Randomized pilot test of a lifestyle physical activity intervention for breast cancer survivors

Multidisciplinary management of breast cancer

Breast cancer, with an increasing incidence, is the most frequently diagnosed cancer in women worldwide. The treatments proposed, generally a combination of surgery, radiotherapy, chemotherapy, endocrine therapy and/or targeted therapy, are constantly improving, allowing a reduction in the mortality rate, but they are still causing many side effects, not only early but also late, which leads us to consider the post-cancer period as a chronic condition. Side effects, reviewed in this commentary, may affect physical functions, psychological status, social situation, body composition, well-being and quality of life of the patient. In view of the extent of these areas in which side effects of breast cancer and of its treatments can be found, the supportive care offered at the end of treatment need to be multidisciplinary. Different supportive care interventions may be proposed to the patients such as psychological and behavioral interventions, complementary therapies, diet interventions, physical activity/rehabilitation or also physiotherapy interventions for example, all having shown some beneficial effects in the literature. The benefits of these supportive care interventions are thereby already established and they are described in this article, but others studies will be needed to clearly define indications and most optimal modalities of application to reduce side effects and improve quality of life of patients.

Exercise for women receiving adjuvant therapy for breast cancer

BACKGROUND

A huge clinical research database on adjuvant cancer treatment has verified improvements in breast cancer outcomes such as recurrence and mortality rates. On the other hand, adjuvant and neoadjuvant therapy with chemotherapy and radiotherapy impacts on quality of life due to substantial short- and long-term side effects. A number of studies have evaluated the effect of exercise interventions on those side effects. This is an updated version of the original Cochrane review published in 2006. The original review identified some benefits of physical activity on physical fitness and the resulting capacity for performing activities of daily life. It also identified a lack of evidence for other outcomes, providing clear justification for an updated review.

OBJECTIVES

To assess the effect of aerobic or resistance exercise interventions during adjuvant treatment for breast cancer on treatment-related side effects such as physical deterioration, fatigue, diminished quality of life, depression, and cognitive dysfunction.

SEARCH METHODS

We carried out an updated search in the Cochrane Breast Cancer Group Specialised Register (30 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2015), MEDLINE (1966 to 30 March 2015), and EMBASE (1966 to 30 March 2015). We did not update the original searches in CINAHL (1982 to 2004), SPORTDiscus (1975 to 2004), PsycINFO (1872 to 2003), SIGLE (1880 to 2004), and ProQuest Digital Dissertations (1861 to 2004). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 30 March 2015. We screened references in relevant reviews and published clinical trials.

SELECTION CRITERIA

We included randomised controlled trials that examined aerobic or resistance exercise or both in women undergoing adjuvant treatment for breast cancer. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction, assessed trials, and graded the methodological quality using Cochrane's 'Risk of bias' tool. Any disagreements were resolved through discussion or by consulting the third review author. We entered data into Review Manager for analysis. For outcomes assessed with a variety of instruments, we used the standardised mean difference (SMD) as a summary statistic for meta-analysis; for those assessed with the same instrument, we used the mean difference (MD).

MAIN RESULTS

For this 2015 update we included a total of 32 studies with 2626 randomised women, 8 studies from the original search and 24 studies from the updated search. We found evidence that physical exercise during adjuvant treatment for breast cancer probably improves physical fitness (SMD 0.42, 95% confidence interval (CI) 0.25 to 0.59; 15 studies; 1310 women; moderate-quality evidence) and slightly reduces fatigue (SMD -0.28, 95% CI -0.41 to -0.16; 19 studies; 1698 women; moderate-quality evidence). Exercise may lead to little or no improvement in health-related quality of life (MD 1.10, 95% CI -5.28 to 7.48; 1 study; 68 women; low-quality evidence), a slight improvement in cancer site-specific quality of life (MD 4.24, 95% CI -1.81 to 10.29; 4 studies; 262 women; low-quality evidence), and an improvement in cognitive function (MD -11.55, 95% CI -22.06 to -1.05; 2 studies; 213 women; low-quality evidence). Exercise probably leads to little or no difference in cancer-specific quality of life (SMD 0.12, 95% CI 0.00 to 0.25; 12 studies; 1012 women; moderate-quality evidence) and little or no difference in depression (SMD -0.15, 95% CI -0.30 to 0.01; 5 studies; 674 women; moderate-quality evidence). Evidence for other outcomes ranged from low to moderate quality. Seven trials reported a very small number of adverse events.

AUTHORS' CONCLUSIONS

Exercise during adjuvant treatment for breast cancer can be regarded as a supportive self care intervention that probably results in less fatigue, improved physical fitness, and little or no difference in cancer-specific quality of life and depression. Exercise may also slightly improve cancer site-specific quality of life and cognitive function, while it may result in little or no difference in health-related quality of life. This review is based on trials with a considerable degree of clinical heterogeneity regarding adjuvant cancer treatments and exercise interventions. Due to the difficulty of blinding exercise trials, all included trials were at high risk for performance bias. Furthermore, the majority of trials were at high risk for detection bias, largely due to most outcomes being self reported.The findings of the updated review have enabled us to make a more precise conclusion that both aerobic and resistance exercise can be regarded as beneficial for individuals with adjuvant therapy-related side effects. Further research is required to determine the optimal type, intensity, and timing of an exercise intervention. Furthermore, long-term evaluation is required due to possible long-term side effects of adjuvant treatment.

Effects of a multicomponent physical activity behavior change intervention on breast cancer survivor health status outcomes in a randomized controlled trial

Little is known about the effects of physical activity behavior change interventions on health outcomes such as lower extremity dysfunction and SF-36 physical health (predictor of mortality) in breast cancer survivors. Furthermore, effect moderators are rarely reported. Therefore, we report the effects of the 3-month BEAT Cancer physical activity behavior change intervention on global health status and health indicators along with moderators of intervention outcomes. Postprimary treatment breast cancer survivors (n = 222) were randomized to BEAT Cancer or usual care (UC). SF-36, muscle strength, body mass index, lower extremity dysfunction (WOMAC), and life satisfaction were measured at 3 months (M3) and 6 months (M6). At M3, adjusted linear mixed-model analyses demonstrated statistically significant effects of BEAT Cancer versus UC on SF-36 physical health [mean between-group difference (M) = 2.1; 95 % confidence interval (CI) 0.3-3.9; p = 0.023], SF-36 mental health (M = 5.2; CI 2.8-7.6; p < 0.001), and all SF-36 subscores. Intervention benefits occurred for lower extremity physical dysfunction (M = -2.7; CI -5.0 to -0.5; p = 0.018), WOMAC total (M = -3.7; CI -6.7 to -0.6; p = 0.018), and life satisfaction (M = 2.4; CI 0.9-3.9; p = 0.001). Statistically significant effects persisted at M6 for mental health and vitality. Baseline value, income, marital status, cancer treatment, cancer stage, and months since diagnosis moderated one or more outcomes. BEAT Cancer improves SF-36, WOMAC, and life satisfaction outcomes with improvements in vitality and mental well-being continuing 3 months postintervention. Several moderators with potential to guide targeting individuals for optimal intervention benefit warrant further study.

Self-reported and automatic cognitions are associated with exercise behavior in cancer survivors

OBJECTIVE

Physical activity is beneficial for cancer survivors, but exercise participation is low in this population. It is therefore important to understand the psychological factors underlying exercise uptake so that more effective interventions can be developed. Social-cognitive theory constructs such as outcome expectancies predict exercise behavior, but self-report measures have several limitations. We examined the associations between implicit (automatic) cognitions and exercise behavior and self-efficacy in endometrial cancer survivors.

