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This study examined among recently diagnosed breast and prostate cancer survivors (N = 678) associations between worry about a future diagnosis of heart disease or cancer and hypothetical and actual adherence to exercise and dietary guidelines. Greater worry about future illness was reported under the hypothetical scenario of non-adherence to guidelines relative to the scenario of adherence. Worry about potential heart disease was associated with actual adherence to guidelines, whereas worry about a potential cancer diagnosis was not. Findings suggest that the motivational properties of worry should be considered when developing interventions to reduce heart disease risk among cancer survivors.
As the number of cancer survivors and their length of survival steadily increase (Bellizzi, Rowland, Jeffery, & McNeel, 2005), long-term health consequences of cancer and its treatments are becoming a public health concern. These health effects include increased risk of cancer recurrence, secondary cancers, and other chronic illnesses, such as heart disease and diabetes (Yabroff, Lawrence, Clauser, Davis, & Brown, 2004). Reasons for increased risk across conditions may include genetic predispositions, treatment-related sequelae, or unhealthy lifestyle practices (Doyle et al., 2006).
Unhealthy lifestyle practices, including decreased exercise and diets consisting of high levels of saturated fat and low intakes of fruits and vegetables (F&Vs), are associated with elevated risk of several cancers, heart disease, and diabetes (American Diabetic Association, 2003; Kushi et al., 2006; Pearson et al., 2002). Conversely, healthy habits may promote cancer survivors’ well-being and longevity. Specifically, exercise may reduce the risk of cancer recurrence and mortality among colorectal cancer and breast cancer patients (Holmes, Chen, Feskanich, Kroenke, & Colditz, 2005; Meyerhardt, Giovannucci, et al., 2006; Meyerhardt, Heseltine, et al., 2006), and a low fat diet may reduce recurrence in postmenopausal breast cancer survivors (Chlebowski et al., 2006). Unfortunately, a significant proportion of cancer survivors do not adhere to national guidelines regarding exercise and diet (Bellizzi et al., 2005; Doyle et al., 2006).
A paucity of research has examined how cancer survivors’ cognitions and emotions affect their adherence to health practices (Rabin & Pinto, 2006). Worry is one cognitive and emotional response to the threat of illness that may facilitate or inhibit health behavior. Many cancer survivors experience some degree of cancer-related worry (Ferrell, Dow, Leigh, Ly, & Gulasekaram, 1995), and, among colorectal cancer survivors, worry has been positively associated with intentions to change health behavior (Mullens, McCaul, Erickson, & Sandgren, 2004). However, little is known about the associations between worry and engagement in lifestyle practices.
In this study, we assessed cancer survivors’ worry about a future diagnosis of heart disease or cancer when posed with hypothetical scenarios of adhering or not adhering to national guidelines for exercise (i.e., 150+ minutes/week of moderate-to-vigorous exercise), F&V consumption (5+ servings/day), or a low-fat diet. Under the assumption that the general public is aware of healthy lifestyle practices, we expected greater worry to be endorsed under the hypothetical scenario of non-adherence to guidelines relative to the scenario of adherence. In addition, we examined variation in worry between the two hypothetical scenarios (i.e., adherence vs. non-adherence) as a function of actual adherence to lifestyle guidelines. Based on prior research that has associated worry with health-protective action (Moser, McCaul, Peters, Nelson, & Marcus, 2007), we expected a greater difference in worry between the hypothetical scenarios among cancer survivors who actually followed the guidelines. We reasoned that cancer survivors who actually adhered to lifestyle guidelines would anticipate greater personal disease risk and associated worry under the hypothetical scenario of non-adherence to lifestyle guidelines relative to the scenario of adherence.
Data were derived from baseline surveys of 678 individuals who had been diagnosed with early-stage (in-situ, localized, or regional) breast cancer (n = 373) or prostate cancer (n = 305) within the past 9 months and who had enrolled in the FRESH START intervention trial (Demark-Wahnefried et al., 2003, 2007). This distance-medicine-based intervention was designed to increase exercise and healthy eating habits among cancer survivors. Participants were primarily Caucasian (84%) or African American (13%) and well-educated (83% with at least some college). The average age was 57.7 years (SD 10.8) and the average time since diagnosis was 3.9 months (SD 2.7). On average, participants exercised for 79.0 minutes/week (SD 140.9), derived 36.4% of their calories from fat (SD 6.6), and ate 5.6 servings of F&V/day (SD 2.9). Overall, 78%, 84%, and 48% of participants did not adhere to the national guidelines for exercise, fat intake, and F&V intake, respectively. Given that participants were newly diagnosed survivors, side effects of recent and ongoing cancer-related treatments may have been barriers to the pursuit of lifestyle changes. Complete descriptions of the sample, measures, and procedures have been previously reported (Demark-Wahnefried et al., 2003, 2007). This study received institutional review board approval.
