Postdiagnosis change in bodyweight and survival after breast cancer diagnosis. Epidemiology. 2012;23:320-327. [PMID: 22317813 DOI: 10.1097/ede.0b013e31824596a1]

Factors associated with weight gain in pre- and post-menopausal women receiving adjuvant endocrine therapy for breast cancer

PURPOSE

Weight gain after breast cancer poses health risks. We aimed to identify factors associated with weight gain during adjuvant endocrine therapy (AET).

METHODS

Women initiating AET enrolled in a prospective cohort. Participants completed FACT-ES plus PROMIS pain interference, depression, anxiety, fatigue, sleep disturbance and physical function measures at baseline, 3, 6, 12, 24, 36, 48 and 60 months. Treatment-emergent symptoms were defined as changes in scores in the direction indicative of worsening symptoms that exceeded the minimal important difference at 3 and/or 6 months compared to baseline. We used logistic regression to evaluate associations of clinicodemographic features and treatment-emergent symptoms with clinically significant weight gain over 60 months (defined as ≥ 5% compared to baseline) in pre- and post-menopausal participants.

RESULTS

Of 309 participants, 99 (32%) were pre-menopausal. The 60 months cumulative incidence of clinically significant weight gain was greater in pre- than post-menopausal participants (67% vs 43%, p < 0.001). Among pre-menopausal participants, treatment-emergent pain interference (OR 2.49), aromatase inhibitor receipt (OR 2.8), mastectomy, (OR 2.06) and White race (OR 7.13) were associated with weight gain. Among post-menopausal participants, treatment-emergent endocrine symptoms (OR 2.86), higher stage (OR 2.25) and White race (OR 2.29) were associated with weight gain while treatment-emergent physical function decline (OR 0.30) was associated with lower likelihood of weight gain.

CONCLUSIONS

Weight gain during AET is common, especially for pre-menopausal women. Clinicodemographic features and early treatment-emergent symptoms may identify at risk individuals.

IMPLICATIONS FOR CANCER SURVIVORS

Patients at risk for weight gain can be identified early during AET.

CLINICAL TRIALS

GOV IDENTIFIER

NCT01937052, registered September 3, 2013.

Synergic Role of Dietary Bioactive Compounds in Breast Cancer Chemoprevention and Combination Therapies

Breast cancer is the most common tumor in women. Chemotherapy is the gold standard for cancer treatment; however, severe side effects and tumor resistance are the major obstacles to chemotherapy success. Numerous dietary components and phytochemicals have been found to inhibit the molecular and signaling pathways associated with different stages of breast cancer development. In particular, this review is focused on the antitumor effects of PUFAs, dietary enzymes, and glucosinolates against breast cancer. The major databases were consulted to search in vitro and preclinical studies; only those with solid scientific evidence and reporting protective effects on breast cancer treatment were included. A consistent number of studies highlighted that dietary components and phytochemicals can have remarkable therapeutic effects as single agents or in combination with other anticancer agents, administered at different concentrations and via different routes of administration. These provide a natural strategy for chemoprevention, reduce the risk of breast cancer recurrence, impair cell proliferation and viability, and induce apoptosis. Some of these bioactive compounds of dietary origin, however, show poor solubility and low bioavailability; hence, encapsulation in nanoformulations are promising tools able to increase clinical efficiency.

Change in Body Mass Index and Cardiovascular Outcomes in Patients With Cancer

OBJECTIVE

To investigate the association between body mass index (BMI) changes and the risk of cardiovascular disease (CVD) in patients with cancer.

PATIENTS AND METHODS

This retrospective observational study used data from the JMDC Claims Database obtained between January 2005, and April 2021. We included 52,344 individuals (median [IQR] age, 53 years [46 to 60 years]; 23,584 [45.1%] men) with cancer and no prior CVD. Patients were classified into 3 groups based on the percentage change in BMI from the initial health checkup to the checkup 1 year later: -5.0% or less (BMI loss), -5.0% to 5.0% (stable BMI), and 5.0% or more (BMI gain). The primary end point was composite CVD events including heart failure, atrial fibrillation, ischemic heart disease, and stroke.

RESULTS

During a median follow-up period of 763 days (IQR, 369 to 1274 days), 3124 composite CVD events were observed. Compared with stable BMI, the hazard ratios (HRs) of BMI loss and gain for CVD events were 1.16 (95% CI, 1.00 to 1.34) and 1.10 (95% CI, 0.96 to 1.25), respectively. A U-shaped association was observed between the BMI changes and CVD events, particularly for nonatherosclerotic CVD outcomes including heart failure and atrial fibrillation. Compared with stable BMI, both BMI loss and gain increased the risk of heart failure (HR, 1.30; 95% CI, 1.08 to 1.57 and HR, 1.22; 95% CI, 1.02 to 1.47, respectively) and atrial fibrillation (HR, 1.70; 95% CI, 1.18 to 2.45 and HR, 1.55; 95% CI, 1.07 to 2.24, respectively).

CONCLUSION

Cancer survivors with BMI loss and gain were at greater risk of CVD. Body mass index loss is associated with a higher risk of CVD.

Body mass index, weight change, and cancer prognosis: a meta-analysis and systematic review of 73 cohort studies

BACKGROUND

Identifying the association between body mass index (BMI) or weight change and cancer prognosis is essential for the development of effective cancer treatments. We aimed to assess the strength and validity of the evidence of the association between BMI or weight change and cancer prognosis by a systematic evaluation and meta-analysis of relevant cohort studies.

METHODS

We systematically searched the PubMed, Web of Science, EconLit, Embase, Food Sciences and Technology Abstracts, PsycINFO, and Cochrane databases for literature published up to July 2023. Inclusion criteria were cohort studies with BMI or weight change as an exposure factor, cancer as a diagnostic outcome, and data type as an unadjusted hazard ratio (HR) or headcount ratio. Random- or fixed-effects models were used to calculate the pooled HR along with the 95% confidence interval (CI).

RESULTS

Seventy-three cohort studies were included in the meta-analysis. Compared with normal weight, overweight or obesity was a risk factor for overall survival (OS) in patients with breast cancer (HR 1.37, 95% CI 1.22-1.53; P < 0.0001), while obesity was a protective factor for OS in patients with gastrointestinal tumors (HR 0.67, 95% CI 0.56-0.80; P < 0.0001) and lung cancer (HR 0.67, 95% CI 0.48-0.92; P = 0.01) compared with patients without obesity. Compared with normal weight, underweight was a risk factor for OS in patients with breast cancer (HR 1.15, 95% CI 0.98-1.35; P = 0.08), gastrointestinal tumors (HR 1.54, 95% CI 1.32-1.80; P < 0.0001), and lung cancer (HR 1.28, 95% CI 1.22-1.35; P < 0.0001). Compared with nonweight change, weight loss was a risk factor for OS in patients with gastrointestinal cancer.

CONCLUSIONS

Based on the results of the meta-analysis, we concluded that BMI, weight change, and tumor prognosis were significantly correlated. These findings may provide a more reliable argument for the development of more effective oncology treatment protocols.

[How could physical activity decrease the risk of breast cancer development and recurrence?]

OBJECTIVES

Breast cancer is the most frequent and deadly cancer among women. In France, 50% of adults are currently overweight, mostly as a result of a sedentary lifestyle. Numerous studies have highlighted overweight, obesity and lack of physical activity as risk factors for the occurrence and prognosis of cancers, particularly breast cancer. The aim of this study was to understand the extent to which physical activity can improve this prognosis, and what the pathophysiology is.

METHODS

The Senology Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) based its responses on an analysis of the international literature using a Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) methodology conducted on the PubMed database between 1994 and 2023.

RESULTS

A total of 70 articles were selected, demonstrating the role of regular physical activity in reducing the risk of breast cancer occurrence and recurrence. This role in controlling carcinogenesis is mediated by metabolic factors such as leptin, adiponectin and insulin, sex hormones and inflammation. The signaling pathways deregulated by these molecules are known carcinogenic pathways which could be used as therapeutic targets adapted to this population, without replacing the essential hygienic-dietary recommendations.

CONCLUSION

Physical activity has a protective effect on breast cancer risk and prognosis. We must therefore continue to raise awareness in the general population and promote physical activity as a means of primary, secondary, and tertiary prevention.

