Associations among physical activity, body mass index, and health-related quality of life by race/ethnicity in a diverse sample of breast cancer survivors

Correlates of health-related quality of life in African Americans diagnosed with cancer: a review of survivorship studies and the Detroit research on cancer survivors cohort

Advances in cancer screening and treatment have improved survival after a diagnosis of cancer. As the number of cancer survivors as well as their overall life-expectancy increases, investigations of health-related quality of life (HRQOL) are critical in understanding the factors that promote the optimal experience over the course of survivorship. However, there is a dearth of information on determinants of HRQOL for African American cancer survivors as the vast majority of cohorts have been conducted predominantly among non-Hispanic Whites. In this review, we provide a review of the literature related to HRQOL in cancer survivors including those in African Americans. We then present a summary of published work from the Detroit Research on Cancer Survivors (ROCS) cohort, a population-based cohort of more than 5000 African American cancer survivors. Overall, Detroit ROCS has markedly advanced our understanding of the unique factors contributing to poorer HRQOL among African Americans with cancer. This work and future studies will help inform potential interventions to improve the long-term health of this patient population.

The role of breast cancer-related arm lymphedema in physical functioning and physical activity participation among long-term African American breast cancer survivors

PURPOSE

Breast cancer-related arm lymphedema (BCRL) is a common chronic and debilitating condition that involves accumulation of lymphatic fluid in the arm or hand. Limited data are available on BCRL in African American women. Lack of physical activity (PA) and poor physical functioning (PF) are both associated with increased morbidity and mortality among breast cancer survivors. We examined the association of BCRL with PA and PF among African American breast cancer survivors.

METHODS

323 African American women who previously participated in a case-only study in three states (TN, GA, SC) completed a survivorship-focused questionnaire (mean: 4.2 years post-diagnosis) in 2015-2016. Validated measures were used to determine BCRL, PF, and PA. Adjusted binary logistic regression models estimated ORs and 95% CIs for the association of BCRL and meeting PA guidelines (≥ 150 min/week), while multinomial logistic regression was used for PF and PA (minutes/week) categorized based on tertiles.

RESULTS

Approximately 32% reported BCRL since diagnosis; 25.4% reported BCRL in the last 12-months. About 26% and 50% reported that BCRL interfered with exercise and ability to do daily activities, respectively. The mean PF among those with BCRL was 51.0(SD:29.0) vs. 68.5(SD:30.1) among those without BCRL. BCRL was associated with lower PF (adjusted-OR for tertile 2: 2.12(95% CI:1.03-4.36) and adjusted-OR for tertile 1: 2.93(95% CI:1.44-5.96)).

CONCLUSIONS

BCRL was associated with lower PF among long-term African American breast cancer survivors. Continued monitoring by health care professionals and increased education and behavioral interventions to support PA and improved PF among survivors living with BCRL are warranted.

Risk of contralateral breast cancer among Asian/Pacific Islander women in the United States

PURPOSE

While breast cancer studies often aggregate Asian/Pacific Islander (API) women, as a single group or exclude them, this population is heterogeneous in terms of genetic background, environmental exposures, and health-related behaviors, potentially resulting in different cancer outcomes. Our purpose was to evaluate risks of contralateral breast cancer (CBC) among subgroups of API women with breast cancer.

METHODS

We conducted a retrospective cohort study of women ages 18 + years diagnosed with stage I-III breast cancer between 2000 and 2016 in the Surveillance, Epidemiology and End Results registries. API subgroups included Chinese, Japanese, Filipina, Native Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other API women. Asynchronous CBC was defined as breast cancer diagnosed in the opposite breast 12 + months after first primary unilateral breast cancer. Multivariable-adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups.

RESULTS

From a cohort of 44,362 API women with breast cancer, 25% were Filipina, 18% were Chinese, 14% were Japanese, and 8% were Indian/Pakistani. API women as an aggregate group had increased risk of CBC (SHR 1.15, 95% CI 1.08-1.22) compared to NHW women, among whom Chinese (SHR 1.23, 95% CI 1.08-1.40), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Native Hawaiian (SHR 1.69, 95% CI 1.37-2.08) women had greater risks.

CONCLUSION

Aggregating or excluding API patients from breast cancer studies ignores their heterogeneous health outcomes. To advance cancer health equity among API women, future research should examine inequities within the API population to design interventions that can adequately address their unique differences.

Dietary Composition, Meal Timing, and Cancer-Related Fatigue: Insights From the Women's Healthy Eating and Living Study

BACKGROUND

Cancer-related fatigue is difficult to treat, and dietary interventions are promising yet underused.

OBJECTIVE

We explored associations between dietary patterns and fatigue, and the effect of a dietary intervention versus control on fatigue using Women's Healthy Eating and Living study data, plus mediators and moderators of the intervention effect.

METHODS

The Women's Healthy Eating and Living study was a randomized controlled trial among early-stage breast cancer survivors. The 4-year intervention encouraged fruits, vegetables, fiber, and 15% to 20% calories from fat. Fatigue outcomes included a 9-item energy scale and a single-item tiredness question. Dietary quality was estimated using a modified Healthy Eating Index (24-hour dietary recall) and serum carotenoid concentrations. Nutrient timing was obtained from 4-day food logs.

RESULTS

Among 2914 total participants, lower body mass index was associated with less tiredness and more energy at baseline (P < .001 for both). Earlier start and end times for daily eating windows were associated with less tiredness (P = .014 and P = .027, respectively) and greater energy (P = .006 and P = .102, respectively). The intervention did not lead to improvements in fatigue on average (P > .125). However, the intervention was more effective for participants who were younger, had fewer comorbidities, and did not have radiation treatment. Mediators included increases in serum carotenoids, increases in the modified Healthy Eating Index, and weight loss/maintenance.

CONCLUSION

Diet quality and earlier eating windows were associated with less fatigue.

IMPLICATIONS FOR PRACTICE

Programs that encourage high diet quality and a morning meal and discourage nighttime eating should be tested for efficacy in reducing cancer-related fatigue in survivorship.

Patterns of Physical Activity and the Role of Obesity and Comorbidities Among Long-term African American Breast Cancer Survivors

PURPOSE

Physical activity (PA) has many health benefits for cancer survivors, but little research has examined patterns and correlates in African American women, who have a higher burden of comorbidities and obesity. We examined PA types and patterns overall and by obesity and comorbidities among long-term (> 5 years) breast cancer survivors.

METHODS

This cross-sectional study included 323 women who were previous participants of a case-only study in three southeastern states. Women completed a survivorship-focused questionnaire using validated measures to collect data on cancer treatment, PA (recreational, household, transportation) and other lifestyle factors, and comorbidities. Logistic regression models estimated adjusted ORs and 95% CIs for total PA (all three types, categorized as tertiles) and meeting PA guidelines (> 150 min/week of exercise).

RESULTS

The mean age of women was 59.1 years (range 27.9-79.5). The most frequent PA types (≥ 1/month) included routine household cleaning (92.9%), shopping (94.7%), walking slowly (42.1%), and walking briskly (40.6%). Less than 40% met PA guidelines. Women with more total comorbidities, arthritis, and obesity had lower levels of total PA (minutes/week) and/or recreational PA. In adjusted models, BMI ≥ 35 kg/m2 was associated with reduced odds of total PA (OR = 0.33, 95% CI 0.12-0.88, highest tertile). Arthritis was associated with reduced odds of meeting PA guidelines (OR = 0.61, 95% CI 36-1.05).

CONCLUSIONS

Close to 60% of African American breast cancer survivors did not meet PA guidelines based on recreational PA participation. Household PA was an important source of PA. Comorbidities and obesity were associated with both reduced total PA and not meeting PA guidelines.

U-shaped association between body mass index and health-related quality of life impairment in Korean cancer survivors: a nationwide representative cross-sectional survey

PURPOSE

Although obesity is an important risk factor for cancer incidence, the effect of body mass index (BMI) on health-related quality of life (HRQoL) after cancer treatment remains unknown. This population-based cross-sectional study assessed different levels of BMI as an important factor associated with impaired HRQoL in long-term cancer survivors.

METHODS

The study enrolled 1104 cancer survivors from the fourth to seventh Korea National Health and Nutrition Examination Surveys (KNHANES 2007-2018) who were alive at least 5 years after their cancer diagnoses. The BMI was classified into four categories: < 20 (underweight), 20-22.9 (healthy weight), 23-24.9 (overweight), and ≥ 25 kg/m2 (obese). Impaired HRQoL was defined as the lowest quartile of European Quality of Life 5-Dimensions (EQ-5D) questionnaire scores.

RESULTS

Cancer survivors who were underweight or obese were more likely to report health problems on each dimension of the EQ-5D compared to the other BMI groups. In multivariate logistic regression analysis, the two extreme BMI categories were significantly associated with impaired HRQoL (BMI < 20 kg/m2: odds ratio [OR] = 1.73, 95% confidence interval [CI] = 1.08-2.86; BMI ≥ 25 kg/m2: OR = 2.14, 95% CI = 1.41-3.25; P trend = 0.049), especially in the gastrointestinal cancer group (P heterogeneity = 0.007). Moreover, the association between underweight/obese and impaired HRQoL showed a significant sex difference (P heterogeneity = 0.019).

