Target Lifestyle Changes at Breast Screening, Suggests Study

Liam Davenport

November 09, 2020

Free lifestyle coaching offered at breast screening visits leads to clinically significant decreases in weight and is welcomed by women attending their appointments, suggests a large UK randomised trial.

The research was presented at the National Cancer Research Institute (NCRI) Virtual Showcase 2020 on November 3.

ActWELL study

The ActWELL study randomised 560 women aged 50–70 years attending routine breast cancer screening to either a lifestyle intervention delivered by volunteers or a comparison group, from more than 3700 women who expressed an interest in taking part.

Following up the women over a year, Annie Anderson, professor of public health nutrition at the University of Dundee, and colleagues, found that women in the intervention group lost 2.5 kg on average, significantly more than those in the comparison group.

Women who received the lifestyle coaching were also more than twice as likely to lose at least five percent of their body weight.

Prof Anderson said in her presentation that the findings show "a community weight management intervention initiated at breast screening clinics and delivered by…coaches can achieve clinically relevant weight loss".

She told Medscape News UK that the volunteer coaches, supplied by the charity Breast Cancer Now, were a key part of the success of the study, saying that the women "really liked" having them.

"Initially some people thought it was going to be a fully trained gym coach or something like that," but once they got used to the idea, they found that the coaches were "a force to be reckoned with".

Volunteers

Manveet Basra, head of public health and wellbeing at Breast Cancer Now, told Medscape UK that the charity had originally planned to train 24 volunteers, with six in each of the four trial locations, coordinated by a full time member of staff.

She said that this had "never been done before" by the charity and was "quite labour intensive".

They also found that, with volunteers giving their time "essentially for free", they had to recruit "a lot more people" than the original 24, and so it was "even more resource intensive than we had initially envisaged".

Ms Basra believes that while the charity’s involvement in the ActWELL pilot showed that it’s possible for volunteer lifestyle coaches to deliver a peer support weight management intervention in the community, there are learnings that would need to be considered to make a future programme roll out viable. It would "warrant a whole load of changes into the screening service, for example," and they would "probably need to ensure that we over-recruit" volunteers "to allow for drop-offs, etc”.

And "if you’ve got more lifestyle coaches, more support is needed", she said, noting they had to periodically recruit administrative support "just to manage all of this".

Nevertheless, Ms Basra said that a number of the volunteers "got really involved and attached to some of their participants and the differences they were making", especially if they had experience of breast cancer either themselves or among their family and friends.

She believes that level of support is not something that would necessarily be available with other programmes, so it’s "unique in that sense".

She commented: "That’s definitely one of the pluses in terms of the value of having a peer-mentoring approach to support people to enable them to change their behaviour.

"I think that makes a massive amount of difference for people, particularly if they don’t necessarily want to link to an app… it’s that real connection with people."

Risk Factors

Prof Anderson began her presentation by saying that there are three main lifestyle risk factors that we know to be associated with breast cancer: alcohol, body fatness, and physical activity.

"We know that weight gain is an independent risk factor, in addition to body fatness."

She went on to say that bariatric surgery data show that patients who undergo the procedure experience a significant reduction in their risk of postmenopausal breast cancer, as well as in the risk of colon, endometrial, and pancreatic cancer.

Moreover, a pooled analysis published in 2019 indicated that sustained weight loss "and I have to underline the word ‘sustained’," was associated with a significant reduction in breast cancer risk in women aged over 50.

Prof Anderson added: "There’s an important issue here that, even for women aged over 50, small amounts of weight loss appear to be associated with reduced risk of post menopausal breast cancer."

In the pooled study, weight loss of between 2 kg and 4.5 kg was associated with an approximately 20% reduction in breast cancer risk among women not taking post-menopausal hormones.

Prof Anderson said that, for the ActWELL study, the team "wanted to use existing assets to facilitate support for women who wished to lose weight".

Building on a feasibility study, they worked with NHS Scotland breast screening clinics and local leisure facilities in four sites, with the aim of recruiting women when they went for a mammogram.

As they were leaving, Prof Anderson explained, the mammographers would say: "You know that lifestyle is related to breast cancer. Might you be interested in a lifestyle trial? I can give you a card and if you’d like more information, please put it in the box."

