Breast Cancer: integrated care ahead of innovation

A reminder issued by Prof Giuseppe Curigliano ahead of the ESMO Breast Cancer Congress this week suggested that therapeutic innovations should go hand in hand with a multidisciplinary, fully integrated approach to patient care.

Breast cancer is a multifaceted disease, the treatment of which can impact women’s lives in many different ways. Chemotherapy, radiotherapy and targeted therapies are core components of the standard course of treatment for breast cancer but carry possible side-effects:

“Among the possible side-effects of these therapies, cardiovascular toxicity is one that needs to be monitored particularly closely. The ESMO Clinical Practice Guidelines on treatment-induced cardiovascular toxicity, which were designed as a roadmap for managing cardiac risk in cancer patients, have made a significant contribution in this field.”

Prof Curigliano also warned of the risk factors that are known to include pathologies like diabetes and hypertension, but also lifestyle factors, such as smoking or obesity:

“A cardiologist is one of several specialists who should have a permanent place on any breast cancer patient’s medical team, and a cardiac assessment should always be performed before the start of treatment to identify pre-existing conditions or risk factors. Being overweight or obese is a risk factor for developing cardiovascular disease – not just for cancer patients, but for the population as a whole. That’s why, when a woman diagnosed with breast cancer is also overweight, it is essential that in addition to consulting with a cardiologist, she also be immediately referred to a qualified dietitian who can help her to lose weight, adopt a healthy lifestyle and improve her overall fitness,” 

Although tools like the ESPEN guidelines on nutrition in cancer patients¹ have helped to standardise practices in this area of patient care, scientific evidence on the efficacy of nutritional intervention among breast cancer patients is still scarce. A study, the preliminary results of which will be presented at the ESMO Breast Cancer Congress in Berlin, has documented the follow-up of 204 early breast cancer patients who received dietary guidelines from a nutritionist shortly after their initial diagnosis.²

Study author Luisa Carbognin from the University of Verona, Italy, commented: 

“We designed this prospective clinical trial with two main objectives: to assess early breast cancer patients’ adherence to dietary guidelines, and to evaluate the effectiveness of nutritional intervention for weight loss or weight maintenance while undergoing treatment.”

In the studied patient sample, over 60% of women were overweight or obese, and presented dietary patterns high in fat and low in dietary fibre. Moreover, almost half of trial participants had gained 5% or more of their usual bodyweight at the time of cancer diagnosis, and a majority reported suffering from nutritional impact symptoms like constipation or indigestion. Neoadjuvant chemotherapy was prescribed to 56 patients, and 92 women received adjuvant chemotherapy. Overall, about 80% of participants underwent endocrine therapy. Carbognin also reported on the dietary intervention that was given to patients:

“The dietary intervention that patients received consisted of monthly contacts with the nutritionist. Nutritional assessments were performed at baseline and six months after enrolment – additional follow-ups are still ongoing. Our interim analyses showed a statistically significant correlation between high adherence to dietary guidelines and weight loss. Weight loss, in turn, appeared to correlate with lower rates of depression, which we assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).”

According to Carbognin, the small sample size and different treatments administered to participants of the study constitute an obstacle to drawing conclusions from its results: 

“As it is still ongoing, however, we hope to increase the sample size and eventually perform sub-group analyses to compare the different treatment settings and explore any potential differences between them. These initial results indicate that adhering to dietary guidelines can be an effective tool for controlling bodyweight. For women with a normal baseline bodyweight, the goal is to maintain a healthy weight and fitness throughout their course of treatment – it therefore makes sense to offer them support from a nutritionist regardless of their weight at diagnosis.”

Commenting on these results, Prof Giuseppe Curigliano concluded:

“The key message here is that a high adherence to dietary guidelines correlates with weight loss. We must warrant though that in the context of this study, the observed weight loss might actually have been conditioned by the toxicity of the chemotherapy that most of these women received Nutrition is an important aspect of patient care in oncology, and further research in this area needs to be encouraged in order to ground clinical practice in scientific fact.” 

