Energy balance and breast cancer risk: a prospective cohort study

Summary While there is evidence that breast cancer risk is positively associated with body mass index (in postmenopausal women) and energy intake and inversely associated with physical activity, few studies have examined breast cancer risk in association with energy balance, the balance between energy intake and expenditure. Therefore, in the cohort study reported here, we studied the independent and combined associations of vigorous physical activity, energy consumption, and body mass index (BMI), with breast cancer risk. The investigation was conducted in 49,613 Canadian women who were participants in the National Breast Screening Study (NBSS) and who completed self-administered lifestyle and food frequency questionnaires between 1980 and 1985. Linkages to national mortality and cancer databases yielded data on deaths and cancer incidence, with follow-up ending between 1998 and 2000. During a mean 16.4 years of follow-up, we observed 2545 incident breast cancer cases. Due to exclusions for various reasons, the analyses were based on 40,318 subjects amongst whom there were 1673 incident cases of breast cancer. Participation in vigorous physical activity and body mass index were not independently associated with breast cancer risk in the total cohort. A statistically significant positive trend was observed, however, between energy intake and breast cancer risk (P _trend = 0.01). Although there was some variation in risk associated with vigorous physical activity, and BMI when the analyses were stratified by menopausal status, these interactions were not statistically significant. The interaction between menopausal status and energy intake, however, was of borderline statistical significance (P _interaction = 0.06), with a statistically significant increased risk of breast cancer associated with highest versus lowest quartile of energy intake among premenopausal women (Hazard Ratio [HR] = 1.45, 95% confidence interval [CI] = 1.13– 1.85, P _trend = 0.001). There was evidence of an increased risk of breast cancer associated with a relatively high body mass index among postmenopausal women in the highest quartile level of energy intake (Hazard Ratio [HR] = 1.72, 95% confidence interval [CI] = 1.01– 2.93, P _trend = 0.05). In addition, there was evidence of an increased risk of breast cancer among premenopausal, physically inactive, overweight/obese women who consumed ≥1972 kcal/day compared to physically active normal weight women who consumed <1972 kcal/day (HR = 1.60, 95% CI = 1.08–2.37). Our data suggest that obese premenopausal women with relatively high energy intake may be at increased risk of breast cancer. In addition, energy imbalance, represented by a relatively high energy intake, lack of participation in vigorous physical activity, and a relatively high body mass index, may be associated with increased breast cancer risk, particularly among premenopausal women.     

Adherence to a randomized controlled trial of aerobic exercise in breast cancer survivors: the Yale exercise and survivorship study

Purpose  To examine predictors of exercise adherence in breast cancer survivors. Methods  Seventy-five breast cancer survivors were randomly assigned to exercise (n = 37) or usual care (n = 38). Demographic, prognostic, physiologic, and psychosocial information was collected at baseline and 6 months. The exercise goal was 30 min of exercise 5 days/week for 6 months. Results  Women randomized to exercise participated in moderate-intensity recreational exercise for 123 ± 52 min/week (81% of the prescribed 150 min/week) over 6 months. Baseline variables associated with better adherence were lower body mass index (BMI), smaller waist circumference, higher amounts of physical activity 6 months prior to enrollment, being in the preparation vs. contemplation Stage of Change and higher FACT-B breast cancer subscale score. After adjusting for these variables, lower BMI and higher Stage of Change continued to be associated with better adherence (p < 0.05). Conclusions  Future studies of exercise and breast cancer prognosis should target obese women for participation, as well as women just beginning to contemplate participation and its benefits after a cancer diagnosis.     

Joint effects of body size,energy intake,and physical activity on breast cancer risk

To evaluate the joint effect of body size, energy intake, and physical activity on breast cancer risk, we analyzed information on body weight history, energy intake, anthropometric measurements, and physical activity patterns in a population based case–control study. Included in this analysis were 3,458 incidence breast cancer cases and 3,474 age-frequency matched controls from the Shanghai Breast Cancer Study. High weight, height, body mass index, waist-to-hip ratio, and weight gain showed stronger associations with breast cancer risk in postmenopausal women than premenopausal women. High total physical activity was inversely associated with postmenopausal breast cancer risk (p for trend = 0.026) and premenopausal breast cancer (p for trend = 0.059). The odds ratios for women with a high waist-to-hip ratio (≥0.84) and low total physical activity (≤10.9 MET-h/day) had the highest risk for breast cancer (OR = 2.7, 95% CI: 1.4–4.9 for postmenopausal women, OR = 2.1, 95% CI: 1.5–3.1 for premenopausal women) compared to their counterpart with low waist-to-hip ratio (<0.76) and high total physical activity (>20.5 MET-h/day). We did not find a statistically significant multiplicative interaction between body size, caloric intake and total physical activity on breast cancer risk.     

