Older Breast Cancer Survivors Research Articles

Correlates of physical activity among older breast cancer survivors: Findings from the Women's Health Initiative LILAC study

IntroductionPhysical activity can attenuate cancer-related declines in physical functioning, improve emotional well-being, and prolong survival among older (≥65 years) breast cancer survivors. However, factors associated with physical activity among older breast cancer survivors are not well-understood. Materials and methodsParticipants were enrolled in the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study. Descriptive statistics, multiple linear regression, and relative risk [RR] regression were used to assess the association of demographic, clinical, physical and psychosocial variables with the total duration of and participation in physical activity among postmenopausal breast cancer survivors. Age-specific correlates (65–74 years vs. 75–84 years vs. ≥85 years) of physical activity were also examined. ResultsThe majority of participants (n = 3710, mean age = 78.8 ± 5.9) were white (90.7%) and had in situ/localized breast cancer (78.9%). Women who had higher education (RR = 1.47 for graduate/professional school versus high school or less, 95% CI: 1.32, 1.63), higher self-rated health (RR = 1.04 for 10 point increase, 95% CI:1.02, 1.07), higher physical functioning (RR = 1.03 for 5 point increase, 95% CI: 1.02, 1.04), and higher social support (RR = 1.41 for social support all of the time versus none of the time, 95% CI: 1.01, 1.96), were more likely to engage in any physical activity. Similar results were observed for duration of physical activity. Among women aged <75, radiation therapy, but not chemotherapy, was associated with longer duration of total physical activity (adjusted difference = 19.7 min/week, 95% CI: 6.1, 33.3), but was not associated with duration among older women. The association between pain and duration of moderate/strenuous activity also differed with age: among women aged <75, those with moderate pain averaged fewer minutes of moderate/strenuous physical activity than those with no pain (adjusted difference:−14.4 min/week, 95% CI:−28.5, −0.1). However, among women aged ≥85, those with moderate pain averaged more minutes of moderate/strenuous physical activity per week than those with no pain (adjusted difference:16.6 min/week; 95% CI:2.9, 30.3). DiscussionMultiple factors were associated with physical activity among older breast cancer survivors in the WHI. Future physical activity interventions should focus on age-related (e.g., comorbidities) and treatment-related factors (e.g., radiation) as well as certain subgroups, such as women with higher symptom burden.

Impact of taxane-based chemotherapy among older women with breast cancer on cognition and quality of life: a longitudinal pooled analysis.

Older cancer patients are susceptible to long-term effects of chemotherapy, including cancer-related cognitive decline and impairments to quality of life. Taxane-based chemotherapies are associated with physical declines among older women and may negatively impact cognitive performance. We sought to examine whether changes in objective and subjective measures of cognitive performance and well-being differ among older breast cancer survivors as a function of taxane-based chemotherapy treatment regimens. Individual-level data were pooled and harmonized from two large prospective studies of older (greater than 60years) breast cancer survivors. Assessments were conducted prior to systemic therapy and up to 36 months after. Cognitive performance was assessed with objective (working memory, processing speed, and executive functions) and subjective tests and physical, emotional, and functional well-being were also assessed. One hundred and sixty-seven (M age = 67.3years) women with 116 receiving chemotherapy with taxanes and 51 without taxanes contributed data. Declines in subjective cognition for both groups were significant between pre-treatment and 12-month follow-up. Significant improvements were seen on a measure of objective cognition (working memory) from 12 to 36 months. Measures of well-being improved from prior to systemic therapy to 12 months. Longitudinal changes across all measures did not vary as a function of receipt of taxane-based treatment. Older women who received treatment with taxanes did not have greater declines in cognitive performance or well-being than women receiving other chemotherapy regimens. Despite older cancer survivors being at greater risk for negative outcomes, treatment with taxane-based chemotherapies does not appear to exacerbate these health consequences.

