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author:("mustin, Karen")
1.  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
2.  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
3.  Recommendations for High-Priority Research on Cancer-Related Fatigue in Children and Adults 
Over the past decades, some scientific progress has been made in understanding and treating cancer-related fatigue (CRF). However, three major problems have limited further progress: lack of agreement about measurement, inadequate understanding of the underlying biology, and problems in the conduct of clinical trials for CRF. This commentary reports the recommendations of a National Cancer Institute Clinical Trials Planning Meeting and an ongoing National Cancer Institute working group to address these problems so that high-priority research and clinical trials can be conducted to advance the science of CRF and its treatment. Recommendations to address measurement issues included revising the current case definition to reflect more rigorous criteria, adopting the Patient Reported Outcomes Measurement Information System fatigue scales as standard measures of CRF, and linking legacy measures to the scales. With regard to the biology of CRF, the group identified the need for longitudinal research to examine biobehavioral mechanisms underlying CRF and testing mechanistic hypotheses within the context of intervention research. To address clinical trial issues, recommendations included using only placebo-controlled trial designs. setting eligibility to minimize sample heterogeneity or enable subgroup analysis, establishing a CRF severity threshold for participation in clinical trials, conducting dissemination trials of efficacious interventions (such as exercise), and combining nonpharmacologic and pharmacologic interventions to exploit the potential synergy between these approaches. Accomplishing these goals has the potential to advance the science of CRF and improve the clinical management of this troubling symptom.
doi:10.1093/jnci/djt242
PMCID: PMC3888121  PMID: 24047960
4.  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
5.  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
6.  Cognitive Training for Improving Executive Function in Chemotherapy-Treated Breast Cancer Survivors 
Clinical breast cancer  2013;13(4):299-306.
Difficulties with thinking and problem solving are very common among breast cancer survivors. We tested a computerized cognitive training program for 41 breast cancer survivors. The training program was associated with significant improvements in thinking and problem-solving skills. Our findings demonstrate potential for our online, home-based cognitive training program to improve cognitive difficulties among breast cancer survivors.
Background
A majority of breast cancer (BC) survivors, particularly those treated with chemotherapy, experience long-term cognitive deficits that significantly reduce quality of life. Among the cognitive domains most commonly affected include executive functions (EF), such as working memory, cognitive flexibility, multitasking, planning, and attention. Previous studies in other populations have shown that cognitive training, a behavioral method for treating cognitive deficits, can result in significant improvements in a number of cognitive skills, including EF.
Materials and Methods
In this study, we conducted a randomized controlled trial to investigate the feasibility and preliminary effectiveness of a novel, online EF training program in long-term BC survivors. A total of 41 BC survivors (21 active, 20 wait list) completed the 48 session training program over 12 weeks. The participants were, on average, 6 years after therapy.
Results
Cognitive training led to significant improvements in cognitive flexibility, verbal fluency and processing speed, with marginally significant downstream improvements in verbal memory as assessed via standardized measures. Self-ratings of EF skills, including planning, organizing, and task monitoring, also were improved in the active group compared with the wait list group.
Conclusions
Our findings suggest that EF skills may be improved even in long-term survivors by using a computerized, home-based intervention program. These improvements may potentially include subjective EF skills, which suggest a transfer of the training program to real-world behaviors.
doi:10.1016/j.clbc.2013.02.004
PMCID: PMC3726272  PMID: 23647804
Chemotherapy; Cognitive flexibility; Memory; Processing speed; Rehabilitation
7.  The Current State of Personal Training: an Industry Perspective of Personal Trainers in a Small Southeast Community 
Although research has identified a number of qualities and competencies necessary to be an effective exercise leader, the fitness industry itself is largely unregulated and lacks a unified governing body. As such, a plethora of personal trainer certifications exists with varying degrees of validity that fail to ensure qualified trainers and, therefore, protect the consumer. It is argued that the potential consequences of this lack of regulation are poor societal exercise adherence, potential injury to the client, and poor public perception of personal trainers. Additionally, it is not known whether personal trainers are meeting the needs of their clients or what criteria are used in the hiring of personal trainers. Thus, the purpose of this investigation was to examine the current state of personal training in a midsized Southeast city by using focus group methodology. Local personal trainers were recruited for the focus groups (n = 11), and the results from which were transcribed, coded, and analyzed for themes using inductive reasoning by the authors. Qualities and characteristics that identified by participants clustered around 4 main themes. Client selection rationale consisted of qualities that influenced a client’s decision to hire a particular trainer (e.g., physique, gender, race). Client loyalty referred to the particular qualities involved in maintaining clients (e.g., motivation skills, empathy, social skills). Credentials referred to formal training (e.g., college education, certifications). Negative characteristics referred to qualities considered unethical or unprofessional (e.g., sexual comments, misuse of power) as well as the consequences of those behaviors (e.g., loss of clients, potential for litigation). These results are discussed regarding the implications concerning college programs, certification organizations, increasing public awareness of expectations of qualified trainers, and a move towards state licensure.
