Women with a history of breast cancer constitute the largest group of female cancer survivors, accounting for approximately 22% of all cancer survivors. As the number of breast cancer survivors continues to grow, it is crucial to identify modifiable factors associated with breast cancer recurrence and survival, and to fully understand optimum methods for risk reduction. This information will likely come from a variety of sources but should include well-designed, high-quality randomized trials and observational studies with adequate statistical power – an example is the Pathways study, a prospective study of breast cancer survivorship, which is expecting to enroll 3000 patients within 2 months of diagnosis to reduce the effect of survival-bias. Recruiting women with late-stage disease, who frequently have different physical and emotional needs than early-stage patients, will provide much-needed information for patients with metastasis. Comprehensive clinical programs with research components, such as the Clinical Breast Care Project, a breast cancer research program based at Walter Reed National Military Medical Center (MD, USA), which includes a state-of-the-art comprehensive breast cancer center and research capabilities are vital for examining environmental factors associated with prognosis. Culturally appropriate intervention programs are needed to examine cultural factors that influence behavior modification and ethnic differences in clinical care among survivors from diverse ethnic and socioeconomic backgrounds.
Specific issues of highest priority that need to be resolved over the next 5 years are:
Who would benefit most from, and thus should participate in, behavioral modification programs? For example, women of advanced age with significant comorbidities or metastatic disease may be unable to participate in certain activity routines or reluctant to adopt new dietary habits;
Whether an optimum combination of lifestyle choices can be determined on an individual patient basis that provides survival and QoL benefits that are superior to a standardized approach;
Healthy lifestyle programs need to be developed for a diverse population of breast cancer survivors that have wider adaptability than those presently available;
Evolution of primary care: medical providers should not discount CAM approaches, given that a majority of patients believe that these alternative therapies improve their QoL. Physicians should be powerful catalysts for promoting behavior change in their patients because they are optimally positioned to deliver guidance regarding health promotion;
Do interactions between molecular factors and behaviors influence breast cancer recurrence and survival? Identifying genetic variation that may enhance or inhibit responses to lifestyle intervention would add an additional level of personalization to patient care.
Finally, despite the potential benefits of a healthy diet, regular physical activity and stress management, relatively few breast cancer survivors meet commonly prescribed dietary and physical activity guidelines. Research has shown that age and ethnic differences influence the likelihood that survivors will adopt healthy lifestyle behaviors, and patients may not fully adhere over the longer-term to self-directed interventions and may miss potential health benefits. To successfully integrate and sustain healthy behaviors in their daily lives, breast cancer patients must overcome a number of barriers, including ongoing challenges of self-motivation, accessibility to health resources and cost.
Overcoming these barriers will require an infrastructure that includes integration of lifestyle modalities into clinical care (short term) and active community-based programs in both urban and rural settings for longer-term adherence. Further research may allow us to better understand the psychology of self-motivation and adherence in order to optimize mechanisms that mediate successful behavioral change.[138,139] Comprehensive programs such as the STEP program, provided as an adjunct to clinical care, which empower patients to make healthy choices in their daily lives and monitor progress over the long term, are also needed to achieve optimal health and QoL. Adaptations of cardiac rehabilitation models may provide the necessary framework to maximize adherence to dietary and physical activity guidelines. In addition, new paradigms are needed to defray out-of-pocket expenses for implementing healthy lifestyles, such as gym memberships, yoga classes, exercise physiologists and dietician consultations, which may be prohibitive to many breast cancer survivors.[141,142]
Expert Rev Pharmacoeconomics Outcomes Res. 2012;12(4):451-464. © 2012 Expert Reviews Ltd.