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1.  Cognitive Complaints in Survivors of Breast Cancer After Chemotherapy Compared With Age-Matched Controls: An Analysis From a Nationwide, Multicenter, Prospective Longitudinal Study 
Journal of Clinical Oncology  2016;35(5):506-514.
Purpose
Cancer-related cognitive impairment is an important problem for patients with breast cancer, yet its trajectory is not fully understood. Some previous cancer-related cognitive impairment research is limited by heterogeneous populations, small samples, lack of prechemotherapy and longitudinal assessments, use of normative data, and lack of generalizability. We addressed these limitations in a large prospective, longitudinal, nationwide study.
Patients and Methods
Patients with breast cancer from community oncology clinics and age-matched noncancer controls completed the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) at prechemotherapy and postchemotherapy and at a 6-month follow-up as an a priori exploratory aim. Longitudinal models compared FACT-Cog scores between patients and controls at the three assessments and adjusted for age, education, race, menopausal status, and baseline reading ability, anxiety, and depressive symptoms. A minimal clinically important difference cutoff determined percentages of impairment over time.
Results
Of patients, 581 patients with breast cancer (mean age, 53 years; 48% anthracycline-based regimens) and 364 controls (mean age, 53 years) were assessed. Patients reported significantly greater cognitive difficulties on the FACT-Cog total score and four subscales from prechemotherapy to postchemotherapy compared with controls as well as from prechemotherapy to 6-month follow-up (all P < .001). Increased baseline anxiety, depression, and decreased cognitive reserve were significantly associated with lower FACT-Cog total scores. Treatment regimen, hormone, or radiation therapy was not significantly associated with FACT-Cog total scores in patients from postchemotherapy to 6-month follow-up. Patients were more likely to report a clinically significant decline in self-reported cognitive function than were controls from prechemotherapy to postchemotherapy (45.2% v 10.4%) and from prechemotherapy to 6-month follow-up (36.5% v 13.6%).
Conclusion
Patients with breast cancer who were treated in community oncology clinics report substantially more cognitive difficulties up to 6 months after treatment with chemotherapy than do age-matched noncancer controls.
doi:10.1200/JCO.2016.68.5826
PMCID: PMC5455314  PMID: 28029304
2.  Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue A Meta-analysis 
JAMA oncology  2017;3(7):961-968.
IMPORTANCE
Cancer-related fatigue (CRF) remains one of the most prevalent and troublesome adverse events experienced by patients with cancer during and after therapy.
OBJECTIVE
To perform a meta-analysis to establish and compare the mean weighted effect sizes (WESs) of the 4 most commonly recommended treatments for CRF—exercise, psychological, combined exercise and psychological, and pharmaceutical—and to identify independent variables associated with treatment effectiveness.
DATA SOURCES
PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Library were searched from the inception of each database to May 31, 2016.
STUDY SELECTION
Randomized clinical trials in adults with cancer were selected. Inclusion criteria consisted of CRF severity as an outcome and testing of exercise, psychological, exercise plus psychological, or pharmaceutical interventions.
DATA EXTRACTION AND SYNTHESIS
Studies were independently reviewed by 12 raters in 3 groups using a systematic and blinded process for reconciling disagreement. Effect sizes (Cohen d) were calculated and inversely weighted by SE.
MAIN OUTCOMES AND MEASURES
Severity of CRF was the primary outcome. Study quality was assessed using a modified 12-item version of the Physiotherapy Evidence-Based Database scale (range, 0–12, with 12 indicating best quality).
RESULTS
From 17 033 references, 113 unique studies articles (11525 unique participants; 78% female; mean age, 54 [range, 35–72] years) published from January 1, 1999, through May 31, 2016, had sufficient data. Studies were of good quality (mean Physiotherapy Evidence-Based Database scale score, 8.2; range, 5–12) with no evidence of publication bias. Exercise (WES, 0.30; 95% CI, 0.25–0.36; P < .001), psychological (WES, 0.27; 95% CI, 0.21–0.33; P < .001), and exercise plus psychological interventions (WES, 0.26; 95% CI, 0.13–0.38; P < .001) improved CRF during and after primary treatment, whereas pharmaceutical interventions did not (WES, 0.09; 95% CI, 0.00–0.19; P = .05). Results also suggest that CRF treatment effectiveness was associated with cancer stage, baseline treatment status, experimental treatment format, experimental treatment delivery mode, psychological mode, type of control condition, use of intention-to-treat analysis, and fatigue measures (WES range, −0.91 to 0.99). Results suggest that the effectiveness of behavioral interventions, specifically exercise and psychological interventions, is not attributable to time, attention, and education, and specific intervention modes may be more effective for treating CRF at different points in the cancer treatment trajectory (WES range, 0.09–0.22).
CONCLUSIONS AND RELEVANCE
Exercise and psychological interventions are effective for reducing CRF during and after cancer treatment, and they are significantly better than the available pharmaceutical options. Clinicians should prescribe exercise or psychological interventions as first-line treatments for CRF.
doi:10.1001/jamaoncol.2016.6914
PMCID: PMC5557289  PMID: 28253393
3.  Exercise Recommendations for the Management of Symptoms Clusters Resulting from Cancer and Cancer Treatments 
Seminars in oncology nursing  2016;32(4):383-393.
