![[Feedback]](/icons/banner/feedbackACT.gif){kind=icon}
![[For Subscribers]](/icons/banner/subscriberACT.gif){kind=icon}
![[Archive]](/icons/banner/archiveACT.gif){kind=icon}
![[Search]](/icons/banner/searchACT.gif){kind=icon}
![[Contents]](/icons/banner/tocACT.gif){kind=icon}
|
|
|
|
|
||
Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA 92093-0901 and * Department of Surgery, Duke University Medical Center, Durham, NC 27710
3To whom correspondence should be addressed.E-mail: clrock{at}ucsd.edu.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONEpidemiologic evidenceStudies testing the effects...LITERATURE CITED |
|---|
KEY WORDS: • breast cancer • nutrition • diet • physical activity • obesity
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONEpidemiologic evidenceStudies testing the effects...LITERATURE CITED |
|---|
203,500 U.S. women will be diagnosed with breast cancer (1
). Breast cancer currently accounts for 31% of the incident cancers and 15% of the cancer deaths among women in this country. A majority of all breast cancers are now diagnosed at a localized stage, which is associated with a 5-year survival rate of 96% (2
). However, women who have been diagnosed with breast cancer remain at increased risk for secondary cancer events, other chronic diseases and premature death despite their "cure" (3
). During the past several decades, numerous epidemiologic and laboratory studies have examined associations between nutritional and lifestyle factors and risk for primary breast cancer, whereas relatively few studies have specifically examined associations between these factors and recurrence or overall survival after diagnosis. Nonetheless, some consistencies are already evident in the results from these studies, and two large randomized trials and several small clinical studies are currently testing whether various aspects of lifestyle can be effectively modified in this population or whether these modifications have an effect on long-term outcomes.
|
Epidemiologic evidence |
|---|
|
TOPABSTRACTINTRODUCTIONEpidemiologic evidenceStudies testing the effects...LITERATURE CITED |
|---|
) epidemiologic studies of the association between nutritional factors and progression or recurrence of breast cancer have generally focused on two major factors: relative body weight (or indicators of obesity, such as body mass index) and diet composition. In most of these studies, relative body weight or dietary intakes were assessed at or near the time of diagnosis, involving cohorts of breast cancer survivors in case-control studies or identified within population cohorts of ongoing longitudinal studies.
Since 1990, 26 published studies examined associations between relative body weight and breast cancer recurrence and survival (4
). In 17 of these studies increased body mass index or body weight was found to be a significant risk factor for recurrent disease, decreased survival or both; in 7 studies no association was evident; and in 2 studies a significant inverse association between weight status and survival was identified (4
). The effect of higher (versus lower) relative body weight was fairly substantial in the studies in which an inverse association was observed, indicated by a 30–540% increased risk of death observed in the heavier women. Body fat distribution was examined in two of the published studies reviewed (4
). One found a higher (versus lower) suprailiac-to-thigh ratio to be associated with reduced survival (5
) and the other found no relationship between the waist-to-hip ratio and survival (6
).
Weight gain often occurs in women after the diagnosis of breast cancer (7
,8
). Few studies, however, have addressed whether postdiagnosis weight gain independently influences disease-free or overall survival, and results are inconsistent (4
). Increased body fatness, regardless of weight gain, has been noted in all five studies that measured body composition changes in women undergoing adjuvant chemotherapy, a common treatment for this disease (4
,9
). Thus weight gain in itself may be too crude a measure to detect these changes. However, losses in lean body mass that may or may not be accompanied by significant weight gain have the potential to affect overall health. Lean body mass is the major determinant of resting energy expenditure; therefore these changes also have implications for long-term weight control.
The association between diet composition and recurrence or overall survival has been examined in 13 studies published since 1985 (4
). All of these studies investigated the relationship between risk for recurrence or survival and intake of fat or high-fat foods, whereas other dietary factors that were quantified and examined vary a great deal across these studies. Also, many of these studies did not adjust for stage at diagnosis and other possible influencing factors, so methodologic flaws (in addition to the well-known limitations of self-reported dietary data) impose some constraints in the interpretation of the findings.
Total fat intake (unadjusted for energy intake) was significantly inversely associated with survival or treatment failure (defined as recurrence or new cancer of the contralateral breast) in 5 of the 12 studies that specifically examined this relationship (4
), and an additional study found a trend for this relationship. However, when energy adjusted, fat intake was associated with increased risk for progressive disease in only one of these studies (10
), and in that study the relationship was evident only in women with estrogen receptor–positive (not estrogen receptor–negative) tumors. In addition to total fat intake, 10 of these studies examined associations between risk and intakes of different types of fat (4
). These findings are inconsistent and do not support the theory that fat type independently contributes to prognosis or survival.
