Reproducibility of physical activity recall over fifteen years: longitudinal evidence from the CARDIA study

Background

To examine the benefits of physical activity (PA) on diseases with a long developmental period, it is important to determine reliability of long-term PA recall.

Methods

We investigated 15-year reproducibility of PA recall. Participants were 3605 White and African-American adults in the Coronary Artery Risk Development in Young Adults study, aged 33–45 at the time of recall assessment. Categorical questions assessed PA before and during high school (HS) and overall PA level at Baseline, with the same timeframes recalled 15 years later. Moderate- and vigorous-intensity scores were calculated from reported months of participation in specific activities.

Results

HS PA recall had higher reproducibility than overall PA recall (weighted kappa = 0.43 vs. 0.21). Correlations between 15-year recall and Baseline reports of PA were r = 0.29 for moderate-intensity scores, and r = 0.50 for vigorous-intensity. Recall of vigorous activities had higher reproducibility than moderate-intensity activities. Regardless of number of months originally reported for specific activities, most participants recalled either no activity or activity during all 12 months.

Conclusion

PA recall from the distant past is moderately reproducible, but poor at the individual level, among young and middle aged adults.

Deriving clinically meaningful cut-scores for fatigue in a cohort of breast cancer survivors: a Health, Eating, Activity, and Lifestyle (HEAL) Study

PURPOSE

To empirically determine clinically meaningful cut-scores on the 0-10 response scale of the revised Piper Fatigue Scale (PFS-R) and its shorter version (PFS-12). Breast cancer survivors were classified (i.e., none, mild, moderate, or severe fatigue) based on the cut-scores, and relationships between these cut-scores and decrements in health-related quality of life (HRQOL) were examined.

METHODS

A total of 857 breast cancer survivors, stages in situ-IIIa, from the Health, Eating, Activity, and Lifestyle (HEAL) Study were eligible. Survivors completed the PFS-R, SF-36, and a sexual health scale approximately 3 years after diagnosis. Multivariate analysis of covariance was used to examine five fatigue severity cut-score models, controlling for demographics, clinical characteristics, comorbidity, and antidepressant use. Multivariate regression was used to examine HRQOL decrements by cut-score category.

RESULTS

Analyses supported two similar fatigue severity cut-score models for the PFS-R and PFS-12: Model A.) none (0), mild (1-3), moderate (4-6), and severe (7-10); and Model D.) none (0), mild (1-2), moderate (3-5), and severe (6-10). For every threshold increase in fatigue severity, clinically meaningful decrements in physical, mental, and sexual health scores were observed, supporting construct validity of the fatigue cut-scores.

CONCLUSION

Standardized fatigue cut-scores may enhance interpretability and comparability across studies and populations and guide treating planning.

Abstract A10: Risk factors for self-reported arm lymphedema among female breast cancer survivors in Health, Eating, Activity, and Lifestyle (HEAL) Study

Background: With increasing breast cancer survival, more women are experiencing complications from breast cancer therapy. Arm lymphedema (ALE), one of the most common post-treatment conditions, is associated with both physical and psychological challenges. As there is no definitive cure for ALE, preventive measures are desired; more research is needed to study modifiable factors. Although previous studies investigated ALE, data from long-term prospective cohort studies are sparse. This study aims to assess timing of ALE onset and to identify epidemiological characteristics associated with developing the condition using long-term follow-up data.

Methods: Data were collected from 672 female breast cancer survivors aged 35-64 at diagnosis participating in the HEAL Study, a population-based, multi-center, multi-ethnic prospective cohort study. Women diagnosed with in situ, localized or regional breast cancer were recruited into the HEAL Study through SEER registries in New Mexico (Non-Hispanic Whites and Latinas), Los Angeles County (Blacks), and Western Washington (Non-Hispanic Whites). Participants provided information on sociodemographic factors, anthropometric factors, hormone use, and lifestyle factors at, on average, 6.2 months after diagnosis. Clinical information was abstracted from SEER registry records and hospital medical records. Women reported presence of ALE and date of first occurrence of ALE at two subsequent questionnaires that occurred, on average, 3.3 years (T1) and 10.2 years (T2) after diagnosis. Time to onset of ALE was calculated as the time from diagnosis until self-reported onset date. Cox proportional hazards models were fit and provided estimates of the hazard ratios (HR) for ALE and its 95% confidence interval (CI) using time since diagnosis as the time scale. Women who died or were lost to follow-up before T2 were censored at T1 because their ALE status after T1 was unknown.

