"There is no expiration date": a qualitative analysis using the Social Cognitive Theory to identify factors influencing physical activity among adults living with advanced cancer

PURPOSE

To identify cognitive, behavioral, environmental, and other factors that influence physical activity in adults with advanced cancer using qualitative, semi-structured interviews.

METHODS

Eighteen semi-structured interviews were conducted with adults living with stage IV breast, prostate, or colorectal cancer; or multiple myeloma recruited from the University of Wisconsin Carbone Cancer Center. We used the Social Cognitive Theory to design the interview guide and a reflexive thematic approach for analysis.

RESULTS

Participants were 62 years old on average and currently receiving treatment. Despite reporting numerous barriers to physical activity, most participants discussed engaging in some physical activity. Participants reported difficulties coping with changes in physical functioning especially due to fatigue, weakness, neuropathy, and pain. While cold weather was seen as a deterrent for activity, access to sidewalks was a commonly reported feature of neighborhood conduciveness for physical activity. Regardless of current activity levels, adults with advanced cancer were interested in engaging in activities to meet their goals of gaining strength and maintaining independence. Having a conversation with a provider from their cancer care team about physical activity was seen as encouraging for pursuing some activity.

CONCLUSIONS

Adults living with advanced cancer are interested in pursuing activity to gain strength and maintain independence despite reported barriers to physical activity. To ensure patients are encouraged to be active, accessible resources, targeted referrals, and interventions designed to address their goals are critical next steps.

RELEVANCE

Integrating conversations about physical activity into oncology care for adults living with advanced cancer is an important next step to encourage patients to remain active and help them improve strength and maintain quality of life and independence.

Addressing differences in cancer: a framework for synergistic programming in cancer prevention and control

Background

Cancer remains a leading cause of death worldwide and continues to disproportionately impact certain populations. Several frameworks have been developed that illustrate the multiple determinants of cancer. Expanding upon the work of others, we present an applied framework for cancer prevention and control designed to help clinicians, as well as public health practitioners and researchers, better address differences in cancer outcomes.

Methods

The framework was developed by the Cancer Prevention and Control Research Network's Health Behaviors Workgroup. An initial framework draft was developed based on workgroup discussion, public health theory, and rapid literature review on the determinants of cancer. The framework was refined through interviews and focus groups with Federally Qualified Health Center providers (n=2) and cancer patients (n=2); participants were asked to provide feedback on the framework's causal pathways, completeness, and applicability to their work and personal life.

Results

The framework provides an overview of the relationships between sociodemographic inequalities, social and structural determinants, and key risk factors associated with cancer diagnosis, survivorship, and cancer morbidity and mortality across the lifespan. The framework emphasizes how health-risk behaviors like cigarette smoking interact with psychological, psychosocial, biological, and psychosocial risk factors, as well as healthcare-related behavior and other chronic diseases. Importantly, the framework emphasizes addressing social and structural determinants that influence health behaviors to reduce the burden of cancer and improve health equity. Aligned with previous theory, our framework underscores the importance of addressing co-occurring risk factors and disease states, understanding the complex relationships between factors that influence cancer, and assessing how multiple forms of inequality or disadvantage intersect to increase cancer risk across the lifespan.

Conclusions

This paper presents an applied framework for cancer prevention and control to address cancer differences. Because the framework highlights determinants and factors that influence cancer risk at multiple levels, it can be used to inform the development, implementation, and evaluation of interventions to address cancer morbidity and mortality.

Key takeaways for knowledge expansion of early-career scientists conducting Transdisciplinary Research in Energetics and Cancer (TREC): a report from the TREC Training Workshop 2022

The overall goal of the annual Transdisciplinary Research in Energetics and Cancer (TREC) Training Workshop is to provide transdisciplinary training for scientists in energetics and cancer and clinical care. The 2022 Workshop included 27 early-to-mid career investigators (trainees) pursuing diverse TREC research areas in basic, clinical, and population sciences. The 2022 trainees participated in a gallery walk, an interactive qualitative program evaluation method, to summarize key takeaways related to program objectives. Writing groups were formed and collaborated on this summary of the 5 key takeaways from the TREC Workshop. The 2022 TREC Workshop provided a targeted and unique networking opportunity that facilitated meaningful collaborative work addressing research and clinical needs in energetics and cancer. This report summarizes the 2022 TREC Workshop's key takeaways and future directions for innovative transdisciplinary energetics and cancer research.

