A review of obesity, insulin resistance, and the role of exercise in breast cancer patients

Prognostic value of insulin resistance in patients with female reproductive system malignancies: A multicenter cohort study

BACKGROUND

Insulin resistance (IR) and systemic inflammation are common in patients with cancer and are associated with poor prognosis. Few studies have reported IR in female reproductive system malignancies. This study investigated the prognostic value of IR and systemic inflammation in this population.

METHODS

A prospective multicenter real-world cohort study involving 571 patients diagnosed with female reproductive system malignancies was conducted. Lipid ratios (low-density lipoprotein-cholesterol/high-density lipoprotein-cholesterol [LHR], total cholesterol/HDL-cholesterol [TCHR], triglyceride/HDL-cholesterol [TGHR], fasting triglyceride/glucose [TyG]) were used to reflect IR. Optimal cut-off values were determined using maximally selected rank statistics. The Kaplan-Meier and Cox regression were used to calculate the hazard ratios for overall survival.

RESULTS

Over half (55.90%) of the 571 patients with female reproductive system malignancies (mean age: 52 years) had cervical cancer. Both IR and inflammation were negatively correlated with overall survival in female reproductive system cancer patients. Multivariate survival analysis showed that patients with high LHR (hazard ratio [HR]: 1.51, 95% confidence interval [CI]: 1.01-2.25, p = .046), high TCHR (HR: 1.90, 95% CI:1.22-2.95, p = .005), high TGHR (HR: 1.66, 95% CI:1.17-2.36, p = .004), high TyG (HR: 1.64, 95% CI:1.13-2.40, p = .010), high neutrophil lymphocyte ratio (NLR, HR: 2.03, 95% CI:1.44-2.86, p = .004) were significantly associated with worse prognosis. By calculating the concordance index of the four IR surrogate indicators, TyG was the most valuable indicator for the prognosis of patients with malignant tumors of the female reproductive system. High TyG combined with high NLR had improved prognostic value (HR: 3.22, 95% CI: 1.97-5.26, p < .001).

CONCLUSIONS

IR can be used as an independent predictor of prognosis in the female reproductive system malignancy population regardless of the IR substitution index. The combination of TyG and NLR could better predict the prognostic outcomes of women with breast cancer.

Phytochemicals in the treatment of inflammation-associated diseases: the journey from preclinical trials to clinical practice

Advances in biomedical research have demonstrated that inflammation and its related diseases are the greatest threat to public health. Inflammatory action is the pathological response of the body towards the external stimuli such as infections, environmental factors, and autoimmune conditions to reduce tissue damage and improve patient comfort. However, when detrimental signal-transduction pathways are activated and inflammatory mediators are released over an extended period of time, the inflammatory process continues and a mild but persistent pro-inflammatory state may develop. Numerous degenerative disorders and chronic health issues including arthritis, diabetes, obesity, cancer, and cardiovascular diseases, among others, are associated with the emergence of a low-grade inflammatory state. Though, anti-inflammatory steroidal, as well as non-steroidal drugs, are extensively used against different inflammatory conditions, they show undesirable side effects upon long-term exposure, at times, leading to life-threatening consequences. Thus, drugs targeting chronic inflammation need to be developed to achieve better therapeutic management without or with a fewer side effects. Plants have been well known for their medicinal use for thousands of years due to their pharmacologically active phytochemicals belonging to diverse chemical classes with a number of these demonstrating potent anti-inflammatory activity. Some typical examples include colchicine (alkaloid), escin (triterpenoid saponin), capsaicin (methoxy phenol), bicyclol (lignan), borneol (monoterpene), and quercetin (flavonoid). These phytochemicals often act via regulating molecular mechanisms that synergize the anti-inflammatory pathways such as increased production of anti-inflammatory cytokines or interfere with the inflammatory pathways such as to reduce the production of pro-inflammatory cytokines and other modulators to improve the underlying pathological condition. This review describes the anti-inflammatory properties of a number of biologically active compounds derived from medicinal plants, and their mechanisms of pharmacological intervention to alleviate inflammation-associated diseases. The emphasis is given to information on anti-inflammatory phytochemicals that have been evaluated at the preclinical and clinical levels. Recent trends and gaps in the development of phytochemical-based anti-inflammatory drugs have also been included.

