Making lifestyle changes after colorectal cancer: insights for program development

Cardiovascular events after elective colorectal cancer surgery in patients with stage I-III disease with no previous cardiovascular disease

BACKGROUND

The risk of cardiovascular events in patients treated for colorectal cancer is debated due to diverging results in previous studies. Colorectal cancer and cardiovascular disease share several risk factors such as physical inactivity, obesity, and smoking. Information about confounding covariates and follow-up time are therefore essential to address the issue. This study aims to investigate the risk of new-onset cardiovascular events for patients with stage I-III colorectal cancer receiving elective surgery compared to a matched population.

MATERIAL AND METHODS

Using a prospective cohort, we compared cardiovascular events among 876 patients treated with elective surgery for incident stage I-III colorectal cancer diagnosed between January 1st, 2001 and December 31st, 2016 to a cancer-free cohort matched by age, sex, and time since enrollment (N = 3504). Regression analyses were adjusted for lifestyle, cardiovascular risk factors, and comorbidity. Multivariable analyses were used to identify risk factors associated with cardiovascular events in the postoperative (<90 days of elective surgery) and long-term phase (>90 days after elective surgery).

RESULTS

After a median follow-up of 3.9 years, the hazard ratio (HR) for incident heart failure was 1.53 (95% CI 1.02-2.28) among patients operated for colorectal cancer. The postoperative risk of myocardial infarction or angina pectoris was associated with the use of lipid-lowering drugs. Long-term risks of cardiovascular events were ASA-score of III+IV and lipid-lowering drugs with HRs ranging from 2.20 to 15.8. Further, the use of antihypertensive drugs was associated with an HR of 2.09 (95% CI 1.06-4.13) for angina pectoris or acute myocardial infarction. Heart failure was associated with being overweight, diabetes, and anastomosis leakage.

CONCLUSION

We observed an increased hazard of heart failure in patients operated on for stage I-III colorectal cancer compared to cancer-free comparisons. We identified several potential risk factors for cardiovascular events within and beyond 90 days of elective surgery.

Health-Promoting Lifestyle in Colorectal Cancer Survivors: A Qualitative Study on the Experiences and Perspectives of Colorectal Cancer Survivors and Healthcare Providers

OBJECTIVE

Understanding the experiences of survivors and healthcare providers about health-promoting lifestyle (HPL) in colorectal cancer (CRC) survivors is important in planning for coping with the disease, managing treatment side effects, increasing survival, and improving quality of life (QOL). This study was conducted to explore the experiences and perspectives of CRC survivors and healthcare providers about HPL in CRC survivors.

METHODS

This descriptive qualitative study was performed in 2020 at Omid and Imam Reza Hospitals in Mashhad, Iran. Participants were CRC survivors (n = 12) and healthcare providers (n = 33) who were selected by purposive sampling. Data were collected using in-depth semi-structured interview by face to face and then analyzed by Zhang and Wildemuth content analysis method. MaxQDA software was used to organize the data.

RESULTS

Following the treatment of cancer, CRC survivors seek to make changes in lifestyle and they choose a HPL that maintains or improves their health. HPL in CRC survivors includes nutrition, activity and rest, health responsibility, interpersonal relations, spiritual growth, and psychological management. The results showed that HPL can lead to motivation, the ability to self-care and improve daily performance, reduce treatment complications, and increase the QOL.

CONCLUSIONS

CRC survivors can help change their lifestyle patterns with healthy eating, treatment adherence, regular physical activity, and good sleep habits. Furthermore, effective personal and social relationships, spiritual growth, and management of psychological disorders develop health-promoting behaviors in them. CRC survivors also face challenges and limitations in their life after treatment; identifying the components of a HPL in CRC survivors can lead to desirable care, treatment, education, and counseling services.

Healthy Eating and Active Lifestyle After Bowel Cancer (HEAL ABC): feasibility randomised controlled trial protocol

Background

Targeting modifiable lifestyle factors including diet and physical activity represents a potentially cost-effective strategy that could support a growing population of colorectal cancer survivors and improve their health outcomes. Currently, effective, evidence-based interventions and resources helping people after bowel cancer to adopt new lifestyle habits are lacking. The aim of this trial is to test the Healthy Eating and Active Lifestyle After Bowel Cancer (HEAL-ABC) intervention to inform a future definitive randomised controlled trial.

