Findings from the present study indicate that breast cancer survivors make efforts to make life changes following the end of adjuvant treatment, and changes in health practices are particularly prevalent. Women often reported increasing the frequency of breast self-exam, eating more fruits and vegetables, increasing physical activity, and cutting back on alcohol and tobacco use, with more than one-fourth of participants reporting each of these positive health behavior changes. Moreover, women who reported making these adaptive changes were indeed doing better than their peers on the health practices examined. Breast cancer survivors also made changes that appeared to be directed toward enhancing emotional and spiritual health, with one-fourth of the sample reporting more frequent avoidance of stressful situations or praying or meditating more. Our results suggest that women are poised to make important lifestyle changes after treatment ends, and this may be a sensitive period for health promotion interventions.
Such changes may be driven by survivors' efforts to alleviate concerns about recurrence by making changes believed to decrease the possibility of recurrence. In fact, most of the changes in health practices match ACS and NCI health guidelines for cancer survivors and breast cancer prevention [8
]. The changes further appear to reflect individual differences in breast cancer survivors' common-sense representations of their cancer, particularly perceptions of the severity of impact of breast cancer and attributions about factors that may have caused cancer and may prevent a recurrence.
We characterized the typical profile of breast cancer survivors' common-sense beliefs about their disease using the model put forth by Leventhal and colleagues [15
]. On average, breast cancer survivors believed they had moderate control over their cancer, they perceived their cancer to have moderate to severe consequences for their lives, and they saw their cancer as more of an acute than chronic condition, although no strongly so.
Moreover, women had fairly strong ideas about what may have caused their cancer and what they could now do to prevent a recurrence. Women rated hormones, environmental toxins or hazards, and genetics or heredity as the most important causes of their cancer, with more than 70% of women citing these factors as important in the development of their cancer, followed by diet, stress and aging. These attributions are at least somewhat consistent with current epidemiological and medical knowledge. Genetics and heredity, along with aging, are known to be strong risk factors for breast cancer, with hormonal factors, obesity (reflected in diet and exercise), and alcohol use conferring more modest risk [31
]. Despite controversy regarding links between environmental toxins, such as pesticides, and breast cancer, no definitive evidence for a causal link has yet been found [32
]. Women frequently named controllable factors as important in preventing a recurrence. Medical checkups and screenings were seen as most critical in preventing a recurrence, followed by eating a healthy diet, having a positive attitude, exercising, and taking medication. The intriguing finding that 92% of participants believed that a positive attitude was important in preventing a cancer recurrence is consistent with our previous report of gynecologic cancer survivors' recurrence prevention beliefs [21
]. Factors such as God's will and chance were seen as less important. This pattern of focusing on controllable factors may be psychologically protective: it may be important for women to believe they can play an instrumental role in preventing recurrence.
Individual differences in common-sense beliefs were modestly successful in explaining behavior changes following treatment, with some domains showing greater predictive utility than others. Contrary to our hypotheses, beliefs about personal control and the course of one's disease were not useful in explaining behavior changes. Beliefs about disease consequences, causal factors, and recurrence prevention were more likely to be related to post-treatment behavior changes, and relationships were in the hypothesized directions. For example, women who perceived more severe consequences of breast cancer were more likely to reduce stress and improve their diet; it may be that these women were more motivated to make changes in their health practices. Post-treatment changes frequently matched participants' causal attributions, with those who attributed the development of their cancer to diet, lack of exercise, or stress making corresponding improvements in their health practices. Changes in health practices similarly corresponded with recurrence prevention beliefs. Women who believed that eating a healthy diet, reducing alcohol use, or reducing stress could prevent a cancer recurrence were more likely to make these changes.
Limitations of this study include the small sample size and relatively homogenous demographics of the sample; almost all participants were Caucasian, and the vast majority were married and well-educated. The sample may be comprised of a more motivated group of individuals who are willing to respond to surveys, although it is important to note that we had a high response rate (90%). Nonetheless, generalizations to other populations of breast cancer survivors may be limited for these reasons. In addition, because it was not feasible to assess health practices prior to diagnosis, we relied on women's self-reports of behavior changes from pre-diagnosis, which may be subject to recall bias. Finally, it is unclear to what extent the behavior changes observed are maintained following the immediate post-treatment period. Maintenance of health behavior may be motivated by different psychosocial factors than those that lead to initial behavior changes [33
]. Future work might examine long-term maintenance of changes in diet, exercise, and substance use, and whether women are more likely to maintain changes made following treatment as compared to changes made at other times in their lives.
Nonetheless, results suggest that the immediate post-treatment period is an opportune time to encourage and educate breast cancer survivors regarding positive health practices. We have previously reported that breast cancer survivors experience distress following the end of treatment related to feeling uncertain as to what they should do for their health [2
]. Education or other interventions that assist women in identifying appropriate dietary, exercise, or emotional health goals may assist not only in promoting good health practices but also in alleviating distress. Consistent with the suggestion that breast cancer survivors may be particularly receptive to this type of guidance, 79% of breast cancer survivors participating in a recent study expressed interest in a health promotion program [34
]. New psychoeducational interventions designed to facilitate post-treatment adjustment by promoting active coping and goal-setting also show promising results [6
Results of the present study also provide insight into how women decide to make behavior changes and what changes they decide to make. Breast cancer survivors' beliefs that the consequences of breast cancer are severe, that potentially modifiable or controllable factors played a role in the development of their cancer, and that controllable factors can prevent a recurrence appear to motivate positive changes in health practices following cancer treatment. Moreover, women make behavior changes that match their beliefs about what may have caused their cancer and what can prevent a recurrence. Recent work suggests that psychoeducational interventions targeting common-sense beliefs can indeed help patients to develop more accurate or adaptive beliefs about their illness [35
], and these changes have shown positive behavioral outcomes [35
]. Assessing attributions and beliefs about cancer, as well as providing tailored psychoeducational interventions and guidance addressing post-treatment behavior changes, may assist women with breast cancer in navigating this important transition from “patient” to “survivor.”