Participants completed the Diet History Questionnaire (DHQ; Subar et al., 2001), which was modified to include regionally consumed foods (e.g., hominy, okra). Responses were used to classify participants as adherent (5+ servings of F&V/day and <30% of calories from fat) or non-adherent to dietary guidelines.
Exercise was assessed using a modified version of the 7-day Physical Activity Recall (PAR; Pereira et al., 1997; Sallis et al., 1985); participants were classified as adherent if they engaged in moderate-to-vigorous exercise for 150+ minutes/week.
Participants rated their level of worry about the possibility of developing heart disease or cancer under the hypothetical scenarios of adherence or non-adherence to guidelines for each of the three lifestyle practices (i.e., F&V intake, fat intake, and exercise). Thus, a total of 12 questions assessed worry [2 (disease type) × 2 (did or did not follow guidelines) × 3 (lifestyle practices)]. For example, participants were asked, “Let’s say you regularly ate a low fat diet, how worried would you be of getting any cancer again in your lifetime?” followed by the question, “Now, if you did not regularly eat a low fat diet, how worried would you be?” Examples of a low fat diet and a description of moderate exercise were provided. Response options were: not at all worried, slightly worried, somewhat worried, very worried, and extremely worried (scored 0 to 4, respectively).
From the resulting 12 worry questions, 6 “worry difference scores” were computed by subtracting the “adherence to guidelines” question from the “non-adherence to guidelines” question within disease type and lifestyle practice. Worry difference scores, ranging from −4 to 4, indicated the magnitude of worry associated with the hypothetical conditions, with higher values suggesting greater worry under hypothetical non-adherence to guidelines relative to hypothetical adherence. T-tests were conducted to determine whether the means of the worry difference scores significantly differed from zero. Significant differences would indicate that worry scores under hypothetical non-adherence to guidelines differ from those under hypothetical adherence.
Means and standard errors for worry as a function of hypothetical lifestyle practices and disease type appear in Table 1. As hypothesized, cancer survivors reported greater worry about a future diagnosis of heart disease or cancer under the hypothetical scenario of non-adherence to guidelines for exercise, F&V consumption, and fat intake than the scenario of adherence (see Table 1). This pattern was more pronounced for heart disease than cancer, as evidenced by higher worry difference scores for heart disease across all health behaviors [M 1.00 vs. M 0.57, p < .0001, for exercise; M 0.91 vs. M 0.75, p < .0002 for F&V; M 1.18 vs. M 0.88, p < .0001 for fat].
Next, we assessed whether worry difference scores would be positively associated with participants’ actual adherence to national lifestyle guidelines. For example, did cancer survivors who actually adhered to exercise guidelines show a greater difference in worry about future cancer or heart disease between hypothetical scenarios (i.e., compliance or noncompliance with exercise guidelines) than survivors who did not adhere to the guidelines? When examining worry about future heart disease, greater worry difference scores were found for survivors who were non-adherent to guidelines versus survivors who did adhere to guidelines for exercise (M 1.20 vs. M 0.95, p < .003) and F&V consumption (M 0.98 vs. M 0.84, p < .03). However, worry difference scores did not vary by actual adherence to a low-fat diet. When examining worry about future cancer, worry difference scores were not significantly related to reports of actual adherence or non-adherence to guidelines for exercise (Ms 0.61 vs. 0.56), F&V consumption (Ms 0.78 vs. 0.72), or fat intake (Ms 0.98 vs. 0.85).
Does worry about a future diagnosis of cancer or heart disease influence the lifestyle practices of cancer survivors? To address this question, we asked breast and prostate cancer survivors to anticipate their degree of worry about potential heart disease and cancer under hypothetical lifestyle scenarios, which reflected their sensitivity to the link between hypothetical health behaviors and personal worry. We then assessed whether this sensitivity was correlated with actual lifestyle practices. Cancer survivors expressed greater worry about a future diagnosis of heart disease or cancer under the hypothetical situation of non-adherence to guidelines for exercise and F&V and fat intake than the situation of adherence. These results were more pronounced for heart disease than cancer.