Methods/design

This is a feasibility randomised controlled trial. A total of 72 survivors who have completed surgery and all anticancer treatments will be recruited. The intervention group will receive HEAL-ABC resources based on behaviour change theory combined with supportive telephone calls informed by motivational interviewing every 2 weeks during the 3-month intervention, and once a month for 6 months to follow-up. Participants in the control group will follow usual care and have access to resources available in the public domain. The study is testing feasibility of the intervention including adherence and ability to collect data on anthropometry, body composition, diet, physical activity, behaviour change, quality of life, blood markers, contact with healthcare services, morbidities and overall survival.

Discussion

The proposed study will add to the evidence base by addressing an area where there is a paucity of data. This study on lifestyle interventions for people after colorectal cancer follows the Medical Research Council guidance on evaluating complex interventions in clinical practice. It focuses on people living after treatment for colorectal cancer and targets an important research area identified by cancer survivors as a research priority reported by the National Cancer Institute and James Lind Alliance UK.

Trial registration

ClinicalTrials.gov NCT04227353 approved on the 13th of January 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00721-y.

Physical Activity and Cancer Care in the Atlantic Canadian Provinces: an Examination of Provider Beliefs, Practices, Resources, Barriers, and Enablers

Despite the well-established benefits of physical activity for cancer survivors, the vast majority of survivors are not sufficiently active to reap these benefits. While cancer-specific physical activity guidelines exist, it remains unclear whether there are sufficient resources to support these recommendations. The purpose of this qualitative study was to describe the available cancer-specific physical activity programs for cancer survivors in Atlantic Canada and explore barriers and enablers to program implementation. Interviews were conducted with a purposefully selected sample of oncology healthcare professionals, administrators, and cancer-specific physical activity program leaders to examine the attitudes and practices of key stakeholders with respect to physical activity and cancer-specific programming. Thirty participants, including 7 oncologists, 7 nurses, 6 allied healthcare professionals, 5 administrators, and 5 program leaders, completed an interview. Three over-arching themes emerged, including (1) knowledge, attitudes and need for physical activity; (2) implementation barriers; and (3) implementation enablers. The results of this study suggest that cancer survivors in Atlantic Canada may require additional resources and support with respect to physical activity throughout their cancer care journey.

The impact of surviving bowel cancer on occupation: A scoping review

Introduction

The number of people surviving bowel cancer is increasing globally, with many of those affected living with long-term psychological and physical sequelae that potentially disrupt occupations.

Method

A scoping review – guided by Arksey and O’Malley’s methodological framework – was conducted to provide an overview of what is known about the impact of having had bowel cancer on occupations, and to reveal the potential role of occupational therapy. A systematic search of four databases and a grey literature repository generated 244 results. Applying inclusion and exclusion criteria, 33 items addressing bowel cancer and occupations were selected and thematically analysed.

Results

Researchers have identified six domains of occupation that are impacted by bowel cancer (social activity, physical activity, sexual activity, employment and role functioning, physical functioning, and self-care) but survivors report a distinct lack of health professional support after completion of medical treatment and being left to devise self-management strategies to accommodate the long-term effects of their cancer.

Conclusion

The sequelae of bowel cancer can have a significant impact on occupational participation. There is scope for increasing and improving occupational therapy input to assist people with cancer-related loss of function to re-engage in valued occupations and improve wellbeing.

Single nucleotide polymorphisms associated with susceptibility for development of colorectal cancer: Case-control study in a Basque population

Given the significant population diversity in genetic variation, we aimed to investigate whether single nucleotide polymorphisms (SNPs) previously identified in studies of colorectal cancer (CRC) susceptibility were also relevant to the population of the Basque Country (North of Spain). We genotyped 230 CRC cases and 230 healthy controls for 48 previously reported CRC-susceptibility SNPs. Only the rs6687758 in DUPS10 exhibited a statistically significant association with CRC risk based on the crude analysis. The rs6687758 AG genotype conferred about 2.13-fold increased risk for CRC compared to the AA genotype. Moreover, we found significant associations in cases between smoking status, physical activity, and the rs6687758 SNP. The results of a Genetic Risk Score (GRS) showed that the risk alleles were more frequent in cases than controls and the score was associated with CRC in crude analysis. In conclusion, we have confirmed a CRC susceptibility locus and the existence of associations between modifiable factors and the rs6687758 SNP; moreover, the GRS was associated with CRC. However, further experimental validations are needed to establish the role of this SNP, the function of the gene identified, as well as the contribution of the interaction between environmental factors and this locusto the risk of CRC.

Colorectal cancer survivors only marginally change their overall lifestyle in the first 2 years following diagnosis

Purpose

A healthy lifestyle after colorectal cancer (CRC) diagnosis may improve prognosis. Data related to lifestyle change in CRC survivors are inconsistent and potential interrelated changes are unknown.

