Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum Proceedings of a Workshop (2018) / Chapter Skim
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They should not be construed as reflecting any group consensus. 2 See http://www.nap.edu/catalog/13348 (accessed April 5, 2017)
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She stressed that the number of cancer survivors is growing rapidly: In 2016, there were more than 15.5 million cancer survivors in the United States; by 2026, this number is expected to reach 20 million. Demark-Wahnefried noted that adult cancer survivors are more likely than the general population to have obesity, experience fatigue, have reduced muscle mass and strength, and to develop heart disease, stroke, osteoporosis, and metabolic syndrome (Greenlee et al., 2016; Henderson et al., 2014)
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Given this interest, the NCPF held a second public workshop, Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum, on February 13 and 14, 2017, in Washington, DC. The purpose of this workshop was to highlight the current evidence base, gaps in knowledge, and research needs on the associations among obesity, physical activity, weight management, and health outcomes for cancer survivors, as well as to examine the effectiveness of interventions for promoting physical activity and weight management among people living with or beyond cancer.
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The workshop statement of task is included in Appendix A and the workshop agenda in Appendix B.5 Terminology and Concepts Discussed at the Workshop Several speakers provided definitions for concepts and terminology used in workshop presentations and discussions. Goodwin defined obesity as having a body mass index (BMI6)
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• Increase public messaging about the importance of diet, weight management, and physical activity for people at risk for cancer, as well as for cancer survivors. (Demark-Wahnefried, Kennedy Sheldon, Ligibel)
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Delivering Weight Management and Physical Activity Interventions to Cancer Survivors • Tailor interventions to the unique needs of different populations, including racial/ethnic minorities, childhood and older adult cancer sur vivors, and rural populations. (Bamman, Befort, Demark- ahnefried, W Stolley)
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Improving Clinician Education, Resources, and Standards • Increase education, training, and outreach to oncologists, oncol ogy nurses, and primary care clinicians about the benefits of weight management and physical activity interventions for cancer urvivors. s (Bamman, Denlinger, Dixon, Goodwin, Kennedy Sheldon, ekhlyudov, N Schmitz)
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• Engage cancer survivors, clinicians, community health workers, advocacy organizations, and institutional partners in designing and implementing studies. (Eakin, Thomson)
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Bamman also described different types of exercise, including endurance or aerobic training, which includes repetitive exercises (e.g., running, walking, and swimming) that produce dynamic muscle contractions of large muscle groups for an extended period of time (Physical Activity Guidelines Advisory Committee, 2008)
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. In addition, the prevalence of obesity is greater among cancer survivors compared to the general population (Greenlee et al., 2016)
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. Being overweight or obese is also associated with a greater susceptibility to chemotherapy-induced cardiotoxicity for patients with breast cancer (Guenancia et al., 2016)
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Ligibel added, "Although we do not know definitively whether metabolism, inflammation, or differences in immunity are responsible for the observed connections between obesity and cancer, we can see that there are biologically plausible mechanisms that could directly affect cancer outcomes in patients who are overweight, obese, and inactive." Goodwin noted that well-conducted randomized controlled trials are needed to understand whether cancer outcomes can be altered through lifestyle interventions. Physical Activity and Cancer Physical activity, exercise, and cardiorespiratory fitness are linked to cancer outcomes, reported Bamman and Kerry Courneya, professor and Canada Research Chair in the Faculty of Physical Education and Recreation at the University of Alberta.
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However, current research has provided a number of insights about the role of weight management and physical activity interventions on other outcomes that are important to cancer survivors and the delivery of cancer care, including the effects on quality of life, fatigue, cancer-related morbidities, treatment completion, and chronic health conditions: "There is strong evidence that exercise and weight management improves quality of life, fitness, body weight, and sleep, and reduces fatigue, lymphedema, and joint pain. But the effects of exercise and weight management on bone mineral density, cognitive function, peripheral neuropathy, and cardio ascular dis v ease biomarkers are uncertain," said Irwin.
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Another systematic review and meta-analysis of supervised exercise in breast cancer survivors also found reductions in cancer-related fatigue and improvements in overall quality of life, she added (Meneses-Echávez et al., 2015)
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More recently, the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) trial randomly assigned approximately 700 breast cancer survivors who were overweight or obese to either a group-based behavioral intervention with telephone counseling and tailored newsletters to support weight loss, or a control group with a less intensive intervention.
