Effect of aerobic exercise on cancer-associated cognitive impairment: A proof-of-concept RCT.

BACKGROUND: Change in cognitive ability is a commonly reported adverse effect by breast cancer survivors. The underlying etiology of cognitive complaints is unclear and to date, there is limited evidence for effective intervention strategies. Exercise has been shown to improve cognitive function in older adults and animal models treated with chemotherapy. This proof-of-concept randomized controlled trial tested the effect of aerobic exercise versus usual lifestyle on cognitive function in postmenopausal breast cancer survivors. METHODS: Women, aged 40 to 65 years, postmenopausal, stages I to IIIA breast cancer, and who self-reported cognitive dysfunction following chemotherapy treatment, were recruited and randomized to a 24-week aerobic exercise intervention (EX; n = 10) or usual lifestyle control (CON; n = 9). Participants completed self-report measures of the impact of cognitive issues on quality of life (Functional Assessment of Cancer Therapy-Cognitive version 3), objective neuropsychological testing, and functional magnetic resonance imaging at baseline and 24 weeks. RESULTS: Compared to CON, EX had a reduced time to complete a processing speed test (trail making test-A) (-14.2 seconds, P < .01; effect size 0.35). Compared to CON, there was no improvement in self-reported cognitive function and effect sizes were small. Interestingly, lack of between-group differences in Stroop behavioral performance was accompanied by functional changes in several brain regions of interest in EX compared to CON at 24 weeks. CONCLUSION: These findings provide preliminary proof-of-concept results for the potential of aerobic exercise to improve cancer-related cognitive impairment and will serve to inform the development of future trials.

Does obesity modify the relationship between physical activity and breast cancer risk?

PURPOSE: With only 5-10% of breast cancer cases attributed to genetic inheritance, prevention efforts have focused on modifiable risk factors. Physical activity plays a role in reducing breast cancer risk; however, the interaction between physical activity and other modifiable risk factors, such as obesity, has received little attention. METHODS: A systematic review and meta-analysis was conducted of studies examining the relationship between physical activity and breast cancer and how it may be modified by body mass index (BMI). RESULTS: A total of 29 papers were included: 18 were cohort and 11 were case-control studies. Overall, a significant reduction in the relative risk of breast cancer was found in postmenopausal women with high versus low levels of physical activity for women with a BMI <25 kg/m2 (RR 0.85, 95% CI 0.79, 0.92) and ≥25 kg/m2 (RR 0.87, 95% CI 0.81, 0.93) but not ≥30 kg/m2 (RR: 0.93, 95% CI 0.76, 1.13). Physical activity was not associated with a significant reduction in risk of breast cancer in premenopausal women in any BMI group. CONCLUSION: The results of this meta-analysis suggest that physical activity is associated with a larger breast cancer risk reduction among women who are normal weight or overweight than among women who are obese. Since the included studies used diverse methods for assessment of physical activity and categories of BMI, results should be interpreted with caution and additional work is needed.

Utilization of bone mineral density testing among breast cancer survivors in British Columbia, Canada.

