggies; see article's Table 1) as well as the risks with high insulin, metabolic syndrome or other biomarkers (see article's Table 3).

Sparano and Strickler in “Breast Cancer Patients Who Are Obese at Diagnosis: Alea Iacta Est? or "Is the Die Cast?" pointed out the concept of the “healthy obese” patient exists that may not have the same risk of recurrence (a hypothesis) as other “morbid obese” (where morbid is unhealthy, not BMI) and that we may need to risk stratify obese patients based on biomarkers.

The juxtaposition of the Glodé and “Obesity and Breast Cancer” articles resonated with me. Given the data (and not just a vague warm and fuzzy sentiment for a healthier lifestyle), why isn’t there an algorithm in the NCCN (or other) guidelines for dietary interventions as adjuvant therapy? To be fair, NCCN does mention diet and exercise (p. 26/148 - BINV-16 and p. 99/148 – MS-35 in version 2.2011): “Evidence suggests that active lifestyle, achieving and maintaining an ideal body weight (20-25 BMI) may lead to optimal breast cancer outcomes.” So, maybe this should be mentioned more prominently in the upfront algorithm, rather than after other adjuvant therapies?

Clinical trials (as mentioned in the Ligibel article) are evaluating various interventions. One currently accruing study is the MA.32 trial "Phase III Trial of Metformin versus Placebo in Early-Stage Breast Cancer" by the National Cancer Institute of Canada (NCIC) Clinical Trials Group and the U.S. NCI.

QUESTIONS

  • I suspect that some of these interventions may have a higher magnitude of benefit than chemotherapy. Can the effects of diet and exercise as adjuvant therapy be incorporated into Adjuvant! Online to help better personalize treatment planning?
  • Would an adequately informed patient choose chemo over a POTENTIALLY (based on individual patient/tumor characteristics) larger risk reduction with diet/exercise?
  • In an Accountable Care Organization (ACO) world with limited resources isn’t this highly important for a potential way to contain costs?
  • Should we be hiring more registered dieticians, physical therapists, personal trainers, and paying for gym memberships rather than chemo?
  • Can we save money, improve health, and spare toxicities (in selected patients)?

I am still trying to decide how to implement these interventions, but I will certainly refer more quickly to diet and exercise programs in the future.

What do you think?

ADDENDUM:
Other Links:

NCI Cancer Bulletin (11/15/11) - "The Emerging Evidence about the Role of Obesity in Cancer" - http://ht.ly/7vlLL

Nature Medicine (10/30/11 online) - "Adipocytes promote ovarian cancer metastasis and provide energy for rapid tumor growth" - http://www.nature.com/nm/journal/v17/n11/full/nm.2492.html

amednews (11/16/11) - AMA helping physicians broach the subject of obesity - http://www.ama-assn.org/amednews/2011/11/14/prsf1116.htm

Metformin and thiazolidinediones are associated with improved breast cancer-specific survival of diabetic women with HER2+ breast cancerHe et al. Ann Oncol (2011) - http://annonc.oxfordjournals.org/content/early/2011/11/09/annonc.mdr534....
Conclusions: Thiazolidinediones and metformin users are associated with better clinical outcomes than nonusers in diabetics with stage ≥2 HER2+ breast cancer. The choice of antidiabetic pharmacotherapy may influence prognosis of this group.

12/2011
Obesity linked to worse survival in #BreastCancer adjuvant therapy - Dr. Sao Jiralerspong @bcmhouston http://ow.ly/aDzaa & @ASCO YIA 2007 http://ow.ly/aDzov

Fasting Might Boost Chemo's Cancer-Busting Properties: Scientific American -- http://bit.ly/zPzm9W

From NPR 4/26/12 -- 

Evidence Mounts That Diet, Exercise Help Survivors Cut Cancer Risk

http://www.npr.org/blogs/health/2012/04/25/151387672/evidence-mounts-that-diet-exercise-help-survivors-cut-cancer-risk?ft=1&f=1128&sc=tw

Effects of a Caloric Restriction Weight Loss Diet and Exercise on
Inflammatory Biomarkers in Overweight/Obese Postmenopausal Women: A
Randomized Controlled Trial

