Optimizing Breast Cancer Care and Prevention

Kalea Wattles, ND, IFMCP
Preventative screenings, a healthy lifestyle that includes exercise and a nutrient-dense diet, and avoiding chronic exposures to cancer-causing substances are all components that may help reduce overall cancer risk. Specific to breast cancer, is it preventable? What impact does lifestyle, from nutrition to sleep to stress management, have not only on prevention but also breast cancer treatment and recovery?

Rebecca Knackstedt, MD, PhD
When I have patients that are specifically preparing for surgery, my number one priority is protein, just because that has shown to be so important during both cancer treatments and surgical recovery.

Kalea Wattles
On this episode of Pathways to Well-Being, we welcome plastic and reconstructive surgeon Dr. Rebecca Knackstedt to discuss optimizing cancer prevention and care and how she incorporates the functional medicine model into her medical practice. Welcome to the show, Dr. Knackstedt.

Rebecca Knackstedt
Thanks so much for having me. Super happy to be here.

Kalea Wattles 
Well, I love watching what you do. You're both a surgeon and a functional medicine practitioner, and I really admire the way that you talk about lifestyle factors, both as a tool for disease prevention but also to prepare patients for surgery to optimize their outcomes or their recovery. And today, we're talking about cancer. And I know for me, when these topics come up, I think our listeners too, we immediately wanna know what can be done in terms of prevention. So let's start there today. From your experience in both clinical practice and research, what are some of the most potent lifestyle modifications that we can focus on for cancer prevention?

Rebecca Knackstedt
Yeah, thanks so much for the question. That is the million-dollar question and something that people always ask about. Usually when a person has come in to see me in my practice, they've already been diagnosed with cancer, but you know, oftentimes they are asking those questions. You know, what could I have done differently? Is there anything I could have done differently? And I think the most important take-home is there's so much we don't know about cancer prevention and breast cancer prevention. We know that only about 5 to 10% of breast cancers are based on a genetic anomaly. 10 to 20% run in families. So if you have a first-degree or second-degree relative with breast cancer, definitely have an increased risk. But we largely don't know why. And when you add those numbers up, there's still 70 or 80% of cancers, and we just don't know why people get them. So we know some things, but there's still a lot that we really don't know.

Kalea Wattles 
That's probably a tough conversation to have because we're all wanting, probably if you have a cancer diagnosis, you're looking back in your timeline and thinking, okay, what factors led to this? And if you know you have a family history, you're probably thinking, okay, what can I modify so I can mitigate some of this risk? I'm wondering, a question that comes up oftentimes when we're talking about hormones, things like birth control or hormone replacement therapy, how do those factors influence our risk for developing cancer?

Rebecca Knackstedt
Yeah, I think when you talk about risk prevention and preventing breast cancer, you've got to break it down into two categories. It's modifiable things, things that we have power over, things that we encounter in our everyday lives: things like diets, exercise, stress, smoking. And then there's things that we really don't have a lot of control over. Once again, things like genetics, family history, but also where you live, whether or not you had kids, whether or not you did any breastfeeding, how long when you went through menopause. So you really got to break it down into those two big categories of things we have control over versus things we really don't have control over

Kalea Wattles 
Yeah, okay, let's focus first on the things that we do have control over because that feels most motivating. These are the things that I can actively participate in. What are some of those most important lifestyle factors in terms of the choices that we can make on the day to day?

Rebecca Knackstedt
Absolutely, I think an important preface to the conversation is that so much of what we know is based on epidemiological studies. So they look at patients who did or didn't develop breast cancer and then look back at their lifestyles and see what they did or didn't do, what they were or weren't exposed to. Those are hard studies. So when I look at data, what I look at are studies that compile other studies, bring them all together, we call those meta-analyses, and there've been a couple meta-analyses looking at what we can do to prevent breast cancer. And a couple things have emerged that we have control over. So big things like sufficient physical activity, getting up, moving around, exercising. Our diet, having a diet that's high in fruits and vegetables, high in fiber, low in red meat, and potentially some saturated fats. Things like oral contraceptive pills, which is somewhat in our control but definitely a modifiable risk and something we should talk to our doctors about. And smoking, of course, smoking is the number one thing that is a modifiable risk factor for pretty much all cancers.

