Lifestyle factors in cancer survivorship

A comparison of chronic conditions and health characteristics between cancer survivors and non-cancer survivors

OBJECTIVE

Cancer survivors have unique healthcare needs. An important consideration for survivorship is chronic diseases and health risk factors. The purpose of this study is to describe demographics, risk factors, and comorbid health conditions in adult cancer survivors.

METHOD

We analyzed 2019 Arizona Behavioral Risk Factor Surveillance System data to compare cancer survivors to non-cancer survivors (aged 18 or older) to assess differences between the two populations. Adjusted and unadjusted population-based estimates and 95% confidence intervals were calculated, and multivariable logistic regression models were performed.

RESULTS

Eight thousand nine-hundred and twenty (8920) respondents (1007 survivors; 7913 non-cancer survivors) were included. Compared to non-cancer survivors, cancer survivors were more likely to be female, 65 years and older, non-Hispanic white, veterans, and less likely to be employed. Survivors had higher rates of coronary heart disease, stroke, chronic obstructive pulmonary disease, kidney disease, hypertension, arthritis, multiple chronic conditions, being overweight, and being a former smoker. Survivors were more likely to report fair/poor health than non-cancer survivors.

DISCUSSION

These findings can be used by healthcare and public health practitioners to evaluate the programmatic efforts and resources, implement targeted interventions toward cancer survivors, and improve health and quality of life.

Lifestyle changes after cancer treatment in patients and their partners: a qualitative study

PURPOSE

Oncologists nowadays promote healthy lifestyle choices more often, focusing on diet, physical activity, smoking, alcohol consumption, and sleep, but the question is whether this is enough to establish actual change. As patients will have to achieve a healthy lifestyle at home in daily life, it is important to understand barriers and facilitators for lifestyle change for both patients and their partners.

METHODS

A qualitative interview study was done among patients who received chemotherapy for testicular (n = 10) or breast cancer (n = 7) and their partners (n = 17). The interview focused on how much they remembered the lifestyle advice given in hospital, whether and what they had adapted since diagnosis, and what they deemed as facilitators and barriers in maintaining lifestyle change.

RESULTS

Results showed that many patients and partners recalled that some advice was given in hospital but experienced this as too general and only at the start of treatment. Social contacts and the entire cancer experience helped facilitate change but were also seen as barriers. Other barriers were not considering healthy behaviors a priority or experiencing unhealthy choices as something nice after a trying time.

CONCLUSIONS

Oncologists and hospitals that provide lifestyle advice should provide cancer- and person-specific lifestyle advice, should offer this advice repeatedly into survivorship, and include the partner, as they are dedicated to improving lifestyle as well.

IMPLICATION FOR CANCER SURVIVORS

Staying healthy after cancer is important to both patients and their partners, and both experience their own facilitators and barriers to achieving this. Seeing a healthy lifestyle as a joint goal might facilitate change.

Cardiorespiratory Fitness and Incidence of Digestive System Cancers in Men

PURPOSE

To assess the association between cardiorespiratory fitness (CRF) and incidence of digestive system cancers (DSCs) in men.

METHODS

A prospective cohort of 4,540 men aged 55.2 ± 13.1 years who were free from malignancy at baseline was studied. Exposure was CRF quantified from treadmill exercise testing (individualized ramp protocol) in metabolic equivalents (METs). Incidence of DSCs was the primary outcome, utilizing medical records of any new diagnosed DSC. Cox proportional hazard analyses were conducted adjusting for established cancer risk factors.

RESULTS

Mean CRF was 8.3 ± 3.5 METs. During 13 ± 7.6 years follow up, 250 (5.5%) DSC cases were diagnosed (colorectal = 163, gallbladder = 46, liver = 23, esophagus = 8, pancreas = 7 and other digestive organ cancers = 3). For each 1-MET increase in CRF there were 6% [Hazard Ratio = 0.94, 95% CI (0.91-0.98), p = 0.006], and 9% [Hazard Ratio = 0.91, 95% CI (0.85-0.97), p = 0.006] lower risks of DSC incidence in the total cohort and among men younger than 60 years old, respectively. Additionally, each 1-MET increase in CRF was associated with 9% lower risks of DSC incidence among never and current smokers. CRF was not associated with DSC incidence among men ≥ 60 years old and among former smokers.

CONCLUSION

Higher CRF was associated with lower risk of DSC incidence in men, particularly in those younger than 60 years, and never and current smokers. These findings suggest that higher CRF has potential preventive benefits against the development of DSCs, although additional large studies are needed. CRF screening and achieving higher levels could serve as a complementary preventive strategy for public health.

Physical Activity, Alcohol, and Cigarette Use in Urological Cancer Patients over Time since Diagnosis

Urological cancers represent a substantial global public health concern, exerting far-reaching effects on both individuals and their families. There is an urgent need to comprehensively understand the transformations in patients' lifestyles and behaviors, given their critical role in the treatment process and overall well-being. This study, involving 128 urological cancer patients, aims to investigate changes in physical activity levels, problematic drinking behaviors assessed through the Alcohol Use Disorders Identification Test (AUDIT), and smoking habits assessed using the Fagerström Test for Nicotine Dependence (FTND) over four distinct time intervals over the subsequent three years from the time of diagnosis and among individuals diagnosed more than three years ago. The results reveal a significant decrease in physical activity levels between study intervals (p < 0.0001), declining from 69% to 45% between the first and second post-diagnosis assessments. Furthermore, the highest levels of problematic substance use, indicated by mean scores, were noted in the first year following diagnosis (AUDIT: 4.20, p = 0.01; FTND: 4.83, p = 0.08). Given the significant impact of physical activity on the prospects of recovery, it is imperative to delve more deeply into the factors contributing to this decline and devise targeted interventions for its improvement. In the context of substance use, it is essential to ascertain whether the initially high levels are a result of coping with the cancer diagnosis or represent a turning point at which patients modify their behaviors and cease their addiction. A more thorough understanding of this phenomenon would enhance the effectiveness of precisely focused interventions.

Characterizing risky alcohol use, cigarette smoking, e-cigarette use, and physical inactivity among cancer survivors in the USA-a cross-sectional study

PURPOSE

Unhealthy lifestyle behaviors are associated with inferior health outcomes among cancer survivors, including increased mortality. It is crucial to identify vulnerable subgroups, yet investigations have been limited. Thus, this study aimed to examine sociodemographic and clinical characteristics associated with risky health behaviors among cancer survivors.

METHODS

We used national, cross-sectional survey data (Health Information National Trends Survey, HINTS 2017-2020) for 2579 cancer survivors. We calculated the prevalence of risky alcohol use, current cigarette smoking, e-cigarette use, and not meeting physical activity guidelines. We performed weighted logistic regression to obtain multivariable-adjusted odds ratios (OR) for the association between each unhealthy behavior with sociodemographic and clinical characteristics.

RESULTS

Overall, 25% showed risky alcohol use, 12% were current cigarette smokers, 3% were current e-cigarette users, and 68% did not meet physical activity guidelines. Cancer survivors who were males, non-Hispanic Whites or African Americans, without a college education, not married and with comorbidities or psychological distress were more likely to have unhealthy behaviors. Those with lung disease or depression were 2 times as likely to smoke cigarette or e-cigarettes and those with psychological distress were 1.6 times as likely to be physically inactive. Moreover, risky drinkers (OR = 1.75, 95% CI = 1.22-2.52) and e-cigarette smokers (OR = 16.40, 95% CI 3.29-81.89) were more likely to be current cigarette smokers.

CONCLUSIONS

We identified vulnerable subpopulations of cancer survivors with multiple unhealthy lifestyle behaviors.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings inform clinicians and program and policy makers of the subgroups of cancer survivors to target for multiple health behavior interventions.

Adherence to healthy lifestyle recommendations in Brazilian cancer survivors

PURPOSE

We aimed to describe the adherence to healthy lifestyle recommendations (regular consumption of fruits, vegetables, and salad greens; limit the consumption of red and processed meat, fast food, sugary and alcoholic beverages; keeping a healthy body weight, being physically activity, and not smoking) of 2314 cancer survivors and 86,517 adults without cancer diagnosis (general population) from the Brazilian National Health Survey, 2019.

