Information Session: Breast Cancer Exercise and Nutrition

Corporate Speakers: 

• Neil Iyengar; Memorial Sloan Kettering; Medical Oncologist 

• Melissa Pilewskie; Memorial Sloan Kettering; Breast Surgical Oncologist 

• Andrea Smith; Memorial Sloan Kettering; Nurse Leader 

• Jessica Scott; Memorial Sloan Kettering; Scientist and Principal Investigator 

PRESENTATION 

Operator:  Good afternoon, and welcome to the Memorial Sloan Kettering Information Session: Breast Cancer, Nutrition and Exercise.  Our host and moderator for today’s call is Dr. Neil Iyengar, medical oncologist at MSK.  I will now turn the call over to Dr. Iyengar.  Please go ahead. 

Neil Iyengar:  Great.  Thank you so much.  Good afternoon, everyone, and welcome to this MSK Information Session.  I am Neil Iyengar, as you heard, a medical oncologist, and I care for people with breast cancer.  It’s my great pleasure to be here with you this afternoon and discuss a topic which I think is really on a lot of people’s minds and certainly a hot topic of research and treatment in the field of cancer in general. 

I am a researcher focused on the relationship between breast cancer and metabolic health.  So, this is, in other words, using interventions like nutrition and exercise or even medications that we traditionally use for diabetes or heart disease but repurposed in the context of reducing the risk of cancer or cancer recurrence. 

As many of you know, October is Breast Cancer Awareness Month.  And we wanted to use this opportunity to address your most pressing concerns about breast cancer, exercise and nutrition.  I also want to make sure that everyone here knows that MSK is working hard to keep you and your loved ones safe when you come in in person for an appointment during these times.  And this is at our main campus in Manhattan or any of our locations at our network sites.  I think you will find, if you haven’t been here already in person, that we are taking all kinds of precautions to keep everyone safe. 

So, now, that being said, I will also mention one more item before we get to the main topic today.  And that is we have an upcoming session, another information session where some of our MSK colleagues will be discussing breast reconstruction, which, of course, is another topic of great interest.  So, certainly stay tuned for that as well. 

Okay.  So, let’s get on to today’s topic.  And I am very excited to share the call with a panel of experts, many of whom, I’m sure, many of you know.  And these are folks who are really experts in their clinical and research fields.  And they will be joining me today to help answer some of the questions that were posed for this call. 

I will note that we received a lot of questions.  I think as of yesterday, it was somewhere over 500 questions.  We will try to get to as many of the questions as we can.  And, fortunately, many of these questions centered around common themes.  And so, with that being said, I do want to remind you that your MSK doctors and your care teams are ready and willing to talk to you directly about your specific concerns. 

So, I certainly encourage you to reach out to your care team after this call if you have specific questions about your care plan and the next steps in your care and particularly if we raise any resources or issues that you think pertains directly to your treatment plan.  Please reach out to your care team for that. 

QUESTIONS AND ANSWERS 

Neil Iyengar:  So, now, getting started, well, let’s address a topic that I think is important to all of us given the times that we are living in.  And that, of course, the pandemic.  And I know that many may be feeling particularly vulnerable during this time.  And, so, I’d like to start by talking about why it’s crucial to continue screening and treatment for cancer. 

And to address that topic, we have Dr. Melissa Pilewskie, who is a breast surgeon here at MSK.  Melissa, could you comment a little bit about balancing the risks of COVID-19 with cancer screening and cancer treatment? 

Melissa Pilewskie:  Absolutely.  Thanks very much, Neil, for the introduction.  I am happy to join everybody this afternoon.  So, obviously, this has been such a scary time for all of us with major health concerns related to the pandemic.  But, it’s so important to realize that the risk of delaying a cancer diagnosis or treatment really outweighs the risk of COVID-19 for most individuals. 

And to echo what you just said, MSK is really taking great steps to ensure that when individuals come in for a screening or treatment that we all stay safe.  And, so, if you are calling for an appointment or coming in to the breast center, you will be asked screening questions and reminded about all of these new precautions with universal masks, hand hygiene, social distancing and COVID testing prior to procedures.  But, all of these efforts have really allowed us to resume our normal practices safely. 

So, aside from how we look and where we are sitting, I feel like we are really back to our normal day-to-day practice in the office and in the operating room.  And, so, I just want to remind everyone on the call that we want you to continue to look after your entire well-being, which right now means getting back to cancer screening because through all of these, cancer really remains more threatening than the virus. 

Neil Iyengar:  Thanks, Melissa.  That I think is such an important message.  And we are all very much concerned.  We have certainly seen drops in cancer screening.  And I think that there is a general concern that as we start to, hopefully, come out of the pandemic, we may start to see larger numbers of cancer cases because of this lack of screening. 

And I think that we can, hopefully, start getting ahead of that now that we’ve put all these precautions in place at MSK and make sure that we get the message out that people continue attending to their basic health needs so that other diseases like cancer don’t become a major problem. 

We also have Andrea Smith with us, who is a nurse leader, and she cares for people with breast cancer.  Andrea, would you be able to comment a little bit on any specific concerns that people have brought up with you and how you have addressed these concerns with regards to screening and treatment? 

Andrea Smith:  Yes.  Thank you, Neil.  Thank you so much for allowing me to be a part of this important panel, especially during Breast Cancer Awareness Month with everything that we have all gone through, as Melissa alluded to, with this global pandemic and health concerns. 

