2. Obesity and Breast Cancer: An Ever Growing Problem Presented By: Dr. Jaixin Niu Dr. Adam Kerievsky Brenda Keith RN MSN OCN Amy Malensek RN OCN CBCN Sara Kiser MS ND

3. Obesity and Breast Cancer: A Medical Oncologist’s Perspective Presented By: Dr. Jiaxin Niu © 2015 Rising Tide

4. Obesity and Breast Cancer Obesity: Body Mass Index (BMI) of 30 or higher Obesity itself was recognized as a disease by the American Medical Association in 2013 © 2015 Rising Tide

5. Prevalence of Obesity USA: 32% of men, 34% women Western Europe: 21% in both Sexes Southeast Asia: 8% men, 5% Women Lancet, 2014 © 2015 Rising Tide

6. Obesity Predicted to Top 60% in 13 States by 2030  Source: Trust for America's Health and the Robert Wood Johnson Foundation

7. 2013 POLL: RISKS OF OBESITY 7% of People surveyed mentioned cancer !!! © 2015 Rising Tide

8. Obesity Increases Cancer Risk Obesity may account for roughly 10% of colorectal cancers, and 25-40% of kidney, esophageal and endometrial cancers As many as 80, 000 cancer diagnoses each year are attributed to Obesity. Obesity will overtake tobacco as the leading preventable cause of cancer.

9. OBESITY AND BREAST CANCER 1.Obesity is a risk factor for breast cancer 2.Diagnostic and therapeutic challenges 3.Obesity is a poor prognostic factor © 2015 Rising Tide

10. Breast Cancer Siegel R, Ma J, Zou Z, et al: Cancer statistics, 2014. CA Cancer J Clin 64:9-29, 2014 Approximately 63, 000 new cases of carcinoma in situ (CIS) will be diagnosed © 2015 Rising Tide

11. Your Breast Cancer Risk 1 in 8 women (12.4%) born in the US will develop breast cancer at some time during their lifetime Howlader N, et al SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations), 2012.SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations) ~ 3 million breast cancer survivors at this time

12. © 2015 Rising Tide Nurses’ Health Study: Obesity Increases Breast Cancer Risk 87143 female nurses aged 30-55 years followed up to 26 years (1976-2002), 4393 developed breast cancer >10 Kg since age 18, 20% postmenopausal non- hormone users Eliassen et al. JAMA 2006; 296: 193 >25 Kg since age 18, 100% postmenopausal non-hormone users

13. © 2015 Rising Tide 87143 female nurses aged 30-55 years followed up to 26 years (1976-2002), 4393 developed breast cancer Eliassen et al. JAMA 2006; 296: 193 15% of breast cancer is attributable to weight gain of 2.0 kg or more since age 18 years Obesity + Hormonal replacement, they account for 1/3 breast cancer cases Nurses’ Health Study: Obesity Increases Breast Cancer Risk

14. © 2015 Rising Tide Nurses’ Health Study: Obesity Increases Breast Cancer Risk 87143 female nurses aged 30-55 years followed up to 26 years (1976-2002), 4393 developed breast cancer Eliassen et al. JAMA 2006; 296: 193 Non-hormone users, sustained weight loss of at least 10 Kg after menopause resulted in a 57% reduction in breast cancer risk

15. © 2015 Rising Tide Obesity Increases Breast Cancer Risk Sinicrope, FA, Dannenberg AJ. JCO 2010

16. Obesity: Advanced Stage Upon Diagnosis a. Larger Tumor b. Higher Grade c. HR-Negative Tumor d. More Positive LNs Breast Cancer Res Treat.Breast Cancer Res Treat. 2008 Sep;111(2):329-42. Breast Cancer Res Treat.Breast Cancer Res Treat. 2010 Aug;122(3):823-33. J Clin Oncol.J Clin Oncol. 2011 Jan 1;29(1):25-31. © 2015 Rising Tide