Objective
To review existing exercise guidelines for cancer patients and survivors for the management of symptom clusters.
Data source
Review of Pubmed literature and published exercise guidelines.
Conclusion
Cancer and its treatments are responsible for a copious number of incapacitating symptoms that markedly impair quality of life (QOL). The exercise oncology literature provides consistent support for the safety and efficacy of exercise interventions in managing cancer- and treatment-related symptoms as well as improving quality of life in cancer patients and survivors.
Implications for Nursing Practice
Effective management of symptoms enhances recovery, resumption of normal life activities and QOL for patients and survivors. Exercise is a safe, appropriate and effective therapeutic option before, during, and after the completion of treatment for alleviating symptoms and symptom clusters.
doi:10.1016/j.soncn.2016.09.002
PMCID: PMC5512003  PMID: 27776835
Exercise; Physical Activity; Cancer; Symptoms; Quality of Life; Yoga; Tai Chi; Aerobic Exercise; Resistance Exercise; Cancer-Related Fatigue; Fatigue; Cognition; Distress; Sarcopenia; Cachexia; Bone Loss
4.  Racial differences in information needs during and after cancer treatment: A nationwide, longitudinal survey by the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program 
Purpose
Before treatment, cancer patients need information about side effects and prognosis, while after treatment they need information to transition to survivorship. Research documenting these needs is limited, especially among racial and ethnic minorities. This study evaluated cancer patients’ needs according to race both before and after treatment.
Methods
We compared white (n=904) to black (n=52) patients receiving treatment at 17 National Cancer Institute Community Oncology Research Program (NCORP) sites on their cancer-related concerns and need for information before and after cancer treatment. Two-sample t-test and chi-squared analyses were used to assess group differences.
Results
Compared to white patients, black patients reported significantly higher concerns about diet (44.3% vs. 25.4 %,) and exercise (40.4% vs. 19.7 %,) during the course of treatment. Compared to whites, blacks also had significantly higher concern about treatment-related issues (white vs. black mean: 25.52 vs. 31.78), self-image issues (7.03 vs. 8.60), family-related issues (10.44 vs. 12.84), and financial concerns (6.42 vs 8.90, all p<0.05). Blacks, compared to whites, also had significantly greater post-treatment information needs regarding follow-up tests (8.17 vs 9.44), stress management (4.12 vs. 4.89), and handling stigma after cancer treatment (4.21 vs 4.89). [all p < 0.05].
Conclusion
Pre-treatment concerns and post-treatment information needs differed by race, with black patients reporting greater information needs and concerns. In clinical practice, tailored approaches may work particularly well in addressing the needs and concerns of black patients.
doi:10.1007/s13187-016-1038-x
PMCID: PMC5074918  PMID: 27097806
Race; cancer survivors; information needs; black and white patients
5.  Multicenter, Randomized Controlled Trial of Yoga for Sleep Quality Among Cancer Survivors 
Journal of Clinical Oncology  2013;31(26):3233-3241.
Purpose
Thirty percent to 90% of cancer survivors report impaired sleep quality post-treatment, which can be severe enough to increase morbidity and mortality. Lifestyle interventions, such as exercise, are recommended in conjunction with drugs and cognitive behavioral therapy for the treatment of impaired sleep. Preliminary evidence indicates that yoga—a mind-body practice and form of exercise—may improve sleep among cancer survivors. The primary aim of this randomized, controlled clinical trial was to determine the efficacy of a standardized yoga intervention compared with standard care for improving global sleep quality (primary outcome) among post-treatment cancer survivors.
Patients and Methods
In all, 410 survivors suffering from moderate or greater sleep disruption between 2 and 24 months after surgery, chemotherapy, and/or radiation therapy were randomly assigned to standard care or standard care plus the 4-week yoga intervention. The yoga intervention used the Yoga for Cancer Survivors (YOCAS) program consisting of pranayama (breathing exercises), 16 Gentle Hatha and Restorative yoga asanas (postures), and meditation. Participants attended two 75-minute sessions per week. Sleep quality was assessed by using the Pittsburgh Sleep Quality Index and actigraphy pre- and postintervention.
Results
In all, 410 survivors were accrued (96% female; mean age, 54 years; 75% had breast cancer). Yoga participants demonstrated greater improvements in global sleep quality and, secondarily, subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and medication use at postintervention (all P ≤ .05) compared with standard care participants.
Conclusion
Yoga, specifically the YOCAS program, is a useful treatment for improving sleep quality and reducing sleep medication use among cancer survivors.
doi:10.1200/JCO.2012.43.7707
PMCID: PMC3757292  PMID: 23940231
6.  Modafinil Moderates the Relationship between Cancer-Related Fatigue and Depression in 541 Patients Receiving Chemotherapy 
Objective
To examine the effect of modafinil on depression via a secondary data analysis of a RCT of modafinil for fatigue in cancer patients. The primary aim is to elucidate factors that contributed to the effectiveness of modafinil in the parent trial.
Methods
541 cancer patients receiving chemotherapy and experiencing fatigue (Brief Fatigue Inventory (BFI) Item 3≥3) were randomized to receive 200mg modafinil (N=260) or placebo (N=281) daily from baseline (Cycle 2) to post-test (Cycle 4). Patients completed the Center for Epidemiologic Studies Depression Scale (CES-D) and POMS Depression-Dejection subscale (POMS-DD) at baseline and post-test. We used linear regression to address the hypothesis that modafinil would be associated with reduced depression, particularly in those experiencing severe fatigue (BFI≥7).
