Physical activity for cancer survivors: meta-analysis of randomised controlled trials

Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis

BACKGROUND

Physical activity improves physical function during and after cancer treatment, but whether physical activity imparts survival benefit remains uncertain.

DESIGN

Using prospective studies published through June 2013, we conducted a systematic review and random-effects meta-analysis of pre- and post-diagnosis physical activity in relation to total and cancer mortality among breast or colorectal cancer survivors.

RESULTS

Sixteen studies of breast cancer survivors and seven studies of colorectal cancer survivors yielded 49095 total cancer survivors, including 8129 total mortality cases and 4826 cancer mortality cases. Comparing the highest versus lowest levels of pre-diagnosis physical activity among breast cancer survivors, the summary relative risks (RRs) of total and breast cancer mortality were 0.77 [95% confidence interval (CI) = 0.69-0.88] and 0.77 (95% CI = 0.66-0.90, respectively. For post-diagnosis physical activity, the summary RRs of total and breast cancer mortality were 0.52 (95% CI = 0.42-0.64) and 0.72 (95% CI = 0.60-0.85), respectively. For pre-diagnosis physical activity among colorectal cancer survivors, the summary RRs of total and colorectal cancer mortality were 0.74 (95% CI = 0.63-0.86) and 0.75 (95% CI = 0.62-0.91), respectively. For post-diagnosis physical activity, the summary RRs of total and colorectal cancer mortality were 0.58 (95% CI = 0.48-0.70) and 0.61 (95% CI = 0.40-0.92), respectively. Each 10 metabolic equivalent task-hour/week increase in post-diagnosis physical activity (equivalent to current recommendations of 150 min/week of at least moderate intensity activity) was associated with 24% (95% CI = 11-36%) decreased total mortality risk among breast cancer survivors and 28% (95% CI = 20-35%) decreased total mortality risk among colorectal cancer survivors. Breast or colorectal cancer survivors who increased their physical activity by any level from pre- to post-diagnosis showed decreased total mortality risk (RR = 0.61; 95% CI = 0.46-0.80) compared with those who did not change their physical activity level or were inactive/insufficiently active before diagnosis.

CONCLUSION

Physical activity performed before or after cancer diagnosis is related to reduced mortality risk among breast and colorectal cancer survivors.

Impact of resistance training in cancer survivors: a meta-analysis

PURPOSE

Current evidence suggests many health benefits from physical activity during and after cancer treatment. However, the optimal exercise program for cancer survivors has not yet been established. The purpose of this meta-analysis was to summarize evidence for the efficacy of resistance training (RT) interventions to improve muscle strength and body composition among adult cancer survivors. We also investigate potential dose-response relationships between intensity, duration, and frequency of RT and assessed outcomes.

METHODS

A systematic literature review of the Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE literature databases was undertaken. Studies were included if they were randomized controlled trials (RCT) comparing RT with an exercise or nonexercise control group in cancer survivors during and after treatment. Thirteen articles from 11 RCT met our inclusion criteria. We performed a random-effects meta-analysis to determine weighted mean differences (WMD) with 95% confidence intervals using the Cochrane Review Manager 5.0.25. A random-effects metaregression model was performed to examine dose-response relationships between RT variables and assessed outcomes.

RESULTS

Quantitative evidence shows a large effect of RT on lower-limb and upper-limb muscle strength (WMD: +14.57 kg, P = 0.0005 and +6.90 kg, P < 0.00001, respectively) and moderate effects on lean body mass and percentage of body fat (WMD: +1.07 kg, P < 0.0001 and -2.08%, P = 0.003, respectively). A small positive effect of RT was noted on Functional Assessment of Cancer Therapy-Fatigue (P = 0.05). Upper-limb muscle strength and percentage of body fat improved to a greater extent when RT interventions were of low to moderate intensity (≤ 75% one-repetition maximum, P = 0.042).

CONCLUSIONS

RT was shown to be associated with clinically important positive effects on muscular function and body composition in patients during treatment or in long-term follow-up.

Steps toward improving diet and exercise for cancer survivors (STRIDE): a quasi-randomised controlled trial protocol

Background

Cancer survivorship rates have increased in developed countries largely due to population ageing and improvements in cancer care. Survivorship is a neglected phase of cancer treatment and is often associated with adverse physical and psychological effects. There is a need for broadly accessible, non-pharmacological measures that may prolong disease-free survival, reduce or alleviate co-morbidities and enhance quality of life. The aim of the Steps TowaRd Improving Diet and Exercise (STRIDE) study is to evaluate the effectiveness of an online-delivered physical activity intervention for increasing walking in cancer survivors living in metropolitan and rural areas of South Australia.

Methods/Design

This is a quasi-randomised controlled trial. The intervention period is 12-weeks with 3-month follow-up. The trial will be conducted at a university setting and community health services in South Australia. Participants will be insufficiently active and aged 18 years or older. Participants will be randomly assigned to either the intervention or control group. All participants will receive a pedometer but only the intervention group will have access to the STRIDE website where they will report steps, affect and ratings of perceived exertion (RPE) during exercise daily. Researchers will use these variables to individualise weekly step goals to increase walking.

The primary outcome measure is steps per day. The secondary outcomes are a) health measures (anthropometric and physiological), b) dietary habits (consumption of core foods and non-core foods) and c) quality of life (QOL) including physical, psychological and social wellbeing. Measures will be collected at baseline, post-intervention and 3-month follow-up.

Discussion

This protocol describes the implementation of a trial using an online resource to assist cancer survivors to become more physically active. It is an innovative tool that uses ratings of perceived exertion and daily affect to create individualised step goals for cancer survivors. The research findings may be of relevance to public health policy makers as an efficacious and inexpensive online-delivered intervention can have widespread application and may improve physical and psychological outcomes among this vulnerable population. Findings may indicate directions for the implementation of future physical activity interventions with this population.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12613000473763.

Physical activity, daily walking, and lower limb lymphedema associate with physical function among uterine cancer survivors

PURPOSE

We sought to quantify the proportion of uterine cancer survivors who self-report poor physical function. We then sought to quantify the association of poor physical function with physical activity (PA), walking, and lower limb lymphedema (LLL), among women with a history of uterine cancer.

