Breast Cancer Survivorship

breast-cancer-survivorship-naturopathic-specialists-condensed.jpg

If you’re like most people who’ve finished treatment for cancer, you’ll be provided with a survivorship plan for your continued care after treatment to detail your health history (as it relates to your cancer diagnosis) and outline what’s coming next.

This plan varies from one person to the next and will be tailored to your individual circumstances.

Your plan may include continued check-ins with your oncology team, primary care provider, and other healthcare providers, including your naturopathic doctor, and while it’s true that this will mean more follow up visits, lab work, imaging, and physical exams; there are two primary reasons that follow up care is important:

  1. To help you to manage potential complications of your cancer or cancer treatments, both short and long-term, and

  2. To monitor you for any signs of cancer recurrence

The complications or side effects from cancer treatment can vary from the acute, those that manifest with treatment, to those that are long-term and linger after treatment is completed.

Interestingly, there are some effects that may not manifest until after treatment is completed, so it’s possible to be declared ‘cancer-free,’ but suddenly have new health challenges to get through.

These could include physical, mental, or emotional symptoms or an amalgam of all three.

All of these aspects should be addressed by your care team to maximize your recovery and minimize the potential for cancer recurrence, or other health issues. 

Dealing With Complications from Your Treatments

Surgery

Side effects from surgery vary widely depending on the type and extent of the surgery that a person undergoes.

For example, there are rarely any side effects to a simple lumpectomy besides short-term bruising and soreness, however, if you have a mastectomy with axillary dissection, a person could experience muscle weakness, loss of sensation, scarring, and lymphedema.

Radiation

Short-term side effects of radiation therapy most commonly include fatigue and a radiation burn.

In the past, radiation to the chest could cause a degree of damage to the heart and lungs. Better technology has largely mitigated these effects, though there is still a chance this could occur. Radiation after surgery may also cause skin contraction and permanent skin changes.
   

Chemotherapy

The long-term side effects of chemotherapy depend largely on the type, dose, and duration of chemotherapy used.  

For instance, Doxorubicin and Herceptin can cause heart damage, and taxanes, such as Taxotere, can cause neuropathy.

Some of the side effects of chemotherapy may be short-term, however many others could linger from months to years after treatment is finished.

Naturopathic medicine can often help to manage both the long and short-term side effects of chemotherapy.
 

Endocrine Therapy 

Endocrine therapy usually lasts for years, so these therapies will often persist long after a person’s other cancer-specific therapies have stopped.

The most common side effects of endocrine therapies in the context of breast cancer are hot flashes, vaginal dryness, joint pain, fatigue, mood changes, and diminished bone density.

Women taking tamoxifen should have yearly pelvic exams due to increased risk of developing endometrial cancer.

Naturopathic medicine can help to minimize or manage many of the side effects likely to occur in connection with endocrine therapy.

Take Stock of Your Emotions

So far, we’ve only touched on the physical complications of cancer treatment.

In truth, any serious health problem, such as cancer, can have a profound mental and emotional impact on a person.

After undergoing cancer treatment and coming out ‘cancer-free’, some individuals find that they have a greater appreciation for life, and look at the world with a renewed sense of optimism and hope.

Others live with a persistent fear that their cancer will return, particularly around the time of their routine follow-ups.

If you’re an individual that struggles with fear or anxiety after your treatment ends, it can help to know that those feelings are totally understandable, and you’re in no way alone for having them.

Everyone experiences an adjustment period when transferring into the role of survivorship, so it’s important not to glance over the emotional component that cancer can cause. The same way we’d recommend seeking help for the physical complications of cancer therapy, we also recommend seeking help for any mental and emotional needs that turn up.

This kind of help can often come from a counselor or other mental health professional, joining an in-person or online support group, getting involved in your local community, or even reaching out to friends and family around you.

Additionally, many cancer survivors also express interest in and benefit from mindfulness-based practices such as meditating, journaling, or even doing yoga.

mindfulness-naturopathic-specialists.jpg
meditation-cancer-survivorship-naturopathic-specialists.jpg
journaling-for-cancer-naturopathic-specialists.jpg
yoga-cancer-survivorship-naturopathic-specialists.jpg

With the right help and approach, it’s possible to do more than just survive after cancer. Many people eventually find that they can thrive after cancer. Learning how to do that is part of the survivor’s experience.

