Breast Cancer Res Treat (2013) 142:423–433 DOI 10.1007/s10549-013-2749-x
EPIDEMIOLOGY
Barriers to physical activity and healthy eating in young breast cancer survivors: modifiable risk factors and associations with body mass index Emily E. Ventura • Patricia A. Ganz • Julienne E. Bower • Liana Abascal Laura Petersen • Annette L. Stanton • Catherine M. Crespi
•
Received: 1 October 2013 / Accepted: 21 October 2013 / Published online: 1 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Physical activity (PA) and healthy eating (HE) are important behaviors to encourage in breast cancer survivors (BCS). We examined associations between various factors and barriers to PA (BPA) and barriers to HE (BHE), as well as relationships between barriers and body mass index (BMI) in younger BCS. Self-reported data from 162 BCS (mean age 48 years) were used. BPA were assessed with a 21-item scale and BHE with a 19-item scale. Participants were classified as high or low on each scale. Sociodemographic, medical, and psychosocial characteristics were compared by high/low barriers. Correlates of continuous BPA and BHE were assessed as were associations among BHE, BPA, and BMI. 61 % of participants were characterized as having low BHE and low BPA; 12 % were high for both. High BHE/high BPA participants had the least favorable scores for depression, perceived stress, social support, fatigue, bladder control, and weight problems. Factors associated with BHE were lower education, higher perceived stress, and more severe weight problems. Factors associated with BPA were more severe bladder
control problems and lower physical well-being. Higher BHE and BPA were significantly and uniquely associated with higher BMI, controlling for covariates. Several biopsychosocial factors (e.g., depression, stress, and fatigue) characterize young BCS who experience barriers to both HE and PA. The correlates of BHE and BPA are distinct. Both BHE and BPA are associated with BMI. These results should be considered in designing interventions for younger women with breast cancer.
E. E. Ventura P. A. Ganz (&) L. Petersen A. L. Stanton C. M. Crespi Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA 90095-6900, USA e-mail: [email protected]
J. E. Bower A. L. Stanton Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
P. A. Ganz Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
L. Abascal Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
P. A. Ganz Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
Keywords Breast cancer Survivorship Diet Physical activity Obesity
Introduction Breast cancer survivors (BCS) constitute the largest segment of female cancer survivors [1]. Most early-stage breast cancer patients have a life expectancy similar to agematched women [2], and there is need to reduce their risk
J. E. Bower A. L. Stanton Cousins Center for Psychoneuroimmunology, Semel Institute, University of California, Los Angeles, Los Angeles, CA, USA
C. M. Crespi Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
123
424
for comorbid conditions and secondary cancers. This is particularly true for younger BCS (i.e., 50 years or younger), for whom several decades of additional survival is anticipated. In a recent systematic review, we identified substantial rates of anxiety and depressive symptoms among younger BCS, along with fertility concerns, menopausal symptoms, and weight gain [3]. Weight gain is of particular concern for BCS, in that excess body weight is a risk factor for cancer recurrence [4]. Younger women may be at increased risk for weight gain as they are more likely to experience premature menopause, induced by adjuvant chemotherapy [5]. In addition, some evidence shows that the association between weight gain after diagnosis and breast cancer survival is greater in pre-menopausal women than in postmenopausal survivors [6]. A recent meta-analysis demonstrated that higher physical activity (PA) was associated with reduced breast cancer-specific mortality as well as overall mortality in BCS [7]. In a previous study in young BCS [8], we found an association between higher levels of PA and lower BMI and blood pressure, as well as higher physical functioning and energy levels. However, participants reported lower levels of PA than was shown in a similar sample of women without cancer, suggesting a need to help young survivors increase PA. In our systematic review [3], we also found that lack of PA and weight gain are common in young BCS. Research linking dietary intake to improved outcomes in survivors is less clear, though there is some evidence to show that reducing fat and alcohol consumption as well as increasing intake of fruits, vegetables, and other sources of dietary fiber such as whole grains may be beneficial [9, 10]. Despite the importance of weight and PA as factors influencing mortality after breast cancer, little is known about the barriers to maintaining normal weight and increasing PA in this setting. We initiated the After Breast Cancer (ABC) study to identify behavioral and lifestyle risk factors for obesity and physical inactivity in younger BCS that would be relevant for future intervention development. This paper presents the results of a crosssectional survey that examined a variety of domains (health-related quality of life, medical and treatment variables, weight and health behaviors), in addition to perceived barriers to PA and healthy eating (HE). The specific questions addressed in this paper are: (1) What are the perceived barriers to HE (BHE) and PA in young BCS and how do women vary by barrier status?; (2) How do the demographic, medical, and psychosocial factors associated with barriers for PA and HE differ?; and (3) Do the perceived BHE and BPA contribute to higher body mass index (BMI) independent of other factors related to high BMI in this population?
