Maximizing Your Maximizing Your Health During and Health During and

After Breast Cancer After Breast Cancer TreatmentTreatment

Julie R. Gralow, M.D.Julie R. Gralow, M.D.Associate Professor, Medical OncologyAssociate Professor, Medical Oncology

University of Washington School of University of Washington School of MedicineMedicine

Fred Hutchinson Cancer Research CenterFred Hutchinson Cancer Research CenterSeattle Cancer Care AllianceSeattle Cancer Care Alliance

Regular Physical Activity and Regular Physical Activity and Good Nutrition Can Help Reduce:Good Nutrition Can Help Reduce:• Heart diseaseHeart disease• High cholesterol levelsHigh cholesterol levels• High blood pressureHigh blood pressure• ObesityObesity• Nicotine addictionNicotine addiction• DiabetesDiabetes• DepressionDepression• Cancer Cancer • OsteoporosisOsteoporosis• InsomniaInsomnia• Age-related declines in muscular strengthAge-related declines in muscular strength

Exercise During Cancer Exercise During Cancer TreatmentTreatment

Exercise During Cancer Exercise During Cancer TreatmentTreatment

Maintaining an exercise Maintaining an exercise program throughout cancer program throughout cancer

treatment is not only safe, but treatment is not only safe, but also an effective way to manage also an effective way to manage

fatigue, depression, and fatigue, depression, and treatment side effectstreatment side effects

Exercise Benefits Physical HealthExercise Benefits Physical Health

• Improved healing and recovery from surgeryImproved healing and recovery from surgery

• Decreased lymphedemaDecreased lymphedema

• Higher energy levels, less fatigueHigher energy levels, less fatigue

• Weight loss/prevent weight gainWeight loss/prevent weight gain

• Decreased nauseaDecreased nausea

• Less painLess pain

• Decreased heart disease and osteoporosisDecreased heart disease and osteoporosis

Exercise Benefits Emotional HealthExercise Benefits Emotional Health

• Improved body and self-imageImproved body and self-image

• Decreased anxietyDecreased anxiety

• Improved social interactionImproved social interaction

• Better sense of controlBetter sense of control

• Improved depression and moodImproved depression and mood

• Better sleep patternsBetter sleep patterns

Fatigue and Quality of Life Fatigue and Quality of Life Outcomes of Exercise During Outcomes of Exercise During

Cancer TreatmentCancer TreatmentMock V et al, Cancer Pract 9: 119-127 2001Mock V et al, Cancer Pract 9: 119-127 2001

• PatientsPatients: 52 breast cancer patients randomized : 52 breast cancer patients randomized to home-based walking program or usual care to home-based walking program or usual care during adjuvant chemotherapy or radiation during adjuvant chemotherapy or radiation therapytherapy

• ResultsResults: Women who exercised > 90 minutes : Women who exercised > 90 minutes per week (divided over 3 or more days) per week (divided over 3 or more days) reported significantlyreported significantly–Less fatigueLess fatigue–Less emotional distressLess emotional distress–Higher functional abilityHigher functional ability–Better quality of lifeBetter quality of life

Exercise and Breast Cancer Post-Exercise and Breast Cancer Post-TreatmentTreatment

Exercise and Survival After Exercise and Survival After Breast Cancer DiagnosisBreast Cancer Diagnosis

Holmes MD et al, JAMA 2005Holmes MD et al, JAMA 2005

• Prospective observational study Prospective observational study

– 2987 nurses in the U.S. Nurses’ Health Study 2987 nurses in the U.S. Nurses’ Health Study diagnosed with stage I, II or III breast cancerdiagnosed with stage I, II or III breast cancer

– Physical activity categories:Physical activity categories:

» < 3 MET hours (metabolic equivalent tasks) per < 3 MET hours (metabolic equivalent tasks) per weekweek

» 3-8.9 MET hours/week3-8.9 MET hours/week

» 9-14.9 MET hours/week9-14.9 MET hours/week

» > 24 MET hours/week> 24 MET hours/week

– 3 MET hours per week is equal to walking at an 3 MET hours per week is equal to walking at an average pace of 2-3 miles /hour for 1 houraverage pace of 2-3 miles /hour for 1 hour

Exercise and Survival After Exercise and Survival After Breast Cancer DiagnosisBreast Cancer Diagnosis

Holmes MD et al, JAMA 2005Holmes MD et al, JAMA 2005

• Results:Results:

– Compared to women with < 3 MET hours/week, risk Compared to women with < 3 MET hours/week, risk of dying of breast cancer was:of dying of breast cancer was:

» 20% less for 3-9 MET hours/week20% less for 3-9 MET hours/week

» 40-50% less for > 9 MET hours/week of exercise40-50% less for > 9 MET hours/week of exercise

• Conclusion:Conclusion:

– Physical activity after a breast cancer diagnosis may Physical activity after a breast cancer diagnosis may reduce the risk of death from this diseasereduce the risk of death from this disease

– The greatest benefit occurred in women who The greatest benefit occurred in women who performed the equivalent of walking 3-5 hours/week performed the equivalent of walking 3-5 hours/week at an average paceat an average pace

What About Lymphedema What About Lymphedema (Arm Swelling After Lymph (Arm Swelling After Lymph

Node Surgery)?Node Surgery)?

