Feasibility of a Physical Activity Index in Clinical Practice: Perspectives of Providers and Cancer Patients.

Physical activity is a common clinical recommendation for cancer survivors, yet the use of clinical tools to counsel patients is understudied. We developed an integrated Physical Activity Index to assist with this task. The purpose of this project was to conduct interviews to assess the feasibility and clinical utility of the Physical Activity Index from both provider and patient perspectives. Our findings indicate that a Physical Activity Index may be a useful tool to facilitate productive patient-provider communication about physical activity goals.

Availability of cancer survivorship support services across the National Cancer Institute Community Oncology Research Program network.

BACKGROUND: National cancer organizations recommend provision of nutrition, physical activity, and mental health supportive services to cancer survivors. However, the availability of these services across diverse community oncology settings remains unclear. METHODS: The National Cancer Institute Community Oncology Research Program (NCORP) is a national network of community oncology practices engaged in cancer research. The 2022 NCORP Landscape Assessment (5UG1CA189824) assessed individual practices' establishment of survivorship clinics and nutrition, physical activity, and mental health services, resources, and/or referrals. Descriptive statistics summarized and logistic regression quantified the association between services, practice, and patient characteristics. RESULTS: Of 46 NCORP community sites, 45 (98%) responded to the survey, representing 259 adult practice groups. A total of 41% had a survivorship clinic; 96% offered mental health, 94% nutrition, and 53% physical activity services, resources, and/or referrals. All 3 services were offered in various formats (eg, in-house, referrals, education) by 51% and in-house only by 25% of practices. Practices with advanced practice providers were more likely to have a survivorship clinic (odds ratio [OR] = 3.19, 95% confidence interval [CI] = 1.04 to 9.76). Practices with at least 30% Medicare patients (OR = 2.54, 95% CI = 1.39 to 4.66) and more oncology providers (OR = 1.02, 95% CI = 1.01 to 1.04) were more likely to have all 3 services in any format. Practices with at least 30% Medicare patients (OR = 3.41, 95% CI = 1.50 to 7.77) and a survivorship clinic (OR = 2.84, 95% CI = 1.57 to 5.14) were more likely to have all 3 services in-house. CONCLUSIONS: Larger oncology practices and those caring for more survivors on Medicare provided more supportive services, resources, and/or referrals. Smaller practices and those without survivorship clinics may need strategies to address potential gaps in supportive services.

Exploring the acceptability of the 'smart cane' to support mobility in older cancer survivors and older adults: A mixed methods study.

INTRODUCTION: Approximately 25% of older cancer survivors (i.e., ≥ 65 years, with cancer history) use ≥1 mobility device, surpassing usage by other older adults. Few tools exist for older "survivors" to regain function or follow lifestyle recommendations. Our goal was to explore opportunities to leverage technology-enabled mobility devices, such as the "smart cane," to support mobility goals in these survivors. The research objective was to assess perceptions related to acceptability, usability and preferences of participants regarding technology-enabled mobility devices in everyday life. MATERIALS AND METHODS: We used a convergent mixed-methods design, analyzing quantitative data followed by qualitative focus groups. A pre-survey derived from the Senior Technology Acceptance Model assessed the acceptability of technology-enabled devices among participants, who also participated in one of three focus groups delivered via Zoom. The Zoom sessions included facilitated 90-min discussions and video demonstration of the smart cane. Focus group sessions were recorded and transcribed verbatim and thematic content analysis was conducted. RESULTS: We recruited 12 older US survivors. Participants were 58% female, aged 68-86, and 16% non-White. From a pre-survey of participants, 83% said that they liked the idea of technology-enhanced mobility device and 100% said they thought they could be skillful at using a technology-enabled device if training was provided. Though participants were enthusiastic about the smart cane overall and felt the smart cane supported independence for older adults, the themes revealed concerns about safety, accessibility and technology support, as well as the concern for negative impact on self-image due to use of a mobility device. There was a strong preference for working with clinical professionals as the most trusted sources for referrals, if a smart cane was suggested. DISCUSSION: Older survivors in our sample found the smart cane very acceptable, and supportive of independence for older adults with cancer and other conditions. Participants also provided many insights that revealed additional research needed to support access, safety and usability for older adults, older survivors and caregivers, especially by partnering with clinical professionals.

