Evaluation of a 12-week home-based walking intervention for breast cancer survivors

Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors

Research has shown that recent post-treatment breast cancer survivors face significant challenges around physical activity as they transition to recovery. This review examined randomized controlled trials targeting physical activity behavior change in breast cancer survivors <5 years post-treatment and described (1) characteristics of interventions for breast cancer survivors as well as (2) effect size estimates for these studies. A systematic search was conducted following PRISMA guidelines with Medline, PubMed, PsycINFO, CINAHL, and Scopus databases. Data were abstracted for primary intervention strategies and other details (e.g., setting, duration, theory use). A subgroup analysis was conducted to assess intensity of exercise supervision/monitoring and intervention effectiveness. The search produced 14 unique behavior intervention trials from the US and abroad published 2005-2013. The mean sample size was 153 participants per study. All interventions included moderate-intensity activities plus various behavioral change strategies. Most interventions were partially or entirely home based. The overall standardized mean difference was 0.47 (0.23, 0.67) with p < 0.001. Most interventions were effective in producing short-term behavior changes in physical activity, but varied greatly relative to intervention strategies and intensity of supervision/monitoring. Highly structured interventions tended to produce larger behavior change effects overall, but many larger effect sizes came from interventions supported by phone counseling or e-mail. We observed that 'more' may not be better in terms of direct supervision/monitoring in physical activity behavior interventions. This may be important in exploring less resource-intensive options for effective behavior change strategies for recent post-treatment survivors.

A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors

Purpose

Little is known about how to improve and create sustainable lifestyle behaviors of cancer survivors. Interventions based on social cognitive theory (SCT) have shown promise. This review examined the effect of SCT-based physical activity and nutrition interventions that target cancer survivors and identified factors associated with their efficacy.

Methods

A systematic search of seven databases identified randomized controlled trials that (i) targeted adult cancer survivors (any point from diagnosis); (ii) reported a primary outcome of physical activity, diet, or weight management; and (iii) included an SCT-based intervention targeting physical activity or diet. Qualitative synthesis and meta-analysis were conducted. Theoretical constructs and intervention characteristics were examined to identify factors associated with intervention efficacy.

Results

Eighteen studies (reported in 33 publications) met review inclusion criteria. Meta-analysis (n = 12) revealed a significant intervention effect for physical activity (standardized mean difference (SMD) = 0.33; P < 0.01). Most studies (six out of eight) that targeted dietary change reported significant improvements in at least one aspect of diet quality. No SCT constructs were associated with intervention effects. There were no consistent trends relating to intervention delivery method or whether the intervention targeted single or multiple behaviors.

Conclusions

SCT-based interventions demonstrate promise in improving physical activity and diet behavior in cancer survivors, using a range of intervention delivery modes. Further work is required to understand how and why these interventions offer promise for improving behavior.

Implications for Cancer Survivors

SCT-based interventions targeting diet or physical activity are safe and result in meaningful changes to diet and physical activity behavior that can result in health improvements.

Effects of the BEAT Cancer physical activity behavior change intervention on physical activity, aerobic fitness, and quality of life in breast cancer survivors: a multicenter randomized controlled trial

Most breast cancer survivors (BCS) are not meeting recommended physical activity guidelines. Here, we report the effects of the Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) behavior change intervention on physical activity, aerobic fitness, and quality of life (QoL). We randomized 222 post-primary treatment BCS to the 3-month intervention (BEAT Cancer) or usual care (UC). BEAT Cancer combined supervised exercise, face-to-face counseling, and group discussions with tapering to home-based exercise. Assessments at baseline, immediately post-intervention (month 3; M3), and 3 months post-intervention (month 6; M6) included accelerometer and self-reported physical activity, submaximal treadmill test, and QoL [Functional Assessment of Cancer Therapy (FACT)-Breast scale]. Adjusted linear mixed-model analyses demonstrated significant effects of BEAT Cancer compared to UC on weekly minutes of ≥ moderate intensity physical activity at M3 by accelerometer [mean between group difference (M) = +41; 95 % confidence interval (CI) = 10-73; p = 0.010] and self-report (M = +93; CI = 62-123; p < 0.001). Statistical significance remained at M6 for self-reported physical activity (M = +74; CI = 43-105; p < 0.001). BEAT Cancer participants were significantly more likely to meet physical activity recommendations at both time points [accelerometer M3 adjusted odds ratio (OR) = 2.2; CI = 1.0-4.8 and M6 adjusted OR = 2.4; CI = 1.1-5.3; self-report M3 adjusted OR = 5.2; CI = 2.6-10.4 and M6 adjusted OR = 4.8; CI = 2.3-10.0]. BEAT Cancer significantly improved fitness at M6 (M = +1.8 ml/kg/min; CI = 0.8-2.8; p = 0.001) and QoL at M3 and M6 (M = +6.4; CI = 3.1-9.7; p < 0.001 and M = +3.8; CI = 0.5-7.2; p = 0.025, respectively). The BEAT Cancer intervention significantly improved physical activity, fitness, and QoL with benefits continuing 3 months post-intervention.

Twenty-five years of research on the effects of exercise training in breast cancer survivors: A systematic review of the literature

AIM: To investigate the role of exercise training the past 25 years on major physiological-psychological outcomes studied thus far in this patient population.

METHODS: PubMed, MedlinePlus, the Cochrane Library, Web of Science, SportDiscus, Embase, Scorpus, and Google Scholar were searched from September to November 2013 to identify exercise training studies that used objective measurements of fitness and/or patient reported outcomes assessed pre and post-exercise training with statistical analyses performed in at least one of the following outcome measurements: Cardiorespiratory function, body composition, muscular strength, fatigue, depression, and overall quality of life. Five reviewers independently identified the studies that met the criteria for the review and discrepancies were resolved by consensus among all authors.

RESULTS: Fifty-one studies were included in this review with 5 from the period between 1989-1999, 11 from 2000-2006, and 35 from 2007-2013. The evolution of study designs changed from aerobic only exercise training interventions (1989-1999), to a combination of aerobic and resistance training (2000-2006), to studies including an arm of resistance training or examining the effects of resistance training as the main mode of exercise (2007-2013). Overall, the benefits of exercise showed improvements in cardiorespiratory function, body composition, strength, and patient reported outcomes including fatigue, depression, and quality of life.

CONCLUSION: Exercise training appears to be safe for most breast cancer patients and improvements in physiological, psychological, and functional parameters can be attained with regular participation in moderate intensity exercise.

Evaluation of a complex intervention to improve activities of daily living of disabled cancer patients: protocol for a randomised controlled study and feasibility of recruitment and intervention

Background

Many cancer patients have problems performing activities of daily living (ADL). A randomised controlled trial was designed to examine the effects of an ADL intervention in addition to standard treatment and care in a hospital setting. The objective of this article was to present the study and to analyse the feasibility of the recruitment process and the intervention.

Methods

Adult disabled cancer patients at Næstved Hospital in Denmark were enrolled between 1 March 2010 and 30 June 2011 and randomised into an ADL intervention or to a control group. The intervention was performed by occupational therapists. The feasibility of the recruitment was analysed with regard to success in achieving the estimated number of participants and identification of barriers, and feasibility of the intervention was based on calculations of patient attendance and patient acceptability. The primary outcome of the randomised controlled trial was patients’ health-related quality of life 2 and 8 weeks after baseline.

Results

A total of 118 disabled cancer patients were enrolled in the study over a time span of 16 months. Very few meetings between occupational therapist and patient were cancelled. Time spent on the intervention varied considerably, but for the majority of patients, time consumption was between 1–3 hours.

