Cancer Survivors’ Adherence to Lifestyle Behavior Recommendations and Associations With Health-Related Quality of Life: Results From the American Cancer Society's SCS-II
Publication: Journal of Clinical Oncology
Abstract
Purpose
To examine the prevalence and clustering of physical activity (PA), fruit and vegetable consumption (5-A-Day), and smoking across six major cancer survivor groups and to identify any associations with health-related quality of life (HRQoL).
Methods
A total of 9,105 survivors of six different cancers completed a national cross-sectional survey that included the lifestyle behavior questions and the RAND-36 Health Status Inventory.
Results
Only a minority of cancer survivors were meeting the 5-A-Day (14.8% to 19.1%) or PA (29.6% to 47.3%) recommendations, whereas most were meeting the smoking recommendation (82.6% to 91.6%). In terms of the lifestyle behavior clusters, only 5% of cancer survivors were meeting all three recommendations. Analyses of covariance generally showed higher HRQoL in survivors who were meeting versus not meeting each lifestyle behavior recommendation with the strongest associations emerging for PA. Trend analyses showed a steep positive association between the number of lifestyle behavior recommendations being met and HRQoL for breast (P < .001), prostate (P < .001), colorectal (P < .001), bladder (P < .001), uterine (P < .001), and skin melanoma (P < .001) cancer survivors.
Conclusion
Few cancer survivors are meeting the PA or 5-A-Day recommendations, and even fewer are meeting all three lifestyle recommendations. The association between the current lifestyle recommendations and HRQoL in cancer survivors appears to be cumulative. Interventions to increase PA and fruit and vegetable consumption and reduce smoking are warranted and may have additive effects on the HRQoL of cancer survivors.
Introduction
More than 10 million Americans have a history of cancer1 and are at increased risk for secondary tumors, cardiovascular disease, diabetes,2-4 and a diminished health-related quality of life (HRQoL).5,6 While these negative outcomes may be the direct result of the disease and its treatments, lifestyle behaviors may also play a role.7-11 As such, cancer survivors characterize an important target population for health promotion efforts.
An important first step in promoting healthy lifestyle behaviors is to determine the degree to which cancer survivors are adhering to physical activity (PA), nutrition, and tobacco recommendations, which have been published by the American Cancer Society.12 Specifically, the recommendations suggest that cancer survivors (1) accumulate at least 150 minutes of moderate-to-strenuous or 60 minutes of strenuous PA per week, (2) consume at least 5 servings of fruits and vegetables each day (ie, 5-A-Day), and (3) not smoke. Unfortunately, recent population-based studies13-15 in the United States and Australia have shown that up to 70% of cancer survivors are not meeting the PA recommendation, 48% to 74%14-17 are not meeting the 5-A-Day recommendation, and 20% to 24% continue to smoke.13-17 Furthermore, several studies13-15 indicate few differences in the prevalence of these behaviors between cancer survivors and those without a history of cancer. Therefore, although a cancer diagnosis has been referred to as a possible “teachable moment” where survivors are likely to be motivated to make lifestyle changes to improve health outcomes,18,19 few are actually making these changes. The lack of change in the face of threat suggests that ways to promote adherence to these recommended behaviors warrant further investigation.15
One area that requires attention is the method used to obtain, date, and stage a cancer diagnosis. To date, national population-based studies13-15 have used self-reported measures to acquire these data, which may be problematic. A second area that requires attention is the lack of studies examining the associations among multiple lifestyle behaviors in cancer survivors, which is of particular interest as researchers20 have suggested that a change in one lifestyle behavior may serve as a stimulus for change in another lifestyle behavior. Indeed, preliminary evidence has shown that smoking, 5-A-Day, and PA are significantly related to each other16,17; however, these studies were limited to a few cancer survivor groups, had relatively small sample sizes, and limited geographic location.
To date, research has shown that PA is positively associated with HRQoL across several cancer groups.7 However, only two studies22,23 examined the smoking/HRQoL relationship in head and neck cancer survivors and found a negative association, whereas only one study16 examined the 5-A-Day/HRQoL relationship in breast, prostate, and colorectal cancer survivors and reported a null finding. Therefore, additional evidence regarding the relationship between HRQoL and smoking/5-A-Day in multiple cancer survivor groups is warranted. Furthermore, preliminary research16 showed that cancer survivors who met more than one lifestyle behavior recommendation reported better HRQoL compared with survivors who met only one recommendation. This may be partially explained by the fact that cancer survivors believe that engaging in more than one lifestyle behavior will reduce their perceived vulnerability (ie, of having a cancer recurrence or dying)24 and/or increase their sense of control over their lives,9 both of which may improve their HRQoL. Unfortunately, only one study16 has examined the behavior cluster/HRQoL issue in cancer survivors and its limitations have been noted above.
