Journal of Physical Activity and Health, 2016, 13, 159 -167 http://dx.doi.org/10.1123/jpah.2014-0493 © 2016 Human Kinetics, Inc.
ORIGINAL RESEARCH
Are Cancer Survivors Physically Active? A Comparison by US States Stacey L. Tannenbaum, Laura A. McClure, Taghrid Asfar, Recinda L. Sherman, William G. LeBlanc, and David J. Lee Background: Cancer survivors who engage in physical activity (PA) have improved quality of life, reduced fatigue, and lower mortality rates. We compare the percentage of cancer survivors meeting PA recommendations for US states, stratified by age and gender, to identify the need for PA education and intervention among cancer survivors. Methods: Pooled data from the 1997–2010 National Health Interview Survey were used to determine and rank age-adjusted PA by state. American Cancer Society guidelines (≥150 min/wk of PA) were used to compare prevalence by state, stratified by age group (< 65 and ≥65) and gender. Results: Thirty-three percent of cancer survivors met PA recommendations. The highest age-adjusted compliance to PA recommendations was in Vermont (59.9%, 95% confidence interval [CI], 40.8–76.3) and the lowest was in Louisiana (14.8%, 95% CI, 9.6–22.1) and Mississippi (15.5%, 95% CI, 10.4–22.3). The lowest percentages meeting recommendations were in Arkansas for males (8.6%, 95% CI, 7.0–10.6), Louisiana for females (12.5%, 95% CI, 6.8–21.9), Louisiana for survivors < 65 (15.6%, 95% CI, 10.5–22.6), and West Virginia for those ≥65 years (12.7%, 95% CI, 7.6–20.6). Conclusions: Meeting PA recommendations by cancer survivors varies markedly by state of residence. Future efforts should target states with low percentages, tailoring interventions to the special needs of this high-risk population. The importance of PA should be incorporated within cancer survivorship care plans. Keywords: cancer epidemiology, physical activity, guidelines and recommendations, health promotion
Cancer survivors are living longer than ever because of advances in treatment modalities and greater screening adherence.1 There were an estimated 13.7 million survivors in the United States in 2012, and 18.1 million survivors are projected for 2020.2,3 It is increasingly common for cancer survivors to live long enough to develop other chronic diseases, secondary cancers, and future cancer-related health complications.4 Adopting healthy behaviors positively affects the health status of cancer survivors.1 The favorable influence of physical activity (PA) in survivors of all cancers, including those still undergoing treatment, is becoming increasingly evident in the published literature.5 Research has shown that PA performed by survivors with various cancer diagnoses improves health-related quality of life,6 improves fitness and physical functioning,7 and reduces fatigue,8 psychological distress, and poor mental health.9 Benefits are evident for those engaged in PA starting at preliminary diagnosis and continuing over the entire course of their disease process.10 Furthermore, research suggests that PA is safe and achievable among those currently being treated for cancer,11 and it should be included as part of a healthy lifestyle for better prognosis beyond treatment, particularly for overweight and obese survivors.12 Cancer survivorship care plans, which are recommended by the Institute of Medicine, could be implemented by primary care physicians or oncologists for the purpose of continuity of structured care, particularly after completion of formal treatment modalities when an information gap regarding self-care is most likely to occur; this would ensure that cancer survivors receive information about the importance of healthy lifestyle behaviors such as PA.13 Tannenbaum ([email protected]), McClure, and Lee are with the Sylvester Comprehensive Cancer Center; Asfar, Sherman, and LeBlanc are with the Dept of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL.
Recent evidence indicates that PA not only improves cancerrelated problems such as fatigue, health-related quality of life, physical functioning, and mental health, but also may prevent the development of new malignancies.6–9,14 These findings suggest that PA should be an integral part of cancer treatment directly after diagnosis and beyond. One study among survivors of colorectal cancer found that those who were engaged in more PA had a lower recurrence rate compared with those who were more sedentary.15 However, according to the American Cancer Society (ACS), many cancer survivors are not meeting PA recommendations, particularly those who are currently undergoing treatment.16 Compared with PA levels of at least 90 minutes per week before diagnosis, 30.6% of survivors reported a decrease and only 15.7% reported an increase in PA levels after cancer diagnosis.17 Although state-specific information on the prevalence of meeting PA recommendations is published for the general population,18 PA information among cancer survivors has been presented at the state level in only one study using the Behavioral Risk Factor Surveillance System (BRFSS).19 However, this study reported only the percentage of cancer survivors not engaging in any PA; no information was provided (eg, frequency of PA or extent of meeting recommended PA levels) about the percentage of those who did engage in PA. In addition, there is no state-level information stratified by gender and age group about differences in the percentage meeting recommendations. Therefore, to fill these gaps, the current study aims to report on variation in meeting PA recommendations by state of residence, stratified by gender and age group (< 65 and ≥ 65 years old) to identify states with the greatest need for PA education and intervention among cancer survivors and their healthcare providers. Mapping PA prevalence to recommendations among cancer survivors in the United States (US) by gender and age group will provide valuable information to guide future prevention and treatment efforts among this highrisk population. 159
160 Tannenbaum et al
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Methods We pooled data from adult and cancer supplemental files of the 1997–2010 National Health Interview Survey (NHIS). The NHIS is an annual cross-sectional multistage probability household survey of a representative sample of the noninstitutionalized civilian U.S. population which was initiated in July of 1957. The NHIS is the main survey used to track the health of the nation. Further information about the NHIS can be found at http://www.cdc.gov/nchs/nhis/ about_nhis.htm; these data are gathered for the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention. One adult household member was selected to answer detailed questions about health status, including cancer history. In 2009, the final response rate (taking nonresponse into account at the family and household levels) was 65.4%, and the conditional response rate was 80.1% (taking received responses from family and households into account).20 To maintain participant confidentiality, state-level data are not available on the NHIS files released publicly. Consequently, analyses were performed at the National Center for Health Statistics Research Data Center (RDC) in Hyattsville, Maryland. We were granted permission for access to the RDC, where we remotely obtained identifiers for states and the District of Columbia (DC) for each participant. Resulting output from data requests are reviewed by RDC staff to ensure that small sample sizes are suppressed prior to release in order to maintain participant confidentiality. All adult cancer survivors ≥ 18 years of age were included in the study (n = 28,338; representing an estimated 14,330,091 persons). Cancer survivors were defined as those who responded “yes” to the question: “Have you ever been told by a doctor or health professional that you had cancer or a malignancy of any kind?” We measured the percentage meeting PA recommendations as defined by a modified version of the ACS guidelines of light/moderate intensity aerobic PA for at least 150 minutes per week.21 Because the majority of our sample data were collected before the cancerspecific PA recommendations of the ACS, we used the PA goals of Healthy People 2010, which was available at that time period, for measuring the percentage meeting the vigorous activity level of at least 60 minutes per week.22 For each survey year in the study, light or moderate PA were determined by participant response to the following questions: “How often do you do light or moderate activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate in times per week?” (MODFREQW) and “About how long do you do these light or moderate activities each time in minutes?” (MODMIN). Vigorous PA was determined using the questions, “How often do you do vigorous activities for at least 10 minutes that cause only heavy sweating or large increases in breathing or heart rate in times per week?” (VIGFREQW) and “About how long do you do these vigorous activities each time in minutes?” (VIGMIN). We then calculated total weekly PA using MODFREQW and MODMIN or VIGFREQW and VIGMIN, and we could then determine whether the participants met PA recommendations. All participant responses to survey questions reported here had been asked by NHIS for all study years. To evaluate meaningful changes in meeting PA recommendations over time, we conducted trend analysis using weighted linear regression of prevalence on year. The prevalence of meeting recommendations among survivors was calculated by state of residence including the DC. Several trend evaluations across states of residence were used: (1) unadjusted to report actual prevalence of meeting PA recommendations, (2) age-adjusted to the 2000
US population to compare state of residence while accounting for variations in age structure, and (3) age-adjusted gender-stratified comparisons and comparisons stratified by age groups (< 65 and ≥ 65 years old). State of residence was then ranked from the highest to lowest percentage meeting recommendations and divided into quartiles. States with a sample size < 50 or a standard error of > 30% of the prevalence were flagged as having unstable estimates.23 We used SAS-Callable SUDAAN (version 10; RTI International, Research Triangle Park, NC) for analyses. Data were weighted to account for the complex survey design, and analyses were adjusted for design effects. The study was approved by the University of Miami institutional review board.