Remember To Be Thankful

If a spouse, sibling, child, parent, or friend has helped to care for you during the active treatment of your disease, it’s important to understand how that relationship can change now that you’re in survivorship.

For many who had helped to care for the basic needs that we couldn't manage on our own, whether around the house or in our treatment regime, their role as a caregiver might be over…or at least change.

For others, maybe the ones closest to us, it may mean helping to manage and assist with complications we now experience and to help ensure that we’re following our survivorship plan.

Caregivers often provide direct help to us in less than ideal circumstances. It’s important to remember that they may also experience mental, emotional, and physical effects.

Remember to help your caregivers take the time to look after themselves so they can continue to help the people they are caring for while maintaining balance for their own health as well.

The Best Ways to Prevent Cancer Recurrence

One of the key objectives in survivorship is to monitor for the recurrence of cancer, that is, to keep an eye out for indications that cancer may be returning.

Other objectives include educating yourself on how to promote a healthy lifestyle in an attempt to further prevent breast cancer recurrence.

Your care team will be able to direct you on the most important steps to take based on your individualized circumstances. If you don’t feel like you know what to do - Ask!

One of the key things we’ve already touched on is how important it is to listen to your doctor when it comes to follow-ups.

Many doctors have found that after just 5 years, many cancer survivors no longer follow-up with their oncologist as per recommendations (1).

Why is this such a problem? I mean, five years seems like a long time, so why bother?

It’s been found that individuals who have undergone treatment for cancer are not only at risk of recurrence of their initial cancer, but also for developing cancer unrelated to their original diagnosis (2).  

There are a number of reasons for this increased risk.

Exposure to radiation and chemotherapy while undergoing treatment, combined with the fact that individuals treated for early-stage breast cancers have been found to live longer than the general population allows more time for new cancers to develop (3).

Following up with your physician, being regularly screened, and making positive lifestyle adjustments that can help to minimize your risk of recurrence.

(All of these three goals can be met by seeing a naturopathic oncologist).

To understand how lifestyle adjustments can impact the risk of recurrence, let’s talk about how two examples in more detail: obesity and even more specifically, visceral fat.

Obesity: Some estimate that obese individuals have a 1.6x increased risk of developing cancer (4). Additionally, obesity has been found to increase the risk of breast cancer recurrence by up to 40% (5).

Visceral Fat: Visceral fat is the fat behind your abdominal muscles that blankets your internal organs. To learn more about visceral fat, see our blog post: What You Should Know About Visceral Fat, or watch the video “Why InBody Testing?” right next to this section.

Overall, elevated levels of visceral fat are associated with worse outcomes as well as increased risk of recurrence in women with cancer (6,7).

Scientists continue to learn more, but some of the reasons that visceral fat contributes to worse outcomes are:

  • Visceral fat causes elevated levels of inflammation in the body (8),

  • Visceral fat increases insulin resistance (9),

  • Visceral fat can contribute to immune dysfunction (10).  

The two best ways to impact your visceral fat levels are diet and exercise. 

Use Your Diet as a Tool to Prevent Recurrence

Diet, like anything that can have a direct impact your health, is something you should probably discuss with your doctor.

That being said, many people have come to appreciate that anti-inflammatory, nutrient-dense, whole foods diets are hard to beat when it comes to diets that can most positively affect the health of the body.

These diets can come in many forms, such as Mediterranean, pescatarian, vegetarian, vegan, paleo, Okinawan diet and so on. Again, your physician may be able to guide you in the direction that is best aligned with your overall health goals.

When it comes to diet and breast cancer, keep these tips in mind:

  • Eat 3-4 cups of vegetables daily. Increased consumption of polyphenols is associated with reduced risk of breast cancer recurrence (11).

  • Consume 1-3 servings of fruit per day, (keep in mind that many fruits are high in sugar and are easy to over-consume). 

  • Avoid conventionally raised red meat and sources of saturated fat. Limit intake of all conventionally raised animal protein and dairy. Increased saturated fat intake is associated with a higher risk of breast cancer recurrence (12). 

  • Limit consumption of refined and highly processed foods. This includes white flour and sugar. It also includes seed oils such as corn, canola, and soybean oil. 

  • Protein should come from plant-based sources, wild caught fish, grass fed beef, pasture raised pork, chicken and eggs. Consuming more DHA and EPA (fat from fish) compared to AA (fat from other animals) is associated with reduced risk of recurrence (13). 