Breast cancer survivors are at high osteoporosis risk. Bone mineral density testing plays a key role in osteoporosis management. We analyzed a historical utilization of bone mineral density testing in breast cancer survivors. The utilization remained low in the 1995-2008 period. Lower socio-economic status and rural residency were associated with lower utilization. INTRODUCTION: To evaluate the utilization of bone mineral density (BMD) testing for female breast cancer survivors aged 65+ surviving ≥ 3 years in British Columbia, Canada. METHODS: A retrospecitve population-based data linkage study. Trends in proportion of survivors with ≥ 1 BMD test for each calendar year from 1995 to 2008 were evaluated with a serial cross-sectional analysis. Associations between factors (socio-demographic and clinical) and BMD testing rates over the period 2006-2008 for 7625 survivors were evaluated with a cross-sectional analysis and estimated as adjusted prevalence ratios (PRadj) using log-binomial models. RESULTS: Proportions of survivors with ≥ 1 BMD test increased from 1.0% in 1995 to 10.1% in 2008. The BMD testing rate in 2006-2008 was 26.5%. Socio-economic status (SES) and urban/rural residence were associated with BMD testing rates in a dose-dependent relationship (p for trend< 0.01). Survivors with lower SES (PRadj = 0.66-0.78) or rural residence (PRadj = 0.70) were 20-30% less likely to have BMD tests, compared with survivors with the highest SES or urban residence. BMD testing rates were also negatively associated with older age (75+) (PRadj = 0.47; 95% CI = 0.42, 0.52), nursing home residency (0.05; 0.01, 0.39), recent osteoporotic fractures (0.21; 0.14, 0.32), and no previous BMD tests (0.26; 0.23, 0.29). CONCLUSION: Utilization of BMD testing was low for breast cancer survivors in BC, Canada. Lower SES and rural residence were associated with lower BMD testing rates. IMPLICATION FOR CANCER SURVIVORS: Female breast cancer survivors, especially those with lower SES or rural residence, should be encouraged to receive BMD tests as recommended by Canadian guidelines.

Quality of life in long-term survivors of adult-onset cancers.

The long-term survival of cancer patients has risen dramatically during the last few decades, yet little is known about the quality of life experienced by these survivors. This paper reviews research on the quality of life in long-term cancer survivors to identify quality-of-life concerns in this population, to provide a critical evaluation of the literature, and to suggest areas for future research. Searches of computerized literature databases were conducted to identify all studies of quality of life in cancer survivors that were published in English language journals during the period from January 1, 1980, through February 12, 1998, and that were based on responses from individuals who have survived 5 or more years after the diagnosis of adult-onset cancers. Thirty-four papers were identified. Most studies utilized self-report questionnaires to measure quality of life. Although methodologies and cancer patient populations varied greatly, most studies showed that many survivors continue to experience negative effects of cancer and/or treatment on their daily lives well beyond the completion of therapy. Sexual functioning and/or satisfaction and psychological functioning were found to be concerns for many survivors. Several reports documented positive coping strategies and enhanced quality of life in long-term cancer survivors, supporting the need to measure positive aspects of quality of life as well as problems in this population. Study designs that more accurately measure quality of life among survivors of cancer by adjusting for the effects of aging and long-term therapy and the impact of second cancers should be utilized. Additional data are needed to understand the needs of long-term survivors, especially of those in groups underrepresented in published quality-of-life studies, and to determine what kinds of support survivors want.

Quality-of-life assessment in cancer treatment protocols: research issues in protocol development.

BACKGROUND: Interest in incorporating quality of life as an end point in clinical studies of cancer treatment has intensified in recent years. PURPOSE: We provide practical suggestions that will assist investigators considering including quality-of-life assessment in phase III therapeutic trials. METHODS: We discuss issues important in study planning, including quality-of-life definition, priority studies for quality-of-life assessment, eligibility requirements, and design. CONCLUSIONS: Many of the problems that quality-of-life studies have encountered, from protocol approval to data analysis, could be addressed and alleviated during protocol development. This discussion is intended to assist and stimulate investigators conducting research in this area.

Trial-related quality of life: using quality-of-life assessment to distinguish among cancer therapies.

Issues in selecting quality-of-life (QOL) measures that are best suited to assessing differences among treatments in cancer clinical trials, as well as challenges to interpreting QOL outcome data, are discussed. When used in the context of randomized trials of cancer therapies, QOL assessments must provide an answer to the question, "Did the treatments differentially affect patient well-being?" In order to detect differences in treatment efficacy against a background of great similarity, the broad concept of QOL needs to be refined to reflect "trial-related QOL." In many cases, this will entail emphasis on actual patient experience of symptoms and functional changes, as opposed to emphasis solely on evaluation and satisfaction. A model is proposed to identify cognitive, emotional, and sociocultural factors that influence a patient's QOL evaluation and that need to be considered in understanding the meaning of QOL data.

