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

A randomized trial to increase physical activity in breast cancer survivors

PURPOSE

Interventions to increase physical activity among breast cancer survivors are needed to improve health and quality of life and possibly to reduce the risk of disease recurrence and early mortality. Therefore, we report the feasibility and preliminary outcomes of a pilot randomized trial designed to increase physical activity in sedentary breast cancer survivors receiving hormone therapy.

METHODS

Forty-one sedentary women on estrogen receptor modulators or aromatase inhibitors for stage I, II, or IIIA breast cancer were randomly assigned to receive a 12-wk multidisciplinary physical activity behavior change intervention or usual care.

RESULTS

Recruitment was 34%, intervention adherence was 99%, and complete follow-up data were obtained on 93%. Most participants (93%) were white with mean age of 53 +/- 9 yr. Differences favoring the intervention group were noted for accelerometer physical activity counts (mean difference = 72,103; 95% confidence interval (CI) = 25,383-119,000; effect size (d) = 1.02; P = 0.004), aerobic fitness (mean difference = 2.9; 95% CI = -0.1 to 5.8; d = 0.64; P = 0.058), back/leg muscle strength (mean difference = 12.3; 95% CI = 0.4-15.9; d = 0.81; P = 0.017), waist-to-hip ratio (mean difference = -0.05; 95% CI = -0.01 to -0.08; d = -0.77; P = 0.018), and social well-being (mean difference = 2.0; 95% CI = 0.3-3.8; d = 0.76; P = 0.03). However, the intervention group also reported a greater increase in joint stiffness (mean difference = 1.1; 95% CI = 0.1-2.2; d = 0.70; P = 0.04).

CONCLUSIONS

A behavior change intervention for breast cancer survivors based on the social cognitive theory is feasible and results in potentially meaningful improvements in physical activity and selected health outcomes. Confirmation in a larger study is warranted.

Physical activity and health outcomes three months after completing a physical activity behavior change intervention: persistent and delayed effects

PURPOSE

We previously reported the effectiveness of a 12-week physical activity behavior change intervention for breast cancer survivors postintervention with this report, aiming to determine delayed and/or persistent effects 3 months after intervention completion.

METHODS

Forty-one sedentary women with stage I, II, or IIIA breast cancer currently receiving hormonal therapy were randomly assigned to receive the 12-week Better Exercise Adherence after Treatment for Cancer intervention or usual care. Assessments occurred at baseline, postintervention, and 3 months postintervention.

RESULTS

Weekly minutes of greater than or equal to moderate intensity physical activity measured by accelerometer showed a significant group by time interaction (F = 3.51; P = 0.035; between group difference in the mean change from baseline to 3 months postintervention, 100.1 minute, P = 0.012). Significant group by time interactions also showed sustained improvements from baseline to 3 months postintervention in strength (F = 3.82; P = 0.027; between group difference, 11.2 kg; P = 0.026), waist-to-hip ratio (F = 3.36; P = 0.041; between group difference, -0.04; P = 0.094), and social well-being (F = 4.22; P = 0.023; between group difference, 3.9; P = 0.039). A delayed reduction in lower extremity dysfunction 3 months postintervention was noted (F = 3.24; P = 0.045; between group difference in the mean change from postintervention to 3 months follow-up; P = -7.6; P = 0.015). No group by time effect was noted for fitness, body mass index, percent fat, bone density, total quality of life (Functional Assessment of Cancer Therapy-General), fatigue, endocrine symptoms, cognitive function, or sleep.

CONCLUSIONS

The intervention resulted in sustained improvements in physical activity, strength, central adiposity, and social well-being with lower extremity function benefits appearing 3 months after intervention completion. Testing translation in a multisite study is warranted.

Exercise in cancer

Physical exercise has attracted increased interest in rehabilitation of oncological patients. The purpose of this paper is to review the literature and summarize the evidence of physical exercise in preventing cancer, its ability in attenuating the effect of cancer and its treatments and to provide guidelines for exercise prescription Review of recent literature by electronic search of MEDline (Pub Med), Cancer lit, Cochrane libraries, CINAHL were done using Keywords and the variables were identified and systematically evaluated. There is strong evidence for reduced risk of colorectal and breast cancer with possible association for prostate, endometrial and lung cancer with increasing physical activity. Exercise helps cancer survivors cope with and recover from treatment; exercise may improve the health of long term cancer survivors and extend survival. Physical exercise will benefit throughout the spectrum of cancer. However, an understanding of the amount, type and intensity of exercise needed has not been fully elucidated. There is sufficient evidence to promote exercise in cancer survivors following careful assessment and tailoring on exercise prescription.

