Weight management and physical activity throughout the cancer care continuum.

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

Adherence to adjuvant endocrine therapy for breast cancer: a qualitative exploration of attribution of symptoms among post-menopausal women.

PURPOSE: Oral adjuvant endocrine therapy (AET) is an effective treatment for hormone receptor positive breast cancer to decrease recurrence and mortality, but adherence is poor. This study explored post-menopausal women's experiences with AET, with a particular focus on adherence to AET as well as distress and symptoms experienced prior to and during AET treatment. METHODS: Participants were recruited from a hospital registry, stratified by adherence to/discontinuation of AET. Telephone interviews followed a semi-structured interview guide and were recorded and transcribed verbatim. Transcripts were systematically coded using team-based coding, with analysis of themes using a grounded theory approach. RESULTS: Thirty-three participants were interviewed; ages ranged from 57 to 86 years. Participants included 10 discontinued patients and 23 patients who completed their AET course or were adherent to AET at the time of interviewing. Both adherent and discontinued patients reported symptoms throughout their AET treatment course, and both attributed symptoms to factors other than AET (e.g., older age and pre-existing comorbidities). However, discontinued patients were more likely to attribute symptoms to AET and to describe difficulty managing their symptoms, with some directly citing symptoms as the reason for discontinuing AET therapy. Conversely, adherent patients were more likely to describe the necessity of taking AET, despite symptoms. CONCLUSIONS: AET adherence was associated with beliefs about AET, symptom attribution, and symptom management. Routine symptom monitoring during AET and addressing both symptoms and patients' understanding of their symptoms may promote adherence to AET.

Equipping Faith-Based Communities for Cancer Support Ministry: A Pilot Study of Cancer Support Training for Members of African-American Churches in the USA.

Church-academic partnerships focused on cancer, generally target cancer screening and prevention, with few focusing explicitly on cancer survivors. With the population of cancer survivors steadily increasing, highlighting the value of faith-based cancer support ministry is paramount. However, many churches may not have the resources to integrate relevant cancer support ministry and may need to identify ways to reach cancer survivors. We piloted cancer support training to help church members to start a cancer support ministry with African-American churches in Milwaukee, WI. We sought to measure the feasibility of a two-day training workshop to build the capacity of churches through recruiting and training church members on how to foster social support and to disseminate cancer information and resources throughout their churches. Our study was guided by the social networks and social support framework, which we applied to cancer survivorship. Our study supports the feasibility of engaging churches in a virtual training to support the development of cancer support ministries to address the needs of African-American cancer survivors. Based on our recruitment success, workshop attendance, evaluation and retention, our results suggest that a two-day workshop was successful in facilitating the initiation of cancer support ministries within African-American churches.

Exploring health behaviors, quality of life, and support needs in African-American prostate cancer survivors: a pilot study to support future interventions.

PURPOSE: Prostate cancer incidence and mortality rates are highest among African-American men. Comorbidity burden and quality of life (QOL) challenges are also high. Many factors drive these differences; health behaviors are important modifiable contributors. Studies document positive results for lifestyle interventions targeting NHW prostate cancer survivors, but inclusion of African-Americans is limited. We conducted an exploratory mixed-methods study with AAPCS to inform the development of a culturally relevant lifestyle intervention. METHODS: Twenty-two AAPCS completed questionnaires and a discussion group on dietary and physical activity patterns, QOL, and unmet needs related to lifestyle changes. RESULTS: Seventy-five percent of the participants were overweight or obese, 82% had physical activity patterns considered insufficiently active and only 10% did resistance training at least twice weekly in accordance with current survivorship guidelines. Diets were high in saturated fat and sugar, low in fiber, fruit, and vegetable intake. PROMIS-29 scores indicated that AAPCS had worse physical functioning, pain interference, and sexual functioning, but less social isolation compared to the general population. Compared to other prostate cancer survivors, participants reported poorer status on all domains. Qualitative data highlighted barriers to healthy lifestyles including access, knowledge, and skills, as well as motivators including health benefits and building strength to feel more "manly." Participants shared high interest in programs to exercise, learn about affordable healthy eating, and bring survivors together to discuss survivorship issues. CONCLUSIONS: Lifestyle interventions targeting AAPCS are warranted. To increase impact of these efforts, consideration of environmental, cultural, and survivor contexts will be key.