METHODS

We developed a score including eight healthy lifestyle recommendations proposed by the World Cancer Research Fund (i.e., the score ranged from 0 to 8; being 0 did not follow any recommendation and 8 followed all recommendations).

RESULTS

Cancer survivors had higher healthy lifestyle score than the general population. In contrast, they presented similar adherence to the recommendations of physical activity, healthy body weight, and quitting smoking. Among cancer survivors, women (OR 1.52; 95%CI 1.12 to 2.06) and widows (OR 1.49; 95%CI 1.02 to 2.18) had greater odds of adherence to healthy lifestyle recommendations, adjusted for other sociodemographic characteristics. However, cancer survivors with complete primary education (OR 0.64; 95%CI 0.44 to 0.94) and higher education (OR 0.58; 95%CI 0.40 to 0.83) had lower adherence to the recommendations.

CONCLUSION

Our findings may be useful to support counseling and interventions aimed at promoting healthy lifestyles for Brazilian cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Healthy lifestyle may reduce mortality and cancer recurrence, and improve quality of life in cancer survivors. Identifying factors associated with the adherence to healthy lifestyle in cancer survivors may be useful to support actions and interventions.

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.

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.

Methylmalonic acid promotes colorectal cancer progression via activation of Wnt/β-catenin pathway mediated epithelial-mesenchymal transition

BACKGROUND

It has been manifested in several studies that age-related metabolic reprogramming is associated with tumor progression, in particular, colorectal cancer (CRC). Here we investigated the role of upregulated metabolites of the aged serum, including methylmalonic acid (MMA), phosphoenolpyruvate (PEP), and quinolinate (QA), in CRC.

METHODS

Functional assays including CCK-8, EdU, colony formation and transwell experiments were used to ascertain which upregulated metabolite of elderly serum was related to tumor progression. RNA-seq analysis was conducted to explore the potential mechanisms of MMA-induced CRC progression. Subcutaneous tumorigenesis and metastatic tumor models were constructed to verify the function of MMA in vivo.

RESULTS

Among three consistently increased metabolites of the aged sera, MMA was responsible for tumorigenesis and metastasis in CRC, according to functional assays. The promotion of Epithelial-mesenchymal transition (EMT) was observed in CRC cells treated with MMA, on the basis of protein expression of EMT markers. Moreover, combined with transcriptome sequencing, Wnt/β-catenin signaling pathway was activated in CRC cells treated with MMA, which was verified by western blot and qPCR experiments. Furthermore, animal assays demonstrated the pro-proliferation and promotion of metastasis role of MMA in vivo.

CONCLUSION

We have identified that age-dependent upregulation of MMA in serum promoted the progression of CRC via Wnt/β-catenin signaling pathway mediated EMT. These collective findings provide valuable insights into the vital role of age-related metabolic reprogramming in CRC progression and propose a potential therapeutic target for elderly CRC.

Association between high body mass index and prognosis of patients with early-stage breast cancer: A systematic review and meta-analysis

Background

A high body mass index (BMI) can indicate overweight or obesity and is a crucial risk factor for breast cancer survivors. However, the association between high BMI and prognosis in early-stage breast cancer (EBC) remains unclear. We aimed to assess the effects of high BMI on the prognosis of patients with EBC.

Methods

The PubMed, Embase, and Cochrane Library databases and proceedings of major oncological conferences related to the effects of BMI on the prognosis of breast cancer were searched up to November 2021. Fixed- and random-effects models were used for meta-analyses. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for disease-free survival (DFS) and overall survival (OS) were extracted from the included literature.

Results

Twenty retrospective cohort studies with 33,836 patients with EBC were included. Overweight patients had worse DFS (HR: 1.16, 95% CI: 1.05-1.27, P = 0.002) and OS (HR: 1.20; 95% CI: 1.09-1.33, P < 0.001). Obesity also had adverse effects on DFS (HR: 1.17, 95% CI: 1.07-1.29, P = 0.001) and OS (HR: 1.30, 95% CI: 1.17-1.45, P < 0.001). Likewise, patients with high BMI had worse DFS (HR: 1.16, 95% CI: 1.08-1.26, P < 0.001) and OS (HR: 1.25, 95% CI: 1.14-1.39, P < 0.001). In subgroup analyses, overweight had adverse effects on DFS (HR: 1.11, 95% CI: 1.04-1.18, P = 0.001) and OS (HR: 1.18, 95% CI: 1.11-1.26, P < 0.001) in multivariate analyses, whereas the relationship that overweight had negative effects on DFS (HR: 1.21, 95% CI: 0.99-1.48, P = 0.058) and OS (HR: 1.39, 95% CI: 0.92-2.10, P = 0.123) was not statistically significant in univariate analysis. By contrast, obesity had adverse effects on DFS (HR: 1.21, 95% CI: 1.06-1.38, P = 0.004 and HR: 1.14, 95% CI: 1.08-1.22, P < 0.001) and OS (HR: 1.33, 95% CI: 1.15-1.54, P < 0.001 and HR: 1.23, 95% CI: 1.15-1.31, P < 0.001) in univariate and multivariate analyses, respectively.

Conclusions

Compared with normal weight, increased body weight (overweight, obesity, and high BMI) led to worse DFS and OS in patients with EBC. Once validated, these results should be considered in the development of prevention programs.

The Future of Breast Cancer Research in the Survivorship Field

Prevalence of survivors of breast cancer has been steadily increasing in the last 20 years. Currently, more than 90% of women diagnosed with early-stage breast cancer are expected to be alive at 5 years from diagnosis thanks to early detection and breakthrough innovations in multimodal treatment strategies. Alongside this advancement in clinical outcomes, survivors of breast cancer might experience several specific challenges and present with unique needs. Survivorship trajectories after diagnosis and treatment of breast cancer can be significantly impacted by long-lasting and severe treatment-related side effects, including physical problems, psychological distress, fertility issues in young women, and impaired social and work reintegration, which add up to patients' individual risk of cancer recurrence and second primary malignancies. Alongside cancer-specific sequelae, survivors still present with general health needs, including management of chronic preexisting or ensuing conditions. Survivorship care should implement high-quality, evidence-based strategies to promptly screen, identify, and address survivors' needs in a comprehensive way and minimize the impact of severe treatment sequelae, preexisting comorbidities, unhealthy lifestyles, and risk of recurrence on quality of life. This narrative review focuses on core areas of survivorship care and discuss the state of the art and future research perspectives in key domains including selected long-term side effects, surveillance for recurrences and second cancers, well-being promotion, and specific survivors' needs.

Dietary patterns related to biological mechanisms and survival after breast cancer diagnosis: results from a cohort study

BACKGROUND

Inflammatory, insulin and oestrogenic pathways have been linked to breast cancer (BC). We aimed to examine the relationship between pre-diagnostic dietary patterns related to these mechanisms and BC survival.

METHODS

The diabetes risk reduction diet (DRRD), inflammatory score of diet (ISD) and oestrogen-related dietary pattern (ERDP) were calculated using dietary data from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Cox proportional hazards models were used to assess associations between dietary patterns and overall mortality and competing risk models for associations with BC-specific mortality.

RESULTS

We included 13,270 BC cases with a mean follow-up after diagnosis of 8.6 years, representing 2340 total deaths, including 1475 BC deaths. Higher adherence to the DRRD score was associated with lower overall mortality (HR1-SD 0.92; 95%CI 0.87-0.96). Greater adherence to pro-inflammatory diets was borderline associated with 6% higher mortality HR1-SD 1.06; 95%CI 1.00-1.12. No significant association with the oestrogen-related dietary pattern was observed. None of the dietary patterns were associated with BC-specific mortality.

CONCLUSIONS

Greater adherence to an anti-diabetic and anti-inflammatory diet prior to diagnosis is associated with lower overall mortality among BC survivors. Long-term adherence to these dietary patterns could be a means to improve the prognosis of BC survivors.

Association of frailty with the incidence risk of cardiovascular disease and type 2 diabetes mellitus in long-term cancer survivors: a prospective cohort study

BACKGROUND

Comorbidities among cancer survivors remain a serious healthcare burden and require appropriate management. Using two widely used frailty indicators, this study aimed to evaluate whether frailty was associated with the incidence risk of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) among long-term cancer survivors.

