Tagged Breast Cancer

Putting Breast Cancer on a Diet

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Linda Guinee, 60, a survivor of breast cancer, particpated in an earlier trial to see if weight-loss could improve her outcome. She lost 15 pounds and increase her physical activity.

Linda Guinee, 60, a survivor of breast cancer, particpated in an earlier trial to see if weight-loss could improve her outcome. She lost 15 pounds and increase her physical activity.Credit Shiho Fukada for The New York Times

Should weight loss be prescribed as a treatment for breast cancer?

Scientists are recruiting thousands of women for a large clinical trial to find out. The plan is to put heavy women age 18 and older who were recently given diagnoses of breast cancer on diets to see if losing weight will keep their cancer from coming back.

“We have been telling women to do this for years, but we don’t really have definitive proof,” said Dr. Jennifer Ligibel, the principal investigator of the Breast Cancer Weight Loss study, who is a breast oncologist in the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute in Boston.

“If it shows that losing weight by increasing physical activity and reducing calories improves survival, weight loss and physical activity could become a standard part of treatment for millions of breast cancer patients around the world,” Dr. Ligibel said.

In a sense, the clinical trial is long overdue. Once a woman is given a breast cancer diagnosis, obesity is associated with a higher risk for recurrence and lower likelihood of survival in women of all ages, Dr. Ligibel said.

Studies showing that obese and overweight women are more likely to die of their breast cancer date back decades. Just two years ago, a meta-analysis crunched the numbers from more than 80 studies involving more than 200,000 women with breast cancer, and reported that women who were obese when diagnosed had a 41 percent greater risk of death, while women who were overweight but whose body mass index was under 30 had a 7 percent greater risk.

But while those studies showed an association between weight and breast cancer mortality, they weren’t designed to find out if weight loss after diagnosis improves survival or reduces the chance of a recurrence.

“Nobody understands biologically why that is,” Dr. Ligibel said, adding that researchers will be collecting blood samples throughout the trial to track metabolic changes that occur with weight loss. Exercise is also part of the program, and participants will work with health coaches. Fitbit is donating all the products that will be used to track their activity and weight.

The researchers will look at markers of inflammation and metabolism, including levels of insulin, insulinlike growth factor and hormones that regulate fat storage.

“There’s a physiology of obesity that happens in everybody, but many of the changes we see in obesity actually are factors that influence the growth of cancer,” said Dr. Pamela Goodwin, one of the study’s investigators and a professor of medicine at Mount Sinai Hospital in Toronto.

These changes include higher insulin and glucose levels, inflammation and an increase in certain proteins, all of which appear to fuel cancer growth, Dr. Goodwin said.

Obesity “makes a great environment for cancer to get a foothold and progress,” said Barbara Gower, a professor of nutrition at the University of Alabama at Birmingham, who is running a small short-term trial to see what happens when women with ovarian cancer remove all sugar and starches from their diet. “The hormonal messages getting through to cancer cells are that it’s a good time to grow, and the nutrition they need is there, too.”

While a drug may target one of the factors, Dr. Ligibel said, weight loss and exercise may be a more powerful intervention because they lead to a combination of changes. “You have something that can potentially change all of them to a metabolically healthy low inflammatory state,” Dr. Ligibel said.

The trial, which will get underway this summer, will cost an estimated $15 million to $20 million. It’s sponsored by the National Cancer Institute and the Alliance for Clinical Trials in Oncology.

Researchers are recruiting 3,200 women from across the United States and Canada who have a recent diagnosis of Stage 2 or Stage 3 breast cancer. Participants must be overweight, with a body mass index of at least 27, and have hormone receptor positive or triple negative tumors. (Women with another type of breast cancer, known as HER2-positive, will not be included because their prognosis does not appear to be associated with weight, researchers said.)

Participants must be 18 but there is no upper age limit, though they must be able to walk “a couple of city blocks and have a life expectancy of at least five years for other causes,” Dr. Ligibel said.

Volunteers will be randomly assigned to either a telephone-based weight loss program or to a control group for comparison. The goal for those in the intervention is to lose 10 percent of their body weight over two years. Participants will continue to be followed for 10 years to see whether their cancer progresses or not.

Weight loss is challenging, and some cancer treatments cause weight gain. But an earlier trial that tested a similar telephone-based weight loss intervention on a smaller scale found that women with breast cancer lost 4 to 5 percent of their body weight, Dr. Goodwin said.

“Breast cancer is a teachable moment,” she added.

The new trial might help doctors identify which patients will benefit most from losing weight, and whether even moderate weight loss is helpful, said Dr. Clifford Hudis, the new chief executive officer of the American Society of Clinical Oncology and former chief of Memorial Sloan Kettering Cancer Center’s breast medicine service, who was involved in the design of the Breast Cancer Weight Loss trial.

