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School of Nursing and Department of Surgery, Duke University Medical Center, Durham, NC 27710
* To whom correspondence should be addressed. E-mail: demar001{at}mc.duke.edu.
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ABSTRACT |
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 TOP ABSTRACT LITERATURE CITED |
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This year in the United States, it is estimated that a diagnosis of cancer will be rendered every 23 s (2). On average, persons diagnosed will have a 65% chance of living beyond 5 y; however, if they are diagnosed with early-stage disease, their chances of survival are much greater (2). Such individuals will join the ever-increasing numbers of cancer survivors in this country, a population of over 10 million, comprising 3–4% of the U.S. citizenry (4). Projections also indicate that this segment will expand rapidly as a result of trends toward aging, continued advances in early detection, and rates of cure (4–9).
Although survivorship should be celebrated, it is important to acknowledge that the impact of cancer is significant and associated with several long-term health and psychosocial sequelae (2,4–12). Cancer survivors are high health care utilizers who have distinct health care needs (13,14). Data clearly show that compared with persons who have not had cancer, cancer survivors are at greater risk for developing second malignancies and other diseases or conditions, such as cardiovascular disease, diabetes, osteoporosis, and functional decline (4–12). In 1993 an analysis by Brown et al. (15), which compared over 1.2 million patient records obtained from the Surveillance Epidemiology End Results (SEER) database with those obtained from the National Center for Health Statistics, found overwhelming evidence that cancer patients die of noncancer causes at a higher rate than persons in the general population; the noncancer relative hazards ratio for cancer patients was estimated at 1.37, with almost half of the deaths being from cardiovascular disease. Data collected over the past decade continue to confirm these findings (10,16–18). Comorbid conditions are believed to result from cancer treatment, genetic predisposition, and common lifestyle factors (4–6).
Lifestyle interventions, such as those that promote a healthful diet, and an active, nonsmoking lifestyle hold promise in reducing adverse cancer-related sequelae and comorbidity among survivors and also may improve quality of life. However, for interventions to be optimally effective, attention must be paid to the distinct needs of this unique population. The purpose of this article is to review the following: 1) dietary, physical activity, and tobacco-use practices among cancer survivors; 2) levels of interest in lifestyle interventions among cancer survivors; 3) preferences, barriers, and other considerations in delivering lifestyle interventions to cancer survivors; and 4) the success of previous lifestyle intervention trials in capturing and retaining representative populations of cancer survivors. In conducting this review, we accessed intervention studies cited in recent review papers of lifestyle factors among cancer survivors and gleaned specific information regarding intervention design as well as subject accrual, retention, and demographics.
Dietary, physical activity, and tobacco-use practices among cancer survivors
Over 30 published studies explored persistent lifestyle practices (i.e., those that extend beyond the initial treatment year) among cancer survivors; a majority of these studies were systematically reviewed by Demark-Wahnefried et al. in 2005 (19), but there have been 4 additional reports since then (20–23). The preponderance of earlier research suggested that the practice of healthful behaviors was higher among cancer survivors than in the population at large, but many of these studies relied on modest-sized convenience samples and were limited in terms of length of follow-up and heterogeneity of cancer type (19). The 3 recent reports using much larger data sets and assessing behaviors in longer-term survivors indicate that few lifestyle differences exist between individuals diagnosed with cancer and healthy populations or noncancer control subjects (20–22). Two of these studies relied on data collected from survivors of several different cancers and who were nested within a national sample that included both cancer cases and controls, thus yielding data that are less likely to be influenced by response bias (20,22).
Analyses of health behaviors of cancer survivors compared with age- and race-matched controls participating in the National Health Initiative Survey-2000 indicate that whereas cancer survivors are 9% (95% CI 1.03, 1.16) more likely to adhere to physical activity guidelines, most are sedentary (20,22). Coups and Ostroff (22) found that smoking rates were significantly higher among younger cancer survivors than population-based control subjects (ages 18–40), but a subsequent and more complete analysis by Bellizzi et al. (20) found no such differences. These recent findings suggest that, by and large, the frequencies of health behaviors among cancer survivors appear no different from those observed in the general population—a population marked by inactivity; overweight and obesity; suboptimal fruit, vegetable, and fiber consumption; and high intakes of fat (20,22). Similar results were found by Caan et al. (21) in another study that exclusively tracked lifestyle behaviors in a cohort of 2321 women with early-stage breast cancer. Thus, findings of these larger, more recent studies contrast with many of the studies previously reported, differences that may be attributable to more heterogeneous samples of survivors who were followed longer.
