Health Behaviours and Cancer Survivorship

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Literature reviews

Cancer is a group of more than 100 diseases which begins when cells change abnormally and multiply over and over without control and crowd out normal cells. This cause a growth called a tumor. Cancer, sometimes, also spread into or invades nearby tissues from a place where it is started, and this is called secondary tumor or metastasis (IARC, 2014)

Cancer is one of the leading cause of morbidity and mortality worldwide. In 2012,  approximately 14 million new cases was reported, and this number expected to increase by 3/4 in the next 2 decades (WHO, 2017).

Globally, it is the second leading cause of death and responsible for 8.8 million deaths in 2015.  This indicating that 1 in 6 deaths is due to cancer. Lung, liver, colorectal, stomach and breast cancers are the most common cancer type in prevalence, and also for the cause of cancer deaths globally (IARC, 2014). Likewise, it is a major cause of illness and death in Australia. In 2014 alone, cancer accounted for about 3 of every 10 deaths and in 2017, the estimated number of people who will die from cancer will be 47,753, which means an average of 131 deaths each day. The number of new cancer cases also increased from 124,465 in 2013 to estimated number of 134,174 in 2017 (AIHW, 2017).

Risk factors for cancer

It is usually hard to identify the exact cause of cancer and distinguish why someone develops cancer and another doesn’t.  But, for the last few decades, various research has been done in this area and shown that certain risk factors may increase or decrease the chance of developing certain cancer (IARC, 2014)

It is now established that cancer is principally caused by environmental factors, of which the most important are tobacco; diet and factors related to diet, including body mass and physical activity; and exposures in the workplace and elsewhere. There are also other endogenous factors whereby a person cannot control over, such as age and family history (WCRF/AICR, 2007).

Cancer survivorship

The definition of “cancer survivor” by itself has some controversy among health professional, people with cancer history and the public as well. Thus, it is important to clear out the definition that will be used in this document. Many people considered a person to be “cancer survivor” just starts from the moment when a person diagnosed with a certain type of cancer and onward, others might also define from the moment that a person has finished his/her initial cancer treatment (Denlinger et al., 2014)

Though over the last few decades various definition has been proposed, the most commonly used in cancer survivorship literature and the definition used in a report by World Cancer Research Fund  and American Institute for Cancer Research (WCRF/AICR) will be used in this document; “The term ‘cancer survivors’ denotes all people who are living with a diagnosis of cancer, and those who have recovered from the disease. In this definition, then, cancer survival begins at the point of diagnosis”. Thus, cancer survivor includes the following population group; i) after diagnosis and before treatment ii) during treatment iii) after treatment and iv) people with secondary cancer or cancer of a different site (WCRF/AICR, 2007).

As the definition of cancer survivor includes everyone from the moment of diagnosis, it can be also considered in continuum and broken down into different stages. Figure 1 presents cancer survivorship in overall health care for cancer control and prevention over time, which is called cancer control continuum.

Due to the result of advancements in the understanding of cancer biology, a remarkable progress has been achieved in cancer prevention and treatment and therefore contributes to the growing trend of cancer survivors over the past few decades. Demographic transition towards an aging population joined with increase of life expectancy also contributed further to this trend (Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005)

A report from Australian Institute of Health and Welfare (AIHW) indicated that the overall five years survival from all cancer combined has been increased over time, from 48% in 1984–1988 to 68% in 2009–2013. At the end of 2012, there was a total of 106,340 and 410,530 people living who had been diagnosed with cancer in the previous one and five years respectively. This represents 1.8% of the Australian population (AIHW, 2017).

Cancer diagnosis and its consequences


Diagnosed with a certain type of cancer have been associated with various consequences to the survivors during and after treatment. They are often reported struggling to balance their lives and wellbeing, and having difficulties to make major decisions in their life due to the cancer experience. Cancer survivors are often in need of personal and emotion support from their family and relatives during the entire duration of survivorship, thus the consequences are not only to a person with cancer, but also families and relatives affected with various socioeconomic burdens.

In recent years, given the fact in advancements of cancer treatment and care that extends the life expectancy of cancer survivors, quality of life among cancer survivor has got the interest of researcher to understand the consequences of cancer on their wellbeing and way of life after treatment. Also, interventions tailored to improve the overall quality of life during cancer survivorship has increasingly become important and let the survivors enjoy their life during the cancer experience. A quality of life (QoL) is a term used to describe the overall wellbeing of an individual in various dimensions, thus researchers often used this term to assess the consequence of cancer diagnosis on survivors. This section presents a short review on the three important dimensions of cancer consequences: psychological, socioeconomic and physical that determine their quality of life (Figure 2).

