Weight and See

CURE, Winter 2008, Volume 7, Issue 5

What to do about weight gain during treatment.

For six months, Kristin Banks suffered through chemotherapy for her stage 2B Hodgkin disease. The series of treatments left her nauseated and disinterested in eating, turned off by the metallic taste that flavored anything she tried.

Her only tolerable food: broccoli. “That’s what I lived on,” Banks says, only half-joking. At least, she thought, she might shed some pounds. Instead, to her frustration, the scale seemed disconnected from her appetite. After treatment ended, Banks weighed about 180 pounds, after adding 20 more to her 5-foot-3-inch frame. “I figured once I stopped treatment I would go back to normal,” she says.

Traditionally, the rigors of cancer treatment have been associated with weight loss, but that’s certainly not always the case. Numerous patients are overweight when they begin chemotherapy and other treatments; two-thirds of U.S. adults are overweight or obese, according to federal data. And some patients soon learn, as did Banks, that medications and other aspects of treatment can actually foster weight gain.

Banks, now age 25, blames the steroids she took along with her chemotherapy regimen. But steroids aren’t the only potential weight gain culprit, physicians and dietitians say. Chemotherapy can play a role, particularly in malignancies such as breast cancer in which treatment may trigger premature menopause. Hormonal therapy also may be influential, although a large-scale study published in 2007 didn’t identify a link, at least involving tamoxifen.

Meanwhile, patients’ healthy intentions are eroded in other ways. Some days, it might seem infeasible to leave the couch, never mind the house. And a few pounds can seem like small potatoes when food that looks comforting, or just plain palatable, beckons from the refrigerator.

But don’t stock up on diet books, even if you hate the number flashing back from the bathroom scale, says Priscilla Furth, MD, a professor at Georgetown University’s Lombardi Comprehensive Cancer Center, who also runs a fitness clinic for breast cancer patients there. “It’s not recommended to be on a diet while you’re on chemotherapy,” she says.

Instead, patients can start adopting a longer-term strategy toward better health, whether that’s walking in the evenings or selecting low-calorie snacks, Furth says. By developing those habits now, they’ll be better positioned to pursue ambitious weight loss goals after treatment ends, she says.

Researchers and physicians are still unraveling the precise causes of weight gain, but they believe that some cancer drugs can be influential, both in altering a patient’s metabolism and their food choices.

Nausea, for example, might force some patients to limit their diets to whatever appeals, or is edible, regardless of the calorie count, says Ingrid Mayer, MD, an oncologist and assistant professor of medicine at the Vanderbilt-Ingram Cancer Center in Nashville. “I’ve seen women go on a milkshake diet because that’s the only thing they can swallow,” she says.

Steroids, such as dexamethasone or prednisone, appear to affect weight directly, by decreasing muscle mass and boosting fluid retention, says Silvia Herszkopf, RD, CDN, head of nutritional ambulatory oncology at Montefiore Medical Center in Bronx, New York. The drugs also can promote weight gain indirectly by fueling a patient’s appetite and increasing insomnia, which could result in late-night raids on the freezer, she says.

Patients who require cumulative or high doses of steroids, such as those with lymphomas or brain malignancies, are most likely to face weight issues, Herszkopf says. Banks, who has undergone several rounds of chemotherapy and a stem cell transplant, says her weight didn’t spiral until 2007, when she was placed on very high doses of steroids to counter breathing problems from treatment-related lung damage. Her steroid dose is much lower now, but her weight remains a high 244 pounds.

“Now I’m not sure if some of my breathing issues are because I’ve gained so much weight,” says Banks, of Auburn, New York. “The prednisone is a double-edged sword.”

Where hormonal treatments are concerned, the weight association is less clear-cut. One theory is that the medications’ ability to block the effects of estrogen in women, or testosterone in men, can alter the metabolism of lipids in the body, Herszkopf says. Breast cancer patients aren’t the only ones potentially impacted. Men with prostate cancer who take hormonal therapies, such as leuprolide or Zoladex (goserelin), also may notice weight gain, she says.

But a recent data analysis from the large-scale WHEL (Women’s Healthy Eating and Living) study didn’t reach a similar conclusion.

