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Connecting the Dots Between Breast Cancer Risk and Obesity
Dr. Vered Stearns discusses researching ways to reduce breast cancer recurrence through effective weight-loss interventions and why we need to bring more discoveries from the lab to the clinic
Women with breast cancer who are overweight or obese experience inferior outcomes compared to those with normal weight despite receiving optimal therapies. Dr. Vered Stearns is conducting studies to both develop effective weight loss interventions and reveal new information about how weight loss may reduce the risk of breast cancer, recurrence, and death.
Last year, Dr. Stearns and other researchers published a study comparing a remote weight loss intervention (including telephone and web-based tools for coaching and tracking diet, exercise, and more) against entirely self-directed methods for women with a history of breast cancer. Her team found that the remote, actively monitored approach not only led participants to lose more weight but, more importantly, positively impacted biomarkers for breast cancer risk.
Dr. Stearns is a professor of oncology and director of the women's malignancies disease group at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University. She is a member of the BCRF Scientific Advisory Board and has been a BCRF Investigator since 2003.
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Read the transcript below:
Chris Riback: Dr. Sterns, Happy New Year. Holiday time and relaxation time seems to often go away quickly. So, I hope you're still able to reap some of the new year benefits.
Dr. Vered Stearns: Happy new year to you as well. I had a relaxing time, and I'm looking forward to 2021.
Chris Riback: I think all of us are, and everyone has been perfectly happy to say goodbye to 2020, that is for sure. I want to talk to you about your study from last year around how best to do that via remote coaching or through more self-directed measures. But let me start with the concept of weight loss more generally. We know that being overweight can bring various health risks to anyone. That's why for many of us it's a new year's resolution, whether we have breast cancer or not. Are the health risks greater for people either at risk of or managing through breast cancer?
Dr. Vered Stearns: That's exactly right. As you know, individuals that are overweight or obese are at risk for many illnesses, but in addition to what we're aware of, such as diabetes or heart disease, people that are overweight or obese are also at risk for several types of cancers. Specifically for the field of my interest, women who are overweight or obese are at a slightly higher risk of developing breast cancer. But more than that, if they develop breast cancer, they are also at risk for inferior outcomes. So this is why trying to help our women lose weight has been a priority.
Chris Riback: As I was researching this and learning more about you and some of your work, I came across the fact that I know you know. I didn't know this, that unfortunately for various reasons, many women gain weight after a cancer diagnosis, which can increase their risk of recurrence and death of course. Why does that occur? Is it physiological, emotional, behavioral, some mix of all of the above?
Dr. Vered Stearns: There are indeed several reasons why women who have been diagnosed with breast cancer gain weight. Not everybody gains weight, I want to emphasize that, but many will. It's probably more likely to happen in women who are still premenopausal at a time of their breast cancer diagnosis, and may undergo several treatments such as chemotherapy or receive some endocrine treatment that will enhance menopause, and maybe it will be a more abrupt menopause. So those are some of the women who struggle a little more with weight gain over time. In addition, when women do get chemotherapy, there's some alteration either in the foods they prefer to eat or with the taste buds or having a little bit less activity, so most women on chemotherapy actually gain some weight. Again, not a lot, and it doesn't necessarily continue, but they do gain some weight. So this is something that we try very much to address from the very beginning of the treatment course.
Chris Riback: When you say address, do you mean surely from a medical health point of view, but is it as well, you know. None of us likes to feel out of shape. None of us likes to feel overweight, and so I would imagine on some level it is both a physical health risk, but also perhaps an emotional mental burden added on top of what one is already obviously going through. Or am I overstating it?
Dr. Vered Stearns: You're absolutely correct. Having a diagnosis of cancer is very scary. It's overwhelming, and there's a lot to think about and plan. So we really try to first concentrate on the treatment, demonstrating how most women survive their cancer or live for many years with their cancer, and then offer in addition to a treatment plan also what my colleagues and I are calling prescription to wellness. We want women to be able to live their lives as well as they want to. The other thing I remind women is that you might have to undergo multiple different treatments for your cancer, and this will take months or a year, and then you might need to be on hormonal therapy for five to 10 years. So this gives us time for continued dialogue.
So at least what I do, I encourage women to continue to eat healthy and to have regular activity during treatment, because it actually minimizes the side effects related to treatment. But if a woman says, "I've never been really very active," or, "I really know I need to make a change in my diet." I don't necessarily ask her to make an immediate change. We start with gradual changes, take a walk around the block or talk to our nutritionist, and then once we go through the acute part of the treatment, then we'll help her with a more rigorous plan. Indeed, in the study that we're talking about today, we enrolled women who were about three or so months from their completion of the acute part of their treatment, because we wanted them to be able to focus on this part of continuing to feel well and be well.