Results: During follow-up, 192 women (29%) experienced ALE; 34 (18%) of these women developed ALE more than three years after diagnosis. The median time to onset of ALE was 11 months (range; 0.5-135). Approximately 58% of women who reported ALE at T1 and completed T2 (n=109) had ALE at T2 (persistent ALE). In a multivariable model, receiving total/modified radical mastectomy (vs. partial/less than total mastectomy; HR=1.43, 95% CI=1.06-1.94), receiving chemotherapy (HR=1.58, 95% CI=1.15-2.17), having 10 or more lymph nodes (LN) removed (vs. no LN removed; HR=3.05, 95% CI=1.81-5.11), having body mass index (BMI)≥30 kg/m2 (vs. BMI<25 kg/m2; HR=1.59, 95% CI=1.09-2.32), and having hypertension (HR=1.47, 95% CI=1.04-2.07) all increased ALE risk. Stratifying by race, hypertension was a risk factor only for black women (HR=2.77, 95% CI=1.67-4.58). Contrary to findings from previous studies, we did not find that radiation therapy increased ALE risk (HR=1.18, 95% CI=0.87-1.58).

Conclusions: This study suggests that ALE can occur years after the initial diagnosis and the majority of ALE persists for a long time. In addition to established risk factors, hypertension was a risk factor, particularly in black women. It is important to increase awareness that ALE can develop later in the survival trajectory and to investigate further the role of hypertension in ALE after breast cancer.

Citation Format: Kayo Togawa, Jane Sullivan-Halley, Yani Lu, Ashley Wilder Smith, Catherine Alfano, Ikuyo Imayama, Anne McTiernan, Marian L. Neuhouser, Huiyan Ma, Rachel Ballard-Barbash, Leslie Bernstein. Risk factors for self-reported arm lymphedema among female breast cancer survivors in Health, Eating, Activity, and Lifestyle (HEAL) Study. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr A10.

Abstract A08: Weight, inflammation, cancer-related symptoms and health-related quality of life among breast cancer survivors

Purpose: Body size, weight change, and inflammatory biomarkers are associated with survival in women with breast cancer. Associations between these factors and cancer-related symptoms and health-related quality of life (HRQOL) are not established.

Patients and methods: The Healthy, Eating, Activity, and Lifestyle Study is a cohort of stage 0-IIIA breast cancer survivors. Height, weight and the inflammatory biomarker C-reactive protein (CRP) were measured at approximately 30-months post-diagnosis. Cancer-related symptoms (arm and chest wall symptoms, vasomotor symptoms, urinary incontinence, vaginal symptoms, cognition/mood problems, sleep, sexual interest/function) and HRQOL (SF-36) were assessed at approximately 39-months post-diagnosis; weight was measured in a subset of women at 4-12 months post-diagnosis. Data on 664 participants were analyzed (n=484 for weight change analysis). We assessed associations between body mass index (BMI, <25, 25-29.9, ≥30kg/m2), post-diagnosis weight change (lost ≥5%, weight change <5%, gained ≥5%), and CRP (tertile) with cancer-related symptoms and HRQOL using analysis of covariance.

Results: Mean (SD) age and BMI at the 30-month assessment were 57.5 (9.9) years old and 28.0 (6.3) kg/m2, respectively. Sixty two percent of the participants were overweight or obese (BMI ≥25 kg/m2). Compared to survivors with BMI <25 kg/m2, obese (BMI ≥30 kg/m2) survivors had 26.0% greater arm symptom scores (adjusted means 0.77 vs. 0.97), 32.0% worse urinary incontinence severity (1.00 vs. 1.32), 11.5% lower physical functioning (77.1 vs. 68.2), but 9.7% less trouble falling asleep (2.59 vs. 2.34) and 17.5% less severe vaginal symptoms (0.80 vs. 0.66, all p<0.05). Overweight (25≥ BMI <30kg/m2) survivors had 23.4% more severe arm symptoms (0.77 vs. 0.95), 30.0% worse urinary incontinence severity (1.00 vs. 1.30), and 5.8% lower physical functioning scores (77.1 vs. 72.6, all p<0.05 vs. BMI <25kg/m2). Compared with survivors with weight change of <5%, participants who gained ≥5% of baseline weight had lower physical functioning (-6.6%), role-physical (-16.8%) and vitality scores (-8.9%); weight loss of ≥5% was associated with less severe arm (-27.0%) and chest wall symptom scores (-29.1%, all p<0.05). Increasing CRP tertile was associated with more severe chest wall symptoms, more difficulty with bladder control, and decreased physical functioning, and role-physical (all Ptrend<0.05). Survivors in the highest CRP tertile [mean(SD) 10.8(12.9)mg/L] had 17.0% greater chest wall symptom scores, 16.0% worse urinary incontinence severity, 17.0% lower physical functioning, and 24.7% lower role-physical scores (all p<0.05 vs. lowest CRP tertile).