METHODS

We included 13,388 long-term cancer survivors (diagnosed with cancer over 5 years before enrolment) free of CVD and 6101 long-term cancer survivors free of T2DM, at the time of recruitment (aged 40-69 years), from the UK Biobank. Frailty was assessed by the frailty phenotype (FP_Frailty, range: 0-5) and the frailty index (FI_Frailty, range: 0-1) at baseline. The incident CVD and T2DM were ascertained through linked hospital data and primary care data, respectively. The associations were examined using Cox proportional hazards regression models.

RESULTS

Compared with non-frail participants, those with pre-frailty (FP_Frailty [met 1-2 of the components]: hazard ratio [HR]=1.18, 95% confidence interval [CI]: 1.05, 1.32; FI_Frailty [0.10< FI ≤0.21]: HR=1.51, 95% CI: 1.32, 1.74) and frailty (FP_Frailty [met ≥3 of the components]: HR=2.12, 95% CI: 1.73, 2.60; FI_Frailty [FI >0.21]: HR=2.19, 95% CI: 1.85, 2.59) had a significantly higher risk of CVD in the multivariable-adjusted model. A similar association of FI_Frailty with the risk of incident T2DM was observed. We failed to find such an association for FP_Frailty. Notably, the very early stage of frailty (1 for FP_Frailty and 0.1-0.2 for FI_Frailty) was also positively associated with the risk of CVD and T2DM (FI_Frailty only). A series of sensitivity analyses confirmed the robustness of the findings.

CONCLUSIONS

Frailty, even in the very early stage, was positively associated with the incidence risk of CVD and T2DM among long-term cancer survivors, although discrepancies existed between frailty indicators. While the validation of these findings is required, they suggest that routine monitoring, prevention, and interventive programs of frailty among cancer survivors may help to prevent late comorbidities and, eventually, improve their quality of life. Especially, interventions are recommended to target those at an early stage of frailty when healthcare resources are limited.

The antitumour effects of caloric restriction are mediated by the gut microbiome

Calorie restriction (CR) and intermittent fasting (IF) without malnutrition reduce the risk of cancer development. Separately, CR and IF can also lead to gut microbiota remodelling. However, whether the gut microbiota has a role in the antitumour effect related to CR or IF is still unknown. Here we show that CR, but not IF, protects against subcutaneous MC38 tumour formation through a mechanism that is dependent on the gut microbiota in female mice. After CR, we identify enrichment of Bifidobacterium through 16S rRNA sequencing of the gut microbiome. Moreover, Bifidobacterium bifidum administration is sufficient to rescue the antitumour effect of CR in microbiota-depleted mice. Mechanistically, B. bifidum mediates the CR-induced antitumour effect through acetate production and this effect is also dependent on the accumulation of interferon-γ⁺CD8⁺ T cells in the tumour microenvironment. Our results demonstrate that CR can modulate the gut taxonomic composition, which should be of oncological significance in tumour growth kinetics and cancer immunosurveillance.

Modifiable Risk Factors, Health Profile and Well-Being of the Elderly Diagnosed with Cancer in Italy: Passi d'Argento Surveillance System 2016-2019 Results

(1) Cases of cancer are expected to increase in the next years and the risk of cancer increases with age. Data 2016-2019 from the Italian population-based surveillance PASSI d'Argento (PdA) allow the description of the physical and psychosocial well-being of people aged ≥65 years diagnosed with cancer (Ca), and the comparison with elderly suffering from other chronic conditions (Ch) and healthy older individuals (H). (2) Data are collected by Local Health Units' professionals using a standardized questionnaire during telephone interviews. (3) A total of 8051 out of the 56,352 interviewees reported a previous diagnosis of cancer: an annual average cancer prevalence of 12.8% (95% CI 12.4-13.3%) corresponding to 1.725 million elderly residing in Italy. In comparison to the H, Ca were more likely to refer bad health (aPR = 4.21; 95% CI: 3.70-4.79), suffer from depressive symptoms (aPR = 2.65; 95% CI: 2.35-2.99), disability (aPR = 2.50; 95% CI: 2.22-2.81) or sensory problems (aPR = 1.51; 95% CI: 1.40-1.63), be frail (aPR = 1.45; 95% CI: 1.30-1.61). Ca are often current smokers (aPR = 1.26; 95% CI: 1.11-1.45) and sedentary (aPR = 1.10; 95% CI: 1.03-1.18). (4) PdA provides valuable information to researchers and policy-makers by showing the difficulties for older people with cancer in contributing socially and accessing basic social and health services, which amplifies the risk of cognitive decline, isolation, and psychological deterioration.

Development of healthy lifestyle consciousness index for gynecological cancer patients

PURPOSE

Healthy lifestyle is related to quality of life (QOL) after cancer diagnosis and prognosis. However, there are few reports on patients conscious of healthy lifestyle and patients requiring medical providers' attention regarding healthy lifestyle. We aimed to develop a healthy lifestyle consciousness index (HLCI) for cancer patients and evaluated its validity in gynecological cancer patients.

METHODS

The HLCI was designed to assess degree of healthy lifestyle consciousness, including items regarding "diet," "exercise," "body weight," and "sleep." Exploratory factor analysis was performed for dimensionality of the scale; Cronbach's alpha was calculated to assess internal-consistency reliability. For criterion-based validity, we calculated proportions of stage III/IV gynecological malignancies in those with categorized HLCI scores based on tertiles. Concurrent validity was evaluated between HLCI and other quality of life (QOL) scales including European Organization for Research and Treatment of Cancer QLQ-C30 in limited patients.

RESULTS

HLCI comprised five 10-point items (0-45); higher values implied improved healthy lifestyle consciousness. Data from 108 gynecological malignancy patients at Kyoto University Hospital were analyzed. The mean age of subjects was 55.8 years; 36.1% of them had uterine corpus cancer; 34.3% were at stage III/IV of gynecological malignancy. The factor analysis revealed HLCI was unidimensional; the reliability based on Cronbach's alpha was satisfactory (0.88). The proportions of stage III/IV gynecological malignancies were 25.7%, 33.3%, and 44.4% in those with first (7-24 points), second (25-30 points), and third (31-46 points) tertiles of HLCI score, respectively. For patients with other QOL scales (n = 25), the mean scores of global health status of QLQ-C30 were 33.3, 50.0, and 83.3 for first, second, and third tertiles of HLCI score, respectively.

CONCLUSION

HLCI was successfully validated; thus, patients with advanced stages or higher QOL might have strong consciousness regarding healthy lifestyle. HLCI may be useful in precision care for improved lifestyles and QOL.

Associations of cigarette smoking, alcohol drinking and body mass index with survival after colorectal cancer diagnosis by anatomic subsite: a prospective patient cohort study in Japan

BACKGROUND

Cigarette smoking, alcohol drinking and obesity are known to be risk factors for colorectal cancer. These factors may affect survival after diagnosis, but evidence has been inconsistent. We investigated subsite-specific associations between prediagnosis smoking, alcohol drinking and body mass index and survival in colorectal cancer.

METHODS

Subjects were 1300 patients (colon 778; rectum 502; concurrent 20) with histologically confirmed colorectal cancer diagnosed during 1997-2013 at a single institution in Japan. Histories of smoking and alcohol drinking, height and prediagnosis weight were assessed using a self-administered questionnaire. Using Cox proportional hazards model, hazard ratios and 95% confidence intervals of mortality were estimated.

RESULTS

During a median follow-up period of 6.7 years, 479 deaths were documented. Ever-smoking was associated with an increased risk of all-cause death among patients with colon cancer (hazard ratio: 1.47; 95% confidence interval: 1.07-2.02 compared with never-smoking). According to colon subsite, this increased risk was clear in patients with proximal colon cancer (hazard ratio: 2.09; 95% confidence interval: 1.28-3.40). There was no association between smoking and rectal cancer survival. Alcohol drinking was not associated with survival for either colon or rectal cancer. Among patients with rectal cancer, higher body mass index was associated with a lower risk of all-cause (Ptrend = 0.0006) and disease-specific death (Ptrend = 0.02). For colon cancer, lower body mass index tended to be associated with a higher risk of all-cause death (Ptrend = 0.05).

