Study protocol to investigate the effect of a lifestyle intervention on body weight, psychological health status and risk factors associated with disease recurrence in women recovering from breast cancer treatment [ISRCTN08045231]

Body weight management in overweight and obese breast cancer survivors

BACKGROUND

Studies suggest that overweight and obese breast cancer survivors are at increased risk of cancer recurrence and have higher all-cause mortality. Obesity has an impact on breast cancer survivor's quality of life (QOL) and increases the risk of longer-term morbidities such as type 2 diabetes mellitus and cardiovascular disease. Many cancer guidelines recommend survivors maintain a healthy weight but there is a lack of evidence regarding which weight loss method to recommend.

OBJECTIVES

To assess the effects of different body weight loss approaches in breast cancer survivors who are overweight or obese (body mass index (BMI) ≥ 25 kg/m2).

SEARCH METHODS

We carried out a search in the Cochrane Breast Cancer Group's (CBCG's) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6), MEDLINE (2012 to June 2019), Embase (2015 to June 2019), the World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP) and Clinicaltrials.gov on 17 June 2019. We also searched Mainland Chinese academic literature databases (CNKI), VIP, Wan Fang Data and SinoMed on 25 June 2019. We screened references in relevant manuscripts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and randomised cross-over trials evaluating body weight management for overweight and obese breast cancer survivors (BMI ≥ 25 kg/m2). The aim of the intervention had to be weight loss.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessed risk of bias for the included studies, and applied the quality of the evidence using the GRADE approach. Dichotomous outcomes were analysed as proportions using the risk ratio (RR) as the measure of effect. Continuous data were analysed as means with the measure of effect being expressed as the mean differences (MDs) between treatment groups in change from baseline values with 95% confidence intervals (CIs), when all studies reported exactly the same outcomes on the same scale. If similar outcomes were reported on different scales the standardised mean difference (SMD) was used as the measure of effect. Quality of life data and relevant biomarkers were extracted where available.

MAIN RESULTS

We included a total of 20 studies (containing 23 intervention-comparisons) and analysed 2028 randomised women. Participants in the experimental groups received weight loss interventions using the core element of dietary changes, either in isolation or in combination with other core elements such as 'diet and exercise', 'diet and psychosocial support' or 'diet, exercise and psychosocial support'. Participants in the controls groups either received usual care, written materials or placebo, or wait-list controls. The duration of interventions ranged from 0.5 months to 24 months. The duration of follow-up ranged from three months to 36 months. There were no time-to-event data available for overall survival, breast cancer recurrence and disease-free survival. There was a relatively small amount of data available for breast cancer recurrence (281 participants from 4 intervention-comparisons with 14 recurrence events; RR 1.95, 95% CI 0.68 to 5.60; low-quality evidence) and the analysis was likely underpowered. Overall, we found low-quality evidence that weight loss interventions for overweight and obese breast cancer survivors resulted in a reduction in body weight (MD: -2.25 kg, 95% CI: -3.19 to -1.3 kg; 21 intervention-comparisons; 1751 women), body mass index (BMI) (MD: -1.08 kg/m2, 95% CI: -1.61 to -0.56 kg/m2; 17 intervention-comparisons; 1353 women), and waist circumference (MD:-1.73 cm, 95% CI: -3.17 to -0.29 cm; 13 intervention-comparisons; 1193 women), and improved overall quality of life (SMD: 0.74; 95% CI: 0.20 to 1.29; 10 intervention-comparisons; 867 women). No increase was seen in adverse events for women in the intervention groups compared to controls (RR 0.94, 95% CI: 0.76 to 1.17; 4 intervention-comparisons; 394 women; high-quality evidence). Subgroup analyses revealed that decreases in body weight, BMI and waist circumference were present in women regardless of their ethnicity and menopausal status. Multimodal weight loss interventions (which referred to 'diet, exercise and psychosocial support') appeared to result in greater reductions in body weight (MD: -2.88 kg, 95% CI: -3.98 to -1.77 kg; 13 intervention-comparisons; 1526 participants), BMI (MD: -1.44 kg/m2, 95% CI: -2.16 to -0.72 kg/m2; 11 studies; 1187 participants) and waist circumference (MD:-1.66 cm, 95% CI: -3.49 to -0.16 cm; 8 intervention-comparisons; 1021 participants) compared to dietary change alone, however the evidence was low quality.

