By Dr. Daniel Morganstern
Medical Oncologist
Medical Director, Cancer Genetics Program
Hartford HealthCare Cancer Institute
If you have been diagnosed with breast cancer in recent years, you probably recall initially being bombarded with statistics.
You may have had a test called a recurrence score, which estimated your percentages, or chances of recurrence of breast cancer elsewhere in the body with different preventive treatments such as chemotherapy or anti estrogen tablets.
Or you may have weighed with your surgeon (or radiation oncologist) the chances of recurrence with breast-conserving surgery (“lumpectomy”) vs. chances with mastectomy. You may have discussed how and when radiation can further reduce the percentages, or risk of a recurrence in the area where the breast cancer started.
You might have even been tested for the BRCA1 or BRCA 2 gene and, more recently, other genes, and learned that besides breast cancer, you had a risk of a certain percent for some other cancer unrelated to breast cancer.
Armed with all this information, for some TMI, you and your treatment team arrived at the best treatment plan for you based on your specific cancer and your own specific concerns and goals. When you finished your initial treatments, you may have celebrated in some fashion and then, bingo, you became a breast cancer survivor!
But as most patients know, this is frequently the end of one road and the beginning of a new journey with its own emotional and physical dimensions, including fears, hopes, dreams and perhaps even disappointments. Later, I find it’s very common for all the percentages and statistics to blur together. Worse yet, sometimes those very same percentages developed at the time of treatment to reassure the path forward become a source of confusion or even anxiety.
I have been struck by how often we mix together two very different statistics: The risk of first getting breast cancer, and the risk of breast cancer recurring. Many are familiar with the fact that breast cancer will occur in 1 in 8 women in their lifetime, or about a 12.5 percent risk. And most are familiar with the notion that the risk increases with each decade of life.
That means a woman is more likely to get diagnosed with breast cancer at 50 than at 30, and more likely to get diagnosed with breast cancer at 70 vs. 50. Some even joke “if you live long enough you’ll get diagnosed with some form of cancer.” And there is a hint of truth to that joke. As our life expectancies increase from better treatments for things like heart disease, the relative likelihood of breast cancer in women or prostate cancer in men does indeed increase.
The appropriate image is that of snow accumulation. As the storm (or years) continues, the pile of snow gets higher and higher. If it snowed long enough, the pile of snow could reach 12 feet. And if you live long enough, as in to age 90, you would have that 12 percent risk of breast cancer.
Yet the risk of recurrence of a previously diagnosed breast cancer is precisely the opposite of this! The image is that of melting snow in a yard. You start out in March with some residual snow in the yard, or maybe piles in the corner of a parking lot. Think of that amount of snow as your ‘leftover risk of the cancer recurring” after your other treatments have already melted quite a bit of the snow (risk) away.
Then, with each week, there is less and less snow, eventually maybe only a small patch in the corner and eventually no snow (even in the corner of the Stop & Shop parking lot!). The same is true for risk of breast cancer returning. For every year, the risk decreases until there is at some point virtually no risk (snow) left whatsoever.
We are certain that by May, there will be absolutely no snow on the ground. How long does it take for all the risk to melt away?
It differs depending on the type and stage of cancer, but the point is that every year that you walk forward, the risk is less and less. The sentiment “I feel like if I live long enough the cancer will come back at me” couldn’t be further from the truth! Yet we can easily all fall into the trap of thinking that way.
After the prescribed course of treatment has been completed, I find that most breast cancer survivors become very interested and motivated to learn about changes in lifestyle that can both help them recover from various treatments and also reduce even further reduce the risk of recurrence — those statistics again!
As it turns out, there has been a lot of research devoted to this area, and the recommendations that your provider may make regarding day-to-day living are very much based in science.
In my view, the three lifestyle aspects where we have the most confidence in making recommendations are:
- Diet.
- Physical Activity.
- Alcohol Intake.
Diet
One last statistic for you: Nearly two-thirds of breast cancer survivors completing therapy are either overweight or obese. Overweight and Obese are medical terms referring to the Body Mass Index (BMI) and your provider can tell you if you fit into one of these medical categories.
And more than one recent randomized study has conclusively shown that breast cancer survivors who adhere to a diet which results in weight loss aiming at a more ideal BMI have a lower risk for recurrence of their cancer. Your oncologist or primary care physician can assist in this process, and develop a realistic and beneficial weight loss goal. They may refer you to a Registered Dietician or other structured weight loss program.
A frequently asked question about diet is whether there are foods from which a breast cancer survivor should steer clear. Although I encourage everyone to work with a dietician in the survivorship phase, I can think of no food, whether soy or red meat, that when consumed in moderation is harmful, and have seen no peer-reviewed published research that suggests otherwise.
Some argue that excessive amounts of saturated fats and red meat may increase risk of other cancers, such as colon cancer. Selecting some protein sources that are leaner may be helpful. All things in moderation (see Item 3).
Physical Activity
Observational data, such as surveying large groups of breast cancer survivors — which is less certain than clinical trials but still quite convincing — shows that returning to a high degree of physical activity after a breast cancer diagnosis can not only make one feel better but also reduce risk of cancer recurrence.
The American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Guidelines recommend 150 minutes of moderate or 75 minutes of strenuous exercise per week, with exercise a minimum of five days per week. This could include a brisk walk. Strength training is also recommended.
Alcohol Intake
Moderation is the key word. We know that consuming more than 5-7 alcoholic beverages of any kind (red wine, beer or spirits) per week may increase the body’s exposure to estrogen, even after menopause, and is likely to increase risk for breast cancer recurrence, particularly in women who are overweight.
That being said, moderate alcohol intake below that amount is not felt to be detrimental as it relates to breast cancer, and many recommend a maximum of one drink per day. As with weight loss, I’m a big fan of setting realistic, achievable goals.
So with the winter’s snow quite literally melted, I wish all readers a healthy and happy spring and summer!
Dr. Daniel Morganstern, a Medical Oncologist, is Medical Director of the Cancer Genetics Program at the Hartford HealthCare Cancer Institute.