Interactions between physical activity and clinical factors in the relationship with quality of life and emotional health outcomes of gynecologic cancer survivors

Abstract

<h3>Objectives:</h3> Physical activity (PA) has been shown to improve physical and emotional outcomes in cancer survivors, however, it is unclear who may benefit most from increased PA. Our objective was to describe the associations between PA and emotional health outcomes and quality of life (QOL) in gynecologic cancer survivors, and if they varied by clinical factors including receipt of chemotherapy or radiation therapy (RT), route of surgery and disease stage. <h3>Methods:</h3> Patients were recruited from an academic gynecologic oncology practice to a prospective cohort study. Participants completed semi-annual validated surveys on QOL, depression, distress and health behaviors. Clinical data was abstracted from medical records. The exposure was adherence to PA guidelines (yes/no; at least 150 minutes of moderate or vigorous PA combined, or 75 minutes of vigorous PA, per week). Potential effect modifiers hypothesized to interact with PA included: receipt of chemotherapy (yes/no), RT (yes/no), disease stage (stage I/II vs. III/IV) and receipt of minimally invasive surgery (yes/no). Primary outcomes in this analysis were continuous scores of distress (NCCN Distress Thermometer), depression (PHQ-8), anxiety (GAD-7), post-traumatic stress disorder (PTSD; PCL-5) and QOL (FACT-G). Linear regression models for each outcome tested for interactions between PA and potential effect modifiers. Models were adjusted for age, disease stage, receipt of chemotherapy, body mass index, type of gynecologic cancer and self-reported pain. <h3>Results:</h3> A total of 362 participants provided sufficient data to be included in this analysis; of those, 213 (59%) met PA guidelines. Mean age was 59.8±10.8 years. Most participants were diagnosed with uterine (40%) or ovarian cancer (43%). We found evidence for an interaction between PA and receipt of chemotherapy with regard to depression (p=0.01), anxiety (p=0.05), and QOL (p=0.05); and between PA and having advanced stage cancer with regard to depression (p=0.03). Interactions favored greater effects between PA and outcomes in those receiving chemotherapy or having advanced stage disease. Among those with more pain (vs. no/little pain), there was an interaction between PA and receipt of chemotherapy with regard to QOL (p=0.03), and between PA and advanced stage with regard to QOL (p=0.02) and depression (p=0.02); but no evidence for interaction among those with no/little pain. We found no evidence of interaction between PA and receipt of RT or minimally invasive surgery with any of the emotional health outcomes or QOL. <h3>Conclusions:</h3> Gynecologic cancer survivors with advanced stage cancer, those who received chemotherapy and those reporting more pain may derive the greatest benefit from PA to improve QOL and emotional health. The complex interplay that exists between PA, pain and emotional health is clinically relevant and warrants further investigation in order to understand how best to support gynecologic cancer survivors and maximize their QOL.