Clinical FeaturesOncology

Secondary Risk Reduction Strategies in Irish Breast Cancer Care

Written by Clara Steele, Final Year Medical Student, Department of Medicine, School of Medicine, University College Cork and Professor Seamus O’Reilly, Consultant Medical Oncologist, Department of Medical Oncology, Cork University Hospital and Cancer Research @UCC, University College Cork

Over the past three decades in Ireland breast cancer survival rates have increased. Improvements in cancer diagnostics and treatments have resulted in age standardised survivorship of over 75% at ten years. Cancer survivorship is causing a shift to that of a chronic condition and is associated with an increased risk of recurrence, new cancer diagnosis and development of other noncommunicable diseases. Over the last fifteen years a substantial body of evidence has emerged on the impact of lifestyle modification on breast cancer related outcomes with studies showing targetable interventions. Secondary risk reduction services are an integral part of cardiovascular disease management and therefore similar strategies should be considered as part of an early breast cancer care treatment plan.

Modifiable lifestyle risk factors including poor diet quality, low physical activity, high body mass index, smoking and alcohol intake, are associated with increased risk in many cancer diagnoses as well as contributing to increased morbidity and mortality. , The Irish National Cancer Strategy Program 2017-2026 estimates that between 30% to 40% of cancer incidence in Ireland is attributable to modifiable lifestyle and environmental factors alone. The report lists several dietary and lifestyle goals including weight reduction and increasing physical activity as targets for primary and secondary disease prevention in Ireland. 3 Considering the modifiability of these risk factors there should be greater emphasis placed on lifestyle interventions for cancer survivors with the aim to integrate these services into Irish breast cancer care treatment pathways.

Breast cancer survivors who are obese are at increased risk of both cancer related mortality and death from all-causes, reported as 33% and 41% respectively. Several studies have shown benefit of lifestyle interventions involving a combination of dietary education, behavioural change advice and physical activity resulting in improvement in anthropometric measures. The efficacy of these interventions is greater amongst patients who were aware of the risk associated with disease recurrence. , Increased physical activity in breast cancer survivorship has been shown to be associated with lower cancer related and all-cause mortality. In addition, a 2018 metanalysis showed an association between increased physical activity and improved quality of life in breast cancer survivors. Furthermore, a randomised control trial involving at a four month supervised exercise program in breast cancer survivors showed improved bone health, physical fitness and improved quality of life.

Poor quality diet, high in saturated fat and sugar and low in fruit and vegetables is associated with increased cancer risk. 2 A systematic review assessing dietary patterns, mortality and recurrence in cancer survivors concluded that reduction of dietary fat after breast cancer diagnosis was associated with increased relapse free time. Furthermore, the study identified that a highquality diet may be beneficial for reducing non breast cancer related mortality. This benefit was confirmed in a recent intervention trial where breast cancer survivors, provided with advice for a low-fat diet post diagnosis, had significantly reduced mortality from all-causes.

Smoking is the significant modifiable risk factor for cancer development. A large scale metaanalysis showed an increase in breast cancer-associated mortality by almost one third in those who continued to smoke post diagnosis. The study also found that mortality in former smokers was the same as never smokers showing that smoking cessation post diagnosis can decrease breast cancer related deaths. A recent French review illustrated that one third of patients who were provided information on smoking post diagnosis quit with the main motivating factor reported as risk of recurrence. This review also identified that about one third of baseline assessments did not include a record of smoking status, an important finding for clinician education.

Alcohol is a known carcinogen however awareness of alcohol as a risk factor for cancer development has been reported as low. Increased lifetime alcohol consumption and heavy episodic drinking amongst moderate lifetime drinkers has been associated with increased risk of breast cancer. Breast cancer screening and or diagnosis may be an important moment for behavioural change education and advice on alcohol reduction. One UK based study in women attending breast screening showed that awareness of alcohol as a risk factor was associated with the knowledge necessary for behaviour change.

Increased body mass, low physical activity, poor quality diet, alcohol and smoking are modifiable risk factors for primary and secondary cancer development. Increasing awareness amongst breast cancer survivors and encouraging engagement to achieve beneficial lifestyle changes is of paramount importance. The evidence outlined above identifies that the time around breast cancer diagnosis is a pivotal moment for lifestyle modification advice and this should be a core focus of secondary risk reduction guidance and clinical practice. Furthermore, sufficient awareness and engagement of healthcare professionals in risk reduction strategies is imperative and is a fundamental principle of the HSEs ‘Making Every Contact Count’ Program. Research has been conducted at Cork University Hospital looking at breast cancer survivors and oncology clinicians awareness of modifiable risk factors and willingness to engage in or refer to secondary risk reduction services, if available. The study included over 300 patients and 30 clinicians and preliminary results will be presented at The European Society of Medical Oncology Conference this September. Full results are expected to be published later this year. There is a need for diagnosis specific lifestyle based interventions however, to our knowledge, no large scale secondary risk reduction service is currently available in Ireland. A strategy such as, the Irish Heart Foundation’s Cardiac Rehabilitation program could be utilised as a blueprint for this urgent public health issue.

In summary, the focus in breast cancer care is often pharmacological prescribing however the evidence supports lifestyle intervention as an important part of the treatment course in this cohort. Patients should be offered counselling on the importance of diet, weight management, increased physical activity, alcohol reduction and smoking cessation at an appropriate time point for them. These interventions have the potential to impact breast cancer related mortality and morbidity as well as decrease chronic disease related risk.

References available on request

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