Findings suggest that survivors may feel more capable of preventing heart disease than cancer by engaging in healthy lifestyle practices, thus abating levels of worry. Support for this notion was obtained when worry was examined relative to actual adherence to lifestyle guidelines. Worry about potential heart disease was associated with actual adherence to guidelines for exercise and F&V consumption, whereas worry about a potential cancer diagnosis was not associated with adherence. At the time of this study, efforts had been made to educate the public about the link between exercise and reduced heart disease risk. Conversely, links between exercise and reduced cancer recurrence had not been established; studies that purport the role of exercise or a low fat diet in increasing survival had yet to be reported (Chlebowski et al., 2006; Meyerhardt, Heseltine, et al., 2006). Results may reflect general knowledge as well as cancer survivors’ personal experience; for example, some participants may have developed cancer despite engagement in exercise and healthy eating.
Limitations of this study include the cross-sectional design and the use of single-item measures of worry that have not been standardized. Although the use of single-item measures reduced respondent burden, participants’ diverse interpretations of worry were not assessed. People’s anticipated worry and other emotional responses are often discordant with how they feel when they experience the event (Kahneman, 2000); however, research supports the notion that anticipated emotions, regardless of their accuracy, often inform decisions, including those that reduce disease risk (Bagozzi, Dholakia, & Basuroy, 2003; Chapman & Coups, 2006; Leone, Perugini, & Bagozzi, 2005; Mellers & McGraw, 2001). Future research should examine longitudinal associations between anticipated levels of worry in relation to these hypothetical scenarios and lifestyle practices of cancer survivors.
Findings suggest that motivational properties of worry should be considered when developing educational interventions to reduce the risk of heart disease among cancer survivors. However, results do not address whether interventions should frame health messages with the goal of reducing or increasing worry. Prior research on the promotion of health behavior suggests that gain-frame messages, or messages that emphasize the benefits to be gained or costs to be avoided, are more persuasive than loss-frame messages (Rothman & Salovey, 1997). Emphasizing the enactment of health practices to reduce worry is an approach that deserves empirical examination among cancer survivors.
FRESH START is supported by the National Institutes of Health through the following grants: CA81191, CA74000, CA63782, and M01-RR-30. The authors wish to acknowledge the memory of Elizabeth C. Clipp, Ph.D., a dear and dedicated co-investigator on the FRESH START team. We also thank Drs. Marci Campbell, Harvey Cohen, Bethany Jackson, P. Kelly Marcom, Bess Marcus, and Thomas Polascik for their guidance in areas of design and implementation, and Drs. Walter Ettinger, Frank Harrell, and Thomas Scott for serving on our external data safety and monitoring board. We are grateful for the contributions and professionalism demonstrated by the staff of People Designs, Inc. (David Farrell, MPH, Jetze Beers, Marley Beers, MFA, and Kristin Trangsrud, MPH) who helped craft the FRESH START intervention materials, and Dr. Cecelia and Len Doak of Patient Learning Associates, Inc. who helped make them easily understandable. The authors also wish to thank the following individuals who have and are continuing to contribute expertise and support: Sreenivas Algoti, MS, Teresa Baker, Rita Freeman, Sonya Goode Green, MPH, Heather MacDonald, Barbara Parker, Shelley