Healthy Lifestyle Behaviors Slow Decline in Long-Term Cancer Survivors

Roxanne Nelson

May 13, 2009

May 13, 2009 — Older long-term survivors of colorectal, breast, and prostate cancer might be able to stave off functional decline by changing dietary and physical-activity behaviors. After participating in a home-based tailored program of telephone counseling and mailed materials, cancer survivors experienced modest weight loss and clinically meaningful improvements in physical function and other health-related quality-of-life domains, researchers report in the May 13 issue of the Journal of the American Medical Association.

The mean baseline Short-Form (SF)-36 physical function score was 75.7, but at the 12-month follow-up, the researchers noted that mean function scores declined less rapidly in the intervention group (−2.15; 95% confidence interval [CI], −0.36 to −3.93) than in the control group (−4.84; 95% CI, −3.04 to −6.63; P = .03).

There was a statistically significant difference in basic lower-extremity function between the 2 groups. Function changed negligibly in the intervention group, whereas a decline in function was observed among the controls.

The 5-year survival rates for early-stage colorectal, breast, and prostate cancer are increasing, and currently exceed 90%, but cancer survivors remain at greater risk for second malignancies, chronic diseases, and accelerated functional decline. Even though lifestyle interventions might reduce the risk for disease and functional decline, the authors note, many older cancer survivors report poor lifestyle behaviors, and few meet the recommendations in health-promotion guidelines. Their dietary and physical-activity behaviors are frequently suboptimal, even though most patients are nonsmokers.

Older Adults Not Targeted

There is great interest in exercise- and diet-related approaches among cancer survivors, but the majority of these interventions for cancer patients have targeted younger individuals, those undergoing treatment, and those with recent diagnoses, the authors write. However, older adults are an important group because cancer and its treatment are associated with accelerated functional decline, and maintaining mobility and functional independence in at-risk older individuals has been established by the Centers for Medicare & Medicaid as the sole priority in aging research.

"Older adults are just as motivated as younger adults," said lead author Miriam C. Morey, PhD, associate professor of medicine at Duke University School of Medicine in Durham, North Carolina. "I believe any nonacute-care visit is an appropriate time to approach cancer survivors about practicing healthier lifestyles."

But reaching out to long-term survivors can be challenging, explained Dr. Morey, because many long-term cancer survivors are no longer under the care of their oncologists.

"The primary-care setting might be a more ideal setting [to approach patients] — one in which primary-care providers serve as the referral source for potential participants who stand to benefit from this type of intervention," she told Medscape Oncology. "We need to find ways to improve provision of lifestyle changes in standard primary care or, alternatively, to develop methods of facilitating self-enrollment, perhaps over the Internet, for programs providing ongoing lifestyle-modification programs."

Thus far, it has been unclear whether long-term cancer survivors could modify their lifestyle behaviors sufficiently to improve functional status. Dr. Morey and colleagues evaluated whether a telephone counseling and mailed print-material-based diet and exercise intervention would be effective in reducing functional decline in older overweight cancer survivors.

Improvement Seen in All Measures

Reach Out to Enhance Wellness (RENEW) is a randomized controlled trial that evaluated the efficacy of a home-based diet and exercise intervention aimed at reorienting the functional trajectory of older long-term survivors of breast, prostate, and colorectal cancer. Included in this cohort were 641 overweight (body mass index, ≥25 and <40 kg/cm2) individuals who were diagnosed with cancer at least 5 years previously, who were 65 years or older at enrollment, and who had no evidence of progressive disease or secondary cancers. Trial recruitment took place from July 1, 2005 to May 17, 2007.

The intervention consisted of a personally tailored workbook and a series of quarterly newsletters, combined with 15 telephone counseling sessions and 8 automated prompts over the course of 12 months. The control group received no intervention during the same time period.

In addition to changes in physical function as measured by the SF-36, the researchers observed significant differences between the intervention and control groups for all targeted behaviors except endurance-exercise frequency. Duration of strength-training exercise increased in the intervention group and remained stable in the control group (mean, 18.7 vs 2.7 minutes per week, respectively), and the duration of endurance exercise also increased for the intervention group (mean 36.3 vs. 23.4 minutes per week). The average intake of fruits and vegetables increased by 1.24 daily servings in the intervention group and by 0.13 daily servings in the control group.

Individuals in the intervention group decreased their daily consumption of saturated fat by 3.06 g, compared with 1.07 g in the control group. An average weight loss of 4.5 pounds was also reported by participants in the intervention group, which is more than double the 2.03-pound weight loss in the control group.

The researchers reported that overall health-related quality of life decreased on every subscale among participants in the control group during the study period, whereas decreases in subscale scores were of lower magnitude and were sustained for overall health and mental health in the intervention group.

"Future studies should not only assess the effect on health and well-being, but also should address cost-related outcomes, especially given that the economic burden associated with functional decline and loss of independence is exceedingly high," they conclude.

Dr. Morey explained that as they work on the next step of their research, their first priority is to try to reduce the costs of the counseling program. "We plan to test a similar intervention that is initially based on mailed materials, with telephone counseling for those who need additional support," she said. "This will reduce costs and enhance generalizability."

The study was funded by the National Institutes of Health and a grant from the Veterans Affairs Research and Development. The researchers have disclosed no relevant financial relationships.

JAMA. 2009;301:1883-1891.

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