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Breast Cancer Res Treat (2013) 142:423–433
Methods Participants and recruitment Study recruitment began in 2009, using the UCLA Health System tumor registry to identify potentially eligible breast cancer patients diagnosed between 2003 and 2007. Eligibility criteria were: stage 1, 2, or 3 breast cancer diagnosed at age B50 years; currently alive and disease free; [1 year post-initial cancer diagnosis; [6 months after cancer treatment (i.e., completed chemotherapy and/or radiation, but could be receiving endocrine therapy); agreed to complete survey; ability to read and write English; female; provides informed consent. Invitation letters were mailed to potential subjects, who were asked to return a mailed response form indicating their interest in participating. Trained research staff screened potential participants via telephone. Eligible participants were mailed consent forms and questionnaire packets to complete and return in postage paid envelopes, and reminder calls were made to return questionnaires. Non-respondents received a second mailing and additional contact by phone to explain the study and screen for eligibility. The study was approved by the UCLA Institutional Review Board and written consent was obtained from each participant. Measures Demographic and medical characteristics Demographic and medical characteristics were assessed with questions used in prior studies [11, 12] (see Table 1 for all variables). Current chronic conditions were assessed using a checklist of 13 conditions. Current height (in feet and inches) as well as current weight and weight (lbs) at diagnosis were assessed via self-report. BMI was calculated in kg/m2. Menstrual history was measured via a series of questions used previously [11]. Quality of life and symptoms Depressive symptoms over the last week were assessed using the Center for Epidemiologic Studies Depression (CES-D) Scale [13]. Perceived stress over the last month was measured with the Perceived Stress Scale (PSS) 10-item version [14]. An 8-item version of the MOS social support survey [15] was used to assess social support. Fatigue severity over the past week was measured with the Fatigue Symptom Inventory (FSI), which was developed for and validated in cancer patients [16–18]. Health-related quality of life (HRQL) over the past month was assessed with the MOS 12-Item Health Survey Short Form (SF-
47.6 (5.6)
Age (years)
109 (67.3 %)
Has children (percent yes)
47 (29.0 %) 24 (14.8 %)
4-year college graduate
Some graduate school
28 (17.3 %) 31 (19.1 %) 17 (10.5 %)
Part-time
Full-time homemaker, full- or part-time volunteer, student, or retired
Unemployed, on temporary medical leave, or permanently disabled
Total sample n = 162 64.8 (2.8) 151.0 (38.3) 25.1 (5.5)
Height (inches) Current weight (lbs)
Current BMI
74 (47.1 %)
Over $100,000
Medical characteristics
27 (17.2 %) 56 (35.7 %)
Under $60,000 $60,001–$100,000
Total family income (n = 157)
86 (53.1 %)
Full-time
41 (25.3 %)
41 (25.3 %)
Some college or AA
Completed graduate school Current employment status
9 (5.6 %)
High school grad, GED, or vocational or training school
Educational attainment (n = 162)
24 (14.8 %)
Lives alone (percent yes)
Married/living as married versus single/ divorced
Marital status 122 (75.3 %)
2 (2.0 %)
3 (1.9 %)
Asian
Other
15 (15.2 %)
9 (5.6 %) 23 (14.2 %)
Black, non-Hispanic
64.5 (2.9) 161.7 (47.7) 27.0b (6.6)
24.0b,c (4.3)
High barriers PA, low barriers HE (n = 29)
11 (37.9 %)
4 (13.8 %) 14 (48.3 %)
3 (10.3 %)
6 (20.7 %)
4 (13.8 %)
16 (55.2 %)
7 (24.1 %)
5 (17.2 %)
7 (24.1 %)
6 (20.7 %)
4 (13.8 %)
20 (69.0 %)
5 (17.2 %)
22 (75.9 %)
1 (3.4 %)
4 (13.8 %)
3 (10.3 %)
2 (6.9 %)
19 (65.5 %)
47.8 (6.0)
High barriers PA, low barriers HE (n = 29)
64.7 (2.8) 143.3a (30.5)
Low barriers PA, low barriers HE (n = 99)
52 (54.2 %)
17 (17.7 %) 27 (28.1 %)
11 (11.1 %)
19 (19.2 %)
18 (18.2 %)
51 (51.5 %)
26 (26.3 %)
16 (16.2 %)
32 (32.2 %)
23 (23.2 %)