Kalea Wattles 
And do we know, I think that this question comes up anytime we recommend alcohol abstinence. For example, people will ask me things like, well, is it that I can never have a drink again? Is it that I reduce the amount I'm having? How do you counsel your patients for those types of questions?

Rebecca Knackstedt
Yeah, that's a hard question. And it's something that we don't know a definitive answer to. And it's a hard discussion too because things like diet and alcohol are so involved in our celebrations, in our day-to-day life, that we still want to enjoy our lives. I think that what the research shows is that high alcohol consumption, so for a woman, you know, one drink per day. More than that is definitely associated with an increased risk of cancers, including breast cancer. But whether or not that one drink a day really impacts our breast cancer risk is kind of an unknown topic. And for a lot of patients, it's not something that they're willing to a hundred percent give up. And I think that that is duly supported in the literature that that would be an okay decision to make.

Kalea Wattles 
I like how you highlighted that really any of these single lifestyle factors are in the context of everything else you're doing, all of your other lifestyle factors, and so it's important to consider that entire context. You mentioned a moment ago that your pregnancy and breastfeeding history might also contribute to your cancer risk to some degree. That concept might be unfamiliar to some of our listeners. Will you just give us a little bit of background in that area?

Rebecca Knackstedt
Sure, so…so many breast, so breast cancers in general are either hormone receptor positive or negative, and they can be a combination thereof. And the ones that are most important in the context of breast cancer are estrogen and progesterone, which also sounds familiar to us for human fertility and female hormones. So those come into play when we're talking about things like pregnancy and breastfeeding, whether or not you had children at all. So what the studies seem to show is that if you don't have any children, you have a slightly increased risk of having breast cancer. Also, if you have a late pregnancy as your first pregnancy, you have an increased risk of breast cancer. So those pregnancy episodes and those breastfeeding episodes seem to be somewhat protective against breast cancer. That being said, I have a lot of patients in my practice who had more than four children and still had breast cancer. So it's not a sure definitive preventative way, but it does seem to be associated with some degree of risk.

Kalea Wattles 
So these are all components that, let's say you're doing a risk analysis with someone, you are going to account for some of these parts of their history.

Rebecca Knackstedt
Absolutely, and I think that what we really consider in this field is that it seems to be additive. So if you have multiple risk factors, that kind of adds up to increase your overall risk. But I think that it's important to think about what that risk is. So when we look at studies, they tell us if you do something or if you don't do something, what is your overall increased risk of developing, in this instance, breast cancer? And really, even for these things that we talk about, the increased risk or protective effect isn't that great. So it's not a five-time or a ten-time increased risk of breast cancer if do things like drink alcohol, don't have children. Somewhere around one to two. So it's not a huge increase. But I think, like you said before, it's all these things that we aim to do every day to live a healthy lifestyle and just add those protective things in our favor to overall decrease our risk.

Kalea Wattles 
Right, yes, so always thinking about in the functional medicine world, we would think about the entire matrix, all of the modifiable lifestyle factors. You mentioned earlier that genetics might play a relatively smaller role than we maybe intuitively imagine. So if someone has maybe a first-degree relative with a breast cancer history, how do we talk to them about lifestyle factors? Do we encourage them to be more aggressive with their modifications to really mitigate that risk?

Rebecca Knackstedt
Yeah, excellent question. And I think we read and hear so much about these genetic risk factors for cancer because a patient who has one of those risk factors genetically might have a 60 to 80% chance of developing cancer. That's super scary. But it's important to know that that still only counts for 5 to 10% of breast cancers. So for that individual that comes into you and is known to have BRCA1 or BRCA2, or one of the other genetic risk factors for breast cancer, or they come in and they had a first-degree relative, especially if they develop cancer at an early age, those are people that we're really concerned about. So yes, talking to them about just overall healthy living, preventing the risk for all cancers. But I think even more importantly, getting in with a high-risk group so they're doing all of the screening to detect any cancer or pre-cancer very early on.