Conclusion: BMI ≥25 kg/m2, weight gain ≥5%, and higher levels of CRP were associated with greater cancer-related symptom scores and poorer HRQOL in breast cancer survivors.

Citation Format: Ikuyo Imayama, Anne McTiernan, Catherine M. Alfano, Marian L. Neuhouser, Stephanie M. George, Ashley Wilder Smith, Richard N. Baumgartner, Kathy B. Baumgartner, Leslie Bernstein, Rachel Ballard-Barbash. Weight, inflammation, cancer-related symptoms and health-related quality of life among breast cancer survivors. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr A08.

Knowledge of energy balance guidelines and associated clinical care practices: the U.S. National Survey of Energy Balance Related Care among Primary Care Physicians

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge of energy balance related guidelines and the association with sociodemographic characteristics and clinical care practices.

METHOD

As part of the 2008 U.S. nationally representative National Survey of Energy Balance Related Care among Primary Care Physicians (EB-PCP), 1776 PCPs from four specialties who treated adults (n=1060) or children and adolescents (n=716) completed surveys on sociodemographic information, knowledge of energy balance guidelines, and clinical care practices.

RESULTS

EB-PCP response rate was 64.5%. For PCPs treating children, knowledge of guidelines for healthy BMI percentile, physical activity, and fruit and vegetables intake was 36.5%, 27.0%, and 62.9%, respectively. For PCPs treating adults, knowledge of guidelines for overweight, obesity, physical activity, and fruit and vegetables intake was 81.4%, 81.3%, 70.9%, and 63.5%, respectively. Generally, younger, female physicians were more likely to exhibit correct knowledge. Knowledge of weight-related guidelines was associated with assessment of body mass index (BMI) and use of BMI-for-age growth charts.

CONCLUSION

Knowledge of energy balance guidelines among PCPs treating children is low, among PCPs treating adults it appeared high for overweight and obesity-related clinical guidelines and moderate for physical activity and diet, and was mostly unrelated to clinical practices among all PCPs.

Comparison of ground reaction forces and contact times between 2 lateral plyometric exercises in professional soccer players

There are no studies which have examined the differences in kinetics between lateral plyometric exercises and the selection of these exercises is largely based on the experience and observation of coaches. This study aimed to compare ground reaction forces (GRF) and contact times (GCT) between 2 lateral plyometric exercises: lateral alternative leg hopping (HOP), and speed lateral footwork (SPEED). 16 professional male soccer players (age: 24.6±5.5 years; and BMI: 21.7±2.2 kg.m - 2) participated in this within-participant repeated measures study. 3-dimensional GRF data were measured by force platform. Our study revealed significant differences between the 2 lateral plyometric exercises in all kinetics parameters (F=573.7, P<0.01). HOP produced significantly longer GCT (0.45 s vs. 0.23 s, P<0.01, large effect), significantly higher values (P<0.05, large effect) in peak force (3.31 vs. 2.47 Body Weight [BW]), peak rate of force development (0.94 vs. 0.29 BW/s), and impulse (0.76 vs. 0.31 BW.s) except for peak force in the medial-lateral (P<0.05, medium effect) and impulse in the anterio-posterior direction (not significant, small effect). Therefore, SPEED is an exercise that aims to increase step frequency because of its short GCT (< 0.25 s) while HOP increases leg strength and power.

Fatigue, inflammation, and ω-3 and ω-6 fatty acid intake among breast cancer survivors

PURPOSE

Evidence suggests that inflammation may drive fatigue in cancer survivors. Research in healthy populations has shown reduced inflammation with higher dietary intake of ω-3 polyunsaturated fatty acids (PUFAs), which could potentially reduce fatigue. This study investigated fatigue, inflammation, and intake of ω-3 and ω-6 PUFAs among breast cancer survivors.

METHODS

Six hundred thirty-three survivors (mean age, 56 years; stage I to IIIA) participating in the Health, Eating, Activity, and Lifestyle Study completed a food frequency/dietary supplement questionnaire and provided a blood sample assayed for C-reactive protein (CRP) and serum amyloid A (30 months after diagnosis) and completed the Piper Fatigue Scale and Short Form-36 (SF-36) vitality scale (39 months after diagnosis). Analysis of covariance and logistic regression models tested relationships between inflammation and fatigue, inflammation and ω-3 and ω-6 PUFA intake, and PUFA intake and fatigue, controlling for three incremental levels of confounders. Fatigue was analyzed continuously (Piper scales) and dichotomously (SF-36 vitality ≤ 50).

