Survivors at higher risk for adverse late outcomes due to psychosocial and behavioral risk factors

Cancer and Stress: Understanding the Connections and Interventions

Stress is ubiquitous in our modern society and contributes to many disease states. This narrative review describes the effect of stress/distress on cancer development and progression. Seminal randomized controlled trials, systematic reviews/meta-analyses, and distress management guidelines from the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), and the Society for Integrative LinearOncology (SIO) are highlighted. We describe the physiological effects of distress, distress assessment, and management. Psychological treatments are summarized. Evidence-based lifestyle modifications and integrative therapies are reviewed in detail, including mindfulness-based techniques, yoga, guided imagery, breathing techniques, hypnosis, exercise, music therapy, qigong/Tai Chi, eye movement desensitization and reprocessing, and improving sleep and heart rate variability. Recognition and treatment of distress can improve quality of life. More research is needed to determine the effects of managing distress on cancer outcomes, as well as the best type and duration of intervention, noting that the benefits of interventions may be specific for patients with different cancer types.

Meaning of nutrition for cancer survivors: a photovoice study

Background

Little is known about how cancer survivors perceive nutrition through the cancer experience and how those perceptions may influence their diet.

Aims

This study aimed to capture the meaning of nutrition for cancer survivors who are post-cancer treatment using a participatory photography method known as photovoice.

Methods

Wang and Burris's photovoice procedure was followed. Recruitment took place via email through existing links with participants from a previous quantitative study. The participants were tasked with taking photographs to represent the meaning of nutrition for them post-treatment. Group workshops and semistructured interviews were conducted to facilitate reflection, dialogue and analysis. Data analysis followed Braun and Clarke's six-phase thematic analysis.

Results

One man and seven women (n=8) across the Island of Ireland were recruited. Participants identified six themes (illustrated with photographs): (1) Fresh is Best, (2) Be kind to yourself, (3) Building Blocks. Be Informed., (4) Post-Treatment Healing Changes, (5) Chemo Rituals and (6) Food for the Soul-Healthy Mind. Healthy Body.

Conclusions

Participants displayed a holistic approach to a healthy lifestyle for recovery post-treatment and maintaining health. While diverse, participants made post-treatment nutritional changes by introducing and eliminating certain foods or food groups. All agreed that being informed and building nutrition knowledge are essential. It is important to clarify the implications cancer has had on diet and health when providing nutrition guidance to ensure that it is appropriate and specific.

Anxiety and Depression in Patients with Breast Cancer: A Cross-sectional Study

BACKROUND: The early management for distress, depression, and anxiety in breast cancer patients can help improves quality of life that adherence patients to cancer treatment. AIM: This study aimed to describe the prevalence and risk factors of anxiety and depression symptomatology of breast cancer patients in the inpatients and outpatient settings. METHODS: This study used a research and development study design. The study was conducted in at the University Clinical Center of Kosovo the Medical Oncology Clinic in Pristina from August to October 2021. The total sample in this study consisted of 50 female breast cancer patients diagnosed at least 6 months before the date of assessment, aged 18 and above, able to communicate in Albanian, signed an informed consent form, negative history of other malignancies, and absence of any temporary acute illness affecting psychological well-being while filling the questionnaire. Questionnaire used in our study is Hospital Anxiety and Depression Scale for assessing anxiety and depression in breast cancer patients. RESULTS: For anxiety score, some of them were caseness level with 82%, while 26% of study participants were in borderline, 6% in caseness, and some of them were in normal level from 68% on the depression score. The patients feel tense or wound up with 44% Mean/SD (14.67 ± 6.02), about feeling afraid that something terrible will happen and patients may have this feel Mean/SD (13 ± 1.66). Over half of them had the feeling of fear as if something awful is about to happen Mean/SD (11.33 ± 4.03) and that the feeling of fear as if they had “butterflies” in the stomach of 62% had the feeling sometimes, beautiful often, and very often Mean/SD (10.33 ± 4.92). CONCLUSION: The results indicate that it is very important to measure the level of anxiety and depression in women with breast cancer, which are two common mental disorders in breast cancer.

[Tobacco and alcohol consumption in women treated for breast cancer in a department of surgical oncology: Frequent behaviours to consider]

INTRODUCTION

Tobacco and alcohol represent the two most important risk factors increasing cancer incidence and mortality, particularly among women with breast cancer. However, few researches have focused on the consumption of psychoactive substances in women treated for breast cancer. The present study describes the prevalence of tobacco and alcohol consumption and their relationships with the sociodemographic, medical and psychological variables in a population of women receiving surgery treatment for breast cancer.

METHODS

Between October 2014 and August 2015, a group of women receiving breast cancer treatment were recruited to participate to a screening and brief intervention program (SBI) for the consumption of tobacco and alcohol, adapted to the oncology context. Data on tobacco and alcohol consumption were collected using two questionnaires : the smoking status identification (NIDA) and alcohol consumption (AUDIT-C). A questionnaire for socio- demographic data and two for psychological data (Thermometer of psychological distress; ESAS), have been used. The medical data were reported by participants and verified on medical records.