METHODS

Physical function was quantified using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) questionnaire. PA, walking, and LLL were measured using self-report questionnaire. PA was calculated using metabolic equivalent hours per week (MET-h week(-1)), and walking was calculated using blocks per day (blocks day(-1)). Logistic regression estimated odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

Among the 213 uterine cancer survivors in our survey (43 % response rate), 35 % self-reported poor physical function. Compared to participants who reported <3.0 MET-h week(-1) of PA, participants who reported ≥18.0 MET-h week(-1) of PA were less likely to have poor physical function (OR 0.03, 95 % CI 0.01-0.10; P trend  < 0.0001). Compared to participants who reported <4.0 blocks day(-1) of walking, participants who reported ≥12.0 blocks day(-1) of walking were less likely to have poor physical function (OR 0.07, 95 % CI 0.03-0.19; P trend  < 0.0001). Compared to participants who did not have LLL, participants with LLL were more likely to have poor physical function (OR 5.25, 95 % CI 2.41-11.41; P < 0.0001).

CONCLUSION

Higher levels of PA and walking associate with a lower likelihood of reporting poor physical function. The presence of LLL associates with a higher likelihood of reporting poor physical function. These findings are hypothesis-generating and should be evaluated in future prospective studies.

Psychological and behavioral approaches to cancer pain management

This review examines evidence for psychological factors that affect pain across the cancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to manage pain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluated pain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancer pain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain.

Physical activity and survival of postmenopausal, hormone receptor-positive breast cancer patients: results of the Tamoxifen Exemestane Adjuvant Multicenter Lifestyle study

BACKGROUND

Physical activity has been related to improved breast cancer outcomes. Especially in the older breast cancer population, physical activity may be important because old age is associated with comorbidities and decreased physical function. The purpose of this study was to investigate the relation between physical activity and overall survival, breast cancer-specific survival, and recurrence in several age groups of postmenopausal breast cancer patients.

METHODS

The Tamoxifen Exemestane Adjuvant Multinational Lifestyle study was a side study of the Tamoxifen Exemestane Adjuvant Multinational trial and prospectively investigated lifestyle habits of postmenopausal, hormone receptor-positive breast cancer patients. The relations between prediagnosis and postdiagnosis physical activity and overall survival, breast cancer-specific survival, and recurrence-free survival were assessed with Cox regression and competing risk regression models.

RESULTS

Among 521 patients, high levels of physical activity before and after the diagnosis were associated with better overall survival (the multivariate hazard ratios were 0.50 [95% confidence interval = 0.26-0.98] and 0.57 (95% confidence interval = 0.26-1.40] for patients who were very active before and after the diagnosis, respectively, in comparison with inactive patients). This was most evident in patients who were 65 years old or older. Physical activity was not significantly associated with breast cancer-specific survival or the relapse-free period.

CONCLUSIONS

Overall survival was better for patients who were active before and after the diagnosis. In contrast with previous studies, breast cancer survival and the risk of recurrence were not significantly associated with physical activity. These findings confirmed the need for more studies investigating the use of physical activity to supplement breast cancer treatment in older patients.

Relation of physical activity time to incident disability in community dwelling adults with or at risk of knee arthritis: prospective cohort study

OBJECTIVE

To investigate whether objectively measured time spent in light intensity physical activity is related to incident disability and to disability progression.

DESIGN

Prospective multisite cohort study from September 2008 to December 2012.

SETTING

Baltimore, Maryland; Columbus, Ohio; Pittsburgh, Pennsylvania; and Pawtucket, Rhode Island, USA.

PARTICIPANTS

Disability onset cohort of 1680 community dwelling adults aged 49 years or older with knee osteoarthritis or risk factors for knee osteoarthritis; the disability progression cohort included 1814 adults.

MAIN OUTCOME MEASURES

Physical activity was measured by accelerometer monitoring. Disability was ascertained from limitations in instrumental and basic activities of daily living at baseline and two years. The primary outcome was incident disability. The secondary outcome was progression of disability defined by a more severe level (no limitations, limitations to instrumental activities only, 1-2 basic activities, or ≥3 basic activities) at two years compared with baseline.

RESULTS

Greater time spent in light intensity activities had a significant inverse association with incident disability. Less incident disability and less disability progression were each significantly related to increasing quartile categories of daily time spent in light intensity physical activities (hazard ratios for disability onset 1.00, 0.62, 0.47, and 0.58, P for trend=0.007; hazard ratios for progression 1.00, 0.59, 0.50, and 0.53, P for trend=0.003) with control for socioeconomic factors (age, sex, race/ethnicity, education, income) and health factors (comorbidities, depressive symptoms, obesity, smoking, lower extremity pain and function, and knee assessments: osteoarthritis severity, pain, symptoms, prior injury). This finding was independent of time spent in moderate-vigorous activities.

CONCLUSION

These prospective data showed an association between greater daily time spent in light intensity physical activities and reduced risk of onset and progression of disability in adults with osteoarthritis of the knee or risk factors for knee osteoarthritis. An increase in daily physical activity time may reduce the risk of disability, even if the intensity of that additional activity is not increased.

Football for life versus antidoping for the masses: ethical antidoping issues and solutions based on the extenuating experiences of an elite footballer competing while undergoing treatment for metastatic testicular cancer

It is thankfully rare for extenuating circumstances to fully test the processes and procedures enshrined in national and world antidoping authorities’ rules and laws. It is also thankfully very rare that a failed drugs test can have some positive implications. Antidoping laws are undoubtedly focused on ensuring fair competition, however, there are occasions when honest athletes discover medical diagnoses through failed antidoping tests. The purpose of this paper is to broadly discuss antidoping considerations encountered, based on the four principles of medical ethics and to propose simple solutions to these problems. Unfortunately, extreme medical circumstances will often test the limits of antidoping and medical processes and with open channels for feedback, these systems can improve. Performance enhancement seems an illogical concept if an athlete’s medical treatment and disease are more inherently performance harming than unintended potential doping, but needs to be carefully managed to maintain fair sport.

Accelerating translation of physical activity and cancer survivorship research into practice: recommendations for a more integrated and collaborative approach

Physical activity has been deemed safe and effective in reducing many negative side effects of treatment for cancer survivors and promoting better overall health. However, most of this research has focused on highly controlled randomized trials and little of this research has been translated into care or policy for survivors. The purpose of the present article is to present a research agenda for the field to accelerate the dissemination and implementation of empirically supported physical activity interventions into care. We provide rationale for the role of basic, behavioral, clinical implementation, and population scientists in moving this science forward and call for a more coordinated effort across different phases of research. In addition, we provide key strategies and examples for ongoing and future studies using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework and pose recommendations for collaborations between researchers and stakeholders to enhance the integration of this research into policy and practice. Overall, we recommend that physical activity and cancer survivorship research use additional study designs, include relevant stakeholders, and be more collaborative, integrated, contextual, and representative in terms of both setting and participants.