CONCLUSIONS

The results indicate that lifestyles identified as risk factors for colorectal cancer may impact differently on patient survival according to anatomic subsite.

Immunoprotecting Effects of Exercise Program against Ovarian Cancer: A Single-Blind, Randomized Controlled Trial

Exercise is known to help the immune function of cancer survivors after cancer cell removal, but there is little information about the effect of exercise on ovarian cancer survivors. We conducted this study to investigate the effects of exercise training on the physical fitness and innate immunity of ovarian cancer survivors (OCS). Twenty-seven OCS between forty-two and sixty-one years of age volunteered for this study. The participants were divided into a control group (COG, n = 15) and an exercise group (EXG, n = 12). The mean (SD) age was 51.07 (5.67) years, and the mean post-operation period was 45.96 (5.88) months. EXG participated in regular exercise training 6 days a week for 12 weeks. Body weight, fat mass, and body mass index of EXE were significantly decreased compared with those of COG. The muscle mass in EXE was increased compared to that of COG. Physical fitness factors showed positive changes in EXG compared to COG. We found that exercise training enhanced lymphocyte and neutrophil counts of leucocytes and total natural killer (NK) and natural killer T (NKT) cell counts of lymphocytes through improved body composition and physical fitness after 12 weeks. Moreover, we found that improved innate immune cells through the exercise program were achieved through an increase in NKG2D+NK receptors and a decrease in KIR2DL3+NK receptors in OCS.

Metabolic reprogramming: a bridge between aging and tumorigenesis

Aging is the most robust risk factor for cancer development, with more than 60% of cancers occurring in those aged 60 and above. However, how aging and tumorigenesis are intertwined is poorly understood and a matter of significant debate. Metabolic changes are hallmarks of both aging and tumorigenesis. The deleterious consequences of aging include dysfunctional cellular processes, the build‐up of metabolic byproducts and waste molecules in circulation and within tissues, and stiffer connective tissues that impede blood flow and oxygenation. Collectively, these age‐driven changes lead to metabolic reprogramming in different cell types of a given tissue that significantly affects their cellular functions. Here, we put forward the idea that metabolic changes that happen during aging help create a favorable environment for tumorigenesis. We review parallels in metabolic changes that happen during aging and how these changes function both as adaptive mechanisms that enable the development of malignant phenotypes in a cell‐autonomous manner and as mechanisms that suppress immune surveillance, collectively creating the perfect environment for cancers to thrive. Hence, antiaging therapeutic strategies that target the metabolic reprogramming that occurs as we age might provide new opportunities to prevent cancer initiation and/or improve responses to standard‐of‐care anticancer therapies.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

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

Still Lost in Transition? Perspectives of Ongoing Cancer Survivorship Care Needs from Comprehensive Cancer Control Programs, Survivors, and Health Care Providers

Public health agencies have played a critical role in addressing the complex health and mental health needs of cancer survivors. We conducted a mixed-methods evaluation via a Web-based survey (n = 51) and focus groups (n = 11) with National Comprehensive Cancer Control Program (NCCCP) recipients and interviews (n = 9) with survivors, health care providers (HCPs), and patient navigators to explore these audiences’ cancer survivorship information needs and strategies to improve resource dissemination. Participants revealed a need for tailored resources and support for survivors on healthy lifestyle, post-treatment survivorship concerns, psychosocial health, and navigating the health system. HCP needs included education on survivorship care plans and care coordination to facilitate the transition between oncology and primary care. HCPs were survivors’ most trusted source for information; however, participants noted difficulties engaging HCPs in survivorship care. These findings can help public health practitioners focus their efforts to better meet the needs of cancer survivors and their HCPs.

Measuring Clinical, Biological, and Behavioral Variables to Elucidate Trajectories of Patient (Reported) Outcomes: The PROFILES Registry

To take cancer survivorship research to the next level, it's important to gain insight in trajectories of changing patient (reported) outcomes and impaired recovery after cancer. This is needed as the number of survivors is increasing and a large proportion is confronted with changing health after treatment. Mechanistic research can facilitate the development of personalized risk-stratified follow-up care and tailored interventions to promote healthy cancer survivorship. We describe how these trajectories can be studied by taking the recently extended Dutch population-based PROFILES (Patient Reported Outcomes Following Initial treatment and Long term Evaluation of Survivorship) registry as an example. PROFILES combines longitudinal assessment of patient-reported outcomes with novel, ambulatory and objective measures (e.g., activity trackers; blood draws; hair samples; online food diaries; online cognitive tests; weighing scales; online symptoms assessment), and cancer registry and pharmacy databases. Furthermore, we discuss methods to optimize the use of a multidomain data collection like return of individual results to participants which may not only improve patient empowerment but also long-term cohort retention. Also, advanced statistical methods are needed to handle high-dimensional longitudinal data (with missing values) and provide insight into trajectories of changing patient (reported) outcomes after cancer. Our coded data can be used by academic researchers around the world. Registries like PROFILES, that go beyond boundaries of disciplines and institutions, will contribute to better predictions of who will experience changes and why. This is needed to prevent and mitigate long-term and late effects of cancer (treatment) and to identify new interventions to promote health.

The Role of Diet in Prognosis among Cancer Survivors: A Systematic Review and Meta-Analysis of Dietary Patterns and Diet Interventions

Cancer survival continues to improve in high-income countries, partly explained by advances in screening and treatment. Previous studies have mainly examined the relationship between individual dietary components and cancer prognosis in tumours with good therapeutic response (breast, colon and prostate cancers). The aim of this review is to assess qualitatively (and quantitatively where appropriate) the associations of dietary patterns and cancer prognosis from published prospective cohort studies, as well as the effect of diet interventions by means of randomised controlled trials (RCT). A systematic search was conducted in PubMed, and a total of 35 prospective cohort studies and 14 RCT published between 2011 and 2021 were selected. Better overall diet quality was associated with improved survival among breast and colorectal cancer survivors; adherence to the Mediterranean diet was associated to lower risk of mortality in colorectal and prostate cancer survivors. A meta-analysis using a random-effects model showed that higher versus lower diet quality was associated with a 23% reduction in overall mortality in breast cancer survivors. There was evidence that dietary interventions, generally combined with physical activity, improved overall quality of life, though most studies were in breast cancer survivors. Further cohort and intervention studies in other cancers are needed to make more specific recommendations.

Using Shared Medical Appointments for Delivering Patient-Centered Care to Cancer Survivors: A Feist-Weiller Cancer Center Pilot Study

Background: Shared medical appointments (SMAs) have shown promise in the care of patients with conditions such as diabetes; however, the impact of lifestyle medicine-based SMAs on the overall health status of cancer survivors remains poorly understood. Materials and Methods: This cross-sectional survey of patients was conducted to study the impact of a unique lifestyle medicine-based survivorship program on cancer survivors. Results: A total of 64 patients were telephonically contacted for the survey, out of which 39 (60.9%) patients responded. All patients (39 of 39, 100%) found the program to be helpful in some way; 26 patients (66.7%) found SMAs to be significantly helpful, while 13 patients (33.3%) found SMAs as only somewhat helpful. The majority noted feeling a great sense of support (35 of 39, 89.7%), followed by improvement in appetite (21 of 39, 54%) and improvement in pain (14 of 39, 35.9%). All patients reported at least some improvement in subjective well-being (SWB); patients who attended >3 appointments reported significant/very significant improvement in SWB (P = .03). Conclusion: SMAs offer promise in the effective delivery of lifestyle medicine-focused care to cancer survivors. Further prospective studies are needed to validate these findings.

Diabetes and Cancer: Risk, Challenges, Management and Outcomes

BACKGROUND

Diabetes mellitus and cancer are commonly coexisting illnesses, and the global incidence and prevalence of both are rising. Cancer patients with diabetes face unique challenges. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in cancer patients.

METHODS

A literature search using keywords in PubMed was performed. Studies that were published in English prior to July 2021 were assessed and an overview of epidemiology, cancer risk, outcomes, treatment-related hyperglycemia and management of diabetes in cancer patients is provided.

