Breast Cancer Information

M. D. Anderson Cancer Center
Speaker: Danielle McGee, RD, LD
Duration: 0 / 19:19

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If you're a breast cancer survivor, I'm sure you're aware of the abundance of information about nutrition related to your cancer. [Pause] There are certain risks that you can't change: genetics, your environment, & your age of menopause. However, there are things you can have an influence over: a high fat diet, obesity, & physical inactivity. A recent study looked at weight gain during chemotherapy. There's an idea called sarcopenic obesity. This is obesity where patients gain weight but they also lose lean body mass- meaning that more of the obesity is from adipose tissue (your fat tissue). This may happen from physical inactivity and a decrease in your energy levels. It could be related to increased calorie intake. But we really think that the increase in activity may be more helpful. Of course, more studies are needed. So, let's look at some specific recommendations. They're consistent with those put out by the American Institute of Cancer Research. First of all, aim for a healthy body weight (which is the goal of these videos). Second, reduce body fat. You can do this by looking at your body fatness & also focusing on your body mass index (or your BMI). You can see the attached table as a handout. If you're interested in calculating your BMI, however, you take your weight in pounds. Multiply it by 703 & divide by your height in inches squared. This will give you your Body Mass Index. We're aiming for a Body Mass Index of 21 to 23. Anything from 18.5 (~18) to 24.9 is considered healthy. Above 25 is considered overweight and over 30 is considered obese. Also, you want to avoid foods that cause weight gain. Also, limit your intake of red meats and other processed animal foods to 2 to 3 times a week (or less). Reduce alcohol intake. For women, this is considered one serving a day (if you already drink), but also aiming to reduce alcohol intake completely is not a bad idea. Know how food is preserved, processed, and prepared. Limit your intake of highly refined, sugary products & carbohydrates. Also, limit your intake of highly processed foods with added sodium. Don't depend on dietary supplements. Most research focuses on encouraging patients to consume vitamins and minerals in food forms as there has been no evidence to support preventing cancer with dietary supplements. The hand out that you'll see entitled Nutrition for Individuals Affected by Cancer or Touched by Cancer will focus on the following issues: aiming for 7 to 11 servings of fruits and vegetables a day. Also, it will answer your questions about organic foods. It provides a list of those foods which includes the most pesticides that you might want to choose as organic options and those that contain the least pesticide residue. It also includes information on healthy fats. It encourages you to limit concentrated sweets and it discusses alcohol consumption. I wanted to provide a list to you of antioxidants and their sources. You'll hear several things listed on the news about Selenium, vitamin E, vitamin C, carotenoids and vitamin A. So, these are food sources of those antioxidants. Here's a good chart for phytochemicals. Phytochemicals have been shown to be helpful in cancer prevention: indoles, saponins… and the list goes on. You'll see that these are listed in food sources as well. The debate goes on with food versus supplements. I always encourage whole food forms versus supplements because of a concept called synergy. Synergy means that the phytochemicals, the vitamins, and the minerals that are in food can interact together and may help the body process them better. It is better to focus on the entire diet instead of just one substance (which is what's included in a supplement form). Supplements may not be helpful and they also maybe harmful. So, sometimes they can be helpful or harmful. Plant-based foods strengthen the body's defenses. Food is more fun than pills so focus on the food forms! Let's address the dietary fats. There's been debate in the pass about low-fat diets in breast cancer versus low-saturated fat or no trans fats with a healthy fat diet. It looks like some evidence is focusing more now on changing the types of fats that breast cancer patients eat. You want to include more monounsaturated fatty acids. These would be things like olives, olive oil, pecans and avocados. Do these in small amounts to prevent weight gain. Also, you want to include more polyunsaturated or omega-3 fatty acid. This is found in high-fat, cold water fish (such as salmon, herring, mackerel, tuna), walnuts and flaxseeds. Include adequate protein in your diet. This turns out to be about 15 to 25 percent of your total calories or about 0.8 to 1 gram per kilogram of protein per day. (If you're looking for your weight in kilograms, take it in pounds & divide that by 2.2. Now you have kilograms.) Some good sources of protein include lean meat, poultry, fish, nuts, beans, cottage cheese, low-fat dairy, nut butters (such as cashew butter, almond butter or peanut butter) egg whites, whey protein powder and hemp protein. Focus on the portion size. When you think about your meat, think the size of a deck of cards. Nuts? About the size of the golf ball. Any kind of peanut butter? The size of a matchbook. Here's my relationship with soy research (and it's okay to laugh!). There's controversial issues