Methods

We assessed dietary intake, physical activity, body mass index (BMI), waist circumference, and smoking among 1072 patients diagnosed with stages I–III CRC at diagnosis, 6 months and 2 years post-diagnosis. An overall lifestyle score was constructed based on the 2018 World Cancer Research Fund/American Institute of Cancer Research recommendations (range 0–7). We used linear mixed models to analyze changes in lifestyle over time.

Results

Participants had a mean (± SD) age of 65 ± 9 years and 43% had stage III disease. In the 2 years following CRC diagnosis, largest changes were noted for sugary drinks (− 45 g/day) and red and processed meat intake (− 62 g/week). BMI (+ 0.4 kg/m²), waist circumference (+ 2 cm), and dietary fiber intake (− 1 g/day) changed slightly. CRC survivors did not statistically significant change their mean intake of fruits and vegetables, alcohol, or ultra-processed foods nor did they change their physical activity or smoking behavior. Half of participants made simultaneous changes that resulted in improved concordance with one component as well as deteriorated concordance with another component of the lifestyle score. Overall lifestyle score changed from a mean 3.4 ± 0.9 at diagnosis to 3.5 ± 0.9 2 years post-diagnosis.

Conclusions

CRC survivors hardly improve their overall lifestyle after diagnosis.

Implications for Cancer Survivors

Given the importance of a healthy lifestyle, strategies to effectively support behavior changes in CRC survivors need to be identified.

Radiofrequency ablation with systemic chemotherapy in the treatment of colorectal cancer liver metastasis: a 10-year single-center study

Objective

To retrospectively evaluate the long-term efficacy and safety of radiofrequency ablation (RFA) with systemic chemotherapy (CT) in treatment of solitary liver metastasis after surgery for colorectal cancer (CRC).

Methods

This single-center study was conducted at the Hunan Provincial Cancer Hospital from June 2006 to December 2015 with median follow-up time of 26 months. Percutaneous ultrasound-guided RFA was carried out on eligible patients with solitary liver metastasis after surgery for CRC. After a week, ablation status was confirmed by MRI. Post MRI, all patients received systemic CT with or without molecular-targeted therapy. Survival rate was evaluated and survival curve was constructed with Kaplan-Meier analysis. Log-rank test and Cox regression model were used for univariate and multivariate analysis, respectively, to determine the independent prognostic factors for survival rate.

Results

A total of 109 eligible patients (mean age, 53.84±11.71; mean tumor mass diameter, 3.4+2.01 cm) were enrolled in this 10-year study. After RFA, 95 patients achieved complete ablation, and 14 patients achieved partial ablation, with median ablation time of 26 minutes (range: 12-120 minutes). The median survival time required for achieving complete and partial ablation was 56.0 and 19.0 months, respectively (P<.01). After RFA and adjuvant systemic CT, the 1-, 3-, and 5-year survival rates were 92.3%, 50.7%, and 41.6%, respectively, with the median (mean) survival time of 39.0 (56.5) months. Age was the only significant independent prognostic factor with better survival rate observed in patients aged ≥50 years than those aged <50 years (P<0.05). The incidence of complications was minimal (1.8%) with only two cases: one biliary fistula and one liver hemorrhage.

Conclusion

RFA combination with systemic CT was safe; it showed long-term efficacy in patients with solitary liver metastasis after surgery for CRC and can be a preferred treatment.

An exploration of needs and preferences for dietary support in colorectal cancer survivors: A mixed-methods study

PURPOSE

To describe the proportion of colorectal cancer (CRC) survivors who perceive a need for dietary support; to examine which socio-demographic, cancer-related, and health-related characteristics are associated with this need; to explore reasons for (not) needing support; and to explore CRC survivors' specific needs and preferences with regard to lifestyle (i.e., dietary, exercise, and/or weight management) support.

METHODS

This mixed-methods study comprised a cross-sectional survey among 1774 Dutch CRC survivors and three focus groups (n = 16). To examine associations, logistic regression analyses were conducted. Focus groups were audio-taped, transcribed verbatim, and analyzed using a thematic approach.

RESULTS

Of 1458 respondents (82%), 1198 (67.5%) were included for analyses. 17.5% reported a need for dietary support. Characteristics associated with this need were: being younger, living without a partner, having a stoma, having diabetes, and being overweight or obese. The main reason for needing support was being unable to initiate and maintain lifestyle changes without support. CRC survivors preferred receiving information soon after diagnosis to make an autonomous, informed decision on improving their lifestyle. They preferred to receive individually-tailored lifestyle support in an autonomy-supportive environment, preferably with involvement of their family and fellow-sufferers.