Evidence for a relationship between the intakes of vegetables, fruit or related nutrients (e.g., ß-carotene, vitamin C) and risk for recurrence or survival is somewhat more supportive, although the effect on risk is modest. Three of the eight studies that examined these intakes found a significant positive relationship with survival, one found a trend for this relationship, and one found a protective effect among women with node-negative disease (62% of the total sample) (4
). The magnitude of the effect was a 20–90% reduction in risk for death in the studies that found a beneficial effect.
None of the seven studies that examined intake of dietary fiber per se found a significant effect on risk for recurrence or survival (4
). However, three of the four studies that examined relationships between recurrence or survival and intakes of high-fiber foods (e.g., vegetables, fruit, cereal-grain products) found intakes of these foods to be inversely associated with progressive disease, at least at a level of marginal significance.
The relationship between alcohol intake and survival was examined in eight of these cohort studies (4
), and none of these investigations found a significant association, although a nonsignificant inverse association was observed in one. These findings contrast with the evidence from epidemiologic studies that have consistently linked alcohol intake with increased risk for primary breast cancer (11
).
To our knowledge only one study published to date has specifically addressed the relationship between exercise or physical activity and survival after the diagnosis of breast cancer (12
), and this investigation did not identify a beneficial effect. Notably, however, physical activity has been strongly linked to quality of life in breast cancer survivors; therefore an indirect relationship has been suggested. In a comprehensive and critical review, Courneya and Friedenreich (13
) found consistent evidence suggesting that physical exercise has a positive effect on quality of life after cancer diagnosis, including physical and functional well-being and psychological and emotional well-being.
Only one study of nutritional factors and recurrence involving serologic data has been published. Saintot et al. (14
) examined the relationship between selected nutrition-related factors and survival using blood samples collected at diagnosis and before treatment in a case-control study of indicators of oxidative stress and risk for breast cancer. In 317 cases followed for a median of 8 y postdiagnosis, an increased risk of recurrence was observed in patients with plasma lipoperoxide concentrations in the highest versus lowest tertile [relative risk (RR) 2.1, 95% confidence interval (CI) 1.1–4.0], adjusted for age at diagnosis, menopausal status and estrogen and progesterone receptor status. Also, women with cholesterol-adjusted plasma 
-tocopherol concentrations > 22 µmol/L (versus those with lower plasma concentrations) also were observed to have increased risk for death (adjusted RR 1.7, 95% CI 1.0–3.0). The investigators hypothesized that both of these factors may reflect intake of foods high in polyunsaturated fatty acids. However, consideration of dietary intakes and other possible influencing factors in the analysis, as well as replication of these findings, would affect interpretation of this report.
Thus the current epidemiologic evidence strongly supports an inverse relationship between relative body weight and survival in women who have been diagnosed with breast cancer. To date observational studies have not examined or reported whether voluntary postdiagnosis weight loss in women who are overweight alters the risk for recurrence or improves overall survival. Likewise a modest protective effect of intakes of vegetables, fruit and related nutrients on disease progression has been observed in the majority of the epidemiologic studies, whereas recent findings relating to fat intake or alcohol intake are not compelling. Observational epidemiologic studies, however, can never prove cause and effect, and currently it is unknown whether dietary or other lifestyle changes have a significant effect on recurrence or survival. Although women typically report making several changes in their diets after being diagnosed with breast cancer (15
,16
), the effect of these spontaneous changes on recurrence or survival has not been systematically examined.
