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Chintamani, Tandon M, Ghosh J. Breast Cancer with Associated Problems. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bell KE, Pfeiffer AG, Schmidt S, Bos L, Russell C, Barnes T, Di Sebastiano KM, Avrutin E, Gibson M, Dubin JA, Mourtzakis M. Low-frequency exercise training improves cardiovascular fitness and strength during treatment for breast cancer: a single-arm intervention study. Sci Rep 2021; 11:22758. [PMID: 34815445 PMCID: PMC8610997 DOI: 10.1038/s41598-021-01962-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/26/2021] [Indexed: 11/09/2022] Open
Abstract
Aerobic and resistance exercise during and after cancer treatment are important for health-related outcomes, however treatment-specific barriers may inhibit adherence. We explored the effect of lower-frequency exercise training on fitness, body composition, and metabolic markers (i.e. glucose and lipids) in a group of recently diagnosed breast cancer patients. Fifty-two females ≥ 18 years with stage I-IIIB breast cancer were instructed to attend 2 cardiovascular and strength training sessions/week over 12 weeks, but program length was expanded as needed to accommodate missed sessions. Pre- and post-intervention, we measured: (1) cardiovascular fitness, (2) isometric strength, (3) body composition (dual-energy X-ray absorptiometry), and (4) fasting glucose, insulin, c-peptide, and lipids. Pre-intervention, participants were 53 ± 10 years old (mean ± SD) and overweight (BMI: 27.5 ± 5.4 kg m-2, 40.1 ± 6.5% body fat). Forty participants completed the program over a median 20 weeks (range: 13-32 weeks, median frequency: 1.2 sessions/week), over which predicted VO2peak improved by 7% (2.2[0.1-4.4] mL/kg/min) (delta[95% CI]), and strength increased by 7-9% (right arm: 2.3[0.1-4.5] N m; right leg: 7.9[2.1-13.7] N m; left leg: 7.8[1.9-13.7] N m). Body composition and metabolic markers were unchanged. An exercise frequency of 1.2 sessions/week stimulated significant improvements in fitness, and may represent a practical target for patients during active treatment.
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Affiliation(s)
- Kirsten E Bell
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Amanda G Pfeiffer
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Schuyler Schmidt
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Lisa Bos
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Caryl Russell
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Tyler Barnes
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Katie M Di Sebastiano
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Egor Avrutin
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Marielle Gibson
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Joel A Dubin
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Marina Mourtzakis
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada.
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WISER Survivor Trial: Combined Effect of Exercise and Weight Loss Interventions on Insulin and Insulin Resistance in Breast Cancer Survivors. Nutrients 2021; 13:nu13093108. [PMID: 34578984 PMCID: PMC8469124 DOI: 10.3390/nu13093108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/14/2022] Open
Abstract
Obesity-associated breast cancer recurrence is mechanistically linked with elevated insulin levels and insulin resistance. Exercise and weight loss are associated with decreased breast cancer recurrence, which may be mediated through reduced insulin levels and improved insulin sensitivity. This is a secondary analysis of the WISER Survivor clinical trial examining the relative effect of exercise, weight loss and combined exercise and weight loss interventions on insulin and insulin resistance. The weight loss and combined intervention groups showed significant reductions in levels of: insulin, C-peptide, homeostatic model assessment 2 (HOMA2) insulin resistance (IR), and HOMA2 beta-cell function (β) compared to the control group. Independent of intervention group, weight loss of ≥10% was associated with decreased levels of insulin, C-peptide, and HOMA2-IR compared to 0–5% weight loss. Further, the combination of exercise and weight loss was particularly important for breast cancer survivors with clinically abnormal levels of C-peptide.
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Lero MW, Shaw LM. Diversity of insulin and IGF signaling in breast cancer: Implications for therapy. Mol Cell Endocrinol 2021; 527:111213. [PMID: 33607269 PMCID: PMC8035314 DOI: 10.1016/j.mce.2021.111213] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 12/13/2022]
Abstract
This review highlights the significance of the insulin receptor (IR) and insulin-like growth factor-1 receptor (IGF-1R) signaling pathway in cancer and assesses its potential as a therapeutic target. Our emphasis is on breast cancer, but this pathway is central to the behavior of many cancers. An understanding of how IR/IGF-1R signaling contributes to the function of the normal mammary gland provides a foundation for understanding its aberrations in breast cancer. Specifically, dysregulation of the expression and function of ligands (insulin, IGF-1 and IGF-2), receptors and their downstream signaling effectors drive breast cancer initiation and progression, often in a subtype-dependent manner. Efforts to target this pathway for the treatment of cancer have been hindered by several factors including a lack of biomarkers to select patients that could respond to targeted therapy and adverse effects on normal metabolism. To this end, we discuss ongoing efforts aimed at overcoming such obstacles.