Perceptions of informed consent by participants in a prostate cancer prevention study.

This study examined perceptions of the informed consent process in healthy men participating in a cancer prevention clinical trial. Specifically, we examined influence of the consent form on participation and understanding, adequacy of the consent process in preparing participants for trial experiences, and perceived needs for additional follow-up strategies. Participants (n = 69) enrolled in the Prostate Cancer Prevention Trial at our institution completed mailed questionnaires approximately 2 years after joining the study. Results indicated that many participants had no remembrance of the consent process, and only a minority reported that the consent process had helped in decision-making about study participation. Eleven men (16%) reported experiencing unexpected study side effects, most related to sexual functioning. Most men (78%) did not feel that they currently needed more information about the study, although virtually all of the respondents wanted to learn the study results. Almost one-third wished to interact with other Prostate Cancer Prevention Trial participants. Results indicate that a signed consent form and initial counseling for a prevention study does not ensure that participants feel they are adequately informed about the study or the side effects. Providing and reinforcing information on a regular and continuous basis is especially important in studies where compliance is required over a period of years.

Physicians' and medical students' perspectives on patients' quality of life.

PURPOSE: To compare medical students' and oncologists' perspectives about patient-related quality of life (QOL). METHOD: In 1996, the authors compared the questionnaire responses of 65 oncologists and 105 medical students in the state of Hawai'i. RESULTS: Participants returned 146 usable questionnaires (response rates: 69% of oncologists and 97% of students). Both groups saw pain and suffering as central to QOL, while medical students also valued autonomy. Both groups indicated that QOL was at least as important as survival in treatment decision making. Students were significantly more likely to emphasize the importance of QOL over survival. Students strongly preferred physician interviews to assess QOL. Most physicians reported assessing QOL in every patient, but only one in ten had used a QOL assessment questionnaire. CONCLUSION: Both students and oncologists expressed considerable interest in QOL and virtually all regarded it as an important part of care. There were more similarities than differences in responses. Future educational programs in both medical school and continuing education should build on these positive attitudes.

Male-female differences in the impact of cancer therapy.

Sex has been shown to be a significant predictor of cancer survival, with females living longer than males. This survival differential could occur because women benefit more than men from cancer treatments. This article reports the results of a study of the adequacy of the current clinical trials literature to examine sex differences in response to cancer therapy. All phase III (randomized) trials of cancers in non-sex-specific sites published between 1988 and 1990 were identified in three cancer-specific and four general medical journals. Of 55 studies that investigated outcomes by sex, 33% reported differences. Future studies should include adequate numbers of male and female participants, where appropriate, to allow generalization of study findings; routine reporting of the sex composition of the study sample in clinical trials reports; and routine analysis of the effects of sex on prognosis and responses to specific treatments.

Building quality of life assessment into cancer treatment studies.

Quality of life is increasingly recognized as an important outcome of cancer treatment. However, quality of life research poses considerable problems in design and implementation. This article provides guidelines for the preparation of phase III therapeutic protocols that include quality of life assessment. The guidelines emphasize the distinct requirements of quality of life research and provide specific recommendations for the questions that need to be addressed in protocol development.

The experience of cancer during early and advanced stages: the views of patients and their mates.

Problems, coping mechanisms and problem resolution were assessed in 112 individuals: patients with early stage cervical cancer or pre-cancer (N = 42) and their mates (N = 19), and patients with advanced stage breast or gynecological cancer (N = 31) and their mates (N = 20). The most common source of concern for all groups was the disease itself; the men were also more likely than the patients to be disturbed by the possibility of the women dying. Taking firm action was the most frequently-mentioned coping strategy; information-seeking was also common among the early stage groups, and religious faith often cited by the advanced stage respondents. Analysis of a particular problem--fear of cancer--showed different coping strategies to be predominant; mates, in contrast to patients, were likely to take direct action and advanced stage groups more likely to discuss their fear of cancer with others. Problem resolution did not vary from group to group. Overall, the similarities among reactions of early and advanced stage patients and mates were more striking than differences, indicating the profound impact of cancer over the course of the disease on patient and family alike.

