The following article appeared in the January/February Issue of Mamm Magazine
written by Gina Maisano

Five Ways to Prevent Recurrence

Your surgeries are done. You finally finished chemo. Radiation is a thing of the past. And now your doctor ships you off to go be normal again. That’s it? You mean there is no more that can be done to make sure this never happens again? Absolutely not! But you will be the one doing the proactive things that will help you stay recurrence free.

 Start At Home

There are three things you can do at home that have an impact on your future survival.

  1. Proper nutrition

 2. Weight control

 3. Exercise

 Yes, these are the same things that were supposed to keep you from getting breast cancer in the first place, but now that you are post diagnosis, there are actual studies to back up how important it is for you to make a few lifestyle changes.

You Are What You Eat
 
When making food choices, repeat  to yourself, “I am what I eat.” Then choose low fat foods, lean meats and healthy, fresh vegetables and fruit.  Low fat, lean, and healthy? Not  bad!  This tip comes in especially handy when you find yourself reaching for high fat, greasy, junk food!

Take a good look. What are you really eating each day? This can best be assessed by keeping a food diary. This should list everything eaten throughout the day for a week and the size of the portions. How much of the diet consists of meat? How many fat grams? How many servings of vegetables and fruits? This is important because long range studies have proven there is a direct link between diet and breast cancer recurrence.

 According to the National Cancer Institute, “The Women’s    Interventional Nutritional Study, or ‘WINS’ was the first large-scale randomized trial to show that a change in diet can improve breast cancer outcomes in women who are receiving conventional treatment for early-stage breast cancer.”  This study proved that after five years, women who decreased their fat intake by 24 grams a day had a 24% reduction in the relative risk of recurrence.  What’s more, women who were estrogen and progesterone receptor negative had a 42% risk reduction which translates into an absolute relapse-free survival rate of 9.5% after 8 years.

 How do you do this? Read the labels. Check out the fat content of the foods you eat in a day. And this applies to the things you use to make your food more  tasty. A tablespoon of  vegetable oil has 14 grams a fat in it. If you are attempting to stay within the guidelines of  30 grams a fat per day this is important to note. There are trade offs that can be made however that help mitigate this. Switch from butter to olive oil. Buy a more expensive cut of meat that has less fat in it. The packaging should tell you how “lean” it is by giving you a percentage of the fat in it. Slow roast foods instead of sautéing or frying them. This brings out more flavor and virtually eliminates the need to add extra fat. Buy fresh foods that you make yourself. This is the best way to control how much fat you are consuming per day. Restaurants use large amounts of fat because it makes the food taste better. One of the most  fatty foods you can order in a restaurant is grilled vegetables. They are saturated in oil before grilling and the vegetables used, zucchini, mushrooms, summer squash, etc. are all very porous and absorb all the grease, making them higher in fat than the hamburger on the menu.

You are Off of Chemo, Now Get the Chemo Weight Off You

Most women gain between 15 to 30 pounds from chemotherapy treatments. Talk about adding insult to injury.  If you are in chemo right now, try to maintain your weight. Don’t try to diet while on chemo. But some of the cravings chemo can cause also make you gain weight. It is a fact that women never crave low fat, low calorie food on chemotherapy.

Dr. Michelle Holmes, MD, DrPH, Associate Professor of Medicine, Harvard Medical School Brigham & Women's Hospital in Boston, Massachusetts, reports on studies that have focused on the importance of maintaining or losing weight post treatment.

“We have published a study showing that the more weight a woman gains after diagnosis, the more likely she is to have a recurrence and die from breast cancer, compared with women who maintain their weight.”

Dr Holmes recognizes that many women gain weight because of the treatments they are on. “It can be challenging for a woman with breast cancer to maintain weight.  It appears that some treatments, although lifesaving, can also promote weight gain.  However, trying to eat and exercise so that she maintains rather than gains weight, while still taking the prescribed treatments, is something a woman with breast cancer can try to do to help herself.”