Change in physical activity during active treatment in a prospective study of breast cancer survivors

Physical activity offers many benefits to breast cancer survivors, yet research on physical activity during the immediate period following a breast cancer diagnosis is limited. In a prospective cohort study of 1,696 women diagnosed with invasive breast cancer in the Kaiser Permanente Northern California Medical Care Program from 2006–2009, we describe change in self-reported physical activity levels from around diagnosis to 6 months post-diagnosis and determine factors associated with change. Participants completed a comprehensive physical activity questionnaire at baseline (2 months post-diagnosis) and at follow-up (8 months post-diagnosis). Predictors of physical activity change were determined by multivariable linear regression. Reductions in all physical activity levels were observed (P < 0.0001); mean (SD) change (h/week) of moderate-vigorous physical activity (MVPA) was −1.28 (4.48) and sedentary behavior was −0.83 (6.95). In fully-adjusted models, overweight and obesity were associated with greater declines in MVPA of −1.58 h/week (SD = 0.92) and −1.29 h/week (SD = 0.93), respectively (P = 0.0079). Receipt of chemotherapy only was also associated with a greater decrease in MVPA (−2.12 h/week; SD = 0.92; P < 0.0001), specifically for recreational activities (−1.62 h/week; SD = 0.64; P = 0.0001). These data suggest challenges in maintaining physical activity levels during active treatment among women with breast cancer. Interventions to encourage physical activity in breast cancer survivors should be pursued.     

Measuring the impact of cancer: a comparison of non-Hodgkin lymphoma and breast cancer survivors

Introduction  

Self-report instruments such as the Impact of Cancer (IOC) are designed to measure quality of life (QOL) impacts that cancer survivors attribute to their cancer experience. Generalizability of QOL findings across distinct diagnostic categories of survivors is untested. We compare measurement of the impact of cancer using the IOC instrument in breast cancer (BC) survivors (n = 1,188) and non-Hodgkin lymphoma (NHL) survivors (n = 652).     

Pre-diagnosis physical activity and mammographic density in breast cancer survivors

Summary Purpose To investigate the association between physical activity (PA) and mammographic density in the year before diagnosis in a population-based sample of 474 women diagnosed with stage 0–IIIA breast cancer and enrolled in the Health, Eating, Activity, and Lifestyle Study. Methods We collected information on PA during an interview administered at a baseline visit scheduled within the first year after diagnosis. Participants recalled the type, duration, and frequency of different PAs for the year prior to their diagnosis. Dense area and percent density were estimated, from mammograms imaged approximately 1 year before diagnosis, as a continuous measure using a computer-assisted software program. Analysis of covariance methods were used to obtain mean density across PA tertiles adjusted for confounders. We stratified analyses by menopausal status and body mass index (BMI) because these factors strongly influence density. Results We observed a statistically significant decline in mammographic dense area (p for trend = 0.046) and percent density (p for trend = 0.026) with increasing level of sports/recreational PA in postmenopausal women with a BMI ≥30 kg/m². Conversely, in premenopausal women with a BMI <‰30 kg/m², we observed a statistically significant increase in percent density with increasing level of sports/recreational PA (p for trend = 0.037). Conclusions Both mammographic dense area and percent density are inversely related to level of sports/recreational PA in obese postmenopausal women. Increasing PA among obese postmenopausal women may be a reasonable intervention approach to reduce mammographic density.     

Hot flashes, fatigue, treatment exposures and work productivity in breast cancer survivors