Abstract 12484: Weekday 16:8 Time-Restricted Eating in Breast Cancer Survivors: Feasibility, Safety, and Effects on Cardiometabolic Health

Introduction: Time-restricted eating (TRE) is a form of intermittent fasting involving ad libitum energy intake within a set time window, commonly 8 hours, followed by a water-only fast for 16 hours (i.e., 16:8 TRE). TRE is a practical approach to improve cardiometabolic health but has not been tested in cancer populations. Hypothesis: TRE is feasible (&gt;85% adherence), safe (no major adverse events), and will improve cardiometabolic health in breast cancer survivors. Methods: Women who completed chemotherapy for early-stage breast cancer 1-6 years earlier, are ≥60 years, have a BMI &gt;25 kg/m 2 , and not taking lipid or glucose-lowering medications were enrolled in a single-arm study of 16:8 TRE on weekdays for 8 weeks. Participants could eat ad libitum between 12-8 pm on weekdays and all weekend. No other dietary or physical activity instructions were given. Adherence was collected by twice daily text messages that asked participants to respond with the times that they started/stopped eating. The Framingham 10-year cardiovascular disease (CVD) risk score and heart age, and ectopic adipose tissue (3T magnetic resonance imaging) were assessed before and after 8 weeks of TRE. Results: Fifteen participants (66±4 years, 31±4 kg/m 2 ) have completed the study. Participants responded to 99% of text messages and adhered to the 16-hour fast a median of 98% of days (range 93-100%). Reported symptoms were minor and transient. At baseline, 73% of participants were at ‘intermediate’ (10-19%) CVD risk, and pharmacological treatment was indicated. Among those at intermediate risk, 8 weeks of TRE decreased the absolute CVD risk by a median of 2% and heart age by 6 years, and reversed the need for pharmacological treatment (i.e., reclassification to ‘low’ risk) or metabolic syndrome in 45%. In all participants, visceral adipose tissue decreased by a median of 6% (p=0.018) and triglycerides by 17% (p=0.008). There were no significant changes in hemoglobin A1c, or ectopic adipose tissue in the liver or thigh. Conclusions: Eight weeks of weekday 16:8 TRE is highly feasible, safe, and reduces CVD risk among older breast cancer survivors with overweight/obesity at moderate CVD risk. Improvements in glucose control and liver/thigh ectopic adipose tissue may require a longer intervention.

Factors influencing utilization of cancer rehabilitation services among older breast cancer survivors in the USA: a qualitative study.

Many older breast cancer survivors experience long-term disability due to cancer and cancer-related treatments. However, less than 20% of older breast cancer survivors utilize cancer rehabilitation services to address cancer-related disability. Further understanding of survivor experiences may reveal strategies to improve uptake cancer rehabilitation services in the USA. Older breast cancer survivors were recruited from university-based registries, previous breast cancer research studies at our institution, community support groups, and geriatric oncology clinics. Participants completed a brief online survey to capture demographic and clinical characteristics. Semi-structured telephone-based interviews were recorded, transcribed, and thematically analyzed. Interviews facilitated conversation about access to rehabilitation and indications for cancer rehabilitation. Participants (n = 14) were, on average, 71years old, primarily White, and an average of 36.5months post-diagnosis. Five participants had formally received rehabilitation for a cancer-related concern. Participants described seven factors that influenced utilization of cancer rehabilitation services: (1) emerging awareness of disability; (2) coping styles; (3) comparison of cancer experience with others; (4) provider interaction; (5) perceptions of cancer diagnosis; (6) social support; and (7) cost of rehabilitation. Older breast cancer survivors consider multiple factors when determining utilization of cancer rehabilitation services. Development of shared decision-making tools addressing the seven described factors may enhance communication and referral to cancer rehabilitation services. Intervention research should adopt frameworks that enhance healthcare accessibility to improve relevance of intervention content and delivery features for older breast cancer survivors.

Medication nonadherence and patient cost responsibility for rural and urban cancer survivors.