Kalea Wattles 

Yeah, that makes great sense to me. And you mentioned before that most of the patients who come to you, they've already received a cancer diagnosis, and so now you're working on supporting them through surgery and making sure that their body is very resilient for healing. Are your lifestyle modifications different in that population than in those who you're truly focusing on primary prevention?

Rebecca Knackstedt
Yeah, excellent question. So when I meet patients, I meet them after they've had a breast cancer diagnosis. And sometimes, they're already into the throes of treatment like chemotherapy, and they're discussing those next stages like surgery. Other patients come in and they know that they have a high risk due to family history or one of these genetic conditions and know that they want to have surgery sometime in the future, but maybe not urgently. So I always tell my patients that preparing for surgery is like preparing for a marathon. Your body needs to be as prepared as possible. And we do that through lifestyle modification. A lot of it is kind of exhausting, you know, focusing so much on exercise, so much on nutrition, that it might be a little much for just our day-to-day lives. So I really tell patients when they're getting ready for surgery or have a cancer diagnosis that they just got to amp up all of those protective features.

Kalea Wattles 
Yeah, I think that's such a helpful way for us to conceptualize what the process looks like. You're preparing for a marathon, because it's easy for us to think about, okay, you have to have adequate fuel, you have to be well-rested. And that translates into a surgical procedure in a way that I can really imagine. We haven't touched on nutrition so much yet, and I think that's a really important part of the work that you do and what you recommend to your patients. And so let's talk about some specific dietary patterns. When we look, you know, in the news and social media, we see all kinds of different suggestions for dietary patterns. Will you talk to us about what the research says in terms of diets like ketogenic diet or a very low carb diet and how that plays into what you're recommending? Does that set us up for success as we're going through a cancer treatment?

Rebecca Knackstedt
Absolutely, it is such a hot topic as to how we can either prevent cancer or, once you have a diagnosis of cancer, how you can optimize your treatment. And that's where my research interests really lie because, once again, those are the people that I see every day. But I think that, once again, it is hard to have a definitive answer. So I tell patients always, you know, high fruits and vegetables, nutrient-dense foods, like making sure that every food they're eating has a purpose. So fueling up with fruits and vegetables, lots of protein, which can be a little bit difficult for vegetarians. Just making sure that they get enough protein. Limiting alcohol just because, once again, they're kind of empty calories that can fill you up and decrease your ability to have those nutrient-dense foods. But when I have patients that are specifically preparing for surgery, my number one priority is protein just because that has shown to be so important during both cancer treatments and surgical recovery.

Kalea Wattles 
So adequate protein, we get that. Recovery, let's say we were going to do something like a ketogenic diet. Is there a certain timing in the timeline of their treatment as they're preparing for chemotherapy or preparing for surgery where that type of dietary pattern would be most appropriate?

Rebecca Knackstedt
So I think that there is, well, I know there's a lot of ongoing research about the efficacy of a ketogenic diet during chemotherapy. And the whole idea of that is that a ketogenic diet limits sugar. And we know that cancer cells like sugar. However, there just aren't really good, prospective studies yet showing us if it matters. There have been no studies to my knowledge looking at a ketogenic diet around the time of surgery. And usually, we actually tell our patients to increase their carbs the day before surgery, kind of like you would for a marathon. And it's just carb loading your body, giving your body that fuel for surgery, fuel to recover. So there really haven't been studies showing that patients, even if they're already on a ketogenic diet and keto-adapted, how that would impact their surgical experience.