Association of Healthy Diet and Physical Activity With Breast Cancer: Lifestyle Interventions and Oncology Education

Global cancer statistics suggest that breast cancer (BC) is the most diagnosed cancer in women, with an estimated 2. 3 million new cases reported in 2020. Observational evidence shows a clear link between prevention and development of invasive BC and lifestyle-based interventions such as a healthy diet and physical activity. The recent findings reveal that even minimal amounts of daily exercise and a healthy diet reduced the risk of BC, mitigated the side effects of cancer treatment, and stopped the recurrence of cancer in the survivors. Despite the myriad benefits, the implementation of these lifestyle interventions in at-risk and survivor populations has been limited to date. Given the need to disseminate information about the role of physical activity and nutrition in BC reduction, the review aimed to present the recent scientific outreach and update on associations between the lifestyle interventions and BC outcomes to narrow the gap and strengthen the understanding more clearly. This review covers more direct, detailed, and updated scientific literature to respond to frequently asked questions related to the daily lifestyle-based interventions and their impact on BC risk and survivors. This review also highlights the importance of the oncology provider's job and how oncology education can reduce the BC burden.

Influence of physician's lifestyle on the prescription of healthy habits to breast cancer patients (LACOG 1218)

BACKGROUND

Healthy lifestyle is capable of positively modifying the survival of breast cancer (BC) patients. We aimed to evaluate how physician's lifestyle influences on the prescription of healthy habits to BC patients.

METHODS

An online questionnaire to evaluate physician lifestyle and prescription of healthy habits to BC patients was developed and circulated by e-mail to physicians dedicated to treat BC patients. A multivariate Poisson regression analysis assessed which factors of physician lifestyle could influence on prescription of healthy habits.

RESULTS

A total of 267 physicians answered the questionnaire from October to November 2018. In terms of physician lifestyle, 228 (85.4%) had healthy eating habits and 236 (88.4%) practiced physical activity. Overall, 84.3% of the physicians advised their BC patients on the importance of lifestyle modification. Physicians who did not exercise regularly have a higher probability of not advising for health lifestyle (RR 2.48; p = 0.0265) as opposite to physicians ≥ 50 years-old (RR 0.37; p = 0.0118). Obesity treatment and management was performed by 45.3% of physicians. Being a breast surgeon (RR 1.29; p = 0.0025) or radiation oncologists (RR 1.82; p = 0.0025) were associated with not performing obesity treatment and management. About 53.4% of physicians referred overweight or obese patients to a dietitian and/or endocrinologist. Male gender (RR 1.35; p = 0.0296), breast surgeons (RR 1.99; p = 0.0001), and clinical practice in public health system (RR 1.53; p = 0.0012) were associated with not referring as opposed to physicians ≥ 50 years-old (RR 0.46; p = 0.0005).

CONCLUSION

Our survey showed some influence of physician's lifestyle on the prescription of healthy habits to BC patients. Physicians who practice physical activity regularly had a higher probability of advising lifestyle modification and about half of physicians did some type of overweight and obese management.

Breast Cancer Diet "BCD": A Review of Healthy Dietary Patterns to Prevent Breast Cancer Recurrence and Reduce Mortality

Breast cancer (BC) represents the most common cancer in women, while overweight and obesity are the second preventable cause of cancer. Weight gain and fat accumulation are common after BC diagnosis; moreover, weight gain during the treatment decreases the survival rate and increases the risk of recurrence in breast cancer survivors (BCS). To reduce the risk of second primary cancer or BC recurrence, and all-cause mortality in BCS, multiple interventions have been investigated to obtain reduction in weight, BMI and/or waist circumference. The aim of this narrative review is to analyze evidence on BCS for their risk of recurrence or mortality related to increased weight or fat deposition, and the effects of interventions with healthy dietary patterns to achieve a proper weight and to reduce fat-related risk. The primary focus was on dietary patterns instead of single nutrients and supplements, as the purpose was to investigate on secondary prevention in women free from disease at the end of their cancer treatment. In addition, BC relation with insulin resistance, dietary carbohydrate, and glycemic index/glycemic load is discussed. In conclusion, obesity and overweight, low rates of physical activity, and hormone receptor-status are associated with poorer BC-treatment outcomes. To date, there is a lack of evidence to suggest which dietary pattern is the best approach for weight management in BCS. In the future, multimodal lifestyle interventions with dietary, physical activity and psychological support after BC diagnosis should be studied with the aim of reducing the risk of BC recurrence or mortality.