AUTHORS' CONCLUSIONS

Weight loss interventions, particularly multimodal interventions (incorporating diet, exercise and psychosocial support), in overweight or obese breast cancer survivors appear to result in decreases in body weight, BMI and waist circumference and improvement in overall quality of life. There was no increase in adverse events. There is a lack of data to determine the impact of weight loss interventions on survival or breast cancer recurrence. This review is based on studies with marked heterogeneity regarding weight loss interventions. Due to the methods used in included studies, there was a high risk of bias regarding blinding of participants and assessors. Further research is required to determine the optimal weight loss intervention and assess the impact of weight loss on survival outcomes. Long-term follow-up in weight loss intervention studies is required to determine if weight changes are sustained beyond the intervention periods.

Dietary interventions for adult cancer survivors

BACKGROUND

International dietary recommendations include guidance on healthy eating and weight management for people who have survived cancer; however dietary interventions are not provided routinely for people living beyond cancer.

OBJECTIVES

To assess the effects of dietary interventions for adult cancer survivors on morbidity and mortality, changes in dietary behaviour, body composition, health-related quality of life, and clinical measurements.

SEARCH METHODS

We ran searches on 18 September 2019 and searched the Cochrane Central Register of Controlled trials (CENTRAL), in the Cochrane Library; MEDLINE via Ovid; Embase via Ovid; the Allied and Complementary Medicine Database (AMED); the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the Database of Abstracts of Reviews of Effects (DARE). We searched other resources including reference lists of retrieved articles, other reviews on the topic, the International Trials Registry for ongoing trials, metaRegister, Physicians Data Query, and appropriate websites for ongoing trials. We searched conference abstracts and WorldCat for dissertations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people following a cancer diagnosis. The intervention was any dietary advice provided by any method including group sessions, telephone instruction, written materials, or a web-based approach. We included comparisons that could be usual care or written information, and outcomes measured included overall survival, morbidities, secondary malignancies, dietary changes, anthropometry, quality of life (QoL), and biochemistry.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two people independently assessed titles and full-text articles, extracted data, and assessed risk of bias. For analysis, we used a random-effects statistical model for all meta-analyses, and the GRADE approach to rate the certainty of evidence, considering limitations, indirectness, inconsistencies, imprecision, and bias.

MAIN RESULTS

We included 25 RCTs involving 7259 participants including 977 (13.5%) men and 6282 (86.5%) women. Mean age reported ranged from 52.6 to 71 years, and range of age of included participants was 23 to 85 years. The trials reported 27 comparisons and included participants who had survived breast cancer (17 trials), colorectal cancer (2 trials), gynaecological cancer (1 trial), and cancer at mixed sites (5 trials). For overall survival, dietary intervention and control groups showed little or no difference in risk of mortality (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.77 to 1.23; 1 study; 3107 participants; low-certainty evidence). For secondary malignancies, dietary interventions versus control trials reported little or no difference (risk ratio (RR) 0.99, 95% CI 0.84 to 1.15; 1 study; 3107 participants; low-certainty evidence). Co-morbidities were not measured in any included trials. Subsequent outcomes reported after 12 months found that dietary interventions versus control probably make little or no difference in energy intake at 12 months (mean difference (MD) -59.13 kcal, 95% CI -159.05 to 37.79; 5 studies; 3283 participants; moderate-certainty evidence). Dietary interventions versus control probably led to slight increases in fruit and vegetable servings (MD 0.41 servings, 95% CI 0.10 to 0.71; 5 studies; 834 participants; moderate-certainty evidence); mixed results for fibre intake overall (MD 5.12 g, 95% CI 0.66 to 10.9; 2 studies; 3127 participants; very low-certainty evidence); and likely improvement in Diet Quality Index (MD 3.46, 95% CI 1.54 to 5.38; 747 participants; moderate-certainty evidence). For anthropometry, dietary intervention versus control probably led to a slightly decreased body mass index (BMI) (MD -0.79 kg/m², 95% CI -1.50 to -0.07; 4 studies; 777 participants; moderate-certainty evidence). Dietary interventions versus control probably had little or no effect on waist-to-hip ratio (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; 106 participants; low-certainty evidence). For QoL, there were mixed results; several different quality assessment tools were used and evidence was of low to very low-certainty. No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