References
1 “ESPEN guidelines on nutrition in cancer patients” by J Arends et al. Clinical Nutrition Volume 36, Supplement 1, 2017. doi: 10.1016/j.clnu.2016.07.015.
2 Abstract 202P_PR ‘Adherence to Dietary Guidelines (DG) and Body Weight Change (BWC) in Early-stage Breast Cancer (EBC): a prospective trial in patients submitted to nutrition evidence-based educational intervention.’ will be presented by Luisa Carbognin during the Poster Display
Session on Friday 3 May 2019, 12:15-13:00 (CEST) in the Exhibition area. Annals of Oncology, Volume 30, 2019 Supplement 3, doi:10.1093/annonc/mdz095

Adherence to Dietary Guidelines (DG) and Body Weight Change (BWC) in Early-stage Breast Cancer (EBC): a prospective trial in patients submitted to nutrition evidence-based educational intervention.
L. Carbognin (1), I. Trestini (1), I. Sperduti (2), E. Fiorio (3), D. Tregnago (3), S. Pilotto (3), G. Scambia (4), G. Tortora (5), M. Milella (6), E. Bria (7)
1.Verona, University of Verona, Verona, Italy, 
2.Regina Elena, Istituto di Biostatistica, Roma, Italy, 
3.Verona, UOC Oncology, AOUI Verona, Verona, Italy, 
4. Fondazione Policlinico Universitario A. Gemelli IRCCS, Division of Gynecologic Oncology, Department of Woman and Child Health,, Roma, Italy, 
5. Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro
Cuore, U.O.C. Medical Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; 11Oncologia Medica,, Roma, Italy,
6. Verona, UOC Oncology, AOUI Verona, University of Verona, Verona, Italy, 7Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Oncologia Medica,, Roma, Italy

Background: Despite weight gain and overweight have been related to an increased risk of recurrence and mortality in patients withEBC, the adherence to nutritional intervention is not entirely explored. Therefore, the aims of this trial were to evaluate theadherence to DG and the effectiveness of nutritional intervention in terms of BWC in patients with EBC undergoing treatment.
Methods: This prospective study included EBC patients addressed to receive neoadjuvant or adjuvant therapy; eligible patientsreceived a nutrition evidence-based educational intervention by a skilled dietitian. Anthropometric and dietary assessments were performed. Adherence to DG was estimated through the validated Med-Diet 14-item questionnaire. Health-Related Quality of Life was analyzed with the EORTC QLQ-C30. Associations between variables and groups according to nutritional variables were analyzed (Chi-square test).

Results: From February 2016 to December 2018, 204 patients were enrolled (median age 49 years). At baseline, 2.5% of patients were underweight, 41.7% were normal weight, 33.3% were overweight and 22.5% were obese. Moreover, 47.5% of patients gained ≥5% of their usual weight. Most patients reported significant nutritional impact symptoms (dyspepsia (51.5%) and constipation
(62.3%)) and presented dietary patterns high in fat (median fat intake was 35.2%) and low in dietary fiber (median fiber intake was 17.2 g/day). A significant correlation between baseline BMI and tension was observed (p<0.0001) as well as BMI and worry, irritability and depression (p<0.0001, p<0.0001 and p=0.008, respectively). Six months after the intervention, the median adherence
to DG was high (median Med-Diet score was 12). A high adherence to nutrition guidelines (defines as a Med-Diet score ≥10, 112 patients) significantly correlated with a weight loss ≥5% from the baseline weight (p=0.005). Furthermore, the weight loss ≥5% was correlated with a lower rate of depression (p=0.05).

Conclusions: These findings suggest that tailored nutritional intervention for women undergoing treatment for EBC may help to improve their adherence to the DG and finally to weight loss.

Legal entity responsible for the study: Luisa Carbognin
Funding: LILT Verona
Disclosure: All authors have declared no conflicts of interest.