I do understand why patients have been reluctant to come in and get their screenings or get their treatment.  And I do want to echo what Melissa said earlier that the benefits of maintaining your screening and your treatment really does outweigh the risk of COVID. 

But, I do want to make sure that our listeners understand all of the safety measured and guidelines and policies that we have put in place here so that when you do come to our facilities – any one of those facilities – that you feel safe while you are here.  That includes developing standards that reflect current knowledge and best practices that is shared by the CDC, which is the Centers for Disease Control. 

Like Melissa said earlier, we screen patients a day before their scheduled visits when they come to MSK, whether that’s a phone call or text message or a portal.  We also screen patients when they come to the site.  We screen them in the lobby or other entrances. 

We have also limited contact so that we can better adhere to social distancing by limiting the amount of patients or – sorry – excuse me – people that come in to our facility and also spacing out time between visits, which also have significantly decreased the number of people we have on the site at one time.  We also offer curbside check-in at some of our regional sites to help minimize patients’ need to wait in the waiting room but, instead, they can do their check in from their car or, again, from one of our building entrances. 

We also have enhanced our cleaning efforts, disinfected and sanitized all of our high-touch and public areas.  We require patients to wear mask and staff to wear mask at all times.  We also provide the masks to anyone what enters our facilities if they do not have one.  Staff also wear PPE when applicable, based on the patient care that they are conducting. 

And all MSK staff are screened for any signs or symptoms of illness on a daily basis by filling out what we call a Health Check Tool.  We have a very robust COVID testing and contract tracing system to enable patients and staff to frequent get tested as necessary.  And we also offer telemedicine visits or televisits where patients can comfortably see their provider, get the [care] they need from the safety and comfort of their home. 

So, I just really want to emphasize all of the safety measures that we’ve put in place all to make sure that when our patients come here to MSK, they do feel that their well-being, that their care is taken seriously and MSK is definitely willing to do whatever needs to be done to make sure our patients can come here and get treated like they need to but in a safe environment. 

Neil Iyengar:  Fantastic.  Excellent, Andrea.  Thank you so much for that information.  I think that really provides a very comprehensive look at everything that we are doing here.  And, so, I hope that answers any questions that folks may have out there about the safety of the environment here at MSK, certainly a safe place to be. 

Okay.  So, let’s now turn to the questions that were submitted with regard to nutrition and diet.  And like I said, we received a lot.  So, we are going to try to lump these into theme areas here.  And many of you asked “What is the best anti-cancer diet” or “Is there a list of food that are best and worst when it comes to cancer?” 

So, I think we can actually dissect this a little bit.  There is a lot to unpack there with that question.  And I’ll just get the ball rolling here and comment a little bit about the relationship between nutrition and breast cancer. 

I think it can be a very confusing field because for a long time, a lot of the data that we saw with regard to nutrition in general and specifically nutrition and cancer came from what we call – what we refer to as nutritional epidemiology studies.   

And these are basically studies that when we look at large groups of people, we can draw some or we can recognize some patterns – and not necessarily conclusions, but they are patterns where we might recognize that a certain type of diet or a certain risk factor may be associated with either the development of cancer or cancer recurrence.  And, so, that was kind of our first clue that nutrition may play role in the risk of developing cancer or cancer recurrence. 

The problem with those kinds of studies, though, is that those epidemiologic or population studies, as they are sometimes referred to, are very, very broad.  They are difficult to apply to the individual and they can be conflicting.  On the one hand, one study may suggest that one food protects you against cancer and another study may suggest that another food is harmful for cancer. 

And, so, one of the themes that I hope to emphasize today is that a lot of the research that we are doing here at MSK is to ask research questions in a way that actually tests these approaches through randomized control trials just like we would test drugs to determine what might be the best approach. 

We don’t – we don’t decide on how to treat someone based on how a huge population of people responds to a drug that may have been applied to a lot of people.  Similarly, when it comes to nutritional recommendations, we shouldn’t be necessarily be making broad recommendations from this kind of observational studies. 

So, with that said, I will also say that we are still in the beginning stages.  There have only been two completed and reported large randomized, controlled trials testing a nutritional intervention, specifically one with testing a plant-forward diet and the other one was testing a high-fiber diet which, in practice, turned out to also be a very plant-forward diet. 

In those two trials, we are testing those kinds of diet to prevent cancer recurrence.  And the results were conflicting.  One trial showed a benefit of following that kind of diet.  And another trial, the other trial, showed that there was no benefit.  And, so, that really tells us that we’ve got a lot of work to do. 

And I think that a lot of it comes down to the individual biology, the type of cancer that you are trying to reduce the risk for and also whether or not the diet fits into your lifestyle.  If you pick a super-restrictive diet that you can’t adhere to, then it shouldn’t be a big surprise that it’s not helpful for changing cancer risk. 

And, so, we are going to talk a little bit more specifically about some of these diets and where we are with the nutritional recommendations.  And, then, I will give you some kind of not – I don’t want to say generic but a little more directed advice in terms of what you could potentially be doing today. 

So, let’s pare it down.  Many of you wondered how some of the popular diets out there may affect breast cancer.  And we also have Dr. Jessica Scott on the call today.  She is a scientist and principal investigator in MSK’s Exercise Oncology service.  And, so, just in broad terms, what’s the current thinking about this kind of popular diets and how they might affect breast cancer risk and recurrence?  And maybe you can also speak a little bit more specifically about the interaction between diet and exercise and whether or not we could look at these in isolation or in combination.  Jess? 