Oncology rehabilitation outcomes over time: a mixed-methods approach

PURPOSE/OBJECTIVES

To evaluate an oncology rehabilitation program over time.

DESIGN

A cross-sectional, retrospective program evaluation using a mixed-methods approach.

SETTING

An outpatient oncology rehabilitation program housed in an urban, hospital-based comprehensive cancer center in Alaska.

SAMPLE

102 cancer survivors who had completed a 10-week oncology rehabilitation program (mean time since completion was 2.5 years).

METHODS

Participants completed a mailed, 28-item retrospective survey to collect perceived activity level recalled at various points in time as well as program perceptions. Open-ended questions elicited narrative comments about motivators and barriers. The Medical Outcomes Study (MOS) SF-36® was completed before and after the program.

MAIN RESEARCH VARIABLES

Health-related quality of life, perceived health status, activity level, motivators, barriers, and program perceptions.

FINDINGS

A small increase in level of activity from precancer to the current time (postrehabilitation) (z = -3.1, p < 0.01) was reported. Most and least helpful motivators emerged from the narrative data, resulting in the shared interpretation of "I have my life back."

CONCLUSIONS

Program motivators were effective in helping cancer survivors maintain some increased activity and retain positive perceptions well after the completion of the program.

IMPLICATIONS FOR NURSING

Survivors who complete a rehabilitation program retain a sense of restoration and caring, and some engage in physical activity over time. Adapting the program based on insights into the survivor perspective may assist oncology rehabilitation clinicians to promote optimum physical activity and sustain healthful change.

The experiences of participants in an innovative online resource designed to increase regular walking among rural cancer survivors: a qualitative pilot feasibility study

PURPOSE

Physical activity has been associated with improved outcomes for cancer survivors. Compared to their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rates after diagnosis of cancer. The aim of this pilot feasibility study was to gain insight into the experiences of rural cancer survivors engaging in an online resource designed to increase regular walking.

METHODS

A 6-week online lifestyle intervention was implemented among eight cancer survivors living in three rural regions of South Australia. Participants used a pedometer to monitor daily steps taken, reported daily steps using a specially designed website and were provided with daily step goals based on their affective state. Participants took part in semi-structured face-to-face interviews to gauge their impressions of the program. Data were analysed using qualitative description and content analysis to derive major themes from the interviews.

RESULTS

The program motivated participants to increase their walking and resulted in improvements in several self-reported physical and quality of life outcomes. The resource was clear and easy to navigate. The three-tiered step goal system reduced feelings of guilt if participants were unable to reach a goal. The step log and graph allowed participants to self-monitor their progress. The forum fostered social support; however, more interaction with intervention personnel was suggested.

CONCLUSIONS

This online pedometer-based walking intervention is feasible and effectively increases motivation for walking and enhances health-related quality of life in South Australian rural cancer survivors. A randomized controlled trial of this intervention is warranted.

Effects of aerobic exercise on cancer-related fatigue in breast cancer patients receiving chemotherapy: a meta-analysis

Increasing scientific evidences suggest that aerobic exercise may improve cancer-related fatigue in breast cancer patients, but many existing studies have yielded inconclusive results. This meta-analysis aimed to derive a more precise estimation of the effects of aerobic exercise on cancer-related fatigue in breast cancer patients receiving chemotherapy. The PubMed, CISCOM, CINAHL, Web of Science, Google Scholar, EBSCO, Cochrane Library, and CBM databases were searched from inception through July 1, 2013 without language restrictions. Crude standardized mean difference (SMD) with 95 % confidence interval (CI) was calculated. Twelve comparative studies were assessed with a total of 1,014 breast cancer patients receiving chemotherapy, including 522 patients in the aerobic exercise group (intervention group) and 492 patients in the usual care group (control group). The meta-analysis results revealed that the Revised Piper Fatigue Scale (RPFS) scores of breast cancer patients in the intervention group were significantly lower than those in the control group (SMD=-0.82, 95% CI=-1.04 ∼ -0.60, P<0.001). However, there was no significant difference in the Functional Assessment of Chronic Illness Treatment-Fatigue scale (FACIT-F) scores between the intervention and control groups (SMD=0.09, 95% CI=-0.07 ∼ 0.25, P=0.224). Subgroup analysis by ethnicity indicated that there were significant differences in RPFS and FACIT-F scores between the intervention and control groups among Asian populations (RPFS: SMD=-1.08, 95% CI=-1.35 ∼ -0.82, P<0.001; FACIT-F: SMD=1.20, 95 % CI=0.70 ∼1.71, P<0.001), but not among Caucasian populations (all P>0.05). The current meta-analysis indicates that aerobic exercise may improve cancer-related fatigue in breast cancer patients receiving chemotherapy, especially among Asian populations.

CRIB--the use of cardiac rehabilitation services to aid the recovery of patients with bowel cancer: a pilot randomised controlled trial (RCT) with embedded feasibility study

INTRODUCTION

Patients with colorectal cancer report ongoing physical and psychological impairments and a high proportion of these patients are overweight, insufficiently active and high-risk drinkers, putting them at risk of poor recovery and risk of recurrence and comorbidities. A challenge is implementing sustainable and effective rehabilitation as part of routine care for this group.

METHODS AND ANALYSIS

A two-arm pilot randomised controlled trial (RCT) with embedded feasibility study undertaken as a phased programme of work. The intervention involves an existing cardiac rehabilitation programme for cardiac patients accepting colorectal cancer patient referrals. The intervention consists of supervised exercise sessions run by a cardiac physiotherapist and information sessions. Phase 1 will involve one research site enrolling 12 patients to assess intervention and study design processes. Semistructured interviews with patients with colorectal cancer and cardiac patients and clinicians will be used to gather data on acceptability of the intervention and study procedures. Phase 2 will involve three sites enrolling 66 patients with colorectal cancer randomised to control or intervention groups. Outcome measures will be taken preintervention and postintervention, for phases 1 and 2. The primary outcome is accelerometer measured physical activity; secondary outcomes are self-report physical activity, quality of life, anxiety, depression, symptoms including fatigue. The following variables will also be examined to determine if these factors influence adherence and outcomes: self-efficacy, risk perception and treatments.