The first purpose of the present study was to estimate the prevalence of PA, 5-A-Day, and smoking in a national representative sample of cancer survivors using a registry-based approach to obtain cancer diagnosis, stage, and time since diagnosis. It was hypothesized that the majority of cancer survivors would not meet the 5-A-Day and PA recommendations, whereas the majority would meet the smoking recommendation.13-15 The second purpose was to identify potential lifestyle behavior clusters among the three behaviors, and it was hypothesized that few survivors would meet all three recommendations.16 The third purpose was to examine the associations between meeting the lifestyle behavior recommendations and HRQoL. It was hypothesized that survivors who met each individual lifestyle behavior recommendation would have significantly higher HRQoL compared with survivors who did not.7,16,22,23 Finally, we examined the association between the lifestyle behavior clusters and HRQoL and hypothesized that meeting an increasing number of lifestyle behavior recommendations would be associated with better HRQoL.16
Methods
Participants
Participants were from the American Cancer Society's Study of Cancer Survivors-II (ACS SCS-II)25 (a national cross-sectional study of HRQoL among cancer survivors identified through population-based cancer registries). To be included, participants had to be at least 18 years of age, diagnosed with a local, regional, or distant Surveillance, Epidemiology, and End Results summary stage cancer (bladder cancer included in situ cancers), a resident of the target state at the time of cancer diagnosis, diagnosed in the calendar year either 2, 5, or 10 years before sampling, and be diagnosed with female breast, prostate, colorectal, bladder, skin melanoma, or uterine cancer, which were chosen due to their positive long-term survival rates.
Procedure
A detailed description of the SCS-II methods is reported elsewhere.25 Briefly, a total of 36,372 cancer survivors were sampled from 16 state cancer registries across the United States. Of these, 2,586 survivors were found to be ineligible due to invalid cancer diagnosis or missing cancer stage information, whereas 4,157 survivors were found to be deceased or ineligible. Of the remaining 29,629 survivors, their physicians were contacted either using an active consent (ie, were contacted for written consent to recruit a given survivor) or passive notification (ie, were sent a letter explaining that recruitment of a given survivor would begin in 3 weeks unless study personnel heard from the physician) procedure before approaching their patient, which resulted in a 91.9% response rate. The remaining 26,802 cancer survivors were invited to participate in the study using an adapted Dillman's tailored design method that included both mail and telephone recruitment data collection procedures. Results showed that 7,616 cancer survivors refused to participate (the most common reasons for refusal were lack of interest in research, lack of time, and being too ill to self-report), 2,885 could not be located, and 7,196 did not respond, leaving a total of 9,105 cancer survivors who agreed to be in the study and completed the questionnaire (adjusted overall consent rate, 32.7%).
Measures
Demographic and medical information was collected via self-report and registry records. Registry data included date of birth, date of diagnosis, sex, cancer group, and stage of disease at diagnosis. Self-reported data included marital status, education, employment status, income, race, and type of treatment. Survivors were also asked whether they experienced various comorbidities in the last 12 months (ie, heart problems, hypertension, chronic back pain, arthritis, stroke, osteoporosis, asthma, emphysema or chronic obstructive pulmonary disease, stomach and/or intestinal problems, and diabetes) by having them check all that applied to them. The comorbidities that were checked were summed to obtain an overall comorbidity score.
PA was measured via the previously validated Godin Leisure-Time Exercise Questionnaire.26,27 A dummy variable was created with two categories (0 = did not meet ACS PA recommendation; 1 = met recommendation). 5-A-Day was measured by asking survivors to place a number between 0 and 7 in the blank beside the question, “How many days per week do you eat at least 5 servings of fruits and vegetables a day?”16 A dummy variable was subsequently created with two categories (0 = did not meet ACS 5-A-Day recommendation; 1 = met 5-A-Day recommendation).12 Smoking was measured via the previously validated item,16 “Do you currently smoke cigarettes on a regular basis” rated on a yes/no scale.
HRQoL was measured using the RAND-36 Health Status Inventory. This measure contains four physical domains (physical functioning, role-physical, bodily pain, and general health) and four mental domains (vitality, social functioning, role-emotional, and mental health) that can be used to formulate an overall global health composite score (ie, HRQoL), which ranges from 0 (worst HRQoL score) to 100 (best HRQoL score). The RAND-36 is a well-validated HRQoL measure28 that has been frequently used in cancer survivors.16,29-31 It was chosen over cancer-specific HRQoL measures because SCS-II focused on long-term cancer survivors for whom the disease- and treatment-specific questions included in most cancer-specific HRQoL measures may be less relevant.