RESULTS

Overall, 8-18% of cancer patients have diabetes as a comorbid medical condition. Diabetes is a risk factor for certain solid malignancies, such as pancreatic, liver, colon, breast, and endometrial cancer. Several novel targeted compounds and immunotherapies can cause hyperglycemia. Nevertheless, most patients undergoing cancer therapy can be managed with an appropriate glucose lowering agent without the need for discontinuation of cancer treatment. Evidence suggests that cancer patients with diabetes have higher cancer-related mortality; therefore, a multidisciplinary approach is important in the management of patients with diabetes and cancer for a better outcome.

CONCLUSIONS

Future studies are required to better understand the underlying mechanism between the risk of cancer and diabetes. Furthermore, high-quality prospective studies evaluating management of diabetes in cancer patients using innovative tools are needed. A patient-centered approach is important in cancer patients with diabetes to avoid adverse outcomes.

Feasibility, acceptability, and effects of behavior change interventions for improving multiple dietary behaviors among cancer survivors: a systematic review

OBJECTIVE

This study aimed to systematically identify and synthesize evidence on the feasibility, acceptability, and effects of behavior change interventions for improving multiple dietary behaviors among cancer survivors.

METHODS

A total of 14 electronic databases and three trial registries were searched. Experimental studies that examined the feasibility, acceptability, and effects of behavior change interventions for improving multiple dietary behaviors among cancer survivors and published in English or Chinese peer-reviewed journals or protocols were considered eligible. The methodological quality of the included studies was evaluated using the revised Cochrane risk-of-bias assessment tool. Data were extracted and synthesized narratively.

RESULTS

Six studies, with a sample size ranging from 50 to 3088, were included. The studies had a high overall risk of bias. Six studies reported feasibility data, and the average eligibility, recruitment, and retention rates at post-intervention were 60.7%, 66.7%, and 90.7%, respectively. Only one study measured the acceptability and reported that 66.6% of participants were satisfied with the intervention. Five out of the six studies that measured fruit and vegetable consumption reported statistically significant positive intervention effects. Two studies reported inconsistent intervention effects on wholegrain consumption. Only one study measured the consumption of processed meat, sugar, and alcohol, which had statistically nonsignificant intervention effect.

CONCLUSIONS

Behavior change interventions for improving multiple dietary behaviors might be feasible and effective to increase fruit and/or vegetable consumption among cancer survivors. Further research is needed to examine the acceptability and effects of the intervention for modifying other dietary behavior.

Second primary cancers: a retrospective analysis of real world data using the enhanced medical research engine ConSoRe in a French comprehensive cancer center

BACKGROUND

Second primary cancers (SPC) account for 18% of all cancers. We used the enhanced medical/health data mining tool ConSoRe to search aggregated data, analyze electronic patient records (EPR), and better characterize patients with SPC.

METHODS

This retrospective cohort study used ConSoRe to identify EPRs from patients with SPC referred to the regional cancer center Leon Bérard from 1993 to 2017, and examined characteristics of patients with SPC, frequencies of first primary cancer (FPC) localization in the global population of patients with SPC, and time to SPC. Data set was extracted on January 1, 2018.

RESULTS

Among 296,530 EPRs, we identified 157,187 patients with FPC, including 13,002 (8%) patients with SPC. Between 2000 and 2010, the rate of SPC was 34%, and 52% of SPC were identified in the last years (2010-2017). In men, main cancers were head and neck cancer, lymphoma, and prostate carcinoma accounting for 15.6%, 12.8%, and 10.5% of FPC, while the three most common SPC were head and neck cancer (13.2%), lung cancer (11.8%) and lymphoma (9.2%). In women, breast cancers, lymphoma, and skin cancers accounted for 48.8%, 8%, and 5.1% of first cancers, and for 31.1%, 7% and 6% of SPC.

CONCLUSION

The data mining tool ConSoRe contributes to access to real world data, and to better characterize patients with SPC. Expanding such approach to any comprehensive center will allow a global overview of the follow-up of patients with cancer, and help to improve long-term management and adapt surveillance.

Updated guidance on the management of cancer treatment-induced bone loss (CTIBL) in pre- and postmenopausal women with early-stage breast cancer

INTRODUCTION

Adjuvant endocrine therapy induces bone loss and increases fracture risk in women with hormone-receptor positive, early-stage breast cancer (EBC). We aimed to update a previous position statement on the management of aromatase inhibitors (AIs) induced bone loss and now included premenopausal women.

METHODS

We conducted a systematic literature search of the medical databases from January 2017 to May 2020 and assessed 144 new studies.

RESULTS

Extended use of AIs beyond 5 years leads to persistent bone loss in breast cancer extended adjuvant trials and meta-analyses. In addition to bone mineral density (BMD), vertebral fracture assessment (VFA) and trabecular bone score (TBS) were shown to independently predict fracture risk in real life prospective studies. FRAX® tool does not seem to be reliable for assessing fracture risk in CTIBL. In premenopausal women, there is strong evidence that intravenous zoledronate prevents bone loss but weak conflicting evidence on reducing disease recurrence from independent randomised controlled trials (RCTs). In postmenopausal women, the strongest evidence for fracture prevention is for denosumab based on a well-powered RCT while there is strong evidence for bisphosphonates (BPs) to prevent and reduce CTIBL but no convincing data on fractures. Adjuvant denosumab has failed to show anticancer benefits in a large, well-designed RCT.

DISCUSSION AND CONCLUSIONS

Extended use of AIs and persistent bone loss from recent data reinforce the need to evaluate fracture risk in EBC women initiated on AIs. Fracture risk should be assessed with clinical risk factors and BMD along with VFA, but FRAX is not adapted to CTIBL. Anti-resorptive therapy should be considered in those with a BMD T-score < -2.0 SD or with ≥ 2 clinical risk factors including a BMD T-score < -1.0 SD. In premenopausal women, intravenous zoledronate is the only drug reported to prevent bone loss and may have additional anticancer benefits. In postmenopausal women, either denosumab or BPs can be prescribed for fracture prevention with pertinent attention to the rebound phenomenon after stopping denosumab. Adjuvant BPs, in contrast to denosumab, have shown high level evidence for reducing breast cancer recurrence in high-risk post-MP women which should be taken into account when choosing between these two.

Awareness of Common Cancer Risk Factors and Symptoms in Saudi Arabia: A Community-Based Study

Objective:

To assess the level of cancer awareness and the relationship between the awareness of common cancer symptoms and risk factors and the sample’s sociodemographic profile.

Methods:

A community-based cross-sectional study conducted in Tabuk city, a convenient sample of 675 participants completed a questionnaire about common factors causing cancer and symptoms related to cancer. Descriptive statistics and chi-squared analysis were used to measure sample characteristics and their association with knowledge of cancer risk factors and symptoms.

Results:

Level of education and family history were significantly related to awareness of cancer risk factors (P= 0.017) and (P= 0.048), respectively. Factors were significantly associated with awareness of cancer symptoms include Gender (P=0.000), nationality (P=0.013), and undergoing regular cancer screening tests (0.008). Internet was the primary source of information about cancer and related significantly to knowledge about cancer symptoms(P=0.000) and risk factors(P=0.00). More than half of the sample scored poorly for knowledge of both cancer risk factors (58.7%) and symptoms (66.2%) in terms of the overall level of cancer awareness. Smoking and heredity were the most identifiable cancer risk factors, and unexplained pain and weight loss were identified by the majority of study participants.

Conclusion:

The level of community knowledge requires further investigation, and more cancer awareness programs need to be conducted. People could be encouraged to use reliable sources of information to obtain accurate cancer information.

Metabolic Classification and Intervention Opportunities for Tumor Energy Dysfunction

A comprehensive view of cell metabolism provides a new vision of cancer, conceptualized as tissue with cellular-altered metabolism and energetic dysfunction, which can shed light on pathophysiological mechanisms. Cancer is now considered a heterogeneous ecosystem, formed by tumor cells and the microenvironment, which is molecularly, phenotypically, and metabolically reprogrammable. A wealth of evidence confirms metabolic reprogramming activity as the minimum common denominator of cancer, grouping together a wide variety of aberrations that can affect any of the different metabolic pathways involved in cell physiology. This forms the basis for a new proposed classification of cancer according to the altered metabolic pathway(s) and degree of energy dysfunction. Enhanced understanding of the metabolic reprogramming pathways of fatty acids, amino acids, carbohydrates, hypoxia, and acidosis can bring about new therapeutic intervention possibilities from a metabolic perspective of cancer.