It’s well recognized that life threatening health events such as cancer are usually stressful and traumatic so that could trigger various psychological distresses (McBride, Clipp, Peterson, Lipkus, & Demark-Wahnefried, 2000). Of the psychological concerns for cancer survivors, fear of recurrence after having treatment (also known as Damocles syndrome), fear of pain, metastasis (secondary cancer) and death, and have been worried about future uncertainties that lie ahead are mostly reported. These cancer-specific distressing conditions are usually creating change on their psychological well-being and often manifested by anxiety, mood shift and depression during and right after diagnosis and treatment (Ferrell & Hassey Dow, 1997; Inhestern et al., 2017). Moreover, individuals with cancer perhaps develop a mental disorder because of cancer or late effect of the treatment (Maria Hewitt, 2006).

Many studies have showed that anxiety and psychiatric distress are generally higher in cancer survivors as compared to the general population (Hinz et al., 2010; Inhestern et al., 2017; Korfage, Essink-Bot, Janssens, Schroder, & de Koning, 2006; Linden, Vodermaier, Mackenzie, & Greig, 2012). In these studies, using Hospital Anxiety and Depression Scale (HADS), significant proportion of cancer survivors were found to be anxious (40% of the survivors) and depressed (20% of the survivors) (Inhestern et al., 2017), the risk of psychiatric distress was almost double that of the general population (Hinz et al., 2010) and clinical and subclinical anxiety observed more than 50% of cancer survivors (Linden et al., 2012). There are, however, some exceptions like the Danish (Osborne, Elsworth, Sprangers, Oort, & Hopper, 2004) and Australian (Groenvold et al., 1999) studies that showed a lower anxiety and depression score among breast cancer survivors.

A review paper by Agency for Healthcare Research and Quality (AHRQ) has indicated that major depression and depressive symptoms have occurred frequently in patients with cancer and the prevalence rate also ranged from 10-25 percent for major depressive disorders and depressive symptoms. The rate could also higher at least fourfold than in the general population (Carr D, 2002). Massie also reported a range of 0-38% for major depression and 0-58% for depression spectrum syndrome (Massie, 2004). Significant variations have been observed among estimates, and this might be attributable to several factors such as conceptualizations and definition of depression, methodological and population variations. Gender, age, and cancer type could also attribute for this possible variation as well.

Some studies showed that the depression and anxiety level have been decreased over the cancer control continuum, with high level of depression in early phase of cancer diagnosis (Burgess et al., 2005; H. R. Smith, 2015), but for some survivor the depression level has been persistent for long period (Stein, Syrjala, & Andrykowski, 2008). In a five-year observational cohort study in breast cancer survivors, found that relatively high level of depression and anxiety (33%) has been observed in the first year of after diagnosis, but the depression level decreased after three and five years of diagnosis to 25% and 15% respectively (Burgess et al., 2005). Studies also revealed that social support and family functioning (Hinz et al., 2010; Inhestern et al., 2017) and being in young age (Hinz et al., 2010; Mehnert & Koch, 2008) were inversely associated with anxiety and depression in cancer survivors.

Socioeconomic issues such as financial concerns related to direct costs of cancer treatment, access to health insurance, affection and relationship with loved one and families, anxiety to return to work, and worried about their work fitness after treatment have become a great concern for survivors, and families following diagnosis to a certain cancer (Carr D, 2002; Linda Sharp, 2010).

In recent years, there is a growing understanding that the substantial financial impact of cancer on newly diagnosed patients, survivors, and to their family. These financial burdens might be related to direct or out-of-pocket cost related to the treatment (e.g. doctors’ fees, travel costs to and from health care center, medication and drugs costs), and indirect expenses because of cancer (e.g. new clothes due to weight change, food and nutrient supplements as a result chemotherapy, and home or childcare) (Linda Sharp, 2010; Longo, Fitch, Deber, & Williams, 2006). Most cancer patients who are working at the time of their diagnosis experience a drop in income, mainly among self-employed workers (Linda Sharp, 2010). Pieces of evidence suggest that there are income-related disparities in the QOL of cancer survivors, with high-income survivors are not only more likely to survive cancer, but they enjoy better quality of life as survivors (Carr D, 2002)

Access to health care insurance is the other socioeconomic concern that cancer survivor’s often experienced. The pre-existing conditions could let them be denied for health coverage or they might be asked to pay more than they could afford by an insurance company with the notion that their health insurance did not cover the costs of cancer screenings, treatments, or follow-up care (Gonzalo et al., 2017).

Aside from psychological and socioeconomic consequences, cancer survivors could also be at risk of late or long-term effects, often related to treatment side effects. Aziz and Rowland have defined that late effects are “unrecognized toxicities that are absent or subclinical at the end of therapy but manifest later with the unmasking of previous unseen injury by developmental processes, or as the result of a failure of compensatory mechanisms with the passage of time, or organ senescence”. Whereas, long-term effects refer to “any side effects or complications of treatment which begin during treatment and continue beyond the end of treatment” (Aziz & Rowland, 2003).