RESULTS

Behavioral (P = .003) and sensory (P = .001) fatigue scale scores were higher by increasing CRP tertile; relationships were attenuated after adjustment for medication use and comorbidity. Survivors with high CRP had 1.8 times greater odds of fatigue after full adjustment (P < .05). Higher intake of ω-6 relative to ω-3 PUFAs was associated with greater CRP (P = .01 after full adjustment) and greater odds of fatigue (odds ratio, 2.6 for the highest v lowest intake; P < .05).

CONCLUSION

Results link higher intake of ω-3 PUFAs, decreased inflammation, and decreased physical aspects of fatigue. Future studies should test whether ω-3 supplementation may reduce fatigue among significantly fatigued breast cancer survivors.

Sleep duration change across breast cancer survivorship: associations with symptoms and health-related quality of life

Sleep duration among breast cancer survivors correlates with fatigue, depression, and health-related quality of life (HRQOL); however, this has not been studied longitudinally. This study investigated patterns of sleep duration change across the early breast cancer survivorship period, their demographic and clinical predictors, and their relationships with subsequent cancer-related symptoms and HRQOL. Breast cancer survivors (n = 572), were assessed 6 months post-diagnosis (current sleep & retrospective reports of pre-diagnosis sleep), 30 months post-diagnosis (sleep), and 39 months post-diagnosis (symptoms, HRQOL). Sleep duration change was determined by examining sleep at each time point in relation to published norms. Analysis of variance and logistic regression models tested demographic and clinical differences between the sleep change groups; linear regression models tested differences in symptoms and HRQOL. Half of the survivors reported no sleep duration change over time; however, 25% reported sleep changes indicating a temporary (5.6%), late-occurring (14%), or sustained (5.9%) change. Survivors reporting sustained or temporary sleep changes were more likely to have been treated with chemotherapy (OR = 2.62, P < 0.001) or gained weight after diagnosis (OR = 1.82, P = 0.04) than those with no sleep change. Sustained sleep changes were related to greater subsequent severity, affective, and sensory aspects of fatigue (βs = 2.0, 2.3, 1.8; all P < 0.0001) and lower vitality (β = -10.8, P = 0.005). Survivors treated with chemotherapy and those who gain weight after diagnosis may have increased risk for sustained sleep duration changes, which may increase their fatigue. These results point to the need for routine assessment of sleep as part of survivorship care.

Long-term ovariectomy decreases serotonin neuron number and gene expression in free ranging macaques

The serotonin system responds to the ovarian steroids, estradiol (E) and progesterone (P), in women and female animal models. In macaques, ovarian steroid administration to ovariectomized (Ovx) individuals improves serotonin neural function through actions on pivotal serotonin-related genes and proteins, such as TPH2 (tryptophan hydroxylase 2), SERT (serotonin reuptake transporter), and the 5HT1A autoreceptor. In addition, ovarian steroid administration reduces gene and protein expression in the caspase-independent pathway and reduces DNA fragmentation in serotonin neurons. This study examines the hypothesis that long-term ovariectomy will lead to a loss of serotonin neurons and compromised gene expression in serotonin neurons. Female Japanese macaques were ovariectomized or tubal ligated (n=5/group) at 3 years of age and returned to their natal troop. After 3 years, the animals were collected, administered a fenfluramine challenge to determine global serotonin availability, and then euthanized. Fev, TPH2, SERT, and 5HT1A expression were examined with digoxigenin in situ hybridization (ISH) and quantitative image analysis. Cell number, positive pixel area, and average pixel density were determined. In the Ovx group, Fev, TPH2, SERT, and 5HT1A showed a significant decease in average and total cell number and positive pixel area. The reduction in Fev-positive neurons suggests that there were fewer serotonin neurons in Ovx animals compared to ovary-intact animals. The decrease in TPH2 in the Ovx animals was consistent with earlier results in 5-month Ovx animals, but it may be due to the decrease in cell number rather than a decrease in expression on an individual cell basis. The decrease in SERT and 5HT1A in long-term Ovx differed from previous studies in short-term Ovx. In summary, long-term ovarian steroid loss resulted in fewer serotonin neurons and overall lower Fev, TPH2, SERT, and 5HT1A gene expression. This may be due to serotonin cell death or to a negative impact on a long-term developmental process in young female macaques.