  • Limit overall carbohydrate intake. There is an association between elevated blood sugar and breast cancer. We recommend that carbohydrates come mainly from starchy vegetables, legumes, and whole grains. 

  • Consume healthy fats such as olive oil, coconut oil, avocado oil, omega 3 from marine sources as well as grass-fed butter

  • Coffee and tea consumption has been linked to improved outcomes in patients with breast cancer (11).  

  • Limit alcohol consumption: It has been well established that alcohol consumption is a risk factor for developing breast cancer (14). 

  • Undergoing periodic fasting has been shown to enhance the immune system, decrease inflammation, decrease blood glucose, enhance cellular repair and much more (15). It also has been shown to decrease the side effects from and increase the efficacy of conventional oncology treatments as well as reduce the risk of breast cancer recurrence (15).

How Exercise Helps Prevent Recurrence

Getting the right amount, and the right kind of exercise is important to good health, but especially so in recovery and survivorship. Movement can help to reduce inflammation, improve insulin sensitivity, stimulate the immune system, and much more (19).

All of these factors combine to reduce the risk of breast cancer recurrence (19).

In fact, 30 minutes of exercise a day, 5 days a week has been shown to reduce breast cancer risk by about 10-20% (18). One study found that regular physical activity reduces breast cancer mortality and recurrence by 40% (17).

As previously stated, exercise is one of the best ways to prevent obesity and maintain healthy levels of body fat, and both cardiovascular and weight training have been found to reduce levels of visceral fat (16).

Next let’s discuss three more key areas to address to limit breast cancer recurrence:

  • Sleep,

  • Keeping Your Stress in Check, and

  • Limiting Your Exposure to Environmental Toxicants

Take a Look at Your Sleep Hygiene

Simple as it sounds, sleep is an extremely important aspect of recovery.

importance-of-sleep-naturopathic-specialists.jpg

Sleep plays an important role in helping to form our immunological memory (20), meaning that taking a cut in our amount and quality of sleep is akin to cutting out some of our body’s natural defenses.

Sleep also plays a role in wound healing, mental health, and much more. 

It has been found that just one night of lost sleep can lead to increased levels of inflammation throughout the body (21).

Getting less than 6 hours of sleep per night has been found to increase the risk of breast cancer recurrence (22). Reduced sleep has also been associated with the development of more aggressive forms of breast cancer (22).

Women who work night shifts have a 30% increased risk of developing breast cancer (23).

We recommend you get between 7-9 hours of sleep per night and working to improve your sleep hygiene. Sleep hygiene refers to the recommended behavioral and environmental practice that is intended to promote better quality sleep. 

Keep these tips in mind for better sleep:

  • Try going to bed and getting up at the same time every day. Avoid napping throughout the day if it impacts your ability to sleep restfully through the night.  

  • Only use your bed for sleep and sex. Do not use your bed to watch tv or work.

  • Avoid caffeine, alcohol, nicotine, and exercise 4-6 hours before bed (depending on how you react to them, and your sensitivity to those substances and activities). 

  • If you can’t fall asleep within 15-30 minutes after getting in bed, get out of bed and do something until you feel sleepy.

  • Create a sleep ritual before bed such as reading, meditating, listening to music or drinking a cup of caffeine-free tea.

  • Once the sun goes down, avoid looking at blue light. Exposure to blue light has been found to inhibit melatonin production, which is known as the sleep hormone (24-25). Lower melatonin levels are associated with an increased risk of developing breast cancer (26). You can try using apps such as night shift or f.lux that alter the screen temperature of your devices to emit a yellow tone instead of blue. Alternatively, you can wear a pair of blue-blocking glasses at night.

  • Avoid having any electronics on in your room while you are trying to sleep.

  • Try keeping your bedroom cool, because this can contribute to helping you fall asleep quicker and stay asleep longer.

If you still can’t get restful sleep after working on your sleep hygiene, consider working with a naturopathic doctor who can prescribe natural sleep-promoting agents. 

Why You Should Keep Your Stress In Check

Stress is an often-overlooked component of our health, but it’s especially important to consider the impact stress can have in recovery.

Chronic stress has been found to impair the immune system, increase inflammation, contribute to increased visceral fat levels, cause insulin resistance, and even affect the way our genes may be expressed (27-32).  

All these factors can increase the risk for cancer development and recurrence, and higher levels of stress have been linked with both an increased incidence of cancer as well as higher cancer mortality (33-34). 