CONCLUSIONS

The results of this study suggest that deviations from normal BMI, such as being underweight or obese, are negatively associated with HRQoL in long-term cancer survivors; to some extent, this may depend on cancer type and sex.

IMPLICATIONS FOR CANCER SURVIVORS

Reaching or maintaining a healthy weight should be emphasized for cancer survivors as a long-term goal even after cancer treatment.

The Role of Spirituality on Physical Activity and Sleep Among African American Long-Term Breast Cancer Survivors

BACKGROUND

African Americans with chronic conditions have reported the importance of spirituality in their lives. Aspects of spirituality have been shown to be related to physical activity (PA) and sleep, and PA and sleep affect quality of life (QOL). This study examined the association between spirituality, PA, and sleep in long-term African American breast cancer survivors.

METHODS

This cross-sectional study included 323 breast cancer survivors who previously participated in a case-only study. During 2015-2016, participants completed a questionnaire focused on survivorship that used validated measures for spirituality, PA, and sleep. Adjusted binary and multinomial logistic regression models estimated odds ratios (aORs) and 95% confidence intervals (CIs) for the associations of spirituality with total PA, meeting PA guidelines, sleep duration, and sleep medication.

RESULTS

The mean age at diagnosis was 54.8 (SD = 9.89) years. The range of spirituality scores was 7-48 (median = 44). Among participants who had a score ≥ 44, 59% had high total PA, 61% met PA guidelines, 59% had high sleep duration, and 55% did not use sleep medication. Higher spirituality score was associated with higher total PA (aOR for ≥ 681 min/week: 1.90, 95% CI: 1.03-3.50), meeting PA guidelines (aOR: 1.78, 95% CI: 1.06-2.98), sleep duration > 7 h/night (aOR: 1.72, 95% CI 1.05-2.83), and lack of sleep medication use (aOR: 0.45, 95% CI: 0.24-0.84).

CONCLUSION

In African American long-term breast cancer survivors, a higher spirituality score increased the likelihood of greater PA and high sleep duration. These results indicate that interventions surrounding spirituality may benefit the QOL of African American breast cancer survivors.

Exercise interventions on body composition and quality of life of overweight/obese breast cancer survivors: a meta-analysis

BACKGROUND

This meta-analysis aimed to assess the effects of exercise interventions on body composition and quality of life in overweight/obese breast cancer survivors.

METHODS

Eligible randomized controlled trials (RCTs) were searched from the Cochrane Library, PubMed, and Embase databases and assessed using the Cochrane Collaboration's assessing risk tool. The effect size was pooled as weighted mean difference (WMD) for body composition variables (i.e., body mass index [BMI], body fat, body weight, fat mass, lean mass, bone mineral density) and quality of life (i.e., physical health and mental health), and the confidence interval (CI) was set as 95%. Since heterogeneity existed, subgroup analysis was conducted to detect the source of heterogeneity.

RESULTS

Eight articles from six RCTs containing 548 overweight/obese breast cancer survivors (BMI ≥ 25 kg/m2) were included and analyzed. Compared to routine care, exercise intervention significantly decreased the body mass index [WMD (95% CI) = -1.37 (-2.50, -0.23) kg/m2] and body fat [WMD (95% CI) = -3.80 (-6.59, -1.01) %] of overweight/obese breast cancer survivors. Exercise intervention showed a tendency to increase physical health [WMD (95% CI) = 2.65 (-10.19, 15.48)] and mental health [WMD (95%CI) = 1.38 (-4.18, 6.95)], but no statistical significance was observed. A subgroup analysis showed the duration of intervention was a source of heterogeneity on body composition. In the 16-week subgroup, exercise intervention decreased fat mass and BMI while increased lean mass and bone mineral density. The 52-week exercise intervention was effective in increasing lean mass. A significant exercise intervention effect on reducing body fat was only detected in the 12-week subgroup.

CONCLUSION

Exercise intervention significantly decreased the body mass index and body fat of overweight/obese breast cancer survivors. The benefits of exercise interventions for overweight/obese breast cancer survivors need more evidence from high-quality RCTs with large sample sizes.

Breast cancer survivorship experiences among Black women

BACKGROUND

Black women experience significant disparities in breast cancer across the care continuum, including survivorship. Ensuring that Black women obtain high-quality follow-up care is critical but understudied. This study was aimed at understanding the experiences and needs of Black women during breast cancer survivorship.

METHODS

Black patients diagnosed with invasive breast cancer within the past 5 years were invited to participate in a focus group and complete a survey. Focus groups examined the following: (1) the transition from active treatment to survivorship; (2) interactions with health care providers; (3) survivorship experiences, information needs, and preferences; and (4) existing educational materials. Results were thematically coded and analyzed for main themes. Surveys collected information on sociodemographics, health care experiences, quality of life, lifestyle, and education needs.

RESULTS

The study enrolled 53 participants, 43 of whom completed a survey and participated in one of 11 focus groups. The median age was 54 years, 44% had private insurance, 81% were English speaking, and 86% had completed their treatment more than a year before. Participants identified the importance of relationships with health care providers, gaps in survivorship care, experiences with cancer-related symptoms, challenges with mental health, worry about recurrence, body image, cancer financial toxicity, and coping through religion and spirituality. Unmet needs were centered around preparation for long-term symptoms, diet and physical activity, emotional support, and more explanations of information resources. Participants reported preferences for educational videos, personal stories, and culturally relevant content.

CONCLUSIONS

Some Black breast cancer survivors may have specific challenges and preferences. Supportive interventions that address these concerns can be responsive and help to ameliorate disparities.

Social-cognitive, demographic, clinical, and health-related correlates of physical activity and sedentary behaviour in newly diagnosed women with breast cancer

PURPOSE

Identifying correlates of physical activity and sedentary behaviour allows for the identification of factors that may be targeted in future behaviour change interventions. This study sought to determine the social-cognitive, demographic, clinical, and health-related correlates of physical activity and sedentary behaviour in individuals recently diagnosed with breast cancer.

METHODS

Data were collected from 1381 participants within 90 days of diagnosis in the Alberta Moving Beyond Breast Cancer (AMBER) Cohort Study. Physical activity and sedentary behaviour were measured with ActiGraph GT3X+® and activPALTM devices, respectively, for seven consecutive days. Correlates were collected via a self-reported questionnaire, medical record extraction, or measured by staff.

RESULTS

Multivariable models were fitted for sedentary behaviour, light physical activity, and moderate-to-vigorous physical activity. Greater sedentary behaviour was associated with higher body fat percentage (BF%) (ß=0.044; p<0.001) and being single (ß=0.542; p<0.002). Lower light physical activity was associated with higher BF% (ß=-0.044; p<0.001), higher body mass index (ß=-0.039; p<0.001), greater disease barrier influence (ß=-0.006; p<0.001), a HER2-positive diagnosis (ß=-0.278; p=0.001), and being single (ß=-0.385; p= 0.001). Lower moderate-to-vigorous physical activity was associated with higher BF% (ß =-0.011; p=0.001), greater disease barrier influence (ß=-0.002; p<0.001), and being of Asian (ß=-0.189; p=0.002) or Indian/South American (ß=-0.189; p=0.002) descent. Greater moderate-to-vigorous physical activity was associated with having greater intentions (ß=0.049; p=0.033) and planning (ß=0.026; p=0.015) towards physical activity.

CONCLUSION

Tailoring interventions to increase physical activity for individuals recently diagnosed with breast cancer may improve long-term outcomes across the breast cancer continuum.

Physical activity in association with mortality among Black women diagnosed with breast cancer in the Southern Community Cohort Study

PURPOSE

Physical activity (PA) is associated with many health benefits. While PA has been associated with reduced mortality after breast cancer diagnosis in many studies, few studies have examined the role of PA in breast cancer survival among underserved and minority populations, including Black women. We investigated PA in association with mortality among Black predominantly low-income breast cancer survivors in the Southern Community Cohort Study (SCCS).

METHODS

Study participants were women diagnosed with incident breast cancer (n = 949) in the SCCS, which is a prospective cohort study of predominantly low-income adults aged 40-79 years recruited from 12 Southeastern states between 2002 and 2009. Participants completed a detailed baseline questionnaire, with annual follow-up for mortality via registry linkages. Cox regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of pre-diagnosis PA (measured via a validated questionnaire) with all-cause and breast cancer-specific mortality.

RESULTS

Breast cancer survivors had a mean age of 61.1 years and most (79.3%) had a household income of < $25,000. In adjusted models, higher levels of total PA (MET-hours/day) were inversely associated with all-cause mortality with HRs (95% CIs): 0.79 (0.59-1.06), 0.66 (0.49-0.90), and 0.60 (0.43-0.84), for Q2, Q3, and Q4 (reference: Q1), respectively, ptrend ≤ 0.01. A similar inverse association was found for breast cancer-specific mortality.

CONCLUSION

Higher levels of pre-diagnosis PA were associated with improved survival among low-income Black breast cancer survivors. Resources to reduce barriers to PA participation and increase support for education and intervention efforts to promote PA among Black women are needed.

