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I have a friend who just turned 40. Not long after, she discovered she had triple negative breast cancer. That means her breast cancer cells do not have receptors for estrogen or progesterone or for the HER2 protein. Those receptors are often targeted for breast cancer medical treatment, but not in her case. Unfortunately, her cancer is less common than the other breast cancers and more aggressive but it is thought to be very responsive to diet.
Contrary to what you might think, my friend is not overweight; nor does she have other obvious nutrition and lifestyle habits, such as smoking, linked to cancer risk. In fact, she is a picture of health. Her skin glows. She is a health scientist who exercises regularly and it shows. I wouldn't have guessed she was 40.
Breast cancer is the most common cancer and leading cause of death in women. The risk of developing breast cancer increases with age with 8 out of 10 cases happening in women over the age of 50 who have been through menopause [1]. However, the later someone goes through menopause, the greater her risk of developing breast cancer, as well as cancer of the ovaries and uterus [2]. My friend's breast cancer is more common in premenopausal women and I suspect she is still in this category. Did you know breast cancer is often more aggressive when it is diagnosed in premenopausal women than when it's found in older postmenopausal women?
There is a lot of information on the internet on how triple negative breast cancer is treated using surgery, radiation and chemotherapy. My friend is getting the best of the best of what western medicine has to offer. Nutritional epidemiology research shows mediterranean diet adherence is wonderful for breast cancer prevention. I was curious, however, to investigate what else she could be doing that goes beyond conventional medicine and nutrition.
This is where I go a bit into the unknown. I don't know my friend's medical and family history nor do I know her personal diet. However, based on her academic achievements and expertise, I have to assume she has a certain commitment to eating as healthfully as humanly possible. So, the following are some important nutrition considerations for her and anyone else dealing with breast cancer either as a diagnosis or as a preventative and I have added the nutrition perspective for the menopausal journey.
Mediterranean diet
To be clear, a healthy, Mediterranean style diet is the best diet choice. It is a whole foods diet with limited processed foods and no processed meats with an emphasis on plant foods. It is most interesting to me that researchers found eating a Mediterranean diet high in fat reduces breast cancer risk [3] and it seems additional olive oil has a profound impact on reducing risk [4]. This study used extra-virgin olive oil (EVOO) at ≥15% of total energy intake which equated to 2.5Tbsp olive oil or 37ml for a 2000 Kcal diet [5]. It also seems adherence to a Mediterranean diet after treatment can prevent relapse. Click here for a really good description of the essential components of the Mediterranean diet including how to follow it.
Healthy Fat
I think it is interesting that higher intake of the right type of fat is a key factor in preventing breast cancer incidence and recurrence. While my friend's breast cancer is not hormone dependent, many breast cancers are indeed related to estrogen metabolism. Healthy fats play a key role in modulating hormone metabolism but they also reduce inflammation which contributes to chronic disease development, such as cancer [6]. Examples of healthy fat choices are flax seeds and fish (omega 3s), evening primrose oil (short chain omega 6/gamma linolenic acid), avocados and olive oil (monounsaturated).
Carbohydrates need to be prioritized much more carefully when a woman goes through her menopause journey. Women have less capacity for healthy carbohydrate metabolism than when they are pre-menopausal. And, guess what? That carbohydrate intake can be replaced by those healthy fats that play such an important role in prevention.
Wise Carbohydrate Choices
So let's talk about carbohydrates. Unfortunately, according to analyses from the Nurses Health Study, high sugar intake, including added sugar, sucrose, and fructose, as well as carbohydrate from fruit juice are associated with a poorer prognosis in women with breast cancer. The good news is that high intake of carbohydrate from vegetables was associated with reduced risk of mortality [7]. Fast acting sugars are those sugars that can give a quick blood sugar rise and then fall at the same rate. They have been shown to cause inflammation and are generally a bad idea. But how should we eat them? The key is to combine them with fiber, fat and sugar to slow the absorption over time and minimize the inflammatory risk of extreme spikes and falls. Even more important, may be the order in which the foods are eaten. Recent research suggests eating fats and proteins first, followed by carbohydrates may be the best way to prevent blood sugar spikes, prevent excess inflammation and prolong the energy you get from your meals [8].
If you are interested in learning how your blood sugar responds to food intake, I am a big fan of continuous glucose monitoring. Learning how your blood sugar uniquely responds to the foods you like to eat can really help you become your own agent of change. Click here if you want to know more about continuous glucose monitoring and the 5 lessons I learned from doing it. You can do the same and learn about your own unique differences!
Adequate Protein
I don't want to leave out protein, however. In fact, there is a significant risk of sarcopenia, or muscle loss, associated with breast cancer chemotherapy and this is also intensified by aging. Protein intake is an important element to restore muscle mass, in addition to movement and exercise [9]. Standard protein requirements are 0.8g/kg of body weight. So, if you are 60kg then your protein requirements are 48g/day. For age-related sarcopenia, up to 1.5g/kg/day has been studied with success [10]. That is equal to 90g/day for a 60kg person. With a decreasing appetite that often accompanies chemotherapy treatments, this is where protein shakes can be very helpful. Increased protein intake has also been found to be an important aspect of healthy aging. This needs to be emphasized since many people decrease their protein intake as they age; and for those women on their menopause journey, a little more protein and a little less carbohydrate might be a good idea. Healthy protein choices include lean chicken, fish, beans, lentils, and tofu.