Accrual to cancer clinical trials: directions from the research literature.

Although randomized clinical trials are the predominant method used to evaluate cancer therapies, only a small proportion of potential participants actually enter onto trials. This paper analyzes the research literature on accrual to cancer therapy trials. The research shows that nonparticipation is influenced by physician and patient variables, as well as by characteristics of the specific protocols. Trials design, especially pre-existing treatment preferences, pose significant problems for physicians and patients. Intervention strategies have focused on alternate trial designs, improving the informed consent process, and increasing knowledge about trials. Additional research should focus on the perspectives of patients who accept and decline trial participation and on interventions designed to affect accrual. Future studies need to be sensitive to patient quality of life considerations as well as practical and ethical issues.

Why me? Attributions and adjustment by cancer patients and their mates at two stages in the disease process.

This research investigated how cancer patients at early and advanced stage disease (N = 73) and their mates (N = 39) attributed causality for the disease, their levels of adjustment and the relationship between attributions and adjustment. Data were collected through semi-structured home interviews. Results indicated that the largest numbers of individuals cited chance as the cause of the cancer, although many reported that they had not asked themselves the question, 'Why me?'. Adjustment measures indicated, in general, more similarities than differences between groups. Attributions were not significant predictors of adjustment. It is suggested that not making strong causal attributions may be adaptive for cancer patients and their families.

Ethnic differences in complementary and alternative medicine use among cancer patients.

OBJECTIVES: This study estimated the prevalence of complementary and alternative medicine (CAM) use and its relation to quality of life (QOL) among cancer patients from diverse ethnic backgrounds. Given the ethnically diverse population in Hawaii, we hypothesized that CAM use may be related to the ancestry and the cultural heritage of cancer patients. DESIGN AND SETTING: Participants for this mail survey were identified through the Hawaii Tumor Registry, a state-wide population-based cancer registry. SUBJECTS: Patients with invasive cancer diagnosed 1995-1996. Of the 2,452 questionnaires received, 1,168 (47.6%) were returned. OUTCOME MEASURES: Prevalence of CAM use and QOL measures. RESULTS: One in four respondents reported at least one CAM therapy since cancer diagnosis. CAM use was highest among Filipino and Caucasian patients, intermediate for Native Hawaiians and Chinese, and significantly lower among Japanese. Some ethnic preferences for CAM followed ethnic folk medicine traditions, e.g., herbal medicines by Chinese, Hawaiian healing by Native Hawaiians, and religious healing or prayer by Filipinos. CAM users reported lower emotional functioning scores, higher symptom scores, and more financial difficulties than nonusers. CONCLUSIONS: This study detected ethnic differences in CAM use, in particular a low use among Japanese patients, and supports the importance of cultural factors in determining the frequency and type of CAM therapies chosen. Consideration of patients' cultural heritage may facilitate communication between physicians and patients about CAM with the goal to achieve optimal cancer care.

Use of quality-of-life outcome assessments in current cancer clinical trials.

During the past decade, the importance of integrating quality of life with other indicators of efficacy in cancer clinical trials has been emphasized. This article reviews quality-of-life assessment in clinical trial reports. All empirical studies using patient ratings published in the Journal of Clinical Oncology from 1992 to 1996 were identified. Of these, 59 articles (4%) included quality-of-life assessment, most frequently measured by self-report questionnaires. Most articles reported clinical trials of symptom management or treatment. Future research needs to specify relationships between quality of life, toxicity, and survival. Continued development of this field requires more frequent inclusion of quality of life in clinical studies.

Why some cancer patients choose complementary and alternative medicine instead of conventional treatment.