On the other hand, people with cancer who reported reduced levels of stress indicated improved outcomes.

Even a ‘mini-vacation’ in your own backyard can help to keep your stress levels in check. Keep working on mindfulness and take breaks from your stressors.

Even a ‘mini-vacation’ in your own backyard can help to keep your stress levels in check. Keep working on mindfulness and take breaks from your stressors.

A strong social support network has been shown to elicit a 40% decreased risk of recurrence in women with breast cancer according to some studies (35).

Yoga and meditation have been found to reduce the stress of patients undergoing treatment for breast cancer. Additionally, both therapies have also been found to reduce the stress associated with the fear of recurrence in women with breast cancer.

Because stress can have such a profound role in healing and eventual outcomes, we recommend women who have had breast cancer incorporate daily stress reduction techniques, and take frequent breaks away from technology such as cell phones, email, social media, computers, and televisions to allow for stress-free ‘mini-vacations’. 

Getting out in nature on a regular basis has also been found to improve immune function and decrease stress hormone levels (36), so even if the vacations are as brief as a quick tour of the backyard, do what you can to make them count. 

Get Rid of Environmental Toxicants

While there is no conclusive evidence that chemicals in our environment cause breast cancer, we do know that many of these chemicals disrupt normal hormone production and can cause other health problems.

We recommend trying to avoid exposure to these endocrine disrupting chemicals as much as possible.

This generally entails being conscious of:

  • What cookware, water bottles, cleaning products, herbicides, pesticides, cosmetics and sunscreen we use, and

  • Taking practical steps to reduce our exposure to environmental toxicants such as herbicides, pesticides, cleaning products containing harmful ingredients, plastics, heavy metals, and indoor or outdoor air pollution.  

A recently published study found that individuals who eat organic produce have a reduced risk of developing cancer (37).

Organic” has become such a sales term that it’s important to actually remember what ‘organic’ is supposed to mean: “foods that are produced without the use of chemical fertilizers, pesticides, or other artificial agents”.

More studies need to be performed to determine if eating ‘organic’ reduces the risk of cancer recurrence.

However, we feel it is prudent to limit consumption of non-organic produce. We are fans of organic fruits and vegetables, but we also understand that many people cannot afford to eat fully organic.

The important thing is to do what you can to limit the largest amount of harmful chemicals from your daily life.

We can’t hope to eliminate all chemicals that we could list as harmful from our food, life, or home; but there are practical steps that anyone can take.

Each year, the environmental working group publishes the dirty dozen list that details which fruits and vegetables are the most heavily sprayed and should be purchased organic. It also published the clean 15 which is a list of the least sprayed fruits and vegetables.

The environmental working group is a great resource to use for people looking to find environmentally responsible products. Find more information at their site: https://www.ewg.org/

There are many other environmental factors to discuss such as hormone replacement therapy, vitamin D, heavy metals, and more.

To know what’s most important and most worthy of your time and energy, we suggest working with a naturopathic oncologist who can assess your needs, perform any necessary lab testing, and recommend therapies that are clinically indicated.

It’s easy to go overboard trying to eliminate or modify environmental risk factors.

Asking a professional for advice is a good way to take care of the biggest most important issues, while not adding stress or making life too restrictive.

Know the Signs of Breast Cancer Recurrence

The first goal after beating cancer is usually to prevent the disease from coming back.

Hopefully, it won’t, but you should still know some of the common signs and symptoms to look out for so you can keep your medical team in the loop without too much of a delay.

Below we list some of the common presentations of breast cancer recurrence…again, while we hope you won’t have to experience any of these symptoms, we recommend seeing your physician if you are experiencing any of the below: 

  • A new lump in the breast or chest wall, or under the arm. 

  • New onset bone or joint pain, as well as fractures or swelling. These could indicate bone metastases.

  • New onset of headaches, seizures, dizziness, confusion, personality changes, or changes in vision, which are possible signs of brain metastases.

  • Sharp chest pain, coughing, shortness of breath, or trouble breathing, which are possible symptoms of lung metastases.

  • Abdominal pain, early satiety (feeling full or like you’ve had enough to eat after just a couple bites of food), itchy skin, or yellow skin, which could indicate liver metastases.

  • Fatigue, fever, chills, nausea, vomiting, or night sweats. 

  • Having a low appetite and/or weight loss.