Results
Modafinil did not have a significant effect on depression, even for those patients with severe fatigue. However, for subjects with severe fatigue (BFI ≥ 7), those receiving modafinil had lower depression scores than controls. Modafinil significantly moderated the relationship between baseline fatigue and CES-D total scores (p = 0.04), and was marginally significant as a moderator for the relationship between baseline fatigue and POMS-DD scores (p = 0.07). Modafinil also significantly moderated the relationship between baseline fatigue and CES-D Positive Affect subscale scores (p = 0.003), but not CES-D Somatic, Negative Affect, or Interpersonal subscale scores.
Conclusion
Modafinil differentially impacts depression based on a patient’s level of fatigue, and reduced depressive symptoms only in those with extreme fatigue. This effect may be driven by increases in positive affective symptoms. These results have significant implications for intervention; in patients with high levels of fatigue, modafinil might also reduce depression. Future RCTs are needed to confirm these results.
doi:10.1097/JCP.0000000000000442
PMCID: PMC4689625  PMID: 26658264
cancer; depression; cancer-related fatigue; modafinil; psychostimulant
7.  Exercise and Cancer-related Fatigue 
US oncology  2009;5(2):20-23.
Cancer-related fatigue is the most common side effect reported by cancer patients during and after treatment. Cancer-related fatigue significantly interferes with a patient’s ability to perform activities of daily living and maintain functional independence and quality of life. Cancer-related fatigue can also interfere with a patient’s ability to complete treatments. The purpose of this article is to provide an overview of cancer-related fatigue, its pathopsychophysiology, and the role of exercise in the management of this side effect.
PMCID: PMC3156559  PMID: 21853012
Cancer; fatigue; exercise; symptoms
8.  Yoga for the Treatment of Insomnia among Cancer Patients: Evidence, Mechanisms of Action, and Clinical Recommendations 
Oncology & hematology review  2014;10(2):164-168.
Up to 90% of cancer patients report symptoms of insomnia during and after treatment. Symptoms of insomnia include excessive daytime sleepiness, difficulty falling asleep, difficulty staying asleep, and waking up too early. Insomnia symptoms are among the most prevalent, distressing and persistent cancer- and cancer treatment-related toxicities reported by patients, and can be severe enough to increase cancer morbidity and mortality. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed, and under-treated in cancer patients. When insomnia symptoms are identified, providers are hesitant to prescribe, and patients are hesitant to take pharmaceuticals due to polypharmacy concerns. In addition, sleep medications do not cure insomnia. Yoga is a well-tolerated mode of exercise with promising evidence for its efficacy in improving insomnia symptoms among cancer patients. This article reviews existing clinical research on the effectiveness of yoga for treating insomnia among cancer patients. The article also provides clinical recommendations for prescribing yoga for the treatment of insomnia in this population.
PMCID: PMC4386006  PMID: 25861453
Yoga; sleep; insomnia; cancer; exercise
9.  YOCAS©® Yoga Reduces Self-Reported Memory Difficulty in Cancer Survivors in a Nationwide Randomized Clinical Trial: Investigating Relationships between Memory and Sleep 
Integrative cancer therapies  2015;15(3):263-271.
Background
Interventions are needed to alleviate memory difficulty in cancer survivors. We previously showed in a Phase III randomized clinical trial (RCT) that YOCAS©® yoga—a program of breathing, gentle Hatha and Restorative postures, and meditation—significantly improved global sleep quality in cancer survivors. This current analysis assessed the effects of YOCAS©® on memory and identified moderating and mediating effects of memory on YOCAS©® improvements in sleep and vice versa. We hypothesized that yoga would reduce memory difficulty in cancer survivors.
Study Design and Methods
In this Phase III RCT, survivors post adjuvant therapy and not participating in yoga were randomized to standard care (SC) or SC with YOCAS©®. The YOCAS©® program consists of pranayama (breathing exercises), 16 Gentle Hatha and Restorative yoga asanas (postures), and meditation (two 75-minute sessions per week over 4 weeks). 328 participants who provided pre- and post-intervention data on the main outcome of the current analysis, memory difficulty (MD Anderson Symptom Inventory), were included. Sleep quality was measured using the Pittsburgh Sleep Quality Index. General linear modeling (GLM) determined the group effect of YOCAS©® on memory difficulty compared to SC. GLM also determined moderation of baseline memory difficulty on post-intervention sleep and vice versa. Path Modeling assessed the mediating effects of changes in memory difficulty on YOCAS©® changes in sleep and vice versa.
Results
YOCAS©® significantly reduced memory difficulty at post-intervention compared to SC (mean change: Yoga=−0.60, SC =−0.16, p<0.05). Baseline memory difficulty did not moderate the effects of post-intervention sleep quality in YOCAS©® compared to SC. Higher baseline sleep quality did moderate the effects of post-intervention memory difficulty in YOCAS©® compared to SC with SC having worse memory difficulty (p<0.05). Changes in sleep quality was a significant partial mediator of reduced memory difficulty in YOCAS©® compared to SC (p<0.05); however, changes in memory difficulty did not significantly mediate improved sleep quality in YOCAS©® compared to SC.