and evidence based on soy. We do know that soy is a good source of fiber and protein. It can help lower cholesterol; however, as a breast cancer survivor, you have to consider whether you're estrogen-receptor positive. Also, if you're taking Arimidex or Tamoxifen this can change the recommendations that your medical team would offer. Let's look at what soy is. Soy contains phytoestrogens: “phyto” (from a plant) estrogen. Isoflavones are types of phytoestrogens. These sources include tofu, flour -- excuse me, tofu, soy flour, miso, tempeh, soy milk, edamame and soy nuts. These are natural forms of isoflavones. The second form of phytoestrogen is called a lignan. These are found in flaxseed (which is the most well-known form) and there's some research indicating that they may act as natural aromatase inhibitors. Here's the debate: some believe that phytoestrogens might act like a human estrogen in the body. However, the others question if those phytoestrogens could help inhibit circulating estrogen in the body and, thus, have a protective effect on breast cancer development and growth. The debate is still out. We really don't know and there's research to support both groups. So, I want to talk about soy foods. When you look at natural forms of soy foods (as we discussed before: soy milk, tofu, edamame, tempeh)- these are the serving sizes of those soy foods. And listed here are the grams of soy protein per serving. My current recommendation is that breast cancer survivors, especially those with hormone receptor positive cancers, avoid high concentrations of soy. High concentrations are those that would be considered as soy supplements and soy protein powders. For the whole soy foods, (meaning those that were listed on the previous slide: tofu, soy milk, edamame) limit those to one to two servings of whole soy foods per day. That's if you already consumed those foods. Soybean lecithin oil and soy sauce do not seem to have significant sources of isoflavones. More government studies are underway. So always ask your medical team for an update and do some research on the American Institute for Cancer Research for yourself. Also, the American Cancer Society or cancer.gov. My summary for phytoestrogens is this: Our primary goal is to avoid weight gain after your breast cancer diagnosis. So, it seems that natural soy products plus a low-saturated fat diet and focusing on eating 7 to 9 servings of fruits and vegetables a day is likely safe and perhaps even beneficial. Calcium and vitamin D: you need at least 1,000 to 1,200 milligrams of calcium per day. Based on your age and your diagnosis or treatment plan, this can also increase from 1,200 to 1,500 milligrams of calcium a day for your needs. You need at least 400 International Units of vitamin D a day. If you're taking calcium, look on the ingredients list and notice if the calcium is calcium carbonate or calcium citrate. Both are fine forms. If you're taking calcium carbonate, though, take that with your meals. Calcium citrate you can take with or without meals. You don't want to take your calcium with high fiber foods because it can prevent the absorption of calcium.

Vitamin D: this is a trend that's up and coming in breast cancer research. The current Recommended Daily Allowance is 400 International Units per day. However, there's some indication that more might be needed. Vitamin D can affect the outcomes in long term health of cancer patients. Lots of new research focuses on setting a goal of 800 to 1,000 International Units of vitamin D a day. Currently, the safe upper limit is set at 2,000 International Units per day. However, you'll notice that if you are vitamin D deficient and your doctors put you on a vitamin D regimen to increase that, safe levels can be at much higher amounts. A supplement is needed for vitamin D in some cases and if you're taking that supplement, make sure you take it with healthy fats since vitamin D is a fat-soluble vitamin. Research indicates that vitamin D might regulate cell growth. It also may induce apoptosis or cell death. It could prevent tumor angiogenesis which is the growth of blood vessels to the tumor cell and it might decrease cell proliferation. There's some research that indicates that it can enhance immune influence sex hormones and IGF-1. So how is vitamin D measured? Typically, you'll see the measure as serum 25-hydroxyvitamin or this indication or symbol listed here. A Vitamin D receptor is activated by 1,25-dihydroxy vitamin D. You want to focus on the 25-hydroxyvitamin D lab level. Vitamin D can be found in two different forms as far as supplements go. Vitamin D3, cholecalciferol, is preferred as vitamin as compared to vitamin D2, ergocalciferol. As far as vitamin D recommendation go, I always encourage my patients to ask your doctor about supplementation. Also, get adequate sun exposure. Thirty minutes of adequate sun exposure provides 10,000 International Units. So right now, most medical doctors are recommending 15 minutes of sun exposure. This would be on the long limbs (your legs and your arms), unprotected (meaning no sunscreen), and trying to get that sun exposure before 11 a.m. or after 3 p.m. Also, you can focus on getting vitamin D in food forms and focusing on food forms that have been fortified. Here's a chart that lists the measurement of your labs for vitamin D. Some facilities measure in different units so I included both here and this is the indication. You'll see that vitamin D deficiencies