While this list is extensive it isn’t exhaustive, so if you’re suspicious of something, or if it would give you peace of mind, bridge the topic with your doctor.

Remember that the goal of covering this information about breast cancer recurrence isn’t to scare you, but to empower you to take charge of your health.

Never Stop

If you’ve followed our blog posts about breast cancer from the start, then you’ve just followed a breast cancer journey from screening, to diagnosis, treatment, and now survivorship.

(If you’ve missed any of the articles that you’d like to go back and read, look for the links to them at the end of this section).

Remember that while being diagnosed with breast cancer can make a person feel overwhelmed, you don’t need to go it alone.

Your medical team will always be there to advise you through all the stages of the disease and should continue to be available to support you as a cancer survivor.

A naturopathic oncologist can perform specialty testing to narrow down what areas may need the most attention and intervention to limit the chance of recurrence, whether through lifestyle modifications that you can implement or through prescription therapies that must be medically supervised.  

Cancer-free is an amazing diagnosis to hear. To help you reach that goal, we recommend working with a naturopathic oncologist at all stages of your treatment. They will be able to help you stay on track with your health goals and guide you through practical steps to keep cancer from gaining its foothold in your life again. 


Written by Adam Kozin. ND

Written by Adam Kozin. ND

(Our blog isn't designed to provide specific medical advice or replace a medical professional.  If you have any specific questions about your health, how to make changes responsibly, or would like to set up an appointment with our clinic, head to our Contact Us page and let us know)!

Links To Our Breast Cancer Blog Series:

Breast Cancer Screening - How to Identify Cancer in Healthy Individuals

Breast Cancer Diagnosis & Staging - The Find Out More About Your Cancer Step

Integrative Breast Cancer Treatments - Learn How Treatment Might Proceed

Breast Cancer Survivorship & Prevention of Recurrence - (You Are Here)

 

References

1.    Pollack, L. A., Adamache, W., Ryerson, A. B., Eheman, C. R., & Richardson, L. C. (2009). Care of long-term cancer survivors. Cancer, 115(22), 5284–5295. https://doi.org/10.1002/cncr.24624

2.    Murphy, C. C., Gerber, D. E., & Pruitt, S. L. (2018). Prevalence of Prior Cancer Among Persons Newly Diagnosed With Cancer. JAMA Oncology, 4(6), 832. https://doi.org/10.1001/jamaoncol.2017.3605

3.    Pruitt, S. L., Laccetti, A. L., Xuan, L., Halm, E. A., & Gerber, D. E. (2017). Revisiting a longstanding clinical trial exclusion criterion: impact of prior cancer in early-stage lung cancer. British Journal of Cancer, 116(6), 717–725. https://doi.org/10.1038/bjc.2017.27

4.    Lauby-Secretan, B., Scoccianti, C., Loomis, D., Grosse, Y., Bianchini, F., & Straif, K. (2016). Body Fatness and Cancer-Viewpoint of the IARC Working Group. Retrieved from https://www.nejm.org/doi/pdf/10.1056/NEJMsr1606602

5.    Jiralerspong, S., & Goodwin, P. J. (2016). Obesity and Breast Cancer Prognosis : Evidence , Challenges , and Opportunities, 34(35). https://doi.org/10.1200/JCO.2016.68.4480

6.    Iwase, T., Sangai, T., Sakakibara, M., Nagashima, T., & Ohtsuka, M. (2017). The impact of quality and quantity of visceral fat on survival outcome of early-stage breast cancer patients with prior chemotherapy. Journal of Clinical Oncology, 35(15_suppl), 584–584. https://doi.org/10.1200/JCO.2017.35.15_suppl.584

7.    Wang, F., Liu, L., Cui, S., Tian, F., Fan, Z., Geng, C., … Yu, Z. (2017). Distinct Effects of Body Mass Index and Waist/Hip Ratio on Risk of Breast Cancer by Joint Estrogen and Progestogen Receptor Status: Results from a Case‐Control Study in Northern and Eastern China and Implications for Chemoprevention. The Oncologist, 22(12), 1431–1443. https://doi.org/10.1634/theoncologist.2017-0148

8.    Dieli-Conwright, C. M., Lee, K., & Kiwata, J. L. (2016). Reducing the Risk of Breast Cancer Recurrence: an Evaluation of the Effects and Mechanisms of Diet and Exercise. Current Breast Cancer Reports8(3), 139–150. https://doi.org/10.1007/s12609-016-0218-3

