Cancer Survivorship Endometrial Cancer: Quality of Life, Physical - - PDF document

4/22/2014 1

Endometrial Cancer: Quality of Life, Physical Activity and Diet

Vivian von Gruenigen, MD Professor and Chair Summa Health System NEOMED

Cancer Survivorship

NCI website

Are Endometrial Cancer Survivors following the same trend?

Obesity and Mortality from Cancer

• Increased body weight was associated with

increase death rates in cancer patients.

• Endometrial cancer patients had the highest

risk of death risk of death

• However, most endometrial cancer patients

present in Stage I disease and are “cured”

» Calle EE. N Engl J Med 2003

Mortality from Cancer According to BMI for U.S. Women.

Gallbladder Esophagus Pancreas Cervix Kidney Uterus C a n c e r 1 2 3 4 5 6 7 MM Colorectal Ovary Liver NHL Breast T y p e

• f

C Relative Risk of Death

Sentinel Event?

Calle EE. N Engl J Med 2003

Endometrial cancer patients are getting

larger

• Prior reviews in the 1970’s found that ~ 30%
• f patients with endometrial cancer were
• bese.

» Anderson BA et al. Am J Obstet Gynecol 1996 y

• Recent research reveals that ~70% of women

were obese.

» von Gruenigen VE et al. J Cancer Integ Med 2005 » Fader AN et al. Gynecol Oncol 2009

Ward KK et al. Gynecol Oncol 2012

4/22/2014 2

80% 100%

GOG #99 Ancillary: Health Obesity Disparities

0% 20% 40% 60% Non-Black Black All Patients <25 25- 30- 35- 40+

BMI Figure 1. BMI Distribution in Endometrial Patients Von Gruenigen et al. Cancer 2006

QOL, Obesity and Endometrial Cancer

• Obesity is associated with poorer QOL in

endometrial cancer survivors

• BMI is inversely associated with physical and

functional well being functional well-being

• Endometrial cancer survivors’ obesity AND

inactivity contributes to poorer QOL

» Smits A et al., Gynecol Oncol 2012 » Basen-Engquist K., Am J Obstet Gynecol 2009

QOL, BMI, Exercise

125 130 135 140 145 150 155 160

FACT-An Scores 120 125 130 135 140 145 150 155 160 FACT-An Scores Regular Exercisers Nonregular Exercisers

Courneya et al. Gynecol Oncol 2005

120 NW OW MO SO VSO

QOL and OS

• There are correlations between QOL, Obesity, OS
• There are correlations between QOL, Cancer, OS
• Do Endometrial Cancer Patients with higher QOL

have increased OS?

• Or is it about the weight and/or PA (self-efficacy)?

Lean et al., Arch Intern Med 1999 Quinten C et al., Lancet Oncol 2009 Oldenburg CS et al, Gynecol Oncol 2013

Line-item analysis of FACT-G

Line Item Direction

• f change

p value

Functional Ability to work Fulfillment of work Able to enjoy life Enjoy things I do for fun <.05 <.05 <.05 <.05 j y g Content with QOL right now <.05 Social Closeness to friends Satisfied with family communication <.01 <.01 Physical Lack of energy NS <.01 Fader AN et al., Obstet Gynecol Int 2011

Endometrial Cancer patients are not healthy

• They do not make spontaneously lifestyle

changes

• Only 1% are meeting the 2006 ACS guidelines

for cancer survivors; (150 minutes/week of moderate ; (

/ to vigorous PA, 5 servings fruit/vegetables per day, no smoking)

• Co-morbidity is as important as pathological

features for predicting OS

» Von Gruenigen et al. Obstet Gynecol 2011 » Robbins JR, et al. Gynecol Oncol 2013

