What Breast Cancer Survivors Should Know About Weight Loss and Long-Term Health

Breast cancer survivorship can involve more than monitoring for cancer recurrence, as survivors may also face changes in weight, cardiovascular health, physical function and emotional well-being.

Dr. Jenni Sheng, a breast medical oncologist at Johns Hopkins Medicine who sees patients at Sibley Memorial Hospital in Washington, D.C., focuses her research on survivorship and cardiometabolic health, including how lifestyle interventions may improve long-term health.

Sheng was also an investigator on the phase 2 A-NEW study, which evaluated an adaptive approach to weight loss among breast cancer survivors. Participants began with behavioral interventions involving diet and exercise, while those who did not achieve at least 5% weight loss after two months could receive an additional weight-management strategy.

In an interview with CURE®, Sheng discussed what breast cancer survivors should know about weight management, why lifestyle changes are only one component of survivorship and how patients can work with their care teams to address their health beyond cancer.

CURE: What does breast cancer survivorship encompass?

Sheng: Survivorship is pretty daunting because it encompasses so much. It's not just the physical components, but the emotional well-being of our patients and their caregivers.

When we think about how we can best support our patients, for example, we talk about nutrition and our dietitians who can be helpful. We think of our partnerships locally and nationally that have physical activity programs. We have programs focused on strength training and resistance training.

We also think about how important it is to have good emotional support and well-being. We have peer support groups or affinity groups, and we make sure education is a priority at all time points. Some of the topics, for example, are bone health or sexual health.

Our job is to make sure that we are assessing people for any treatment-related toxicities that they've developed and making sure that they know which resources, both locally and externally, might be available to them.

What do you hope breast cancer survivors take away from the A-NEW study?

I hope people realize that behavioral interventions can be really effective. We see that about half of patients actually do lose a significant amount of weight with no addition of medication, and within about eight weeks of behavioral intervention, we were able to identify those patients.

I think what some people need to know is that there need to be some additive strategies for people who may not be responding as quickly to just diet and exercise changes.

Dietary and physical activity changes are the foundation of the treatment of excess weight, but on top of that, there are certain people who may benefit from other strategies, like an oral agent or a subcutaneous FDA-approved medication.

I don't think there's a one-size-fits-all [approach]. What we're learning about weight loss is that it isn't just looking at these components. The quality of sleep may be very important as we're thinking about other factors that are impacting your appetite and maybe the reward system. We know that mood can also be really important. For example, depression and anxiety [should be] well treated.

What I hope patients take away from this is that it's not just diet and exercise. For some people, yes, that can yield the right result for you, and that's exciting. But don't lose hope because there are some other unique strategies that can be a little bit more personalized for individuals who are motivated, making all those lifestyle changes and wanting to see more response.

Why should excess weight be discussed as part of breast cancer survivorship?

As a breast medical oncologist, my job is to make sure that I give a recommendation for the best breast cancer treatment, and I'm following patients through a period of surveillance. Oftentimes that could be five years or 10 years.

I think I have a unique opportunity to address many of the [long-term effects] of breast cancer treatment and a breast cancer diagnosis. We know that two-thirds of our patients struggle with excess weight, and we know that a lot of our patients gain weight after a diagnosis.

It's a priority to make sure we talk about the detriment of excess weight and that we're encouraging patients to lose weight and find the right strategies for themselves.

Who Should Breast Cancer Survivors Talk to About Weight-Loss Medications?

As an oncologist, I actually don't prescribe weight-loss medication. If that's the next best step for a patient, I always tell them to have a conversation with their primary care doctor. If they feel comfortable and have some expertise, they may take the initiative to do that. They may recommend that you go to an obesity medicine clinic.

Every institution or every center may have different resources. There are also many partnerships that people have throughout the region, and those may be resources that people can use for more structured exercise programs.

We try our very best to make sure that patients who are interested in a nutrition or dietary consultation have access to that. There are some really great nonprofit organizations that offer that resource to breast cancer survivors. Even if they don't have access to that locally where they're getting care, it is something that, at large, patients can have access to.

What Should Breast Cancer Survivors Do if Diet and Exercise Aren’t Helping Them Lose Weight?

I don't think there's a one-size-fits-all [approach].