|
Studies testing the effects of lifestyle modification |
|---|
|
TOPABSTRACTINTRODUCTIONEpidemiologic evidenceStudies testing the effects...LITERATURE CITED |
|---|
15% energy from fat). The rationale for WINS is based on differential survival rates in women diagnosed with breast cancer across countries with various intakes of dietary fat and on laboratory studies suggesting that fat intake may affect breast cancer progression (17
). Preliminary data indicate good adherence, with an average reduction from 33% to 20% energy from fat at 6 mo into the study (18
). In the Women’s Healthy Eating and Living (WHEL) Study, the target population is 3109 women who were diagnosed with early-stage breast cancer within the preceding 4 y and were randomly assigned to a study group after completing initial therapies (19
). The rationale for the WHEL Study is based on laboratory evidence for a beneficial effect of plant constituents such as carotenoids, phytochemicals and fiber in addition to evidence from the epidemiologic studies described previously. The primary emphasis of the WHEL Study intervention is on increased intake of vegetables and fruits, with daily dietary goals of five vegetable servings, 16 oz (437 mL) of vegetable juice, three fruit servings, 15–20% energy from fat and 30 g dietary fiber. Feasibility study reports and preliminary trial data from this study indicate excellent adherence (20
–22
). In both the WINS and WHEL Study, participants will be followed for an average of >6 y, and results are anticipated after 2005. For breast cancer survivors, lifestyle modifications and interventions relating to weight control involve two distinct issues. One issue is whether weight gain after diagnosis can be prevented in women at risk of gaining weight, and the second issue is whether weight loss can be achieved in women who are overweight or obese at (or after) the diagnosis of breast cancer. Whether either of these strategies can influence risk for recurrence or overall survival is the ultimate research question.
A few small studies testing whether diet counseling or increased physical activity can prevent weight gain in women during the immediate postdiagnosis period have had mixed results. Women who were provided intensive diet counseling to achieve energy-restricted diets did not exhibit differences in weight gain compared with control subjects in a randomized trial of 104 women with early-stage breast cancer (23
). In another small randomized controlled study involving 24 early-stage breast cancer patients receiving adjuvant chemotherapy, prescribing aerobic exercise did not significantly affect weight gain, although significant differences were observed in the change in percent body fat (averaging -0.51% in the treatment group versus +2.19% in the control group) (24
). Both diet and physical activity were the behavioral targets in two small studies that found a significant reduction in body weight (or weight maintenance in those not overweight) in women recently diagnosed with breast cancer (25
,26
). Follow-up analysis in one of these studies revealed that the strongest predictor of success of the program was increased physical activity (25
).
Numerous studies have tested a variety of interventions to promote weight loss and maintenance in the general population of overweight and obese women. Findings from those studies, and data collected from individuals who have lost weight and successfully maintained the loss, provide insight about which strategies are likely to be most successful in promoting weight loss in overweight or obese breast cancer survivors (27
,28
). For example, successful weight loss and maintenance of that loss are characterized by high levels of regular physical activity (27
). Emphasizing increased physical activity in weight-loss programs for obese women is associated with significant weight loss (29
), and a dose-response relationship between the amount of exercise and long-term weight loss is typically observed (30
). Breast cancer survivors in particular may benefit from increased physical activity and exercise that includes strength training to restore lean muscle mass. In a small pilot study of 10 premenopausal breast cancer patients receiving adjuvant chemotherapy, a 6-mo program focused on strength training (and included aerobic exercise and guidance toward a low-fat, high-vegetable and high-fruit diet) resulted in significant changes in total body weight of -2.0 ± 1.3 kg and percent body fat of -1.3 ± 1.2% compared with historic controls who experienced gains of 2.2 ± 0.4 kg and 1.8 ± 1.6%, respectively (31
).
Breast cancer survivors are similar to women in the general population with regard to dieting behavior and concern with shape and weight (32
). Unhealthy attitudes and behaviors are common in women who have experienced weight concerns and made numerous attempts to lose weight, which often results in a chaotic eating pattern that is characterized by periods of dietary restriction followed by episodes of overeating. In overweight women who binge eat or who overeat in response to negative thoughts and emotions, cognitive-behavioral therapy has been shown to promote normalization of the eating pattern; when combined with increased exercise this type of intervention promotes significant weight loss (33
). Although low-fat diets promote weight loss only when energy intake is concurrently limited (28
,34
), informed food choices may help to promote a modest reduction in energy intake. For example, strategies that reduce the energy density of the diet (e.g., increased dietary fiber) may help to maintain meal satiety at a lower level of energy intake (35
).
In the Healthy Weight Management for Breast Cancer Survivors Study, we are examining the effect of a group-based program that aims to increase physical activity and promote healthy eating attitudes and behaviors on measured weight change at the end of an intensive treatment period (16 wk) and at 1 y, compared with a wait-list control group, in 85 overweight and obese breast cancer survivors. The intervention emphasizes increased physical activity, including aerobic exercise, strength training and increased lifestyle activity, within a structured cognitive-behavioral therapy curriculum. Dietary guidance is individualized and emphasizes the inclusion of low-energy-density food choices in the planned meal pattern, but excessive dieting behavior is discouraged. An additional research question being addressed in the study is whether individualized telephone counseling can further increase the adherence to increased physical activity in a subset of the group program study participants. Results of these research efforts are anticipated in 2003.