2 (2.0 %)
66 (66.7 %)
12 (12.1 %)
76 (76.8 %)
5 (5.1 %)
7 (6.9 %)
111 (68.5 %) 16 (9.9 %)
Hispanic
70 (70.7 %)
47.9 (5.7)
Low barriers PA, low barriers HE (n = 99)
White, non-Hispanic
Ethnicity (n = 162)
Total sample n = 162
Demographic characteristics
24.5 (4.6)
65.3 (2.6) 149.1 (30.1)
Low barriers PA, high barriers HE (n = 15)
4 (28.6 %)
2 (14.3 %) 8 (57.1 %)
2 (13.3 %)
2 (13.3 %)
1 (6.7 %)
10 (66.7 %)
5 (33.3 %)
–
3 (20.0 %)
6 (40.0 %)
1 (6.7 %)
8 (53.3 %)
4 (26.7 %)
9 (60.0 %)
–
2 (13.3 %)
–
6 (40.0 %)
7 (46.7 %)
46.5 (5.2)
Low barriers PA, high barriers HE (n = 15)
Table 1 Descriptive characteristics of participants by responses to the barriers to healthy eating (HE) and barriers to physical activity (PA) scales
28.6c (7.8)
65.7 (2.2) 176.3a (50.9)
High barriers PA, high barriers HE (n = 19)
7 (38.9 %)
4 (22.2 %) 7 (38.9 %)
1 (5.3 %)
4 (21.1 %)
5 (26.3 %)
9 (47.4 %)
3 (15.8 %)
3 (15.8 %)
5 (26.3 %)
6 (31.6 %)
2 (10.5 %)
15 (78.9 %)
3 (15.8 %)
15 (78.9 %)
–
2 (10.5 %)
1 (5.3 %)
1 (5.3 %)
15 (78.9 %)
46.8 (4.7)
High barriers PA, high barriers HE (n = 19)
0.001
0.39 0.002
p value2
0.24
0.92
0.35
0.47
0.50
0.54
0.07
0.73
p value2
Breast Cancer Res Treat (2013) 142:423–433 425
123
123 24.5 (5.5)
BMI at diagnosis (n = 158)
93 (57.4 %) 4 (2.5 %) 11 (6.8 %) 1.2 (1.1) 3.4 (1.5)
Post Unknown–hysterectomy
Unknown–treatment-related amenorrhea
Count of co-morbidities (0–13, n = 161)
Years since diagnosis
61 (37.9 %)
Lumpectomy only
40 (24.7 %) 15 (9.3 %) 86 (53.1 %) 36 (22.9 %) 98 (60.5 %) Total sample n = 162 14.1 (10.1) 16.7 (6.7) 75.1 (22.5) 73.8 (27.0) 6.3 (2.6) 47.9 (9.6) 47.1 (10.8)
Had chemotherapy only (percent yes)
Had Radiation only (percent yes)
Had both chemotherapy and radiation (percent yes)
Received Herceptin or other biotherapy (percent yes, n = 157)
Currently receiving endocrine therapy
Quality of life and symptoms
CES-D
PSS (n = 161)
MOS emotional social support (n = 162)
MOS instrumental social support (n = 161)
FSI Level of fatigue on the day felt most fatigued during the last week
SF-12 physical component (n = 159)
SF-12 mental component (n = 159) 1.4 (1.3) 0.2 (0.4) 0.5 (0.8)
Hot flashes
Nausea
Bladder control
BCPT symptom scales
21 (13.0 %)
Had neither chemotherapy nor radiation
Chemotherapy and/or radiation
100 (62.1 %)
Mastectomy only
Type of surgery (n = 161)
54 (33.3 %)
Pre
Menopausal status
Total sample n = 162
Medical characteristics
Table 1 continued
15.0 (12.4)
12.2a (8.7)
65.3 (31.8) 6.8 (2.5) 43.6f,h (10.1)
79.7d (23.0) 5.8e (2.7) 49.5f,g (8.7)
0.7 (0.8)
0.4k (0.7)
1.4 (1.2) 0.3 (0.4)
0.2 (0.4)
1.4 (1.3)
49.1 (9.4)
46.2 (13.5)
68.3 (26.1)
79.6c (19.5)
j
17.9 (6.9)
15.2 (6.1)
b
High barriers PA, low barriers HE (n = 29)
19 (65.5 %)
7 (25.0 %)
22 (75.9 %)
2 (6.9 %)
3 (10.3 %)
2 (6.9 %)
15 (51.7 %)
14 (48.3 %)
3.5 (1.5)
1.2 (1.3)
3 (10.3 %)
16 (55.2 %) 2 (6.9 %)
Low barriers PA, low barriers HE (n = 99)
61 (61.6 %)
22 (22.9 %)
46 (46.5 %)
9 (9.1 %)
29 (29.3 %)
15 (15.2 %)
31 (31.3 %)
68 (68.7 %)
3.3 (1.5)
1.1 (0.9)
8 (8.1 %)
60 (60.6 %) –
8 (27.6 %)
26.4d (7.2)
23.4d,e (4.4) 31 (31.3 %)
High barriers PA, low barriers HE (n = 29)
Low barriers PA, low barriers HE (n = 99)
0.7 (1.1)
0.1 (0.2)
1.5 (1.3)
41.2 (9.6)
j
51.7h,i (8.0)
7.0 (2.4)
65.8 (27.3)
71.3 (22.6)
19.5 (7.0)
18.3 (11.9)
Low barriers PA, high barriers HE (n = 15)
8 (53.3 %)
3 (21.4 %)
5 (33.3 %)
3 (20.0 %)
5 (33.3 %)
2 (13.3 %)
7 (50.0 %)
7 (50.0 %)
3.1 (1.5)
0.9 (0.9)
–
4 (26.7 %) 1 (6.7 %)
10 (66.7 %)
24.5 (4.7)
Low barriers PA, high barriers HE (n = 15)
1.0k (1.0)
0.3 (0.5)
1.4 (1.1)
42.8 (11.6)
43.0g,i (10.9)
7.6e (1.7)
62.5d (31.7)
64.8c (26.1)
20.7b (7.2)
19.5a (9.4)
High barriers PA, high barriers HE (n = 19)
10 (52.6 %)
4 (21.1 %)
13 (68.4 %)
1 (5.3 %)
3 (15.8 %)
2 (10.5 %)
8 (42.1 %)
11 (57.9 %)
3.7 (1.4)
1.8 (1.7)
–
13 (68.4 %) 1 (5.3 %)
5 (26.3 %)
28.1e (6.9)
High barriers PA, high barriers HE (n = 19)
0.003
0.53
1.0
0.01
0.001
0.01
0.006
0.01
0.002
0.008
p value
0.76
0.99
0.14
0.16
0.57
0.07
0.031
0.002