The 2007 study, which tracked weight in 3,088 breast cancer patients for six years post-diagnosis, found that chemotherapy was significantly associated with weight gain regardless of the regimen used. Women who received chemotherapy were 65 percent more likely to have gained significant weight than women who did not receive either chemotherapy or tamoxifen. A significant weight gain was defined as at least 5 percent above their pre-diagnosis threshold. (For a 150-pound woman, that translates to about 7 pounds.) “But weight didn’t significantly increase with tamoxifen, which everyone thought would happen,” says John Pierce, PhD, WHEL’s principal investigator.

Previous studies showing a weight gain link to tamoxifen were limited by methodological issues, including a small study size or relatively brief follow-up, Pierce says. But Vanderbilt’s Mayer isn’t necessarily convinced. In the WHEL analysis, the women involved had a mean age of 53 at the beginning of the study, indicating that a significant number were likely past menopause and thus less vulnerable to tamoxifen’s anti-estrogenic effects, she says. “And, on a day-to-day basis, we see that all of the time—that tamoxifen does cause weight gain” in pre- and postmenopausal women.

The WHEL study reinforces what anyone who struggles with weight knows all too well: pounds are much easier to accumulate than to jettison. Only 10 percent of the women were able to return to their pre-diagnosis weight at any point during the six-year period.

Weight gain is really on everyone’s radar screen now. I am now taking time to talk about weight with my patients.

At Philadelphia’s Fox Chase Cancer Center, Eileen Trombetta, RD, LDN, urges her patients not to count—or to consciously cut out—calories during treatment. “First of all, they are dealing with a lot with their cancer and going through their treatment,” says Trombetta, a nutrition support coordinator. Plus, there’s always the risk that a fad diet might interfere with cancer treatment, she says.

She does encourage patients to limit snacking and portion size, along with other weight-savvy strategies, such as increasing consumption of fruits and vegetables. She educates them about salt intake, particularly if steroids or another cancer treatment promote fluid retention. When a treat beckons, she provides low-fat alternatives to consider, like low-fat frozen yogurt instead of ice cream.

Watching food intake is helpful, albeit only half the equation, says Pierce, who wishes more cancer patients would try harder to remain active. “To keep your weight down, you’ve got to expend a bit more energy,” he says.

These days, cancer patients and recent survivors have another incentive to guard against weight creep. Studies indicate that an individual’s weight does influence their recurrence risk, at least where breast malignancies are concerned. Indeed, the Women’s Intervention Nutrition Study (WINS), which involved more than 2,400 postmenopausal women with localized breast cancer, concluded that decreasing dietary fat intake may significantly reduce the risk of recurrence.

Exercise is also a key ingredient to survival and should complement dietary approaches, experts say. A recent study of colorectal cancer patients found that those who walked at an average pace for at least six hours per week had a 47 percent improvement in disease-free survival. In breast cancer, research has shown regular aerobic exercise can improve body fat levels.

“Weight gain is really on everyone’s radar screen now,” says Nicholas Robert, MD, a breast cancer specialist and chairperson of the cancer committee at Inova Fairfax Hospital in Falls Church, Virginia. “I am now taking time to talk about weight with my patients.”

Amanda Leija was distressed to watch her weight inch upward as she completed two chemotherapy regimens, first Adriamycin (doxorubicin) followed by Taxol (paclitaxel), to treat her inflammatory breast cancer. By the time she wrapped up chemotherapy in early 2008, the scale had reached 182 pounds—20 more pounds than when she began treatment. “To me, it didn’t seem like I was eating a whole lot,” she says.

But the treatment did alter some of her routines, dietary and otherwise, she acknowledges. Leija was encouraged by family members to consume more red meat to boost a lagging red blood cell count. And she quickly learned that baking cookies and other treats brightened the chemo room for both the patients and the clinicians. “The nurses really miss me,” she says with a laugh.

In recent months, though, the Texas woman has started fighting back. She tries to avoid fried foods, sodas, and other less nutritious choices. She also joined a gym with a very specific goal in mind—training for the Breast Cancer 3-Day Walk in Dallas/Fort Worth this past November. She completed 34 miles of the 60-mile walk, and she’s already determined to participate next year.