LIFESTYLE MANAGEMENT

Lifestyle management is a subspecialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions (ACLM, 2022). Pillars of this medical practice are informative to the whole-person care of those with breast cancer. These include physical activity, sleep hygiene, stress management, a nutritious diet, avoiding risky substances, and fostering positive social connections (ACLM, 2022).

Physical Activity

Physical activity is essential for recovery and maintaining good health. Regular physical activity after a cancer diagnosis can have a positive effect on quality of life, including physical (balance and flexibility), functional (reducing fatigue, improving heart and bone health), psychological, and emotional well-being (boosting energy and mood) (ACLM, 2022). It is recommended that cancer survivors engage in at least 150 minutes of moderate to vigorous physical activity each week. Activity should be spread out in shorter sessions each day, for example, 30 minutes most days of the week.

Patients on certain treatment regimens, such as those that may cause osteoporosis, are encouraged to incorporate regular weight-bearing exercise for bone health. Patients who have specific concerns or chronic conditions may benefit from a consultation with a physical therapist who can tailor a therapeutic fitness program designed for their unique needs during the treatment, recovery, and survivorship period.

The following are recommendations for discussing physical activity with patients with breast cancer:

• Encourage an initial discussion with their healthcare provider; focus on any long-term medical conditions.
• Plan a strategy; encourage patients to start slowly with 10-, 20-, and 30-minute sessions of some form of moderate activity each day. Encourage strength training as well as aerobic exercise.
• Choose activities patients enjoy; it is easier to stick with a plan when doing something enjoyable.
• Help patients explore new ways to exercise, including dancing, walking, climbing stairs, swimming, etc.
• Get the patient a pedometer (or step-counting app), since tracking progress can be a great way to see positive feedback.
• Encourage physical activity as a daily habit.
  (NCCN, 2022b)

Sleep Hygiene

Nearly half of patients with cancer report having problems with sleep. The most common issues are insomnia and abnormal sleep-wake cycles. Causes of sleep issues for people with breast cancer include:

• Physical changes from cancer surgeries or radiation (i.e., lymphedema)
• Side effects from medications used to treat or manage the symptoms of cancer (i.e., hormone therapy, corticosteroids, narcotics)
• Hospitalizations
• Stress

Managing issues with sleep can be difficult. However, some promising strategies include maintaining good sleep habits by ensuring a comfortable place to sleep, maintaining regular bowel/bladder habits, performing regular physical activity during the day, eating a well-balanced diet, and strategically timing medication administration (i.e., taking steroids in the morning).

Poor sleeping habits can contribute to other physical and mental issues. It is important for healthcare providers to routinely assess a patient’s sleep in order to effectively promote healthy sleep habits (NCI, 2022a).

Stress Management

Managing stress can be difficult for patients with breast cancer. Meditation and relaxation techniques can be successful ways to mitigate stress. Meditation is a simple form of relaxation that can be performed anywhere. Meditation and focused breathing can assist breast cancer patients during medical encounters such as procedures or chemotherapy administration. Meditation focuses on deep breathing with eyes closed for at least 5 to 10 minutes. Many patients find that adding soothing music or sounds can also help with relaxation.

Guided imagery is a form of meditation that includes forming a pleasant mental image to focus on while breathing deeply. Tai chi, described as a form of “moving meditation,” may also be appropriate as both a form of meditation and as gentle exercise (ASCO, 2022b).

Referrals to social work or other mental health services can be helpful for patients who have difficulty managing stress. Healthcare providers should routinely assess stress and explore factors contributing to stress in order to effectively direct patients to appropriate resources.

Nutrition

Nutrition is an incredibly important part of caring for people with breast cancer, particularly for those who are being treated with systemic therapies for extended periods of time and those recovering from surgical procedures or radiation.

Most healthcare practitioners agree that eating a healthful diet makes sense for anyone, and especially for people with breast cancer. Eating healthy can speed recovery, strengthen the immune system, restore energy, and reduce risk of cancer recurrence.