Conclusions
In this large nationwide trial, YOCAS©® yoga significantly reduces patient-reported memory difficulty in cancer survivors. Trials designed to assess the impact of YOCAS©® on multiple cognitive domains in cancer survivors are needed with assessment of moderating and mediating factors.
doi:10.1177/1534735415617021
PMCID: PMC4884662  PMID: 26621521
memory difficulty; cancer-related cognitive impairment; yoga; “chemobrain”; quality of life; cancer survivor
10.  Designing exercise clinical trials for older adults with cancer: Recommendations from 2015 Cancer and Aging Research Group NCI U13 Meeting 
Journal of geriatric oncology  2016;7(4):293-304.
Cancer and its treatment can lead to a myriad of adverse events and negatively impact quality of life of older cancer patients and survivors. Unmet physical activity needs vary across the cancer continuum and remain an important yet understudied area of research in this population. Exercise interventions have been shown to be effective in treating both the physical and psychological declines associated with cancer and its treatment, with a potential to improve cancer-related outcomes. Despite the current evidence, exercise is clearly underutilized due to several barriers and knowledge gaps in existing trials that include appropriate population identification, design, and outcome measures selection. The benefits of regular exercise in both the primary and secondary prevention of chronic conditions are well established in the non-cancer population. In older cancer patients and survivors, further research is needed before exercise gains widespread acceptance. The Cancer and Aging Research Group convened experts in exercise, aging and cancer to evaluate current scientific evidence and knowledge gaps in geriatric exercise oncology. This report summarizes these findings and provides future research directions.
doi:10.1016/j.jgo.2016.04.007
PMCID: PMC4969104  PMID: 27197916
Exercise; Cancer; Older patients; Geriatric recommendations
11.  Tai Chi Chuan for Breast Cancer Survivors 
Medicine and sport science  2008;52:209-217.
Background/Aims
Treatment for breast cancer produces side effects that diminish functional capacity and quality of life (QOL) among survivors. Tai Chi Chuan (TCC) is a moderate form of exercise that may improve functional capacity and QOL in these individuals. Women who completed treatment for breast cancer were randomized to receive TCC or psychosocial support therapy for 12 weeks (60 min; three times weekly).
Results
The TCC group demonstrated significant improvements in functional capacity, including aerobic capacity, muscular strength, and flexibility, as well as QOL; the psychosocial support therapy group showed significant improvements only in flexibility, with declines in aerobic capacity, muscular strength, and QOL.
Conclusions
The TCC group exhibited significant improvements in functional capacity and QOL. These data suggest that TCC may enhance functional capacity and QOL among breast cancer survivors.
doi:10.1159/000134301
PMCID: PMC3927648  PMID: 18487900
12.  The effect of YOCAS©® yoga for musculoskeletal symptoms among breast cancer survivors on hormonal therapy 
Up to 50 % of breast cancer survivors on aromatase inhibitor therapy report musculoskeletal symptoms such as joint and muscle pain, significantly impacting treatment adherence and discontinuation rates. We conducted a secondary data analysis of a nationwide, multisite, phase II/III randomized, controlled, clinical trial examining the efficacy of yoga for improving musculoskeletal symptoms among breast cancer survivors currently receiving hormone therapy (aromatase inhibitors [AI] or tamoxifen [TAM]). Breast cancer survivors currently receiving AI (N = 95) or TAM (N = 72) with no participation in yoga during the previous 3 months were randomized into 2 arms: (1) standard care monitoring and (2) standard care plus the 4-week yoga intervention (2×/week; 75 min/session) and included in this analysis. The yoga intervention utilized the UR Yoga for Cancer Survivors (YOCAS©®) program consisting of breathing exercises, 18 gentle Hatha and restorative yoga postures, and meditation. Musculoskeletal symptoms were assessed pre- and post-intervention. At baseline, AI users reported higher levels of general pain, muscle aches, and total physical discomfort than TAM users (all P ≤ 0.05). Among all breast cancer survivors on hormonal therapy, participants in the yoga group demonstrated greater reductions in musculoskeletal symptoms such as general pain, muscle aches and total physical discomfort from pre-to post-intervention than the control group (all P ≤ 0.05). The severity of musculoskeletal symptoms was higher for AI users compared to TAM users. Among breast cancer survivors on hormone therapy, the brief community-based YOCAS©® intervention significantly reduced general pain, muscle aches, and physical discomfort.
doi:10.1007/s10549-015-3351-1
PMCID: PMC4467273  PMID: 25814054
Exercise; Yoga; Aromatase inhibitor-induced musculoskeletal symptoms; Arthralgias
13.  The Effect of Cigarette Smoking on Cancer Treatment–Related Side Effects 
The Oncologist  2011;16(12):1784-1792.
The study assessed the effect of smoking on total symptom burden, the sum of 12 common treatment-related side effects, in patients undergoing treatment for cancer using data from private medical oncology practices that were part of the National Cancer Institute's Community Clinical Oncology Program. Smokers had a higher total symptom burden than nonsmokers during cancer treatment, and this persisted at a follow-up 6 months after treatment.
Learning Objectives
After completing this course, the reader will be able to: Describe the influence of cigarette smoking on side effects during cancer treatment and following the end of cancer treatment.Identify areas in your practice in which smoking status can be assessed on a regular basis and devise a plan for disseminating cessation information and free cessation aids.