Unemployment Status Subsequent to Cancer Diagnosis and Therapies: A Systematic Review and Meta-Analysis

The purpose of our study is to examine whether cancer and treatments are associated with job loss or changes in employment status. Eight prospective studies were included in the systematic review and meta-analysis, with a population aged 18-65 years, analyzing treatment regimen and psychophysical and social status in post-cancer follow-up of at least 2 years. In the meta-analysis, a comparison was made between recovered unemployed cases and cases from a standard reference population. Results are summarized graphically using a forest plot. We showed that cancer and subsequent treatment are risk factors for unemployment with an overall relative risk of 7.24 (lnRR: 1.98, 95% CI: 1.32-2.63) or for change in employment status. Individuals undergoing chemotherapy and/or radiation treatment and those with brain and colorectal cancers are more likely to develop disabilities that negatively affect the risk of unemployment. Finally, variables such as low level education, female sex, older age, and being overweight before starting therapy are associated with higher risk of unemployment. In the future, it will be necessary for people with cancer to have access to specific health, social welfare, and employment support programs. In addition, it is desirable that they become more involved in their choice of therapeutic treatment.

Effects of Combined Interventions of Exercise and Diet or Exercise and Supplementation on Breast Cancer Patients: A Systematic Review

This systematic review investigated the effects of exercise interventions combined with diet and/or dietary supplement interventions on anthropometry, body composition, metabolic biomarkers, physical function, healthy lifestyles, quality of life, psychosocial variables and fatigue for women with breast cancer. A systematic search was performed in the PubMed and Web of Science databases (from inception to 1 March 2022). A review was carried out following the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines. The methodological quality and the risk of bias of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale. A total of 13 randomised controlled trial studies were included, comprising 1569 breast cancer patients. The main finding of this systematic review is that groups performing interventions combining exercise plus diet show significant improvements in cardiorespiratory fitness, muscular strength, body composition, quality of life, fatigue, anxiety, depression and sleep compared to control groups. On the other hand, the use of interventions combining exercise plus supplementation does not result in an improvement compared to groups using exercise alone or supplementation alone.

Bibliometric analysis of global research on physical activity and sedentary behavior in the context of cancer

Objective

Numerous studies focusing on sedentary behavior (SB) and physical activity (PA) in the context of cancer have been reported in recent years. We analyzed and visualized studies on SB and PA in patients with cancer over the last 20 years using scientometric methods, to provide insights on gaps and deficiencies in the literature, and to inform future research guidelines.

Methods

All relevant studies in the field from 2001 to October 2022 were reviewed using bibliometric tools, including VOSviewer, Bibliometric online analysis platform, and biblioshiny, to determine the most influential countries, institutions, journals, and authors. We explored current research hotpots and potential research trends, based on keyword clustering and dynamic changes. Our research focuses on PA, SB, and cancer across the entire cancer continuum, from primary prevention to treatment to cancer survivorship.

Results

Scientometric analysis identified 4,382 relevant manuscripts on SB and PA in the context of cancer, with a 10-fold increase in articles over the past 20 years. The United States, Canada, and Australia were the most influential countries. The journal, Supportive Care in Cancer, had the highest number of publications, while Clinical Oncology had the highest H-index. K.S. Courneya was the most influential author in this field, with the highest number of publications, total citations, and H-index. Keyword analysis revealed that current research is focused on PA and SB in patients with breast cancer, quality of life, and aerobic exercise. Future frontiers include cancer prehabilitation programs and cardiorespiratory fitness, and remote intervention and social support.

Conclusion

By using bibliometrics, we conducted a comprehensive review of SB and PA in cancer-related studies. The current research focused on exercise and sedentariness in breast cancer patients and the role of PA in improving quality of life in survivorship. Emerging research foci were generally around cancer prehabilitation programs and remote intervention issues for PA. In addition, some publication deficits are noted: studies of PA and SB in less common cancers; the recommended doses and intensities of exercise for cancer; the timing of interventions for prehabilitation and the establishment of individualized exercise protocols. These deficiencies align with the needs for future research topics.

Physical, Leisure, and Daily Living Activities in Patients Before, During, and After Radiotherapy for Cancer: Which Patients Need Support in Activities?

BACKGROUND

Avoiding inactivity and staying active during cancer therapy have great health effects.

OBJECTIVE

The aims of this study were to describe level of daily, leisure, and physical activities before, during, and after radiotherapy and to investigate whether patients who had not restored activity level after radiotherapy differed from patients who had restored activity level regarding different characteristics.

METHODS

In this descriptive longitudinal study, 196 patients undergoing pelvic-abdominal radiotherapy reported their activity level at baseline, weekly during radiotherapy, and at 1 month after radiotherapy.

RESULTS

Patients decreased activity level during radiotherapy (P < .001 for all activities): physical activity (34% of patients decreased level), walking (26%), leisure activities (44%), social activities (15%), housework (34%), shopping (28%), and activities in general (28%). Almost half (47%) had not restored activity level after radiotherapy. Patients with colorectal cancer, older than 65 years, who had less education than university, and high capacity in overall daily activities at baseline were more likely than other patients not to restore activity level after radiotherapy. The patients not restoring their activity level after radiotherapy were more likely than others to experience anxious mood (P = .016), depressed mood (P = .003), and poor quality of life (P = .003) after radiotherapy.

CONCLUSION

Patients' activity level decreased during radiotherapy, and almost half of patients did not restore activity level after radiotherapy.

IMPLICATIONS FOR PRACTICE

Given that restored activity level after radiotherapy was less common in certain subgroups and that patients who restored activity level experienced better quality of life and less frequent anxious and depressed mood, cancer nursing professionals should consider supporting these subgroups of patients in performing activities.

Effects of Mobile Healthcare Applications on the Lifestyle of Patients With Breast Cancer: A Protocol for a Randomized Clinical Trial

PURPOSE

Physical activity (PA) in patients with breast cancer is associated with improved quality of life (QoL); however, many breast cancer survivors do not meet the recommended PA level. This study aims to evaluate the effect of digital health interventions using mobile apps to promote PA and QoL in patients with postoperative breast cancer. This study will also identify effective digital intervention methods and perform an economic analysis. The main hypothesis is that the use of mobile healthcare apps will improve health-related quality of life (HRQOL), promote PA, and reduce healthcare costs.

METHODS

The Promotion of a better lifestyle (PA) with Precise and Practicable digital healthcare in postoperative CANCER patients through a Multi-Disciplinary Network (P4CancerMDnet) study is examined by a prospective 4-group randomized controlled trial with a concurrent cost-utility evaluation. Patients are randomly assigned to 3 different mobile app intervention groups or control groups in a 1:1:1:1 ratio. The intervention group is encouraged to use the assigned mobile app. The targeted outcomes are HRQOL, metabolic health markers, and quality-adjusted life-years. The outcomes will be measured at the 6- and 12-month follow-ups.

DISCUSSION

This study will contribute towards a better lifestyle and HRQOL through digital healthcare for postoperative breast cancer patients. These findings are expected to provide evidence of the effectiveness of mobile apps for breast cancer survivors.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0005447.

Eat, sleep, play: health behaviors and their association with psychological health among cancer survivors in a nationally representative sample

BACKGROUND

Cancer survivors are able to live much longer today than in the past due to advances in treatment. The promotion of health behaviors is important to address among cancer survivors. Not only can health behaviors reduce the risk of comorbidities, but they may also be key to improving psychological health among cancer survivors, such as psychological distress, perceptions of one's general health, and distress of cancer mortality (i.e., cancer fatalism). Our overall goal is to 1) determine which individual health behaviors (e.g., fruit consumption, physical activity, and sleep) are associated with psychological health among cancer survivors and 2) determine if the number of health behaviors engaged in is associated with better psychological health among cancer survivors.

METHODS

Using data from the HINTS 5 Cycle III survey (N = 856 cancer survivors), we compared whether participants who met guidelines for seven health behaviors (e.g., fruit and vegetable consumption, moderate physical activity, sleep duration) had improved psychological health. Multiple ordinal regression models controlling for sociodemographic variables were used to determine if meeting more recommendations was related to psychological health and then specifically which behaviors were of greatest importance to psychological health.

RESULTS

Meeting guidelines for sleep quality and moderate physical activity was associated with higher general health and meeting guidelines for vegetable intake and better sleep quality was associated with less psychological distress. Although the associations were not significant, cancer survivors who met more of the health behavior guidelines reported higher general health, lower psychological distress, and less distress about what could be done to lower one's chances to get cancer.

CONCLUSIONS

Meeting the guidelines for individual and multiple health behaviors is associated with favorable psychological health among cancer survivors. The findings can contribute to the development of health behavior interventions that focus on multiple health behaviors to improve psychological health and quality of life among cancer survivors.

A systematic scoping review of post-treatment lifestyle interventions for adult cancer survivors and family members

PURPOSE

Supporting the health of cancer survivors and their families from diagnosis through survivorship is a recognized priority. However, the extent to which health promotion efforts after the completion of acute treatment attend to the needs of adult survivors and families is unclear. This systematic scoping review summarizes the key characteristics of post-treatment lifestyle interventions aiming to improve diet, physical activity, and/or weight-related outcomes for adult cancer survivors and family members.