U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients

BACKGROUND

Overweight and obesity are substantial problems in the U.S., but few national studies exist on primary care physicians' (PCPs') clinical practices regarding overweight and obesity.

PURPOSE

To profile diet, physical activity, and weight control practice patterns of PCPs who treat adults.

METHODS

A nationally representative survey of 1211 PCPs sampled from the American Medical Association's Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included PCPs' assessment, counseling, referral, and follow-up of diet, physical activity, and weight control in adult patients with and without chronic disease and PCPs' use of pharmacologic treatments and surgical referrals for overweight and obesity.

RESULTS

The survey response rate was 64.5%. Half of PCPs (49%) reported recording BMI regularly. Fewer than 50% reported always providing specific guidance on diet, physical activity, or weight control. Regardless of patients' chronic disease status, <10% of PCPs always referred patients for further evaluation/management and <22% reported always systematically tracking patients over time concerning weight or weight-related behaviors. Overall, PCPs were more likely to counsel on physical activity than on diet or weight control (p's<0.05). More than 70% of PCPs reported ever using pharmacologic treatments to treat overweight and 86% had referred for obesity-related surgery.

CONCLUSIONS

PCPs' assessment and behavioral management of overweight and obesity in adults is at a low level relative to the magnitude of the problem in the U.S. Further research is needed to understand barriers to providing care and to improve physician engagement in tracking and managing healthy lifestyles in U.S. adults.

Pediatricians' and family physicians' weight-related care of children in the U.S

BACKGROUND

Few national data exist to assess primary care physicians' (PCPs') clinical practices with regard to childhood obesity.

PURPOSE

To survey pediatricians and family practice physicians regarding their assessment, counseling, and management of diet, physical activity, and weight status among pediatric patients in the primary care setting.

METHODS

A nationally representative cross-sectional survey of pediatricians and family practice physicians sampled from the American Medical Association (AMA) Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included physicians' self-reported practice behaviors regarding assessments of pediatric patients' weight status, counseling of diet and physical activity, and referrals and follow-ups.

RESULTS

Response rate excluding physicians listed as "no-contact" by the AMA was 73.7% among pediatricians and 66.9% among family physicians. Less than 50% of all PCPs assessed BMI percentiles regularly in children. Eighteen percent of all PCPs reported referring children for further evaluation or management. Fifty-eight percent of all PCPs reported never, rarely, or only sometimes tracking patients over time concerning weight or weight-related behaviors. Pediatricians were more likely than family physicians to assess weight status and provide behavioral counseling (p's<0.001).

CONCLUSIONS

Active PCP participation in assessing or managing childhood obesity in the primary care setting appears low relative to the frequency of the problem in the U.S. Interventions to reduce the barriers to physician engagement in the assessment and management of healthy lifestyles are needed to prevent and control childhood obesity.

Duration of physical activity and serum 25-hydroxyvitamin D status of postmenopausal women

PURPOSE

To investigate whether the association between physical activity and serum 25-hydroxyvitamin D (25(OH)D) concentrations is independent of sun exposure, body size, and other potential explanatory variables.

METHODS

By using data from a sample of 1343 postmenopausal women from the Women's Health Initiative, we used linear regression to examine the associations of duration (minutes/week) of recreational activity and of yard work with 25(OH)D concentrations (nmol/L).

RESULTS

In age-adjusted analyses, positive associations were observed between 25(OH)D concentrations and both duration of recreational physical activity (β = 0.71, SE [0.09], p <.001) and yard work (β = 0.36, SE [0.10], p = .004). After further adjustment for vitamin D intake, self-reported sunlight exposure, waist circumference, and season of blood draw, 25(OH)D was significantly associated with recreational activity (β = 0.21, SE [0.09], p = .014) but not with yard work (β = 0.18, SE [0.09], p = .061). Interactions were observed between season and both recreational activity (P(interaction) = .082) and yard work (P(interaction) = .038) such that these activity-25(OH)D associations were greater during summer/fall compared with winter/spring. Self-reported sunlight exposure and measures of body size did not modify the associations.

CONCLUSIONS

The observed age-adjusted activity-25(OH)D associations were attenuated after adjusting for explanatory variables and were modified by season of blood draw. Adopting a lifestyle that incorporates outdoor physical activity during summer/fall, consuming recommended amounts of vitamin D, and maintaining a healthy weight may improve or maintain vitamin D status in postmenopausal women.