METHOD

This was a longitudinal study to examine predictors of exercise behavior in female endometrial cancer survivors who all received an exercise intervention. Participants (N = 100, mean age of 57.0) completed questionnaires to assess self-report exercise-related measures (outcome expectancy and attitudes about and identification with exercise) and reaction time (RT) tasks to assess implicit exercise cognitions (expectancy accessibility, implicit attitudes about exercise, and implicit self-identification with exercise) at baseline and at 2, 4, and 6 months at follow-up. Exercise behavior was measured using accelerometers and self-report. Data were analyzed using linear mixed models.

RESULTS

Expectancy accessibility was associated with exercise duration independent of the corresponding self-report measure. Exercise implicit attitudes and self-identification were prospectively associated with exercise self-efficacy only after adjustment for the corresponding self-report measures and baseline self-efficacy. Self-report measures were also associated with study outcomes.

CONCLUSIONS

Both self-reported cognitions and implicit cognitions may be useful to identify individuals at risk of failing to exercise. Individuals so identified might be provided with a different or more intensive intervention. The data also suggest cognitive targets for intervention. (PsycINFO Database Record

Feasibility and preliminary efficacy of adding behavioral counseling to supervised physical activity in kidney cancer survivors: a randomized controlled trial

BACKGROUND

Supervised physical activity (PA) improves short-term health outcomes in cancer survivors, but longer-term adherence is rarely achieved.

OBJECTIVE

The aim of this study was to evaluate the feasibility and preliminary efficacy of adding behavioral counseling to supervised PA in kidney cancer survivors (KCSs).

METHODS

Thirty-two KCSs were randomized to a 4-week supervised PA program plus standard exercise counseling (SPA + EC group; n = 16) or a 4-week supervised PA plus behavioral counseling based on the Theory of Planned Behavior (SPA + BC group; n = 16). The primary outcome was self-reported PA at 12 weeks. Secondary outcomes were quality of life, anthropometric measures, cardiorespiratory fitness, and physical function.

RESULTS

Follow-up rates for outcomes at 12 weeks were 88% and 94% for fitness testing and questionnaires, respectively. Adherence to the interventions was 94% in both groups with a 6% attrition rate. Analyses of covariance revealed that PA minutes at 12 weeks favored the SPA + BC group by +34 minutes (95% confidence interval, -62 to 129), which was a small effect size (d = 0.21) not reaching statistical significance (P = .47). Moreover, the SPA + BC group increased their 6-minute walk by 48 m more than the SPA + EC group (95% confidence interval, 1-95; d = +0.64; P = .046). There were no significant changes in quality of life measures.

CONCLUSIONS

This pilot study provides preliminary evidence that adding behavioral counseling to supervised PA in KCSs is feasible and may improve PA and fitness in the short-term. Larger and longer-term trials are needed.

IMPLICATIONS FOR PRACTICE

Oncology nurses may consider adopting behavioral counseling strategies in addition to supervised PA to motivate KCSs to maintain PA.

Use of Theory in Behavior Change Interventions

OBJECTIVE

Theory use may enhance effectiveness of behavioral interventions, yet critics question whether theory-based interventions have been sufficiently scrutinized. This study applied a framework to evaluate theory use in physical activity interventions for breast cancer survivors. The aims were to (1) evaluate theory application intensity and (2) assess the association between extensiveness of theory use and intervention effectiveness.

METHODS

Studies were previously identified through a systematic search, including only randomized controlled trials published from 2005 to 2013, that addressed physical activity behavior change and studied survivors who were <5 years posttreatment. Eight theory items from Michie and Prestwich's coding framework were selected to calculate theory intensity scores. Studies were classified into three subgroups based on extensiveness of theory use (Level 1 = sparse; Level 2 = moderate; and Level 3 = extensive).

RESULTS

Fourteen randomized controlled trials met search criteria. Most trials used the transtheoretical model ( n = 5) or social cognitive theory ( n = 3). For extensiveness of theory use, 5 studies were classified as Level 1, 4 as Level 2, and 5 as Level 3. Studies in the extensive group (Level 3) had the largest overall effect size ( g = 0.76). Effects were more modest in Level 1 and 2 groups with overall effect sizes of g = 0.28 and g = 0.36, respectively.

CONCLUSIONS

Theory use is often viewed as essential to behavior change, but theory application varies widely. In this study, there was some evidence to suggest that extensiveness of theory use enhanced intervention effectiveness. However, there is more to learn about how theory can improve interventions for breast cancer survivors.

Effects of exercise intervention in breast cancer survivors: a meta-analysis of 33 randomized controlled trails

Background

Exercise is associated with favorable outcomes in cancer survivors. The purpose of this meta-analysis is to comprehensively summarize the effects of exercise intervention in breast cancer survivors.

Methods

A systematic search of PubMed, Elsevier, and Google scholar was conducted up to March 2015. References from relevant meta-analyses and reviews were also checked.

Results

Thirty-three randomized controlled trials were included in this meta-analysis, including 2,659 breast cancer survivors. Compared with the control group, quality of life was significantly improved in exercise intervention group, especially in mental health and general health subscales of short form 36 questionnaire, as well as emotion well-being and social well-being subscales of the Functional Assessment of Cancer Therapy. Besides, exercise alleviated the symptoms of depression and anxiety in the exercise group. Furthermore, exercise was also associated with positive outcomes in body mass index, lean mass, and muscle strength. In addition, the serum concentration of insulin, insulin-like growth factor-II, and insulin-like growth factor binding protein-1 was significantly reduced in exercise intervention group. However, based on the current data of this meta-analysis, there were no significant differences in sleep dysfunction or fatigue between groups.

Conclusion

Our study suggested that exercise intervention was beneficial to breast cancer survivors. Therefore, exercise should be recommended to this patient group.

Can physical activity help to maintain cognitive functioning and psychosocial well-being among breast cancer patients treated with chemotherapy? A randomised controlled trial: study protocol

BACKGROUND

Evidence suggests chemotherapy treatment for breast cancer is associated with side effects such as cognitive impairment in domains of memory, attention, concentration and executive function. Cognitive impairments reported by patients have been associated with higher levels of emotional distress. To date, intervention studies to alleviate cognitive impairment associated with chemotherapy have focused on psycho-educational techniques or cognitive training. Studies have not yet considered physical activity as a potential for alleviating cognitive problems. Physical activity interventions are reported to be effective in alleviating emotional distress and fatigue in those with breast cancer. They have also been reported to improve cognitive functioning in the elderly, in those suffering with dementia and in children. We propose that physical activity could also help to alleviate cognitive impairments in women diagnosed with breast cancer. The study has been designed using a recently developed taxonomy of behaviour change techniques to reliably report the content of the intervention to allow future replication.

METHOD

This study will deliver a home-based moderate intensity walking intervention to women diagnosed with breast cancer mid-way through their chemotherapy treatment and will compare them to patients receiving usual care alone. The primary outcome measure for this intervention is changes in an objective measure of memory assessed using the Digit Span. Secondary outcome measures include: objective measures of executive function; attention; visual spatial skills; self report cognitive function; self-report fatigue; anxiety; depression; mood and self-esteem. As emotional distress has been associated with self-reporting of cognitive problems, this intervention will further test whether emotional distress mediates between the amount of walking undertaken during the intervention period and levels of self-reported cognitive functioning.