These recent data provide us with a shift in paradigm and the potential realization that although many cancer patients report healthful lifestyle changes after diagnosis, these changes may not generalize to all populations of cancer survivors or may be temporary. Therefore, some cancer survivors may experience the "teachable moment" and change their lifestyle behaviors, but may slip back into unhealthful lifestyle practices over time and resume the very behaviors (e.g., smoking, being sedentary, being overweight) that initially placed them at increased risk. Given higher rates of comorbidity within this population and evidence that diet, exercise, and tobacco use keenly affect overall health, these recent data support a need for lifestyle interventions that target this vulnerable population and perhaps point to a greater need than previously thought (4–23).
Levels of interest in lifestyle interventions among cancer survivors
Several studies, including one by Wold et al., suggest that although most survivors attribute their cancer diagnosis to factors beyond their control (with the exception of tobacco use), they often become interested in modifying their diet and exercise behaviors postdiagnosis in hopes of preventing recurrence (24–28). Surveys among adult survivor populations suggest extremely high to very high interest in diet (54%) and exercise (51%) interventions as well as comparable interest in smoking cessation programs (60%) among adult cancer survivors who currently smoke (29). These findings are remarkably similar in pediatric cancer survivor populations, with even higher levels of interest noted among their parents (30). Van Weert et al. (31) recently reported even higher levels of interest (80%) in multiple behavior interventions. Thus, the cancer diagnosis may signal an opportune time—a teachable moment—for undertaking health behavior change (19).
Preferences, barriers, and other considerations in delivering lifestyle interventions to cancer survivors
Although cancer survivors may have high levels of interest in lifestyle interventions, they may have special needs (e.g., fatigue, incontinence, lymphedema, food intolerances or digestive disorders, long-term addiction to tobacco products) that must be taken into account if attempts to promote exercise, healthful dietary change, and smoking cessation are to be successful (5,19,22,32–35). The timing of interventions may be critically important because the teachable moment may best be capitalized on if interventions are offered soon after diagnosis. In a survey study of 978 breast and prostate cancer survivors, Demark-Wahnefried et al. (29) found that the most preferred lifestyle interventions were initiated at diagnosis or soon thereafter; however, interventions that were offered "anytime" also garnered high scores. Furthermore, findings of this study and another by McBride et al. (36) found that breast cancer survivors were significantly more likely than prostate cancer survivors to harbor the psychological stress of a diagnosis for longer and therefore may have higher levels of interest in interventions offered further out from diagnosis (Fig. 1). Certainly issues such as concurrent demands of treatment and rehabilitation are key concerns in the timing of interventions, and therefore appropriate balance is necessary in determining the optimal time at which the patient is both physically and psychologically prepared and motivated to undertake behavior change.
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Behavioral theory is another underutilized resource. Several behavioral theories can serve as useful frameworks to guide interventions, yet a review of 28 randomized trials of dietary, exercise, and smoking cessation interventions suggests that fewer than one-third are theoretically based (42–69). Two recent reviews of dietary and exercise interventions found the key to success to be the fit between the study population and the intervention (70,71). Behavioral interventions that integrate survivors' specific needs into a well-chosen and solid theory-driven framework are likely to yield success. A solidly designed intervention not only has an increased probability of promoting behavior change but also has the advantage of being perceived by participants as a well-conceived study, which is more likely to reduce attrition (72). Survivors reported various levels of success for lifestyle interventions that rely on social cognitive theory (32,50,51,54,61,62,65), the theory of planned behavior (44,45,65), and the transtheoretical model (35,55,63).
Interventions also must overcome well-known barriers (19,29,34). For cancer survivors a key barrier is that of distance (19,34). Although Jones and Courneya (73) found that a majority of 307 cancer survivors preferred face-to-face exercise counseling, this preference was only assessed for a 1-session class. Other researchers found that distance presents a significant barrier for in-person programs, especially among older cancer survivors, of whom 61% are at least 65 y of age (19,74–77). In a review of exercise interventions, van der Bij et al. (78) noted that most exercise programs never reach the people whom they would benefit most. Thus, given obvious barriers to dissemination, there is a distinct need for home-based lifestyle interventions among cancer survivors. Telephone counseling is the traditional means of addressing the barrier of distance and has been used with various levels of success with cancer survivors as well as in other high-risk populations (51,55,61–63,75,79–82). Web-based formats offer future promise (75); however, cancer is a disease associated with aging, and receptivity for computer-based programs is most likely a decade away (29). Interventions delivered via mailed print materials receive the highest levels of interest, not only in a sample of 978 breast and prostate cancer survivors (mean age 63 y) (29) but also among 209 childhood cancer survivors (mean age 19 y) (30) (Fig. 2). The majority (n = 19) of 28 randomized lifestyle intervention trials were clinic based (42–69), but in recent years there has been a trend toward home-based programs or clinic- and home-based hybrids (32,51,60–63,68). This is especially relevant for interventions that target highly mobile or geographically dispersed survivor populations (e.g., childhood cancer survivors) or those that propose long-term follow-up.
