Do diet and exercise play a role in breast cancer risk or survival? Jennifer Ligibel, MD, director of the Zakim Center for Integrative Therapies at Dana-Farber, discusses the benefits of a healthy lifestyle for young women with cancer. This presentation was originally given on Oct. 16, 2015 at the Young Women with Breast Cancer Forum, hosted by the Program for Young Women with Breast Cancer in the Susan F. Smith Center for Women's Cancers at Dana-Farber Cancer Institute, in Boston, Mass. Learn more: http://www.susanfsmith.org

1. Health Behaviors and Breast Cancer
in Young Women
Jennifer Ligibel, MD
Dana-Farber Cancer Institute
Dana-Farber Annual Young Women’s Forum
October 16, 2015

2. Health behaviors are increasingly linked to
breast cancer
Energy we take in Energy we “spend” What remains
(Food) (Exercise + Metabolism) (Weight)
_
=
Each of these factors has been linked to breast cancer

3. Health Behaviors and Breast Cancer
• What does the evidence show about the links
between health behaviors and breast cancer?
• Is there any evidence specifically in young
women?
• What do guidelines recommend in terms of
health behaviors in young women with breast
cancer?

4. Obesity has become dramatically more
common in US over last 25 years
Trends in Obesity Prevalence (%), Adults 18 and Older, US,
1985-2010
http://www.cdc.gov/obesity/data/trends.html

5. What is obesity?
We all know that obesity means weighing too
much, but how much too much?
Is this the same for every person?

6. How much should a woman weigh?
• Old calculation:
– 100 pounds for first 5 feet
– 5 pounds for each additional inch
• Did not take into consideration different body
frames, ethnicities, etc
• Did not differentiate between a little extra weight
and a lot

7. Body Mass Index
• Calculated according to the formula: kilograms/(meters)2
• Allows for creation of weight categories:
• Underweight: BMI <18.5 kg/m2
• Normal weight: BMI 18.5-24.9 kg/m2
• Overweight: BMI 25-29.9 kg/m2
• Obese: BMI ≥30 kg/m2
» Class 1 obesity: 30-35
» Class 2 obesity: 35-40
» Class 3 obesity: >40

8. So what does this mean for an actual person?
For a 5’4” woman:
Normal weight: 110-144
Overweight: 145-173
Obese: 174+
Obesity is 30+ pounds of excess weight for 5’4” woman

9. Many studies show heavier women more likely
to develop breast and other cancers

10. Obesity is also linked to poor survival in
women with breast cancer
• 100+ studies have looked to see if a woman’s
weight at the time she is diagnosed with breast
cancer is linked to her risk of cancer recurrence
• Normal weight women had a 35% lower rate of
breast cancer recurrence compared to obese
women

11. Example of a study looking at weight and
breast cancer recurrence
• Enrolled 2005 patients
between 1997 and 1999
• All patients treated with
modern chemotherapy
• All patients received
appropriate treatment
regardless of weight
CALGB 9741

12. Even 15 years ago, many patients were
overweight or obese
BMI in CALGB 9741:
– 1% Underweight
(<18.5 kg/m2)
– 33% Normal Weight
(18.5-24.9 kg/m2)
– 33% Overweight
(25-29.9 kg/m2)
– 33% Obese
( ≥ 30 kg/m2)

13. Results: Leaner women had lower risk of
breast cancer recurrence
• Each 1 unit increase in BMI linked to a 1.5%
increase in risk of breast cancer recurrence (and in
risk of death)
• For example, compared to a normal weight woman:
• An overweight woman had an 8% increase in risk of recurrence
• An obese woman had a 17% increase in risk of recurrence

14. There are also links between physical
activity and breast cancer recurrence

15. Women who exercised (even a little) have
lower risk of breast cancer recurrence
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Recurrence *
< 1 hour
1-3 hours
3-5 hours
> 5 hours
MET-Hrs/week
*p=0.05, # p<0.004
50% FEWER CANCER
RECURRENCES IN WOMEN
WHO EXERCISED > 3
HOURS/WEEK

16. What kind of exercise were these women
doing?
• The most common exercise was walking at a
moderate pace
• Benefits seen with walking at a 3-mile-per-hour
pace for half an hour per day
• Not necessary to run a marathon! (of course
you always can if you like)