Analytic Plan
Descriptive statistics for each cancer group were calculated and the percentage of cancer survivors meeting each lifestyle behavior recommendation was calculated. Next, the frequencies of each lifestyle behavior were combined to form eight possible mutually exclusive lifestyle behavior clusters. To examine the association of each lifestyle behavior with HRQoL, a one-way analysis of covariance controlling for potential demographic and medical confounders was conducted for each lifestyle behavior. Finally, to determine whether meeting an increasing number of lifestyle behavior recommendations would lead to a significantly better HRQoL, we performed a trend analysis32 controlling for the same confounders identified in the previous analyses. The analyses were conducted separately for each cancer survivor group.
Results
Participant Characteristics
A total of 2,885 female breast, 2,226 prostate, 1,918 colorectal, 586 bladder, 729 uterine, and 761 skin melanoma cancer survivors were included in the study. The demographic and medical characteristics are provided in Table 1. Briefly, prostate cancer survivors were the oldest and most likely to be married, whereas uterine cancer survivors had the greatest number of comorbidities. Skin cancer survivors were most likely to be white, employed, have a postgraduate degree, annual income of at least $75,000, and localized cancer diagnosis. Breast and skin cancer survivors were also most likely to have had surgery.
Individual Lifestyle Behaviors and Behavior Clusters by Cancer Survivor Group
Descriptive statistics are presented in Table 2. Overall, a majority of survivors were not meeting the 5-A-Day (80.0% to 85.2%) or PA (52.7% to 70.4%) recommendations, whereas the opposite was true for smoking (82.6% to 91.6%). Five lifestyle behavior clusters emerged (Table 3). At least 3.6% of survivors were meeting all three lifestyle behavior recommendations (3.6% to 5.8%), the PA plus smoking recommendation (14.0% to 26.1%), the 5-A-Day plus smoking recommendation (7.1% to 13.8%), the smoking only recommendation (49.6% to 61.5%), or were not meeting any recommendation (7.3% to 12.5%). However, less than 3.6% met the remaining recommendations and were dropped from subsequent analyses because their sample sizes were too small to justify analyzing separately.
Association of Individual Lifestyle Behaviors With HRQoL
The HRQoL unadjusted and adjusted means and standard deviations for each lifestyle behavior are presented in Table 4. Results from the analysis of covariance controlling for age, race/ethnicity, education, marital status, disease stage, and number of comorbid conditions (ie, confounders identified from previous analyses) showed that there was a significant main effect for PA across all six cancer groups such that cancer survivors who met the recommendation had significantly higher HRQoL compared with those who did not. Breast, prostate, and colorectal cancer survivors who met the 5-A-Day or smoking recommendation had significantly higher HRQoL compared with those who did not. No significant differences were observed for bladder or uterine cancer survivors regarding 5-A-Day or smoking. Skin melanoma survivors who met the 5-A-Day recommendation reported significantly higher HRQoL compared with those who did not; however, no HRQoL differences were observed regarding the smoking recommendation.
Association of Lifestyle Behavior Clusters With HRQoL
Before conducting the trend analysis, we combined the PA plus smoke and 5-A-Day plus smoke mutually exclusive categories into one and analyzed four categories (Table 5) to create the linear trend, which was coded as −3 (met no lifestyle behavior recommendation), −1 (met the smoking only recommendation), +1 (met the smoking recommendation plus either the PA or 5-A-Day recommendation), and +3 (met all three lifestyle behavior recommendations).32 Results showed that the linear trend was significant for breast (F[1,2420] = 78.76; P < .001), prostate (F[1,1912] = 62.44; P < .001), colorectal (F[1,1608] = 45.32; P < .001), bladder (F[1,462] = 17.23; P < .001), uterine (F[1,614] = 12.26; P < .001), and skin melanoma (F[1,642] = 31.00; P < .001) cancer survivors. Cancer survivors meeting more lifestyle behaviors reported higher HRQoL for all six cancer groups.