Jessica Scott:  Yes.  Thanks so much, Neil.  I’m so please to participate in this MSK information panel.  And the questions surrounding diet and breast cancer risk is such an important one.  And as you so elegantly outlined, we have – the majority of our information is from these population studies where the individuals or patients use self-reported diet.  And those are very limited because, as you mentioned, I can’t remember what I have for lunch.  So, it’s tough to get those broad spectrum of what individuals ate over the past week. 

And that’s why it’s so important to do, as you mentioned, those randomized controlled trials.  But, as you alluded, too, we know that there are – based on those observational studies, there are indeed patterns suggesting that plant-based diets, in particular, are associated with a reduced risk of dying from breast cancer and there are some studies showing a reduced risk of recurrence. 

But, again, that’s why we really need these studies that look at really quantifying what diet is and how that improves certain outcomes.  And I know in your studies you have a lot of interest in plant-based diets and other diets and how that may influence some of the biological factors looking at cancer recurrence or breast cancer risk. 

Neil Iyengar:  Yes.  Absolutely.  And before I get into that, Jess, is there any evidence out there to suggest that there may be some type of diet which is more optimal for pairing with exercise or a specific type of exercise program?  Or is that still a question? 

Jessica Scott:  Just like you mentioned, it’s still a lot of work that needs to be done.  But, I think what we know so far at the – one of the leading candidates is this high-fiber or plant-based diets.  And there is still so much work that needs to be done and it’s a young field.  But, what the data suggests so far is that the fiber from plant-based food is so important in some of the biological factors driving that cancer risk. 

Neil Iyengar:  Great.  Yes.  And, so, Jess is alluding to one of our ongoing trials right now at MSK where we are testing a combination of exercise with plant-based diet for people who have been diagnoses with stage-one to three hormone receptor-positive breast cancer.  And I think that there will be some information available later if folks are interested in looking at that trial. 

And that kind of brings up another question that folks have asked.  It’s “Do vegetarians have fewer cases of cancer?”  And I think that’s a very valid question because if we are saying plant-based diet is beneficial, then, certainly, you would think vegetarians have fewer cases of cancer. 

But, what I think is interesting is we have to be very specific about how we define some of these diets.  There was a great study from the Women’s Health Initiative that look at this question.  And at first [half] in their first report, the answer was no, there was no reduction in the number of cases of cancer in people who identified themselves as vegetarians. 

But, when you took a little bit of a deeper dive, it became clear that if you were eating Cheetos and Twinkies every day, that’s a vegetarian diet technically.  Right?  And that’s going to be very different than, let’s say, you are eating nuts and high-fiber foods that are less processed. 

So, the investigators in the Women’s Health Initiatives went a step further and identified a healthy plant-based diet versus an unhealthy plant-based diet.  And the results were fascinating.  In folks who were consuming large amounts of fiber, there were lower levels of inflammation.  There were better levels of hormones that protect people against cancer. 

And, so, that was our first clue that this kind of a diet – a high-fiber, plant-based healthy diet, which is minimally processed food – could be protecting us from either cancer recurrence or at least reducing our risk of developing cancer.  But, again, these trials are under way.  And, so, the best we could advise right now is consider enriching your diet with more plants and less processed foods.  And, certainly, speak to your oncologist or your doctor or your nutritionist to talk about specific changes that can be made in your diet. 

Another popular diet that people asked about was intermittent fasting.  I won’t spend too much time talking on this because we’ve got other topics to get to and we’ve got a great piece that MSK recently published where we summarized some of the recent data with regard to intermittent fasting. 

I think the bottom line on intermittent fasting is if it’s a topic that – or if it’s a pattern that works in your schedule, the nice thing that people like about intermitting fasting is that it gives you a lot of freedom in terms of what food you actually eat.  The only restrictive thing about it is that you have to fast.  And, so, you need to be able to fit that into your schedule.  Some people like that.  Some people don’t. 

I have friends who have lost lots of weight with that type of approach.  But, of course, that’s anecdotal evidence.  And we do have some recent data.  There was a large clinical trial of intermittent fasting that was published which actually suggested that it wasn’t any better than non-fasting diets for losing weight. 

And, so, there was a little bit of a red flag in that trial as well because people in the intermittent fasting arm actually lost a little bit of their muscle mass, which is certainly not something we want people to experience, especially if they are dealing with cancer because muscle is a great reserve for improving the way that our body processes sugar. 

And, so, right now, I am not actively recommending intermittent fasting.  But, of course, like anything in medicine and science, that could change depending on the data and the trial that – as they are completed.  But, if you want to know more about that and where the data stands, do take a look at that article. 

The next diet that people ask a lot about was low-carb and ketogenic diets.  And specifically, we got questions such as “Can a low-carbohydrate diet reduce the risk of developing breast cancer or reduce the risk of developing breast cancer recurrence?” 

I think an important point to emphasize here is, again, while we don’t have specific data to guide us on which diet we should select, we do have big picture data.  And we do know that a condition like obesity, for example, does increase the risk of developing cancer – certain types of cancer – at least 13 different types of cancer – and that obesity increases the risk of being resistant to your cancer therapy. 