ETHICS AND DISSEMINATION

Full ethical approval was granted by NRES Committees-North of Scotland (13/NS/0004; IRAS project ID: 121757) on 22 February 2013. The proposed work is novel in that it aims to test the feasibility and acceptability of using an evidence-based and theory driven existing cardiac rehabilitation service with patients with colorectal cancer. Should this model of rehabilitation prove to be clinically and cost effective we aim to conduct a randomised controlled trial of this intervention to measure effectiveness.

TRIAL REGISTRATION REFERENCE

ISRCTN63510637; UKCRN id 14092.

Energy balance and metabolism after cancer treatment

Unfavorable physiological, biological, and behavioral alterations during and following treatment for cancer may lead to chronic energy imbalance predisposing to a myriad of deleterious health conditions including obesity, dyslipidemia, and the metabolic syndrome. In addition to the cardiovascular and musculoskeletal effects of these conditions, energy imbalance and metabolic changes after cancer treatment can also affect cancer-related morbidity and mortality. To this end, lifestyle interventions such as diet and physical activity are especially relevant to mitigate the deleterious impact of chronic energy imbalance in cancer survivors.

Symptom distress and quality of life after stereotactic radiosurgery in patients with pituitary tumors: a questionnaire survey

Background

Stereotactic radiosurgery (SRS) is a common treatment for recurrent or residual pituitary adenomas. The persistence of symptoms and treatment related complications may impair the patient’s quality of life (QOL).

Purpose

The purpose of this study was to examine symptom distress, QOL, and the relationship between them among patients with pituitary tumors who had undergone SRS.

Methods

This study used a cross-sectional design and purposive sampling. We enrolled patients diagnosed with pituitary tumors who had undergone SRS. Data were collected at the CyberKnife Center at a medical center in Northern Taiwan in 2012. A questionnaire survey was used for data collection. Our questionnaire consisted of 3 parts the Pituitary Tumor Symptom Distress Questionnaire, the World Health Organization Quality of Life Instrument Short-Form (WHOQOL-BREF), and a demographic questionnaire.

Results

Sixty patients were enrolled in the study. The most common symptoms reported by patients after SRS were memory loss, fatigue, blurred vision, headache, sleep problems, and altered libido. The highest and lowest scores for QOL were in the environmental and psychological domains, respectively. Age was positively correlated with general health and the psychological domains. Level of symptom distress was negatively correlated with overall QOL, general health, physical health, and the psychological and social relationships domains. The scores in the psychological and environmental domains were higher in males than in females. Patients with ≤6 symptoms had better overall QOL, general health, physical health, and psychological and social relationships than those with >6 symptoms.

Conclusion

Symptom distress can affect different aspects of patient QOL. Levels of symptom distress, number of symptoms, age, and gender were variables significantly correlated with patient QOL. These results may be utilized by healthcare personnel to design educational and targeted interventional programs for symptom management to improve patient QOL.

Upper limb physical function and adverse effects after breast cancer surgery: a prospective 2.5-year follow-up study and preoperative measures

OBJECTIVE

To examine upper limb physical function and adverse effects after axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) in patients with breast cancer to identify impairments that can inform rehabilitation strategies.

DESIGN

Prospective longitudinal cohort. Upper limb measurements were studied preoperatively and 2.5 years after breast cancer treatment.

SETTING

Hospital setting.

PARTICIPANTS

Two groups of patients with early-stage primary breast cancer (N=391): the ALND surgery group (mean age, 55±10y) and the SLNB group (mean age, 57±10y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Arm lymphedema (≥10% increased arm volume relative to control arm volume), grip strength (in kilograms), shoulder mobility, pain intensity during isometric shoulder abduction (on a 100-mm visual analog scale), and body mass index (kg/m(2)). Parametric/nonparametric tests were used for hypothesized changes and differences, and regression analysis was used for confounding factors.

RESULTS

We observed more adverse effects in women treated with ALND than with SLNB after 2.5 years (P<.05): arm lymphedema (17% vs 3%), grip strength reduction (12% vs 2%), and shoulder abduction-provoked pain (increase of 6% vs decrease of 50%). The adverse effects were similar for affected and control upper limbs for all outcomes except arm lymphedema, which occurred only on the affected side.

CONCLUSIONS

Adverse effects in both affected and control/unaffected upper limb were observed after 2.5-year follow-up in both ALND and SLNB groups, but a higher prevalence was observed in the ALND group. Thus, women going through ALND surgery may benefit from further postoperative physical therapy, including resistance and strength exercise, focusing on pain management.

A Community-Based Exercise and Support Group Program in African-American Breast Cancer Survivors (ABCs)

African-American (AA) women have higher rates of breast cancer (BCa) mortality than Caucasian women, and a recent study using data from the Surveillance, Epidemiology and End Results (SEER) registry suggests that this disparity may be due, in part, to the poorer health status of AAs at diagnosis and not treatment related issues. Randomized controlled trials involving supervised aerobic and resistance exercise have shown improved body composition and improvement in cancer-related biomarkers in BCa patients and may lead to improved recurrence and survival rates; however, most trials have focused on Caucasians and many have been conducted in academic- and clinic-based settings. We evaluated the feasibility of conducting a 20-week, supervised, resistance training, group exercise intervention coupled with a support group and home walking program utilizing facilities and personnel at a community cancer support center (The Gathering Place, Beachwood, Ohio) in AA Stage I-III BCa survivors who were within 12 months of completing treatment (surgery, chemotherapy, and/or breast irradiation); and, evaluated the potential effects of this intervention on physical measures and cancer-related biomarkers. 27 patients provided informed consent and 19 participated in the program. On average, attendance rates were 70.0% ± 19.1% for the exercise sessions and 63.1% ± 13.8% for the support group. We observed a significant decrease in circulating C-peptide levels (B: 893.9 ± 399.1 pg/mL; EOI: 723.9 ± 319.0 pg/mL; p=0.01). Although we did not observe a significant decrease in weight in the entire sample, there was a significant decrease in waist circumference and percent total body fat among those who attended 70% or more of the exercise sessions. In summary, we demonstrated that conducting lifestyle interventions in AA BCa survivors in a community setting is feasible. Future interventions should invoke strategies to enhance adherence and include a structured dietary intervention to enable greater weight loss.

Interventions to improve exercise behaviour in sedentary people living with and beyond cancer: a systematic review

BACKGROUND

To systematically review the effects of interventions to improve exercise behaviour in sedentary people living with and beyond cancer.