METHODS

We retrieved relevant studies from six databases using keywords. Studies were appraised for quality and limited to English-language, peer-reviewed journal articles published in or after 2005.

RESULTS

A total of 2,376 articles were obtained from the databases; 14 main articles (and 2 supplemental articles) representing 14 unique interventions were retained for our analysis. Most interventions were designed to modify aspects of participant diet and physical activity (in combination) or physical activity alone; cited social cognitive theory as a guiding or interpretative framework; included survivors of multiple cancer types; and were limited to one type of familial relationship (e.g., spouse/partner, sister). Where reported, intervention samples were predominantly White.

CONCLUSIONS

Few post-treatment interventions concurrently target cancer survivor and family members' positive lifestyle behaviors. Positive findings highlight the potential for expanding this area of intervention research and increasing understanding of individual and familial factors that contribute to successful post-treatment family interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Promoting cancer survivors' healthy behaviors within the family context could capitalize on existing support networks and improve the health of family members in supportive roles.

A phase III randomized trial of weight loss to reduce cancer-related fatigue among overweight and obese breast cancer patients: MEDEA Study design

Background

Elevated body mass index (BMI) represents a risk factor for cancer-related fatigue (CRF). Weight loss interventions are feasible and safe in cancer survivors, leading to improved cardio-metabolic and quality of life (QOL) outcomes and modulating inflammatory biomarkers. Randomized data are lacking showing that a lifestyle intervention aimed at weight loss, combining improved diet, exercise, and motivational counseling, reduces CRF. Motivating to Exercise and Diet, and Educating to healthy behaviors After breast cancer (MEDEA) is a multi-center, randomized controlled trial evaluating the impact of weight loss on CRF in overweight or obese survivors of breast cancer. Herein, we described the MEDEA methodology.

Methods

Patients (N = 220) with stage I–III breast cancer and BMI ≥ 25 kg/m², within 12 months of primary treatment, and able to walk ≥ 400 m are eligible to enroll. Participants are randomized 1:1 to health education alone vs. a personalized telephone-based weight loss intervention plus health education. Both arms receive a health education program focusing on healthy living. Patients in the intervention arm are paired with an individual lifestyle coach, who delivers the intervention through 24 semi-structured telephone calls over 1 year. Intervention goals include weight loss ≥ 10% of baseline, caloric restriction of 500–1000 Kcal/day, and increased physical activity (PA) to 150 (initial phase) and 225–300 min/week (maintenance phase). The intervention is based on the social cognitive theory and is adapted from the Breast Cancer Weight Loss trial (BWEL, A011401). The primary endpoint is the difference in self-reported CRF (EORTC QLQ-C30) between arms. Secondary endpoints include the following: QOL (EORTC QLQ-C30, -BR45, -FA12), anxiety, and depression (HADS); weight and BMI, dietary habits and quality, PA, and sleep; health care costs (hospital-admissions, all-drug consumption, sick leaves) and cost-effectiveness (cost per quality-adjusted life-year); and patient motivation and satisfaction. The primary analysis of MEDEA will compare self-reported CRF at 12 months post-randomization between arms, with 80.0% power (two-sided α = 0.05) to detect a standardized effect size of 0.40.

Discussion

MEDEA will test the impact of a weight loss intervention on CRF among overweight or obese BC survivors, potentially providing additional management strategies and contributing to establish weight loss support as a new standard of clinical care.

Trial registration

ClinicalTrials.govNCT04304924

The effects of a clinic-based weight loss program on health-related quality of life and weight maintenance in cancer survivors: A randomized controlled trial

OBJECTIVE

The Healthy Living and Eating After Cancer Trial demonstrated that a clinic-based weight loss program reduced body weight, as compared with a waitlist control group, over 15 weeks. Here we report the impact of the weight loss intervention on health-related quality-of-life outcomes at week 15, and maintenance of weight loss to week 30.

METHODS

This trial randomized cancer survivors of solid tumors and hematologic malignancies (breast cancer: 76.7%) to a 15-week group-based weight loss program (n = 30) or a waitlist control group (n = 30). Participants were not blinded to group assignment. Participants completed a variety of health-related quality-of-life outcome measures at baseline and week 15. From week 15 to week 30, participants initially randomized to the weight loss program were followed with no additional intervention, and participants initially randomized to the waitlist control group commenced the weight loss program.

RESULTS

Over the 15 weeks, the weight loss program improved physical functioning (6.2 ± 2.9; p = 0.02; d = 0.31) and reduced insomnia symptoms (-17.1 ± 7.4; p = 0.03; d = -0.30) as measured by the EORTC QLQ-C30, and sleep disturbance (-4.9 ± 1.6; p = 0.005; d = -0.40) as measured by PROMIS, compared to waitlist control. After a weight loss of 4.6 ± 3.9 kg, from week 15 to week 30, participants who were initially randomized to the weight loss program maintained their prior weight loss (+0.6 ± 3.5 kg) and participants who were initially randomized to the waitlist control group lost weight (-3.4 ± 2.9 kg; p < 0.001).

CONCLUSIONS

In cancer survivors with overweight or obesity, a 15-week clinic-based weight loss program improved health-related quality-of-life outcomes and produced sustained weight loss to week 30.

Higher Level of Sports Activities Participation during Five-Year Survival Is Associated with Better Quality of Life among Chinese Breast Cancer Survivors

Simple Summary

Engaging in sports activities is strongly encouraged for cancer survivors. We aim to investigate the association between the level of sports activities participation post-diagnosis and quality of life (QoL) among Chinese women with early-stage breast cancer during the first five years of survival. Notably, we confirm in this work that regular participation in sports activities following cancer diagnosis may have a positive effect on patients’ QoL.

Abstract

Evidence about the association between the level of sports activities participation post-diagnosis and quality of life (QoL) among Chinese women with early-stage breast cancer is limited. A validated modified Chinese Baecke questionnaire was used to prospectively measure sports activities among a breast cancer cohort at four time-points: baseline and 18, 36, and 60 months after diagnosis (sports activities during the previous 12 months before each interview); QoL was measured at the same time. In total, 1289, 1125, and 1116 patients were included in the analyses at 18-, 36- and 60-month follow-up, respectively. The percentages of patients who belonged to no (0 metabolic equivalent of task (MET)-hours per week), low-level (<10 MET-hours/week), and high-level (≥10 MET-hours/week) sports activities group were 20.7%, 45.5%, and 33.8% at 18-month follow-up, respectively; the corresponding figures at 36 and 60 months differed slightly. Using data from the three follow-ups, generalized estimating equation (GEE) analyses showed that higher levels of sports activities participation were associated with better QoL in several items as well as fewer symptoms. The present findings in Chinese women with breast cancer provide important evidence on the beneficial effect of regular participation in sports activities following cancer diagnosis on patients’ QoL.

¡Mi Vida Saludable! A randomized, controlled, 2 × 2 factorial trial of a diet and physical activity intervention among Latina breast cancer survivors: Study design and methods

BACKGROUND

Most Latina breast cancer survivors do not meet diet and physical activity (PA) guidelines for cancer survivors and effective lifestyle interventions to adopt and maintain these recommendations are limited, especially among underserved populations. Here we describe the design, methods and enrollment of a 2 × 2 factorial-designed trial testing the separate effects of the ¡Mi Vida Saludable! (My Healthy Life!) intervention program on changes in diet and PA behaviors among Latina breast cancer survivors.

METHODS

Latinas with a history of stage 0-III breast cancer, no evidence of recurrent/metastatic disease, and > 90 days post-treatment were primarily identified via cancer registries and physician referral. Participants were randomized to four arms: 1) 4 weeks of in-person group sessions plus 11 months of eHealth communication, 2) in-person group sessions alone, 3) eHealth alone, or 4) control. All participants received a Fitbit to self-monitor PA. Assessments at baseline, 6 and 12 months include diet, PA, anthropometrics, predictors and mediators of behavior change, psychosocial and quality of life outcomes, and blood draw.

RESULTS

Of 884 women screened between January 2016 and September 2018, 27% were eligible. Primary reasons for ineligibility included not being willing/able to participate due to work/life responsibilities, health reasons, or transportation. Of 241 eligible women, 167 completed baseline assessment and enrolled.

CONCLUSIONS

We successfully enrolled a diverse group of breast cancer survivors representing more than 15 Latin American nationalities to a diet and physical activity trial. If effective, the ¡Mi Vida Saludable! program can be implemented by community groups and medical centers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02780271, registered May 2016.