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A year-long program of resistance training and aerobic exercise significantly decreased joint pain in breast cancer survivors taking aromatase inhibitors compared to usual care (Irwin et al., 2015)
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"Exercise is important not only for cancer outcomes, but also for cardiovascular disease endpoints," Irwin said. Several large studies of weight loss interventions for breast cancer survivors have shown it is possible to achieve at least a 5 percent weight loss, Irwin reported (Befort et al., 2016; Goodwin et al., 2014; Rock et al., 2015)
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. This study found that cancer survivors enrolled in either type of diet had similar weight loss and reduced levels of fasting glucose.
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TABLE 1 Summary of Ongoing Randomized Controlled Trials with Disease Recurrence and Mortality Endpoints INTERVAL BWEL CHALLENGE DIANA-5 MCRPC LIVES SUCCESS C N 3,136 962 1,241 866 1,040 ~1,400 Disease Breast Colon Breast Prostate Ovarian Breast Stage II–III II–III I–III IV II–IV II–III Intervention 2-year weight loss 3-year exercise 4+-year medicinal 2+-year exercise 2-year diet and 2-year weight loss diet and exercise exercise Primary endpoint IDFS DFS IDFS OS PFS DFS Correlative Blood Tissue Blood Blood Blood Blood Blood NOTE: BWEL = Breast Cancer WEight Loss; CHALLENGE = Colon Health and Life-Long Exercise Change; DFS = disease-free survival; DIANA = Diet and Androgens; IDFS = invasive disease-free survival; INTERVAL-MCRPC = INTense Exercise foR surVivAL Among Men with Metastatic Castrate-Resistant Prostate Cancer; LIVES = Lifestyle Intervention for Ovarian Cancer Enhanced Survival; OS = overall survival; PFS = progression-free survival. SOURCE: Ligibel presentation, February 13, 2017.
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Courneya reported on the Colon Health and Life-Long Exercise Change (CHALLENGE) trial, the first phase III trial to evaluate the effects of exercise on disease-free survival in colon cancer survivors (Courneya et al., 2014b)
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The German SUCCESS C trial, which is assessing the role of a nthracycline-free chemotherapy in women with early-stage breast cancer, has an embedded lifestyle intervention program for women who have a BMI between 24 and 40. The embedded analysis will evaluate an intensive lifestyle intervention program on disease-free survival and will assess the predictive role of cancer-associated and obesity-related biomarkers for the prediction of disease recurrence and survival (Rack et al., 2010)
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She added that some of these trials will be large enough to perform subset analyses, such as comparisons among women with hormone receptor-positive or hormone receptor-negative breast cancer. However, Ligibel said that the trial results may not be generalizable to all cancer survivors.
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Andrew Dannenberg, associate director of cancer prevention at the Sandra and Edward Meyer Cancer Center at Weill Cornell Medical College, agreed, and noted the complexity of fat remodeling in response to exercise -- he said it depends on the dose of exercise and the amount of weight loss achieved, and the timing of biomarker assessment matters. However, Dannenberg said that conducting such biomarker analyses in response to exercise and weight management interventions will be very informative over time.
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" Dannenberg added, "There are a lot of people who have a BMI of 24 and are getting a pat on the back, who in fact are hyperadipose with evidence of metabolic abnormality. I would argue that many of these individuals 10 to 20 years later will show up in the clinic with type 2 diabetes, heart disease, and cancer, and there should be a big push toward early detection and intervention in that cohort." Interventions for Weight Management and Physical Activity in Other Populations Several speakers discussed the role of weight management and physical activity interventions in other populations and how these interventions may be relevant to cancer survivors.
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. Studies in patients with diabetes have found that modest weight loss is achievable with a low-calorie diet and moderate physical activity, and this weight loss is linked to a reduction in biomarkers associated with diabetes and cardiovascular disease, Apovian said.