METHODS

Only randomised controlled trials (RCTs) that compared an exercise intervention to a usual care comparison in sedentary people with a homogeneous primary cancer diagnosis, over the age of 18 years were eligible. The following electronic databases were searched: Cochrane Central Register of Controlled Trials MEDLINE; EMBASE; AMED; CINAHL; PsycINFO; SportDiscus; PEDro from inception to August 2012.

RESULTS

Fourteen trials were included in this review, involving a total of 648 participants. Just six trials incorporated prescriptions that would meet current recommendations for aerobic exercise. However, none of the trials included in this review reported intervention adherence of 75% or more for a set prescription that would meet current aerobic exercise guidelines. Despite uncertainty around adherence in many of the included trials, the interventions caused improvements in aerobic exercise tolerance at 8-12 weeks (SMD=0.73, 95% CI=0.51-0.95) in intervention participants compared with controls. At 6 months, aerobic exercise tolerance is also improved (SMD=0.70, 95% CI=0.45-0.94), although four of the five trials had a high risk of bias; hence, caution is warranted in its interpretation.

CONCLUSION

Expecting the majority of sedentary survivors to achieve the current exercise guidelines is likely to be unrealistic. As with all well-designed exercise programmes, prescriptions should be designed around individual capabilities and frequency, duration and intensity or sets, repetitions, intensity of resistance training should be generated on this basis.

Effect of a diet and physical activity intervention on body weight and nutritional patterns in overweight and obese breast cancer survivors

Energy restriction from a low-calorie diet and increased energy expenditure induced by physical activity (PA) could promote weight loss/maintenance and be important determinants of breast cancer (BC) prognosis. The aim of this study was to assess participation and adherence of overweight and obese BC survivors to a lifestyle intervention and to demonstrate the capacity of this intervention to induce weight loss and nutritional changes. This single-arm pre-post study, which involved one-hourly weekly diet sessions delivered by a dietician and 75-min bi-weekly PA sessions of moderate-to-high intensity led by PA monitors, was offered to overweight and obese BC survivors shortly after treatment. Before and after the intervention, anthropometry, dietary information, quality of life (QoL) and cardiorespiratory fitness (CRF) were collected. A total of 112 BC survivors were invited to participate: 42 of them started the intervention and 37 completed it. Participants attended more than 90 % of the sessions offered and showed a significant weight loss of 5.6 ± 2.0 kg, as well as significant decreases in body mass index, fat mass and waist circumference. Significant decreases in total energy (-25 %), fat (-35 %), saturated fat (-37 %) and carbohydrate (-21 %) intakes were observed while QoL and CRF showed significant increases. This feasibility study demonstrated the success of a short-term diet and PA intervention to induce weight loss and promote healthful changes in BC survivors. Assessing the long-term effects of these changes, and in particular their possible impact of BC prognosis, and designing interventions reaching a wider number of BC survivors are still issues to be addressed.

Epithelial cancers in the post-genomic era: should we reconsider our lifestyle?

The age-related epithelial cancers of the breast, colorectum and prostate are the most prevalent and are increasing in our aging populations. Epithelial cells turnover rapidly and mutations naturally accumulate throughout life. Most epithelial cancers arise from this normal mutation rate. All elderly individuals will harbour many cells with the requisite mutations and most will develop occult neoplastic lesions. Although essential for initiation, these mutations are not sufficient for the progression of cancer to a life-threatening disease. This progression appears to be dependent on context: the tissue ecosystem within individuals and lifestyle exposures across populations of individuals. Together, this implies that the seeds may be plentiful but they only germinate in the right soil. The incidence of these cancers is much lower in Eastern countries but is increasing with Westernisation and increases more acutely in migrants to the West. A Western lifestyle is strongly associated with perturbed metabolism, as evidenced by the epidemics of obesity and diabetes: this may also provide the setting enabling the progression of epithelial cancers. Epidemiology has indicated that metabolic biomarkers are prospectively associated with cancer incidence and prognosis. Furthermore, within cancer research, there has been a rediscovery that a switch in cell metabolism is critical for cancer progression but this is set within the metabolic status of the host. The seed may only germinate if the soil is fertile. This perspective brings together the different avenues of investigation implicating the role that metabolism may play within the context of post-genomic concepts of cancer.

A pilot phase II RCT of a home-based exercise intervention for survivors of AML

BACKGROUND

Fatigue is the most common and disabling symptom affecting quality of life (QOL) and daily function in patients who have completed treatment for acute myeloid leukemia (AML). Although trials in patients with various solid tumors have reported improved fatigue and QOL following exercise interventions, there have been no studies in AML patients post treatment.

METHODS

Forty patients aged ≥ 40 years who had completed treatment for AML were enrolled in a 12-week randomized phase II exercise intervention to determine feasibility (recruitment, retention, and adherence), efficacy, and safety of the intervention. Patients assigned to the exercise group received an individualized, moderate-intensity, 12-week home-based exercise program with weekly telephone support from a certified exercise physiologist. QOL, fatigue, and fitness outcomes were measured at baseline, 6 weeks, and 12 weeks. Between-group differences in 12-week change scores were calculated using linear regression adjusting for age and baseline function.

RESULTS

Recruitment and retention rates were 38% and 91%, respectively. Adherence was low at 28%. Analyses did not suggest statistically significant or clinically important benefits in QOL, fatigue, or physical fitness with the intervention. The level of adherence did not appear to impact outcomes. There were no adverse events.

CONCLUSION

A home-based exercise program for post-treatment AML patients age 40 years or older can be safely delivered with reasonable recruitment and high retention. However, feasibility was hampered by low adherence. Further research and program modification are needed to better understand and overcome barriers to exercise delivery and adherence in AML survivors.

Distress, problems and supportive care needs of patients treated with auto- or allo-SCT

Hematological malignancies and treatment with hematopoietic SCT are known to affect patients' quality of life. The problem profile and care needs of this patient group need clarification, however. This study aimed to assess distress, problems and care needs after allo- or auto-SCT, and to identify risk factors for distress, problems or care needs. In this cross-sectional study, patients treated with allo-SCT or auto-SCT for hematological malignancies completed the Distress Thermometer and Problem List. Three patient groups were created: 0-1, 1-2.5 and 2.5-5.5 years after transplantation. After allo-SCT, distress and the number of problems tended to be lower with longer follow-up. After auto-SCT, distress was highest at 1-2.5 year(s). Patients mainly reported physical problems, followed by cognitive-emotional and practical problems. A minority reported care needs. Risk factors for distress as well as problems after allo-SCT included younger age, shorter time after transplantation and GVHD. A risk factor for distress as well as problems after auto-SCT was the presence of comorbid diseases. Up to 5 years after auto-SCT or allo-SCT, patients continue to experience distress and problems. Judged by prevalence, physical problems are first priority in supportive care, followed by cognitive-emotional and practical problems.