Motivational strategies to improve adherence to physical activity in breast cancer survivors: A systematic review and meta-analysis

Two behavioral change-based strategies for promoting adherence to physical activity (PA) suggested to have the greatest potential are the pedometer and Motivational Interviewing (MI). However, there are no comparisons between these two strategies identifying which one is more effective for improving PA adherence. This systematic review and meta-analysis aimed to determine which PA motivation strategy is more effective for promoting adherence to self-directed PA in female breast cancer survivors. Studies implementing self-directed PA which used a step tracker and/or MI for motivation in female breast cancer survivors were identified from the following databases at two timepoints, September 2019 and June 2020: CENTRAL, PubMed, CINAHL, PsycINFO, and Sportdiscuss. Sixteen randomized controlled trials (RCTs) were selected for data extraction, whereas ten RCTs were included in meta-analysis. Meta-analysis was performed on pooled data to estimate the standardized mean differences in PA duration and step count, and 95% confidence intervals. The number of participants meeting PA recommendations was also analyzed. Subgroup analysis was performed for three motivational strategies (pedometer combined with counselling, with print material or with motivational interviewing). Meta-analysis showed that pedometer combined with another intervention has a small effect on step count (p = 0.03) and a moderate effect on duration of moderate-vigorous physical activity (MVPA) (p = <0.0001) compared to controls. Additionally, motivational strategies increase the number of participants who meet a PA goal (p = 0.005). The findings of this review endorse the use of a step tracker combined with counselling, print material or MI based on behavioral change theory. This approach provided the most consistent positive effect on adherence to self-directed PA among breast cancer survivors. Future studies should evaluate differences between measures of adherence to self-directed PA, to identify the best motivation strategy for improving patient adherence and health outcomes. Systematic review registration: PROSPERO Registration number CRD42020148542.

Disparities in the long-term survival of adolescent and young adult diffuse large B cell lymphoma survivors

PURPOSE

The population of adolescent and young adult (AYA, ages 15-39 years) diffuse large B-cell lymphoma (DLBCL) survivors is growing, however long-term overall survival patterns and disparities are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of race/ethnicity, sex, socioeconomic status, and rurality on long-term survival in 5-year DLBCL survivors using an accelerated failure time model.

RESULTS

Included were 4767 5-year survivors of AYA DLBCL diagnosed between the years 1980 and 2009 with a median follow-up time of 13.4 years. Non-Hispanic Black survivors had significantly worse long-term survival than non-Hispanic White survivors (Survival Time Ratio (STR): 0.53, p < 0.0001). Male sex (STR: 0.57, p < 0.0001) and older age at diagnosis were also associated with reduced long-term survival. There was no evidence that survival disparities improved over time.

CONCLUSIONS

Racial disparities persist well into survivorship among AYA DLBCL survivors. Studies investigating specific factors associated with survival disparities are urgently needed to better address these disparities.

"Moving Forward": Older Adult Motivations for Group-Based Physical Activity After Cancer Treatment

Background

Engagement in physical activity (PA) post-treatment can improve health outcomes and quality of life among cancer survivors. The purpose of this study is to explore United States (US) older adult cancer survivors’ (OACS) reasons for engaging in group-based PA classes, to identify themes supporting exercise motivations in the context of cancer recovery.

Methods

OACS participating in a fitness program at a large US comprehensive cancer center completed semi-structured interviews. Transcripts were analyzed using modified grounded theory, and demographic data were analyzed descriptively.

Results

Modified grounded theory analysis (n = 25; age M = 70.92, SD = 10.82; 9 cancer types) identified individual rationales for exercise grounded in collective experience. Participants’ internal motivations for PA are shaped by the desire for control over an uncertain future and post-treatment body, obtained by literally “moving forward” post-cancer; this is supported by external motivations for social connections that present a positive model of survivorship, within a setting that instills confidence and safety.

Conclusions

Exercise can be a way for older adults to tap into internal and external motivations that support cancer survivorship. Interventions that make explicit connections between exercise and cancer recovery, facilitate interpersonal interaction, and promote a sense of safety may be the most effective. The concepts identified in this study can inform the development of future interventions to improve long-term behavior change among OACS and evaluate existing PA programs.

Socio-Demographic and General Health Factors Associated with Quality of Life in Long-Term Breast Cancer Survivors from Southwestern Poland

Background: Identification of factors associated with quality of life (QOL) in breast cancer survivors can contribute to better functioning in this group of patients. The study aimed to assess the association between QOL and anthropometric, sociodemographic, and medical characteristics in postmastectomy women from southwestern Poland, 9.4 (±6.5) years after completed treatment. Materials and methods: QOL was estimated with the SF-36v2 questionnaire in 250 survivors aged 62.8 (±8.0) years with previously histologically confirmed invasive breast cancer. Results: Women in this study rated their overall QOL with an average of 60.7 (±17.9), Mental Component Summary of 62.8 (±19.8), and Physical Component Summary of 57.5 (±18.8) points. The use of multivariate regression analysis revealed that depression, chronic diseases, abdominal obesity, and pregnancy history have a statistically significant negative effect on the QOL of women after mastectomy, whereas participation in regular physical activity, living with a partner, the education level ≥ 12 years, and living in the city were associated with a higher QOL assessment. There were no significant relationships between QOL and the age, time since surgery, type of treatment, smoking, and occupational status of the patients. Conclusions: Health education, greater social support, specialist care in the treatment of comorbidities, and propagation of a physically active lifestyle can improve the physical and mental functioning of breast cancer survivors long after diagnosis and treatment.

Impact of Race, Ethnicity, and Socioeconomic Status over Time on the Long-term Survival of Adolescent and Young Adult Hodgkin Lymphoma Survivors

BACKGROUND

Although there are growing numbers of adolescent and young adult (AYA) Hodgkin lymphoma (HL) survivors, long-term overall survival (OS) patterns and disparities in this population are underreported. The aim of the current study was to assess the impact of race/ethnicity, socioeconomic status (SES), rurality, diagnosis age, sex, and HL stage over time on long-term survival in AYA HL survivors.

METHODS

The authors used the Surveillance, Epidemiology, and End Results (SEER) registry to identify survivors of HL diagnosed as AYAs (ages 15-39 years) between the years 1980 and 2009 and who were alive 5 years after diagnosis. An accelerated failure time model was used to estimate survival over time and compare survival between groups.

RESULTS

There were 15,899 5-year survivors of AYA HL identified, with a median follow-up of 14.4 years and range up to 33.9 years from diagnosis. Non-Hispanic black survivors had inferior survival compared with non-Hispanic white survivors [survival time ratio (STR): 0.71, P = 0.002]. Male survivors, older age at diagnosis, those diagnosed at higher stages, and those living in areas of higher SES deprivation had unfavorable long-term survival. There was no evidence of racial or sex-based survival disparities changing over time.

CONCLUSIONS

Racial, SES, and sex-based disparities persist well into survivorship among AYA HL survivors.

IMPACT

Disparities in long-term survival among AYA HL survivors show no evidence of improving over time. Studies investigating specific factors associated with survival disparities are needed to identify opportunities for intervention.

Efficacy of physical therapy interventions on quality of life and upper quadrant pain severity in women with post-mastectomy pain syndrome: a systematic review and meta-analysis

Purpose

To determine the efficacy of physical therapy interventions on quality of life (QoL) and pain severity in post-mastectomy pain syndrome (PMPS).

Methods

Multiple databases were searched from database inception to October 2020. Searches were limited to human studies published in either English or Chinese in peer-reviewed journals with full text available for randomized controlled trials conducted on females. Trials comparing the effectiveness of physical therapy interventions against control conditions on QoL and pain were included.

Results

Eighteen trials were included in the review. The pooled analysis of the four exercise trials revealed a significant effect of the intervention on general [standardized mean difference [SMD]: 0.87 (95%CI: 0.36, 1.37); p = 0.001], physical [SMD: 0.34 (95%CI: 0.01, 0.66); p = 0.044], and mental health components [SMD: 0.27 (95%CI: 0.03, 0.51); p = 0.027] of QoL compared with the control condition. Meta-analyses of six exercise trials, two myofascial release trials, and two acupuncture trials revealed a significant improvement in pain severity in the treatment group than in the control group. However, meta-analyses of two studies revealed a non-significant effect of compression therapy compared to control on pain severity.

Conclusion

Our meta-analyses found that exercise is beneficial for improving the QoL and pain severity of women with PMPS. Future studies are needed to determine the optimal parameters for exercise interventions designed to improve QoL and pain severity in women with PMPS. The effect of acupuncture, myofascial release, and compression therapy remains inconclusive, and future research is required to validate the effect of these interventions on PMPS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02926-x.

A randomized trial of exercise and diet on health-related quality of life in survivors of breast cancer with overweight or obesity

BACKGROUND

Obesity is a chronic, relapsing, and progressive disease; it is associated with poor health-related quality of life (HRQOL) in survivors of breast cancer.

METHODS

In this 2 × 2 factorial trial, 351 survivors of breast cancer with overweight or obesity were randomized to 1 of 4 treatment groups for 52 weeks: control, exercise alone, diet alone, or exercise plus diet. HRQOL end points were measured at baseline and at week 52 using the 36-Item Medical Outcomes Survey-Short Form (SF-36). Repeated measures analysis of covariance quantified the estimated treatment difference (ETD).

