Current Nutrition Reports

, Volume 3, Issue 1, pp 9–15 | Cite as

The Association Between Adiposity and Breast Cancer Recurrence and Survival: A Review of the Recent Literature

  • Maria AzradEmail author
  • Wendy Demark-Wahnefried
Cancer (MF Leitzmann, Section Editor)


Breast cancer (BC) is the most common and second deadliest malignancy among American women. Many factors contribute to BC prognosis, but a key modifiable lifestyle factor is body weight. In this review, we update the reader on the association between adiposity and poor BC outcomes. We summarize the findings from studies that show obesity to be a risk factor for BC recurrence and reduced survival, including research that shows that treatment with aromatase inhibitors in hormone-receptor positive BC survivors who are obese may not be as effective as for normal-weight women. In addition, we summarize the findings from studies that show that obesity-induced changes in glucose metabolism, type-2 diabetes, and metabolic syndrome contribute to negative outcomes in BC survivors. Given the evidence, there is a critical need to determine whether weight loss can improve outcomes in BC survivors.


Breast neoplasms Recurrence Survival Mortality Aromatase Aromatase inhibitor Adiposity Obesity Overweight Body fat Body mass index Body weight Insulin Estrogen-receptor positive Hormone-receptor positive Estrogen Glucose Glucose metabolism c-peptide HOMA Type 2 diabetes Metabolic syndrome Hormones 



The authors are supported by the following grants from the National Institutes of Health (NIH): R01CA148791, R25CA047888, and P30CA13148.