One of the major concern for cancer survivors are at increased risk of cancer, either a recurrence for which they were treated or secondary cancer that either a metastasized to other organ or different cancer that is unrelated to the first. In US, one in six of all cancer incidents has been reported as multiple primary cancer including secondary tumor (Travis et al., 2012). This increased risk of secondary cancer has mainly linked to treatment side effects such as radiation and chemotherapy, but also hereditary, some interaction between treatment and an intrinsic susceptibility (Daher, Daigle, Bhatia, & Durand, 2012; Travis et al., 2012) and environmental risk factors such as lifestyle factors (smoking, alcohol, poor exercise and unhealthy diet) (Demark-Wahnefried, Rock, Patrick, & Byers, 2008) might increase the chance. Radiotherapy has been remaining the most successful treatment for cancer, with an estimated 50% of cancer patients have received this therapy (Travis et al., 2012). However, the same therapy that improves survivor’s ability to survive with their illnesses (e.g. radiation), could also have troubling side effects which led the survivors to psychological and physical difficulties (DeFrank, Mehta, Stein, & Baker, 2007).

Treatment related side effects are so varied and the degree of manifestations also depends on several factors including the complexity of cancer itself, the wide collection of therapies that can be administered as treatment, the dose, type and intensity of treatment (e.g. chemotherapy, radiation, surgery), age and health status of the individual at the time of treatment. Many tissue and body systems are impaired due to these treatment side effects and resulting a significant change in physical functioning of the body (such as persistent swelling (lymphedema), changes in bladder and bowel functioning, weight loss and gain, bone density loss (osteoporosis), hair loss and change, sleeping difficulties) and causing other chronic diseases such as CVD, and post treatment fatigue, pain, and sexual and urinary problems. Some survivors experience late side effects, which could be manifested months and years after treatment (Glare et al., 2014; Maria Hewitt, 2006; Stein et al., 2008).

Cardiovascular (CV) diseases including ischemic heart disease, stroke, and heart failure, after second malignancies, have been considered as the most serious and life-threatening events of morbidity and mortality among cancer survivors (Daher et al., 2012; Travis et al., 2012). A community based retrospective cohort study in the US, involved more than 32,000 cancer survivors and 73,000 comparison group, revealed that survivors of multiple myeloma, carcinoma of the lung/bronchus, non-Hodgkin lymphoma and breast cancer had significantly higher CVD risk when compared with non-cancer controls (Armenian et al., 2016).

Other disabling and continuous physical health consequences that occur during and continues after cancer treatments are pain and fatigue (Glare et al., 2014; Karthikeyan, Jumnani, Prabhu, Manoor, & Supe, 2012), sexual dysfunction or inability to have and enjoy with relationship (Averyt & Nishimoto, 2014) and appearance and body image dissatisfaction (DeFrank et al., 2007). In a recent review by Glare and colleagues, the prevalence of chronic severe pain, that could inhibit their physical functioning, was reported ranged approximately from 5% to 10% in cancer survivors (Glare et al., 2014).

Role of lifestyle behaviors during cancer survivorship

Many observational and randomized control trial studies have revealed that maintaining healthy lifestyle behaviors such as diet, regular physical exercise, quit smoking and alcohol consumption after cancer diagnosis and during treatment results in improving cancer survivor’s treatment outcomes, quality of life, and lower the risk of death and improve overall survival (WCRF/AICR, 2007), and thus become a major concern for organizations working on cancer prevention and control to provide a wide range of advice for cancer survivors on their general way of lifestyle behavior including dietary habit, how they should exercise, and the types of supplements they need to consider after receiving cancer diagnosis and treatment (Rock et al., 2012) The detail recommendations from American Institute of Cancer Research (WCRF/AICR) are given in Table 3.

This section reviews the role of healthy behaviors related to cancer survivor and treatment outcome such as reducing fatigue and pain, reducing cancer recurrence, improve survival, reducing other morbidities and mortality, and then followed by reviewing the prevalence and compliance of such behaviors in cancer survivors.

The role of physical activity in cancer related outcomes

The role of exercise in reducing many cancer risks, including the most common cancers; lung, endometrial, colon, and possibly prostate cancer, is well established. World Cancer Research Fund and the American Cancer Research Institute (WCRF/AIRC) also produced same conclusion that physical exercising has a beneficial effect in the prevention of various cancer risks. Also, observational studies around the world consistently showed that a significant reduction of cancer risks has been documented among those who are active. For example, Lynch (2011), using a systematic analysis of 73 studies conducted in different part of the world, found that 25% reduction of breast cancer risk among those women who are physically active as compared to women who are less active or with a sedentary lifestyle (Lynch, Neilson, & Friedenreich, 2011).

Although the effect size is varying with the type, intensity and duration, generally exercising programs have been found beneficial for cancer survivors and been equally effective as different medical procedures (Stein et al., 2008). In the mid-year of 19th century, the role of exercising in cancer treatment and during survivorship hadn’t been well recognized and wasn’t part of the cancer treatment strategy. At that period, the prevailing idea was cancer patient need to avoid any excretion or energy loss during cytotoxic treatment (Luebbert, Dahme, & Hasenbring, 2001). In late 19th century, however, a pioneer randomized control trials among patient who undergoing treatment (chemotherapy) by Winningham in 1988 among 42 breast cancer patients (Winningham & MacVicar, 1988) and again in 1989 among 45 stage-II breast cancer women (Winningham, MacVicar, Bondoc, Anderson, & Minton, 1989) revealed that aerobic exercising was indeed beneficial in improving functional capacity, and decreasing treatment induced side effects.