Evidence demonstrated little effects of dietary interventions on overall mortality and secondary cancers. For comorbidities, no evidence was identified. For nutritional outcomes, there was probably little or no effect on energy intake, although probably a slight increase in fruit and vegetable intake and Diet Quality Index. Results were mixed for fibre. For anthropometry, there was probably a slight decrease in body mass index (BMI) but probably little or no effect on waist-to-hip ratio. For QoL, results were highly varied. Additional high-quality research is needed to examine the effects of dietary interventions for different cancer sites, and to evaluate important outcomes including comorbidities and body composition. Evidence on new technologies used to deliver dietary interventions was limited.

The Impact of Lifestyle Interventions in Breast Cancer Women after Completion of Primary Therapy: A Randomized Study

Objective

Many breast cancer survivors have unmet physical and psychological needs. Therefore, current study aimed to evaluate the impact of a lifestyle interventions program on fatigue, quality of sleep, quality of life (QoL), and body mass index (BMI) in women with breast cancer.

Materials and Methods

This randomized controlled trial study (RCT) was carried between 2012 and 2015, and included 80 women with breast cancer. They were divided into two groups via a random allocation process: 40 women were allocated to the lifestyle interventions group, and 40 to the control group. Women in the lifestyle group received dietary energy-restriction training and practiced supervised aerobic exercises for 45-60 minutes three times per week throughout 24 weeks and the control group continued their routine life.

Results

Differences between the two groups were significantly high for those who participated in the intervention group; this group reported significantly less fatigue, less BMI, improved QoL and better quality of sleep as compared to the control group (p<0.05).

Conclusion

Breast cancer survivors may physically and psychologically benefit from participating in a healthy lifestyle interventions program. This program can help relieve fatigue, maintain healthy BMI, improve QoL and enhance the quality of sleep in women with breast cancer. Lifestyle interventions program may provide a non-pharmacologic adjunctive therapy for symptom management in breast cancer survivors.

Healthy Lifestyle Behaviors of Breast Cancer Survivors

The purpose of this secondary analysis was to describe the extent to which women with breast cancer, who participated in a randomized control trial on exercise, adopted American Cancer Society (ACS) guidelines for healthy lifestyle behaviors. Women in the study exercised during cancer treatment and for 6 months after completion of treatment. The sample included 106 women, average age 50.7 years (SD = 9.6). Adherence to guidelines for 5 servings of fruits and vegetables ranged from 36% (n = 28) to 39% (n = 36). Adherence with alcohol consumption guidelines was 71% (n = 28) to 83% (n = 30). Adherence with meeting a healthy weight ranged from 52% (n = 33) to 61% (n = 31). Adherence with physical activity guidelines ranged from 13% (n = 30) to 31% (n = 35). Alcohol and healthy weight guidelines were followed by more than half of the participants, but physical activity and dietary guidelines were followed by far fewer women. Further prospective clinical studies are indicated to determine whether interventions are effective in producing a healthy lifestyle in cancer survivors.