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

INTRODUCTION

Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.

METHODS

More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer 'stem' cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.

RESULTS

The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.

CONCLUSIONS

With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study

OBJECTIVE

To determine the comparative effectiveness of exercise versus drug interventions on mortality outcomes.

DESIGN

Metaepidemiological study.

ELIGIBILITY CRITERIA

Meta-analyses of randomised controlled trials with mortality outcomes comparing the effectiveness of exercise and drug interventions with each other or with control (placebo or usual care).

DATA SOURCES

Medline and Cochrane Database of Systematic Reviews, May 2013.

MAIN OUTCOME MEASURE

Mortality.

DATA SYNTHESIS

We combined study level death outcomes from exercise and drug trials using random effects network meta-analysis.

RESULTS

We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent exercise trials, our review collectively included 305 randomised controlled trials with 339,274 participants. Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14,716 participants were randomised to physical activity interventions in 57 trials. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). Inconsistency between direct and indirect comparisons was not significant.

CONCLUSIONS

Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

Understanding barriers to exercise implementation 5-year post-breast cancer diagnosis: a large-scale qualitative study

Due to the amount of literature supporting exercise participation after cancer diagnosis, there has been recent interest in barriers to exercise engagement among cancer patients. However, little is known regarding reasons why people choose to disengage and how this disengagement occurs over time. This study aimed to qualitatively study the perceived barriers to exercise implementation, 5-year post-breast cancer diagnosis. Eighty-three female breast cancer survivors participated in a one-to-one semi-structured interview, regarding their experience of exercise over the past 5 years following their original participation in a group-based structured exercise intervention after diagnosis (41 from intervention and 42 from original control group). The data were analysed using inductive thematic analysis. The findings included three main themes and several subthemes regarding the women's perceived barriers: psychological barriers (lack of motivation, fears, dislike of gym, not being the 'sporty type'), physical barriers (the ageing process, cancer treatment and other physical co-morbidities, fatigue and weight gain) and contextual and environmental barriers (employment, traditional female care-giving roles, proximity/access to facilities, seasonal weather). The findings add inductive support to the current survivor health research advocating the use of activity immediately after diagnosis, as well as the need for tailored activity programmes in order to overcome potential obstacles.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important.

OBJECTIVES

To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour?

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative.

MAIN RESULTS

Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials.None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%).

AUTHORS' CONCLUSIONS

Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.

African-American breast cancer survivors' preferences for various types of physical activity interventions: a Sisters Network Inc. web-based survey

BACKGROUND

Needs assessments are essential to developing lifestyle interventions for minority populations. To our knowledge, no physical activity (PA) needs assessment studies have been conducted for African-American (AA) breast cancer survivors. The purpose of this study was to determine the PA intervention preferences of AA breast cancer survivors and determine whether these preferences differ according to medical and sociodemographic factors.

METHODS

AA breast cancer survivors (n = 475, mean age = 54 years) were recruited using ads sent via email and social media sites. Preferences for the mode of intervention delivery were assessed via web-based questionnaires. Descriptive statistics were used to characterize their interests in PA interventions, and subgroup differences were assessed.

RESULTS

About 49 % (142 out of 291) of the participants who completed the survey were obese and 54 % did not meet the recommended guidelines for PA. Most (90 %) participants reported that they could participate in PA, and many (67 %) indicated that they were interested in receiving program materials. Participants expressed the greatest interest in email (50 %)-, web (48 %)-, or mail-based (45 %) over group (39 %), and telephone (10 %). Women also expressed the greatest interest in participating in studies that promoted walking and resistance or strength training. Intervention preferences did not differ significantly (P > 0.05) across sociodemographic or medical factors.

CONCLUSION

Most AA breast cancer survivors can participate in PA, and many are interested in interventions that promoted walking and resistance training and were delivered via the email or web. The development of culturally sensitive interventions that provide activities consistent with preferences can assist AA breast cancer survivors to adopt and maintain a healthy lifestyle.

IMPLICATIONS FOR CANCER SURVIVORS

Despite evidence that AA breast cancer survivors are at increased risk for poor breast cancer-specific outcomes, they are underrepresented in clinical trials promoting positive health behaviors. In this study, we propose to assess their exercise preferences and receptivity to a culturally appropriate PA intervention developed in collaboration with the Sisters Network Inc. Health promotion programs developed in collaboration with a community-based organization may aid in the development of research tools and resources that AA breast cancer survivors are receptive to using.

Daily life behaviors and depression risk following stroke: a preliminary study using ecological momentary assessment

Approximately one-third of stroke survivors have symptoms of depression. A better understanding of the early risk factors implicated in this form of comorbidity may contribute to the development of early prevention strategies and to improving outcomes for this population. The current study uses ecological momentary assessment techniques to identify behavioral risk factors for depression 3 months after stroke. Thirty-six participants completed ambulatory monitoring of daily life circumstances (location, social environment, and activity) 5 times per day during a 1-week period after hospital discharge. Clinician-administered measures of depression were also provided before discharge and 3 months later. Ambulatory monitoring revealed that depression scores at 3 months were lower among individuals with more social interactions but higher among those who reported having sports activities and working in the week following hospital discharge. Daily life behaviors may have important implications for understanding the risk of poststroke depression, and mobile technologies may provide important contributions to their investigation.

Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.

Effect of physical exercise on muscle mass and strength in cancer patients during treatment--a systematic review

Cancer treatment and its side effects may cause muscle wasting. Physical exercise has the potential to increase muscle mass and strength and to improve physical function in cancer patients undergoing treatment. A systematic review was conducted to study the effect of physical exercise (aerobic, resistance or a combination of both) on muscle mass and strength in cancer patients with different type and stage of cancer disease. Electronic searches were performed up to January 11th 2012, identifying 16 randomised controlled trials for final data synthesis. The studies demonstrated that aerobic and resistance exercise improves upper and lower body muscle strength more than usual care. Few studies have assessed the effect of exercise on muscle mass. Most studies were performed in patients with early stage breast or prostate cancer. Evidence on the effect of physical exercise on muscle strength and mass in cancer patients with advanced disease is lacking. More exercise studies in patients with advanced cancer and at risk of cancer cachexia are warranted.