In fact, we know that folks who have a body mass index of 30 or greater – and that’s your weight in kilograms divided by your height in meters square – folks who have a BMI or greater have a higher risk of developing resistance to their cancer treatment no matter what type of cancer they have.  And, so, the big picture there is certainly to avoid obesity. 

But, if you are thinking to yourself, “I’m not obese; I’m in the clear,” well, I’ve got some not-so-great news for you also.  We, unfortunately, learned that if you have a normal body mass index but you have a body [fat] level of 33% or greater, you also might have an increased risk of developing breast cancer. 

And, so, I think we certainly have to make sure that we are keeping our body composition in mind, our fat-to-muscle ratio, and really eating food that are preventing obesity and that are keeping our muscle mass healthy.  A low-carbohydrate diet may be a way to do that.  If that is something that you can adhere to, then, by all means, I would encourage following a low-carbohydrate diet. 

Now, an extreme version of a low-carbohydrate diet is the ketogenic diet, where you are eating typically less than 40 grams of carbohydrates a day.  A low-carbohydrate diet is [typically] up to 100 kilograms of – or 100 grams, rather, not kilograms – 100 grams of carbohydrates a day.  That’s considered to be a low-carb.  But, ketogenic diet is less than 30 to 40.  And that’s because that diet is designed to keep your body in ketosis, which is a form of almost near-starvation, really, to be frank. 

And we’ve got some data from mouse models of cancer that a ketogenic diet may be helpful for very specific types of cancer.  These are cancers with a mutation in a gene called PIK3CA or the PI 3-kinase enzyme.  And that can affect certain types of breast cancer, certain types of endometrial or uterine cancer, certain types of blood cancers. 

And the data in those mouse models suggests that a ketogenic diet can make cancer treatments for those types of cancers more effective.  There are a couple of trials that are now testing that approach in humans.  There is a trial testing that approach for certain types of lymphoma.  And we have a trial that will be opening soon at Memorial testing a ketogenic diet versus a low-carbohydrate diet versus a diabetes called an SGLT2 inhibitor for patients who have metastatic breast cancer.  And, so, more to come on that. 

But, at this moment in time, I am not necessarily recommending the ketogenic diet unless a person really likes that diet for weight loss.  If that’s your ticket to maintaining a healthy weight, then I think that that is okay to follow as long as you are not dipping on to the malnourished side.  And a less intense version or way of doing that is a low-carbohydrate diet. 

So, many people also had questions about specific foods.  And there was a lot of interest in soy (inaudible).  One person asked, “I’ve heard conflicting information about whether someone who had been diagnosed with an estrogen receptor-positive breast cancer should stay away from soy.” 

So, let me turn it over to Melissa to address that question.  Melissa, what do you tell your patients with estrogen receptor-positive breast cancer and whether soy is good or bad? 

Melissa Pilewskie:  Thanks, Neil.  So, this is a question that comes up all the time – I would say, honestly, on a daily basis when we are in the clinic.  And the concern here makes sense.  We know that the majority of breast cancers are triggered by hormones in our body.  And soy is a type of plant-based hormone or considered a phytoestrogen.  And, so, there is concern that consumptions of soy could trigger these cancer cells. 

But, I would say that the recent data doesn’t appear to support that concern.  There is a recent meta-analysis that I saw that looked at 18 different studies that were assessing soy intake both looking at the risk of developing breast cancer as well as the breast cancer recurrence.  And the overall data from all of these studies shows that not only did increasing soy intake appear to not be harmful but that there actually may be some benefit with that. 

So, from that take home, I think it’s reassuring that a diet with soy does not appear to increase breast cancer risk.  So, I tell my patients that they should continue a healthy diet and think about foods in moderation.  But, I don’t think that this is something we have to check off the list. 

Neil Iyengar:  That’s really helpful.  Andrea, do you get a lot of questions about soy, and do you take a similar approach as Melissa just outlined? 

Andrea Smith:  Yes, I do – patients for the same reasons [as was outlined].  What she just spoke is exactly what I hear.  There’s a lot of information about soy and the potential risk of breast cancer for patients who consume soy within their diet.  So, I think that Melissa’s explanation is exactly what patients need to hear. 

They need to understand the risk and that they are – based on the studies that we have seen, it is reassuring that a normal, healthy diet that has some soy really does not impact or has a higher risk for patients to develop breast cancer.  So, I echo exactly what she said.  A patient may need more specific information or – about supplements or soy diets or any kind of nutrition. 

I do offer them a nutrition referral to one of our amazing nutritionists that we have here within the institutions.  But, overall, that’s pretty much that message that I give to patients.  And I also make sure that I discuss it with their clinical team, right, because some patients are on certain medications that they may have questions about. 

So, it’s always, obviously, good to make sure that I do involve the clinical team.  But, just as a rule of thumb, just generally, I do basically say pretty much not too scientific level as (inaudible).  But, within my nursing scope, I do basically reassure patients about a healthy diet with some soy really does not increase their breast cancer risk. 

Neil Iyengar:  Great.  Okay.  Well, I certainly hope that that helps to put to rest a lot of concerns there.  Another controversial topic is, of course, sugar.  And this has been of high interest to our listeners here.  Many people asked if sugar can act as a – as a fuel for cancer tumors.  And this is an area of a lot of active research.  Certainly, our institutions and others have laboratories that are dedicated to this question. 

