Mechanisms of association between physical functioning and breast cancer mortality: evidence from the Women's Healthy Eating and Living Study

Systemic inflammation and changes in physical well-being in patients with breast cancer: a longitudinal study in community oncology settings

BACKGROUND

Chemotherapy adversely affects physical well-being and inflammation may be related to changes in physical well-being. We evaluated the association of systemic inflammation with changes in physical well-being.

METHODS

In a prospective study of 580 patients with stages I-III breast cancer we assessed immune cell counts, neutrophil:lymphocyte ratio (NLR), lymphocyte:monocyte ratio (LMR), and platelet:lymphocyte ratio (PLR) within 7 days before chemotherapy (pre-chemotherapy). Physical well-being was assessed using the Functional Assessment of Cancer Therapy: General-Physical Well-being subscale (FACT-PWB) pre-chemotherapy and 1 month and 6 months post-chemotherapy. Clinically meaningful decline in physical well-being was determined as decreasing FACT-PWB by more than one point from pre-chemotherapy level, and non-resilience defined as having decline post-chemotherapy and not returning to within one-point of pre-chemotherapy FACT-PWB by 6 months post-chemotherapy. Multivariable logistic regressions examined the association between inflammation and changes in physical well-being, adjusting for sociodemographic and clinical characteristics.

RESULTS

Fifty-nine percent (310/529) and 36% (178/501) of participants had physical well-being decline post-chemotherapy and 6 months post-chemotherapy, respectively. Fifty percent (147/294) were non-resilient. Low NLR and PLR were associated with 1.78 (P = .01) and 1.66 (P = .02) fold greater odds of having a decline in physical well-being 6 months post-chemotherapy compared to those with high NLR and PLR, respectively. Low NLR and PLR were associated with 1.92 (P = .02) and 2.09 (P = 0.01) fold greater odds of being non-resilient 6 months post-chemotherapy compared to those with high NLR and PLR, respectively.

CONCLUSION

Low NLR and PLR were associated with chemotherapy-induced changes in physical well-being independent of sociodemographic and clinical risk factors.

The impact of age on physical functioning after treatment for breast cancer, as measured by patient-reported outcome measures: A systematic review

PURPOSE

This systematic review aims to explore the impact of age on physical functioning post-treatment for early-stage, locally advanced, or locally recurrent breast cancer, as measured by patient-reported outcome measures (PROMs), identify PROMs used and variations in physical functioning terms/labels.

METHODS

MEDLINE, EmBase, PsycINFO, CINAHL and AMED were searched, along with relevant key journals and reference lists. Risk of bias (quality) assessment was conducted using a Critical Appraisal Skills Programme checklist. Data was synthesised through tables and narrative.

RESULTS

28,207 titles were extracted from electronic databases, resulting in 44 studies with age sub-groups, and 120 without age sub-groups. Of those with findings on the impact of age, there was variability in the way findings were reported and 21 % found that age did not have a significant impact. However, 66 % of the studies found that with older age, physical functioning declined post-treatment. Comorbidities were associated with physical functioning declines. However, findings from sub-groups (breast cancer stage, treatment type and time post-treatment) lacked concordance. Twenty-eight types of PROM were used: the EORTC QLQ-C30 was most common (50.6 %), followed by the SF-36 (32.3 %). There were 145 terms/labels for physical functioning: 'physical functioning/function' was used most often (82.3 %).

CONCLUSIONS

Findings point towards an older age and comorbidities being associated with more physical functioning declines. However, it was not possible to determine if stage, treatment type and time since treatment had any influence. More consistent use of the terminology 'physical functioning/function' would aid future comparisons of study results.

Low physical function following cancer diagnosis is associated with higher mortality risk in postmenopausal women

BACKGROUND

Postmenopausal women with cancer experience an accelerated physical dysfunction beyond what is expected through aging alone due to cancer and its treatments. The aim of this study was to determine whether declines in physical function after cancer diagnosis are associated with all-cause mortality and cancer-specific mortality.

METHODS

This prospective cohort study included 8068 postmenopausal women enrolled in the Women's Health Initiative with a cancer diagnosis and who had physical function assessed within 1 year of that diagnosis. Self-reported physical function was measured using the 10-item physical function subscale of the 36-Item Short Form Health Survey. Cause of death was determined by medical record review, with central adjudication and linkage to the National Death Index. Death was adjudicated through February 2022.

RESULTS

Over a median follow-up of 7.7 years from cancer diagnosis, 3316 (41.1%) women died. Our results showed that for every 10% difference in the physical function score after cancer diagnosis versus pre-diagnosis, all-cause mortality and cancer-specific mortality were reduced by 12% (hazard ratio [HR] = 0.88, 95% confidence interval  [95% CI] = 0.87 to 0.89 and HR = 0.88, 95% CI = 0.86 to 0.91, respectively). Further categorical analyses showed a significant dose-response relationship between postdiagnosis physical function categories and mortality outcomes (P < .001 for trend), where the median survival time for women in the lowest physical function quartile was 9.1 years (Interquartile range [IQR] = 8.6-10.6 years) compared with 18.4 years (IQR = 15.8-22.0 years) for women in the highest physical function quartile.

