Dr. Silvana Spadafora, MD, FRCPC, Michela Febbraro, and Jane Howard 2010 Northern Health Research Conference Sudbury, O

1. A Retrospective Study Examining Post-Diagnosis BMI Changes in Breast Cancer Patients Referred to the ADCP after the Implementation of Wellness Initiatives Dr. Silvana Spadafora, MD, FRCPC, Michela Febbraro, and Jane Howard 2010 Northern Health Research Conference Sudbury, Ontario

2. Breast Cancer Facts • Breast cancer is the most frequently diagnosed cancer among Canadian women and is the second-leading cause of cancer-related death • Recent literature suggests that the 5 and 10 year survival rates are 89% and 80%, respectively Breast Cancer Statistics. Retrieved May 24, 2010, from www.cancer.ca Kim, C., Kang, D., Park, J. (2009). A Meta-Analysis of Aerobic Exercise Interventions for Women with Breast Cancer, Western Journal of Nursing Research, 31(4), 437-461.

3. Breast Cancer and Weight Gain • Breast cancer patients receiving adjuvant chemotherapy often experience weight gain and/or adverse body composition changes after diagnosis • 50-96% of breast cancer patients experience significant weight gain • Gains between 5 and 13.6 lbs are most common but it is not uncommon for gains of 22 lbs or greater to occur Demark-Wahnefried, W., Rimer, B.K., Winer, E.P. (1997). Weight gain in women diagnosed with breast cancer. Journal of the American Dietetic Association, 97(5): 519-529. Rooney, M., Wald, A. (2007). Interventions for the management of weight and body composition changes in women with breast cancer. Clinical Journal of Oncology Nursing, 11(1): 41-52.

4. The Consequences of Post-Diagnosis Weight Gain • An increased BMI or body weight is associated with higher rates of breast cancer recurrence and poorer survival rates • Weight gain also predisposes patients to several other comorbidities such as: • cardiovascular disease • diabetes • hypertension • orthopedic disturbances Rooney, M., Wald, A. (2007). Interventions for the management of weight and body composition changes in women with breast cancer. Clinical Journal of Oncology Nursing, 11(1): 41-52. Harvie, M.N., Campbell, A.B., Howell, A. (2004). Energy balance in early breast cancer patients receiving adjuvant chemotherapy. Breast Cancer Research and Treatment 83: 201-210.

5. The Consequences of Post-Diagnosis Weight Gain • Weight gain also results in • a loss of self-esteem • altered self-image • anxiety concerning appearance • reduced quality of life Rooney, M., Wald, A. (2007). Interventions for the management of weight and body composition changes in women with breast cancer. Clinical Journal of Oncology Nursing, 11(1): 41-52.

6. Why is this important? • The comorbidities associated with weight gain will have a negative effect on their lives and could result in premature death unrelated to their initial cancer diagnosis

7. Benefits of Weight Loss/Maintenance After Diagnosis • Weight loss and/or weight maintenance after diagnosis has a positive impact on treatment outcome and survival • Diet and physical activity both have important roles to play in weight management Miller, A.B., Linseisen, J. (2010). Achievements and future of nutritional cancer epidemiology. International Journal of Cancer, 126, 1531-1537.

8. Benefits of Physical Activity • Decrease in body fat • Increase in lean tissue • Maintenance of bone mineral density • Improved stamina, flexibility, strength, and fitness • Improved confidence and quality of life • Increase in energy levels and management of pain and nausea during treatment • Management of lymphedema Rooney, M., Wald, A. (2007). Interventions for the management of weight and body composition changes in women with breast cancer. Clinical Journal of Oncology Nursing, 11(1): 41-52. Milne, H.M., Wallman, K.E., Gordon, S., Courneya, K.S. (2008) Effects of a combined aerobic and resistance exercise program in breast cancer survivors: a randomized controlled trial. Breast Cancer Research and Treatment, 108: 279-288. Irwin, M.L., Alvarez-Reeves, M., Cadmus, L., Mierzejewski, E., Mayne, S.T., Yu, H. Chung, G.G., Jones, B., Knobf, M.T., DiPietro, L. (2009). Exercise Improves Body Fat, Lean Mass, and Bone Mass in Breast Cancer Survivors. Obesity, 17, 1534-1541.