Translating physical activity interventions for breast cancer survivors into practice: an evaluation of randomized controlled trials

BACKGROUND

Although physical activity (PA) interventions have been effective for improving health outcomes in breast cancer survivors, little is known relative to their potential for translation into practice.

PURPOSE

This review was designed to provide a quantitative estimate of the reporting of both internal and external validity in recent studies of PA in breast cancer survivors (BCS).

METHODS

The Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was utilized to assess the reporting of internal and external validity in 25 randomized controlled trials (RCTs) of PA and BCS published between 1998 and 2008. Each trial was evaluated relative to the degree it met criteria for each of the above dimensions.

RESULTS

The majority of studies in this review reported dimensions reflecting internal validity. The overall level of detail relative to external validity of PA interventions was rarely reported, limiting the generalizability of study findings.

CONCLUSIONS

As with many RCTs of health behavior change, detail relative to contextual elements of published PA interventions in BCS is limited. It is recommended that future physical activity interventions in BCS be designed to facilitate scalable and sustainable interventions for improving health outcomes in this population.

Physical activity and obesity in endometrial cancer survivors: associations with pain, fatigue, and physical functioning

OBJECTIVE

This study aims to determine the prevalence of physical activity and obesity and their relationship to physical functioning (PF), fatigue, and pain in endometrial cancer survivors.

STUDY DESIGN

Surveys were mailed to 200 survivors of endometrial cancer diagnosed within the last 5 years; 61% were returned. Surveys assessed physical activity, height and weight, comorbid health problems, PF, fatigue, and pain.

RESULTS

In all, 22% exercised in the past month at the level of current public health recommendations, 41% reported no physical activity, and 38% reported some activity. A total of 16% were overweight and 50% were obese. Both lower body mass index (BMI) and higher physical activity were related to better PF. Higher physical activity was related to less fatigue, primarily for patients of normal BMI.

CONCLUSION

Results suggest endometrial cancer survivors' obesity and inactivity contributes to poorer quality of life. This population could benefit from quality-of-life interventions incorporating physical activity.

Review of physical activity measurement using accelerometers in older adults: considerations for research design and conduct

OBJECTIVE

Accelerometers are being increasingly used in studies of physical activity (PA) among older adults, however the use of these monitors requires some specialized knowledge and up-to-date information on technological innovations. The purpose of this review article is to provide researchers with a guide to some commonly-used accelerometers in order to better design and conduct PA research with older adults.

METHODS

A literature search was conducted to obtain all available literature on commonly-used accelerometers in older adult samples with specific attention to articles discussing research design.

RESULTS

The use of accelerometers in older adults requires a basic understanding of the type being used, rationale for their placement, and attention to calibration when needed. The updated technology in some monitors should make study conduct less difficult, however comparison studies of the newer versus the older generation models will be needed.

CONCLUSIONS

Careful considerations for design and conduct of accelerometer research as outlined in this review should help to enhance the quality and comparability of future research studies.

A meta-analysis of aerobic exercise interventions for women with breast cancer

The purpose of this meta-analysis was to examine the effectiveness of aerobic exercise interventions on cardiopulmonary function and body composition in women with breast cancer. Of 24 relevant studies reviewed, 10 studies (N = 588) met the inclusion criteria. The findings indicated that aerobic exercise significantly improved cardiopulmonary function as assessed by absolute VO2 peak (standardized mean difference [SMD] .916, p < .001), relative VO2 peak (SMD .424, p < .05), and 12-minute walk test ( SMD .502, p < .001). Similarly, aerobic exercise significantly improved body composition as assessed by percentage body fat (SMD -.890, p < .001), but body weight and lean body mass did not change significantly. Aerobic exercise during or after cancer adjuvant therapy seems to be an effective means of improving cardiopulmonary function and decreasing percentage body fat in women with breast cancer. Further studies are needed to examine the long-term benefits of aerobic exercise.

