Move Onward, Press Forward, and Take a Deep Breath: Can Lifestyle Interventions Improve the Quality of Life of Women With Breast Cancer, and How Can We Be Sure?

Abstract

“The quality of life is more important than life itself.” Few would argue with this statement. But the originating source might surprise you. Was it a renowned psychologist, a famous painter, or perhaps an unrivaled hedonist? No, these words were first uttered by Alexis Carrell, a French surgeon and 1912 Nobel Prize laureate recognized for his work on vascular suture and organ transplantation. In this issue, two articles report the results of randomized trials that targeted quality of life (QOL) as their primary outcome. Although both studies tested lifestyle interventions among women with breast cancer and share several similarities, they are distinctly different. The article by Courneya et al reports the results of a trial (n 242) that compared aerobic or resistance exercise with usual care. Although this group of investigators is renowned for delivering exercise interventions that are well received and that improve QOL, the results of this trial are somewhat different from other reports from this group. Although secondary end points such as self-esteem were significantly improved in both intervention arms and other arm-specific differences were observed (such as increased aerobic fitness in the aerobic arm and increased muscular strength, lean body mass, and chemotherapy completion rates in the resistance exercise arm), fatigue, depression, anxiety, and, most importantly, QOL did not differ among women assigned to the exercise interventions compared with women assigned to usual care. These findings are distinctly different from those that Courneya et al reported in the Journal of Clinical Oncology in 2003. The results of this smaller (n 52), two-armed trial found a significant increase in QOL with an aerobic exercise intervention compared with usual care, with change scores of 9.1 14.1 v 0.3 8.5 points, respectively (P .001). So why are these findings so discrepant? Was it the intervention? Not likely, since both interventions used graduated thrice weekly aerobic regimens. Was it the outcome measure? This is a possibility because there are differences between the Functional Assessment of Cancer Therapy–Breast and Functional Assessment of Cancer Therapy–Anemia scales; however, this still is unlikely. Instead, the most likely difference was that participants in the current study were actively receiving chemotherapy, whereas patients in the previous study had completed their primary treatment. Having conducted studies among patients who are in active treatment compared with patients who have completed therapy, it is easy to recognize and fully appreciate the data offered by these two trials, including adherence and attrition rates of 98.5% and 1.9%, respectively, for the former trial and 68% to 72% and 7.9%, respectively, in the most recent study. These rates are still admirable, but they point to the challenges in developing effective interventions that must overcome the host of barriers in patients who are receiving active treatment. Behavioral interventions that are instituted in these patients come during a period when patients are saddled with competing time constraints and also when their emotional and physical energies are being drained. However, such interventions also may demonstrate their greatest impact during this time of treatment. Although QOL may not necessarily be an outcome that is responsive during this point in time, other end points, such as those observed by Courneya et al (ie, improved strength, fitness, lean body mass, and chemotherapy completion rates), are certainly important outcomes. The trial conducted by Moadel et al is helpful in discerning the time period when behavioral interventions might be most effective in improving QOL. This study is distinctly different from that of Courneya et al in that it tested the efficacy of yoga, a mindfulness-based intervention, compared with an exercise intervention for improving QOL among breast cancer survivors. The sample accrued for this study (n 128) was diverse in terms of ethnic and racial minorities (42% African American, 23% Hispanic, 23% non-Hispanic white, and 4% other) and educational level (76% high school or less and 24% with at least some college). This is an admirable achievement because two thirds of lifestyle interventions conducted to date have relied on samples that are at least 90% white and 80% college educated. The study is also unique with respect to treatment completion, with roughly half of the sample in active treatment and the other half having completed their therapy. Like the findings of Courneya et al, no significant differences in QOL, fatigue, or distress were observed between women randomly assigned to yoga and women assigned to usual care, although a significant difference was found for social wellbeing, with the yoga arm experiencing significantly lesser decreases than women in usual care (change scores were 0.51 v 2.78, JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 25 NUMBER 28 OCTOBER 1 2007