The other thing I wanted to mention is that women do really like the idea of getting as much information as possible about other activities that can help them reduce the risk of cancer coming back, and being able to change their diet or change their physical activity or other intervention that can help reduce inflammation is something that can help control and it will help reduce your risk of cancer recurrence.
Chris Riback: Yes, it was just going through my mind and listening to you that having, in a situation that surely must feel so far out of one's control, to have even minimal tools that one can control or even have the feeling of control has to be useful, and to segue even more into your research, powerful. Let's pick up on the power. What is POWER-remote weight loss intervention, and how does it compare to self-directed weight loss intervention?
Dr. Vered Stearns: Yes, thank you for providing me the opportunity to tell you a little bit about our work. The POWER stands for “practice-based opportunities for weight reduction.” The very initial POWER study was actually conducted by our collaborators from internal medicine, Dr. Larry Appel, and others who also participate in the breast cancer study. In the initial study, the investigators compared weight reduction strategy, an in-person strategy when the person at high-risk—so in that particular first study cardiovascular disease or heart disease—will come and meet with a coach in person and have their weight taken and vital signs and so on, on a regular basis.
That was compared to what they call a remote intervention, where there was a one-time visit with a coach, and then everything was done through the internet and a phone with a coach. This was compared to what's called a self-directed intervention, which basically means you provide the patients with educational material and they followed whatever they wanted. If they wanted to try and lose weight on their own, they could. What that study showed was that the patients who participated in either the in-person POWER arm or in the remote POWER arm, both lost similar amount of weight over a 24 month period. You see this result almost immediately within three to six months. Those that were in the self-directed arm had a little bit more trouble losing weight.
So, we board this remote intervention. Basically, we felt our patients are busy. They want to live their lives. We need to help them lose weight, but we need to do it in a way that will be with little interference. What we did in our study was to have two arms. One is the POWER-remote arm, or the patient would meet one time with a coach, and then the intervention will be done via a smartphone or internet-based platform where they can log in their foods and activity and communicate with a coach, and then a self-directed arm. In both arms, patients received the same amount of intervention. In our particular study, the coaching was for a year, and we also collected some baseline, and then over time questionnaires related to mood and sleep and other activities, and also blood samples to look at inflammatory and other biomarkers.
Chris Riback: I want to ask you about the biomarkers and what you ended up seeing there. I'm curious though, what did you hear from the patients, and what did you hear from the coaches? What do the coaches say about the interactions and the feedback that they were getting, I guess, in real-time from the patients?
Dr. Vered Stearns: So let me start with the patients. First, our patients were thrilled to be able to join a study where there's an intervention, where we're trying to help them to do something that was difficult for them to do on their own. Part of why I started this study was that I'd sit in clinic with my patients and they’d tell me that they were eating very little, and they were exercising, and they're just not able to lose weight. I knew they were trying very hard, so we wanted to provide them the coaching they needed. So it was very easy to enroll.
We enrolled patients not just from our site, but we publicized it to the community. So patients were very, very happy to have this opportunity. And to coaches, some of the coaches worked previously on the cardiovascular study I described to you. So, we actually had all educational forum, and I have to thank my colleague, Cesar Santa-Maria, who really developed some of the educational materials where we actually taught the coaches about breast cancer. They knew a lot about weight loss, but we talked to him about some of the potential symptoms or treatments that our patients have gone through that they may not be as familiar with.
Chris Riback: I would imagine for the coaches, it's very fulfilling to realize that the work that they are accustomed to doing now can be applied as well, and you're helping find ways to apply that work as well to this potentially whole new population that can get such benefits from their coaching. I would have to assume that's got to be very fulfilling.
Dr. Vered Stearns: Absolutely. This has been an incredible collaboration that's expanding. In addition to our colleagues that I already mentioned in internal medicine, we have a behavioral psychologist. We have individuals who are specialized in nutrition and individuals from endocrinology. It's been a very rewarding collaboration.
Chris Riback: Tell me about the impact on biomarkers. So you went through the study. What was the impact on biomarkers for breast cancer risk and ability to improve patient outcomes?
Dr. Vered Stearns: So, as I mentioned previously, in this study we compared several biomarkers, and we chose biomarkers that are either related to obesity or to breast cancer risk. Many of those biomarkers are what we call inflammatory biomarkers. So some of the biomarkers we looked at are adiponectin and leptin, which are commonly altered in individuals who are overweight and obese. We also looked at lipid profiles. We looked at insulin and glucose and a C-reactive protein. The other maybe more novel biomarker we looked at was telomere length, and what we've seen is that has been consistent with other studies. We did see positive changes in leptin, and also modulation in inflammatory biomarkers and lipid profiles. So overall, it suggests that losing weight is good for you in many ways as it relates to heart disease and diabetes, but additionally, you may be helpful in reducing the risk of cancer. Again, perhaps through having less inflammation and less insulin resistance.