Looking back: a review of policy implications for exercise oncology

The evidence to support the benefits of exercise for people living with and beyond cancer is robust. Still, exercise oncology interventions in the United States are only eligible for coverage by third-party payers within the restrictions of cancer rehabilitation settings. Without expanded coverage, access will remain highly inequitable, tending toward the most well-resourced. This article describes the pathway to third-party coverage for 3 programs that address a chronic disease and utilize exercise professionals: the Diabetes Prevention Program, Supervised Exercise Training for Peripheral Artery Disease, and Cancer Rehabilitation. Lessons learned will be applied toward expanding third-party coverage for exercise oncology programming.

Associations of life course obesity with endometrial cancer in the Epidemiology of Endometrial Cancer Consortium (E2C2)

BACKGROUND

Adult obesity is a strong risk factor for endometrial cancer (EC); however, associations of early life obesity with EC are inconclusive. We evaluated associations of young adulthood (18-21 years) and adulthood (at enrolment) body mass index (BMI) and weight change with EC risk in the Epidemiology of Endometrial Cancer Consortium (E2C2).

METHODS

We pooled data from nine case-control and 11 cohort studies in E2C2. We performed multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for BMI (kg/m2) in young adulthood and adulthood, with adjustment for BMI in adulthood and young adulthood, respectively. We evaluated categorical changes in weight (5-kg increments) and BMI from young adulthood to adulthood, and stratified analyses by histology, menopausal status, race and ethnicity, hormone replacement therapy (HRT) use and diabetes.

RESULTS

We included 14 859 cases and 40 859 controls. Obesity in adulthood (OR = 2.85, 95% CI = 2.47-3.29) and young adulthood (OR = 1.26, 95% CI = 1.06-1.50) were positively associated with EC risk. Weight gain and BMI gain were positively associated with EC; weight loss was inversely associated with EC. Young adulthood obesity was more strongly associated with EC among cases diagnosed with endometrioid histology, those who were pre/perimenopausal, non-Hispanic White and non-Hispanic Black, among never HRT users and non-diabetics.

CONCLUSIONS

Young adulthood obesity is associated with EC risk, even after accounting for BMI in adulthood. Weight gain is also associated with EC risk, whereas weight loss is inversely associated. Achieving and maintaining a healthy weight over the life course is important for EC prevention efforts.

Abstract P229: The Associations Between Muscular Strengthening Activity, Physical Function, and All-Cause Mortality Among Older Adults With Cardiovascular Disease

Background: CVD is the leading cause of mortality in the US. Strong evidence suggests that aerobic physical activity (PA) is associated with reducing the risk of mortality among those with CVD. However, the extent to which muscular strengthening activity (MSA), as well as measures of physical functioning (PF), is related to mortality risk reduction is unknown in those with CVD.

Purpose: To examine the associations between MSA and PF with all-cause mortality among a representative sample of the US with CVD.

Methods: Participants aged ≥50 years (n=5,531; mean age 64.3 years, 52% female) from the 1999-2006 NHANES with complete covariates and outcomes were included. A subset (n=2,094) had MEC-measured PF data (time to peak force in seconds [TPF]; peak force in newtons [PF-N]; time to complete a 20-foot walk in seconds [TCW]) available at baseline through 2002. MSA volume was dichotomized as meeting (≥2 days/week) vs not meeting current MSA guidelines (<2 days/week). Multivariable Cox proportional hazards regression models estimated associations (HR) between (1) MSA categories, and (2) quartiles of PF [TPF, TCW, PN-F], with all-cause mortality in the overall sample, and then stratified by enrollment age (<50-64 years and ≥65 years).

Results: A total of 2,046 deaths from any cause were identified over the 69,386 person-years of follow-up. Null associations were observed between MSA categories with mortality in multivariable models. Age stratified models revealed lower risk of all-cause mortality in adults ≥65 years meeting MSA guidelines versus insufficient MSA (HR 0.85, 0.73-0.99); however this association was not observed in adults aged 50-64 (HR 1.17, 0.82-1.65). Dose-response reductions in all-cause mortality risk were found across all quartiles for TCW and PF-N but not for TPF. These findings were consistent in adults aged 50-64 years and ≥65 years.

Conclusions: Results suggest that meeting MSA recommendations is particularly beneficial for lowering all-cause mortality risk among those ≥65 years. Further, higher levels of PF appear to be associated with lower all-cause mortality risk among adults, supporting the role of assessing PF a potential indicator of future mortality risk. These findings collectively underscore the importance of including MSA in exercise prescriptions for older adults with CVD.

