Scientific conferences and music festivals are both large gatherings of like-minded people assembled to watch experts present their skills, but aside from that, they don’t typically have much in common. Thus, a special session entitled, “Sex, Drugs, Rock and Roll” at the 2024 San Antonio Breast Cancer Symposium (SABCS), held December 10-13, may seem a bit out of place.
But just as music festivals spotlight artists who could use more exposure, this special session discussed survivorship topics that often fly under the radar. Following a diagnosis of breast cancer, patients may have questions about how supplements, exercise, and diet may affect their prognosis or symptoms. They may also experience changes to their sexual self-image that they find difficult to discuss with their oncologist.
“This session is based on information [and] questions that are relevant to the daily lives of people with cancer—for researchers, for doctors, and for patient advocates,” said session moderator Christine Ambrosone, PhD, from Roswell Park Comprehensive Cancer Center. “We’ve brought together people who can talk about benefits [and] maybe the cons of a number of modifiable factors.”
Sex(ual Health and Intimacy During Breast Cancer Treatment)
Treatment for breast cancer can affect a patient’s physical, emotional, and mental health in a variety of ways. Sexual health intersects with all of these facets and yet is not commonly discussed between patients and their providers, according to Don S. Dizon, MD, of the Brown University Health Cancer Institute. When patients experience changes to their sexual health following a breast cancer diagnosis, those changes can encompass a variety of elements, Dizon explained.
“[Sexual health] is a complicated, multi-domain issue,” Dizon said. “If I ask this audience, ‘how many of you are having issues with intercourse,’ I will get one set of answers. If I ask the audience, ‘how many of you are having issues with your partner as it relates to your intimacy,’ I would get a very different answer.”
In terms of physical symptoms, women taking endocrine therapy often experience vaginal dryness and pain with sex. If physicians are aware of these issues, they can recommend or prescribe interventions such as vaginal moisturizers, topical numbing agents, and dilator therapy, Dizon said.
But sexual health problems often run deeper, Dizon explained, affecting the emotional and mental aspects of intimacy. In one study, the percentage of women who considered their chest a component of their sexuality dropped significantly after surgery for breast cancer, most notably from 95% to 47% among patients receiving a mastectomy without breast reconstruction.
Further, women frequently report a loss of libido during breast cancer treatment, but Dizon emphasized that a decrease in sexual interest could have a variety of causes. He recommended a couple of pharmacological agents, in addition to relationship and intimacy counseling, as potential interventions.
“After cancer, everyone deserves a sex life,” Dizon concluded.
Drugs (and Supplements to Mitigate Symptoms)
Sexual side effects aren’t the only symptoms patients deal with during breast cancer treatment. For other issues—including pain, fatigue, and nausea—patients sometimes turn to holistic options such as cannabis or dietary supplements.
Heather Greenlee, ND, PhD, MPH, from Fred Hutch Cancer Center, reviewed what we do and do not know about how holistic therapies interact with breast cancer care. The antioxidant effects of melatonin and multivitamins can potentially dampen the efficacy of certain therapeutics that work by inducing oxidative stress. Fish oil and omega-3 fatty acids may increase the risk of bleeding in patients with breast cancer, and some supplements are being investigated for potential estrogenic effects.
Greenlee therefore stressed the importance of patients talking to their oncologist about any holistic therapies they’re using, which can be difficult when it comes to drugs like cannabis that carry a heavy stigma. Studies have shown that 42% of breast cancer patients report using cannabis to alleviate their symptoms. However, Greenlee showed that only around 22% of patients report cannabis use to their doctors overall, and the number drops to 11% in states where medical marijuana is illegal.
“When we’re thinking about interactions and understanding safety, we really need to have an environment where patients can have safe discussions with [physicians] about what they’re doing,” Greenlee said.
According to recent guidelines from the American Society of Clinical Oncology (ASCO), cannabis may improve treatment-related nausea and vomiting when combined with other antiemetic agents, but the evidence does not support the use of cannabis to treat any other symptoms. Greenlee also emphasized that there is no reliable evidence that cannabis can improve breast cancer outcomes.