Since then, rapidly accumulated experimental studies have documented that a sort of physical exercising does not only help people from getting cancer risks but also reduced risk of cancer recurrence and longer survival after a cancer diagnosis among survivors. In particular improving physical functioning and quality of life (Baruth, Wilcox, Der Ananian, & Heiney, 2015; Groeneveldt et al., 2013; Murtezani et al., 2014; Skinner et al., 2016; Stein et al., 2008), improving cardiovascular fitness (Kampshoff et al., 2015; Sprod, Hsieh, Hayward, & Schneider, 2010) and reducing psychological and emotional distresses (Campo et al., 2013; Luebbert et al., 2001; Mehnert et al., 2011; Murtezani et al., 2014; Stein et al., 2008).

Depressive mood or distressing shortly upon diagnosis to a certain cancer is the most common experience in cancer survivor’s due to several stressors and emotional disorders, which may continue even long after treatment in some cases (Pasquini & Biondi, 2007). It is estimated to be four times higher in cancer survivors as compared to the general population and more than half of cancer survivors experience symptoms of depression (Massie, 2004). To this concern, studies have shown that physical exercise is positively associated with the reduction of emotional and distressing symptom. Mehnert (2011) conducted a randomized control trial in breast cancer patient shortly after chemotherapy or radiotherapy treatment. The study found that a 10 week (twice per week) exercising program which includes gymnastics, walking, movement games, relaxation, and jogging have a significant effect on reducing anxiety (p = 0.03), depression (p = 0.05) (Mehnert et al., 2011). Improved effect of exercising over reducing psychological and emotional wellbeing parameters such as anxiety, depression among breast cancer survivors also observed in interventions such as a randomized control trail of moderate-intensity progressing muscle relaxation (PMR) exercising over a 10-week period in Kosovo (Murtezani et al., 2014), and in a trial of 3 or 6 months exercising program in USA (Sprod et al., 2010). Moreover, a recent randomized control trial in the US which aimed to evaluate the effects of a 12-week qigong intervention found that the intervention had a significant effect in improving anxiety (p=0.01) and distress (p=0.02) in prostate cancer survivors (Campo et al., 2013).

A comprehensive systematic analysis of 15 randomized control trials conducted in 1980s and 1990s revealed that relaxation training proved to have a significant positive effect, with an effect size ranged from 0.08 to 0.54, on reduction of depression, anxiety, hostility and improvement of the overall mood, and the study recommend that it is safe and feasible integrating relaxation training into clinically routine medical treatment for cancer survivors (Luebbert et al., 2001)

Aside from concerns in psychological and emotional distresses, physical function and health related quality of life also a concern for cancer survivors which could be improved by exercising programs. In a recent randomized control trial among 60 women who are suffering from breast cancer revealed that a 10 week (two days per week) supervisory group exercise intervention have significantly improved health related quality of life (HRQoL) (P<0.001), as measured by EORTC QLQ-C30 questionnaire, in the intervention group than the control group. Improved total score of functions and symptoms of QoL, which was measured by EORTC QLQ-BR23, also associated with the exercising intervention (Shobeiri, Masoumi, Nikravesh, Heidari Moghadam, & Karami, 2016). The beneficial effect of exercising program has not been proven in some studies. For example, Thorsen (2005) did not find an improved effect of home based flexible training on mental distress and HRQoL parameters among one 111 cancer survivors who had completed chemotherapy before the study. A positive effect on cardiovascular fitness and fatigue score, however, was observed in this study (Thorsen et al., 2005).

In 2015, Mishra and colleague have done a Cochrane database systematic review on evaluating the effect of exercising program on overall and specific HRQoL outcomes among adult cancer survivors during treatment. A total of 56 randomized and quasi-randomized trials, with 2286 participants randomized into exercise and 1985 participants randomized into comparison group were included in this review and found that exercising intervention has a positive effect on overall and certain HRQoL domains. Specifically, the review revealed that greater reduction was found in anxiety among breast cancer survivors and reduction in depression, fatigue, and sleep disturbances, and improvement in HRQoL, emotional well-being, physical functioning, and role function also found among cancer survivors other than breast cancer. Compared to a mild exercise program, moderate or vigorous exercising also showed greater association in HRQoL, physical functioning, and reduction in anxiety, fatigue, and sleep disturbances (Mishra et al., 2012).