Your goal should be a healthy weight, not becoming a swimsuit model. Every little bit helps your future prognosis.

THE "E" WORD

 You can’t escape it. Breast cancer does not give you a Get Out of Exercise Free card. In fact, it is just the opposite. Exercise may very well give you a Stay Free From Recurrence card.

According to Dr. Holmes, “Exercise may be beneficial for women with breast cancer.  We studied almost 3,000 women with breast cancer.  We asked them what sorts of recreational physical activity they participated in and how many hours per week they did it.  We made sure to ask them after they had completed their treatment for breast cancer.  We followed these women for up to 18 years, and made note of the ones who died.

Women with breast cancer who did the equivalent of 3 to 5 hours of walking per week were 50% less likely to die from breast cancer death, compared to inactive women with breast cancer.  Both walking and more vigorous activity contributed to this benefit. 

 It is hard to exercise while in treatment. Women should try to move around as much as possible because it does help with some of the side effects such as fatigue and joint pains. But once treatment ends, a reasonable program that you design for yourself, that lets you call the shots, can help keep you healthy and cancer free as long as you remember to do it for thirty minutes a day at least 5 days a week.

Exercise does not only occur in a gym. You can do it anywhere if you stop thinking of exercise as going for the burn and thinking of it as fun. You aren’t going to work out- you are going to play. Give yourself a recess during the day for play time. If you have kids, play with them and get your heart rate up. Start taking your dog for walks. Nicki Dwyer, a nurse from Chicago, stopped letting her dog, Mister, out on his own in her yard and put a leash on him and went for long walks. She found herself looking forward to that time and also discovered she felt better and was getting back into shape again.

Exercise doesn’t have to be a chore, but a chore can be exercise. Who needs Hollywood trainers and tanning salons? Mowing your lawn gives you a work out and a tan all at the same time. Plus, your yard looks better when you are done.

Dr. Holmes reports, “The good news is that women do not have to run marathons for maximum benefits.   That level of exercise matches the recommendations of the federal government for 30-60 minutes of moderate activity on most days of the week.”

Start slowly, go at your own pace, make sure you have done something today. Little things can add up to a lot. Walk the dog, take the stairs, park in the farthest parking spot and walk briskly to the store – these all add up and help you. The things you do around the house count too. Mowing your lawn, vacuuming, shoveling the driveway, raking leaves, gardening, all get your heart rate up.  Mary Beth Kirtz, a breast cancer survivor from upstate New York keeps track of her progress with a pedometer. It is a great way to gauge how much or how little you moved in a day. Your target should be 10,000 steps a day. It may take baby steps to get there, but they all count!

Take Your Medicine

If your cancer was estrogen and/or  progesterone positive, there are drugs known as endocrine therapy,  that you can take to help you live a long, recurrence free life. But there is a catch, you have to take them.  There are large studies being conducted right now on patient compliance. It seems that people stop taking their medicine at home because they do not like the side effects, or they start to feel better or they just don’t want to take pills anymore. You cannot be one of them. If you have the opportunity to benefit from endocrine therapy you have to find a way to stay on it to keep cancer away.

Endocrine therapy drugs include,  Tamoxifen (Nolvadex),  the oldest and most well known. This drug is a SERM, or selective estrogen-receptor modulator. This blocks the action of estrogen in the breast and other tissues in the body where estrogen receptors hide inside cells. Premenopausal and postmenopausal women can take this drug to help keep their cancer at bay. The second generation endocrine therapy drugs are known as aromatase inhibitors, such as Arimidex (anastrozole), Aromasin (exemestane), and Femara (letrozole.) They work differently in the body and can only be taken by women who are post menopausal because their mechanism correlates with the way a post menopausal woman’s body synthesizes estrogen. Aromatase inhibitors (AIs) can help block the growth of estrogen dependent tumors by lowering the amount of estrogen in the body.

These drugs are partly responsible for the lower mortality rate from breast cancer in recent years. They work. They keep your estrogen dependent cancer away. But they do have a down side. The side effects of these drugs can be debilitating.