And I think it’s important, again, to go back to that concept of dietary patterns.  What is the overall dietary pattern?  I tell people who have been diagnosed with cancer that cancer cells are – they are malignant.  We call them malignant for a reason.  And they are malignant in nature as well.  By the very nature of being a cancer cell, the biology of that cell, that cell can produce sugar even if you deprive it of sugar.  It’s the type of metabolism that actually defines – it’s one of the things that define a cancer call. 

And, so, I generally – I don’t recommend a high-sugar diet.  But, at the same time, I don’t think it’s necessary to be absolutely all or nothing in terms of sugar because we do know that cancer cells can take foods that we would even consider to be healthy and convert them into sugar. 

Now, of course, since that’s what we are working against – we are working against cells that can do that – the last thing that we want to do is then bathe them in further simple sugars.  And, so, I do think it’s important as part of a balanced diet to make sure that whatever type of energy source we are putting into our body we are mindful of that energy source and we are doing that for a purpose, either for a metabolic health purpose – so, we are eating a piece of fruit because it’s sweet and it tastes good but also because it has a lot of fiber and that fiber will help to wash out that sugar exposure – or you are mindful of the fact that you are eating a piece of chocolate cake as a celebratory event for your son’s or daughter’s birthday and that’s okay to do once in a while. 

And, so, this question about sugar really needs to be taken in the context of the greater dietary patter.  And consistency is important.  If you are eating sugar every meal every day, that’s going to be a problem.  But, if you are eating a high-sugar food once in a while, that’s okay. 

And you can avoid sugar, generally speaking, by avoiding processed food.  So, if you are not drinking colas, if you are not eating packaged food, then by virtue of that kind of dietary pattern, you’ve already really reduced your sugar intake. 

Now, you can take it to the next level.  And we’ve got a lot of questions about sugar in fruit.  One person asked if eating berries is bad for people with cancer because of sugar fueling the tumor.  There have been studies that have looked at specific types of sugar.  So, for example, fructose is a type of sugar that’s often found in fruits. 

And there have been studies – again, not in humans – that have shown that fructose can directly stimulate tumor growth especially in cancers like colon cancer where the tumors are in the lumen or directly exposed to some of the foods that we are putting into our body.  Again, that hasn’t been validated in humans. 

And I think when we start to think this kind of reductionist view where we are really isolating specific nutrients, then we lose sight of the big picture because, certainly, berries are healthy for a number of other reasons.  Certainly, the nutritional content of berries is better than a lot of the other foods that we have available to us.  And, again, when we think about the fiber content of fruits, that’s certainly better than a lot of processed foods that have added sugar and minimal fiber. 

And, so, I don’t recommend avoiding fruit if people are worried about the sugar content.  Now, I think that this recommendation can be personalized.  And, so, if a person is battling with obesity or overweight and they are generally eating what may be labeled as a healthy diet but it turns out it’s very high in high-fructose fruits, then maybe for that person some moderation would be helpful. 

And, so, as a general rule of thumb, I think that consistency and moderation is key.  And to further personalize those recommendations, meeting with a nutritionist can be certainly helpful. 

Another really controversial and high-interest topic was alcohol, alcohol and breast cancer.  And we know that some alcoholic beverages have a lot of sugar in them, too.  And, so, on that kind of same theme, Melissa, let me turn it to you.  Many people ask if there is a connection between alcohol and breast cancer and if drinking after treatment increases the chance of recurrence.  What are your thoughts about that? 

Melissa Pilewskie:  So, what we have seen – consistently, the epidemiologic studies looking at this relationship between alcohol consumption and breast cancer risk do show a relationship here where women who, on average, drink more than one drink per day do have a modest increase in breast cancer risk. 

So, this falls under that same premise that I counsel women to drink in moderation.  It’s not that you can’t ever have a glass of wine but that drinking alcohol in excess is associated with a small increase in risk.  I think it’s also important to keep the amount of risk in perspective when we are thinking about different variables here. 

When I say a modest increase in risk, when we think about what we call relative risk or how much increased risk there is compared to somebody who doesn’t drink, the average risk, if we label that as a number one with increasing alcohol consumption – and relative risk is on the order of about 1.2 to 1.5. 

So, that’s a small increase in comparison to somebody who has a strong family history or an atypical breast biopsy where that relative risk is anywhere upwards of a two to six times in increased risk.  So, it’s a small increased risk.  But, it’s also something that we have control over as opposed to those other factors.  So, I always outline this data with my patients so that they know that this is something that they should pay attention to. 

Neil Iyengar:  Great.  Thank you.  That’s very helpful.  And let’s now turn to risk factors that maybe we don’t so much have control over.  A lot of people asked about genetic mutations that make them more likely to develop breast cancer and including what that means for their family. 

So, Dr. Pilewskie works closely with people at high risk for breast cancer.  She is the director of an MSK program called RAISE, which stands for Risk Assessment, Imaging, Surveillance and Education.  Melissa, can you tell us about the relationship between diet and exercise and cancer in people who have a genetic predisposition and are high risk due to that? 

Melissa Pilewskie:  Yes.  So, let me back up and just start with the second part of that first.  So, we know that a genetic risk is really a growing area of breast cancer risk that – this list just keeps getting longer.  A lot of us have heard of the BRCA1 and 2 mutations, which are the most common that we see.  But, there are now a number of identified genes that if a woman is born with this abnormal gene it can increase the likelihood of developing a breast cancer or other types of cancers. 