Cancer, cognitive impairment, and meditation

BACKGROUND AND OBJECTIVES

Cancer-related cognitive impairment has been acknowledged as a substantial limiting factor in quality of life among cancer patients and survivors. In addition to deficits on behavioral measures, abnormalities in neurologic structure and function have been reported. In this paper, we review findings from the literature on cognitive impairment and cancer, potential interventions, meditation and cognitive function, and meditation and cancer. In addition, we offer our hypotheses on how meditation practice may help to alleviate objective and subjective cognitive function, as well as the advantages of incorporating a meditation program into the treatment of cancer patients and survivors for cancer-related cognitive deficits.

FINDINGS

Various factors have been hypothesized to play a role in cancer-related cognitive impairment including chemotherapy, reduced hormone levels, proinflammatory immune response, fatigue, and distress. Pharmacotherapies such as methylphenidate or modafinil have been suggested to alleviate cognitive deficits. While initial reports suggest they are effective, some pharmacotherapies have side effects and may not relieve other symptoms associated with multimodal cancer treatment including sleep disturbance, nausea and pain. Several recent studies investigating the effects of meditation programs have reported behavioral and corresponding neurophysiological modulations that may be particularly effective in alleviating cancer-related cognitive impairment. Such programs also have been shown to reduce stress, fatigue, nausea and pain, and improve mood and sleep quality.

CONCLUSIONS

With the increasing success of cancer treatment and the ability to return to previous family, social, and work activities, symptom management and quality of life are an essential part of survivorship. We propose that meditation may help to improve cancer-related cognitive dysfunction, alleviate other cancer-related sequelae, and should be fully investigated as an adjuvant to cancer treatment.

Physical activity and function in older, long-term colorectal cancer survivors

OBJECTIVE

Increasing age and cancer history are related to impaired physical function. Since physical activity has been shown to ameliorate age-related functional declines, we evaluated the association between physical activity and function in older, long-term colorectal cancer survivors.

METHODS

In 2006-2007, mailed surveys were sent to colorectal cancer survivors, aged > or = 65 years when diagnosed during 1995-2000, and identified through a state cancer registry. Information on physical activity, physical function, and relevant covariates was obtained and matched to registry data. Analysis of covariance and linear regression were used to compare means and trends in physical function across levels of activity in the final analytic sample of 843 cases.

RESULTS

A direct, dose-dependent association between physical activity and function was observed (p(trend) < .001), with higher SF-36 physical function subscores in those reporting high versus low activity levels (65.0 +/- 1.7 vs. 42.7 +/- 1.7 (mean +/- standard error)). Walking, gardening, housework, and exercise activities were all independently related to better physical function. Moderate-vigorous intensity activity (p(trend) < .001) was associated with function, but light activity (p(trend) = 0.39) was not.

CONCLUSION

Results from this cross-sectional study indicate significant associations between physical activity and physical function in older, long-term colorectal cancer survivors.

Effects of activity strategy training on pain and physical activity in older adults with knee or hip osteoarthritis: a pilot study

OBJECTIVE

To examine effects of activity strategy training (AST), a structured rehabilitation program taught by occupational therapists and designed to teach adaptive strategies for symptom control and engagement in physical activity (PA).

METHODS

A randomized controlled pilot trial was conducted at 4 sites (3 senior housing facilities and 1 senior center) in southeastern, lower Michigan. Fifty-four older adults with hip or knee osteoarthritis (mean +/- SD age 75.3+/-7.1 years) participated. At each site, older adults were randomly assigned to 1 of 2 programs: exercise plus AST (Ex + AST) or exercise plus health education (Ex + Ed). The programs involved 8 sessions over 4 weeks with 2 followup sessions over a 6-month period, and were conducted concurrently within each site. Pain, total PA and PA intensity (measured objectively by actigraphy and subjectively by the Community Healthy Activities Model Program for Seniors questionnaire), arthritis self-efficacy, and physical function were assessed at baseline and posttest.

RESULTS

At posttest, participants who received Ex + AST had significantly higher levels of objective peak PA (P=0.02) compared with participants who received Ex + Ed. Although not statistically significant, participants in Ex + AST tended to have larger pain decreases, increased total objective and subjective PA, and increased physical function. No effects were found for arthritis self-efficacy.

CONCLUSION

Although participants were involved in identical exercise programs, participants who received AST tended to have larger increases in PA at posttest compared with participants who received health education. Future studies will be needed to examine larger samples and long-term effects of AST.

Theories underlying health promotion interventions among cancer survivors

OBJECTIVES

To review the theories that have been the basis for randomized controlled trials (RCTs) promoting health behavior change among adults diagnosed and treated for cancer.

DATA SOURCES

Electronic databases and recent review papers.