 “You hit a point where you feel so completely debilitated from the side effects, that you say I'd rather live a shorter life with some type of quality as opposed to going on trying to cope with the side effects,” says Valerie Vinciguerra of Brooklyn, New York, about her attempts with three aromatase inhibitors and the prospect of starting a new one. But she stuck with it. She chose to stay protected by endocrine therapy because she knows the alternative can be much more devastating than the side effects, which do, in time, lesson to a great degree.

Brenda Brittian, of Hickory, North Carolina, reports her reasoning for stopping Femara, “Honestly, quality of life means more to me, being able to get on the floor and play with my grandchildren or go for hikes in the woods - well, those things just won out.  I know I'm taking a risk.  I understand fully what I have chosen but it was MY choice and one I know in my heart I won't regret. The laughter and joy of my granddaughter taking my face between her hands, as we were sitting on the floor playing, and saying "Nana, you're my buddy" and the fact I know I could not have done that with the joint pain I was suffering for the short time I took the Femara has proven to me it was the right choice.”

 Women must work with their doctors to find a way to combat the side effects which can range from joint pain, GI disturbances, loss of energy, hot flashes and general malaise.

Constantine Kaniklidis, medical researcher with the European Association for Cancer Research (EACR) and founder of evidencewatch.com, has reported the findings of several studies that show that there are ways to improve a woman’s ability to ease the adverse effects of endocrine therapy so she keeps taking it and by extension, keeps her cancer at bay.  According to Kaniklidis, “For women on aromatase inhibitors two viable options exist: Switching to tamoxifen which tends to induce musculoskeletal and menopausal symptoms at a significantly lower level of severity than aromatase inhibitors and the option of estrogen add-back in the form of very low dose of estradiol replacement using a transdermal patch that would reduce or reverse negative impact of aromatase inhibitors on bone metabolism.  The very low dose estrogen add-back regimen can be implemented with any transdermal patch delivering 0.015 mg estradiol replaced twice weekly.

Although we are awaiting further data from clinical trials to weigh in on the efficacy and safety of the above innovative strategies, nonetheless, these options are not irrational in the face of the ravages that endocrine therapy  can impact on the quality of the lives, reasonable enjoyment, and functioning of vast numbers of women. In the cases in which the adverse impact of the endocrine therapy is such as to force partial or total noncompliance of otherwise significantly valuable disease treatment and/or risk reduction, the risk of noncompliance is likely to be much higher over whatever small risk the relieving strategy might be associated with, if any.”

 Don’t Even Think About Slacking Off

 Yes, you are sick of the doctor and of tests and just want to put this all behind you. Will that way of thinking keep your cancer from coming back? The first time it caught you by surprise. Now you are a seasoned warrior. You know better. You know that the earliest anything is found- whether a new cancer or a recurrence, the more successful it will be to treat. A woman must become her own best advocate and be even more vigilant about early detection than she was before her diagnosis. Women who have had breast cancer are at a higher risk of developing it again either in the same breast or in the other breast. Surprisingly, women are reluctant to get follow-up care post treatment. This is not something to be taken lightly. If a woman has had breast conserving surgery, that breast must be screened as well as the unaffected breast on a regular basis. According to Dr. Alice Kim, radiologist with  Nassau Radiologic Group based in Garden City, New York,

  “Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment.  Recurrence is possible, even if you have had a mastectomy.  Therefore it is of utmost importance for women to continue self breast examination, checking the treated area and the other breast each month.”

 Some women feel that once chemotherapy is finished they can stop seeing the doctors who treated them. But that is not correct. A breast cancer survivor must be pro-active in protecting her future health. What does this include? “ Keeping your scheduled follow up appointments with your doctor who will perform a breast examination, order lab or imaging tests as needed and ask about any symptoms you might have.  These appointments may be every three to four months initially and less often the longer you are cancer free.” Dr. Kim responds.