Adapting an Evidence-Based Exercise and Education Program for Older Breast Cancer Survivors for the REJOIN Trial.

Physical activity (PA) promotes survival and mitigates symptoms in older breast cancer survivors (BCS), especially to reduce joint pain associated with adjuvant hormonal treatment. The purpose is to describe the adaptation process for an evidence-based exercise and education curriculum (i.e., Fit & Strong!) to support older BCS participating in the Using Exercise to Relieve Joint Pain and Improve Aromatase Inhibitor Adherence in Older Breast Cancer Survivors trial. We reviewed all educational materials with scientific/clinical experts to identify necessary content changes. Next, we conducted semistructured phone interviews with BCS to review all educational materials and conducted a real-time pretest for the trial. Overall, BCS found the adapted materials and experience acceptable (mean score of 9.2/10 for satisfaction). Content changes included simplifying exercise instructions, prioritizing content related to the trial goals, and updating photographs. Because of COVID, the pretest was conducted via Zoom. Our multistep adaptation process provided an acceptable intervention to meet the needs of older BCS. Lessons learned will be applied to the forthcoming pilot trial.

Light-intensity and moderate-to-vigorous intensity physical activity among older adult breast cancer survivors with obesity: A narrative review.

BACKGROUND: With an aging population, rising incidence of breast cancer, improved survival rates, and obesity epidemic, there will be a growing population of older adult breast cancer survivors with obesity. This complex population, often with multimorbidity, is at risk for several poor health outcomes, including recurrence, cardiovascular disease, dementia, and diabetes, and a number of deleterious symptoms, including a worsened inflammatory profile, breast cancer- related lymphedema, mobility disability, cognitive impairment, anxiety, and depressive symptoms. A wealth of meta-analytic and randomized controlled trial evidence show that adherence to World Health Organization and 2018 United States Physical Activity guidelines-based levels of moderate-to-vigorous physical activity (MVPA) reduces risk of all-cause mortality, and improves symptoms. However, few survivors engage in recommended levels of MVPA, and symptoms related to their multimorbidity may preclude engaging in sufficient levels of MVPA. Additional research of MVPA in this population is warranted; however, understudied light-intensity physical activity (LIPA) may be a more pragmatic target than MVPA among this complex population facing extensive challenges meeting MVPA recommendations. Large benefits are likely to occur from increasing these survivors' total activity, and LIPA prescriptions may be a more pragmatic approach than MVPA to aid this transition. METHODS: We present a broad, narrative review of the evidence for MVPA and LIPA in this population on an array of health outcomes across the translational science spectrum (clinical, implementation, and public health), and identify a number of directions for future research focused on understanding the potential diverse health effects of LIPA. CONCLUSION: Additional LIPA research is warranted, as LIPA prescriptions may be a pragmatic strategy to effectively promote physical activity to this complex population.

Assessment of a Community-Based Exercise Program for Older Adults in a Mixed Rural/Urban Catchment Area: Silver Sneakers in Central Pennsylvania.

The purpose of our study was to understand the capacity of Silver Sneakers, a federally funded and community-based exercise program, to serve older adults (aged ≥65 years) in our mixed rural/urban catchment area of central Pennsylvania. We identified 139 registered Silver Sneakers program locations; of these, 18 were closed because of the COVID-19 pandemic. We used questionnaires to interview Silver Sneakers program staff by telephone (n = 80 of 121, response rate of 66%). Most programs were offered by private gyms (52%). Fewer programs were in rural counties than in urban counties. Most facilities reported that membership was equally mixed by gender, and member retention strategies included program perks and promotion of Silver Sneakers as a Medicare benefit. Most (89%) programs were able to continue classes during the pandemic, in part by adapting to video platforms. Overall, Silver Sneakers programs offer a sustainable option to facilitate access to exercise programs and reduce barriers to physical activity among older adults in our catchment area.

Rethinking physical activity assessment in cancer survivors: a multi-component approach using NHANES data.