Kalea Wattles 
I can really appreciate how these recommendations are so thoughtful, thinking about how the body needs to utilize these nutrients in preparation for what's to come. I just really respect and appreciate that. I'm wondering, I always think about this, when you're making all these recommendations and you're managing the patient's care plan, I'm assuming that there's some other team members that are collaborating. Will you just give us a preview of what other provider types you are working with as you build this collaborative care team?

Rebecca Knackstedt
Yeah, so I'm lucky to work at a cancer center. So we have, for every patient, they get multidisciplinary treatments. So when a patient comes in with a diagnosis of breast cancer, they're meeting with breast surgery and medical oncology. They're meeting with genetics to determine if they have a genetic risk factor that they didn't know about it. They're meeting with a nutritionist before they even start their chemotherapy journey. There's social work that can talk to them about, just making sure their social networks are as strong as they can be, making sure that there's loved ones that can help take care of them. Psychiatry and psychology is so important for this whole journey. This is such a stressful experience and just being able to help patients navigate in a healthy, mentally healthy way. So I'm really lucky to be at a place that has all of these providers touch base with patients along their journey. And I know that's not the case at all hospitals or medical systems.

Kalea Wattles 
But what a beautiful system, and I'm sure the patients feel deeply nourished by that. As we're talking about all of these nutrition recommendations and hearing you say, "Protein is so important as you're getting ready for surgery," we read a lot about cancer and red meat specifically and saturated fat, and it's a little bit tough to sift through all of the opposing recommendations about that. Will you give us your perspective on that topic?

Rebecca Knackstedt
That is such a hard topic, and I think that red meat has been demonized so much in the literature and social media. Studies have been taken a lot out of context to make people so afraid of red meats. And when I talk to patients about that, about how to get their optimal protein source, I talk to them about making healthy meat choices if they're a non-vegetarian; and then if they're a vegetarian, good alternatives. I think the take home message from a lot of those red meat studies is that they were looking at processed meat or not farm-raised meat. So I always tell patients that if you choose to eat meat, have it be farm-raised if possible. Make healthy choices in regards to meat. You can always do lean meats like chicken, fish, shrimp and add other sources of healthy fats like avocados or grass-fed butter. So that's a good way to circumnavigate some of the scary literature out there in regards to red meat.

Kalea Wattles 
That's very helpful and reassuring. I'm wondering as your clinical experience developed and you started focusing on nutrition, if this wasn't always a part of your practice inherently, did you see a change in your patients’ recovery times once you started really focusing on adequate protein before surgery?

Rebecca Knackstedt
Yeah, what kind of brought me to it is I've always been interested in nutrition. And then as a plastic surgery resident, I was at the Cleveland Clinic, and we were taking care of some just really medically complex, really unhealthy patients and would go to see them in the morning super early, and you, there would be remnants of last night's dinner, and there was, you know, cake and half-eaten cinnamon rolls and two liter bottles of Coke and candy scattered around the room. And I knew just from my nutrition background that that was so detrimental to their healing recovery. But as surgeons and medical providers, we really don't have time to talk to patients about these things. And we're certainly not taught these topics during med school. So just making sure that patients have that information is hard but so critical to their recovery. So when I started my practice, you know, I made a commitment to myself and my patients that I was going to talk to my patients about these things. And I found that some patients adopt it, some don't. Anecdotally, the patients that do adopt it seem to have a faster recovery and just bouncing back to their normal selves’ day-to-day lives. But that's actually an area that we are studying in a prospective trial.

Kalea Wattles 
Cool, we'll have to keep our eyes out to learn more about that. But what I keep thinking about with the way that you're approaching nutrition for cancer treatment or prevention is that it's really teaching skills and habits that I'm sure many patients carry for years afterwards and adopt as part of a healthy lifestyle. And I think that's such a powerful part of this whole story.

Rebecca Knackstedt
Absolutely, and I think the really important thing is that it is obviously so critical to gear the patients up for their treatments and for their surgery and for their recovery. But there's really well-done studies showing that it impacts even long-term mortality from breast cancer. Things like the amount of sleep you're getting, the amount of physical activity you have—although it's super critical during that acute surgical period and recovery period—actually impacts your mortality. So like you said, super important to maintain those long-term lifestyle changes.