Conclusions

Despite difficulties with recruitment, participation was considered feasible and the intervention was accepted among patients. Missing data in the follow-up period were mostly due to death among participants. Very few participants declined to complete questionnaires during follow-up.

The muscle mass, omega-3, diet, exercise and lifestyle (MODEL) study - a randomised controlled trial for women who have completed breast cancer treatment

Background

Loss of lean body mass (LBM) is a common occurrence after treatment for breast cancer and is related to deleterious metabolic health outcomes [Clin Oncol, 22(4):281–288, 2010; Appl Physiol Nutr Metab, 34(5):950–956, 2009]. The aim of this research is to determine the effectiveness of long chain omega-3 fatty acids (LCn-3s) and exercise training alone, or in combination, in addressing LBM loss in breast cancer survivors.

Methods/design

A total of 153 women who have completed treatment for breast cancer in the last 12 months, with a Body Mass Index (BMI) of 20 to 35 kg/m², will be randomly assigned to one of 3 groups: 3g/d LCn-3s (N-3), a 12-week nutrition and exercise education program plus olive oil (P-LC) or the education program plus LCn-3s (EX+N-3). Participants randomised to the education groups will be blinded to treatment, and will receive either olive oil placebo (OO+N-3) or LCn-3 provision, while the N-3 group will be open label. The education program includes nine 60-75min sessions over 12 weeks that will involve breast cancer specific healthy eating advice, plus a supervised exercise session run as a resistance exercise circuit. They will also be advised to conduct the resistance training and aerobic training 5 to 7 days per week collectively. Outcome measures will be taken at baseline, 12-weeks and 24-weeks. The primary outcome is % change in LBM as measured by the air displacement plethysmograhy. Secondary outcomes include quality of life (FACT-B + 4) and inflammation (C-Reactive protein: CRP). Additional measures taken will be erythrocyte fatty acid analysis, fatigue, physical activity, menopausal symptoms, dietary intake, joint pain and function indices.

Discussion

This research will provide the first insight into the efficacy of LCn-3s alone or in combination with exercise in breast cancer survivors with regards to LBM and quality of life. In addition, this study is designed to improve evidence-based dietetic practice, and how specific dietary prescription may link with appropriate exercise interventions.

Trials registration

ACTRN12610001005044; and World Health Organisation Universal trial number: U1111-1116-8520.

A pilot study of a home-based motivational exercise program for African American breast cancer survivors: clinical and quality-of-life outcomes

INTRODUCTION

African American breast cancer survivors engage in less physical activity compared with their Caucasian counterparts. There is a need for exercise intervention research that focuses on improving the overall health and long-term survivorship of African American breast cancer survivors, especially because they often have worse outcomes than Caucasian survivors. Study objectives were to determine whether African American participants increase physical activity and explore whether exercise had a positive impact on fitness and health.

METHODS

African American breast cancer survivors, stage 0 to IIIA, within 2 years of completing primary cancer treatments were recruited for a 16-week home-based aerobic and resistance training exercise pilot study. Outcome measures assessed at baseline and postintervention included physical activity questionnaires and accelerometry, cardiopulmonary function (VO2peak) with gas exchange, muscle strength, Selective Functional Movement Assessment, and dual energy X-ray absorptiometry scans for body composition analysis. Assessments for fatigue and quality of life (QOL) were also completed at baseline and postintervention. Motivational interviewing was utilized to determine goals and explore exercise facilitators/barriers. Participants completed weekly exercise logs and received weekly phone calls. Wilcoxon signed rank tests were used to detect significant changes in physical activity and also changes in fitness/health parameters, fatigue, and QOL. Spearman correlation coefficients were used to examine relationships between physical activity and health measures.

RESULTS

A total of 17 women enrolled; 13 completed the intervention (76%). Mean age of the participants was 51 years. There was a significant increase in total minutes of weekly physical activity postintervention ( : = 271 minutes, S: = 151; : = .001). Significant improvements were found in cardiopulmonary fitness as measured by VO2peak with a mean increase of 2.03 mL/kg/min ( : = .01). Several strength measures significantly increased and also functional movement ( : = .005). Positive correlations existed between physical activity and several physical measures, with significant relationships between functional movement and some strength measures (eg, left arm extension: RS : = 0.61, : = .002). Total QOL and fatigue scores improved, but neither was significant.

CONCLUSIONS

The intervention led to increased physical activity. As a result of increased levels of physical activity, improvements on several fitness/health parameters occurred.

Testing the 'teachable moment' premise: does physical activity increase in the early survivorship phase?

PURPOSE

Little is known about objectively measured physical activity during the early survivorship period. This study measured physical activity, fatigue, and quality of life (QOL) in breast cancer patients over the first year after completion of chemotherapy and compared results to a matched non-cancer group.

METHODS

Data was obtained from 24 breast cancer subjects (mean ± SD) 50.9 ± 12.8 years at time points of 6 weeks, 6 months and 1 year after completion of adjuvant chemotherapy and from 20 matched women. The following variables were assessed, physical activity (RT3 accelerometer and International Physical Activity Questionnaire), quality-of-life (EORTC QLQ C-30) and fatigue (Brief Fatigue Inventory).

RESULTS

At 6 weeks after completion of chemotherapy, high levels of sedentary behaviour were found (6.8 ± 1.9 h sedentary per day), which did not improve, and was no different to the comparison group (6.5 ± 1.4 h). Less light activity was performed in the cancer cohort compared to the comparison group (p = 0.003). Body mass index (BMI) increased significantly in the cancer cohort (p = 0.015) and 1 year after chemotherapy finished only 13% (n = 3) had a BMI <25, while the comparable value was 45% (n = 9) in the non-cancer group. The QOL domain of cognitive function improved over the first 6 months (p = 0.034) but physical functioning declined (p = 0.008) over this time period. Fatigue did not change, and at the 1-year time point, 38% of the cancer patients (n = 11) reported high levels of fatigue.

CONCLUSION

This study highlighted the unchanging sedentary behaviour and weight gain of breast cancer survivors during the first year after completion of chemotherapy, which may inform rehabilitation models in this population.

Recruiting young adult cancer survivors for behavioral research

Young adults have been dramatically underrepresented in cancer survivorship research. One contributing factor is the difficulty recruiting this population. To identify effective recruitment strategies, the current study assessed the yield of strategies used to recruit young survivors for an exercise intervention including: clinic-based recruitment, recruitment at cancer-related events, mailings, telephone-based recruitment, advertising on the internet, radio, television and social networking media, distributing brochures and word-of-mouth referrals. When taking into account the strategies for which we could track the number of survivors approached, recruitment at an oncology clinic was the most productive: 38 % of those approached were screened and 8 % enrolled. When evaluating which strategy yielded the greatest percentage of the sample, however, mailings were the most productive. Given widespread use of the internet and social networking by young adults, investigators should also consider these low-cost recruitment strategies.

A qualitative synthesis of trials promoting physical activity behaviour change among post-treatment breast cancer survivors

BACKGROUND

Health outcome trials have provided strong evidence that participating in regular physical activity can improve the quality of life and health of post-treatment breast cancer survivors. Focus is now needed on how to promote changes in physical activity behaviour among this group.

PURPOSE

This systematic review examines the efficacy of behavioural interventions for promoting physical activity among post-treatment breast cancer survivors.

METHODS

Behavioural intervention studies published up until July 2012 were identified through a systematic search of two databases: MEDLINE and CINAHL, and by searching reference lists of relevant publications and scanning citation libraries of project staff.