RESULTS

In a total of 11 months, 120 women with breast cancer were included in this study. A large majority of patients were hospitalized for a first-time cancer (80.8%), type invasive ductal carcinoma (70.8%) and were receiving surgery as primary treatment (45%). Furthermore, 30.8% of the women reported tobacco consumption and 38.4% high-risk alcohol consumption. Regarding mental health, 40.8% presented moderate to intense levels of psychological distress. No significant relationships were found between consumption scores and sociodemographic, medical or psychological characteristics. Only the patient's age was negatively associated with tobacco consumption.

DISCUSSION

Tobacco and at-risk alcohol consumption are frequently reported behaviors during breast cancer treatment. Intervention strategies targeting risk behaviors related to addictive consumption should be implemented during the full treatment of breast cancer patients.

Self-reported health, lifestyle and social circumstances of Australian adult cancer survivors: A propensity score weighted cross-sectional study

BACKGROUND

With the prevalence of cancer survivors increasing, their unique needs must be better understood. We examined the health, lifestyles and social circumstances of adults with and without a history of cancer.

METHODS

We performed a cross-sectional study, using exposure and outcome data from the baseline survey (2006-2009) of participants in the 45 and Up Study, a prospective cohort study in New South Wales, Australia. We compared 20,811 cancer registry-verified adult cancer survivors with 207,148 participants without a history of cancer using propensity score weighting and accounting for multiple testing. The propensity weighting included age, sociodemographic factors and number of self-reported co-morbidities.

RESULTS

Cancer survivors were more likely to report poorer physical and psychological health and quality of life compared to those without a cancer history, with most deficits still evident more than 10 years after cancer diagnosis. Cancer survivors were more likely to have a higher body mass index, but were less likely to smoke. Cancer survivors had greater functional limitations, including sexual, and were less likely to work full time, volunteer and spend time outdoors. Their social connectedness was, however, similar. Those with haematological cancer, lung cancer, or distant metastases, and those diagnosed at an older age, had the greatest health deficits and functional limitations.

CONCLUSIONS

A history of cancer is associated with poorer health and less paid and unpaid work. Our findings reinforce the importance of routine long-term, integrated multidisciplinary care for cancer survivors and indicate the subgroups with the greatest unmet needs.

Stress and Physical Activity in Rural Cancer Survivors: The Moderating Role of Social Support

PURPOSE

Social support (SS) has been shown to moderate the relationship between psychological distress and physical activity (PA) in adults, including those with no history of cancer and cancer survivors (CS). The purpose of this study was to explore the relationship between stress and leisure-time PA and test if SS is a moderator of this relationship in rural CS.

METHODS

CS were recruited to Partnering to Prevent and Control Cancer (PPCC) and completed questionnaires assessing sociodemographics, leisure-time PA, perceived stress, and SS. Hierarchical multivariable linear regression was used to assess the moderating role of SS on the association between stress and PA.

FINDINGS

Cancer survivors (N = 219) were in their mid-60s (M age = 64.3 ± 12.5 years) and overweight/obese (M BMI = 29.5 ± 6.8 kg/m² ); over half were women (60.7%) and insufficiently active (59.4%); and 42.1% reported moderate-to-high perceived stress. Perceived stress was negatively correlated with PA (r = -.183, P = .044) and SS (r = -.470, P < .001), and SS was positively correlated with PA (r = .205, P = .025). However, SS did not moderate the association between stress and PA.

CONCLUSIONS

Rural CS reported higher stress and less PA than previously reported by urban CS, potentially contributing to rural cancer health disparities. Although previous studies have shown success in building SS to reduce stress and promote PA in CS, our results do not support the stress-buffering hypothesis in rural cancer survivors. Further research is needed to understand factors related to PA in rural CS and determine strategies to reduce psychological distress and promote healthy behaviors in an effort to improve cancer survivorship.

Understanding Distress Among Patients With Cancer Receiving Specialized, Supportive Care Services

BACKGROUND

Cancer and its treatment can cause persistent psychosocial consequences for patients. Although distress among the general cancer population has been well studied, many patients who report high distress do not receive specialty, follow-up care. We know little about the distress needs of those who attend appointments with support services. Improved knowledge of this subpopulation of patients with cancer may improve supportive care service delivery.

METHODS

This is a descriptive chart review that examines results from a cancer distress tool in an outpatient supportive care clinic and explores factors associated with distress among patients who attend an appointment for support beyond usual oncologic care. All adult patients with a cancer diagnosis presenting to the supportive care clinic during a 120-day period for an initial intake completed a self-report needs assessment tool. A review of medical records was then conducted. Primarily descriptive statistics, mean comparison, and correlational analysis summarized the data.

