Abstract P6-12-01: Can exercise influence survival following breast cancer? Evidence from randomised, controlled trials

Background: The Exercise for Health (EfH) trials were randomized, controlled trials designed to evaluate an 8-month pragmatic, exercise intervention, commencing 6 weeks post-surgery for women with newly diagnosed breast cancer residing in urban- or rural/regional areas. Outcomes for these exploratory analyses were overall survival (OS), breast cancer-specific survival (BCS) and disease-free survival (DFS). Methods: Consenting urban-residing women (EfH 1, n=194) and rural/regional-residing women (EfH 2, n=143) were randomized to exercise or usual care. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for OS, BCS and DFS (exercise group, n=207, 65% urban women; usual care group, n=130, 46% urban women), with and without adjustment for prognostic factors including trial (urban/rural), age, body mass index, disease stage and presence of comorbidities. Further exploratory subgroup analyses were also conducted to assess whether effect on OS, BCS and DFS differed according to prognostic variables. Results: After a median follow-up of 8.3 years (IQR: 8.0-8.7 years) there were 11 (5.3%) deaths in the exercise group compared with 15 (11.5%) deaths in the usual care group (Table 1).

Table 1 Overall, breast cancer-specific and disease-free survival events by group allocation. All patientsUsual careExercise n=337n = 130n = 207 n (%)n (%)n (%)Breast cancer-related deaths20 (5.9)10 (7.7)10 (4.8)Non-breast cancer-related deaths6 (1.8)5 (3.8)1 (0.5)Overall survival events26 (7.7)15 (11.5)11 (5.3)Recurrence of breast cancer20 (5.9)8 (6.2)12 (5.8)Alive at follow-up9 (2.7)3 (2.3)6 (4.6)Deceased by follow-up11 (3.3)5 (3.1)6 (4.6)New primary breast cancer13 (3.9)5 (3.8)8 (3.9)Alive at follow-up13 (3.9)5 (3.8)8 (6.2)Deceased by follow-up0 (0.0)0 (0.0)0 (0.0)Disease-free survival events*48 (14.2)23 (17.7)25 (12.1)* Disease-free survival events include recurrence of breast cancer, new primary breast cancers, and all-cause deaths. Note that women who had recurrence and died before follow-up only count once towards disease-free survival events.

HRs for the exercise group were: OS: 0.45, 95% CI=0.20-0.96; p=0.04; BCS: 0.61, 95% CI=0.25-1.46, p=0.26; and DFS: 0.66, 95% CI=0.38-1.17; p=0.16 (adjusted analyses yielded similar results). With the exception of BCS for those with a body mass index >30, all HRs for subgroup analyses favored exercise, with effect on OS for women of younger age (<55), those with stage II+ disease, and those with 1+ comorbidity at baseline significant (p<0.05). Effect of exercise on DFS was also significant (p<0.05) for urban women. Conclusion: Findings suggest that an individually-prescribed and monitored exercise program integrated during and beyond treatment for breast cancer, and that was designed to cater for all women, irrespective of place of residence and access to health services, has clear potential to influence survival.

Citation Format: Hayes SC, Steele M, Spence R, Gordon L, Battistutta D, Bashford J, Pyke C, Saunders C, Eakin E. Can exercise influence survival following breast cancer? Evidence from randomised, controlled trials [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-01.

Exercise following breast cancer: exploratory survival analyses of two randomised, controlled trials

PURPOSE

The Exercise for Health trials were randomised, controlled trials designed to evaluate an 8-month pragmatic exercise intervention, commencing 6 weeks post-surgery for women with newly diagnosed breast cancer residing in urban or rural/regional Australia. For these exploratory analyses, the primary and secondary outcomes were overall survival (OS) and disease-free survival (DFS), respectively.

METHODS

Consenting urban- (n = 194) and rural/regional-residing women (n = 143) were randomised to exercise (intervention delivered face-to-face or by telephone) or usual care. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for survival outcomes (exercise group, n = 207, 65% urban women; usual care group, n = 130, 46% urban women).

RESULTS

After a median follow-up of 8.3 years, there were 11 (5.3%) deaths in the exercise group compared with 15 (11.5%) deaths in the usual care group (OS HR for the exercise group: 0.45, 95% CI 0.20-0.96; p = 0.04). DFS events for the exercise versus usual care group were 25 (12.1%) and 23 (17.7%), respectively (HR: 0.66, 95% CI 0.38-1.17; p = 0.16). HRs for OS favoured exercise irrespective of age, body mass index, stage of disease, intervention compliance, and physical activity levels at 12 months post-diagnosis, although were stronger (p < 0.05) for younger women, women with stage II + disease, women with 1 + comorbidity at time of diagnosis, higher intervention compliance and for those who met national physical activity guidelines at 12 months post-diagnosis.