RESULTS

Eight out of the ten identified studies reported positive intervention effects on aerobic physical activity behaviour, ranging from during the intervention period to 6 months post-intervention. Only two studies reported intervention effect sizes. The identification of factors related to efficacy was not possible because of the limited number and heterogeneity of studies included, as well as the lack of effect sizes reported. Nonetheless, an examination of the eight studies that did yield significant intervention effects suggests that 12-week interventions employing behaviour change techniques (e.g., self-monitoring and goal setting) derived from a variety of theories and delivered in a variety of settings (i.e., one-on-one, group or home) can be effective at changing the aerobic physical activity behaviour of breast cancer survivors in the mid- to long terms.

CONCLUSIONS

Behavioural interventions do hold promise for effectively changing physical activity behaviour among breast cancer survivors. However, future research is needed to address the lack of studies exploring long-term intervention effects, mediators of intervention effects and interventions promoting resistance-training activity, and to address issues impacting on validity, such as the limited use of objective physical activity measures and the use of convenience samples.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying effective ways of assisting breast cancer survivors to adopt and maintain physical activity is important for enhancing the well-being and health outcomes of this group.

Feasibility and efficacy of a supervised exercise intervention in de-conditioned cancer survivors during the early survivorship phase: the PEACH trial

PURPOSE

This study aims to evaluate the feasibility and efficacy of an 8-week supervised exercise program in de-conditioned cancer survivors within 2-6 months of chemotherapy completion.

METHODS

Participants were randomly assigned to an 8-week, twice-weekly, supervised aerobic exercise training regime (n = 23) or a usual care group (n = 20). Feasibility was assessed by recruitment rate, program adherence and participant feedback. The primary outcome was aerobic fitness assessed by the Modified Bruce fitness test at baseline (0 weeks), post-intervention (8 weeks) and at 3-month follow-up. Secondary outcomes included physical activity, waist circumference, fatigue and quality of life.

RESULTS

The recruitment rate was 81 % and adherence to the supervised exercise was 78.3 %. Meaningful differences in aerobic fitness between the exercise and usual care groups at both the 8-week [mean 3.0 mL kg(-1) min(-1) (95 % CI -1.1-7.0)] and 3-month follow-up [2.1 mL kg(-1) min(-1) (-2.3-6.6)] were found, although these differences did not achieve statistical significance (p values >0.14). Self-reported physical activity increased in the exercise group (EG) compared to the usual care group at both 8-week (p = 0.01) and 3-month follow-up (p = 0.03) and significant differences in favour of the EG were found for physical well-being at both the 8-week (p = 0.03) and 3-month follow-up (p = 0.04). Improvements in fatigue (p = 0.01), total quality of life plus fatigue (p = 0.04), and a composite physical functioning score (p = 0.01) at the 3-month follow-up were also found.

CONCLUSION

The PEACH trial suggests that 8 weeks of supervised aerobic exercise training was feasible and may improve aerobic fitness, fatigue and quality of life in de-conditioned cancer survivors during the early survivorship phase.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise interventions commenced in the early survivorship phase appear safe, feasible and may lead to improvements in QOL and fatigue.

Feasibility and efficacy of a supervised exercise intervention in de-conditioned cancer survivors during the early survivorship phase: the PEACH trial

PURPOSE

This study aims to evaluate the feasibility and efficacy of an 8-week supervised exercise program in de-conditioned cancer survivors within 2-6 months of chemotherapy completion.

METHODS

Participants were randomly assigned to an 8-week, twice-weekly, supervised aerobic exercise training regime (n = 23) or a usual care group (n = 20). Feasibility was assessed by recruitment rate, program adherence and participant feedback. The primary outcome was aerobic fitness assessed by the Modified Bruce fitness test at baseline (0 weeks), post-intervention (8 weeks) and at 3-month follow-up. Secondary outcomes included physical activity, waist circumference, fatigue and quality of life.

RESULTS

The recruitment rate was 81 % and adherence to the supervised exercise was 78.3 %. Meaningful differences in aerobic fitness between the exercise and usual care groups at both the 8-week [mean 3.0 mL kg(-1) min(-1) (95 % CI -1.1-7.0)] and 3-month follow-up [2.1 mL kg(-1) min(-1) (-2.3-6.6)] were found, although these differences did not achieve statistical significance (p values >0.14). Self-reported physical activity increased in the exercise group (EG) compared to the usual care group at both 8-week (p = 0.01) and 3-month follow-up (p = 0.03) and significant differences in favour of the EG were found for physical well-being at both the 8-week (p = 0.03) and 3-month follow-up (p = 0.04). Improvements in fatigue (p = 0.01), total quality of life plus fatigue (p = 0.04), and a composite physical functioning score (p = 0.01) at the 3-month follow-up were also found.

CONCLUSION

The PEACH trial suggests that 8 weeks of supervised aerobic exercise training was feasible and may improve aerobic fitness, fatigue and quality of life in de-conditioned cancer survivors during the early survivorship phase.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise interventions commenced in the early survivorship phase appear safe, feasible and may lead to improvements in QOL and fatigue.

A home-based exercise intervention to increase physical activity among people living with HIV: study design of a randomized clinical trial

Background

While combination antiretroviral therapy has extended the life expectancy of those infected with human immunodeficiency virus (HIV), there is a high prevalence of comorbidities that increase the risk of cardiovascular morbidity and mortality among people living with HIV/AIDS (PLWHA). The side effects associated with antiretroviral therapy (ART) lead to multiple metabolic disorders, making the management of these metabolic issues and risk of cardiovascular disease (CVD) in those treated with ART a critical issue. Clinical research trials, primarily clinical exercise, rarely include this population due to unique challenges in research methods with underserved minority populations living with a life threatening illness like HIV/AIDS. This paper describes the rationale and design of a randomized clinical trial evaluating the feasibility of a home-based exercise program designed to increase physical activity (PA) and reduce the risk of CVD in PLWHA.

Methods/design

PLWHA being treated with ART will be randomly assigned to one of two groups: a home-based PA intervention or standard care. All participants will receive an educational weight loss workbook and pedometer for self-monitoring of PA. Only those in the intervention group will receive additional elastic Thera-bands® for strength training and behavioral telephone based coaching.

Discussion

This study will evaluate the feasibility of a home-based program designed to increase PA among PLWHA. Further, it will evaluate the effectiveness of such a program to decrease modifiable risk factors for CVD as a secondary outcome. This study was funded by the NIH/NINR R21 Grant 1R21NRO11281.

Trial registration

Clinical Trial Identifier NCT01377064

Reliability and validity of the Mywellness Key physical activity monitor

Background

This study evaluated the reliability and criterion validity of the Mywellness Key accelerometer (MWK) using treadmill protocols and indirect calorimetry.

Methods

Twenty-five participants completed two four-stage 20-minute treadmill protocols while wearing two MWK accelerometers. Reliability was assessed using raw counts. Validity was assessed by comparing the estimated VO₂ calculated from the MWK with values from respiratory gas exchange.

Results

Good overall and point estimates of reliability were found for the MWK (all intraclass correlations > 0.93). Generalizability theory coefficients showed lower values for running speed (0.70) versus walking speed (all > 0.84), with the majority of the overall percentage of variability derived from the participant (68%–88% of the total 100%). Acceptable validity was found overall (Pearson’s r = 0.895–0.902, P < 0.0001), with an overall mean absolute error of 16.22% and a coefficient of variance of 16.92%. Bland-Altman plots showed an overestimation of energy expenditure during the running speed, but total kilocalories were underestimated during the protocol by approximately 10%.