DISCUSSION

The development of an effective intervention for preventing difficulties in emotional and cognitive functioning of cancer patients' post-treatment will help to guide health care professionals to improve patients' overall quality of life. It will also provide direction for future research, ultimately to improve the day to day functioning of breast cancer survivors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50709297.

Is Quality of Life Related to Cardiorespiratory Fitness in Overweight and Obese Breast Cancer Survivors?

This study assessed changes in quality of life (QoL) and cardiorespiratory fitness (CRF) during a diet and physical activity (PA) intervention in breast cancer (BC) survivors and investigated the relation between these changes. The intervention of this single-arm pre-post study involved supervised, 1-hour weekly, diet sessions and 75-minute bi-weekly PA sessions of moderate-to-high intensity. This 12-week intervention targeted overweight/obese women who had recently completed BC treatment. Pre- and post-CRF and QoL measurements were compared using paired t-tests. Linear regression models, including baseline participants' characteristics and weight change, were used to assess the association between changes in CRF and QoL. The 37 BC survivors who completed the intervention between May 7, 2012 and July 27, 2012 showed significant increases in CRF and QoL. Peak oxygen uptake (mL/kg/min) increased from 19.0 ± 2.8 to 24.0 ± 4.1 while peak workload (watts/kg) increased from 1.3 ± 0.3 to 1.7 ± 0.3. Although statistical significance was not reached, the increase in workload seemed associated with increases in physical, mental, and general health and with a decrease in fatigue. This lifestyle intervention improved BC survivors' QoL and CRF and suggested possible relationships between CRF and QoL. More research needs to confirm these associations and promote lifestyle interventions aiming at improving BC survivors' QoL.

Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors

Research has shown that recent post-treatment breast cancer survivors face significant challenges around physical activity as they transition to recovery. This review examined randomized controlled trials targeting physical activity behavior change in breast cancer survivors <5 years post-treatment and described (1) characteristics of interventions for breast cancer survivors as well as (2) effect size estimates for these studies. A systematic search was conducted following PRISMA guidelines with Medline, PubMed, PsycINFO, CINAHL, and Scopus databases. Data were abstracted for primary intervention strategies and other details (e.g., setting, duration, theory use). A subgroup analysis was conducted to assess intensity of exercise supervision/monitoring and intervention effectiveness. The search produced 14 unique behavior intervention trials from the US and abroad published 2005-2013. The mean sample size was 153 participants per study. All interventions included moderate-intensity activities plus various behavioral change strategies. Most interventions were partially or entirely home based. The overall standardized mean difference was 0.47 (0.23, 0.67) with p < 0.001. Most interventions were effective in producing short-term behavior changes in physical activity, but varied greatly relative to intervention strategies and intensity of supervision/monitoring. Highly structured interventions tended to produce larger behavior change effects overall, but many larger effect sizes came from interventions supported by phone counseling or e-mail. We observed that 'more' may not be better in terms of direct supervision/monitoring in physical activity behavior interventions. This may be important in exploring less resource-intensive options for effective behavior change strategies for recent post-treatment survivors.

Effects of the BEAT Cancer physical activity behavior change intervention on physical activity, aerobic fitness, and quality of life in breast cancer survivors: a multicenter randomized controlled trial

Most breast cancer survivors (BCS) are not meeting recommended physical activity guidelines. Here, we report the effects of the Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) behavior change intervention on physical activity, aerobic fitness, and quality of life (QoL). We randomized 222 post-primary treatment BCS to the 3-month intervention (BEAT Cancer) or usual care (UC). BEAT Cancer combined supervised exercise, face-to-face counseling, and group discussions with tapering to home-based exercise. Assessments at baseline, immediately post-intervention (month 3; M3), and 3 months post-intervention (month 6; M6) included accelerometer and self-reported physical activity, submaximal treadmill test, and QoL [Functional Assessment of Cancer Therapy (FACT)-Breast scale]. Adjusted linear mixed-model analyses demonstrated significant effects of BEAT Cancer compared to UC on weekly minutes of ≥ moderate intensity physical activity at M3 by accelerometer [mean between group difference (M) = +41; 95 % confidence interval (CI) = 10-73; p = 0.010] and self-report (M = +93; CI = 62-123; p < 0.001). Statistical significance remained at M6 for self-reported physical activity (M = +74; CI = 43-105; p < 0.001). BEAT Cancer participants were significantly more likely to meet physical activity recommendations at both time points [accelerometer M3 adjusted odds ratio (OR) = 2.2; CI = 1.0-4.8 and M6 adjusted OR = 2.4; CI = 1.1-5.3; self-report M3 adjusted OR = 5.2; CI = 2.6-10.4 and M6 adjusted OR = 4.8; CI = 2.3-10.0]. BEAT Cancer significantly improved fitness at M6 (M = +1.8 ml/kg/min; CI = 0.8-2.8; p = 0.001) and QoL at M3 and M6 (M = +6.4; CI = 3.1-9.7; p < 0.001 and M = +3.8; CI = 0.5-7.2; p = 0.025, respectively). The BEAT Cancer intervention significantly improved physical activity, fitness, and QoL with benefits continuing 3 months post-intervention.

A clinical study to assess the efficacy of belly dancing as a tool for rehabilitation in female patients with malignancies

PURPOSE

This prospective, non-randomised follow-up study was designed to compare the health-related quality of life (HRQoL), perceived social support (PSS) and overall life satisfaction (OLS) in female patients receiving standard medical care for malignant diseases with or without additional belly dancing.

METHOD

The patients were recruited in the Outpatient Department of the National Institute of Oncology, Budapest, Hungary during the period of 2008-2009. 55 patients joined the one-year-long rehabilitation program (research group, RG) while 59 age-matched patients who received only standard medical care volunteered for clinical assessment (control group, CG). HRQoL, PSS and OLS were assessed using validated questionnaires: EORTC QLQ-C30, F-SozU-K14, and Campbell's OLS, respectively. The scores obtained in RG and CG were controlled for baseline socio-demographic characteristics and evaluated by ANCOVA analysis.

RESULTS

It was found that patients of the RG scored better at both the baseline and follow-up than the CG, and the differences between the two groups' measured parameters increased further during the course of the study. The respective baseline values in RG and CG were 56.6 ± 10.3 vs 63.5 ± 12 for HRQoL, 65.2 ± 5.5 vs 57.4 ± 8.8 for PSS and 57.4 ± 8.1 vs 48.4 ± 10.7 for OLS. The corresponding follow-up scores were 51.9 ± 4.4 vs 59.9 ± 11.2 (F = 10.637, p = 0.001) for HRQoL, 67.5 ± 2.7 vs 53.9 ± 10.5 (F = 2.646, p = 0.000) for PSS and 59.5 ± 9.6 vs 45.0 ± 11.5 (F = 2.402, p = 0.001) for OLS.

CONCLUSIONS

Belly dance intervention can be applied as a complementary rehabilitation method to improve HRQoL, PSS and OLS in female patients treated for malignant diseases.

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.

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.

Effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in breast cancer patients

The aim of this study was to explore the effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in patients who completed breast cancer treatment. Sixty breast cancer patients were randomised into three groups, as supervised exercise group, home exercise group and education group. Angiogenesis and apoptosis-related cytokine levels and quality of life (EORTC QOL-C30: European Organisation for Research and Treatment of Cancer Quality of Life C30), fatigue (Brief Fatigue Inventory) and depression (BDI: Beck Depression Inventory) scores were compared before and after a 12-week exercise programme. After the exercise programme, statistically significant decreases were found in interleukin-8 and neutrophil activating protein-78 levels in the home exercise group (P < 0.05). The education group showed a statistically significant increase in monocyte chemoattractant protein-1 level (P < 0.05). Functional score and global health score of EORTC QOL-C30 in the supervised exercise group and functional score of EORTC QOL-C30 in the home exercise group increased significantly after exercise programme (P < 0.05). BDI score was significantly lower in the supervised exercise group after the exercise programme (P < 0.05). Changes in angiogenesis and apoptosis-related molecules in the study groups suggest a possible effect of exercise on these parameters. Exercise programmes are safe and effective on quality of life and depression in breast cancer patients whose treatments are complete.

The efficacy of psychosocial intervention for pain in breast cancer patients and survivors: a systematic review and meta-analysis

Persistent pain after breast cancer treatment is prevalent, and not all patients respond sufficiently to pharmacological treatment. Pain is recognized as a multi-dimensional phenomenon, which includes psychological and social components, and several clinical trials have investigated the efficacy of psychosocial interventions on pain in cancer patients and survivors. Our aim was to systematically review and quantify the existing research on the effect of psychosocial interventions on pain in breast cancer patients and survivors. Two independent raters reviewed 474 abstracts for eligibility, leading to the identification of 26 independent and eligible studies published between 1983 and 2012, which were assessed for their methodological quality and subjected to meta-analytic evaluation. A total of 1786 participants were included in the analyses. A statistically significant and robust overall effect size was found across all included studies (Hedges g = 0.37, 95 % CI: 0.20-0.40; p < 0.001). However, the effect size was considerably smaller (0.21), when adjusted for possible publication bias. Furthermore, the results were heterogeneous, and when exploring the sources of heterogeneity, studies of higher methodological quality were found to yield a more conservative effect size (g = 0.21, 95 % CI: 0.02-0.41) than studies of poorer quality (g = 0.65, 95 % CI: 0.25-1.04). The results also indicated that patient educational approaches yielded a larger effect size (g = 0.64) than relaxation-based interventions (g = 0.31, 95 % CI: -0.05-0.67) and supportive group therapy (g = 0.17, 95 % CI: 0.02-0.32). Taken together, while suggestive of psychosocial intervention as an effective tool in the management of pain among breast cancer patients and survivors, the results should be interpreted as preliminary. The methodological quality of the existing research varied considerably, and only few studies had selected patients on the basis of the presence of pain and included pain as the primary outcome.

Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior

Although pain is common among post-treatment breast cancer survivors, studies that are longitudinal, identify a case definition of clinically meaningful pain, or examine factors contributing to pain in survivors are limited. This study describes longitudinal patterns of pain in long-term breast cancer survivors, evaluating associations of body mass index (BMI), physical activity, sedentary behavior with mean pain severity and above-average pain. Women newly diagnosed with stages 0-IIIA breast cancer (N = 1183) were assessed, on average, 6 months (demographic/clinical characteristics), 30 months (demographics), 40 months (demographics, pain), 5 years (BMI, physical activity, and sedentary behavior), and 10 years (demographics, pain, BMI, physical activity, and sedentary behavior) post-diagnosis. This analysis includes survivors who completed pain assessments 40 months post-diagnosis (N = 801), 10 years post-diagnosis (N = 563), or both (N = 522). Above-average pain was defined by SF-36 bodily pain scores ≥1/2 standard deviation worse than age-specific population norms. We used multiple regression models to test unique associations of BMI, physical activity, and sedentary behavior with pain adjusting for demographic and clinical factors. The proportion of survivors reporting above-average pain was higher at 10 years than at 40 months (32.3 vs. 27.8 %, p < 0.05). Approximately one-quarter of survivors reported improved pain, while 9.0 % maintained above-average pain and 33.1 % reported worsened pain. Cross-sectionally at 10 years, overweight and obese survivors reported higher pain than normal-weight survivors and women meeting physical activity guidelines were less likely to report above-average pain than survivors not meeting these guidelines (p < 0.05). Longitudinally, weight gain (>5 %) was positively associated, while meeting physical activity guidelines was inversely associated, with above-average pain (OR, 95 % CI = 1.76, 1.03-3.01 and 0.40, 0.20-0.84, respectively) (p < 0.05). Weight gain and lack of physical activity place breast cancer survivors at risk for pain long after treatment ends. Weight control and exercise interventions should be tested for effects on long-term pain in these women.

Pain, movement, and mind: does physical activity mediate the relationship between pain and mental health among survivors of breast cancer?

OBJECTIVES

This study examined the relationship between pain and mental health outcomes of depression and affect among survivors of breast cancer. The mediating role of physical activity was also tested.

METHODS

Survivors of breast cancer (N=145) completed self-report measures of pain symptoms at baseline, wore an accelerometer for 7 days, and reported levels of depression symptoms and negative and positive affect 3 months later. Hierarchical linear regression analyses, controlling for personal and cancer-related demographics, were used to test the association between pain symptoms and each mental health outcome, as well as the mediation effect of physical activity.

RESULTS

Pain positively predicted depression symptoms [F(6,139)=4.31, P<0.01, R=0.15] and negative affect [F(5,140)=4.17, P<0.01, R=0.13], and negatively predicted positive affect [F(6,139)=2.12, P=0.03, R=0.08]. Physical activity was a significant (P<0.01) partial mediator of the relationship between pain and depression and between pain and positive affect.

DISCUSSION

Participation in physical activity is one pathway through which pain influences mental health. Efforts are needed to help survivors of breast cancer manage pain symptoms and increase their level of physical activity to help improve mental health.

Exercise interventions on health-related quality of life for cancer survivors

BACKGROUND

Cancer survivors experience numerous disease and treatment-related adverse outcomes and poorer health-related quality of life (HRQoL). Exercise interventions are hypothesized to alleviate these adverse outcomes. HRQoL and its domains are important measures for cancer survivorship.

OBJECTIVES

To evaluate the effectiveness of exercise on overall HRQoL and HRQoL domains among adult post-treatment cancer survivors.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, PEDRO, LILACS, SIGLE, SportDiscus, OTSeeker, and Sociological Abstracts from inception to October 2011 with no language or date restrictions. We also searched citations through Web of Science and Scopus, PubMed's related article feature, and several websites. We reviewed reference lists of included trials and other reviews in the field.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing exercise interventions with usual care or other nonexercise intervention to assess overall HRQoL or at least one HRQoL domain in adults. Included trials tested exercise interventions that were initiated after completion of active cancer treatment. We excluded trials including people who were terminally ill, or receiving hospice care, or both, and where the majority of trial participants were undergoing active treatment for either the primary or recurrent cancer.

DATA COLLECTION AND ANALYSIS

Five paired review authors independently extracted information on characteristics of included trials, data on effects of the intervention, and assessed risk of bias based on predefined criteria. Where possible, meta-analyses results were performed for HRQoL and HRQoL domains for the reported difference between baseline values and follow-up values using standardized mean differences (SMD) and a random-effects model by length of follow-up. We also reported the SMDs between mean follow-up values of exercise and control group. Because investigators used many different HRQoL and HRQoL domain instruments and often more than one for the same domain, we selected the more commonly used instrument to include in the SMD meta-analyses. We also report the mean difference for each type of instrument separately.