And, so, knowing this information becomes really powerful because if we can identify this prior to a cancer diagnosis, it really impacts what we do for screening or in terms of what our options for risk reduction are.  So, just to keep, again, our risk in perspective, the average woman’s risk in the United States right now is 12%.  For somebody with a BRCA mutation, that lifetime risk is upwards of 70% to 75%.  So, it’s a dramatic change in our baseline risk, which alters how we follow people. 

It’s an interesting question to think about within those women who are at highest risk for a genetic reason what the relationship between diet and exercise are.  And I will tell you that I don’t think that we fully understand this.  I don’t know of good data showing a scientific relationship that exercise or diet would have a different impact on risk among women with a genetic mutation. 

But, we don’t understand.  We do have some data for other high-risk populations – I mean specifically women with a lesion called lobular carcinoma in situ, or LCIS, where obesity didn’t appear to have the same impact on breast cancer risk as it does in the general population.  So, I think that this is an area that we are still investigating.  There is a lot of interest in identifying how different risk factors merge and impact one another. 

Neil Iyengar:  Yes.  And I think that’s a really important point about the evolving nature of the data.  I think it’s really interesting.  One of the – one of the attendees today asked specifically with a lot of breast cancer history in her family how important it is for her teenage daughter to avoid some foods like meats and fats. 

And I think, as Dr. Pilewskie said, we don’t yet have that data in terms of how – what we talk about in terms of diet and exercise in the general population may apply directly to people, say, with a BRCA1 or 2 mutation.  One thing that I think is really interesting and something to point out here is if we go back to the original report in the early ‘90s where Dr. Dr. Mary-Claire King published the relationship between the BRCA gene and breast cancer risk, in her analysis, she looked at two modifiable risk factors and the age of onset. 

And she found that people who are obese at the time of menarche – that is, when a woman’s period starts – or reported low amounts of physical activity during their teenage or early 20 years and have a BRCA1 or 2 mutation, they were generally younger than their counterparts when they develop their breast cancer.  It doesn’t necessarily mean that those risk factors further increase the risk of developing breast cancer. 

But, for whatever reason, that group of people with a genetic mutation who are obese or have low levels of physical activity were younger when they presented with their breast cancer.  And, so, I think that raises a lot of interesting questions about whether or not modifying those risk factors can be helpful like it is for the general population. 

Some people ask if the overall guidance like diet in breast cancer depends on the type of cancer, that is, whether it’s hormone receptor-positive or triple negative, whether it’s localized or metastatic.  Melissa, do have any thoughts about this? 

Melissa Pilewskie:  Yes.  And I think that this highlights really the areas of ongoing research.  These are important questions.  We know that these risk factors are not universal for all types of breast cancer.  A lot of the data – and, obviously, Neil, you can speak to this. 

But, looking at obesity has really been shown to be a risk specifically for hormone receptor-positive cancer frequently in post-menopausal women.  But, the data that I highlighted looking at soy, for example, showed some mild protection regardless of the estrogen receptor status.  So, I do think that it’s a mix and we are not going to see the same results across the board here. 

Neil Iyengar:  Yes.  Absolutely.  I couldn’t agree more.  I think – I think it is going to be very disease- or tumor-specific.  I know that we have a lot of materials to cover and we are getting close to the top of the hour.  So, I’d like to know turn to the other major part of this conversation.  And that’s exercise. 

And, of course, Dr. Scott is an expert is exercise oncology.  Jess, what are we learning about the risk of breast cancer including breast cancer recurrence and the relationship with exercise? 

Jessica Scott:  Yes.  This is another great question.  And similar to the diet question we discussed earlier, there are numerous observational studies or those population studies showing that women who participate in regular exercise before their cancer diagnosis and women who participate in exercise after treatment were less likely to have their cancer come back or have a recurrence. 

And there are also studies that have shown women who participate in exercise either before treatment or after treatment were less likely to die from breast cancer or any other causes such as cardiovascular disease compared to those who are inactive.  If we look at these studies together, they really highlight the importance of not only diet but also exercise in preventing breast cancer, preventing recurrence and improving survival years following a breast cancer diagnosis. 

Neil Iyengar:  Yes.  That’s really interesting.  And what – to get a little more specific about that, people have asked – a lot of people have asked about guidance with regard to what kind of exercise is best.  Is it cardio?  Is it strength training, yoga, stretching and so forth?  Do we have any data to guide us on this question? 

Jessica Scott:  Yes.  That’s one of the most common questions we get asked.  It’s “What is the best exercise program for me?”  And the phrase that we like to use in our group is “one size of exercise does not fit all.”  And it’s a lot like diet where we don’t know specifically what form of exercise may be the best. 

We have several clinical trials starting or ongoing right now where we are looking at what is the best dose of exercise to either prevent breast cancer recurrence or prevent some of the late cardiovascular effects of breast cancer therapy.  But, based on the observational studies I just highlighted, it looks like aerobic exercise or exercise where you are doing continuous movement over at least 15 minutes of time that gets your heart rate up – that’s the one that appears to have the strongest association with increase survival. 

So, we suggest if you are not currently active that it’s a great idea to start with even just a walk around the block.  That’s a great place to start.  And, then, slowly increase your exercise level from there.  So, aerobic exercise is one great one. 

But, there are also numerous other studies showing a relationship between strength training, yoga, stretching and lots of other exercise and improvements in other outcomes.  So, we are obviously very interested in reducing the risk of breast cancer recurrence and increasing survival.  But, there are other outcomes such as reducing fatigue or improving sleep that are also very important. 