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Affiliation(s)
- Michael W Lero
- Department of Molecular, Cell & Cancer Biology, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Leslie M Shaw
- Department of Molecular, Cell & Cancer Biology, University of Massachusetts Medical School, Worcester, MA, 01605, USA.
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Li M, Song L, Yuan J, Zhang D, Zhang C, Liu Y, Lin Q, Wang H, Su K, Li Y, Ma Z, Liu D, Dong J. Association Between Serum Insulin and C-Peptide Levels and Breast Cancer: An Updated Systematic Review and Meta-Analysis. Front Oncol 2020; 10:553332. [PMID: 33194614 PMCID: PMC7658676 DOI: 10.3389/fonc.2020.553332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 10/08/2020] [Indexed: 01/07/2023] Open
Abstract
Background Several studies have reported that hyperinsulinemia plays a part in the etiology of breast cancer. However, no consensus has been reached. Therefore, we conducted a meta-analysis to explore the role of insulin and C-peptide in breast cancer. Methods A systematic search in PubMed, Embase, and The Cochrane Library was conducted up to September, 2020. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used to measure effect sizes. Publication bias was assessed using the Egger test. Stability of these results was evaluated using sensitivity analyses. Results Fourteen articles including 27,084 cases and five articles including 2,513 cases were extracted for serum insulin levels and C-peptide levels. We found that C-peptide levels were positively associated with breast cancer with overall SMD = 0.37 (95% CI = 0.09–0.65, I2 = 89.1%). Subgroup analysis by control source illustrated a positive relationship between breast cancer and C-peptide levels in population-based control. Subgroup analysis by C-peptide level indicated a positive correlation between breast cancer and C-peptide levels no matter C-peptide levels in case group is ≤3 ng/ml or >3 ng/ml. Subgroup analysis by age showed that C-peptide level positively correlated to breast cancer in women between the ages of 50 and 60. However, we did not identify any relationship between breast cancer and insulin levels (SMD = 0.22, 95% CI = −0.06–0.50, I2 = 97.3%). Conclusion This meta-analysis demonstrated that C-peptide levels were positively related to breast cancer in women, and no relationship between insulin levels and breast cancer was found.
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Affiliation(s)
- Manwen Li
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Limin Song
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Junhua Yuan
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Di Zhang
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Caishun Zhang
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Yuan Liu
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Qian Lin
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Haidan Wang
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China
| | - Kaizhen Su
- Clinical Medicine Department, Medical College, Qingdao University, Qingdao, China
| | - Yanrun Li
- Clinical Medicine Department, Medical College, Qingdao University, Qingdao, China
| | - Zhengye Ma
- Clinical Medicine Department, Medical College, Qingdao University, Qingdao, China
| | - Defeng Liu
- Clinical Medicine Department, Medical College, Qingdao University, Qingdao, China
| | - Jing Dong
- Special Medicine Department, School of Basic Medicine, Qingdao University, Qingdao, China.,Physiology Department, Medical College, Qingdao University, Qingdao, China
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Alan O, Akin Telli T, Aktas B, Koca S, Ökten IN, Hasanov R, Basoglu T, Arikan R, Demircan NC, Ercelep O, Kaya S, Ugurlu MU, Kaya H, Akgul Babacan N, Dane F, Yumuk PF. Is insulin resistance a predictor for complete response in breast cancer patients who underwent neoadjuvant treatment? World J Surg Oncol 2020; 18:242. [PMID: 32907593 PMCID: PMC7488234 DOI: 10.1186/s12957-020-02019-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Neoadjuvant chemotherapy is the standard front-line treatment modality in locally advanced breast cancer. Achieving pathological complete response (pCR) is a significant prognostic factor for prolonged disease-free and overall survival. Insulin resistance is defined as a pathological condition in which insulin effect is impaired in peripheral target tissues such as the skeletal muscle, liver, and adipose tissue. The relationship between breast cancer and insulin resistance is controversial. In this study, our aim is to evaluate the role of insulin resistance, body mass index (BMI), metabolic syndrome, and inflammation markers to predict complete response in breast cancer patients who underwent neoadjuvant treatment. METHODS Data from 55 locally advanced non-diabetic breast cancer patients, treated with neoadjuvant chemotherapy between 2015 and 2017, were retrospectively evaluated. Homeostatic model assessment, IR = insulin resistance (HOMA-IR) was calculated by using the obtained insulin and fasting blood glucose values before neoadjuvant chemotherapy (fasting insulin × fasting glucose/405). We considered a cut-off of 2.5 for insulin resistance. The systemic inflammatory index (SII), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) were calculated. RESULTS Twenty-five patients had no insulin resistance. The most common pathologic subtype (56%) was hormone receptor (HR) positive and human epidermal growth factor receptor-2 (Her-2)-negative invasive ductal carcinoma. Sixteen (29%) patients had a pathological complete response (pCR). We found that the probability of pCR in patients with insulin resistance was 4.7 times lower than that in patients without insulin resistance [OR: 4.7 (95%CI 1.7-17.2), p = 0.01]. CONCLUSION Our results revealed that insulin resistance may have a negative effect on pathological complete response (pCR) following neoadjuvant therapy particularly with hormone-positive and Her-2-negative cases of non-diabetic breast cancer.