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"When you lose lean body mass, you no longer need as many calories to fuel your body, and that is probably one of the big reasons that it is very important to exercise while you are losing weight, so that you can keep that lean body mass" she said. Apovian emphasized the importance of providing a behavioral intervention in addition to diet to help participants avoid regaining weight, citing a number of studies that found long-term weight loss can be achieved when it is accompanied by long-term, regular support (Elmer et al., 2006; Tate et al., 2001, 2003; Wadden, 1993)
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Irwin added that the completed studies on weight management and exercise interventions in cancer survivors have limitations. She said that a number of the studies did not control well for potential sources of confounding, such as whether patients assigned to exercise or weight loss interventions received more attention than what was given to other participants.
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, and require strong evidence." Courneya added that recurrence is a primary concern of cancer survivors, and some cancer survivors are willing to forego quality-of-life benefits for small improvements in survival. G oodwin added that some patients find it burdensome to adopt lifestyle changes, and many breast cancer survivors feel guilty when they do not lose weight or do not become more physically active, and worry that by not making these lifestyle changes, their cancer will recur.
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There has been a burgeoning of information relating to the benefits of physical activity and weight loss in terms of cancer rehabilitation and recovery, symptom control, general health promotion, and reduction in risk of obesity-associated illnesses that many of our patients with cancer are dealing with." Pinto suggested that clinicians should recommend physical activity to cancer survivors, and pointed out that exercise is currently not usually part of a cancer treatment plan or survivorship care. "This is an area where there are multiple missed opportunities at different times and points after diagnosis," she said.
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They want to be engaged fully in their life and be able to function as active citizens and take care of their families and themselves. Fitness and weight management are key to that" (see Box 2)
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, they are going to tell you they want help related to eating, nutrition, and exercise." Two cancer survivors at the workshop described their expe riences with weight management and physical activity since diagnosis. Karen Cochrane Karen Cochrane, a patient advocate and educator in patient health and safety information at Children's of Alabama, is a 53-year old nurse who was recently diagnosed with breast cancer.
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achieve the most beneficial treatment outcome." Harrison was diagnosed with metastatic prostate cancer 14 years ago, and has received multiple treatments since his diagnosis, in what he termed "prostate cancer chess -- it makes a move and then we make a move." He realized that throughout his cancer treatments, he was affected by weight gain and muscle and strength loss, and that these concerns were not being addressed. He said that he experienced joint pain and Courneya and Goodwin noted that some studies suggest weight loss is linked to adverse outcomes in certain cancers.
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Why not address those things from the very beginning with weight management and physical activity because they keep other parts of our system functioning well? This is not rocket science.
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Thomson pointed out that there may be a teachable moment after a cancer diagnosis, with oncology nurses reporting that patients are highly receptive to interventions targeting health behaviors during their cancer treatment (Karvinen et al., 2015)
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Denlinger agreed: "You have to give those messages early and often in order to make changes." Patient Screening, Assessment, Triage, and Referral Basen-Engquist stated that clinicians will need to screen cancer survivors to determine whether they could benefit from lifestyle intervention programs, and clinicians will also need to assess the risks of different intervention options for individual patients. Basen-Engquist suggested using an approach analogous to the 5As model that clinicians use to connect people to smoking cessation programs.11 The components of the 5As model are: 1.
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Denlinger added that the latest guidelines on physical activity for cancer survivors from the National Comprehensive Cancer Network (NCCN) includes a risk assessment tool for physical activity-induced adverse events, including an algorithm for how best to implement physical activity recommendations based on that risk assessment, patients' current or prior exercise behavior, and how well they tolerate exercise (Denlinger and Ligibel, 2013)
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In a telephone-based weight loss program among 210 rural breast cancer survivors, she said that 69 percent reported a new or worsening medical condition, with 47 percent
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TABLE 2A Risk Assessment Tool for Determining What Types of Exercise May Need Clinical Supervision Based on a 38 Cancer Survivor's Current Health and the Level of Physical Activity Least Restrictive Alternative Level IV: Survivor with Consult with physician/ Cancer rehabilitation Cancer rehabilitation problematic symptoms and/or rehabilitation professional prior refractory impairments to exercise in home-based or community program Level III: Survivor with cancer- Community/home-based Consult with physician/ Supervised exercise program, or cancer treatment–related program rehabilitation professional prior cancer-specific after consult impairments, uncomplicated by to exercise in home-based or with physician/rehabilitation other systemic problems community program professional Level II: No specific cancer- Self-selected activity, Community/home-based Consult with physician/ or cancer treatment–related self-monitoring program following appropriate rehabilitation professional prior impairments, but with comorbid self-guided screening (e.g., to exercise in home-based or or other conditions that may be American College of Sports community program Risk Level of Survivor exacerbated by exercise Medicine/American Heart Association Questionnaires) a Level I: Post-treatment survivor, Self-selected activity, Community/home-based Consult with physician/ no/well-managed comorbidities, self-monitoring program rehabilitation professional prior no cancer-specific morbidity to exercise in home-based or community program Reduce sedentary behavior, light Moderate-intensity aerobic Vigorous intensity aerobic (e.g., intensity exercise (e.g., walking)
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Agenda for translating physical activity, nutrition, and weight management interventions for cancer survivors into clinical and community practice. Obesity 25:S9–S22.