Unhealthy behaviors after breast cancer: Capitalizing on a teachable moment to promote lifestyle improvements

BACKGROUND

This study assessed the prevalence and risk factors of unhealthy behaviors among survivors of early-stage breast cancer.

METHODS

Women (n = 9556) from the CANcer TOxicity cohort (NCT01993498) were included. Physical activity (PA), tobacco and alcohol consumption, and body mass index were assessed at diagnosis and at years 1 and 2 after diagnosis. A behavior was defined as unhealthy if patients failed to meet PA recommendations (≥10 metabolic equivalent task hours per week), reduce/quit tobacco, or decrease alcohol consumption to less than daily, or if they gained substantial weight over time. Multivariable-adjusted generalized estimating equations explored associations with unhealthy behaviors.

RESULTS

At diagnosis, 41.7% of patients were inactive, 18.2% currently used tobacco, 14.6% consumed alcohol daily, and 48.9% were overweight or obese. At years 1 and 2, unhealthy PA behavior was reported among 37.0% and 35.6% of patients, respectively, unhealthy tobacco use behavior was reported among 11.4% and 9.5%, respectively, and unhealthy alcohol behavior was reported among 13.1% and 12.6%, respectively. In comparison with the previous assessment, 9.4% and 5.9% of underweight and normal-weight patients had transitioned to the overweight or obese category at years 1 and 2, respectively, and 15.4% and 16.2% of overweight and obese patients had gained ≥5% of their weight at years 1 and 2, respectively. One in 3 current tobacco smokers and 1 in 10 daily alcohol users reported improved behaviors after diagnosis. Older women (5-year increment) were more likely to be inactive (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 1.01-1.05) and report unhealthy alcohol behavior (aOR, 1.28; 95% CI, 1.23-1.33) but were less likely to engage in unhealthy tobacco use (aOR, 0.81; 95% CI, 0.78-0.85). Being at risk for depression (vs not being at risk for depression) was associated with reduced odds of unhealthy tobacco use (aOR, 0.67; 95% CI, 0.46-0.97) and with a higher likelihood of unhealthy alcohol behavior (aOR, 1.58; 95% CI, 1.14-2.19). Women with a college education (vs a primary school education) less frequently reported an unhealthy PA behavior (aOR, 0.61; 95% CI, 0.51-0.73) and were more likely to report unhealthy alcohol behavior (aOR, 1.85; 95% CI, 1.37-2.49). Receipt of chemotherapy (vs not receiving chemotherapy) was associated with higher odds of gaining weight (aOR, 1.51; 95% CI, 1.23-1.87) among those who were overweight or obese at diagnosis.

CONCLUSIONS

The majority of women were adherent to healthy lifestyle behaviors at the time of their breast cancer diagnosis, but a significant subset was nonadherent. Unhealthy behaviors tended to persist after the breast cancer diagnosis, having varying clinical, psychological, sociodemographic, and treatment-related determinants. This study will inform more targeted interventions to promote optimal health.

Care for Breast Cancer Survivors

The number of cancer survivors is increasing globally. More than 15.5 million Americans in 2016 and 1.3 million Koreans in 2013 were living with cancer history. This growing population is expected to increase due to marked development of cancer treatment and early detection. Especially, breast cancer is the second most common cancer in Korean women with relatively favorable 5-year survival rate. Cancer survivors generally face various physical, psychological, and social problems including late-effect or long-term effect after cancer treatment and high risk for second primary cancer and comorbid chronic diseases such as cardiovascular disease and bone health. Breast cancer survivors also encounter wide range of health problems. To satisfy their complex needs, comprehensive supports are required. We categorized the strategy of comprehensive care for breast cancer survivors into (1) Surveillance for primary cancer, (2) Screening of second primary cancer, (3) Management of comorbid health condition, (4) Promoting healthy lifestyle behaviors, and (5) Preventive care. In the future, studies for providing best comprehensive care for breast cancer survivors are needed according to the individuals' demand.

Provider Discussion about Lifestyle by Cancer History: A Nationally Representative Survey

BACKGROUND

Providers are uniquely positioned to encourage health-promoting behaviors, particularly among cancer survivors where patients develop trust in providers.

METHODS

We utilized the National Health Interview Survey to identify adults who reported a visit to a provider in the prior year (44,385 individuals with no cancer history and 4,792 cancer survivors), and reported prevalence of provider discussions on weight loss, physical activity, diet, and smoking. We used generalized linear mixed models to examine predicted prevalence of provider lifestyle discussions by cancer history overall, and among those who do not meet body mass index (BMI), activity, or smoking guidelines.

RESULTS

Among those with a BMI of 25-<60 kg/m², 9.2% of those with a cancer history and 11.6% of those without a cancer history reported being told to participate in a weight loss program (P < 0.001). Overall, 31.7% of cancer survivors and 35.3% of those with no cancer history were told to increase their physical activity (P < 0.001). Only 27.6% of cancer survivors and 32.2% of those with no cancer history reported having a general discussion of diet (P < 0.001). Among smokers, 67.3% of cancer survivors and 69.9% of those with no cancer history reported counseling on smoking (P = 0.309).

CONCLUSIONS

Fewer cancer survivors, who are at increased risk for health complications, are reporting provider discussions about critical lifestyle issues than those with no cancer history.

IMPACT

Our nationally representative results suggest that providers are missing an opportunity for influencing patient lifestyle factors, which could lead to mitigation of late and long-term effects of treatment.

The Role of Nutritional Support in Cured/Chronic Patients

Improvements in Clinical Oncology, due to earlier diagnoses and more efficient therapeutic strategies, have led to increased numbers of long-term survivors, albeit many with chronic diseases. Dealing with the complex care needs of these survivors is now an important part of Medical Oncology. Suitable diet and physical activity regimes will be important in maintaining their health. This paper will review what we know and what we can do in the near future for these patients.

Age-induced accumulation of methylmalonic acid promotes tumour progression

From age 65 onwards, the risk of cancer incidence and associated mortality is substantially higher^1–6. Nonetheless, our understanding of the complex relationship between age and cancer is still in its infancy^2,3,7,8. For decades, this link has largely been attributed to increased exposure time to mutagens in older individuals. However, this view does not account for the well-established role of diet, exercise and small molecules that target the pace of metabolic aging^9–12. Here, we show that metabolic alterations that occur with age can render a systemic environment favorable to progression and aggressiveness of tumors. Specifically, we show that methylmalonic acid (MMA), a by-product of propionate metabolism, is significantly up-regulated in the serum of older people, and functions as a mediator of tumor progression. We traced this to MMA’s ability to induce SOX4 and consequently eliciting a transcriptional reprogramming that can endow cancer cells with aggressive properties. Thus, accumulation of MMA represents a novel link between aging and cancer progression, implicating MMA as a novel therapeutic target for advanced carcinomas.

Changes in lifestyle among prostate cancer survivors: A nationwide population-based study

Objective

Long‐term information on lifestyle changes among prostate survivors is lacking. In this nationwide, population‐based study we investigated the prevalence of lifestyle changes, factors associated with lifestyle changes and associations between lifestyle changes and general quality of life.

Methods

All men registered in the National Prostate Cancer Register of Sweden diagnosed in 2008 with low‐risk prostate cancer at age 70 years or younger were sent a questionnaire. Logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals for factors potentially associated with lifestyle change.

Results

Out of 1288, 1720 men (75%) were responded. A total of 279 (22%) reported a positive lifestyle change regarding diet or exercise. Poor functional outcomes after treatment was associated with exercising less (OR 1.6, 95% CI 1.2‐2.1) and less interest in social activities and relationships (OR 1.8, 95% CI 1.5‐2.1). Men who exercised more (OR 7.9, 95% CI 4.4‐14) and men who had an increased interest in relationships and social activities (OR 5.2, 95% CI 2.1‐13) reported higher general quality of life.

Conclusions

A considerable proportion of men reported making positive lifestyle changes after the prostate cancer diagnosis. The time after diagnosis may be a teachable moment that facilitates lifestyle interventions. Poor functional outcomes after treatment may reduce the willingness to engage in positive lifestyle change, which need be considered when supporting men after treatment. Men who made a positive lifestyle change, regardless of whether it was exercise or regarding relationships and social activities more often reported a high level of general quality of life.