“If I tell patients they need to lose 20 pounds, they just roll their eyes and say it’s impossible,” Dr. Hudis said. “But if we could say they only need to lose 3 percent of their body weight, that wouldn’t be so scary. That’s more manageable.”

Diet High in Saturated Fats May Be Linked to Dense Breasts

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Teenage girls who eat a diet high in saturated fat are at increased risk of developing dense breasts, a study concludes. Dense breasts contain more fibrous and connective tissue than normal and are a risk factor for breast cancer.

Researchers studied 177 girls, ages 10 to 18 at the start of the study, who periodically filled out dietary recall questionnaires. The scientists measured breast density by M.R.I. when the members of the group were 25 to 29 years old. The study is in Cancer Epidemiology, Biomarkers & Prevention.

Average dense breast volume in those in the lowest quarter for saturated fat intake was 16.4 percent, compared with 21.5 percent for those in the highest quarter.

Consumption of unsaturated fats had the opposite associations — the higher the consumption of unsaturated fats, the lower the average dense breast volume.

“We looked only at the associations of breast density with fat intake,” said the senior author, Joanne F. Dorgan, an epidemiologist at the University of Maryland School of Medicine. “Whether this will then be related to an increase in breast cancer later in life, we don’t know. But breast density itself is associated with increased risk.”

The authors controlled for many health factors, but they acknowledge that unknown variables could have affected their results.

“This is all observational data,” Dr. Dorgan said, “and needs to be confirmed before we can make health recommendations.”

Notifications About Dense Breasts Can Be Hard to Interpret

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Dr. Dorothy Lam explains the results of a mammogram to a patient at Swedish Covenant Hospital in Chicago in 2015.

Dr. Dorothy Lam explains the results of a mammogram to a patient at Swedish Covenant Hospital in Chicago in 2015.Credit Taylor Glascock for The New York Times

About 40 percent of women who have mammograms are found to have dense breast tissue, a normal finding that can make it harder to detect cancer. But many of these women receive letters in the mail about the finding that can be hard to decipher, a new study found.

“Twenty percent of the population only reads at an eighth-grade level, and many more don’t read at a much higher level than that,” said Nancy R. Kressin, one of the study’s authors who is a professor at Boston University School of Medicine and a senior researcher at the Veterans Affairs Boston Healthcare System.

“For many women, these notifications are not going to be easy to read” and might even be alarming, she said. “We’ve talked to some women who received these letters, and their reaction was ‘Oh my God, I have cancer.’ ”

Dense breast tissue means that a woman’s breasts have more connective and fibrous tissue than usual. Dense breasts both increase the risk of breast cancer and make it less likely that tumors will be seen on a mammogram, but having dense breasts does not mean a woman has cancer.

The study, published as a letter in JAMA, analyzed the notification letters sent out in 23 states and found that many use such complex language that patients need a college degree to understand them. The letters sent out in New Jersey and Connecticut were written at a postgraduate degree level, the report found. Yet only 12 percent of American adults have proficient health literacy, according to the National Assessment of Adult Literacy.

For years women were not routinely informed of the finding. Now, 26 states have laws on the books that require mammography testing facilities to tell women who have the breast cancer imaging scans if they have dense breast tissue as part of their results, according to Nancy Cappello, who founded Are You Dense?, a nonprofit organization that educates the public about the risks of dense breast tissue.

She acknowledged that the notification letters, which are crafted during the legislative process and are different in every state, may be complex but said they are meant to trigger a discussion between the patient and her doctor.

The notifications were “never intended to replace conversations, but to enhance them,” said Dr. Cappello, who was given a diagnosis of advanced breast cancer in early 2004, weeks after receiving a “normal” result from a mammogram. After her diagnosis, she learned that she had dense breast tissue. But although she had been having mammograms every year for over a decade, she was never informed she had dense breasts and that the scans were less reliable as a result.

She called the study “shortsighted” because it evaluated several sentences of a letter in isolation, “without assessing the readability of the entire report.”

“Why don’t the authors question the readability levels of all medical reporting results that patients receive?” Dr. Cappello asked.

The new analysis in JAMA measured the readability and understandability of notification letters and found that most were written at a level higher than the recommended seventh- or eighth-grade readability level, and many were at a high school or college readability level.

All of the letters informed women that dense breasts can mask cancer on mammography. Most also informed women that dense breasts are associated with an increased cancer risk and mentioned the option of getting screened by another method, suggesting the woman talk to her doctor.

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No Regrets After Double Mastectomy, but Questions Remain

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Vivien Foldes is one of a growing number of women with breast cancer who are having a double mastectomy.