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SOURCES: Eakin presentation, February 13, 2017; Translational Behavioral Medicine, Exercise for breast cancer survivors: Bridging the gap between evidence and practice, 1, 2011, 539–544, Hayes, S
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"People will travel an hour or two to get high-quality curative cancer care, but they [may not] travel in order to go to a [recreational facility]
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, active follow-up of an oncologist's referral by a physical therapist was critical to the adoption of the program by breast cancer survivors. BOX 3 Strength After Breast Cancer Program Kathryn Schmitz, professor of public health sciences and associate director of population sciences at The Pennsylvania State University's College of Medicine, reported on the Strength After Breast Cancer Program, which has been disseminated to breast cancer survivors in more than 380 locations across the country.
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Whether cancer survivors would benefit more from having a program tailored to their cancer-specific needs or a more broad-based weight management or physical activity program has not been sufficiently investigated yet, Basen-Engquist said, and the determination may depend on the health condition of the survivor, the risk level of the activity, and the survivor's comfort level with that activity. Eakin compared two Australian lifestyle intervention programs (one designed for cancer survivors and the other for the general population)
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He discussed two Y programs relevant to cancer survivorship, improved physical activity, and reducing the risk for chronic diseases -- LIVESTRONG at the YMCA and the YMCA's Diabetes Prevention Pro gram (DPP)
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The 12-week program is delivered to small groups and includes cardiovascular conditioning, strength training, and balance and flexibility exercises provided by YMCA-certified instructors during two 75- to 90-minute sessions per week. YMCA program staff undergo training to improve interpersonal interactions with cancer survivors.
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. d See https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes prevention-program-dpp/Pages/default.aspx (accessed August 15, 2017)
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"We do everything we can, given that these are population-based programs, to err on the side of being inclusive in a safe way," Eakin said. Cancer survivors also participate in a brief pre- and post program assessment for program evaluation.
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. Program Comparison Eakin found that for both programs, only 10 percent of cancer survivors who were screened were determined to be ineligible for the program.
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She described ScaleDown, a weight loss intervention delivered via text messaging synched with a smart scale (see Box 6)
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Breast, Cost savings Prostate Mixed-delivery Reach/dissemination Safety* Breast modalities Cost savings Endometrial NOTE: BMI = body mass index; DAMES = Daughters and Mothers Against Breast Cancer; ENERGY = Exercise and Nutrition to Enhance Recovery and Good Health for You; IT = information technology; LEAN = Lifestyle, Exercise, and Nutrition; LISA = Lifestyle Intervention in Adjuvant Treatment of Early Breast Cancer; RENEW = Reach out to ENhancE Wellness; STONE = Survivors Taking on Nutrition and Exercise; SUCCEED = Survivors of Uterine Cancer Empowered by Exercise and Healthy Diet; WW = Weight Watchers.
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Over 14 years, less weight gain Fit4Life, Huang et al., 2014; −6.4 kg at 6 months McCarroll et al., 2015 −0.3 versus +0.1 BMI FRESH START, Demark-Wahnefried et al., No change 2007; Park et al., 2016 6% versus 1.5% control (12 months) ENERGY, Rock et al., 2015; von Gruenigen −3.5 kg versus +1.4 kg et al., 2008; Stepping STONE, Sheppard et −0.8 kg versus +0.2 kg al., 2016
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Approximately half of the people who continued to use Scale Down for 6 months were still weighing themselves 4 to 5 days per week at the end of that time frame. Mean weight loss at 6 months was 6 percent of body weight.