Oral Potentially Malignant Disorders and Oral Cavity Cancer

The Surveillance, Epidemiology, and End Results program from the National Cancer Institute reports that the aggregate number of oral cavity and pharyngeal cancer cases has been increasing over the past decade and, despite an overall decline in oral cavity cancers, this increase is largely related to a dramatic increase in cancers involving oropharyngeal subsites. Early detection of oral cavity cancers is commensurate with improved survival, and opportunistic screening by trained clinicians to detect oral cavity cancer and oral potentially malignant disorders is recommended by the American Dental Association and the American Academy of Oral Medicine.

Relationships Between Fear of Cancer Recurrence and Lifestyle Factors Among Cancer Survivors

We examine the relationships between fear of cancer recurrence (FCR), physical activity, smoking status, and engagement in healthier habits in a US population-based sample of post-treatment cancer survivors. We used data from the 2011 Medical Expenditure Panel Survey (MEPS) Experience with Cancer Survivorship Supplement. Multivariable logistic regression was used to test the relationship of FCR to physical activity, smoking status, and engagement in healthier habits. In all analyses, MEPS survey weights were applied to account for the survey design. Compared with those reporting no FCR, survivors reporting high FCR had significantly lower odds of reporting that they were not currently smokers (odds ratio [OR] = 0.46; 95% CI 0.24, 0.91) and those with any level of FCR had significantly higher odds of reporting healthier habits since diagnosis relative to those with no FCR (low FCR OR = 1.97; 95% CI 1.36, 2.85; high FCR OR = 2.40; 95% CI 1.33, 4.32). FCR was not associated with the odds of reporting physical activity. Findings from this large population-based survey suggest that some of survivors' lifestyle factors may be related to their level of FCR. Understanding the effects of FCR on lifestyle factors may help survivors, survivorship care providers, and policy makers better understand important differences among cancer survivors and personalize interventions in clinical care.

Tobacco Dependence Treatment in Oncology: Initial Patient Clinical Characteristics and Outcomes from Roswell Park Comprehensive Cancer Center

Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study examined implementation outcomes in a cohort of cancer survivors (CSs) who smoked cigarettes in the first year of an ongoing process to develop and implement a robust Tobacco Treatment Service at Roswell Park Comprehensive Cancer Center. We provide a comprehensive description of the new tobacco use assessment and referral process, and of the characteristics of cancer survivors who agreed to treatment including traditional tobacco-related psychosocial and cancer treatment-related characteristics and novel characteristics such as delay discounting rates. We also examine characteristic differences among those who agreed to treatment between those who attended and those who did not attend treatment. As the new tobacco assessment was implemented, the number of referrals increased dramatically. The mean number of treatment sessions attended was 4.45 (SD = 2.98) and the six-month point prevalence intention to treat abstinence rate among those who attended was 22.7%. However, only 6.4% agreed to treatment and 4% attended at least one treatment session. A large proportion of cancer survivors who agreed to treatment were women, of older age, of lower socioeconomic status (SES), and who had high levels of depressive symptomology. The findings demonstrate that the implementation of system changes can significantly improve the identification of cancer survivors who use tobacco and are referred to tobacco use treatment. Among those who attend, treatment is effective. However, the findings also suggest that a systematic assessment of barriers to engagement is needed and that cancer survivors may benefit from additional treatment tailoring. We present plans to address these implementation challenges. Systematic electronic medical record (EMR)-sourced referral to tobacco treatment is a powerful tool for reaching cancer survivors who smoke, but more research is needed to determine how to enhance engagement and tailor treatment processes.

Cardiorespiratory fitness and cancer in men with cardiovascular disease: Analysis from the Veterans Exercise Testing Study

Background

Cardiovascular disease and cancer share similar risk factors and are the leading causes of death worldwide. This study aimed to assess the association between cardiorespiratory fitness, cancer incidence and cancer mortality in men with cardiovascular disease.

Methods

Baseline cardiorespiratory fitness (treadmill exercise test) was assessed in 565 men aged 58.9 ± 17 with documented cardiovascular disease and free from any malignancy. Cox multivariable hazard models, population attributable fraction and exposure impact number were analyzed in model accounting for competing events for cancer outcomes.

Results

Mean cardiorespiratory fitness was 7.6 ± 3.4 metabolic equivalents. During a 12.0 ± 7.5 year follow-up, 147 participants developed any type of cancer, 70 died from cancer, and five died from causes other than cancer as competing events. Compared to low cardiorespiratory fitness (&lt;5 metabolic equivalents), moderate (5–10 metabolic equivalents) and high cardiorespiratory fitness (&gt;10 metabolic equivalents) were associated with 50% (0.50, 95% confidence interval (0.27–0.91)) and 68% (0.32 (0.11–0.88)) reduced risks for cancer mortality (p trend = 0.026), respectively. Survival time was longer among individuals with moderate (20.8 (19.7–22) years) and high (24.9 (23–26.7) years) compared to low cardiorespiratory fitness (17.2 (15.1–19.3) years), p &lt; 0.001. Population attributable fraction and exposure impact number for cancer mortality were 13% (4.1–17.7) and 10.8 (5.1–56.4), p = 0.01, respectively. Cardiorespiratory fitness was not associated with cancer incidence.

Conclusion

Higher cardiorespiratory fitness was independently associated with lower risk of cancer mortality and extended survival time in men with cardiovascular disease, although it was not associated with cancer incidence. Improving cardiorespiratory fitness through supervised exercise rehabilitation programs could potentially serve as a cost-effective public-health strategy for secondary prevention and survivorship in men with cardiovascular disease.

Adherence to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern reduces the risk of colorectal cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Colorectal cancer (CRC) has become a major concern due to industrialization and dietary changes generated by it. Many of the components of the DASH (Dietary Approach to Stop Hypertension) diet are associated with the risk of CRC. However, the relationship between DASH dietary pattern and CRC has not been studied yet in a systematic review and meta-analysis. The present study was conducted to review the studies investigating the relationship between DASH diet and the risk of CRC.

METHODS

PubMed and Scopus search engines were searched to find relevant publications from inception up to September 2019. All the observational studies that addressed the association between DASH diet and CRC were included in the systematic review and meta-analysis. All the steps including data base search, screening, and data extraction were carried out by two researchers, independently.

RESULTS

Eight studies included in this systematic review and 5 studies (out of 8 studies included in the systematic review) were included in the meta-analysis. Combining 12 effects sizes from 5 studies, a significant inverse association between adherence to the DASH diet and risk of CRC was found (RR: 0.80; 95% CI: 0.74, 0.85). Based on the result of this study, individuals with greater adherence to DASH diet had 20% lower risk of CRC.

CONCLUSION

The current study demonstrates that the risk of CRC is negatively associated with the adherence to the DASH dietary pattern.

The effectiveness of distance‐based interventions for smoking cessation and alcohol moderation among cancer survivors: A meta‐analysis

OBJECTIVE

The objective of this study is to evaluate current evidence for the effectiveness of distance-based interventions to support smoking cessation (SC) or alcohol moderation (AM) among cancer survivors. Secondary, differences in effectiveness are explored regarding multibehaviour interventions versus single-behaviour interventions targeting SC or AM only.

METHODS

A systematic search of PubMed, PsycINFO, Web of Science, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials was conducted. Intervention studies with and without control groups and randomized controlled trials were included. Random effects meta-analyses were conducted for the main outcomes: SC and AM rates at the follow-up closest to 6 months. Using subgroup analyses and meta-regression, effectiveness of single-behaviour versus multibehaviour interventions was evaluated.

RESULTS

A total of 17 studies with 3796 participants; nine studies on SC only, eight studies on multibehaviour interventions including an SC or AM module, and no studies on AM only were included. All studies had at least some concerns regarding bias. Distance-based SC interventions led to higher cessation rates than control conditions (10 studies, odds ratio [OR] = 1.56; 95% CI, 1.13-2.15, P = .007). Single-behaviour SC interventions reduced smoking rates compared with baseline (risk difference [RD] = 0.29; 95% CI, 0.19-0.39, P < .0001), but multibehaviour interventions did not (RD = 0.13; 95% CI, -0.05 to 0.31, P = 0.15). There was insufficient evidence that distance-based multibehaviour interventions reduced alcohol use compared with controls (three studies, standardized mean difference [SMD] = 0.12; 95% CI, -0.08 to 0.31, P = .24).