Conclusion

Good validity was found during light and moderate walking, while running was slightly overestimated. The MWK may be useful for clinicians and researchers interested in promotion or assessment of physical activity.

How social cognitive theory can help oncology-based health professionals promote physical activity among breast cancer survivors

PURPOSE

The majority of post treatment breast cancer survivors do not engage in physical activity (PA) at the recommended level. The promotion of PA among this group has the potential to dramatically improve quality of life and health outcomes. To maximise effectiveness, programs should be theory-based and address key determinants of PA behaviour. Social Cognitive Theory (SCT) has shown particular promise for developing and guiding PA interventions, but future research regarding how each SCT construct relates to PA among this group is needed. This study aims to explore how core SCT constructs impact on PA participation among post treatment breast cancer survivors, and gain greater insights into how to shape PA program strategies that will be appealing and effective for this group.

METHODS

Post treatment breast cancer survivors were recruited from the Breast Cancer Network Australia's review and survey group. Semi-structured telephone interviews examined PA patterns and SCT constructs and data were analysed thematically.

RESULTS

Eight post treatment breast cancer survivors participated in the study. Changes in activity level since diagnosis were common; in most cases this reflected a decline in PA. Key social cognitive and environmental influences on PA were described under the following themes: knowledge, outcome expectations, self-efficacy and personal, behavioural and environment facilitators and inhibitors.

CONCLUSION

The results of this study demonstrate the utility of SCT for guiding PA programs. Insight into how social cognitive factors may influence PA behaviour in this group is offered and direction for how oncology-based health professionals can promote PA among breast cancer survivors is provided.

Body composition changes in females treated for breast cancer: a review of the evidence

Body composition changes cannot be precisely captured using body weight or body mass index measures. Therefore, the primary purpose of this review was to characterize the patterns of body composition change in females treated for breast cancer including only studies that utilize imaging technologies to quantify adipose tissue and lean body mass (LBM). We reviewed PubMed for studies published between 1971 and 2012 involving females diagnosed with breast cancer where computed axial tomography , dual-energy X-ray absorptiometry, or magnetic resonance imaging were employed for body composition assessment. Of the initial 440 studies, 106 papers were evaluated and 36 papers met all eligibility criteria (15 observational and 21 intervention trials). Results of these studies revealed that body weight did not consistently increase. Importantly, studies also showed that body weight did not accurately depict changes in lean or adipose tissues. Further findings included that sarcopenic obesity as a consequence of breast cancer treatment was not definitive, as menopausal status may be a substantial moderator of body composition. Overall, the behavioral interventions did not exhibit consistent or profound effects on body composition outcomes; approximately half showed favorable influence on adiposity while the effects on LBM were not apparent. The use of tamoxifen had a clear negative impact on body composition. The majority of studies were conducted in predominantly white survivors, highlighting the need for trials in minority populations. Collectively, these studies were limited by age, race, and/or menopause status matched control groups, overall size, and statistical power. Very few studies simultaneously collected diet and exercise data-two potential factors that impact body composition. Future breast cancer trials should prioritize precise body composition methodologies to elucidate how these changes impact recurrence, prognosis, and mortality, and to provide clinicians with appropriate advice regarding lifestyle recommendations in this growing sector of the population.

Social support and physical activity engagement by cancer survivors

Less than 20% of adult cancer survivors participate in physical activity and, as a result of such inactivity, cancer survivors are at increased risk for developing chronic diseases. Studies have linked social support as a predictor of physical activity participation in healthy adults. The primary goal of this systematic review is to examine the relationship between social support and physical activity engagement in adult cancer survivors and determine whether additional research is needed in this area. Several databases were searched and articles were systematically extracted according to the inclusion and exclusion criteria. That search yielded 69 articles, 22 of which were identified and included in this review. Fifty percent of the studies showed a significant relationship between social support and physical activity engagement; however, 59% of the participants were breast cancer survivors. The findings suggest that additional research is needed to develop social support strategies that will increase physical activity engagement in adult survivors of cancers other than breast cancer.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Water versus land-based multimodal exercise program effects on body composition in breast cancer survivors: a controlled clinical trial

GOALS OF WORK

Our aim was to compare the effects of land versus water multimodal exercise programs on body composition and breast cancer-specific quality of life in breast cancer survivors.

PATIENTS AND METHODS

Ninety-eight breast cancer survivors were assigned to three groups: control, land exercise, and water exercise. Both exercise groups participated in an 8-week multimodal program. Adiposity was measured by anthropometry (body mass index, waist circumference) and bioelectrical impedance (body fat and muscle lean body mass). Incidence of clinically significant secondary lymphedema was also assessed. Finally, specific quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life BR-23.

MAIN RESULTS

Using ANCOVA, significant group × time interactions for body fat percentage (F = 3.376; P = 0.011) and lean body mass (F = 3.566; P = 0.008) were found. Breast cancer survivors in the land exercise group exhibited a greater decrease in percentage of body fat than those in the water exercise (P < 0.001) and control (P = 0.002) groups. The ANCOVA revealed a significant group × time interaction for waist circumference (F = 4.553; P = 0.002): breast cancer survivors in the control group showed a greater waist circumference when compared to water (P = 0.003) and land (P < 0.001) exercise groups. A significant group × time interaction was also found for breast symptoms (F = 9.048; P < 0.001): participants in the water exercise group experienced a greater decrease of breast symptoms than those in the land exercise (P < 0.01) and control (P < 0.05) groups.

CONCLUSION

Land exercise produced a greater decrease in body fat and an increase in lean body mass, whereas water exercise was better for improving breast symptoms.

Effects of a physical activity behavior change intervention on inflammation and related health outcomes in breast cancer survivors: pilot randomized trial

BACKGROUND

The goal of this pilot study was to determine the magnitude and direction of intervention effect sizes for inflammatory-related serum markers and relevant health outcomes among breast cancer survivors (BCSs) receiving a physical activity behavior change intervention compared with usual care.

METHODS

This randomized controlled trial enrolled 28 stage I, II, or IIIA BCSs who were post-primary treatment and not regular exercisers. Participants were assigned to either a 3-month physical activity behavior change intervention group (ING) or usual care group (UCG). Intervention included supervised aerobic (150 weekly minutes, moderate-intensity) and resistance (2 sessions per week) exercise that gradually shifted to home-based exercise. Outcomes were assessed at baseline and 3 months.

RESULTS

Cardiorespiratory fitness significantly improved in the ING versus the UCG (between-group difference = 3.8 mL/kg/min; d = 1.1; P = .015). Self-reported sleep latency was significantly reduced in the ING versus the UCG (between group difference = -0.5; d = -1.2; P = .02) as was serum leptin (between-group difference = -9.0 ng/mL; d = -1.0; P = .031). Small to medium nonsignificant negative effect sizes were noted for interleukin (IL)-10 and tumor necrosis factor (TNF)-α and ratios of IL-6 to IL-10, IL-8 to IL-10, and TNF-α to IL-10, whereas nonsignificant positive effect sizes were noted for IL-6 and high-molecular-weight adiponectin.

CONCLUSIONS

Physical activity behavior change interventions in BCSs can achieve large effect size changes for several health outcomes. Although effect sizes for inflammatory markers were often small and not significant, changes were in the hypothesized direction for all except IL-6 and IL-10.

Promoting physical activity in patients with colon adenomas: a randomized pilot intervention trial

BACKGROUND

Physical activity decreases risk of colon polyps and colon cancer and might reduce risk of colon cancer recurrence. Focusing on recent calls for translation of epidemiologic evidence into clinical care, our pilot study delivered an evidence-based physical activity intervention in adults with polyps, who are thus at elevated risk of developing colon cancer. The objective was to evaluate change in physical activity, measured by steps per day and minutes of moderate/vigorous physical activity.