MAIN RESULTS

We included 40 trials with 3694 participants randomized to an exercise (n = 1927) or comparison (n = 1764) group. Cancer diagnoses in study participants included breast, colorectal, head and neck, lymphoma, and other. Thirty trials were conducted among participants who had completed active treatment for their primary or recurrent cancer and 10 trials included participants both during and post cancer treatment. Mode of the exercise intervention included strength training, resistance training, walking, cycling, yoga, Qigong, or Tai Chi. HRQoL and its domains were measured using a wide range of measures.The results suggested that exercise compared with control has a positive impact on HRQoL and certain HRQoL domains. Exercise resulted in improvement in: global HRQoL at 12 weeks' (SMD 0.48; 95% confidence interval (CI) 0.16 to 0.81) and 6 months' (0.46; 95% CI 0.09 to 0.84) follow-up, breast cancer concerns between 12 weeks' and 6 months' follow-up (SMD 0.99; 95% CI 0.41 to 1.57), body image/self-esteem when assessed using the Rosenberg Self-Esteem scale at 12 weeks (MD 4.50; 95% CI 3.40 to 5.60) and between 12 weeks' and 6 months' (mean difference (MD) 2.70; 95% CI 0.73 to 4.67) follow-up, emotional well-being at 12 weeks' follow-up (SMD 0.33; 95% CI 0.05 to 0.61), sexuality at 6 months' follow-up (SMD 0.40; 95% CI 0.11 to 0.68), sleep disturbance when comparing follow-up values by comparison group at 12 weeks' follow-up (SMD -0.46; 95% CI -0.72 to -0.20), and social functioning at 12 weeks' (SMD 0.45; 95% CI 0.02 to 0.87) and 6 months' (SMD 0.49; 95% CI 0.11 to 0.87) follow-up. Further, exercise interventions resulted in decreased anxiety at 12 weeks' follow-up (SMD -0.26; 95% CI -0.07 to -0.44), fatigue at 12 weeks' (SMD -0.82; 95% CI -1.50 to -0.14) and between 12 weeks' and 6 months' (SMD -0.42; 95% CI -0.02 to -0.83) follow-up, and pain at 12 weeks' follow-up (SMD -0.29; 95% CI -0.55 to -0.04) when comparing follow-up values by comparison group.Positive trends and impact of exercise intervention existed for depression and body image (when analyzing combined instruments); however, because few studies measured these outcomes the robustness of findings is uncertain.No conclusions can be drawn regarding the effects of exercise interventions on HRQoL domains of cognitive function, physical functioning, general health perspective, role function, and spirituality.Results of the review need to be interpreted cautiously owing to the risk of bias. All the trials reviewed were at high risk for performance bias. In addition, the majority of trials were at high risk for detection, attrition, and selection bias.

AUTHORS' CONCLUSIONS

This systematic review indicates that exercise may have beneficial effects on HRQoL and certain HRQoL domains including cancer-specific concerns (e.g. breast cancer), body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain at varying follow-up periods. The positive results must be interpreted cautiously due to the heterogeneity of exercise programs tested and measures used to assess HRQoL and HRQoL domains, and the risk of bias in many trials. Further research is required to investigate how to sustain positive effects of exercise over time and to determine essential attributes of exercise (mode, intensity, frequency, duration, timing) by cancer type and cancer treatment for optimal effects on HRQoL and its domains.

Promoting physical activity in patients with colon adenomas: a randomized pilot intervention trial

BACKGROUND

Physical activity decreases risk of colon polyps and colon cancer and might reduce risk of colon cancer recurrence. Focusing on recent calls for translation of epidemiologic evidence into clinical care, our pilot study delivered an evidence-based physical activity intervention in adults with polyps, who are thus at elevated risk of developing colon cancer. The objective was to evaluate change in physical activity, measured by steps per day and minutes of moderate/vigorous physical activity.

METHODS

Sixteen adults with adenomas detected and removed at screening colonoscopy were recruited to a 12-week physical activity intervention. Participants were randomized to receive a standard (30 minutes/day) or high (60 minutes/day) walking program. Physical activity was measured via blinded pedometer and accelerometer at baseline and follow-up. Intervention messages focused on self-monitoring using pedometers and overcoming barriers to engaging in physical activity.

RESULTS

Participants in both arms significantly increased objectively measured minutes of moderate/vigorous physical activity over the course of the intervention. Both arms exceeded the intervention goal, but there was not a significant difference between arms at follow-up. Results were similar for pedometer measured physical activity, with a significant overall increase in steps/day from baseline to follow-up, but no between arm difference in change.

CONCLUSION

Simple interventions of minimal contact time focusing on walking can significantly increase physical activity in individuals at increased risk of developing colon cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01476631.

Fatigability in osteoarthritis: effects of an activity bout on subsequent symptoms and activity

BACKGROUND

Older adults with osteoarthritis (OA) are more likely to experience increased fatigue following bouts of physical activity than those without OA. The highly "fatigable" nature of this population is problematic as it has been linked to OA severity and decreased function. This study examined the effects of engaging in standardized lab-based physical tasks on subsequent fatigue, pain, and activity in older adults with OA.

METHODS

Thirty-five older adults with OA performed lab-based tasks (sweeping, grocery shopping, and walking) in 15-minute circuits until they felt too fatigued to continue. Fatigue and pain were self-reported (0-10 scale) following each circuit and at set intervals during a 4-day baseline (pretask) and a 5-day posttask home period. Activity was tracked via wrist-worn accelerometer. Multilevel modeling was used to examine levels and patterns of fatigue, pain, and activity across the study period.

RESULTS

The lab-based tasks altered subsequent levels and patterns of fatigue and activity but had no effects on pain. Compared with baseline, on the day of the lab-based tasks, fatigue was higher and more stable, and activity was significantly lower and dropped steadily toward evening. Activity returned to baseline levels and patterns by the day following the lab-based tasks while fatigue was lower for 3 days following task performance.

CONCLUSIONS

Among older adults with OA, a bout of standardized physical activity resulted in increased fatigue and reduced activity, but effects were short-lived. Future studies will need to identify factors that differentiate people who are particularly fatigable in order to target interventions.

Passion in breast cancer survivors: examining links to emotional well-being

This study (1) identified the activities that breast cancer survivors report as passionate; (2) examined whether levels of passion differed based on the types of passionate activities reported and; (3) examined the association between harmonious and obsessive passion and emotional well-being. Early post-treatment breast cancer survivors (N = 177) reported passionate physical activities as most prevalent, and reported higher harmonious passion scores compared to women reporting relaxing and social leisure activities. Harmonious passion was associated with higher positive affect and lower cancer worry. Obsessive passion was linked to higher negative affect, cancer worry, and posttraumatic growth. Passion is important for enhanced well-being.

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

OBJECTIVE

To systematically evaluate the effects of physical activity in adult patients after completion of main treatment related to cancer.

DESIGN

Meta-analysis of randomised controlled trials with data extraction and quality assessment performed independently by two researchers.

DATA SOURCES

Pubmed, CINAHL, and Google Scholar from the earliest possible year to September 2011. References from meta-analyses and reviews.

STUDY SELECTION

Randomised controlled trials that assessed the effects of physical activity in adults who had completed their main cancer treatment, except hormonal treatment.

RESULTS

There were 34 randomised controlled trials, of which 22 (65%) focused on patients with breast cancer, and 48 outcomes in our meta-analysis. Twenty two studies assessed aerobic exercise, and four also included resistance or strength training. The median duration of physical activity was 13 weeks (range 3-60 weeks). Most control groups were considered sedentary or were assigned no exercise. Based on studies on patients with breast cancer, physical activity was associated with improvements in insulin-like growth factor-I, bench press, leg press, fatigue, depression, and quality of life. When we combined studies on different types of cancer, we found significant improvements in body mass index (BMI), body weight, peak oxygen consumption, peak power output, distance walked in six minutes, right handgrip strength, and quality of life. Sources of study heterogeneity included age, study quality, study size, and type and duration of physical activity. Publication bias did not alter our conclusions.