Results Trend analysis revealed that prevalence of meeting PA recommendations increased slightly but was not significant (P = .29) for cancer survivors over the 14-year period (results not shown). Stateranked prevalence of meeting age-adjusted PA recommendations is portrayed in Table 1. Overall, 32% of cancer survivors met ageadjusted PA recommendations. There was a 4-fold variation ranging from 14.8% to 59.9% with the lowest in Louisiana (14.8%, 95% confidence interval [CI], 9.6–22.1) and Mississippi (15.5%, 95% CI, 10.4–22.3). The highest percentage meeting recommendations was seen in Vermont, with nearly 60% meeting recommendations (59.9%, 95% CI, 40.8–76.3). In 31 states, only 1 in 3 cancer survivors met PA recommendations; in 17 states, less than 1 in 4 met these guidelines. Meeting unadjusted and age-adjusted PA recommendations are displayed by quartiles in a map of the contiguous US, Alaska, and Hawaii (Figure 1). Fifty-eight percent of states in the lowest quartile in both analyses were in the South. The age-adjusted percentage meeting PA recommendations, stratified by gender, is shown in Table 2. More females than males were living in states (including DC) with less than 25% meeting PA recommendations. For males, Kansas (63.8%, 95% CI, 55.4–71.4) and Maine (63.7%, 95% CI, 57.3–69.6) had the highest prevalence of meeting PA recommendations, whereas Arkansas had the lowest (8.6%, 95% CI, 7.0–10.6). Females living in Vermont had the highest prevalence at 58.4% (95% CI, 42.5–72.7), whereas females from Louisiana had the lowest (12.5%, 95% CI, 6.8–21.9). When stratifying the sample by the 2 age groups (< 65 and ≥ 65 years), approximately 1 in 3 cancer survivors aged < 65 years met PA recommendations (Table 3). In contrast, less than 1 in 4 survivors aged ≥ 65 years met the guidelines. For the younger age group, there was a 3-fold variation, with the highest prevalence in Maine (51.0%, 95% CI, 46.4–55.5) and the lowest in Louisiana (15.6%, 95% CI, 10.5–22.6); for older survivors, there was a 2-fold variation, with older survivors living in Maine at the highest prevalence (42.7%, 95% CI, 35.4–50.3) and older individuals living in West Virginia at the lowest prevalence (12.7%, 95% CI, 7.6–20.6). Among states with stable estimates, there was a considerable difference between the age groups in the number meeting < 25% of the PA recommendation (ie, in 27 of 43 states in older adults compared with 7 of 43 in younger cancer survivors).
Discussion This study is the first to evaluate differences by state of residence in meeting cancer-specific PA recommendations among cancer survivors by gender and age. We found that, overall, 32.6% of ageadjusted cancer survivors met ACS cancer survivor guidelines for ≥
JPAH Vol. 13, No. 2, 2016
Table 1 Comparison of the Age-Adjusted Prevalence of Physical Activity (PA) Compliance and Highest to Lowest Prevalence Ranking of PA Compliance in Cancer Survivors Among All 50 States and DC Using Data from the National Health Interview Survey (1997–2010)
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
US State Total Vermont Maine Massachusetts Colorado Utah Hawaii DC Wisconsin Minnesota Kansas California Alabama New Jersey Florida Arizona Rhode Island Maryland Washington Oregon Wyoming Illinois North Dakota West Virginia Nebraska Michigan Pennsylvania Virginia New York Idaho Texas North Carolina Iowa Georgia New Mexico Connecticut Delaware Missouri Montana Kentucky South Carolina Ohio New Hampshire Nevada Alaska Indiana Tennessee Oklahoma Arkansas South Dakota Mississippi Louisiana
Sample N
Prevalence
95% CI
Rank
28,338 51 197 630 424 254 141 58 580 534 325 2898 547 705 2062 562 107 485 678 437 64 1056 79 206 202 1029 1213 785 1485 140 1884 909 397 664 226 306 80 668 117 496 391 1222 126 188 35 606 575 377 374 91 278
32.6 59.9 49.5 44.9 42.9 42.8 40.3 39.4 39.3 38.8 38.0 37.9 37.2 36.9 36.4 36.3 36.1 35.3 35.1 35.1 34.5 34.5 34.3 34.2 33.8 32.7 32.7 32.5 32.3 31.8 31.4 31.3 31.2 30.9 30.0 29.0 27.1 27.0 27.0 26.9 26.8 25.8 25.7 24.9 20.9a 20.6 20.3 20.0 17.2 15.8 15.5
31.4–33.8 40.8–76.3 43.7–55.4 36.8–53.2 33.5–52.8 33.4–52.8 35.0–45.8 22.4–59.5 30.7–48.5 33.8–44.2 31.6–44.9 34.3–41.6 31.3–43.6 27.4–47.5 31.3–41.8 28.8–44.5 22.1–52.9 27.7–43.7 28.7–42.2 26.0–45.5 16.1–59.1 29.3–40.0 14.3–61.9 24.1–45.9 21.2–49.2 25.8–40.5 28.1–37.7 22.0–45.1 26.2–39.0 21.8–43.9 27.8–35.2 25.1–38.1 23.9–39.5 24.2–38.6 13.4–54.2 21.8–37.5 15.1–43.8 20.7–34.4 20.0–35.3 24.1–30.0 18.4–37.3 21.8–30.1 18.8–34.0 17.7–33.8 13.8–30.4 14.9–27.9 14.8–27.2 14.3–27.4 12.8–22.6 8.2–28.2 10.4–22.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
394
14.8
9.6–22.1
51
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
estimate based on sample size < 50 and standard error > 30% of prevalence. JPAH Vol. 13, No. 2, 2016
161
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Figure 1 — Prevalence of self-reported PA compliance color coded by quintiles among US cancer survivors shown unadjusted and age-adjusted from NHIS 1997–2010.
162
JPAH Vol. 13, No. 2, 2016
Table 2 Comparison of the Prevalence and Ranking of Physical Activity Compliance in Cancer Survivors Among All 50 States and DC Between Males and Females Using Data From the National Health Interview Survey (1997–2010)
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Age-adjusted males US State Total Alaska Alabama Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Sample N 10,750 9 203 140 237 1115 168 111 25 41 903 235 52 153 44 395 209 101 183 151 239 170 79 384 196 246 111 43 349 31 85 42 283 80 74 555 429 150 151 461 39 161 44 216 685 89 310 23 236 218 77 19
% Prevalence 36.1 18.4a 45.3 8.6 42.9 41.5 46.6 31.8 47.9 a 10.5 a 35.3 36.9 60.9 25.4 37.7 a 43.3 30.2 63.8 39.7 22.8 45.1 46.9 63.7 33.0 50.6 14.7 6.6 12.0 a 35.9 15.3 a 22.4 48.9 a 43.5 29.4 31.4 35.1 32.6 20.4 22.1 42.4 44.8 a 41.0 22.3 a 12.2 32.4 31.7 35.3 36.4 a 29.5 56.3 31.1 60.0 a
95% CI 33.6–38.6 4.6–51.2 31.2–60.2 7.0–10.6 32.1–54.4 34.6–48.6 34.7–58.9 19.4–47.4 29.6–66.8 4.9–21.3 28.0–43.3 20.1–57.6 47.9–72.5 16.2–37.6 31.5–44.2 34.1–52.9 20.4–42.2 55.4–71.4 27.3–53.7 13.2–36.5 33.9–56.7 35.3–58.9 57.3–69.6 21.1–47.6 39.6–61.7 9.4–22.4 2.7–15.0 4.6–27.5 24.5–49.2 8.0–27.5 13.6–34.5 29.3–68.9 27.6–61.0 17.8–44.5 19.2–47.0 26.4–44.8 23.6–43.1 10.9–34.9 11.5–38.4 33.2–52.1 36.8–53.0 31.7–50.9 9.9–42.6 8.4–17.5 25.0–40.7 22.7–42.4 24.7–47.7 18.4–59.2 21.7–38.7 45.8–66.3 17.0–49.9 52.2–67.4
Age-adjusted females Rank 44 11 50 16 18 10 31 8 49 26 22 3 38 21 15 35 1 20 39 12 9 2 28 6 46 51 48 24 45 40 7 14 37 33 27 29 43 42 17 13 19 41 47 30 32 25 23 36 5 34 4
Sample N 17,588 26 344 234 325 1783 256 195 33 39 1159 429 89 244 96 661 397 224 313 243 391 315 118 645 338 422 167 74 560 48 117 84 422 146 114 930 793 227 286 752 68 230 47 359 1199 165 475 28 442 362 129 45
% Prevalence 30.7 22.1 a 32.8 18.4 a 32.7 35.4 38.8 28.7 46.6 a 46.5 a 36.5 26.6 36.2 34.2 30.1 31.6 17.4 30.7 23.3 12.5 43.4 32.8 48.1 32.4 33.2 29.0 19.2 29.5 27.7 38.0 a 35.6 20.9 34.0 27.4 21.2 31.2 22.8 16.9 37.4 28.4 30.0 24.3 12.5 a 23.5 30.5 43.7 32.9 58.4 a 37.4 32.4 34.4 30.3 a
95% CI 29.4–32.0 14.7–31.9 24.8–41.8 13.8–24.2 23.3–43.7 31.3–39.8 32.3–45.8 20.0–39.3 32.7–61.1 33.1–60.4 30.6–42.9 21.9–31.8 30.8–41.9 25.3–44.3 20.5–41.8 25.3–38.5 12.4–23.8 25.6–36.4 19.7–27.2 6.8–21.9 34.7–52.5 24.3–42.6 36.2–60.2 25.6–40.0 28.4–38.4 22.2–36.9 12.9–27.6 22.4–37.7 21.7–34.7 13.4–70.8 21.0–53.5 15.0–28.4 26.6–42.3 11.1–53.3 13.6–31.5 24.4–38.9 18.9–27.3 10.4–26.3 30.5–44.9 22.8–34.7 13.1–54.9 16.6–34.0 6.5–22.6 16.6–32.1 26.7–34.7 37.8–49.7 21.8–46.4 42.5–72.7 29.2–46.4 24.4–41.4 24.4–46.0 11.6–59.1
Rank 43 21 47 22 14 7 34 3 4 11 38 12 16 30 25 48 27 41 50 6 20 2 23 18 33 46 32 36 8 13 45 17 37 44 26 42 49 9 35 31 39 51 40 28 5 19 1 10 24 15 29
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
estimate based on sample size < 50 and standard error > 30% of prevalence.