4 Background: Little is known about the specific out-of-pocket costs which may lead to prescription nonadherence in older cancer survivors, and how patterns may differ for those living in rural areas. This study quantified patient costs overall and by residence for older cancer survivors who did and did not report cost-related prescription nonadherence. Methods: This retrospective cohort study used data from the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource (SEER-CAHPS) from 2007-2015. Older cancer survivors self-reported cost-related prescription nonadherence in the prior six months. Patient cost responsibility (deductibles, coinsurance, copayments) was summed for all medical care received in the year prior to survey. Differences in patient cost responsibility by cost-related adherence was estimated using gamma generalized linear models adjusted for patient age, race, sex, education, dual Medicaid enrollment status, residence, comorbidity count, cancer type, stage, and phase of care. Models stratified by urban/rural residence as designated by Rural-Urban continuum codes assessed effect modification. Results: Of 11,829 older adult survivors of prostate (37%), breast (32%), colorectal (14%), gynecologic (10%), or lung (6%) cancer, 12% reported any cost-related prescription nonadherence in the prior year. Median age of survivors was 76 (interquartile range [IQR] 71-82), 15% had less than a high school degree, 59% had at least one non-cancer comorbidity, and 16% had ever been dual eligible. Prevalence of cost-related nonadherence was similar by patient characteristics. Median cost responsibility in the year prior to survey was $1,529 (IQR $744-$2,959) for patients reporting nonadherence and $1,123 (IQR $572-$2,362) for those reporting adherence. In adjusted models, patients reporting nonadherence had $656 higher patient cost responsibility in the year prior (95% CI $564-$760) compared to those reporting adherence. Approximately half of the difference in cost was outpatient spending (β = $277, 95% CI $210-$359). Differences in cost responsibility for patients reporting nonadherence compared to adherence were smaller for patients residing in rural areas (18% of respondents; β = $341, 95% CI $177-$564) compared to those residing in urban areas (82% of respondents; β = $715, 95% CI $613-$830). Conclusions: Compared to those reporting adherence, cost-related prescription nonadherence was associated with higher health care cost responsibility in cancer survivors. Furthermore, prescription adherence decisions may be more cost-sensitive for patients living in rural compared to urban areas. Interventions to address out-of-pocket health care costs, particularly for rural cancer survivors, could aid in increased prescription adherence and subsequent health outcomes.

Meaning Making for Psychological Adjustment and Quality of Life in Older Long-Term Breast Cancer Survivors.

Objectives: This study aims to explore in depth the meaning and meaning discrepancies among older Norwegian breast cancer survivors in light of the meaning making model by Park (2013).Design: We utilized a qualitative design collecting data using semi-structured interviews of 23 elderly breast cancer survivors 7–8 years after treatment. The interviews followed an interview guide structured along three main themes: “everyday life activities,” “follow-up-care experiences” and “health status and QoL.”Results: Several health problems were reported by the women in the aftermaths of the disease, such as sleeping problems, pain, and fatigue—including cognitive and emotional impairments. Meaning discrepancies were concentrated on six main themes: shifting perspectives and priorities, growing sense of autonomy, widening the limits of normality, dissociating oneself from the disease, embracing alternative health services, and feeling lucky. The women engaged in a wide range of coping techniques as efforts to change global meaning, and to develop a more positive view on the cancer experience. Common coping efforts across the six main themes were social comparison, denial, positive reappraisal, problem-focused coping, and revaluing ordinary events.Conclusion: Many cancer patients report on unmet needs for help with their meaning making, and the facilitation of meaning making processes is rarely included in the follow-up care of cancer survivors. The findings of the present study may help health care professionals provide care for women who have experienced breast cancer. The concrete knowledge of common coping efforts in the meaning making process may contribute to the development of future interventions and for gaining a deeper understanding for older survivors of breast cancer.

Medical care disruptions during the first six months of the COVID-19 pandemic: the experience of older breast cancer survivors.

PurposeOlder cancer survivors required medical care during the COVID-19 pandemic, but there are limited data on medical care in this age group.MethodsWe evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors aged 60–98 from five US regions (n = 321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included interruptions in seeing or speaking to doctors, receiving medical treatment or supportive therapies, or filling prescriptions since the pandemic began. Logistic regression models evaluated associations between care disruptions and education, medical, psychosocial, and COVID-19-related factors. Multivariate models included age, county COVID-19 death rates, comorbidity, and post-diagnosis time.ResultsThere was a high response rate (n = 262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4–73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were higher with each year of education (OR 1.22, 95% CI 1.08–1.37, p = < 0.001) and increased depression by CES-D score (OR 1.04, CI 1.003–1.08, p = 0.033) while increased tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97–0.99, p = 0.012). There was a trend between disruptions and comorbidities (unadjusted OR 1.13 per comorbidity, 95% CI 0.99–1.29, p = 0.07). Adjusting for covariates, higher education years (OR1.23, 95% CI 1.09–1.39, p = 0.001) and tangible social support (OR 0.98 95% CI 0.97–1.00, p = 0.006) remained significantly associated with having care disruptions.ConclusionOlder breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions.Clinicaltrials.gov IdentifierNCT03451383

Exercise training partially rescues impaired mucosal associated invariant t-cell mobilization in breast cancer survivors compared to healthy older women.