Fasting C-peptide levels and death resulting from all causes and breast cancer: the health, eating, activity, and lifestyle study

PURPOSE

To examine the association between serum C-peptide, a marker of insulin secretion, measured 3 years after a breast cancer diagnosis, and death resulting from all causes and breast cancer.

PATIENTS AND METHODS

This was a prospective, observational study of 604 women enrolled onto the Health, Eating, Activity, and Lifestyle (HEAL) Study who were diagnosed with local or regional breast cancer between 1995 and 1998 and observed until death or December 31, 2006, whichever came first. The hazard ratio (HR) for all deaths and deaths owing to breast cancer and 95% CIs for the HR were estimated using multivariable stratified Cox regression analyses.

RESULTS

Among women without type 2 diabetes, fasting C-peptide levels were associated with an increased risk of death resulting from all causes and from breast cancer. A 1-ng/mL increase in C-peptide was associated with a 31% increased risk of any death (HR = 1.31; 95% CI, 1.06 to 1.63; P = .013) and a 35% increased risk of death as a result of breast cancer (HR = 1.35; 95% CI, 1.02 to 1.87, P = .048). Associations between C-peptide levels and death as a result of breast cancer were stronger in certain subgroups, including women with type 2 diabetes, women with a body mass index less than 25 kg/m(2), women diagnosed with a higher stage of disease, and women whose tumors were estrogen receptor positive.

CONCLUSION

Treatment strategies to reduce C-peptide levels in patients with breast cancer, including dietary-induced weight loss, physical activity, and/or use of insulin-lowering medications, should be explored.

Associations of insulin resistance and adiponectin with mortality in women with breast cancer

PURPOSE

Overweight or obese breast cancer patients have a worse prognosis compared with normal-weight patients. This may be attributed to hyperinsulinemia and dysregulation of adipokine levels associated with overweight and obesity. Here, we evaluate whether low levels of adiponectin and a greater level of insulin resistance are associated with breast cancer mortality and all-cause mortality.

PATIENTS AND METHODS

We measured glucose, insulin, and adiponectin levels in fasting serum samples from 527 women enrolled in the Health, Eating, Activity, and Lifestyle (HEAL) Study, a multiethnic, prospective cohort study of women diagnosed with stage I-IIIA breast cancer. We evaluated the association between adiponectin and insulin and glucose levels (expressed as the Homeostatic Model Assessment [HOMA] score) represented as continuous measures and median split categories, along with breast cancer mortality and all-cause mortality, using Cox proportional hazards models.

RESULTS

Increasing HOMA scores were associated with reduced breast cancer survival (hazard ratio [HR], 1.12; 95% CI, 1.05 to 1.20) and reduced all-cause survival (HR, 1.09; 95% CI, 1.02 to 1.15) after adjustment for possible confounders. Higher levels of adiponectin (above the median: 15.5 μg/mL) were associated with longer breast cancer survival (HR, 0.39; 95% CI, 0.15 to 0.95) after adjustment for covariates. A continuous measure of adiponectin was not associated with either breast cancer-specific or all-cause mortality.

CONCLUSION

Elevated HOMA scores and low levels of adiponectin, both associated with obesity, were associated with increased breast cancer mortality. To the best of our knowledge, this is the first demonstration of the association between low levels of adiponectin and increased breast cancer mortality in breast cancer survivors.

Posttraumatic growth and health-related quality of life in a racially diverse cohort of breast cancer survivors

This study examined the relationship between race, religiosity, and posttraumatic growth as well as the association between growth and physical and mental health-related quality of life (HRQOL) in breast cancer survivors (N = 802; M age = 57.2). Multivariate analyses revealed that African American breast cancer survivors reported higher levels of posttraumatic growth than White women. However, this relationship was mediated by religiosity. We found an inverse association with growth and mental HRQOL which might be explained by the fact that growth co-occurs with distress and perhaps women in this sample are still struggling with their disease.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

Impact of cancer on health-related quality of life of older Americans

BACKGROUND

The impact of cancer on health-related quality of life (HRQOL) is poorly understood because of the lack of baseline HRQOL status before cancer diagnosis. To our knowledge, this is the first population-based study to quantify the nature and extent of HRQOL changes from before to after cancer diagnosis for nine types of cancer patients and to compare their health with individuals without cancer.

