Perceptions of weight management counseling among gynecologic cancer survivors: opportunities for enhancing survivorship care

Scalable Telehealth Cancer Care: integrated healthy lifestyle program to live well after cancer treatment

Northwestern University's Center for Scalable Telehealth Cancer Care (STELLAR) is 1 of 4 Cancer Moonshot Telehealth Research Centers of Excellence programs funded by the National Cancer Institute to establish an evidence base for telehealth in cancer care. STELLAR is grounded in the Institute of Medicine's vision that quality cancer care includes not only disease treatment but also promotion of long-term health and quality of life (QOL). Cigarette smoking, insufficient physical activity, and overweight and obesity often co-occur and are associated with poorer treatment response, heightened recurrence risk, decreased longevity, diminished QOL, and increased treatment cost for many cancers. These risk behaviors are prevalent in cancer survivors, but their treatment is not routinely integrated into oncology care. STELLAR aims to foster patients' long-term health and QOL by designing, implementing, and sustaining a novel telehealth treatment program for multiple risk behaviors to be integrated into standard cancer care. Telehealth delivery is evidence-based for health behavior change treatment and is well suited to overcome access and workflow barriers that can otherwise impede treatment receipt. This paper describes STELLAR's 2-arm randomized parallel group pragmatic clinical trial comparing telehealth-delivered, coach-facilitated multiple risk behavior treatment vs self-guided usual care for the outcomes of reach, effectiveness, and cost among 3000 cancer survivors who have completed curative intent treatment. This paper also discusses several challenges encountered by the STELLAR investigative team and the adaptations developed to move the research forward.

Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations

PURPOSE

To generate direct observational evidence for understanding how diet, nutrition, and weight-related topics are discussed during follow-up after treatment for gynecological cancer, as recommended by survivorship care guidelines.

METHODS

Conversation analysis of 30 audio-recorded outpatient consultations, involving 4 gyne-oncologists, 30 women who had completed treatment for ovarian or endometrial cancer, and 11 family members/friends.

RESULTS

From 21 instances in 18 consultations, diet, nutrition, or weight-related talk continued beyond initiation if the issue raised was ostensibly relevant to the clinical activity being undertaken at the time. These instances led to care-related outcomes (i.e., general dietary recommendations, referral to support, behavior change counseling) only when the patient identified needing further support. Diet, nutrition, or weight-related talk was not continued by the clinician if it was not apparently related to the current clinical activity.

CONCLUSIONS

The continuation of diet, nutrition, or weight-related talk during outpatient consultations after treatment for gynecological cancer, and the subsequent delivery of care-related outcomes, depends on its immediate clinical relevance and the patient indicating needing further support. The contingent nature of these discussions means there can be missed opportunities for the provision of dietary information and support post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

If seeking information or support for diet, nutrition, or weight-related issues post-treatment, cancer survivors may need to be explicit regarding their need for this during outpatient follow-up. Additional avenues for dietary needs assessment and referral should be considered to optimize the consistent delivery of diet, nutrition, and weight-related information and support after treatment for gynecological cancer.

Barriers to and facilitators of a healthy lifestyle for patients with gynecological cancer: a systematic review of qualitative and quantitative research with healthcare providers and patients

The prevalence of an unhealthy lifestyle among patients with gynecological cancer is high and associated with increased risk of all-cause mortality. Although lifestyle changes have the potential to improve outcomes, lifestyle counseling is not routinely integrated into standard care. This review explores research on the barriers to and facilitators of both the promotion of healthy lifestyles by healthcare providers (HCPs) and healthy lifestyle changes by patients with gynecological cancer. The Theoretical Domains Framework (TDF) was used to deductively code the identified factors for a comprehensive understanding of the barriers and facilitators. A search across five databases yielded a total of 12,687 unique studies, of which 43 were included in the review. Of these 43, 39 included gynecological cancer patients and only 6 included HCPs. Among the barriers identified for HCPs, most studies evaluated barriers regarding weight loss counseling. Limited knowledge, reluctance to address weight loss, skepticism about the benefits, and workload concerns were commonly reported barriers for HCPs. HCPs will benefit from education and training in lifestyle counseling, including effective communication skills like motivational interviewing. Gynecological cancer patients lacked tools, support, knowledge, and faced mental health issues, environmental constraints, and physical limitations. The review emphasizes the importance of addressing these barriers and utilizing identified facilitators, such as social support, to promote and support healthy lifestyle behaviors on the part of patients and their promotion by HCPs. Future research should focus not only on patients but also on supporting HCPs and implementing necessary changes in current practices.