CONCLUSION

An exercise intervention delivered during and beyond treatment for breast cancer, and that was designed to cater for all women irrespective of place of residence and access to health services, has clear potential to benefit survival. Trial numbers: ACT RN: 012606000233527; ACT RN: 12609000809235.

Abstract PD08-08: Exercise for Health: A Randomised, Controlled Trial of an Exercise Intervention for Women with Breast Cancer — Effect on Upper-Body Function

Background: Impairments in upper-body function are common during and following breast cancer and may persist into long-term survivorship. An objective of the Exercise for Health program was to assess the effect participation in an 8 month exercise program (initiated 6 weeks after breast cancer surgery) has on upper-body function and associated symptoms.

Methods: Women residing in an Australian metropolitan city and diagnosed with invasive breast cancer were eligible to participate in this randomised, controlled trial. Consenting women were allocated to either a face-to-face delivered exercise group (FG, n=67), a telephone-delivered exercise group (TG, n=67) or a usual-care group (UG, n=60). At 6 weeks (pre-intervention), 6 months (mid-intervention) and 12 months (postintervention) after surgery upper-body function was assessed via self-report using the Disability of the Arm, Shoulder and Hand questionnaire and clinically using an incremental maximal upper-body strength test. The presence and severity of upper-body symptoms such as pain, weakness and numbness were assessed using a 5-point Likert scale, while lymphoedema was measured clinically using bioimpedance spectroscopy.

Results: Women in the exercise intervention groups reported greater improvements (p=0.02) in perceived upper-body function (indicated by negative scores) between 6 weeks and 6 months post-surgery, (FG, mean=-6.3; TG, mean=-11.9) when compared to changes observed in the UG (mean=-4.2) and maintained these improvements by 12-months PS. Similar findings were observed for clinically measured upper-body function (P&lt;0.01). At 12 months post-surgery, those in the UG were 1.5 times more likely to report at least one moderate to severe upper-body function symptom. The number of lymphoedema cases did not differ between the groups at mid-or post-intervention.

Discussion: These results demonstrate that exercise interventions, delivered over the phone or face-to-face, can facilitate improvements in upper-body function during and following breast cancer treatment without adversely increasing risk of developing lymphoedema or other arm-related symptoms. This is particularly important since function is directly associated with a woman's ability to carry out daily tasks and has been shown to predict quality of life.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-08.

Abstract P2-14-03: Does the Mode of Delivering an Exercise Intervention Following Breast Cancer Influence Effect on Quality of Life? Results from a Randomized, Controlled Trial

Background: Participating in an exercise intervention during and following breast cancer has been associated with a range of physical and psychosocial benefits that ultimately improve quality of life. However, studies that have demonstrated such effects have largely assessed the effect of clinic-based interventions in well-controlled settings. Questions remain whether a more ‘pragmatic’ exercise intervention could influence quality of life and whether the manner by which the intervention is delivered would influence effect?

Methods: Exercise for Health is a randomized, controlled trial of an eight-month, exercise intervention delivered face-to-face or over the telephone, over 16 sessions with a qualified Exercise Physiologist. Women from urban areas of Queensland diagnosed with unilateral breast cancer in 2006/2007 were eligible to participate and were allocated to either the face-to-face group (FG; n=67), the telephone group (TG; n=67), or the usual-care group (UG; n=60). Quality of life was assessed using the Functional Assessment of Cancer Therapy-Breast questionnaire (FACT-B+4) at six weeks (pre-intervention), six months (mid-intervention) and 12 months (three months post-intervention) post-surgery. Repeated measures analysis of variance was used to assess time and group effects and the potential for an age by group interaction. Differences over time or between groups of at least eight points reflect a clinically meaningful difference and data was analyzed using intention-to-treat principles.

Results: Pre-, mid-and post-intervention, younger (&lt;50 years) breast cancer survivors reported lower QoL when compared with older women (50+ years), however differences were only clinically relevant pre-intervention (mean, 112.6 vs. 120.9). While all women experienced improvements in QoL overtime, only those in the FG and TG experienced improvements of clinical and statistical significance. For younger women, the mode of delivery did not influence effect of the intervention on QoL (mean QoL mid-intervention: 122.3 and 123.2 for FG and TG, respectively; mean QoL post-intervention: 127.9 and 128.9, respectively). However, there was preliminary evidence to suggest that older women responded better to exercise advice delivered over the phone with the TG reporting the highest levels of QoL mid-and post-intervention (128.7 and 130.2, respectively) compared with the FG (118.8 and 124.4, respectively). Discussion: This work demonstrates that an exercise intervention designed to be delivered in the real-world setting can optimize QoL during and following treatment for breast cancer. Results also suggest that the telephone may be an effective medium for delivering exercise counseling. This is particularly important for women living in more rural areas who may have limited access to specialist services and also has potential cost-benefits over face-to-face or clinic-based delivery modes.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-03.