17. Obesity: Therapeutic Challenges Wound healing Lymphedema Radiation planning Breast Cancer Res Treat.Breast Cancer Res Treat. 2008 Sep;111(2):329-42. Breast Cancer Res Treat.Breast Cancer Res Treat. 2010 Aug;122(3):823-33. J Clin Oncol.J Clin Oncol. 2011 Jan 1;29(1):25-31. Delivery of systemic therapy © 2015 Rising Tide

18. Obesity: Therapeutic Challenges Timing of Chemotherapy Biagi JJ, et al. J Clin Oncol 29: 111s, 2011 Colleoni M, et al. J Clin Oncol 18: 584-590, 2000 Meta-analysis of 15,327 patients : initiation of Adjuvant chemotherapy Each 4-week delay: 8% in recurrence HR- patients: initiation of Adjuvant chemotherapy < 20 days vs 21-86 days: 60% vs 34% 10-year DFS © 2015 Rising Tide

19. Obesity: Therapeutic Challenges Dosing of Chemotherapy Biagi JJ, et al. J Clin Oncol 29: 111s, 2011 Colleoni M, et al. J Clin Oncol 18: 584-590, 2000 Compelling evidence that reduction from standard dose and dose-intensity may compromise OS Many oncologists use ideal body weight to calculate BSA or to CAP BSA at 2.0 m 2 Up to 40% of obese patients were undertreated © 2015 Rising Tide

20. Obesity: Therapeutic Challenges Dosing of Chemotherapy Griffs, JJ, et al. J Clin Oncol 30 2012 Pharmacokinetics of some but not all drugs may be altered in obese patients ! © 2015 Rising Tide

21. Obesity: Therapeutic Challenges Efficacy of Chemotherapy Litton, J, et al. J Clin Oncol 26 2008 Over 1100 Patients receiving neoadjuvant chemotherapy (1990-2004, using actual weight at MDACC) Overweight Obese Patients 40% to achieve pCR (pathological complete remission) © 2015 Rising Tide

22. Obesity: Therapeutic Challenges Compliance of Hormonal Therapy Henry, NL, et al. J Clin Oncol 30 2012 AIs (anastrozole, letrozole and exemestane) have similar benefits and toxicities Myalgia & Arthralgia in up to 60% patients Median time to discontinuation is 6 months Discontinuation Rate 30-50%, 75% due to musculoskeletal toxicities © 2015 Rising Tide

23. Obesity: Therapeutic Challenges Risk Factors for AI-induced Arthralgia Henry, NL, et al. J Clin Oncol 30 2012 Previous HRT or young age Previous chemotherapy, in particular, Taxane Obesity © 2015 Rising Tide

24. Obesity: Therapeutic Challenges Efficacy of Hormonal Therapy ATAC (Arimidex, TAM, Alone or in Combination) Sestak I et al. JCO 2010;28:3411-3415 Hazard plots for anastrozole versus tamoxifen by body mass index (BMI) group © 2015 Rising Tide

25. Obesity : Worse Outcome ATAC (Arimidex, TAM, Alone or in Combination) All breast cancer recurrences according to body mass index (BMI) group Sestak I et al. JCO 2010;28:3411-3415 © 2015 Rising Tide

26. Obesity: After Diagnosis Clin Oncol (R Coll Radiol).Clin Oncol (R Coll Radiol). 2002 Feb;14(1):64-7. Clinical Nutrition 29 (2010) 187–191 ~ 60% of patients gained weight after adjuvant or neoadjuvant chemotherapy with average weight gain 6-10 Ibs The effect of adjuvant hormonal therapy is controversial ~ 50% breast cancer survivors are overweight or obese © 2015 Rising Tide

27. Obesity: Worse Prognosis Marianne Ewertz, Maj-Britt Jensen, KatrínA´. Gunnarsdo´ttir, Inger Højris, Erik H. Jakobsen Danish Breast Cancer Cooperative Group Dataset of 53816 patients 18967 patients (35%): BMI data available 30 years of follow-up: 1977-2006 © 2015 Rising Tide