RESULTS

At baseline, participants had a mean (SD) age of 59.4 years (8.7), body mass index of 34.0 kg/m² (5.9), and 71 participants (20.2%) self-reported fair or poor general health. After 52 weeks, compared with control, the exercise plus diet improved the physical health summary score (ETD: 5.39; 95% CI, 0.55-10.22); exercise alone (ETD: -1.91; 95% CI, -6.60 to 2.79) and diet alone (ETD: 3.16; 95% CI, -1.52 to 7.83) did not change the physical health summary score. Compared with control, exercise alone (ETD: -0.27; 95% CI, -6.60 to 2.79), diet alone (ETD: 3.25; 95% CI, -1.41 to 7.91), and the exercise plus diet (ETD: 1.75; 95% CI, -2.90 to 6.39) did not change the mental health summary score. Exercise alone did not impact any HRQOL subscale; diet alone improved the vitality subscale; exercise plus diet improved the physical functioning, role-physical and vitality subscales.

CONCLUSION

In survivors of breast cancer with overweight or obesity, exercise plus diet improved select HRQOL end points at week 52.

A Pilot and Feasibility Mobile Health Intervention to Support Healthy Behaviors in African American Breast Cancer Survivors

African American breast cancer (AA BC) survivors are more likely to have cancer-related comorbidities compared with other women, ultimately putting them at higher risk for overall mortality and breast cancer-specific mortality. Survivorship care guidelines emphasize the importance of attention to obesity, weight management, and physical activity. Mobile technologies have been effective for improving health behaviors among cancer survivors, though few studies have focused on AA BC survivors. Creating Healthy Actions through Technology (CHAT) was a 4-week pilot intervention that employed an ecological momentary assessment (EMA) to improve survivors' physical activity and diet behaviors. We evaluated the acceptability, feasibility, and impact of a mHealth intervention for AA BC survivors. Participants (N = 22) were randomized to intervention (n = 13) or control (n = 9). All participants completed daily EMAs via smartphone for 4 weeks and wore accelerometers for seven consecutive days at baseline, 4, and 8 weeks. Intervention participants additionally received tailored health messages. Diet was measured using a self-reported questionnaire and physical activity with accelerometers. Participant engagement was high. Of 84 EMA assessments, the average response was 63 (SD 16.1). Participant accelerometer wear was at least 6 of the 7 days (SD 1.7) for each assessment. Eighty-five percent of participants reported the intervention helped change behaviors. Intervention participants reduced their sedentary time by 4.37 (SD = 7.14) hours/day versus controls (p = .05), reduced fast food intake by 1.5 servings (p = 0.008), and increased vigorous activity by 0.56 (SD = 28.10) minutes, which was non-significant (p = 0.959). Findings show feasibility and acceptability and potential of the intervention to positively impact physical activity among AA BC survivors.

Body Mass Index and Total Symptom Burden in Myeloproliferative Neoplasms Discovery of a U-shaped Association

Elevated body mass index (BMI) is a global health problem, leading to enhanced mortality and the increased risk of several cancers including essential thrombocythemia (ET), a subtype of the Philadelphia-chromosome negative myeloproliferative neoplasms (MPN). Furthermore, evidence states that BMI is associated with the severity of symptom burden among cancer patients. MPN patients often suffer from severe symptom burden. The purpose of this study was to examine whether deviations from a normal BMI in an MPN population are associated with higher symptom burden and reduced quality of life (QoL). A combined analysis of two large cross-sectional surveys, the Danish Population-based Study, MPNhealthSurvey (n = 2044), and the international Fatigue Study (n = 1070), was performed. Symptoms and QoL were assessed using the validated Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF). Analysis of covariance was used to estimate the effects of different BMI categories on symptom scores while adjusting for age, sex, and MPN subtype. A U-shaped association between BMI and Total Symptom Burden was observed in both datasets with significantly higher mean scores for underweight and obese patients relative to normal weight (mean difference: underweight 5.51 (25.8%), p = 0.006; obese 5.70 (26.6%) p < 0.001). This is an important finding, as BMI is a potentially modifiable factor in the care of MPN patients.

Physical activity barriers and resources among black women with a history of breast and endometrial cancer: a systematic review

Physical inactivity is a significant public health problem among black women. However, there is limited evidence regarding barriers to physical activity and the availability of opportunities to engage in physical activity, specifically for posttreatment black women with a history of cancer.

PURPOSE

The purpose of this paper was to systematically review, summarize, and synthesize findings on physical activity-related research including barriers, facilitators, and resources for physical activity among posttreatment black women with a history of breast and endometrial cancer.

METHODS

We developed a comprehensive search strategy and conducted searches in the following databases: PsycINFO, Web of Science, Cochrane, PubMed, and Sociological Abstracts. Summary measures were described qualitatively (e.g., themes) and quantitatively (e.g., frequencies).

RESULTS

This review identified 35 eligible articles describing 12 intervention and 23 observational studies. We described intervention preferences (e.g., resistance activities), beliefs about physical activity, and benefits of physical activity for quality of life (e.g., improvements in social wellbeing) in black cancer survivors. In addition, very few studies identified barriers to physical activity (n = 7) and focused on increasing physical activity (n = 12) among black women with a history of cancer. The most common reported barriers among the target population were fatigue, lack of social support, weather, illness/health issues, cost, time constraints, living too far away, and inability/unwillingness to obtain physician clearance, whereas the most common facilitators were faith, other health concerns, and social support.

CONCLUSIONS/IMPLICATIONS

Future studies should target barriers, facilitators, and culturally adapted strategies for physical activity at all levels of influence to develop multi-level interventions to engage and improve physical activity among black women with a history of breast and endometrial cancer.

PROTOCOL REGISTRATION NUMBER

CRD42018110008.

Relationship of objectively measured physical activity and sedentary behaviour with health-related quality of life among breast cancer survivors

Background

Lack of physical activity throughout one’s lifetime has been associated with obesity and it is also an important risk factor of breast cancer. This study aimed to determine the relationship between objectively measured physical activity and sedentary behaviour with health-related quality of life (HRQoL) among breast cancer survivors in the East Coast region of Peninsular Malaysia.

Methods

A cross-sectional study involving 83 breast cancer survivors was carried out in two main government referral hospitals in the region. Participants wore the ActivPAL3™ microdevice physical activity monitor for seven consecutive days. The validated European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ–C30) and Breast Cancer Supplementary Measure (EORTC QLQ-BR23) were used to measure their HRQoL. Multiple linear regression analysis was conducted to determine the relationship between objectively measured physical activity and sedentary behaviour with HRQoL.

Results

Longer time spent on moderate to vigorous physical activity (MVPA) was significantly associated with an improvement of HRQoL (p = 0.039) whereas longer time spent on sedentary behaviour significantly reduced the functioning score (p = 0.005). In addition, prolonged sedentary bouts were also significantly associated with better body image that led to improved HRQoL (p = 0.013).

Conclusions

The study findings suggest that an increase in the time spent on MVPA was associated with improved HRQoL while sedentary behaviour was associated with poorer HRQoL among breast cancer survivors. Thus, it is essential to displace sedentary behaviour with MVPA to improve the quality of life of breast cancer survivors.

Perceptions of non-Western immigrant women on having breast cancer and their experiences with treatment-related changes in body weight and lifestyle: A qualitative study

BACKGROUND

The number of non-Western immigrants with breast cancer in the Netherlands has increased over the past decades and is expected to triple by 2030. Due to insufficient representation in clinical studies, it is unclear what the specific experiences and needs of these women are. Understanding how culture and religion affect these women's experience of breast cancer and how they deal with chemotherapy and treatment-related changes in body weight and lifestyle is crucial for health care professionals to be able to provide effective support.

METHODS

A qualitative study was conducted using semi-structured interviews with 28 immigrant women with a history of breast cancer treated with chemotherapy.

RESULTS

Women often associated breast cancer with taboo, death or bad luck. Religion offered these women guidance, strength and meaning to the disease, but also limited the women to openly talk about their disease. Women perceived lifestyle factors to have little influence on the development and treatment of cancer. After treatment, however, their thinking changed and these lifestyle factors became of paramount importance to them. They realised that they missed out on information about managing their own diet, exercise and body weight and were eager to share their experiences with other women in their culture with newly diagnosed breast cancer.

CONCLUSION

Women became aware during and after breast cancer treatment that it was difficult for them to actively deal with their illness under the influence of their culture and religion. Based on their own experiences and acquired knowledge, they would like to give advice to newly diagnosed women on how to deal with breast cancer within their own culture and religion. Their recommendations could be used by mosques, churches, support groups and health care professionals, to ensure interventions during breast cancer treatment meet their religious and cultural needs and thus improve their quality of life.

Nutrition Indicators, Physical Function, and Health-Related Quality of Life in Breast Cancer Patients

OBJECTIVE

This study aimed to investigate how nutrition indicators and physical function may influence Health-related Quality of Life (HRQoL) of breast cancer patients undergoing treatment.

METHODS

This was a cross sectional study among a total of 163 breast cancer patients. Series of measurements including anthropometry, biochemical, and dietary were employed to assess patients' nutritional status while physical function was assessed by handgrip strength. HRQoL of patients was determined using European Organization for Research and Treatment of Cancer quality of life questionnaire Core 30 (EORTC-QLQ-C30) version 3.0. Multiple linear regression was used to identify factors associated with HRQoL.