A Step toward Understanding Diet Quality in Urban African-American Breast Cancer Survivors: A Cross-sectional Analysis of Baseline Data from the Moving Forward Study.

PURPOSE: Little is known about the dietary behaviors of African-American breast cancer survivors (AABCS). We sought to describe dietary intake and quality in AABCS and examine associations with demographic, social, lifestyle, and body composition factors to potentially inform the development of effective dietary interventions. METHODS: Baseline data from a prospective weight loss trial of 210 AABCS were assessed. A food frequency questionnaire was used to evaluate dietary intake and diet quality via the Healthy Eating Index 2010 (HEI-2010) and Alternative Healthy Eating Index 2010 (AHEI-2010). Linear regression analysis was conducted to determine the most influential variables on diet quality. RESULTS: Mean HEI- and AHEI-2010 total scores were 65.11 and 56.83 indicating that diet quality needs improvement. Women were the least adherent to recommendations for intake of whole grains, dairy, sodium, empty calories, sugary beverages, red/processed meats, and trans-fat. Increased self-efficacy for healthy eating behaviors, more years of education (AHEI only), negative smoking status, smaller waist circumference, and increased physical activity (HEI only) were significantly associated with higher diet quality scores. CONCLUSION: Our findings suggest the diet quality of AABCS needs improvement. Intervention programs may achieve higher diet quality in AABCS by focusing on increasing self-efficacy for healthy eating behaviors.

A feasibility study of breast cancer genetic risk assessment in a federally qualified health center.

BACKGROUND: The US Preventive Services Task Force (USPSTF) endorses routine screening for genetic risk of breast and/or ovarian cancer as a component of primary health care. Implementation of this recommendation may prove challenging, especially in clinics serving disadvantaged communities. METHODS: The authors tested the feasibility of implementing the USPSTF mandate at a federally qualified health center (FQHC) to identify women who were eligible for genetic counseling (GC). A 12-month usual-care phase was followed by a 12-month intervention phase, during which time cancer genetic risk assessment (CGRA) was systematically performed for all women aged 25 to 69 years who presented for an annual examination. Women who were eligible for GC were recruited to participate in the study. RESULTS: After initiating CGRA, 112 women who were eligible for GC consented to study participation, and 56% of them received a referral for GC from their primary care physician. A subgroup of 50 participants were seen by the same primary care physician during both the usual-care and intervention phases. None of these patients was referred for GC during usual care, compared with 64% after the initiation of CGRA (P < .001). Only 16% of referred participants attended a GC session. CONCLUSIONS: Implementing USPSTF recommendations for CGRA as a standard component of primary health care in FQHCs is feasible and improves referral of minority women for GC, but more work is needed to understand the beliefs and barriers that prevent many underserved women from accessing cancer genetic services.

Repurposing existing medications as cancer therapy: design and feasibility of a randomized pilot investigating propranolol administration in patients receiving hematopoietic cell transplantation.

BACKGROUND: Repurposing existing medications for antineoplastic purposes can provide a safe, cost-effective, and efficacious means to further augment available cancer care. Clinical and preclinical studies suggest a role for the ß-adrenergic antagonist (ß-blocker) propranolol in reducing rates of tumor progression in both solid and hematologic malignancies. In patients undergoing hematopoietic cell transplantation (HCT), the peri-transplant period is a time of increased activity of the ß-adrenergically-mediated stress response. METHODS: We conducted a proof-of-concept randomized controlled pilot study assessing the feasibility of propranolol administration to patients between ages 18-75 who received an autologous HCT for multiple myeloma. Feasibility was assessed by enrollment rate, tolerability, adherence, and retention. RESULTS: One hundred fifty-four patients underwent screening; 31 (20%) enrolled in other oncology trials that precluded dual trial enrollment and 9 (6%) declined to enroll in the current trial. Eighty-nine (58%) did not meet eligibility requirements and 25 (16%) were eligible; of the remaining eligible patients, all were successfully enrolled and randomized. The most common reasons for ineligibility were current ß-blocker use, age, logistics, and medical contraindications. 92% of treatment arm patients tolerated and remained on propranolol for the study duration; 1 patient discontinued due to hypotension. Adherence rate in assessable patients (n = 10) was 94%. Study retention was 100%. CONCLUSIONS: Findings show that it is feasible to recruit and treat multiple myeloma patients with propranolol during HCT, with the greatest obstacle being other competing oncology trials. These data support further studies examining propranolol and other potentially repurposed drugs in oncology populations. TRIAL REGISTRATION: This randomized controlled trial was registered at clinicaltrials.gov with the identifier NCT02420223 on April 17, 2015.