Ikuyo Imayama, Cornelia M. Ulrich, Catherine M. Alfano, Chiachi Wang, Liren
Xiao, Mark H. Wener, Kristin L. Campbell, Catherine Duggan, Karen E.
Foster-Schubert, Angela Kong, Caitlin E. Mason, Ching-Yun Wang, George L.
Blackburn, Carolyn E. Bain, Henry J. Thompson, and Anne McTiernan
Cancer Res 2012;72 2314-2326
http://cancerres.aacrjournals.org/cgi/content/abstract/72/9/2314?etoc
Findings suggest that weight loss with or without exercise may reduce risk
of breast cancer, possibly due to a reduction in systemic inflammation that
may support tumor development or progression.

 

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Comments

L. Michael Glode, MD, FACP, FASCO

Nov, 14 2011 10:31 PM

Interesting comments, and thanks for the reference to my blog. Someone at our medical center is talking about "why doctors don't recommend weight loss" this week. I can't find much in the literature about this, but it is fairly clear that some of us have trouble losing weight ourselves, while others are very successful at keeping weight off as we age. Given the abundant evidence in rodent models that there is really only ONE intervention that prolongs lifespan (calorie restriction), it may come down to the old conundrum of quality versus quanity - a decision made every day in our clinics when patients elect toxic therapies with limited (but proven) survival benefit.

Michael A. Thompson, MD, PhD

Nov, 14 2011 11:01 PM

@ Mike G. -
True. Knowing we should lose weight (or exercise, etc) is not the problem, but rather doing it.  However, cancer is a powerful motivator (at least for some women such as in these studies). Interestingly, I saw this tweet today from the N Engl J Med:  POWER: Enhanced weight-loss counseling helps about 1/3 obese pts achieve longterm, clin meaningful weight loss.   With the conclusions that: "Enhanced weight-loss counseling helps about one third of obese patients achieve long-term, clinically meaningful weight loss. (Funded by the National Heart, Lung, and Blood Institute; POWER-UP ClinicalTrials.gov number, NCT00826774.)"

Peter Paul Yu, MD, FASCO, FACP

Nov, 20 2011 5:40 PM

I attended my practice's finance committee meeting last week and it included our quarterly financial performance report on programs such as our weight management program. As usual, this program either breaks even (this month) or loses a small amount. We have accepted this breakeven status for as long as I can remember since it provides a useful serivce for a small part of the patients that receive care at our integrated medical group. Lately however I have come to realize that the consequences of obesity underlie cardiovascular, diabetes, cancer risk and a host of other medical problems that this program can help us understand how to manage better . We should add our voice to this chorus.

Michael A. Thompson, MD, PhD

Nov, 23 2011 9:55 AM

I just saw this: http://annonc.oxfordjournals.org/content/early/2011/11/09/annonc.mdr534.short?rss=1

He X, Esteva FJ, Ensor J, et al. Metformin and thiazolidinediones are associated with improved breast cancer-specific survival of diabetic women with HER2+ breast cancer. Ann Oncol. 2011.

Conclusions:

  • Thiazolidinediones and metformin users are associated with better clinical outcomes than nonusers in diabetics with stage ≥2 HER2+ breast cancer.
  • The choice of antidiabetic pharmacotherapy may influence prognosis of this group.

Ved Joshi

Apr, 03 2012 8:45 AM

To treat Obesity we always need and weight loss plan. The exercise is the the best way of treatment to control obesity or to treat other health diseases. Here the information given in this post is really very helpful and informative and will also help the people to lower the risk of diseases.
Causes of hypoglycemia

James M. Sinclair, MD

Apr, 06 2012 11:44 AM

I find the challenge of obesity in my practice similar to the challenge of discussing goals of care/end of life issues. I know it is the right thing to do with plenty of data to support it but it is so much more difficult than suggesting Carbo/Alimta/Avastin for advanced lung cancer. This takes less time, generates more income and expects much less from the patient and family. I find the comment about breaking even or losing money on nutritional counseling intriguing. It is the right thing to do but how do we keep the lights on in the office at the same time? Fortunately my cancer center has good nutritional counseling and we have wonderful donors that have given enough money for us to pay for the dietician if the insurance won't pay. That same insurance company will happily cover herceptin! 10 years ago I heard about an insurance company that offered a discount on high tier meds like Femara if the patient attended the gym twice a week. I think that is brilliant but it doesn't exist any more.  

