The golden moment

In June this year, Marjolein Smidt held her oration following her appointment as professor in 2020. She holds a chair at Maastricht University in oncological surgery, with a focus on mammary surgery (breast surgery). However, the research she carries out is much broader than that. Marjolein also tackles colorectal cancer by researching the microbiome1For example, she looks at how the microbiome affects the knock-on effects of chemotherapy and how that in turn affects the effectiveness of cancer treatment. The title of Smidt's oration is Even goed met minder (Just as good with less). This puts into words what drives her as an oncological surgeon: can we achieve at least as well for patients by actually doing less in treatment, research and care? Attention to lifestyle is also essential for Smidt. "There is a connection between cancer and lifestyle… we just can't ignore that anymore".

What can you say about the relationship between lifestyle and breast cancer?

Marjolein Smidt: "During the Covid pandemic – when many conferences were held online and you could easily watch the sessions back – it became clearer than ever to me that there is a strong relationship between the development of breast cancer and lifestyle. At one conference in particular I summarised all these contributions. When you gather all the stories together, you realise how shocking it really is that we are doing all kinds of things to improve breast cancer treatment, but we have not paid enough attention to the role lifestyle plays in all of it. If you look exclusively at breast cancer, obesity is the most important of all lifestyle factors. Overall, obesity is related to more than 200 diseases and, according to the World Health Organisation (WHO), by 2005 more than 50% of all diseases were considered to be lifestyle-related. This puts a huge burden on the healthcare system.”

So there will now also be a lifestyle guideline for breast cancer?

"It is because lifestyle is so important that we are now approaching this in collaboration with the Nederlandse Vereniging voor Heelkunde (Netherlands surgery association, NVvH). Additionally, together with a large group, we wrote a guideline for the Netherlands – and also one for Europe – in which we state, among other things, that lifestyle should be discussed when combatting breast cancer. That guideline is now up for review. These are small but important steps we are taking. Lifestyle is not only a risk factor before starting any treatment protocol, you also see that people with a worse quality of lifestyle have a worse quality of life after treatment. The guideline – which explains the risks of factors such as diet, smoking and alcohol use – requires us as doctors to discuss those risks in our interactions with the patient. The good thing about that is that we then give the patient the chance to actively do something themselves. It's really important that the guideline is there. I actually think that if you don't say those things, you are at fault. You have to ensure you have time during the outpatient clinic appointments to discuss it."

"There is a connection between cancer and lifestyle… we just can't ignore that anymore".

Do you manage to make this a topic of conversation?

"We had 2 students contact a group of patients after the outpatient clinic visit to ask them: 'Lifestyle was talked about during the visit. What did you think about that and have you done anything about it?' What happened? Most people found it a positive contribution and went on to implement changes in their daily routine. The doctors might perceive it as getting in the way, but patients didn't think it was a bad idea at all. They said: 'then I won't drink those glasses of alcohol' or 'then I will exercise more'. Of course, there are also people who don't make any changes, but remarkably often than not, there was a good response. I find that very hopeful. The outpatient visit really is the golden moment to discuss these kinds of important things. It is the opportunity we have as doctors. We must take advantage of it.

Do you know what it is? Quitting smoking is really hard. So is quitting alcohol and the same goes for changing your diet. Liesbeth van Rossum (Professor of obesity and internist-endocrinologist at Erasmus MC) says that at a certain amount of excess weight, your sense of hunger breaks down. It is best to prevent people from becoming overweight. However, yes, we live in an obesogenic world: a world that constantly tempts people to eat. Take the fact that 80% of the food in the supermarket is not healthy, as was recently reported in the Dutch national newspaper NRC. That simply cannot be! The Dutch government needs to take action against that. Lifestyle choises can be the cause of so much misery. We can’t waste any time. Especially when you consider that the effects of primary prevention will not be felt tomorrow, and the healthcare system is at risk of going awry."

What further developments in your field should we keep an eye on?

"In terms of microbiome research, a lot is going on. This includes what you eat and how that affects your gut bacteria. Three quarters of the DNA you carry is not yours but it plays a role in all the working processes in your body. There is already a good study in melanomas, where people who don't respond to a certain treatment were given a faecal transplant4 from people who do respond to that treatment. Then you see that some of the group will still respond. Those are really very good and promising results. How your microbiome is put together is really decisive."

What are you most proud of, considering all the different things that you do?

"Perhaps what I enjoy most is mentoring university students and PhD students who are doing research. I love to see that they also become infected with that curiosity and often continue researching even after that." Marjolein points to a group portrait in her room. "That shows most of today's researchers. Each one is seeking their own path: research on imaging, on breast cancer treatment, radiotherapy and cancer research other than breast cancer. By doing it together, achieve more."

If you could wake up tomorrow and change something in your area of work, what would it be?

"What I would really like to change is to make sure there is much more focus on lifestyle among children and teenagers than there is now. Seinarjoki, a city in Finland has made this change up with great effect. What it is about is getting children and teenagers back to moving more, sitting still less often in lessons, making school playgrounds more appealing and eating more healthily. It may be paternalistic to seemingly make these decisions for young people but if your brain is not fully mature and you don't have the conditioning nor the conditions to make the right choices yourself then we as adults and as a government need to start securing that. The long-term consequences and costs are so great for the whole society. So great that we will not be able to bear those costs nor pay for them."

Wouldn't you prefer to spend all your time focussed on lifestyle?

"Definitely not! The connection with my other work only makes my message better. Moreover I really enjoy my clinical work. But a lot has yet to be done. A colleague recently said – when I got angry about the advance of the electric bicycle: 'you want to go back in time'. Then I think: apparently some things were just better back then. It's not bad at all to think that certain things used to be better. The tricky thing is that people get the feeling that something is being taken away. I am then reminded of the song Over de Muur by Klein Orkest. Freely translating the lyrics, they say: 'what is freedom worth if you can't do anything with it'. In our case, 'what is the right to unhealthy life worth if you end up sick and then we have nothing to offer you in terms of care, due to overburdened care and too few staff'. How fair is that?"

Finally, suppose supermarkets only sold healthier foods. What would you really miss?

Laughing: "Granted, I would miss the paprika flavoured crisps. But OK, so be it".

1 What is microbiome? The microbiome is the unique set of (trillions of) bacteria that everyone has in their gut. It is further formed by the viruses, fungi and yeasts present in the intestines. This set can weigh as much as 1.5 kilos. The microbiome is partly formed on the basis of genes, environment, age and medication use but how a person lives (degree of exercise, sleep, eating and relaxation) also affects the microbiome. Nutrition is the most determining factor in this. More and more is becoming known about the role that microbiome plays in development and prevention and the effectiveness of cancer treatments.


3 The concept of primary prevention involves preventing health problems by countering their causes.

4 In patients with a disrupted microbiome, you can administer bacteria from the stool of a donor with a healthy microbiome to help the patient recover.

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