PURPOSE: To confirm that a multi-component physical activity index (PAI), with physical activity (PA)-related behaviors and performance measures, enhances PA assessment for adults with cancer history ("survivors") vs. for the general population for key health variables. METHODS: Data from 2011 to 2014 NHANES were analyzed (n = 9620 adults, including 866 survivors). We generated PAI scores by calculating subscales for activity-related behaviors (i.e., moderate-to-vigorous PA and TV viewing hours/sedentary time) (n/8) and performance (i.e., cardiorespiratory fitness and muscle strength) (n/8), then combined for an overall PAI score (n/16 points). Dependent variables (self-reported health, multimorbidity, and functional limitations) were dichotomized and tested with logistic regression to estimate associations with PAI variables. RESULTS: Survivors obtaining 22.5 + MET hours/week of PA were >5× more likely to report excellent health than non-exercisers (OR = 5.5, 95% CI 3.27-9.28). We observed a general decrease in likelihood of multimorbidity and functional limitations with increasing PA. Models with the combined score showed that higher PAI scores had larger positive associations with all three for all adults. Survivors with higher PAI scores were >30% more likely to report excellent self-rated health (OR = 1.3, 95% CI 1.2-1.4) and 20% less likely to report multimorbidity and functional limitations compared to survivors with lower PAI scores, considering covariates. CONCLUSIONS: Greater PA-related behavior and performance was beneficial for adults irrespective of cancer history. However, using a combined score elucidates unique needs and benefits for survivors vs. for general population. IMPLICATIONS FOR CANCER SURVIVORS: Using a multi-component approach to PA assessment could help in developing validated tools to plan exercise programs and interventions for survivors.

Study design and methods for the using exercise to relieve joint pain and improve AI adherence in older breast cancer survivors (REJOIN) trial.

BACKGROUND: Aromatase Inhibitors (AIs) are recommended for survival in post-menopausal breast cancer survivors (BCS) with hormone-sensitive disease. AI Adherence is suboptimal, especially in older BCS. Joint pain is a common AI-related symptom that is associated with low AI adherence. The Using Exercise to Relieve Joint Pain in Older Breast Cancer Survivors (REJOIN) Trial will evaluate the efficacy of a self-management intervention (exercise + education) to increase knowledge/self-efficacy for symptom management, reduce joint pain and potentially increase AI adherence in older BCS planning to take AIs. METHODS: This randomized controlled pilot trial will include sedentary BCS, 65 years and older, diagnosed with stage I-III hormone-sensitive breast cancer, who have completed primary cancer treatment and are planning to initiate AIs. We will adapt an evidence-based physical activity program for older adults that includes bi-weekly, supervised exercise sessions plus 30 min of education. The 16-week intervention program includes: 8-weeks of supervised sessions plus 8-weeks of self-guided home sessions with periodic phone coaching. We will conduct geriatric assessments plus measurements of exercise, joint pain, and AI adherence (baseline, 4, 6 and 12 months). DISCUSSION: REJOIN is one of the first trials to exclusively target older BCS using a self-management intervention, informed by geriatric assessment and exercise physiology, to improve health outcomes in survivorship. The REJOIN trial could lay the foundation for transdisciplinary research that bridges the gap between clinical and public health perspectives in healthy aging, with the opportunity to translate clinical interventions into non-pharmacological tools for a growing, yet underserved population of older survivors. TRIAL REGISTRATION: NCT03955627.

Mobility Device Use and Mobility Disability in U.S. Medicare Beneficiaries With and Without Cancer History.