CONCLUSIONS

This study has provided knowledge on appropriate support for CRC survivors in need for dietary support to improve health outcomes by promoting adherence to lifestyle and body weight recommendations. Findings can be used to better identify CRC survivors in need for dietary support, and to tailor lifestyle support to their needs and preferences in order to promote uptake, adherence, and effectiveness.

Psychological symptoms and subsequent healthy lifestyle after a colorectal cancer diagnosis

OBJECTIVE

Although medical professionals recommend lifestyle changes following a colorectal cancer (CRC) diagnosis to improve outcomes, such changes are not consistently implemented. This study examines whether higher distress is associated with lower likelihood of engaging in favorable behaviors after CRC diagnosis.

METHOD

Women from the Nurses' Health Study prospective cohort who completed anxiety (n = 145) and depression (n = 227) symptom scales within 4 years after receiving a CRC diagnosis were included. Measures of lifestyle (diet, physical activity, alcohol, smoking, body mass index [BMI]) were queried prediagnosis, when psychological symptoms were assessed (1988 and 1992, respectively), and then every 4 years thereafter until 2010. Women were categorized according to initial psychological symptoms levels and followed through 2010 or until last follow-up completed.

RESULTS

Higher versus lower anxiety symptoms were significantly related to unhealthier lifestyle scores throughout follow-up (β = -0.25, CI [-0.44, -0.05]); however, the rate of change over time was similar across groups (pinteraction effect = 0.41). Stratified analyses hinted that higher anxiety and depression symptoms were related to increased odds of reporting a future unhealthy lifestyle within 10-years postdiagnosis. Beyond 10 years, anxiety became statistically unrelated with future lifestyle, and higher depressive symptoms were associated with lower odds of subsequently having an unhealthy lifestyle, albeit nonstatistically significant (OR = 0.35, 95% CI [0.10, 1.24], p = 0.10).

CONCLUSIONS

Among women with CRC, higher anxiety and depression symptoms were associated with subsequent unhealthier lifestyle in the 10 years following diagnosis. With replication, such findings may suggest that treating psychological symptoms early in the cancer trajectory may not solely reduce psychological distress but also promote healthier lifestyle. (PsycINFO Database Record

The use of cardiac rehabilitation services to aid the recovery of patients with bowel cancer: a pilot randomised controlled trial with embedded feasibility study

Background

Colorectal cancer (CRC) survivors are not meeting the recommended physical activity levels associated with improving their chances of survival and quality of life. Rehabilitation could address this problem.

Objectives

The aims of the Cardiac Rehabilitation In Bowel cancer study were to assess whether or not cardiac rehabilitation is a feasible and acceptable model to aid the recovery of people with CRC and to test the feasibility and acceptability of the protocol design.

Design

Intervention testing and feasibility work (phase 1) and a pilot randomised controlled trial with embedded qualitative study (phase 2), supplemented with an economic evaluation. Randomisation was to cardiac rehabilitation or usual care. Outcomes were differences in objective measures of physical activity and sedentary behaviour, self-reported measures of quality of life, anxiety, depression and fatigue. Qualitative work involved patients and clinicians from both cancer and cardiac specialties.

Setting

Three colorectal cancer wards and three cardiac rehabilitation facilities.

Participants

Inclusion criteria were those who were aged > 18 years, had primary CRC and were post surgery.

Results

Phase 1 (single site) – of 34 patient admissions, 24 (70%) were eligible and 4 (17%) participated in cardiac rehabilitation. Sixteen clinicians participated in an interview/focus group. Modifications to trial procedures were made for further testing in phase 2. Additionally, 20 clinicians in all three sites were trained in cancer and exercise, rating it as excellent. Phase 2 (three sites) – screening, eligibility, consent and retention rates were 156 (79%), 133 (67%), 41 (31%) and 38 (93%), respectively. Questionnaire completion rates were 40 (97.5%), 31 (75%) and 25 (61%) at baseline, follow-up 1 and follow-up 2, respectively. Forty (69%) accelerometer data sets were analysed; 20 (31%) were removed owing to invalid data.

Qualitative study

CRC and cardiac patients and clinicians were interviewed. Key themes were benefits and barriers for people with CRC attending cardiac rehabilitation; generic versus disease-specific rehabilitation; key concerns of the intervention; and barriers to participation (CRC participants only).

Economic evaluation

The average out-of-pocket expenses of attending cardiac rehabilitation were £50. The costs of cardiac rehabilitation for people with cancer are highly dependent on whether it involves accommodating additional patients in an already existing service or setting up a completely new service.

