Remote Coaching Can Help Breast Cancer Survivors Achieve Healthy Weight Loss

05/05/2020

A telephone-coaching and web-based weight loss plan referred to by scientists as the “POWER-remote intervention” and delivered to overweight and obese breast cancer survivors helped half of them lose 5% or more of their body weight after six months — and to keep it off for 12 months, according to a new study led by Johns Hopkins Kimmel Cancer Center researchers.

Obesity is a major risk factor for many cancers, including breast cancer, the researchers note. In addition, most women gain weight following a breast cancer diagnosis, which has been associated with a 1.5-fold increased risk of breast cancer recurrence and death. Factors that can contribute to weight gain after breast cancer diagnosis include use of chemotherapy and the transition between pre- to post-menopause, as many women are diagnosed during this time, or they may receive treatment that affects ovarian function (i.e., GnRH agonists — not tamoxifen or aromatase inhibitors).

In an effort to demonstrate that a potentially scalable weight loss program could be effective and result in favorable biological changes associated with cancer risk, the new trial recruited 87 women with stage 0-III (meaning minimally to moderately invasive) breast cancer, with a body mass index of 25 or higher, who had completed surgery, and any prescribed radiation and chemotherapy.

A diverse group of patients, ages 30 to73, including 20% African American women, was randomly divided into two groups, with 45 women completing the “POWER-remote intervention” and 42 completing a self-directed weight loss plan.

Women participating in the POWER-remote intervention received telephone-based behavioral weight loss coaching — weekly for the first three months, then monthly until month 12 throughout the 12-month study — along with access to a web-based platform to monitor their diet, exercise, and weight. Women in the self-directed weight loss group received one coaching session at the start of the study, along with standard diet and exercise guidelines provided by the National Heart, Lung, and Blood Institute.

After six months, 51% of women assigned to the POWER-remote intervention lost 5% or more of their body weight, compared with 12% of those who participated in a self-directed weight loss program. At 12 months after the start of the study, 51% of those in POWER-remote group maintained their weight loss, compared with 17% of those in the self-directed group.

The average weight loss in the remote coaching group after six and 12 months was 4.6 kilograms (10.1 pounds), compared with 0.5 kilograms (1.1 pounds) at six months and 0.4 kilograms (.9 pounds) at 12 months among the self-directed group.

Weight loss among the women in the trial was also linked to a significant decrease in leptin levels after six months. The POWER-remote group had almost a 50% decrease in leptin, whereas the self-control group essentially had unchanged levels. Leptin, a hormone released primarily by fat cells, and therefore a biomarker for weight gain, has been shown to increase breast cancer cell proliferation, invasion and migration. Weight loss also produced small decreases among some inflammatory molecules, called adipocytokines, although the level of loss was not statistically significant, the researchers said. Obesity is associated with high levels of adipocytokines, which can drive the molecular pathways that encourage cancer growth and spread.

“The results of our study showed that the POWER-remote coaching is a feasible and effective weight loss intervention for breast cancer survivors,” says Johns Hopkins Sidney Kimmel Comprehensive Cancer Center investigator Cesar A. Santa-Maria, M.D., M.S.C.I., assistant professor of oncology.

“Clearly, leptin was the most significant biomarker change we observed; however, we do not know if additional changes would be observed in other inflammatory markers or adipocytokines if more profound weight loss were to occur,” he added.

The researchers also compared changes in telomere length in chromosomes within blood cells among the women in the trial. Shortened telomeres, the chromosomal “end caps” that prevent DNA degradation, have also been associated with breast cancer in some studies. There was no significant change in telomere length associated with weight loss in the study.

“Since telomere length is something that changes over years, a longer duration of sustained weight loss may impact this marker,” said Santa-Maria.

The findings were published February 18 in Clinical Cancer Research.

Santa-Maria cautioned that the sustained weight loss in the POWER-remote group has not yet been shown in the study group to improve survival or limit recurrence. “Weight gain after diagnosis of breast cancer can affect prognosis negatively, however, we do not yet know definitively if weight loss can improve prognosis,” said Santa-Maria. “Understanding chemical biomarker changes related to breast cancer risk and prognosis may help us understand this relationship between weight changes and prognosis better.”

There are no weight loss guidelines specifically tailored to breast cancer patients, “but, in general, we recommend a heart-healthy diet and regular physical activity — at least 150 minutes of aerobic activity each week,” said Vered Stearns, M.D., Breast Cancer Research Chair in Oncology and Director of the Women’s Malignancies Program at the Johns Hopkins Kimmel Cancer Center.

The findings have prompted the researchers to pursue further weight loss studies, says Stearns. “We are completing a study in which women who are overweight and obese and who also have sleeping disturbance are randomized to a sleep intervention for eight weeks, followed by the POWER behavioral intervention for all women for six months,” says Stearns. “We will soon open a study in which women who are not able to lose weight after eight weeks of POWER will also receive a weight loss medication. We will continue to study biomarkers that may help to predict successful weight loss and also patient-reported outcomes.”

Other Johns Hopkins researchers involved in the study were Janelle W. Coughlin, Dipali Sharma, Mary Armanios, Amanda L. Blackford, Colleen Schreyer, Arlene Dalcin, Ashley Carpenter, Gerald J. Jerome, Deborah Armstrong, Roisin M. Connolly, John Fetting, Robert Miller, Karen L. Smith, Claire Snyder, Andrew Wolfe, Antonio C. Wolff, Chiung-Yu Huang, and Lawrence J. Appel; along with Greater Baltimore Medical Center researchers Madhu Chaudhry and Gary Cohen.

The research was supported by the Breast Cancer Research Foundation, Cigarette Restitution Fund, National Institutes of Health (P30 CA006973) and Commonwealth Foundation Johns Hopkins Precision Medicine Initiative.

Healthways, Inc. developed the website for both interventions used in the POWER trial, in collaboration with Johns Hopkins investigators, and provided coaching effort for the transtelephonic intervention. Healthways also provided some research funding to supplement NIH support. Under an institutional consulting agreement with Healthways, the Johns Hopkins University received fees for advisory services to Healthways during the POWER trial. Faculty members who participated in the consulting services received a portion of the University fees.

On the basis of POWER trial results, Healthways developed and is commercializing a weight-loss intervention program called Innergy.tm Under an agreement with Healthways, Johns Hopkins faculty monitor the Innergy programs content and process (staffing, training and counseling) and outcomes (engagement and weight loss) to ensure consistency with the corresponding arm of the POWER Trial. Johns Hopkins receives fees for these services, and faculty members who participate in the consulting services receive a portion of these fees. Johns Hopkins receives royalty on sales of the Innergy program.