BACKGROUND/OBJECTIVES: To examine the prevalence of mobility device use in U.S. community-dwelling older adults including older adults with cancer history ("survivors") and to estimate mobility disability noting variation by cancer history, cancer site, and other factors to improve early detection of mobility limitations. DESIGN: Cross-sectional analysis from the 2011 National Health and Aging Trends Study. SETTING: In-person interviews in the homes of study participants. PARTICIPANTS: Nationally representative sample of community-dwelling Medicare beneficiaries, aged 65 and older (n = 6,080 including 1,203 survivors). MEASUREMENTS: Participants were asked about cancer history, pain that limited activity, mobility device use (eg, canes, walkers, wheelchairs, and scooters), history of falls, and medical conditions plus they were assessed for approximate mobility disability using a 3-m gait speed test. The results were scored on a scale of 0 to 4 (0 = lowest, 4 = highest) using criteria from the National Institute on Aging. RESULTS: A total of 19% of older adults and 23% of survivors reported using one or more mobility device, most commonly a single-point cane. Approximately 10% of breast, 6% of prostate, and 3% of colorectal cancer survivors reported using two or more devices in the past month. Survivors had lower mean gait speed scores (2.27) than adults without cancer history (2.39). In regression models, survivors were 18% less likely than adults without cancer history to score high on the gait speed test (odds ratio = .82; P < .05). Prior mobility device use, history of multiple falls, unhealthy weight, Black race, multimorbidity, and pain that limited activity were associated with lower gait speed scores in all participants (all P < .05). CONCLUSION: A greater proportion of older survivors used mobility devices than adults without cancer history. Mobility device use varied by cancer site and was highest in survivors of breast, colorectal, and gynecological cancer. Survivors were also more likely to show signs of mobility disability, based on gait speed, compared with adults without cancer history. These indications, although modest, suggest that older survivors may require special attention to functional changes in survivorship.

Prostate cancer in Pennsylvania: The role of older age at diagnosis, aggressiveness, and environmental risk factors on treatment and mortality using data from the Pennsylvania Cancer Registry.

BACKGROUND: To assess: (a) cancer treatment in prostate cancer survivors (PCS) by age at diagnosis (ADx) and prostate cancer (PC) aggressiveness; (b) potential impact on PC mortality; and (c) these results in the context of environmental/behavioral risk factors on PCS in Pennsylvania. METHODS: Prostate cancer survivors ages ≥40 years were identified from the 2004-2014 Pennsylvania Cancer Registry (PCR). Demographic/clinical descriptors and PC treatment were extracted from PCR. Prostate cancer aggressiveness was defined by clinical/pathologic Gleason score and tumor stage. Logistic and Cox regression analyses tested associations between treatment received and PC-specific mortality. County-level data from the Pennsylvania BRFSS were used to estimate cancer-related behavioral risk factors (eg, smoking, physical inactivity, fruit/vegetable consumption [FV], alcohol use) and used as covariates. RESULTS: There were 90 694 PCS ages 40-105 years (mean age = 66.19 years, SD = 9.25) included. Most were non-Hispanic white men (83%). Prostate cancer survivors ≥75 years were least likely to receive any treatment but men ages 65-74 were more likely to receive combined therapies (OR = 1.47; 95% CI 1.28, 1.69) vs PCS ages 40-54 years, controlling for covariates. Prostate cancer survivors 55-75+ with aggressive PC who received any treatment vs no definitive treatment had significantly reduced mortality. Men from counties with high obesity and smoking rates were significantly less likely to receive any treatment than men living in counties with lower rates of these risk factors. Prostate cancer survivors who lived in counties with high rates of physical inactivity and had high rates of sufficient FV consumption were slightly more likely to receive cancer treatment vs no definitive treatment compared to men who lived in counties with high rates of physical activity and lower FV consumption. CONCLUSIONS: We observed a general age-related decline in receipt of treatment. Prostate cancer survivors ages ≥75 years were significantly less likely to get any cancer treatment compared to younger PCS. However, most men with more aggressive disease who received any treatment had greatly reduced PC mortality, regardless of age. Considering environmental/behavioral risk factors may attenuate PC risk and inform treatment options.

Rural-urban differences in meeting physical activity recommendations and health status in cancer survivors in central Pennsylvania.