A qualitative synthesis of trials promoting physical activity behaviour change among post-treatment breast cancer survivors

BACKGROUND

Health outcome trials have provided strong evidence that participating in regular physical activity can improve the quality of life and health of post-treatment breast cancer survivors. Focus is now needed on how to promote changes in physical activity behaviour among this group.

PURPOSE

This systematic review examines the efficacy of behavioural interventions for promoting physical activity among post-treatment breast cancer survivors.

METHODS

Behavioural intervention studies published up until July 2012 were identified through a systematic search of two databases: MEDLINE and CINAHL, and by searching reference lists of relevant publications and scanning citation libraries of project staff.

RESULTS

Eight out of the ten identified studies reported positive intervention effects on aerobic physical activity behaviour, ranging from during the intervention period to 6 months post-intervention. Only two studies reported intervention effect sizes. The identification of factors related to efficacy was not possible because of the limited number and heterogeneity of studies included, as well as the lack of effect sizes reported. Nonetheless, an examination of the eight studies that did yield significant intervention effects suggests that 12-week interventions employing behaviour change techniques (e.g., self-monitoring and goal setting) derived from a variety of theories and delivered in a variety of settings (i.e., one-on-one, group or home) can be effective at changing the aerobic physical activity behaviour of breast cancer survivors in the mid- to long terms.

CONCLUSIONS

Behavioural interventions do hold promise for effectively changing physical activity behaviour among breast cancer survivors. However, future research is needed to address the lack of studies exploring long-term intervention effects, mediators of intervention effects and interventions promoting resistance-training activity, and to address issues impacting on validity, such as the limited use of objective physical activity measures and the use of convenience samples.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying effective ways of assisting breast cancer survivors to adopt and maintain physical activity is important for enhancing the well-being and health outcomes of this group.

Prevalence and Predictors of the Short-Term Trajectory of Anxiety and Depression in the First Year After a Cancer Diagnosis: A Population-Based Longitudinal Study

Purpose

Few studies have examined psychological adjustment for cancer survivors in late treatment and early survivorship stages. Our study investigated the prevalence and short-term trajectories of anxiety, depression, and comorbid anxiety-depression among adult cancer survivors, and identified the individual, disease, health behavior, psychological, and social predictors of chronic and late psychological morbidity.

Methods

A heterogeneous sample of adult cancer survivors was recruited from two state-based cancer registries. A total of 1,154 survivors completed self-report questionnaires at 6 (Time 1) and 12 months (Time 2) postdiagnosis. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale with cases identified by a subscale cutoff score ≥ 8. Logistic regression analyses identified Time 1 characteristics associated with anxiety and/or depression at Time 2.

Results

The point prevalence of anxiety (Time 1, 22%; Time 2, 21%), depression (13% at both timepoints) and comorbid anxiety-depression (9% at both timepoints) was similar at 6 and 12 months postdiagnosis. The most prevalent Time 1 to Time 2 trajectory was noncase for anxiety (70%), depression (82%), and comorbid anxiety-depression (87%). While psychological morbidity at Time 1 was the strongest predictor of psychological morbidity at Time 2, being diagnosed with lung cancer and health risk behaviors (smoking, insufficient physical activity) were also strong predictors.

Conclusion

Targeted psychological screening of vulnerable survivors and early intervention may prevent the onset and/or reduce the severity of psychological morbidity in early survivorship. Trials of risk reduction interventions targeting psychological functioning and health risk behaviors seem warranted.

Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions

Physical activity during and after cancer treatment has beneficial effects on a number of physical and psychosocial outcomes. This paper aims to discuss the existing physical activity guidelines for cancer survivors and to describe future research directions to optimize prescriptions. Studies on physical activity during and after cancer treatment were searched in PubMed, Clinicaltrials.gov, Australian New Zealand Clinical Trials Registry, and Dutch Trial registry. Physical activity guidelines for cancer survivors suggest that physical activity should be an integral and continuous part of care for all cancer survivors. However, the development of these guidelines has been limited by the research conducted. To be able to develop more specific guidelines, future studies should focus on identifying clinical, personal, physical, psychosocial, and intervention moderators explaining 'for whom' or 'under what circumstances' interventions work. Further, more insight into the working mechanisms of exercise interventions on health outcomes in cancer survivors is needed to improve the efficacy and efficiency of interventions. Finally, existing programs should embrace interests and preferences of patients to facilitate optimal uptake of interventions. In conclusion, current physical activity guidelines for cancer survivors are generic, and research is needed to develop more personalized physical activity guidelines.

Perceived benefits and barriers to exercise for recently treated patients with multiple myeloma: a qualitative study

BACKGROUND

Understanding the physical activity experiences of patients with multiple myeloma (MM) is essential to inform the development of evidence-based interventions and to quantify the benefits of physical activity. The aim of this study was to gain an in-depth understanding of the physical activity experiences and perceived benefits and barriers to physical activity for patients with MM.

METHODS

This was a qualitative study that used a grounded theory approach. Semi-structured interviews were conducted in Victoria, Australia by telephone from December 2011-February 2012 with patients who had been treated for MM within the preceding 2-12 months. Interviews were transcribed and analysed using the constant comparison coding method to reduce the data to themes. Gender differences and differences between treatment groups were explored.

RESULTS

Twenty-four interviews were completed. The sample comprised 13 females (54%), with a mean age of 62 years (SD = 8.8). Sixteen (67%) participants had received an autologous stem cell transplant (ASCT). All participants currently engaged in a range of light to moderate intensity physical activity; walking and gardening were the most common activities. Recovery from the symptoms of MM and side effects of therapy, psychological benefits, social factors and enjoyment were important benefits of physical activity. Barriers to physical activity predominately related to the symptoms of MM and side effects of therapy, including pain, fatigue, and fear of infection. Low self- motivation was also a barrier. Women participated in a more diverse range of physical activities than men and there were gender differences in preferred type of physical activity. Women were more likely to report psychological and social benefits; whereas men reported physical activity as a way to keep busy and self-motivation was a barrier. Patients treated with an ASCT more often reported affective benefits of participation in physical activity and fatigue as a barrier. Patients treated with other therapies (e.g., chemotherapy, radiotherapy) were more likely to report pain as a barrier.