Rusincovitch, Rachel Schanberg, MS, and Russell Ward. We also are grateful to our participating institutions (Duke University Medical Center, Durham Regional Hospital, Durham VA Medical Center, Maria Parham Hospital, Raleigh Community Hospital, and Rex Healthcare), cancer registrars/patient care coordinators (Renee Gooch, Blanche Sellars, Dortch Smith, Donna Thompson, and Cheri Willard), and participating physicians (Drs. Victor E. Abraham, Anjana Acharya, David Albala, Alex Althausen, Everett Anderson, Roger F. Anderson, Mitchell Anscher, Guillermo Arana, Carlos Arcangelli, Sucha Asbell, Michael Aspera, James N. Atkins, Cheryl Aylesworth, Margaret Barnes, Brian Bauer, Louis Baumann, Michael Beall, Gregory Bebb, Michael Beecher, John Bell, Marc Benevides, Brian C. Bennett, Robert Bennett, Robert Bennion, James Benton, Stuart Bergman, William R. Berry, Kelly Blair, Kimberly Blackwell, Gayle Blouin, Peter Blumencranz, William Bobbitt, Daniel Borison, William Bouchelle, Elaine Bouttell, Don Boychuk, Barb Boyer, Albert Brady, Thomas Brammer, Scott Brantley, Joanna Brell, Charles Brendler, Thomas Brennan, Donald Brennan, Elizabeth Brew, Thomas Bright, Philip Brodak, Dieter Bruno, Dale Bryansmith, Niall Buckley, Walter W. Burns, W. Woodrow Burns, Thomas Buroker, Barbara Burtness, Amanullah Buzdar, David Caldwell, Elizabeth E. Campbell, Susan Campos, Sean Canale, Woodward Cannon, Dominick Carbone, Albert Casazza, George Case, Michael Cashdollar, Stanton Champion, Nitin Chandramouli, Marie Chenn, S. Chew, Stephen Chia, Warren Chin, Richard Chiulli, Elaine Chottiner, Walter Chow, Peter Clark, Kenneth Collins, Barry Conway, Suzanne Conzen, David Cook, John Corman, Shawn Cotton, D. Scott Covington, Edwin B. Cox, Frank Critz, Nancy J. Crowley, Sam Currin, Brian Czernieki, Brian Czito, Bruce Dalkin, John T. Daniel, John Danneberger, Leroy Darkes, Glenn Davis, Walter E. Davis, Jean de Kernion, Pat DeFusco, Fletcher Derrick, Margaret Deutsch, Gayle Dilalla, Robert Diloreto, Craig Donatucci, Michael Donovan, John Doster, Bradford Drury, Paul Dudrick, William Dunlap, Edward Eigner, Maha Elkordy, Matthew Ellis, Richard Evans, Jerry Fain, Anne Favret, Ira Fenton, Dirk Fisher, James Foster, Wyatt Fowler, Jeffrey Freeland, Daniel Frenning, Ralf Freter, Michael Frontiera, Michele Gadd, Anthony Galanos, Ronald Garcia, Antonio Gargurevich, Helen Garson, Morris Geffen, Gregory Georgiade, Ward Gillett, Paul Gilman,, Jeffrey Gingrich, Deborah Glassman, John Gockerman, Richard Goodjoin, J. Phillip Goodson, Joel Goodwin, Teong Gooi, Jeffrey Gordon, Narender Gorukanit, James Gottesman, Lav Goyal, William Graber, Margaret Gradison, Gordon Grado, Mark Graham, Michael Grant, Stephen Greco, Carl Greene, Peter Grimm, Nima Grissom, Irina Gurevich, Carol Hahn, Alex Haick, Craig Hall, Edward Halperin, Sabah Hamad, R. Erik Hartvigsen, Harold Harvey, Paul Hatcher, James Hathorn, Robert Hathorn, Carolyn Hendricks, David Hesse, Martin Hightower, Peter Ho, Leroy Hoffman, Frankie Ann Holmes, Sidney Hopkins, Samuel Huang, Robert Huben, Cliff Hudis, Thelma Hurd, Sally Ingram, Philip Israel, Naresh Jain, Nora Jaskowiak, Jean Joseph, Jacqueline Joyce, Walton Joyner, Ray Joyner, Scott Kahn, Sachin Kamath, Carsten Kampe, Michael Kane, Richard Kane, Michael Kasper, Uday Kavde, Thomas Keeler, Douglas Kelly, Michael Kent, Kevin Kerlin, Kenneth Kern, Huathin Khaw, Jay Kim, Houston Kimbrough, Charmaine Kim-Sing, John Kishell, Petras Kisielius, George Kmetz, Lawrence Knott, Ronald Konchanin, Cyrus Kotwall, Kenneth Kotz, Charles Kraus, Bruce Kressel, Alan Kritz, John Lacey, Susan Laing, David Larson, Barry Lee, W. Robert Lee, Douglas Leet, Natasha Leighl, George Leight, Paul LeMarbre, Herbert Lepor, Seth Lerner, Margaret Levy, Lori Lilley, Steve Limentani, Robert Lineberger, Lenis Livesay, Fred