ENhAncing Lifestyle Behaviors in EndometriaL CancEr (ENABLE): A Pilot Randomized Controlled Trial

PURPOSE

Endometrial cancer is associated with the highest comorbid disease burden of any cancer. The aim of this trial was to assess the feasibility and safety of an allied health intervention during adjuvant treatment.

METHODS

A mixed-methods pilot randomized (2:1) controlled trial with concealed allocation and assessor-blinding. Eligibility criteria: adjuvant endometrial cancer treatment scheduled, disease stage I-IIIC1, ECOG 0-2 and able to perform unsupervised physical activity (PA). Participants received usual care and 8 sessions of weekly, individualized, lifestyle education (diet and PA) with behavior change and social support (intervention group), delivered predominantly by telehealth, or usual care alone. Feasibility outcomes: recruitment and consent rates, decline reasons, program acceptability, intervention adherence and retention.

RESULTS

22/44 eligible patients (50%, 95%CI: 36%, 64%) were recruited over 10 months (14 intervention, 8 usual care). The recruitment rate was 2.2 patients/month (95%CI: 1.4, 3.3). Patients who declined had too much going on (7/22, 32%) or were not interested (6/22, 27%). Mean (SD) age and BMI were 63.2 years (6.8) and 31.9 kg/m² (6.7). A majority were FIGO stage I (15/22, 68%) and received vaginal brachytherapy (14/22, 64%). Adherence was high, 11/14 (79%, 95%CI: 52%, 92%) participants attended >70% of scheduled sessions. Retention was 100% (95%CI: 85%, 100%) at 9 weeks, however completion of objective measures was impacted by COVID-19 restrictions. Telehealth and online questionnaires enabled participation. No serious adverse events occurred.

CONCLUSION

The intervention was acceptable to participants with high levels of adherence and retention. Trial findings will be used to design a future RCT.

TRIAL REGISTRATION

The trial was registered on www.anzctr.org.au (ACTRN12619000631101) 29/04/2019.

Weight and weight control behaviors during long-term endometrial cancer survivorship: Results of the Laparoscopic Approach to Cancer of the Endometrium long-term follow-up study

BACKGROUND

Overweight or obesity is common in endometrial cancer (EC). This study aimed to examine sociodemographic, clinical, and psychosocial characteristics associated with being discontent with current weight and use of weight control methods among long-term EC survivors.

METHODS

Women diagnosed with early-stage EC who participated in the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial (n = 516) were invited to complete a long-term follow-up survey at least 4.5 years after treatment. Chi-square test and multivariate logistic regression models adjusted for time since surgery were used to determine factors associated with being discontent with current weight.

RESULTS

On average 9 years after surgery, 190/259 (73%) of participants were currently discontent with their weight, and 146 (56%) had used one or more weight loss methods during the past 12 months. Women who were discontent with their weight were more likely to be younger than 70 years (p < 0.000), and used one or more weight loss methods ever or during the past 12 months (p < 0.000). Among the weight loss methods used, exercise (40.1%), meal reductions (52.7%), or fat/sugar reductions (48.5%) were much more commonly reported than fasting (2.6%) or designated weight loss programs (2.3%).

CONCLUSIONS

Our study provides evidence that the majority of long-term EC survivors in this clinical trial population are discontent with their weight and over half continue to use multiple methods to lose weight each year. These data indicate that health professionals and lifestyle educators need to assess weight issues, and develop a tailored plan to address the specific needs of long-term survivors to assist them become content with their weight after treatment for EC.

Diet and nutrition in patients who have received pelvic radiotherapy: A mixed-methods study to explore dietary habits, nutritional awareness, and experiences of nutritional care

OBJECTIVES

Individuals who have survived cancer may benefit from dietary modifications to improve quality of life and future health outcomes. The aim of this study was to explore dietary habits and experiences of nutritional support in patients with a cancer diagnosis who have received radiotherapy to the pelvic area.

METHODS

A mixed-methods approach was used. Individuals diagnosed with a pelvic cancer (anal, bladder, rectal, and cancers of the reproductive organs), either undergoing or having completed pelvic radiotherapy 6 to 24 mo previously, were invited to participate in a postal survey. A purposive subsample was also invited to take part in telephone interviews. Thematic analysis of interview data was undertaken and integrated with data from quantitative analysis.

RESULTS

The survey was completed by 254 (38%) respondents. Two-thirds of respondents (170) reported dietary changes since diagnosis; most notable changes were reduction of sugary foods (48%) and alcohol (41%). Receipt of support from the health care team was significantly associated with dietary change (odds ratio, 3.26; 95% confidence interval, 1.58-6.75); however, only 43% (108) had received dietary support from the health care team. Of the respondents, 68% (171) said they would like to receive additional dietary support. The effect of the condition on diet was highlighted in the theme "Impact of diagnosis and treatments on dietary choices." Self-management of disease was influenced by personal resources, social resources, comorbidities and disabilities, influence of work, regaining normality, and barriers to dietary changes.