[Physical activity after breast cancer diagnosis and survival: A systematic review]

INTRODUCTION

The benefits of physical activity (PA) in breast cancer are currently recognized in primary prevention. The World Cancer Research Fund (WCRF) and then the National Cancer Institute (INCa) have reported conflicting results regarding the impact of post-diagnosis PA on breast cancer outcomes. The aim of this systematic review is to assess the association between PA after breast cancer diagnosis and overall mortality, specific mortality and risk of breast cancer recurrence in the literature.

METHODS

Randomized trials, prospective cohorts and meta-analyses studying post-diagnosis PA and overall mortality, breast cancer mortality or risk of recurrence after breast cancer published between January 1, 2014 and October 1, 2019 were included. The articles selected by the INCa report prior to 2014 were included in the literature review.

RESULTS

Eighteen articles have been selected. Studies unanimously concluded that overall mortality was reduced by post-diagnosis PA practice. For specific mortality, 5 meta-analyses showed a significant decrease in breast cancer mortality and 2 found a decrease in the risk of recurrence.

CONCLUSION

Post-diagnosis PA reduces overall mortality and appears to impact specific breast cancer mortality and risk of recurrence. However, these results need to be confirmed by larger randomized trials.

The effect of modifiable risk factors on breast cancer aggressiveness among black and white women

INTRODUCTION

Although breast cancer incidence is higher among white women, black women are more likely to have aggressive tumors with less favorable histology, and to have a worse prognosis. Obesity and alcohol consumption have been identified as two modifiable risk factors for breast cancer, while physical activity may offer protection. Little however is known about the association of these factors with race on the severity of breast cancer.

METHODS

Data collected as part of a large prospective study looking at insulin resistance and race among women with breast cancer was queried for patient characteristics, lifestyle factors and tumor characteristics. The association with Nottingham Prognostic Index (NPI) was assessed with different models using univariate and multivariate linear regression.

RESULTS

Among 746 women in our cohort, 82% (n = 615) were white and 18% (n = 131) were black, mean age 58 years. Black patients were more likely to have high BMI (31.0 vs. 26.7, p < 0.0001), comorbidities (69% vs 55%, p = 0.01), self-reported poor diet (70% vs 42%, p < 0.001), be sedentary (56% vs 46%, p = 0.03) and were less likely to consume alcohol (8% vs 32%, p < 0.0001) compared to white patients. Overall, 137 (18%) of the patients had poorer prognosis (NPI > 4.4), which was significantly associated with younger age (55.6 vs 58.5 years, p = 0.02), black race (27% vs 15%, p = 0.001), triple negative cancer (15% vs 6%, p = 0.003), and poor diet (54% vs 45%, p = 0.046) compared to patients with better prognosis (NPI ≤ 4.4). On multivariate analysis, (model R² = 0.12; p < 0.001), age (β = -0.011 per year, p = 0.002), healthy diet (β = -0.195, p = 0.02), and exercise (β = -0.004, p = 0.02) were associated with better prognosis, while black race (β = 0.247, p = 0.02) and triple negative cancer (β = 0.908, p < 0.0001) were associated with poor prognosis. Neither alcohol use nor BMI was significantly associated with NPI.

CONCLUSION

Among modifiable risk factors, diet and exercise are associated with NPI. Unmodifiable factors including race and biologic subtype remain the most important determinants of prognosis.

Moderate exercise training since adolescence reduces Walker 256 tumour growth in adult rats

KEY POINTS

Cancer growth, cell proliferation and cachexia index can be attenuated by the beneficial programming effect of moderate exercise training, especially if it begins in adolescence. Walker 256 tumour-bearing rats who started exercise training during adolescence did not revert the basal low glycaemia and insulinaemia observed before tumour cell inoculation. The moderate exercise training improved glucose tolerance and peripheral insulin sensitivity only in rats exercised early in adolescence. The chronic effects of our exercise protocol are be beneficial to prevent cancer cachexia and hold clear potential as a nonpharmacological therapy of insulin sensitization.