The degree of effects from exercising program varying with the type, intensity, and duration of the exercise. Dimeo and colleagues compared the effect of two therapies; an aerobic exercise (30 min stationary biking, five times weekly) and a progressive relaxation training (45 min, three times per week). They found aerobic exercising technique has significantly improved physical performance (p=0.01) of cancer survivors compared to the relaxation techniques, but both techniques found to be equally effective for improving fatigue and global health score as a measure of quality of life (QoL) (Dimeo, Thomas, Raabe-Menssen, Propper, & Mathias, 2004). Better improvements in a six-month exercising program with regards to cardiovascular fitness and fatigue compared to a 3-month exercising intervention were also found in study by Sprod and colleagues (Sprod et al., 2010).

Role of nutrition and diet during cancer survivorship

The role of healthy dietary pattern in cancer prevention and control is well recognized. Therefore, unhealthy diet and nutrition have been considered the major risk factors in the prognosis of various cancer types, and plays a large role in determining the quality of life and long-term survival after cancer diagnosis, such as alleviating treatment-related symptoms, reducing cancer recurrence and cancer specific mortality (Bazzan, Newberg, Cho, & Monti, 2013). American Institute for Cancer Research in collaboration with World Cancer Research Fund has produced a general guideline on dietary pattern of foods and drinks for cancer survivors. Initially, the guideline was intended for the prevention of cancer risks but later extended to cancer survivors due to having similar effects on survivors (Doyle et al., 2006).

The effect of adherence to this is guideline has been studied in different population throughout the world in relation to cancer outcomes such as cancer recurrence and cancer related mortality among cancer survivors. Two dietary patterns are commonly used for comparison in these studies; the “prudent diets” or guidelines-based diets, which characterized by a diet high in fruits, vegetables, whole grains, poultry, fish, and legumes. The second is a “Western diets” which characterized by a diet high in red and processed meats, sweets or sugar, refined grain, potatoes, French fries and dietary fat.

The positive effect of “prudent” dietary pattern on cancer recurrence (Chlebowski et al., 2006; Gold et al., 2009), cancer specific mortality (Kabat, Matthews, Kamensky, Hollenbeck, & Rohan, 2015; McCullough et al., 2016; Meyerhardt et al., 2007; Pierce et al., 2007), all-cause mortality (McCullough et al., 2016; Meyerhardt et al., 2007; Pierce et al., 2007; Schwedhelm, Boeing, Hoffmann, Aleksandrova, & Schwingshackl, 2016) and quality of life (Demark-Wahnefried et al., 2004; Wayne et al., 2006) have been found among cancer survivors. Likewise, an elevated risk with the Western type of dietary pattern also depicted in these studies. Moreover, the prudent type of dietary pattern believed to have a protective effect for many chronic diseases such as diabetes, cardiovascular diseases and proven to reduce blood pressure (Fung et al., 2003; Yokoyama et al., 2014).

In a recent (2016) systematic review of 12 observational studies by Kohler and colleagues found that adherence to established cancer prevention guidelines was significantly associated with reductions in cancer related mortality and all-cause mortality in survivors; all-cancer incidence and mortality reduced by 10% to 61%, and reduced incidence of cancer at specific sites; 19-60% in breast cancer, 23-60% in endometrial cancer and 27%–52% reduction in colorectal cancer (Kohler et al., 2016). In other meta-analysis conducted by Balter and colleagues, evaluated 11 observational studies published from 1998 to 2012, revealed that cancer-specific mortality was averted by 22% with good adherence to guidelines, and specifically a 21% risk reduction was found for colorectal cancer (Bälter, Möller, & Fondell, 2012)

In a specific study, Meyerhardt and colleagues (2007) also compared the effect of dietary pattern after cancer diagnosis, classified dietary pattern as “Prudent” Vs “Western”, among 1009 stage III colon cancer survivors. The study found that recurrence or death was significantly associated with higher intake of a Western dietary pattern. Those survivors with highest quantile intake of Western dietary pattern experienced a higher risk of cancer recurrence or death (AHR=3.25, 95% CI: 2.04-5.19; P<.001), cancer recurrence (AHR=2.85, 95% CI, 1.75-4.63) and overall mortality (AHR= 2.32, 95% CI, 1.36-3.96). However, a significant effect had not been found from the prudent dietary pattern related to patient outcome (Meyerhardt et al., 2007). In a similar study by Kroenke among breast cancer survivor from Nurse’s Health Study revealed that higher intake of prudent dietary pattern and a lower intake of Western dietary pattern may protect breast cancer survivors against all-cause mortality, but a significant effect was not observed for breast cancer mortality (C. H. Kroenke, Fung, Hu, & Holmes, 2005).

Obesity or body fatness is the cognizant risk factor for various chronic diseases including the prognosis of cancers, i.e., breast, colorectal, endometrial, prostate, esophageal, kidney, pancreas, thyroid, and gallbladder, with possible dose-response relationship (Lauby-Secretan et al., 2016). According to the recent cancer progress report from American Association for Cancer Research (AACR), obesity/overweight is a major risk factor with attributing nearly 25% cancer incidences, which is next to smoking (Arteaga et al., 2014). Pooled analysis of epidemiological studies also showed that obesity has 1.5 to 1.8 relative risk to cancer burden, but the estimate would be varying with cancer type and relatively strong in breast and prostate cancer (Lauby-Secretan et al., 2016). Thus, a considerable proportion of cancer patients is being overweight or obese at the time of diagnosis.