p value2
426 Breast Cancer Res Treat (2013) 142:423–433
427
12)[19] yielding two subscales: physical component summary (PCS) and mental component summary (MCS), with normative data available for the general population, and individuals with chronic conditions. These scales have been widely used in studies of BCS [3, 8, 11, 12]. Breast cancer-related symptoms were measured with the Breast Cancer Prevention Trial (BCPT) symptom scales [20].
Analysis of variance (ANOVA) used to compare participants by barrier quadrants for continuous variables and Chi square tests for categorical variables 2
1
For menopausal status, the low PA/high HE group differs significantly from all three other groups
Barriers to physical activity and healthy eating
p \ 0.05 was deemed statistically significant and is shown in bold
Superscripts a–n indicate pairs which differ significantly. Barrier groups were created based on mean responses to each of the two scales. Participants were considered to have low barriers for each of the scales if they reported a mean response of less than 2.5 and to have high barriers if they reported a mean response of 2.5 or higher. Both BHE and BPA scale response options ranged from 1 to 5 with 1 representing ‘‘never’’ and 5 representing ‘‘very often.’’ Additional scale and item descriptions: Currently receiving endocrine therapy: e.g., Tamoxifen, Femara, Aromasin, Arimidex, Lupron, or Zoladex (percent yes); Depression: Center for Epidemiologic Studies Depression Scale, (CES-D), higher = more depressed); Stress: Perceived Stress Scale, (PSS), higher = more perceived stress, n = 161; Social support: MOS emotional social support, higher = more support, n = 162; MOS instrumental social support, higher = more support, n = 161; Well-being: Short Form Health Survey (SF-12): physical component, higher = higher functioning, Short Form Health Survey (SF-12): mental component, higher = higher functioning; Breast cancer-related symptoms, Breast Cancer Prevention Trial Symptom checklist, (BCPT symptom scales), scales range from 0 to 4 with higher indicating greater severity of symptoms
0.002
EPIDEMIOLOGY
Barriers to physical activity and healthy eating in young breast cancer survivors: modifiable risk factors and associations with body mass index Emily E. Ventura • Patricia A. Ganz • Julienne E. Bower • Liana Abascal Laura Petersen • Annette L. Stanton • Catherine M. Crespi
•
Received: 1 October 2013 / Accepted: 21 October 2013 / Published online: 1 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Physical activity (PA) and healthy eating (HE) are important behaviors to encourage in breast cancer survivors (BCS). We examined associations between various factors and barriers to PA (BPA) and barriers to HE (BHE), as well as relationships between barriers and body mass index (BMI) in younger BCS. Self-reported data from 162 BCS (mean age 48 years) were used. BPA were assessed with a 21-item scale and BHE with a 19-item scale. Participants were classified as high or low on each scale. Sociodemographic, medical, and psychosocial characteristics were compared by high/low barriers. Correlates of continuous BPA and BHE were assessed as were associations among BHE, BPA, and BMI. 61 % of participants were characterized as having low BHE and low BPA; 12 % were high for both. High BHE/high BPA participants had the least favorable scores for depression, perceived stress, social support, fatigue, bladder control, and weight problems. Factors associated with BHE were lower education, higher perceived stress, and more severe weight problems. Factors associated with BPA were more severe bladder
control problems and lower physical well-being. Higher BHE and BPA were significantly and uniquely associated with higher BMI, controlling for covariates. Several biopsychosocial factors (e.g., depression, stress, and fatigue) characterize young BCS who experience barriers to both HE and PA. The correlates of BHE and BPA are distinct. Both BHE and BPA are associated with BMI. These results should be considered in designing interventions for younger women with breast cancer.
