Journal of Cancer Survivorship

Physical activity barriers and resources among black women with a history of breast and endometrial cancer: a systematic review

Physical inactivity is a significant public health problem among black women. However, there is limited evidence regarding barriers to physical activity and the availability of opportunities to engage in physical activity, specifically for posttreatment black women with a history of cancer. The purpose of this paper was to systematically review, summarize, and synthesize findings on physical activity-related research including barriers, facilitators, and resources for physical activity among posttreatment black women with a history of breast and endometrial cancer. We developed a comprehensive search strategy and conducted searches in the following databases: PsycINFO, Web of Science, Cochrane, PubMed, and Sociological Abstracts. Summary measures were described qualitatively (e.g., themes) and quantitatively (e.g., frequencies). This review identified 35 eligible articles describing 12 intervention and 23 observational studies. We described intervention preferences (e.g., resistance activities), beliefs about physical activity, and benefits of physical activity for quality of life (e.g., improvements in social wellbeing) in black cancer survivors. In addition, very few studies identified barriers to physical activity (n = 7) and focused on increasing physical activity (n = 12) among black women with a history of cancer. The most common reported barriers among the target population were fatigue, lack of social support, weather, illness/health issues, cost, time constraints, living too far away, and inability/unwillingness to obtain physician clearance, whereas the most common facilitators were faith, other health concerns, and social support. Future studies should target barriers, facilitators, and culturally adapted strategies for physical activity at all levels of influence to develop multi-level interventions to engage and improve physical activity among black women with a history of breast and endometrial cancer. CRD42018110008.

Exercise adherence in a randomized controlled trial of exercise on quality of life in ovarian cancer survivors

Factors associated with improving exercise in ovarian cancer survivors remain unknown. We explored characteristics associated with exercise adherence among women treated for ovarian cancer in the Women's Activity and Lifestyle Study in Connecticut (WALC) randomized controlled trial. We evaluated adherence among women randomized to the WALC exercise intervention (N = 74). Women had to be exercising ≤ 90 min/week and post-treatment. The intervention included 25 telephone-based exercise counseling sessions over 6 months. Adherence was defined as 150 min/week of moderate/vigorous-intensity exercise. We evaluated factors associated with exercise adherence and duration using multivariate logistic and linear regression. The number of sessions sufficient to achieve 150 min/week was modeled with an unadjusted receiver operating characteristic (ROC) curve. Women were 57.3 ± 8.8 years old and 1.7 ± 1.0 years since diagnosis. The mean exercise time over 6 months was 166.0 ± 66.1 min/week, and 64.9% of women met the 150 min/week goal. Women attended 22.8 ± 3.6 (92%) counseling sessions. No cancer recurrence during the study (OR = 9.15, 95% CI: 1.09-44.02) and greater session attendance (OR = 1.21, 95% CI: 1.02-1.43) were related to meeting the exercise goal. Greater session attendance (P < 0.01) and higher baseline activity level (P = 0.02) were associated with greater average weekly exercise duration. The ROC curve suggested attending 18 counseling sessions was optimal to meet the exercise goal. Women attending more counseling sessions or with no cancer recurrence during the study were more likely to meet the exercise goal. More research is needed to understand ideal counseling intensity for ovarian cancer survivors. Eighteen counseling sessions are sufficient for ovarian cancer survivors to achieve 150 min/week exercise.

Cancer worry is associated with increased use of supportive health care—results from the multinational InCHARGE study