ABSTRACT

We tested the hypothesis that moderate exercise training, performed early, starting during adolescence or later in life during adulthood, can inhibit tumour cell growth as a result of changes in biometric and metabolic markers. Male rats that were 30 and 70 days old performed a treadmill running protocol over 8 weeks for 3 days week^-1 , 44 min day^-1 and at 55-65% V ̇ O 2 max . After the end of training, a batch of rats was inoculated with Walker 256 carcinoma cells. At 15 days after carcinoma cell inoculation, the tumour was weighed and certain metabolic parameters were evaluated. The data demonstrated that physical performance was better in rats that started exercise training during adolescence according to the final workload and V ̇ O 2 max . Early or later moderate exercise training decreased the cachexia index, cell proliferation and tumour growth; however, the effects were more pronounced in rats that exercised during adolescence. Low glycaemia, insulinaemia and tissue insulin sensitivity was not reverted in Walker 256 tumour-bearing rats who trained during adolescence. Cancer growth can be attenuated by the beneficial programming effect of moderate exercise training, especially if it begins during adolescence. In addition, improvement in glucose-insulin homeostasis might be involved in this process.

Efficacy of Complementary Therapies in the Quality of Life of Breast Cancer Survivors

Breast cancer (BC) is the most common cancer diagnosed in women and the second most common cancer overall, ranking as the fifth cause of death from cancer. The chronicity of the disease produces long-term physiological and psychological manifestations, which adversely affect the quality of life of the individual. The primary treatment while managing cancer presents with various debilitating side effects. With the recent advances in treatment techniques that have improved the survival rate, patients suffer from continuing posttreatment complications. Patients seem to cope well with the stress of treatment of BC and sustain a normal life; however, the deterioration in physical well-being makes the patient functionally inefficient. Exercise has been proven to be an effective, safe, and feasible tool in combating the adverse effects of treatment, prevents complications and decreases the risk of BC-specific mortality. This review briefly presents an overview of the burden of the disease and its management strategies. Owing to the heterogeneity of the population and the multitude of therapies they receive, the response of each patient to treatment is different and so is the magnitude of adverse effects. The review discusses the late sequelae following treatment and evidence supporting the role of physical activity in their management. In conclusion, there is a need for personalized physical activity plans to be developed to suit the individual and their circumstances.

Chronic Effects of Resistance Training in Breast Cancer Survivors

Objective. To analyse effects of resistance training (RT) in breast cancer survivors (BCS) and how protocols and acute variables were manipulated. Methods. Search was made at PubMed, Science Direct, and LILACS. All articles published between 2000 and 2016 were considered. Studies that met the following criteria were included: written in English, Spanish, or Portuguese; BCS who have undergone surgery, chemotherapy, and/or radiotherapy; additional RT only; analysis of muscle performance, body mass composition (BMC), psychosocial parameters, or blood biomarkers. Results. Ten studies were included. PEDro score ranged from 5 to 9. Rest interval and cadence were not reported. Two studies reported continuous training supervision. All reported improvements in muscle strength, most with low or moderate effect size (ES), but studies performed with high loads presented large ES. Five described no increased risk or exacerbation of lymphedema. Most studies that analysed BMC showed no relevant changes. Conclusions. RT has been shown to be safe for BCS, with no increased risk of lymphedema. The findings indicated that RT is efficient in increasing muscle strength; however, only one study observed significant changes in BMC. An exercise program should therefore consider the manipulation of acute and chronic variables of RT to obtain optimal results.