Discussion
The present study showed that a minority of cancer survivors are meeting the PA (ie, 29.6% to 47.3%) or 5-A-Day (14.8% to 18.2%) recommendations, which is consistent with previous research.13-15 The prevalence estimates for these two lifestyle behaviors are below those found in the healthy population where 48.7% of adults are meeting the PA recommendation33 and 23.8% are meeting the 5-A-Day recommendation.33 The opposite was true for smoking. Specifically, the majority of survivors were meeting the recommendation to not smoke (88.1% to 91.6%), which is actually better than the national average for healthy adults (79.5% are nonsmokers33). This suggests that a cancer diagnosis may have greater potential to be a “teachable moment” across several cancer groups in terms of changing smoking behavior, but it may be less effective in changing PA and fruit and vegetable consumption. This finding is significant given that PA and nutrition may play a significant role in reducing cancer recurrence and mortality8-11 and may combine to achieve an even greater effect.21
Previous research16 had identified three mutually exclusive lifestyle behavior clusters in cancer survivors (ie, met all three lifestyle behavior recommendations, the PA plus smoking recommendations, or the smoking only recommendation). The current study replicated these three clusters and introduced two more (ie, survivors who met the 5-A-Day plus smoking recommendation and survivors who did not meet any lifestyle behavior recommendation). Although novel, it is concerning that up to 12.5% of cancer survivors are not meeting any lifestyle behavior recommendation, and less than 10% on average across the cancer groups are meeting two or more recommendations. This suggests that it may be important to develop a multibehavioral lifestyle intervention rather than develop single behavior interventions. Although intervening on multiple behaviors simultaneously represents a challenge from an intervention perspective, doing so may provide an important opportunity to maximize the potency of the intervention20 from an outcomes perspective. Importantly, such an intervention should rely on a sound theoretical framework34,35 that takes multiple levels (ie, intrapersonal, interpersonal, institutional, community, and policy) into account.36
Consistent with previous research,7,16 our results showed that cancer survivors who met the PA guideline reported higher HRQoL compared with those who did not. What is novel, though, is that the effect of meeting the 5-A-Day or smoking recommendations on HRQoL varied by cancer group. For example, meeting either one of the recommendations was associated with significantly better HRQoL in breast, prostate, and colorectal cancer survivors, but had no association in bladder or uterine cancer survivors. Coupling these findings together would suggest that PA is a key lifestyle behavior that should be incorporated into all interventions to improve HRQoL in cancer survivors. However, special attention may need to be given to cancer group when considering smoking and 5-A-Day.
Another noteworthy finding is that meeting an increasing number of lifestyle behavior recommendations was associated with better HRQoL, which extended previous findings16,17 to bladder, uterine, and skin melanoma cancer survivors. Although cancer survivors have attributed a reduced chance of cancer recurrence to engaging in a healthy lifestyle,24 which we hypothesize may partially explain an improved HRQoL, there may be other mechanisms to explain the additive effect on HRQoL. For example, PA has been proposed to improve HRQoL in cancer survivors through its effects on cardiovascular fitness, muscular strength, fatigue, and patient-rated physical functioning in terms of activities of daily living.37 Furthermore, research has shown that fruit and vegetable consumption and smoking are negatively associated with depression,9,22,23 which has been shown to be negatively associated with HRQoL.22,23 Therefore, it may be that several mechanisms are interacting across the three lifestyle behaviors to induce the greatest HRQoL benefit. Whatever the case may be, it appears that meeting multiple lifestyle behavior recommendations may not only be beneficial from a cancer recurrence/mortality perspective, but also from a HRQoL perspective.
Despite the study's strengths (ie, multiple cancer groups, registry-identified cancer diagnosis and staging, lifestyle behavior clusters), there are limitations that need consideration. First, the self-report assessments used for the lifestyle behaviors are typically inferior to objective indicators. Future research should attempt to employ such objective measures to further evaluate the pattern of findings in the present study. Second, prediagnosis lifestyle behaviors were not measured. However, we did not believe it was feasible to ask 5- and 10-year cancer survivors about the frequency of their prediagnosis behaviors. Nonetheless, it will be important for researchers to examine lifestyle behaviors prospectively to determine the variation in these behaviors across time and whether this variation influences HRQoL. Third, the current study suggested an associative relationship between the lifestyle behavior clusters and HRQoL. Although a vital first step, future studies need to develop randomized controlled trials (to compare the influence of multibehavior v single behavior v usual care conditions on HRQoL) to establish whether the lifestyle behavior clusters cause improved HRQoL. Fourth, the overall response rate was relatively low (32.7%) suggesting that the results may not generalize to all cancer survivors in the population. Smith et al25 note that survivors who were younger (18 to 54 years), women, white, and had local or regionalized cancer were more likely to be recruited into the study. Although such a response rate and bias is not uncommon, future registry-based cancer survivor studies need to build on the methodology used by SCS-II to improve the response rate of cancer survivors whose cancers have been historically under-represented relative to other cancer groups. Finally, using an additive approach for summing the comorbidities may not be optimal as different comorbidities may have stronger or weaker effects on HRQoL. Future studies should attempt to create a weighting system for the comorbidities before creating a comorbidity score.
In summary, our results showed that the prevalence of lifestyle behaviors are low for PA and 5-A-Day. Moreover, these lifestyle behaviors appear to cluster together in five main patterns. From a HRQoL perspective, all three health behaviors had an independent association with HRQoL, although PA clearly showed the strongest association. Finally, we found evidence that the associations of these three lifestyle behaviors with HRQoL may be additive.
Author's Disclosures of Potential Conflicts of Interest
The author(s) indicated no potential conflicts of interest.