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Affiliation(s)
- Ozkan Alan
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey.
| | - Tugba Akin Telli
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Bilge Aktas
- Division of Medical Oncology, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Sinan Koca
- Division of Medical Oncology, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Ilker Nihat Ökten
- Division of Medical Oncology, Medeniyet University School of Medicine, Istanbul, Turkey
| | - Rahib Hasanov
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Tugba Basoglu
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Rukiye Arikan
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Nazim Can Demircan
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Ozlem Ercelep
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Serap Kaya
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Mustafa Umit Ugurlu
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Handan Kaya
- Department of Pathology, Marmara University School of Medicine, Istanbul, Turkey
| | - Nalan Akgul Babacan
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Faysal Dane
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
| | - Perran Fulden Yumuk
- Division of Medical Oncology, Marmara University School of Medicine, Marmara University Pendik Education and Research Hospital, Fevzi Cakmak Mah, Muhsin Yazicioglu C, No 10, Ust Kaynarca, 34890, Istanbul, Turkey
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Borgquist S, Rosendahl AH, Czene K, Bhoo-Pathy N, Dorkhan M, Hall P, Brand JS. Long-term exposure to insulin and volumetric mammographic density: observational and genetic associations in the Karma study. Breast Cancer Res 2018; 20:93. [PMID: 30092829 PMCID: PMC6085687 DOI: 10.1186/s13058-018-1026-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 07/18/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Long-term insulin exposure has been implicated in breast cancer etiology, but epidemiological evidence remains inconclusive. The aims of this study were to investigate the association of insulin therapy with mammographic density (MD) as an intermediate phenotype for breast cancer and to assess associations with long-term elevated circulating insulin levels using a genetic score comprising 18 insulin-associated variants. METHODS We used data from the KARolinska MAmmography (Karma) project, a Swedish mammography screening cohort. Insulin-treated patients with type 1 (T1D, n = 122) and type 2 (T2D, n = 237) diabetes were identified through linkage with the Prescribed Drug Register and age-matched to 1771 women without diabetes. We assessed associations with treatment duration and insulin glargine use, and we further examined MD differences using non-insulin-treated T2D patients as an active comparator. MD was measured using a fully automated volumetric method, and analyses were adjusted for multiple potential confounders. Associations with the insulin genetic score were assessed in 9437 study participants without diabetes. RESULTS Compared with age-matched women without diabetes, insulin-treated T1D patients had greater percent dense (8.7% vs. 11.4%) and absolute dense volumes (59.7 vs. 64.7 cm3), and a smaller absolute nondense volume (615 vs. 491 cm3). Similar associations were observed for insulin-treated T2D, and estimates were not materially different in analyses comparing insulin-treated T2D patients with T2D patients receiving noninsulin glucose-lowering medication. In both T1D and T2D, the magnitude of the association with the absolute dense volume was highest for long-term insulin therapy (≥ 5 years) and the long-acting insulin analog glargine. No consistent evidence of differential associations by insulin treatment duration or type was found for percent dense and absolute nondense volumes. Genetically predicted insulin levels were positively associated with percent dense and absolute dense volumes, but not with the absolute nondense volume (percentage difference [95% CI] per 1-SD increase in insulin genetic score = 0.8 [0.0; 1.6], 0.9 [0.1; 1.8], and 0.1 [- 0.8; 0.9], respectively). CONCLUSIONS The consistency in direction of association for insulin treatment and the insulin genetic score with the absolute dense volume suggest a causal influence of long-term increased insulin exposure on mammographic dense breast tissue.