Interventions to promote energy balance and cancer survivorship: priorities for research and care

The growing population of cancer survivors worldwide and the growing epidemics of obesity and physical inactivity have brought increased attention to the role that interventions to promote exercise and a healthy body weight may play in mitigating the chronic and late effects of cancer. In this light, the authors describe the similarities and differences in research and clinical priorities related to energy balance interventions among post-treatment cancer survivors in Europe versus North America. Randomized controlled trials that targeted nutrition, exercise, and weight are reviewed to determine the affect on survivorship outcomes. Interventions focused on improving prognosis or survival are investigated along with the emerging literature on the interventions targeting pathways and mechanisms of prognosis or survival. Current North American and European guidelines for diet, exercise, and weight control among cancer survivors also are investigated along with the implications of the current state of this science for clinical care. Finally, the authors delineate future European and American priorities for research and care involving energy balance among survivors. It is hoped that this dialogue launches an international conversation that will lead to better research and care for all post-treatment cancer survivors.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Weight change and survival after breast cancer in the after breast cancer pooling project

BACKGROUND

Weight change after a breast cancer diagnosis has been linked to lower survival. To further understand effects of postdiagnostic weight variation on survival, we examined the relationship by comorbid status and initial body mass index (BMI).

METHODS

The current analysis included 12,915 patients with breast cancer diagnosed between 1990 and 2006 with stage I-III tumors from four prospective cohorts in the United States and China. HRs and 95% confidence intervals (CI) representing the associations of five weight change categories [within <5% (reference); 5%-<10% and ≥10% loss and gain] with mortality were estimated using Cox proportional hazards models.

RESULTS

Mean weight change was 1.6 kg. About 14.7% women lost and 34.7% gained weight. Weight stability in the early years postdiagnosis was associated with the lowest overall mortality risk. Weight loss ≥10% was related to a 40% increased risk of death (HR, 1.41; 95% CI, 1.14-1.75) in the United States and over three times the risk of death (HR, 3.25; 95% CI: 2.24, 4.73) in Shanghai. This association varied by prediagnosis BMI, and in the United States, lower survival was seen for women who lost weight and had comorbid conditions. Weight gain ≥10% was associated with a nonsignificant increased risk of death.

CONCLUSIONS

Prevention of excessive weight gain is a valid public health goal for breast cancer survivors. Although intentionality of weight loss could not be determined, women with comorbid conditions may be particularly at risk of weight loss and mortality.

IMPACT

Weight control strategies for breast cancer survivors should be personalized to the individual's medical history.

Pragmatic lifestyle intervention in patients recovering from colon cancer: a randomized controlled pilot study

OBJECTIVE

To investigate the feasibility of a pragmatic lifestyle intervention in patients who had recently completed surgery and chemotherapy for colon cancer and to obtain preliminary data of its impact on important health outcomes.

DESIGN

A prospective, randomized, controlled pilot trial.

SETTING

University rehabilitation facility.

PARTICIPANTS

Eighteen (N=18) colon cancer survivors (mean age=69y; range, 52-80y), Dukes stage A to C.

INTERVENTIONS

Participants were randomized 6 to 24 months postoperatively to either a 12-week program of combined exercise and dietary advice or standard treatment.

MAIN OUTCOME MEASURES

Exercise and dietary behavior, fatigue, health-related quality of life (QOL), aerobic exercise tolerance, functional capacity, muscle strength, and anthropometery were assessed at baseline and immediately after the intervention.

RESULTS

Adherences to supervised and independent exercise during the intervention were 90% and 94%, respectively, and there was low attrition (6%). The lifestyle intervention elicited improvements in exercise behavior (P=.068), fatigue (P=.005), aerobic exercise tolerance (P=.010), chair sit-to-stand performance (P=.003), and waist-to-hip ratio (P=.002). A positive change in dietary fiber intake (P=.044) was also observed in the intervention group. No change in QOL was observed (P=.795).

CONCLUSIONS

These preliminary results suggest that a pragmatic lifestyle intervention implemented 6 to 24 months after primary treatment for colon cancer was feasible. We observed a significant impact on dietary behavior, fatigue, aerobic exercise tolerance, functional capacity, and waist-to-hip ratio. These findings need to be confirmed with a larger-scale definitive randomized controlled trial.