To determine the mucosal associated invariant T (MAIT) cell response to acute exercise before (PRE) and after (POST) 16weeks of exercise training in breast cancer survivors (BCS) and healthy older women (CON). Age-matched BCS and CON performed 45min of intermittent cycling at 60% peak power output wattage. Blood samples were obtained at rest, immediately (0h) and 1h after exercise to determine MAIT cell counts, frequency, and intracellular cytokine expression. At PRE, MAIT cell counts were greater in CON (137%) than BCS at 0h (46%, p<0.001), with increased MAIT cell frequency in CON but not BCS. TNFα+ and IFNγ+ MAIT cell counts increased at 0h by ~120% in CON (p<0.001), while BCS counts and frequencies were unchanged. Similar deficits were observed in CD3+ and CD3+ CD8+ cells. At POST, exercise-induced mobilization and egress of MAIT cell counts and frequency showed trends towards improvement in BCS that approached levels in CON. Independent of group, TNFα frequency trended to improve (p=0.053). MAIT mobilization in older BCS following acute exercise was attenuated; however, exercise training may partially rescue these initial deficits, including greater sensitivity to mitogenic stimulation. Using acute exercise before and after interventions provides a unique approach to identify age- and cancer-related immuno-dysfunction that is less apparent at rest.

A randomized-controlled trial comparing supervised aerobic training to resistance training followed by unsupervised exercise on physical functioning in older breast cancer survivors

IntroductionThis study compared the relative efficacy of aerobic training to resistance training on physical functioning in older breast cancer survivors and determined whether benefits could be maintained by transitioning to unsupervised home-based training. Materials and methodsEarly-stage, post-treatment, older (≥65 years) breast cancer survivors (n = 114; mean age 72 years) were randomized to 12 months of supervised aerobic (n = 37), resistance (n = 39) or stretching (active control; n = 38) training followed by 6 months of unsupervised home-based training. Outcomes included aerobic capacity by 6-min walk distance (6MWD; m), maximal upper and lower body strength (1-repetition maximum; kg); physical function by short physical performance battery (SPPB), SF-36 and Late Life Function and Disability Instruments. ResultsOver 12-months of supervised exercise, all groups improved in muscle strength and SPPB scores, but resistance trained women also improved 6MWD. Improvements in upper and lower body strength in the resistance group were significantly greater than those in the stretching control (+2.5 kg vs. +1.8 kg; p = 0.05) and aerobic groups (+8.3 kg vs +2.7 kg; p = 0.047), respectively, with trends for greater improvements in 6MWD (+57.9 m vs. +22.5 m; p = 0.057) and self-report physical function (+4.8 vs. -4.4; 0.066) in resistance trained women versus controls. Compared to values at 12 months, there were no changes during unsupervised training in any measure within or between groups, except for self-reported advanced lower extremity function which improved in the resistance group and fell in the aerobic group (+1.3 vs. -3.1; p = 0.043). DiscussionSupervised exercise can improve strength and physical functioning among older breast cancer survivors. Resistance training may lead to better improvements compared to aerobic or flexibility training, whether in a supervised or unsupervised setting.Clinicaltrials.govNCT00662103

Relationship between cognitive functioning and frailty in older breast cancer survivors

IntroductionThe relationship between cognitive function and frailty in older, long-term breast cancer survivors was examined. Materials and methodsBreast cancer survivors who were diagnosed and treated at 60 years of age or above and were 5–15 year disease-free survivors and non-cancer controls matched on age and education were evaluated with neuropsychological tests and the Comprehensive Geriatric Assessment which was used to assess frailty based on a deficit accumulation frailty index (DAFI). ResultsUnadjusted regression analyses revealed that cancer survivors scored significantly lower on the Language (P = 0.015), Attention, Processing Speed, Executive Function (APE) (P = 0.015), and Learning and Memory (LM) (P = 0.023) domains compared to controls. However, only the LM domain remained significantly different (P = 0.002) in the adjusted analysis. Survivors had significantly higher DAFI scores compared to controls (p = 0.006) and significantly more survivors were categorized as pre-frail or frail (35%) compared to controls (23%, P = 0.009). Increasing frailty scores were associated with worse cognitive performance across all domains (all Ps ≤ 0.004). For the LM domain, there was a significant interaction (P = 0.019) between DAFI score and survivorship vs control status. Survivors demonstrated a significant linear decline in LM scores as DAFI scores increased, whereas controls demonstrated comparable scores between the robust and pre-frail DAFI groups, demonstrating decline in the frailty group only. ConclusionOlder, long-term breast cancer survivors had lower cognitive performance and higher levels of frailty compared to controls. For the Learning and Memory domain, the decline in performance began in the pre-frail range for survivors, but not controls.

