Understanding the Essential Meaning of Measured Changes in Weight and Body Composition Among Women During and After Adjuvant Treatment for Breast Cancer: A Mixed-Methods Study

Factors associated with weight gain in pre- and post-menopausal women receiving adjuvant endocrine therapy for breast cancer

PURPOSE

Weight gain after breast cancer poses health risks. We aimed to identify factors associated with weight gain during adjuvant endocrine therapy (AET).

METHODS

Women initiating AET enrolled in a prospective cohort. Participants completed FACT-ES plus PROMIS pain interference, depression, anxiety, fatigue, sleep disturbance and physical function measures at baseline, 3, 6, 12, 24, 36, 48 and 60 months. Treatment-emergent symptoms were defined as changes in scores in the direction indicative of worsening symptoms that exceeded the minimal important difference at 3 and/or 6 months compared to baseline. We used logistic regression to evaluate associations of clinicodemographic features and treatment-emergent symptoms with clinically significant weight gain over 60 months (defined as ≥ 5% compared to baseline) in pre- and post-menopausal participants.

RESULTS

Of 309 participants, 99 (32%) were pre-menopausal. The 60 months cumulative incidence of clinically significant weight gain was greater in pre- than post-menopausal participants (67% vs 43%, p < 0.001). Among pre-menopausal participants, treatment-emergent pain interference (OR 2.49), aromatase inhibitor receipt (OR 2.8), mastectomy, (OR 2.06) and White race (OR 7.13) were associated with weight gain. Among post-menopausal participants, treatment-emergent endocrine symptoms (OR 2.86), higher stage (OR 2.25) and White race (OR 2.29) were associated with weight gain while treatment-emergent physical function decline (OR 0.30) was associated with lower likelihood of weight gain.

CONCLUSIONS

Weight gain during AET is common, especially for pre-menopausal women. Clinicodemographic features and early treatment-emergent symptoms may identify at risk individuals.

IMPLICATIONS FOR CANCER SURVIVORS

Patients at risk for weight gain can be identified early during AET.

CLINICAL TRIALS

GOV IDENTIFIER

NCT01937052, registered September 3, 2013.

Racial differences in weight perception among Black and White women diagnosed with breast cancer

PURPOSE

Black women are more likely than White women to have obesity, and obesity is associated with worse breast cancer prognosis. Weight perception, however, has not been studied as a potential mediator of obesity disparities in women with breast cancer. In this study, we sought to describe racial differences and the association of lifestyle factors with weight perception.

METHODS

In this cross-sectional study design, Black and White women with a new primary breast cancer were surveyed about socio-demographics, weight perception, diet, and exercise habits. Height and weight were measured at enrollment. We classified women with a BMI ≥ 25 kg/m2 or waist circumference ≥ 88 cm who reported that they were "about the right weight" as under-perceivers. Chi-square and t tests were used to assess study variables (e.g., race, physical activity) associated with under-perception of weight. Logistic regression models were fit to evaluate for racial differences in under-perception while controlling for other covariates.

RESULTS

Of 1,197 women with newly diagnosed breast cancer, the average age was 58 years, and 909 (75.9%) were White. Nine hundred eighteen (77%) had stage I cancer, 1,035 (87%) had estrogen receptor positive cancer, and 795 (66%) were privately insured at time of diagnosis. Seven hundred eighty-nine (66%) women had abdominal obesity (waist circumference ≥ 88 cm), while 366 (31%) women had a BMI ≥ 25 kg/m2. Overall, 24% of women were under-perceivers. Compared to White women, Black women with WC ≥ 88 cm more frequently under-perceived their weight (24% vs. 14% p < 0.0001) were more obese with BMI > 30 kg/m2 (51% vs. 23%, p < 0.0001) and had lower physical activity (22% vs. 77%, p < 0.0001). After controlling for age, education, and stage, Black women remained more likely to under-perceive their weight relative to White women for those with BMI ≥ 25 kg/m2 (OR: 2.64; 95% CI: 1.4-4.6) or waist circumference ≥ 88 cm (OR: 2.89; 95% CI: 1.8-4.5). With respect to lifestyle factors, among women with BMI ≥ 25 kg/m2, those who met physical activity guidelines were less likely to under-perceive their weight compared to those who did not meet physical activity guidelines (OR: 0.37; 95% CI: 0.2-0.6), regardless of race.

CONCLUSIONS

We found racial differences in weight perception and identified social determinants and lifestyle factors such as lower education and physical inactivity that influenced under-perception of weight among newly diagnosed breast cancer patients.