28. Obesity: Worse Prognosis Marianne Ewertz, Maj-Britt Jensen, KatrínA´. Gunnarsdo´ttir, Inger Højris, Erik H. Jakobsen Cumulative incidence of recurrence in relation to body mass index (BMI) © 2015 Rising Tide

29. Obesity: Worse Prognosis Chan DSM, et al. Annals of Oncology June, 2014 82 Studies: ~ 213, 000 breast cancer survivors with 41,500 deaths (23,200 breast cancer-specific death ) BMI >30, increases total mortality 40% (75% for premenopausal, 35% for postmenopausal) BMI and Breast Cancer Survival © 2015 Rising Tide

30. OBESITY AND BREAST CANCER 1.Obesity is a risk factor for breast cancer 2.Diagnostic and therapeutic challenges 3.Obesity is a poor prognostic factor © 2015 Rising Tide

31. 10/1/2014 Education and Awareness Clinical GuidanceResearch Promotion

32. Obesity and Breast Cancer: How to Assess Your Patient Presented By: Amy Malensek RN OCN CBCN © 2015 Rising Tide

33. Assessment Barriers Barriers to assessing patients with obesity How to approach patients with obesity Different assessment styles and goals based on the timeline of your patient’s treatment plan © 2015 Rising Tide

34. Barriers Knowledge base – Being comfortable with knowledge that you have regarding the disease process and treatment plan Personal comfort zone – Being comfortable with asking the right questions at the right time – Knowing how and when to begin those difficult conversations © 2015 Rising Tide

35. Physical Assessment Head to toe: remember side effects of disease, as well as treatment Assessment will have a different focus depending on the stage of treatment Before Treatment During Treatment After Treatment © 2015 Rising Tide

36. Mobility Are they able to move around with ease? Are they having difficulty with ADLs Is it related to Pain or Neuropathy, Or Both © 2015 Rising Tide

37. Appetite Decreased or Increased Have their taste sensations changed Are they having Nausea/Diarrhea/Constipation © 2015 Rising Tide

38. Psychosocial Assessment Understanding that all patients will have psychosocial needs Fatigue Irritability Anxiety Depression (more than 47% of breast cancer patients report suffering from some level of depression) © 2015 Rising Tide

39. Other Barriers Do they have underlying metabolic disorders – Thyroid – Hormonal imbalances – Other Genetic disorders © 2015 Rising Tide

40. Other Barriers Are they afraid to talk to you….. Are you afraid to talk to them © 2015 Rising Tide

41. How Can I Improve Understanding your personal barriers will allow you to become more open to your patient’s needs Practice your communication and assessment skills © 2015 Rising Tide

42. Conclusion Gaining a new understanding into the patient perspective will allow for you to better understand the needs of your patient Active listening and careful observation will give you a much clearer picture of what your patient is experiencing Realizing the stigma that has been placed on patients with obesity can improve the patient experience © 2015 Rising Tide

43. Clinical Challenges of Obesity & Breast Cancer Presented By: Brenda Keith RN MSN AOCNS

44. Physical Challenges Challenges in screening and diagnosis Surgical complications Implications for treatment Survivorship issues

45. PHYSICIAL: Challenges in Screening and Diagnosis Women may delay or avoid screening – Embarrassment – Pain – Inadequate equipment – Negative provider attitudes – Unsolicited weight-loss advice and routine weighing Provider barriers – Difficulty doing exams – Inadequate equipment and education – Challenges overcoming patient barriers and refusal Ferrante, et al. (2010) Family Physicians' Barriers to Cancer Screening in Extremely Obese Patients

46. Challenges of Imaging Studies Miller, J. (2005). Imaging and obese patients. From Radiology Rounds: A newsletter for referring physicians, Massachusetts General Hopsital, Department of Radiology. Retrieved March 20, 2015, from http://www.mghradrounds.org/index.php?src=gendocs&link=2005_july

47. PHYSICAL: Surgical complications Complications after breast reconstruction – Wound complications – VTE – Pneumonia – Implant and flap failure Fischer, J., et al. (2013). Impact of obesity on outcomes in breast reconstruction: Analysis of 15,937 patients from the ACS-NSQIP datasets. Journal of the American College of Surgeons, 217(4), 656-664.