Dietary omega-3 fatty acids and endometrial cancer risk in the Epidemiology of Endometrial Cancer Consortium: An individual-participant meta-analysis

BACKGROUND

Limited data from prospective studies suggest that higher dietary intake of long-chain omega-3 polyunsaturated fatty acids (LCn3PUFA), which hold anti-inflammatory properties, may reduce endometrial cancer risk; particularly among certain subgroups characterized by body mass and tumor pathology.

MATERIALS AND METHODS

Data from 12 prospective cohort studies participating in the Epidemiology of Endometrial Cancer Consortium were harmonized as nested case-control studies, including 7268 endometrial cancer cases and 26,133 controls. Habitual diet was assessed by food frequency questionnaire, from which fatty acid intakes were estimated. Two-stage individual-participant data mixed effects meta-analysis estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) through logistic regression for associations between study-specific energy-adjusted quartiles of LCn3PUFA and endometrial cancer risk.

RESULTS

Women with the highest versus lowest estimated dietary intakes of docosahexaenoic acid, the most abundant LCn3PUFA in diet, had a 9% increased endometrial cancer risk (Quartile 4 vs. Quartile 1: OR 1.09, 95% CI: 1.01-1.19; P trend = 0.04). Similar elevated risks were observed for the summary measure of total LCn3PUFA (OR 1.07, 95% CI: 0.99-1.16; P trend = 0.06). Stratified by body mass index, higher intakes of LCn3PUFA were associated with 12-19% increased endometrial cancer risk among overweight/obese women and no increased risk among normal-weight women. Higher associations appeared restricted to White women. The results did not differ by cancer grade.

CONCLUSION

Higher dietary intakes of LCn3PUFA are unlikely to reduce endometrial cancer incidence; rather, they may be associated with small to moderate increases in risk in some subgroups of women, particularly overweight/obese women.

Feasibility and acceptability of home-based strength training in endometrial cancer survivors

PURPOSE

Physical activity is important for healthy cancer survivorship, yet many endometrial cancer survivors do not participate in recommended muscle-strengthening activity. The purpose of this study was to determine the feasibility of home-based muscle strengthening activity in endometrial cancer survivors.

METHODS

Forty post-treatment endometrial cancer survivors were enrolled in a randomized trial, of twice-weekly home-based strength exercise versus wait-list control. The intervention included educational materials, exercise equipment (dumbbells, resistance bands), and support/feedback via video coaching sessions. Participants completed the exercises twice per week for 10 weeks, with a 5-week follow-up period. Feasibility was measured by program adherence, as well as safety of and satisfaction with the study.

RESULTS

On average, participants were 60.9 years old (SD = 8.7), had a BMI of 39.9 kg/m2 (SD = 15.2), and were 2.9 years (SD = 1.2) since diagnosis. The majority (83%) had stage I disease at diagnosis. Seventy-five percent adhered to the exercise prescription of twice/week, with 85% of participants missing fewer than 3 of the workouts. Forty percent of participants continued workouts during the 5-week follow-up. Participants were highly satisfied with intervention. No injuries or adverse everts occurred.

CONCLUSION

This home-based program was feasible in endometrial cancer survivors. While adherence was measured, future research should focus on long-term maintenance of exercise and should explore progressions and modifications of exercises at a distance for various abilities.

IMPLICATIONS FOR CANCER SURVIVORS

Muscle strengthening activities are recommended for all cancer survivors. This study shows that a home-based muscle strengthening exercise is feasible in endometrial cancer survivors.

Independent and joint associations of weightlifting and aerobic activity with all-cause, cardiovascular disease and cancer mortality in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

OBJECTIVES

Both aerobic moderate to vigorous physical activity (MVPA) and muscle-strengthening exercise (MSE) are recommended, but the mortality benefits of weightlifting, a specific type of MSE, are limited.

METHODS

In the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, we used Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% CIs for the associations between weightlifting and mortality, adjusting for demographics, lifestyle and behavioural risk factors. The sample included 99 713 adults who completed the follow-up questionnaire that assessed weightlifting who were subsequently followed up through 2016 to determine mortality (median 9, IQR 7.6-10.6 years).

RESULTS

Mean age at the follow-up questionnaire was 71.3 (IQR 66-76) years, 52.6% female, with mean body mass index of 27.8 (SD 4.9) kg/m². Weightlifting was associated with a 9% lower risk of all-cause mortality (HR=0.91 (95% CI 0.88 to 0.94)) and CVD mortality (0.91 (95% CI 0.86 to 0.97)) after adjusting for MVPA. Joint models revealed that adults who met aerobic MVPA recommendations but did not weightlift had a 32% lower all-cause mortality risk (HR=0.68 (95% CI 0.65 to 0.70)), while those who also reported weightlifting 1-2 times/week had a 41% lower risk (HR=0.59 (95% CI 0.54 to 0.64)), both compared with adults reporting no aerobic MVPA or weightlifting. Without adjustment for MVPA, weightlifting was associated with lower cancer mortality (HR=0.85 (95% CI 0.80 to 0.91)).