PURPOSE: This study explored rural-urban differences in meeting physical activity (PA) recommendations and health status in cancer survivors in central Pennsylvania and associations between PA and health status. METHODS: Cancer survivors (N = 2463) were identified through a state cancer registry and mailed questionnaires assessing PA and health status. Rural-urban residence was based on county of residence at diagnosis. Participants self-reported frequency and duration of leisure-time PA and were classified as meeting: (1) aerobic recommendations (≥ 150 min/week), (2) muscle-strengthening recommendations (≥ 2 times/week), (3) both aerobic and muscle-strengthening recommendations, or (4) neither recommendation. Logistic regression models examined associations between rural-urban residence and meeting PA recommendations and associations between PA and health status, adjusting for age, cancer type, gender, and income. RESULTS: Nearly 600 (N = 591, 24.0%) cancer survivors returned completed questionnaires (rural 9.5%, urban 90.5%). Half (50.0%) of rural cancer survivors reported no leisure-time PA compared to 35.2% of urban cancer survivors (p = 0.020), and urban cancer survivors were 2.6 times more likely to meet aerobic PA recommendations (95% CI 1.1-6.4). Odds of reporting good physical and mental health were 2.3 times higher among survivors who reported meeting aerobic recommendations compared to those who did not meet PA recommendations (95% CI 1.1-4.5), adjusting for rurality and covariates. CONCLUSIONS: Results demonstrate persistent rural-urban differences in meeting PA recommendations in cancer survivors and its association with self-reported health. IMPLICATIONS FOR CANCER SURVIVORS: Findings underscore the need for interventions to increase PA in rural cancer survivors in an effort to improve health status and reduce cancer health disparities.

Author Correction: Suicide among cancer patients.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Physical Activity in Older Cancer Survivors: What Role Do Multimorbidity and Perceived Disability Play?

PURPOSE: (a) To describe the relationship of multimorbidity and physical activity (PA) in cancer survivors and (b) to explore perceived disability and PA in middle-aged and older survivors. METHODS: The authors analyzed the data from cancer survivors (N = 566), identified using the Pennsylvania Cancer Registry, who responded to a Behavioral Risk Factor Surveillance System-derived questionnaire. They created age groups (e.g., 45-54 years, 55-64 years, 65-74 years, and 75 years and older) and calculated a composite score of eight common comorbidities (e.g., chronic obstructive pulmonary disease, heart disease) to assess multimorbidity. Logistic regression was used to estimate the association of demographic and behavioral/clinical risk factors (e.g., multimorbidity, perceived disability, body mass index) with PA. RESULTS: Most respondents were females (62%), older (mean age = 68 years) and represented diverse cancer sites, including breast (n = 132), colorectal (n = 102), gynecologic (n = 106), prostate (n = 111), and lung (n = 80). PA participation was mixed; 44% of survivors reported achieving >150 min of aerobic PA, but half of lung and 37% of gynecologic survivors reported no PA (0 min/week). Higher multimorbidity (odds ratio = 0.82, confidence  interval [0.69, 0.98], p < .05), obesity (odds ratio = 0.51, confidence  interval [0.30, 0.86], p < .05), and perceived disability (odds ratio = 0.49, confidence  interval [0.32, 0.77], p < .001) were negatively associated with PA participation. Strength training was suboptimal across all survivors. CONCLUSION: Most older survivors experienced comorbid conditions, and this was associated with less PA. Survivors who perceived themselves as disabled or who were obese were half as likely as others to participate in PA. This suggests an increasing need to address both physical and psychological limitations in designing PA interventions for real-world needs. Exercise interventions that address the unique needs of older survivors for multimorbidity, obesity, and perceived disability may strengthen opportunities for PA.

A population-based study of cardiovascular disease mortality risk in US cancer patients.

AIMS: This observational study characterized cardiovascular disease (CVD) mortality risk for multiple cancer sites, with respect to the following: (i) continuous calendar year, (ii) age at diagnosis, and (iii) follow-up time after diagnosis. METHODS AND RESULTS: The Surveillance, Epidemiology, and End Results program was used to compare the US general population to 3 234 256 US cancer survivors (1973-2012). Standardized mortality ratios (SMRs) were calculated using coded cause of death from CVDs (heart disease, hypertension, cerebrovascular disease, atherosclerosis, and aortic aneurysm/dissection). Analyses were adjusted by age, race, and sex. Among 28 cancer types, 1 228 328 patients (38.0%) died from cancer and 365 689 patients (11.3%) died from CVDs. Among CVDs, 76.3% of deaths were due to heart disease. In eight cancer sites, CVD mortality risk surpassed index-cancer mortality risk in at least one calendar year. Cardiovascular disease mortality risk was highest in survivors diagnosed at <35 years of age. Further, CVD mortality risk is highest (SMR 3.93, 95% confidence interval 3.89-3.97) within the first year after cancer diagnosis, and CVD mortality risk remains elevated throughout follow-up compared to the general population. CONCLUSION: The majority of deaths from CVD occur in patients diagnosed with breast, prostate, or bladder cancer. We observed that from the point of cancer diagnosis forward into survivorship cancer patients (all sites) are at elevated risk of dying from CVDs compared to the general US population. In endometrial cancer, the first year after diagnosis poses a very high risk of dying from CVDs, supporting early involvement of cardiologists in such patients.