A review of the cost-effectiveness of face-to-face behavioural interventions for smoking, physical activity, diet and alcohol

OBJECTIVE

To assess the evidence for the cost-effectiveness of health behaviour interventions that address the major behavioural risk factors for chronic disease, including smoking, physical inactivity, poor diet, and alcohol misuse.

METHODS

Medical and economic databases were searched for relevant economic evaluations. Studies were critically appraised using a published 35-point checklist, and the results are described using a narrative approach, noting methodological limitations. The review included 64 studies from 1995-2005, including 17 reports on multiple behaviour interventions.

RESULTS

There was considerable variation among the studies by target populations, intervention components, primary outcomes, and economic methods, but the reported incremental cost-effectiveness ratios were consistently low (e.g. <14,000 Euros per quality-adjusted life-year gained for smoking-cessation programmes in 2006 Euros) as compared to certain preventive pharmaceutical and invasive interventions. Interventions targeting high-risk-population subgroups were relatively better value for money as compared to those targeting general populations.

DISCUSSION

In general, the results of this review demonstrate favourable cost-effectiveness for smoking interventions, physical activity interventions and multiple behaviour interventions in high-risk groups. Although alcohol and dietary interventions appeared to be economically favourable, it is difficult to draw conclusions because of the variety in study outcomes. However, methodological limitations weaken the generalizability of findings, and suggest that the results of any given study should be considered carefully when being used to inform resource allocation.

Population-based interventions for the prevention of fall-related injuries in older people

BACKGROUND

Fall-related injuries are a significant cause of morbidity and mortality in the older population. Summary information about counter-measures that successfully address the risk factors for fall-related injuries in research settings has been widely disseminated. However, less available is evidence-based information about successful roll-out of these counter-measures in public health programmes in the wider community. Population-based interventions in the form of multi-strategy, multi-focused programmes are hypothesised to result in a reduction in population-wide injury rates. This review tests this hypothesis with regards to fall-related injuries among older people.

OBJECTIVES

To assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people.

SEARCH STRATEGY

The search strategy was based on electronic searches, handsearches of selected journals and snowballing from reference lists of selected publications.

SELECTION CRITERIA

Studies were independently screened for inclusion by two reviewers. Included studies were those that reported changes in medically treated fall-related injuries among older people following the implementation of a controlled population-based intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Meta-analysis was not appropriate, due to the heterogeneity of the included studies.

MAIN RESULTS

Out of 23 identified studies, five met the criteria for inclusion. There were no randomised controlled trials. Significant decreases or downward trends in fall-related injuries were reported in all five of the included studies with the relative reduction in fall-related injuries ranging from 6 to 33%.

AUTHORS' CONCLUSIONS

Despite methodological limitations of the evaluation studies reviewed, the consistency of reported reductions in fall-related injuries across all programmes support the preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach. Research is also required to elucidate the barriers and facilitators in population-based interventions that influence the extent to which population programmes are effective.

Health behavior changes after a cancer diagnosis: what do we know and where do we go from here?

Survival rates for certain types of cancer have improved over the past few decades. Changing unhealthy behaviors such as smoking, poor diet, and sedentary life-style among individuals who have been diagnosed with cancer may help to reduce cancer treatment sequelae, possibly reduce risk of recurrence for specific types of cancer, and reduce risk for other common diseases such as cardiovascular disease, obesity, and hypertension. This article reports the prevalence of each of these behaviors among those diagnosed with cancer and reviews interventions that have targeted these risk behaviors. There is considerable variation in the type of research questions asked, the methodologic quality of the research, sample sizes, and the outcomes observed across studies focusing on changing the three health risk behaviors. In the final section, we provide guidelines for researchers in developing health behavior interventions for individuals diagnosed with cancer and highlight challenges that should be addressed.