RESULTS

Nearly 48% of individuals rated very severe distress in at least one area of functioning. Areas with the highest average distress ratings included pain, fatigue, sleep, and anxiety. No significant associations were found between total distress scores and demographic or illness-related variables. Anxiety and depression were higher among those scheduled to see a behavioral health specialist than a palliative provider.

CONCLUSIONS

Patient and illness factors were not associated with needs among those who attended appointments with support providers. Study results suggest that a biopsychosocial approach from interdisciplinary providers is warranted to manage the needs of patients referred for additional supportive care.

Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

Temporal trends in net and crude probability of death from cancer and other causes in the Australian population, 1984-2013

BACKGROUND

While net probabilities of death in the relative survival framework ignore competing causes of death, crude probabilities allow estimation of the real risk of cancer deaths. This study quantifies temporal trends in net and crude probabilities of death.

METHODS

Australian population-based cohort of 2,015,903 people aged 15-89 years, diagnosed with a single primary invasive cancer from 1984 to 2013 with mortality follow-up to 31 December 2014. Survival was analyzed with the cohort method. Flexible parametric relative survival models were used to estimate both probability measures by diagnosis year for all cancers and selected leading sites.

RESULTS

For each site, excess mortality rates reduced over time, especially for prostate cancer. While both the 10-year net and crude probability of cancer deaths decreased over time, specific patterns varied. For example, the crude probability of lung cancer deaths for males aged 50 years decreased from 0.90 (1984) to 0.79 (2013); whereas the corresponding probabilities for kidney cancer were 0.64 and 0.18 respectively. Patterns for crude probabilities of competing deaths were relatively constant. Although for younger patients, both net and crude measures were similar, crude probability of competing deaths increased with age, hence for older ages net and crude measures were different except for lung and pancreas cancers.

CONCLUSIONS

The observed reductions in probabilities of death over three decades for Australian cancer patients are encouraging. However, this study also highlights the ongoing mortality burden following a cancer diagnosis, and the need for continuing efforts to improve cancer prevention, diagnosis and treatment.

Pilot Study of Dose-Response Effects of Exercise on Change in C-Reactive Protein, Cortisol, and Health-Related Quality of Life Among Cancer Survivors

Fatigue, stress, and depression contribute to poor health-related quality of life (HRQoL) among cancer survivors. This study examined the effects of combined aerobic and resistance training (CART) on HRQoL and biomarkers of stress. Cancer survivors (n = 76, 91% female, 39% breast cancer, 32% gynecologic cancer) were enrolled in CART for three 60-min sessions, weekly, for 26 weeks. Participants completed the National Institutes of Health's Patient Reported Outcomes Measurement Information System (NIH PROMIS) fatigue assessment and the SF-36. Cortisol and c-reactive protein (CRP) were assessed using volunteered blood specimens. Baseline fatigue scores were worse for participants completing treatment within the last year, compared to long-term survivors [F = (2, 59) = 3.470, p = 0.038]. After 26 weeks, fatigue scores improved by a noteworthy two points [M = 52.72, standard deviation, SD = 10.10 vs. M = 50.67, SD = 10.14; t(48) = 1.7145, p = 0.092]. Pre- to postintervention improvements in bodily pain [M = 50.54, SD = 9.51 vs. M = 48.20, SD = 10.07; t(33) = 2.913, p = 0.006] and limitations in social functioning [M = 50.60, SD = 9.17 vs. M = 47.75, SD = 11.66; t(33) = 2.206, p = 0.034], as well as a mean decrease of 1.64 ± 10.11 mg/L in CRP levels [t(107) = 1.261, p = 5.965], were observed. Participants within 1 year of treatment completion experienced greater improvements in post CRP levels compared to those who had treatment 1–4 years (p = 0.030) and 5 or more years ago (p = 0.023). Physical functioning, fatigue, fear/anxiety, social role satisfaction, and CRP levels improved following participation in this exercise intervention. Oncologists should consider recommending CART as soon as medically feasible following the cessation of cancer treatment.

Frequency of psychological distress in gynecologic cancer patients seen in a large urban medical center

Psychological distress in cancer is a well-documented phenomenon, but additional information is needed about demographic and disease correlates in diverse populations with different forms of cancer. This study focused on gynecologic cancers. Using the Distress Thermometer and the Hospital Anxiety and Depression Scale, this study examined distress levels in 94 women with gynecologic cancer who were being treated as outpatients at a large urban medical center. The distress levels in this sample were lower than in comparable studies, raising questions about openness to reporting distress. Those who reported higher levels of distress were more likely to also report a mental health diagnosis or psychiatric medication. This suggests that an alternate form for distress screening may involve inquiring about mental health treatment. In this sample, younger women and those with higher educational achievement or private health insurance had higher levels of distress. Conversely, there were no relations between distress levels and disease characteristics, indicating that, for example, women with early stage disease have just as much risk of distress as those with later-stage disease.