 All women who have had breast cancer are considered at high risk for getting another breast cancer. There is only one way to ensure she finds anything while it is still small and easy to treat: “Continued annual screening mammography is paramount in detecting early recurrence and/or second primary lesions.  In addition to mammography, annual breast MRI examinations should be considered as part of the screening regimen in these high risk women” concludes Dr. Kim.

HOPE

 After years of running for the cure, walking for the cure, eating yogurt for the cure, wearing jeans for the cure it looks like we are getting closer to that cure now more than ever. We may not be able to prevent breast cancer in the first place, but if you are a survivor, there is something you should know. One of the first places breast cancer recurs to is the bone. Once in the bone it can travel. If there was a way to keep it out of the bone then fewer women would get distant metastasis.

There may be a way. It is happening right now. Currently there are studies ongoing looking into the use of bone strengthening drugs, known as bisphosphonates, as a prophylactic measure to prevent future bone metastasis in early stage breast cancer patients.  According to Dr. Alexander Patterson, Head of the Division of Medical Oncology, University of Calgary, “Studies are on-going examining this question of possible prevention of bone metastases." The Powles trial suggested this might be possible and requires independent confirmation.  Part of this confirmation was announced by Dr.  Allan Lipton from Penn State reporting at the San Antonio Breast Cancer Symposium on December 15, 2007 the exciting findings that zolendronic acid (Zometa) not only decreased the risk of bone lesion progression but also was associated with a 50% higher overall survival.

Dr. Julie Gralow, Associate Professor Medical Oncology, University of Washington and the Fred Hutchinson Research Center reports,  “Drugs that inhibit bone breakdown are commonly used to treat osteoporosis. High doses of these drugs, called bisphosphonates, are also effective in reducing bone breakdown due to cancer involving the bone. Preliminary studies suggest that the same high doses used to treat bone metastases may also prevent bone metastasis in the first place. Ongoing studies are evaluating several drugs, including Clodronate, Boniva, and Zometa.”

According to Dr. Gralow, who is the principle investigator closely monitoring this study,

"Bone is a common site of distant recurrence in breast cancer. If we can reduce bone metastases, there is a good chance we can also reduce deaths due to breast cancer.”

These studies are being watched very carefully by the oncology community and breast cancer survivors alike, because they may have the potential to stop breast cancer metastasis in women with early stage disease. This means that women will actually be able to prevent breast cancer from returning in the most common place it recurs to.  The implications of this potential are breathtaking for any woman who has had breast cancer.

 What You Can Do in Review

Eat a healthy diet. Lose the weight you gained on chemo and maintain a healthy weight. Exercise/Play at least 5 days a week for a half hour. Take your medicine. If you have side effects, work with your doctor on ways to counteract them, or switch medications. Don’t let your guard down. Be your own best advocate and be vigilant in post treatment screening. While you are doing these things, the study continues and positive results keep being reported that someday, very soon, you will be able to take a common bone strengthening drug that has the potential to protect you from your cancer returning to its most vulnerable spot.

 Good Foods/ Bad Foods

BAD                                                               GOOD

White Flour                                                 Whole grains

Sugar                                                         Fresh Fruit    

Hydrogenated fat                                         Olive, canola & omega-3 rich fish oils

High sodium                                               Fresh vegetables

Chemically processed foods                          Lean Protiens

Fatty muscle meats                                       Nuts

Under five grams of fat, under five grams of sugar, and over five grams of fiber.

Quick substitutes that make a difference

Roast your foods slowly instead of sautéing or frying them. This brings out the flavor and eliminates the need to add extra fat

Switch from white rice to whole grain brown rice

Switch from regular pasta to whole grain pasta

Drink seltzer instead of processed sodas                      

Try to keep things organic

Reduce your consumption of muscle meats

Increase your consumption of vegetables and fruits

NOTE!

Constantine Kaniklidis of Breast Cancer Evidencewatch, is The Chief of Research and Guidance on the No Surrender Breast Cancer Forum. We are so lucky to have his constant wisdom and guidance.