Although much remains to be learned, findings from epidemiologic and clinical studies suggest that lifestyle factors such as diet and physical activity are among the determinants of risk for recurrence or disease progression after the diagnosis of breast cancer. The findings quite consistently indicate that overweight and obesity independently reduce likelihood of survival; some evidence also indicates that increased intakes of vegetables, fruit and related nutrients may be associated with reduced risk. Two large clinical trials are currently testing whether a modification in diet composition can influence risk for recurrence and survival; results from these studies will be known within the next few years. After the diagnosis of breast cancer, healthy weight control that emphasizes increased physical activity to promote maintenance or restoration of lean body mass is a strategy that is fairly well supported by evidence to date. Current research efforts are aimed toward the development of strategies that successfully promote weight loss in overweight and obese breast cancer survivors.
|
ACKNOWLEDGMENTS |
|---|
|
FOOTNOTES |
|---|
2 Supported in part by National Cancer Institute grants CA90413 and CA69375 (CLR) and CA92468, CA81191 and AG11268 (WDW).
4 Abbreviations used: CI, confidence interval; RR, relative risk; WHEL Study, Women’s Healthy Eating and Living Study; WINS, Women’s Intervention Nutrition Study.
|
LITERATURE CITED |
|---|
|
TOPABSTRACTINTRODUCTIONEpidemiologic evidenceStudies testing the effects...LITERATURE CITED |
|---|
1. Jemal, A., Thomas, A., Murray, T. & Thun, M. (2002) Cancer Statistics, 2002. CA Cancer J. Clin. 52:23-47.
2. American Cancer Society (2002) Cancer Facts & Figures 2002 2002 American Cancer Society Atlanta, GA. .
3. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (1992) Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 339:1-15.[Medline]
4. Rock, C. L. & Demark-Wahnefried, W. (2002) Nutrition and survival after the diagnosis of breast cancer: a review of the evidence. J. Clin. Oncol. 20(14):3302-3316.
5. Kumar, N. B., Cantor, A., Allen, K. & Cox, C. E. (2000) Android obesity at diagnosis and breast carcinoma survival: evaluation of the effects of anthropometric variables at diagnosis, including body composition and body fat distribution and weight gain during life span, and survival from breast carcinoma. Cancer 88:2751-2757.[Medline]
6. Zhang, S., Folsom, A. R., Sellers, T. A., Kushi, L. H. & Potter, J. D. (1995) Better breast cancer survival for postmenopausal women who are less overweight and eat less fat. The Iowa Women’s Health Study. Cancer 76:275-283.[Medline]
7. Demark-Wahnefried, W., Rimer, B. K. & Winer, E. P. (1997) Weight gain in women diagnosed with breast cancer. J. Am. Diet. Assoc. 97:519-529.[Medline]
8. Rock, C. L., Flatt, S. W., Newman, V., Caan, B. J., Haan, M. N., Stefanick, M. L., Faerber, S. & Pierce, J. P. (1999) Factors associated with weight gain in women after diagnosis of breast cancer. J. Am. Diet. Assoc. 99:1212-1221.[Medline]
9. Demark-Wahnefried, W., Peterson, B. L., Winer, E. P., Marks, L., Aziz, N., Marcom, P. K., Blackwell, K. & Rimer, K. (2001) Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy. J. Clin. Oncol. 19:2381-2389.
10. Holm, L. E., Nordevang, E., Hjalmar, M. L., Lindbrink, E., Callmer, E. & Nilsson, B. (1993) Treatment failure and dietary habits in women with breast cancer. J. Natl. Cancer Inst. 85:32-36.
11. Smith-Warner, S. A., Spiegelman, D., Yaun, S. S., Van Den Brandt, P. A., Folson, A. R., Goldbohm, A., Graham, S., Holmberg, L., Howe, G. R., Marshall, J. R., Miller, A. B., Potter, J. D., Speizer, F. E., Willett, W. C., Wolk, A. & Hunter, D. J. (1998) Alcohol and breast cancer in women: a pooled analysis of cohort studies. J. Am. Med. Assoc. 279:535-540.