4/22/2014 3

Feasibility and effectiveness of a lifestyle intervention program in obese endometrial cancer patients: A randomized trial

von Gruenigen VE, Gynecol Oncol 2008

Social Cognitive Theory: Self-Efficacy

• Self-efficacy is a mental factor that plays a role

in weight loss and weight management

• It is defined as an individual’s belief in his or her

ability to perform and succeed in challenging i i situations

• Self-efficacy has been connected with positive

health related decisions

Shin H, Shin J, Liu PY, et al. Nutr Res. 2011 Bandura A. Psych Rev 1977 Byrne, S. J Psychosom Res. 2002 Grembowski D, Patrick D, Diehr P. J Health Soc Behav. 1993

Group Sessions

Month 1 July 2005 Weight loss goal setting Physical activity Increase F&V intake Month 2 August Increase whole grain & dairy intake Dealing with barriers; negative thinking Behavior modification Grocery shopping / Nutrition facts, labels Month 3 September Relapse prevention Month 4 October Eating out;social issues Month 5 Nov Stress Management Month 6 Dec Review of topics

Effects of Weight Loss on Eating Assessments

Variables Baseline 3 mos 6 mos 12 mos Time x Grou p P* Weight self-efficacy Total (0-180) Weight losers Weight gainers 107 (37) 114 (36) 134 (36) 127(34) 135 (34) 117(34) 138 (34) 123 (31) <0.01 Three-factor eating Three factor eating Restraint (0-21) Weight losers Weight gainers Disinhibition (0-16) Weight losers Weight gainers Hunger (0-14) Weight losers Weight gainers 10 (5) 10 (5) 8 (3) 8 (4) 6 (4) 5 (3)

• 13 (4)

10 (5) 7 (3) 8 (4) 5 (3) 5 (3) 0.01 0.05 0.36

Data are presented as the mean (standard deviation). * p value for repeated measures ANOVA or independent samples t-test (eating inventory)l

Exercise Improvement

25 30 35 40 45 ETS) Intervention 5 10 15 20 25 Baseline 3 mos 6 mos 12 mos LSI (ME Intervention Control + 16.4 METS/wk

• 1.3

Weight Loss

1 2 3 4 5 ge (kg)

• 5
• 4
• 3
• 2
• 1

1 Baseline 3 mos 6 mos 12 mos Weight chang Intervention Control

• 3.5 kg

+1.4

4/22/2014 4

Survivors of Uterine Cancer Empowered by Exercise and healthy Diet

Von Gruenigen VE et al. Gynecol Oncol 2012

Results

• Adherence was 84%
• Mean difference in PA minutes between groups

at 6 months was 100, p=0.03 and at 12 months was 89, p=0.02.

• Mean difference in kilocalories consumed was -

217.8 (p<0.001) at 6 months and -187.2 (p<0.001) at 12 months.

• Mean [95% CI] difference in fruit and vegetable

servings was 0.91 servings/day at 6 months and 0.92 at 12 months (p<0.001).

21 22

30% achieved 5% weight loss

Lifestyle and Mobile Technology

• During recent years, mobile phones have

become the major conduit for communication and information

• According to PEW the types of health apps
• According to PEW, the types of health apps

used on smartphones are dominated by exercise, diet, and weight-loss apps

• More accurate self-logging
• Personalized messages

 4 weeks: ancillary active, healthcare-provider interface  Encouraging exercise and nutritional guidance

Novel exercise, weight-loss, and dietary approaches in

• verweight endometrial and breast cancer survivors

(NEWDAY)

PROVIDER INTERVENTION Physician Minimum weekly contact via email, social media, or phone Registered Dietician Nutritional Analysis and Support Research Assistants Emotional support, technical trouble- shooting

4/22/2014 5

25

Conclusions

• We do not have 5-year lifestyle outcomes in

endometrial cancer patients

• This population has health disparities

Lif l i i i l i hi i

• Lifestyle intervention trials in this patient

population are feasible and necessary

Safety in Teams

• Thanks to team at University Hospital of

Cleveland and Summa Health System

• Special thanks to Heidi Frasure and Dr.

Michele McCarroll Michele McCarroll