METHODS

The Surveillance, Epidemiology, and End Results cancer registry data were linked with the Medicare Health Outcomes Survey (MHOS) data; data were collected from Medicare beneficiaries who were aged 65 years and older from 1998 through 2003. Cancer patients (n = 1432; with prostate, breast, colorectal, lung, bladder, endometrial, or kidney cancers; melanoma; or non-Hodgkin lymphoma [NHL]) were selected whose first cancer diagnosis occurred between their baseline and follow-up MHOS assessments. Control subjects without cancer (n = 7160) were matched to cancer patients by use of propensity scores that were estimated from demographics and comorbid medical conditions. Analysis of covariance models were used to estimate changes in HRQOL as assessed with the Medical Outcomes Study Short Form-36 survey (mean score = 50, SD = 10). All statistical tests were two-sided.

RESULTS

Patients with all cancer types (except melanoma and endometrial cancer) reported statistically significant declines in physical health (mean scores: prostate cancer = -3.4, 95% confidence interval [CI] = -2.5 to -4.2; breast cancer = -3.5, 95% CI = -2.5 to -4.5; bladder cancer = -4.3, 95% CI = -2.5 to -6.1; colorectal cancer = -4.4, 95% CI = -3.3 to -5.5; kidney cancer = -5.7, 95% CI = -3.2 to -8.2; NHL = -6.7, 95% CI = -4.4 to -9.1; and lung cancer = -7.5, 95% CI = -5.9 to -9.2) compared with the control subjects (mean score = -1.8, 95% CI = -1.6 to -2.0) (all P < .05). However, only lung (mean score = -5.4, 95% CI = -3.5 to -7.2), colorectal (mean score = -3.5, 95% CI = -2.2 to -4.7), and prostate (mean score = -2.8, 95% CI = -1.8 to -3.7) cancer patients showed statistically significant decreases in mental health relative to the mean change of the control subjects (mean score = -1.2, 95% CI = -0.9 to -1.4) (all P < .05).

CONCLUSION

These findings provide validation of the specific deleterious effects of cancer on HRQOL and an evidence base for future research and clinical interventions aimed at understanding and remediating these effects.

Psychological distress and quality of life associated with genetic testing for breast cancer risk

This study investigated short- and long-term psychological outcomes associated with BRCA1/2 genetic testing in women with a personal or family history of breast cancer. Participants included 126 women considering genetic testing. Questionnaires were administered prior to testing, one week, three and six months after result disclosure. Results indicated no systematic effects of testing based on personal cancer history. Mutation carriers and women who elected not to be tested reported greater perceived risk and intrusive and avoidant thoughts at follow-up time points than did women who received negative (uninformative) or variant results. Mutation carriers reported more distress at the three-month follow-up but by six months the effects of test result on distress dissipated and groups were comparable. Cluster analyses identified two groups of individuals based on distress at baseline; these groups were used to predict psychological outcomes after testing. Distress remained constant in both groups: those who were high at baseline remained high and those who were low remained low. Test results did not moderate this effect. Results suggest that genetic testing for BRCA1/2 does not increase distress or have deleterious effects on quality of life over the long term. However, sub-groups of women may report more distress over time. These data indicate the need for more targeted counseling to individuals who report high levels of distress when considering genetic testing.

Race/ethnicity, physical activity, and quality of life in breast cancer survivors

PURPOSE

To examine associations between recreational physical activity and quality of life (QOL) in a multiethnic cohort of breast cancer survivors, specifically testing whether associations are consistent across racial/ethnic groups after accounting for relevant medical and demographic factors that might explain disparities in QOL outcomes.

METHODS

Data were collected from a population-based cohort of non-Hispanic White (n = 448), Black (n = 197), and Hispanic (n = 84) breast cancer survivors (stage 0-IIIa) in the Health, Eating, Activity, and Lifestyle Study. Physical activity was assessed approximately 2.5 years after breast cancer diagnosis, with QOL assessed on average 6 to 12 months later. We used structural equation modeling to examine relationships between meeting recommended levels of physical activity and QOL, stratifying by race/ethnicity and adjusting for other demographic, comorbidity, and treatment effects.

RESULTS

Structural equation modeling indicated that meeting recommended levels of physical activity had significant positive associations with QOL for Black and non-Hispanic White women (P < 0.05). Fewer Black women reported meeting recommended physical activity levels (P < 0.001), but meeting recommendations was associated with better QOL. Post hoc tests showed that meeting physical activity recommendations was specifically associated with better vitality, social functioning, emotional roles, and global QOL (P < 0.05 for all).

CONCLUSIONS

These results suggest that meeting recommended levels of physical activity is associated with better QOL in non-Hispanic White and Black breast cancer survivors. Findings may help support future interventions among breast cancer survivors and promote supportive care that includes physical activity, although more research is needed to determine these relationships among Hispanic and other ethnic minority women.