12. Rohan, T. E., Fu, W. & Hiller, J. E. (1995) Physical activity and survival from breast cancer. Eur. J. Cancer Prev. 4:419-424.[Medline]
13. Courneya, K. S. & Friedenreich, C. M. (1999) Physical exercise and quality of life following cancer diagnosis: a literature review. Ann. Behav. Med. 21:171-179.[Medline]
14. Saintot, M., Mathieu-Daude, H., Astre, C., Grenier, J., Simony-Lafontaine, J. & Gerber, M. (2002) Oxidant-antioxidant status in relation to survival among breast cancer patients. Int. J. Cancer 97:574-579.[Medline]
15. Maunsell, E., Drolet, M., Brisson, J., Robert, J. & Deschenes, L. (2002) Dietary change after breast cancer: extent, predictors, and relation with psychological distress. J. Clin. Oncol. 20:1017-1025.
16. Thomson, C., Flatt, S. W., Rock, C. L., Ritenbaugh, C., Newman, V. & Pierce, J. P. (2002) Increased fruit, vegetable and fiber intake and lower fat intake reported among women previously treated for invasive breast cancer. J. Am. Diet. Assoc. 102:801-808.[Medline]
17. Wynder, E. L., Cohen, L. A., Muscat, J. E., Winters, B., Dwyer, J. T. & Blackburn, T. (1997) Breast cancer: weighing the evidence for a promoting role of dietary fat. J. Natl. Cancer Inst. 89:766-775.
18. Chlebowski, R. T., Blackburn, G. L., Buzzard, I. M., Rose, D. P., Martino, S., Khandekar, J. D., York, R. M., Jeffery, R. W., Elashoff, R. M. & Wynder, E. L. (1993) Adherence to a dietary fat intake reduction program in postmenopausal women receiving therapy for early breast cancer. The Women’s Intervention Nutrition Study. J. Clin. Oncol. 11:2072-2080.
19. Pierce, J. P., Faerber, S., Wright, F., Rock, C. L., Newman, N., Flatt, S. W., Kealey, S., Jones, V. E., Wasserman, L., Caan, B. J., Haan, M., Gold, E., Hollenbach, K. A., Jones, L., Marshall, J. R., Ritenbaugh, C., Stefanick, M. L., Thomson, C., Natarajan, L. & Gilpin, E. A. () A randomized trial of the effect of a plant based dietary pattern on breast cancer recurrence: the Women’s Healthy Eating and Living (WHEL) Study. Control. Clin. Trials (in press).
20. Pierce, J. P., Faerber, S., Wright, F. A., Newman, V., Flatt, S. W., Kealey, S., Rock, C. L., Hryniuk, W. & Greenberg, E. R. (1997) Feasibility of a randomized trial of a high-vegetable diet to prevent breast cancer recurrence. Nutr. Cancer 28:282-288.[Medline]
21. Rock, C. L., Flatt, S. W., Wright, F. A., Faerber, S., Newman, V., Kealey, S. & Pierce, J. P. (1997) Responsiveness of carotenoids to a high vegetable diet intervention designed to prevent breast cancer recurrence. Cancer Epidemiol. Biomarkers Prev. 6:617-623.[Abstract]
22. McEligot, A. J., Rock, C. L., Flatt, S. W., Newman, V., Faerber, S. & Pierce, J. P. (1999) Plasma carotenoids are biomarkers of long-term high vegetable intake in women with breast cancer. J. Nutr. 129:2258-2263.
23. Loprinzi, C. L., Athmann, L. M., Kardinal, C. G., O’Fallon, J. R., See, J. A., Bruce, B. K., Dose, A. M., Miser, A. W., Kern, P. S., Tschetter, L. K. & Rayson, S. (1996) Randomized trial of dietician counseling to try to prevent weight gain associated with breast cancer adjuvant chemotherapy. Oncology 53:228-232.[Medline]
24. Winningham, M. L., MacVicar, M. G., Bondoc, M, Anderson, J. I. & Minton, J. P. (1989) The effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. Oncol. Nurs. Forum 16:683-689.[Medline]
25. Goodwin, P., Esplen, M. J., Butler, K., Winocur, J., Pritchard, K., Brazel, S., Gao, J. & Miller, A. (1998) Multidisciplinary weight management in locoregional breast cancer: results of a phase II study. Breast Cancer Res. Treat. 48:53-64.[Medline]
26. McTiernan, A., Ulrich, C., Kumai, C., Bean, D., Schwartz, R., Mahlock, J., Hastings, R., Gralow, J. & Potter, J. D. (1998) Anthropometric and hormone effects of an eight-week exercise-diet intervention in breast cancer patients: results of a pilot study. Cancer Epidemiol. Biomarkers Prev. 7:477-481.