Vivien Foldes is one of a growing number of women with breast cancer who are having a double mastectomy.Credit Uli Seit for The New York Times

Vivien Foldes says she does not regret having her breasts removed five years ago after she was found to have an early-stage cancer.

But there are things Ms. Foldes, a 58-year-old accountant from Woodmere, N.Y., wishes she had known when she chose a double mastectomy, like the fact that the process of reconstruction would drag on for five months and leave her forever unable to sleep on her stomach. Or that it would leave her with no sensation “from the front all the way to the back in the entire bra area,” she said. “Nothing. Zero. Zip.”

Ms. Foldes says there are days that she asks herself, “Should I have done it?” But, she said, her mother had two types of cancer, and she wanted to be proactive: “I didn’t want to be waiting for the other shoe to drop.”

Ms. Foldes is one of a growing number of women opting to have both breasts removed after a diagnosis of breast cancer, even though doctors say the operation does not improve the chances of survival. Now a new study, based on surveys of thousands of women, suggests women who have double mastectomies also do not benefit from a big improvement in quality of life, either. The study was published online in the Journal of Clinical Oncology earlier this month

“Quite a few studies have shown that in patients who don’t have a genetic mutation that increases breast cancer risk, the benefit from removing the healthy breast — purely from a cancer perspective — is zero to tiny at best,” said Dr. E. Shelley Hwang, the chief of breast surgery at Duke Cancer Institute, who led the study.

What she wanted to find out was, “If it doesn’t extend longevity, does it at least improve their quality of life?”

Dr. Hwang concluded that the benefits were marginal. “I don’t want to sound terribly negative; some women had very good results and are happy they made the decision,” she said. But, she added, “You’re not better off, you’re not happier, you don’t feel better about yourself sexually by having the healthy breast removed.”

The number of women opting to remove the cancerous breast and the healthy breast – a procedure known as contralateral prophylactic mastectomy or C.P.M. — has surged in recent years. In 2011, about 11 percent of women who were having a mastectomy for cancer chose C.P.M., compared with less than 2 percent in 1998.

Many breast cancer doctors are concerned by the trend, which they expect to increase. Women with early-stage breast cancer have the same odds of survival whether they have a lumpectomy or a mastectomy, and research suggests the risk of a cancer in the contralateral breast is low. But patients say they want to eliminate even the most negligible risk of a recurrence or cancer in their healthy breast.

“Nine times out of 10, the women are the ones who decide,” Dr. Hwang said. “They have cancer, they never want to deal with it again, they just want both breasts off, and they can’t rest until the other breast is done.”

But Dr. Hwang says she has seen the downside of double mastectomies. Surgical complications can occur during reconstruction, which is often a protracted process, and many women have unrealistic expectations about what the new breasts will look and feel like after reconstruction.

Surgery usually leaves the patient with no sensation in the breast area, and the extensive operations can also result in chronic pain.

“One patient said she couldn’t feel hugs anymore when she snuggled up to her kids,” Dr. Hwang said. “That really affected me.”

Many women are influenced by family history. Valerie Garguilo, 54, of Bellport, N.Y., watched her sister die in 2008 after a seven-year bout with breast cancer that was treated with a lumpectomy followed by two recurrences and two more lumpectomies, and then metastasis to her bones and brain. When Ms. Garguilo was found to have a stage-zero cancer herself four years ago, she opted for a double mastectomy, even though she tested negative for harmful genetic mutations.

“I wanted to do whatever I could to cut my chances of a recurrence; I wasn’t going to keep going in for lumpectomies,” she said.

Some women say they do not believe studies that report no difference in survival rates. “I feel like a lumpectomy can’t possibly get everything out,” said Maria Sawicki, 67, of Massapequa, N.Y., who needed a mastectomy on her affected breast but removed her other breast as well. “The littlest thing can be missed.”

For the study, 3,977 volunteers who had had mastectomies — including 1,598 who had had both breasts removed — completed an extensive survey, called BREAST-Q. The survey measured physical well-being, which asks about neck, arm and upper back pain, mobility and the ability to lift the arms; psychosocial well-being, which focuses on body image and confidence in social settings; sexual well-being, including sexual confidence and feelings of attractiveness and comfort level during sex; and breast satisfaction. The last question asks whether bras and clothes fit well, whether the breasts are symmetrical and whether one is comfortable with one’s appearance, clothed and unclothed.

After adjusting for differences between the groups, the researchers found that women who had had double mastectomies had slightly higher scores on psychosocial well-being and breast satisfaction — the differences were only about a point higher on a scale of 100. But scores on the other domains of physical and sexual well-being did not differ from those of women who did not have double mastectomies.