Chris Riback: I'm curious, was there impact on the people who did the remote coaching and did the remote weight loss? Was there additional behavioral change or ongoing behavioral change for them even after? Were you able to look at that at all? Did they, in a sense, stay with the program even once the program might have ended, more than the self-directed? I'm assuming that they did, but I don't know if that was something that you had the opportunity to look at.
Dr. Vered Stearns: In this particular study, we have not looked at benefits beyond one year. But in the previous study I described to you in the cardiovascular disease prevention, we know the benefits, the people who lose weight at three to six months seem to be able to maintain this weight loss at 12 and 24 months. It seems to be fairly sustained. So once you are able to create this change in behavior, you teach people what works for them. What we do here is coaching in an individualized way. Each person has perhaps a different weakness, and we're able to coach them to teach them how to use different tools to maybe eat differently, or have new methods of physical activity, to create this new balance that leads to weight loss in their situation. So every individual is different, but once you have been able to help an individual lose weight, it seems to be fairly sustained.
Chris Riback: Well, personally, I happen to have two weaknesses, Ben and Jerry's. It's both of them. So, you would have to do double work with me, because it's really both of them.
Dr. Vered Stearns: Part of it is that you should not avoid your weaknesses altogether, but know how to use them in a way that you continue to enjoy your weakness, but also lose some weight while doing it.
Chris Riback: Thank you, Doctor. Now I see why your patients love you so much. I love that advice. Thank you. You're hired. There's another personal health wellness area that I understand that you have recently reported on out in San Antonio, and that was on sleep. What did you study? What did you find, and what should we know about?
Dr. Vered Stearns: Thank you for highlighting this recent presentation. My colleague, Jenny Sheng, with other collaborators Janelle Coughlin and Michael Smith have looked at the same patients that we talked about who enrolled in our POWER-remote study. What they looked at was whether they had a sleep disturbance and whether that affected their weight loss. We know that sleep disturbance is very common in cancer survivor and is associated with obesity, suboptimal eating behaviors, and metabolism. So what we did here, we looked at people who reported poor sleep at baseline, and then we looked at whether they were able to lose weight in a similar fashion.
What we found was that patients who had poor sleep were having more difficulty losing weight. My colleague, Dr. Coughlin, actually has an ongoing study right now, which is also supported in part by Breast Cancer Research Foundation, where all the patients received the six months intervention, the POWER- remote intervention. But prior to the weight loss intervention, they're randomized to an eight week sleep intervention or not. So we're trying to figure out whether helping people sleep better before they're starting the weight loss strategy will be helpful. So we're looking forward to reporting that in the next year or so.
Chris Riback: That will be very interesting to hear about, and it's another resolution. Among the things so interesting to someone like me about your work is you're hitting on these wellness areas that we all think about, and we all know that we should be doing. We all know we shouldn't be eating seven pints of Ben and Jerry's, to exaggerate the point, but we know that being fit and carrying extra weight is a negative thing. We know we should be sleeping better. To be able to tie that directly to the physical benefits and the biomarkers that you're talking about for breast cancer, it has to go back to one of the points that you raised at the beginning. Very, very empowering. There's so much about it that we can't control. Here are some things and some tools that can put some aspects of it, with help, a little bit back into your control.
Dr. Vered Stearns: That's absolutely the message that we're sharing with our patients. We don't always have an explanation of why one develops breast cancer. We have some medical treatments that will be helpful, but the additional wellness strategies can help even further, and that's absolutely in their control.
Chris Riback: Let me ask you about the patients and your patients, because I read a great quote of yours. You were talking about physician scientists, people who move seamlessly between the laboratory and clinic, between the science and the patient. You said, and I'm quoting you here, "I was impressed not only with the breadth of their scientific knowledge, but even more so with their ability to translate state of the art research into the specific context of patient treatments." Why does that combination speak so strongly to you?
Dr. Vered Stearns: As a physician, I want to continue and provide the best possible treatments and hopefully cures for our patients. I know that what we have available to us today is still limited to some degree, don't get me wrong. We've had amazing, amazing advancements in the last few years and decades, but still some individuals will have a breast cancer recurrence, are diagnosed with advanced breast cancer or other types of cancer for that matter. And would die after disease. Even if they live with it for years, this is something that influences every day of their lives. So I'm hopeful that we can continue and improve outcomes across the continuum of breast cancer. To do that, I feel that we need to bring new scientific discoveries from the laboratory to the clinic.