9.    Godinho-Mota, J. C. M. (2018). VISCERAL ADIPOSITY AND INSULIN RESISTANCE INCREASE THE RISK OF BREAST CANCER: A CASE-CONTROL STUDY. Nutrición Hospitalaria. https://doi.org/10.20960/nh.1441

10.  Meza-Perez, S., & Randall, T. D. (2017). Immunological Functions of the Omentum. Trends in Immunology, 38(7), 526–536. https://doi.org/10.1016/J.IT.2017.03.002

11.  Braakhuis, A., Campion, P., Bishop, K., Braakhuis, A. J., Campion, P., & Bishop, K. S. (2016). Reducing Breast Cancer Recurrence: The Role of Dietary Polyphenolics. Nutrients, 8(9), 547. https://doi.org/10.3390/nu8090547

12.  Chlebowski, R. T., Aragaki, A. K., Anderson, G. L., Simon, M. S., Manson, J. E., Neuhouser, M. L., … Prentice, R. L. (2018). Association of Low-Fat Dietary Pattern With Breast Cancer Overall Survival. JAMA Oncology, e181212. https://doi.org/10.1001/jamaoncol.2018.1212

13.  Patterson, R. E., Flatt, S. W., Newman, V. A., Natarajan, L., Rock, C. L., Thomson, C. A., … Pierce, J. P. (2011). Marine Fatty Acid Intake Is Associated with Breast Cancer Prognosis. The Journal of Nutrition141(2), 201–206. https://doi.org/10.3945/jn.110.128777

14.  LoConte, N. K., Brewster, A. M., Kaur, J. S., Merrill, J. K., & Alberg, A. J. (2017). Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, JCO2017761155. https://doi.org/10.1200/JCO.2017.76.1155

15.  Marinac, C. R., Nelson, S. H., Breen, C. I., Hartman, S. J., Natarajan, L., Pierce, J. P., … Patterson, R. E. (2016). Prolonged Nightly Fasting and Breast Cancer Prognosis. JAMA Oncology2(8), 1049–55. https://doi.org/10.1001/jamaoncol.2016.0164

16.  Hunter, G. R., Brock, D. W., Byrne, N. M., Chandler-Laney, P. C., Del Corral, P., & Gower, B. A. (2010). Exercise training prevents regain of visceral fat for 1 year following weight loss. Obesity (Silver Spring, Md.)18(4), 690–5. https://doi.org/10.1038/oby.2009.316

17.  Holmes, M. D., Chen, W. Y., Feskanich, D., Kroenke, C. H., & Colditz, G. A. (2005). Physical Activity and Survival After Breast Cancer Diagnosis. JAMA293(20), 2479. https://doi.org/10.1001/jama.293.20.2479

18.  Hamer, J., & Warner, E. (2017). Lifestyle modifications for patients with breast cancer to improve prognosis and optimize overall health. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 189(7), E268–E274. https://doi.org/10.1503/cmaj.160464

19.  Dieli-Conwright, C. M., Lee, K., & Kiwata, J. L. (2016). Reducing the Risk of Breast Cancer Recurrence: an Evaluation of the Effects and Mechanisms of Diet and Exercise. Current Breast Cancer Reports, 8(3), 139–150. https://doi.org/10.1007/s12609-016-0218-3

20.  Besedovsky, L., Lange, T., & Born, J. (2012). Sleep and immune function. Pflügers Archiv - European Journal of Physiology, 463(1), 121–137. https://doi.org/10.1007/s00424-011-1044-0

21.  Mullington, J. M., Simpson, N. S., Meier-Ewert, H. K., & Haack, M. (2010). Sleep loss and inflammation.Best Practice & Research. Clinical Endocrinology & Metabolism24(5), 775–84. https://doi.org/10.1016/j.beem.2010.08.014

22.  Thompson, C. L., & Li, L. (2012). Association of sleep duration and breast cancer OncotypeDX recurrence score. Breast Cancer Research and Treatment, 134(3), 1291–5. https://doi.org/10.1007/s10549-012-2144-z

23.  Yuan, X., Zhu, C., Wang, M., Mo, F., Du, W., & Ma, X. (2018). Night Shift Work Increases the Risks of Multiple Primary Cancers in Women: A Systematic Review and Meta-analysis of 61 Articles. Cancer Epidemiology Biomarkers & Prevention27(1), 25–40. https://doi.org/10.1158/1055-9965.EPI-17-0221