48. PHYSICAL: Treatment complications Radiation – Radiation pneumonitis – Fibrosis – Poorer cosmetic outcome – Ipsilateral arm edema Iyengar, et al. (2013). Obesity, Inflammation and Cancer. In A. Dannenberg & N. Berger (eds.) Obesity, Inflammation and Cancer. Springer: New York.

49. Psychosocial Implications Bias, stigma and discrimination due to weight – Bias or stigma: negative weight-related attitudes toward an overweight or obese individual – Discrimination: Unequal, unfair treatment of people because of their weight Perception about causes of obesity Consequences – Personal and social well-being – Emotional health Puhl, R. Understanding the Stigma of Obesity and its Consequences. Obesity Action Coalition.

50. Psychosocial Implications Considerable social consequences associated with obesity The language used to discuss obesity can either promote or reduce weight bias and stigmatization Puhl, R. (2014). Language and Obesity: Putting the person before the disease. Medscape. July 24, 2014.

51. Psychosocial Implications Weight bias in health care – Perceptions of obesity among HCPs – Reactions of patients to weight discrimination Nadglowski, J. (2014). Understanding Obesity: Weight stigma and its consequences. Obesity Action Coalition. http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000003266/Nadglowski%20-%20Key%20Note.pdf

52. Psychosocial Implications Patients may feel overwhelmed by cancer diagnosis Additional burden of talking about their weight Lawrence, L. (2014). Cancer Care Faces a Growing Crisis: Obesity. ASCO Connection, September 2014, 16-23.

53. Psychosocial Implications Role of HCP in addressing weight bias and stigma of obesity Addressing weight loss may be a new area of discussion – Discussing obesity may be uncomfortable for healthcare providers Lawrence, L. (2014). Cancer Care Faces a Growing Crisis: Obesity. ASCO Connection, September 2014, 16-23.

54. Clinicians lack knowledge and critical skills in assessment and management of obesity – Providers often do not counsel patients about weight – If providers do counsel patients about weight, they often do not discuss specific recommendations for behavior change – Reasons for inadequate counseling Lack of training and competency in obesity management Jay, M., et al. 2010; Kraschnewski, M., et al. 2013; Huang, J., et al. 2004; Jay, M., et al. 2008

55. Addressing Obesity in the Clinic Society of Gynecologic Oncology

56. Addressing Obesity in the Clinic Ask permission to discuss weight Acknowledge that obesity is a disease with multiple causes – Culture – Environment – Genetics Understand that patients may feel blame, shame, and guilt about their weight Vallis, M., et al. 2013; Via, M. & Mechanick, J. 2014; Dalle, G., et al. 2013; Ahmed, S., et al. 2002

57. Summary Ways to reduce weight stigma – Approach patients with sensitivity – Recognize complex etiology of obesity – Avoid stereotyping – Emphasize behavior changes – Offer concrete advice – Acknowledge difficulty of lifestyle changes – Create a supportive healthcare environment O’Reilly, K. (2013). Confronting bias against obese patients.. From American Medical News. Retrieved Mach 20, 2015 from http://www.amednews.com/article/20130902/profession/130909988/4/

58. Obesity and Breast Cancer: Supplement Usage and Contraindications Presented By: Dr. Adam Kerievsky © 2015 Rising Tide

59. Objectives Introduction Regulation of Weight-Loss Dietary Supplements Three common ingredients in weight loss supplements Safety considerations Drug-Herb interactions © 2015 Rising Tide

60. Introduction Americans spend roughly $2 billion a year on weight-loss dietary supplements [2] Weight-loss is one of the top 20 reasons why people take dietary supplements.[3] © 2015 Rising Tide