This article is available for continuing medical education credit at CME.TheOncologist.com
Background.
Cigarette smoking has long been implicated in cancer development and survival. However, few studies have investigated the impact of smoking on symptom burden in cancer survivors during treatment and at survivorship stage. This study examines the influence of cigarette smoking on side effects among 947 cancer patients during and 6 months following treatment.
Methods.
Patients diagnosed with cancer and scheduled to receive chemotherapy and/or radiation therapy reported on current smoking status (yes, no) and total symptom burden [the sum of 12 common symptoms (fatigue, hair loss, memory, nausea, depression, sleep, pain, concentration, hot flashes, weight loss, skin problems, and dyspnea) scored on an 11-point scale ranging from 0 = “not present” to 10 = “as bad as you can imagine”] during treatment and at 6-month follow-up. The adjusted mean total symptom burden by smoking status was determined by analysis of covariance controlling for age, gender, race, education, occupation, treatment, cancer site, and Karnofsky performance score.
Results.
During treatment, smokers (S) had a significantly higher total symptom burden than nonsmokers (NS) (S = 46.3 vs. NS = 41.2; p < 0.05). At 6-month follow-up, smokers continued to report a higher total symptom burden than nonsmokers (S = 27.7 vs. NS = 21.9; p < 0.05). Participants who quit smoking before treatment levels had a total symptom burden similar to nonsmokers.
Conclusion.
Smoking was associated with an increased symptom burden during and following treatments for cancer. Targeted cessation efforts for smokers to decrease symptom burden may limit the likelihood of treatment interruptions and increase quality of life following treatment.
doi:10.1634/theoncologist.2011-0169
PMCID: PMC3248778  PMID: 22135122
Cancer control; Smoking; Symptom management; Symptom burden
14.  Effects of Yoga on Cancer-Related Fatigue and Global Side-Effect Burden in Older Cancer Survivors 
Background
Sixty percent of cancer survivors are 65 years of age or older. Cancer and its treatments lead to cancer-related fatigue and many other side effects, in turn, creating substantial global side-effect burden (total burden from all side effects) which, ultimately, compromises functional independence and quality of life. Various modes of exercise, such as yoga, reduce cancer-related fatigue and global side-effect burden in younger cancer survivors, but no studies have specifically examined the effects of yoga on older cancer survivors.
Objectives
The purpose of this study was to assess the effects of a 4-week yoga intervention (Yoga for Cancer Survivors: YOCAS©®) on overall cancer-related fatigue, and due to its multidimensional nature, the subdomains of cancer-related fatigue (general, physical, emotional, and mental) and global side-effect burden in older cancer survivors.
Materials and Methods
We conducted a secondary analysis on data from a multicenter phase III randomized controlled clinical trial with 2 arms (standard care and standard care plus a 4-week YOCAS©® intervention). The sample for this secondary analysis was 97 older cancer survivors (≥ 60 years of age), between 2 months and 2 years post-treatment, who participated in the original trial.
Results
Participants in the YOCAS©® intervention arm reported significantly lower cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden than participants in the standard care arm following the 4-week intervention period (p<0.05).
Conclusions
YOCAS©® is an effective standardized yoga intervention for reducing cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden among older cancer survivors.
doi:10.1016/j.jgo.2014.09.184
PMCID: PMC4297736  PMID: 25449185
cancer-related fatigue; side-effects; cancer; yoga; exercise
15.  Cigarette Smoking Disparities among Sexual Minority Cancer Survivors 
Preventive medicine reports  2015;2:283-286.
Objective
Sexual minority (i.e., lesbian, gay, and bisexual) adults smoke cigarettes at higher rates than heterosexual adults. Smoking after receiving a cancer diagnosis is a major health concern, yet risk of continued smoking among sexual minority cancer survivors is as yet unknown. The current study examines current smoking among sexual minority vs. heterosexual adult cancer survivors.
Method
Data drawn from the 2010 Behavioral Risk Factor Surveillance System survey in five states (Alaska, California, Massachusetts, New Mexico, and Wisconsin) included items about sexual orientation, cancer diagnosis, and tobacco use. The analytic sample included 124 sexual minority and 248 propensity score matched heterosexual adult cancer survivors.
Results
Bivariate analysis showed that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts (OR=2.03, 95%CI:1.09–3.80). In exploratory analyses stratified by sex, sexual minority disparities in prevalence of smoking post-cancer showed a trend toward significance among females, not males.
Conclusion
The current study offers preliminary evidence that sexual minority status is one variable among many that must be taken into account when assessing health behaviors post-cancer diagnosis. Future research should identify mechanisms leading from sexual minority status to increased rates of smoking and develop tailored smoking cessation interventions.
doi:10.1016/j.pmedr.2015.04.004
PMCID: PMC4430723  PMID: 25984441
Smoking; Neoplasms; Sexuality; Homosexuality; Female; Homosexuality; Male; Minority Health
16.  Polarity Therapy for Cancer-Related Fatigue in Patients With Breast Cancer Receiving Radiation Therapy: A Randomized Controlled Pilot Study 
Integrative Cancer Therapies  2011;10(1):27-37.