Negative psychological consequences of breast cancer among recently diagnosed ethnically diverse women.

OBJECTIVE: Breast cancer has psychological consequences that impact quality of life. We examined factors associated with negative psychological consequences of a breast cancer diagnosis, in a diverse sample of 910 recently diagnosed patients (378 African American, 372 white, and 160 Latina). METHODS: Patients completed an in-person interview as part of the Breast Cancer Care in Chicago study within an average of 4 months from diagnosis. The Cockburn negative psychological consequences of breast cancer screening scale was revised to focus on a breast cancer diagnosis. Path analysis assessed predictors of psychological consequences and potential mediators between race/ethnicity and psychological consequences. RESULTS: Compared to white counterparts, bivariate analysis showed African American (ß = 1.4, P < .05) and Latina (ß = 3.6, P < .001) women reported greater psychological consequences. Strongest predictors (P < .05 for all) included unmet social support (ß = .38), and provider trust (ß = .12), followed by stage at diagnosis (ß = .10) and perceived neighborhood social disorder (ß = .09).The strongest mediator between race/ethnicity and psychological consequences was unmet social support. CONCLUSIONS: African American and Latina women reported greater psychological consequences related to their breast cancer diagnosis; this disparity was mediated by differences in unmet social support. Social support represents a promising point of intervention.

Mediation of Racial and Ethnic Disparities in Estrogen/Progesterone Receptor-Negative Breast Cancer by Socioeconomic Position and Reproductive Factors.

Hispanic and non-Hispanic black breast cancer patients are more likely than non-Hispanic white patients to be diagnosed with breast cancer that is negative for estrogen and progesterone receptors (ER/PR-negative). This disparity might be transmitted through socioeconomic and reproductive factors. Data on 746 recently diagnosed breast cancer patients (300 non-Hispanic white, 303 non-Hispanic black, 143 Hispanic) were obtained from the population-based Breast Cancer Care in Chicago Study (Chicago, Illinois, 2005-2008). Income, educational level, and census tract measures of concentrated disadvantage and affluence were combined into a single measure of socioeconomic position (SEP). Parity and age at first birth were combined into a single measure of reproductive factors (RPF). We constructed path models to estimate direct and indirect associations of SEP and RPF, and we estimated average marginal controlled direct associations. Compared with non-Hispanic white patients, non-Hispanic black patients and Hispanic patients were more likely to have ER/PR-negative disease (28% and 20% for non-Hispanic black patients and Hispanic patients, respectively, vs. 12% for non-Hispanic white patients; P ≤ 0.001). The ethnic disparity in ER/PR-negative breast cancer (prevalence difference = 0.13, 95% confidence interval: 0.07, 0.18) was reduced by approximately 60% (prevalence difference = 0.05, 95% confidence interval: -0.04, 0.13) after control for SEP and RPF. At least part of the ethnic disparity in the aggressiveness of breast tumors might be transmitted through social influences on tumor biology.

Health Behavior and Weight Changes Among Ethnic and Racial Minority Preschoolers and Their Parents: Associations Across 1 Year.