METHODS

Sixteen adults with adenomas detected and removed at screening colonoscopy were recruited to a 12-week physical activity intervention. Participants were randomized to receive a standard (30 minutes/day) or high (60 minutes/day) walking program. Physical activity was measured via blinded pedometer and accelerometer at baseline and follow-up. Intervention messages focused on self-monitoring using pedometers and overcoming barriers to engaging in physical activity.

RESULTS

Participants in both arms significantly increased objectively measured minutes of moderate/vigorous physical activity over the course of the intervention. Both arms exceeded the intervention goal, but there was not a significant difference between arms at follow-up. Results were similar for pedometer measured physical activity, with a significant overall increase in steps/day from baseline to follow-up, but no between arm difference in change.

CONCLUSION

Simple interventions of minimal contact time focusing on walking can significantly increase physical activity in individuals at increased risk of developing colon cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01476631.

Who will drop out and who will drop in: exercise adherence in a randomized clinical trial among patients receiving active cancer treatment

BACKGROUND

Adherence has significantly affected the efficacy of a randomized clinical trial (RCT) to test exercise interventions.

OBJECTIVE

The aims of this study were to analyze exercise-related adherence patterns among patients receiving active cancer treatment and to identify factors related to exercise adherence and contamination in both the intervention and control groups.

METHODS

This is a secondary analysis of data from an RCT of a home-based walking intervention for patients receiving active cancer treatment. Hierarchical Poisson regression analysis was used to identify factors related to exercise adherence and exercise contamination in the exercise intervention and control groups.

RESULTS

A total of 126 patients finished the study. Exercise adherence rate in the intervention group was 32.35%, whereas exercise contamination rate in the control group was 12.07%. Independent predictors of adherence for the exercise group were baseline physical fitness, pretreatment fatigue level, treatment-related mood disturbance, and marital status (P < .01); exercise history significantly predicted exercise contamination (P < .00) in the control group.

CONCLUSION

Adherence remains an issue in an exercise RCT among patients on active cancer treatment. Adherence is related to symptom, physical function, and exercise history.

IMPLICATIONS FOR PRACTICE

Exercise researchers should consider stratifying samples based on pretreatment variables found to be significantly associated with outcome variables in this study to reduce confounding effects. Oncology clinicians can use the study findings to appropriately tailor strategies to encourage exercise adherence among patients receiving active cancer treatment so that these patients can receive the known benefits of exercise.

Physical activity for cancer survivors: meta-analysis of randomised controlled trials

OBJECTIVE

To systematically evaluate the effects of physical activity in adult patients after completion of main treatment related to cancer.

DESIGN

Meta-analysis of randomised controlled trials with data extraction and quality assessment performed independently by two researchers.

DATA SOURCES

Pubmed, CINAHL, and Google Scholar from the earliest possible year to September 2011. References from meta-analyses and reviews.

STUDY SELECTION

Randomised controlled trials that assessed the effects of physical activity in adults who had completed their main cancer treatment, except hormonal treatment.

RESULTS

There were 34 randomised controlled trials, of which 22 (65%) focused on patients with breast cancer, and 48 outcomes in our meta-analysis. Twenty two studies assessed aerobic exercise, and four also included resistance or strength training. The median duration of physical activity was 13 weeks (range 3-60 weeks). Most control groups were considered sedentary or were assigned no exercise. Based on studies on patients with breast cancer, physical activity was associated with improvements in insulin-like growth factor-I, bench press, leg press, fatigue, depression, and quality of life. When we combined studies on different types of cancer, we found significant improvements in body mass index (BMI), body weight, peak oxygen consumption, peak power output, distance walked in six minutes, right handgrip strength, and quality of life. Sources of study heterogeneity included age, study quality, study size, and type and duration of physical activity. Publication bias did not alter our conclusions.

CONCLUSIONS

Physical activity has positive effects on physiology, body composition, physical functions, psychological outcomes, and quality of life in patients after treatment for breast cancer. When patients with cancer other than breast cancer were also included, physical activity was associated with reduced BMI and body weight, increased peak oxygen consumption and peak power output, and improved quality of life.

Recruiting participants to walking intervention studies: a systematic review

PURPOSE

Most researchers who are conducting physical activity trials face difficulties in recruiting participants who are representative of the population or from specific population groups. Participants who are often the hardest to recruit are often those who stand to benefit most (the least active, from ethnic and other minority groups, from neighbourhoods with high levels of deprivation, or have poor health). The aim of our study was to conduct a systematic review of published literature of walking interventions, in order to identify the impact, characteristics, and differential effects of recruitment strategies among particular population groups.

METHODS

We conducted standard searches for studies from four sources, (i) electronic literature databases and websites, (ii) grey literature from internet sources, (iii) contact with experts to identify additional "grey" and other literature, and (iv) snowballing from reference lists of retrieved articles. Included studies were randomised controlled trials, controlled before-and-after experimental or observational qualitative studies, examining the effects of an intervention to encourage people to walk independently or in a group setting, and detailing methods of recruitment.

RESULTS

Forty seven studies met the inclusion criteria. The overall quality of the descriptions of recruitment in the studies was poor with little detail reported on who undertook recruitment, or how long was spent planning/preparing and implementing the recruitment phase. Recruitment was conducted at locations that either matched where the intervention was delivered, or where the potential participants were asked to attend for the screening and signing up process. We identified a lack of conceptual clarity about the recruitment process and no standard metric to evaluate the effectiveness of recruitment.

CONCLUSION

Recruitment concepts, methods, and reporting in walking intervention trials are poorly developed, adding to other limitations in the literature, such as limited generalisability. The lack of understanding of optimal and equitable recruitment strategies evident from this review limits the impact of interventions to promote walking to particular social groups. To improve the delivery of walking interventions to groups which can benefit most, specific attention to developing and evaluating targeted recruitment approaches is recommended.

Cancer Journey Survivorship Expert Panel, Howell D, Hack T, Oliver T, Chulak T, Mayo S, Aubin M, Chasen M, Earle C, Friedman A, Green E, Jones G, Jones J, Parkinson M, Payeur N, Sabiston C, Sinclair S. Survivorship services for adult cancer populations: a pan-Canadian guideline

OBJECTIVE

Our goal was to develop evidence-based recommendations for the organization and structure of cancer survivorship services, and best-care practices to optimize the health and well-being of post-primary treatment survivors. This review sought to determine the optimal organization and care delivery structure for cancer survivorship services, and the specific clinical practices and interventions that would improve or maximize the psychosocial health and overall well-being of adult cancer survivors.

DATA SOURCES

We conducted a systematic search of the Inventory of Cancer Guidelines at the Canadian Partnership Against Cancer, the U.S. National Guideline Clearinghouse, the Canadian Medical Association InfoBase, medline (ovid: 1999 through November 2009), embase (ovid: 1999 through November 2009), Psychinfo (ovid: 1999 through November 2009), the Cochrane Library (ovid; Issue 1, 2009), and cinahl (ebsco: 1999 through December 2009). Reference lists of related papers and recent review articles were scanned for additional citations.

METHODS

Articles were selected for inclusion as evidence in the systematic review if they reported on organizational system components for survivors of cancer, or on psychosocial or supportive care interventions HOWELL et al. designed for survivors of cancer. Articles were excluded from the systematic review if they focused only on pediatric cancer survivor populations or on populations that transitioned from pediatric cancer to adult services; if they addressed only pharmacologic interventions or diagnostic testing and follow-up of cancer survivors; if they were systematic reviews with inadequately described methods; if they were qualitative or descriptive studies; and if they were opinion papers, letters, or editorials.