Kalea Wattles 
Along this line of nutrition, we've talked about how we might utilize a low carbohydrate diet. We've talked about the importance of adequate dietary protein. I know you have a special interest in omega-3 fatty acids as well. Will you tell us a little bit about the role that they might play in breast cancer treatment?

Rebecca Knackstedt
Yeah, I love omega-3s, and they have unfortunately been super demonized in our field of surgery because they were thought to increase a patient's risk of bleeding. For whatever reason, they have historically been associated with increased risk of surgical bleeding, which made surgeons and anesthesiologists super afraid to let patients be on those around the time of surgery. There have been large studies that have come out, meta-analyses of 50+ studies, that have shown it to be safe around the time of surgery, which I think is super exciting. We can encourage our patients to take it around the time of surgery. But omega-3s are awesome. We know from our training that the American diet is so high in omega-6s, which are important but also not anti-inflammatory as omega-3s. So surgery and chemotherapy is such an inflammatory experience. It's so critical to tip the scale in that omega-6 to omega-3 ratio to favor the omega-3s. So I love omega-3 supplements. Most patients don't feel really well enough during chemo and after surgery to eat salmon or take krill oil. So having something like an omega-3 supplement is very easy for a patient to implement.

Kalea Wattles 
My mind is spinning thinking about just the connection between inflammation and metabolic health and estrogen, and it's beautiful to reduce inflammation during this phase. But again, it's building this resiliency for longevity, which I think is so helpful and important. I think that there are some other nutrients that are being studied for their benefit in breast cancer treatment. And I know you have published some papers on nutrition. Will you talk to us about some other nutrients that we might think about or focus on or at least keep our eye on in the research?

Rebecca Knackstedt
Yeah, absolutely, so I think, once again, protein is paramount. Our whole goal when we are treating a patient with breast cancer is to prevent a condition called sarcopenia. Sarcopenia just means a loss of muscle mass, so decreased muscle mass for whatever reason, medical condition, decreased nutritional intake, aging. But sarcopenia has been shown to decrease a woman's response to chemotherapy, actually limit the amount of chemotherapy that she can receive, increase surgical outcomes or negative outcomes after surgery, increase mortality risks. So protein, paramount. So I love whey protein. Whey protein is super bioavailable. You can literally mix it in your coffee or your orange juice. Patients don't mind the taste of it, and it's cheap. So that is a supplement that I love. We talked about omega-3s. I love probiotics. I think that we can all agree that the microbiome is being associated in everything. You know, we used to think it was just in the gut, and now it's been linked to psychiatric diseases, cancer development, inflammation. And then you have surgery, which requires anesthesia, which we know ruins your microbiome. We give you antibiotics, which ruins your microbiome. So I put my patients on a really high-dose probiotic before surgery and after surgery just to prevent all of those complications.

Kalea Wattles 
I think it's so commendable that you're thinking about, okay, what is accessible in terms of finances but also the mode of delivery and how can we incorporate both food-based sources of these nutrients and supplements when we need to. On this topic of sarcopenia, let's talk about exercise because I imagine that there's some exercise recommendations that can help to maintain our lean muscle mass. How are you talking to your patients about exercise in terms of frequency or intensity? Are there specific recommendations in the literature?