61. Dietary supplements promoted for weight loss Manufacturers market these products with various claims: – Reduce macronutrient absorption – Reduce appetite – Reduce body fat, and weight – Increase metabolism and thermogenesis. © 2015 Rising Tide

62. Use of nonprescription dietary supplements for weight loss is common among Americans. J Am Diet Assoc. 2007 Mar;107(3):441-7.[5] Adults aged > or =18 years (n=9,403) completed a cross-sectional population- based telephone survey of health behaviors. © 2015 Rising Tide

63. Study Details: Approximately 15.2% of U.S. adults have used a weight-loss dietary supplement at some point in their lives, with more women reporting use (20.6%) than men (9.7%), highest use was among women aged 18 to 34 years (16.7%) © 2015 Rising Tide

64. Dietary supplements for body-weight reduction: a systematic review. Am J Clin Nutr 2004;79:529-36. The objective of the study was to assess the evidence on the effectiveness of dietary supplements in reducing body weight. Five systematic reviews and meta- analyses and 25 additional trials were included and reviewed. © 2015 Rising Tide

65. Study Details: The reviewed studies provide some encouraging data but no evidence beyond a reasonable doubt that any specific dietary supplement is effective for reducing body weight. © 2015 Rising Tide

66. Regulation of Weight-Loss Dietary Supplements Unlike drugs, dietary supplements do not require premarket review or approval by the FDA. © 2015 Rising Tide

67. Tainted products FDA has discovered hundreds of "dietary supplements" containing drugs or other chemicals, particularly in products for weight loss. The "extra ingredients" generally aren't listed on the label, but could cause serious side effects or interact in dangerous ways with medicines or other supplements. © 2015 Rising Tide

68. Tainted Products FDA has found weight-loss products tainted with prescription drug ingredients such as: – Sibutramine – Fluoxetine – Triamterene © 2015 Rising Tide

69. Common Ingredients in Weight-Loss Dietary Supplements Caffeine (as added caffeine or from guarana, kola nut, yerba mate, or other herbs) – Evidence of Safety – Evidence of Efficacy – Proposed Mechanism of Action © 2015 Rising Tide

70. Common Ingredients in Weight-Loss Dietary Supplements Green coffee bean extract (Coffea aribica, Coffea canephora, Coffea robusta – Evidence of Safety – Evidence of Efficacy – Proposed Mechanism of Action

71. Marketer Who Promoted a Green Coffee Bean Weight- Loss Supplement Agrees to Settle FTC Charges The FTC charged that Duncan and his companies, Pure Health LLC and Genesis Today, Inc., deceptively claimed that the supplement could cause consumers to lose 17 pounds and 16 percent of their body fat in just 12 weeks without diet or exercise, and that the claim was backed up by a clinical study. [10] © 2015 Rising Tide

72. Marketer Who Promoted a Green Coffee Bean Weight-Loss Supplement Agrees to Settle FTC Charges Lindsey Duncan and the companies he controlled agreed to settle Federal Trade Commission charges that they deceptively touted the supposed weight-loss benefits of green coffee bean extract through a campaign that included appearances on The Dr. Oz Show, The View, and other television programs. After appearing on Dr. Oz, Duncan and his companies sold tens of millions of dollars’ worth of the extract, according to the FTC. Under the FTC settlement, the defendants are barred from making deceptive claims about the health benefits or efficacy of any dietary supplement or drug product, and will pay $9 million dollars.[10] © 2015 Rising Tide

73. Common Ingredients in Weight-Loss Dietary Supplements Green tea (Camellia sinensis) and green tea extract – Evidence of Safety – Evidence of Efficacy – Proposed Mechanism of Action © 2015 Rising Tide

74. Potential Mechanisms for Interactions with pharmaceuticals Combined use of Herbs with Pharmaceuticals may increase or decrease the effects of either substance, leading potentially to greater toxicity or treatment failure. Most known drug interactions are due to changes in metabolic routes related to altered expression or functionality of cytochrome P450 (CYP) isoenzymes, responsible for activating or inactivating many drugs. CYP3A4/5 is perhaps most important as it is involved in metabolizing almost half of all conventional medications. CYP2D6 and CYP2C9 rank second and third, respectively, in the number of drugs affected.[12] © 2015 Rising Tide