CONCLUSION

Weightlifting and MVPA were associated with a lower risk of all-cause and CVD mortality, but not cancer mortality. Adults who met recommended amounts of both types of exercise appeared to gain additional benefit.

The Role of Home-Based Exercise in Maintaining Skeletal Muscle During Preoperative Pancreatic Cancer Treatment

Loss of skeletal muscle and inferior muscle quality are associated with poor prognosis in patients undergoing preoperative treatment for pancreatic cancer, so maintaining skeletal muscle health before surgery may help accelerate patients' functional recovery and improve their quality of life following surgery. While exercise helps maintain or increase skeletal muscle in individuals undergoing cancer treatment, its efficacy during pancreatic cancer treatment is unclear. Accordingly, in this study we compared changes in skeletal muscle quantity (skeletal muscle index [SMI]) and quality (skeletal muscle density [SMD]) during preoperative pancreatic cancer treatment in participants in a home-based exercise program (EP) and a historical cohort of patients who received the usual care (UC) with no formal exercise programming. Recommendations for the EP cohort included both aerobic and resistance exercise. We assessed changes in SMI and SMD using computed tomography scans administered at treatment planning (T0, prior to EP enrollment) and preoperative restaging (T1) for 33 EP and 64 UC patients and compared changes between groups. The UC patients had statistically significant SMI decreases from T0 to T1 (-1.4 ± 3.8 cm²/m²; p = .005), while the EP patients did not (0.2 ± 3.2 cm²/m²; p = .7). The SMI loss was significantly worse for the UC than for the EP patients (p = .03). Neither group demonstrated statistically significant changes in SMD from T0 to T1, nor did the groups differ in the amount of change in SMD. An adjusted linear regression model demonstrated that EP participation was significantly associated with better SMI maintenance (p = .02). These results suggest that participation in a home-based EP during preoperative treatment may help improve skeletal muscle health and clinical and quality of life outcomes for pancreatic cancer survivors.

Factors Influencing Exercise Following Pancreatic Tumor Resection

BACKGROUND

We previously demonstrated associations between exercise during pancreatic cancer treatment and quality of life and physical fitness prior to pancreatectomy. In this study, we quantified exercise among survivors following pancreatic tumor resection and characterized concordance with established guidelines.

METHODS

We quantified exercise frequency, duration, and intensity among survivors who underwent pancreatectomy for adenocarcinoma or a neuroendocrine tumor at our center from 2000 to 2017 and compared them with American College of Sports Medicine Guidelines for Cancer Survivors. Additional surveys measured motivation to exercise, barrier self-efficacy, quality of life, and fatigue. Multivariable models were constructed to evaluate associations between clinicodemographic and psychosocial variables and guideline concordance, and between guideline concordance and quality of life and fatigue.

RESULTS

Of 504 eligible survivors, 262 (52%) returned surveys. Only 62 participants (24%) reported meeting both aerobic and strengthening guidelines; 103 (39%) reported meeting neither. Adjusted analyses demonstrated that higher autonomous motivation was associated with higher aerobic and strengthening guideline concordance (both p < 0.01). Higher barrier self-efficacy and older age were associated with higher aerobic guideline concordance (p < 0.01). We identified no significant associations between guideline concordance and tumor type, time since surgery, or recent cancer therapy (all p > 0.05). We found favorable associations between aerobic guideline concordance and both quality of life and fatigue (both p < 0.001).

CONCLUSIONS

Less than one-quarter of participants exercised sufficiently to meet national exercise guidelines following pancreatectomy. To maximize exercise and related benefits, interventions should help survivors increase intrinsic motivation and overcome barriers to exercise.

Longitudinal assessment of post-surgical physical activity in endometrial and ovarian cancer patients

OBJECTIVE

Physical activity plays a key role in cancer survivorship. The purpose of this investigation was to (a) describe the post-surgical physical activity trajectories of endometrial (n = 65) and ovarian (n = 31) cancer patients and (b) identify clinical and demographic predictors of physical activity over time.