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Currently, breast cancer survivors comprise the largest segment of cancer survivors and are the focus of the majority of lifestyle intervention trials. However, the efforts made in this area may be disproportionate because 60% of the randomized trials have targeted breast cancer survivors, yet women with breast cancer comprise only 22% of the survivor population (8). Lifestyle interventions that target other populations of cancer survivors need to be developed and tested. The same holds true for time since diagnosis, as most (54%) trials have targeted survivors who are within 1 y of diagnosis. As mentioned previously, interventions offered proximal to diagnosis are well timed to take advantage of the teachable moment created by the cancer diagnosis; however, lifestyle interventions are needed for long-term cancer survivors, a population that has not been specifically targeted but for whom need is great (8,20,22). Newly launched into the field is the RENEW (Reach-out to Enhance Wellness) study (CA106919), a randomized controlled trial that will test the efficacy of a home-based (telephone counseling plus mailed materials) intervention in improving the physical functioning of older (65+ y) survivors of colorectal, breast, and prostate cancer who are at least 5 y out from diagnosis. This trial is still recruiting subjects, and results are years away; other studies also are needed to address the needs of long-term survivors.
In general, lifestyle intervention trials also share many of the challenges that are common to clinical trials. For example, there is bias toward recruitment of survivors who are white and highly educated. Our review of the 28 lifestyle intervention trials reported to date (42–69) showed that sociodemographic data on study samples are only haphazardly reported: only 50% of the papers contained such information. However, of the trials that reported sociodemographic characteristics, two-thirds described populations that were 90–100% white, and four-fifths had populations that were college-educated (42–69). In addition, many reports lack information regarding the proportion of contacted subjects who agreed to participate as well as the proportion who ultimately were randomly assigned to treatment. In the 13 (of 28) trials that have published this information, agreement to participate and subsequent random assignment range widely, from 18% to 92% and 9% to 97.5%, respectively. Even at the lower ranges, these data show that interest in lifestyle intervention trials may be greater than for clinical trials, which tend to range between 2% and 6% (83–85).
Although noneligibility and not agreeing to random assignment are leading barriers for all clinical trials, reasons for nonparticipation in lifestyle intervention trials differ somewhat in that lack of interest, lack of time, and travel are more frequently cited as reasons for refusal (rather than discomfort with the medical setting or procedures, concern regarding side effects, or desire for another form of treatment) (83–85). Indeed, if we are to work toward interventions that can be disseminated broadly to the larger population of survivors, efforts must be made to recruit representative populations and to craft interventions that overcome common barriers. At the very least, information about characteristics of the study sample and proportionate uptake and percentage of random assignment should be requisite in publishing such reports. The adoption of standardized measures, such as the newly proposed Recruitment Index (number of days to accrue 1 analyzable patient), may be helpful in interpreting the generalizability of findings as well as advancing the science of clinical trials management (86).
The generalizability of findings also can be influenced by attrition (87,88). Of the 28 trials that were reviewed, data on attrition were available in 24, with rates ranging from 0 to 50% (mean 13.3%). Of concern is the fact that attrition exceeded 15% (a standard generally accepted for generalizability of findings) in 9 of the 24 trials (87,88). Therefore, more attention is also needed in reporting these data.
Cancer survivors are a vulnerable population likely to benefit from the practice of healthful lifestyle behaviors and report high levels of interest in interventions aimed at improving their diet, exercise, and tobacco-use behaviors. More research is needed to develop effective interventions for the wide spectrum of cancer survivors—interventions that are theoretically grounded, optimally timed, delivered via appropriate channels, and overcome barriers to recruitment and retention.
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FOOTNOTES |
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2 Author Disclosure: No relationships to disclose.
3 Support: NIH grants: CA92468, CA81191, CA106919, AG11268, CA62215; the Susan G. Komen Foundation; and the American Institute for Cancer Research.
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