27. Wing, R. R. & Hill, J. O. (2001) Successful weight loss maintenance. Annu. Rev. Nutr. 21:323-341.[Medline]
28. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Am. J. Clin. Nutr. 68:899-917.[Medline]
29. Anderson, R. E., Wadden, T. A., Bartlett, S. J., Zemel, B., Verde, T. J. & Franckowiak, S. C. (1999) Effects of lifestyle activity vs structured aerobic exercise in obese women. J. Am. Med. Assoc. 281:335-340.
30. Jakicic, J. M., Winters, C., Lang, W. & Wing, R. R. (1999) Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women. J. Am. Med. Assoc. 282:1554-1560.
31. Demark-Wahnefried, W., Kenyon, A. J., Eberle, P. & Kraus, W. E. (2002) Preventing sarcopenic obesity among breast cancer patients receiving adjuvant chemotherapy: a feasibility study. Clin. Exerc. Physiol. 4:44-49.
32. Rock, C. L., McEligot, A. J., Flatt, S. W., Sobo, E. J., Wilfley, D. E., Jones, V. E., Hollenbach, K. A. & Marx, R. D. (2000) Eating pathology and obesity in women at risk for breast cancer recurrence. Int. J. Eating Dis. 27:172-179.[Medline]
33. Pendleton, V. R., Goodrick, G. K., Poston, W. S. C., Reeves, R. S. & Foreyt, J. P. (2001) Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int. J. Eating Dis. 31:172-184.
34. Rock, C. L., Thomson, C., Caan, B. J., Flatt, S. W., Newman, V., Ritenbaugh, C., Marshall, J. R., Hollenbach, K. A., Stefanick, M. L. & Pierce, J. P. (2001) Reduction in fat intake is not associated with weight loss in most women after breast cancer diagnosis: evidence from a randomized controlled trial. Cancer 91:25-34.[Medline]
35. Rolls, B. J. & Bell, E. A. (2000) Dietary approaches to the treatment of obesity. Med. Clin. North Am. 84:401-418.[Medline]
This article has been cited by other articles:
|
|
 |
|
  L. H. Kushi, M. L. Kwan, M. M. Lee, and C. B. Ambrosone Lifestyle Factors and Survival in Women with Breast Cancer J. Nutr., January 1, 2007; 137(1): 236S - 242S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. C. M. Thiebaut, A. Schatzkin, R. Ballard-Barbash, and V. Kipnis Dietary Fat and Breast Cancer: Contributions From a Survival Trial J Natl Cancer Inst, December 20, 2006; 98(24): 1753 - 1755. [Full Text] [PDF]
|
|
|
|
 |
|
 M. R. Stolley, L. K. Sharp, A. M. Wells, N. Simon, and L. Schiffer Health Behaviors and Breast Cancer: Experiences of Urban African American Women Health Educ Behav, October 1, 2006; 33(5): 604 - 624. [Abstract] [PDF]
|
|
|
|
 |
|
 R. L. Ahmed, W. Thomas, D. Yee, and K. H. Schmitz Randomized Controlled Trial of Weight Training and Lymphedema in Breast Cancer Survivors J. Clin. Oncol., June 20, 2006; 24(18): 2765 - 2772. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. L. Rock Dietary Counseling Is Beneficial for the Patient With Cancer J. Clin. Oncol., March 1, 2005; 23(7): 1348 - 1349. [Full Text] [PDF]
|
|
|
|
|
|
M. L. Irwin, A. McTiernan, R. N. Baumgartner, K. B. Baumgartner, L. Bernstein, F. D. Gilliland, and R. Ballard-Barbash Changes in Body Fat and Weight After a Breast Cancer Diagnosis: Influence of Demographic, Prognostic, and Lifestyle Factors J. Clin. Oncol., February 1, 2005; 23(4): 774 - 782. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Mai, A. K Kant, A. Flood, J. V Lacey Jr, C. Schairer, and A. Schatzkin Diet quality and subsequent cancer incidence and mortality in a prospective cohort of women Int. J. Epidemiol., February 1, 2005; 34(1): 54 - 60. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. S. Selvan, A. V. Wilkinson, R. Chamberlain, and M. L. Bondy Social and Dietary Changes Associated with Obesity and Breast Cancer Risk Journal of Health Management, October 1, 2004; 6(2): 103 - 114. [Abstract] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