IMPLICATIONS FOR CANCER SURVIVORS

Since obesity is associated with worse breast cancer outcomes, identifying optimal modifiable factors to intervene upon to support weight management among breast cancer survivors is clinically important. Breast cancer patients' perceptions about their weight provide insight that may inform lifestyle behavior interventions to reduce obesity during survivorship care.

Body acceptance in women with breast cancer: A concept analysis using a hybrid model

BACKGROUND

Women with breast cancer undergo drastic physical changes which can impact their body image. Accepting the altered body has recently been highlighted as the key to body image improvement, however, there is no clear definition or conceptualization of it. This study clarified the concept of body acceptance in women with breast cancer, using a hybrid model.

METHODS

In the theoretical phase, the attributes and working definitions of the concept were identified through an extensive literature review. Individual in-depth interviews were conducted during the fieldwork phase to elucidate the concept and verify the attributes derived from the theoretical phase. Finally, in the final analytic phase, the findings were compared and integrated.

RESULTS

The theoretical and fieldwork phases included 20 out of the 579 articles extracted from the literature search and five women who had undergone breast cancer surgery, respectively. Body acceptance was defined as "acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment".

CONCLUSIONS

Body acceptance has been identified as a key factor directly related to the overall quality of life. This study provides a theoretical basis for developing effective interventions and consequently facilitates their provision in practice.

Energy balance in cancer survivors at risk of weight gain: a review

PURPOSE

The study of energy balance [i.e., energy intake (EI) and energy expenditure (EE)] is a powerful tool for understanding body weight regulation and may contribute to our understanding of rapid weight gain risk in certain cancer survivors post-diagnosis. The purpose of this review was to summarize studies that assessed longitudinal, prospective changes in components of energy balance from diagnosis/start of treatment to any duration of follow-up in cancer survivors with prior evidence of weight gain (breast, prostate, thyroid, gynecologic, testicular, and acute lymphoblastic leukemia) RESULTS: The available literature suggests that energy balance components may be altered in cancer survivors who have a heightened risk of weight gain post-diagnosis. The evidence for EI was overall inconsistent. Conversely, decreases in resting and physical activity EE during the active phases of treatment (e.g., chemotherapy, hypothyroid state) were commonly noted, which then slowly rebounded towards baseline levels at the end of treatment and during follow-up assessments. Much of this evidence is based on data collected from breast cancer survivors, which highlights a paucity of data currently available on other cancer types.

CONCLUSIONS

While there is growing acknowledgement that weight management interventions in cancer survivors are needed, it is important to recognize that changes in both behavioral (EI, physical activity EE) and passive (resting EE, thermic effect of food) components of energy balance may occur post-diagnosis. This information can help to inform weight management interventions which often entail modifications in diet and/or physical activity.

Tackling the adverse health effects of excess body fat in breast cancer: where does physical activity fit in?

Weight gain is commonly observed during and after breast cancer treatment due to chemotherapy and endocrine therapies, induced menopause, changes in metabolism and food intake and decreased physical activity. Systematic reviews show that women who are overweight or obese at diagnosis, and those who gain weight, have poorer breast cancer survival outcomes than women of a healthy weight, irrespective of menopausal status. Excess body weight after breast cancer also increases the risk of type 2 diabetes mellitus and CVD. The adverse impact of excess body weight on survival outcomes is clearly shown for women with oestrogen receptor-positive (ER+) breast cancer, which accounts for 70 % of all breast cancer cases. Higher body fat is thought to increase the risk of ER+ recurrence because of increased aromatase activity. However, this could be compounded by other risk factors, including abnormal insulin and adipokine metabolism, impaired anti-tumour immunity and chronic low-grade systemic inflammation. Observational evidence linking poorer survival outcomes with excess body fat and low physical activity in women recovering from early-stage curative-intent breast cancer treatment is reviewed, before reflecting on the proposed biological mechanisms. The issues and sensitivities surrounding exercise participation amongst overweight breast cancer patients is also discussed, before providing an overview of the co-design process involved in development of an intervention (support programme) with appropriate content, structure and delivery model to address the weight management challenges faced by overweight ER+ breast cancer patients.

Barriers and enablers of weight management after breast cancer: a thematic analysis of free text survey responses using the COM-B model

Background

Weight gain is common after breast cancer. The aim of this study was to identify and describe the barriers to and enablers of successful weight management for women with breast cancer.

Methods

This was a combined inductive and deductive framework analysis of free text responses to an anonymous cross-sectional survey on weight after breast cancer. Women were recruited mainly through the Breast Cancer Network Australia Review and Survey Group. We applied deductive thematic analysis to free text responses to questions on barriers, enablers, research priorities, and one open-ended question at the end of the survey using the Capability, Opportunity, Motivation and Behaviour (COM-B) model as a framework. Subthemes that arose from the inductive analysis were mapped onto the COM-B model framework. Findings were used to identify behaviour change intervention functions.