RESULTS

Breast cancer patients perceived moderately their overall quality of life (QoL), with the mean global health status (GHS) score of 69.12. Emotional functioning was the poorest functional scale while fatigue was the most distressing symptom presented by the patients. Approximately 20% of patients had low corrected arm muscle area while more than half had low hemoglobin level. More than 90% of patients did not meet the overall dietary recommendation and had poor handgrip strength. Mid-upper arm circumference (MUAC) was associated with GHS (β: 0.906; 95% CI: 0.22, 1.56) and cognitive functioning (β: -1.543; 95% CI: -3.07, -0.01). Handgrip strength was positively associated with most of HRQoL outcomes.

CONCLUSIONS

Breast cancer patients reported overall good nutritional status and moderate QoL during treatment. Being well-nourished improved HRQoL and handgrip strength could be a potential proxy for functional outcomes as well as overall QoL.

Predictors of Quality of Life in Young Adults Diagnosed With Cancer

A cross-section correlational study was conducted to evaluate the overall quality of life in young adults (AYAs) diagnosed with cancer, and the impact of health-related and non-health-related factors on their quality of life. Fifty-six AYA cancer survivors were recruited to elicit the impact of biological function (cancer type and comorbidity), symptoms, functional status, general perception of health status, gender, and characteristics of the environment on quality of life. Participants experienced higher than average quality of life. Symptoms, functional status, and general perception of health status were significant predictors of quality of life in this group of AYAs diagnosed with cancer. In delivering quality cancer care, nurses must be able to thoroughly assess symptom status, AYA cancer survivors' perception of their health status, and functioning in order to implement supportive measures to help improve their quality of life.

Calidad de Vida: a systematic review of quality of life in Latino cancer survivors in the USA

BACKGROUND

Cancer is the leading cause of death among Hispanics/Latinos. Thus, understanding health-related quality of life (HRQOL) needs among this diverse racial/ethnic group is critical. Using Ferrell's multidimensional framework for measuring QOL, we synthesized evidence on HRQOL needs among Hispanic/Latino cancer survivors.

METHODS

We searched MEDLINE/PubMed, EMBASE, CINAHL, and PsycINFO, for English language articles published between 1995 and January 2020, reporting HRQOL among Hispanic/Latino cancer survivors in the USA.

RESULTS

Of the 648 articles reviewed, 176 met inclusion criteria, with 100 of these studies focusing exclusively on breast cancer patients and no studies examining end-of-life HRQOL issues. Compared with other racial/ethnic groups, Hispanics/Latinos reported lower HRQOL and a higher symptom burden across multiple HRQOL domains. Over 80% of studies examining racial/ethnic differences in psychological well-being (n = 45) reported worse outcomes among Hispanics/Latinos compared with other racial/ethnic groups. Hispanic/Latino cancer survivors were also more likely to report suboptimal physical well-being in 60% of studies assessing racial/ethnic differences (n = 27), and Hispanics/Latinos also reported lower social well-being relative to non-Hispanics/Latinos in 78% of studies reporting these outcomes (n = 32). In contrast, reports of spiritual well-being and spirituality-based coping were higher among Hispanics/Latinos cancer survivors in 50% of studies examining racial/ethnic differences (n = 15).

DISCUSSION

Findings from this review point to the need for more systematic and tailored interventions to address HRQOL needs among this growing cancer survivor population. Future HRQOL research on Hispanics/Latinos should evaluate variations in HRQOL needs across cancer types and Hispanic/Latino subgroups and assess HRQOL needs during metastatic and end-of-life disease phases.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q

Purpose

An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis.

Methods

Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis.

Results

Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (β = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (β = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (β = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05).

Conclusion

Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

Exercise Promotion and Distress Reduction Using a Mobile App-Based Community in Breast Cancer Survivors

Physical activity (PA) enhancement and mental distress reduction are important issues in cancer survivorship care. Mobile technology, as an emerging method for changing health behaviors, is gaining attention from many researchers. This study aimed to investigate the effect of a mobile app-based community on enhancing PA and decreasing distress in breast cancer survivors. We conducted a non-randomized, prospective, interventional study that had a mobile community-later arm and mobile community-first arm. With an Android smartphone app (WalkON®), daily walk steps and weekly distress scores using app-based Distress Thermometer (DT) questionnaires were collected from participants for about 12 weeks. To examine the difference in weekly step counts before and during the community activity, we used a paired t-test method. For a comparative analysis, we referred to a previous prospective observational study without a mobile community intervention that had the same setting as the present study. After propensity score matching (PSM), multivariable regression modeling with difference-in-difference (DID) was performed to estimate the effect of the mobile app-based community on PA and mental distress. From January to August 2018, a total of 64 participants were enrolled in this study. In the univariate analysis, after participation in the mobile community, the participants showed a significant increase in total weekly steps (t = -3.5341; P = 0.00208). The mean of the differences was 10,408.72 steps. In the multivariate analysis after PSM, the mobile community significantly increased steps by 8,683.4 per week (p value <0.0001) and decreased DT scores by 0.77 per week (p value = 0.009) in the mixed effect model. In the two-way fixed effect model, the mobile community showed a significant increase in weekly steps by 8,723.4 (p value <0.0001) and decrease in weekly DT by 0.73 (p value = 0.013). The mobile app-based community is an effective and less resource-intensive tool to increase PA and decrease distress in breast cancer survivors. Trial Registration: NCT03190720, NCT03072966.

Physical activity and quality of life in African American cancer survivors: The Detroit Research on Cancer Survivors study

BACKGROUND

The benefit of regular exercise in improving cancer outcomes is well established. The American Cancer Society (ACS) released a recommendation that cancer survivors should engage in at least 150 minutes of moderate to vigorous physical activity (PA) per week; however, few report meeting this recommendation. This study examined the patterns and correlates of meeting ACS PA recommendations in the Detroit Research on Cancer Survivors (ROCS) cohort of African American cancer survivors.

METHODS

Detroit ROCS participants completed baseline and yearly follow-up surveys to update their health and health behaviors, including PA. This study examined participation in PA by select characteristics and reported health-related quality of life (HRQOL) as measured with the Functional Assessment of Cancer Therapy and Patient-Reported Outcomes Measurement Information System instruments.

RESULTS

Among the first 1500 ROCS participants, 60% reported participating in regular PA, with 24% reporting ≥150 min/wk. Although there were no differences by sex, prostate cancer survivors were the most likely to report participating in regular PA, whereas lung cancer survivors were the least likely (P = .022). Survivors who reported participating in regular PA reported higher HRQOL (P < .001) and lower depression (P = .040).

CONCLUSIONS

Just 24% of African American cancer survivors reported meeting the ACS guidelines for PA at the baseline, but it was encouraging to see increases in activity over time. Because of the established benefits of regular exercise observed in this study and others, identifying and reducing barriers to regular PA among African American cancer survivors are critical for improving outcomes and minimizing disparities.

Using a cultural dance program to increase sustainable physical activity for breast cancer survivors-A pilot study

BACKGROUND

Studies have shown that physical activity can reduce the risk of mortality for female breast cancer patients and improve quality of life, reduce weight, and alter circulating biomarker levels. We conducted a pilot trial to determine the feasibility of increasing physical activity through a cultural dance intervention to achieve similar benefits.

METHODS

Conducted a pilot trial implementing a cultural dance intervention to increase and sustain physical activity for breast cancer survivors, which consisted of a six-month group-based intervention of Hula Dance. Anthropometric measures, fasting blood draws, and self-reported questionnaires to assess physical activity, mood, and quality of life, were completed at baseline, at the end of the 6-month intervention (time point month-6), and at two additional post-intervention time points (month-12 and month-24) to assess sustainability.

RESULTS

A total of 11 women with a median age of 63 years were enrolled in the intervention trial. Eight of the 11 (73%) completed the trial to month-12 and demonstrated an overall significant increase in weekly moderate exercise. There were no significant changes in intra-individual body mass index (BMI). However, there was a sustained post-intervention reduction in waist circumference and significant changes in circulating biomarker levels. For the self-reported measures, there was a significant increase in vigor/activity (p < 0.001; Profile of Mood States-Short Form).

CONCLUSION

Our intervention pilot trial demonstrated that a cultural dance program could achieve a sustainable increase in physical activity for breast cancer survivors, with potential to improve quality of life, increase vigor, and decrease levels of circulating cytokines associated with obesity and inflammation.

Assessing Physical Activity Behavior of Cancer Survivors by Race and Social Determinants of Health

Introduction:

Black cancer survivors remain at a higher risk for secondary cancers, cancer recurrence, and comorbid conditions than non-Hispanic White survivors. Physical activity may help improve health outcomes and overall quality of life. We assessed cancer survivors’ physical activity by race/ethnicity and the effect of social determinants of health (SDH) constructs (i.e., economic stability, education, and access to health care) on physical activity.

Methods:

This was a cross-sectional analysis of data from the 2016 Behavioral Risk Factor Surveillance System. The outcome variable was physical activity after cancer diagnosis and the predictor variables were SDH and race. Multivariable logistic regressions were used to examine associations between race and physical activity and the effect of SDH on physical activity.