Growing studies are also demonstrating that gaining weight during or after cancer treatment has been a common scenario, this is perhaps related to the chemotherapy and physical inactivity, and could produce unfavorable effects related to cancer outcomes; cancer recurrence, cancer-related mortality and other obesity related comorbidities such as diabetes, hypertension and heart disease in cancer survivors. Kroenke et al. found that those breast cancer survivors who gained weight (0.5 kg/m2 and more) in post-diagnosis period had an elevated risk of recurrence and all-cause mortality (C. Kroenke, Chen, Rosner, & Holmes, 2005). Moreover, weight gain could compromise the functional ability and quality of life during survivorship (Rutledge & Demark-Wahnefried, 2016).

Given the fact, obesity is the main health risk and preventable cause of cancer, plus accumulative evidence that demonstrates adverse effect of overweight/obesity on overall health and cancer recurrence among survivors, many interventions given emphasis on weight management/weight loss either through diet or exercising program. Randomized control trials have also been conducted in searching intervention strategies, i.e. optimal time (Haseen, Murray, O’Neill, O’Sullivan, & Cantwell, 2010), type (Campbell et al., 2009; Harrigan et al., 2016) that promoting dietary and overall behavioral change among survivors. These interventions are usually aimed to satisfy the recommendations from AICR/WCRF for cancer survivors that satisfying caloric requirements and maintain a healthy weight.

Some studies also associated the effect of specific nutrients with cancer recurrence, cancer mortality and their effect with treatment drugs. Fink and colleagues in 2007, and Guha and colleagues in 2009 found reduced hazard ratio (HR) of all-cause mortality with the highest quantile intake of flavones and isoflavones among cancer survivor, thus these studies conclude that cancer mortality may be reduced in association with high levels of dietary flavones and isoflavones (Fink et al., 2007; Guha et al., 2009).


Tobacco use and effects on cancer survivors 

Researchers known for many years that cigarette smoking is the predominant cause of lung cancer, with 80-90% of lung cancer incidences are caused by cigarette smoking and 20-40% times higher in lifetime smoker compared to nonsmokers (Ozlu & Bulbul, 2005). But, many other types of cancer incidence are also associated with smoking habit including bladder, head and neck, esophagus, stomach, kidney, cervix, and pancreas (IARC, 2014). Although smoking habit is a strong and modifiable risk factor for many cancers, continuing use of tobacco after cancer diagnosis is common among survivors, and cessation interventions were not created a significant change in countries such as Canada, and some Asia and European countries (Sitas et al., 2014). For example, close to 60% cancer survivors in the Korean National Health and Nutrition Examination Surveys (from 2007 to 2011) (Kim, Kim, Park, Shin, & Song, 2015), and 65% of survivors in the Shanghai Cohort Study (Tao, Wang, Gao, & Yuan, 2013) have continued smoking after diagnosed with cancer. In a systematic and meta-analysis of studies evaluating the tobacco smoking cessation interventions revealed that the therapeutic interventions such as counseling, and nicotine replacement therapy are not found to be an effective strategy in decreasing cessation rate among survivors (Nayan, Gupta, Strychowsky, & Sommer, 2013).

Evidence are still limited regarding the benefit of smoking cessation after cancer diagnosis, but a considerable attention has been given in recent years to the impact of smoking outcomes in cancer survivors. Findings are demonstrating that several adverse effects are been related with the habit of cigarette smoking before and after cancer diagnosis, and during treatment as well, such as increasing the probability of secondary cancer (Gan et al., 2013; Tabuchi et al., 2013), postoperative complications including risk of infection during surgery and slow wound healing after surgery (Gajdos et al., 2012), and interfering with effectiveness of chemotherapy drugs and radiation treatments (Burke, Miller, Saad, & Abraham, 2009). Smoking after cancer diagnosis associated with increasing cancer related and all-cause mortality (Moreira et al., 2014; Tao et al., 2013; Yang, Jacobs, Gapstur, Stevens, & Campbell, 2015), cancer recurrences; for example, in breast cancer (Bishop, Killelea, Chagpar, Horowitz, & Lannin, 2014), bladder cancer (Hou et al., 2017), and prostate cancer (Kenfield, Stampfer, Chan, & Giovannucci, 2011; Moreira et al., 2014) and shorter survival period and deteriorated quality of life (Gritz & Demark-Wahnefried, 2009; Mayadev, Lim, Durbin-Johnson, Valicenti, & Alvarez, 2016). The American Cancer Society (ACS) has estimated, each year 30% of cancer deaths in the United States is due to tobacco use (ACS, 2014).