Flavonoids for Health
Polyphenols are components of our food that protect the body from oxidative stress that can lead to diseases such as cancer. Flavonoids are a type of polyphenol and are found in plant foods, such as soybeans, cocoa, wine, tea, onions and elderberries [11]. Early research had demonstrated these flavonoids increase expression of tumor suppressor genes and contribute to decreasing breast cancer metastasis and progression [12]. Consider adding some of these plant foods to your diet.
Microbiome Balance
The balance of bacteria in the gut microbiome and breast tissue has been implicated in breast cancer development. Not only does the gut bacteria regulate estrogen metabolism but it plays an important role in metabolizing the chemotherapeutic treatments used in breast cancer. The gut bacteria also play a role in modulating the immune system [13]. So that means it is an important consideration no matter what kind of breast cancer an individual has. In my friend's case, her breast cancer is not estrogen dominant, but that state of her gut microbiome can still influence her response to chemotherapy and her capacity to keep her immune system strong. Many soluble fibers are considered prebiotics because they feed the good bacteria in the gut. Probiotics comprise different types of bacteria that can be taken by mouth to optimize the balance of bacteria in the gut. They seem to have a role in prevention and treatment of breast cancer but more research is needed [14]. However, the best way to strengthen immunity and reduce inflammation is to get probiotics from fermented foods, such as kimchi and kefir [15]. These foods can even be made at home and can offer some relief from the gastrointestinal distress side effects chemotherapy. I suggest eating small doses at first to build up tolerance.
Supplementation? Yes or No?
What about supplementation? Research on antioxidant micronutrient supplementation in human trials on breast cancer has been limited but early research is promising [16]. Smaller studies show supplementing chemotherapy and radiation therapy with selenium alleviates side effects, improves quality of life and may augment the therapeutic effects [17]. Early research in mice has shown decreased tumor growth and metastasis from a combination of selenium and the omega 3 fatty acids, eicosapentaenoic acid (EPA) docosahexaenoic acid acid (DHA) in combination with low dose chemotherapy in triple negative breast cancer [18]. Unfortunately, this research has not been confirmed in human studies. There does seem to be a link between omega 3 fatty acids carried by lipoproteins in the blood and breast cancer severity [19]. However, supplementation of some micronutrients, like vitamin E and beta carotene can increase cancer rates.
Vitamin C is a water-soluble vitamin that is not stored in the body. If you don't eat any foods high in vitamin C today, you will not have any vitamin C to use in your system. Dietary vitamin C intake is associated with a reduced risk of breast cancer mortality [20]. So, if you don't take in your high vitamin C foods, such as oranges, kiwis, or strawberries; consider that vitamin C supplementation may be necessary. Vitamin C is one supplement that does not usually have toxicity associated with it. However, if you have a tendency to develop kidney stones, be aware high dose vitamin C supplementation can worsen their development [21].
Vitamin D metabolites play important roles in multiple physiologic pathways that affect cancer development and metastasis. Low vitamin D concentrations are common in breast cancer and triple negative breast cancer patients seem to have the lowest vitamin D levels in their blood [22]. Evaluating 25 hydroxy-vitamin D3 and 1,25 hydroxy-vitamin D3 levels are an important component of breast cancer prevention and therapy [23]. Do not hesitate to ask your doctor or dietitian to check this regularly, even if you spend time in the sun. We don’t yet understand all of the factors involved in abnormally low vitamin D levels but we do know there are genetic polymorphisms that predispose people to low vitamin D. Remember your doctor is focused on many dynamics of managing your health, particularly if you are going through chemotherapy or radiation therapy for breast cancer. Just because your doctor does not suggest it, does not mean it is not a good idea.
It is important to tailor a personalized diet and supplementation regimen to your individual biochemistry and look at how you can meet your needs with foods first and supplements second. A great way to do this is through monitoring micronutrient status. At PhenomX Health, we use a micronutrient finger stick test to evaluate 34 micronutrients in your blood and understand where you need to emphasize nutrient intake to optimize your health. This includes your omega 3 fats and minerals like selenium. If you are interested in using our test, you can click on the button below.
In summary, I would tell my friend the Mediterranean diet is the best foundational approach for breast cancer prevention and treatment. Emphasis on healthy fats, such as olive oil and omega 3s (flax seeds and fish or omega 3 supplements) will help her through her breast cancer journey and prevent its recurrence later. Emphasize protein to ensure it is sufficiently adequate, along-side her fitness routine, to prevent the muscle loss associated with chemotherapy. Choose complex carbohydrates wisely and eat them with fat and protein, avoiding simple and fast acting sugars. Consider continuous glucose monitoring if she is concerned about her glucose metabolism response. Fermented vegetables might help her regain an optimum microbiome balance in her gut, starting with small amounts. I suggest she take vitamin C daily and monitor her vitamin D closely, supplementing as needed. I would encourage her to take the initiative to get a micronutrient profile from her blood to see what nutrients may be insufficient or deficient so she knows what nutrients she should emphasize. This is not commonly done in the hospital setting, which is why we offer a test for 34 nutrients. Click on the button below for more information.
At PhenomX Health, we are committed to empowering women to personalize their own nutrition and take charge of their health. I hope this article was helpful to you wherever you are in your health journey.
Sincerely
Dr. Colleen Fogarty Draper