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Originally published as JCO Early Release 10.1200/JCO.2008.20.6011 on January 12 2009 © 2009 American Society of Clinical Oncology.
In ReplyDepartment of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
Department of Clinical Cancer Prevention, The University of Texas M. D. Anderson Cancer Center, Houston, TX In his letter, Daniell raises some interesting observations regarding body weight status and breast cancer. In particular, he states that patients who are obese may present with specific biologic profiles, such as a tendency toward more estrogen receptor–negative tumors, as seen in our analysis,1 or present with advanced stage at diagnosis.2 Furthermore, Daniell suggests that weight loss as an intervention after treatment for breast cancer is not supported by evidence, and may in fact cause harm by increasing the guilt of a patient with breast cancer over her weight, especially when increased weight after adjuvant treatment may make future weight loss even more difficult.3 Given the question of weight management after treatment for breast cancer, Kroenke et al4 evaluated 5,204 women who participated in the Nurses' Health Study and found that increased weight before diagnosis and weight gain after diagnosis were positively associated with death as a result of breast cancer. Interestingly, the relationships were more pronounced in nonsmokers. However, in another large cohort study, there were no observations of an association between postdiagnosis weight gain and increased risk of poorer breast cancer prognosis.5 In contrast, in a comprehensive literature review, Chlebowski et al6 cited multiple studies demonstrating that women who experienced weight gain after diagnosis are at greater risk for recurrence and death. In our analysis, we found that when our overweight and obese groups were compared with those of normal weight, there was a significant decrease in the achievement of a pathologic complete response to neoadjuvant chemotherapy. In multivariate analysis, there was no difference in breast cancer–specific survival between women with obese or overweight status and women with a normal body mass index. Median overall survival data were not obtained for obese and overweight patients. However, obese patients did appear to have a significantly shorter survival time than did normal or underweight patients.1 Dignam et al7 assessed obesity in the setting of the National Surgical Adjuvant Breast and Bowel Project protocol B-14 trial and found an increased risk of contralateral breast cancer and decreased overall survival in obese women versus women of normal weight, but there was no difference in the risk of breast cancer recurrence. Research regarding associations between weight status and clinical outcomes continue. However, there are significant limitations in the ability of observational studies to ascertain cause and effect of weight loss interventions in this patient population. Randomized controlled trials are needed before definitive evidence of benefit or harm can be established. Until such trials are conducted, we agree with Daniell that there is a paucity of data to support weight loss as a specific strategy for improving breast cancer survival. That said, there is a wealth of strong data that supports the benefits of weight loss in controlling cardiovascular disease and diabetes, which are important competing causes of death in this patient population.8 Thus, we need to look beyond our oncology specialty to help patients achieve overall good health practices.9,10 A multidisciplinary approach to weight management that includes physicians, nutritionists, exercise, and psychosocial expertise can provide patients with breast cancer who are highly motivated to avoid weight gain or achieve weight loss with the necessary emotional support. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Litton JK, Gonzalez-Angulo AM, Warneke CL, et al: Relationship between obesity and pathologic response to neoadjuvant chemotherapy among women with operable breast cancer. J Clin Oncol 26:4072–4077, 2008. 2. Cui Y, Whiteman M, Flaws J, et al: Body mass and stage of breast cancer at diagnosis. Int J Cancer 98:279–283, 2002.[CrossRef][Medline] 3. Saquib N, Flatt S, Natarajan L, et al: Weight gain and recovery of pre-cancer weight after breast cancer treatments: Evidence from the women's healthy eating and living (WHEL) study. Breast Cancer Res Treat 105:177–186, 2007.[CrossRef][Medline] 4. Kroenke CH, Chen WY, Rosner B, et al: Weight, weight gain, and survival after breast cancer diagnosis. J Clin Oncol 23:1370–1378, 2005. 5. Caan B: Pre-diagnosis body mass index, post-diagnosis weight change, and prognosis among women with early stage breast cancer. Cancer Causes Control 19:1319–1328, 2008.[CrossRef][Medline] 6. Chlebowski RT, Aiello E, McTiernan A: Weight loss in breast cancer patient management. J Clin Oncol 20:1128–1143, 2002. 7. Dignam JJ, Wieand K, Johnson K, et al: Obesity, tamoxifen use and outcomes in women with estrogen-receptor positive early-stage breast cancer. J Natl Cancer Inst 95:1467–1476, 2003. 8. Schairer C, Mink PJ, Carroll L, et al: Probabilities of death from breast cancer and other causes among female breast cancer patients. J Natl Cancer Inst 96:1311–1321, 2004. 9. From Cancer Patient to Cancer Survivor: Lost in Transition. Hewitt M, Greenfield S, and Stovall E, Washington, DC: National Academies Press, 2005. 10. Brown J, Byers T, Thompson K, et al: Nutrition during and after cancer treatment: A guide for informed choices by cancer survivors. CA Cancer J Clin 51:153–187, 2001.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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