And as was highlighted earlier in the discussion, it’s really a young field and there is a lot of work that still needs to be done.  But, so, far, the data suggests that it’s never too late to start exercise to see some benefits. 

Neil Iyengar:  I think that’s such an important point, Jess, that we are seeing several studies which are essentially showing us – underscoring that last point that you made that if you haven’t – if you’ve never exercised, starting later rather than never starting can still get you a lot of the benefits of exercise.  So, it’s never too late to start. 

The other point that you raised which I think is really fascinating is this concept of the dose of exercise.  And I know you have a lot of trials that are testing different doses of exercise.  And I think this might be a good opportunity to highlight some of those.  I will just mention we have a trial going on right now adjusting different doses of exercise for people with metastatic breast cancer.  So, it’s certainly something that people can look into if they want more information about that trial.  And I know, Jess, you are doing similar trials in earlier-stage breast cancer.  Is that right? 

Jessica Scott:  Yes.  Exactly.  So, we are looking at women that recently completed treatment.  And, so, one to five years post treatment, what is the optimal exercise dose?  So, right now, the guidelines suggest 150 minutes per week.  So, about 30 minutes several times per week is a great dose.  And we are looking at whether if you go a little bit higher do you have more benefits. 

And we were also looking at results from a study in women that are at high risk for breast cancer.  So, we are really interested in this across the spectrum of breast cancer starting before diagnosis.  Melissa outlined in those women that are high risk during therapy what is the optimal dose of exercise and post therapy and concluding what you trial is looking in the metastatic phase.  It’s all really important to look at this not just as a one-size-fits-all approach in all of these – in all different forms of treatments. 

Neil Iyengar:  Absolutely.  The other thing that is on a lot of people’s minds is – in the current situation with regard to COVID, I think people are wondering how we are conducting our trails in terms of whether or not people have to come in or not.  So, I think it’d be great if you could briefly talk about that.  And, also, what are some things that people can do at home in terms of exercise? 

Jessica Scott:  Yes.  So, it’s certainly been a challenging year in terms of COVID.  But, what we are doing with our trials is we are actually delivering treadmills to patients’ homes and we are doing supervised exercise.  So, all patients receive a treadmill and an iPad that, at the end of the trial, they return to MSK. 

And our exercise physiologist will supervise them from our “mission control” at MSK.  So, that alleviates having to travel into the city to do that supervised exercise, which is so important in our trials where, as you mentioned, earlier, we are really trying to take a precise approach to delivering exercise.  So, that’s one approach that we are doing in a lot of our trials. 

But, if listeners are interested in starting an exercise program at home, exercise is certainly – avoiding COVID risk at home is certainly the way to go.  If there are stairs available, these are great tools to get your heart rate elevated if you do a couple of repeats of going up and down the stairs. 

And there are also other potential exercises that help with strengthening leg muscles.  Neil, earlier on, you mentioned the importance of muscle mass.  So, we really try and target leg muscle because that’s a high source of muscle doing things such as repeats of sitting and rising from a chair or even doing lunges.  These things can be done in even really small spaces.  So, it’s really about starting to get active and trying to get moving as much as possible.  We think that’s the important step to take. 

Neil Iyengar:  Great.  That’s really helpful.  And I’ll also just comment on some of the clinical initiatives and maybe, Andrea, you can comment on this as well.  But, we are trying – apart from the clinical trials that Jess so well summarized, there are – there is a clinical initiative known as the Optimal Living Program in the breast service which is just beginning.  It’s just starting its rollout.  But, the goal there is to get people involved in a nutritional or dietary plan or an overall plan that addresses well-being right at the point of diagnosis.  Andrea, can you tell us a little bit more about the Optimal Living Program? 

Andrea Smith:  Yes.  Absolutely.  Thanks, Neil.  So, as Neil just mentioned, we have an Optimal Living Wellness Program that we started last year within a few of our medicine oncology practices.  And basically, the purpose of this program is to really bring all of these service that we have available to MSK – I’m sorry – MSK at the forefront of the patient’s care.  We want to introduce it early.  We want them to understand that they have all of these services that are – that are geared towards nutrition, that’s geared towards exercise, that’s geared towards acupuncture or massage therapy, social work, financial assistance. 

We give them all this information and we are the one that actually helps to coordinate that care so that when patients fill out the survey, that really is individualized to what their needs are.  They are immediately then referred to one of our nurse navigator who then review that survey care plan with the patient.  And based on their responses, that nurse navigator will then refer patients – recommend and refer patients to our services based on how they respond to questions. 

So, the Optimal Living Wellness Program is really a way for patients to, one, know what we have available; two, to actually create a care plan that’s specific to their needs based on their responses they do within the survey and, then, actually have a team – a dedicated team that is there and available to them to answer questions to coordinate their care, to give them the referrals, to give them whatever information and, then, follow them alongside their cancer journey. 

So, it’s a very exciting program.  We are thrilled the fact that we were able to relaunch after things have kind of calmed down with our response to COVID.  But, it is definitely a really – a rewarding program.  And there is (inaudible) different services, like I said before, that’s available under this one umbrella that patients can actually take advantage of while they are at home. 

So, I could go on and on about it.  But, that’s really kind of what I think is the essence, right, of the foundation of the program.  And we are just excited to have it to be able to offer it to our patients.  It’s really [good].  Sorry I get really passionate about it, but it’s really (inaudible). 