METHODS

96 participants wore an Actiwatch accelerometer for three days at each of three time points (one week, one month and four months) after surgical intervention for their endometrial or ovarian cancer diagnosis. Analyses were conducted using linear mixed effects regression modeling in SAS 9.4.

RESULTS

For both tumor types, although physical activity levels increased with time after surgery, even at four months patients were performing only a small fraction of the 150 minutes of recommended weekly moderate to vigorous physical activity. At 1 week, subjects were completing on average 14 minutes/week (SD = 4) of moderate-to-vigorous physical activity, compared to 14 minutes/week (SD = 2) of moderate-to-vigorous physical activity at four months post-surgery (p < .05). Better self-rated health was associated with higher physical activity (p = 0.02) in endometrial cancer survivors only. BMI, age, surgery type and use of neoadjuvant chemotherapy were not associated with activity over time.

CONCLUSIONS

Our findings suggest that physical activity levels are different for those with better self-rated health, but those individuals are still insufficiently active. This study adds new information describing the trajectories and variables that influence physical activity in gynecologic cancer survivors after surgery and highlights the need for health promotion interventions in this population.

Automatic Identification of Physical Activity Type and Duration by Wearable Activity Trackers: A Validation Study

Background

Activity trackers are now ubiquitous in certain populations, with potential applications for health promotion and monitoring and chronic disease management. Understanding the accuracy of this technology is critical to the appropriate and productive use of wearables in health research. Although other peer-reviewed validations have examined other features (eg, steps and heart rate), no published studies to date have addressed the accuracy of automatic activity type detection and duration accuracy in wearable trackers.

Objective

The aim of this study was to examine the ability of 4 commercially available wearable activity trackers (Fitbits Flex 2, Fitbit Alta HR, Fitbit Charge 2, and Garmin Vívosmart HR), in a controlled setting, to correctly and automatically identify the type and duration of the physical activity being performed.

Methods

A total of 8 activity types, including walking and running (on both a treadmill and outdoors), a run embedded in walking bouts, elliptical use, outdoor biking, and pool lap swimming, were tested by 28 to 34 healthy adult participants (69 total participants who participated in some to all activity types). Actual activity type and duration were recorded by study personnel and compared with tracker data using descriptive statistics and mean absolute percent error (MAPE).

Results

The proportion of trials in which the activity type was correctly identified was 93% to 97% (depending on the tracker) for treadmill walking, 93% to 100% for treadmill running, 36% to 62% for treadmill running when preceded and followed by a walk, 97% to 100% for outdoor walking, 100% for outdoor running, 3% to 97% for using an elliptical, 44% to 97% for biking, and 87.5% for swimming. When activities were correctly identified, the MAPE of the detected duration versus the actual activity duration was between 7% and 7.9% for treadmill walking, 8.7% and 144.8% for treadmill running, 23.6% and 28.9% for treadmill running when preceded and followed by a walk, 4.9% and 11.8% for outdoor walking, 5.6% and 9.6% for outdoor running, 9.7% and 13% for using an elliptical, 9.5% and 17.7% for biking, and was 26.9% for swimming.

Conclusions

In a controlled setting, wearable activity trackers provide accurate recognition of the type of some common physical activities, especially outdoor walking and running and walking on a treadmill. The accuracy of measurement of activity duration varied considerably by activity type and tracker model and was poor for complex sets of activity, such as a run embedded within 2 walking segments.

Predictors of discordance in self-report versus device-measured physical activity measurement

PURPOSE

Accurate measurement of free-living physical activity is challenging in population-based research, whether using device-based or reported methods. Our purpose was to identify demographic predictors of discordance between physical activity assessment methods and to determine how these predictors modify the discordance between device-based and reported physical activity measurement methods.

METHODS

Three hundred forty-seven adults from the Survey of the Health of Wisconsin wore the ActiGraph accelerometer for 7 days and completed the Global Physical Activity Questionnaire. Multivariate linear regression was conducted to assess predictors of discordance including gender, education, body mass index, marital status, and other individual level characteristics in physical activity reporting.

RESULTS

Seventy-seven percent of men and 72% of women self-reported meeting the U.S. Centers for Disease Control and Prevention guidelines for aerobic activity but when measured by accelerometer, only 21% of men and 17% of women met guidelines. Demographic characteristics that predicted discordance between methods in multivariate regression included greater educational attainment (P < .001) and partnered status (P = .003).

CONCLUSIONS

These varying levels of discordance imply that comparisons of self-reported activity among groups defined by (or substantially varying by) educational attainment or marital status should be done with considerable caution as observed differences may be due, in part, to systematic, differential measurement biases among groups.