DATA EXTRACTION AND SYNTHESIS

Evidence was selected and reviewed by three members of the Cancer Journey Survivorship Expert Panel (SM, TC, TKO). The resulting summary of the evidence was guided further and reviewed by the members of Cancer Journey Survivorship Expert Panel. Fourteen practice guidelines, eight systematic reviews, and sixty-thee randomized controlled trials form the evidence base for this guidance document. These publications demonstrate that survivors benefit from coordinated post-treatment care, including interventions to address specific psychosocial, supportive care, and rehabilitative concerns.

CONCLUSIONS

Ongoing high-quality research is essential to optimize services for cancer survivors. Interventions that promote healthy lifestyle behaviours or that address psychosocial concerns and distress appear to improve physical functioning, psychosocial well-being, and quality of life for survivors.

Physical Activity and Breast Cancer Survivorship

The completion of primary treatment for breast cancer has been referred to as a “teachable moment” for health behavior change, suggesting that women are receptive to receiving physical activity counseling. However, the majority of breast cancer survivors are not sufficiently active. Health care providers may play a pivotal role in increasing patients’ physical activity behavior, yet physician counseling for physical activity is not done regularly. One reason for this failure may relate to the limited guidelines put forward to assist health care providers in how best to optimize the benefits of physical activity among breast cancer survivors. To help provide guidelines for physical activity counseling with breast cancer survivors, the authors synthesized evidence-based recommendations based on a review of 30 intervention studies. The evidence on (1) type, (2) intensity, and (3) frequency and duration of physical activity for this population was examined. On the basis of the reviewed studies, the authors find that physical activity programs for breast cancer survivors should include aerobic training at least 3 times/wk for 30 minutes, resistance training 2 to 3 times/wk (6-12 exercises), and flexibility training 3 times/wk for 50 to 60 minutes to obtain health benefits. The provision of these recommendations may facilitate effective and consistent delivery of physical activity counseling to breast cancer survivors.

Endometrial cancer survivors' assessment of the benefits of exercise

OBJECTIVE

The majority of women who have had endometrial cancer remain at risk for obesity related diseases. The social cognitive theory was used to explore their beliefs about exercise to aid in the development of effective interventions.

METHODS

Women who had been treated for Stage I endometrial cancer were asked about their level of exercise to determine if they had been exercising regularly for more than 6 months (exercisers vs non-exercisers). They were asked to rate the likelihood that exercise would result in various health outcomes (expectations) and to rate the importance of these outcomes (expectancies). Scores for how likely exercise would result in an outcome of importance were calculated. Height and weight were obtained from nurses for calculation of BMI. Statistics were conducted using SPSS v 15.

RESULTS

There were 106 valid questionnaires (86% participation rate); 41% were exercisers. Mean BMI was significantly lower in exercisers (31.6 ± 1.2 vs. 37.3 ± 1.2, p=0.001); a significantly greater proportion reported not having diabetes, heart disease or hypertension (69.8% vs. 49.2%, p=0.035). Exercisers were significantly more likely to report that feeling better physically and emotionally versus reducing the risk of diseases were likely and important outcomes of exercise (18.2 ± 0.8 vs 15.0 ± 1.0, p=0.002).

CONCLUSIONS

Exercisers identified outcomes of exercise that are more immediate and subjective as being important and likely outcomes of exercise. Focusing on these aspects of exercise (feeling better physically and emotionally) may aid in the development of effective interventions for non-exercisers.

Better exercise adherence after treatment for cancer (BEAT Cancer) study: rationale, design, and methods

Most breast cancer survivors do not engage in regular physical activity. Our physical activity behavior change intervention for breast cancer survivors significantly improved physical activity and health outcomes post-intervention during a pilot, feasibility study. Testing in additional sites with a larger sample and longer follow-up is warranted to confirm program effectiveness short and longer term. Importantly, the pilot intervention resulted in changes in physical activity and social cognitive theory constructs, enhancing our potential for testing mechanisms mediating physical activity behavior change. Here, we report the rationale, design, and methods for a two-site, randomized controlled trial comparing the effects of the BEAT Cancer physical activity behavior change intervention to usual care on short and longer term physical activity adherence among breast cancer survivors. Secondary aims include examining social cognitive theory mechanisms of physical activity behavior change and health benefits of the intervention. Study recruitment goal is 256 breast cancer survivors with a history of ductal carcinoma in situ or Stage I, II, or IIIA disease who have completed primary cancer treatment. Outcome measures are obtained at baseline, 3 months (i.e., immediately post-intervention), 6 months, and 12 months and include physical activity, psychosocial factors, fatigue, sleep quality, lower extremity joint dysfunction, cardiorespiratory fitness, muscle strength, and waist-to-hip ratio. Confirming behavior change effectiveness, health effects, and underlying mechanisms of physical activity behavior change interventions will facilitate translation to community settings for improving the health and well-being of breast cancer survivors.

The comparative effectiveness of a team-based versus group-based physical activity intervention for cancer survivors

PURPOSE

Physical activity benefits cancer survivors, but the comparative effectiveness of a team-based delivery approach remains unexplored. The hypothesis tested was that a team-based physical activity intervention delivery approach has added physical and psychological benefits compared to a group-based approach. A team-based sport accessible to survivors is dragon boating, which requires no previous experience and allows for diverse skill levels.

METHODS

In a non-randomized trial, cancer survivors chose between two similarly structured 8-week programs, a dragon boat paddling team (n = 68) or group-based walking program (n = 52). Three separate intervention rounds were carried out in 2007-2008. Pre-post testing measured physical and psychosocial outcomes.

RESULTS

Compared to walkers, paddlers had significantly greater (all p < 0.01) team cohesion, program adherence/attendance, and increased upper-body strength. For quality-of-life outcomes, both interventions were associated with pre-post improvements, but with no clear-cut pattern of between-intervention differences.

CONCLUSIONS

These hypothesis-generating findings suggest that a short-term, team-based physical activity program (dragon boat paddling) was associated with increased cohesion and adherence/attendance. Improvements in physical fitness and psychosocial benefits were comparable to a traditional, group-based walking program. Compared to a group-based intervention delivery format, the team-based intervention delivery format holds promise for promoting physical activity program adherence/attendance in cancer survivors.

How many steps/day are enough? For older adults and special populations

Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore this review was conducted to translate public health recommendations in terms of steps/day. Normative data indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800 steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively. There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time. However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding) value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to truly translate public health guidelines, these steps should be taken over and above activities performed in the course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately 7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect whole-day estimates of recommended physical activity.

Physical activity motivation and cancer survivorship

Physical activity (PA) participation has been shown to be helpful in improving physical and mental well-being among cancer survivors. The purpose of this chapter is to review the literature on the determinants of physical activity motivation and behavior among cancer survivors. Using theories of behavior change, researchers have sought to identify the correlates of motivation that predict the participation in regular physical activity in observational studies, while intervention studies have focused on manipulating those factors to support the initiation of physical activity. The majority of this work has been conducted with breast cancer survivors, and there is an interest in expanding this work to survivors of others cancers (e.g., prostate, lung, and colorectal cancer). Results suggest that constructs from the Theory of Planned Behavior (TPB), Transtheoretical Model (TTM), and Social Cognitive Theory (SCT) are associated with greater motivation for physical activity, and some of these constructs have been used in interventions to promote physical activity adoption. There is scope for understanding the determinants of physical activity adoption in various cancer survivor populations. Much more needs to done to identify the determinants of maintenance of physical activity.

