By Jennifer Ligibel, MD, as told to Ana Gascón
I'm a professor of medicine at Harvard Medical School and the director of the Zakim Center for Integrative Therapies and Healthy Living at the Dana-Farber Cancer Institute. I am also a senior physician in the breast oncology program.
Early in my medical training, I was really interested in primary care and specifically women's health. My continuity clinic was in a women's health center, and I really enjoyed having long-term relationships with patients. But I found myself drawn to managing more complex medical situations. I found that oncology would bring together my interest and desire to care for women over the long term. I could also help them manage a very complicated time medically, when women are diagnosed with cancer, breast cancer in particular.
I've been a breast oncologist for 22 years now and have treated thousands of patients. This is an exciting time in breast oncology, with the development of many new treatment strategies, allowing more personalized treatments based on the type of breast cancer and other factors. Even with these advances, not all patients have good outcomes, and many patients experience side effects from cancer treatment that worsen their quality of life. My patients often ask me what they can do themselves to live longer, feel better, and keep breast cancer from coming back. Here are four steps I recommend.
1. Stick to your endocrine therapy
When I talk to my patients about helping to avoid breast cancer recurrence, I tell them that the most important thing they can do if they have a hormonally driven cancer is to take their antiestrogen treatment. This isn't always easy. We know that these medications can cause side effects, but study after study has shown that for women with hormonally driven cancers, blocking or lowering hormones is the most effective way to prevent their cancers from coming back.
I also encourage my patients, if they're having a hard time with these medications, to talk to their doctors. We have many ways to ease the side effects of antiestrogen treatments. It's really important that women take these medicines. We can help them feel better while they're taking them.
2. Make time to exercise
I also tell my patients they should exercise during and after their cancer treatment. Exercise has been shown to lower the side effects of cancer treatment, ease tiredness, help women preserve their strength and endurance, and lessen anxiety and depression. Early research shows that people who are more active after their cancer diagnosis may have a lower risk of recurrence and be more likely to survive their breast cancer.
When patients ask me what the "best" kind of exercise is, I usually tell them that it's the kind they will stick to and continue to do over time.
We do know that there is good data showing that strength training is important to help maintain muscle mass. This is really important for people who are getting treatment, especially chemotherapy, which can lead to muscle loss.
Aerobic exercise or cardio is also really important for cardiovascular (heart) health and for avoiding fatigue and loss of stamina.
Finally, there is also evidence about the value of mind-body types of exercise, such as yoga and tai chi. These can help people feel better and help ease the stress and anxiety people often experience during their cancer treatment and afterward. Taking part in different kinds of exercise can help people stay engaged, increasing the likelihood that they will stick with their exercise program.
We need more evidence about the effect of exercise on outcomes such as cancer recurrence, but exercise is definitely an important part of cancer treatment for women with breast cancer.
3. Maintain a healthy weight
I also tell women to try to keep a healthy weight. A lot of research has shown us that women with obesity who are diagnosed with breast cancer have a higher risk of their cancer coming back and a higher risk of dying from it. We don't know yet whether losing weight will cut the risk of cancer coming back. There's a lot of great research going on right now trying to study that, but we do know that losing weight lowers the risk of heart disease and diabetes, which are also very common in women after breast cancer diagnosis. We also know that losing weight will help lower the risk of things such as lymphedema (swelling) and improve quality of life.
We are just finishing a very large trial called the Breast Cancer Weight Loss (BWEL) trial for women who are overweight when they're diagnosed with breast cancer. We're testing to see if taking part in a weight loss program, including structured exercise and a calorie restriction program, will improve their odds of surviving their breast cancer.
That study enrolled almost 3,200 women from across the U.S. and Canada. We've shown that the program helped women lose weight and that it improved their metabolism and lowered inflammation. We're waiting now to learn whether that has an impact on cancer recurrence and survival.
Like exercise, we need more evidence that weight loss lowers the risk of breast cancer recurrence. But we already know that maintaining a healthy weight helps people feel better and cuts the risk of heart disease and diabetes — conditions that can be a bigger risk than breast cancer itself for some patients.
4. Eat Fruit, veggies, and whole grains
Finally, one of the things that my patients ask me most frequently is: What should I eat after a cancer diagnosis? And I feel like this is the area where we have the least satisfying answers. There is a lot of research that has looked at whether eating particular foods or following particular dietary patterns (like "low fat" or "low carb") affects the recurrence of breast cancer. But the results are not very consistent.
What we do know from large studies is that people who eat healthier diets—like more whole foods, fruits, vegetables, and whole grains—tend to be healthier and have a lower risk of getting cancer.
Studies that ask large groups of people what they eat and then follow them over time show that people who have healthier diets — more whole foods vs. processed foods, whole grains, fruits, and vegetables — seem to be healthier overall and have lower rates of developing cancer. But there's no clear research in terms of how diet affects breast cancer recurrence and survival.
We also don't have much evidence at all about some of the things people ask me most frequently, such as whether they should follow a ketogenic diet or engage in fasting. There is some really fascinating early evidence in animals, but at this point, we don't have enough information to tell patients whether they should be following one of these more restrictive diets. Unfortunately, sometimes people drive themselves a little crazy trying to pursue a perfect diet.
I personally recommend a general heart-healthy diet — one rich in whole grains, fruits and vegetables, and lean protein — for patients with breast cancer, recognizing that we need to support health holistically while we wait for more cancer-specific information. I also counsel women that a healthy diet is a long-term strategy. Eating a piece of cake at a birthday party is not going to make your cancer come back. It is important to give yourself grace to veer from a "perfect" diet sometimes.