Comorbidity, cognitive dysfunction, physical functioning, and quality of life in older breast cancer survivors

PurposeOlder breast cancer survivors (BCS) may be at greater risk for cognitive dysfunction and other comorbidities; both of which may be associated with physical and emotional well-being. This study will seek to understand these relationships by examining the association between objective and subjective cognitive dysfunction and physical functioning and quality of life (QoL) and moderated by comorbidities in older BCS.MethodsA secondary data analysis was conducted on data from 335 BCS (stages I–IIIA) who were ≥ 60 years of age, received chemotherapy, and were 3–8 years post-diagnosis. BCS completed a one-time questionnaire and neuropsychological tests of learning, delayed recall, attention, working memory, and verbal fluency. Descriptive statistics and separate linear regression analyses testing the relationship of each cognitive assessment on physical functioning and QoL controlling for comorbidities were conducted.ResultsBCS were on average 69.79 (SD = 3.34) years old and 5.95 (SD = 1.48) years post-diagnosis. Most were stage II (67.7%) at diagnosis, White (93.4%), had at least some college education (51.6%), and reported on average 3 (SD = 1.81) comorbidities. All 6 physical functioning models were significant (p < .001), with more comorbidities and worse subjective attention identified as significantly related to decreased physical functioning. One model found worse subjective attention was related to poorer QoL (p < .001). Objective cognitive function measures were not significantly related to physical functioning or QoL.ConclusionsA greater number of comorbidities and poorer subjective attention were related to poorer outcomes and should be integrated into research seeking to determine predictors of physical functioning and QoL in breast cancer survivors.

Cognitive dysfunction prevalence and associated factors in older breast cancer survivors

ObjectivesThe purpose of this study was to examine the prevalence and factors associated with objective and subjective cognitive dysfunction in older breast cancer survivors (BCS). Materials and MethodsThis cross-sectional descriptive study leveraged previously collected data from older BCS (n = 335). Separate linear regression models were used to determine relationships between demographic factors (age, education), medical factors (comorbidities), disease factors (time since diagnosis, cancer stage), cancer-related symptoms (depressive symptoms, anxiety, fatigue, sleep disturbance) and cognitive dysfunction measures, including objective learning, delayed recall, attention, executive function-working memory, verbal fluency and subjective attentional function. ResultsCognitive dysfunction was prevalent with up to 18.6% of older BCS experiencing mild-moderate dysfunction (1.5 standard deviations below mean of non-cancer controls) in at least one cognitive domain. Poor to moderate subjective attentional function was reported by 26% of older BCS. More depressive symptoms were significantly related to poorer cognitive function including learning (p < .01), delayed recall (p < .05), verbal fluency (p < .001), and subjective attentional function (p < .001) but not attention and executive function-working memory. Age, education, anxiety, and fatigue were also negatively associated with cognitive function in some models (p < .05–0.001). ConclusionCognitive dysfunction is common among older BCS and depressive symptoms, anxiety, and fatigue are related factors. Importantly, depressive symptoms were not only related to self-report, but also to cognitive performance. Healthcare providers should be aware of and assess for related factors and cognitive dysfunction itself in older BCS even years after diagnosis and treatment thorough geriatric assessment. Future longitudinal research is needed to discern these relationships.

Trajectories of fatigue in a population-based sample of older adult breast, prostate, and colorectal cancer survivors: an analysis using the SEER-MHOS data resource.