Results:

Among 3,787 cancer survivors, 91.6% self-identified as White and 8.4% as Black. Blacks were more likely than Whites to report low economic stability, low access to health care, and low health literacy (all p s < .01). Blacks were less likely than Whites to engage in physical activity after controlling for demographic and clinical factors (adjusted odds ratio [ORAdj] = 0.71; 95% confidence interval [CI] = 0.56–0.91; p = .01) and after additional adjustment of SDH (ORAdj = 0.77; 95% CI = 0.60–0.99; p = .04).

Conclusions:

The findings suggest that though Black cancer survivors are less than White to engage in physical activity, and SDH partially explained the racial difference in physical activity behaviors. These findings highlight the need to address barriers to health-care access, economic stability, and educational attainment.

An exploratory decision tree analysis to predict physical activity compliance rates in breast cancer survivors

Background: The study of physical activity in cancer survivors has been limited to one cause, one effect relationships. In this exploratory study, we used recursive partitioning to examine multiple correlates that influence physical activity compliance rates in cancer survivors. Methods: African American breast cancer survivors (N = 267, Mean age = 54 years) participated in an online survey that examined correlates of physical activity. Recursive partitioning (RP) was used to examine complex and nonlinear associations between sociodemographic, medical, cancer-related, theoretical, and quality of life indicators. Results: Recursive partitioning revealed five distinct groups. Compliance with physical activity guidelines was highest (82% met guidelines) among survivors who reported higher mean action planning scores (P < 0.001) and lower mean barriers to physical activity (P = 0.035). Compliance with physical activity guidelines was lowest (9% met guidelines) among survivors who reported lower mean action and coping (P = 0.002) planning scores. Similarly, lower mean action planning scores and poor advanced lower functioning (P = 0.034), even in the context of higher coping planning scores, resulted in low physical activity compliance rates (13% met guidelines). Subsequent analyses revealed that body mass index (P = 0.019) and number of comorbidities (P = 0.003) were lowest in those with the highest compliance rates. Conclusion: Our findings support the notion that multiple factors determine physical activity compliance rates in African American breast cancer survivors. Interventions that encourage action and coping planning and reduce barriers in the context of addressing function limitations may increase physical activity compliance rates.

Acculturation and Adherence to Physical Activity Recommendations Among Chinese American and Non-Hispanic White Breast Cancer Survivors

Chinese American breast cancer survivors' adherence to recommended physical activity (PA) guidelines has been understudied. This study investigated their PA adherence by acculturation level (vs. non-Hispanic White (NHW) survivors). One hundred ninety five Chinese and 202 NHW breast cancer survivors (stage 0-III) responded to a cross-sectional survey including a self-reported PA questionnaire. PA adherence referred to meeting PA recommendations for cancer survivors. Acculturation among Chinese was defined by proxies of U.S. residency, English proficiency, and interview language. Logistic regression was performed to examine factors associated with PA adherence. More-acculturated Chinese survivors' PA adherence rate was 76%. Less-acculturated Chinese survivors' adherence rate (60%) was significantly lower than that of NHWs (80%) (OR 0.38, 95%CI 0.19, 0.75). Less-acculturated Chinese survivors were also less likely to engage in vigorous-intensity PA than NHWs (p < 0.01). Future research on less-acculturated Chinese survivors' motivation for PA to promote their adherence is needed.

Health Behaviors and Lifestyle Interventions in African American Breast Cancer Survivors: A Review

Background: African American breast cancer survivors have a higher incidence of estrogen receptor negative and basal-like (e.g., triple negative) tumors, placing them at greater risk for poorer survival when compared to women of other racial and ethnic groups. While access to equitable care, late disease stage at diagnosis, tumor biology, and sociodemographic characteristics contribute to health disparities, poor lifestyle characteristics (i.e., inactivity, obesity, and poor diet) contribute equally to these disparities. Lifestyle interventions hold promise in shielding African American survivors from second cancers, comorbidities, and premature mortality, but they are often underrepresented in studies promoting positive behaviors. This review examined the available literature to document health behaviors and lifestyle intervention (i.e., obesity, physical activity, and sedentary behavior) studies in African American breast cancer survivors. Methods: We used PubMed, Academic Search Premier, and Scopus to identify cross-sectional and intervention studies examining the lifestyle behaviors of African American breast cancer survivors. Identified intervention studies were assessed for risk of bias. Other articles were identified and described to provide context for the review. Results: Our systematic review identified 226 relevant articles. The cross-sectional articles indicated poor adherence to physical activity and dietary intake and high rates of overweight and obesity. The 16 identified intervention studies indicated reasonable to modest study adherence rates (>70%), significant reductions in weight (range -1.9 to -3.6%), sedentary behavior (-18%), and dietary fat intake (range -13 to -33%) and improvements in fruit and vegetable intake (range +25 to +55%) and physical activity (range +13 to +544%). The risk of bias for most studies were rated as high (44%) or moderate (44%). Conclusions: The available literature suggests that African American breast cancer survivors adhere to interventions of various modalities and are capable of making modest to significant changes. Future studies should consider examining (a) mediators and moderators of lifestyle behaviors and interventions, (b) biological outcomes, and (c) determinants of enhanced survival in this population.

Exploring tensions within young breast cancer survivors' physical activity, nutrition and weight management beliefs and practices

Purpose: Although the benefits of physical activity, healthy eating, and weight management for breast cancer survivors are well established, little is known about how best to promote these practices among women diagnosed before age 40 years. We conducted a qualitative study to explore young breast cancer survivors' beliefs and practices regarding physical activity, nutrition, and weight management.Methods: Semi-structured interviews were conducted with 12 women (M_age=36 years, SD=3.4) who were within 5 years of breast cancer diagnosis. Data were analyzed using thematic analysis.Results: Participants' accounts revealed several tensions between the factors motivating them to engage in physical activity, healthy eating, and weight management and those deterring them. Tensions were captured within three themes: (1) prolonging life with a healthy lifestyle versus enjoying living; (2) perceiving benefits versus barriers, and; (3) seeking social connection versus protecting the self from social threats. Participants also noted preferences, which if considered could help them maintain healthy lifestyle practices.Conclusions: Although young breast cancer survivors value physical activity, healthy eating, and weight management, they are constantly weighing the benefits of these practices against their perceived drawbacks. To facilitate long-term participation among young breast cancer survivors, future programing must address their conflicting beliefs and priorities.Implications for RehabilitationPhysical activity, healthy eating, and weight management can play an important role in the health and wellbeing of breast cancer survivors.Young breast cancer survivors experience a 'tug-of-war' between the factors motivating them to be active and eat healthy and those deterring them.Following treatment for breast cancer, young women would benefit from tailored lifestyle-based programing that addresses their conflicting beliefs and priorities.Tailored programing might involve strategically scheduled program times or flexible programs designed to include the participation of family and friends.

Health and Racial Disparity in Breast Cancer

Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. It currently affects more than one in ten women worldwide. The chance for a female to be diagnosed with breast cancer during her lifetime has significantly increased from 1 in 11 women in 1975 to 1 in 8 women (Altekruse, SEER Cancer Statistics Review, 1975-2007. National Cancer Institute, Bethesda, 2010). This chance for a female of being diagnosed with cancer generally increases with age (Howlader et al, SEER Cancer Statistics Review, 1975-2010. National Cancer Institute, Bethesda, 2013). Fortunately, the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in the White population. Although the mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic population has continued to grow. The goal of the work presented in this book chapter is to highlight similarities and differences in breast cancer morbidity and mortality rates among non-Hispanic white and non-Hispanic black populations. This book chapter also provides an overview of breast cancer, racial/ethnic disparities in breast cancer, breast cancer incidence and mortality rate linked to hereditary, major risk factors of breast cancer among minority population, breast cancer treatment, and health disparity. A considerable amount of breast cancer treatment research have been conducted, but with limited success for African Americans compared to other ethnic groups. Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities. In addition, it is vital that leaders and medical professionals from minority population groups be represented in decision-making in research so that racial disparity in breast cancer can be well-studied, fully addressed, and ultimately eliminated in breast cancer.

Adherence to Diet and Body Weight Recommendations among Cancer Survivors after Completion of Initial Cancer Treatment: A Systematic Review of the Literature

This systematic review of the literature aimed to 1) provide an overview of the extent to which cancer survivors adhere to diet and body weight recommendations after completion of initial treatment and 2) gain insight into characteristics associated with adherence to these recommendations. Four databases were searched for relevant papers. We included observational studies describing adherence to recommendations on body mass index (BMI), waist-to-hip ratio and waist circumference, fruit and vegetable intake, and alcohol consumption of adult (≥18 yr) cancer survivors after the completion of initial treatment (i.e. surgery, chemotherapy, and radiotherapy). Of the 2,830 articles retrieved from the database search, 12 articles were included. Adherence to the recommendation on BMI varied from 34% to 77%; adherence to the fruit and vegetable recommendation varied from 9% to 83%; and adherence to the recommendation on alcohol consumption varied from 62% to 96.8%. Adherence to waist-to-hip ratio (43%) and waist circumference recommendations (11%) was described in one study among overweight breast cancer survivors. The results of these studies generally suggest that adherence to the recommendation on alcohol intake is relatively high and that adherence to the recommendation on body weight and fruit and vegetable intake should particularly be promoted.