Background
Cancer-related fatigue (CRF) is the most frequently reported side effect of cancer and its treatment. In previous research, Polarity Therapy (PT), an energy therapy, was shown to reduce CRF in patients receiving radiation. This study reports on a small randomized clinical trial designed to collect preliminary data on the efficacy of PT compared with an active control (massage) and passive control (standard care) for CRF among cancer patients receiving radiation therapy.
Methods
Forty-five women undergoing radiation therapy for breast cancer were randomized to I of 3 weekly treatment conditions. Patients received standard clinical care, 3 modified massages, or 3 PT treatments. CRF and healthrelated quality of life (HRQL) were assessed during baseline and the 3 intervention weeks.
Results
TResults show CRF ratings were reduced after PT. The effect sizes for PT versus modified massage and versus standard care were small when using the primary measure of CRF (Brief Fatigue Inventory) and large when using the secondary measure of CRF (Daily CRF Diaries).The effect size was medium when assessing the benefit of PT on maintaining HRQL compared with standard care with very little difference between the PT and modified massage conditions. Patients’ feedback showed that both the modified massage and PT treatments were deemed useful by radiation patients. Conclusion. The present pilot randomized clinical trial supports previous experimental research showing that PT, a noninvasive and gentle energy therapy, may be effective in controlling CRF. Further confirmatory studies as well as investigations of the possible mechanisms of PT are warranted.
doi:10.1177/1534735410397044
PMCID: PMC3085180  PMID: 21382958
cancer-related fatigue; radiation; Polarity Therapy; massage; quality of life; complementary and integrative medicine
17.  Disparities in psychological distress impacting lesbian, gay, bisexual and transgender cancer survivors 
Psycho-oncology  2015;24(11):1384-1391.
Objective
Recent studies have highlighted disparities in cancer diagnosis between lesbian, gay, bisexual and transgender (LGBT) and heterosexual adults. Studies have yet to examine disparities between LGBT and heterosexual cancer survivors in prevalence of psychological distress.
Methods
Data for the current study were drawn from the LIVESTRONG dataset, a US national survey that sampled 207 LGBT and 4899 heterosexual cancer survivors (all cancer types, 63.5% women, mean age 49) in 2010. Symptoms of psychological distress were assessed with dichotomous yes/no items in three symptom clusters (depression related to cancer, difficulties with social relationships post-cancer, fatigue/energy problems). We selected a sample of 621 heterosexual survivors matched by propensity score to the 207 LGBT survivors and assessed disparities in count of symptoms using Poisson regression. We also performed subgroup analyses by self-reported sex.
Results
Relative to heterosexuals, LGBT cancer survivors reported a higher number of depression and relationship difficulty symptoms. Exploratory analyses revealed that disparities in number of symptoms were visible between gay, bisexual, and transgender versus heterosexual men but not between lesbian, bisexual, and transgender versus heterosexual women.
Conclusions
This study highlights several disparities in psychological distress that exist between LGBT and heterosexual survivors. A need remains for interventions tailored to LGBT survivors and for studies examining disparities within subgroups of LGBT survivors.
doi:10.1002/pon.3746
PMCID: PMC4517981  PMID: 25630987
18.  A 4-Week Home-Based Aerobic and Resistance Exercise Program During Radiation Therapy: A Pilot Randomized Clinical Trial 
During radiation therapy, cancer patients may report cancer-related fatigue (CRF), which impairs aerobic capacity, strength, muscle mass, and, ultimately, quality of life (QOL). The purpose of this pilot clinical trial was to examine the feasibility and initial efficacy of a home-based aerobic and progressive resistance exercise intervention for aerobic capacity, strength, muscle mass, CRF, and QOL. Daily steps walked (DSW), daily minutes of resistance exercise (MRE), and number of resistance exercise days (RED) were assessed to evaluate intervention adherence. Breast and prostate cancer patients (n = 38) beginning radiation therapy were randomized to undergo 4 weeks of exercise or no exercise. Participants in the exercise group demonstrated good adherence to the exercise intervention, with significantly more DSW, MRE, and RED at post intervention and 3 month follow-up than controls. Participants in the exercise intervention exhibited significantly higher QOL and significantly lower CRF post intervention and at 3-month follow-up than controls. Results of this pilot study provide positive preliminary evidence that exercise during radiation may be beneficial for cancer patients.
PMCID: PMC3034389  PMID: 19831159
19.  Exercise for the Management of Side Effects and Quality of Life among Cancer Survivors 
Current sports medicine reports  2009;8(6):325-330.
Physical activity may play an important role in the rehabilitation of cancer survivors during and following treatment. Current research suggests numerous beneficial outcomes are experienced in cancer survivors undergoing exercise interventions during or following cancer treatment. Exercise not only plays a role in managing side effects but also improves functional capacity and quality of life. The purpose of this article is to provide an overview of the oncology literature supporting the use of exercise as an effective intervention for improving cancer-related fatigue, other side effects, functional capacity, and quality of life among cancer survivors.
doi:10.1249/JSR.0b013e3181c22324
PMCID: PMC2875185  PMID: 19904073
20.  Hot Flashes Severity, Complementary and Alternative Medicine Use, and Self-Rated Health in Women with Breast Cancer 
Explore (New York, N.Y.)  2014;10(4):241-247.