CONCLUSION

Several theories have been used in intervention development: Transtheoretical Model, Motivational Interviewing, Social Learning and Social Cognitive Theory, Theory of Planned Behavior, and Cognitive Behavioral Theory. There is support for the efficacy of some of these interventions. However, there has been limited assessment of theory-based constructs and examination of the mediational role of theoretical constructs in intervention efficacy.

IMPLICATIONS FOR NURSING PRACTICE

There is a need to apply theory in the development of interventions to assess the effects of the intervention on the constructs and to conduct mediational tests of these constructs.

Dimensions of physical activity and their relationship to physical and emotional symptoms in breast cancer survivors

BACKGROUND

Many breast cancer survivors experience long term sequelae, including fatigue, decreased physical functioning, pain, and psychological distress. Physical activity can ameliorate these problems, but there is little research on how activity should be performed to be most beneficial. This study explores how dimensions of physical activity (total energy expenditure, frequency, and duration) are associated with symptoms among breast cancer survivors.

METHODS

We conducted a secondary analysis of data on physical activity behavior and symptoms in a cross-sectional study (n = 148) of breast cancer survivors who were off treatment and had been diagnosed within the past 5 years.

RESULTS

Multivariate analyses showed that total energy expenditure was associated with better general health (p = 0.006) and fewer depressive symptoms (p = 0.014), while frequency of activity was linearly related to physical functioning (p = 0.047), pain (0.057), general health (p < 0.001), and depressive symptoms (p < 0.001). Duration was related to physical functioning, pain, and general health, but the worst outcomes were reported by the participants with the shortest and longest duration of activity (quadratic trend p values = 0.002, 0.003, 0.008, respectively).

DISCUSSION/CONCLUSIONS

Greater total energy expenditure, higher physical activity frequency, and moderate duration were associated with better outcomes for most symptoms, although there was no relationship between any of the dimensions of physical activity and fatigue.

IMPLICATIONS FOR CANCER SURVIVORS

The association of better outcomes with higher energy expenditure, higher frequency of activity, and moderate duration indicates that increasing activity through multiple short bouts may be the most beneficial for breast cancer survivors. However, randomized studies are needed to confirm this finding.

Rehabilitation in Cancer Survivors: Interaction between Lifestyle and Physical Activity

Cancer survivors are exposed to greater risk than the general population for several diseases: second primary and/or recurring cancer, sarcopenic obesity, metabolic syndrome and the related cardiovascular diseases, osteoporosis, decreased fatigue endurance, accelerated functional impairment and postural dysfunction; this is due to many factors, not only chemo/radiotherapy for cancer treatment and genetic predisposition, but also inappropriate lifestyle behaviour. The main interest of research on survival should be focused on the identification of the interventions capable of preventing premature mortality and on improving the patient's quality of life (QoL). Rehabilitating exercise and physical activity are effective tools to reach this goal, especially if combined with an appropriate lifestyle tailored to the individual needs, to provide a new comprehensive welfare model developed under the oncologist's supervision.

The impact of momentary pain and fatigue on physical activity in women with osteoarthritis

OBJECTIVE

To examine the daily life patterns of both pain and fatigue symptoms and objective physical activity (using ambulatory monitoring) in women with symptomatic lower extremity osteoarthritis (OA), and to evaluate how momentary symptoms impact physical activity levels.

METHODS

Sixty women age >or=55 years (40 with knee or hip OA and 20 matched controls) participated in an observational study involving 2 laboratory visits and a 5-day home data collection period. During the home period physical activity levels were assessed continuously, and symptoms were inputted 6 times a day into an enhanced accelerometer at prespecified time points.

RESULTS

In the OA group as compared with the control group over the 5-day period, average physical activity was significantly lower (P = 0.02) and peak physical activity tended to be lower (P = 0.06). Although pain and fatigue overall were of moderate severity in this cohort, fatigue escalated throughout each day. In a hierarchical linear model, fatigue was most strongly associated with physical activity (beta = -30.1, P < 0.0001). Pain was more weakly associated with physical activity and in the direction opposite to what was hypothesized (beta = 16.9, P = 0.04).

CONCLUSION

Momentary reports of fatigue negatively predicted physical activity levels and were much more strongly related to physical activity than momentary pain. In order to help women with knee or hip OA manage symptoms and become more physically active, it may be important to emphasize fatigue management.