Suicide among cancer patients.

Our purpose is to identify cancer patients at highest risk of suicide compared to the general population and other cancer patients. This is a retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 1973-2014. Among 8,651,569 cancer patients, 13,311 committed suicide; the rate of suicide was 28.58/ 100,000-person years, and the standardized mortality ratio (SMR) of suicide was 4.44 (95% CI, 4.33, 4.55). The predominant patients who committed suicide were male (83%) and white (92%). Cancers of the lung, head and neck, testes, bladder, and Hodgkin lymphoma had the highest SMRs ( > 5-10) through the follow up period. Elderly, white, unmarried males with localized disease are at highest risk vs other cancer patients. Among those diagnosed at < 50 years of age, the plurality of suicides is from hematologic and testicular tumors; if > 50, from prostate, lung, and colorectal cancer patients.

Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship.

Accreditation standards are at the forefront of evolving healthcare systems, setting metrics for high-quality care. Healthcare outcomes (health, experience, cost, provider satisfaction/burn out) are becoming mutual goals of the patient, provider, payer, and healthcare system. Achieving high-quality outcomes in cancer care necessitates collaboration among interdisciplinary teams of clinical providers, administrators, patient advocates, caregivers, and researchers. Dissemination and implementation science provides necessary frameworks to organize the efforts of these implementation teams, inclusive of identifying facilitators and barriers to implementation of accreditation standards. Since 2015, cancer distress screening has been mandated for continued cancer center accreditation by the American College of Surgeon's Commission on Cancer. Cancer centers have thus become real world implementation laboratories. We present the current context of distress screening, highlighting prior research and key areas of future research. We consider multiple levels of cancer care delivery and the use of interdisciplinary teams to help cancer center teams adopt, implement, and maintain efficient distress screening programs. Finally, we present a case study to identify methods for successful implementation of distress screening at one cancer center and then describe efficiencies that can be introduced using elements from human factors engineering, e- and m-health screening platforms, and community partnerships.

Healthy Living After Cancer Treatment: Considerations for Clinical and Community Practice.

As the number of US cancer survivors now reaches almost 16 million, understanding how to care for survivors after cancer treatment has demanded national attention. Increasingly, compelling benefits of lifestyle behaviors for cancer prevention and control have been demonstrated. In particular, physical activity is recommended as a central component of healthy living after cancer treatment. However, survivors struggle to achieve recommended physical activity and other behaviors for reasons that are still not well understood. Further, as greater than 60% of cancer survivors are older than 65 years, there is a unique opportunity to increase engagement of older adults in health programs and clinical trials. This article considers evidence from two reviews: a review on epidemiology studies of lifestyle and cancer and a review on different behavioral intervention strategies to achieve positive behavioral changes in cancer survivors. Both reviews offer important evidence on the role of lifestyle in life after cancer treatment. However, more investigation is needed on the practice of lifestyle medicine for cancer survivors, including ways to extend the reach of health promotion beyond cancer clinics, to primary care and community settings.

Electronic Health Information Exchange Opportunities for Self-management of Care: Responses from Older Adults With and Without Cancer History in the United States.

PURPOSE OF STUDY: Of 15.5 million US cancer survivors, 80% are ≥ 55 years. Supporting older patients in care self-management through electronic health information (EHI) exchange may enhance recovery. We assessed: (1) perceived importance of EHI access to adults ≥ 55 years (incl survivors) and (2) age-related preferences for EHI exchange. RECENT FINDINGS: Older adults are one of the fastest-growing user groups for internet/technologies. Most older adults 55-64 years are active internet users, and use among adults ≥ 65 years is growing quickly as baby boomers mature. Understanding EHI patient-provider exchange preferences may provide opportunities for older patients but also begin to address the future needs of other patient populations, including cancer survivors. We observed a "digital divide" for perceived importance of EHI access and EHI exchange interests. Engaging older adults (i.e., ≥ 75 years) to improve comfort/experience with technologies may support EHI use in self-management. Survivors may have distinct EHI needs/preferences than older adults without cancer history.