Context
Hot flashes (HF) are a common distressing symptom in women with breast cancer (BC). Current pharmacologic options are moderately effective and are associated with bothersome side effects. Complementary and alternative medicine is commonly used by cancer patients. However, information on the association of hot flashes severity with such use and self-rated health is lacking.
Objective
To examine the hot flashes severity in women with breast cancer and its association with complementary and alternative medicine use and self-rated health (SRH).
Design
Longitudinal multicenter study to assess information needs of cancer outpatients.
Participants
Patients with a diagnosis of breast cancer who were scheduled to undergo chemotherapy and/or radiotherapy.
Outcome Measures
Hot flashes severity (0 = not present and 10 = as bad as you can imagine), use of complementary and alternative medicine (yes/no), and self-rating of health (SRH) status post-treatment and six-months thereafter (1–5, higher score = better SRH).
Results
The majority of women with HF (mean age = 54.4 years) were Caucasian and married, with higher education, and 93% had received surgical treatment for BC. At the end of treatment, 79% women reported experiencing HF [mean severity = 5.87, standard deviation (SD) = 2.9]; significantly more severe HF were reported by younger women with poor SRH, better performance status, and those reporting doing spiritual practices. At follow-up, 73% had HF (mean severity = 4.86, SD = 3.0), and more severe HF were reported by younger women with poor self-rated health who had undergone chemotherapy plus radiotherapy, used vitamins, and did not exercise.
Conclusions
A high percentage of women experienced hot flashes at the end of treatment and at six-month follow-up. A significant association of hot flashes severity with spiritual practice, increased vitamin use, and reduced exercise emphasize the need for future studies to confirm the results. This can facilitate safe use of complementary and alternative medicine and favorable outcomes while managing cancer-related hot flashes.
doi:10.1016/j.explore.2014.04.003
PMCID: PMC4325272  PMID: 25037667
Breast cancer; hot flashes; complementary and alternative medicine; self-rated health
21.  Women's Perspectives of Personal Trainers: A Qualitative Study 
The sport journal  2011;14(1):0104.
Personal trainers play an integral role in the day-to-day operation of the facilities in which they work. Research has identified a number of qualities and competencies necessary to be an effective exercise leader, but there is little scholarly work addressing clients' attitudes related to the performance of personal trainers. Utilizing focus group methodology, female clients of personal trainers were recruited to provide viewpoints related to the desirable qualities of personal trainers, as well as opinions regarding trainer certification and academic preparation. Responses of the participants were transcribed, coded, and analyzed for themes. Four global themes emerged: Selection Rationale, Personal Trainer Rationale, Loyalty Rationale and Negative Characteristics. Selection Rationale consisted of qualities that influence a client's decision to hire a particular trainer (e.g., physique, results observed in other clients, social skills). Personal Trainer Rationale referred to the clients' reasons (e.g., frustration with current fitness level) for hiring a specific trainer. Loyalty Rationale referred to the credentials of a personal trainer that solidify the client/trainer relationship and Negative Characteristics referred to qualities considered unethical or unprofessional. The results suggest that undergraduate exercise science programs should devote additional time toward the development of future fitness trainers' affective qualities and that clients' would benefit from information about the credentials of personal trainers.
PMCID: PMC4439248  PMID: 26005398
qualifications; certifications; credentials; licensure; attitudes; dispositions
22.  Cigarette smoking disparities among sexual minority cancer survivors 
Preventive Medicine Reports  2015;2:283-286.
Objective
Sexual minority (i.e., lesbian, gay, and bisexual) adults smoke cigarettes at higher rates than heterosexual adults. Smoking after receiving a cancer diagnosis is a major health concern, yet risk of continued smoking among sexual minority cancer survivors is as yet unknown. The current study examines current smoking among sexual minority vs. heterosexual adult cancer survivors.
Method
Data drawn from the 2010 Behavioral Risk Factor Surveillance System survey in five states (Alaska, California, Massachusetts, New Mexico, and Wisconsin) included items about sexual orientation, cancer diagnosis, and tobacco use. The analytic sample included 124 sexual minority and 248 propensity score matched heterosexual adult cancer survivors.
Results
Bivariate analysis showed that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts (OR = 2.03, 95%CI:1.09–3.80). In exploratory analyses stratified by sex, sexual minority disparities in prevalence of smoking post-cancer showed a trend toward significance among females, not males.
Conclusion
The current study offers preliminary evidence that sexual minority status is one variable among many that must be taken into account when assessing health behaviors post-cancer diagnosis. Future research should identify mechanisms leading from sexual minority status to increased rates of smoking and develop tailored smoking cessation interventions.
Highlights
•We examine cigarette smoking in sexual minority vs. heterosexual cancer survivors in the BRFSS.•We use propensity score matching to control for confounding demographic variables.•Rates of continued smoking are higher in sexual minority survivors.•Analyses stratified by sex show disparities at a trend level among sexual minority females, not males.
doi:10.1016/j.pmedr.2015.04.004
PMCID: PMC4430723  PMID: 25984441
Smoking; Neoplasms; Sexuality; Homosexuality; Female; Homosexuality; Male; Minority health
23.  Bone Health Issues in Breast Cancer Survivors: A Medicare Current Beneficiary Survey (MCBS) Study 
Purpose
Breast cancer treatments (chemotherapy and hormone therapy) can cause a rapid loss in bone mineral density, leading to osteoporosis and fractures later in life. Fortunately, preventative measures (vitamin D, exercise, etc.) can delay bone loss if employed early enough. This study compares the prevalence of osteoporosis and osteoporosis-related discussions with physicians among female breast cancer survivors and females with no cancer history to determine if breast cancer patients are being correctly advised on their high risk of bone loss.