Author Contributions
Conception and design: Christopher M. Blanchard, Kevin Stein
Provision of study materials or patients: Christopher M. Blanchard, Kevin Stein
Collection and assembly of data: Kevin Stein
Data analysis and interpretation: Christopher M. Blanchard, Kevin Stein
Manuscript writing: Christopher M. Blanchard, Kerry S. Courneya, Kevin Stein
Final approval of manuscript: Christopher M. Blanchard, Kerry S. Courneya, Kevin Stein
| Characteristic | Breast (%) | Prostate (%) | Colorectal (%) | Bladder (%) | Uterine (%) | Skin Melanoma (%) |
|---|---|---|---|---|---|---|
| No. of survivors | 2,885 | 2,226 | 1,918 | 586 | 729 | 761 |
| Age, years | ||||||
| Mean | 63.2 | 72.2 | 70.2 | 70.8 | 66.5 | 60.2 |
| SD | 12.2 | 8.5 | 11.0 | 11.1 | 11.2 | 13.4 |
| Male | 0 | 100 | 53.2 | 74.7 | 0 | 50.1 |
| Married | 59.2 | 83.2 | 66.8 | 73.5 | 56.98 | 77.8 |
| Education | ||||||
| High school or less | 36.6 | 35.2 | 43.1 | 42.8 | 36.5 | 23.9 |
| Vocation/some college | 28.0 | 23.2 | 24.6 | 23.0 | 29.2 | 30.4 |
| College graduate | 15.0 | 15.5 | 12.8 | 13.1 | 14.8 | 18.8 |
| Postgraduate | 14.3 | 19.9 | 14.0 | 15.5 | 14.1 | 23.1 |
| Employed | 40.6 | 27.7 | 28.4 | 25.7 | 32.9 | 52.1 |
| Income | ||||||
| $0-$39,999 | 40.9 | 39.5 | 46.8 | 44.8 | 46.1 | 25.5 |
| $40,000-$74,999 | 22.0 | 24.9 | 20.6 | 23.5 | 19.5 | 30.5 |
| ≥ $75,000 | 16.0 | 27.7 | 11.5 | 13.5 | 11.8 | 27.7 |
| Race | ||||||
| White | 72.0 | 74.6 | 78.0 | 80.7 | 82.9 | 95.9 |
| Black | 12.4 | 12.8 | 10.8 | 8.5 | 8.0 | 3.0 |
| Hispanic | 9.0 | 8.2 | 7.1 | 6.0 | 6.2 | 1.1 |
| Years since diagnosis | ||||||
| 2 | 34.2 | 36.7 | 33.4 | 34.3 | 37.3 | 33.8 |
| 5 | 35.8 | 37.1 | 35.3 | 37.5 | 35.4 | 31.9 |
| 10 | 29.9 | 26.2 | 31.3 | 28.2 | 27.3 | 34.3 |
| Treatment | ||||||
| Surgery | 95.1 | 67.8 | 92.2 | 88.9 | 90.8 | 95.9 |
| Chemotherapy | 58.9 | 14.5 | 58.2 | 34.6 | 21.4 | 15.8 |
| Radiation therapy | 62.8 | 49.8 | 31.3 | 15.4 | 43.1 | 9.5 |
| Hormone therapy | 12.9 | 7.1 | 10.9 | 8.5 | 11.1 | 6.4 |
| Immunotherapy | 61.0 | 22.1 | 11.6 | 8.7 | 12.3 | 6.8 |
| BMT | 13.2 | 8.2 | 11.2 | 28.0 | 9.2 | 11.3 |
| Stage* | ||||||
| In situ | 0 | 0 | 0 | 42.8 | 0 | 0 |
| Localized | 70.3 | 81.6 | 46.9 | 51.2 | 85.3 | 93.4 |
| Regional | 28.8 | 16.9 | 59.8 | 5.3 | 12.5 | 5.5 |
| Distant | 0.9 | 1.5 | 3.3 | 0.7 | 2.2 | 1.1 |
| No. of comorbidities | ||||||
| Mean | 1.6 | 1.4 | 1.6 | 1.6 | 1.9 | 1.2 |
| SD | 1.5 | 1.3 | 1.4 | 1.5 | 1.5 | 1.2 |
Abbreviations: SD, standard deviation; BMT, bone marrow transplantation.
*
All cancers were staged using Surveillance, Epidemiology, and End Results Summary Stage coding procedures. In situ cancer is early cancer that is present only in the layer of cells in which it began. Localized cancer is cancer that is limited to the organ in which it began, without evidence of spread. Regional cancer is cancer that has spread beyond the original (primary) site to nearby lymph nodes or organs and tissues. Distant cancer is cancer that has spread from the primary site to distant organs or distant lymph nodes.
| Cancer Group | Physical Activity (%) | 5-A-Day (%) | Smoking (%) |
|---|---|---|---|
| Breast | 37.1 | 18.2 | 88.1 |
| Prostate | 43.2 | 15.6 | 91.6 |
| Colorectal | 35.0 | 15.9 | 91.3 |
| Bladder | 36.0 | 16.3 | 82.6 |
| Uterine | 29.6 | 19.1 | 91.1 |
| Skin melanoma | 47.3 | 14.8 | 89.0 |
Abbreviation: 5-A-Day, consumed five servings of fruits and vegetables each day.