NCCN Guidelines Insights: Survivorship, Version 1.2016

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common consequences of cancer and cancer treatment. They are intended to aid health care professionals who work with survivors of adult-onset cancer in the posttreatment period, including those in general oncology, specialty cancer survivor clinics, and primary care practices. Guidance is also provided to help promote physical activity, weight management, and proper immunizations in survivors. This article summarizes the NCCN Survivorship panel's discussions for the 2016 update of the guidelines regarding the management of anxiety, depression, posttraumatic stress disorder-related symptoms, and emotional distress in survivors.

Identifying Psychosocial Distress and Stressors Using Distress-screening Instruments in Patients With Localized and Advanced Penile Cancer

BACKGROUND

We examined the effects of treatment on the psychological well-being of patients with localized or advanced penile cancer using screening questionnaires to determine the consecutive need for psychosocial care. Penile cancer is a rare, but highly aggressive, malignancy. The psychological stress of patients with penile cancer arises from the cancer diagnosis per se and the corresponding consequences of treatment. In addition, cancer-specific distress results (eg, fear of metastasis, progression, relapse, death). Studies of the psychosocial stress of penile cancer patients are rare.

MATERIAL AND METHODS

We undertook a prospective analysis of the data from patients with penile cancer who had undergone surgery or chemotherapy from August 2014 to October 2016 at our department. Patients were evaluated using standardized questionnaires for stress screening and the identification for the need for psychosocial care (National Comprehensive Cancer Network Distress Thermometer and Hornheider screening instrument) and by assessing the actual use of psychosocial support.

RESULTS

The average stress level was 4.5. Of all the patients, 42.5% showed increased care needs at the time of the survey. Younger patients, patients undergoing chemotherapy, and patients with recurrence were significantly more integrated with the psychosocial care systems. Finally, 67% of all patients received inpatient psychosocial care.

CONCLUSION

Owing to the potentially mutilating surgery, patients with penile cancer experience increased psychological stress and, consequently, have an increased need for psychosocial care. Therefore, the emotional stress of these patients should be recognized and support based on interdisciplinary collaboration offered.

Long-term effects of a web-based cancer aftercare intervention on moderate physical activity and vegetable consumption among early cancer survivors: a randomized controlled trial

BACKGROUND

The number of cancer survivors is growing. Negative physical and psychosocial consequences of cancer treatment can occur during survivorship. Following healthy lifestyle recommendations is beneficial to increase quality of life and to reduce the risk of cancer recurrence and comorbidities. To meet individual needs, web-based interventions can supply a large population of cancer survivors with easily accessible and personalized information. Evidence concerning the long-term effects of web-based cancer aftercare interventions on lifestyle outcomes is limited. The present study evaluates the 12-month effects of a fully automated web-based cancer aftercare intervention. We investigated whether the previously determined 6-month effects on moderate physical activity and vegetable intake were maintained over 12 months. Possible moderator effects of using specific intervention modules, gender, age, and education were also explored.

METHOD

A two-armed randomized controlled trial was conducted using online self-report questionnaires among survivors of various types of cancer (N = 462). The intervention group had access to the online intervention for 6 months, and the control group received access after 12-months. Multilevel linear regression analyses (complete cases and intention-to-treat) were conducted to explore 12- month effects.

RESULTS

A significant intervention effect after 12 months was found for moderate physical activity (complete cases: B = 128.475, p = .010, d = .35; intention-to-treat: B = 129.473, p = .011). Age was the only significant moderator (p = .010), with the intervention being effective among participants aged younger than 57 years (B = 256.549, p = .000, d = .59). No significant intervention effect remained for vegetable consumption after 12 months (complete cases: B = 5.860, p = .121; intention-to-treat: B = 5.560, p = .132).

CONCLUSION

The online cancer after care intervention is effective in increasing and maintaining moderate physical activity in the long term among early cancer survivors younger than 57 years. Short-term increases in vegetable consumption were not sustained in the long term. These findings indicate the value and potential of eHealth interventions for cancer survivors. Based on the study results, web-based self-management interventions could be recommended for younger cancer survivors (<57 years of age) as a possible method to increase physical activity.

TRIAL REGISTRATION

Dutch Trial Register NTR3375 . Registered 29 March 2012.

Do cancer survivors develop healthier lifestyle behaviors than the cancer-free population in the PLCO study?

BACKGROUND

Current studies report mixed results in health status and health behaviors after a diagnosis of cancer. The aim of our study is to investigate potential differences in lifestyle factors among cancer survivors and cancer-free individuals in a prospective cohort study conducted in the United States.

METHODS

Using data from the Prostate, Lung, Colorectal and Ovarian (PLCO) Trial, 10,133 cancer survivors were identified and compared to 81,992 participants without cancer to evaluate differences in body mass index (BMI), smoking, NSAID use, and physical activity.