doi:10.1519/JSC.0b013e3181660dab
PMCID: PMC4021014  PMID: 18438226
qualifications; certifications; credentials; education; licensure
8.  Chemotherapy-Induced Nausea and Vomiting 
US oncology  2008;4(1):19-23.
Despite treatment advances, nausea and vomiting, especially anticipatory nausea and vomiting, delayed nausea and vomiting and nausea alone, are still the most common, expected and feared side effects among patients receiving chemotherapy. Of the 70 to 80% of cancer patients who experience chemotherapy-induced nausea and vomiting many will delay or refuse future chemotherapy treatments and contemplate stopping all treatments because of fear of further nausea and vomiting. The purpose of this chapter is to provide an overview of the patho-psychophysiology of CINV, the recommended guidelines for standard treatment, and highlight newer targeted treatment approaches.
PMCID: PMC3994039  PMID: 24761161
9.  Current Pharmacotherapy for Chemotherapy-Induced Nausea and Vomiting in Cancer Patients 
Expert opinion on pharmacotherapy  2013;14(6):757-766.
Introduction
Nausea and vomiting are two of the most frequent and troubling side effects patients experience during chemotherapy, interfering with compliance with cancer therapies and quality of life. While newly available treatments have improved our ability to manage nausea and vomiting, anticipatory and delayed nausea and vomiting are still major problems for patients receiving chemotherapy. Many cancer patients consider delaying future chemotherapy cycles and some contemplate stopping chemotherapy altogether because of their fear of experiencing further nausea and vomiting.
Areas Covered
The purpose of this article is to provide an overview of the patho-psychophysiology of chemotherapy-induced nausea and vomiting, the recommended guidelines for treatment, current agents in late-stage clinical trials, and future research needs to address the continued challenges of treatment-related nausea and vomiting.
Expert Opinion
Despite advances in pharmaceutical and behavioral therapies, and the provision of standard clinical guidelines for effectively managing chemotherapy-induced nausea and vomiting (CINV), patients continue to experience CINV. Moreover, control of nausea, acute and delayed, and anticipatory nausea and vomiting (ANV) remains an important, unmet need among cancer patients. It is critical to focus attention on better understanding the mechanisms underlying nausea, anticipatory symptoms, and delayed symptoms.
doi:10.1517/14656566.2013.776541
PMCID: PMC3938333  PMID: 23496347
cancer treatments; chemotherapy; nausea; vomiting; chemotherapy-induced; nausea and vomiting; anticipatory nausea and vomiting; emesis
10.  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
11.  Treatment of Nausea and Vomiting During Chemotherapy 
US oncology & hematology  2011;7(2):91-97.
Nausea and vomiting are two of the most troubling side effects patients experience during chemotherapy. While newly available treatments have improved our ability to manage nausea and vomiting, anticipatory and delayed nausea and vomiting are still a major problem for patients receiving chemotherapy. Many cancer patients will delay or refuse future chemotherapy treatments and contemplate stopping chemotherapy altogether because of their fear of experiencing further nausea and vomiting. The purpose of this article is to provide an overview of the patho-psychophysiology of chemotherapy-induced nausea and vomiting and the recommended guidelines for treatment.
PMCID: PMC3898599  PMID: 24466408
Cancer; chemotherapy; nausea; vomiting
12.  Impact of paroxetine on sleep problems in 426 cancer patients receiving chemotherapy: A trial from the University of Rochester Cancer Center Community Clinical Oncology Program 
Sleep medicine  2012;13(9):1184-1190.