To assess use of health care following a diagnosis of endometrial, cervical, and ovarian cancer in the Netherlands, Norway, and Denmark. Furthermore, to analyze the association between cancer worry and use of supportive care. An international multicenter cross-sectional questionnaire study was undertaken among female cancer survivors with endometrial, cervical, or ovarian cancer 1-7 years post diagnosis. We investigated different aspects of cancer survivorship and follow-up care. Health care use included information on the use of supportive health care, general practitioner (GP), and follow-up visits to the department of gynecology. Cancer worry was assessed with the Impact of Cancer (IoCv2) questionnaire. A total of 1433 women completed the questionnaire. Health care use decreased from time of diagnosis and was higher among cervical and ovarian cancer survivors than endometrial cancer survivors. Twenty-five percent of the women with ovarian cancer reported severe cancer worry, in contrast to 10 and 15% of women diagnosed with endometrial and cervical cancer, respectively. Women with severe worry had significantly higher use of supportive care activities. In a multivariable regression analysis, cancer worry remained a significant correlate for use of supportive health care services irrespective of disease severity or prognosis. The strongest association was found for use of a psychologist (OR 2.1 [1.71-2.58]). Cancer worry is associated with increased use of supportive care. Targeted, timely, and accessible psychological support aimed at severe cancer worry may improve survivorship care and ensure optimal referral of patients in need of additional care.

Prevalence of long-term opioid use after radiotherapy for cervical cancer in a Brazilian cancer center

This study aimed to describe the clinical and demographic profile of cervical cancer patients exploring risk factors for prolonged use of opioids. The database of the Brazilian National Cancer Institute was queried out and 214 women with cervical cancer diagnosed between January 2014 and December 2015 who underwent isolated external beam radiation therapy (EBRT) or chemoradiotherapy (CRT) with complete response were included. Patients who no longer used opioids 6 months after completion of radiation therapy were classified as stoppers; patients who continued using opioids were non-stoppers. Variables were comparatively evaluated as risk factors for prolonged use of opioids. The median age was 49.4 years. Most women were non-white (64.5%) and had ECOG Performance Status (PS) ≥ 1 (76.6%), International Federation of Gynecology and Obstetrics (FIGO) stage II-III (84.1%), and squamous cell carcinoma (82.7%). Smoking and alcohol consumption rates were, respectively, 44.9% and 39.7%. The median time from diagnosis to the onset of EBRT was 111 days (interquartile range 66.2). Most patients underwent CRT (88.8%). The rate of non-stoppers was 65.0%. By multivariate analysis, prescription of strong opioids (p = 0.005) and disease recurrence (p < 0.001) were suggested as independent factors for prolonged use of opioids. The rate of prolonged use of opioids after radiotherapy is alarming. Prescription of strong opioids and disease recurrence might be independent risk factors for its persistent use. These results reveal an unmet and urgent need to implement public multiprofessional support programs with well-established protocols for dependence withdrawal, as well as stricter national measures of control in opioid prescription.

Effect of exercise on body composition among women with ovarian cancer

Obesity is associated with a higher risk of mortality in women with ovarian cancer. Exercise has improved body composition among cancer survivors, yet no randomized controlled trial has explored the effect of exercise on body composition in women with ovarian cancer. In this analysis, we examined the effect of a six-month aerobic exercise intervention on body composition among ovarian cancer survivors in the Women's Activity and Lifestyle Study in Connecticut (WALC). Women with ovarian cancer (N = 144) were randomized in a 1:1 ratio to 6 months of an aerobic exercise intervention or attention-control, and body composition was measured as a secondary outcome at baseline and 6 months via dual-energy X-ray absorptiometry (DEXA). Women with at least one DEXA scan were included in the analysis (N = 103). On average, participants were 57.1 (± 8.7) years old and 1.6 (± 0.9) years since diagnosis. Women randomized to exercise maintained weight during the trial (- 0.11 kg, P = 0.82), while women in attention-control gained weight (+ 1.40 kg, P = 0.03); however, the between-group difference did not reach statistical significance (P = 0.09). We found no statistically significant differences by study arm for changes in body fat percentage, bone mineral density, or lean body mass. Weight was maintained as a result of a 6-month aerobic exercise intervention among post-treatment ovarian cancer survivors. Future exercise and healthy eating interventions should consider additional measures (e.g., computer tomography scans, D Moderate-intensity aerobic exercise may help ovarian cancer survivors maintain weight.