24.  Wood, B., Rea, M. S., Plitnick, B., & Figueiro, M. G. (2013). Light level and duration of exposure determine the impact of self-luminous tablets on melatonin suppression. Applied Ergonomics44(2), 237–240. https://doi.org/10.1016/J.APERGO.2012.07.008

25.  Figueiro, M., Plitnick, B., & Rea, M. (2017). DOES THE NIGHT SHIFT MODE FOR YOUR TABLET LIMIT MELATONIN SUPPRESSION? Sleep40(suppl_1), A290–A290. https://doi.org/10.1093/sleepj/zsx050.782

26.  Schernhammer, E. S., & Hankinson, S. E. (2005). Urinary Melatonin Levels and Breast Cancer Risk. JNCI: Journal of the National Cancer Institute, 97(14), 1084–1087. https://doi.org/10.1093/jnci/dji190

27.  Liu, Y.-Z., Wang, Y.-X., & Jiang, C.-L. (2017). Inflammation: The Common Pathway of Stress-Related Diseases. Frontiers in Human Neuroscience, 11, 316. https://doi.org/10.3389/fnhum.2017.00316

28.  Kemeny, M. E., & Schedlowski, M. (2007). Understanding the interaction between psychosocial stress and immune-related diseases: A stepwise progression. Brain, Behavior, and Immunity, 21(8), 1009–1018. https://doi.org/10.1016/j.bbi.2007.07.010

29.  Glaser, R., & Kiecolt-Glaser, J. K. (2005). Stress-induced immune dysfunction: implications for health. Nature Reviews Immunology, 5(3), 243–251. https://doi.org/10.1038/nri1571

30.  Antoni, M. H., Lutgendorf, S. K., Cole, S. W., Dhabhar, F. S., Sephton, S. E., McDonald, P. G., … Sood, A. K. (2006). The influence of bio-behavioural factors on tumour biology: pathways and mechanisms. Nature Reviews Cancer, 6(3), 240–248. https://doi.org/10.1038/nrc1820

31.  Unternaehrer, E., Luers, P., Mill, J., Dempster, E., Meyer, A. H., Staehli, S., … Meinlschmidt, G. (2012). Dynamic changes in DNA methylation of stress-associated genes (OXTR, BDNF ) after acute psychosocial stress. Translational Psychiatry2(8), e150–e150. https://doi.org/10.1038/tp.2012.77

32.  Aschbacher, K., Kornfeld, S., Picard, M., Puterman, E., Havel, P., Stanhope, K., … Epel, E. (2014). Chronic Stress Increases Vulnerability to Diet-Related Abdominal Fat, Oxidative Stress, and Metabolic Risk. Psychoneuroendocrinology46, 14. https://doi.org/10.1016/J.PSYNEUEN.2014.04.003

33.  Ducasse, H., Arnal, A., Vittecoq, M., Daoust, S. P., Ujvari, B., Jacqueline, C., … Thomas, F. (2015). Cancer: an emergent property of disturbed resource-rich environments? Ecology meets personalized medicine. Evolutionary Applications, 8(6), 527–40. https://doi.org/10.1111/eva.12232

34.  Chida, Y., Hamer, M., Wardle, J., & Steptoe, A. (2008). Do stress-related psychosocial factors contribute to cancer incidence and survival? Nature Clinical Practice Oncology5(8), 466–475. https://doi.org/10.1038/ncponc1134

35.  Kroenke, C. H., Michael, Y. L., Poole, E. M., Kwan, M. L., Nechuta, S., Leas, E., … Chen, W. Y. (2017). Postdiagnosis social networks and breast cancer mortality in the After Breast Cancer Pooling Project. Cancer, 123(7), 1228–1237. https://doi.org/10.1002/cncr.30440

36.  Li, Q., Morimoto, K., Kobayashi, M., Inagaki, H., Katsumata, M., Hirata, Y., … Miyazaki, Y. (n.d.). A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects. Journal of Biological Regulators and Homeostatic Agents, 22(1), 45–55. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18394317

37.  Baudry, J., Assmann, K. E., Touvier, M., Allès, B., Seconda, L., Latino-Martel, P., … Kesse-Guyot, E. (2018). Association of Frequency of Organic Food Consumption With Cancer Risk. JAMA Internal Medicine. https://doi.org/10.1001/jamainternmed.2018.4357