So the example we talked about today, here we have a weight loss intervention, but what we're trying to do is learn, why do some people lose weight? What we didn't mention is that about half of the women lost at least 5 percent of their weight and the intervention arm, but about 50 percent did not, and those women worked as hard. So what is it? Is there something biologically different, or are there other parameters? We just mentioned sleep for example, or a biomarker that can help us tell women better whether they're going to be able to lose weight with a behavioral strategy, or whether they need something else. To help us with some of these answers, we work with amazing laboratory scientists. In this example, Dr. [Dipali] Sharma did most of our cytokine work, and Dr. [Mary] Armanios did some of our telomere work. So lots of people were thinking about the same problem, but from a different perspective, and I think that that's going to bring more solutions and more cures and discoveries.
Chris Riback: We certainly would hope so. I'm curious as well about you. How did you get into this? I mean, going back, where did you grow up? For you, was it always science? Was it always research and medicine? Did you ever think, perhaps, that instead you'd be a fiction novelist or world-class skier? How'd you get into this?
Dr. Vered Stearns: I always wanted to be a physician. My own memory is to the age of five or so when my grandfather was in the hospital for many weeks, and my mother was one of the primary caretakers for him. I spent lots of time observing the amazing teams that took care of him, and it inspired me to be a physician. I thought he had lung cancer and died of that cancer, and whether that story's exactly right or not, I cannot ensure, but it inspired me to want to be a physician. And then I was always strong in sciences, and was able to attend medical school, and always was interested in oncology.
When I started doing my clinical rotations, that interest even increased, because what I liked about oncology was that you are specialized, but you're also become the primary care physician, if you will, of that patient. You get very, very close to the patient, the family. So are you able to have this close relationship while also being a specialist. And then during my fellowship, this is when I really decided that I wanted to pursue breast cancer related research, and my clinic on breast cancer and this by working by other Breast Cancer Research Foundation recipients, Marc Lippman, Dan Hayes, and Nancy Davidson. So I've been inspired by working with them to continue their legacy and improve outcomes of those living with and beyond breast cancer.
Chris Riback: What do folks like me just not understand? What part of the battle to cure breast cancer do you wish perhaps people heard better or understood more?
Dr. Vered Stearns: The way I think about breast cancer today has really evolved over the two decades that I have been practicing. Years ago, we thought of breast cancer as maybe one or two diseases, but since that time, we understand that there are several subtypes of breast cancer, and even within breast cancer, there are multiple subtypes. So what makes it challenging is that many of our studies focus on the larger subtypes, if you will, and now we have to get a little bit more specific into those smaller categories within the larger categories. this is where it becomes more difficult, because even though breast cancer is relatively common in Western societies, when you need to do those various specific studies, you really do need to conduct those over many sites and centers. Some of our most important studies have been international in nature. So this is very challenging.
The other thing that people need to know is that it takes sometimes years to conduct and report results. This is even more compounded in studies of prevention, cancer prevention, because even though you might be delivering an intervention and comparing it to some control, you need to wait years to count the number of cancer to develop, to know if your intervention benefited people. The number of individual expense that goes along with it are just very large, and that's been one of the most challenging type of studies to conduct.
Chris Riback: Yes. Time and patience are hard, very hard under normal circumstances, surely even harder under the circumstances that you're trying to do research on. Dr. Stearns, to close out, I'd be remiss if I didn't ask. BCRF, what role have they played in your research?
Dr. Vered Stearns: The Breast Cancer Research Foundation has been instrumental in my research over the years in several ways. First and foremost, of course, is the funding that allowed us to conduct series of studies. I've described at least a couple to you today, but over the years, we've conducted several studies. Those are types of studies that are difficult to sometimes get funded or to do in a comprehensive manner with some of the more traditional federal base agencies. So what the BCRF has allowed me to do is to trust that I can deliver on what I told the BCRF leadership I can do, and then I can take those results and create or design larger studies, and bring other grants to support the work. So leveraging the initial fundings from BCRF and provide that additional support to new studies, and this has been really an incredible resource over the years.
The second thing is by developing collaborations and partnership with other BCRF grantees, I have numerous collaborations. I can't even start counting them with you. Those have been, again, very important for us to advance the science. I will add another benefit, which is the BCRF also supports education and mentorship of a lot of our young faculty members. Throughout the years in partnership with other foundations, such as the American Society of Clinical Oncology, among other many of our trainees received young investigator award or other career development award. Again, BCRF has been instrumental to that. In fact, I was a recipient of the advanced career research award from the BCRF over a decade ago. Again, those have all been instrumental to our continued pursuit in improving all outcomes related to breast cancer.
Chris Riback: Well, thank you for that, and thank you for your collaboration and mentorship and work and research, and for your conversation today.
Dr. Vered Stearns: Thank you very much, Chris.