Stigma, social support, and spirituality: associations with symptoms among Black, Latina, and Chinese American cervical cancer survivors

Few studies have examined experiences of stigma and factors associated with symptoms among cervical cancer survivors from diverse racial and ethnic backgrounds. We investigated survivorship experiences and patient-reported outcomes in the SPADE symptom cluster (sleep disturbance, pain interference, anxiety, depression, and energy/fatigue) among Black, Latina, and Chinese American women diagnosed with cervical cancer. In two phases of research with cervical cancer survivors, we collected qualitative data through individual interviews (N=12; recruited through community referrals) and quantitative data from an observational cohort study (N=91; recruited through 4 national cancer registries). We coded interview transcripts to describe the survivors' experiences. We then evaluated associations between social support, spirituality, and SPADE symptom cluster domains using linear regression models. Qualitative analysis yielded four themes: perceptions of stigma, empowerment, physical and psychological effects, and social support. These concepts revolved around internal and external stigmas, emotional responses, strengthened faith, and different social support types. Quantitative analyses indicated that greater spirituality was associated with lower symptom burden on all five SPADE domains (p<0.01). We observed nuanced associations between specific types of social support and SPADE domains. The survivorship experiences of Black, Latina, and Chinese American women with cervical cancer are negatively influenced by perceptions of stigma. Higher scores on spirituality and varied types of social support were significantly associated with fewer symptoms in the SPADE symptom cluster. Results suggest targets for future interventions to reduce symptom burden among women diagnosed with cervical cancer by leveraging spirituality and social support.

Patient-reported outcomes of non-pharmacological interventions for endometrial cancer survivors: a systematic review

The objective of this review was to assess the efficacy of non-pharmacological interventions on endometrial cancer (EC) survivors' QOL, and their use of patient-reported outcome measures (PROMs). We conducted a systematic review of randomized controlled trials (RCTs) of non-pharmacological interventions that assessed the impact of intervention on EC survivors' general and domain-specific QOL (i.e., physical, psychological, and social well-being) using PROMs. Of the 3178 studies identified, 28 full-text articles were reviewed, and 10 were included in the review. Nine RCTs assessed at least one PROM as a primary outcome and six assessed a PROM as a secondary outcome, but few studies used validated PROMs. Significant improvements in general QOL were found in two studies, domain-specific QOL in three studies, and both general and domain-specific QOL in three studies; however, effect sizes ranged from small to large and no significant effects were found for social well-being and few were found for psychological well-being. Few non-pharmacological interventions for EC survivors targeted QOL, even though QOL was assessed as either a primary or secondary outcome of the RCT. Despite this, findings suggest that non-pharmacological interventions for EC survivors hold promise for improving general and domain-specific QOL. Use of validated PROMs would greatly enhance outcome reporting and facilitate comparisons across studies. More interventions are also needed that address social and psychological functioning in this population. Our review highlights a need to (1) expand non-pharmacological RCTs for EC survivors, (2) increase the use of validated PROMs measuring QOL, and (3) address psychosocial domains of QOL when developing interventions for this population.

Feasibility and acceptability of home-based strength training in endometrial cancer survivors

Physical activity is important for healthy cancer survivorship, yet many endometrial cancer survivors do not participate in recommended muscle-strengthening activity. The purpose of this study was to determine the feasibility of home-based muscle strengthening activity in endometrial cancer survivors. Forty post-treatment endometrial cancer survivors were enrolled in a randomized trial, of twice-weekly home-based strength exercise versus wait-list control. The intervention included educational materials, exercise equipment (dumbbells, resistance bands), and support/feedback via video coaching sessions. Participants completed the exercises twice per week for 10 weeks, with a 5-week follow-up period. Feasibility was measured by program adherence, as well as safety of and satisfaction with the study. On average, participants were 60.9 years old (SD = 8.7), had a BMI of 39.9 kg/m This home-based program was feasible in endometrial cancer survivors. While adherence was measured, future research should focus on long-term maintenance of exercise and should explore progressions and modifications of exercises at a distance for various abilities. Muscle strengthening activities are recommended for all cancer survivors. This study shows that a home-based muscle strengthening exercise is feasible in endometrial cancer survivors.

