October 2010 Issue

Nutrition Therapy During Breast Cancer Treatment
By Lindsey Getz
Today’s Dietitian
Vol. 12 No. 10 P. 60

RDs can be instrumental in creating a comprehensive care plan for patients, one that emphasizes achieving a healthy weight through appropriate diet and exercise strategies.

Breast cancer has become a familiar diagnosis for American women. It’s likely you either know someone who has been diagnosed or you’ve received a diagnosis yourself. In the United States, breast cancer incidence in women is about one in eight (13%), making it the most commonly diagnosed cancer in women next to skin cancer. Fortunately, as a result of early detection and improved treatment options, it’s also become an increasingly survivable disease. As of 2008, there are about 2.5 million U.S. women who are breast cancer survivors. There are a multitude of cancer treatment centers and programs throughout the country, and dietitians play an important role in a comprehensive survival plan. No matter what the course of treatment, nutrition should be a vital component.

The exact path that nutritional therapy takes may differ by cancer center and physician, but the core objective of achieving healthy weight loss or maintenance is the same. Dietitians specializing in oncology nutrition say it is critical that a nutritional program for breast cancer patients focus on maintaining a healthy weight during cancer treatments.

“Many breast cancer patients find themselves gaining weight during treatment,” says Julie Lanford, MPH, RD, CSO, LDN, wellness director for Cancer Services, Inc in Winston-Salem, N.C., and author of CancerDietitian.com. “It’s not completely clear why this happens, but it appears that body composition often changes during treatment; muscle is lost while fat is gained. This can be a result of treatment itself as well as the fact that many people lower their physical activity while in treatment. And on top of lowered physical activity, calorie intake may increase as a result of food being prepared by family and friends as well as the misconception that all cancer patients lose weight, resulting in a focus on increasing calories.”

With breast cancer, the research indicates that maintaining a healthy weight can be a matter of life and death, making it vital that patients follow a smart nutrition plan. In fact, a study from the Johns Hopkins Bloomberg School of Public Health in Baltimore found that for every 11 lbs gained, the risk of dying from a breast cancer diagnosis increased by 14%.

“Data continue to accumulate that weight gain during breast cancer treatment is associated with increased risk of recurrence and death from breast cancer,” says Diana Dyer, MS, RD, author of A Dietitian’s Cancer Story. “In my view, it is imperative that women know about this data from the beginning of treatment and have the appropriate nutritional education and support from an RD at their cancer center to minimize weight gain from happening during treatments. It is just not optimal or comprehensive cancer care to wait until after the fact—the weight gain has already occurred—to then refer the woman to a dietitian.”

Carolyn Lammersfeld, MS, RD, CSO, LD, CNSD, national director of nutrition for the Cancer Treatment Centers of America, agrees that educating patients from the start is critical. “From the very first visit, we help patients understand that we want them to maintain a healthy weight and not gain weight during treatment,” she says. “The goal is to work on modifying behaviors in order to help maintain weight or even gradually lose weight, as long as it’s coming from healthy eating and activity level. Sometimes this can be a difficult or uncomfortable subject in the beginning, but we have a team approach in which we offer support from more than one professional. We have a mind/body team that can help provide the tools to address these issues.”

Because of the importance of healthy body weight in the fight against breast cancer, many nutritional programs for patients with breast cancer also encourage physical activity. This can be a catch-22 that must be discussed with the patient. Since breast cancer treatment can make patients tired, they are often less likely to participate in physical activity. However, physical activity can actually be a successful way to fight the exhaustion, says Lanford. “At this point, there are no medications or other treatments that can combat fatigue unless it’s a result of low iron or another clinical issue,” she says. “For most breast cancer patients dealing with fatigue, the current strategy is to work on physical activity to maintain muscle mass, which gives energy, and to focus on healthy eating strategies to make sure the body has all the nutrients it needs to function optimally.”

A Comprehensive Plan
The exact components of nutrition therapy for patients with breast cancer will depend on the type of cancer they have, their treatment regimen, and their level of interest in nutrition and lifestyle therapy, says Lanford. However, all patients should undergo a nutrition screening by a healthcare provider or nutrition professional. “This screening may then trigger a more comprehensive nutrition assessment and ongoing intervention or may result in simply referring them to the available nutrition resources in their area,” explains Lanford.

Cynthia Thomson, PhD, RD, an associate professor of nutritional sciences at the Arizona Cancer Center at the University of Arizona, says that at the time of diagnosis, it is important to assess past dietary patterns and behaviors, weight history, and physical activity patterns, among other key areas. “It is clear that physical function influences QOL [quality of life] and outcomes among cancer patients,” she adds. “Working to enhance the nutrition quality of the diet, promoting physical activity as tolerated, and monitoring weight/adiposity will promote higher physical function and QOL. Further, it is well established that all cancer therapies impact diet and nutritional health in some way, whether reduced intake, constipation, or other issues. These can all be addressed with appropriate medical nutrition therapies.”

In the preoperative stage, Thomson says she focuses on the adequacy of a patient’s diet, especially in relation to postsurgical healing. She encourages patients to avoid supplements that could alter clotting in relation to postsurgical bleeding. After an operation, she encourages patients to continue a higher-protein diet, reach weight stabilization, and focus on increasing a variety of quality plant-based foods, higher-fiber foods, and fluids to address post-op constipation and other issues.