The most important factor in a woman’s overall well-being, the new study found, was whether she had had reconstructive surgery. Most women who had had such surgery reported substantially higher quality of life scores, whether they had single or double mastectomies.

“That’s a much more powerful intervention to improve quality of life than a contralateral prophylactic mastectomy,” Dr. Hwang said.

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Living With Cancer: A Woman Like Me

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A Woman like Me

A clip from “A Woman Like Me.”

By FILM PRESENCE on Publish Date February 3, 2016.

We commonly assume that cancer afflicts the aging or aged, but approximately 16 percent of breast cancer deaths involve women under the age of 50. How can or should an alarming death sentence be confronted in midlife? The personal challenges posed by incurable disease unfold in an absorbing documentary about movie-making, “A Woman Like Me,” which opened in New York in October and became available on Netflix this January.

The co-directors of “A Woman Like Me,” Alex Sichel and Elizabeth Giamatti, consider the roles played by temperament, spirituality and art as two vigorous women attempt to reconcile themselves to a terminal prognosis. The film portrays Ms. Sichel confronting metastatic breast cancer by making two movies.

The first is a documentary of herself in the hospital with medical personnel and at home with her family. Ms. Sichel, who received the diagnosis just before her daughter started kindergarten, is shown dealing with her ambivalence about the traditional therapies she undertakes. Her parents, sisters and husband struggle on camera with their ambivalence about the holistic therapies she also undertakes.

Braided with the documentary, the second movie Ms. Sichel makes is fictional: The actress Lili Taylor plays a buoyant alter ego, Anna, who must respond to the same dire diagnosis. The fictional narrative of “A Woman Like Me” centers on a happier version of Alex Sichel so she can watch someone stepping lightly through her fraught terrain.

For example, Anna sits with a friend in a restaurant and interrogates the waitress. Is there dairy in the vegetarian dish? Are there gluten-free options? Her friend orders the cavatelli, Anna steamed kale without salt. After a pause, though, she changes her mind; she will have the cavatelli as well as a glass of Cabernet. In the near future, she says, she does not want to look back on “pointless good behavior.”

In contrast, Ms. Sichel presents herself in a series of tortured conversations with a variety of advisers as she hurtles between fear and hope on an emotional roller coaster. She visits a meditation center and consults a Buddhist teacher, but equanimity often eludes her. Intermittently sad and angry, yet terrified of dying angry, she tries to find serene memories, only to recall her sorrow at her grandmother’s death, whereas Anna remembers her grandmother’s cooking.

“A Woman Like Me” hints that some people may be endowed with a disposition that facilitates their making peace with their imminent demise, although maybe those people exist only in fiction. Yet both stormy Alex and sunny Anna try to learn how to acknowledge their looming mortality. In especially poignant scenes, Alex and Anna must come to terms with their grief at losing their young children and also with their children’s future grief at losing them.

Anna copes with cancer most dramatically when she rehearses her death with her husband. Enlisting his help, she promises to refrain from moaning, but wants to know what his final words to her will be. And then she encourages him to drape a white sheet over her head. Anna’s directing the scene with her husband tells us something about Alex Sichel’s decision to spend the last year of her life co-directing a movie.

Like Anna’s rehearsing, Ms. Sichel’s movie-making is a testament to creativity and to the multiplicity of the self. Ms. Sichel refutes what cancer will inevitably make of her by imagining what she makes of it. In “A Woman Like Me,” she offers a defense of cancer art as a way of envisioning and practicing mortality. Throughout the film she espouses the efficacy of Buddhism, but the creator of Anna provides us proof of the value of story-telling.

If Alex Sichel could not become a sunnier person, she could envision herself being one. Through this endeavor, she and her co-director, Ms. Giamatti, illuminate what it means to live with incurable cancer not, as Ms. Giamatti put it during a phone conversation, in a “Halcion or Hollywood” manner, but in all its messy and contradictory intensity.

After watching the movie, I was upset at learning that Ms. Sichel died on June 23, 2014, at the age of 50, and then I was surprised at my distress since the end of the film makes it abundantly clear that she was suffering advanced disease. Yet somehow I could not believe that this engaged and engaging woman was dead. My reaction also testifies to the power of art, for Alex Sichel and her double Anna continue to touch and instruct people like me by showing us characters like ourselves.

If we cannot attain complete and lasting tranquility in the face of a death sentence, we can nevertheless conceive of a series of precarious, provisional moments of acceptance. Story-telling serves not as an escape from the reality of disease but as an assertion of the self against what will eventually happen.

Terrible as cancer is, it has prompted people to produce astonishing art. The power of this meta-movie resides not in retrospective platitudes about women with metastatic disease but in its representations of their urgent exertions to imagine the unimaginable.

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