RESULTS

Cancer survivors, compared to the cancer-free, were significantly less likely to engage in physical activity (odds ratio (OR) = 0.82, 95% CI = 0.77-0.88). Compared to those who were obese at baseline, cancer survivors were more likely to be at normal BMI at follow-up compared to the cancer-free (OR = 1.90, 95% CI = 1.42-2.54). Cancer survivors were less likely to report regular aspirin use as compared to the cancer-free population (OR = 0.86, 95 % CI = 0.82-0.92). Of the current smokers, cancer survivors were more likely to be former smokers at follow-up compared to the cancer-free (OR = 1.50, 95% CI = 1.30-1.74).

CONCLUSION

Upon stratification by baseline health markers, cancer survivors practice healthier lifestyle habits such as smoking cessation and maintenance of a healthy weight. However, cancer survivors are less likely to be physically active as compared to cancer-free individuals, regardless of baseline practices.

IMPLICATIONS FOR CANCER SURVIVORS

For cancer survivors who reported poor health status and behaviors at baseline, a cancer diagnosis may encourage the practice of healthier lifestyle behaviors.

Planning for the future: the role of nurse practitioners and physician assistants in survivorship care

The number of cancer survivors in the United States now approaches 12 million individuals, with an estimated 7.2% of the general population aged 18 years or older reporting a previous cancer diagnosis. These figures highlight a number of questions about the care of survivors-how patients at risk for a known set of health problems should be followed, by whom, and for how long. At the same time that oncologists are developing strategies to provide services to this growing population, there are economic and systems challenges that have relevance to the previous questions, including a predicted national shortage of physicians to provide oncology services. Nurse practitioners (NPs) and physician assistants (PAs) have been identified as members of the health care team who can help reduce the oncology supply and demand gap in a number of ways. The ASCO Study of Collaborative Practice Arrangements (SCPA) in 2011 concluded that oncology patients were aware and satisfied when their care was provided by NPs and PAs; there was an increase in productivity in practices that utilized NPs and PAs; utilizing the full scope of practice of NPs and PAs was financially advantageous; and, physicians, NPs, and PAs are highly satisfied with their collaborative practices. Increasingly, the oncology and health policy literature contains evidence supporting innovative provider models. There is still much work to be done to move beyond pilot data to establish the true value of these models.

Interest in Health Behavior Intervention Delivery Modalities Among Cancer Survivors: A Cross-Sectional Study

Background

Effective, broad-reaching channels are important for the delivery of health behavior interventions in order to meet the needs of the growing population of cancer survivors in the United States. New technology presents opportunities to increase the reach of health behavior change interventions and therefore their overall impact. However, evidence suggests that older adults may be slower in their adoption of these technologies than the general population. Survivors’ interest for more traditional channels of delivery (eg, clinic) versus new technology-based channels (eg, smartphones) may depend on a variety of factors, including demographics, current health status, and the behavior requiring intervention.

Objective

The aim of this study was to determine the factors that predict cancer survivors’ interest in new technology-based health behavior intervention modalities versus traditional modalities.

Methods

Surveys were mailed to 1871 survivors of breast, prostate, and colorectal cancer. Participants’ demographics, diet and physical activity behaviors, interest in health behavior interventions, and interest in intervention delivery modalities were collected. Using path analysis, we explored the relationship between four intervention modality variables (ie, clinic, telephone, computer, and smartphone) and potential predictors of modality interest.

Results

In total, 1053 respondents to the survey (56.3% response rate); 847 provided complete data for this analysis. Delivery channel interest was highest for computer-based interventions (236/847, 27.9% very/extremely interested) and lowest for smartphone–based interventions (73/847, 8.6%), with interest in clinic-based (147/847, 17.3%) and telephone-delivered (143/847, 16.9%) falling in between. Use of other technology platforms, such as Web cameras and social networking sites, was positively predictive of interest in technology-based delivery channels. Older survivors were less likely to report interest in smartphone–based diet interventions. Physical activity, fruit and vegetable consumption, weight status, and age moderated relationships between interest in targeted intervention behavior and modality.

Conclusions

This study identified several predictors of survivor interest in various health behavior intervention delivery modalities. Overall, computer-based interventions were found to be most acceptable, while smartphones were the least. Factors related to survivors’ current technology use and health status play a role in their interest for technology-based intervention versus more traditional delivery channels. Future health behavior change research in this population should consider participants’ demographic, clinical, and lifestyle characteristics when selecting a delivery channel. Furthermore, current health behavior interventions for older cancer survivors may be best delivered over the Internet. Smartphone interventions may be feasible in the future following further adoption and familiarization by this particular population.