In a systematic review of evidence on the effect of stopping smoking among bladder cancer survivors, poor prognosis in treatment outcomes was associated with their smoking habit in most reviewed studies (Aveyard et al., 2002). Moreover, a pooled analysis of 10 randomized control trials by Parsons and colleagues revealed that continued smoking after cancer diagnosis had significantly associated with increased risk of all-cause mortality (HR=2.94, 95% CI; 1.15 to 7.54) and cancer recurrence (HR=1.86, 95% CI; 1.01 to 3.41). Further, the study pointed out smoking cessation after diagnosis of early stage lung cancer improves prognostic outcomes (Parsons, Daley, Begh, & Aveyard, 2010).  A recent meta-analysis of studies among colorectal cancer survivor found a hazard ratio (HR) of 1.26 related to smoking after cancer diagnosis on all-cause mortality compared with never-smokers (Walter, Jansen, Hoffmeister, & Brenner, 2014). Yang B., also found, from the Cancer Prevention Study II Nutrition Cohort, post diagnosis current smoking had significantly associated with all-cause mortality (RR= 2.22 (95% CI, 1.58 to 3.13) and colorectal cancer–specific mortality (RR=1.92 (95% CI, 1.15 to 3.21) (Yang et al., 2015).


Alcohol consumption and effects on cancer survivors

There is a strong scientific consensus that alcohol drinks are a convincing human carcinogen for several type of cancers including head and neck cancer (Freedman, Schatzkin, Leitzmann, Hollenbeck, & Abnet, 2007), cancer of the esophagus (Fan, Yuan, Wang, Gao, & Yu, 2008; Peng, Chen, & Huo, 2016), liver cancer (Chuang, Lee, Wu, Straif, & Hashibe, 2015), breast cancer (Smith-Warner et al., 1998), and colorectal cancer (Fedirko et al., 2011; Wakai et al., 2005). Research evidence also showed there is dose-response relationship between alcohol consumption and risk of cancer: the more alcohol drinks in regular base the higher the risk of developing alcohol-associated cancer (Bagnardi et al., 2015; Chuang et al., 2015). In contrast, some studies showed moderate consumption of alcohol associated with reduced cancer risk relative to non-drinkers. For example, Freedman and colleagues found consumption of alcohol up to one drink per day associated with reduced risk of head and neck cancer (Freedman et al., 2007).

Evidence are very limited, and controversial on the health impact of alcohol consumption before and after cancer diagnosis among survivors. Pre-diagnostic alcohol consumption, with a moderate to high volume, didn’t show a significant health effect on specific or overall survival in several cancer studies (Lowry, Kapphahn, Chlebowski, & Li, 2016; Newcomb et al., 2013), but other studies suggested that not drinking status or a slight alcohol consumption led to improved disease specific or overall survival (Din, Allen, Satariano, Demb, & Braithwaite, 2016; Reding et al., 2008) or a vise-verse; a higher intake led to increased cancer mortality (Mayne, Cartmel, Kirsh, & Goodwin, 2009) among cancer survivors. Post-diagnostic or continuing alcohol consumption after cancer diagnosis was associated with cancer recurrence (HR; 1.34; 95% CI 1.00 -1.82) and breast cancer specific mortality (HR; 1.51 95% CI 1.00-2.28) in LACE study, which includes 1897 women diagnosed with early stage breast cancer (Kwan et al., 2010). A greater effect was found for post-menopausal and obese/overweight women in this study. Some other studies, however, found a contrasting evidence that showed non-conclusive association between post diagnosis alcohol intake and survival, e.g. in breast cancer survivors (Newcomb et al., 2013).  A systematic review of eight studies by Rock & Demark-Wahnefried in 2002, revealed no significant association between alcohol intake and survival among those who had been diagnosed with breast cancer (Rock & Demark-Wahnefried, 2002). In WHEL study, which encompasses 3088 middle-aged women who had been diagnosed and treated for breast cancer, also showed that light alcohol consumption did not associate with breast cancer recurrence and all-cause mortality. In contrast, a moderate intake (> 300 g/month) was protective against all-cause mortality in non-obese women (HR = 0.69, CI=0.49-0.97) (Flatt et al., 2010).

Few studies are associating the effect of alcohol consumption and quality of life among cancer survivors. Still, findings are inconsistent. No association between alcohol consumption and QoL have been found in some studies, for example in head and neck cancer survivors (Duffy et al., 2007), whereas others have reported better QoL and improved physical and role functioning among drinkers as compared to non-drinkers (Allison, 2002). The cross – sectional nature of these studies, however, does not show the real association between alcohol consumption and QoL, thus more researches with better study design are warranted.

Overall, given the limitation of studies conducted among cancer survivors related to alcohol consumption, and contradictions in their findings, AICR/WCRF and ACS concluded that alcohol consumption is associated with various cancer types, and the effect of alcohol consumption is well acknowledged, mainly with higher dose on survivor’s health status; survival time, cancer recurrence and death. To this end, it is recommended that survivors need to avoid alcohol consumption or if they decided to drink, they need to limit their intake not more than two drinks per day for men and one drink a day for women (Table 3).  Also, recommended that drinking of alcohol with only meal (WCRF/AICR, 2007).