A social-ecologic approach to assessing support for disease self-management: the Chronic Illness Resources Survey

We report on the development and validation of an instrument to assess support and resources for chronic illness management (the Chronic Illness Resources Survey; CIRS). The 64-item full instrument and the 29-item Brief CIRS are based on a social-ecologic model, designed to apply across chronic diseases, and assess support and resources at each of seven levels (e.g., family and friends, physician and health care team, neighborhood/community). A prospective evaluation with 123 patients having heart disease, arthritis, diabetes, and/or COPD revealed that the overall instrument, as well as subscales and the brief instrument, had acceptable internal consistency, moderate to high test-retest reliability, good construct validity, and moderate concurrent and prospective criterion validity. We discuss potential uses of the CIRS for assessment, feedback, tailoring intervention, and evaluation and make recommendations for future research.

Self-efficacy expectations predict survival for patients with chronic obstructive pulmonary disease

The validity of self-efficacy expectations as predictors of mortality was evaluated for 119 patients with chronic obstructive pulmonary disease (COPD). Patients completed 4 physiological measures that represent common clinical indicators of disease severity: (a) forced expiratory volume in 1 s (FEV1.0), (b) arterial blood gas measurement of resting partial pressure of oxygen (PaO2), (c) single-breath diffusing capacity (DLCO), and (d) maximum oxygen uptake (VO2max) during exercise. In addition, self-reported self-efficacy expectation for walking on a treadmill was measured. Self-efficacy was a significant univariate predictor of 5-year survival. However, when controlling for FEV1.0 in multivariate survival analysis, self-efficacy had only a marginal effect. We concluded that simple self-report scales could provide significant information about health status.

Self-efficacy expectations predict survival for patients with chronic obstructive pulmonary disease

The validity of self-efficacy expectations as predictors of mortality was evaluated for 119 patients with chronic obstructive pulmonary disease (COPD). Patients completed 4 physiological measures that represent common clinical indicators of disease severity: (a) forced expiratory volume in 1 s (FEV1.0), (b) arterial blood gas measurement of resting partial pressure of oxygen (PaO2), (c) single-breath diffusing capacity (DLCO), and (d) maximum oxygen uptake (VO2max) during exercise. In addition, self-reported self-efficacy expectation for walking on a treadmill was measured. Self-efficacy was a significant univariate predictor of 5-year survival. However, when controlling for FEV1.0 in multivariate survival analysis, self-efficacy had only a marginal effect. We concluded that simple self-report scales could provide significant information about health status.

Development and evaluation of a smokeless tobacco cessation program: a pilot study

A multicomponent, cognitive-behavioral intervention program, offered to 25 chronic, adolescent male users of smokeless tobacco, was divided into three sessions and involved self-monitoring of smokeless tobacco use, awareness of health risks, behavioral coping strategies, frequent phone contact, and relapse prevention training. Biochemical (carbon monoxide and cotinine) verification of self-reports was obtained, information about subject and environmental characteristics collected, and a 3-month follow-up conducted. Twenty-one of the 25 subjects completed treatment; 9 participants were abstinent at the conclusion of the program, and 4 remained successful in quitting at the 3-month follow-up. Participants who did not achieve complete abstinence reported substantial reductions in smokeless tobacco use, and no increase in cigarette consumption occurred as a result of reducing or quitting use of it. Subjects successful in achieving cessation had consumed a smaller amount of smokeless tobacco at baseline and were more likely to be involved in school athletics.

Acetohydroxy acid synthetase with a pH optimum of 7.5 from Neurospora crassa mitochondria: characterization and partial purification

An acetohydroxy acid synthetase (AAS) has been found associated with the mitochondrial fraction of wild-type Neurospora crassa. It has a pH optimum of 7.5 and is presumed to be homologous to the pH 8.0 AAS that synthesizes the valine and isoleucine precursors in bacteria and yeast. The enzyme was characterized and purified 30- to 60-fold. The AAS activity of intact mitochondria requires thiamine pyrophosphate (TPP), Mn(2+) or Mg(2+), and flavine adenine dinucleotide (FAD), and is sensitive to end product inhibition by l-valine. This inhibition is pH-dependent and noncompetitive with respect to pyruvate. Activity is slightly repressed during exponential growth in the presence of valine, isoleucine, and leucine. Extraction of the AAS from the mitochondria has a profound influence on the following properties: pH optimum, sensitivity to l-valine, response to FAD, binding of TPP, apparent K(m), and stability at 0 to 4 C. The catalytic properties of the partially purified enzyme are described. Two forms of the partially purified AAS can be isolated from preparative Sephadex G-200 chromatographic columns. Both forms are electrophoretically and antigenically similar but one form has an estimated molecular weight of 110,000 to 120,000 whereas the predominant form is a much larger and more buoyant molecule.