CONCLUSION

Postmenopausal women with low physical function after cancer diagnosis may be at higher risk of mortality from all causes and cancer-related mortality.

Acute health-related quality of life outcomes and systemic inflammatory markers following contemporary breast cancer surgery

Contemporary breast cancer surgical procedures vary greatly by the amount of tissue removed, anesthesia time, and reconstruction. Despite historical literature comparing the health-related quality of life (HRQOL) after lumpectomy and mastectomy, HRQOL data are limited regarding contemporary surgical procedures. Further, biological processes (e.g., inflammation) associated with HRQOL outcomes have not been described. We conducted two studies to examine differences in post-operative physical and mental functioning, pain, fatigue, and systemic inflammatory markers including interleukin (IL)-6, tumor necrosis factor (TNF)-α, and C-reactive protein (CRP) in women with early-stage breast cancer. Study 1 assessed women before and after surgery (n = 27) and Study 2 used a large cross-sectional sample (n = 240) to confirm findings from Study 1 and included a no-surgery comparison group. In Study 1, women who received mastectomy had lower physical functioning than lumpectomy (ps < 0.05), and those who received bilateral mastectomy had worse pain (p < 0.01) and fatigue (p = 0.029) than lumpectomy. Results were replicated in Study 2: mastectomy groups exhibited poorer physical functioning (ps < 0.01) and greater pain (ps < 0.001) than lumpectomy, and bilateral mastectomy was associated with worse fatigue (p < 0.05). Women who received bilateral mastectomy had higher levels of CRP than lumpectomy (p < 0.01) and higher TNF-α than the no-surgery group (p < 0.05). All surgery groups exhibited higher IL-6 than no-surgery (ps < 0.05). More extensive surgery is associated with poorer postoperative HRQOL. As compared to lumpectomy and no-surgery, mastectomy is associated with higher concentrations of systemic inflammatory markers.

Physical functioning, frailty and risks of locally-advanced breast cancer among older women

Objective

Women with multiple comorbidities have competing health needs that may delay screening for early detection of breast cancer. Our objective was to determine associations between physical functioning and frailty with risk of locally-advanced breast cancer (BC).

Methods

We conducted a retrospective cohort study of women 65 years and older diagnosed with first primary stage I-III BC using the Surveillance, Epidemiology and End Results Medicare Health Outcome Survey Data Resource. Physical health-related quality of life was measured using Veterans RAND 12 Item Health Survey scales within two years before diagnosis; frailty was determined by calculating deficit-accumulation frailty index (DAFI) scores. Multivariable modified Poisson regression models were used to estimate rate ratios (RR) and 95% confidence intervals (CI) for risk of locally-advanced (stage III) versus early-stage (I-II) BC.

Results

Among 2411 women with a median age of 75 years at BC diagnosis, 2189 (91%) were diagnosed with incident stage I-II BC and 222 (9%) were diagnosed at stage III. Compared to women with early-stage disease, women with locally-advanced BC had lower physical component scores (37.8 vs. 41.4) and more classified as pre-frail or frail (55% vs. 50%). In multivariable models, frailty was not associated with increased risk of locally-advanced disease. However, worse physical function subscale scores (lowest vs. upper quartile; RR = 1.56, 95% CI 1.04–2.34) were associated with risk of locally-advanced BC.

Conclusions

Breast cancer screening among non-frail older women should be personalized to include women with limited physical functioning if the benefits of screening and early detection outweigh the potential harms.

•

Older women have competing health needs that may delay early detection of breast cancer.

•

Women with locally-advanced disease had lower health-related quality of life prior to diagnosis.

•

Worse physical functioning was associated with risk of locally-advanced breast cancer.

PAVING the Path to Wellness for Breast Cancer Survivors: Lifestyle Medicine Education and Group Interventions

There are over 3.5 million breast cancer survivors living in the United States. Key elements of breast cancer survivorship care include monitoring for disease recurrence, addressing medical and psychosocial consequences of treatment, and educating about lifestyle interventions which decrease risk of recurrence, improve quality of life, and improve outcome. We have developed the PAVING the Path to Wellness Program for Breast Cancer Survivors in order to provide education on evidence-based topics from lifestyle medicine, with the goal to help women adopt healthy habits and improve well-being after cancer treatment. The 12-week program includes all 6 pillars of lifestyle medicine, as well as positive psychology, gratitude, and goal setting work. The PAVING the Path to Wellness Program for Breast Cancer Survivors empowers breast cancer survivors with knowledge regarding evidence-based lifestyle recommendations and helps them achieve an improved sense of well-being following treatment. On completion of the program, participants specifically reported an improvement in attitude and well-being. Next steps involve developing a strategy to offer this program to a larger group of cancer survivors.