Rebecca Knackstedt
Yeah, excellent question. Exercise, as we all know, is important for preventing basically every disease and for promoting wellness. And there's studies specific to the breast cancer literature that if you do exercise during your treatment, you have improved quality of life, you decrease your incidence of sarcopenia, you decrease your complications after surgery, once again, impacting mortality for your breast cancer diagnosis. There's not really great studies telling whether we should do high intensity or yoga or weightlifting or Pilates. But I think that if you just encourage patients to move, get that muscle building, weight building, especially as women, we are losing muscle so fast once we get past the age of 30, just doing whatever they can do that's sustainable and getting their muscle development. Importantly, it's been shown to be safe during chemo because patients come in and say, you know, is it safe for me to exercise during chemo? And it is, there's studies showing that it is. And then, I think also importantly is what if a patient comes in and they're like, "I just, I can't exercise." "I'm too sick." Or, "I don't have the financial resources." Or "I'm too busy with life." There's supplements that have shown to kind of mimic exercise and decrease some of the muscle mass loss that is expected with things like surgery. And that's protein supplementation. Omega-3s have actually been shown to decrease their loss, and HMB, which is big in the building body space that have all been shown to decrease muscle mass loss, which is kind of like what exercise does.

Kalea Wattles 
Well, I can see why whey protein and omega-3s might be at the top of your list because there seems to be a multitude of benefits.

Rebecca Knackstedt
Absolutely.

Kalea Wattles 
I can't forget about sleep because this is something, in general, I think we take sleep for granted, and it's such a source of healing and regeneration. And I can just imagine how important this is no matter where you are in your cancer journey. How do you talk to your patients about sleep and the importance of sleep? And then, what recommendations do you give them if they're like, "You know what? I really need some support in this area."

Rebecca Knackstedt
Yeah, I think we all have bad sleep, you know, whether or not we have a cancer diagnosis. And then you get a cancer diagnosis and that's stressful and anxiety-provoking and sometimes painful. There have been studies looking at before a woman starts chemo, what is the incidence of bad sleep? It's about 30%. And then during chemo, it climbs up to about 60%. So more than half of women are having objectively bad sleep. And why do we care? Because sleep is associated with all bad outcomes during your cancer treatments and then also your surgical recovery. It's been associated with increased complications after surgery, longer times in the hospital, decreased ability to do things like exercise and have healthy choices because you're sleep-deprived. Importantly, you know, there are ways that we can improve patients’ sleep that are low risk. So things like for breast cancer patients, yoga, acupuncture, low-dose melatonin, meditation, those have all been shown to, specifically in breast cancer patients, improve their quality of sleep.

Kalea Wattles 
I'm very excited that, again, there's lifestyle modifications, there's some supplements that you can use because people probably need a combination of these things. You mentioned, just the stress and anxiety of a cancer diagnosis is likely contributing to poor sleep. That's when we get in bed, it's quiet time, we're ruminating about things. What types of recommendations do you make to cope with the stress and anxiety? Is it a counseling referral? Is it mind-body medicine? What tools are available?

Rebecca Knackstedt
Yeah, I think that we forget when a patient has specifically a breast cancer diagnosis, how it impacts every part of her life. You know, it's not just a cancer diagnosis and the fear of treatment and needing surgery, but it's inherently a part of our body that is so associated with femininity and our confidence and how we feel about ourselves. And that can be very stressful for a lot of patients. So once again, I'm lucky enough that we have counselors, that is what they treat. They specifically deal with patients who have breast cancer, and that's their area of expertise, which is amazing. So I always ask patients, if they're talking to someone, who is their social support at home, you know, do they have a loved one, a family friend, a neighbor that they can talk to about stuff? And especially if they say no, I really want to get them hooked up with some type of meditation, counseling that can help them through this stressful period.

Kalea Wattles 
Yeah, I was going to ask about the social support because I hope everyone has someone at home that they can go to, but you're right. It probably isn't the case. I am picturing that there's probably some breast cancer groups where women can connect. Is that something that you have found to be helpful and beneficial for cancer patients?

Rebecca Knackstedt
Absolutely, I think that the breast cancer community is probably one of the most connected and resourceful communities that we treat. I always recommend that patients go on to the American Cancer Society and the Susan G. Komen websites. They can actually connect with a person somewhere across the country that has a similar diagnosis, similar age, and can talk one-on-one about things that are, you know, bothering them or questions they have. Specific to the reconstructive space, I actually tell my patients to join Facebook groups. There are so many out there. And while they can be a huge source of misinformation, and I always warn patients of that, it can also be a place where patients feel free to show their results to other patients and talk to them about difficulties or complications in a judgment-free zone. So I always encourage that as well.