Recruiting and retaining breast cancer survivors into a randomized controlled exercise trial: the Yale Exercise and Survivorship Study

BACKGROUND

Given observational findings that physical activity reduces breast cancer risk, improves survival, and improves quality of life in breast cancer survivors, a need has been identified for randomized controlled trials that test the efficacy of exercise on biological mechanisms associated with breast cancer survival. The primary aims of the Yale Exercise and Survivorship Study were to 1) determine the feasibility of recruiting breast cancer survivors into a randomized controlled trial of the effects of exercise on biological markers and/or mechanisms associated with survival, 2) compare the effectiveness of various recruitment strategies on accrual rates and baseline characteristics, and 3) report adherence to the exercise trial.

METHODS

Seventy-five postmenopausal breast cancer survivors self-referred into the trial or were recruited through the New Haven Tumor [corrected] Registry and randomly assigned to an exercise (n = 37) or usual-care (n = 38) group. The exercise group participated in 150 min/wk of supervised gym-based and home-based aerobic exercise for 6 months. The usual-care group was instructed to maintain current physical activity level.

RESULTS

A total of 75 women (an accrual rate of 9.5%) were randomized to the trial. Rates of accrual were higher for women who self-referred into the study (19.8%) compared with women recruited via the cancer registry (7.6%); however, demographic, physiologic, and prognostic characteristics did not differ between the 2 recruitment strategies. On average, exercisers increased moderate- intensity to vigorous-intensity aerobic exercise by 129 minutes per week compared with 44 minutes per week among usual-care participants (P < .001). Women in the exercise-intervention group increased their average pedometer steps by 1621 steps per day compared with a decrease of 60 steps per day among women in the usual-care group (P < .01).

CONCLUSIONS

Findings from this study will provide useful information for investigators who are conducting exercise trials in cancer populations, clinicians who are treating women diagnosed with breast cancer, and exercise professionals who are developing community-based exercise programs for cancer survivors.

Methodologic issues in exercise intervention research in oncology

OBJECTIVES

To review randomized controlled trials that offered exercise interventions for adults diagnosed and treated for cancer related to design, sample, type of intervention, and outcomes.

DATA SOURCES

Several electronic databases were searched and recent review papers were scanned to identify relevant publications.

CONCLUSION

Exercise adoption seems clearly feasible for early stage cancer patients, particularly breast cancer patients. Data support positive effects for physical functioning, quality of life, and psychological well-being. Effects for patients with later-stage disease and other cancers are less clear. The impact of exercise adoption on biomarkers of disease status, immune functioning, and hormone levels should also be examined.

IMPLICATIONS FOR NURSING PRACTICE

There are many opportunities for nurses to promote exercise in clinical care and in a research context.

Complementary therapies for cancer pain

Pharmacologic treatment of pain does not always meet patients' needs and may produce difficult side effects. Complementary therapies, which are safe, noninvasive, and generally considered to be relatively free of toxicity, may be used adjunctively with standard pain management techniques to improve outcome and reduce the need for prescription medication. Approaches such as acupuncture, massage therapy, mind-body interventions, and music therapy effectively reduce pain, enhance quality of life, and provide patients with the opportunity to participate in their own care. Such therapies have an important role in modern pain management.

Cognitive behaviour therapy for fatigued cancer survivors: long-term follow-up

An earlier randomised-controlled trial demonstrated the positive effects of cognitive behaviour therapy (CBT), especially designed for fatigued cancer survivors in reducing fatigue, functional impairments and psychological distress. In the current prospective study, we were able to examine the long-term effect of CBT in patients who completed the therapy. Predictors of fatigue severity at follow-up were exploratory investigated. Sixty-eight patients who completed CBT were assessed at pretreatment, post-treatment and at follow-up (mean follow-up 1.9 years (s.d. 1.0), range: 1–4 years). To analyse possible predictors of treatment outcome a linear regression (enter) was carried out. Improvements on fatigue severity, functional impairment and psychological distress after CBT appeared to remain stable during a follow-up period. Patients who were not fatigued anymore at follow-up were not different from a reference group of non-fatigued cancer survivors. The explorative regression analysis showed that fatigue severity, psychological distress and somatic attributions at pretreatment contributed to persistent fatigue severity at follow-up. Cognitive behaviour therapy, especially designed for post-cancer fatigue, is successful in reducing fatigue and functional impairment in cancer survivors. Moreover, these positive effects were maintained at about 2 years after finishing CBT.