Introduction  While fatigue has been associated with work limitations the combined influence of specific diagnosis and treatment exposures based on medical records on work limitations in breast cancer survivors is currently unknown. Since symptom burden and perceived health can interfere with work, the present study investigated the relationship among these variables and work outcomes. Methods  Medical chart abstraction, demographic measures, SF 36, the Work Limitations Questionnaire (WLQ) and measures of symptom burden, including hot flushes were obtained in 83 breast cancer survivors a mean of three years post treatment. OLS and poisson regression were used to determine the relationship of these factors to work productivity and work absences. Results  Breast cancer survivors reported a mean reduction in productivity of 3.1% below the healthy worker norm. This amounts to a loss of 2.48 hours of work over two weeks of full time employment. Stages 1 and 2 were related to work limitations. After controlling for stage, fatigue and hot flashes were each associated with work performance losses of 1.6% (p = 0.05) and 2.2% (p < 0.001), respectively. Protective factors included marriage and greater personal earned income. Conclusions  Fatigue and hot flashes are important factors related to work productivity in breast cancer survivors even at three years post treatment. Implications for survivors  Therapy for hot flashes should be given serious consideration in breast cancer survivors who are experiencing work limitations. Sources of Support: Department of Defense Breast Cancer Research Program Concept Development Award: “Chemo-Brain,” “Lost work productivity and Career Success: A Pilot Study” (DAMD 17-01-0785).     

Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior

Although pain is common among post-treatment breast cancer survivors, studies that are longitudinal, identify a case definition of clinically meaningful pain, or examine factors contributing to pain in survivors are limited. This study describes longitudinal patterns of pain in long-term breast cancer survivors, evaluating associations of body mass index (BMI), physical activity, sedentary behavior with mean pain severity and above-average pain. Women newly diagnosed with stages 0–IIIA breast cancer (N = 1183) were assessed, on average, 6 months (demographic/clinical characteristics), 30 months (demographics), 40 months (demographics, pain), 5 years (BMI, physical activity, and sedentary behavior), and 10 years (demographics, pain, BMI, physical activity, and sedentary behavior) post-diagnosis. This analysis includes survivors who completed pain assessments 40 months post-diagnosis (N = 801), 10 years post-diagnosis (N = 563), or both (N = 522). Above-average pain was defined by SF-36 bodily pain scores ≥1/2 standard deviation worse than age-specific population norms. We used multiple regression models to test unique associations of BMI, physical activity, and sedentary behavior with pain adjusting for demographic and clinical factors. The proportion of survivors reporting above-average pain was higher at 10 years than at 40 months (32.3 vs. 27.8 %, p < 0.05). Approximately one-quarter of survivors reported improved pain, while 9.0 % maintained above-average pain and 33.1 % reported worsened pain. Cross-sectionally at 10 years, overweight and obese survivors reported higher pain than normal-weight survivors and women meeting physical activity guidelines were less likely to report above-average pain than survivors not meeting these guidelines (p < 0.05). Longitudinally, weight gain (>5 %) was positively associated, while meeting physical activity guidelines was inversely associated, with above-average pain (OR, 95 % CI = 1.76, 1.03–3.01 and 0.40, 0.20–0.84, respectively) (p < 0.05). Weight gain and lack of physical activity place breast cancer survivors at risk for pain long after treatment ends. Weight control and exercise interventions should be tested for effects on long-term pain in these women.     

Exercise programming and counseling preferences in bladder cancer survivors: a population-based study

Introduction Despite growing evidence of the benefits of exercise in cancer survivors, exercise participation rates are low. Understanding the unique exercise programming and counseling preferences of different cancer survivor groups may facilitate the delivery of optimal exercise programs in these growing populations. To date, no study has examined these preferences in bladder cancer survivors. Materials and methods Participants were 397 bladder cancer survivors who completed a mailed survey in the province of Alberta, Canada. Results The majority of survivors indicated they would be interested (81.1%) and able (84.3%) to participate in an exercise program designed for bladder cancer survivors. We also found strong preferences for home-based exercise programming (53.7%), walking (81.1%), moderate intensity activity (61.7%) and unsupervised sessions (70.6%). Logistic regression analyses showed that older survivors were more likely to prefer to exercise at home (77 vs. 68%; OR = 4.21, 95% CI = 0.188–0.962, p = 0.040), do light intensity exercise (33 vs. 16%; OR = 4.50, 95% CI = 0.208–0.940, p = 0.034) and want unsupervised exercise sessions (75 vs. 62%; OR = 4.60, 95% CI = 1.07–4.08, p = 0.032). Body mass index, age, adjuvant therapy, marital status, income and education also influenced some exercise preferences. Conclusions These findings suggest that bladder cancer survivors are interested in receiving exercise counseling and have some consistent programming preferences including exercising at home, walking, and moderate intensity exercise. Many preferences were modified by demographic and medical factors. Implications for cancer survivors Understanding the unique exercise preferences of bladder cancer survivors may be used to inform the design and delivery of exercise programs in this growing population.     