CONCLUSIONS

Physical activity has positive effects on physiology, body composition, physical functions, psychological outcomes, and quality of life in patients after treatment for breast cancer. When patients with cancer other than breast cancer were also included, physical activity was associated with reduced BMI and body weight, increased peak oxygen consumption and peak power output, and improved quality of life.

Survivorship services for adult cancer populations: a pan-Canadian guideline

OBJECTIVE

Our goal was to develop evidence-based recommendations for the organization and structure of cancer survivorship services, and best-care practices to optimize the health and well-being of post-primary treatment survivors. This review sought to determine the optimal organization and care delivery structure for cancer survivorship services, and the specific clinical practices and interventions that would improve or maximize the psychosocial health and overall well-being of adult cancer survivors.

DATA SOURCES

We conducted a systematic search of the Inventory of Cancer Guidelines at the Canadian Partnership Against Cancer, the U.S. National Guideline Clearinghouse, the Canadian Medical Association InfoBase, medline (ovid: 1999 through November 2009), embase (ovid: 1999 through November 2009), Psychinfo (ovid: 1999 through November 2009), the Cochrane Library (ovid; Issue 1, 2009), and cinahl (ebsco: 1999 through December 2009). Reference lists of related papers and recent review articles were scanned for additional citations.

METHODS

Articles were selected for inclusion as evidence in the systematic review if they reported on organizational system components for survivors of cancer, or on psychosocial or supportive care interventions HOWELL et al. designed for survivors of cancer. Articles were excluded from the systematic review if they focused only on pediatric cancer survivor populations or on populations that transitioned from pediatric cancer to adult services; if they addressed only pharmacologic interventions or diagnostic testing and follow-up of cancer survivors; if they were systematic reviews with inadequately described methods; if they were qualitative or descriptive studies; and if they were opinion papers, letters, or editorials.

DATA EXTRACTION AND SYNTHESIS

Evidence was selected and reviewed by three members of the Cancer Journey Survivorship Expert Panel (SM, TC, TKO). The resulting summary of the evidence was guided further and reviewed by the members of Cancer Journey Survivorship Expert Panel. Fourteen practice guidelines, eight systematic reviews, and sixty-thee randomized controlled trials form the evidence base for this guidance document. These publications demonstrate that survivors benefit from coordinated post-treatment care, including interventions to address specific psychosocial, supportive care, and rehabilitative concerns.

CONCLUSIONS

Ongoing high-quality research is essential to optimize services for cancer survivors. Interventions that promote healthy lifestyle behaviours or that address psychosocial concerns and distress appear to improve physical functioning, psychosocial well-being, and quality of life for survivors.

Better exercise adherence after treatment for cancer (BEAT Cancer) study: rationale, design, and methods

Most breast cancer survivors do not engage in regular physical activity. Our physical activity behavior change intervention for breast cancer survivors significantly improved physical activity and health outcomes post-intervention during a pilot, feasibility study. Testing in additional sites with a larger sample and longer follow-up is warranted to confirm program effectiveness short and longer term. Importantly, the pilot intervention resulted in changes in physical activity and social cognitive theory constructs, enhancing our potential for testing mechanisms mediating physical activity behavior change. Here, we report the rationale, design, and methods for a two-site, randomized controlled trial comparing the effects of the BEAT Cancer physical activity behavior change intervention to usual care on short and longer term physical activity adherence among breast cancer survivors. Secondary aims include examining social cognitive theory mechanisms of physical activity behavior change and health benefits of the intervention. Study recruitment goal is 256 breast cancer survivors with a history of ductal carcinoma in situ or Stage I, II, or IIIA disease who have completed primary cancer treatment. Outcome measures are obtained at baseline, 3 months (i.e., immediately post-intervention), 6 months, and 12 months and include physical activity, psychosocial factors, fatigue, sleep quality, lower extremity joint dysfunction, cardiorespiratory fitness, muscle strength, and waist-to-hip ratio. Confirming behavior change effectiveness, health effects, and underlying mechanisms of physical activity behavior change interventions will facilitate translation to community settings for improving the health and well-being of breast cancer survivors.

Randomized pilot test of a simultaneous stage-matched exercise and diet intervention for breast cancer survivors

PURPOSE/OBJECTIVES

To investigate the feasibility and preliminary effects of a simultaneous stage-matched exercise and diet (SSED) intervention in breast cancer survivors.

DESIGN

Randomized, controlled trial.

SETTING

Oncology outpatient treatment clinics at the National Cancer Center in South Korea.

SAMPLE

45 women with breast cancer who completed their cancer therapy.

METHODS

Participants were assigned to the SSED intervention group (n = 23) or a control group (n = 22). Participants in the SSED group received a 12-week individualized intervention promoting prescribed exercise and a balanced diet through stage-matched telephone counseling and a workbook.

MAIN RESEARCH VARIABLES

Program feasibility, behavioral outcomes (stage of motivational readiness for exercise and diet, physical activity, and diet quality), and quality-of-life (QOL) outcomes (functioning and global QOL, fatigue, anxiety, and depression).

FINDINGS

Participant evaluations of the SSED intervention indicated that it was feasible and acceptable. All women felt that the overall intervention contents were appropriate, and 95% believed that the intervention helped to promote healthy behaviors. Objective data also supported the SSED intervention's feasibility (i.e., 91% completed the trial and 100% of intervention calls were received). When compared to control, the SSED intervention group showed significantly greater improvement in motivational readiness for exercise and diet, emotional functioning, fatigue, and depression.

CONCLUSIONS

Preliminary results suggest that the SSED intervention delivered via telephone counseling and workbook is feasible and beneficial for positive behavioral and QOL outcomes.

IMPLICATIONS FOR NURSING

Nurse-led lifestyle interventions may improve QOL for cancer survivors.

Exercise interventions for cancer survivors: a meta-analysis of quality of life outcomes

BACKGROUND

Exercise improves quality of life (QOL) in cancer survivors, although characteristics of efficacious exercise interventions for this population have not been identified.

PURPOSE

The present meta-analysis examines the efficacy of exercise interventions in improving QOL in cancer survivors, as well as features that may moderate such effects.

METHOD

Studies were identified and coded, and QOL effect sizes were calculated and analyzed for trends.

RESULTS

Overall, exercise interventions increased QOL, but this tendency depended to some extent on exercise and patient features. Although several features were associated with effect sizes, models revealed that interventions were particularly successful if they targeted more intense aerobic exercise and addressed women. These tendencies emerged over longer periods of time and were more prominent in studies with higher methodological quality.

CONCLUSION

Appropriately designed exercise interventions enhance QOL for cancer survivors and this pattern is especially evident for women. Limitations are discussed.

Quality-of-life measurement in randomized clinical trials in breast cancer: an updated systematic review (2001-2009)

BACKGROUND

Quality-of-life (QOL) measurement is often incorporated into randomized clinical trials in breast cancer. The objectives of this systematic review were to assess the incremental effect of QOL measurement in addition to traditional endpoints (such as disease-free survival or toxic effects) on clinical decision making and to describe the extent of QOL reporting in randomized clinical trials of breast cancer.