Maximizing exercise in breast cancer survivors

Regular physical exercise can maximize physical, mental, and social well-being during and after treatment in breast cancer survivors. An exercise program following cancer therapy is facilitated by instilling a positive attitude toward exercise, confidence in conquering barriers, and a supportive social environment. The purpose of this article is to describe the benefits of moderate exercise in breast cancer survivors and propose a comprehensive approach for the cancer care team in maximizing survivor efforts to improve their physical strength and endurance after completion of adjuvant therapy for breast cancer (surgery, chemotherapy, and/or radiation). A moderate exercise program can help most survivors become more physically and mentally fit and energetic. Understanding factors that prompt the initiation of healthy lifestyle choices among breast cancer survivors is critical to encouraging an attitude of healthy living.

Glucose as a prognostic factor in non-diabetic women with locally advanced cervical cancer (IIB-IVA)

OBJECTIVE

The aim of this study was to evaluate the association between pretreatment random plasma glucose levels and cancer prognosis in non-diabetic women with locally advanced cervical cancer treated with CCRT (concurrent chemoradiation) or RT (radiation therapy) only.

METHODS

We investigated the non-fasting plasma glucose levels checked during the initial work up before treatment in 134 non-diabetic patients with locally advanced cervical cancer. Based on the survival time and the progression-free interval (PFI) recorded in the electronic medical records Cox proportional hazard regression models were used to estimate the hazard ratio (HR) for overall survival and PFI according to the various level of glucose and a cut-off level (<102 mg/dL and >or=102 mg/dL), adjusting for clinical covariates.

RESULTS

A shorter overall survival and PFI was observed in the group with higher glucose levels (HR, 1.03; p=0.002, HR, 1.02; p=0.001, respectively) and more than 102 mg/dL, by univariate analyses (HR, 3.21; p=0.012, HR, 2.20; p=0.006, respectively). Multivariate analysis, adjusting for clinical FIGO stage, performance status, treatment type (CCRT vs. RT) and chemotherapeutic regimen types showed that patients with higher glucose levels or more than >or=102 mg/dL had shorter overall survival times (HR, 1.02; p=0.015, HR, 2.54; p=0.049, respectively) and PFI (HR, 1.02; p=0.003, HR, 1.88; p=0.031, respectively).

CONCLUSION

This investigation provides evidence supporting the prognostic value of glucose levels in non-diabetic women with locally advanced cervical cancer treated with radiation therapy and/or concurrent chemotherapy; high glucose levels were associated with a greater risk for recurrence and mortality in these patients.

Aerobic Exercise Intensity in Breast Cancer Patients: A Preliminary Investigation

Purpose: This study compared the heart rate (HR), rate of perceived exertion (RPE), and blood lactate (BL) responses to aerobic exercise between posttreated breast cancer patients and apparently healthy, age-matched controls. Methods: Seven patients and 7 control subjects underwent a submaximal treadmill test for the estimation of Vo2max. Exercise intensities of 40%, 60%, and 70% of Vo2max were calculated from the treadmill test and randomly examined between groups during three 9-minute exercise bouts on 3 different days. Independent samples t tests were used to examine the HR, RPE, and BL responses at each intensity between groups. Results: No significant differences were observed between the control and patient groups for HR, RPE, and BL at 40% (101 ± 9 vs 101 ± 11 bpm, P = .979; 8 ± 1 vs 9 ± 3, P = .237; and 1.11 ± 0.73 vs 1.26 ± 0.64 mmol/L, P = .188, respectively) and 60% (127 ± 17 vs 117 ± 13 bpm, P = .523; 12 ± 2 vs 11 ± 3, P = .267, and 3.83 ± 2.48 vs 2.23 ± 1.65 mmol/L, P = .237, respectively) of Vo2max . At 70% of Vo2max, no significant differences were found for HR (151 ± 27 vs 135 ± 13 bpm, P = .704) and RPE (14 ± 1 vs 13 ± 3, P = .181), but lower BL responses were observed in the patient group (7.70 ± 1.62 vs 3.29 ± 1.08 mmol/L, P < .0005). Conclusions: The results suggest similar HR, RPE, and BL responses between patients and control subjects at 40%, 60%, and 70% of Vo2max , except for BL at 70% of Vo2max. The lower BL response in the patient group at 70% of Vo2max was somewhat unexpected. Further research is needed to confirm or refute the results of this study to allow for a clearer understanding of the physiological responses of breast cancer patients to aerobic exercise at moderate or higher intensities so that safer aerobic exercise prescriptions can be developed for this population.