Screening of physical distress in breast cancer survivors: Concurrent validity of the Distress Thermometer and Problem List

Several studies support the validity and psychometric properties of the DT&PL for measuring psychosocial distress in breast cancer survivors (BCSs). However, next to psychosocial problems, it is equally important to identify distress caused by limitations in physical functioning. Validity of the DT&PL for the identification of physical problems in BCSs has not yet been investigated. Therefore, the purpose of the present study is to investigate the concurrent validity and psychometric properties of the Dutch DT&PL in BCSs for the identification of physical problems. Ninenty BCSs completed the DT&PL, ShortForm‐36 (SF‐36) and the Dutch Disability of the Arm, Shoulder and Hand questionnaire (DASH). Forty‐seven % of BCSs reported a high level of distress on the DT&PL (score ≥5). Distressed BCS showed increased physical and emotional problems and problems at the upper limb region. The scores obtained with the DT&PL correlated weakly to strongly with subscales for physical functioning of the SF‐36 (r = ?0.224 to r = ?0.676; p < 0.05) and with limitations in physical functioning at the upper limb region (DASH; r = 0.380 to r = 0.619; p < 0.01). In conclusion, the Dutch DT&PL is a multidimensional instrument showing good concurrent validity for the screening of physical problems.     

Addressing the needs of young breast cancer survivors at the 5 year milestone: can a short-term, low intensity intervention produce change?

Background  Today, the 5-year relative survival rate for cancer is 65% and there are 10.5 million survivors. The largest group of survivors are those of breast cancer. Reductions in mortality are occurring at a greater rate for women under age 50 at diagnosis than among older women. Aims  Our goal was to design a socio-educational intervention for 5-year survivors aged 50 or younger at diagnosis and test the hypotheses that women in the intervention group would show greater improvement than controls with respect to (1) knowledge of breast cancer, its treatment, and long-term health concerns; (2) lifestyle habits (i.e., exercise and diet); and (3) communication with family and physicians. Methods  Using a randomized controlled trial with a pre-post design, 404 women who were 5 years from diagnosis and cancer-free (response rate 54%) were randomly assigned to an intervention or delayed intervention (control) group and were assessed at pre-test (baseline) and 6 months later (96% retention). The intervention consisted of three 6-h workshops over a 3 month period. Four series of workshops were held at different geographical areas in the greater San Francisco Bay Area. The workshops included activities and information to promote physical, social, emotional, and spiritual well-being. The intervention design was based on findings from focus groups and a survey of 185 cancer-free 5-year survivors that assessed changes since the early months after diagnosis in physical, social, emotional, and spiritual concerns (response rate 73%). Results  Consistent with our first hypothesis, at post-test, women in the intervention group, on average, had greater knowledge regarding breast cancer, its treatment, and their own future health than did those in the control group (p = 0.015). Hypothesis 2 was partially supported as women in the intervention group were more likely than the control group to report an increased amount of physical activity (p = 0.036), but not significant dietary changes. Social support was related to increased self report of physical activity. With the exception of the last series of workshops, the intervention group did not report improved communications with family, friends, and physicians (hypothesis 3). Conclusions  A short-term intervention can affect knowledge levels and physical activity but not diet or communication in the family. Implications for Cancer Survivors  The intervention was related to greater knowledge related to breast cancer, and increased report of physical activity. The program was not related to changes in reported diet or family communication. The study was funded by the NIH, NCI R01-CA 078951. The authors gratefully acknowledge the contributions of Ingrid Oakley-Girvan, Ph.D., Merrilee Morrow, Ingrid Peterson, M.P.H., Subo Chang, M.S. and Monica Johnston, M.S.     

Assessment of problems and symptoms in survivors of childhood acute lymphoblastic leukaemia

Significant physical and psychosocial problems and related symptoms are observed in cancer survivors after treatment as well as during the treatment period. This study was aimed to assess problems and symptoms in childhood acute lymphoblastic leukaemia (ALL) survivors. Study was applied in three hospitals in Ankara/Turkey with 91 children who were diagnosed and treated with ALL and with their family. Data were collected using the data collection form developed by the researchers. The variables were investigated using the Mann–Whitney U and chi‐square test. The most common physical problems and symptoms seen in survivors are respiratory system infections (40.7%), reduction in bone mineral density (26.4%), exercise intolerance (45.1%), pain (41.8%) and fatigue (29.7%). Among the most frequent social problems experienced, educational problems (19.8%) is indicated. In children carrying increased duration of therapy, urinary system infections (p = .016), anorexia (0.020) and pain (p = .007) rates are increasing. Many problems and symptoms related to disease and treatment in survivors of ALL have been realised. Therefore, planning and implementation of nursing interventions required to sustaining and developing survivor's health status are important.     