American College of Sports Medicine roundtable on exercise guidelines for cancer survivors

Early detection and improved treatments for cancer have resulted in roughly 12 million survivors alive in the United States today. This growing population faces unique challenges from their disease and treatments, including risk for recurrent cancer, other chronic diseases, and persistent adverse effects on physical functioning and quality of life. Historically, clinicians advised cancer patients to rest and to avoid activity; however, emerging research on exercise has challenged this recommendation. To this end, a roundtable was convened by American College of Sports Medicine to distill the literature on the safety and efficacy of exercise training during and after adjuvant cancer therapy and to provide guidelines. The roundtable concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups. Implications for disease outcomes and survival are still unknown. Nevertheless, the benefits to physical functioning and quality of life are sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans, with specific exercise programming adaptations based on disease and treatment-related adverse effects. The advice to "avoid inactivity," even in cancer patients with existing disease or undergoing difficult treatments, is likely helpful.

Physical activity interventions to improve daily walking activity in cancer survivors

Background

Cancer patients may benefit from physical exercise programs. It is unclear, however, how sustained levels of physical activity are best achieved in this population. A systematic review was performed to summarize the current evidence of the effect of physical activity interventions on daily walking activity enhancement in cancer survivors, and to review the literature for its methodological quality.

Methods

A search in Medline, PEDro and the Cochrane databases was performed for English literature citations (randomized controlled trials; 'RCTs'). In a first step, one reviewer abstracted data from the included studies on patients, physical activity interventions and outcomes. Two independent reviewers reviewed the methodological quality of these studies. Data were pooled using random-effects calculations.

Results

Our search identified 201 citations. Five RCTs that reported changes in daily step activity over time were identified, and were reviewed for methodological quality and substantive results. The median score across studies for methodological quality based on the PEDro criteria was 8. These 5 RCTs evaluated 660 participants with a mean age of 53.6 (SD 4.2) years. The mean change in daily step activity for patients with a physical exercise intervention was 526 daily steps (SD 537), with a range from -92 to 1299 daily steps. The data of three studies reporting the effect of combined physical activity and counseling on daily walking activity in breast cancer survivors were pooled, however; the I² was 79%, indicating statistical heterogeneity between the three trials.

Conclusion

The 5 RCTs reviewed were of good methodological quality. Together they suggest that combined physical activity and counseling improves daily step activity in (breast) cancer survivors. Studies that define a step goal appear to be more effective in improving daily walking activity than studies that do not do so. However, the current results should be interpreted with caution because of the observed clinical and statistical heterogeneity. Future studies are warranted to evaluate the effects of goal targeted physical activity, with or without counseling, on daily walking in various cancer populations.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Objective monitoring of physical activity after a cancer diagnosis: challenges and opportunities for enhancing cancer control

BACKGROUND: Because physical activity (PA) provides multiple medical and psychosocial benefits after a cancer diagnosis, greater integration of objective activity monitoring into research and clinical practice is warranted. OBJECTIVES: To review randomized PA trials in cancer survivors after diagnosis using an accelerometer or pedometer and make recommendations for integrating objective monitoring into research and practice. MAJOR FINDINGS: Ten published PA and post-cancer diagnosis randomized trials have used pedometers (n=3), accelerometers (n=3), or both (n=4). Pedometers were primarily used to motivate PA adherence with several studies also using unblinded pedometers to assess the intervention effect on PA adherence. Accelerometers were primarily used to assess PA adherence after a PA intervention with one study using accelerometers to assess PA increase as a benefit of a non-PA intervention. One study used accelerometers to document sufficient ground forces for improving bone density in cancer survivors. Across studies, the reported objective monitoring outcome varied and was not always consistent with the stated intervention goal. CONCLUSIONS: PA and post-cancer diagnosis randomized trials have used objective monitoring primarily for motivation and/or adherence assessment. Investigators and practitioners are encouraged to expand the use of objective monitoring to also include understanding mechanisms of PA benefits and assess non-PA treatment modality effects. Future clinical and research protocols should consider the 1) outcome to be measured and reported, 2) need (or not) for blinding of the instrument outputs to participants, 3) appropriateness of activity intensity cutpoints for interpreting accelerometer data, and 4) logistical issues relevant to cancer survivors after diagnosis.

Changes in the Body Image and Relationship Scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema

The aim of this study was to evaluate the impact of a twice-weekly strength training intervention on perceptions of body image in 234 breast cancer survivors (112 with lymphedema) who participated in the Physical Activity and Lymphedema (PAL) trial. The study population included two hundred and thirty-four women randomly assigned to twice-weekly strength training or control group that completed the 32-item Body Image and Relationships Scale (BIRS) at baseline and 12 months. Percent change in baseline to 12-month BIRS total and subscale scores, upper and lower body strength, and general quality of life (QOL) were compared by intervention status. A series of multiple linear regression models including indicator variables for subgroups based on age, marital status, race, education, BMI, and strength change were used to examine differential intervention impact by subgroup. Strength and QOL variables were assessed as mediators of the intervention effect on BIRS.

RESULTS

Baseline BIRS scores were similar across intervention and lymphedema status. Significantly greater improvement in BIRS total score was observed from baseline to 12 months in treatment vs. control participants (12.0 vs. 2.0%; P < 0.0001). A differential impact of the intervention on the Strength and Health subscale was observed for older women (>50 years old) in the treatment group (P = 0.03). Significantly greater improvement was observed in bench and leg press among treatment group when compared to control group participants, regardless of lymphedema. Observed intervention effects were independent of observed strength and QOL changes. Twice-weekly strength training positively impacted self-perceptions of appearance, health, physical strength, sexuality, relationships, and social functioning. Evidence suggests the intervention was beneficial regardless of prior diagnosis of lymphedema. Strength and QOL improvements did not mediate the observed intervention effects.

Psychological effects and mediators of a group multi-component program for breast cancer survivors

This study evaluated the short-term impact of YWCA Encore, a mixed-modality group exercise and information support program for breast cancer patients situated in the community setting. Australian post-surgical breast cancer patients (N = 162) were assigned to either the 8-week Encore intervention or a Waitlist control. Intervention impact was assessed in terms of quality of life, cancer-specific distress, and social support. Changes in familiarity with exercise, self-efficacy and social support were tested as mediators of the intervention impact on quality of life. Overall adherence and satisfaction with the program were high. Significant enhancements at follow-up for quality of life and social support were evident for intervention compared with control participants. Familiarity with exercise and self-efficacy satisfied the requirements for mediation of quality of life. These findings provide evidence for psychosocial benefits of YWCA Encore multi-component program and support the use of such community-based programs for breast cancer survivors. The role of exercise familiarity and self-efficacy as probable mediators of the multi-component intervention is a critical finding and highlights the need for future investigations into the underlying mediating processes of similar interventions for cancer patients.

Risks and benefits of physical activity among breast cancer survivors who have completed treatment

Worldwide, over 1 million cases of breast cancer are diagnosed each year. In the USA, approximately 185,000 women are newly diagnosed annually. Nearly 90% of newly diagnosed cancer patients in the USA will live for 5 years beyond diagnosis and there are estimated to be 2.4 million breast cancer survivors currently living in the USA. There are unique challenges in meeting the medical needs of these survivors. Persistent impairment and increased medical risks can occur as a result of treatment, including changes to the cardiovascular, pulmonary, endocrine, immune, musculoskeletal, neurological and lymphatic systems. Physical activity can cause positive changes in each of these body systems. However, physiologic impairments and altered risks for cardiopulmonary, bone health, neurosensory and other outcomes among breast cancer survivors can cause confusion regarding the safety of returning to exercise after treatment. In this article, we review the adverse effects of cancer treatments on the body systems affected by and used to perform exercise, the risks of exercise among breast cancer survivors, the effects of exercise on persistent treatment toxicities, whether exercise may prevent recurrence or mortality, as well as providing guidance for exercise testing and prescription among breast cancer survivors.

