Keep on exercising, researchers advise older breast cancer survivors

One year of exercise can ensure steady maintenance of bone density to help prevent fractures

To build and maintain muscle strength, it is best for older breast cancer survivors to follow an ongoing exercise program of resistance and impact training. This advice comes from Jessica Dobek of the Oregon Health and Science University, lead author of a study published in Springer’s Journal of Cancer Survivorship. Dobek is part of a research team, headed by Dr. Kerri Winters-Stone, that found that the bone benefit from one year of such training could be maintained, even with less exercise, up to a year later, which could help prevent bone fractures in the long run.

Older women form the largest group of breast cancer survivors. They face many challenges in maintaining a healthy body composition and optimal physical functioning due to the combined effects of cancer treatment, ageing and reduced physical activity. Cancer treatment is associated with loss of bone density, loss of lean body mass and increases in body fat. The associated changes in body composition place older breast cancer survivors at higher risk of obesity-related disease, breast cancer recurrence, frailty and fractures.

Exercise is one way in which to combat the side effects and long-term effects of cancer treatment. In previous research, Dobek and Winters-Stone found that a one-year-long exercise regimen of resistance and impact training helped build muscle strength and stopped bone loss among a group of breast cancer survivors. As they wanted to determine if these benefits continued or were reversed after completing the intervention, follow-up assessments were done one year later on 44 women who were part of the original study. Their bone mineral density of the hip and spine, muscle mass, fat mass and maximal upper and lower body strength were measured.

Their follow-up study is the first to report on long-term changes in body composition and muscle strength in older breast cancer survivors who had previously participated in a supervised resistance and impact training intervention trial.

They found that spine bone mineral density can be preserved in older breast cancer survivors even after formal exercise training stops. Some women continued to engage in exercise, albeit at a lower level, in the year after formal training stopped while others stopped exercising altogether. The sustained prevention of bone loss through moderate levels of exercise might translate to fewer fractures in later life. On the other hand, the findings also show that muscle strength declined more quickly than bone density and may require continued participation in a supervised exercise program where the degree of effort can be sustained at a higher level.

“Exercise programs aimed at improving musculoskeletal health should be considered in the long-term care plan for breast cancer survivors,” advises Dobek. “Though further work is needed, our results may provide a beginning knowledge about the type, volume and length of exercise training needed to preserve bone health among long-term cancer survivors at risk of fracture.”

Dobek et al., (2013). Musculoskeletal changes after 1 year of exercise in older breast cancer survivors, Journal of Cancer Survivorship. DOI 10.1007/s11764-013-0313-7 [Abstract]

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Menopause symptoms worse in cancer survivors

Cancer survivors were twice as likely to experience severe menopausal symptoms compared to women who have not had cancer, a new Australian study has found.

The study ( published in Menopause, the Journal of the North American Menopause Society) was led by the University of Melbourne and the Royal Women’s Hospital Melbourne, with the King Edward Memorial Hospital and the University of Western Australia.

Lead author, Dr Jennifer Marino of the University of Melbourne and the Royal Women’s Hospital said the study was the biggest of its kind to assess the impact of menopausal symptoms on the quality of life of cancer survivors.

“Our study showed for the first time, that cancer survivors experienced more severe and frequent menopausal symptoms (such as hot flushes and night sweats) than patients who did not have cancer,” Dr Marino said.

More than 151,000 (around one in 25) women in Australia are cancer survivors with more than one third of those are breast cancer survivors.

Almost 1,000 cancer survivors (mostly breast cancer) and 155 non-cancer patients aged 40 to 60, who attended the Menopause Symptoms After Cancer Clinic at the King Edward Memorial Hospital in Western Australia, were surveyed to determine a range of factors including severity of menopausal symptoms, impact on quality of life and sexual function.

Cancer survivors had twice as many hot flushes (six compared with three in 24 hours) and were twice as likely to report severe or very severe flushes as non-cancer patients. More than 200 cancer survivors reported experiencing more than 10 flushes a day.

Interestingly, the mental health of cancer survivors appeared to be better than the non-cancer patients.

“The study revealed the cancer survivors were less troubled by symptoms of anxiety and depression than women attending the menopause service who had never had cancer,” Dr Marino said.

Senior author Professor Martha Hickey said menopausal symptoms were a frequent and distressing effect of cancer treatments in women.

“In women with hormone sensitive cancer such as breast cancer, effective treatments reduce estrogen levels and this commonly leads to menopausal symptoms,” she said.

Co-author Professor Christobel Saunders, Deputy Head of the University of Western Australia School of Surgery, said the findings were significant in providing an improved understanding of the nature and impact of menopause on cancer survivors while also highlighting the need for better support services for menopausal women without cancer.

Marino et al., (2013). Nature and severity of menopausal symptoms and their impact on quality of life and sexual function in cancer survivors compared with women without a cancer history. Menopause, EPub Ahead of Print doi:10.1097/GME.0b013e3182976f46 [Abstract]

Racial disparities in health care among older male cancer survivors

Older African-American and Hispanic men who have survived cancer are less likely than their white counterparts to see a specialist or receive basic preventive care, such as vaccinations, according to new research from Wake Forest Baptist Medical Center.

Researchers examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors. They found that disparities are evident among older, but not younger, cancer survivors, despite their access to Medicare.

Lead author Nynikka Palmer, Dr.P.H., a postdoctoral fellow at Wake Forest Baptist, said they identified 2,714 men 18 and older from the 2006-2010 National Health Interview Survey who reported a history of cancer. The researchers looked at health care receipt in four self-reported measures: primary care visit, specialist visit, flu vaccination and pneumonia vaccination.