METHODS

We conducted a search of MEDLINE for English-language articles published between May-June 2001 and October 2009 that reported: 1) a randomized clinical trial of breast cancer treatment (excluding prevention trials), including surgery, chemotherapy, hormone therapy, symptom control, follow-up, and psychosocial intervention; 2) the use of a patient self-report measure that examined general QOL, cancer-specific or breast cancer-specific QOL or psychosocial variables; and 3) documentation of QOL outcomes. All selected trials were evaluated by two reviewers, and data were extracted using a standardized form for each variable. Data are presented in descriptive table formats.

RESULTS

A total of 190 randomized clinical trials were included in this review. The two most commonly used questionnaires were the European Organization for Research and Treatment of Cancer QOL Questionnaire and the Functional Assessment of Cancer Therapy/Functional Assessment of Chronic Illness Therapy. More than 80% of the included trials reported the name(s) of the instrument(s), trial and QOL sample sizes, the timing of QOL assessment, and the statistical method. Statistical power for QOL was reported in 19.4% of the biomedical intervention trials and in 29.9% of the nonbiomedical intervention trials. The percentage of trials in which QOL findings influenced clinical decision making increased from 15.2% in the previous review to 30.1% in this updated review for trials of biomedical interventions but decreased from 95.0% to 63.2% for trials of nonbiomedical interventions. Discordance between reviewers ranged from 1.1% for description of the statistical method (yes vs no) to 19.9% for the sample size for QOL.

CONCLUSION

Reporting of QOL methodology could be improved.

Exercise Intervention for Cancer Survivors with Heart Failure: Two Case Reports

RATIONALE: Cardiotoxicity is a troubling long-term side effect of chemotherapy cancer treatment, affecting therapy and quality of life (QOL). Exercise is beneficial in heart failure (HF) patients and in cancer survivors without HF, but has not been tested in cancer survivors with treatment induced HF. METHODS: We present case studies for two survivors: a 56-year old female Hodgkin's lymphoma survivor (Pt 1) and a 44-year old male leukemia survivor (Pt 2). We conducted a 16-week exercise program with the goal of 30 minutes of exercise performed 3 times per week at a minimum intensity of 50% heart rate reserve (HRR) or '12' rating of perceived exertion (RPE). RESULTS: Pt 1 improved from 11.5 minutes of exercise split over two bouts at an RPE of 14 to a 30 minute bout at an RPE of 15. Pt 2 improved from 11 minutes of exercise split over two bouts at an RPE of 12 to an 18 minute bout at an RPE of 12. Both improved in VO(2) peak (Pt 1: 13.9 to 14.3 mlO(2)/kg/min; Pt 2: 12.5 to 18.7 mlO(2)/kg/min). Ejection fraction increased for Pt 2 (25-30% to 35-40%) but not for Pt 1 (35-40%). QOL as assessed by the SF-36 Physical Component Scale (PCS) improved from 17.79 to 25.31 for Pt 1 and the Mental Component Scale (MCS) improved from 43.84 to 56.65 for Pt 1 and from 34.79 to 44.45 for Pt 2. CONCLUSIONS: Properly designed exercise interventions can improve physical functioning and quality of life for this growing group of survivors.

Accelerometry and self-report in sedentary populations

OBJECTIVES

To determine whether self-reported exercise duration and intensity matched accelerometer data in sedentary endometrial cancer survivors and age-matched controls.

METHODS

Participants were asked to wear an accelerometer and self-report exercise bouts, duration, and intensity for one week. Self-reported duration was compared with accelerometer data.

RESULTS

Self-reported exercise-bout duration matched accelerometer duration 93% for survivors and 99% for controls. Self-reported exercise-bout intensity matched accelerometer intensity 70% for survivors and 66% for controls. There were no significant differences between groups.

CONCLUSIONS

Sedentary endometrial cancer survivors and controls self-reported duration and intensity of physical activity consistent with accelerometer data.

Design of the Steps to Health Study of Physical Activity in Survivors of Endometrial Cancer: Testing a Social Cognitive Theory Model

Physical activity has been shown to benefit cancer survivors' physical functioning, emotional well-being, and symptoms. Physical activity may be of particular benefit to survivors of endometrial cancer because they are more likely to be obese and sedentary than the general population, as these are risk factors for the disease, and thus experience a number of related co-morbid health problems. However, there is little research systematically studying mechanisms of physical activity adherence in cancer survivor populations. This paper describes the design of the Steps to Health study, which applies a Social Cognitive Theory-based model of endometrial cancer survivors' adoption and maintenance of exercise in the context of an intervention to increase walking or other moderate intensity cardiovascular activity. In Steps to Health we will test the influence of self-efficacy and outcome expectations on adherence to exercise recommendations, as well as studying the determinants of self-efficacy. Endometrial cancer survivors who are at least 6 months post-treatment are provided with an intervention involving print materials and telephone counseling, and complete assessments of fitness, activity, self-efficacy and outcome expectations, and determinants of self-efficacy every two months for a six month period. In addition to testing an innovative model, the Steps to Health study employs multiple assessment methods, including ecological momentary assessment, implicit tests of cognitive variables, and ambulatory monitoring of physical activity. The study results can be used to develop more effective interventions for increasing physical activity in sedentary cancer survivors by taking into account the full complement of sources of self-efficacy information and outcome expectations.

Physical activity motivation and cancer survivorship

Physical activity (PA) participation has been shown to be helpful in improving physical and mental well-being among cancer survivors. The purpose of this chapter is to review the literature on the determinants of physical activity motivation and behavior among cancer survivors. Using theories of behavior change, researchers have sought to identify the correlates of motivation that predict the participation in regular physical activity in observational studies, while intervention studies have focused on manipulating those factors to support the initiation of physical activity. The majority of this work has been conducted with breast cancer survivors, and there is an interest in expanding this work to survivors of others cancers (e.g., prostate, lung, and colorectal cancer). Results suggest that constructs from the Theory of Planned Behavior (TPB), Transtheoretical Model (TTM), and Social Cognitive Theory (SCT) are associated with greater motivation for physical activity, and some of these constructs have been used in interventions to promote physical activity adoption. There is scope for understanding the determinants of physical activity adoption in various cancer survivor populations. Much more needs to done to identify the determinants of maintenance of physical activity.

Exercise interventions for cancer survivors: a meta-analysis of quality of life outcomes

BACKGROUND

Exercise improves quality of life (QOL) in cancer survivors, although characteristics of efficacious exercise interventions for this population have not been identified.

PURPOSE

The present meta-analysis examines the efficacy of exercise interventions in improving QOL in cancer survivors, as well as features that may moderate such effects.

METHOD

Studies were identified and coded, and QOL effect sizes were calculated and analyzed for trends.

RESULTS

Overall, exercise interventions increased QOL, but this tendency depended to some extent on exercise and patient features. Although several features were associated with effect sizes, models revealed that interventions were particularly successful if they targeted more intense aerobic exercise and addressed women. These tendencies emerged over longer periods of time and were more prominent in studies with higher methodological quality.

CONCLUSION

Appropriately designed exercise interventions enhance QOL for cancer survivors and this pattern is especially evident for women. Limitations are discussed.

