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Improving diet and exercise can reduce survivors' risk of cancer-related fatigue, poor physical functioning, and potentially recurrence. A cancer diagnosis can represent a “teachable moment,” leading survivors to make positive changes in diet and exercise behaviors; however, little is known about how often this occurs or about factors that enhance or limit survivors' ability to make these changes. This cross-sectional descriptive study investigated both the prevalence and clustering of self-reported changes in diet and exercise and how these changes related to ongoing cancer-related symptoms, social support, and stressful life events among long-term breast cancer survivors.
Survivors (n=227, response rate=72%) of a prior Cancer and Leukemia Group B treatment trial, on average 12 years post-diagnosis, completed a mailed survey assessing health behavior changes since diagnosis and current symptoms, social support, and stressful life events.
Over half of survivors reported making positive exercise or diet changes since diagnosis: over 25% reported making exercise and diet changes. ANCOVA models showed that survivors who reported increasing their exercise also reported lower fatigue. Trends were also found between increased fruit and vegetable intake and decreased fatigue and between increased exercise and increased social support.
These results underscore the need for health promotion efforts among survivors. Exercise promotion is especially needed since more survivors attempted to change dietary behaviors than exercise on their own. Further, fatigue may limit survivors' ability to change their health behaviors; alternatively, survivors who increase their exercise may experience less fatigue.
Over 2.3 million breast cancer survivors in the United States live with increased risk for recurrence and second cancers, as well as cardiovascular disease, and many potentially debilitating symptoms including fatigue, decreased physical functioning, and decreased health-related quality of life (HRQOL)(Committee on Cancer Survivorship: Improving Care and Quality of Life, 2006). Thus it is imperative to identify strategies for reducing the risk of these problematic long-term effects of cancer and treatment.
Improving the diet and exercise behaviors of cancer survivors is one promising strategy. Recent reviews of the literature in survivors have shown that lifestyle changes have the potential to improve fatigue, physical functioning, and HRQOL (Jones & Demark-Wahnefried, 2006; McNeely et al., 2006; McTiernan, 2004; Schmitz et al., 2005) and decrease risk of recurrence (M. D. Holmes, Chen, Feskanich, Kroenke, & Colditz, 2005; Jones & Demark-Wahnefried, 2006; Meyerhardt et al., 2006).
A cancer diagnosis can represent a “teachable moment,” leading survivors to make positive changes in diet and exercise behaviors (Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005); however, reports differ on the number of survivors who make these changes (Demark-Wahnefried, Pinto, & Gritz, 2006; Pinto & Trunzo, 2005). It is not clear how these changes cluster together; e.g., if survivors attempt to change “everything” or focus on a specific behavior to change, or if positive or negative changes in health behaviors relate to ongoing cancer-related symptoms, stress, or social support. Healthy behaviors may improve symptoms and stress; however, problematic levels of symptoms, stressful life events, and poor social support may limit the opportunity to make positive exercise and dietary changes.
Little is known about these issues especially among long-term cancer survivors; thus, this study sought to investigate (1) the prevalence and clustering of self-reported changes in diet and exercise; and (2) how changes in these behaviors may relate to ongoing cancer-related symptoms, social support, and stressful life events among long-term breast cancer survivors.
Participants were recruited into the current study (Cancer and Leukemia Group B (CALGB) 79804) from among the 1,572 breast cancer survivors who had participated in a chemotherapy treatment trial (CALGB 8541(Wood et al., 1994)) from 1985-1991. At study start, 314 women were alive and disease-free and had approval from their physician to participate; 245 (78%) returned the surveys. Participants did not differ from CALGB 8541 survivors who did not participate except that more whites versus non-whites chose to participate (p<0.0001). Of the 245 participants who completed surveys, 227 participants (93%) provided data on changes in health behaviors and were included in the analyses presented here.
CALGB 79804 was approved by the Institutional Review Board of each participating institution. Patient registration and data collection were managed by the CALGB Statistical Center. The patient's address, phone number, and disease status (alive and disease-free) were confirmed and the study treating physician was contacted for permission to approach the patient. A consent form and questionnaire were mailed to each eligible participant, with a postage-paid return envelope. Non-respondents were contacted by phone, and, if necessary, the survey was conducted by phone (n=8).
Health Behaviors were assessed by asking participants “Since your breast cancer diagnosis, have you done any of the following?” Follow-up questions then asked survivors to report increases or decreases in their “exercise habits” and dietary intake (fat, fiber, fruits and vegetables). Each was dichotomized indicating change in the direction of better health (e.g., higher exercise, lower fat) vs. no change or change not reflecting better health.