Lifestyle behavior after cancer diagnosis: does cancer diagnosis trigger behavioral change?

The various consequence of cancer diagnosis and the role of health behaviors; exercising, diet and nutrition, smoking, and alcohol consumption during survivorship period have been covered in the previous sections. In this section, we further reviewing the adherence and practice of these behaviors in survivors and the teachable moment of cancer diagnosis.

Likewise, to the general population, adopting of healthy lifestyle practices such as a healthful diet, being physically active, quit smoking, reduce alcohol consumption have some notable benefits for people diagnosed with cancer; the benefits are not only reducing cancer recurrence and co-morbidities and mortalities but also improving survivor’s quality of life. To these effects, organization such as ACS and AICR/WCRF have developed a guideline for survivors regarding maintaining a healthy behavior during survivorship period. Many epidemiological studies also acknowledged these benefits for survivors (Alice Bender, 2013; Chlebowski et al., 2006).

Moreover, given the benefits mentioned above, there is a general notion that a cancer diagnosis itself could provide a ‘teachable or wake up moment’, whereby survivors would highly motivated to adopt risk-reducing healthy behaviors to further preventing risk events during the course of survivorship and to improve survival and quality of life (Chlebowski et al., 2006; McBride, Emmons, & Lipkus, 2003).

To date, many studies have been conducted in this population group and trying to figure out survivors’ lifestyle behavior after cancer diagnosis. However, inconsistencies have been observed among research findings on the practice of healthy behavior after cancer diagnosis, some studies supporting the teachable moment of cancer diagnosis (Alfano et al., 2009; Keenan, 2009; Patterson et al., 2003; Satia et al., 2004), in contrast, other population based studies using national health survey data or observational longitudinal studies concluded that there are few differences between cancer survivors and those without a history of cancer in the prevalence of unhealthy behaviors, whereby survivors demonstrating similar rates of unhealthy behaviors (smoking, inactivity, inadequate diet, and overweight/obesity) to those found in the general adult population (Anderson et al., 2017; Bidstrup et al., 2013; Broderick, Hussey, Kennedy, & O’Donnell, 2014; Coups & Ostroff, 2005; Courneya, Katzmarzyk, & Bacon, 2008; Dontje et al., 2016; Eakin et al., 2007; Grimmett, Wardle, & Steptoe, 2009; Jackson, Williams, Steptoe, & Wardle, 2014; W. A. Smith, Nolan, Robison, Hudson, & Ness, 2011; Williams, Steptoe, & Wardle, 2013).

Also, in some longitudinal studies, it is revealed that healthy behaviors changes made by survivors are either temporal, meaning that the compliance to recommended behaviors are getting diminished after few months or years, and survivors back to their previous unhealthy behaviors after a while (Anderson et al., 2017; Greenlee et al., 2016), or the compliance was limited to few recommended behaviors (Newsom et al., 2012). In a recent study by Anderson and colleague (2017) on breast cancer survivors, they found that survivors were 11-16% less likely to make positive change in behaviors; exercise, eating healthy foods, maintaining a healthy weight with each 5-year increase in diagnosis age (OR = 0.84-0.89; p < 0.05) (Anderson et al., 2017)

A systematic review by Demark-Wahnefried and Pinto & Trunzo have shown that cancer survivors do actually make lifestyle changes following cancer diagnosis and the evidence was supporting the idea of the teachable moment, but the authors questioned the quality of data from these studies due to the possibility of respondents bias and other confounders, for example, the inclusion of respondents who had been more likely engaged in healthy behaviors before diagnosis.. Small sample size and insufficient power also the other limitations they have mentioned (Demark-Wahnefried et al., 2005; Pinto & Trunzo, 2005).

It is not clear that whether this contradiction is a result of the cross-sectional nature of the studies or the impact of the teachable moment decreases over time and survivors do indeed change their unhealthy behavior but the changes are not sustained. Moreover, what characteristics of survivors predict compliance with lifestyle recommendations after a cancer diagnosis are not well known. For example, were the survivors who meet the physical activity recommendations also more active than their peers prior to their cancer diagnosis? For such questions, a well-designed longitudinal observation of cancer survivors from their pre-diagnosed period has needed.

We, therefore, propose the present study to provide benchmark data by exploring the following objectives using a longitudinal data on middle-aged cohort from the Australian Longitudinal Study on Women’s Health:

  1. Prevalence of health behaviors in cancer survivors and match control group
  2. The impact of cancer diagnosis on health lifestyle: is cancer diagnosis a teachable moment for survivors to adopt a health behavior?
  3. Assess the adherence of health behavior recommendations among cancer survivors
  4. Longitudinal change in lifestyle behavior after cancer diagnosis: is survivors’ compliance to the recommended health behavior for a long time?

The above objectives are the overall aim and focus of this research proposal. However, since the concept of health behavior is broad and includes various sub-components, further specific objective could also be considered within this framework.

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