CONCLUSION

Lack of routine provision of nutritional care to patients after a cancer diagnosis and patient interest in this area highlighted unmet needs in managing diet-related problems and leading a healthy future lifestyle.

Needs, preferences, and experiences of adult cancer survivors in accessing dietary information post-treatment: A scoping review

INTRODUCTION

To support provision of healthy lifestyle information tailored to patients' needs and preferences, this review maps adult cancer survivors' self-reported needs, preferences, and experiences accessing dietary information post-treatment.

METHODS

A scoping review of research published within the past decade conducted using PRISMA-ScR guidelines. Seven databases were searched in June 2020.

RESULTS

Of 15,973 articles identified, 57 met eligibility criteria. Studies most frequently included survivors of breast cancer (49%), persons aged 40+ years (95%), ≤5 years post-diagnosis (54%), and residing in North America (44%). Cancer survivors commonly identified needing information regarding healthy eating, particularly practical skills, and support in changing dietary behaviours. Preferences included specific recommendations, direct communication with healthcare professionals, and peer support from other cancer survivors. In practice, survivors frequently reported receiving generic advice from healthcare professionals, limited dietary follow-up, and lack of referral to support. Unmet needs in healthcare settings led to dietary information-seeking elsewhere; however, survivors indicated difficulty identifying credible sources. Personal beliefs and desire for involvement in care motivated dietary information-seeking post-treatment.

CONCLUSION

Cancer survivors' experiences accessing dietary information post-treatment do not align with needs and preferences. Less is known about survivors who are young adults, >5 years post-diagnosis, and living in rural areas.

Diet and nutrition information and support needs in pelvic radiotherapy: A systematic, mixed-methods review

INTRODUCTION

This study aimed to review diet and nutrition information and support needs of cancer patients who receive pelvic radiotherapy to inform the development of interventions to improve this area of care.

METHODS

The systematic review followed the PRISMA guidelines. Six electronic databases were searched for peer-reviewed studies of any design that assessed diet and nutrition needs after a pelvic cancer diagnosis. Narrative synthesis was used to integrate findings.

RESULTS

Thirty studies (12 quantitative, 15 qualitative, 3 mixed-methods) were included. Four themes, "content of dietary information"; "sources of information"; "sustaining dietary change"; and "views on the role of diet post-treatment," summarised evidence about provision of nutritional guidance following diagnosis, but also contrasting views about the role of diet post-diagnosis. Qualitative studies contributed considerably more to the synthesis, compared to quantitative studies. Included studies were of moderate to good quality; selection bias in quantitative studies and poor evidence of credibility and dependability in qualitative studies were highlighted.

CONCLUSION

There is some evidence of lack of nutrition support in pelvic cancer survivors, but methodological limitations of included studies may have had an impact on the findings. Future, prospective studies that focus on diet and nutrition needs post-diagnosis are warranted to improve care.

Interleukin-6 and body mass index, tobacco use, and sleep in gynecologic cancers

OBJECTIVE

Elevated body mass index (BMI), tobacco use, and sleep disturbance are common health concerns among women with gynecologic cancers. The extent to which these factors are associated with systemic inflammation in gynecologic cancers is unknown. This is a significant literature gap given that (a) chronic, systemic inflammation may mediate relationships between behavioral health factors and cancer outcomes; and (b) elevated BMI, tobacco use, and sleep disturbances can be modified via behavioral interventions. This study examined Interleukin-6 (IL-6) relations with BMI, tobacco use history, and sleep disturbances in patients undergoing surgery for suspected gynecologic cancer.

METHOD

Participants were 100 women (M age = 58.42 years, SD = 10.62 years) undergoing surgery for suspected gynecologic cancer. Smoking history was determined by participant self-report. Sleep quality/disturbance was assessed via the Pittsburgh Sleep Quality Index. BMI was abstracted from electronic health records. Presurgical serum IL-6 concentrations were determined using Enzyme-Linked Immunosorbent Assay.

RESULTS

Controlling for the cancer type and stage, regression analyses revealed higher BMI, β = 0.258, p = .007, and former/current smoking status, β = 0.181, p = .046, were associated with higher IL-6. IL-6 did not differ between former and current smokers, β = 0.008, p = .927. Global sleep quality, sleep latency, and sleep efficiency were not associated with IL-6.