Do long term cancer survivors have better health-promoting behavior than non-cancer populations?: case-control study in Korea

BACKGROUND

We compared the health-promoting behavior of long-term cancer survivors with those of the general population to identify necessary behavioral interventions to reduce the health risk among cancer patients.

MATERIALS AND METHODS

We used data from the 2007 and 2012 Korea National Health and Nutrition Examination Surveys (KNHANES IV [2007~2009] and KNHANES V [2010~2012]) on smoking status, alcohol use, physical exercise, and disease screening. We compared long-term cancer survivors with members of the general population; the controls were matched by propensity score matching. A multiple logistic regression model was used to investigate the association between cancer status and health-promoting behavior.

RESULTS

Long-term cancer survivors had a lower risk of smoking than the general population controls (OR: 0.42, 95%CI: 0.25-0.71). In addition, the long-term cancer survivors had a lower risk of alcohol use than the general population controls (OR: 0.70, 95%CI: 0.50-0.98). However, in terms of physical exercise and disease screening, no statistically significant differences were detected (physical exercise OR: 1.01, 95%CI: 0.75-1.35; disease screening OR: 1.27, 95%CI: 0.93-1.74). All covariates were adjusted.

CONCLUSIONS

The long-term cancer survivors had a much lower risk of smoking and alcohol use than the general population controls. However, almost no differences in physical exercise and screening for cancer recurrence or secondary disease were detected between the long-term cancer survivors and general population controls. To reduce the health risks and challenges facing long-term cancer survivors, interventions to encourage physical exercise and screening for cancer recurrence and secondary disease should be implemented.

Lifestyle Factors in Cancer Survivorship: Where We Are and Where We Are Headed

Advances in early detection and curative therapies have led to an increased number of cancer survivors over the last twenty years. With this population comes the need to evaluate the late and long term effects of cancer treatment and develop recommendations about how to optimally care for these survivors. Lifestyle factors (diet, body weight, physical activity, and smoking) have been linked to a higher risk of many medical comorbidities (cardiovascular, metabolic, etc.). There is increasing evidence linking these factors to the risk of developing cancer and likely cancer-related outcomes. This link has been studied extensively in common cancers like breast, colon, prostate, and lung cancers through observational studies and is now being prospectively evaluated in interventional studies. Realizing that survivors are highly motivated to improve their overall health after a diagnosis of cancer, healthy lifestyle recommendations from oncology providers can serve as a strong tool to motivate survivors to adopt health behavior changes. Our article aims to review the evidence that links lifestyle factors to cancer outcomes and provides clinical recommendations for cancer survivors.

Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors

BACKGROUND

A cancer diagnosis may provide a 'teachable moment' in cancer recovery. To better understand factors influencing lifestyle choices following diagnosis, we examined associations between time since diagnosis and symptom burden with recommended dietary (e.g., five or more fruit/vegetable servings/day), physical activity (e.g., >150 active min, 3-5 times/week), and smoking behaviors (i.e., eliminate tobacco use) in cancer survivors.

METHODS

We analyzed cross-sectional survey data collected from breast (n = 528), colorectal (n = 106), and prostate (n = 419) cancer survivors following active treatment at The University of Texas MD Anderson Cancer Center. Four regression models were tested for behaviors of interest. Additionally, we assessed symptom burden as a potential moderator and/or mediator between time since diagnosis and behaviors.

RESULTS

Respondents were mostly female (55%) and non-Hispanic White (68%) with a mean age of 62.8 ± 11.4 years and mean time since diagnosis of 4.6 ± 3.1 years. In regression models, greater time since diagnosis predicted lower fruit and vegetable consumption (B = -0.05, p = 0.02) and more cigarette smoking (B = 0.06, p = 0.105). Greater symptom burden was a significant negative predictor for physical activity (B = -0.08, p < .001). We did not find evidence that symptom burden moderated or mediated the association between time since diagnosis and health behaviors.

CONCLUSION

We assessed the prevalence of recommended behaviors in the context of other challenges that survivors face, including time since diagnosis and symptom burden. Our results provide indirect evidence that proximity to a cancer diagnosis may provide a teachable moment to improve dietary and smoking behaviors and that symptom burden may impede physical activity following diagnosis. Copyright © 2015 John Wiley & Sons, Ltd.