Background
Sleep problems are a frequent distressing symptom in cancer patients, yet little is known about their treatment. Sleep problems and depression frequently co-occur, leading healthcare professionals to treat depression with the expectation that sleep problems will also improve. The purpose of this study was to compare the effect of paroxetine to placebo on sleep problems via a secondary data analysis of a RCT designed to compare the effects of paroxetine to placebo on fatigue in cancer patients undergoing chemotherapy. A previously published report found a significant effect of paroxetine on depression in this cohort.
Methods
A total of 426 patients were randomized following Cycle 2 of chemotherapy to receive either 20 mg of paroxetine or placebo. Sleep problems were assessed using questions from the Hamilton Depression Inventory three times during chemotherapy.
Results
A total of 217 patients received paroxetine and 209 received placebo. Significantly fewer patients taking paroxetine reported sleep problems compared to patients on placebo (Paroxetine 79% versus Placebo 88%; p < 0.05). These differences remained significant even after controlling for baseline sleep problems and depression (p < 0.05).
Conclusion
Paroxetine had a significant benefit on sleep problems in both depressed and non-depressed cancer patients. However, rates of sleep problems remained high even among those effectively treated for depression with paroxetine. There is a need to develop and deliver sleep-specific interventions to effectively treat sleep-related side effects of cancer treatments. These findings suggest that sleep problems and depression are prevalent and co-morbid. Cancer progression, its response to treatment, and overall patient survival are intricately linked to host factors, such as inflammatory response and circadian rhythms, including sleep/wake cycles. Sleep problems and depression are modifiable host factors that can influence inflammation and impact cancer progression and quality of life. Future research should focus on discovering the pathogenesis of sleep dysregulation and depression in cancer so that better treatment approaches can be developed to ameliorate these symptoms.
doi:10.1016/j.sleep.2012.06.001
PMCID: PMC3664933  PMID: 22858235
13.  Health-related quality of life and biomarkers in breast cancer survivors participating in tai chi chuan 
Introduction
Breast cancer survivors experience diminished health-related quality of life (HRQOL). We report on the influence of tai chi chuan exercise (TCC) on HRQOL and explore associations between changes in HRQOL and biomarkers.
Methods
Breast cancer survivors (N=21) were randomly assigned to TCC or standard support therapy (SST) for 12 weeks (three times/week; 60 min/session). Interleukin-6, interleukin-8 (IL-8), insulin-like growth factor-1 (IGF-1), insulin-like growth factor-binding protein (IBFBP)-1, IGFBP-3, glucose, insulin, and cortisol were measured pre- and postintervention. Overall HRQOL and subdomains were assessed at preintervention (T1), midintervention (T2) and postintervention (T3) and biomarkers at T1 and T3.
Results
The TCC group improved in total HRQOL (T1–T2: CS=8.54, P=0.045), physical functioning (T1–T2:CS=1.89, P=0.030), physical role limitations (T1–T2 CS=1.55, P=0.023), social functioning (T1–T3:CS=1.50, P=0.020), and general mental health (T1–-T2:CS=2.67, P=0.014; T1–T3: CS=2.44, P=0.019). The SST improved in social functioning (T1–T2:CS=0.64, P=0.043) and vitality (T1–T2:CS=0.90, P=0.01). There were relationships between changes in IGF-1 and overall HRQOL (r=−0.56; P<0.05), physical role limitation (r=−0.68; P<0.05), and social functioning (r=−0.56; P<0.05). IGFBP-1 changes were associated with physical role limitation changes (r=0.60; P<0.05). IGFBP-3 changes were associated with physical functioning changes (r=0.46; P≤0.05). Cortisol changes were associated with changes in physical role limitations (r=0.74; P<0.05) and health perceptions (r=0.46; P<0.05). Glucose changes were associated with emotional role limitation changes (r=−0.70; P<0.001). IL-8 changes were associated with emotional role limitation changes (r=0.59; P<0.05).
Discussion/conclusions
TCC may improve HRQOL by regulating inflammatory responses and other biomarkers associated with side effects from cancer and its treatments. Implications for cancer survivors TCC may be an intervention capable of improving HRQOL in breast cancer survivors.
doi:10.1007/s11764-011-0205-7
PMCID: PMC3664952  PMID: 22160628
Breast cancer; Inflammation; Exercise; Quality of life
14.  Reduced hippocampal volume and verbal memory performance associated with interleukin-6 and tumor necrosis factor-alpha levels in chemotherapy-treated breast cancer survivors 
Brain, behavior, and immunity  2012;30(0):S109-S116.