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However, she pointed out that not all rural participants have access to Wi-Fi, and this program will use devices with cellular data plans. Basen-Engquist added she has started recruiting endometrial cancer survivors to a weight loss and physical activity program that uses information and coaching provided via Facetime on an iPad.13 This technology will also enable coaches to observe participants as they complete resistance training.
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, and usual care among breast and colorectal cancer survivors found that the oncologist's recommendation alone did not improve the exercise levels (Park et al., 2015)
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Thomson said a systematic review found that motivational interviewing of cancer survivors was effective for a variety of lifestyle behaviors (Spencer and Wheeler, 2016)
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. She added that there also is a higher incidence of obesity among cancer survivors who are Hispanic and African American compared to whites (Greenlee et al., 2016)
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Stolley added that opportunities for interventions to engage friends and family as social support can aid behavioral change and maintenance of these behaviors. She also suggested creating links between community organizations and clinical practices providing cancer survivorship care, because survivors want resources in their own communities (Crookes et al., 2016; Stolley et al., 2006; Whitt-Glover et al., 2014)
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"You could have the same basic weight loss intervention for a 40-year-old with three kids at home and an [older adult] , but you are going to contextualize that differently for those populations.
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She noted that lifestyle interventions need to be tailored to both ends of the age spectrum, especially given the prevalence of suboptimal diets and insufficient physical activity among both populations (40–70 percent of childhood cancer survivors and 52–85 percent of older adult cancer survivors have suboptimal diets; 54–84 percent of childhood cancer survivors and 53–70 percent of older adult cancer survivors are insufficiently physically active) (Blanchard et al., 2008; Ford et al., 2014; Niu et al., 2015; Zhang et al., 2012)
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She stressed that clinicians need to give special consideration to childhood and older adult cancer survivors when devising weight management and exercise interventions. For example, children who are on stringent diets may be susceptible to stunting and the development of sarcopenia.
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. To tailor weight management and physical activity interventions for childhood and older adult cancer survivors, Demark-Wahnefried said that remote programs or programs with transportation support are critically needed.
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. Rural cancer survivors report poorer health status, more psychological distress, higher rates of depression and anxiety, and greater gaps in understanding about cancer and the effects of cancer treatment (Burris and Andrykowski, 2010; Weaver et al., 2013b)
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In one study of rural breast cancer survivors, 54 percent reported sedentary behaviors, and only 19 percent reported meeting physical activity recommendations (Rogers et al., 2009)
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," Denlinger said. For example, Denlinger conducted a patient chart review of adherence to NCCN disease-specific survivorship guidelines for colorectal cancer and non-small cell lung cancer, and found that clinicians documented physical activity and healthy diet counseling in fewer than 20 percent of colorectal cancer survivors and approximately 30 percent of lung cancer survivors (Denlinger et al., 2015)
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Dietz added that lack of expertise in obesity, weight management, and physical activity extends to primary care clinicians. He said that fewer than half of those surveyed knew that the recommended level of physical activity was 150 minutes per week; only one-third knew that multiple types of
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Patient-Centered Terminology for People with Obesity Dietz said that many clinicians do not use appropriate language when discussing obesity and weight management with their patients. He emphasized that clinicians should recognize that obesity is a disease and not an identity.
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Buzaglo noted that patients often under estimate the side effects from their cancer treatment, such as neuropathy, that can be a barrier to adhering to physical activity guidelines. Christopher Cogle, professor of medicine at the University of Florida College of Medicine, noted that many cancer survivors can experience strong, vacillating emotions that influence physical activity and weight management, including elation, anxiety, and depression.
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Integrating Clinical and Community-Based Programs and Resources Dietz suggested utilizing a framework that integrates clinical and c ommunity-based systems of care in order to deliver weight management and physical activity interventions to cancer survivors (Dietz et al., 2015) (see Figure 3)
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Equity Training & Education Care Delivery Community Community • Information Systems •Information Systems Family & Individual Systems Systems • Decision Support •Decision Support Empowerment and Engagement • Resources • Resources • Delivery System Design •Delivery System Design • Services • Services •Self Management Support • Self Management Support • Supportive • Supportive •Local patient environment • Local Patient Environment Environment Environment •Clinicians • Clinicians • Social Norms • Social norms Integration Convener, Advocacy, Data Exchange, Financing, Governance/Regulation, Referral Processes, Communications Metrics Population Health FIGURE 3 Framework for integrated clinical and community systems of care. 69 SOURCES: Dietz presentation, February 14, 2017; Dietz et al., 2015.