JPAH Vol. 13, No. 2, 2016
163
Table 3 Comparison of the Prevalence and Ranking of Physical Activity Compliance in Cancer Survivors Among All 50 States and DC Between Different Age Groups Using Data From the National Health Interview Survey (1997–2010) ≥ 65 years
18–64 years
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
US State Total Alaska Alabama Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Sample N
% Prevalence
95% CI
Rank
Sample N
% Prevalence
95% CI
Rank
13,644 21 244 172 271 1417 253 142 31 38 844 348 64 195 75 506 318 147 268 184 296 233 103 509 272 312 142 59 429 30 97 63 335 108 104 654 589 188 218 551 42 187 33 313 1019 129 366 23 335 245 89 33
32.6 30.2a 27.7 16.0 43.0 38.3 48.5 39.3 38.0 a 35.8 a 33.5 33.6 41.4 28.0 38.6 31.1 23.0 35.0 25.7 15.6 39.7 34.0 51.0 33.2 38.7 23.0 16.4 28.4 30.3 25.2 a 29.7 38.2 37.6 25.0 28.7 36.7 28.4 16.7 38.4 31.8 38.3 a 31.0 20.8 a 20.9 29.0 40.5 33.6 54.4 a 34.5 45.0 33.1 42.3 a
31.6–33.6 20.8–41.7 19.6–37.5 10.1–24.6 35.8–50.6 35.5–41.2 38.0–59.1 26.6–53.7 16.6–65.4 20.1–55.3 30.1–37.0 27.6–40.2 29.4–54.5 20.7–36.8 27.4–51.14 26.8–35.9 17.0–30.45 27.0–44.0 22.2–29.5 10.5–22.6 32.9–46.9 26.2–42.9 46.4–55.5 28.0–38.8 34.9–42.7 18.8–27.8 10.0–25.6 19.4–39.5 24.0–37.6 9.5–52.0 16.4–47.6 31.9–45.0 30.5–45.3 17.5–34.5 17.6–43.2 32.8–40.9 24.1–33.1 11.5–23.6 27.4–50.7 26.9–37.2 24.5–54.4 25.1–37.6 10.1–38.2 15.4–27.7 25.9–32.2 29.7–52.3 26.1–42.0 43.3–65.1 29.4–39.9 39.5–50.7 19.7–49.9 23.9–63.1
33 40 50 5 14 3 10 17 20 26 25 7 39 12 30 44 21 41 51 9 23 2 27 11 45 49 37 32 42 34 16 18 43 36 19 38 48 13 29 15 31 47 46 35 8 24 1 22 4 28 6
14,694 14 303 202 291 1481 171 164 27 42 1218 316 77 202 65 550 288 178 228 210 334 252 94 520 262 356 136 58 480 49 105 63 370 118 84 831 633 189 219 662 65 204 58 262 865 125 419 28 343 335 117 31
23.1 13.8 a 23.4 18.3 26.0 27.2 29.1 22.3 31.7 a 30.0 a 29.2 15.0 35.3 25.3 22.7 20.9 13.8 26.3 16.8 15.2 24.8 22.2 42.7 25.0 30.5 20.5 13.8 10.0 23.1 20.2 a 15.9 27.7 21.0 15.4 30.9 20.2 18.5 18.0 25.8 21.3 22.4 14.8 17.0 19.1 24.6 27.6 22.6 34.7 a 28.8 25.0 12.7 18.7 a
22.3–24.0 5.2–31.9 18.7–28.9 11.9–27.2 21.3–31.3 24.7–29.9 18.9–41.9 16.8–28.9 18.4–48.9 12.7–55.8 26.3–32.3 10.9–20.4 27.1–44.5 19.3–32.3 17.2–29.4 16.1–26.8 9.5–19.8 20.0–33.8 11.8–23.5 8.7–25.1 18.8–32.0 16.3–29.6 35.4–50.3 20.3–30.4 23.6–38.4 16.2–25.5 6.9–25.5 3.7–24.6 18.3–28.9 14.4–27.5 8.4–28.2 15.3–44.8 16.5–26.3 9.2–24.6 21.4–42.4 16.5–24.4 14.9–22.8 12.5–25.2 20.1–32.3 18.8–24.0 10.7–41.0 10.1–21.3 9.2–29.4 14.4–25.0 21.1–28.4 20.9–35.4 19.0–26.6 13.0–65.5 24.7–33.4 20.1–30.7 7.6–20.6 10.1–32.1
49 22 38 15 13 9 27 4 7 8 45 2 17 24 31 47 14 41 44 20 28 1 19 6 32 48 51 23 34 42 11 30 43 5 33 37 39 16 29 26 46 40 35 21 12 25 3 10 18 50 36
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
164
estimate based on sample size < 50 and standard error > 30% of prevalence. JPAH Vol. 13, No. 2, 2016
Physical Activity in Cancer Survivors by State 165
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
150 or 60 min/wk of light/moderate or vigorous intensity aerobic PA, respectively. Our findings suggests that cancer survivors residing in states with a lower prevalence of meeting recommendations are at greater risk for poorer quality of life, physical functioning and fitness, and increased fatigue and mortality than in states with higher PA prevalence. The 2015 goals of the ACS for cancer survivors are that 70% of survivors follow the recommended PA guidelines.21 We found that none of the states came close to meeting this goal, which may call into question whether this goal is realistic. Our findings are somewhat different from those of the BRFSS findings for PA participation.19 However, BRFSS solely reported the prevalence of those who did not participate in any PA, whereas we compared and ranked age-adjusted prevalence to current PA guidelines for cancer survivors, so our results are not directly comparable. For example, BRFSS placed Louisiana in the range of 30.8–33.9% who performed no PA, but 12 other states had a larger proportion of residents who were completely inactive.19 In our study, we found Louisiana to have the lowest age-adjusted percentage of cancer survivors meeting recommendations of PA. In addition, BRFSS reported that West Virginia had the highest percentage of cancer survivors with no PA (42.3%), whereas in our study West Virginia ranked 23rd; that is, an age-adjusted 34.2% met PA recommendations. The state with the lowest percentage of physically inactive residents was Oregon (21.4%) in the BRFSS; in our study, Oregon ranked 19th best for meeting PA recommendations at an age-adjusted 35.1%. The findings from our study may be related to health behavior clustering in these states. For example, of states in the lowest quartile for meeting PA recommendations, more than half also have the highest prevalence of obesity (of at least 15.2%),24 and half also have the highest prevalence of smoking (of at least 23.0%).18 Moreover, of the 14 states with the lowest cigarette excise taxes,24 we found that less than 30% met recommendations for PA in 12 of these states. These states may generally be lacking in preventive care programs, which in turn could affect health outcomes of chronically ill patients. These states may also have limited resources for cancer survivors (eg, few community or recreational centers), although we know of no studies comparing the quality of cancer care across the states. Males (36.1%) had a higher age-adjusted prevalence of meeting PA recommendations than females (30.7%). Males in 6 states had at least 50% prevalence of meeting PA recommendations, whereas only females living in 1 state (Vermont) achieved 50% prevalence. These findings may be explained by the fact that females in the lowest quartile of meeting PA recommendations demonstrate other higher risk behaviors/conditions compared with males. For example, in the states with the lowest quartile of meeting PA recommendations in females, 58% and 50% are obese and smokers, respectively, compared with 50% and 42% for these same characteristics in males, respectively.18,24 These results may also be related to cancer type and treatment. For example, prostate cancer, the most common type of cancer in males, is often diagnosed but not treated, whereas breast cancer, the most common type in females, is nearly always treated with invasive regimens that can create physical or mental barriers that may preclude some women from engaging in the recommended amounts of PA.25–27 In addition, the percentage of cancer survivors ≥ 65 years meeting PA recommendations was lower than that for cancer survivors < 65 years; the percentage of older survivors was 10 points lower (23.1%) than that of younger survivors (32.6%). A recent study that compared state variations in the prevalence of PA in a nationally representative sample of older adults using pooled NHIS data found similar results.28 For older adults, comorbidities and other
functional limitations may be added impediments to PA, as is the case in the general population, whereas younger survivors may be able to perform more activities.29 Maine and Colorado were within the top 10 states for the highest percentage meeting PA recommendations in all analyses (ie, age adjusted, age-adjusted and stratified by gender, and stratified by age). One explanation could be that survivors residing in Maine and Colorado practice better health behaviors overall. For example, previous evidence about meeting PA recommendations in the general population indicates that Colorado has the lowest percentage of people with obesity.24 In term of healthy eating, 1 in 3 survivors living in Colorado and Maine were found to eat 2 or more servings of fruit/day.24 Among states in the top 10 for meeting PA recommendations, Florida was the only state from the South (ranked 8th in adults aged 65 and older). Likewise, of the top 10 states ranked highest by the ACS for overweight and obesity, 7 were Southern states.24 BRFSS also found that those residing in the South had the highest prevalence of inactivity (34.3%).19 Aside from health behaviors, another reason for the overall low PA prevalence could be related to fear or hesitancy to engage in PA after a diagnosis of cancer, especially if survivors’ were undergoing treatment, had other comorbidities, or were experiencing fatigue. Lower prevalence in specific states may be related to having fewer resources available for PA interventions. These states and the others below the target level of PA compliance need cost-effective interventions to educate cancer survivors about the benefits of increased PA during the treatment of cancer and beyond and to encourage increased engagement in PA. For example, community-based interventions, which use social-support strategies such as buddy systems or support groups, have been effective in mobilizing vulnerable population groups to increase PA.30 Tailoring social-support interventions for the specific needs of cancer survivors related to cancer type, stage of cancer diagnosis and treatment, and prognosis would help increase PA in this population; however, other within-state barriers to PA, such as environmental conditions, time constraints, or lack of support, may also deleteriously influence behaviors and so also need to be addressed. Encouragement from primary care physicians and oncologists to increase PA according to the ACS guidelines for cancer survivors, even during treatment, may beneficially affect the health of cancer survivors. The NHIS does not contain information on whether cancer survivors received information or recommendations on PA from their physician or healthcare provider; however, according to a recent study, only 19% of cancer survivors remember their physician addressing their level of PA after cancer diagnosis.17 Cancer survivorship care plans, as recommended by the Institute of Medicine, use a patient-centered approach to ensure patients’ immediate and long-term needs are being met while encouraging healthcare providers, such as primary care physicians, oncologists, physical rehabilitation medicine physicians, and physical therapists, to effectively dispense valuable information; this includes promoting the adoption of healthy lifestyle behaviors such as PA and providing aid in locating community support services that offer PA opportunities.13 Our findings present healthcare providers residing in states with lower prevalence of meeting PA recommendations the momentum to initiate effectual communication with cancer survivors about the importance of PA as a vital part of their total treatment and survivorship cancer care plan. It is important to note several study limitations. Because of limited sample size, we were unable to present stable prevalence estimates for some states.23 Furthermore, unlike the BRFSS, which is designed as a state-specific survey, the NCHS does not supply
JPAH Vol. 13, No. 2, 2016
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
166 Tannenbaum et al
state-specific sampling weights for the NHIS. Although the pooling of data for states across survey years does enhance precision (see, for example, NCHS publication in Public Health Reports),31 the lack of state-specific weights can lead to imprecision in our estimates. Both cancer history and PA compliance were based on self-report, which can be subject to reporting bias. Because of small sample sizes, factors that could influence PA levels between states such as cancer site, time since diagnosis, race/ethnicity, and socioeconomic status were not considered when determining whether PA recommendations were met. The NHIS does not contain data on other potentially relevant clinical factors such as cancer grade. Lastly, because of sample size limitations, we were unable to determine whether states with a smaller proportion of cancer survivors meeting PA recommendations also had a higher proportion of smokers and overweight or obese individuals. A major strength of this study, however, was the overall large sample size and our unique access to the RDC, which allowed for prevalence comparisons of meeting PA recommendations in cancer survivors by state of residence. Another strength of the study was the in-person household administration of the NHIS (vs the telephone administration used by the BRFSS), which yields much larger response rates, generates more detailed information, and removes the bias of telephone noncoverage.32 Therefore, the reporting and comparison of cancer-specific estimates from the NHIS and the BRFSS should be routinely undertaken given the relative balance of the strengths and limitations of both survey systems.