As for supplements, the Society for Integrative Oncology and ASCO have issued clinical practice guidelines detailing supplements and other holistic strategies that can or cannot alleviate treatment-associated pain, fatigue, and nausea. For breast cancer patients, adding ginger to standard antiemetics may be offered to help with nausea and vomiting, ginseng may be offered to help with fatigue, and lavender aromatherapy may help with anxiety. Greenlee also touched on supplements the guidelines found to be ineffective—such as aloe vera for radiation skin reactions, guarana for fatigue, and soy for hot flashes—or even harmful, such as acetyl-l-carnitine for peripheral neuropathy.
“[The list of supplements we can recommend] is a pretty short list, but we’re hoping that it’s going to grow over time when we have better data,” Greenlee said. “At the same time, there’s a whole host of other nonpharmacologic approaches that can be just as effective or more effective than dietary supplements.”
Rock(ing, and Other Exercise Plans for Patients)
Whether you’re rocking out to your favorite song, rocking on the waves in a kayak, or rocking into a new yoga pose, moving more and sitting less can substantially benefit patients with breast cancer, according to Rikki Cannioto, PhD, EdD, from Roswell Park Comprehensive Cancer Center.
The U.S. Centers for Disease Control and Prevention (CDC) recommend that adults undergo a minimum of 150 to 300 minutes of moderate exercise or 75 to 150 minutes of vigorous exercise per week combined with two days of muscle-strengthening exercise. However, a progress report by the National Institutes of Health (NIH) showed that only 14% of female cancer survivors and 13% of all cancer survivors aged 65 or older meet the CDC guidelines. More strikingly, 40% to 60% of cancer survivors are completely physically inactive.
Cannioto reviewed data showing that exercise interventions during treatment can mitigate side effects and improve quality of life, but until recently, the effects of exercise on treatment outcomes were inconclusive. She and her colleagues performed a meta-analysis in which they pooled outcome data from three studies of exercise interventions during breast cancer treatment. Compared with physical inactivity, meeting the CDC guidelines was associated with a 48.5% decrease in mortality and a 31% decrease in the risk of recurrence.
“This is important because, to date, an association of post-diagnosis physical activity with breast cancer recurrence has not been well established in the literature,” Cannioto said. “There are actually few reports that look at, specifically, whether or not meeting the federal guideline for physical activity is associated with survival.”
But even if you can’t meet the CDC guidelines, any level of physical activity is associated with benefits compared with inactivity. Cannioto showed that there is no minimum threshold for daily steps or weekly physical activity that can decrease all-cause mortality. In fact, the steepest benefits were observed when moving from no physical activity to a small amount.
“The message to move more and sit less throughout the day is a very important one,” Cannioto said. “Some physical activity is better than none, and adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits.”
Roll(s, and Other Dietary Considerations)
Many patients diagnosed with cancer also have questions about what they should be eating and drinking, explained Lawrence H. Kushi, ScD, of the Kaiser Permanente Northern California Division of Research.
Popular dietary patterns like the Mediterranean diet and Dietary Approaches to Stop Hypertension (DASH) may be attractive to patients due to their widespread health claims, but can they improve breast cancer outcomes? Kushi and colleagues evaluated how adherence to four different dietary quality indices—the American Cancer Society Nutrition Guidelines, Mediterranean diet, DASH, and 2015 Healthy Eating Index—associated with mortality.
For each dietary index, progressively higher adherence correlated significantly with lower risk of breast cancer-specific and all-cause mortality, a finding that has since been backed up by several other independent studies, Kushi showed.
“There’s a lot of evidence that dietary patterns can influence risk of overall mortality and outcomes after breast cancer; the evidence is growing,” Kushi said.
Some patients may also have questions about alcohol intake. While alcohol consumption is a known risk factor for the development of breast cancer and at least five other cancer types, little is known about how drinking affects outcomes after a breast cancer diagnosis, Kushi said.
Kushi and colleagues found no significant differences in breast cancer recurrence between nondrinkers and those who drink occasionally or regularly. However, Kushi pointed out a systematic review of studies that found a weak association between alcohol consumption and recurrence risk, especially in postmenopausal women. He emphasized that more research is needed in this area to reach a firm conclusion.