Survival impact of integrative cancer care in advanced metastatic breast cancer

Integrative cancer treatment is of substantial interest to many cancer patients. Research is needed to evaluate the effects of integrative treatment on patient outcomes. We report survival data for a consecutive case series of advanced metastatic breast cancer patients who received a comprehensive clinical program combining conventional treatments with nutrition and supplementation, fitness and mind-spirit instruction at the Block Center for Integrative Cancer Treatment. Treatment outcomes using integrative care for this disease have not previously been documented; survival data will thus contribute to decisions concerning future research directions and design. Ninety consecutive patients with metastatic breast cancer diagnosed during 1984-1997 who received chemotherapy at the integrative cancer center were included. Prognostic factors, treatments and survival from onset of metastases were determined from analysis of scans, labs, pathology and medical records. The log-rank test and Cox proportional hazards analyses were used, and a Kaplan-Meier curve was calculated. All patients had metastatic disease at baseline, 96% were relapsed and 52% had received prior chemotherapy for metastatic disease. Median age at onset of metastasis was 46 years. Median survival was 38 months (95% CI 27,48). Published literature on populations with somewhat more favorable prognostic factors treated in conventional clinics showed median survivals of 20 to 23 months. Through the 1990s, median survival reported in metastatic breast cancer trials or observations generally ranged from 12 to 24 months. Five-year survival was 27% for Center versus 17% for comparison patients. Despite a higher proportion of younger and relapsed patients, survival of metastatic breast cancer patients at the Center was approximately double that of comparison populations and possibly even higher compared to trials published during this period. Explanations for the advantage relative to conventional treatment alone may include the nutritional, nutraceutical, exercise and psychosocial interventions, individually or in combination; self-selection of patients cannot be ruled out. Further research to evaluate the impact of integrative breast cancer treatment on survival is warranted.

A weight loss intervention for African American breast cancer survivors, 2006

INTRODUCTION

Breast cancer survival rates are lower for African American women than for white women. Obesity, high-fat diets, and lack of regular physical activity increase risk for breast cancer recurrence, comorbid conditions, and premature death. Eighty-two percent of African American women are overweight or obese, partly because of unhealthy eating and exercise patterns. Although successful weight loss and lifestyle interventions for breast cancer survivors are documented, none has considered the needs of African American breast cancer survivors. This study assessed the feasibility and impact of Moving Forward, a culturally tailored weight loss program for African American breast cancer survivors.

METHODS

The study used a pre-post design with a convenience sample of 23 African American breast cancer survivors. The 6-month intervention was theory-based and incorporated qualitative data from focus groups with the targeted community, urban African American breast cancer survivors. Data on weight, body mass index (BMI), diet, physical activity, social support, and quality of life were collected at baseline and at 6 months.

RESULTS

After the intervention, we noted significant differences in weight, BMI, dietary fat intake, vegetable consumption, vigorous physical activity, and social support.

CONCLUSION

This is the first published report of Moving Forward, a weight loss intervention designed for African American breast cancer survivors. Although a randomized trial is needed to establish efficacy, the positive results of this intervention suggest that this weight loss intervention may be feasible for African American breast cancer survivors. Lifestyle interventions may reduce the disparities in breast cancer mortality rates.