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Affiliation(s)
- Signe Borgquist
- Division of Oncology and Pathology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden. .,Clinical Trial Unit, Skåne University Hospital, Lund, Sweden.
| | - Ann H Rosendahl
- Division of Oncology and Pathology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Sweden
| | - Nirmala Bhoo-Pathy
- Julius Centre University of Malaya (JCUM), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mozhgan Dorkhan
- Global Medical Affairs, Novo Nordisk A/S, Søborg, Denmark.,Institution for Clinical Sciences, Lund University, Lund, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Sweden.,Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Judith S Brand
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Sweden.,Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
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Giles ED, Jindal S, Wellberg EA, Schedin T, Anderson SM, Thor AD, Edwards DP, MacLean PS, Schedin P. Metformin inhibits stromal aromatase expression and tumor progression in a rodent model of postmenopausal breast cancer. Breast Cancer Res 2018; 20:50. [PMID: 29898754 PMCID: PMC6000949 DOI: 10.1186/s13058-018-0974-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 04/30/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity and type II diabetes are linked to increased breast cancer risk in postmenopausal women. Patients treated with the antidiabetic drug metformin for diabetes or metabolic syndrome have reduced breast cancer risk, a greater pathologic complete response to neoadjuvant therapy, and improved breast cancer survival. We hypothesized that metformin may be especially effective when targeted to the menopausal transition, as this is a lifecycle window when weight gain and metabolic syndrome increase, and is also when the risk for obesity-related breast cancer increases. METHODS Here, we used an 1-methyl-1-nitrosourea (MNU)-induced mammary tumor rat model of estrogen receptor (ER)-positive postmenopausal breast cancer to evaluate the long-term effects of metformin administration on metabolic and tumor endpoints. In this model, ovariectomy (OVX) induces rapid weight gain, and an impaired whole-body response to excess calories contributes to increased tumor glucose uptake and increased tumor proliferation. Metformin treatment was initiated in tumor-bearing animals immediately prior to OVX and maintained for the duration of the study. RESULTS Metformin decreased the size of existing mammary tumors and inhibited new tumor formation without changing body weight or adiposity. Decreased lipid accumulation in the livers of metformin-treated animals supports the ability of metformin to improve overall metabolic health. We also found a decrease in the number of aromatase-positive, CD68-positive macrophages within the tumor microenvironment, suggesting that metformin targets the immune microenvironment in addition to improving whole-body metabolism. CONCLUSIONS These findings suggest that peri-menopause/menopause represents a unique window of time during which metformin may be highly effective in women with established, or at high risk for developing, breast cancer.
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Affiliation(s)
- Erin D Giles
- Department of Nutrition & Food Science, Texas A&M University, 373 Olsen Blvd; 2253 TAMU, College Station, TX, 77843, USA.
| | - Sonali Jindal
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mailing Code: L215, Portland, OR, 97239, USA
| | - Elizabeth A Wellberg
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Troy Schedin
- Department of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Steven M Anderson
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Ann D Thor
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Dean P Edwards
- Departments of Molecular & Cellular Biology and Pathology Immunology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Paul S MacLean
- Anschutz Health & Wellness Center, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA.,Department of Medicine, Divisions of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA.,Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Pepper Schedin
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mailing Code: L215, Portland, OR, 97239, USA.,Knight Cancer Institute, Oregon Health & Science University, 1130 NW 22nd Ave #100, Portland, OR, 97239, USA
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Avilés-Jurado FX, Flores JC, Gumà J, Ceperuelo-Mallafré V, Casanova-Marqués R, Gómez D, Vendrell JJ, León X, Vilaseca I, Terra X. Prognostic relevance of insulin resistance on disease-free survival in head and neck squamous cell carcinomas: Preliminary results. Head Neck 2017; 39:2501-2511. [DOI: 10.1002/hed.24919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/05/2017] [Accepted: 07/14/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Francesc Xavier Avilés-Jurado
- Otorhinolaryngology Head and Neck Surgery Department; Hospital Clínic; Barcelona Catalonia
- HJ23 Otolaryngology Disease Research Group; Insitut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili; Tarragona Catalonia Spain
| | - Joan Carles Flores
- HJ23 Otolaryngology Disease Research Group; Insitut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili; Tarragona Catalonia Spain
- Otorhinolaryngology Head and Neck Surgery Department; Hospital Universitari de Tarragona Joan XXIII, Insitut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili; Tarragona Catalonia Spain
| | - Josep Gumà
- Oncology Department; IISPV, Universitat Rovira I Virgili, Hospital Universitari Sant Joan de Reus; Catalonia Spain