Many survivors of breast cancer show significant cognitive impairments, including memory deficits. Inflammation induced by chemotherapy may contribute to hippocampal changes that underlie these deficits. In this cross-sectional study, we measured bilateral hippocampal volumes from high-resolution magnetic resonance images in 42 chemotherapy-treated breast cancer survivors and 35 healthy female controls. Patients with breast cancer were, on average, 4.8 ± 3.4 years off-therapy. In a subset of these participants (20 breast cancer, 23 controls), we quantified serum cytokine levels. Left hippocampal volumes and memory performance were significantly reduced and interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNFα) concentrations were significantly elevated in the breast cancer group compared to controls. In the breast cancer group, lower left hippocampal volume was associated with higher levels of TNFα and lower levels of IL-6 with a significant interaction between these two cytokines suggesting a potential modulatory effect of IL-6 on TNFα. Verbal memory performance was associated with cytokine levels and left hippocampal volume in both groups. These findings provide evidence of altered hippocampal volume and verbal memory difficulties following breast cancer chemotherapy that may be mediated by TNFα and IL-6.
doi:10.1016/j.bbi.2012.05.017
PMCID: PMC3665606  PMID: 22698992
Breast cancer; Chemotherapy; Interleukin-6; Tumor necrosis factor-alpha; Memory; Hippocampus; MRI
15.  Exercise and Cancer Treatment Symptoms in 408 Newly Diagnosed Older Cancer Patients 
Journal of geriatric oncology  2012;3(2):90-97.
While the benefits of exercise for managing cancer-and treatment-related side effects has been shown among various populations of cancer survivors, a relative dearth of information exists among older cancer patients.
Objectives
To determine the prevalence of exercise participation during and after primary cancer treatment in older (≥65 years) and the oldest (≥80 years) cancer patients and to examine the relationships between exercise, symptoms, and self-rated health (SRH).
Materials and Methods
408 newly diagnosed older cancer patients (mean age=73, range=65-92) scheduled to receive chemotherapy and/or radiation therapy reported symptoms and SRH prior to, during, and 6 months after treatment, and exercise participation during and following treatment.
Results
Forty-six percent of older and 41% of the oldest patients reported exercising during treatment. Sixty percent of older and 68% of the oldest patients reported exercising in the 6 months thereafter. Older patients who exercised during treatment reported less shortness of breath and better SRH during treatment, and better SRH following treatment. The oldest patients who exercised during treatment reported less memory loss and better SRH during treatment and less fatigue and better SRH following treatment. The oldest patients who exercised following treatment reported less fatigue, skin problems, and total symptom burden following treatment.
Conclusion
These data suggest a willingness of older cancer patients to attempt exercise during and after treatment. Exercise during these times is associated with less severe symptoms; further clinical research examining the efficacy of formal exercise interventions to reduce symptoms and improve SRH in older cancer patients is needed.
doi:10.1016/j.jgo.2012.01.002
PMCID: PMC3376161  PMID: 22712028
elderly; exercise; physical activity; neoplasms; side effects; symptoms; chemotherapy; radiation therapy
16.  Prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer 
Nature and science of sleep  2012;4:151-162.
Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.
doi:10.2147/NSS.S18895
PMCID: PMC3593248  PMID: 23486503
cancer; sleep; chemotherapy; intervention; circadian rhythm; cognitive behavioral therapy
17.  Prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer 
Nature and Science of Sleep  2012;4:151-162.
Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.
doi:10.2147/NSS.S18895
PMCID: PMC3593248  PMID: 23486503
cancer; sleep; chemotherapy; intervention; circadian rhythm; cognitive behavioral therapy
18.  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
19.  Age-related Differences in Symptoms and Their Interference with Quality of Life in 903 Cancer Patients Undergoing Radiation Therapy 
Journal of geriatric oncology  2011;2(4):225-232.
Structured Abstract
Objectives
To evaluate the relationship of age with symptoms and interference with daily function and QOL during RT.