J. Long, Richard Love, Mark Lucas, James Lugg, Charles Lusch, H. Kim Lyerly, Janet Macheledt, Thomas Maddox, Patrick Maguire, Mark Makhuli, Rajeev Malik, Mary Manascalco-Theberge, P. Kelly Marcom, Manfred Marcus, Neal Mariados, Lawrence Marks, Shona Martin, Eric Matayoshi, Gordon Mathes, Mark McClure, Scott McGinnis, David McLeod, Warren McMurry, William McNulty, Robert McWilliams, Cynthia Menard, Mani Menon, Richard Michaelson, Michael Mikolajczyk, David Miles, Dixie Mills, Jesse Mills, David Mintzer, David Molthorp, Allen Mondzac, Gustavo Montana, Angelica Montesano, Leslie Montgomery, Joseph O. Moore, William Morgan, Patricia Morrison, Michael A. Morse, Jacek Mostwin, Judd Moul, Brian Murphy, William Muuse, J. William Myers, Richard S. Myers, Richard Mynatt, Gene Naftulin, Vishwanath Nagale, Niam Nazha, Charles Neal, James Neidhart, Joseph D. Neighbors, Philip Newhall, Robert Nichols, William Niedrach, Peter Oh, John Oh, John A. Olson, Robert Ornitz, David Ornstein, Alexander Panutich, Maria Papaspyrou, Steven Papish, Dhaval Parikh, James Parsons, George Paschal, Robert Paterson, Dev Paul, David F. Paulson, Samuel Peretsman, Jorge Perez, Mark Perman, Thomas Polascik, Klaus Porzig, David C. Powell, Kenneth Prebil, Glenn Preminger, Adele Preto, Leonard Prosnitz, Robert Prosnitz, Scott K. Pruitt, Robert Reagan, Carl Reese, John Reilly, Robert Renner, Alan Rice, Melvin Richter, Adrien Rivard, Ralph Roan, Cary Robertson, Steve Robeson, Linda Robinson, Mark Romer, Eric Rosen, Amy Rosenthal, Alison Ross, William Russell, Lewis Russell, Charles Scarantino, Candace Schiffer, Mark Schoenberg, Mark Scholz, William Schuessler, Stuart Schwartzberg, Janell Seeger, Victoria Seewaldt, Hillard Seigler, Pearl Seo, Phillip Shadduck, Timothy Shafman, Rohit Shah, Arieh Shalhav, Peter Shapiro, Fred Shapiro, Heather Shaw, Robert Siegel, Daniel Silver, Mary Simmonds, Jane Skelton, Barbara Smith, Mitchell Sokoloff, Douglas Sorensen, Angela Soto-Hamlin, Alexander Sparkuhl, Thomas Spears, Merle Sprague, Mark St. Lezin, Steven J. Stafford, B. Dino Stea, Gary Steinberg, Patricia Steinecker, Mary Stewart, Jerry Stirman, Lewis Stocks, Christopher Stokoe, Warren Streisand, Mark Sturdivant, Paul Sugar, Steven Sukh, Perry Sutaria, Linda Sutton, Phillip Sutton, John Sylvester, Beth Szuck, Darrell Tackett, Ernesto Tan, Sharon Taylor, John Taylor, Dina Tebcherany, Chris Teigland, Marcos Tepper, Haluk Tezcan, William Thoms, Ellis Tinsley, Jr., Lisa Tolnitch, Angel Torano, Frank Tortora, William Truscott, Theodore Tsangaris, Peter Tucker, Walter Tucker, Ingolf Tuerk, Wade Turlington, Richard Tushman, Michael Tyner, Pascal Udekwu, Eric Uhlman, Linda Vahdat, Louis Vandermolen, George Vassar, Margaret Vereb, Johannes Vieweg, Daniel Vig, Tom Vo, Walter Vogel, David Wahl, B. Alan Wallstedt, Patrick Walsh, Philip Walther, Robert Waterhouse, Charles Wehbie, Seth Weinreb, Marissa Weiss, Raul Weiss, Geoffrey White, Edward Whitesides, Lee Wilke, Hamilton Williams, Matthew Wilner, Don Wilson, James S. Wilson, Bristol Winslow, Rachel Wissner, James Wolf, Lawrence Womack, Charles Woodhouse, Clifford Yaffe, Daniel Yao, Richard Yelverton, Lemuel Yerby, Mark Yoffe, Martin York, Gregory Zagaja, Kenneth Zeitler, Elizabeth Zubek, and Raul Zunzunegui). Most of all, we are indebted to the many cancer survivors who helped us pilot test, re-test, and then formally test the intervention.
Catherine E. Mosher, Memorial Sloan-Kettering Cancer Center.
Isaac M. Lipkus, Duke University Medical Center.
Richard Sloane, Duke University Medical Center.
William E. Kraus, Duke University Medical Center.
Denise Clutter Snyder, Duke University Medical Center.
Bercedis Peterson, Duke University Medical Center.
Lee W. Jones, Duke University Medical Center.
Wendy Demark-Wahnefried, Duke University Medical Center.