| | | | | | - David Gómez
- Radiation Oncology Department; Hospital Universitari Sant Joan de Reus; Catalonia Spain
| | - Joan Josep Vendrell
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas (CIBERDEM); Madrid Spain
- Endocrinology Department; Hospital Universitari de Tarragona Joan XXIII, Insitut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili; Tarragona Catalonia Spain
| | - Xavier León
- Otorhinolaryngology Head and Neck Surgery Department, Hospital de la Santa Creu i Sant Pau and Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN, MICINN, ISCIII); Universitat Autònoma de Barcelona; Barcelona Spain
| | - Isabel Vilaseca
- Otorhinolaryngology Head and Neck Surgery Department; Hospital Clínic; Barcelona Catalonia
- Centro de Investigación Biomédica en Red de enfermedades Respiratorias (CIBER-Res); Universitat de Barcelona; Barcelona Spain
| | - Ximena Terra
- MoBioFood Research Group; Biochemistry and Biotechnology Department, Universitat Rovira i Virgili; Campus Sescel·lades, Tarragona Spain
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Bruno E, Roveda E, Vitale J, Montaruli A, Berrino F, Villarini A, Venturelli E, Gargano G, Galasso L, Caumo A, Carandente F, Pasanisi P. Effect of aerobic exercise intervention on markers of insulin resistance in breast cancer women. Eur J Cancer Care (Engl) 2016; 27:e12617. [DOI: 10.1111/ecc.12617] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 12/20/2022]
Affiliation(s)
- E. Bruno
- Department of Biomedical Sciences for Health; University of Milan; Milan Italy
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
| | - E. Roveda
- Department of Biomedical Sciences for Health; University of Milan; Milan Italy
| | - J. Vitale
- IRCCS Istituto Ortopedico Galeazzi; Milan Italy
| | - A. Montaruli
- Department of Biomedical Sciences for Health; University of Milan; Milan Italy
| | - F. Berrino
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
| | - A. Villarini
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
| | - E. Venturelli
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
| | - G. Gargano
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
| | - L. Galasso
- Department of Biomedical Sciences for Health; University of Milan; Milan Italy
| | - A. Caumo
- Research Centre of Metabolism; IRCCS Policlinico San Donato Milanese; Milan Italy
| | - F. Carandente
- Department of Biomedical Sciences for Health; University of Milan; Milan Italy
| | - P. Pasanisi
- Department of Predictive & Preventive Medicine; Fondazione IRCCS Istituto Nazionale dei Tumori; Milan Italy
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Ferroni P, Riondino S, Laudisi A, Portarena I, Formica V, Alessandroni J, D'Alessandro R, Orlandi A, Costarelli L, Cavaliere F, Guadagni F, Roselli M. Pretreatment Insulin Levels as a Prognostic Factor for Breast Cancer Progression. Oncologist 2016; 21:1041-9. [PMID: 27388232 DOI: 10.1634/theoncologist.2015-0462] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/09/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Based on the hypothesis that impaired glucose metabolism might be associated with survival outcomes independently of overt diabetes, we sought to investigate the prognostic value of routinely used glycemic parameters in a prospective study of breast cancer (BC) patients. PATIENTS AND METHODS Fasting blood glucose, insulin and HbA1c levels, and insulin resistance (assessed by the Homeostasis Model Assessment [HOMA] index) at diagnosis were evaluated in 286 nondiabetic BC patients (249 with primary cancer, 37 with metastatic) with respect to those parameters' possible associations with clinicopathological features and survival outcomes. As a control group, 143 healthy women matched in a 2:1 ratio for age, blood lipid levels, and body mass index were also investigated. RESULTS Fasting blood glucose level (mean ± SD: 99 ± 26 vs. 85 ± 15 mg/dL), insulin level (median: 10.0 vs. 6.8 μIU/mL), and HOMA index (median: 2.2 vs. 1.4), but not HbA1c level, were significantly elevated in BC patients compared with control subjects. Receiver operating characteristics analysis showed comparable areas for blood glucose and insulin levels, and HOMA index (ranging from 0.668 to 0.671). Using a cutoff level of 13 μIU/mL, insulin had the best specificity (92%) and sensitivity (41%), was significantly associated with disease stage, and acted as a negative prognostic marker of progression-free survival (hazard ratio: 2.17; 95% confidence interval: 1.13-4.20) independently of menopausal status, disease stage, hormone receptor status, and human epidermal growth factor receptor 2 and Ki67 expression. CONCLUSION These results suggest that insulin determination might provide prognostic information in BC and support the hypothesis that lifestyle and/or pharmacological interventions targeting glucose metabolism could be considered to improve survival outcome of selected BC patients. IMPLICATIONS FOR PRACTICE Pretreatment insulin levels may represent a biomarker of adverse prognosis in nondiabetic women with breast cancer, independently of other well-established prognostic factors (i.e., stage, hormone receptors, HER2/neu, and Ki67). This finding has important implications, because it provides the rationale for lifestyle or insulin-targeting pharmacologic interventions as a means of improving breast cancer outcomes not only in early stages, but also in advanced-stage breast cancer patients with aggressive tumor phenotypes (HER2-negative hormone-resistant, or triple-negative breast cancer), in which treatments are still challenging. The possibility of using insulin as a biomarker to guide insulin-targeted interventions also should be taken into account.