A review of exercise interventions to improve bone health in adult cancer survivors

INTRODUCTION

Cancer-treatment induced bone loss and associated fracture risk is a growing concern for cancer survivors. Exercise offers a non-pharmacologic strategy for preserving bone health during and after treatment, but only until recently has it been studied for its efficacy and safety in cancer survivors. The purpose of this review is to provide an early qualitative evaluation of exercise trials in adult cancer survivors with bone health as a primary or secondary endpoint.

METHODS

Databases were searched for exercise trials in adult cancer survivors that reported data on bone health (bone mineral density (BMD) and/or bone remodeling markers) as an outcome measure and were published and indexed prior to January 1st, 2010. Data relevant to evaluation of study design, sample, exercise protocol, bone health assessment, statistical approach and findings were extracted, summarized and interpreted.

RESULTS

Eight trials were identified that met criteria for inclusion in the review. While most studies were conducted in breast cancer survivors, remaining study attributes including rigor, design, exercise program characteristics and length varied considerably across studies. Only three of the eight studies were controlled exercise trials with usual care control groups. Of these, two reported significant group x time interactions where aerobic exercise preserved BMD at the spine or whole body compared to losses in controls and none reported exercise benefits at the hip.

CONCLUSIONS

The recent emergence of exercise studies in cancer survivors with bone outcomes highlights the importance of this area of cancer survivorship. Collectively, the studies are limited in number and are too varied to warrant conclusions regarding the skeletal benefits of exercise during or after cancer treatment, though early results are encouraging and more rigorous study should follow.

An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis

INTRODUCTION

Approximately 11.1 million cancer survivors are alive in the United States. Activity prescriptions for cancer survivors rely on evidence as to whether exercise during or after treatment results in improved health outcomes. This systematic review and meta-analysis evaluates the extent to which physical activity during and post treatment is appropriate and effective across the cancer control continuum.

METHODS

A systematic quantitative review of the English language scientific literature searched controlled trials of physical activity interventions in cancer survivors during and post treatment. Data from 82 studies were abstracted, weighted mean effect sizes (WMES) were calculated from 66 high quality studies, and a systematic level of evidence criteria was applied to evaluate 60 outcomes. Reports of adverse events were abstracted from all studies.

RESULTS

Quantitative evidence shows a large effect of physical activity interventions post treatment on upper and lower body strength (WMES = 0.99 & 0.90, p < 0.0001 & 0.024, respectively) and moderate effects on fatigue and breast cancer-specific concerns (WMES = -0.54 & 0.62, p = 0.003 & 0.003, respectively). A small to moderate positive effect of physical activity during treatment was seen for physical activity level, aerobic fitness, muscular strength, functional quality of life, anxiety, and self-esteem. With few exceptions, exercise was well tolerated during and post treatment without adverse events.

CONCLUSIONS

Current evidence suggests many health benefits from physical activity during and post cancer treatments. Additional studies are needed in cancer diagnoses other than breast and with a focus on survivors in greatest need of improvements for the health outcomes of interest.

Physical activity and breast cancer survivorship

A diagnosis of breast cancer is associated with treatments that have physiologic effects beyond the intended curative therapy. The first section of this chapter provides and integrative physiology review of the effects of breast cancer treatment on the body systems used by and affected by physical activity, including effects of chemotherapy, radiation, and surgery. In later sections, we review the literature on physical activity and breast cancer from the point of diagnosis and for the balance of life. The efficacy of physical activity for supportive cancer care outcomes is reviewed separately from the purported usefulness of physical activity for disease-free and overall survival from breast cancer. The current evidence supports the safety of physical activity during and after breast cancer therapy. The supportive cancer care outcomes for which there is sufficient evidence of efficacy during and after breast cancer treatment include fitness, fatigue, body size, and quality of life. Further, there is growing evidence that upper body exercise does not pose additional risk for negative lymphedema outcomes among survivors with and at risk for lymphedema. For overall survival, the evidence is largely observational, with sufficient evidence that physical activity does confer benefit. Finally, we outline future directions for research on physical activity among breast cancer survivors, including expanding to focus on subsets of the population not included in most prior studies (minority women and older women), tailoring of interventions to stages of cancer most likely to benefit, expanding to study women with metastatic cancer, and new modes of exercise, such as team sports, martial arts, and Pilates.

Exercise improves body fat, lean mass, and bone mass in breast cancer survivors

Given the negative effects of a breast cancer diagnosis and its treatments on body weight and bone mass, we investigated the effects of a 6-month randomized controlled aerobic exercise intervention vs. usual care on body composition in breast cancer survivors. Secondary aims were to examine the effects stratified by important prognostic and physiologic variables. Seventy-five physically inactive postmenopausal breast cancer survivors were recruited through the Yale-New Haven Hospital Tumor Registry and randomly assigned to an exercise (n = 37) or usual care (n = 38) group. The exercise group participated in 150 min/week of supervised gym- and home-based moderate-intensity aerobic exercise. The usual care group was instructed to maintain their current physical activity level. Body composition was assessed at baseline and 6-months through dual-energy X-ray absorptiometry (DXA) by one radiologist blinded to the intervention group of the participants. On an average, exercisers increased moderate-intensity aerobic exercise by 129 min/week over and above baseline levels compared with 45 min/week among usual care participants (P < 0.001). Exercisers experienced decreases in percent body fat (P = 0.0022) and increases in lean mass (P = 0.047) compared with increases in body fat and decreases in lean mass in usual care participants. Bone mineral density (BMD) was also maintained among exercisers compared with a loss among usual care participants (P = 0.043). In summary, moderate-intensity aerobic exercise, such as brisk walking, produces favorable changes in body composition that may improve breast cancer prognosis.

Expected values for steps/day in special populations

OBJECTIVE

To assemble expected values for free-living steps/day in special populations living with chronic illnesses and disabilities.

METHOD

Studies identified since 2000 were categorized into similar illnesses and disabilities, capturing the original reference, sample descriptions, descriptions of instruments used (i.e., pedometers, piezoelectric pedometers, accelerometers), number of days worn, and mean and standard deviation of steps/day.

RESULTS

Sixty unique studies represented: 1) heart and vascular diseases, 2) chronic obstructive lung disease, 3) diabetes and dialysis, 4) breast cancer, 5) neuromuscular diseases, 6) arthritis, joint replacement, and fibromyalgia, 7) disability (including mental retardation/intellectual difficulties), and 8) other special populations. A median steps/day was calculated for each category. Waist-mounted and ankle-mounted instruments were considered separately due to fundamental differences in assessment properties. For waist-mounted instruments, the lowest median values for steps/day are found in disabled older adults (1214 steps/day) followed by people living with COPD (2237 steps/day). The highest values were seen in individuals with Type 1 diabetes (8008 steps/day), mental retardation/intellectual disability (7787 steps/day), and HIV (7545 steps/day).

CONCLUSION

This review will be useful to researchers/practitioners who work with individuals living with chronic illness and disability and require such information for surveillance, screening, intervention, and program evaluation purposes.