in rickets levels are included. Also, you can look at the possible desirable level for overall health and disease prevention. A study was done on vitamin D deficiency or insufficiency and these numbers will show you that deficiency is less than 20 nanograms per milliliter, insufficiency ,as such, an optimal dose or optimum level is greater than 32 nanograms per milliliter. This can be common even in sun-belt areas. So just because you live in a sunny area, you can't always assume that you have adequate vitamin D. Also, it was found to be common in women despite their race, their geographic location, their age or their history of vitamin D intake. The study was done among American and Norwegian patients. So what about vitamin D in foods? This slide shows the item (cod liver oil, salmon and mackerel eggs, fortified milk, shiitake mushrooms, and even sun-dried mushrooms), the serving size, and it indicates the amount (International Units of vitamin D in that food. Next, let's talk about alcohol. There are some studies that indicate risk of breast cancer in female survivors even with one to two servings a day. If you do drink alcohol, make sure that you're getting adequate folic acid and speak with your dietitian or medical team about this. One serving is 12 ounces of beer, 5 ounces of wine, 1.5 ounces of 80 proof liquor. What about lymphedema? Lymphedema is the poor drainage of the lymphatic system. This can be experienced up to 30 years after surgery. There's lack of evidence for nutrition related to lymphedema; however, we have seen some help with a low sodium diet and also avoiding caffeine intake. This should be managed by physical therapy and also recommendations can be made for a compression sleeve. Anytime a patient has lymphedema, you want to monitor blood protein levels and also monitor weight. This will be where your medical team can come in. Make sure that you eat adequate protein (that 0.8 to 1.0 gram per kilogram of body weight as we discussed before) and be sure to see a physical therapist with lymphedema expertise-someone who is aware of your situation and its treatment. Mammograms: we get complaints of painful mammogram and there's no definite data, but some suggest that they may be less painful for women who take vitamin E (400 International Units) consistently everyday for several months. But once again, this has not been proven. Others recommend avoiding caffeine for about two weeks before your mammograms and attempt to schedule your mammograms after your menstrual cycle or when breast pain is naturally less for you. Menopause: the most common side effect of menopause that we hear about is going to be a symptom (or excuse me) symptoms related to hot flushes, sweats, trouble sleeping and also dryness. Non-hormonal medications (the most common ones we prescribe) are Effexor and Neurontin. There are some complimentary and alternative medicine therapies; however, these are not recommended for breast cancer survivors because of their potential for estrogenic activity. These supplements (currently listed) include black cohosh, dong quai, ginseng, kava, red clover and soy. Studies based on soy foods and isoflavone supplements for the treatment of menopause and hot flushes have not been proven to provide benefit. Some indicate that they're may be help when avoiding caffeine, spicy foods, tea, coffee, alcohol and smoking. There have been other indications of benefits of a yoga practice for menopausal symptoms. What about coffee, tea, or caffeine in the risk of breast cancer? In a study that focused on this, there was no association between caffeinated and decaffeinated products found for pre-menopausal breast cancers. There was a weak inverse relationship for the rest of post-menopausal breast cancer. So, I typically tell my patients, “one to two servings of caffeine a day if you're already drinking caffeinated products”. Physical activity: the importance of physical activity is up and coming in the breast cancer research world. We think that it may protect against post-menopausal breast cancer. The recommendations (right now) are set at moderate activity for improved survival. This would mean 3 to 5 hours a week of brisk walking. Interestingly, there's little evidence of a correlation between higher intensity and increased benefit-meaning vigorous physical activity (doing more & doing longer amounts) doesn't necessarily show to have more benefits for cancer risk. So, focus on that moderate activity (3 to 5 hours of brisk walking a week). However, there's no harm in more activity or vigorous activity. It's time to get moving! Here's some examples of moderate physical activity: brisk walking, hiking, gardening or yard work, dancing, golf, cycling, or weight training. I also want to inform you of opportunities. Always look at what--what research studies you could participate in. Find support groups. This is where a lot of information comes out and it provides you with the opportunity to discuss your ideas and recent research findings. Check out www.caring4cancer.com, the American Institute of Cancer Research, and also cancer.gov for more information. If you have specific questions related to cancer and nutrition, meet with your dietitian. You can contact M. D. Anderson's Department of Clinical Nutrition at 713-563-5167 to schedule an appointment. [Background music] So, in conclusion, small changes towards the ideal are helpful only if they're real. Thank you for your participation in these videos.