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Affiliation(s)
| | - Silvia Riondino
- Interinstitutional Multidisciplinary Biobank, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Anastasia Laudisi
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Ilaria Portarena
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Vincenzo Formica
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Jhessica Alessandroni
- Interinstitutional Multidisciplinary Biobank, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy
| | - Roberta D'Alessandro
- Interinstitutional Multidisciplinary Biobank, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy
| | - Augusto Orlandi
- Anatomic Pathology, Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | | | | | - Fiorella Guadagni
- San Raffaele Roma Open University, Rome, Italy Interinstitutional Multidisciplinary Biobank, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
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Nam S, Park S, Park HS, Kim S, Kim JY, Kim SI. Association Between Insulin Resistance and Luminal B Subtype Breast Cancer in Postmenopausal Women. Medicine (Baltimore) 2016; 95:e2825. [PMID: 26945364 PMCID: PMC4782848 DOI: 10.1097/md.0000000000002825] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Currently, there is limited information on the clinical characteristics of breast cancer patients with insulin resistance. Hence, the purpose of this study was to investigate the association between insulin resistance and clinicopathological factors in newly diagnosed breast cancer patients without diabetes. We assessed 760 patients with breast cancer treated between 2012 and 2014. We compared the clinicopathological characteristics between patients with and without insulin resistance using univariate and multivariate analyses, including after stratification by menopausal status. Insulin resistance was defined according to the homeostatic model assessment of insulin resistance. Of 760 patients, 26.4% had insulin resistance. Age, menopausal status, body mass index, tumor size, histologic grade, Ki-67 expression, and breast cancer subtype significantly differed according to the presence of insulin resistance. Multivariate analysis revealed that postmenopausal status and obesity were significantly associated with insulin resistance. In postmenopausal women, older age, obesity, larger tumor size, advanced stage, and high proliferative luminal B subtype were significantly associated with insulin resistance. In contrast, in premenopausal patients, only obesity was related to insulin resistance. Multivariate analysis indicated that insulin resistance was independently correlated with obesity, larger tumor size, and the luminal B/human epidermal growth factor receptor-2-negative subtype in postmenopausal but not premenopausal patients. Insulin resistance was significantly associated with larger tumors and proliferative luminal B subtype breast cancer in postmenopausal women only. These findings suggest that insulin resistance could mechanistically induce tumor progression and might be a good prognostic factor, and that it could represent a therapeutic target in postmenopausal patients with breast cancer.
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Affiliation(s)
- Sanggeun Nam
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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14
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Ferroni P, Riondino S, Buonomo O, Palmirotta R, Guadagni F, Roselli M. Type 2 Diabetes and Breast Cancer: The Interplay between Impaired Glucose Metabolism and Oxidant Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2015:183928. [PMID: 26171112 PMCID: PMC4480937 DOI: 10.1155/2015/183928] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Metabolic disorders, especially type 2 diabetes and its associated complications, represent a growing public health problem. Epidemiological findings indicate a close relationship between diabetes and many types of cancer (including breast cancer risk), which regards not only the dysmetabolic condition, but also its underlying risk factors and therapeutic interventions. This review discusses the advances in understanding of the mechanisms linking metabolic disorders and breast cancer. Among the proposed mechanisms to explain such an association, a major role is played by the dysregulated glucose metabolism, which concurs with a chronic proinflammatory condition and an associated oxidative stress to promote tumour initiation and progression. As regards the altered glucose metabolism, hyperinsulinaemia, both endogenous due to insulin-resistance and drug-induced, appears to promote tumour cell growth through the involvement of innate immune activation, platelet activation, increased reactive oxygen species, exposure to protumorigenic and proangiogenic cytokines, and increased substrate availability to neoplastic cells. In this context, understanding the relationship between metabolic disorders and cancer is becoming imperative, and an accurate analysis of these associations could be used to identify biomarkers able to predict disease risk and/or prognosis and to help in the choice of proper evidence-based diagnostic and therapeutic protocols.