Randomised controlled trial of a supervised exercise rehabilitation program for colorectal cancer survivors immediately after chemotherapy: study protocol

BACKGROUND

Colorectal cancer (CRC) diagnosis and the ensuing treatments can have a substantial impact on the physical and psychological health of survivors. As the number of CRC survivors increases, so too does the need to develop viable rehabilitation programs to help these survivors return to good health as quickly as possible. Exercise has the potential to address many of the adverse effects of CRC treatment; however, to date, the role of exercise in the rehabilitation of cancer patients immediately after the completion of treatment has received limited research attention. This paper presents the design of a randomised controlled trial which will evaluate the feasibility and efficacy of a 12-week supervised aerobic exercise program (ImPACT Program) on the physiological and psychological markers of rehabilitation, in addition to biomarkers of standard haematological outcomes and the IGF axis.

METHODS/DESIGN

Forty CRC patients will be recruited through oncology clinics and randomised to an exercise group or a usual care control group. Baseline assessment will take place within 4 weeks of the patient completing adjuvant chemotherapy treatment. The exercise program for patients in the intervention group will commence a week after the baseline assessment. The program consists of three supervised moderate-intensity aerobic exercise sessions per week for 12 weeks. All participants will have assessments at baseline (0 wks), mid-intervention (6 wks), post-intervention (12 wks) and at a 6-week follow-up (18 wks). Outcome measures include cardio-respiratory fitness, biomarkers associated with health and survival, and indices of fatigue and quality of life. Process measures are participants' acceptability of, adherence to, and compliance with the exercise program, in addition to the safety of the program.

DISCUSSION

The results of this study will provide valuable insight into the role of supervised exercise in improving life after CRC. Additionally, process analyses will inform the feasibility of implementing the program in a population of CRC patients immediately after completing chemotherapy.

TRIAL REGISTRATION

ACTRN012606000395538.

Aromatase inhibitor-associated arthralgia syndrome

Aromatase inhibitors (AIs) are widely used as an adjuvant endocrine treatment in postmenopausal women with early-stage breast cancer. Clinical trials have assessed 5 years of AI therapy, either as an alternative to tamoxifen for primary adjuvant therapy of breast cancer, or after 5 years of adjuvant tamoxifen. Treatment of 2-3 years' duration after 2-3 years of tamoxifen has also been studied. AI therapy brings side effects related to estrogen deprivation, and this side effect profile differs in clinically relevant ways from that seen with tamoxifen. In particular, the selective estrogen receptor modulatory effects of tamoxifen contribute to menopausal symptoms, vaginal discharge, and the rare but worrisome risks of thromboembolism and uterine carcinoma. By contrast, the low levels of estrogen achieved with aromatase inhibition contribute to menopausal symptoms, vaginal dryness and sexual dysfunction, and accelerated bone demineralization with risk of osteoporosis and osteoporotic fracture. Clinical experience also suggests that AI therapy is associated with a novel musculoskeletal side effect consisting of an arthralgia syndrome. The actual incidence of AI-associated arthralgias or musculoskeletal symptoms is not known, though such symptoms are quite prevalent and appear more commonly with AI use than with tamoxifen. Arthralgias can be a reason for discontinuation of AI treatment. The possible mechanisms of AI-associated arthralgia are unclear. Estrogen deficiency causes bone loss, which in turn contributes to arthralgia. Less well-studied functions of estrogen include regulating immune cells and cytokines involved in bone remodeling, and modulating pain sensitivity at the level of the central nervous system. Arthralgia and arthritis have seldom been rigorously differentiated in clinical trials of AIs. Assessment of inflammatory and rheumatologic markers, as well as detailed evaluation of patient symptoms using appropriate quality-of-life instruments, may be warranted in order to understand both the symptoms and the etiology of the arthralgia syndrome. Treatment options for arthralgia (primarily non-steroidal anti-inflammatory drugs) are currently inadequate, but areas of active research include high-dose vitamin D and new-targeted therapies to inhibit bone loss.