OBJECTIVE: To determine whether parent health behavior changes and feeding practices were associated with child changes in body mass index z-score and related health behaviors over the course of 1 year. METHODS: Anthropometric data from 590 child-parent dyads of ethnic/racial minority groups were collected at baseline, 14 weeks (postintervention), and 1-year follow-up. Additionally, parent screen time and feeding practices and child dietary consumption, diet quality, physical activity, and screen time were collected. RESULTS: Random effects growth models revealed that changes in child screen time moved in tandem with parent screen time from baseline to 14-week postintervention and from postintervention to 1-year follow-up. Greater parental monitoring predicted greater reduction in child calorie consumption at 1 year. CONCLUSIONS: Future studies should include innovative ways to explicitly involve parents in prevention efforts.

Health behaviors of minority childhood cancer survivors.

BACKGROUND: Available data have suggested that childhood cancer survivors (CCSs) are comparable to the general population with regard to many lifestyle parameters. However, to the authors' knowledge, little is known regarding minority CCSs. This cross-sectional study describes and compares the body mass index and health behaviors of African American, Hispanic, and white survivors with each other and with noncancer controls. METHODS: Participants included 452 adult CCSs (150 African American, 152 Hispanic, and 150 white individuals) recruited through 4 childhood cancer treating institutions and 375 ethnically matched noncancer controls (125 in each racial/ethnic group) recruited via targeted digit dial. All participants completed a 2-hour in-person interview. RESULTS: Survivors and noncancer controls reported similar health behaviors. Within survivors, smoking and physical activity were found to be similar across racial/ethnic groups. African American and Hispanic survivors reported lower daily alcohol use compared with white individuals, but consumed unhealthy diets and were more likely to be obese. CONCLUSIONS: This unique study highlights that many minority CCSs exhibit lifestyle profiles that contribute to an increased risk of chronic diseases and late effects. Recommendations for behavior changes must consider the social and cultural context in which minority survivors may live.

Study design and protocol for moving forward: a weight loss intervention trial for African-American breast cancer survivors.

BACKGROUND: Breast cancer survival rates are significantly lower among African-American women compared to white women. In addition, African-American women with breast cancer are more likely than white women to die from co-morbid conditions. Obesity is common among African-American women, and it contributes to breast cancer progression and the development and exacerbation of many weight-related conditions. Intervening upon obesity may decrease breast cancer and all-cause mortality among African-American breast cancer survivors. METHODS/DESIGN: Moving Forward is a weight loss intervention being evaluated in a randomized trial with a projected sample of 240 African American breast cancer survivors. Outcomes include body mass index, body composition, waist:hip ratio, and behavioral, psychosocial and physiological measures. Survivors are randomized to either a 6-month guided weight loss intervention that involves twice weekly classes and text messaging or a self-guided weight loss intervention based on the same materials offered in the guided program. The guided intervention is being conducted in partnership with the Chicago Park District at park facilities in predominantly African-American neighborhoods in Chicago. Recruitment strategies include direct contact to women identified in hospital cancer registries, as well as community-based efforts. Data collection occurs at baseline, post-intervention (6 months) and at a 12-month follow-up. DISCUSSION: This study evaluates a community-based, guided lifestyle intervention designed to improve the health of African-American breast cancer survivors. Few studies have addressed behavioral interventions in this high-risk population. If successful, the intervention may help reduce the risk for breast cancer recurrence, secondary cancers, and co-morbid conditions, as well as improve quality of life. TRIAL REGISTRATION: U.S. Clinicaltrials.gov number: NCT02482506, April 2015.

Stay on Track: A Pilot Randomized Control Trial on the Feasibility of a Diet and Exercise Intervention in Patients with Breast Cancer Receiving Radiotherapy.