Feasibility study to evaluate compliance of physical activity over a long time period and its influence on the total activity score, glucose metabolism and physical and psychological parameters following breast cancer

Despite recommendations that patients with breast cancer ought to undertake physical exercise, a majority of breast cancer patients fail to change their lifestyle and to increase their physical activity following diagnosis. In this clinical intervention feasibility study, compliance and sustainability of a walking training program over 24 weeks in patients with breast cancer following treatment were examined. The endpoints were retention rates after 12 and 24 weeks (6 months) and serum levels of glucose metabolism, the total activity score, endurance, a subjectively perceived exertion-during-endurance stress test, quality of life and fatigue. A supervised walking training session for 60-75 min twice-weekly over 6 months in 35 patients with breast cancer following treatment was examined. The study retention at 12 weeks was 27/35 (77%), and at 24 weeks 24/35 (69%). After 24 weeks, the glycated hemoglobin (HbA1c) score was significantly lowered following the intervention (P=0.001). Insulin and glucose levels remained unchanged. Significant improvements were measured in the patients' body mass index (P=0.001), endurance (P=0.013) and in psychological parameters such as fatigue (P=0.008) and the quality of life (P=0.007). Furthermore, the patients exhibited significant improvements in their subjectively perceived exertion during an endurance-stress test (P=0.079) and in their total activity score (P=0.931). The present study demonstrated an increase in total activity resulting from the supervised walking training program twice-weekly over 6 months. Significant changes in long-term parameters of glucose metabolism, such as in the HbA1c score, also occurred. Furthermore, significant improvements in physical and psychological parameters were observed.

G9A performs important roles in the progression of breast cancer through upregulating its targets

Breast cancer (BC) is the most common type of malignancy in females worldwide, however, its underlying mechanisms remain poorly understood. The present study aimed to investigate the mechanisms behind the development and progression of BC and identify potential biomarkers for it. The chromatin immunoprecipitation-DNA sequencing (ChIP-Seq) dataset GSM1642516 and gene expression dataset GSE34925 were downloaded from the Gene Expression Omnibus database. Affy and oligo packages were used for the background correction and normalization of the gene expression dataset. Based on Limma package and the criteria of a fold change >1.41 or <0.71, and a false discovery rate adjusted P-value <0.05, differentially-expressed genes (DEGs) in euchromatic histone lysine methyltransferase 2 (G9A) -knockout (KO) breast samples compared with control samples were identified. The Database for Annotation, Visualization and Integrated Analysis was used for the functional enrichment analysis of the DEGs. Bowtie 2 and model-based analysis of ChIP-Seq version 14 (macs14) were used for the mapping of raw reads and the identification of G9A binding sites (peaks), respectively. In addition, overlapping genes between the DEGs and genes in the peaks located in −3000 to 3000 bp centered in the transcription start sites (conpeaks) were screened out and microRNAs (miRNAs) believed to regulate those overlaps were identified through the TargetScan database. A total of 217 DEGs were identified in G9A-KO samples, which were mainly involved in the biological processes and pathways associated with the inflammatory response and cancer progression. A total of 10,422 peaks, containing 1,210 conpeaks involving 1,138 genes, were identified. Among the 1,138 genes, 15 were overlapped with the DEGs, and 35 miRNAs were identified to regulate those overlaps. Insulin-induced gene 1 was regulated by 9 genes in the miRNA-gene regulation network, which may indicate its importance in the progression of BC. The present study identified potential biomarkers of BC that may be useful in the diagnosis and treatment of patients with the disease.

Clinically Relevant Physical Benefits of Exercise Interventions in Breast Cancer Survivors

Evidence is currently limited for the effect of exercise on breast cancer clinical outcomes. However, several of the reported physical benefits of exercise, including peak oxygen consumption, functional capacity, muscle strength and lean mass, cardiovascular risk factors, and bone health, have established associations with disability, cardiovascular disease risk, morbidity, and mortality. This review will summarize the clinically relevant physical benefits of exercise interventions in breast cancer survivors and discuss recommendations for achieving these benefits. It will also describe potential differences in intervention delivery that may impact outcomes and, lastly, describe current physical activity guidelines for cancer survivors.

Community-based participatory research to improve life quality and clinical outcomes of patients with breast cancer (DianaWeb in Umbria pilot study)

INTRODUCTION

Breast cancer (BC) is the most frequent cancer in Europe and the International Agency for Research on Cancer (IARC) has estimated over 460 000 incident cases per year. Survival among patients with BC has increased in the past decades and EUROCARE-5 has estimated a 5-year relative survival rate of 82% for patients diagnosed in 2000-2007. There is growing evidence that lifestyle (such as a diet based on Mediterranean principles associated with moderate physical activity) may influence prognosis of BC; however, this information is not currently available to patients and is not considered in oncology protocols. Only a few epidemiological studies have investigated the role of diet in BC recurrence and metastasis.