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She advocated for improved access to and support of community-based programs for weight management and physical activity. Increasing Patient Awareness A number of workshop participants suggested that cancer survivors should be better informed about the associations among weight, physical activity, and patient outcomes, as well as the availability of lifestyle interventions programs.
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Dixon stated, "I am a huge fan of educating physicians [and] nurses about nutrition because there is a lot that those clinicians can do to get the ball moving forward, and if the patient hears it from three different c linicians and then gets a referral to a dietitian, they are more likely to be interested in that intervention and more receptive to it." In addition, Demark-Wahnefried noted that both childhood and older adult cancer survivors are generally unaware of their increased risk for adverse health effects of cancer and its treatment -- including sarcopenia and frailty -- and clinicians need to increase awareness among these patient populations.
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clear from a regulatory standpoint," he said. Anand Parekh, chief medical advisor at the Bipartisan Policy Center, added that, "Payers are all over the map when it comes to coverage of many of these types of nonpharmacologic and nonsurgical interventions" for obesity treatment.
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Based on their review, Anthem created preferred "cancer care pathways." For oncology practices that choose to use one of the pathways, or to have their patients participate in a precision medicine clinical trial, Anthem provides enhanced reimbursement to cover the costs of treatment planning and care coordination. Kraft added that it will be beneficial for Anthem to share information with participating practices about the importance of weight management, exercise, and strength building.
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Nobody puts their money where their mouth is." He said that it is expensive and time consuming to provide effective weight loss interventions, and the benefits of that weight loss are not seen for many years "so the people who pay for the care are not the people who are benefiting from the care," and he added, "This is a business and political problem, not a medical problem. How do you create a business case for investments in weight management so that it is compelling enough to get people to actually invest in it?
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longterm benefits is to measure things at the community level and hold people accountable for those community indicators," he said. Parekh noted lessons learned for cancer survivorship care and weight management related to insurance benefits, saying that interventions have to be evidence based, a broad array of clinicians need to be reimbursed for providing the benefit, and patient cost sharing can be a deterrent to uptake.
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Payal Martin, public health advocate and analyst at Payal Shah Martin, LLC, asked if a mandate was needed for insurers to reimburse weight loss or physical activity programs. Kraft responded that the most important determinant is the evidence base for an intervention.
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Kennedy Sheldon said that when it comes to weight management, the focus of many practicing oncology nurses today is still to prevent patients from losing weight during treatment. "We need to educate nurses better, particularly those in cancer care or those working with cancer survivors, who need to get the message out that weight control is important, not just for reducing the risk of recurrences, but also of second primary cancers," Kennedy Sheldon said.
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Schmitz suggested using continuing education and licensure to train clinicians about the benefits of exercise for cancer survivors. Bamman agreed, adding that such training could include the distinction between resistance and aerobic exercise, the goals of each, and how they differ from the goals of a weight management program.
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"That is not enough, so we need to do some more work on that," she said. She added that the ACSM developed an educational resource for clinicians called Exercise is Medicine.29 Morris pointed out that physical therapists have been treating cancer survivors for almost 50 years, and in 1983, the APTA recognized the 28 See https://certification.acsm.org/acsm-cancer-exercise-trainer (accessed June 2, 2017)
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These efforts have resulted in more than 25 publications, and the Oncology Section is developing clinical practice guidelines to further assist clinicians in providing better care for cancer survivors. Standards for implementing weight management and physical activity programs are also needed, Longjohn suggested.
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Denlinger suggested a number of cancer survivorship, weight management, and physical activity resources for clinicians (see Box 8)
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. i See https://www.nhlbi.nih.gov/health/educational/wecan/tools-resources/weight management.htm (accessed August 29, 2017)
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Buzaglo agreed that it would be worthwhile to have the AHA involved in such collaborations, as well as patient advocates. Apovian also suggested the Obesity Society "can align and collaborate with oncology to promote obesity medicine so we can get more obesity treatment services covered by third-party payers and for nonphysician clinicians." Schmitz reported that the ACSM has a Cancer Interest Group,35 and she is trying to convene a roundtable of representatives from the ACSM, APTA, ASCO, American Academy of Physical Medicine and Rehabilitation, ONS, and other organizations to generate a position statement about physical activity for cancer survivors.