17. What about diet?
• Many studies look at
diet and breast cancer
• No convincing evidence
that ANY type of food or
supplement changes
risk of developing
breast cancer

18. What about diet and cancer recurrence?
• Two studies were performed to see if changing
women’s diets lowered risk of breast cancer
recurrence
• Only research to date testing the impact of a
change in behavior after cancer diagnosis to
improve cancer survival rates

19. The Women’s Interventional
Nutrition Study (WINS)
• Assigned 2400 breast
cancer survivors to low fat
diet or to usual diet group
• Diet group cut fat to 20%
of calories and lost 6 lbs
• Diet group had 25% lower
risk of breast cancer
recurrence

20. The Women’s Healthy Eating and
Living Study (WHEL)
• Assigned 3000 breast cancer survivors to dietary
change group or usual diet group
• Diet: high in fruits, vegetables and fiber and low
in fat
• Diet group changed diet but did not lose weight
• NO change in cancer recurrence rates

21. What do WINS and WHEL tells us about
diet, weight and breast cancer?
• Making a change in a lifestyle behavior after
cancer diagnosis could improve survival
• Changing behavior in large groups of survivors
is possible
• Factors most likely to improve cancer outcomes
unclear. Low fat diet? Weight loss?

22. Do we know anything about
health behaviors and breast
cancer in young women?

23. Weight and breast cancer in young
women
• Many studies suggest that obesity may be
linked to a lower risk of developing breast
cancer in young women
• However, evidence increasingly suggests that
obesity at the time of breast cancer diagnosis
may a strong risk factor for cancer recurrence

24. What else do we know about health behaviors
and breast cancer in young women?
• Most studies don’t include enough young
women to be able to draw strong conclusions
• Need more information about current patterns of
health behaviors in young women, as well as
ways to help women live healthier lives after
breast cancer diagnosis

26. Patient Eligibility
Invite all women seen in practice who are:
– Newly-diagnosed (within 3 months of diagnosis)
– Able to read and write English
– Woman aged 18-45 years at diagnosis
– Stage I-III breast cancer, with no known recurrence
or evidence of metastatic breast disease

27. The Young and Strong Health Behaviors
• The Young and Strong Study provides unique insight
into health behaviors in young women with breast
cancer:
• Enrolled 467 women
• Patients came from community and academic sites
• Average age 40
• Collected information about exercise and weight close to
diagnosis and several times during the first year after dx

28. Health Behaviors shortly after
breast cancer diagnosis
• Average BMI: 27kg/m2
• Average minutes of exercise: 85 minutes/week
• Women not doing any exercise: 52%

29. Changes in health behaviors
• Weight increased on average by 3 pounds
• Exercise increased to 130 minutes per week
• Women reporting no exercise decreased to 31%

30. Health Behavior Guidelines for breast
cancer survivors
Rock et al. Ca Cancer J Clin, 2012

31. Clinical Healthy Living Offerings at DFCI
• Women’s exercise class at BodyScapes
• Zakim Center offerings:
• Yoga
• Tai Chi/QiGong
• Healthy Living Weight Management
• Exercise consultations
through Adult Survivorship

32. Lifestyle intervention studies at Dana-Farber
• Exercise and weight loss studies at Dana-Farber
• Exercise and metformin
• Mind body intervention after breast surgery
• Opening soon: Breast Cancer Weight Loss (BWEL) Study
• To learn more: Call 617-632-5934

33. Acknowledgements
• All the patients who have
volunteered for our
studies!
• Team at DFCI
• Laura Shockro
• Nancy Campbell
• Anita Giobbie-Hurder & Bill Barry
• Casey Peira
• Liz Frank
• Deborah Dillion
• Eric Winer
• Ann Partridge
• Jeff Meyerhardt
• Collaborators
• Melinda Irwin (Yale)
• Pam Goodwin (Univ of Toronto)
• Anne McTiernan (FHCRC)
• Lee Jones (Duke)
• Funding:
• Susan G Komen
Foundation/Society for Women’s
Health Research
• NIH and NCI TREC
• LIVESTRONG Foundation
• CALGB
• ASCO
• Spivak and McMackin Foundations