Weight Training and Lymphedema in Weight Training and Lymphedema in Breast Cancer SurvivorsBreast Cancer Survivors

Ahmed RL et al, J Clin Oncol 2005Ahmed RL et al, J Clin Oncol 2005

• PatientsPatients: 45 breast cancer survivors following axillary lymph : 45 breast cancer survivors following axillary lymph node dissectionnode dissection

• StudyStudy: Randomized to weight training program or not: Randomized to weight training program or not– Weight training sessions 2x per week for 6 monthsWeight training sessions 2x per week for 6 months– For upper body, initially used no weights or only wrist For upper body, initially used no weights or only wrist

weights, weight gradually increased if no symptoms of weights, weight gradually increased if no symptoms of lymphedema developedlymphedema developed

• ResultsResults::– None of the women in the weight training program None of the women in the weight training program

experienced a noticeable change in arm swellingexperienced a noticeable change in arm swelling– Frequency of new lymphedema, or worsening of existing Frequency of new lymphedema, or worsening of existing

lymphedema, was similar in both groupslymphedema, was similar in both groups

Nutrition, Body Weight and Breast Nutrition, Body Weight and Breast CancerCancer

--Maintain good Maintain good body weightbody weight

-Low fat diet-Low fat diet

-High fiber-High fiber

-Increase fruits -Increase fruits and vegetablesand vegetables

-Limit alcohol-Limit alcohol

Nutrition and Survival after the Nutrition and Survival after the Diagnosis of Breast Cancer: A Diagnosis of Breast Cancer: A

Review of the EvidenceReview of the EvidenceRock CL et al, JCO 20:3302-16, 2002Rock CL et al, JCO 20:3302-16, 2002

• Being overweight or obese is associated with Being overweight or obese is associated with poorer prognosis in a majority of studiespoorer prognosis in a majority of studies

• Treatment-related weight gain influences Treatment-related weight gain influences survival, quality of life, other diseasessurvival, quality of life, other diseases

• Dietary fat: 5 of 12 studies showed inverse Dietary fat: 5 of 12 studies showed inverse relationship with survivalrelationship with survival

• Fruits and vegetables: majority of studies Fruits and vegetables: majority of studies showed favorable relationship with survivalshowed favorable relationship with survival

Breast Cancer and AlcoholBreast Cancer and AlcoholMore than 2 drinks/day associated with increased breast More than 2 drinks/day associated with increased breast

cancer risk!cancer risk!

Women’s Intervention Nutrition Study Women’s Intervention Nutrition Study (WINS)(WINS)

Chlebowski R et al, JNCI 98, 2006Chlebowski R et al, JNCI 98, 2006

• PatientsPatients: 2,437 postmenopausal women with early stage : 2,437 postmenopausal women with early stage breast cancer (age 48-79)breast cancer (age 48-79)

• InterventionIntervention: Randomized within 1 year of surgery to:: Randomized within 1 year of surgery to:

– dietary intervention (8 biweekly counseling sessions by dietary intervention (8 biweekly counseling sessions by nutritionists and support throughout)nutritionists and support throughout)

– versus controlversus control

• ResultsResults::

Fat intake/day at 12 monthsFat intake/day at 12 months

Intervention groupIntervention group 33.3 gms (+/- 16.7)33.3 gms (+/- 16.7)

Control groupControl group 51.3 gms (+/- 24.4)51.3 gms (+/- 24.4)

Women’s Intervention Nutrition Study Women’s Intervention Nutrition Study (WINS)(WINS)

Chlebowski R et al, JNCI 98, 2006Chlebowski R et al, JNCI 98, 2006

• Results (cont.)Results (cont.): :

Relapses (60 month follow-up)Relapses (60 month follow-up)GroupGroup DietDiet Control Control

All ptsAll pts 96/975 (9.8%)96/975 (9.8%) 181/1462 (12.3%)181/1462 (12.3%)

24% reduction in breast cancer recurrence in diet intervention group24% reduction in breast cancer recurrence in diet intervention group

Conclusion: Lifestyle interventions can reduce Conclusion: Lifestyle interventions can reduce recurrences in breast cancer patientsrecurrences in breast cancer patients

Optimizing Health After Breast Optimizing Health After Breast Cancer Diagnosis and TreatmentCancer Diagnosis and Treatment

• Exercise regularlyExercise regularly

• Avoid obesity, control weightAvoid obesity, control weight

• Eat a healthy diet: low fat, high fiber, low Eat a healthy diet: low fat, high fiber, low alcoholalcohol

• Avoid smokingAvoid smoking

• Wear sunscreenWear sunscreen

• Reduce stressReduce stress

• Control known diseases: high blood pressure, Control known diseases: high blood pressure, diabetes, high cholesterol, osteoporosisdiabetes, high cholesterol, osteoporosis

Optimizing Health After Breast Optimizing Health After Breast Cancer Diagnosis and TreatmentCancer Diagnosis and Treatment

• The majority of The majority of breast cancer breast cancer patients can look patients can look forward to a long forward to a long life after cancer life after cancer diagnosis and diagnosis and treatmenttreatment

• Cancer patients Cancer patients should not forget should not forget about all aspects about all aspects of health and well-of health and well-beingbeing