She added that it took "less than a minute for the mammographer to endorse lifestyle and to flag the opportunity for an intervention".

"We had a huge number of women who were interested," Prof Anderson said. "We couldn’t possibly cope with all of them and were somewhat taken aback by the interest."

Women who filled out the card were contacted by a research nurse to assess their eligibility, and women with a body mass index of over 25 kg/m2 were included, while those already undergoing treatment for cancer, on a specialised diet, diagnosed with type 1 diabetes and/or using insulin excluded.

Of 3769 women who expressed an interest, 1711 were screened and 560 underwent an assessment of their weight, waist circumference and blood pressure. They also had blood tests and filled out questionnaires on lifestyle, quality of life and their knowledge of screening and lifestyle.

The participants were then given a cancer prevention leaflet before being randomised to either the ActWELL lifestyle programme (n=278) or a comparison group (n=281).

The programme consisted of an initial hour long visit giving personalised diet advice and developing a pedometer walking plan with a volunteer coach from Breast Cancer Now, followed by a second visit and nine 15-minute phone calls over the next 12 months.

The comparison group received a leaflet on body weight, physical activity, and alcohol. Both groups completed questionnaires at 12 weeks and had a repeat assessment at 12 months.

Results

The mean age of the participants was 59.1 years, and 48.8% were obese. The majority (63.2%) were post-menopausal, and a further 8.2% reported being peri-menopausal.

Prof Anderson said that the volunteer coaches delivered 523 coaching sessions and 1915 support calls to the intervention participants over the course of the study.

Twelve-month data on 240 (81%) intervention and 227 (85%) comparison group participants indicated that the mean weight reduction was 2.5 kg in the intervention group and 1.2 kg in the comparison group.

This gave an adjusted mean difference between the intervention and comparison groups of -1.3kg (p=0.003).

The team calculated that women in the intervention group were significantly more likely to lose at least 5% of their body weight compared with those in the comparison group, with an odds ratio of 2.20 (p=0.0005).

Women in the intervention group also had a non-significant increase in daily step counts, at an adjusted mean difference versus the comparison group of 483 steps.

Women were generally supportive of the idea of receiving lifestyle screening at breast cancer screening visits, with 35.5% of 467 women saying that it would make them more likely to attend and 64.2% saying it would make no difference to whether or not they attended. Only 0.2% said it would make them less likely to attend for screening.

Prof Anderson told Medscape News UK that there is "work already out there to show that women are interested in receiving advice and support about lifestyle through breast cancer screening clinics, but up until now it’s not really been picked up at all by any national screening programmes".

She explained that it is "partially because screeners really don’t want to risk anything that might put people off coming for screening".

"We know for example that obesity can be quite a sensitive topic and there is anxiety that, if women think they are going to hear about obesity, they won’t come for their breast cancer screening."

Consequently, there has been "quite a bit of resistance within the screening community in putting lifestyle and screening together".

Prof Anderson believes, however, that women who go for breast cancer screening "have taken the step of accepting an invitation", and are consequently open to talking about what could influence their cancer risk.

But she explained that, when women go to the screening clinic, "they’re with the mammographer for 6 minutes, and that’s it".

"They are in and out and, you know, it’s a missed opportunity."

She continued: "In the waiting rooms I’ve been in, there’s no health information material at all. There’s nothing that says: You can do something about breast cancer risk. So it’s a real gap that’s not being addressed."

Professor Anderson believes that women "would be more interested in coming to screening if there was more in it for them, basically".

She nevertheless said that offering lifestyle advice and coaching at breast cancer screening visits should be just one way in which to tackle body fat as a modifiable risk factor.

"I think in terms of individual support for obesity, there’s no one approach that’s going to work for everybody," she explained.

"Some people like slimming groups, others like to go online, and this particular intervention that we’ve used, I think should be one part of the portfolio that can be offered to people."

The study was funded by the Scottish government.

No relevant financial relationships declared.

NCRI Virtual Showcase 2020: Abstract: A volunteer lifestyle coach programme can support weight management in women attending routine breast screening clinics - the ActWELL study. Presented November 3.

Editor's note, 10 November 2020: Some of Manveet Basra's quotes were amended for clarity after a request from Breast Cancer Now.

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