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Affiliation(s)
- Patrizia Ferroni
- San Raffaele Rome University, IRCCS San Raffaele Pisana, Research Center, Via di Val Cannuta 247, 00166 Rome, Italy
| | - Silvia Riondino
- San Raffaele Rome University, IRCCS San Raffaele Pisana, Research Center, Via di Val Cannuta 247, 00166 Rome, Italy
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Oreste Buonomo
- Department of Surgery, Division of Surgical Oncology, Tor Vergata Clinical Center, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Raffaele Palmirotta
- San Raffaele Rome University, IRCCS San Raffaele Pisana, Research Center, Via di Val Cannuta 247, 00166 Rome, Italy
| | - Fiorella Guadagni
- San Raffaele Rome University, IRCCS San Raffaele Pisana, Research Center, Via di Val Cannuta 247, 00166 Rome, Italy
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
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15
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Ferguson R, Gallagher E, Cohen D, Tobin-Hess A, Alikhani N, Novosyadlyy R, Haddad N, Yakar S, LeRoith D. Hyperinsulinemia promotes metastasis to the lung in a mouse model of Her2-mediated breast cancer. Endocr Relat Cancer 2013; 20:391-401. [PMID: 23572162 PMCID: PMC4093836 DOI: 10.1530/erc-12-0333] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Her2 oncogene is expressed in ∼25% of human breast cancers and is associated with metastatic progression and poor outcome. Epidemiological studies report that breast cancer incidence and mortality rates are higher in women with type 2 diabetes. Here, we use a mouse model of Her2-mediated breast cancer on a background of hyperinsulinemia to determine how elevated circulating insulin levels affect Her2-mediated primary tumor growth and lung metastasis. Hyperinsulinemic (MKR(+/+)) mice were crossed with doxycycline-inducible Neu-NT (MTB/TAN) mice to produce the MTB/TAN/MKR(+/+) mouse model. Both MTB/TAN and MTB/TAN/MKR(+/+) mice were administered doxycycline in drinking water to induce Neu-NT mammary tumor formation. In tumor tissues removed at 2, 4, and 6 weeks of Neu-NT overexpression, we observed increased tumor mass and higher phosphorylation of the insulin receptor/IGF1 receptor, suggesting that activation of these receptors in conditions of hyperinsulinemia could contribute to the increased growth of mammary tumors. After 12 weeks on doxycycline, although no further increase in tumor weight was observed in MTB/TAN/MKR(+/+) compared with MTB/TAN mice, the number of lung metastases was significantly higher in MTB/TAN/MKR(+/+) mice compared with controls (MTB/TAN/MKR(+/+) 16.41±4.18 vs MTB/TAN 5.36±2.72). In tumors at the 6-week time point, we observed an increase in vimentin, a cytoskeletal protein and marker of mesenchymal cells, associated with epithelial-to-mesenchymal transition and cancer-associated fibroblasts. We conclude that hyperinsulinemia in MTB/TAN/MKR(+/+) mice resulted in larger primary tumors, with more mesenchymal cells and therefore more aggressive tumors with more numerous pulmonary metastases.
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Ferguson RD, Gallagher EJ, Scheinman EJ, Damouni R, LeRoith D. The epidemiology and molecular mechanisms linking obesity, diabetes, and cancer. VITAMINS AND HORMONES 2013; 93:51-98. [PMID: 23810003 DOI: 10.1016/b978-0-12-416673-8.00010-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The worldwide epidemic of obesity is associated with increasing rates of the metabolic syndrome and type 2 diabetes. Epidemiological studies have reported that these conditions are linked to increased rates of cancer incidence and mortality. Obesity, particularly abdominal obesity, is associated with insulin resistance and the development of dyslipidemia, hyperglycemia, and ultimately type 2 diabetes. Although many metabolic abnormalities occur with obesity and type 2 diabetes, insulin resistance and hyperinsulinemia appear to be central to these conditions and may contribute to dyslipidemia and altered levels of circulating estrogens and androgens. In this review, we will discuss the epidemiological and molecular links between obesity, type 2 diabetes, and cancer, and how hyperinsulinemia and dyslipidemia may contribute to cancer development. We will discuss how these metabolic abnormalities may interact with estrogen signaling in breast cancer growth. Finally, we will discuss the effects of type 2 diabetes medications on cancer risk.