E. E. Ventura P. A. Ganz (&) L. Petersen A. L. Stanton C. M. Crespi Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA 90095-6900, USA e-mail: [email protected]
J. E. Bower A. L. Stanton Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
P. A. Ganz Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
L. Abascal Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
P. A. Ganz Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
Keywords Breast cancer Survivorship Diet Physical activity Obesity
Introduction Breast cancer survivors (BCS) constitute the largest segment of female cancer survivors [1]. Most early-stage breast cancer patients have a life expectancy similar to agematched women [2], and there is need to reduce their risk
J. E. Bower A. L. Stanton Cousins Center for Psychoneuroimmunology, Semel Institute, University of California, Los Angeles, Los Angeles, CA, USA
C. M. Crespi Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
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424
for comorbid conditions and secondary cancers. This is particularly true for younger BCS (i.e., 50 years or younger), for whom several decades of additional survival is anticipated. In a recent systematic review, we identified substantial rates of anxiety and depressive symptoms among younger BCS, along with fertility concerns, menopausal symptoms, and weight gain [3]. Weight gain is of particular concern for BCS, in that excess body weight is a risk factor for cancer recurrence [4]. Younger women may be at increased risk for weight gain as they are more likely to experience premature menopause, induced by adjuvant chemotherapy [5]. In addition, some evidence shows that the association between weight gain after diagnosis and breast cancer survival is greater in pre-menopausal women than in postmenopausal survivors [6]. A recent meta-analysis demonstrated that higher physical activity (PA) was associated with reduced breast cancer-specific mortality as well as overall mortality in BCS [7]. In a previous study in young BCS [8], we found an association between higher levels of PA and lower BMI and blood pressure, as well as higher physical functioning and energy levels. However, participants reported lower levels of PA than was shown in a similar sample of women without cancer, suggesting a need to help young survivors increase PA. In our systematic review [3], we also found that lack of PA and weight gain are common in young BCS. Research linking dietary intake to improved outcomes in survivors is less clear, though there is some evidence to show that reducing fat and alcohol consumption as well as increasing intake of fruits, vegetables, and other sources of dietary fiber such as whole grains may be beneficial [9, 10]. Despite the importance of weight and PA as factors influencing mortality after breast cancer, little is known about the barriers to maintaining normal weight and increasing PA in this setting. We initiated the After Breast Cancer (ABC) study to identify behavioral and lifestyle risk factors for obesity and physical inactivity in younger BCS that would be relevant for future intervention development. This paper presents the results of a crosssectional survey that examined a variety of domains (health-related quality of life, medical and treatment variables, weight and health behaviors), in addition to perceived barriers to PA and healthy eating (HE). The specific questions addressed in this paper are: (1) What are the perceived barriers to HE (BHE) and PA in young BCS and how do women vary by barrier status?; (2) How do the demographic, medical, and psychosocial factors associated with barriers for PA and HE differ?; and (3) Do the perceived BHE and BPA contribute to higher body mass index (BMI) independent of other factors related to high BMI in this population?