Elevated extracellular matrix protein 1 in circulating extracellular vesicles supports breast cancer progression under obesity conditions

The cargo content in small extracellular vesicles (sEVs) changes under pathological conditions. Our data shows that in obesity, extracellular matrix protein 1 (ECM1) protein levels are significantly increased in circulating sEVs, which is dependent on integrin-β2. Knockdown of integrin-β2 does not affect cellular ECM1 protein levels but significantly reduces ECM1 protein levels in the sEVs released by these cells. In breast cancer (BC), overexpressing ECM1 increases matrix metalloproteinase 3 (MMP3) and S100A/B protein levels. Interestingly, sEVs purified from high-fat diet-induced obesity mice (D-sEVs) deliver more ECM1 protein to BC cells compared to sEVs from control diet-fed mice. Consequently, BC cells secrete more ECM1 protein, which promotes cancer cell invasion and migration. D-sEVs treatment also significantly enhances ECM1-mediated BC metastasis and growth in mouse models, as evidenced by the elevated tumor levels of MMP3 and S100A/B. Our study reveals a mechanism and suggests sEV-based strategies for treating obesity-associated BC.

Dietary and serum advanced glycation end-products and clinical outcomes in breast cancer

One in five women with breast cancer will relapse despite ideal treatment. Body weight and physical activity are strongly associated with recurrence risk, thus lifestyle modification is an attractive strategy to improve prognosis. Trials of dietary modification in breast cancer are promising but the role of specific diets is unclear, as is whether high-quality diet without weight loss can impact prognosis. Advanced glycation end-products (AGEs) are compounds produced in the body during sugar metabolism. Exogenous AGEs, such as those found in food, combined with endogenous AGEs, make up the total body AGE load. AGEs deposit in tissues over time impacting cell signaling pathways and altering protein functions. AGEs can be measured or estimated in the diet and measured in blood through their metabolites. Studies demonstrate an association between AGEs and breast cancer risk and prognosis. Here, we review the clinical data on dietary and serum AGEs in breast cancer.

The relation between excess adiposity and breast cancer in women: Clinical implications and management

BACKGROUND

Breast cancer (BC) is the most common cancer in women. While the combination of improved screening, earlier detection, and advances in therapeutics has resulted in lower BC mortality, BC survivors are now increasingly dying of cardiovascular disease. Cardiovascular disease in the leading cause of non-cancer related mortality among BC survivors. This situation underscores the critical need to research the role of modifiable cardiometabolic risk factors, such as excess adiposity, that will affect BC remission, long-term survivorship, and overall health and quality of life.

PURPOSE

First, this review summarizes the evidence on the connection between adipose tissue and BC. Then we review the data on weight trends after BC diagnosis with a focus on the effect of weight gain on BC recurrence and BC- and non-BC-related death. Finally, we provide a guide for weight management in BC survivors, considering the available data on the effect of weight loss interventions on BC.

Post-diagnosis weight trajectories and mortality among women with breast cancer

Weight gain after breast cancer diagnosis is associated with adverse health outcomes. Yet, few studies have characterized post-diagnosis weight change in the modern treatment era or populations most at risk for weight changes. Among women diagnosed with stages I-III breast cancer in the Smilow Care Network (2013-2019; N = 5441), we abstracted demographic and clinical characteristics from electronic health records and survival data from tumor registries. We assessed if baseline characteristics modified weight trajectories with nonlinear multilevel mixed-effect models. We evaluated body mass index (BMI) at diagnosis and weight change 1-year post-diagnosis in relation to all-cause and breast cancer-specific mortality with Cox proportional hazard models. Women had 34.4 ± 25.5 weight measurements over 3.2 ± 1.8 years of follow-up. Weight gain was associated with ER/PR-, HER2+ tumors, BMI ≤ 18.5 kg/m2, and age ≤ 45 years (+4.90 kg (standard error [SE] = 0.59), +3.24 kg (SE = 0.34), and +1.75 kg (SE = 0.10), respectively). Weight loss was associated with BMI ≥ 35 kg/m2 and age ≥ 70 years (-4.50 kg (SE = 0.08) and -4.34 kg (SE = 0.08), respectively). Large weight loss (≥10%), moderate weight loss (5-10%), and moderate weight gain (5-10%) 1-year after diagnosis were associated with higher all-cause mortality (hazard ratio [HR] = 2.93, 95% confidence interval [CI] = 2.28-3.75, HR = 1.32, 95% CI = 1.02-1.70 and HR = 1.39, 95% CI = 1.04-1.85, respectively). BMI ≥ 35 kg/m2 or BMI ≤ 18.5 kg/m2 at diagnosis were also associated with higher all-cause mortality. Weight change after a breast cancer diagnosis differed by demographic and clinical characteristics highlighting subgroups at-risk for weight change during a 5-year period post-diagnosis. Monitoring and interventions for weight management early in clinical care are important.

Body composition, energy expenditure and caloric intake among breast cancer patients at a teaching hospital in Nigeria-a cross sectional study

Objective

This cross-sectional study was conducted on the associations between body composition, energy expenditure and caloric intake among 45 Nigerian breast cancer patients.

Methods

Forty-five Nigerian breast cancer patients were measured and analysed for their body composition, energy expenditure and caloric intake. Statistical analyses included a chi-square test, Student's t-test, paired t-test, Spearman correlation and linear regression using Statistical Package for the Social Sciences 23.0.

Results

The body fat indices (body mass index (BMI), fat mass index (FMI), and body fats percentage) show that more than 50% of breast cancer patients were either overweight or obese. The Spearman correlation showed that fat-free mass (FFM) was the most strongly correlated with energy expenditure (r = 0.84). BMI and (FMI - fat mass in relation to height) were significantly correlated with the Harris-Benedict equation for energy expenditure (p < 0.001; p = 0.002), but they were not correlated significantly with the Karnofsky performance status. A paired t-test showed that caloric intake was significantly higher than total energy expenditure (p < 0.001). FFM was the best predictor of resting energy expenditure (REE).

Conclusion

In conclusion, FFM remains the best predictor of REE. High body mass and high caloric intake indicate the need for support from nutritional programmes.

Associations of Post-Diagnosis Lifestyle with Prognosis in Women with Invasive Breast Cancer

BACKGROUND

Lifestyle habits can impact breast cancer development, but its impact on breast cancer prognosis remains unclear. We investigated associations of post-diagnosis lifestyle with mortality and recurrence in 1,964 women with invasive breast cancer enrolled in the Kaiser Permanente Northern California Pathways Study shortly after diagnosis with lifestyle information at baseline (2005-2013) and the 2-year follow-up.

METHODS

We calculated a post-diagnosis lifestyle score (range, 0-18) based on 9 diet, physical activity, and body weight recommendations from the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO) using follow-up data (body weight also included baseline data); higher scores indicate greater guideline concordance. Similarly, we calculated a pre-diagnosis lifestyle score using baseline data to investigate pre- to post-diagnosis changes. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazard models, with follow-up through December 2018 (observing 290 deaths and 176 recurrences).

RESULTS

The 2-year post-diagnosis lifestyle score was inversely associated with all-cause mortality (ACM; HR per 2-point increase = 0.90; 95% CI, 0.82-0.98), and breast cancer-related mortality (HR, 0.79; 95% CI, 0.67-0.95), but not recurrence. Relative to women who maintained low concordance with recommendations at both time points, women who maintained high concordance had a lower risk of ACM (HR, 0.61, 95% CI, 0.37-1.03). Improved concordance with some specific recommendations (particularly PA) may be associated with a lower hazard of ACM (HRPA, 0.52; 95% CI, 0.35-0.78).

CONCLUSIONS

Results suggest that women with breast cancer may benefit from a post-diagnosis lifestyle aligned with ACS/ASCO guidelines.

IMPACT

This information may potentially guide lifestyle recommendations for breast cancer survivors to reduce mortality risk.