| Behavior Cluster | Breast (%) | Prostate (%) | Colorectal (%) | Bladder (%) | Uterine (%) | Skin Melanoma (%) |
|---|---|---|---|---|---|---|
| PA plus 5-A-Day plus smoke | 4.5 | 5.1 | 4.6 | 3.6 | 3.7 | 5.8 |
| PA plus 5-A-Day | 0.6 | 0.3 | 0.2 | 0.3 | 0.0 | 0.4 |
| PA plus smoke | 16.8 | 22.8 | 15.6 | 14.9 | 14.0 | 26.1 |
| 5-A-Day plus smoke | 11.2 | 8.9 | 9.2 | 10.4 | 13.8 | 7.1 |
| PA Only | 1.8 | 1.1 | 0.8 | 3.6 | 0.8 | 2.6 |
| 5-A-Day only | 1.5 | 0.7 | 1.4 | 1.6 | 1.0 | 1.1 |
| Smoke only | 55.0 | 54.2 | 61.5 | 53.1 | 59.1 | 49.6 |
| No guideline met | 8.6 | 6.9 | 6.7 | 12.5 | 7.6 | 7.3 |
| Percentage total | 100 | 100 | 100 | 100 | 100 | 100 |
Abbreviations: PA, physical activity; 5-A-Day, consumed five servings of fruits and vegetables each day.
| Met Recommendation | Breast | Prostate | Colorectal | Bladder | Uterine | Skin Melanoma | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | |||||||
| PA | ||||||||||||||||||
| Yes | ||||||||||||||||||
| Mean | 52.1 | 52.9 | 53.1 | 53.6 | 52.9 | 52.4 | 53.0 | 52.3 | 53.0 | 52.9 | 53.8 | 53.7 | ||||||
| SD | 8.6 | 10.7 | 8.6 | 10.0 | 8.5 | 11.8 | 8.2 | 10.3 | 7.6 | 10.9 | 7.5 | 8.9 | ||||||
| No | ||||||||||||||||||
| Mean | 46.5 | 48.8 | 48.5 | 49.8 | 46.1 | 47.5 | 46.7 | 47.7 | 46.3 | 48.6 | 49.3 | 50.6 | ||||||
| SD | 10.3 | 12.5 | 10.4 | 10.9 | 10.9 | 14.9 | 11.3 | 14.4 | 10.5 | 16.6 | 10.3 | 9.5 | ||||||
| d† | 0.7 | 0.4 | 0.5 | 0.3 | 0.7 | 0.4 | 0.6 | 0.4 | 0.7 | 0.3 | 0.5 | 0.3 | ||||||
| 5-A-Day | ||||||||||||||||||
| Yes | ||||||||||||||||||
| Mean | 49.5 | 51.8 | 51.1 | 52.5 | 49.1 | 50.6 | 50.1 | 51.6 | 48.7 | 49.9 | 54.1 | 54.4 | ||||||
| SD | 10.2 | 10.4 | 10.1 | 9.9 | 10.8 | 11.2 | 11.2 | 10.7 | 10.5 | 10.6 | 7.9 | 8.7 | ||||||
| No | ||||||||||||||||||
| Mean | 46.9 | 49.3 | 49.3 | 50.5 | 47.5 | 48.7 | 47.6 | 49.8 | 47.1 | 49.1 | 50.1 | 51.1 | ||||||
| SD | 10.5 | 14.4 | 10.2 | 12.9 | 10.8 | 17.0 | 10.9 | 15.8 | 10.9 | 14.5 | 9.8 | 10.2 | ||||||
| d† | 0.3 | 0.2 | 0.2 | 0.2 | 0.2 | 0.1 | 0.2 | 0.1 | 0.2 | 0.1 | 0.5 | 0.4 | ||||||
| Smoke | 47.7 | 49.8 | 49.8 | 50.9 | 48.1 | 49.3 | 48.3 | 50.3 | 47.7 | 49.4 | 50.7 | 51.6 | ||||||
| Yes | ||||||||||||||||||
| Mean | 47.7 | 49.8 | 49.8 | 50.9 | 48.1 | 49.3 | 48.3 | 50.3 | 47.7 | 49.4 | 50.7 | 51.6 | ||||||
| SD | 10.4 | 14.6 | 10.2 | 13.1 | 10.7 | 17.1 | 10.9 | 15.7 | 10.7 | 14.6 | 9.6 | 10.4 | ||||||
| No | ||||||||||||||||||
| Mean | 44.9 | 48.1 | 46.5 | 47.2 | 44.2 | 45.7 | 45.9 | 48.5 | 44.1 | 48.3 | 48.8 | 49.8 | ||||||
| SD | 11.6 | 10.5 | 11.4 | 9.8 | 11.4 | 10.9 | 11.9 | 11.1 | 12.2 | 10.5 | 11.2 | 9.3 | ||||||
| d† | 0.3 | 0.1 | 0.3 | 0.3 | 0.4 | 0.3 | 0.2 | 0.1 | 0.3 | 0.1 | 0.2 | 0.2 | ||||||
Abbreviations: SD, standard deviation; PA, physical activity; 5-A-Day, consumed five servings of fruits and vegetables each day; d = Mean1 − Mean2/SDpooled.