Changes in prospectively collected patient-reported outcomes among women with incident endometrial cancer

Abstract Purpose We examined associations between patient and treatment characteristics with longitudinally collected patient-reported outcome (PRO) measures to provide a data-informed description of the experiences of women undergoing treatment for endometrial cancer. Methods We administered National Institutes of Health Patient Reported Outcomes Measurement Information System (PROMIS) questionnaires at the preoperative visit and at 6 and 12 months after surgery. Anxiety, depression, fatigue, sleep disturbance, pain, physical function, and ability to participate in social roles were assessed. Analysis of variance (ANOVA) and linear mixed models were used to examine associations between patient characteristics and PRO measures at baseline and through time. Results Of 187 women enrolled, 174 (93%) and 103 (69%) completed the 6- and 12-month questionnaires, respectively. Anxiety was substantially elevated at baseline (half of one population-level standard deviation) and returned to general population mean levels at 6 and 12 months. Younger age, Medicaid/None/Self-pay insurance, prevalent diabetes, and current smoking were associated with higher symptom burden on multiple PRO measures across the three time points. Women with aggressive histology, higher disease stage, or those with adjuvant treatment had worse fatigue at 6 months, which normalized by 12 months. Conclusions We observed a high symptom burden at endometrial cancer diagnosis, with most PRO measures returning to general population means by 1 year. Information on risk factor-PRO associations can be used during the clinical visit to inform supportive service referral. Implications for Cancer Survivors These findings can inform clinicians’ discussions with endometrial cancer survivors regarding expected symptom trajectory following diagnosis and treatment.

Barriers and enablers to participation in physical activity among women diagnosed with ovarian cancer

Abstract Purpose Ovarian cancer is the leading cause of death among gynecological cancers, with low survival rates and a high disease burden. Despite the known benefits, most women reduce their participation in physical activity following diagnosis. Little is known about ovarian cancer survivors’ experiences of physical activity. The primary aim of this study was to explore the barriers and enablers to participation in physical activity among women diagnosed with ovarian cancer. Methods A qualitative descriptive study design was conducted via semi-structured interviews with nine women diagnosed with ovarian cancer (stages I–IV; 40–77 years). The interviews took place at the participant’s home via telephone or online video conferencing software Coviu©. An inductive thematic approach was used. The organization and coding of data were completed using NVivo computer software (Version 12.6.0, QSR International Pty Ltd.). Weekly discussions occurred among the research team to ensure that themes accurately represented participant views. The consolidated criteria for reporting qualitative studies (COREQ) 32-item checklist were followed. Results The main barriers to physical activity participation that emerged were (i) the lack of referral to an exercise professional within the multidisciplinary cancer team, (ii) fear of injury after surgery and during treatment, and (iii) treatment-related side effects. However, many of the participants perceived benefits of physical activity related to (i) enhanced physical and psychological health, (ii) improved cancer outcomes, and (iii) social benefits as key enablers of physical activity participation. Conclusions Physical activity interventions for women with ovarian cancer should address the modifiable barriers identified in this study. A key focus should be to streamline timely referral pathways within the multidisciplinary team, including exercise professionals, dietitians, psychologists, and specialists nurses following a diagnosis of ovarian cancer. Further research and service development are needed to optimize supported self-management through (i) education about the importance of physical activity to both healthcare professionals and women alike, (ii) enhanced symptom management for women, which was identified as a barrier to participation, and (iii) the development of shared care plans and patient center goals to address any fears or concerns. Implications for cancer survivors People diagnosed with ovarian cancer have low participation levels of physical activity. Cancer care professionals’ support could increase physical activity uptake and reduce some of the burden of an ovarian cancer diagnosis.