Postdiagnosis body fatness, weight change and breast cancer prognosis: Global Cancer Update Program (CUP global) systematic literature review and meta-analysis

Previous evidence on postdiagnosis body fatness and mortality after breast cancer was graded as limited-suggestive. To evaluate the evidence on body mass index (BMI), waist circumference, waist-hip-ratio and weight change in relation to breast cancer prognosis, an updated systematic review was conducted. PubMed and Embase were searched for relevant studies published up to 31 October, 2021. Random-effects meta-analyses were conducted to estimate summary relative risks (RRs). The evidence was judged by an independent Expert Panel using pre-defined grading criteria. One randomized controlled trial and 225 observational studies were reviewed (220 publications). There was strong evidence (likelihood of causality: probable) that higher postdiagnosis BMI was associated with increased all-cause mortality (64 studies, 32 507 deaths), breast cancer-specific mortality (39 studies, 14 106 deaths) and second primary breast cancer (11 studies, 5248 events). The respective summary RRs and 95% confidence intervals per 5 kg/m2 BMI were 1.07 (1.05-1.10), 1.10 (1.06-1.14) and 1.14 (1.04-1.26), with high between-study heterogeneity (I2  = 56%, 60%, 66%), but generally consistent positive associations. Positive associations were also observed for waist circumference, waist-hip-ratio and all-cause and breast cancer-specific mortality. There was limited-suggestive evidence that postdiagnosis BMI was associated with higher risk of recurrence, nonbreast cancer deaths and cardiovascular deaths. The evidence for postdiagnosis (unexplained) weight or BMI change and all outcomes was graded as limited-no conclusion. The RCT showed potential beneficial effect of intentional weight loss on disease-free-survival, but more intervention trials and well-designed observational studies in diverse populations are needed to elucidate the impact of body composition and their changes on breast cancer outcomes.

Energy balance in cancer survivors at risk of weight gain: a review

PURPOSE

The study of energy balance [i.e., energy intake (EI) and energy expenditure (EE)] is a powerful tool for understanding body weight regulation and may contribute to our understanding of rapid weight gain risk in certain cancer survivors post-diagnosis. The purpose of this review was to summarize studies that assessed longitudinal, prospective changes in components of energy balance from diagnosis/start of treatment to any duration of follow-up in cancer survivors with prior evidence of weight gain (breast, prostate, thyroid, gynecologic, testicular, and acute lymphoblastic leukemia) RESULTS: The available literature suggests that energy balance components may be altered in cancer survivors who have a heightened risk of weight gain post-diagnosis. The evidence for EI was overall inconsistent. Conversely, decreases in resting and physical activity EE during the active phases of treatment (e.g., chemotherapy, hypothyroid state) were commonly noted, which then slowly rebounded towards baseline levels at the end of treatment and during follow-up assessments. Much of this evidence is based on data collected from breast cancer survivors, which highlights a paucity of data currently available on other cancer types.

CONCLUSIONS

While there is growing acknowledgement that weight management interventions in cancer survivors are needed, it is important to recognize that changes in both behavioral (EI, physical activity EE) and passive (resting EE, thermic effect of food) components of energy balance may occur post-diagnosis. This information can help to inform weight management interventions which often entail modifications in diet and/or physical activity.

The Effect of Exercise on Weight and Body Composition of Breast Cancer Patients Undergoing Chemotherapy: A Systematic Review

BACKGROUND

Chemotherapy is a primary adjuvant treatment strategy for breast cancer patients, accompanied by weight gain and negative changes in body composition. However, it is unknown whether exercise is effective in preventing said weight gain and mitigating body composition changes of breast cancer patients undergoing treatment.

OBJECTIVES

The current study used meta-analysis with trial sequential analysis to determine exercise effect on weight and body composition of breast cancer patients undergoing chemotherapy.

METHODS

Cochrane Library, PubMed, EMBASE, EBSCO, Scopus, and SinoMed were searched (from the database start date up to August 16, 2021) for randomized controlled studies evaluating the effect of exercise on weight or body composition among breast cancer patients during chemotherapy. RevMan software and TSA Software were used to assess the risk of bias and analyze study results.

RESULTS

In total, 13 studies comprising 1828 participants were included. Meta-analysis showed that exercise could lead to lower weight, body mass index (BMI), and percentage of body fat during chemotherapy for breast cancer patients, and muscular strength showed significant improvement. Trial sequential analysis showed that evidence of muscular strength was sufficient, but BMI evidence requires further confirmation.

CONCLUSION

This meta-analysis found significant differences in body weight, BMI, percentage of body fat, and muscular strength between exercise intervention groups and control groups.

IMPLICATIONS FOR PRACTICE

Exercise during chemotherapy is beneficial in preventing weight gain and negative changes in body composition. Medical practitioners should encourage patients to start exercising during chemotherapy. However, further studies are required because insufficient sample sizes meant that outcomes of body composition remain unconfirmed.

Adipose tissue levels of polybrominated diphenyl ethers in relation to prognostic biomarkers and progression-free survival time of breast cancer patients in eastern area of southern China: A hospital-based study

Evidence indicates that individual or groups of polybrominated diphenyl ethers (PBDEs) are associated with risk of breast cancer (BC). Epidemiological studies of PBDEs and BC progression are scarce. This study aimed to investigate the relationships between PBDE burdens in adipose tissues and prognostic biomarkers of BC as well as progression-free survival (PFS) of patients for the first time. The concentrations of 14 PBDE congeners in breast adipose tissues of 183 cases from the eastern area of southern China were analyzed by gas chromatography-mass spectrometry (GC-MS). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression models for the associations between PBDE levels and prognostic biomarkers. Kaplan-Meier and Cox regression analyses were conducted to identify the correlations between PBDEs and PFS. The results showed that BDE-99 and 190 levels were positively associated with clinical stage and N stage respectively (OR = 2.61 [1.26-5.40], OR = 2.78 [1.04-7.46]). Concentrations of BDE-28 and BDE-183 were negatively associated with the expression of estrogen receptor (ER) (OR = 0.30 [0.11-0.81]; 0.39 [0.15-0.99]) and progesterone receptor (PR) (OR = 0.36 [0.14-0.92]; 0.37 [0.15-0.91]), and increased BDE-47 was associated with lower human epidermal growth factor receptor 2 (HER2) expression (OR = 0.44 [0.23-0.86]). Adipose levels of BDE-71, 99, 138, 153, 154 and total PBDEs were positively associated with p53 expression (all P < 0.05). Finally, BDE-47, 99 and 183 were considered as independent prognostic factors for shorter PFS in the Cox models (adjusted hazard ratios = 3.14 [1.26-7.82]; 2.25 [1.03-4.94]; 2.60 [1.08-6.25], respectively). The recurrence risk and prognosis of BC may be closely bound to the body burdens of certain PBDE congeners. Further epidemiological and experimental studies are needed for confirmation.

Reversing the Genomic, Epigenetic, and Triple-Negative Breast Cancer-Enhancing Effects of Obesity

The reversibility of the procancer effects of obesity was interrogated in formerly obese C57BL/6 mice that lost weight via a nonrestricted low-fat diet (LFD) or 3 distinct calorie-restricted (CR) regimens (low-fat CR, Mediterranean-style CR, or intermittent CR). These mice, along with continuously obese mice and lean control mice, were orthotopically injected with E0771 cells, a mouse model of triple-negative breast cancer. Tumor weight, systemic cytokines, and incidence of lung metastases were elevated in the continuously obese and nonrestricted LFD mice relative to the 3 CR groups. Gene expression differed between the obese and all CR groups, but not the nonrestricted LFD group, for numerous tumoral genes associated with epithelial-to-mesenchymal transition as well as several genes in the normal mammary tissue associated with hypoxia, reactive oxygen species production, and p53 signaling. A high degree of concordance existed between differentially expressed mammary tissue genes from obese versus all CR mice and a microarray dataset from overweight/obese women randomized to either no intervention or a CR diet. Assessment of differentially methylated regions in mouse mammary tissues revealed that obesity, relative to the 4 weight loss groups, was associated with significant DNA hypermethylation. However, the anticancer effects of the CR interventions were independent of their ability to reverse obesity-associated mammary epigenetic reprogramming. Taken together, these preclinical data showing that the procancer effects of obesity are reversible by various forms of CR diets strongly support translational exploration of restricted dietary patterns for reducing the burden of obesity-associated cancers.

PREVENTION RELEVANCE

Obesity is an established risk and progression factor for triple-negative breast cancer (TNBC). Given rising global rates of obesity and TNBC, strategies to reduce the burden of obesity-driven TNBC are urgently needed. We report the genomic, epigenetic, and procancer effects of obesity are reversible by various calorie restriction regimens.

Associations of adiposity and weight change with recurrence and survival in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Adiposity and weight change among patients with breast cancer are associated with mortality, but there is limited evidence on the associations with distant recurrence or other causes of death or on central adiposity. Moreover, the relationship with breast cancer subtypes and by menopause status is unclear.