Cancer, comorbidities, and health-related quality of life of older adults

This study examined the physical and mental health of 126,685 males and females age 65 or over, with and without cancer that completed a Medicare Health Outcomes Survey (MHOS) between 1998-2002. Cancer information was ascertained through the National Cancer Institute's (NCI's) Surveillance, Epidemiology and End Results (SEER) program and linked to MHOS data. Results indicated that across most cancer types, cancer patients reported significantly more comorbid conditions and poorer physical and mental health compared with patients without cancer. Negative associations were most pronounced in those with two or more comorbidities and in those diagnosed with cancer within the past year.

Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study

PURPOSE

To investigate the association between pre- and postdiagnosis physical activity (as well as change in prediagnosis to postdiagnosis physical activity) and mortality among women with breast cancer.

PATIENTS AND METHODS

This was a prospective observational study of 933 women enrolled onto the Health, Eating, Activity, and Lifestyle Study who were diagnosed with local or regional breast cancer between 1995 and 1998 and observed until death or September 2004, whichever came first. The primary outcomes measured were total deaths and breast cancer deaths. The primary exposures were physical activity in the year before and 2 years after diagnosis and the pre- to postdiagnosis change in physical activity.

RESULTS

Compared with inactive women, the multivariable hazard ratios (HRs) for total deaths for women expending at least 9 metabolic equivalent hours per week (approximately 2 to 3 h/wk of brisk walking) were 0.69 (95% CI, 0.45 to 1.06; P = .045) for those active in the year before diagnosis and 0.33 (95% CI, 0.15 to 0.73; P = .046) for those active 2 years after diagnosis. Compared with women who were inactive both before and after diagnosis, women who increased physical activity after diagnosis had a 45% lower risk of death (HR = 0.55; 95% CI, 0.22 to 1.38), and women who decreased physical activity after diagnosis had a four-fold greater risk of death (HR = 3.95; 95% CI, 1.45 to 10.50).

CONCLUSION

Moderate-intensity physical activity after a diagnosis of breast cancer may improve prognosis.

Physical activity, long-term symptoms, and physical health-related quality of life among breast cancer survivors: a prospective analysis

INTRODUCTION

Many breast cancer survivors experience persistent physical symptoms of cancer and treatment that can decrease health-related quality of life (HRQOL). This prospective study investigated physical activity (PA), occurrence of physical symptoms, and HRQOL in a large, ethnically-diverse cohort of breast cancer survivors.

MATERIALS AND METHODS

Survivors (n = 545), on average 6 months post-diagnosis, were assessed in person or by mail at baseline (retrospective reports of pre-diagnosis PA), at 29 months post-diagnosis (post-diagnosis PA), and at 39 months post-diagnosis (pain, hormone symptoms, sexual interest/dysfunction, fatigue, physical subscales of HRQOL). Linear regression and analysis of covariance assessed the relationships between pre- and post-diagnosis PA and PA change after cancer with symptoms and HRQOL.

RESULTS

Greater pre-diagnosis PA was associated with better physical functioning at 39 months (betas 1.1-2.3; all p < 0.01) but was generally unrelated to symptoms. Greater post-diagnosis sports/recreational PA was related to less fatigue and better physical functioning (betas -0.146, 2.21; both p < 0.01). Increased PA after cancer was related to less fatigue and pain and better physical functioning (all p < 0.01). Significant positive associations were found for moderate to vigorous and vigorous sports/recreation PA, not household activity. Results were similar for Hispanic and non-Hispanic White women.

DISCUSSION/CONCLUSIONS

Increased PA, especially after cancer, was consistently related to better physical functioning and to reduced fatigue and bodily pain, underscoring the need for PA promotion among survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors may be able to decrease fatigue and bodily pain and be better able to pursue daily activities through increasing recreational PA after cancer.

Cigarette smoking and health-related quality of life in Medicare beneficiaries

This study examined associations between cigarette smoking, cancer, and self-reported physical (SF-36 Physical Component Summary Score, [PCS]) and mental health (SF-36 Mental Component Summary Score, [MCS]) among 123,567 Medicare beneficiaries enrolled in managed care plans. As expected for a sample of older individuals, the SF-36 PCS mean (42.6) was lower than the U.S. general population mean of 50. The SF-36 MCS mean (51.7) for the sample was higher than the general population mean. In addition, least squares means revealed significantly poorer health for current smokers and those who recently quit, regardless of their cancer status. Although statistically significant, the differences between current smokers and never smokers were small among those with or without cancer. Encouraging smokers to quit and providing abstinence support to persons who have recently quit may help reduce health-related impacts of cigarette use.