Conclusion To our knowledge, no other study has compared the percentage of cancer survivors meeting PA recommendations by state of residence and by age and gender. Cancer survivors who engage in PA have improved quality of life, less recurrence, and other positive health outcomes related to cancer treatment. The recent development of these cancer survivor-specific PA guidelines should help to increase awareness of the benefits of PA in this group as well as lend confidence among survivors to begin a PA program. It is clear, though, that even with specified guidelines, many states still fall short of the goals. Targeting health care providers who are practicing in states with poor prevalence of meeting PA recommendations (particularly in southern states) with interventions to increase their awareness of the importance of PA for their cancer patients is greatly needed. In addition, future efforts should focus on developing and updating PA prevention and treatment interventions tailored to the specific needs of cancer survivors using the cancer survivorship care plan. Special attention should be also devoted to female cancer survivors and adults ≥ 65 years of age. Acknowledgments Funding for this study was provided by Bankhead Coley Cancer Research Grant 1BG06-341963.
References 1. Robien K, Bechard L, Elliott L, Fox N, Levin R, Washburn S. American Dietetic Association: revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in oncology nutrition care. J Am Diet Assoc. 2010;110:310–317. PubMed doi:10.1016/j.jada.2009.11.001 2. American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013.
3. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103:117–128. PubMed doi:10.1093/jnci/djq495 4. Rowland JH. Cancer survivorship: rethinking the cancer control continuum. Semin Oncol Nurs. 2008;24:145–152. PubMed doi:10.1016/j. soncn.2008.05.002 5. Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2010;4:87–100. PubMed doi:10.1007/s11764-009-0110-5 6. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012;8:CD008465. PubMed 7. Courneya KS, Sellar CM, Stevinson C, et al. Randomized controlled trial of the effects of aerobic exercise on physical functioning and quality of life in lymphoma patients. J Clin Oncol. 2009;27:4605–4612. PubMed doi:10.1200/JCO.2008.20.0634 8. Peddle CJ, Au H-J, Courneya KS. Associations between exercise, quality of life, and fatigue in colorectal cancer survivors. Dis Colon Rectum. 2008;51:1242–1248. PubMed doi:10.1007/s10350-0089324-2 9. Zhao G, Li C, Li J, Balluz LS. Physical activity, psychological distress, and receipt of mental healthcare services among cancer survivors. J Cancer Surviv. 2013;7:131–139. PubMed doi:10.1007/s11764-0120254-6 10. Alfano CM, Smith AW, Irwin ML, et al. Physical activity, long-term symptoms, and physical health-related quality of life among breast cancer survivors: a prospective analysis. J Cancer Surviv. 2007;1:116– 128. PubMed doi:10.1007/s11764-007-0014-1 11. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56:323–353. PubMed doi:10.3322/canjclin.56.6.323 12. Campbell KL, Van Patten CL, Neil SE, et al. Feasibility of a lifestyle intervention on body weight and serum biomarkers in breast cancer survivors with overweight and obesity. J Acad Nutr Diet. 2012;112:559–567. PubMed doi:10.1016/j.jada.2011.10.022 13. Hewitt ME, Greenfield S, Stovall E. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2006. 14. Curtis RE, Freedman DM, Ron E, et al. New Malignancies Among Cancer Survivors: SEER Cancer Registries, 1973–2000 (NIH Publication No. 05-5302). Bethesda, MD: National Cancer Institute; 2006. 15. Meyerhardt JA, 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. 2006;24:3535–3541. PubMed doi:10.1200/JCO.2006.06.0863 16. Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with healthrelated quality of life: results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26:2198–2204. PubMed doi:10.1200/ JCO.2007.14.6217 17. Blanchard CM, Denniston MM, Bakeunce System, United States, 2009. MMWR Surveill Summ. 2012;61:1–23. http://www.cdc.gov/ mmwr/preview/mmwrhtml/ss6101a1.htm. 18. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. http://www.cdc.gov/mmwr/preview/mmwrhtml/ ss6309a1.html. Published 2014. Accessed March 2016 19. Underwood JM, Townsend JS, Stewart SL, et al. Surveillance of Demographic Characteristics and Health Behaviors Among Adult Cancer Survivors—Behavioral Risk Factor Surveillance System, United States, 2009. MMWR Surveill Summ. 2012;61:1–23. http:// www.cdc.gov/mmwr/preview/mmwrhtml/ss6101a1.htm. 20. Moriarty C. National Health Interview Survey Sample Adult and Sample Child: Nonresponse Bias Analysis. Division of Health Interview Statistics, National Center for Health Statistics Web site. http://
JPAH Vol. 13, No. 2, 2016
Physical Activity in Cancer Survivors by State 167
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
www.cdc.gov/nchs/data/nhis/nr_bias_analysis_report_2009_NHIS. pdf. Published 2009. Updated December 2, 2015. Accessed March 2016. 21. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62:242–274. PubMed doi:10.3322/caac.21142 22. Healthy People 2010. 2012 National Health Interview Survey (NHIS) Public Use Data Release. NHIS Survey Description. ftp://ftp.cdc. gov/pub/health_statistics/nchs/Dataset_Documentation/NHIS/2012/ srvydesc.pdf. Published 2012. Accessed March 2016. 23. Klein RJ, Proctor SE, Boudreault MA, Turczyn KM. Healthy People 2010 criteria for data suppression. Healthy People 2010 Stat Notes. 2002;(24):1–12. http://www.cdc.gov/nchs/data/statnt/statnt24.pdf. Accessed May 2012. 24. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2013. Atlanta: American Cancer Society; 2013. 25. Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics 2012. CA Cancer J Clin. 2012;62:220–241. PubMed doi:10.3322/caac.21149 26. National Cancer Institute. Prostate Cancer Treatment–For Health Professionals (PDQ). Available from: http://www.cancer.gov/types/ prostate/hp/prostate-treatment-pdq#Section_1679. Updated February 11, 2016. Accessed March 2016.