Kalea Wattles 
Yeah, I see in action how you're connecting so many, what we call nodes of the matrix, these body systems with our modifiable lifestyle factors. But also then the center of the matrix, our mental, emotional, spiritual health, which, I think, at times, can be underappreciated or undertreated, but you're really bringing it into the fold. We hear often from providers who are going through IFM training, especially when, you know, they're in a busy setting, maybe a hospital setting, they have trouble incorporating some of the functional medicine principles just because it requires time. We've heard a little bit about how you've been able to do that with a collaborative care team. But I think our providers who are listening will want to know, as a reconstructive surgeon, how are you, just the logistics of bringing the functional medicine principles into your patient care?

Rebecca Knackstedt
Yeah, it's hard. So I'm a plastic surgeon. So in the system that I work, I can't bill for things like lifestyle counseling or stress and anxiety. And at the end of the day, when you work for a hospital, that's what they're interested in. So I've tried to find ways to circumnavigate that so that I can still address these topics with my patients while staying in the confines of what I need to do in a day. So I've made handouts for my patients. I have five handouts that I get to all my patients. It talks about things like stress, anxiety, sleep, nutritional support supplements, what they should take, what dosage they should take, supplement brands that I recommend, things to bring to the hospital with them just to improve their sleep, and even things like a blender if they're staying for a long time so they can make protein shakes in their hospital room. I've had patients do that, it's amazing. So I think just trying to find little ways to bring it into your practice. Not all patients are receptive to these interventions, and I think that that's not something that we can overcome. But even if a couple patients adopt a couple of these strategies, it's just going to overall improve their outcomes.

Kalea Wattles 
Like you said, it's cumulative, so we add a little bit of movement, we add a little dietary protein, and now we're making a big impact on our care. We've talked through a couple different stages of treatment. We have those who are really focusing on primary prevention. We've talked about those who've received a diagnosis. Let's say someone has gone through cancer treatment, perhaps they're in remission, they really want to stay in good health and prevent cancer recurrence. Are there different types of lifestyle factors that you're focusing on for that population? Or it's very similar to those who might be preparing for surgery or even just focusing on prevention in the first place?

Rebecca Knackstedt
Yeah, good question. I think that, in general, they tend to be the same, but I think that the difference is that oftentimes, the patient who started their cancer journey is a very different patient from when they end. You know, for patients who need neoadjuvant chemo or adjuvant chemo, radiation, multiple surgeries, it takes such a toll on the body. And for some patients who needed chemo, they actually go into menopause early. So it's just been helping patients get over these new changes. Probably a little bit of increased fatigue, probably a loss of lean muscle mass, maybe a gain of some subcutaneous fat. So just getting them back to their baseline and resetting and then restarting all of those preventative things like we've already talked about

Kalea Wattles 
In the functional medicine world, we use a tool that's called the functional medicine timeline, which is essentially a map of a patient's history from birth until their current day. And we use that as a tool to, I think, help patients understand why they're on this health trajectory but also to motivate and anchor into all of these positive changes so that we can change that trajectory. And I imagine in your practice, cancer's very serious, and like you said, it's very scary. And I presume that framing the timeline in a way that, "Look, this was a big deal in your health trajectory, but we have all of these tools that can help you to optimize wellness no matter where you are." I imagine that's a really motivating and powerful factor. Is that coming into the way that you talk to your patients about their story?

Rebecca Knackstedt
Yeah, absolutely, once again, once people have met me, you know, they've already gotten that diagnosis. So then it's, what's next? And one of the things that I love about being a plastic surgeon is that I see patients for years after they've finished their cancer journey. So they've finished their treatments. They've finished their reconstruction. But I follow them for the rest of their lives, for their reconstruction revisions. So I get to see how they bounce back or don't after their cancer treatment has come to completion, and how their body changes and how their family life changes really, and their relationships with their spouses and loved ones. So it's exciting to see how they emerge from the other side. And then it allows me to help them get back on track.