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Methods Participants and recruitment Study recruitment began in 2009, using the UCLA Health System tumor registry to identify potentially eligible breast cancer patients diagnosed between 2003 and 2007. Eligibility criteria were: stage 1, 2, or 3 breast cancer diagnosed at age B50 years; currently alive and disease free; [1 year post-initial cancer diagnosis; [6 months after cancer treatment (i.e., completed chemotherapy and/or radiation, but could be receiving endocrine therapy); agreed to complete survey; ability to read and write English; female; provides informed consent. Invitation letters were mailed to potential subjects, who were asked to return a mailed response form indicating their interest in participating. Trained research staff screened potential participants via telephone. Eligible participants were mailed consent forms and questionnaire packets to complete and return in postage paid envelopes, and reminder calls were made to return questionnaires. Non-respondents received a second mailing and additional contact by phone to explain the study and screen for eligibility. The study was approved by the UCLA Institutional Review Board and written consent was obtained from each participant. Measures Demographic and medical characteristics Demographic and medical characteristics were assessed with questions used in prior studies [11, 12] (see Table 1 for all variables). Current chronic conditions were assessed using a checklist of 13 conditions. Current height (in feet and inches) as well as current weight and weight (lbs) at diagnosis were assessed via self-report. BMI was calculated in kg/m2. Menstrual history was measured via a series of questions used previously [11]. Quality of life and symptoms Depressive symptoms over the last week were assessed using the Center for Epidemiologic Studies Depression (CES-D) Scale [13]. Perceived stress over the last month was measured with the Perceived Stress Scale (PSS) 10-item version [14]. An 8-item version of the MOS social support survey [15] was used to assess social support. Fatigue severity over the past week was measured with the Fatigue Symptom Inventory (FSI), which was developed for and validated in cancer patients [16–18]. Health-related quality of life (HRQL) over the past month was assessed with the MOS 12-Item Health Survey Short Form (SF-
47.6 (5.6)
Age (years)
109 (67.3 %)
Has children (percent yes)
47 (29.0 %) 24 (14.8 %)
4-year college graduate
Some graduate school
28 (17.3 %) 31 (19.1 %) 17 (10.5 %)
Part-time
Full-time homemaker, full- or part-time volunteer, student, or retired
Unemployed, on temporary medical leave, or permanently disabled
Total sample n = 162 64.8 (2.8) 151.0 (38.3) 25.1 (5.5)
Height (inches) Current weight (lbs)
Current BMI
74 (47.1 %)
Over $100,000
Medical characteristics
27 (17.2 %) 56 (35.7 %)
Under $60,000 $60,001–$100,000
Total family income (n = 157)
86 (53.1 %)
Full-time
41 (25.3 %)
41 (25.3 %)
Some college or AA
Completed graduate school Current employment status
9 (5.6 %)
High school grad, GED, or vocational or training school
Educational attainment (n = 162)
24 (14.8 %)
Lives alone (percent yes)
Married/living as married versus single/ divorced
Marital status 122 (75.3 %)
2 (2.0 %)
3 (1.9 %)
Asian
Other
15 (15.2 %)
9 (5.6 %) 23 (14.2 %)