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Affiliation(s)
- Rosalyn D Ferguson
- Division of Endocrinology, Diabetes and Bone Diseases, Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, P.O. Box 1055, New York, USA
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17
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Garrisi VM, Tufaro A, Trerotoli P, Bongarzone I, Quaranta M, Ventrella V, Tommasi S, Giannelli G, Paradiso A. Body mass index and serum proteomic profile in breast cancer and healthy women: a prospective study. PLoS One 2012; 7:e49631. [PMID: 23226214 PMCID: PMC3511468 DOI: 10.1371/journal.pone.0049631] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 10/15/2012] [Indexed: 12/31/2022] Open
Abstract
Epidemiological studies suggest a possible association between BMI, diagnosis and clinical-pathological breast cancer characteristics but biological bases for this relationship still remain to be ascertained. Several biological mechanisms play a role in the genesis and progression of breast cancer. This study aimed to investigate relationships between BMI and breast cancer diagnosis/progression in a Southern Italian population and to try to interpret results according to the serum proteomic profile of healthy and breast cancer patients. BMI, presence or absence of breast cancer and its clinical-pathological characteristics were analyzed in a series of 300 breast cancer women and compared with those of 300 healthy women prospectively. To investigate whether obesity is associated with alterations in serum protein profile, SELDI-ToF approach was applied.Alcohol consumption (22.7% vs 11.3%; p<0.001) and postmenopausal status (65.7% vs 52%; p<0.001) but not BMI resulted significantly different in patients vs controls. Conversely, BMI was significantly associated with a larger-tumour size (BMI> = 30 respect to normal weight: OR = 2.49, 95% CI 1.25-4.99, p = 0.0098) and a higher probability of having positive axillary lymph node (OR = 3.67, CI 95% 2.16-6.23, p<0.0001). Multivariate analysis confirmed the association of breast cancer diagnosis with alcohol consumption (OR = 2.28;CI 1.36-3.83; p<0.0018). Serum protein profile revealed the presence of significant (p-value <0,01) differentially expressed peaks m/z 6934, m/z 5066 in high BMI breast cancer patients vs healthy subjects and m/z 6934, m/z 3346 in high vs low BMI breast cancer patients.The analysis of pathological features of cancer indicates that normal weight women have a significantly higher probability of having a smaller breast cancer at time of diagnosis and negative axillary lymph nodes while increased BMI is associated with an altered protein profile in breast cancer patients. Further studies to identify specific proteins found in the serum and their role in breast cancerogenesis and progression are in progress.
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Affiliation(s)
- Vito Michele Garrisi
- Clinical Experimental Oncology Department, National Cancer Research Centre, Istituto Tumori Giovanni Paolo II, Bari, Italy.
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Diorio C, Lemieux J, Provencher L, Hogue JC, Vachon É. Aromatase inhibitors in obese breast cancer patients are not associated with increased plasma estradiol levels. Breast Cancer Res Treat 2012; 136:573-9. [DOI: 10.1007/s10549-012-2278-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 09/25/2012] [Indexed: 11/30/2022]
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The evolution of mindfulness-based physical interventions in breast cancer survivors. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:758641. [PMID: 22997532 PMCID: PMC3446749 DOI: 10.1155/2012/758641] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 06/27/2012] [Indexed: 02/05/2023]
Abstract
Survivors of breast cancer are faced with a multitude of medical and psychological impairments during and after treatment and throughout their lifespan. Physical exercise has been shown to improve survival and recurrence in this population. Mind-body interventions combine a light-moderate intensity physical exercise with mindfulness, thus having the potential to improve both physical and psychological sequelae of breast cancer treatments. We conducted a review of mindfulness-based physical exercise interventions which included yoga, tai chi chuan, Pilates, and qigong, in breast cancer survivors. Among the mindfulness-based interventions, yoga was significantly more studied in this population as compared to tai chi chuan, Pilates, and qigong. The participants and the outcomes of the majority of the studies reviewed were heterogeneous, and the population included was generally not selected for symptoms. Yoga was shown to improve fatigue in a few methodologically strong studies, providing reasonable evidence for benefit in this population. Improvements were also seen in sleep, anxiety, depression, distress, quality of life, and postchemotherapy nausea and vomiting in the yoga studies. Tai chi chuan, Pilates, and qigong were not studied sufficiently in breast cancer survivors in order to be implemented in clinical practice.
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