METHODS

We conducted a systematic review and meta-analysis of prospective studies of breast cancer patients investigating the associations of general and central adiposity (body mass index [BMI] and waist circumference [WC], respectively), before and after diagnosis, and weight change, with all-cause mortality, breast cancer-specific mortality (BCSM), and recurrence.

RESULTS

173 studies (519,544 patients, 60,249 deaths overall, and 25,751 breast cancer deaths) were included. For BMI  < 1 year post diagnosis, compared with normal weight women, the summary relative risk (RR) for obese women was 1.21 (1.15-1.27) for all-cause mortality, 1.22 (1.13-1.32) for BCSM, 1.12 (1.06-1.18) for recurrence, and 1.19 (1.11-1.28) for distant recurrence. Obesity was associated with all-cause mortality and BCSM in patients with ER+ or HER2+ tumors, whereas no clear association was observed in patients with triple-negative tumors. Similar associations were observed by menopausal status. Stronger associations were observed in East Asians than Europeans. Central adiposity was associated with all-cause mortality, while large weight gain was associated with all-cause mortality, BCSM, and recurrence.

CONCLUSION

Higher adiposity is associated with all-cause mortality, BCSM, recurrence, and distant recurrence in breast cancer patients, with similar associations by menopausal status and some evidence of heterogeneity by subtypes. Weight gain is also associated with recurrence and survival among breast cancer patients.

Association of Obesity and Luminal Subtypes in Prognosis and Adjuvant Endocrine Treatment Effectiveness Prediction in Chinese Breast Cancer Patients

Purpose

To evaluate the influence of obesity on clinicopathological characteristics of breast cancer; to explore the effect of obesity on the prognosis and performance of endocrine therapy in breast cancer patients.

Methods

Patients with luminal/HER2-negative early breast cancer were included and categorized into the non-obese (BMI<28kg/m²) and obese (BMI≥28kg/m²) groups according to body mass index (BMI). Clinicopathological characteristics and treatment modalities were compared between groups. Interaction of adjuvant endocrine therapy with obesity was analyzed.

Results

A total of 2,875 patients were included: 2,598 non-obese and 277 obese. A higher rate of patients with comorbidities (OR: 2.83, 95%CI 2.13-3.74, P<0.001) or PR-positive tumor (OR: 1.63, 95%CI 1.03-2.58, P=0.037) were identified in the obese group. Obesity was not associated with disease recurrence (P=0.839) or overall survival (P=0.140) in the whole population. Subgroup analysis did show an association with worse relapse-free survival (RFS, HR 3.48, 95%CI 1.31-9.22, P=0.012) and overall survival (OS, HR 4.67, 95%CI 1.28-16.95, P=0.019) in luminal A breast cancer. These results could not be reproduced in the luminal B subtype with a RFS (HR 0.78, 95%CI 0.41-1.49, P=0.454) or OS (HR 1.17, 95%CI 0.50-2.74, P=0.727). Furthermore, obesity did not impact endocrine therapy effectiveness in Tamoxifen or the aromatase inhibitor group (RFS: interact P=0.381; OS: interact P=0.888).

Conclusions

The impact of obesity on prognosis interacted with luminal subtype status in Chinese breast cancer patients which was not related with endocrine treatment modality.

Association between weight change and breast cancer prognosis

PURPOSE

Results of the associations between weight change after breast cancer diagnosis and prognosis were inconsistent. The modification effects of menopausal status and endocrine therapy on the associations remain poorly understood.

METHODS

A total of 2016 breast cancer patients were recruited between October 2008 and January 2018 and followed up until December 31, 2019 in Guangzhou. Multivariate Cox models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) for progression-free survival (PFS) in association with weight change after diagnosis.

RESULTS

Weight loss at 2 years (HR = 1.34, 95% CI 0.87-2.06) or more than 2 years (HR = 1.95, 95% CI 1.22-3.10) after diagnosis increased risk of breast cancer progression. The adverse effect of weight loss was significantly more pronounced in post-menopausal than pre-menopausal women, particularly for weight loss at 2 years after diagnosis, with the HRs and 95% CIs of 2.41 (1.25-4.63) and 0.90 (0.49-1.64), respectively. Weight gain tended to reduce the risk of disease progression among patients with endocrine therapy but not for those with non-endocrine therapy; the significant interaction between weight gain at 2 years after diagnosis and endocrine therapy was observed (P_interaction = 0.042).

CONCLUSION

Our finding suggested that weight loss was detrimental to breast cancer prognosis, particularly for post-menopausal women, while weight gain may be a potential beneficial indicator for the patients with endocrine therapy but not for those with non-endocrine therapy.

Influence of physician's lifestyle on the prescription of healthy habits to breast cancer patients (LACOG 1218)

BACKGROUND

Healthy lifestyle is capable of positively modifying the survival of breast cancer (BC) patients. We aimed to evaluate how physician's lifestyle influences on the prescription of healthy habits to BC patients.

METHODS

An online questionnaire to evaluate physician lifestyle and prescription of healthy habits to BC patients was developed and circulated by e-mail to physicians dedicated to treat BC patients. A multivariate Poisson regression analysis assessed which factors of physician lifestyle could influence on prescription of healthy habits.

RESULTS

A total of 267 physicians answered the questionnaire from October to November 2018. In terms of physician lifestyle, 228 (85.4%) had healthy eating habits and 236 (88.4%) practiced physical activity. Overall, 84.3% of the physicians advised their BC patients on the importance of lifestyle modification. Physicians who did not exercise regularly have a higher probability of not advising for health lifestyle (RR 2.48; p = 0.0265) as opposite to physicians ≥ 50 years-old (RR 0.37; p = 0.0118). Obesity treatment and management was performed by 45.3% of physicians. Being a breast surgeon (RR 1.29; p = 0.0025) or radiation oncologists (RR 1.82; p = 0.0025) were associated with not performing obesity treatment and management. About 53.4% of physicians referred overweight or obese patients to a dietitian and/or endocrinologist. Male gender (RR 1.35; p = 0.0296), breast surgeons (RR 1.99; p = 0.0001), and clinical practice in public health system (RR 1.53; p = 0.0012) were associated with not referring as opposed to physicians ≥ 50 years-old (RR 0.46; p = 0.0005).

CONCLUSION

Our survey showed some influence of physician's lifestyle on the prescription of healthy habits to BC patients. Physicians who practice physical activity regularly had a higher probability of advising lifestyle modification and about half of physicians did some type of overweight and obese management.

Benefits of weight loss programs for breast cancer survivors: a systematic reviews and meta-analysis of randomized controlled trials

BACKGROUND

Obesity and weight gain have been associated with poor disease-specific and health-related outcomes in breast cancer survivors (BCS). But the benefits of weight loss in managing BCS have not been elucidated.

OBJECTIVE

To evaluate the beneficial effects of weight loss programs in randomized controlled trials on BCS.

METHODS

We searched English databases PubMed, the Cochrane Library, EMBASE, Scopus, Web of Science, CINAHL, and Chinese databases China National Knowledge Infrastructure (CNKI), Weipu Information Chinese Periodical Service Platform (VIP), China Biomedical Literature Service System (SinoMed), and Wanfang from the inception to January 2021 and collected randomized controlled trials (RCTs) of weight loss programs for BCS. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies. The data synthesis was performed on RevMan (version 5.3), and the publication bias was calculated with STATA (version 15.1).

RESULTS

Ten RCTs were included in the meta-analysis. The current study showed that diet and exercise interventions resulted in significant improvements in body weight (MD =  - 4.43 kg, 95%CI: - 6.23 to - 2.63, P < 0.00001), waist circumference (MD =  - 2.81 cm, 95%CI: - 4.37 to - 1.26, P = 0.004), hip circumference (MD =  - 3.01 cm, 95%CI: - 4.24 to - 1.77, P < 0.0001), body mass index (MD =  - 1.69 kg/m², 95%CI: - 2.16 to - 1.21, P < 0.00001), systolic blood pressure (MD =  - 12.12 mmHg, 95%CI: - 18.97 to - 5.27), p = 0.0005), C-reactive protein (MD =  - 1.83 mg/L, 95% CI: - 2.74 to - 0.91, p < 0.0001), body fat (MD =  - 1.19 kg, 95%CI: - 1.75 to - 0.63, P < 0.001), fat mass (MD =  - 2.29 kg, 95%CI: - 3.12 to - 1.46, P < 0.0001), and lean body mass (MD =  - 2.15 kg, 95%CI: - 3.66 to - 0.65, P = 0.005). Alternatively, compared with the effects of control interventions, weight loss programs did not affect fat-free mass, total cholesterol, low-density leptin cholesterol, glucose, insulin, and leptin (P > 0.05).