Kalea Wattles 
I always am curious on a personal note, as someone who works with breast cancer patients every day, what are the things that you do for your own health to prevent cancer with all you know? What are the things that you do in your daily life?

Rebecca Knackstedt
Yeah, I think that I am bad at stress and anxiety. I think that a lot of healthcare providers are. So that is for sure a weakness that I need to work on. But for me, I've always prioritized sleep. Everyone that knows me knows that sleep is super, super important to me. I have two little kids, so it's not always the easiest. But exercise, and for me, exercise is one of those things that's like brushing your teeth. It's something that you do every day. Whether or not I have to wake up early to do it, it's so important to me because I know that it prevents so many diseases and disease states. And then making healthy eating choices. You know, I'm a firm believer in the 80-20 approach, where I want to eat healthy and make good choices, but I also want to enjoy life, and you know, enjoy celebrations. So I try to prioritize those. And then, I take a lot of supplements too to offset my diet on surgery days.

Kalea Wattles 
Yes, so you're finding a balance and really focusing on those modifiable lifestyle factors, the things we can control. And I guess maybe that's a theme that has emerged for me is that there are these things, yes, you have to plan, and you have to make time, but they're within our control, which is so empowering. I think you mentioned that you're involved in some ongoing research, and can you give us a little sneak peek without giving too much away? Or are you able to tell us, what's coming up in the field of breast cancer research in terms of lifestyle factors and nutrition?

Rebecca Knackstedt
Yeah, absolutely. So that has always been my research and trust, and not only preparing patients for surgery but even starting to intervene when they're starting neoadjuvant chemotherapy, which is months before surgery. We're really supporting them through their cancer journey, from diagnosis all the way through recovery. So we have some studies that we're looking at doing nutritional support during chemotherapy, so targeted supplementation that will help patients tolerate chemo better and just recover faster so they can get to that next stage in their cancer treatments. There are amazing researchers where I'm at looking at mitochondrial function. So even looking at the impact of chemotherapy on mitochondria and how that impacts biological aging in your ability to recover after surgery. And then how all of these things can be modified with exercise. So doing exercise interventions during chemo or in preparation for surgery. There's so many things that we can research. It really is just a black box just waiting to be explored, which is very exciting.

Kalea Wattles 
Very exciting, we'll keep our eye on it. And I just have to acknowledge the way that you have mentioned, now, mitochondrial health, hormones, metabolic health, inflammation, adrenal health, this is the functional medicine matrix come to life. It really is a systems biology in action, which is so fascinating to see. Dr. Knackstedt, if there's other functional medicine clinicians listening who work with breast cancer patients, what advice do you have? What do you want them to take away from this episode as they go back into the clinic?

Rebecca Knackstedt
Yeah, I think that just remembering all of the aspects of a patient that is impacted, that are impacted by a breast cancer diagnosis. You know, I think that when we see a patient with breast cancer or any cancer, we're just overwhelmed by the words of cancer, you know, we need to cure their cancer, get rid of their cancer. But I think just remembering that their mind and body from head to toe is being impacted by this new diagnosis, and I think just really, once again, using the functional medicine approach to treat every aspect of the patient to help her get through her journey, recover from her treatments, and then get her back to the best state of health that she can be is so important and something that functional medicine providers are really poised to do.

Kalea Wattles 
Yes, that's been my takeaway, that functional medicine is really well suited to support these patients no matter where they are in their cancer treatment. So thank you, Dr. Knackstedt, so much for being with us, for sharing your insights. It's clear that you have such passion for this community, and we're so grateful to have you as part of the functional medicine community. Thank you so much for being with us today.

Rebecca Knackstedt
Thanks so much for having me.

Kalea Wattles 
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Rebecca Knackstedt
The future is functional.