Fatigue was measured with the vitality subscale of the Medical Outcomes Study SF-36 health status measure (Ware J.E. Jr., 1996). Since the vitality subscale is coded 0-100 with increasing scores indicating greater vitality, the direction of fatigue is coded as the reverse: lower scores represent greater fatigue. Depression symptoms during the past week were measured with the CES-D 20-item short form total score(Radloff, 1977), with higher scores indicating worse depression symptomology. Fear of Recurrence was assessed with a modified form of the Breast Cancer Anxiety and Screening Behavior Scale, a 21-item reliable and valid scale that assessed the intrusive and avoidant thoughts related to breast cancer (Kash, 1995). We used 14 of the items relevant to breast cancer survivors, omitting 7 items relevant only to high-risk women or to breast cancer screening. Higher scores indicated more frequent symptoms. Satisfaction with Sexual Functioning was assessed with the Sexual Satisfaction scale of the Watts Sexual Functioning Questionnaire (Watts, 1982) where higher scores indicated worse sexual satisfaction. Body Satisfaction was assessed with the summed 10-item Self-Concept Scale, which assessed the participants' satisfaction with different body areas and their weight (Polivy, 1977) where higher scores indicated greater body satisfaction.
Social Support was measured with the 20-item MOS Social Support Survey (Sherbourne & Stewart, 1991) total score where higher scores indicated greater perceived social support.
Stressful life events were assessed with the 11-item Life Events Scale (Wilcox et al., 2003), adapted from the Social Readjustment Rating Scale (T. H. Holmes & Rahe, 1967) to measure the occurrence of a variety of potentially stressful life events, as well as the perceived emotional impact of the event. Higher scores on this scale represented a worse burden of stressful life events.
Demographic and Clinical Variables were obtained from the CALGB 8541 database, including demographics; date of study entry into CALGB 8541 and original treatment arm; menopausal status; performance status (Karnofsky); number of positive nodes at diagnosis; and tumor size, histological grade, and estrogen receptor status. Table 1 shows the demographic and clinical characteristics of the 227 participants included in these analyses.
For this exploratory analysis, descriptive statistics were used to describe participants' characteristics, overall health behavior changes, and the numbers of survivors who changed specific groups of health behaviors. ANCOVA models adjusting for age, race, education, menopausal status, relationship status, surgery type, radiation therapy, CALGB 8541 treatment arm, and time since diagnosis were used to generate adjusted means on cancer-related symptoms, social support, and stress variables by each dichotomous health behavior change variable. Statistical analyses were performed by statisticians at the CALGB Statistical Center (JEH, JMD, & KD).
Overall, 58% of these long-term breast cancer survivors reported making positive changes in exercise and/or dietary intake since their diagnosis. Nearly 32% of the survivors reported increasing their exercise, 44% reported decreasing their fat intake, 42% reported increasing their fiber intake, and 43% reported increasing their consumption of fruits and vegetables. Approximately 5% of survivors reported increasing their exercise without making dietary changes and 26.5% of survivors reported making at least one positive dietary change without changing their exercise behavior. Some participants reported making multiple behavior changes: 26.5% reported making positive changes in their exercise and at least one diet behavior, with 18.5% reporting making positive changes in exercise and all three dietary behaviors.
Table 2 presents the adjusted mean cancer-related symptom scores for survivors who did vs. did not positively change their exercise or dietary intake. Survivors who reported increasing their exercise since diagnosis with breast cancer reported less fatigue (e.g., greater vitality scores) compared to those women who reported decreasing or maintaining their pre-diagnosis exercise level (65.2 vs. 58.7, respectively; p = .03). There was a similar trend toward less fatigue among women who reported increasing their fruit and vegetable intake, compared to women who reported decreasing or maintaining their pre-diagnosis dietary patterns (62.9 vs. 58.0, respectively; p = .08). There were no other differences in symptoms.
Table 2 also presents the adjusted mean social support and stressful life events scores for survivors who did vs. did not positively change their exercise or dietary intake. There was a trend for survivors who reported increasing their exercise after breast cancer diagnosis to report greater social support than survivors who reported decreasing or maintaining their pre-diagnosis level (78.9 vs. 73.1, respectively; p = .06). There were no differences in social support between survivors who did and did not change their dietary intake. Stressful life events scores did not differ by any exercise or diet change group.
More survivors treated with the intensive-dose chemotherapy regimen in the original treatment trial (CALGB 8541) reported an increase in their exercise behavior compared to those treated with the low-dose chemotherapy regimen (p=.05; data not shown). There were no other differences in health behavior changes by original CALGB treatment arm.
This study sought to determine the prevalence and clustering of self-reported diet and exercise changes in long-term breast cancer survivors. Over half of long-term survivors in this study reported making positive exercise or diet changes since diagnosis. While encouraging, there is still a definite need for health promotion efforts. These results underscore the need for targeting diet and exercise among survivors to improve cancer-related symptoms and HRQOL, and reduce the risk for breast cancer recurrence, second cancers, mortality, and comorbid conditions.
Health promotion efforts should capitalize on a cancer diagnosis as a “teachable moment” to change health behaviors (Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005). Some survivors are interested in changing both exercise and diet, since over 25% of survivors in this study attempted to make both of these changes on their own. However, survivors may need more assistance changing their exercise behaviors, since this study found that they were less likely to try this on their own.