CONCLUSIONS

This review summarizes the benefits of weight loss programs for BCS. The results indicated that weight loss programs could significantly improve specific anthropometric outcomes but not affect biochemical indicators. Researchers should tailor weight loss interventions to the body fat status of BCS. Evidence to support the translation of effective weight loss intervention programs into wider-scale implementation is needed to be part of routine survivorship care.

Yoga Therapy During Chemotherapy for Early-Stage and Locally Advanced Breast Cancer

Background:

Chemotherapy is associated with decreased quality of life (QOL), fatigue, depression, and weight gain in patients with breast cancer. Weight gain is associated with poorer prognosis. Yoga improves QOL, fatigue, and mood in women with breast cancer but its effect on treatment-related weight gain has not been studied. The aim of this trial was to determine the feasibility of personalized yoga therapy in women receiving treatment for early-stage or locally advanced breast cancer and assess its impact on weight gain.

Methods:

Thirty women were randomized 1:1 to receive yoga therapy by a certified yoga therapist during treatment or a control group. Participants in the yoga arm were asked to complete three 30 minute yoga sessions weekly (which included movement, breath work, mindfulness, and relaxation) throughout adjuvant or neoadjuvant chemotherapy (N = 29) or endocrine (N = 1); the control arm received breast cancer treatment without yoga. For comparability between participants randomized to yoga therapy, the single patient treated with endocrine therapy was excluded from the analysis. Primary outcomes were feasibility and weight change. Additional outcomes were mood, fatigue, QOL, serum tumor necrosis factor-alpha (TNF-alpha), and C-reactive protein (CRP) as immune mediator biomarkers.

Results:

Mean age was 51.6 years, 75.9% were white and 24.1% were people of color, reflecting the cancer center population. 80% had stage II-III disease. Enrollment was completed in 9 months. Compliance was lower than predicted; however, participants participated in on average 1.7 yoga sessions/week for a mean 15.6 weeks duration. There were no adverse events. Control arm participants gained on average 2.63% body weight during treatment while yoga participants lost 0.14% body weight (weight change = −0.36 in yoga arm vs. 2.89 in standard of care arm, Wilcoxon rank sum test P = .024). Control participants reported increased fatigue and decreased QOL, while yoga participants reported no change in QOL. No significant change in TNF-alpha or CRP was noted in either arm.

Conclusion:

This feasibility study suggests that personalized yoga therapy is beneficial for QOL and weight maintenance among women undergoing chemotherapy for early-stage or locally advanced breast cancer. Weight maintenance associated with yoga therapy may be of clinical significance in this population given the poorer prognosis associated with weight gain in breast cancer survivors.

Trial Registration:

NIH Clinicaltrials.gov #NCT03262831; August 25, 2017. https://clinicaltrials.gov/ct2/show/NCT03262831

Metabolic Syndrome in Breast Cancer Patients: An Observational Study

Background:

The reported association between metabolic syndrome (MetS) and breast cancer may have a significant impact on the incidence and mortality related to breast cancer. We undertook this study to find if the disease is different in patients with MetS.

Materials and Methods:

Patients with biopsy-proven breast cancer were divided into groups based on the presence or absence of MetS (according to the IDF definition of 2006) and also based on menopausal status. The presence of known risk and prognostic factors were also recorded, and the groups were compared.

Results:

A total of 305 patients were recruited, of which 191 (62.6%) had MetS. Patients with MetS were older than those without (52.1 versus 48.3 years, P = .014) and had a lower incidence of nulliparity (4.1% vs 12.8%, P = .005) and dense breasts (2.9% in MetS vs 10.8% in no MetS, P = .009). On further dividing into premenopausal and postmenopausal, these differences persisted only in premenopausal patients. MetS group had a lower number of HER2-positive tumours (14.3% for MetS, 23.9% for no MetS; P = .036). After dividing into premenopausal and postmenopausal, significant differences were observed in distant metastases (5.4% in MetS vs 16.1% in no MetS, P = .045) and in grade (higher grade in MetS, P = .05) in premenopausal patients. In postmenopausal patients, difference was observed in HER2 positivity (12.3% in MetS vs 28.8% in no MetS, P = .008).

Conclusions:

Breast cancer in patients with MetS may not be significantly different from breast cancer in patients without MetS.

Effect of the Lifestyle, Exercise, and Nutrition (LEAN) Study on Long-Term Weight Loss Maintenance in Women with Breast Cancer

Lifestyle interventions among breast cancer survivors with obesity have demonstrated successful short-term weight loss, but data on long-term weight maintenance are limited. We evaluated long-term weight loss maintenance in 100 breast cancer survivors with overweight/obesity in the efficacious six-month Lifestyle, Exercise, and Nutrition (LEAN) Study (intervention = 67; usual care = 33). Measured baseline and six-month weights were available for 92 women. Long-term weight data were obtained from electronic health records. We assessed weight trajectories between study completion (2012-2013) and July 2019 using growth curve analyses. Over up to eight years (mean = 5.9, SD = 1.9) of post-intervention follow-up, both the intervention (n = 60) and usual care (n = 32) groups declined in body weight. Controlling for body weight at study completion, the yearly weight loss rate in the intervention and usual care groups was -0.20 kg (-0.2%/year) (95% CI: 0.06, 0.33, p = 0.004) and -0.32 kg (-0.4%/year) (95% CI: 0.12, 0.53, p = 0.002), respectively; mean weight change did not differ between groups (p = 0.31). It was encouraging that both groups maintained their original intervention period weight loss (6% intervention, 2% usual care) and had modest weight loss during long-term follow-up. Breast cancer survivors in the LEAN Study, regardless of randomization, avoided long-term weight gain following study completion.

Returning to work by thyroid cancer survivors 5 years after diagnosis: the VICAN survey

PURPOSE

Return to work (RTW) following cancer diagnosis is a challenge for both the patient and society. As thyroid cancer (TC) incidence is increasing, this study aims to assess difficulties in returning to work and income changes in TC survivors 5 years post-diagnosis.

METHODS

This study belongs to the national VICAN survey conducted in France among TC patients diagnosed between January and June 2010. Data were collected through phone interviews, medical surveys and from the national medico-administrative register in 2012 and 2015. We used multivariate logistic regressions to investigate TC impact on employment and income changes.

RESULTS

Of 146 patients, 121(82.9%) were women; the mean age was 42 years (SD = 8.34), 119 (81.3%) were diagnosed at an early stage, and 142(97.6%) underwent thyroidectomy. At 5 years post-diagnosis, 116 (79.7%) of the TC survivors were professionally active, 22 (15.4%) were unemployed and 8 (4.90%) were receiving disability. Among the patients employed at the time of diagnosis (n = 122), 15 (12.3%) had not returned to work 5 years post-diagnosis. Between 2 and 5 years post-diagnosis, there was no significant improvement in rates of RTW. At 5 years post-diagnosis, 90 (61.6%) reported an income decline. All TC survivors who have not returned to work were women and declared higher fatigue. Moreover, in multivariate analyses, not returning to work was associated with weight gain (OR = 8.41 (1.21; 58.23)) and working arrangements (6.90 (1.18-38.48)), while income decline was associated with comorbidities (OR = 2.28 (1.07; 4.86)) and to be engaged in manual work (OR = 2.28 (1.07; 4.88)).

CONCLUSION

This study highlights that, despite a good prognostic, up to 12.3% of TC survivors had not returned to work and 61.6% reported an income decline, 5 years post-diagnosis. Weight gain, fatigue, to be a woman and working-type arrangement were associated with higher probability of not returning to work.

IMPLICATIONS FOR CANCER SURVIVORS

TC affects a young working population. Our study identified potentially vulnerable TC survivors and important modifiable factors which may help TC survivors to be professionally active and, therefore, increase their overall quality of life.

Impact of post-diagnosis weight change on survival outcomes in Black and White breast cancer patients

PURPOSE

To evaluate weight change patterns over time following the diagnosis of breast cancer and to examine the association of post-diagnosis weight change and survival outcomes in Black and White patients.