27. National Cancer Institute. Breast Cancer Treatment–For Health Professionals (PDQ): General Information about Breast Cancer. http://www.cancer.gov/types/breast/hp/breast-treatment-pdq. Updated February 2, 2016. Accessed March 2016. 28. Tannenbaum SL, Kachan D, Fernandez CA, et al. State variations of chronic disease risk factors in older Americans. Prev Chronic Dis. 2012;9:E177. PubMed doi:10.5888/pcd9.120143 29. Courneya KS, Vallance JKH, NcNeely ML, Karvinen KH, Peddle CJ, Mackey JR. Exercise issues in older cancer survivors. Crit Rev Oncol Hematol. 2004;51:249–261. PubMed doi:10.1016/j.critrevonc.2004.05.001 30. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002;22(4 Suppl 1):73–107. PubMed doi:10.1016/S07493797(02)00434-8 31. Davis WW, Parsons VL, Xie D, et al. State-based estimates of mammography screening rates based on information from two health surveys. Public Health Rep. 2010;125:567–578. PubMed 32. Nelson DE, Powell-Griner E, Town M, Kovar MG. A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. Am J Public Health. 2003;93:1335–1341. PubMed doi:10.2105/AJPH.93.8.1335
JPAH Vol. 13, No. 2, 2016
ORIGINAL RESEARCH
Are Cancer Survivors Physically Active? A Comparison by US States Stacey L. Tannenbaum, Laura A. McClure, Taghrid Asfar, Recinda L. Sherman, William G. LeBlanc, and David J. Lee Background: Cancer survivors who engage in physical activity (PA) have improved quality of life, reduced fatigue, and lower mortality rates. We compare the percentage of cancer survivors meeting PA recommendations for US states, stratified by age and gender, to identify the need for PA education and intervention among cancer survivors. Methods: Pooled data from the 1997–2010 National Health Interview Survey were used to determine and rank age-adjusted PA by state. American Cancer Society guidelines (≥150 min/wk of PA) were used to compare prevalence by state, stratified by age group (< 65 and ≥65) and gender. Results: Thirty-three percent of cancer survivors met PA recommendations. The highest age-adjusted compliance to PA recommendations was in Vermont (59.9%, 95% confidence interval [CI], 40.8–76.3) and the lowest was in Louisiana (14.8%, 95% CI, 9.6–22.1) and Mississippi (15.5%, 95% CI, 10.4–22.3). The lowest percentages meeting recommendations were in Arkansas for males (8.6%, 95% CI, 7.0–10.6), Louisiana for females (12.5%, 95% CI, 6.8–21.9), Louisiana for survivors < 65 (15.6%, 95% CI, 10.5–22.6), and West Virginia for those ≥65 years (12.7%, 95% CI, 7.6–20.6). Conclusions: Meeting PA recommendations by cancer survivors varies markedly by state of residence. Future efforts should target states with low percentages, tailoring interventions to the special needs of this high-risk population. The importance of PA should be incorporated within cancer survivorship care plans. Keywords: cancer epidemiology, physical activity, guidelines and recommendations, health promotion
Cancer survivors are living longer than ever because of advances in treatment modalities and greater screening adherence.1 There were an estimated 13.7 million survivors in the United States in 2012, and 18.1 million survivors are projected for 2020.2,3 It is increasingly common for cancer survivors to live long enough to develop other chronic diseases, secondary cancers, and future cancer-related health complications.4 Adopting healthy behaviors positively affects the health status of cancer survivors.1 The favorable influence of physical activity (PA) in survivors of all cancers, including those still undergoing treatment, is becoming increasingly evident in the published literature.5 Research has shown that PA performed by survivors with various cancer diagnoses improves health-related quality of life,6 improves fitness and physical functioning,7 and reduces fatigue,8 psychological distress, and poor mental health.9 Benefits are evident for those engaged in PA starting at preliminary diagnosis and continuing over the entire course of their disease process.10 Furthermore, research suggests that PA is safe and achievable among those currently being treated for cancer,11 and it should be included as part of a healthy lifestyle for better prognosis beyond treatment, particularly for overweight and obese survivors.12 Cancer survivorship care plans, which are recommended by the Institute of Medicine, could be implemented by primary care physicians or oncologists for the purpose of continuity of structured care, particularly after completion of formal treatment modalities when an information gap regarding self-care is most likely to occur; this would ensure that cancer survivors receive information about the importance of healthy lifestyle behaviors such as PA.13 Tannenbaum ([email protected]), McClure, and Lee are with the Sylvester Comprehensive Cancer Center; Asfar, Sherman, and LeBlanc are with the Dept of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL.
Recent evidence indicates that PA not only improves cancerrelated problems such as fatigue, health-related quality of life, physical functioning, and mental health, but also may prevent the development of new malignancies.6–9,14 These findings suggest that PA should be an integral part of cancer treatment directly after diagnosis and beyond. One study among survivors of colorectal cancer found that those who were engaged in more PA had a lower recurrence rate compared with those who were more sedentary.15 However, according to the American Cancer Society (ACS), many cancer survivors are not meeting PA recommendations, particularly those who are currently undergoing treatment.16 Compared with PA levels of at least 90 minutes per week before diagnosis, 30.6% of survivors reported a decrease and only 15.7% reported an increase in PA levels after cancer diagnosis.17 Although state-specific information on the prevalence of meeting PA recommendations is published for the general population,18 PA information among cancer survivors has been presented at the state level in only one study using the Behavioral Risk Factor Surveillance System (BRFSS).19 However, this study reported only the percentage of cancer survivors not engaging in any PA; no information was provided (eg, frequency of PA or extent of meeting recommended PA levels) about the percentage of those who did engage in PA. In addition, there is no state-level information stratified by gender and age group about differences in the percentage meeting recommendations. Therefore, to fill these gaps, the current study aims to report on variation in meeting PA recommendations by state of residence, stratified by gender and age group (< 65 and ≥ 65 years old) to identify states with the greatest need for PA education and intervention among cancer survivors and their healthcare providers. Mapping PA prevalence to recommendations among cancer survivors in the United States (US) by gender and age group will provide valuable information to guide future prevention and treatment efforts among this highrisk population. 159
160 Tannenbaum et al
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Methods We pooled data from adult and cancer supplemental files of the 1997–2010 National Health Interview Survey (NHIS). The NHIS is an annual cross-sectional multistage probability household survey of a representative sample of the noninstitutionalized civilian U.S. population which was initiated in July of 1957. The NHIS is the main survey used to track the health of the nation. Further information about the NHIS can be found at http://www.cdc.gov/nchs/nhis/ about_nhis.htm; these data are gathered for the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention. One adult household member was selected to answer detailed questions about health status, including cancer history. In 2009, the final response rate (taking nonresponse into account at the family and household levels) was 65.4%, and the conditional response rate was 80.1% (taking received responses from family and households into account).20 To maintain participant confidentiality, state-level data are not available on the NHIS files released publicly. Consequently, analyses were performed at the National Center for Health Statistics Research Data Center (RDC) in Hyattsville, Maryland. We were granted permission for access to the RDC, where we remotely obtained identifiers for states and the District of Columbia (DC) for each participant. Resulting output from data requests are reviewed by RDC staff to ensure that small sample sizes are suppressed prior to release in order to maintain participant confidentiality. All adult cancer survivors ≥ 18 years of age were included in the study (n = 28,338; representing an estimated 14,330,091 persons). Cancer survivors were defined as those who responded “yes” to the question: “Have you ever been told by a doctor or health professional that you had cancer or a malignancy of any kind?” We measured the percentage meeting PA recommendations as defined by a modified version of the ACS guidelines of light/moderate intensity aerobic PA for at least 150 minutes per week.21 Because the majority of our sample data were collected before the cancerspecific PA recommendations of the ACS, we used the PA goals of Healthy People 2010, which was available at that time period, for measuring the percentage meeting the vigorous activity level of at least 60 minutes per week.22 For each survey year in the study, light or moderate PA were determined by participant response to the following questions: “How often do you do light or moderate activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate in times per week?” (MODFREQW) and “About how long do you do these light or moderate activities each time in minutes?” (MODMIN). Vigorous PA was determined using the questions, “How often do you do vigorous activities for at least 10 minutes that cause only heavy sweating or large increases in breathing or heart rate in times per week?” (VIGFREQW) and “About how long do you do these vigorous activities each time in minutes?” (VIGMIN). We then calculated total weekly PA using MODFREQW and MODMIN or VIGFREQW and VIGMIN, and we could then determine whether the participants met PA recommendations. All participant responses to survey questions reported here had been asked by NHIS for all study years. To evaluate meaningful changes in meeting PA recommendations over time, we conducted trend analysis using weighted linear regression of prevalence on year. The prevalence of meeting recommendations among survivors was calculated by state of residence including the DC. Several trend evaluations across states of residence were used: (1) unadjusted to report actual prevalence of meeting PA recommendations, (2) age-adjusted to the 2000
US population to compare state of residence while accounting for variations in age structure, and (3) age-adjusted gender-stratified comparisons and comparisons stratified by age groups (< 65 and ≥ 65 years old). State of residence was then ranked from the highest to lowest percentage meeting recommendations and divided into quartiles. States with a sample size < 50 or a standard error of > 30% of the prevalence were flagged as having unstable estimates.23 We used SAS-Callable SUDAAN (version 10; RTI International, Research Triangle Park, NC) for analyses. Data were weighted to account for the complex survey design, and analyses were adjusted for design effects. The study was approved by the University of Miami institutional review board.
Results Trend analysis revealed that prevalence of meeting PA recommendations increased slightly but was not significant (P = .29) for cancer survivors over the 14-year period (results not shown). Stateranked prevalence of meeting age-adjusted PA recommendations is portrayed in Table 1. Overall, 32% of cancer survivors met ageadjusted PA recommendations. There was a 4-fold variation ranging from 14.8% to 59.9% with the lowest in Louisiana (14.8%, 95% confidence interval [CI], 9.6–22.1) and Mississippi (15.5%, 95% CI, 10.4–22.3). The highest percentage meeting recommendations was seen in Vermont, with nearly 60% meeting recommendations (59.9%, 95% CI, 40.8–76.3). In 31 states, only 1 in 3 cancer survivors met PA recommendations; in 17 states, less than 1 in 4 met these guidelines. Meeting unadjusted and age-adjusted PA recommendations are displayed by quartiles in a map of the contiguous US, Alaska, and Hawaii (Figure 1). Fifty-eight percent of states in the lowest quartile in both analyses were in the South. The age-adjusted percentage meeting PA recommendations, stratified by gender, is shown in Table 2. More females than males were living in states (including DC) with less than 25% meeting PA recommendations. For males, Kansas (63.8%, 95% CI, 55.4–71.4) and Maine (63.7%, 95% CI, 57.3–69.6) had the highest prevalence of meeting PA recommendations, whereas Arkansas had the lowest (8.6%, 95% CI, 7.0–10.6). Females living in Vermont had the highest prevalence at 58.4% (95% CI, 42.5–72.7), whereas females from Louisiana had the lowest (12.5%, 95% CI, 6.8–21.9). When stratifying the sample by the 2 age groups (< 65 and ≥ 65 years), approximately 1 in 3 cancer survivors aged < 65 years met PA recommendations (Table 3). In contrast, less than 1 in 4 survivors aged ≥ 65 years met the guidelines. For the younger age group, there was a 3-fold variation, with the highest prevalence in Maine (51.0%, 95% CI, 46.4–55.5) and the lowest in Louisiana (15.6%, 95% CI, 10.5–22.6); for older survivors, there was a 2-fold variation, with older survivors living in Maine at the highest prevalence (42.7%, 95% CI, 35.4–50.3) and older individuals living in West Virginia at the lowest prevalence (12.7%, 95% CI, 7.6–20.6). Among states with stable estimates, there was a considerable difference between the age groups in the number meeting < 25% of the PA recommendation (ie, in 27 of 43 states in older adults compared with 7 of 43 in younger cancer survivors).