A second purpose of this study was to evaluate how positive or negative changes in exercise and diet behaviors may relate to ongoing cancer-related symptoms, social support, and stressful life events. In this study, women who reported increasing their exercise behavior also reported lower fatigue. Given the cross-sectional relationship, it is not clear whether survivors who increased their exercise experienced decreased fatigue, as is commonly found in intervention studies, (e.g.(McNeely et al., 2006)), or whether survivors with significant fatigue found it impossible to increase their exercise. Additional evidence for the latter comes from the similar trend found in the current study between decreased fatigue among survivors who increased their fruit and vegetable intake. This may indicate a subgroup of fatigued women in need of assistance implementing health behavior changes in a well-paced manner so that they do not exacerbate their fatigue by trying to change too much too fast.
In contrast to the fatigue results, there were no associations between changing diet behaviors and other cancer-symptoms. This study found a trend toward a relationship between increased social support and increasing exercise. While it may be that exercise improves social support through socializing while exercising, it is more likely that social support for exercise and managing life demands makes it more likely that women can make positive changes in exercise. It is likely that women need support through the process of making these changes, and help with problem-solving ways to meet the demands of their lives while successfully changing their exercise and diet behaviors.
No association was found between stressful life events and health behavior changes. The low mean score on the stressful life events scale found in this study means that on average, participants experienced one very stressful event in the past year. It may be that a relationship between stressful life events and changing health behaviors would have been detected with a wider variation in stressful life event scores.
Weaknesses of this study include its cross-sectional design, small predominately white, married sample, self-reported diet and exercise changes using a non-validated scale, and lack of information on weight which may affect behavior change. Also not known are the initial (pre-cancer) levels of participants' health behaviors or whether they changed their exercise and diet by a clinically meaningful amount. Future studies should investigate these relationships using a prospective design with objective measurements of behavior change. Despite these weaknesses, these results have important implications for future intervention studies, given the paucity of research conducted with long-term survivors. Such interventions have the potential to make a substantial public health impact for the over 2.3 million breast cancer survivors in the US through improvements in both the quality and the quantity of life.
The research for CALGB 79804 was supported, in part, by grants from the National Cancer Institute (CA31946) to the Cancer and Leukemia Group B (Richard L. Schilsky, MD, Chairman) and to the CALGB Statistical Center (Stephen George, PhD, CA33601). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute. In addition this study was funded by the National Institutes of Health Grants: AG16602, CA79883, and CA57707.
CALGB Statistical Office, Durham, NC — Stephen George, Ph.D.; supported by CA33601
Christiana Care Health Services, Inc. CCOP, Wilmington, DE–Irving M. Berkowitz, D.O.; supported by CA45418
Dana Farber Cancer Institute, Boston, MA–George P Canellos, M.D.; supported by CA32291
Dartmouth Medical School - Norris Cotton Cancer Center, Lebanon, NH–Marc S. Ernstoff, M.D.; supported by CA04326
Duke University Medical Center, Durham, NC–Jeffrey Crawford, M.D.; supported by CA47577
Massachusetts General Hospital, Boston, MA–Michael L. Grossbard, M.D.; supported by CA12449
Mount Sinai School of Medicine, New York, NY–Lewis R. Silverman, M.D.; supported by CA04457
North Shore - Long Island Jewish Medical Center, Manhasset, NY, Daniel R Budman, M.D., supported by CA35279
Rhode Island Hospital, Providence, RI–Louis A. Leone, M.D.; supported by CA08025
Roswell Park Cancer Institute, Buffalo, NY–Ellis Levine, M.D.; supported by CA02599
Southeast Cancer Control Consortium Inc. CCOP, Goldsboro, NC–James N. Atkins, M.D.; supported by CA45808
Southern Nevada Cancer Research Foundation CCOP, Las Vegas, NV–John Ellerton, M.D.; supported by CA35421
SUNY Upstate Medical University, Syracuse, NY–Stephen L. Graziano, M.D.; supported by CA21060
Syracuse Hematology-Oncology Assoc. CCOP, Syracuse, NY, Jeffrey Kirshner, M.D., supported by CA45389
University of California at San Diego, San Diego, CA–Stephen L Seagren, M.D.; supported by CA11789
University of Chicago Medical Center, Chicago, IL–Gini Fleming, M.D.; supported by CA41287
University of Maryland Cancer Center, Baltimore, MD–David Van Echo, M.D.; supported by CA31983
University of Massachusetts Medical Center, Worcester, MA, Mary Ellen Taplin, M.D., supported by CA37135
University of Minnesota, Minneapolis, MN–Bruce A Peterson, M.D.; supported by CA16450
University of Missouri/Ellis Fischel Cancer Center, Columbia, MO–Michael C Perry, M.D.; supported by CA12046
University of North Carolina at Chapel Hill, Chapel Hill, NC–Thomas C. Shea, M.D.; supported by CA47559
Wake Forest University School of Medicine, Winston-Salem, NC–David D Hurd, M.D.; supported by CA03927
Walter Reed Army Medical Center, Washington, DC–Joseph J. Drabeck, M.D.; supported by CA26806
Washington University School of Medicine, St. Louis, MO, Nancy Bartlett, MD, supported by CA77440
The authors report no conflicts of interest pertaining to this manuscript.
Some of these results were presented at the Cancer Survivorship: Embracing the Future conference held in Washington, DC, October, 2006.