METHODS

The study included 2888 women diagnosed with non-metastatic breast cancer in 2000-2017 in Chicago. Longitudinal repeated measures of weight and height were collected, along with a questionnaire survey including questions on body size. Multilevel mixed-effects models were used to examine changes in body mass index (BMI). Delayed entry Cox proportional hazards models were used to investigate the impacts of changing slope of BMI on survival outcomes.

RESULTS

At diagnosis, most patients were overweight or obese with a mean BMI of 27.5 kg/m² and 31.5 kg/m² for Blacks and Whites, respectively. Notably, about 45% of the patients had cachexia before death and substantial weight loss started about 30 months before death. In multivariable-adjusted analyses, compared to stable weight, BMI loss (> 0.5 kg/m²/year) showed greater than 2-fold increased risk in overall survival (hazard ratio [HR] = 2.60, 95% CI 1.88-3.59), breast cancer-specific survival (HR = 3.05, 95% CI 1.91-4.86), and disease-free survival (HR = 2.12, 95% CI 1.52-2.96). The associations were not modified by race, age at diagnosis, and pre-diagnostic weight. BMI gain (> 0.5 kg/m²/year) was also related to worse survival, but the effect was weak (HR = 1.60, 95% CI 1.10-2.33 for overall survival).

CONCLUSION

BMI loss is a strong predictor of worse breast cancer outcomes. Growing prevalence of obesity may hide diagnosis of cancer cachexia, which can occur in a large proportion of breast cancer patients long before death.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Postdiagnosis weight change is associated with poorer survival in breast cancer survivors: A prospective population-based patient cohort study

More women are surviving after breast cancer due to early detection and modern treatment strategies. Body weight also influences survival. We aimed to characterize associations between postdiagnosis weight change and prognosis in postmenopausal long-term breast cancer survivors. We used data from a prospective population-based patient cohort study (MARIE) conducted in two geographical regions of Germany. Breast cancer patients diagnosed 50 to 74 years of age with an incident invasive breast cancer or in situ tumor were recruited from 2002 to 2005 and followed up until June 2015. Baseline weight was ascertained at an in-person interview at recruitment and follow-up weight was ascertained by telephone interview in 2009. Delayed entry Cox proportional hazards regression was used to assess associations between relative weight change and all-cause mortality, breast cancer mortality, and recurrence-free survival. In total, 2216 patients were included. Compared to weight maintenance (within 5%), weight loss >10% increased risk of all-cause mortality (HR 2.50, 95% CI 1.61, 3.88), breast cancer mortality (HR 3.07, 95% CI 1.69, 5.60) and less so of recurrence-free survival (HR 1.43, 95% CI 0.87, 2.36). Large weight gain of >10% also increased all-cause mortality (HR 1.64, 95% CI 1.02, 2.62) and breast cancer mortality (HR 2.25, 95% CI 1.25, 4.04). Weight maintenance for up to 5 years in long-term breast cancer survivors may help improve survival and prognosis. Postdiagnosis fluctuations in body weight of greater than 10% may lead to increased mortality. Survivors should be recommended to avoid large deviations in body weight from diagnosis onwards to maintain health and prolong life.

Experiences of African American Breast Cancer Survivors Using Digital Scales and Activity Trackers in a Weight Gain Prevention Intervention: Qualitative Study

BACKGROUND

The use of digital tools to promote daily self-weighing and daily activity tracking may be a promising strategy for weight control among African American breast cancer survivors (AABCS). There have been no studies exploring the acceptability and feasibility of using digital tools for weight control or qualitative studies characterizing perceptions of daily self-weighing and daily activity tracking among AABCS.

OBJECTIVE

This study aimed to explore the subjective experiences of daily self-weighing and daily activity tracking using digital tools, including wireless scales and activity trackers, in a sample of AABCS participating in two technology-based weight gain prevention interventions over 6 months.

METHODS

Semistructured interviews (N=21) were conducted in person or over the phone, were audio recorded, and then transcribed verbatim. Each transcript was read to identify key themes and develop a codebook. Each transcript was coded using Atlas.ti software, and code outputs were used to identify overarching themes and patterns in the data.

RESULTS

On average, participants were 52.6 (SD 8.3) years of age, with obesity at baseline (BMI 33.1 kg/m2, SD 5.9), and weighed on 123.4 (SD 48.0) days out of the 168 days (73.5%) in the study period. Women tended to attribute their weight gain to cancer treatment and framed program benefits in terms of improved quality of life and perceptions of prolonging their survival following treatment. Using the smart scale for daily self-weighing was viewed as the tool by which participants could control their weight and improve their health and well-being posttreatment. The activity tracker increased awareness of physical activity and motivated participants to be more active.

CONCLUSIONS

Participants reported positive experiences and benefits from daily self-weighing and daily activity tracking. Findings suggest that daily self-weighing and daily activity tracking using digital tools are well-received, acceptable, and feasible intervention strategies for AABCS in the context of posttreatment weight management.

How are missing data in covariates handled in observational time-to-event studies in oncology? A systematic review

Background

Missing data in covariates can result in biased estimates and loss of power to detect associations. It can also lead to other challenges in time-to-event analyses including the handling of time-varying effects of covariates, selection of covariates and their flexible modelling. This review aims to describe how researchers approach time-to-event analyses with missing data.

Methods

Medline and Embase were searched for observational time-to-event studies in oncology published from January 2012 to January 2018. The review focused on proportional hazards models or extended Cox models. We investigated the extent and reporting of missing data and how it was addressed in the analysis. Covariate modelling and selection, and assessment of the proportional hazards assumption were also investigated, alongside the treatment of missing data in these procedures.

Results

148 studies were included. The mean proportion of individuals with missingness in any covariate was 32%. 53% of studies used complete-case analysis, and 22% used multiple imputation. In total, 14% of studies stated an assumption concerning missing data and only 34% stated missingness as a limitation. The proportional hazards assumption was checked in 28% of studies, of which, 17% did not state the assessment method. 58% of 144 multivariable models stated their covariate selection procedure with use of a pre-selected set of covariates being the most popular followed by stepwise methods and univariable analyses. Of 69 studies that included continuous covariates, 81% did not assess the appropriateness of the functional form.

Conclusion

While guidelines for handling missing data in epidemiological studies are in place, this review indicates that few report implementing recommendations in practice. Although missing data are present in many studies, we found that few state clearly how they handled it or the assumptions they have made. Easy-to-implement but potentially biased approaches such as complete-case analysis are most commonly used despite these relying on strong assumptions and where often more appropriate methods should be employed. Authors should be encouraged to follow existing guidelines to address missing data, and increased levels of expectation from journals and editors could be used to improve practice.

Changes in weight, body composition, and physical activity among patients with breast cancer under adjuvant chemotherapy

PURPOSE

Breast cancer patients are more likely to gain than lose weight during chemotherapy. Weight gain due to chemotherapy in breast cancer patients increases the likelihood of complications and the risk of recurrence. The study aimed to investigate changes in weight, body composition, and physical activity in breast cancer patients receiving adjuvant chemotherapy.

METHOD

This was a prospective longitudinal study. The participants of this study were 37 patients who underwent adjuvant chemotherapy between August 2016 and March 2017 at a University hospital, Seoul, South Korea. We measured weight and body composition using a bioelectrical impedance method, and physical activity through a questionnaire, three times during the study period. The collected data were analyzed using descriptive statistics and repeated measures analysis.

RESULTS

There were no changes in weight, body mass index (BMI), body composition, and physical activity during adjuvant chemotherapy. There were no statistically significant differences in weight and BMI according to clinical characteristics. However, there were significant differences in total body water, muscle mass, and body fat percentage according to menopause status. The changes in physical activity showed no differences according to clinical characteristics.

CONCLUSIONS

There was no significant change in weight, body composition, and physical activity during adjuvant chemotherapy in participants with breast cancer. However, total body water, muscle mass, and body fat percentage differed according to menopause status, and body fat percentage appeared to increase rapidly in premenopausal participants following adjuvant chemotherapy. We should pay close attention to the weight of premenopausal women receiving adjuvant chemotherapy.