CONCLUSIONS

Patients with MM experience debilitating effects of their condition and therapy, which influences their level and intensity of physical activity participation. Physical activity programs should be individualised; take into consideration gender differences and the impact of different types of therapy on physical activity; and focus on meeting the psychological, coping and recovery needs of patients.

Differential effects of cardiovascular and resistance exercise on functional mobility in individuals with advanced cancer: a randomized trial

OBJECTIVE

To compare the effects of resistance and cardiovascular exercise on functional mobility in individuals with advanced cancer.

DESIGN

Prospective, 2-group pretest-posttest pilot study with randomization to either resistance or cardiovascular exercise mode.

SETTING

Comprehensive community cancer center and a hospital-based fitness facility.

PARTICIPANTS

Volunteer sample of individuals (N=66; 30 men; 36 women; mean age, 62y) with advanced cancer recruited through the cancer center, palliative care service, rehabilitation department, and a local hospice.

INTERVENTIONS

Ten weeks of individualized resistance or cardiovascular exercise, prescribed and monitored by oncology-trained exercise personnel.

MAIN OUTCOME MEASURES

Functional mobility was assessed using the Short Physical Performance Battery (SPPB); self-reported pain and fatigue were assessed secondarily using visual analog scales. Data were analyzed using a split plot 2×2 analysis of variance (α=.05).

RESULTS

Fifty-two patients (78.8%) completed the study: 23 (67.7%) of 34 patients in the resistance arm and 29 (90.6%) of 32 patients in the cardiovascular arm. No participant withdrew because of study adverse events. Ten-week outcomes (n=52) included a significant increase in SPPB total score (P<.001), increase in gait speed (P=.001), and reduction in fatigue (P=.05). Although cardiovascular exercise participants had a modestly greater improvement in SPPB total score than resistance training participants (F1,49=4.21, P=.045), the difference was not confirmed in a subsequent intention-to-treat analysis (N=66).

CONCLUSIONS

Individuals with advanced cancer appear to benefit from exercise for improving functional mobility. Neither resistance nor cardiovascular exercise appeared to have a strong differential effect on outcome.

A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue

PURPOSE

The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults.

METHODS

The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009.

RESULTS

Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process.

CONCLUSIONS

Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.

Examination of the association of diet and persistent cancer-related fatigue: a pilot study

PURPOSE/OBJECTIVES

To examine associations between diet and persistent cancer-related fatigue (PCRF) in cancer survivors.

DESIGN

A cross-sectional pilot study.

SETTING

A university cancer center in Michigan.

SAMPLE

40 adult cancer survivors who were recruited from July 2007 to August 2008 and had completed all cancer treatments at least 12 weeks prior to recording their dietary intakes and fatigue severity.

METHODS

Participants' fatigue was assessed with the Brief Fatigue Inventory (BFI). Based on the BFI score, participants were placed into one of three fatigue levels: no fatigue, moderate fatigue, or severe fatigue. Dietary data were collected using a four-day food diary and analyzed using Nutrition Data System for Research software. Diet data were collected during the same week that fatigue was measured.

MAIN RESEARCH VARIABLES

Fatigue and dietary intake.

FINDINGS

Mean daily intake of whole grains, vegetables, and, in particular, green leafy vegetables and tomatoes were significantly higher in the nonfatigued group compared to fatigued cancer survivors. Also, cancer survivors reporting no fatigue had significantly higher intakes of certain anti-inflammatory and antioxidant nutrients.

CONCLUSIONS

Increased consumption of whole grains, vegetables, and foods rich in certain anti-inflammatory nutrients was associated with decreased levels of PCRF. Additional rigorous studies are required to investigate possible mechanisms and causal relationships regarding the benefits of particular diets on PCRF.

IMPLICATIONS FOR NURSING

Nurses, as one of the main providers of care to cancer survivors, should continue to follow National Comprehensive Cancer Network recommendations until additional data on diet and fatigue are evaluated.

KNOWLEDGE TRANSLATION

Nurses should be aware of national guidelines for nutritional recommendations for treating cancer-related fatigue. In addition, nurses should ask about and record the cancer survivor's typical dietary intake. Referrals to registered dietitians, in accordance with national guidelines for cancer survivors, should be considered when advising a fatigued patient.

Physical activity and risk of lung cancer: a meta-analysis of prospective cohort studies

BACKGROUND

Previous studies investigating the association of physical activity with risk of lung cancer reported conflicting results. In order to update and improve available evidence on any link, a meta-analysis was performed.

METHOD

We searched the PubMed database for prospective cohort studies investigating the relation of physical activity with risk of lung cancer. The pooled relative risk (RR) with its 95% confidence intervals (95%CI) was used to assess the association.

RESULTS

We included 14 prospective studies with a total of 1,644,305 participants, with 14,074 incident lung cancer cases documented during follow-up. Meta-analysis of all 14 studies suggested both high and medium levels of physical activity to be associated with decreased risk of lung cancer compared to the reference group with low level of physical activity (for high level, RR = 0.77, 95%CI 0.73-0.81, P < 0.001; for medium level, RR = 0.87, 95%CI 0.83-0.90, P < 0.001). Subgroup analyses by gender found obvious associations in both men and women. No publication bias was observed.

CONCLUSION

Our findings suggest that high and medium levels of physical activity have a beneficial effect on lung cancer by reducing the overall risk of tumour development among both men and women.

Interventions to promote energy balance and cancer survivorship: priorities for research and care

The growing population of cancer survivors worldwide and the growing epidemics of obesity and physical inactivity have brought increased attention to the role that interventions to promote exercise and a healthy body weight may play in mitigating the chronic and late effects of cancer. In this light, the authors describe the similarities and differences in research and clinical priorities related to energy balance interventions among post-treatment cancer survivors in Europe versus North America. Randomized controlled trials that targeted nutrition, exercise, and weight are reviewed to determine the affect on survivorship outcomes. Interventions focused on improving prognosis or survival are investigated along with the emerging literature on the interventions targeting pathways and mechanisms of prognosis or survival. Current North American and European guidelines for diet, exercise, and weight control among cancer survivors also are investigated along with the implications of the current state of this science for clinical care. Finally, the authors delineate future European and American priorities for research and care involving energy balance among survivors. It is hoped that this dialogue launches an international conversation that will lead to better research and care for all post-treatment cancer survivors.