Barthel Index-based functional status as a prognostic factor in young and middle-aged adults with newly diagnosed gastric, colorectal and lung cancer: a multicentre retrospective cohort study

OBJECTIVES

Functional status assessments of activities of daily living may improve prognostic precision during initial diagnostic evaluations in young and middle-aged adults with cancer. However, the association between pretreatment functional status and survival in these patients is poorly understood. This study aimed to evaluate the prognostic value of functional status in young and middle-aged patients with cancer.

DESIGN

Multicentre retrospective cohort study.

SETTING

We used a cancer registry from Osaka Prefecture, Japan. The data were linked to administrative claims data from 35 hospitals in the same prefecture.

PARTICIPANTS

Patients aged 18-69 years who received new diagnoses of gastric, colorectal or lung cancer between 2010 and 2014.

MAIN OUTCOME MEASURE

Cox proportional hazards models of 5-year all-cause mortality were developed to examine the prognostic impact of pretreatment functional status, which was categorised into three levels of functional disability (none, moderate and severe) based on Barthel Index scores. The models controlled for age, sex, comorbidities, cancer stage and tumour histology.

RESULTS

We analysed 12 134 patients. Higher mortality risks were significantly associated with moderate functional disability (adjusted HR 1.44 (95% CI 1.18 to 1.75), 1.35 (95% CI 1.08 to 1.68) and 1.74 (95% CI 1.50 to 2.03) in patients with gastric, colorectal and lung cancer, respectively) and severe functional disability (adjusted HR 3.56 (95% CI 2.81 to 4.51), 2.37 (95% CI 1.89 to 2.95) and 2.34 (95% CI 2.00 to 2.75) in patients with gastric, colorectal and lung cancer, respectively).

CONCLUSION

Accounting for functional status at cancer diagnosis may improve the prediction of survival time in young and middle-aged adults with cancer. Functional status has potential applications in survival predictions and risk adjustments when analysing outcomes in patients with cancer.

Functional Decline and Resilience in Older Women Receiving Adjuvant Chemotherapy for Breast Cancer

OBJECTIVES

To analyze self-reported changes in physical function in older women with breast cancer receiving adjuvant chemotherapy.

DESIGN

Secondary analysis of the Cancer and Leukemia Group B (CALGB) 49907 prospective randomized clinical trial.

SETTING

CALGB institutions in the United States.

PARTICIPANTS

Women aged 65 and older with Stage I to III breast cancer enrolled in CALGB 49907 who had physical function data from before and after receipt of adjuvant chemotherapy (N=256; mean age 71.5, range 65-85).

MEASUREMENTS

Participants were administered the physical function subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire before chemotherapy, at the end of chemotherapy, and 12 months after chemotherapy initiation. Functional decline was defined as a more than 10-point decrease from baseline at each time point. Resilience was defined as return to within 10 points of baseline. Multivariable regression was used to examine pretreatment characteristics associated with physical function changes.

RESULTS

Of 42% of participants who had physical function decline from before to the end of chemotherapy, 47% recovered by 12 months (were resilient). Almost one-third experienced functional decline from before chemotherapy to 12 months later. Pretreatment fatigue was a risk factor for functional decline from before to the end of chemotherapy (P=.02). Risk factors for functional decline at 12 months included pretreatment dyspnea (P=.007) and being unmarried (P=.01).

CONCLUSION

Functional decline was common in older women receiving adjuvant chemotherapy for breast cancer in a clinical trial. Although half recovered their physical function, one-third had a clinically meaningful decline at 12 months. Strategies are needed to prevent functional decline in older adults receiving chemotherapy. J Am Geriatr Soc 67:920-927, 2019.

Weight Lifting and Physical Function Among Survivors of Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial

PURPOSE

Survivors of breast cancer may experience deterioration of physical function. This is important because poor physical function may be associated with premature mortality, injurious falls, bone fracture, and disability. We conducted a post hoc analysis to explore the potential efficacy of slowly progressive weight lifting to reduce the incidence of physical function deterioration among survivors of breast cancer.

METHODS

Between October 2005 and August 2008, we conducted a single-blind, 12-month, randomized controlled trial of twice-per-week slowly progressive weight lifting or standard care among 295 survivors of nonmetastatic breast cancer. In this post hoc analysis of data from the Physical Activity and Lymphedema Trial, we examined incident deterioration of physical function after 12 months, defined as a ≥ 10-point decrease in the physical function subscale of the Medical Outcomes Short-Form 36-item questionnaire.

RESULTS

The proportion of participants who experienced incident physical function deterioration after 12 months was 16.3% (24/147) in the control group and 8.1% (12/148) in the weight lifting group (relative risk, 0.49; 95% CI, 0.25 to 0.96; P = .04). No serious or unexpected adverse events occurred that were related to weight lifting.

CONCLUSION

Slowly progressive weight lifting compared with standard care reduced the incidence of physical function deterioration among survivors of breast cancer. These data are hypothesis generating. Future studies should directly compare the efficacy of weight lifting with other modalities of exercise, such as brisk walking, to appropriately inform the development of a confirmatory study designed to preserve physical function among survivors of breast cancer.