Neil Iyengar:  Yes.  Thanks, Andrea.  I mean I think folks here can really sense the excitement that we have with regard to the Optimal Living Program and the comprehensive care being offered by that initiative.  Okay.  So, I just want to wrap up with two more topics quickly before we conclude the call that was on – that were on a lot of people’s minds.  One is surgery and, then, the next one is supplement. 

So, let’s address briefly the surgical questions.  And a common theme was what to do in terms of exercise to relieve pain after treatment and whether or not there are any suggesting exercise after lumpectomy and radiation.  So, maybe I’ll start with Jess and I think it would be good to turn it over to Melissa as well to talk a little bit about do we know anything about exercise in the post-surgical setting.  And, then, Melissa, maybe you could talk a little bit about when it’s safe to exercise in the post-surgical setting. 

Jessica Scott:  Yes.  Thanks, Neil.  I think one of the most important considerations is to try and maintain mobility.  And at MSK, we’ve got a team of excellent physical therapists that can help guide patients through certain exercise after surgery or radiation.  And MSK is also really unique in that we have an [integrated] medicine program with other programs to help such as acupuncture.  And those other additions may help reduce pain. 

Neil Iyengar:  Yes.  That’s great.  Very helpful.  And how soon can people start, Melissa?  What’s the general recommendation in terms of exercise after, let’s say, a mastectomy or a lumpectomy? 

Melissa Pilewskie:  Right.  So, our general goal is for women to get back – to resume their normal pre-surgery activity or to increase it based on everything that we have reviewed today.  So, in my practice, what I counsel women is that after a lumpectomy, after two weeks you can really get back to normal physical activity. 

And with a mastectomy with reconstruction, it’s usually about four to six weeks.  So, as long as everything is healing well after that kind of general timeframe, we really want people to get back to exercising to stretch through that hard tissue to improve range of motion? 

Neil Iyengar:  Is that helpful for lymphedema? 

Melissa Pilewskie:  Yes.  So, I think that this is an important topic and a little bit of a misnomer.  I hear a lot of patients saying that they have been counseled not to exercise to reduce lymphedema risk.  And it’s actually the opposite.  So, when we are talking about lymphedema, we are referring to swelling in the arm that can happen after surgery and radiation treatment.  And the consensus guidelines are really that exercise is beneficial both for prevention and for treatment and, so, definitely helpful in that arena. 

Neil Iyengar:  Great.  Good to know.  So, we got a lot of questions about supplements.  And I’ll just summarize by saying that folks are really asking about are there specific supplements or supplements in general.  And I think it’s important to underscore that, generally speaking, the healthiest way to get any nutrient is through food, through whole foods. 

And what we know from a number of studies both in the laboratory and in people is that promising supplements tend to lose their potency when they are not delivered with the synergy of the food – the whole food that they come in.  Right?   

And, so, taking a pill form – in other words, taking a pill form of a specific vitamin or of a specific food substance – take turmeric, for example – may not be as helpful as actually getting it in the food form, whether that – we will go – let’s stick with the turmeric example since there have been some clinical trials there where the pill form has not actually panned out to be helpful, at least in the cancer context but, perhaps, the root itself or powder or grinding the powder in food may be helpful. 

Again, more work or studies to be done there.  But, generally speaking, I think it’s important to keep in mind the more we can get from our foods, the more likely we are to derive a benefit from that substance. 

The other thing that I’ll mention is that I generally – right at the very beginning, as I am with any new medical intervention, I am very skeptical until it’s been proven effective.  And the reason is we have to be careful of two things.  We have to be careful of harm.  We want to make sure that nothing is doing harm.  And we also have to be careful that it’s not interfering with the person’s cancer therapy. 

I think some of the recent data about probiotics for patients with melanoma are really alarming.  We know from two studies now that probiotics can reduce the efficacy of melanoma treatments.  And, so, whether that translates to other cancers we don’t know.  But, I think that gives us a lot of pause about taking supplements.  So, certainly, talk to your doctor.  Talk to your clinical team. 

If you have a supplement in mind, think about getting it through the food rather than through a pill.  And our integrated medicine service has physicians and researchers who specialize in supplements and potential interactions with cancer therapy.  And so, certainly, ask your care team about meeting with one of the integrated medicine providers to address the supplement question for you specifically. 

So, we are at 5 o’clock, and that’s our time.  So, I do want to thank everyone today who have submitted questions.  And to all of you who have made the time to join the call today, I certainly hope that you found this information helpful.  I’d really like to thank our amazing panel.  It was really such an honor to be joined by the other panelists today.  And I think, hopefully, you got a lot of information from everyone here today. 

We do plan to host more calls like this in the future and look forward to speaking with you again.  There will be a replay of this call available soon on our website.  That’s mskcc.org.  You can also find more information about our upcoming sessions on that website, including the upcoming session on breast reconstruction. 

We are really dedicated to moving your cancer care forward and want to encourage you to be in touch with your MSK doctors and the care team with regard to your care specifically and to get that message out there.  Don’t delay screening.  Don’t delay cancer screening.  It’s really important.  And the MSK environment is a safe place to be.  So, please be safe.  Take care of yourself and your loved ones.  Thank you for joining us today.  Have a great evening to everyone.  Thank you. 

Operator:  This concludes today’s call.  Thank you for joining Memorial Sloan Kettering’s Information Session for patients and caregivers.  Have a good evening.