A 12-year overview of fertility preservation practice in Nordic pediatric oncology centers

Abstract Purpose Fertility preservation is the only option to safeguard fertility following gonadotoxic treatments. This study aimed to provide an updated status on fertility preservation for pediatric cancer patients in the Nordic countries. Methods A questionnaire consisting of 14 questions was sent to directors of 18 main pediatric oncology centers in the Nordic countries in 2010 and 2022. We received information regarding indications, guidelines, counseling, and available fertility preservation options. Results The response rates were 89% in 2010 and 72% in 2022. The results reveal an increase in clinical practice guidelines on fertility preservation for cancer patients, from 25% in 2010 to 70% in 2022. Counseling on fertility preservation options in 2022 was more specific and offered to most patients who fulfilled indications for fertility preservation (from 19 to 77%). Sperm cryopreservation continues to be the predominant fertility preservation method for pubertal boys in the Nordic countries. However, there has been a notable increase in the availability of testicular tissue preservation for prepubertal boys (0 to 62%). A similar increase in the offer of ovarian tissue preservation for prepubertal girls (0 to 92%) was observed among pediatric cancer patients. Conclusions The past decade has shown commendable advancements in fertility preservation for pediatric cancer patients in the Nordic countries. Implications for Cancer Survivors As fertility care evolves globally, continuous assessment of regional practices and challenges is imperative to enhance the quality of care and life for pediatric cancer survivors in the Nordic regions.

Increasing physical activity levels following treatment for cervical cancer: an intervention mapping approach

Abstract Purpose The purpose of this study was to utilise the intervention mapping (IM) protocol as a framework with which to develop an intervention underpinned by relevant behaviour change theory to promote physical activity (PA) following treatment for cervical cancer. Methods The six steps of the IM protocol were followed. A qualitative semi-structured interview study and a rapid review of the literature were conducted along with the development of a logic model of the problem and a logic model of change to inform intervention development. Results An intervention was developed which aims to increase PA levels following treatment for cervical cancer, tailored to address key findings from the IM needs assessment. These include embedding behavioural and social strategies that help participants to overcome perceived barriers to PA participation; goal setting strategies to gradually increase PA levels with a view of reaching relevant PA guidelines for cancer survivors and feedback to encourage self-assessment of well-being and PA capability. Conclusion This study maps the development of a novel PA intervention for those who have been treated for cervical cancer. The use of a systematic development framework was necessary as little insight exists regarding PA preferences after treatment for cervical cancer. Implications for Cancer Survivors PA behaviour is associated with positive physical and psychological health outcomes for cancer survivors. Optimising targeted promotion of PA behaviour following treatment for cervical cancer may result in an enhanced survivorship experience through increased PA behaviour and improved quality of life (QOL).

Changes in physical function in older women with endometrial cancer with or without adjuvant therapy

To evaluate changes in physical function (PF) for older women with endometrial cancer (EC) + / - adjuvant therapy in the Women's Health Initiative Life and Longevity after Cancer cohort. This study examined women ≥ 70 years of age with EC with available treatment records. Change in PF was measured using the RAND-36 and compared between groups using Wilcoxon rank-sum tests. Multivariable median regression was used to compare the changes in scores while adjusting for confounding variables. Included in the study were 287 women, 150 (52.3%) women who did not receive adjuvant therapy and 137 (47.7%) who received adjuvant therapy. When comparing PF scores, there was a statistically significant difference in the median percent change in functional decline, with a greater decline in those who received adjuvant therapy (- 5.9% [- 23.5 to 0%]) compared to those who did not (0 [- 18.8 to + 6.7%]), p = 0.02). Results were not statistically significant after multivariable adjustment, but women who underwent chemotherapy had a greater percent change (median ∆ - 13.8% [- 35.5 to 0%]) compared to those who received radiation alone (median ∆ - 5.9% [- 31.3 to 0%]) or chemotherapy and radiation (median ∆ - 6.5% [- 25.8 to + 5.7%]. Older women with EC who received adjuvant therapy experienced greater change in PF than those who did not receive adjuvant therapy, particularly women who received chemotherapy. These results were not statistically significant on multivariate analysis. EC survivors may experience changes in PF because of chemotherapy and/or radiation therapy. Additional supportive care may need to be provided to older women to mitigate functional decline.