Discussion This study is the first to evaluate differences by state of residence in meeting cancer-specific PA recommendations among cancer survivors by gender and age. We found that, overall, 32.6% of ageadjusted cancer survivors met ACS cancer survivor guidelines for ≥
JPAH Vol. 13, No. 2, 2016
Table 1 Comparison of the Age-Adjusted Prevalence of Physical Activity (PA) Compliance and Highest to Lowest Prevalence Ranking of PA Compliance in Cancer Survivors Among All 50 States and DC Using Data from the National Health Interview Survey (1997–2010)
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
US State Total Vermont Maine Massachusetts Colorado Utah Hawaii DC Wisconsin Minnesota Kansas California Alabama New Jersey Florida Arizona Rhode Island Maryland Washington Oregon Wyoming Illinois North Dakota West Virginia Nebraska Michigan Pennsylvania Virginia New York Idaho Texas North Carolina Iowa Georgia New Mexico Connecticut Delaware Missouri Montana Kentucky South Carolina Ohio New Hampshire Nevada Alaska Indiana Tennessee Oklahoma Arkansas South Dakota Mississippi Louisiana
Sample N
Prevalence
95% CI
Rank
28,338 51 197 630 424 254 141 58 580 534 325 2898 547 705 2062 562 107 485 678 437 64 1056 79 206 202 1029 1213 785 1485 140 1884 909 397 664 226 306 80 668 117 496 391 1222 126 188 35 606 575 377 374 91 278
32.6 59.9 49.5 44.9 42.9 42.8 40.3 39.4 39.3 38.8 38.0 37.9 37.2 36.9 36.4 36.3 36.1 35.3 35.1 35.1 34.5 34.5 34.3 34.2 33.8 32.7 32.7 32.5 32.3 31.8 31.4 31.3 31.2 30.9 30.0 29.0 27.1 27.0 27.0 26.9 26.8 25.8 25.7 24.9 20.9a 20.6 20.3 20.0 17.2 15.8 15.5
31.4–33.8 40.8–76.3 43.7–55.4 36.8–53.2 33.5–52.8 33.4–52.8 35.0–45.8 22.4–59.5 30.7–48.5 33.8–44.2 31.6–44.9 34.3–41.6 31.3–43.6 27.4–47.5 31.3–41.8 28.8–44.5 22.1–52.9 27.7–43.7 28.7–42.2 26.0–45.5 16.1–59.1 29.3–40.0 14.3–61.9 24.1–45.9 21.2–49.2 25.8–40.5 28.1–37.7 22.0–45.1 26.2–39.0 21.8–43.9 27.8–35.2 25.1–38.1 23.9–39.5 24.2–38.6 13.4–54.2 21.8–37.5 15.1–43.8 20.7–34.4 20.0–35.3 24.1–30.0 18.4–37.3 21.8–30.1 18.8–34.0 17.7–33.8 13.8–30.4 14.9–27.9 14.8–27.2 14.3–27.4 12.8–22.6 8.2–28.2 10.4–22.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
394
14.8
9.6–22.1
51
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
estimate based on sample size < 50 and standard error > 30% of prevalence. JPAH Vol. 13, No. 2, 2016
161
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Figure 1 — Prevalence of self-reported PA compliance color coded by quintiles among US cancer survivors shown unadjusted and age-adjusted from NHIS 1997–2010.
162
JPAH Vol. 13, No. 2, 2016
Table 2 Comparison of the Prevalence and Ranking of Physical Activity Compliance in Cancer Survivors Among All 50 States and DC Between Males and Females Using Data From the National Health Interview Survey (1997–2010)
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
Age-adjusted males US State Total Alaska Alabama Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Sample N 10,750 9 203 140 237 1115 168 111 25 41 903 235 52 153 44 395 209 101 183 151 239 170 79 384 196 246 111 43 349 31 85 42 283 80 74 555 429 150 151 461 39 161 44 216 685 89 310 23 236 218 77 19
% Prevalence 36.1 18.4a 45.3 8.6 42.9 41.5 46.6 31.8 47.9 a 10.5 a 35.3 36.9 60.9 25.4 37.7 a 43.3 30.2 63.8 39.7 22.8 45.1 46.9 63.7 33.0 50.6 14.7 6.6 12.0 a 35.9 15.3 a 22.4 48.9 a 43.5 29.4 31.4 35.1 32.6 20.4 22.1 42.4 44.8 a 41.0 22.3 a 12.2 32.4 31.7 35.3 36.4 a 29.5 56.3 31.1 60.0 a
95% CI 33.6–38.6 4.6–51.2 31.2–60.2 7.0–10.6 32.1–54.4 34.6–48.6 34.7–58.9 19.4–47.4 29.6–66.8 4.9–21.3 28.0–43.3 20.1–57.6 47.9–72.5 16.2–37.6 31.5–44.2 34.1–52.9 20.4–42.2 55.4–71.4 27.3–53.7 13.2–36.5 33.9–56.7 35.3–58.9 57.3–69.6 21.1–47.6 39.6–61.7 9.4–22.4 2.7–15.0 4.6–27.5 24.5–49.2 8.0–27.5 13.6–34.5 29.3–68.9 27.6–61.0 17.8–44.5 19.2–47.0 26.4–44.8 23.6–43.1 10.9–34.9 11.5–38.4 33.2–52.1 36.8–53.0 31.7–50.9 9.9–42.6 8.4–17.5 25.0–40.7 22.7–42.4 24.7–47.7 18.4–59.2 21.7–38.7 45.8–66.3 17.0–49.9 52.2–67.4
Age-adjusted females Rank 44 11 50 16 18 10 31 8 49 26 22 3 38 21 15 35 1 20 39 12 9 2 28 6 46 51 48 24 45 40 7 14 37 33 27 29 43 42 17 13 19 41 47 30 32 25 23 36 5 34 4
Sample N 17,588 26 344 234 325 1783 256 195 33 39 1159 429 89 244 96 661 397 224 313 243 391 315 118 645 338 422 167 74 560 48 117 84 422 146 114 930 793 227 286 752 68 230 47 359 1199 165 475 28 442 362 129 45
% Prevalence 30.7 22.1 a 32.8 18.4 a 32.7 35.4 38.8 28.7 46.6 a 46.5 a 36.5 26.6 36.2 34.2 30.1 31.6 17.4 30.7 23.3 12.5 43.4 32.8 48.1 32.4 33.2 29.0 19.2 29.5 27.7 38.0 a 35.6 20.9 34.0 27.4 21.2 31.2 22.8 16.9 37.4 28.4 30.0 24.3 12.5 a 23.5 30.5 43.7 32.9 58.4 a 37.4 32.4 34.4 30.3 a
95% CI 29.4–32.0 14.7–31.9 24.8–41.8 13.8–24.2 23.3–43.7 31.3–39.8 32.3–45.8 20.0–39.3 32.7–61.1 33.1–60.4 30.6–42.9 21.9–31.8 30.8–41.9 25.3–44.3 20.5–41.8 25.3–38.5 12.4–23.8 25.6–36.4 19.7–27.2 6.8–21.9 34.7–52.5 24.3–42.6 36.2–60.2 25.6–40.0 28.4–38.4 22.2–36.9 12.9–27.6 22.4–37.7 21.7–34.7 13.4–70.8 21.0–53.5 15.0–28.4 26.6–42.3 11.1–53.3 13.6–31.5 24.4–38.9 18.9–27.3 10.4–26.3 30.5–44.9 22.8–34.7 13.1–54.9 16.6–34.0 6.5–22.6 16.6–32.1 26.7–34.7 37.8–49.7 21.8–46.4 42.5–72.7 29.2–46.4 24.4–41.4 24.4–46.0 11.6–59.1
Rank 43 21 47 22 14 7 34 3 4 11 38 12 16 30 25 48 27 41 50 6 20 2 23 18 33 46 32 36 8 13 45 17 37 44 26 42 49 9 35 31 39 51 40 28 5 19 1 10 24 15 29
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
estimate based on sample size < 50 and standard error > 30% of prevalence.