Limitations and conclusions

The main limitation is that this is a small feasibility and pilot study. The main novel finding is that cardiac rehabilitation for cancer and cardiac patients together is feasible and acceptable, thereby challenging disease-specific rehabilitation models.

Future work

This study highlighted important challenges to doing a full-scale trial of cardiac rehabilitation but does not, we believe, provide sufficient evidence to reject the possibility of such a future trial. We recommend that any future trial must specifically address the challenges identified in this study, such as suboptimal consent, completion, missing data and intervention adherence rates and recruitment bias, and that an internal pilot trial be conducted. This should have clear ‘stop–proceed’ rules that are formally reviewed before proceeding to the full-scale trial.

Trial registration

Current Controlled Trials ISRCTN63510637.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 4, No. 24. See the NIHR Journals Library website for further project information.

Exploring the validity of the Fantastic Lifestyle Checklist in an inner city population of people presenting with suicidal behaviours

PURPOSE

Although patients demonstrate a range of problematic health-related lifestyle behaviours preceding suicidal behaviour, there is little research that routinely measure these behaviours. This paper seeks to establish the utility of health-related lifestyle measure (Fantastic Lifestyle Checklist) in people presenting to a major inner city Emergency Department with a range of suicidal behaviours.

METHODS

From 2007-2014, data from the 366 patients who had completed the Fantastic Lifestyle Checklist, after referral by the Emergency Department to a service for people with deliberate self-harm or suicidal ideation, were included in the analysis study. A Maximum Likelihood factor analysis was performed to assess the factor structure of the Fantastic Lifestyle Checklist and the resultant factors were explored in relation to measures of health; namely the Depression, Anxiety and Stress Scale and the 12-item Short-Form Health Survey.

RESULTS

A three-component factor structure emerged comprising Component 1 'positive life investments', Component 2 'poor emotional regulation' and Component 3 'poor health behaviours'. There was a significant negative correlation between 'positive life investments' and each of the Depression, Anxiety and Stress scales subscales and significant positive associations with 'poor emotional regulation' and Short Form Health Survey-12 mental health scores. Only the Short Form Health Survey-12 physical health subscale was weakly correlated with 'poor health behaviours', in females.

CONCLUSION

Our findings support the construct and concurrent validity of the Fantastic Lifestyle Checklist measure. The three factors obtained for the Fantastic Lifestyle Checklist were coherent and seem useful for research and clinical practice.

Is referral of postsurgical colorectal cancer survivors to cardiac rehabilitation feasible and acceptable? A pragmatic pilot randomised controlled trial with embedded qualitative study

OBJECTIVES

(1) Assess whether cardiac rehabilitation (CR) is a feasible and acceptable model of rehabilitation for postsurgical colorectal cancer (CRC) survivors, (2) evaluate trial procedures. This article reports the results of the first objective.

DESIGN AND SETTING

A pragmatic pilot randomised controlled trial with embedded qualitative study was conducted in 3 UK hospitals with CR facilities. Descriptive statistics were used to summarise trial parameters indicative of intervention feasibility and acceptability. Interviews and focus groups were conducted and data analysed thematically.

PARTICIPANTS

People with CRC were considered for inclusion in the trial if they were ≥ 18 years old, diagnosed with primary CRC and in the recovery period postsurgery (they could still be receiving adjuvant therapy). 31% (n=41) of all eligible CRC survivors consented to participate in the trial. 22 of these CRC survivors, and 8 people with cardiovascular disease (CVD), 5 CRC nurses and 6 CR clinicians participated in the qualitative study.

INTERVENTION

Referral of postsurgical CRC survivors to weekly CR exercise classes and information sessions. Classes included CRC survivors and people with CVD. CR nurses and physiotherapists were given training about cancer and exercise.

RESULTS

Barriers to CR were protracted recoveries from surgery, ongoing treatments and poor mobility. No adverse events were reported during the trial, suggesting that CR is safe. 62% of participants completed the intervention as per protocol and had high levels of attendance. 20 health professionals attended the cancer and exercise training course, rating it as excellent. Participants perceived that CR increased CRC survivors' confidence and motivation to exercise, and offered peer support. CR professionals were concerned about CR capacity to accommodate cancer survivors and their ability to provide psychosocial support to this group of patients.

CONCLUSIONS

CR is feasible and acceptable for postsurgical CRC survivors. A large-scale effectiveness trial of the intervention should be conducted.

TRIAL REGISTRATION NUMBER

ISRCTN63510637.