Results

One hundred thirty-three women provided free text responses. Most women were of Caucasian origin and had been diagnosed with non-metastatic breast cancer, with a mean age of 59.1 years. Women's physical capability to adopt and sustain healthy lifestyle habits was significantly affected by treatment effects and physical illness, and some lacked psychological capability to self-regulate the face of stress and other triggers. Limited time and finances, and the social impact of undergoing cancer treatment affected the ability to control their diet. Frustration and futility around weight management were prominent. However, some women were confident in their abilities to self-regulate and self-monitor lifestyle behaviours, described support from friends and health professionals as enablers, and welcomed the physical and psychological benefits of being active in the context of embracing transformation and self-care after cancer.

Conclusion

Women need specific advice and support from peers, friends and families and health professionals. There is a substantial gap in provision of supportive care to enable women to adopt and sustain healthy lifestyles. Environmental restructuring (including financial support), incentivization (creating an expectation of looking and feeling better), persuasion and coercion (aiming to prevent recurrence), and equipping women with specific knowledge and skills, would also facilitate optimal lifestyle behaviours and weight management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13980-6.

The Impact of Dietary Counselling on Achieving or Maintaining Normal Nutritional Status in Patients with Early and Locally Advanced Breast Cancer Undergoing Perioperative Chemotherapy

Background: Obesity is an independent prognostic factor and is associated with poorer response to oncological treatment of breast cancer. Obesity is associated with shorter overall survival and shorter time to recurrence. Material and methods: The study included 104 breast cancer patients qualified for neoadjuvant chemotherapy. The control group consisted of 40 patients who refused to participate in the study. Consultation before chemotherapy included: author's diet questionnaire, body composition analysis, nutrition education. After chemotherapy, the effects of the first dietary advice were evaluated. Results: More than half of all women had a BMI above normal before treatment. Analysis of the effects of nutrition education showed a significant improvement in body composition. After education, a slight increase in body weight and a significant decrease in fat mass and fat percentage were observed. In women who did not participate in education, a statistically significantly greater increase in body weight after chemotherapy was noted. Nutrition education of the study group did not prevent adverse changes in lipid profile resulting from chemotherapy. Conclusions: Dietary counselling prior to neoadjuvant chemotherapy may limit weight gain and may also influence fat mass reduction. Implementation of dietary recommendations does not guarantee maintenance of normal lipid parameters during chemotherapy.

Healthy Eating as a New Way of Life: A Qualitative Study of Successful Long-Term Diet Change

Background

Improving diet quality has been shown to be an effective way to improve health and well-being. Yet information on how to assist those wanting to transition to and maintain a healthier diet is still limited. The aim of this study was to explore what motivated people to initiate and maintain a healthy diet.

Methods

Semi-structured interviews were conducted with 20 participants (all Australian residents) who had made significant improvements to their diets and had maintained these changes for a minimum of two years (n_female = 15, n_male = 5, M_age = 37.7, SD = 12.4). The transcripts were analysed using thematic analysis which identified five overarching themes: A desire to feel better, investigation and learning, helpful habits, benefits, and values.

Results

Participants reported a strong wish to feel better and investigated the role of diet as a possible way to improve well-being. Through daily habits and continuous engagement with the topic, healthy eating became a way of life for many participants. Experiencing the benefits of a healthier diet and having developed strong values regarding diet and health supported long-term maintenance.

Conclusions

Findings from the present study contribute to the literature in highlighting the importance of internal motivation and autonomy for health behaviours. Findings may inform the development of healthy eating interventions. Encouraging autonomy, fostering values aligned with a healthier diet, and helping individuals establish daily habits is likely to support change.

Existential phenomenology as a unifying philosophy of science for a mixed method study

This article discusses how existential phenomenology may serve as a frame in a mixed-methods study of changes in weight and body composition among women in adjuvant treatment for breast cancer. In accordance with ontologically and epistemologically fundamental assumptions in nursing, we link mixed-methods and existential phenomenology from the perspective of the French philosopher Maurice Merleau-Ponty and his notion of a unified body subject. Letting this perspective permeate our philosophy, methodology and issues at the method level in mixed-method research undermines the distinction between first- and third-person perspective when applying and integrating different data sources in a mixed-methods study. Applying Merleau-Ponty's third way, the women's bodily experiences appear as gestalt; a 'figure' against a ground of existential threats that are grasped through insight from data integrating in joint displays, which revealed the women's experiences on a deep existential level. Existential phenomenology as a frame in mixed-method studies can speak not only to nurses but also to a multidisciplinary audience in a shared attempt to deepen the understanding of a patient's healthcare problem.