75. Variable inhibitory effect of different brands of commercial herbal supplements on human CYP3A4 Among the supplements tested, Green Tea Extract produced the most pronounced inhibition of CYP3A4, which ranged from 5.6% by Nature's Resource to 89.9% by Natrol Green Tea Extract (GTE) product. This study suggests that GTE use may cause significant interactions with drugs metabolized by CYP3A4. However, the effect on CYP3A4 varied among different brands of GTE, possibly due to variations in their content of the herbal product's active ingredients. [13] Botanicals pose the highest risk for interactions and thus require the most vigilance. © 2015 Rising Tide

76. Is the patient currently receiving cytotoxic, targeted, or immunotherapy ? No Yes Is the patient currently on hormonal or androgen deprivation therapy? No Is the patient currently off chemotherapy or on a drug holiday? No Has the patient completed therapy or does not need therapy at this time? Figure 1. Approach to patients taking a particular herbal product Yes High risk for drug-herb interaction. Discuss risk with patient. Where appropriate, suggest non- herbal alternative for side effect mitigation, immune function support, and/or improving quality of life Similar to Scenario 1. High risk for drug- herb interaction. Discuss risk with patient. Where appropriate, suggest non-herbal options. If they not taking other medications with a narrow therapeutic index/ high risk for adverse effects (e.g. methadone, warfarin, benzodiazepines), consider allowing them to take herbal products during the drug holiday. Recommend that they discontinue herbal products at least 7 days prior to returning for re-evaluation to allow a sufficient wash out period should they need to resume anti-cancer therapy at their follow up visit. If the patient is on medications that may pose a risk, recommend non-herbal options and discuss the relative risks. Similar to Scenario 3, as long as the patient is not on other medications that may pose a risk, consider allowing use of herbal products. If the patient has a hormone-sensitive cancer, advise against the use of any herbs with estrogenic potential. Scenario 1Scenario 2Scenario 3 Scenario 4 © 2015 Rising Tide

77. Websites Epocrates.com Naturaldatabase.com Pubmed.org-search for the herb AND CYP450 micromedexsolutions.com Consumerlab.com © 2015 Rising Tide

78. Conclusion

79. Obesity and Breast Cancer: Nutrition Presented By: Sarah Kiser MS RD

80. Background Overweight, poor diet, and physical inactivity: – Increase risk and recurrence – Associated with poorer prognosis Many breast cancer survivors are overweight at time of diagnosis and gain weight during treatment Thomson CA. Nutr Clin Pract. 2012;27:636-650. Increased risk for other chronic diseases −Heart disease −Diabetes −High blood pressure

81. Nutrition Assessment Assessment – Weight history – Diet history and food preferences – Bioelectrical impedance analysis (BIA) – Energy needs – Waist circumference – Physical activity

82. Nutrition Assessment BMI = body mass index; kg/m 2 BMR = basal metabolic rate; the amount of energy expended while at rest

83. Metabolic Health Padwal RS, Pajewski NM, Allison DB, Sharma AM. CMAJ. 2011;183(14):E1059-E1066. Gunter MJ, Xie X, Xue X, et al. Cancer Res. 2015;75(2):270-274. Fasting insulin HOMA-IR Fasting glucose Aerobic fitness Triglycerides Blood pressure Edmonton Obesity Staging System – independently predicted increased mortality even after adjustment for adiposity

84. Nutrition Intervention Intervention – Education and counseling – Diet modification – Physical activity

85. Diet Modification National Weight Control Registry – 78% eat breakfast daily – 75% weigh themselves at least once a week – 62% watch less than 10 hours of TV per week – 90% exercise about 1 hour per day Macronutrient composition not as important as negative calorie balance Meal replacements may be useful tool Food and activity tracking http://nwcr.ws/default.htm

86. Diet Modification Energy needs – Indirect calorimetry Metabolic cart Handheld calorimeters – Estimated BMR equations Mifflin-St. Jeor formula – Men: BMR = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) + 5 – Women: 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) – 161 Mifflin MD, St Jeor ST, Hill LA, et al. Am J Clin Nutr. 1990;51(2):241-247. Frankenfield DF, Roth-Yousey L, Compher C, et al. J Acad Nutr Diet. 2005;105(5):775-789.