Eating a low-fat diet such as the Mediterranean diet may provide health benefits for cancer patients. The basic structure of the Mediterranean diet includes:

• Increased intake of fresh fruits and vegetables (7–10 servings per day)
• Use of whole grains (whole grain breads, cereals, and pasta)
• Use of olive oil instead of butter or margarine
• Adding herbs and spices instead of salt to enhance flavors
• Eating fresh fish and poultry instead of red meat
• Eating low-fat dairy products (e.g., Greek yogurt)

At times, nutritional drinks (e.g., Boost, Ensure) or enteral nutrition by way of a gastrostomy tube may be used to provide nutrients during acute cancer treatment when eating is difficult due to appetite changes, mucositis, and/or changes in taste. A referral to a registered dietitian can assist patients who have nutritional concerns during and after the treatment period.

VITAMINS AND MINERALS

Food is the best source of vitamins and minerals, but sometimes food fails to provide enough of certain nutrients, especially during recovery from cancer and its treatments.

More than half of all patients with cancer take one or more supplements, with or without their doctor’s approval. Common supplements used by patients include calcium and vitamin D for bone health, vitamins C and E for antioxidant effects, St. John’s wort for depression, garlic extract for blood pressure, and echinacea to enhance the immune system. Taking these supplements during treatment may interfere with or decrease the effectiveness of cancer-directed therapies (i.e., systemic therapy, radiation) (ASCO, 2022b).

• Patients should be cautioned not to take megadoses of vitamins and minerals because some vitamins can be toxic in large doses.
• Patients should be advised to discuss taking antioxidants such as vitamins C and E with their oncologist and integrative health practitioner. Patients may believe that taking antioxidants will enhance and protect their body’s normal cells, but use of antioxidants may also have a protective effect on tumor cells, thus making chemotherapy and radiation less effective. Radiation therapy and some types of chemotherapy work by generating free radicals to damage the DNA of tumor cells; taking antioxidants may block the therapeutic effect needed to kill tumor cells (ASCO, 2022b).

Supplement use is controversial because of limited research. However, the Office of Dietary Supplements at the National Institutes of Health was established in 1995 to create scientific databases on vitamins, minerals, and herbs (see “Resources” at end of course).

Fostering Positive Social Connections

Patients with breast cancer are often faced with radical changes to their lives as a result of the diagnosis. Few aspects of care are as important as maintaining positive relationships between the patient and their support system. A cancer diagnosis can place tremendous stress on these relationships. It is vital for the patient’s healthcare provider—and advocate—to connect patients and their loved ones to resources that maintain and foster positive social connections.

It is important for patients to pick the right time and place to break the news to their loved ones: time enough for asking and answering questions and a place where it is okay to cry, hug, and talk openly. Loved ones will be experiencing some of the same feelings as the patient—shock, fear, anger, and denial, plus empathy for the situation and sorrow at the possible loss this disease might cause. The patient is the only one who can decide whom to tell and how much to tell them. Some patients may not want to “go public” about their breast cancer but instead confine the news to immediate family and friends. Some patients cope by sharing their story openly with extended family and friends through social media such as Facebook or CaringBridge. The choice is very personal for each patient.

Family and friends may not know how to respond even though they may want to offer support. What they want most of all is for the patient to be okay again. Patients who explain their situation as they learn more about it can help loved ones deal with the news and show them how they might help. Patients may keep a list of those who offer, “Let me know if there’s anything I can do.” These people can be called on for help as needed: for a ride to medical appointments, to run errands, to prepare food, to help set up online tools for practical support issues, to care for children or pets, or just to drop by for a visit. Family and friends are often delighted to be of help.

Many patients fear that breast cancer will affect their relationships with others, particularly their sexual partners. This is particularly true for women who choose mastectomy; even some women who choose lumpectomy are surprised at the impact of the scar.

Concerns about relationships and sexuality can be particularly important to young women with breast cancer. Many young women are single and seeking to establish relationships. Almost all young women are working and just beginning to build a career. Some have no health insurance. Some are just starting families, and others have very young children. Young women also are likely to be diagnosed at a later stage and to have more aggressive tumors. Chemotherapy treatment may impair fertility and/or the ability to breastfeed if they do have children.

Many patients with breast cancer find comfort in talking with survivors and joining a professionally facilitated support group of people who are currently in treatment. Healthcare providers can provide resources to local support groups to patients when available.