Black, non-Hispanic
64.5 (2.9) 161.7 (47.7) 27.0b (6.6)
24.0b,c (4.3)
High barriers PA, low barriers HE (n = 29)
11 (37.9 %)
4 (13.8 %) 14 (48.3 %)
3 (10.3 %)
6 (20.7 %)
4 (13.8 %)
16 (55.2 %)
7 (24.1 %)
5 (17.2 %)
7 (24.1 %)
6 (20.7 %)
4 (13.8 %)
20 (69.0 %)
5 (17.2 %)
22 (75.9 %)
1 (3.4 %)
4 (13.8 %)
3 (10.3 %)
2 (6.9 %)
19 (65.5 %)
47.8 (6.0)
High barriers PA, low barriers HE (n = 29)
64.7 (2.8) 143.3a (30.5)
Low barriers PA, low barriers HE (n = 99)
52 (54.2 %)
17 (17.7 %) 27 (28.1 %)
11 (11.1 %)
19 (19.2 %)
18 (18.2 %)
51 (51.5 %)
26 (26.3 %)
16 (16.2 %)
32 (32.2 %)
23 (23.2 %)
2 (2.0 %)
66 (66.7 %)
12 (12.1 %)
76 (76.8 %)
5 (5.1 %)
7 (6.9 %)
111 (68.5 %) 16 (9.9 %)
Hispanic
70 (70.7 %)
47.9 (5.7)
Low barriers PA, low barriers HE (n = 99)
White, non-Hispanic
Ethnicity (n = 162)
Total sample n = 162
Demographic characteristics
24.5 (4.6)
65.3 (2.6) 149.1 (30.1)
Low barriers PA, high barriers HE (n = 15)
4 (28.6 %)
2 (14.3 %) 8 (57.1 %)
2 (13.3 %)
2 (13.3 %)
1 (6.7 %)
10 (66.7 %)
5 (33.3 %)
–
3 (20.0 %)
6 (40.0 %)
1 (6.7 %)
8 (53.3 %)
4 (26.7 %)
9 (60.0 %)
–
2 (13.3 %)
–
6 (40.0 %)
7 (46.7 %)
46.5 (5.2)
Low barriers PA, high barriers HE (n = 15)
Table 1 Descriptive characteristics of participants by responses to the barriers to healthy eating (HE) and barriers to physical activity (PA) scales
28.6c (7.8)
65.7 (2.2) 176.3a (50.9)
High barriers PA, high barriers HE (n = 19)
7 (38.9 %)
4 (22.2 %) 7 (38.9 %)
1 (5.3 %)
4 (21.1 %)
5 (26.3 %)
9 (47.4 %)
3 (15.8 %)
3 (15.8 %)
5 (26.3 %)
6 (31.6 %)
2 (10.5 %)
15 (78.9 %)
3 (15.8 %)
15 (78.9 %)
–
2 (10.5 %)
1 (5.3 %)
1 (5.3 %)
15 (78.9 %)
46.8 (4.7)
High barriers PA, high barriers HE (n = 19)
0.001
0.39 0.002
p value2
0.24
0.92
0.35
0.47
0.50
0.54
0.07
0.73
p value2
Breast Cancer Res Treat (2013) 142:423–433 425
123
123 24.5 (5.5)
BMI at diagnosis (n = 158)
93 (57.4 %) 4 (2.5 %) 11 (6.8 %) 1.2 (1.1) 3.4 (1.5)
Post Unknown–hysterectomy
Unknown–treatment-related amenorrhea
Count of co-morbidities (0–13, n = 161)
Years since diagnosis
61 (37.9 %)
Lumpectomy only
40 (24.7 %) 15 (9.3 %) 86 (53.1 %) 36 (22.9 %) 98 (60.5 %) Total sample n = 162 14.1 (10.1) 16.7 (6.7) 75.1 (22.5) 73.8 (27.0) 6.3 (2.6) 47.9 (9.6) 47.1 (10.8)
Had chemotherapy only (percent yes)
Had Radiation only (percent yes)
Had both chemotherapy and radiation (percent yes)
Received Herceptin or other biotherapy (percent yes, n = 157)
Currently receiving endocrine therapy
Quality of life and symptoms
CES-D
PSS (n = 161)
MOS emotional social support (n = 162)
MOS instrumental social support (n = 161)
FSI Level of fatigue on the day felt most fatigued during the last week
SF-12 physical component (n = 159)
SF-12 mental component (n = 159) 1.4 (1.3) 0.2 (0.4) 0.5 (0.8)
Hot flashes
Nausea
Bladder control
BCPT symptom scales
21 (13.0 %)
Had neither chemotherapy nor radiation
Chemotherapy and/or radiation
100 (62.1 %)
Mastectomy only
Type of surgery (n = 161)
54 (33.3 %)
Pre
Menopausal status
Total sample n = 162
Medical characteristics
Table 1 continued
15.0 (12.4)
12.2a (8.7)
65.3 (31.8) 6.8 (2.5) 43.6f,h (10.1)
79.7d (23.0) 5.8e (2.7) 49.5f,g (8.7)
0.7 (0.8)
0.4k (0.7)
1.4 (1.2) 0.3 (0.4)
0.2 (0.4)
1.4 (1.3)
49.1 (9.4)
46.2 (13.5)
68.3 (26.1)
79.6c (19.5)
j
17.9 (6.9)
15.2 (6.1)
b
High barriers PA, low barriers HE (n = 29)
19 (65.5 %)
7 (25.0 %)
22 (75.9 %)
2 (6.9 %)
3 (10.3 %)