87. Diet Modification American Institute for Cancer Research (AICR) guidelines – Avoid sugary beverages – Limit consumption of energy-dense foods (particularly processed foods high in sugar, high in sodium, low in fiber, and high in fat) – Eat a variety of vegetables, fruits, whole grains, and legumes http://www.aicr.org

88. Diet Modification AICR guidelines – Limit consumption of red meat to <18 oz/wk and avoid processed meats – Limit alcoholic drinks to two for men and one for women daily – Be as lean as possible without becoming underweight – Be physically active for at least 30 minutes every day – Do not rely on supplements to protect against cancer http://www.aicr.org

89. Physical Activity 2008 Physical Activity Guidelines for Americans – Avoid inactivity – Achieve at least 150 minutes of moderate intensity PA or 75 minutes of vigorous activity PA per week or a combination At least 3 days per week At least 10 minute bouts – Muscle strengthening 2x/week – at least one set for 8-12 muscle groups

90. Physical Activity PA for weight maintenance – 150-200 minutes per week to prevent a weight gain of <3% in most adults PA for weight loss – <150 minutes/week – minimal weight loss – 150-225 minutes/week – moderate weight loss (2- 3 kg)  30-45 minutes on 5 days per week – 225-420 minutes/week – significant weight loss (5-7.5 kg)  30-60 minutes per day American College of Sports Medicine. Medicine and Science in Sport and Exercise. 2009;41(2):459-471.

91. Dietary factors – ↑ risk Alcohol – even low to moderate intake – Women’s Health Initiative (WHI) » 1 alcoholic drink daily associated with 82% greater risk for breast cancer » Follow-up analysis – ER+ disease associated with alcohol intake – LACE cohort » Alcohol intake at >3 drinks/week increased recurrence risk by 35%, particularly in postmenopausal and overweight/obese women – Recommendation: <1 drink/day Thomson CA. Nutr Clin Pract. 2012;27:636-650. Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431.

92. Dietary Factors – ↑ risk Dietary fat – Women’s Intervention Nutrition Study (WINS) » Low-fat diet group: 24% lower risk of relapse than control group after 5 years of follow-up » Had only modest weight loss – 2.7 kg less than control group at 5 years – Another epidemiological analysis showed that higher intake of butter, margarine, and lard was associated with 30% higher risk for recurrent disease Thomson CA. Nutr Clin Pract. 2012;27:636-650. Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431. Chlebowski RT, Blackburn GL, Thomson CA, et al. J Natl Cancer Inst. 2006;98(24):1768-76. Blackburn GL, Wang KA. Am J Clin Nutr. 2007;86(suppl):878S-81S.

93. Dietary Factors – ↓ risk Vegetables and fruits – Dietary fiber can modify estrogen concentration – Women’s Healthy Eating and Living (WHEL) study » Women who ate at least 5 servings of fruits and vegetables per day, along with exercise equivalent to walking 30 minutes 6 days/week had 50% reduced risk of recurrence regardless of weight loss Thomson CA. Nutr Clin Pract. 2012;27:636-650. Li CI, Chlebowski RT, Freiberg M, et al. J Natl Cancer Inst. 2010;102(18):1422-1431. Pierce JP, Stefanick ML, Flatt SW, et al. JCO. 2007;25(17): 2345-2351.

94. Summary Lifestyle modification even with modest weight loss can attenuate risk Overall diet quality matters Be available as support system and encourage small changes