“Overall, our results suggest that older minority male cancer survivors may need specific support to ensure they receive necessary post-treatment care,” Palmer said.

The study was recently published online ahead of print in the American Journal of Public Health.

Even when the researchers adjusted for factors that contribute to disparities, such as education and health insurance, they found that African American and Hispanic male cancer survivors 65 years and older may not be receiving appropriate follow-up care and preventive care. Palmer said this is a concern “because regular follow-up care is important to monitor for recurrence, new cancers, and late and long-term effects of cancer and its treatment, particularly for those with more co-morbidities.”

Overall, among older survivors, approximately 39 percent of African-Americans and 42 percent of Hispanics did not see a specialist, compared with 26 percent of older non-Hispanic whites. Likewise, about 40 percent of African-American and Hispanic cancer survivors did not receive the flu vaccination, compared with 22 percent of non-Hispanic white cancer survivors.

Similarly, 51 percent of African-Americans and 59 percent of Hispanic cancer survivors did not report receiving the pneumonia vaccine, compared with 29 percent of non-Hispanic whites.

“These findings are consistent with other reports of health care use among cancer survivors and suggest there may be differences in types of Medicare health plans, supplemental insurance and out-of-pocket costs among older survivors that could be contributing to this disparity,” Palmer said.

Palmer said further study is needed to identify other factors that may influence racial/ethnic disparities among male survivors, such as patients’ beliefs about care after cancer and patient-provider communication.

Palmer et al., (2013). Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors. Am. J. Public Health103: 1306-1313 [Abstract]

Study finds strong pregnancy outcomes for survivors of childhood cancer

Although women who survived childhood cancer face an increased risk of infertility, nearly two-thirds of those who tried unsuccessfully to become pregnant for at least a year eventually conceived, according to clinical researchers at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Brigham and Women’s Hospital. This is comparable to the rate of eventual pregnancy among all clinically infertile women.

“Most women think that if they had cancer as a child, then they’ll never have children. It turns out that many of them can get pregnant. It just might be a little harder,” said senior author Lisa Diller, MD, chief medical officer of Dana-Farber/Boston Children’s and medical director of the David B. Perini, Jr. Quality of Life Clinic at Dana-Farber Cancer Institute.

The paper, published July 13 in Lancet Oncology, is the first large-scale study of female childhood cancer survivors that examines outcomes for those who experienced infertility, as defined by the typical clinical definition of infertility (attempting to conceive for a year or more without success).

Overall, 15.9 percent of women who survived childhood cancer were affected by infertility, with 12.9 percent trying to conceive for at least one year without success. The remainder of survivors included in the infertile group had ovarian failure and may not have even attempted pregnancy. In a comparison group comprised of sisters of childhood cancer survivors, 10.8 percent experienced infertility. This translates to a roughly 50 percent higher risk of infertility among the survivors of childhood cancer.

The new study is based on data from the Childhood Cancer Survivor Study, a cohort study of five-year survivors from 26 institutions who were under 21 when diagnosed with cancer between 1970 and 1986. Researchers studied 3,531 sexually active female survivors, age 18-39, and a control group of 1,366 female siblings of participants in the large-scale survivor study.

“This is the first study to examine direct questions about infertility and the use of infertility services,” said lead author Sara Barton, MD, a clinical fellow of reproduction and infertility at Brigham and Women’s Hospital at the time of the research. “Previous studies used surrogate markers. Parenthood. Pregnancy. Births. These don’t take into account people’s intent. They don’t take into account how long it took to achieve pregnancy.”

Among survivors of childhood cancer who had been trying unsuccessfully to get pregnant for at least a year, 64 percent conceived after, on average, another six months, compared with an average of five months for clinically infertile women in the control group who eventually conceived.

Women whose cancer was treated with alkylating agent chemotherapy or high-dose radiation to the abdomen or pelvis were most at risk of infertility. Although pediatric oncologists have changed a number of treatment protocols over the last several decades to reduce late effects, alkylating agents and radiation continue to be used.

“Women getting alkylating agents or radiation to the pelvis or abdomen should be triaged for fertility preservation. In addition to being at highest risk to report infertility, female cancer survivors who received those cancer therapies were the least likely to conceive once they had infertility,” said Barton, who is now a staff physician at the Heartland Center for Reproductive Medicine and clinical professor at the University of Nebraska Medical School. The new research, she added, will help clinicians offer guidance to current patients based on the treatment protocol for their cancer. “If you’re newly diagnosed with Hodgkin’s lymphoma, for instance, you may be slightly more likely to experience infertility, but I don’t necessarily think you need to delay your therapy to freeze your eggs.”

The researchers also found that only 42 percent of cancer survivors who sought treatment for infertility were prescribed medication, compared with 75 percent in the control group. Both groups – 69 percent of survivors and 73 percent in the control group – were similarly likely to seek medical help for their infertility.

Prior research has found that survivors of childhood cancer face a greater risk of infertility but, once pregnant, are not at greater risk for miscarriage or stillbirth.

“What we found delivers a really nice message to clinicians,” Diller said. “If you have a patient who is a childhood cancer survivor and is self-reporting clinical infertility, the chances are good that she will become pregnant. Women who have a history of childhood cancer treatment should consider themselves likely to be fertile. However, it might be important to see an expert sooner rather than later if a desired pregnancy doesn’t happen within the first six months.”

Barton et al., (2013). Infertility, infertility treatment, and achievement of pregnancy in female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study cohort. The Lancet Oncol., DOI: 10.1016/S1470-2045(13)70251-1 [Abstract]