The idea that people who are overweight or obese can benefit by shedding pounds through exercise and a healthy diet is hardly headline-making. But UCHealth is now part of a national trial that takes aim at a more provocative question: Can weight loss help breast cancer survivors prevent their disease from recurring?
The Breast Cancer Weight Loss Study (BWEL), sponsored by the National Cancer Institute’s Alliance for Clinical Trials in Oncology, focuses on overweight and obese women who have survived early-stage breast cancer. The aim: use two different approaches to provide them with information about the importance of maintaining healthy lifestyles, including losing weight safely, and measure the results.
One group of patients will receive a “standardized intervention” that includes mailings, webinars, magazines, newsletters and cards on the subject. The second group will get the same materials, but they will also take part in a two-year telephone counseling program that pairs them with trained coaches staffing a BWEL call center at the Dana-Farber Cancer Institute in Boston. These coaches will advise patients about strategies to manage their weight by increasing their activity and following a healthy diet. Patients who complete the study will have a total of 42 telephone sessions with coaches.
In a nod to technology’s growing role in health care, participants in the second group will use products from Fitbit, a trial partner with Dana Farber, to monitor their activity levels, calories burned, heart rate, weight and other measures. The tools, including a fitness tracker and wireless scale, are essential to the study, said Jennifer Ligibel, MD, a breast cancer specialist at Dana Farber’s Susan F. Smith Center for Women’s Cancers and principal investigator for the BWEL trial.
“We need an objective means to evaluate if what we do is working,” Ligibel said in a phone interview. “A key to losing weight is for people to be able to track their progress. We want to do anything we can to increase their motivation. Over time, we need things to keep people engaged, to keep things new.”
Weighing the risks
More than 1,100 sites, including UCHealth, are involved in the trial, which aims to enroll some 3,100 patients overall. Researchers will follow patients for 10 years after they enroll, comparing rates of breast cancer recurrence in the two groups. A fundamental question to be answered is whether weight loss should be standard treatment for breast cancer patients – and if so, the most effective ways to deliver it.
“Exercise may play a role in reducing the risk of recurrence in breast cancer patients, but in particular in this trial, we want to look at how exercise is obtained,” said Regina Brown, MD, principal investigator for UCHealth, which is recruiting patients at UCHealth’s University of Colorado Hospital in Aurora; Memorial Hospital in Colorado Springs; and Poudre Valley Hospital in Fort Collins. Brown is also medical director of Oncology at the UCHealth Lone Tree Medical Center.
The BWEL trial is exploring ground that has intrigued researchers for many years, Brown said. “When we think about what we call the obesity issue, we know that an element of inflammation goes with it,” she said. “We also know that there is a connection between inflammation and cancer.”
Brown also noted that studies have linked excess body weight and higher than normal body mass index to increased risk of postmenopausal breast cancer. Aromatase, a protein found in fat, stimulates the production of estrogen, Brown explained. About 80 percent of all breast cancers have a receptor for estrogen.
Oncologists can treat breast cancer in postmenopausal women who have these hormone-receptor-positive cells with drugs that block aromatase, Brown said. Such targeted therapies are primary cancer-fighting tools. The BWEL trial targets the “secondary setting,” as Brown put it – preventing the cancer from recurring. But the weight-loss work could one day go farther, she added.
“We may be able to take the data, apply it, and say, ‘Now, based on these tools, can we help to prevent cancer in the first place?’” Brown said.
Actively engaging patients
The outcome of the BWEL trial will not be known for years, but Brown stressed that increasing activity, reaching and maintaining a healthy weight, following a nutritious diet and generally sticking to a healthy lifestyle brings immediate benefits to cancer survivors.
“Patients who are more active do better with their symptoms,” such as pain and nausea, Brown said.
That’s one of the underlying assumptions of the University of Colorado Cancer Center’s BFitBWell program. Launched in 2013, BFitBWell (which is not connected to the BWEL trial), provides a three-month regimen of structured physical activity, led by exercise physiologists, to help strengthen people who have been diagnosed with cancer or who are getting treatment for it.
BFitBWell has assisted 378 patients since its inception, said Program Manager Nicole Klochak, CES, CPT, and now has two full-time exercise specialists. Recently hired part-time data specialist and professional research assistant Jared Scorsone is gathering data to assess the program’s effectiveness in improving patients’ overall strength, preserving lean muscle mass and relieving symptoms.