Clinical Integration of Digital Solutions in Health Care: An Overview of the Current Landscape of Digital Technologies in Cancer Care

Digital health constitutes a merger of both software and hardware technology with health care delivery and management, and encompasses a number of domains, from wearable devices to artificial intelligence, each associated with widely disparate interaction and data collection models. In this review, we focus on the landscape of the current integration of digital health technology in cancer care by subdividing digital health technologies into the following sections: connected devices, digital patient information collection, telehealth, and digital assistants. In these sections, we give an overview of the potential clinical impact of such technologies as they pertain to key domains, including patient education, patient outcomes, quality of life, and health care value. We performed a search of PubMed ( www.ncbi.nlm.nih.gov/pubmed ) and www.ClinicalTrials.gov for numerous terms related to digital health technologies, including digital health, connected devices, smart devices, wearables, activity trackers, connected sensors, remote monitoring, electronic surveys, electronic patient-reported outcomes, telehealth, telemedicine, artificial intelligence, chatbot, and digital assistants. The terms health care and cancer were appended to the previously mentioned terms to filter results for cancer-specific applications. From these results, studies were included that exemplified use of the various domains of digital health technologies in oncologic care. Digital health encompasses the integration of a vast array of technologies with health care, each associated with varied methods of data collection and information flow. Integration of these technologies into clinical practice has seen applications throughout the spectrum of care, including cancer screening, on-treatment patient management, acute post-treatment follow-up, and survivorship. Implementation of these systems may serve to reduce costs and workflow inefficiencies, as well as to improve overall health care value, patient outcomes, and quality of life.

The impact of body size changes on recurrence risk depends on age and estrogen receptor status in primary breast cancer

PURPOSE

To investigate the prognostic impact of body size changes during the first postoperative year in breast cancer.

METHODS

A cohort of 1,317 primary breast cancer patients included in Sweden (2002-2014) underwent body size measurements at the preoperative and 1-year visits (n = 1,178). Landmark survival analyses were used to investigate how postoperative weight gain or loss (> 5%) or change in waist-hip ratio (WHR) categories (≤ 0.85 or > 0.85) impact prognosis.

RESULTS

Median age at inclusion was 61 years and body mass index 25.1 kg/m². After a median follow-up of 5.0 years from inclusion, 165 recurrences and 77 deaths occurred. Weight gain (17.0%) conferred over twofold recurrence risk only in patients < 50 years (P_interaction = 0.033). Weight loss (8.6%) was only associated with a poor prognosis in patients ≥ 70 years, but not after restriction analysis. Weight change did not impact prognosis in patients 50 to < 70 years. Changes between WHR categories were associated with differential recurrence risk depending on estrogen receptor (ER) status (P_interaction = 0.007), with higher recurrence risk in patients with ER+ tumors and lower recurrence risk with ER- tumors.

CONCLUSION

Both changes in terms of weight and WHR category yielded independent prognostic information. Further research is imperative before recommending weight loss for all overweight breast cancer patients.

Phase II Feasibility Study of a Weight Loss Intervention in Female Breast and Colorectal Cancer Survivors (SWOG S1008)

OBJECTIVE

This study aimed to test the feasibility of a 12-month weight loss intervention using telephone-based counseling plus community-situated physical activity (PA) in female breast cancer (BC) and colorectal cancer (CRC) survivors.

METHODS

This multisite cooperative group study enrolled sedentary, female, postmenopausal BC and CRC survivors with BMI ≥ 25 kg/m2 to receive 12-month fitness center memberships and telephone counseling encouraging 150 min/wk of PA and a 500-kcal/ddecrease in energy intake. Feasibility criteria included accrual, adherence, and retention. Target weight loss was ≥ 5%.

RESULTS

Among 25 BC survivors, median baseline BMI was 37.2 (range: 27.7-54.6), accrual occurred in 10 months, 60% and 28% met diet and exercise goals, 80% provided 12-month measures, and average weight loss was 7.6% (95% CI: -3.9%, 19.2%). Among 23 CRC survivors, median BMI was 31.8 (range: 26.4-48.7), accrual occurred in 24 months, 61% and 17% met diet and exercise goals, 87% provided measures, and average weight loss was 2.5% (95% CI: -8.2%, 13.3%).

CONCLUSIONS

It is feasible to recruit and retain BC survivors in a cooperative group diet and PA weight loss trial. BC survivors achieved clinically meaningful weight loss but did not meet a priori adherence goals. In CRC survivors, recruitment was more difficult, and the intervention was less effective.

The Obesity and the Risk of Breast Cancer among Pre and Postmenopausal Women

Background: Breast cancer is the most common cancer among women worldwide and the obesity is one of the factors related to the risk of breast cancer mainly in postmenopausal women. This study investigated the association between obesity in pre- and postmenopausal women with the development of breast cancer and the expression of estrogen, progesterone, HeR-2 and triple-negative (TN) receptors. Methods: A case-control study was conducted on 100 patients with recently diagnosed breast cancer and 400 age-matched controls. The women were divided into pre- and post-menopausal groups. Results: The multivariate analysis showed that postmenopausal women with a BMI ≥ 30 kg/m2 at pre-diagnosis and at the most recent measurement were 1.50 (95% CI 1.06-2.13) and 1.56 (95% CI 1.11-2.21) times more likely to develop breast cancer, respectively. These women had a prevalence of obesity of 27.7% when considering pre-diagnosis BMI and 29.4% when analyzing the indicator of recent BMI. When only the cases regarding the presence of obesity with clinicopathological variables were analyzed, a total of 95.2% of the postmenopausal women with pre-diagnostic obesity according to BMI presented the positive estrogen receptor (ER) subtype. Conclusions: In Brazilian women, there is an association between obesity and the risk of breast cancer postmenopause; moreover, there is an association between the occurrence of the positive ER subtype in postmenopausal women and pre-diagnostic obesity according to BMI.

Changes in metabolic risk, insulin resistance, leptin and adiponectin following a lifestyle intervention in overweight and obese breast cancer survivors

Adiposity and physical activity are modifiable factors that could be important determinants of breast cancer (BC) prognosis through their effects on endogenous reproductive hormones, chronic inflammation and metabolic changes. Therefore, it is necessary to evaluate whether offering lifestyle interventions to BC survivors could affect the levels of certain biomarkers involved in these mechanisms. We designed a pre-post intervention study offering diet and exercise sessions over 12 weeks to 42 overweight/obese BC survivors. Before and after the intervention, we obtained dietary information, anthropometry and cardiorespiratory fitness (CRF) measurements and blood samples to measure metabolic risk, insulin resistance and adipokines biomarkers. Wilcoxon signed-rank tests and Spearman partial correlation coefficients were used to compare pre- and post-measurements and assess the correlations between changes in biomarkers and changes in anthropometry and CRF. Breast cancer survivors showed significant improvements in metabolic risk biomarkers and insulin resistance indicators along with a non-significant leptin decrease and a significant adiponectin decrease. The improvements in metabolic risk biomarkers, insulin resistance indicators and leptin were moderately correlated (0.32 ≤ |r| ≤ 0.55) with the decrease in body mass index and the increase in CRF. Diet and exercise interventions implemented in overweight/obese BC survivors may improve metabolic risk, insulin resistance and leptin biomarkers.

Body mass index and prognosis of breast cancer: An analysis by menstruation status when breast cancer diagnosis

OBJECTIVE

To examine whether obesity/overweight is a risk predictor for breast cancer recurrence and death by menopausal status in a retrospective study.

METHODS

We performed a retrospective analysis of 1017 breast cancer patients treated in our hospital from January 2004 to December 2012. Three groups were divided according to body mass index (BMI) when breast cancer diagnosis: normal weight, BMI < 25.0 kg/m; overweight, 25.0≤BMI < 30.0 kg/m; and obesity, BMI≥30.0 kg/m. The clinicopathological characteristics and clinical outcomes of patients within 5 years following breast cancer diagnosed were analyzed. Subgroup analyses of BMI on breast cancer prognosis were analyzed according to the menopausal status when breast cancer diagnosis. The Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Overweight and obesity groups were associated with larger size tumors, older age, increased proportion of postmenopausal patients and less patients choosing anthracycline and/or taxane regimen. The 5-year disease-free survival (DFS) and overall survival (OS) decreased in overweight and obese patients (P < .001), and both overweight and obesity were independent predictors for increased risks of breast cancer relapse and death (P < .001). When stratified by menopausal status, both overweight and obesity were associated with reduced 5-year DFS and OS in postmenopausal patients (P < .050), and multivariate analysis showed that the risk of relapse and breast cancer mortality in these 2 groups also increased (P < .050). Among premenopausal patients, the risks of relapse and death were significantly increased in obesity group rather than overweight group by multivariate analysis.

CONCLUSION

Overweight and obesity might be independently associated with poorer prognosis for breast cancer patients, and the effects of overweight on the breast cancer prognosis seem to be related to menopausal status.