2 (6.9 %)
15 (51.7 %)
14 (48.3 %)
3.5 (1.5)
1.2 (1.3)
3 (10.3 %)
16 (55.2 %) 2 (6.9 %)
Low barriers PA, low barriers HE (n = 99)
61 (61.6 %)
22 (22.9 %)
46 (46.5 %)
9 (9.1 %)
29 (29.3 %)
15 (15.2 %)
31 (31.3 %)
68 (68.7 %)
3.3 (1.5)
1.1 (0.9)
8 (8.1 %)
60 (60.6 %) –
8 (27.6 %)
26.4d (7.2)
23.4d,e (4.4) 31 (31.3 %)
High barriers PA, low barriers HE (n = 29)
Low barriers PA, low barriers HE (n = 99)
0.7 (1.1)
0.1 (0.2)
1.5 (1.3)
41.2 (9.6)
j
51.7h,i (8.0)
7.0 (2.4)
65.8 (27.3)
71.3 (22.6)
19.5 (7.0)
18.3 (11.9)
Low barriers PA, high barriers HE (n = 15)
8 (53.3 %)
3 (21.4 %)
5 (33.3 %)
3 (20.0 %)
5 (33.3 %)
2 (13.3 %)
7 (50.0 %)
7 (50.0 %)
3.1 (1.5)
0.9 (0.9)
–
4 (26.7 %) 1 (6.7 %)
10 (66.7 %)
24.5 (4.7)
Low barriers PA, high barriers HE (n = 15)
1.0k (1.0)
0.3 (0.5)
1.4 (1.1)
42.8 (11.6)
43.0g,i (10.9)
7.6e (1.7)
62.5d (31.7)
64.8c (26.1)
20.7b (7.2)
19.5a (9.4)
High barriers PA, high barriers HE (n = 19)
10 (52.6 %)
4 (21.1 %)
13 (68.4 %)
1 (5.3 %)
3 (15.8 %)
2 (10.5 %)
8 (42.1 %)
11 (57.9 %)
3.7 (1.4)
1.8 (1.7)
–
13 (68.4 %) 1 (5.3 %)
5 (26.3 %)
28.1e (6.9)
High barriers PA, high barriers HE (n = 19)
0.003
0.53
1.0
0.01
0.001
0.01
0.006
0.01
0.002
0.008
p value
0.76
0.99
0.14
0.16
0.57
0.07
0.031
0.002
p value2
426 Breast Cancer Res Treat (2013) 142:423–433
427
12)[19] yielding two subscales: physical component summary (PCS) and mental component summary (MCS), with normative data available for the general population, and individuals with chronic conditions. These scales have been widely used in studies of BCS [3, 8, 11, 12]. Breast cancer-related symptoms were measured with the Breast Cancer Prevention Trial (BCPT) symptom scales [20].
Analysis of variance (ANOVA) used to compare participants by barrier quadrants for continuous variables and Chi square tests for categorical variables 2
1
For menopausal status, the low PA/high HE group differs significantly from all three other groups
Barriers to physical activity and healthy eating
p \ 0.05 was deemed statistically significant and is shown in bold
Superscripts a–n indicate pairs which differ significantly. Barrier groups were created based on mean responses to each of the two scales. Participants were considered to have low barriers for each of the scales if they reported a mean response of less than 2.5 and to have high barriers if they reported a mean response of 2.5 or higher. Both BHE and BPA scale response options ranged from 1 to 5 with 1 representing ‘‘never’’ and 5 representing ‘‘very often.’’ Additional scale and item descriptions: Currently receiving endocrine therapy: e.g., Tamoxifen, Femara, Aromasin, Arimidex, Lupron, or Zoladex (percent yes); Depression: Center for Epidemiologic Studies Depression Scale, (CES-D), higher = more depressed); Stress: Perceived Stress Scale, (PSS), higher = more perceived stress, n = 161; Social support: MOS emotional social support, higher = more support, n = 162; MOS instrumental social support, higher = more support, n = 161; Well-being: Short Form Health Survey (SF-12): physical component, higher = higher functioning, Short Form Health Survey (SF-12): mental component, higher = higher functioning; Breast cancer-related symptoms, Breast Cancer Prevention Trial Symptom checklist, (BCPT symptom scales), scales range from 0 to 4 with higher indicating greater severity of symptoms
0.002