Design
A prospective observational study.
Setting
A university-based radiation oncology department.
Participants
903 cancer patients who received radiation therapy (RT). The mean age was 61 yrs (18-92) and 41% were ≥ 65 yrs.
Measurements
A symptom inventory was administered pre- and post-RT. Patients rated 10 symptoms and their interference with daily function and QOL on a Likert scale from 0 (not present) to 10 (as bad as possible). A total symptom score was calculated by adding the ratings of individual symptoms. T-tests, Pearson correlation coefficients, and mixed modeling were used to investigate relationships between symptoms and their interference with daily function and QOL.
Results
For older and younger patients, the total symptom score worsened during RT (p's < .001). There were no differences in the change in total symptom burden and interference with QOL between older and younger patients during RT. After RT, although younger patients reported significantly worse pain (p = .03), nausea (p <.01), and sleep disturbance (p <.01), symptom interference with walking was more severe in older patients (p = .01). Mixed modeling showed that older age (p=<.001), time of survey (after RT, p<.001), and age*time interaction (p<.001) increased the likelihood of reporting that symptoms interfered with walking.
Conclusion
The prevalence of symptoms was similar for older and younger patients during RT. Older patients are more likely to report that symptoms interfere with walking after RT.
doi:10.1016/j.jgo.2011.08.002
PMCID: PMC3415272  PMID: 22888384
elderly; cancer; symptoms; radiotherapy
20.  Interventions to Alleviate Symptoms Related to Breast Cancer Treatments and Areas of Needed Research 
Journal of cancer science & therapy  2011;Suppl 2:S2-001.
Treatments for breast cancer produce a host of side effects, which can become debilitating. Some cancer treatment-related side effects occur in up to 90% of patients during treatment and can persist for months or years after treatment has ended. As the number of breast cancer survivors steadily increases, the need for cancer control intervention research to alleviate side effects also grows. This review provides a general overview of recent clinical research studies of selected topics in the areas of symptom management for breast cancer with a focus on cognitive difficulties, fatigue, cardiotoxicity, bone loss, insomnia, and cancer pain. We review both pharmacological and behavioral intervention clinical research studies, conducted with breast cancer patients and survivors. Additionally, clinical perspectives on symptom management and recommendations for areas of needed research are provided.
PMCID: PMC3408313  PMID: 22855701
Cancer treatment; Symptom management; Side effects; Interventions; Intervention mechanisms
21.  Cancer-Related Stress and Complementary and Alternative Medicine: A Review 
A cancer diagnosis elicits strong psychophysiological reactions that characterize stress. Stress is experienced by all patients but is usually not discussed during patient-healthcare professional interaction; thus underdiagnosed, very few are referred to support services. The prevalence of CAM use in patients with history of cancer is growing. The purpose of the paper is to review the aspects of cancer-related stress and interventions of commonly used complementary and alternative techniques/products for amelioration of cancer-related stress. Feasibility of intervention of several CAM techniques and products commonly used by cancer patients and survivors has been established in some cancer populations. Efficacy of some CAM techniques and products in reducing stress has been documented as well as stress-related symptoms in patients with cancer such as mindfulness-based stress reduction, yoga, Tai Chi Chuan, acupuncture, energy-based techniques, and physical activity. Much of the research limitations include small study samples and variety of intervention length and content. Efficacy and safety of many CAM techniques and some herbs and vitamin B and D supplements need to be confirmed in further studies using scientific methodology. Several complementary and alternative medicine therapies could be integrated into standard cancer care to ameliorate cancer-related stress.
doi:10.1155/2012/979213
PMCID: PMC3403456  PMID: 22844341
22.  Conducting Cancer Control and Survivorship Research via Cooperative Groups: A Report from the American Society of Preventive Oncology 
As the number of cancer survivors expands, the need for cancer control and survivorship research becomes increasingly important. The National Cancer Institute (NCI) Cooperative Groups may offer a viable platform to perform such research. Observational, preventive, and behavioral research can often be performed within the cooperative group setting, especially if resources needed for evaluation are fairly simple, if protocols are easily implemented within the typical clinical setting, and if interventions are well standardized. Some protocols are better suited to cooperative groups than are others, and there are advantages and disadvantages to conducting survivorship research within the cooperative group setting. Behavioral researchers currently involved in cooperative groups, as well as program staff within the NCI, can serve as sources of information for those wishing to pursue symptom management and survivorship studies within the clinical trial setting. The structure of the cooperative groups is currently changing, but going forward, survivorship is bound to be a topic of interest and one that perhaps may be more easily addressed using the proposed more centralized structure.
doi:10.1158/1055-9965.EPI-11-0176
PMCID: PMC3124556  PMID: 21502540
23.  Association of Cancer With Geriatric Syndromes in Older Medicare Beneficiaries 
Journal of Clinical Oncology  2011;29(11):1458-1464.