For some people, [diet and exercise] can yield the right result for you, and that's exciting. But don't lose hope because there are some other unique strategies that can be a little bit more personalized for individuals who are motivated, making all those lifestyle changes and wanting to see more response.

We also have to think about other factors. Sleep quality may be very important. Mood can also be really important, so making sure depression and anxiety are well treated [matters].

What are some of the barriers that can make weight management more difficult for certain survivors?

There may be something going on from a biological level, or maybe there's something environmental that could contribute. I think we're still trying to figure out exactly what that is.

Other things that we think about are: Does your socioeconomic environment impact this? [What about] your access to resources or gyms, or whether or not you're employed? Maybe that impacts how much time and how easy it is to engage in physical activity.

Do you have other responsibilities for caregiving for parents or children?

These are so many things that we often think about, especially for younger women who may be employed and have all these other competing responsibilities.

We really do want patients to be able to prioritize themselves and their cardiac health, thinking about what we're going to do to make sure that they have a lower risk of developing diabetes, high blood pressure and heart disease.

What conversations should oncology teams be having with survivors about these longer-term health concerns?

From an oncology perspective, we want to acknowledge what's going on with patients in terms of their weight and how strong they're feeling throughout this period of time.

Many of our patients, two-thirds of them walking through the door, already have excess weight to begin with. We have this unique opportunity during five to 10 years where we're not just focused on breast cancer treatment or breast cancer surveillance, but patients really do have this strong relationship with us and they value what we're telling them.

If we ask them, “How are you staying active?” or “Have you thought about strategies to lose that extra weight?” bringing up that conversation is so important.

At these visits, we often talk about key elements of survivorship, and I do think that thinking about other comorbidities is really important. Maybe patients already have prediabetes, high blood pressure or other medical conditions that are important to bring together.

If a survivor isn't ready to discuss weight management at one appointment, should the care team continue bringing it up?

Approaches to weight loss are not going to come from the cancer team, but it behooves us to have that conversation with them when they're in the clinic with us and constantly encourage them.

Maybe they're not interested in weight loss at this moment, but when they come back in three months or six months, ask again. Maybe they will be receptive.

Maybe you have a clinical trial. Maybe you have a partnership locally where they can engage in some dietary modifications or exercise changes.

As they're going through whatever strategy or approach, you also have to reassess. Maybe you're checking your weight at a three-month interval, whichever program you decide to do. There should be someone who is taking a little bit of ownership for this, and it could also be a primary care doctor.

Why is reconnecting with primary care particularly important after breast cancer treatment?

Sometimes after a cancer diagnosis, our patients are really entrenched in the medical oncology clinic. They are here very frequently. Sometimes they're not actually regularly seeing their primary care doctors at all.

[We need to] refocus everything to, “Hey, as we focus on your breast cancer survivorship, it's really important for your overall health to make sure that you're engaging with the right people to follow you and to really help you if your major goal is weight loss.”

Is there a time when you would caution a survivor against starting weight-loss medication?

If a patient is starting new treatments for their breast cancer, and it could be chemotherapy or endocrine therapy, I usually tell patients that's not the ideal time to introduce a weight-loss medication.

Make sure you're at a point where everything is very stable in terms of your breast cancer care.

You can certainly incorporate diet and exercise changes. Those are actually proven to help with, let's say, chemotherapy-related fatigue or aromatase inhibitor musculoskeletal symptoms.

But whenever it comes to medications, I tell people you want to make sure that you're in a pretty good place to do that, and you have a prescribing physician who's following you closely.

What should patients continue asking their cancer teams as they move further into survivorship?

It's really important for patients to continue to ask, whether you're at a local institution or a large academic center, “Are there any clinical trials that can help me as I'm going through this survivorship period?”

Sometimes that's a question of weight management: “Is there a weight-loss study that I'd be eligible for?” In terms of patients who may have higher-risk breast cancers: “Are there any new medications or drugs that I should be aware of?”

I think that there's a lot of excitement and there's a lot of change in the breast cancer space. It's really important for patients, when they're coming in to see their cancer team, to ask: “Is there anything new? Is there anything different in the research?”

Editor’s note: This interview has been edited for clarity and conciseness.

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