Correlates of positive health behaviors in cancer survivors: results from the 2010 LIVESTRONG survey

Positive health-promoting behaviors, including lifestyle factors (e.g., physical activity) and appropriate health service utilization (e.g., screening for secondary cancers), can minimize the health risks and challenges facing cancer survivors. The goal of this article is to examine factors associated with positive health behaviors in 2,615 posttreatment cancer survivors who completed the 2010 LIVESTRONG survey. Multivariate logistic regression was used to model odds of reporting each of six positive health behaviors "as a result of your experience with cancer": three "healthy lifestyle" behaviors and three "health care utilization" behaviors. In fully adjusted models, factors associated with greater likelihood of engaging in positive lifestyle behaviors (e.g., physical activity, changing diet) included sociodemographic factors, greater knowledge about how to reduce cancer risk; and reporting more psychological benefits due to cancer (ps <.01). Factors associated with greater likelihood of attending medical appointments and obtaining recommended cancer screenings included older age, better patient-provider communication, greater knowledge about how to reduce cancer risk, and more psychological benefits of cancer (ps <.01). Results suggest that knowledge about how to prevent cancer and benefit finding after cancer are related to positive health behaviors broadly, whereas better patient-provider communication is associated with positive cancer screening and health care utilization but not healthy lifestyle behaviors. Clinical interventions targeting these modifiable factors could maximize positive health behavior changes among cancer survivors, affecting risk for cancer recurrence as well as overall health and well-being.

Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation

Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

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.

Survivorship: introduction and definition. Clinical practice guidelines in oncology

Many cancer survivors experience physical and/or psychosocial side effects, which can be severe, debilitating, and sometimes permanent. These NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common consequences of cancer and cancer treatment for health care professionals who work with survivors of adult-onset cancer in the posttreatment period. These introductory sections of the guidelines include the panel's definition of cancer survivors, a discussion of the effects of cancer and its treatment, general principles and standards for survivorship care, and guidance regarding screening for problems that require further assessment.

Alcohol Consumption and Breast Cancer Survival: A Meta- analysis of Cohort Studies

BACKGROUND AND OBJECTIVES

Evidence for associations between alcohol consumption with breast cancer survival are conflicting, so we conducted the present meta-analysis.

METHODS

Comprehensive searches were conducted to find cohort studies that evaluated the relationship between alcohol consumption with breast cancer survival. Data were analyzed with meta-analysis software.

RESULTS

We included 25 cohort studies. The meta-analysis results showed that alcohol consumption was not associated with increased breast cancer mortality and recurrence after pooling all data from highest versus lowest comparisons. Subgroup analyses showed that pre-diagnostic or post-diagnostic consumpotion, and ER status did not affect the relationship with breast cancer mortality and recurrence. Although the relationships of different alcohol consumption with breast cancer mortality and recurrence were not significant, there seemed to be a dose-response relationship of alcohol consumption with breast cancer mortality and recurrence. Only alcohol consumption of >20 g/d was associated with increased breast cancer mortality, but not with increased breast cancer recurrence.

CONCLUSION

Although our meta-analysis showed alcohol drinking was not associated with increased breast cancer mortality and recurrence, there seemed to be a dose-response relationship of alcohol consumption with breast cancer mortality and recurrence and alcohol consumption of >20 g/d was associated with increased breast cancer mortality.

Smoking at time of diagnosis and breast cancer-specific survival: new findings and systematic review with meta-analysis

INTRODUCTION

In women with breast cancer who smoke, it is unclear whether smoking could impair their survival from the disease.

METHODS

We examined the relation of smoking at diagnosis to breast cancer-specific and overall survival among 5,892 women with invasive breast cancer treated in one Canadian center (1987 to 2008). Women were classified as never, former or current smokers. Current smokers were further classified according to total, intensity and duration of smoking. Deaths were identified through linkage to population mortality data. Cox proportional-hazards multivariate models were used. A systematic review with meta-analysis combines new findings with published results.

RESULTS

Compared with never smokers, current smokers at diagnosis had a slightly, but not statistically significant, higher breast cancer-specific mortality (hazard ratio = 1.15, 95% confidence interval (CI): 0.97 to 1.37). Among current smokers, breast cancer-specific mortality increased with total exposure to, intensity and duration of smoking (all Ptrend <0.05). Compared to never smokers, breast cancer-specific mortality was 32 to 56% higher among heavy smokers (more than 30 pack years of smoking, more than 20 cigarettes per day or more than 30 years of smoking). Smoking at diagnosis was associated with an increased all-cause mortality rate. A meta-analysis of all studies showed a statistically significant, 33% increased mortality from breast cancer in women with breast cancer who are smokers at diagnosis compared to never smokers (hazard ratio = 1.33, 95% CI: 1.12 to 1.58).

CONCLUSIONS

Available evidence to date indicates that smoking at diagnosis is associated with a reduction of both overall and breast cancer-specific survival. Studies of the effect of smoking cessation after diagnosis on breast cancer-specific outcomes are needed.

Anatomic subsite of primary colorectal cancer and subsequent risk and distribution of second cancers

BACKGROUND

Individuals with a history of colorectal cancer (CRC) have an increased risk of subsequent cancer. In this study, the authors used cancer registry data to evaluate whether this increased risk of cancer after CRC differed by anatomic subsite of a first CRC.

METHODS

Individuals diagnosed with a first primary CRC between 1992 and 2009 were identified from 12 Surveillance, Epidemiology, and End Results (SEER) cancer registries. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing the incidence of subsequent cancers in these patients who had an index CRC versus the cancer incidence rates in the general population. SIRs were calculated for cancers at anatomic sites within and outside the colorectum in analyses stratified by subsite of the index CRC.