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Eakin suggested that another key to success is collaborating early in the development of the program with partners and stakeholders, including patients, clinicians, and advocacy organizations. "The earlier we involve them, the better," she said, noting that to develop the Healthy Living after Cancer program, she met with colleagues at cancer councils throughout Australia over a 2-year period to assess their cancer survivorship needs, the programming currently offered, and their willingness to adopt an integrated telephone-based program.
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Improving Measures and Endpoints Pinto emphasized the importance of identifying noncancer causes of death, especially cardiovascular outcomes, in addition to cancer outcomes. She also suggested assessing whether healthy behaviors are maintained over 37See https://react.center (accessed April 26, 2017)
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"We have to think about the minimal dose of exercise needed because that will have immediate bearing on the feasibility of implementing these interventions to reach a greater number of cancer survivors," she said. As an example, she cited a trial comparing three different exercise doses (Courneya et al., 2013)
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Thomson noted that studies demonstrating effective weight loss -- and more specifically, weight management in cancer survivors -- have included psychologists or other behavioral scientists, biostatisticians, and a wide array of clinicians, including oncologists, dietitians, exercise physiologists, and health coaches. She added that some intervention studies would benefit from greater involvement of adaptive design specialists and software engineers early in the research process.
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Pinto agreed, noting that in addition to expanding the diversity of study participants, studies should also include participants with fatigue or quality-of-life issues the interventions are designed to target. Thomson noted that most studies of weight loss interventions that have demonstrated an effect have enrolled the "worried well," or cancer survivors who already are healthier at baseline than the general population.
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This study showed that despite participants having substantial symptoms, it was possible to work with them and have a positive impact on weight loss (Kenzik et al., 2015)
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It brought me to my feet," and added, "That is our mission -- to get cancer survivors back on their feet and hopefully back to where they were before their diagnosis." She stressed, "We need to provide physical activity and weight management as a part of the standard of care," and noted that these interventions need to be personalized. "We still do not know whether weight management and physical activity will reduce cancer recurrence or metastasis, but we do know about other benefits [from these interventions]
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2017. Barriers to recruitment and adherence in a randomized controlled diet and exercise weight loss intervention among minority breast cancer survivors.
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2014. Protocol and recruitment results from a randomized controlled trial comparing group phone-based versus newsletter interventions for weight loss maintenance among rural breast cancer survivors.
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2012. Yoga for persistent fatigue in breast cancer survivors: A randomized controlled trial.
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2003. Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: Cardiopulmonary and quality of life outcomes.
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2016. Social networks and social support for healthy eating among Latina breast cancer survivors: Implications for social and behavioral interventions.
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2009. A pilot trial of spirituality counseling for weight loss maintenance in African American breast cancer survivors.
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2016. A qualitative evaluation of a group phone based weight loss intervention for rural breast cancer survivors: Themes and mechanisms of success.
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2013. A pilot randomized controlled trial of a commercial diet and exercise weight loss program in minority breast cancer survivors.
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2015. Lifestyle factors associated with cognitive functioning in breast cancer survivors.
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2004. Effects of an oncologist's recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: A single-blind, randomized controlled trial.
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2015. Symptoms, weight loss, and physical function in a lifestyle intervention study of older cancer survivors.
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2017. Get healthy after breast cancer -- examining the feasibility, acceptability and outcomes of referring breast cancer survivors to a general population telephone-delivered program targeting physical activity, healthy diet and weight loss.
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2015. Feasibility of a lifestyle intervention for overweight/obese endometrial and breast cancer survivors using an interactive mobile application.
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2016. Impact of a behavioral weight loss intervention on comorbidities in overweight and obese breast cancer survivors.
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2015. Weight loss interventions for breast cancer survivors: Impact of dietary pattern.
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2013. Effect of a diet and physical activity intervention on body weight and nutritional patterns in overweight and obese breast cancer survivors.
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2000. Meeting the needs of rural breast cancer survivors: What still needs to be done?
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2012. Do childhood cancer survivors meet the diet and physical activity guidelines?
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Key Terms
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