ArcaMax

DEAR DR. ROACH: I am a 69-year-old female in excellent health, other than having been treated for breast cancer eight years ago. (I underwent surgery, chemotherapy, radiation, then five years on an aromatase inhibitor.) Since then, I have gained 40 pounds. I am 5 feet, 2 inches tall, and weigh 178 pounds. I have been unable to lose the weight despite working out at least 1 hour every day and following a healthy (Mediterranean-style) diet.

I am told by my oncologist that being within a healthy BMI weight range is one of the best things I can do to prevent reccurrence. I was told by another physician to limit my calories to 1,000 per day, but I found it difficult to maintain this low of a caloric intake given my activity level. Why can't I lose weight despite all of my efforts? -- D.K.

ANSWER: The answer to this is beyond my power to answer, except to say that humans have evolved to be able to survive with very little food, and we have adaptations that let us survive. Most people in industrial countries no longer have times of prolonged famine, so the human trait of holding on to our energy supplies (mostly fat) is no longer adaptive, since excess weight is associated with an increased risk of many chronic diseases.

In the case of breast cancer, women with a higher BMI do have higher rates of recurrence compared to women in the "normal" range, which was defined as 18.5-25. (This is well below the average weight among women in the United States.) The BMI is a flawed measurement but is still commonly used in studies.

In a large study, women with a BMI of 18.5-25 had a 1.7% risk of recurrence per year, while women with a BMI of 30-35 (yours is 32.4) had a 2.2% risk of recurrence per year. This is a significant amount but may not be as much as you were expecting. I disagree that weight is a major factor in breast cancer reoccurrence.

In most of my patients, I recommend against weight loss as a primary goal. I would much rather have my patients eat well (a Mediterranean-style diet is an excellent choice) and exercise regularly (1 hour a day is great) than restrict calories to lose weight. However, there are times when weight loss is important in addition to a healthy diet and exercise.

In postmenopausal women with breast cancer, it is reasonable to consider that an effective means of weight loss might reduce cancer recurrences, but this is unproven. I did read studies showing that GLP-1 drugs like semaglutide (Wegovy) or tirzepatide (Zepbound) were effective for weight loss in women with breast cancer. However, different kinds of studies would be needed to see whether they (or another kind of weight-loss treatment, such as bariatric surgery) reduce relapse rates.

Since these drugs are very expensive, it is difficult to afford them for most people without insurance, and insurance companies generally require either severe obesity or a demonstration of weight-related morbidities (such as sleep apnea) to prescribe these drugs. For now, this would be a conversation between you and your breast oncologist, general doctor, or an expert in weight loss.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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