METHODS AND ANALYSIS

DianaWeb is a community-based participatory research dedicated to patients with BC and represents a collaborative effort between participants and research institutions to determine if specified changes in lifestyle would result in improved outcomes in terms of quality of life or survival. The aim of the study is to recruit a large number of participants, to monitor their lifestyle and health status over time, to provide them tips to encourage sustainable lifestyle changes, to analyse clinical outcomes as a function of baseline risk factors and subsequent changes, and to share with patients methodologies and results. DianaWeb uses a specific interactive website (http://www.dianaweb.org/) and, with very few exceptions, all communications will be made through the web. In this paper we describe the pilot study, namely DianaWeb in Umbria.

ETHICS AND DISSEMINATION

DianaWeb does not interfere with prescribed oncological treatments; rather, it recommends that participants should follow the received prescriptions. The results will be used to plan guidelines for nutrition and physical activity for patients with BC. The pilot study was approved by the ethics committee of the University of Perugia (reference number 2015-002), and is supported by Fondazione Cassa di Risparmio di Perugia (2013.0185 021).

The Role of Docosahexaenoic Acid (DHA) in the Control of Obesity and Metabolic Derangements in Breast Cancer

Obesity represents a major under-recognized preventable risk factor for cancer development and recurrence, including breast cancer (BC). Healthy diet and correct lifestyle play crucial role for the treatment of obesity and for the prevention of BC. Obesity is significantly prevalent in western countries and it contributes to almost 50% of BC in older women. Mechanisms underlying obesity, such as inflammation and insulin resistance, are also involved in BC development. Fatty acids are among the most extensively studied dietary factors, whose changes appear to be closely related with BC risk. Alterations of specific ω-3 polyunsaturated fatty acids (PUFAs), particularly low basal docosahexaenoic acid (DHA) levels, appear to be important in increasing cancer risk and its relapse, influencing its progression and prognosis and affecting the response to treatments. On the other hand, DHA supplementation increases the response to anticancer therapies and reduces the undesired side effects of anticancer therapies. Experimental and clinical evidence shows that higher fish consumption or intake of DHA reduces BC cell growth and its relapse risk. Controversy exists on the potential anticancer effects of marine ω-3 PUFAs and especially DHA, and larger clinical trials appear mandatory to clarify these aspects. The present review article is aimed at exploring the capacity of DHA in controlling obesity-related inflammation and in reducing insulin resistance in BC development, progression, and response to therapies.

APPL1-Mediating Leptin Signaling Contributes to Proliferation and Migration of Cancer Cells

Leptin has been implicated in tumorigenesis and tumor progression, particularly in obese patients. As a multifunctional adaptor protein, APPL1 (containing pleckstrin homology domain, phosphotyrosine binding domain, and a leucine zipper motif 1) plays a critical role in regulating adiponectin and insulin signaling pathways. Currently, high APPL1 level has been suggested to be related to metastases and progression of some types of cancer. However, the intercourse between leptin signaling pathway and APPL1 remains poorly understood. Here, we show that the protein levels and phosphorylation statues of APPL1were highly expressed in tissues from human hepatocellular carcinoma and triple-positive breast cancer. Leptin stimulated APPL1 phosphorylation in a time-dependent manner in both human hepatocellular carcinoma HepG2 cell and breast cancer MCF-7 cell. Overexpression or suppression of APPL1 promoted or attenuated, respectively, leptin-induced phosphorylation of STAT3, ERK1/2, and Akt in the cancer cells, accompanied with enhanced or mitigated cell proliferation and migration. In addition, we identified that APPL1 directly bound to both leptin receptor and STAT3. This interaction was significantly enhanced by leptin stimulation. Our results suggested that APPL1 positively mediated leptin signaling and promoted leptin-induced proliferation and migration of cancer cells. This finding reveals a novel mechanism by which leptin promotes the motility and growth of cancer cells.