Cognitive function and discontinuation of adjuvant hormonal therapy in older breast cancer survivors: CALGB 369901 (Alliance).

PURPOSE: To investigate the effects of cognitive function on discontinuation of hormonal therapy in breast cancer survivors ages 65+ ("older"). METHODS: Older breast cancer survivors with invasive, non-metastatic disease, and no reported cognitive difficulties were recruited from 78 Alliance sites between 2004 and 2011. Eligible survivors (n = 1280) completed baseline interviews; follow-up was conducted annually for up to 7 years. Survivors with estrogen-receptor-positive (ER+) cancers who initiated hormonal therapy (n = 990) were included. Self-reported cognitive function was measured using the EORTC-QLQ30 scale; a difference of eight points on the 0-100 scale was considered clinically significant. Based on varying rates of discontinuation over time, discontinuation was evaluated separately for three time periods: early (<1 year); midpoint (1-3 years); and late discontinuation (>3-5 years). Cox models for each time period were used to evaluate the effects of cognition immediately preceding discontinuation, controlling for age, chemotherapy, and other covariates. RESULTS: Survivors were 65-91 years old (mean 72.6 years), and 79% had stages 1 or 2A disease. Overall, 43% discontinued hormonal therapy before 5 years. Survivors who reported lower cognitive function in the period before discontinuation had greater hazards of discontinuing therapy at the treatment midpoint (HR 1.22 per 8-point difference, CI 1.09-1.40, p < 0.001), considering covariates, but cognition was not related to discontinuation in the other periods. CONCLUSIONS: Self-reported cognitive problems were a significant risk factor for discontinuation of hormonal therapy 1-3 years post-initiation. Additional research is needed on the temporality of cognitive effects and hormonal therapy to support survivorship care needs of older survivors.

Deconstructing Decisions to Initiate, Maintain, or Discontinue Adjuvant Endocrine Therapy in Breast Cancer Survivors: A Mixed-Methods Study.

PURPOSE/OBJECTIVES: Adjuvant endocrine therapy (AET) has been shown to improve survival in hormone receptor-positive breast cancer survivors, but as many as half do not complete recommended treatment. Management of medication-related side effects and engagement with providers are two potentially modifiable factors, but their associations with adherence are not well understood. The aims were to build on survey results to qualitatively explore survivors' experiences with prescribed AET to (a) describe appraisal and management of AET side effects and (b) deconstruct decisions to initiate, discontinue, or maintain AET.
. RESEARCH APPROACH: The authors used a mixed-methods explanatory sequence research design with a qualitative emphasis.
. SETTING: Survivors were recruited from a clinical cancer registry maintained at the University of Texas Southwestern Medical Center, which includes the Harold C. Simmons Comprehensive Cancer Center (National Cancer Institute-designated), in Dallas.
. PARTICIPANTS: 452 survivors completed a survey, and 30 took part in telephone interviews.
. METHODOLOGIC APPROACH: Qualitative methods were used in which the authors recorded and transcribed interviews for analysis and used open coding to reduce data into themes.
. FINDINGS: Among adherent survivors, the themes of tolerance of side effects and perseverance were strong. Nonadherent survivors expressed more difficulty managing side effects and perceived fewer benefits when side effects were bothersome. The most common side effects mentioned by all survivors were menopausal symptoms and joint pain; less common side effects were cognitive decline and cardiac distress. Some sought advice from their oncology team. Nonadherent survivors appeared initially motivated to maintain AET but identified a tolerance limit for side effects after which a provider's recommendation was less influential in their decision to maintain or discontinue AET.
. INTERPRETATION: This study elucidated adherence as a complex continuum of behaviors, appraisals, and decision points. These insights may be particularly useful in counseling survivors taking AET and promoting timely delivery of clinical interventions to enhance adherence.
. IMPLICATIONS FOR NURSING: Nurses should be involved in the planning and implementation of clinical interventions to manage side effects and other barriers to AET adherence.