JPAH Vol. 13, No. 2, 2016
163
Table 3 Comparison of the Prevalence and Ranking of Physical Activity Compliance in Cancer Survivors Among All 50 States and DC Between Different Age Groups Using Data From the National Health Interview Survey (1997–2010) ≥ 65 years
18–64 years
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
US State Total Alaska Alabama Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Sample N
% Prevalence
95% CI
Rank
Sample N
% Prevalence
95% CI
Rank
13,644 21 244 172 271 1417 253 142 31 38 844 348 64 195 75 506 318 147 268 184 296 233 103 509 272 312 142 59 429 30 97 63 335 108 104 654 589 188 218 551 42 187 33 313 1019 129 366 23 335 245 89 33
32.6 30.2a 27.7 16.0 43.0 38.3 48.5 39.3 38.0 a 35.8 a 33.5 33.6 41.4 28.0 38.6 31.1 23.0 35.0 25.7 15.6 39.7 34.0 51.0 33.2 38.7 23.0 16.4 28.4 30.3 25.2 a 29.7 38.2 37.6 25.0 28.7 36.7 28.4 16.7 38.4 31.8 38.3 a 31.0 20.8 a 20.9 29.0 40.5 33.6 54.4 a 34.5 45.0 33.1 42.3 a
31.6–33.6 20.8–41.7 19.6–37.5 10.1–24.6 35.8–50.6 35.5–41.2 38.0–59.1 26.6–53.7 16.6–65.4 20.1–55.3 30.1–37.0 27.6–40.2 29.4–54.5 20.7–36.8 27.4–51.14 26.8–35.9 17.0–30.45 27.0–44.0 22.2–29.5 10.5–22.6 32.9–46.9 26.2–42.9 46.4–55.5 28.0–38.8 34.9–42.7 18.8–27.8 10.0–25.6 19.4–39.5 24.0–37.6 9.5–52.0 16.4–47.6 31.9–45.0 30.5–45.3 17.5–34.5 17.6–43.2 32.8–40.9 24.1–33.1 11.5–23.6 27.4–50.7 26.9–37.2 24.5–54.4 25.1–37.6 10.1–38.2 15.4–27.7 25.9–32.2 29.7–52.3 26.1–42.0 43.3–65.1 29.4–39.9 39.5–50.7 19.7–49.9 23.9–63.1
33 40 50 5 14 3 10 17 20 26 25 7 39 12 30 44 21 41 51 9 23 2 27 11 45 49 37 32 42 34 16 18 43 36 19 38 48 13 29 15 31 47 46 35 8 24 1 22 4 28 6
14,694 14 303 202 291 1481 171 164 27 42 1218 316 77 202 65 550 288 178 228 210 334 252 94 520 262 356 136 58 480 49 105 63 370 118 84 831 633 189 219 662 65 204 58 262 865 125 419 28 343 335 117 31
23.1 13.8 a 23.4 18.3 26.0 27.2 29.1 22.3 31.7 a 30.0 a 29.2 15.0 35.3 25.3 22.7 20.9 13.8 26.3 16.8 15.2 24.8 22.2 42.7 25.0 30.5 20.5 13.8 10.0 23.1 20.2 a 15.9 27.7 21.0 15.4 30.9 20.2 18.5 18.0 25.8 21.3 22.4 14.8 17.0 19.1 24.6 27.6 22.6 34.7 a 28.8 25.0 12.7 18.7 a
22.3–24.0 5.2–31.9 18.7–28.9 11.9–27.2 21.3–31.3 24.7–29.9 18.9–41.9 16.8–28.9 18.4–48.9 12.7–55.8 26.3–32.3 10.9–20.4 27.1–44.5 19.3–32.3 17.2–29.4 16.1–26.8 9.5–19.8 20.0–33.8 11.8–23.5 8.7–25.1 18.8–32.0 16.3–29.6 35.4–50.3 20.3–30.4 23.6–38.4 16.2–25.5 6.9–25.5 3.7–24.6 18.3–28.9 14.4–27.5 8.4–28.2 15.3–44.8 16.5–26.3 9.2–24.6 21.4–42.4 16.5–24.4 14.9–22.8 12.5–25.2 20.1–32.3 18.8–24.0 10.7–41.0 10.1–21.3 9.2–29.4 14.4–25.0 21.1–28.4 20.9–35.4 19.0–26.6 13.0–65.5 24.7–33.4 20.1–30.7 7.6–20.6 10.1–32.1
49 22 38 15 13 9 27 4 7 8 45 2 17 24 31 47 14 41 44 20 28 1 19 6 32 48 51 23 34 42 11 30 43 5 33 37 39 16 29 26 46 40 35 21 12 25 3 10 18 50 36
Abbreviations: DC, District of Columbia; CI, confidence interval. a Unstable
164
estimate based on sample size < 50 and standard error > 30% of prevalence. JPAH Vol. 13, No. 2, 2016
Physical Activity in Cancer Survivors by State 165
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
150 or 60 min/wk of light/moderate or vigorous intensity aerobic PA, respectively. Our findings suggests that cancer survivors residing in states with a lower prevalence of meeting recommendations are at greater risk for poorer quality of life, physical functioning and fitness, and increased fatigue and mortality than in states with higher PA prevalence. The 2015 goals of the ACS for cancer survivors are that 70% of survivors follow the recommended PA guidelines.21 We found that none of the states came close to meeting this goal, which may call into question whether this goal is realistic. Our findings are somewhat different from those of the BRFSS findings for PA participation.19 However, BRFSS solely reported the prevalence of those who did not participate in any PA, whereas we compared and ranked age-adjusted prevalence to current PA guidelines for cancer survivors, so our results are not directly comparable. For example, BRFSS placed Louisiana in the range of 30.8–33.9% who performed no PA, but 12 other states had a larger proportion of residents who were completely inactive.19 In our study, we found Louisiana to have the lowest age-adjusted percentage of cancer survivors meeting recommendations of PA. In addition, BRFSS reported that West Virginia had the highest percentage of cancer survivors with no PA (42.3%), whereas in our study West Virginia ranked 23rd; that is, an age-adjusted 34.2% met PA recommendations. The state with the lowest percentage of physically inactive residents was Oregon (21.4%) in the BRFSS; in our study, Oregon ranked 19th best for meeting PA recommendations at an age-adjusted 35.1%. The findings from our study may be related to health behavior clustering in these states. For example, of states in the lowest quartile for meeting PA recommendations, more than half also have the highest prevalence of obesity (of at least 15.2%),24 and half also have the highest prevalence of smoking (of at least 23.0%).18 Moreover, of the 14 states with the lowest cigarette excise taxes,24 we found that less than 30% met recommendations for PA in 12 of these states. These states may generally be lacking in preventive care programs, which in turn could affect health outcomes of chronically ill patients. These states may also have limited resources for cancer survivors (eg, few community or recreational centers), although we know of no studies comparing the quality of cancer care across the states. Males (36.1%) had a higher age-adjusted prevalence of meeting PA recommendations than females (30.7%). Males in 6 states had at least 50% prevalence of meeting PA recommendations, whereas only females living in 1 state (Vermont) achieved 50% prevalence. These findings may be explained by the fact that females in the lowest quartile of meeting PA recommendations demonstrate other higher risk behaviors/conditions compared with males. For example, in the states with the lowest quartile of meeting PA recommendations in females, 58% and 50% are obese and smokers, respectively, compared with 50% and 42% for these same characteristics in males, respectively.18,24 These results may also be related to cancer type and treatment. For example, prostate cancer, the most common type of cancer in males, is often diagnosed but not treated, whereas breast cancer, the most common type in females, is nearly always treated with invasive regimens that can create physical or mental barriers that may preclude some women from engaging in the recommended amounts of PA.25–27 In addition, the percentage of cancer survivors ≥ 65 years meeting PA recommendations was lower than that for cancer survivors < 65 years; the percentage of older survivors was 10 points lower (23.1%) than that of younger survivors (32.6%). A recent study that compared state variations in the prevalence of PA in a nationally representative sample of older adults using pooled NHIS data found similar results.28 For older adults, comorbidities and other
functional limitations may be added impediments to PA, as is the case in the general population, whereas younger survivors may be able to perform more activities.29 Maine and Colorado were within the top 10 states for the highest percentage meeting PA recommendations in all analyses (ie, age adjusted, age-adjusted and stratified by gender, and stratified by age). One explanation could be that survivors residing in Maine and Colorado practice better health behaviors overall. For example, previous evidence about meeting PA recommendations in the general population indicates that Colorado has the lowest percentage of people with obesity.24 In term of healthy eating, 1 in 3 survivors living in Colorado and Maine were found to eat 2 or more servings of fruit/day.24 Among states in the top 10 for meeting PA recommendations, Florida was the only state from the South (ranked 8th in adults aged 65 and older). Likewise, of the top 10 states ranked highest by the ACS for overweight and obesity, 7 were Southern states.24 BRFSS also found that those residing in the South had the highest prevalence of inactivity (34.3%).19 Aside from health behaviors, another reason for the overall low PA prevalence could be related to fear or hesitancy to engage in PA after a diagnosis of cancer, especially if survivors’ were undergoing treatment, had other comorbidities, or were experiencing fatigue. Lower prevalence in specific states may be related to having fewer resources available for PA interventions. These states and the others below the target level of PA compliance need cost-effective interventions to educate cancer survivors about the benefits of increased PA during the treatment of cancer and beyond and to encourage increased engagement in PA. For example, community-based interventions, which use social-support strategies such as buddy systems or support groups, have been effective in mobilizing vulnerable population groups to increase PA.30 Tailoring social-support interventions for the specific needs of cancer survivors related to cancer type, stage of cancer diagnosis and treatment, and prognosis would help increase PA in this population; however, other within-state barriers to PA, such as environmental conditions, time constraints, or lack of support, may also deleteriously influence behaviors and so also need to be addressed. Encouragement from primary care physicians and oncologists to increase PA according to the ACS guidelines for cancer survivors, even during treatment, may beneficially affect the health of cancer survivors. The NHIS does not contain information on whether cancer survivors received information or recommendations on PA from their physician or healthcare provider; however, according to a recent study, only 19% of cancer survivors remember their physician addressing their level of PA after cancer diagnosis.17 Cancer survivorship care plans, as recommended by the Institute of Medicine, use a patient-centered approach to ensure patients’ immediate and long-term needs are being met while encouraging healthcare providers, such as primary care physicians, oncologists, physical rehabilitation medicine physicians, and physical therapists, to effectively dispense valuable information; this includes promoting the adoption of healthy lifestyle behaviors such as PA and providing aid in locating community support services that offer PA opportunities.13 Our findings present healthcare providers residing in states with lower prevalence of meeting PA recommendations the momentum to initiate effectual communication with cancer survivors about the importance of PA as a vital part of their total treatment and survivorship cancer care plan. It is important to note several study limitations. Because of limited sample size, we were unable to present stable prevalence estimates for some states.23 Furthermore, unlike the BRFSS, which is designed as a state-specific survey, the NCHS does not supply
JPAH Vol. 13, No. 2, 2016
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
166 Tannenbaum et al
state-specific sampling weights for the NHIS. Although the pooling of data for states across survey years does enhance precision (see, for example, NCHS publication in Public Health Reports),31 the lack of state-specific weights can lead to imprecision in our estimates. Both cancer history and PA compliance were based on self-report, which can be subject to reporting bias. Because of small sample sizes, factors that could influence PA levels between states such as cancer site, time since diagnosis, race/ethnicity, and socioeconomic status were not considered when determining whether PA recommendations were met. The NHIS does not contain data on other potentially relevant clinical factors such as cancer grade. Lastly, because of sample size limitations, we were unable to determine whether states with a smaller proportion of cancer survivors meeting PA recommendations also had a higher proportion of smokers and overweight or obese individuals. A major strength of this study, however, was the overall large sample size and our unique access to the RDC, which allowed for prevalence comparisons of meeting PA recommendations in cancer survivors by state of residence. Another strength of the study was the in-person household administration of the NHIS (vs the telephone administration used by the BRFSS), which yields much larger response rates, generates more detailed information, and removes the bias of telephone noncoverage.32 Therefore, the reporting and comparison of cancer-specific estimates from the NHIS and the BRFSS should be routinely undertaken given the relative balance of the strengths and limitations of both survey systems.