Compliance with Ethics Guidelines

Conflict of Interest

Maria Azrad and Wendy Demark-Wahnefried declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    American Cancer Society. BC Facts & Figures 2013-2014. Atlanta: American Cancer Society, Inc; 2013.Google Scholar
  2. 2.
    Protani M, Coory M, Martin JH. Effect of obesity on survival of women with breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat. 2010;123:627–35.PubMedCrossRefGoogle Scholar
  3. 3.
    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief. 2012;82:1–8.PubMedGoogle Scholar
  4. 4.
    Folkerd EJ, Dixon JM, Renshaw L, A'Hern RP, Dowsett M. Suppression of plasma estrogen levels by letrozole and anastrozole is related to body mass index in patients with breast cancer. J Clin Oncol. 2012;30:2977–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. CA Cancer J Clin. 2010;60:207–21.PubMedCrossRefGoogle Scholar
  6. 6.
    Esposito K, Chiodini P, Colao A, Lenzi A, Giugliano D. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care. 2012;35:2402–11.PubMedCrossRefGoogle Scholar
  7. 7.
    Longcope C, Baker R, Johnston CC. Androgen and estrogen metabolism: relationship to obesity. Metabolism. 1986;35:235–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Jiralerspong S, Kim ES, Dong W, et al. Obesity, diabetes, and survival outcomes in a large cohort of early-stage breast cancer patients. Ann Oncol. 2013;24:2506–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Kamineni A, Weinmann S, Shy KK, et al. Efficacy of screening in preventing cervical cancer among older women. Cancer Causes Control. 2013;24:1653–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Ademuyiwa FO, Groman A, O'Connor T, et al. Impact of body mass index on clinical outcomes in triple-negative BC. Cancer. 2011;117:4132–40.PubMedCrossRefGoogle Scholar
  11. 11.
    Dawood S, Lei X, Litton JK, et al. Breast Impact of body mass index on survival outcome among women with early stage triple-negative breast cancer. Cancer. 2012;12:364–72.Google Scholar
  12. 12.
    Francis P, Crown J, Di Leo A, et al. Adjuvant chemotherapy with sequential or concurrent anthracycline and docetaxel: Breast International Group 02–98 randomized trial. J Natl Cancer Inst. 2008;100:121–33.PubMedCrossRefGoogle Scholar
  13. 13.
    de Azambuja E, McCaskill-Stevens W, Francis P, et al. The effect of body mass index on overall and disease-free survival in node-positive breast cancer patients treated with docetaxel and doxorubicin-containing adjuvant chemotherapy: the experience of the BIG 02–98 trial. Breast Cancer Res Treat. 2010;119:145–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Sparano JA, Wang M, Zhao F, et al. Obesity at diagnosis is associated with inferior outcomes in hormone receptor-positive operable breast cancer. Cancer. 2012;118:5937–46.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Crozier JA, Moreno-Aspitia A, Ballman KV, et al. Effect of body mass index on tumor characteristics and disease-free survival in patients from the HER2-positive adjuvant trastuzumab trial N9831. Cancer. 2013;119:2447–54.PubMedCrossRefGoogle Scholar
  16. 16.••
    Ewertz M, Jensen MB, Gunnarsdóttir KÁ, et al. Effect of obesity on prognosis after early-stage BC. J Clin Oncol. 2011;29:25–31. The study was conducted in Denmark and included 18,967 breast cancer patients with up to 30-year follow-up. Results showed that obese women had increased risk for distant metastases and death and that chemotherapy and endocrine therapy may be less effective in this patient population.PubMedCrossRefGoogle Scholar
  17. 17.
    Kwan ML, Chen WY, Kroenke CH, et al. Pre-diagnosis body mass index and survival after breast cancer in the After Breast Cancer Pooling Project. Breast Cancer Res Treat. 2012;132:729–39.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.•
    Chen X, Lu W, Zheng W, et al. Obesity and weight change in relation to breast cancer survival. Breast. 2010;122:823–33. The study was conducted in a Chinese population that included more than 5,000 subjects with nearly 4-year follow-up. Results showed that obesity before and at diagnosis were poor prognostic factors. Importantly, this study also showed that weight gain after diagnosis was associated with inferior outcomes.Google Scholar
  19. 19.
    Conroy SM, Maskarinec G, Wilkens LR, et al. Obesity and breast cancer survival in ethnically diverse postmenopausal women: the Multiethnic Cohort Study. Breast Cancer Res Treat. 2011;129:565–74.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Burstein HJ, Prestrud AA, Seidenfeld J, et al. American Society of Clinical Oncology clinical practice guideline: update on adjuvant endocrine therapy for women with hormone receptor-positive breast cancer. J Clin Oncol. 2010;28:3784–96.PubMedCrossRefGoogle Scholar
  21. 21.
    Howell A, Cuzick J, Baum M, et al. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years' adjuvant treatment for BC. Lancet. 2005;365:60–2.PubMedCrossRefGoogle Scholar
  22. 22.••
    Sestak I, Distler W, Forbes JF, et al. Effect of body mass index on recurrence in tamoxifen and anastrozole treated women: an exploratory analysis from the ATAC trial. J Clin Oncol. 2010;28:3411–5. This was one of the earlier studies to investigate the efficacy of AIs in obese breast cancer patients. The results are from secondary analyses of large, double-blind, randomized clinical trial and showed that tamoxifen is equally effect across BMI categories, yet AIs may not confer the same protection for women with higher BMI.PubMedCrossRefGoogle Scholar
  23. 23.
    Schmid M, Jakesz R, Samonigg H, et al. Randomized trial of tamoxifen versus tamoxifen plus aminoglutethimide as adjuvant treatment in postmenopausal breast cancer patients with hormone receptor-positive disease: Austrian breast and colorectal cancer study group trial 6. J Clin Oncol. 2003;21:984–90.PubMedCrossRefGoogle Scholar
  24. 24.
    Pfeiler G, Stöger H, Dubsky P, et al. Efficacy of tamoxifen ± aminoglutethimide in normal weight and overweight postmenopausal patients with hormone receptor-positive breast cancer: an analysis of 1509 patients of the ABCSG-06 trial. Br J Cancer. 2013;108:1408–14.PubMedCrossRefGoogle Scholar
  25. 25.
    Jakesz R, Greil R, Gnant M, et al. Extended adjuvant therapy with anastrozole among postmenopausal BC patients: results from the randomized Austrian Breast and Colorectal Cancer Study Group Trial 6a. J Natl Cancer Inst. 2007;99:1845–53.PubMedCrossRefGoogle Scholar
  26. 26.
    Gnant M, Pfeiler G, Stöger H, et al. The predictive impact of body mass index on the efficacy of extended adjuvant endocrine treatment with anastrozole in postmenopausal patients with breast cancer: an analysis of the randomized ABCSG-6a trial. Br J Cancer. 2013;109:589–96.PubMedCrossRefGoogle Scholar
  27. 27.
    Gnant M, Mlineritsch B, Schippinger W, et al. Endocrine therapy plus zoledronic acid in premenopausal breast cancer. N Engl J Med. 2009;360:679–91.PubMedCrossRefGoogle Scholar
  28. 28.
    Pfeiler G, Königsberg R, Fesl C, et al. Impact of body mass index on the efficacy of endocrine therapy in premenopausal patients with breast cancer: an analysis of the prospective ABCSG-12 trial. J Clin Oncol. 2011;29:2653–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Goodwin PJ, Pritchard KI. Obesity and hormone therapy in breast cancer: an unfinished puzzle. J Clin Oncol. 2010;28:3405–7.PubMedCrossRefGoogle Scholar
  30. 30.•
    Erickson K, Patterson RE, Flatt SW, et al. Clinically defined type 2 diabetes mellitus and prognosis in early-stage breast cancer. J Clin Oncol. 2011;29:54–60. The study included a large number of study participants from the United States with median 10-year follow-up. The study observed that higher hemoglobin A1c, a clinical marker of abnormal glucose metabolism, was significantly associated with increased mortality from breast cancer.PubMedCrossRefGoogle Scholar
  31. 31.
    Goodwin PJ, Ennis M, Pritchard KI, et al. Insulin- and obesity-related variables in early-stage breast cancer: correlations and time course of prognostic associations. J Clin Oncol. 2012;30:164–71.PubMedCrossRefGoogle Scholar
  32. 32.
    Duggan C, Irwin ML, Xiao L, et al. Associations of insulin resistance and adiponectin with mortality in women with breast cancer. J Clin Oncol. 2011;29:32–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Irwin ML, Duggan C, Wang CY, et al. Fasting C-peptide levels and death resulting from all causes and breast cancer: the health, eating, activity, and lifestyle study. J Clin Oncol. 2011;29:47–53.PubMedCrossRefGoogle Scholar
  34. 34.
    Minicozzi P, Berrino F, Sebastiani F, et al. High fasting blood glucose and obesity significantly and independently increase risk of breast cancer death in hormone receptor-positive disease. Eur J Cancer. 2013 pii: S0959-8049(13)00759-4. doi:  10.1016/j.ejca.2013.08.004.
  35. 35.••
    Bjørge T, Lukanova A, Jonsson H, et al. Metabolic syndrome and breast cancer in theme-can (metabolic syndrome and cancer) project. Cancer Epidemiol Biomarkers Prev. 2010;19:1737–45. This study includes a large number of study participants from three European countries with 11-year follow-up. The study measured several metabolic outcomes and concluded that metabolic syndrome is associated with death from breast cancer and that glucose also was an independent factor contributing to increased death.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Nutrition SciencesUniversity of Alabama at Birmingham (UAB)BirminghamUSA
  2. 2.UAB Comprehensive Cancer CenterUniversity of Alabama at BirminghamBirminghamUSA

Personalised recommendations