PURPOSE: Among patients with breast cancer undergoing radiotherapy, posttreatment cardiovascular disease and worsened quality of life (QoL) are leading causes of morbidity and mortality. To overcome these negative radiotherapy effects, this prospective, randomized clinical trial pilots a 12-week Stay on Track exercise and diet intervention for overweight patients with nonmetastatic breast cancer undergoing whole-breast radiotherapy. EXPERIMENTAL DESIGN: The intervention group (n = 22) participated in three personal exercise and dietary counseling sessions, and received three text reminders/week to adhere to recommendations. The control group (n = 22) was administered a diet/exercise information binder. All patients received a Fitbit, and at baseline, 3 months, and 6 months, measurements of biomarkers, dual-energy X-ray absorptiometry scans, QoL and physical activity surveys, and food frequency questionnaires were obtained. A satisfaction survey was administered at 3 months. RESULTS: Stay on Track was well received, with high rates of adherence and satisfaction. The intervention group showed an increase in self-reported physical activity and preserved QoL, a decrease in body mass index and visceral fat, and higher American Cancer Society/American Institute of Cancer Research dietary adherence. The control participants had reduced QoL, anti-inflammatory markers, and increased metabolic syndrome markers. Both groups had decreased overall body mass. These changes were within group effects. When comparing the intervention and control groups over time, there were notable improvements in dietary adherence in the intervention group. CONCLUSIONS: Targeted lifestyle interventions during radiotherapy are feasible and could decrease cardiovascular comorbidities in patients with breast cancer. Larger-scale implementation with longer follow-up can better determine interventions that influence cardiometabolic health and QoL. SIGNIFICANCE: This pilot study examines cardiometabolic benefits of a combined diet and exercise intervention for patients with breast cancer undergoing radiotherapy. The intervention included an activity tracker (FitBit) and text message reminders to promote adherence to lifestyle interventions. Large-scale implementation of such programs may improve cardiometabolic outcomes and overall QoL among patients with breast cancer.

Diet and physical activity in childhood cancer survivors: a review of the literature.

Treatment advances have led to a growing population of childhood cancer survivors. Many are at risk for developing treatment-related late effects. Diet and physical activity may affect levels of health risk. A number of papers have examined these behaviors in childhood cancer survivors. The purpose of this study was to provide a review and summary of the published studies in the areas of diet, physical activity, and related interventions among childhood cancer survivors. A systematic search was conducted for studies published prior to October 2009. Descriptive and intervention studies that included survivors of childhood cancers and a measurement of diet and/or physical activity were reviewed. Twenty-six manuscripts met criteria: ten addressed diet; 20 addressed physical activity, and six included intervention studies. Results suggest that childhood cancer survivors engage in health-promoting activities at rates comparable to the general population. Behavioral interventions have mostly targeted physical activity. Results, overall, are not encouraging, due primarily to difficulties recruiting and retaining participants. Although more rigorous studies are needed, recommendations for health-promoting behaviors should be a regular topic of discussion between health care providers and their childhood cancer survivor patients.

A weight loss intervention for African American breast cancer survivors, 2006.

INTRODUCTION: Breast cancer survival rates are lower for African American women than for white women. Obesity, high-fat diets, and lack of regular physical activity increase risk for breast cancer recurrence, comorbid conditions, and premature death. Eighty-two percent of African American women are overweight or obese, partly because of unhealthy eating and exercise patterns. Although successful weight loss and lifestyle interventions for breast cancer survivors are documented, none has considered the needs of African American breast cancer survivors. This study assessed the feasibility and impact of Moving Forward, a culturally tailored weight loss program for African American breast cancer survivors. METHODS: The study used a pre-post design with a convenience sample of 23 African American breast cancer survivors. The 6-month intervention was theory-based and incorporated qualitative data from focus groups with the targeted community, urban African American breast cancer survivors. Data on weight, body mass index (BMI), diet, physical activity, social support, and quality of life were collected at baseline and at 6 months. RESULTS: After the intervention, we noted significant differences in weight, BMI, dietary fat intake, vegetable consumption, vigorous physical activity, and social support. CONCLUSION: This is the first published report of Moving Forward, a weight loss intervention designed for African American breast cancer survivors. Although a randomized trial is needed to establish efficacy, the positive results of this intervention suggest that this weight loss intervention may be feasible for African American breast cancer survivors. Lifestyle interventions may reduce the disparities in breast cancer mortality rates.

Mobile phone text messaging to promote healthy behaviors and weight loss maintenance: a feasibility study.