OBJECTIVES: We examined cancer patients' reasons for declining all or part of recommended cancer treatment and choosing complementary and alternative medicine (CAM). STUDY DESIGN: This was a qualitative interview study. POPULATION: Fourteen cancer survivors who reported having declined all or part of the recommended conventional treatment (surgery, chemotherapy, or radiation) were included. The participants were a subset from a multi-ethnic (Asian, Native Hawaiian, and white) group of 143 adults diagnosed with cancer in 1995 or 1996 who were recruited through a population-based tumor registry and interviewed about CAM. OUTCOMES MEASURED: We performed semistructured interviews regarding experience with conventional cancer treatment and providers, use of CAM, and beliefs about disease. RESULTS: All participants used 3 or more types of CAM, most commonly herbal or nutritional supplements. Across the board, participants stated that their reason for declining conventional treatment was to avoid damage or harm to the body. The majority of participants also felt that conventional treatment would not make a difference in disease outcome, and some but not all participants perceived an unsatisfactory or alienating relationship with health care providers. Some participants reported that their discovery of CAM contributed to their decision to decline conventional treatment, and participants generally perceived CAM as an effective and less harmful alternative to conventional treatment. CONCLUSIONS: Cancer patients may benefit from interventions (eg, patient education, improvements in physician-patient communication, and psychologic therapy) to facilitate treatment decision making through increased understanding of conventional and CAM treatments and to identify barriers to treatment for individual patients.

Use of complementary and alternative medicine in Hawaii cancer patients.

This research investigated complementary and alternative medicine (CAM) use by Hawai'i cancer patients. Thirty-six percent of patients used CAM, most commonly religious/spiritual therapy and herbal treatments. CAM use was linked with younger age, female gender, Catholic religion, and more education. More research is needed to inform decision-making.

Use of complementary and alternative medicine in Hawaii cancer patients.

This research investigated complementary and alternative medicine (CAM) use by Hawaii cancer patients. Thirty-six percent of patients used CAM, most commonly religious/spiritual therapy and herbal treatments. CAM use was linked with younger age, female gender, Catholic religion, and more education. More research is needed to inform decision-making.

Barriers to mammography in a low income, multiethnic clinic population.

Breast cancer-related knowledge, attitudes, behaviors and barriers to obtaining a mammogram were assessed in women attending a primary care clinic serving a low-income minority population. Although most women believed in the value of mammograms, fewer than one in six was compliant with guidelines, and there were considerable deficits in knowledge about breast cancer risk. Ethnic and age differences in responses have implications for health program planning.

Physical activity levels of cancer survivors in Canada: findings from the Canadian Community Health Survey.

PURPOSE: Physical activity may reduce many side effects of cancer treatment and may improve survival. The purpose of this analysis was to compare physical activity in cancer patients and survivors to those who have never had cancer and examine changes between 2005-2006 and 2009-2010. METHODS: Data were extracted from the 2005-2006 and 2009-2010 Canadian Community Health Survey. Respondents were asked whether they currently have or had cancer in the past and about physical activity. Based on duration and type of reported activity, respondents were classified as inactive, moderately active, or active. Logistic regression was used to assess the relationship between cancer history and physical activity. Differences in physical activity by survey cycle according to cancer status were also examined. RESULTS: After adjustment, respondents with cancer were more likely to be inactive than those who had never had cancer (OR = 1.39, 95 % CI 1.21-1.58, inactive vs. active), while individuals with previous cancer did not differ from population levels. The odds of being moderately active or inactive did not vary over time in those with current or previous cancer; however, respondents who had never had cancer were less likely to be moderately active or inactive in 2009-2010 (OR = 0.94, 95 % CI 0.92-0.96, inactive vs. active). CONCLUSIONS: Individuals with cancer are less likely to be active than those who have never had cancer, but those with a history of cancer have similar physical activity levels to population levels. Activity levels in all three groups are much lower than recommended. IMPLICATIONS FOR CANCER SURVIVORS: It is encouraging to note that those with cancer history are not less likely than the general population to be physically active. Individuals with a history of cancer have much to gain from participation in physical activity and health care providers should continue to encourage physical activity in accordance with published guidelines.