Pre-diagnostic changes in body mass index and mortality among breast cancer patients

PURPOSE

We investigated whether changes in body mass index (BMI) before a breast cancer diagnosis affected mortality and whether trajectories more accurately predict overall mortality compared to a single measure of BMI.

METHODS

Our prospective cohort comprised 2012 women with breast cancer who reported their weight in each decade from 20 to 50-64 years of age. We used trajectory analysis to identify groups with similar development patterns in BMI and Cox proportional hazards models to examine the association between trajectory groups and mortality, and interactions with oestrogen receptor status and smoking. We used c-index statistics to compare the trajectory model with the single measure model of BMI.

RESULTS

We identified three distinct trajectory groups, with a mean BMI at age 20 of 19, 22 and 24 increasing to 23 (normal-to-normal), 29 (normal-to-overweight) and 37 (normal-to-obese) at 50-64 years of age, respectively. Women in the normal-to-obese trajectory group experienced significantly higher overall mortality than those in the normal-to-normal trajectory group (HR 1.76, 95% CI 1.21‒2.56). The association declined to a non-significant level after adjustments for clinical prognostic factors. Although not significant, the same tendency was seen for breast cancer-specific mortality. The association was strongest in women with oestrogen receptor-negative tumours. Weight changes over time were not significantly different from a single BMI measure before diagnosis to predict survival.

CONCLUSION

Weight gain affects overall mortality after breast cancer but clinical prognostic factors largely eliminate the association. Using trajectories of weight changes did not improve the predictive value compared to a single measure of BMI.

Determinants of Weight Gain During Adjuvant Endocrine Therapy and Association of Such Weight Gain With Recurrence in Long-term Breast Cancer Survivors

BACKGROUND

Weight gain is a negative prognostic factor in breast cancer (BC) patients. The risk factors for weight gain during adjuvant endocrine therapy (ET) and the extent to which such weight gain is associated with disease recurrence remain unclear.

PATIENTS AND METHODS

We retrospectively identified a cohort of women with a diagnosis of stage I-III, hormone receptor-positive, human epidermal growth factor receptor 2-negative BC from January 1997 to August 2008, who had received initial treatment at the MD Anderson Cancer Center, had completed 5 years of ET, and had remained free of locoregional or distant relapse or contralateral BC for ≥ 5 years after diagnosis. The weight change at the end of 5 years of ET was measured as the percentage of the change in weight from the start of ET, with a weight gain of > 5% considered clinically significant. Multivariable logistic regression and Cox proportional hazards models were used to assess the determinants of such weight gain and the risk of recurrence after 5 years.

RESULTS

Of 1282 long-term BC survivors, 432 (33.7%) had a weight gain of > 5% after 5 years of ET. Women who were premenopausal at diagnosis were 1.40 times more likely than women who were postmenopausal at diagnosis to have a weight gain of > 5%. Asian women had the lowest risk of gaining weight. The recurrence risks of patients who had gained weight and those who had not were not significantly different.

CONCLUSION

Premenopausal BC patients had an increased risk of weight gain after 5 years of ET; however, BC patients with a weight gain of > 5% did not have an increased risk of disease recurrence.

Impact of baseline BMI and weight change in CCTG adjuvant breast cancer trials

Background

We hypothesized that increased baseline BMI and BMI change would negatively impact clinical outcomes with adjuvant breast cancer systemic therapy.

Methods

Data from chemotherapy trials MA.5 and MA.21; endocrine therapy MA.12, MA.14 and MA.27; and trastuzumab HERA/MA.24 were analyzed. The primary objective was to examine the effect of BMI change on breast cancer-free interval (BCFI) landmarked at 5 years; secondary objectives included BMI changes at 1 and 3 years; BMI changes on disease-specific survival (DSS) and overall survival (OS); and effects of baseline BMI. Stratified analyses included trial therapy and composite trial stratification factors.

Results

In pre-/peri-/early post-menopausal chemotherapy trials (N = 2793), baseline BMI did not impact any endpoint and increased BMI from baseline did not significantly affect BCFI (P = 0.85) after 5 years although it was associated with worse BCFI (P = 0.03) and DSS (P = 0.07) after 1 year. BMI increase by 3 and 5 years was associated with better DSS (P = 0.01; 0.01) and OS (P = 0.003; 0.05). In pre-menopausal endocrine therapy trial MA.12 (N = 672), patients with higher baseline BMI had worse BCFI (P = 0.02) after 1 year, worse DSS (P = 0.05; 0.004) after 1 and 5 years and worse OS (P = 0.01) after 5 years. Increased BMI did not impact BCFI (P = 0.90) after 5 years, although it was associated with worse BCFI (P = 0.01) after 1 year. In post-menopausal endocrine therapy trials MA.14 and MA.27 (N = 8236), baseline BMI did not significantly impact outcome for any endpoint. BMI change did not impact BCFI or DSS after 1 or 3 years, although a mean increased BMI of 0.3 was associated with better OS (P = 0.02) after 1 year. With the administration of trastuzumab (N = 1395) baseline BMI and BMI change did not significantly impact outcomes.

Conclusions

Higher baseline BMI and BMI increases negatively affected outcomes only in pre-/peri-/early post-menopausal trial patients. Otherwise, BMI increases similar to those expected in healthy women either did not impact outcome or were associated with better outcomes.

Clinical Trials numbers

CAN-NCIC-MA5; National Cancer Institute (NCI)-V90-0027; MA.12-NCT00002542; MA.14-NCT00002864; MA.21-NCT00014222; HERA, NCT00045032;CAN-NCIC-MA24; MA-27-NCT00066573.

Association between changes in body fat and disease progression after breast cancer surgery is moderated by menopausal status

Background

Obesity is linked to poor disease outcomes in breast cancer patients. However, this link was mostly based on body weight or BMI rather than body-fat. The purpose of this study was to evaluate the relationship between body-fat gain and disease progression in Taiwanese women after breast cancer surgery and how this relationship is influenced by menopausal status.

Methods

Body fat percentage was measured 1 day before and 6 months after surgery in 131 women with stages 0–III breast cancer. Disease outcomes (metastasis and death) were assessed by chart review and telephone contact 7 to 8 years after diagnosis. These data were analyzed by multivariate Cox proportional hazard model analysis.

Results

The percentage of women with over 5% gain in body-fat was 56% for premenopausal and 42% for postmenopausal. Rates of distant metastasis and all-cause mortality were 17.6 and 9.9%, respectively over the follow-up period. Distant metastases were predicted in postmenopausal but not premenopausal women with breast cancer by increased body fat percentage (HR = 1.3, p = 0.035), after controlling other potential covariates, including disease severity, estrogen receptor expression, progesterone receptors expression, age, and exercise habit before diagnosis. Survival was not significantly associated with body-fat percentage gains.

Conclusions

Our results suggest that increased body fat percentage 6 months after breast surgery is an important predictor of distant metastasis in postmenopausal Taiwanese women with breast cancer. Clinicians may need to measure patients’ body fat periodically. Our findings should be validated in studies with a longer follow-up time.

A role of low dose chemical mixtures in adipose tissue in carcinogenesis

The Halifax project recently hypothesized a composite carcinogenic potential of the mixture of low dose chemicals which are commonly encountered environmentally, yet which are not classified as human carcinogens. A long neglected but important fact is that adipose tissue is an important exposure source for chemical mixtures. In fact, findings from human studies based on several persistent organic pollutants in general populations with only background exposure should be interpreted from the viewpoint of chemical mixtures because serum concentrations of these chemicals can be seen as surrogates for chemical mixtures in adipose tissue. Furthermore, in conditions such as obesity with dysfunctional adipocytes or weight loss in which lipolysis is increased, the amount of the chemical mixture released from adipose tissue to circulation is increased. Thus, both obesity and weight loss can enhance the chance of chemical mixtures reaching critical organs, however paradoxical this idea may be when fat mass is the only factor considered. The complicated, interrelated dynamics of adipocytes and chemical mixtures can explain puzzling findings related to body weight among cancer patients, including the obesity paradox. The contamination of fat in human diet with chemical mixtures, occurring for reasons similar to contamination of human adipose tissue, may be a missing factor which affects the association between dietary fat intake and cancer. The presence of chemical mixtures in adipose tissue should be considered in future cancer research, including clinical trials on weight management among cancer survivors.