Purpose
To identify whether a history of cancer is associated with specific geriatric syndromes in older patients.
Patients and Methods
Using the 2003 Medicare Current Beneficiary Survey, we analyzed a national sample of 12,480 community-based elders. Differences in prevalence of geriatric syndromes between those with and without cancer were estimated. Multivariable logistic regressions were used to evaluate whether cancer was independently associated with geriatric syndromes.
Results
Two thousand three hundred forty-nine (18%) reported a history of cancer. Among those with cancer, 60.3% reported one or more geriatric syndromes as compared with 53.2% of those without cancer (P < .001). Those with cancer overall had a statistically significantly higher prevalence of hearing trouble, urinary incontinence, falls, depression, and osteoporosis than those without cancer. Adjusting for possible confounders, those with a history of cancer were more likely to experience depression (adjusted odds ratio [OR], 1.15; 95% CI, 1.02 to 1.30; P = .023), falls (adjusted OR, 1.17; 95% CI, 1.04 to 1.32; P = .010), osteoporosis (adjusted OR, 1.21; 95% CI, 1.06 to 1.38; P = .004), hearing trouble (adjusted OR, 1.28; 95% CI, 1.08 to 1.52; P = .005), and urinary incontinence (adjusted OR, 1.42; 95% CI, 1.20 to 1.69; P < .001). Analysis of specific cancer subtypes showed that lung cancer was associated with vision, hearing, and eating trouble; prostate cancer was associated with incontinence and falls; cervical/uterine cancer was associated with falls and osteoporosis; and colon cancer was associated with depression and osteoporosis.
Conclusion
Elderly patients with cancer experience a higher prevalence of geriatric syndromes than those without cancer. Prospective studies that establish the causal relationships between cancer and geriatric syndromes are necessary.
doi:10.1200/JCO.2010.31.6695
PMCID: PMC3082984  PMID: 21402608
24.  Differential Expression of Cytokines in Breast Cancer Patients Receiving Different Chemotherapies: Implications for Cognitive Impairment Research 
Supportive Care in Cancer  2011;20(4):831-839.
Purpose
In many neurodegenerative diseases abnormal concentrations of cytokines and chemokines affect neuronal integrity leading to cognitive impairments; altered levels of these molecules could also play a role in cancer- and cancer-treatment related cognitive difficulties. Patients receiving doxorubicin-based (with cyclophosphamide, or cyclophosphamide plus fluorouracil; AC/CAF) chemotherapy or cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy report experiencing cognitive difficulties; because these regimens work by different modes of action, it is possible that they differentially affect cytokine levels.
Methods
This secondary study examined the relationships between cytokine levels (i.e., IL-6, IL-8, and MCP-1) and type of chemotherapy among 54 early-stage breast cancer patients receiving AC/CAF or CMF. Cytokine levels were assessed at two time-points: prior to on-study chemotherapy cycle 2 (Cycle 2) and after 2 consecutive chemotherapy cycles (prior to on-study cycle 4; Cycle 4).
Main Results
Analyses of variance using Cycle 2 levels as a covariate (ANCOVA) were used to determine differences between chemotherapy groups. Levels of IL-6, IL-8, and MCP-1 increased in the AC/CAF group and decreased in the CMF group; the only significant between-group change was in IL-6 (p<0.05).
Conclusions
These preliminary results suggest that AC/CAF chemotherapy is more cytokine inducing than CMF; future studies should explore the distinct inflammatory responses elicited by different chemotherapy regimens.
doi:10.1007/s00520-011-1158-0
PMCID: PMC3218259  PMID: 21533812
chemotherapy; cytokines; cancer; cognitive impairment; immune response
25.  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

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