Over the long term, Thomson helps motivate patients to adhere to the plan and continue to maintain or attain a healthy weight. She generally promotes gradual weight loss (approximately 0.5 lbs per week) starting six to eight weeks post-op. “My approach promotes physical activity, but the patient ‘dictates’ the specifics of the intervention depending on their interest/commitment to specific behavior change,” she continues. “This is a highly motivated patient population, and early support for improvement in lifestyle is generally well accepted. The challenge is to keep motivation high during times of emotional and mental stress, which is common in treatment and posttreatments phases of care.”

Many dietitians say that for a patient with early-stage breast cancer—which most have—the dietary recommendations aren’t significantly different from ones they’d offer any patient focusing on healthy weight loss or maintenance. Because these patients aren’t dealing with malnutrition or anorexia issues, which are more typical in late-stage cases, the focus is on a balanced diet. For instance, Lanford instructs her breast cancer patients to eat 4 to 5 cups of colorful fruits and vegetables per day, consume plenty of fiber, include healthful fats such as cold-water fish and walnuts in their diet, get plenty of fluids, engage in daily physical activity, and limit alcohol consumption.   

Like weight, alcohol consumption is another hot-button issue, especially for patients with breast cancer. Studies have linked the use of alcohol with breast cancer, so keeping consumption under control is important. “But it’s another area that can sometimes be uncomfortable for dietitians to ask about,” admits Lammersfeld. “However, because of our team approach, we have other professionals that can assist the individual as well. If the patient is using alcohol to help deal with stress, we can ensure that the patient finds other healthy ways to manage their stress.”

Enhancing Quality of Life
The right nutrition program is not only helpful and healing to the body but also to the mind. Thomson reminds dietitians that patients often embrace a nutrition plan for the feeling of control it gives them over their situation. “Importantly, diet is one therapy that the patient can ‘control,’” she explains, “while chemo and radiation are treatments that the patient attends but has little control over. This makes diet an important issue for the patient. They are seeking control at a time when they feel they have little. So it’s important to remember that an improvement in diet can not only increase their well-being but promote post-op healing, reduce the risk for comorbidities during and after cancer, and provide a sense of active participation in one’s own healing process.”

“One of the most beneficial things about nutrition change is that it puts control in the hands of the patient,” says Lanford. “So many things about cancer are out of the patient’s control, but nutrition and healthy lifestyle are things they can control. Being empowered to make healthy choices through increased fruit and vegetables [intake], smart beverage choices, more physical activity, and proper portions can really improve the patient’s quality of life for the better, regardless of how it even affects weight.”

Because of this, patients are typically very receptive to the guidance a dietitian can provide. Patients with cancer tend to be very motivated and want to take back some of the power they feel they’ve lost since being diagnosed. “Since a cancer diagnosis is often viewed as a ‘teachable moment’ by the newly diagnosed patient, all nutrition information can be appropriately coordinated by the RD to include tips for reducing the risk of longer-term complications of treatments such as osteoporosis (increased risk of early osteoporosis is a side effect of some antiestrogen drugs used to treat breast cancer), heart disease (increased risk secondary to radiation treatments with left-sided breast cancer and also weight gain issues during or after treatment), and diabetes (increased risk due to weight gain),” adds Dyer.

An oncology RD can also help newly diagnosed patients sort through the volumes of potentially misleading, inaccurate, and confusing nutrition information with which they may become inundated, adds Dyer. “RDs—particularly CSOs [certified specialists in oncology nutrition]—have the knowledge base to sort through the questions and bring relevant research to the discussion regarding how various foods, diets, and herbal and vitamin supplements can impact the cancer process,” she says.

Also important in helping patients sort through and process information, as well as finding their best nutritional path, is forming a relationship built on trust, says Lammersfeld. Patients are looking for some stability in their lives. “For the patient to establish a relationship and know they’re going to meet with the same person each and every time is comforting,” she says. “The dietitian becomes a credible resource to help weed through all the information out there. If you don’t have any opportunity to establish a relationship with your patient, you can’t expect any change. The patient needs someone on their side for the long term. It helps reinforce motivation and keeps the patient on track.”

While it seems obvious that a dietitian should be on the team of specialists helping patients through their breast cancer battle, it’s not always an option. In many places, a healthy dietary and living program is not part of the treatment plan. Lanford says that in areas where a specific program hasn’t been designated for the patient, it is possible for the patients to participate through other healthy lifestyle programs offered to the public through community organizations or hospital wellness programs. “But I do caution patients to make sure they ask their doctor or healthcare provider for any specific limitations that they may need to tell the program that they go to, especially if it’s a program not specializing in care for cancer patients,” she advises. “Oftentimes while the programs have good intentions, they are not aware of the specifics in dealing with oncology patients. It’s always best for patients to seek programs led by dietitians and other professionals specializing in cancer treatment.”

A Little Help Can Go a Long Way
For dietitians, helping patients with breast cancer fight the battle can be greatly rewarding. Lanford says one patient in particular sticks out in her mind. “She was very confused about what she should be eating,” Lanford recalls. “She had heard so many things about sugar, soy, meat, and organics, and she was frustrated by what seemed to be conflicting and very restrictive advice. After coming to my classes and understanding that the best diet for her could be incorporated without completely changing everything about how she ate, [it] gave her a lot of freedom and hope that she could make a difference in her healing and her risk for recurrence. She started feeling better, had more energy, and felt good about what she was doing for herself.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.