American College of Sports Medicine roundtable on exercise guidelines for cancer survivors

Early detection and improved treatments for cancer have resulted in roughly 12 million survivors alive in the United States today. This growing population faces unique challenges from their disease and treatments, including risk for recurrent cancer, other chronic diseases, and persistent adverse effects on physical functioning and quality of life. Historically, clinicians advised cancer patients to rest and to avoid activity; however, emerging research on exercise has challenged this recommendation. To this end, a roundtable was convened by American College of Sports Medicine to distill the literature on the safety and efficacy of exercise training during and after adjuvant cancer therapy and to provide guidelines. The roundtable concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups. Implications for disease outcomes and survival are still unknown. Nevertheless, the benefits to physical functioning and quality of life are sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans, with specific exercise programming adaptations based on disease and treatment-related adverse effects. The advice to "avoid inactivity," even in cancer patients with existing disease or undergoing difficult treatments, is likely helpful.

Risks and benefits of physical activity among breast cancer survivors who have completed treatment

Worldwide, over 1 million cases of breast cancer are diagnosed each year. In the USA, approximately 185,000 women are newly diagnosed annually. Nearly 90% of newly diagnosed cancer patients in the USA will live for 5 years beyond diagnosis and there are estimated to be 2.4 million breast cancer survivors currently living in the USA. There are unique challenges in meeting the medical needs of these survivors. Persistent impairment and increased medical risks can occur as a result of treatment, including changes to the cardiovascular, pulmonary, endocrine, immune, musculoskeletal, neurological and lymphatic systems. Physical activity can cause positive changes in each of these body systems. However, physiologic impairments and altered risks for cardiopulmonary, bone health, neurosensory and other outcomes among breast cancer survivors can cause confusion regarding the safety of returning to exercise after treatment. In this article, we review the adverse effects of cancer treatments on the body systems affected by and used to perform exercise, the risks of exercise among breast cancer survivors, the effects of exercise on persistent treatment toxicities, whether exercise may prevent recurrence or mortality, as well as providing guidance for exercise testing and prescription among breast cancer survivors.

An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis

INTRODUCTION

Approximately 11.1 million cancer survivors are alive in the United States. Activity prescriptions for cancer survivors rely on evidence as to whether exercise during or after treatment results in improved health outcomes. This systematic review and meta-analysis evaluates the extent to which physical activity during and post treatment is appropriate and effective across the cancer control continuum.

METHODS

A systematic quantitative review of the English language scientific literature searched controlled trials of physical activity interventions in cancer survivors during and post treatment. Data from 82 studies were abstracted, weighted mean effect sizes (WMES) were calculated from 66 high quality studies, and a systematic level of evidence criteria was applied to evaluate 60 outcomes. Reports of adverse events were abstracted from all studies.

RESULTS

Quantitative evidence shows a large effect of physical activity interventions post treatment on upper and lower body strength (WMES = 0.99 & 0.90, p < 0.0001 & 0.024, respectively) and moderate effects on fatigue and breast cancer-specific concerns (WMES = -0.54 & 0.62, p = 0.003 & 0.003, respectively). A small to moderate positive effect of physical activity during treatment was seen for physical activity level, aerobic fitness, muscular strength, functional quality of life, anxiety, and self-esteem. With few exceptions, exercise was well tolerated during and post treatment without adverse events.

CONCLUSIONS

Current evidence suggests many health benefits from physical activity during and post cancer treatments. Additional studies are needed in cancer diagnoses other than breast and with a focus on survivors in greatest need of improvements for the health outcomes of interest.

Exercise, tea consumption, and depression among breast cancer survivors

PURPOSE To examine the association of lifestyle factors and supplement use with depression among breast cancer survivors. PATIENTS AND METHODS In a population-based cohort study conducted between April 2002 and December 2006 in Shanghai, China, a total of 1,399 women who were diagnosed with stage 0 to III breast cancer completed 6-month and 18-month postdiagnosis, in-person interviews. Information on sociodemographic, clinical, and lifestyle factors were collected through the interviews and through review of medical charts at approximately 6 months postdiagnosis. A metabolic equivalent (MET) score was calculated from reported exercise activities. Quality of life (QOL) was evaluated by the Medical Outcomes Short Form-36 Health Survey at 6 months postdiagnosis. Depressive symptoms were measured by using a 20-item Center for Epidemiological Studies-Depression Scale at approximately 18 months postdiagnosis. Results Overall, 26% of women reported depressive symptoms and 13% met the criteria of clinical depression at 18 months postdiagnosis. Women with a higher exercise level (ie, >/= 8.3 MET h/wk) were less likely to have depression than nonexercisers; the multivariate adjusted odds ratios (ORs) were 0.71 (95% CI, 0.47 to 1.07) for mild depression and 0.56 (95% CI, 0.35 to 0.88) for clinical depression in analyses controlled for sociodemographic and clinical factors and baseline QOL. Women who increased their exercise level had lower risk for depression. Regular tea consumption (ie, > 100 g dried tea leaves/mo) was inversely associated with overall depression (OR, 0.39; 95% CI, 0.19 to 0.84). No associations were found for dietary intake or supplement use with depression. CONCLUSION Regular exercise participation and tea consumption may play an important role in the prevention of depression among breast cancer survivors.

Physical activity and breast cancer survivorship

A diagnosis of breast cancer is associated with treatments that have physiologic effects beyond the intended curative therapy. The first section of this chapter provides and integrative physiology review of the effects of breast cancer treatment on the body systems used by and affected by physical activity, including effects of chemotherapy, radiation, and surgery. In later sections, we review the literature on physical activity and breast cancer from the point of diagnosis and for the balance of life. The efficacy of physical activity for supportive cancer care outcomes is reviewed separately from the purported usefulness of physical activity for disease-free and overall survival from breast cancer. The current evidence supports the safety of physical activity during and after breast cancer therapy. The supportive cancer care outcomes for which there is sufficient evidence of efficacy during and after breast cancer treatment include fitness, fatigue, body size, and quality of life. Further, there is growing evidence that upper body exercise does not pose additional risk for negative lymphedema outcomes among survivors with and at risk for lymphedema. For overall survival, the evidence is largely observational, with sufficient evidence that physical activity does confer benefit. Finally, we outline future directions for research on physical activity among breast cancer survivors, including expanding to focus on subsets of the population not included in most prior studies (minority women and older women), tailoring of interventions to stages of cancer most likely to benefit, expanding to study women with metastatic cancer, and new modes of exercise, such as team sports, martial arts, and Pilates.

Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up

BACKGROUND. The influence of physical activity on the development of arm lymphedema (ALE) after breast cancer surgery with axillary node dissection has been debated. We evaluated the development of ALE in two different rehabilitation programs: a no activity restrictions (NAR) in daily living combined with a moderate resistance exercise program and an activity restrictions (AR) program combined with a usual care program. The risk factors associated with the development of ALE 2 years after surgery were also evaluated. MATERIAL AND METHODS. Women (n = 204) with a mean age of 55+/-10 years who had axillary node dissection were randomized into two different rehabilitation programs that lasted for 6 months: NAR (n = 104) or AR (n = 100). The primary outcomes were the difference in arm volume between the affected and control arms (Voldiff, in ml) and the development of ALE. Baseline (before surgery) and follow-up tests were performed 3 months, 6 months, and 2 years after surgery. Data were analyzed using ANCOVA and regression analysis. RESULTS. Voldiff did not differ significantly between the two treatment groups. Arm volume increased significantly over time in both the affected and the control arms. The development of ALE from baseline to 2 years increased significantly in both groups (p < 0.001). The only risk factor for ALE was BMI > 25 kg/m(2). CONCLUSION. Patients that undergo breast cancer surgery with axillary lymph node dissection should be encouraged to maintain physical activity in their daily lives without restrictions and without fear of developing ALE.