*
Mean adjusted for race, stage, marital status, education, age, and total number of comorbidities.
†
d = 0.2 (small effect); d = 0.5 (moderately large effect); d = 0.8 (large effect).
| Met Behaviors | Breast | Prostate | Colorectal | Bladder | Uterine | Skin Melanoma | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | Raw | Adj* | |||||||
| Met all three behaviors | ||||||||||||||||||
| Mean | 54.1 | 52.8 | 53.5 | 53.3 | 53.7 | 52.8 | 54.7 | 54.5 | 53.4 | 51.6 | 56.9 | 55.4 | ||||||
| SD | 8.3 | 9.1 | 8.1 | 8.9 | 8.3 | 10.0 | 8.6 | 9.6 | 8.9 | 9.3 | 6.0 | 8.5 | ||||||
| Met PA plus smoke or 5-A-Day plus smoke | ||||||||||||||||||
| Mean | 50.3 | 49.7 | 52.5 | 51.8 | 50.7 | 50.2 | 50.9 | 49.7 | 50.5 | 49.5 | 52.7 | 51.9 | ||||||
| SD | 9.3 | 9.0 | 9.0 | 8.9 | 9.9 | 9.5 | 10.3 | 9.5 | 9.6 | 9.2 | 7.9 | 8.6 | ||||||
| Met smoke only | ||||||||||||||||||
| Mean | 45.5 | 45.8 | 47.6 | 48.1 | 46.5 | 46.7 | 46.3 | 46.7 | 45.9 | 46.3 | 48.6 | 49.2 | ||||||
| SD | 10.6 | 9.2 | 10.6 | 8.9 | 10.9 | 9.6 | 11.0 | 9.5 | 10.8 | 9.3 | 10.3 | 8.6 | ||||||
| Met no behaviors | ||||||||||||||||||
| Mean | 43.9 | 44.8 | 45.2 | 45.2 | 43.9 | 44.2 | 44.4 | 44.8 | 43.0 | 44.4 | 45.8 | 46.2 | ||||||
| SD | 11.7 | 9.0 | 11.1 | 10.2 | 11.7 | 9.5 | 12.1 | 9.5 | 11.9 | 9.2 | 12.3 | 8.5 | ||||||
Abbreviations: SD, standard deviation; PA, physical activity; 5-A-Day, consumed five servings of fruits and vegetables each day.
*
Mean adjusted for race, stage, marital status, education, age, and total number of comorbidities.
Supported intramural funding from the American Cancer Society.
Presented at the 2008 Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, March 26-29, 2008, San Diego, CA.
Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.
References
1.
American Cancer Society: Cancer Facts & Figures. American Cancer Society, Atlanta, GA, 2007
2.
Bines J, Gradishar W: Primary care issues for the breast cancer survivor. Compr Ther 23::605,1997-611,
3.
Brown B, Braunder C, Minotte M: Noncancer deaths in white adult cancer patients. J Natl Cancer Inst 85::979,1993-987,
4.
Talamini R, Franceschi S, Favero A, et al: Selected medical conditions and risk of breast cancer. Br J Cancer 75::1699,1997-1703,
5.
Anderssen B: Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 70::590,2002-610,
6.
Shephard R: Exercise in the prevention and treatment of cancer: An update. Sports Med 15::258,1993-280,
7.
Courneya K: Exercise in cancer survivors: An overview of research. Med Sci Sports Exerc 35::1846,2003-1852,
8.
Emmons K, Li F, Whitton J, et al: Predictors of smoking initiation and cessation among childhood cancer survivors: A report from the Childhood Cancer Survivor Study. J Clin Oncol 20::1608,2002-1616,
9.
Maunsell E, Drolet M, Brisson J, et al: Dietary change after breast cancer: Extent, predictors, and relation with psychological distress. J Clin Oncol 29::1017,2002-1025,
10.
Meyerhardt J, Giovannucci E, Holmes M, et al: Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol 24::3527,2006-3534,
11.
Meyerhardt J, Heseltine D, Niedzwiecki D, et al: Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: Findings from CALGB 89803. J Clin Oncol 24::3535,2006-3541,
12.