“Exercise is therapy,” said Klochak, noting that it’s an effective inflammation fighter and a way for patients to proactively battle the draining effects of surgery, chemotherapy and radiation, such as fatigue, shortness of breath and muscle atrophy. It’s also a boost for quality of life and a hedge against depression for the most basic of reasons, Klochak said.
“Exercise is a part of treatment that patients can control,” she said. “It can help to restore a sense of normalcy in their lives.”
An important part of the BFitBWell approach centers on helping patients understand why it’s so important to take on the rigors of physical activity, even when they might not feel up to it, Klochak said.
“We tell them to think of it literally as another pill,” she said. “Exercise can have similar benefits in terms of saving lives.”
Bouncing back by pumping up
Andrea Meyers, 63, of Denver, is not enrolled in the BWEL trial, nor is she obese. But she can speak to the physical and psychological trauma of a breast cancer diagnosis – and to the ways that getting active helped get her life back on track.
A retired teacher and professional musician – she plays the cello in the Arapahoe Philharmonic and serves on its Education Committee – Meyers was diagnosed with breast cancer about a year ago after a mammogram. She underwent a double mastectomy at a Littleton hospital and struggled to come to terms with the prospect of an arduous recovery period.
“It turned everything in my life upside-down,” Meyers said. Apart from the physical challenges, she struggled to confront the new reality imposed by the disease. The cello that had long tuned the harmony of her life stayed in its case, untouched. Getting out of bed or off the couch required an exertion of will.
“I was very depressed, listless and miserable,” Meyers said.
She had had one chemotherapy session at a community provider when she met UCHealth medical oncologist Anthony Elias, MD – a violinist and fellow member of the Philharmonic. She took Elias up on his offer to help with her treatment and switched her chemotherapy regimen to the University of Colorado Cancer Center. During physical therapy designed for cancer patients at the Lone Tree Health Center, Meyers saw a brochure for BFitBWell and decided to learn more. She enrolled in the program in early July for a $59 monthly membership with the Anschutz Health and Wellness Center, where she would have her workout sessions.
After a standard physical function assessment, the BFitBWell team developed an individualized exercise prescription for Meyers. It initially taxed her depleted resources, but the regular workout routine offered a welcome roadmap to recovery and a way to prepare for what would be 19 radiation treatments.
“I was aware of what I was facing physically and mentally, and the program gave me concrete objectives,” Meyers said.
From survivor to warrior
On a recent morning at the Wellness Center, a bright and fit Meyers demonstrated some of the exercises she followed during her three months with BFitBWell. Exercise specialist Ian Moran guided her through the paces, which started with a warm-up session on a treadmill in the first-floor workout room, bathed in natural light.
After a few minutes, Meyers and Moran moved to an open exercise area on the second floor. Moran took out a heavy ball and placed it on the floor. Meyers balanced the ball with one hand on the alternate knee and lifted her legs while extending her free arm as Moran counted off the reps. She then put her legs in two purple disks resembling frisbees and alternately drove them forward and back. She stepped up and down on a wooden box while holding a pair of 10-pound dumbbells; worked long, heavy battle ropes up and down, as if playing drums; and pulled long, elastic straps while leaning back, her heels dug in to the floor.
After a time, Meyers was breathing heavily from the exertion of these and other routines. But she was far from overtaxed. “I love it,” she said. “I remember at the beginning of all this how shaky I was.”
The circuit is designed to build core stability and overall strength with a variety of exercises, Moran said, but always with an eye toward safety and attention to what each individual can handle.
“We want to make the activities of daily living easier for them, and to have them leave feeling better than when they came in,” he said.
For Meyers, who will have breast reconstructive surgery sometime during the next four to eight months, the term “core strength” has multiple meanings. She is confident that exercise has not only deepened her physical reserves, but also toughened her mental resolve.
“I want to be healthy and not tired for reconstruction,” she said. “I want to be alive, and I know I have to be mentally ready if I’m going to be a viable candidate for stronger outcomes from my surgery.”
With the help of BFitBWell, Meyers no longer thinks of herself simply as a survivor, but rather as a warrior in battling back from, and beyond, her disease. Ligibel believes the BWEL trial can help clinicians determine how best to help put overweight and obese breast cancer survivors on the same path. The study aims to contribute to growing bodies of literature that separately link obesity and breast cancer recurrence, and show that carefully crafted interventions, such as one tested in the ENERGY trial, can help survivors lose weight.
“We’re building on these studies,” Ligibel said. “It’s at least important to do so in the short term to improve patients’ quality of life.”
For more information about the BWEL trial at UCHealth, contact Lisa Lopez at 720-553-1133 or [email protected].