Cognitive Processing Variables in Breast Cancer: Worry and Distress at the End of Treatment

This study assessed the influence of cognitive processing variables on cancer worries and distress after breast cancer treatment. In multivariate analyses, while independent variables were intolerance of uncertainty and intrusive thoughts, constructs' variables were anxiety and depression symptoms and cancer-related worries. The intolerance to uncertainty had a tendency to influence on distress and concerns about cancer after the end of treatment (Wilks' λ = 0.687, p = 0.074). Whereas, thought intrusion had a significant influence on distress and cancer related worries (Wilks' λ = 0.228, p = 0.000). Cognitive variables could be addressed by the oncology nurse when considering the patients' concerns related to cancer and psychological distress.     

Association of Expression of Kruppel-Like Factor 4 and Kruppel-Like Factor 5 with the Clinical Manifestations of Breast Cancer

Kruppel-like factors (KLFs) are import modulators of cell proliferation, differentiation, and transformation and have recently been considered possible prognostic factors in breast cancer. In this study, we investigated the correlation between KLF4 and KLF5 expression and the clinical manifestations of breast cancer by immunohistochemical analysis. We observed increased KLF4 and KLF5 expression in tumor cells (invasive and in situ carcinomas), consistent KLF4 and KLF5 expression in in situ and invasive carcinomas, significant associations between KLF4 expression and tumor grade (p = 0.033), size (p = 0.035) and stage (p = 0.006), and an association between KLF5 expression and tumor grade (p = 0.033). Interestingly, we observed a relationship between increasing age and KLF4 expression (p = 0.007), with a tendency towards greater expression in tumor cells in patients over 50 years old. Moreover, KLF5 nuclear localization was restricted to non-tumor breast ducts and lobules; however, loss of nuclear expression of KLF5 in in situ and invasive carcinomas was observed. Although the mechanism of the loss of KLF5 nuclear expression is not clear, this phenomenon may imply a possible tumor-suppressor-like role for KLF5 in breast cancer tumorigenesis. The expression of KLF4 and KLF5 in breast cancer patients in Taiwan is similar to that in Western countries, except for the uncertainty surrounding its prognostic significance. Further clarification of the underlying mechanisms of KLF4 and KLF5 expression and their correlations with breast cancer outcomes is necessary.     

Circadian rhythms,symptoms, physical functioning,and body mass index in breast cancer survivors

Introduction  

Research has been limited in circadian activity rhythms and their relationship with health status in early-stage breast cancer survivors. Maintaining strong circadian parameters may reduce symptoms and improve physical functioning and disease-free survival.     

Cosmetic Outcome 1–5 Years After Breast Conservative Surgery,Irradiation and Systemic Therapy

The late side-effects of the local therapy of early breast cancer depend on many patient- and therapy-related parameters. We aimed at investigating the factors that influence the cosmetic and functional outcomes among our breast cancer patients after breast-conserving surgery and conformal radiotherapy, with or without adjuvant systemic therapy. A study was made of the association of the cosmetic outcome after a median follow-up time of 2.4 years and the clinical data on 198 patients extracted from a prospectively compiled database. Breast tenderness occurred more frequently among patients ≤50 years old (p < 0.05). Long-term side effects were related to radiotherapy-related factors the most, while no effect of the systemic therapy could be detected. The risk of hyperpigmentation, breast edema and breast fibrosis increased by 18%, 23% and 7%, respectively for every 100 cm³ increase in the irradiated breast volume, while that of breast edema and breast fibrosis increased by 21% and 12%, respectively for every 10 cm³ increase in the boost volume. Patients who received a photon boost were significantly more likely to develop breast edema and fibrosis than those who received electrons (p < 0.005). Dose inhomogeneity was related to the volume of the irradiated breast (p = 0.037). Dyspigmentation developed more often among patients older than 50 years, while smoking favoured both dyspigmentation and teleangiectasia. Breast edema was related to dyspigmentation (p = 0.003), fibrosis (p < 0.001) and breast asymmetry (p = 0.032), whereas none of these abnormalities were associated with teleangiectasia. Body image changes were more frequent at a younger age (p < 0.005), while the need to change clothing habits occurred more often at an older age (p < 0.05). Radiotherapy-related parameters appear to exert the greatest effect on the overall cosmetic outcome after breast-conserving surgery and postoperative radiotherapy.