9. Physical Activity Recommendations • Although literature has not decided upon the ideal physical activity intervention program, the following are elements of successful programs: • Combination of aerobic, strength, and flexibility activities • Realistic goal setting and education • Group exercise sessions • Post-program follow up • Exercise programs that define their goal as weight loss or increased stamina are more successful than programs with broader goals such as decreasing breast cancer recurrence or risk of cardiovascular disease Ballard-Barbash, R., Hunsberger, S., Alciati, M.H., Blair, S.N. Goodwin, P.J., McTiernan, A., Wing, R. Shatzkin, A.. (2009). Journal of the National Cancer Institute, 101, 630-643. Kremers, S. Ruebsaet, A., Martens, M. Gerards, S., Jonkers, R., Candel, M., deWeedt, I., de Vries, N. (2010). Obesity Reviews, 11, 371-379.

10. Diet and Nutrition • When combined with physical activity a diet based on Canada’s Food Guide can help support healthy and maintainable weight loss Mefferd, K., Nichols J.F., Pakiz, B. (2006). A cognitive behavioural therapy intervention to promote weight loss improves body composition and blood lipid profiles among overweight breast cancer survivors. Breast Cancer Research and Treatment, 104: 145-152.

11. Responsibility of Healthcare Professionals • It is important that healthcare professionals become aware that weight management represents an important goal to achieve in the overall care of breast cancer patients • The next step is to define ways to effectively educate and motivate patients

12. Wellness at the Algoma District Cancer Program • At the ADCP our focus for breast cancer patients has shifted from illness to wellness • A Wellness Class was implemented at the ADCP in 2008 • The Wellness Class: • Provides information about action planning, healthy • eating and physical activity • Is run by a nurse, dietitian and physiotherapist

13. Other Community Resources • Aquafit Classes at the Delta Hotel • Bosom Buddy Walkers Program • Cooking Classes Upstairs at Rome’s • Grocery Store Walk Through sponsored by Algoma Public Health • Massage Therapy, Wellness Products

14. Breast Cancer Rehabilitation Program • 8 week program at Sault College • Offered to breast cancer patients who have completed their treatment • 1 group session per week • 45 minute class • Incorporates aerobic, strengthening and flexibility components • 10-15 minute education session before each class • Each participant is provided with an individualized exercise routine for home • The program goal is to regain energy levels and stamina • 2 sessions have been completed

15. How are we doing? • In order to assess the effectiveness of the wellness initiatives a retrospective chart audit was conducted • The BMI of breast cancer patients at diagnosis, and at 6, 12, and 24 months post diagnosis were recorded • Data on patients diagnosed in 2007 and 2008 has been collected, and 2009 data is ongoing

16. Results

17. Results • The baseline cohort experienced an average gain of 1.32kg at 6 months, 1.71kg at 12 months, and 1.06kg at 24 months • 85% of patients in the baseline cohort were overweight at diagnosis • The second cohort experienced an average loss of 0.67kg at 6 months, 1.22kg at 12 months, and 3.11kg at 24 months • 67% of patients in the second cohort were overweight at diagnosis

18. Conclusions • The majority of breast cancer patients at the ADCP in 2007 and 2008 were overweight at diagnosis • Women in the baseline cohort experienced an average gain post diagnosis while the second cohort experienced an average loss post diagnosis • These results may be attributed to success of the Wellness Classes which began in 2008

19. Future Plans and Considerations • The study will be shortened to 3 years instead of the intended 5 • Further Promotion of Wellness Classes and community resources • Extension of wellness class to other cancer types

20. Thank you