Michael A. Thompson, MD, PhD

Apr, 18 2012 1:21 PM

James -

Thank you for your comments.
I agree that obesity and exercise are tough to work on in the cancer or general population.
I think a systems approach (possibly with carrots and sticks...) will work better than relying on individual patients or physicians to overcome such behavioral barriers.

Anyone else have insurance company or other "systems" examples that are trying to implement this?
 

Nathaniel Isonguyo Usoro, MD, MBBCh

Apr, 28 2012 6:38 PM

This is very interesting about obesity and breast cancer. However in my practice in West Africa I rarely encounter obese breast cancer patients. Most of them eat a lot of vegetables. They are also mostly young premenopausal women.

Michael A. Thompson, MD, PhD

Feb, 13 2013 4:05 PM

A small but interesting study of n=30 breast cancer survivors...
http://www.researchprotocols.org/2013/1/e11/

Development and Formative Evaluation of a Web-Based Self-Management Exercise and Diet Intervention Program With Tailored Motivation and Action Planning for Cancer Survivors 
JMIR Res Protoc 2013;2(1):e11
Myung Kyung Lee, RN, MPH, PhD; Hyeoun-Ae Park, RN, PhD, FAAN; Young Ho Yun, MD, PhD; Yoon Jung Chang, MD, PhD

Conclusions: 
The use of Internet technology allowed immediate and easy access to interventions, real-time monitoring of progress, online education, tailored action planning, and tailored short message services using mobile phones. 

Michael A. Thompson, MD, PhD

Oct, 11 2013 9:14 AM

Recreational Physical Activity and Leisure-Time Sitting in Relation to Postmenopausal Breast Cancer Risk

by Janet S. Hildebrand, Susan M. Gapstur, Peter T. Campbell, Mia M. Gaudet, and Alpa V. Patel Cancer Epidemiol Biomarkers Prev October 2013 22; 1906 http://cebp.aacrjournals.org/content/22/10/1906.full

*Abstract* Epidemiologic evidence supports an inverse association between physical activity and postmenopausal breast cancer. Whether associations exist for moderate activities, such as walking, and whether associations differ by estrogen receptor (ER) status, body mass index (BMI, kg/m2), adult weight gain, or use of postmenopausal hormones (PMH) is unclear. The relation between time spent sitting and breast cancer also is unclear. Among 73,615 postmenopausal women in the American Cancer Society Cancer Prevention Study II Nutrition Cohort, 4,760 women were diagnosed with breast cancer between 1992 and 2009. Extended Cox regression was used to estimate multivariable-adjusted relative risks (RR) of breast cancer in relation to total recreational physical activity, walking, and leisure-time sitting. Differences in associations by ER status, BMI, weight gain, and PMH use were also evaluated. The most active women (those reporting >42 MET-hours/week physical activity) experienced 25% lower risk of breast cancer than the least active [0–Sitting time was not associated with risk. These results support an inverse association between physical activity and postmenopausal breast cancer that does not differ by ER status, BMI, weight gain, or PMH use. The finding of a lower risk associated with ≥7 hours/week of walking may be of public health interest.

Discussion: Study Links Walking to Lower Breast Cancer Risk http://www.cancer.org/cancer/news/news/study-links-walking-to-lower-breast-cancer-risk

By Stacy Simon Researchers from the American Cancer Society have found that walking at least 7 hours per week is associated with a 14% lower risk of developing breast cancer after menopause. This finding is consistent with many other studies that show regular exercise can help women lower their risk of breast cancer. New information in this study found the exercise helped women whether or not they were overweight, and helped them even if they gained weight during the study.

From Tweet: MT @OHSUKnight: @AmericanCancer >7h/wk walking 14% rel risk reduction BreastCancer http://ow.ly/pHdUr CEBP: http://ow.ly/pHilk #bcsm

Michael A. Thompson, MD, PhD

Dec, 03 2013 8:30 PM

27-Hydroxycholesterol Links Hypercholesterolemia and Breast Cancer Pathophysiology
Nelson et al.
Science http://ow.ly/rqoxA #bcsm


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