Fatigue is one of the most common and distressing symptoms experienced by cancer survivors. Understanding fatigue trajectories from pre- to post-diagnosis could inform fatigue prevention and management strategies. We used the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey (SEER-MHOS) linked data resource to characterize fatigue trajectories and their predictors 1214 older adult survivors of breast, colorectal, or prostate cancer. Fatigue was measured prior to the cancer diagnosis (T0) and at two timepoints after diagnosis (T1: mean = 20months and T2: mean = 39months post-diagnosis). Latent growth curve modeling and mixed effects models for repeated measurements were used to investigate fatigue experiences before and after a cancer diagnosis. Overall, mean fatigue T-scores declined (T0 = 50, T1 = 46, and T2 = 45) indicating worsening fatigue over time. Four latent trajectory subgroups were identified: severe fatigue worsening over time (8.2% of sample), severe fatigue persisting over time (14.4%), no fatigue pre-diagnosis and mild fatigue post-diagnosis (44.4%), and not fatigued (33%). Age, cancer stage, comorbidities, and depressed mood predicted membership in the two trajectory groups experiencing severe fatigue that persisted or that worsened post-diagnosis. Older age, advanced cancer stage at diagnosis, and depressed mood were significantly associated with worsening fatigue from T1 to T2 (all p < 0.0001). Evaluating cancer patients for depressive symptoms and considering prior fatigue levels, age, comorbid conditions, and cancer stage may help providers anticipate fatigue trajectories and implement pre-emptive strategies to lessen fatigue impact.

Study design and methods for the using exercise to relieve joint pain and improve AI adherence in older breast cancer survivors (REJOIN) trial

BackgroundAromatase Inhibitors (AIs) are recommended for survival in post-menopausal breast cancer survivors (BCS) with hormone-sensitive disease. AI Adherence is suboptimal, especially in older BCS. Joint pain is a common AI-related symptom that is associated with low AI adherence. The Using Exercise to Relieve Joint Pain in Older Breast Cancer Survivors (REJOIN) Trial will evaluate the efficacy of a self-management intervention (exercise + education) to increase knowledge/self-efficacy for symptom management, reduce joint pain and potentially increase AI adherence in older BCS planning to take AIs. MethodsThis randomized controlled pilot trial will include sedentary BCS, 65 years and older, diagnosed with stage I-III hormone-sensitive breast cancer, who have completed primary cancer treatment and are planning to initiate AIs. We will adapt an evidence-based physical activity program for older adults that includes bi-weekly, supervised exercise sessions plus 30 min of education. The 16-week intervention program includes: 8-weeks of supervised sessions plus 8-weeks of self-guided home sessions with periodic phone coaching. We will conduct geriatric assessments plus measurements of exercise, joint pain, and AI adherence (baseline, 4, 6 and 12 months). DiscussionREJOIN is one of the first trials to exclusively target older BCS using a self-management intervention, informed by geriatric assessment and exercise physiology, to improve health outcomes in survivorship. The REJOIN trial could lay the foundation for transdisciplinary research that bridges the gap between clinical and public health perspectives in healthy aging, with the opportunity to translate clinical interventions into non-pharmacological tools for a growing, yet underserved population of older survivors.Trial registration: NCT03955627

Balance Confidence and Falls Self-Efficacy in Older Breast Cancer Survivors.

The aim of the study was to examine the reliability, validity, and measurement error of balance confidence and fall-related self-efficacy measures in older breast cancer survivors. A cross-sectional study was performed. The Activities-Specific Balance Confidence Scale (ABC), the shorter, six-item version of the ABC (ABC-6), and the Modified Falls Efficacy Scale (MFES) were completed by 35 older breast cancer survivors. Absolute reliability was examined with Cronbach's alpha, test-retest reliability with intraclass correlation coefficient, and Pearson's correlation coefficient for construct validity. Absolute reliability was good for the ABC. Test-retest reliability was good for the ABC and the ABC-6 and moderate for the MFES. Construct validity was present for all measures. Breast cancer survivors' balance confidence measures should be assessed with either the ABC or the ABC-6, whereas falls self-efficacy should be examined with the MFES. Nurses and other health professionals who treat breast cancer survivors should include assessing psychological factors associated with falls using the ABC, the ABC-6, or the MFES as low balance confidence or falls self-efficacy contribute to increased falls risk.

IMPROVE, a community-based exercise intervention versus support group to improve functional and health outcomes among older African American and Non-Hispanic White breast cancer survivors from diverse socioeconomic backgrounds: Recruitment strategies and baseline characteristics.