CONCLUSIONS

Distance-based SC interventions are effective in supporting SC among cancer survivors. Single-behaviour SC interventions appear more effective than multibehaviour interventions. No evidence was found for the effectiveness of distance-based AM interventions for cancer survivors.

Randomized Phase II Trial of Exercise, Metformin, or Both on Metabolic Biomarkers in Colorectal and Breast Cancer Survivors

Background

Observational data support inverse relationships between exercise or metformin use and disease outcomes in colorectal and breast cancer survivors, although the mechanisms underlying these associations are not well understood.

Methods

In a phase II trial, stage I–III colorectal and breast cancer survivors who completed standard therapy were randomly assigned to structured exercise or metformin or both or neither for 12 weeks. The primary outcome was change in fasting insulin levels; secondary outcomes included changes in other blood-based energetic biomarkers and anthropometric measurements. Analyses used linear mixed models.

Results

In total, 139 patients were randomly assigned; 91 (65%) completed follow-up assessments. Fasting insulin levels statistically significantly decreased in all three intervention arms (−2.47 μU/mL combination arm, −0.08 μU/mL exercise only, −1.16 μU/mL metformin only, + 2.79 μU/mL control arm). Compared with the control arm, all groups experienced statistically significant weight loss between baseline and 12 weeks (−1.8% combination arm, −0.22% exercise only, −1.0% metformin only, +1.55% control). The combination arm also experienced statistically significant improvements in the homeostatic model assessment for insulin resistance (−30.6% combination arm, +61.2% control) and leptin (−42.2% combination arm, −0.8% control), compared with the control arm. The interventions did not change insulin-like growth factor–1 or insulin-like growth factor binding protein–3 measurements as compared with the control arm. Tolerance to metformin limited compliance (approximately 50% of the participants took at least 75% of the planned dosages in both treatment arms).

Conclusions

The combination of exercise and metformin statistically significantly improved insulin and associated metabolic markers, as compared to the control arm, with potential greater effect than either exercise or metformin alone though power limited formal synergy testing. Larger efforts are warranted to determine if such a combined modality intervention can improve outcomes in colorectal and breast cancer survivors.

Continuing increased risk of second cancer in long-term testicular cancer survivors after treatment in the cisplatin era

Using complete information on total treatment burden, this population-based study aimed to investigate second cancer (SC) risk in testicular cancer survivors (TCS) treated in the cisplatin era. The Cancer Registry of Norway identified 5,625 1-year TCS diagnosed 1980-2009. Standardized incidence ratios (SIRs) were calculated to evaluate the total and site-specific incidence of SC compared to the general population. Cox regression analyses evaluated the effect of treatment on the risk of SC. After a median observation time of 16.6 years, 572 TCS developed 651 nongerm cell SCs. The SC risk was increased after surgery only (SIR 1.28), with site-specific increased risks of thyroid cancer (SIR 4.95) and melanoma (SIR 1.94). After chemotherapy (CT), we observed 2.0- to 3.7-fold increased risks for cancers of the small intestine, bladder, kidney and lung. There was a 1.6- to 2.1-fold increased risk of SC after ≥2 cycles of cisplatin-based CT. Radiotherapy (RT) was associated with 1.5- to 4.4-fold increased risks for cancers of the stomach, small intestine, liver, pancreas, lung, kidney and bladder. After combined CT and RT, increased risks emerged for hematological malignancies (SIR 3.23). TCS treated in the cisplatin era have an increased risk of developing SC, in particular after treatment with cisplatin-based CT and/or RT.

Benefits of Aerobic Exercise for Breast Cancer Survivors: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Physical exercise may be beneficial to breast cancer (BC) survivors. Here, we systematically summarized the effects of aerobic exercise in BC survivors. We conducted a systematic review of randomized controlled trials (RCTs).

METHODS

We searched PubMed, Web of knowledge, Scopus, Cochrane Central, Virtual Health Library and PEDRO databases for relevant RCTs, comparing aerobic exercise with usual care among BC survivors. Data were extracted and evidence was synthesized narratively.

RESULTS

Twelve studies were included in this systematic review. Studies reported that aerobic exercise can significantly improve the quality of life in BC survivors. Moreover, aerobic exercise alleviated the symptoms of depression and anxiety. However, current evidence from the included studies showed that there was no significant benefit for aerobic exercise in terms of weight loss.

CONCLUSION

Our study suggests that aerobic exercise is beneficial to BC survivors.

CLINICAL RELEVANCE

Aerobic exercise should be recommended in the therapeutic and rehabilitative regimens of BC survivors.
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The UroLife study: protocol for a Dutch prospective cohort on lifestyle habits in relation to non-muscle-invasive bladder cancer prognosis and health-related quality of life

INTRODUCTION

Patients with non-muscle-invasive bladder cancer (NMIBC) have a good survival but are at high risk for tumour recurrence and disease progression. It is important to identify lifestyle habits that may reduce the risk of recurrence and progression and improve health-related quality of life (HRQOL). This paper describes the rationale and design of the UroLife study. The main aim of this study is to evaluate whether lifestyle habits are related to prognosis and HRQOL in patients with NMIBC.

METHODS AND ANALYSIS

The UroLife study is a multicentre prospective cohort study among more than 1100 newly diagnosed patients with NMIBC recruited from 22 hospitals in the Netherlands. At 6 weeks and 3, 15 and 51 months after diagnosis, participants fill out a general questionnaire, and questionnaires about their lifestyle habits and HRQOL. At 3, 15 and 51 months after diagnosis, information about fluid intake and micturition is collected with a 4-day diary. At 3 and 15 months after diagnosis, patients donate blood samples for DNA extraction and (dietary) biomarker analysis. Tumour samples are collected from all patients with T1 disease to assess molecular subtypes. Information about disease characteristics and therapy for the primary tumour and subsequent recurrences is collected from the medical records by the Netherlands Cancer Registry. Statistical analyses will be adjusted for age, gender, tumour characteristics and other known confounders.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Committee for Human Research region Arnhem-Nijmegen (CMO 2013-494). Patients who agree to participate in the study provide written informed consent. The findings from our study will be disseminated through peer-reviewed scientific journals and presentations at (inter)national scientific meetings. Patients will be informed about the progress and results of this study through biannual newsletters and through the website of the study and of the bladder cancer patient association.

Healthy lifestyle discussions between healthcare providers and older cancer survivors: Data from 12 cancer centers in the Southeastern United States

Background

Little is known about the prevalence of healthy lifestyle (HLS) discussions between providers and older cancer survivors.

Methods

We utilized cross‐sectional data from older cancer survivors (≥65 years) seen at 12 southeastern cancer centers during 2013‐2015. Data on demographics, time since diagnosis, weight, height, and healthy behaviors were collected. Respondents were asked if providers (oncologists, other physicians, and/or nurses) discussed exercise, healthy diet, weight management, and/or smoking cessation during clinical encounters. Descriptive statistics and bivariate associations between HLS topics and survivor characteristics were calculated.

Results

Among 1460 cancer survivors, mean age was 74 years (SD 6), most were white (81%), and >1 year postdiagnosis (84%). The majority (71%) reported discussing at least one of three HLS topics (exercise 49%, healthy diet 53%, vegetable consumption 28%); 17% received counseling on all three. Weight loss was recommended to 33% of overweight/obese survivors and smoking cessation to 85% of current smokers. Oncologists and nurses discussed HLS less frequently compared to other physicians. Younger survivors (65‐74 years) received recommendations for exercise, weight loss, and tobacco cessation more often than older survivors (≥75 years). Compared to white respondents, minorities reported discussions on all topics more often except for tobacco cessation. Excluding tobacco cessation, survivors with recent cancer diagnoses (<1 year) reported HLS discussions more often than survivors >1 year postdiagnosis.

Conclusion

Despite the American Cancer Society's recommendations, older survivors reported a low prevalence of HLS discussions with their providers, with some variation by demographic groups. Strategies are needed to promote these important discussions in this population.