Conclusion To our knowledge, no other study has compared the percentage of cancer survivors meeting PA recommendations by state of residence and by age and gender. Cancer survivors who engage in PA have improved quality of life, less recurrence, and other positive health outcomes related to cancer treatment. The recent development of these cancer survivor-specific PA guidelines should help to increase awareness of the benefits of PA in this group as well as lend confidence among survivors to begin a PA program. It is clear, though, that even with specified guidelines, many states still fall short of the goals. Targeting health care providers who are practicing in states with poor prevalence of meeting PA recommendations (particularly in southern states) with interventions to increase their awareness of the importance of PA for their cancer patients is greatly needed. In addition, future efforts should focus on developing and updating PA prevention and treatment interventions tailored to the specific needs of cancer survivors using the cancer survivorship care plan. Special attention should be also devoted to female cancer survivors and adults ≥ 65 years of age. Acknowledgments Funding for this study was provided by Bankhead Coley Cancer Research Grant 1BG06-341963.
References 1. Robien K, Bechard L, Elliott L, Fox N, Levin R, Washburn S. American Dietetic Association: revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in oncology nutrition care. J Am Diet Assoc. 2010;110:310–317. PubMed doi:10.1016/j.jada.2009.11.001 2. American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013.
3. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103:117–128. PubMed doi:10.1093/jnci/djq495 4. Rowland JH. Cancer survivorship: rethinking the cancer control continuum. Semin Oncol Nurs. 2008;24:145–152. PubMed doi:10.1016/j. soncn.2008.05.002 5. Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2010;4:87–100. PubMed doi:10.1007/s11764-009-0110-5 6. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012;8:CD008465. PubMed 7. Courneya KS, Sellar CM, Stevinson C, et al. Randomized controlled trial of the effects of aerobic exercise on physical functioning and quality of life in lymphoma patients. J Clin Oncol. 2009;27:4605–4612. PubMed doi:10.1200/JCO.2008.20.0634 8. Peddle CJ, Au H-J, Courneya KS. Associations between exercise, quality of life, and fatigue in colorectal cancer survivors. Dis Colon Rectum. 2008;51:1242–1248. PubMed doi:10.1007/s10350-0089324-2 9. Zhao G, Li C, Li J, Balluz LS. Physical activity, psychological distress, and receipt of mental healthcare services among cancer survivors. J Cancer Surviv. 2013;7:131–139. PubMed doi:10.1007/s11764-0120254-6 10. Alfano CM, Smith AW, Irwin ML, et al. Physical activity, long-term symptoms, and physical health-related quality of life among breast cancer survivors: a prospective analysis. J Cancer Surviv. 2007;1:116– 128. PubMed doi:10.1007/s11764-007-0014-1 11. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56:323–353. PubMed doi:10.3322/canjclin.56.6.323 12. Campbell KL, Van Patten CL, Neil SE, et al. Feasibility of a lifestyle intervention on body weight and serum biomarkers in breast cancer survivors with overweight and obesity. J Acad Nutr Diet. 2012;112:559–567. PubMed doi:10.1016/j.jada.2011.10.022 13. Hewitt ME, Greenfield S, Stovall E. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2006. 14. Curtis RE, Freedman DM, Ron E, et al. New Malignancies Among Cancer Survivors: SEER Cancer Registries, 1973–2000 (NIH Publication No. 05-5302). Bethesda, MD: National Cancer Institute; 2006. 15. Meyerhardt JA, 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. 2006;24:3535–3541. PubMed doi:10.1200/JCO.2006.06.0863 16. Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with healthrelated quality of life: results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26:2198–2204. PubMed doi:10.1200/ JCO.2007.14.6217 17. Blanchard CM, Denniston MM, Bakeunce System, United States, 2009. MMWR Surveill Summ. 2012;61:1–23. http://www.cdc.gov/ mmwr/preview/mmwrhtml/ss6101a1.htm. 18. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. http://www.cdc.gov/mmwr/preview/mmwrhtml/ ss6309a1.html. Published 2014. Accessed March 2016 19. Underwood JM, Townsend JS, Stewart SL, et al. Surveillance of Demographic Characteristics and Health Behaviors Among Adult Cancer Survivors—Behavioral Risk Factor Surveillance System, United States, 2009. MMWR Surveill Summ. 2012;61:1–23. http:// www.cdc.gov/mmwr/preview/mmwrhtml/ss6101a1.htm. 20. Moriarty C. National Health Interview Survey Sample Adult and Sample Child: Nonresponse Bias Analysis. Division of Health Interview Statistics, National Center for Health Statistics Web site. http://
JPAH Vol. 13, No. 2, 2016
Physical Activity in Cancer Survivors by State 167
Downloaded by University of California on 09/19/16, Volume 13, Article Number 2
www.cdc.gov/nchs/data/nhis/nr_bias_analysis_report_2009_NHIS. pdf. Published 2009. Updated December 2, 2015. Accessed March 2016. 21. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62:242–274. PubMed doi:10.3322/caac.21142 22. Healthy People 2010. 2012 National Health Interview Survey (NHIS) Public Use Data Release. NHIS Survey Description. ftp://ftp.cdc. gov/pub/health_statistics/nchs/Dataset_Documentation/NHIS/2012/ srvydesc.pdf. Published 2012. Accessed March 2016. 23. Klein RJ, Proctor SE, Boudreault MA, Turczyn KM. Healthy People 2010 criteria for data suppression. Healthy People 2010 Stat Notes. 2002;(24):1–12. http://www.cdc.gov/nchs/data/statnt/statnt24.pdf. Accessed May 2012. 24. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2013. Atlanta: American Cancer Society; 2013. 25. Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics 2012. CA Cancer J Clin. 2012;62:220–241. PubMed doi:10.3322/caac.21149 26. National Cancer Institute. Prostate Cancer Treatment–For Health Professionals (PDQ). Available from: http://www.cancer.gov/types/ prostate/hp/prostate-treatment-pdq#Section_1679. Updated February 11, 2016. Accessed March 2016.
27. National Cancer Institute. Breast Cancer Treatment–For Health Professionals (PDQ): General Information about Breast Cancer. http://www.cancer.gov/types/breast/hp/breast-treatment-pdq. Updated February 2, 2016. Accessed March 2016. 28. Tannenbaum SL, Kachan D, Fernandez CA, et al. State variations of chronic disease risk factors in older Americans. Prev Chronic Dis. 2012;9:E177. PubMed doi:10.5888/pcd9.120143 29. Courneya KS, Vallance JKH, NcNeely ML, Karvinen KH, Peddle CJ, Mackey JR. Exercise issues in older cancer survivors. Crit Rev Oncol Hematol. 2004;51:249–261. PubMed doi:10.1016/j.critrevonc.2004.05.001 30. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002;22(4 Suppl 1):73–107. PubMed doi:10.1016/S07493797(02)00434-8 31. Davis WW, Parsons VL, Xie D, et al. State-based estimates of mammography screening rates based on information from two health surveys. Public Health Rep. 2010;125:567–578. PubMed 32. Nelson DE, Powell-Griner E, Town M, Kovar MG. A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. Am J Public Health. 2003;93:1335–1341. PubMed doi:10.2105/AJPH.93.8.1335
JPAH Vol. 13, No. 2, 2016