Diet and weight management by people with nonmetastatic colorectal cancer during chemotherapy: mixed methods research

Aim: To investigate self-management of dietary intake by colorectal cancer patients receiving chemotherapy. Methods: A questionnaire was administered to 92 patients with nonmetastatic colorectal cancer receiving chemotherapy treatment at a UK cancer center in 2018–19. A maximum variation sample of 20 patients who completed the questionnaire were interviewed. Results: More than three in five patients were at nutritional risk but fewer than one in five were concerned about dietary intake or weight. Self-management of diet and weight was inconsistent with achieving the nutritional intake recommended by clinical guidelines on nutrition in cancer. Conclusion: There is potential for psychoeducation to support change in self-management of nutritional risk, with implications for better treatment tolerance and outcomes including quality of life.

Perception of women with breast cancer undergoing chemotherapy: a comprehensive analysis

ABSTRACT Objective: To comprehensively analyze the perception of women with breast cancer on the experience of undergoing chemotherapy. Method: This was a qualitative, descriptive, phenomenological study, supported by the Merleau-Ponty philosophy. It was conducted in a chemotherapy outpatient clinic with 20 participants who completed a phenomenological interview. Results: The phenomenological data analysis demonstrated that the perception of women about the experience of chemotherapy is about change, not only of the physical body, but of their identity, and that it considers existential aspects. Three categories emerged from the experience of alopecia, fatigue, and spirituality, respectively: the body itself, the current and habitual body, and transcendence. Final considerations: Bodily changes, and the existential implications perceived by the women in this study, analyzed from the Merleau-Ponty perspective, makes it possible to consider body concept, and provides support for humanized care based on singularity and the socio-cultural context.

Lifestyle change experiences among breast cancer survivors participating in a pilot intervention: A narrative thematic analysis

PURPOSE

Healthy lifestyle adoption among breast cancer (BC) survivors remains a poorly understood process. This study aimed to qualitatively examine the unique change trajectories of BC survivors who partook in a pilot version of the Healthy Lifestyle Modification After Breast Cancer (HLM-ABC) intervention.

METHODS

A sample of four BC survivors were studied intensively through longitudinal interviews conducted at four time points with each participant: (1) pre-treatment, (2) mid-way treatment, (3) post-treatment, and (4) three-months following their participation in the HLM-ABC. A multiple-case study, narrative analysis was applied to 15 interviews, resulting in individual narratives as well as shared 'thematic intersections' elucidating cross-participant experiences.

RESULTS

The findings showed that participants offered unique styles of authorship, characterized by diverse struggles, victories, and motivational insights, organized around the following intersecting themes: (1)Weight management prescription as a motivator or deterrent, (2) 'Time for me' is time away from my family, and (3) Patterns of opposition to lifestyle change. These women's rich, storied accounts suggest experiences of personal growth and imply that existential concerns can be both motivating and deterring in relation to health behavior change.

CONCLUSION

This research provides a comprehensive and nuanced grasp of healthy lifestyle modification in the survivorship stage of BC.

Changes in body composition during and after adjuvant or neo-adjuvant chemotherapy in women with breast cancer stage I-IIIB compared with changes over a similar timeframe in women without cancer

Purpose

Body weight and body composition may change during and after adjuvant or neo-adjuvant chemotherapy for breast cancer. However, most studies did not include a comparison group of women without cancer, thus could not assess whether observed changes differed from age-related fluctuations in body weight and body composition over time. We assessed changes in body composition during and after chemotherapy in breast cancer patients compared with age-matched women not diagnosed with cancer.

Methods

We recruited 181 patients with stage I–IIIb breast cancer and 180 women without cancer. In patients, we assessed body composition using a dual-energy X-ray scan before start of chemotherapy (T1), shortly after chemotherapy (T2), and 6 months after chemotherapy (T3); for the comparison group, the corresponding time points were recruitment (T1) and 6 (T2) and 12 (T3) months.

Results

Fifteen percent of patients and 8% of the comparison group gained at least 5% in body weight between T1 and T3. Among the comparison group, no statistically significant changes in body weight, or body composition were observed over time. Body weight of patients significantly increased from baseline (72.1 kg ± 0.4 kg) to T2 (73.3 kg ± 0.4 kg), but decreased to 73.0 kg ± 0.4 kg after chemotherapy (T3). Lean mass of patients significantly increased from 43.1 kg ± 0.5 kg at baseline to 44.0 kg ± 0.5 kg at T2, but returned to 43.1 kg ± 0.5 kg at T3. There were no differential changes in fat mass over time between patients and the comparison group.

Conclusions

Changes in body weight and body composition during and after chemotherapy for early stage breast cancer were modest, and did not differ substantially from changes in body weight and body composition among women without cancer.