Methods
The 2003 Medicare Current Beneficiary Survey, a nationally representative sample of 550 women with a breast cancer history and 6,673 women with no cancer history aged ≥65, was used. The first set of dependent variables collected information on bone health (osteoporosis, falls, and fractures). The second set of dependent variables collected information on bone health discussions with their physician. Multivariate logistic regression models were used to evaluate whether breast cancer was independently associated with bone health issues.
Results
After adjustment for confounders, a breast cancer diagnosis was found to be associated with a higher prevalence of an osteoporosis diagnosis over their lifetime (adjusted odds ratio [ORadj] = 1.32, 95% confidence interval [95%CI]=1.08-1.61) and falls in the previous year (ORadj=1.23, 95%CI=1.01-1.51) compared to respondents without a cancer diagnosis. However, breast cancer respondents were not more likely than respondents without a cancer diagnosis to discuss osteoporosis with their physician (ORadj=1.20, 95%CI=0.96-1.50) or be told they are at high risk for osteoporosis (ORadj=1.41, 95%CI=0.95-2.10).
Conclusions
A breast cancer diagnosis was associated with an increased prevalence of osteoporosis and falls. Nevertheless, breast cancer respondents were not more likely to discuss osteoporosis with their physician nor were they more likely to be considered high risk for osteoporosis. Increased dialogue between physician and breast cancer patient pertaining to bone loss are needed.
doi:10.1007/s00520-013-1967-4
PMCID: PMC4049181  PMID: 24043289
24.  Yoga as Treatment for Insomnia Among Cancer Patients and Survivors: A Systematic Review 
Many cancer patients and survivors, between 15 to 90%, report some form of insomnia or sleep quality impairment during and post-treatment, such as excessive daytime napping, difficulty falling asleep, difficulty staying asleep, and waking up too early. Insomnia and sleep quality impairment are among the most prevalent and distressing problems reported by cancer patients and survivors, and can be severe enough to increase cancer mortality. Despite the ubiquity of insomnia and sleep quality impairment, they are under-diagnosed and under-treated in cancer patients and survivors. When sleep problems are present, providers and patients are often hesitant to prescribe or take pharmaceuticals for sleep problems due to poly pharmacy concerns, and cognitive behavioral therapy for insomnia can be very difficult and impractical for patients to adhere to throughout the cancer experience. Research suggests yoga is a well-tolerated exercise intervention with promising evidence for its efficacy in improving insomnia and sleep quality impairment among survivors. This article provides a systematic review of existing clinical research on the effectiveness of yoga for treating insomnia and sleep quality impairment among cancer patients and survivors.
PMCID: PMC4204627  PMID: 25343044
Yoga; sleep; insomnia; cancer; survivorship; exercise
25.  The Effect of Various Vitamin D Supplementation Regimens in Breast Cancer Patients 
Annals of surgical oncology  2012;19(8):2590-2599.
Purpose
Vitamin D deficiency in patients treated for breast cancer is associated with numerous adverse effects (bone loss, arthralgia, and falls). The first aim of this study was to assess vitamin D status, determined by 25-OH vitamin D levels, among women diagnosed with breast cancer according to demographic/clinical variables and bone mineral density (BMD). The second aim of this study was to evaluate the effect of daily low-dose and weekly high-dose vitamin D supplementation on 25-OH vitamin D levels.
Methods
This retrospective study included 224 women diagnosed with Stage 0-III breast cancer who received treatment at the James P. Wilmot Cancer Center at the University of Rochester Medical Center. Total 25-OH vitamin D levels (D2 + D3) were determined at baseline for all participants. Vitamin D deficiency was defined as a 25-OH vitamin D level < 20 ng/mL, insufficiency as 20-31 ng/mL, and sufficiency as ≥ 32 ng/mL. BMD was assessed during the period between 3 months prior to and 6 months following the baseline vitamin D assessment. Based on the participants’ baseline levels, they received either no supplementation, low-dose supplementation (1,000 IU/day), or high-dose supplementation (≥ 50,000 IU/week), and 25-OH vitamin D was reassessed in the following 8-16 weeks.
Results
Approx 66.5% had deficient/insufficient vitamin D levels at baseline. Deficiency/insufficiency was more common among non-Caucasians, women with later-stage disease, and those who had previously received radiation therapy (p<0.05). Breast cancer patients with deficient/insufficient 25-OH vitamin D levels had significantly lower lumbar BMD (p=0.03). Compared to the no supplementation group, weekly high-dose supplementation significantly increased 25-OH vitamin D levels, while daily low-dose supplementation did not significantly increase levels.
Conclusions
Vitamin D deficiency and insufficiency were common among women with breast cancer and associated with reduced BMD in the spine. Clinicians should carefully consider vitamin D supplementation regimens when treating vitamin D deficiency/insufficiency in breast cancer patients.
doi:10.1245/s10434-012-2297-3
PMCID: PMC4158737  PMID: 22446898

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