Doyle C, Kushi L, Byers T, et al: Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide to informed choices. CA Cancer J Clin 56::323,2006-353,
13.
Bellizzi K, Rowland J, Jeffery D, et al: Health behaviors of cancer survivors: Examining opportunities for cancer control intervention. J Clin Oncol 23::8884,2005-8893,
14.
Coups E, Ostroff J: A population-based estimate of the prevalence of behavioral risk factors among adult cancer survivors and noncancer controls. Prev Med 40::702,2005-711,
15.
Eakin E, Youlden D, Baade P, et al: Health behaviors of cancer survivors: Data from an Australian population-based survey. Cancer Causes Control 18::881,2007-894,
16.
Blanchard C, Stein K, Baker F, et al: Association between current lifestyle behaviors and health-related quality of life in breast, colorectal, and prostate cancer survivors. Psychol Health 19::1,2004-13,
17.
Demark-Wahnefried W, Peterson B, McBride C, et al: Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinomas. Cancer 88::674,2000-684,
18.
Demark-Wahnefried W, Aziz N, Rowland J, et al: Riding the crest of the teachable moment: Promoting long-term health after the diagnosis of cancer. J Clin Oncol 23::5814,2005-5830,
19.
McBride C, Ostroff J: Teachable moments for promoting smoking cessation: The context of cancer care and survivorship. Cancer Control 10::325,2003-333,
20.
Emmons K, McBride C, Puleo E, et al: Project PREVENT: A randomized control trial to reduce multiple behavioral risk factors for colon cancer. Cancer Epidemiol Biomarkers Prev 14::1453,2005-1459,
21.
Pierce J, Stefanick M, Flatt S, et al: Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J Clin Oncol 25::2345,2007-2351,
22.
Duffy S, Ronis D, Valenstein M, et al: Depressive symptoms, smoking, drinking, and quality of life among head and neck cancer survivors. Psychosomatics 48::142,2007-148,
23.
Duffy S, Terrell J, Valenstein M, et al: Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer survivors. General Hospital Psychiatry 24::140,2002-147,
24.
Stewart D, Cheung A, Duff S, et al: Attributions of cause and recurrence in long-term breast cancer survivors. Psychooncology 10::179,2001-183,
25.
Smith T, Stein K, Mehta C, et al: The rationale, design, and implementation of the American Cancer Society's studies of cancer survivors. Cancer 109::1,2007-12,
26.
Godin G, Shepard RJ: A simple method to assess exercise behavior in the community. Can J Appl Sport Sci 10::141,1985-146,
27.
Jacobs DR, Ainsworth BE, Hartman TJ, et al: A simultaneous evaluation of ten commonly used physical activity questionnaires. Med Sci Sports Exerc 25::81,1993-91,
28.
Hays R: RAND-36 Health Status Inventory. San Antonio, TX, The Psychological Corporation, Harcourt Brace and Company, 1998
29.
Camilleri-Brennan J, Steele R: Prospective analysis of quality of life and survival following mesorectal excision for rectal cancer. Br J Surg 88::1617,2001-1622,
30.
Ganz P, Rowland J, Desmond K, et al: Life after breast cancer: Understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16::501,1998-514,
31.
Penson D, Stoddard M, Pasta D, et al: The association between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer. J Clin Epidemiol 54::350,2001-358,
32.
Rosenthal R, Rosnow R, Rubin D: Contrasts and effect sizes in behavioral research: A correlational approach. Cambridge, United Kingdom, Cambridge University Press, 2000
33.
Centers for Disease Control and Prevention: Behavioral risk factor surveillance system survey data. Atlanta, GA, US Department of Health and Human Services, Centers for Disease Control and Prevention, 2005
34.
Baranowski T, Anderson C, Carmack C: Mediating variable framework in physical activity interventions: How are we doing? How might we do better? Am J Prev Med 15::266,1998-297,
35.
Baranowski T, Cullen K, Baranowski J: Psychosocial correlates of dietary intake: Advancing dietary intervention. Annu Rev Nutr 19::17,1999-40,
36.
Emmons K: Health behaviors in a social context, in Berkman L, Kawachi I (eds): Social Epidemiology. Oxford, United Kingdom, Oxford University Press, pp 242,2000-266
37.
Courneya KS, Mackey JR, Bell GJ, et al: Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: Cardiopulmonary and quality of life outcomes. J Clin Oncol 21::1660,2003-1668,
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© 2008 by American Society of Clinical Oncology.
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Published in print: May 01, 2008
Published online: September 21, 2016
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Cancer Survivors’ Adherence to Lifestyle Behavior Recommendations and Associations With Health-Related Quality of Life: Results From the American Cancer Society's SCS-II. JCO 26, 2198-2204(2008).
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Journal of Clinical Oncology 2008 26:13, 2198-2204
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