There is a need to investigate newer strategies pertaining to the maintenance of healthy behaviors and weight. We investigated the feasibility of mobile phone text messaging to enable ongoing communication with African-American women participating in a weight management program. Ninety-five African-American women participated in this pilot study and received regularly scheduled text messages. Forty-two of these women chose to create 165 personal text messages that included tips on healthy eating and physical activity, as well as reminders to drink water and expressions of encouragement. A commercially available client-based application transmitted these personal messages and general health messages at least three times per week. The software transmitted over 4500 text messages during the first 4 months with 114 returned as undeliverable. Participants expressed generally positive attitudes toward incoming text messages, with only one participant declining to continue after enrollment. This study demonstrated early feasibility and acceptability of text messaging as a method for promoting healthy behaviors for weight maintenance.

Comparative Effectiveness Trial of an Obesity Prevention Intervention in EFNEP and SNAP-ED: Primary Outcomes.

There is a need to disseminate evidence-based childhood obesity prevention interventions on a broader scale to reduce obesity-related disparities among underserved children. The purpose of this study was to test the comparative effectiveness of an evidence-based obesity prevention intervention, Hip-Hop to Health (HH), delivered through Expanded Food and Nutrition Education Program (EFNEP) and the Supplemental Nutrition Assistance Program-Education (SNAP-Ed) versus the standard curriculum delivered by the programs (Standard Nutrition Education (NE)). A nonequivalent control group design was delivered to compare the effectiveness of HH to NE on weight gain prevention and health behavior outcomes at EFNEP and SNAP-Ed sites. One hundred and fifty-three caregiver-child dyads (n = 103 in the HH group; n = 50 in the NE group) participated in the study. HH is an evidence-based dietary and physical activity intervention for low-income preschool children. The NE curriculum provided lessons for children that are consistent with the Dietary Guidelines for Americans 2010. Data were collected on demographics, anthropometrics, and behavioral variables for parent-child dyads at baseline and postintervention. Mixed model methods with random effects for site and participant were utilized. No differences in child or caregiver diet, physical activity, or screen time by group were found. No between-group differences in child BMI z-score were found; however, caregivers in the HH group lost significantly more weight than those in the NE group. Results from this trial can inform future dissemination efforts of evidenced-based programs for underserved families.

Associations between fiber intake and Body Mass Index (BMI) among African-American women participating in a randomized weight loss and maintenance trial.

INTRODUCTION: African-American women are at increased risk for obesity, and therefore it is important to identify dietary factors that have the potential to prevent weight gain within this population. The purpose of the current study was to examine associations between daily fiber intake and Body Mass Index (BMI) over the course of an 18-month weight loss intervention for African-American women. METHODS: Anthropometric measures and the Block Food Frequency Questionnaire were administered at baseline, 6-month, and 18-month follow-up between 2008 and 2010. A mixed-effects linear regression model with random intercept and time slope was used to model associations between fiber consumption and BMI controlling for time trend. RESULTS: Associations between fiber consumption and BMI were significantly different over time (ß̂Fiber∗Time=-0.07,p-value=0.003). There was no association between fiber intake and BMI at baseline; however, there was a significant inverse relation between fiber consumption and BMI at 6 months, and the association was even stronger at 18 months. CONCLUSIONS: Results from this study suggest that dietary fiber consumption may be particularly important within weight loss interventions tailored for African-American women.

Health behaviors and breast cancer: experiences of urban African American women.

Breast-cancer survival rates are lower among African American women compared to White women. Obesity may contribute to this disparity. More than 77% of African American women are overweight or obese. Adopting health behaviors that promote a healthy weight status may be beneficial because obesity increases risk for recurrence. Studies among White breast-cancer survivors indicate that many make health behavior changes after diagnosis. This cross-sectional pilot study collected quantitative and qualitative data on the attitudes, beliefs, barriers, and facilitators related to health behavior changes in 27 overweight/obese African American breast-cancer survivors. Results indicated that most participants reported making dietary changes since their diagnosis, and some had increased their physical activity. Focus groups provided rich details on the barriers and facilitators for behavior change. These results begin to address the significant gap in our knowledge of African American breast-cancer survivors' health behaviors and underscore the need for culturally competent health behavior interventions.