CONCLUSIONS

Higher BMI and any history of tobacco use predicted higher IL-6 among women undergoing surgery for suspected gynecologic cancers. Cognitive-behavioral interventions targeting primary and secondary obesity and tobacco use prevention may reduce systemic inflammation and optimize cancer outcomes in this population. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Healthcare providers' discussions of physical activity with older survivors of cancer: Potential missed opportunities for health promotion

OBJECTIVES

Physical activity (PA) promotes physical functioning and health-related quality of life in older survivors of cancer. Using a population-based sample of Medicare Advantage beneficiaries, we aimed to characterize the survivors who reported discussing PA with their healthcare provider.

MATERIALS AND METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) cancer registries was linked with the 2008-2014 Medicare Health Outcomes Survey (MHOS). Older survivors diagnosed with localized- or regional-stage female breast, prostate, or colorectal cancer ≥24 months prior to survey and had visited a healthcare provider in the previous year were included in the multiple logistic regression model. Best-fitting models were identified using the Hosmer and Lemeshow Goodness-of-Fit test.

RESULTS

The final sample (N = 5630) included 3006 survivors who reported discussing PA and 2624 survivors who did not report discussing PA. Older survivors of cancer were significantly more likely to report discussing PA if they had a history of cardiovascular disease (p < .001), diabetes (p < .001), or musculoskeletal disease (p < .001); had a history of fall(s) in the previous twelve months (p = .003); or were obese (p < .001).

DISCUSSION

PA is an important aspect of the management of cancer, other comorbid conditions, and maintenance of physical functioning in older adulthood. The results suggest that PA discussions are not occurring consistently across survivors, and key opportunities for health promotion are being missed. Future work should identify ways to encourage these conversations in all cancer follow-up appointments.

Diet, physical activity, and health-related outcomes of endometrial cancer survivors in a behavioral lifestyle program: the Diet and Exercise in Uterine Cancer Survivors (DEUS) parallel randomized controlled pilot trial

OBJECTIVES

To explore the effectiveness of a theory-based behavioral lifestyle intervention on health behaviors and quality of life in endometrial cancer survivors.'

METHODS

This was a secondary analysis of a randomized controlled pilot trial conducted in two UK hospitals enrolling disease-free stage I-IVA endometrial cancer survivors. Participants were allocated to an 8-week group-based healthy eating and physical activity intervention or usual care using 1:1 minimization. Participants were followed up at 8 and 24 weeks, with the 8-week assessment being blinded. Diet, physical activity, and quality of life were measured with the Alternative Healthy Eating Index 2010, Stanford 7-Day Physical Activity Recall, and the EORTC Quality of life Questionnaire Core 30, respectively. We analyzed all eligible participants using the intention-to-treat approach in complete cases, adjusting for baseline values, body mass index, and age.

RESULTS

We enrolled 60 of the 296 potentially eligible endometrial cancer survivors (May - December 2015). Fifty-four eligible participants were randomized to the intervention (n=29) or usual care (n=31), and 49 had complete follow-up data (n=24 in the intervention and n= 25 in usual care). Intervention adherence was 77%. At 8 weeks, participants in the intervention improved their diet compared to usual care (difference in Alternative Healthy Eating Index 2010 score 7.5 (95% CI: 0.1 to 14.9), P=0.046) but not their physical activity (0.1 metabolic equivalent-h/day 95% CI: (-1.6 to 1.8), P=0.879), or global quality of life score (5.0 (95% CI: -3.4 to 13.3), P=0.236). Global quality of life improved in intervention participants at 24 weeks (difference 8.9 (95% CI: 0.9 to 16.8), P=0.029). No intervention-related adverse events were reported.

CONCLUSIONS

The potential effectiveness of the intervention appeared promising. A future fully-powered study is needed to confirm these findings.

TRIAL REGISTRATION NUMBER

NCT02433080.

Weight and Eating Concerns in Women's Reproductive Health

PURPOSE OF REVIEW

Women's weight status affects their reproductive functioning, and, likewise, women's lifetime weight trajectories are influenced by reproductive events. We examine the relationship between polycystic ovary syndrome (PCOS), pregnancy, the postpartum period, and gynecological cancers with weight, body image, and other psychiatric issues.

RECENT FINDINGS

Women with overweight or obesity are at higher risk for PCOS, and the mood and anxiety symptoms often comorbid with PCOS are linked to weight as well as the core symptoms of the disorder. Excessive gestational weight gain can influence one's body image and mood, and it predicts lasting effects on postpartum weight retention. Finally, overweight and obesity are related to several gynecological cancers. These diseases also impact mood, anxiety, and poor body image. Weight management interventions may be of some benefit in improving the disease states and pregnancy outcomes discussed here, but feasibility, logistics, and costs are issues that remain in delivering such interventions.