RESULTS

Cancer incidence rates were significantly higher in individuals who had a previous CRC than in the general population (SIR, 1.15; 95% CI, 1.13-1.16). Individuals with an index CRC located between the transverse and descending colon experienced the greatest increased risk both overall (SIR, 1.29-1.33) and particularly with respect to the risk of a second CRC (SIR, 2.53-3.35). The incidence of small intestinal cancer was elevated significantly regardless of the index CRC subsite (SIR, 4.31; 95% CI, 3.70-4.77), and the incidence of endometrial cancer was elevated in those who had an index CRC in the proximal colon (SIR, 1.37-1.79).

CONCLUSIONS

The risk of second cancer after CRC differs by anatomic site of the first tumor and is particularly pronounced for those with prior CRC located in the transverse to descending colon. The mechanisms underlying this pattern of second cancer risk remain unknown.

Alcohol consumption before and after breast cancer diagnosis: associations with survival from breast cancer, cardiovascular disease, and other causes

PURPOSE

Alcohol intake is associated with increased risk of breast cancer. In contrast, the relation between alcohol consumption and breast cancer survival is less clear.

PATIENTS AND METHODS

We assessed pre- and postdiagnostic alcohol intake in a cohort of 22,890 women with incident invasive breast cancer who were residents of Wisconsin, Massachusetts, or New Hampshire and diagnosed from 198 to 200 at ages 20 to 79 years. All women reported on prediagnostic intake; a subsample of 4,881 reported on postdiagnostic intake.

RESULTS

During a median follow-up of 11.3 years from diagnosis, 7,780 deaths occurred, including 3,484 resulting from breast cancer. Hazard ratios (HR) and 95% CIs were estimated. Based on a quadratic analysis, moderate alcohol consumption before diagnosis was modestly associated with disease-specific survival (compared with nondrinkers, HR = 0.93 [95% CI, 0.85 to 1.02], 0.85 [95% CI, 0.75 to 0.95], 0.88 [95% CI, 0.75 to 1.02], and 0.89 [95% CI, 0.77 to 1.04] for two or more, three to six, seven to nine, and ≥ 10 drinks/wk, respectively). Alcohol consumption after diagnosis was not associated with disease-specific survival (compared with nondrinkers, HR = 0.88 [95% CI, 0.61 to 1.27], 0.80 [95% CI, 0.49 to 1.32], 1.01 [95% CI, 0.55 to 1.87], and 0.83 [95% CI, 0.45 to 1.54] for two or more, three to six, seven to nine, and ≥ 10 drinks/wk, respectively). Results did not vary by beverage type. Women consuming moderate levels of alcohol, either before or after diagnosis, experienced better cardiovascular and overall survival than nondrinkers.

CONCLUSION

Overall alcohol consumption before diagnosis was not associated with disease-specific survival, but we found a suggestion favoring moderate consumption. There was no evidence for an association with postdiagnosis alcohol intake and breast cancer survival. This study, however, does provide support for a benefit of limited alcohol intake for cardiovascular and overall survival in women with breast cancer.

Multiple primary cancers among colorectal cancer survivors in Queensland, Australia, 1996-2007

PURPOSE

To quantify the demographic and clinical factors associated with an increased risk of multiple primary cancers (MPCs) among colorectal cancer survivors.

METHODS

Standardized incidence ratios for MPCs were calculated for residents of Queensland, Australia, who were diagnosed with a first primary colorectal cancer between 1996 and 2005 and survived for at least 2 months. Relative risk ratios were calculated for all MPCs combined and selected individual sites using multivariate Poisson models.

RESULTS

A total of 1,615 MPCs were observed among 15,755 study patients. The cohort had a significant excess risk of developing subsequent colorectal (SIR = 1.47, 95 % CI 1.30-1.66) or non-colorectal (SIR = 1.24, 95 % CI 1.18-1.31) cancers relative to the incidence of cancer in the general population. Age at initial diagnosis, follow-up time, initial colorectal subsite, and surgical treatment were independently associated (p < 0.01) with the overall risk of developing MPCs after adjustment. The relative risk ratio was 1.23 (95 % CI 1.07-1.41) for those aged 20-59 years compared with the 70-79 age group and 0.82 (95 % CI 0.72-0.92) for 1-5-year follow-up relative to the first year. The likelihood of being diagnosed with a MPC was 33 % higher (95 % CI 1.12-1.56) for surgically treated patients and 45 % higher (95 % CI 1.29-1.64) after proximal colon cancers relative to rectal cancer.

CONCLUSIONS

While these population-based results do not incorporate all possible risk factors, they form an important foundation from which to further investigate the etiological causes that result in the development of MPCs among colorectal cancer survivors.