Behavioral intervention studies in older breast cancer survivors, particularly older African American (AA) and socioeconomic status-disadvantaged breast cancer survivors, are lacking. To inform future studies, the authors examined recruitment strategies in older breast cancer survivors who participated in an exercise intervention study. IMPROVE is a randomized trial designed to evaluate a group-based exercise intervention versus a support group (ClinicalTrials.gov identifier, NCT02763228). Participants were aged ≥65 years who had survived stage I through III breast cancer and were within 5 years of treatment completion. Participants were recruited through multiple approaches, including peripheral, linguistic, and constituent-involving strategies that incorporated the identification of potentially eligible patients from 3 local hospitals and from State of Ohio registries and through direct clinician and community organization referrals. Between October 2016 and November 2019, 7487 patients were screened, 4790 were potentially eligible, and 213 were randomized into the study. The eligible:randomization rates were 4.4% overall and 84%, 8%, and 2% for recruitment using direct referrals, hospital registries, and state registries, respectively. The median age of the randomized cohort was 70 years (range, 65-88 years) and included 44% AA and 44% socioeconomic status-disadvantaged breast cancer survivors. Compared with all registry-eligible patients, directly referred-eligible patients were more likely to be AA versus Non-Hispanic White (41% vs 19%; P = .006), to be contacted successfully (100% vs 33%; P < .0001), and to accept study participation (88% vs 16%; P < .0001). Direct referrals appeared to be the most efficient strategy for recruiting AA survivors. Behavioral intervention studies seeking to target older AA and socioeconomic status-disadvantaged breast cancer survivors should include strategies that foster direct referrals to study participation.

Protective Effects of APOE ε2 Genotype on Cognition in Older Breast Cancer Survivors: The Thinking and Living With Cancer Study.

BackgroundCancer-related cognitive decline (CRCD) has been linked to apolipoprotein E (APOE) gene ε4 polymorphisms. APOE ε4 polymorphisms are also the strongest genetic risk for late-onset Alzheimer disease (AD), whereas ε2 polymorphisms protect against AD. However, the effects of ε2 polymorphisms on CRCD have not been evaluated.MethodsWe evaluated nonmetastatic breast cancer survivors (n = 427) and matched noncancer controls (n = 407) ages 60-98 years assessed presystemic therapy from August 2010 to December 2017 with annual follow-up to 24 months. Neuropsychological assessment measured attention, processing speed, executive function, and learning and memory. Linear mixed-effects models tested the effects of having an ε2 allele (vs none) on longitudinal cognitive domain z scores by treatment group (chemotherapy with or without hormonal therapy, hormonal therapy, and control) controlling for covariates; participants with ε2/ε4 genotype were excluded. Sensitivity analyses examined effects of other covariates and any ε4 positivity.ResultsThere was an interaction with genotype for attention, processing speed, and executive functioning domain scores (Beta = 0.32, 95% confidence interval = 0.00 to 0.65); the chemotherapy group with an ε2 allele had higher scores at baseline and maintained higher scores over time compared with those without an ε2 allele, and this protective effect was not seen for other groups. There was no effect of ε2 on learning and memory domain scores.Conclusions APOE ε2 polymorphisms may protect against CRCD in older breast cancer survivors receiving chemotherapy. With replication, this information could be useful for survivorship care and informing future studies of possible links to AD and defining mechanisms of protection.

Deficit Accumulation Frailty Trajectories of Older Breast Cancer Survivors and Non-Cancer Controls: The Thinking and Living With Cancer Study.

We evaluated deficit accumulation and how deficits affected cognition and physical activity among breast cancer survivors and non-cancer controls. Newly diagnosed nonmetastatic survivors (n = 353) and matched non-cancer controls (n = 355) ages 60-98 years without neurological impairments were assessed presystemic therapy (or at enrollment for controls) from August 2010 to December 2016 and followed for 36 months. Scores on a 42-item index were analyzed in growth-mixture models to determine deficit accumulation trajectories separately and combined for survivors and controls. Multilevel models tested associations between trajectory and cognition (FACT-Cog and neuropsychological tests) and physical activity (IPAQ-SF) for survivors and controls. Deficit accumulation scores were in the robust range, but survivors had higher scores (95% confidence intervals [CI]) than controls at 36 months (0.18, 95% CI = 0.16 to 0.19, vs 0.16, 95% CI = 0.14 to 0.17; P = .001), and averages included diverse deficit trajectories. Survivors who were robust but became frailer (8.8%) had similar baseline characteristics to those remaining robust (76.2%) but experienced a 9.6-point decline self-reported cognition (decline of 9.6 vs 3.2 points; P = .04) and a 769 MET minutes per week decline in physical activity (P < .001). Survivors who started and remained prefrail (15.0%) had self-reported and objective cognitive problems. At baseline, frail controls (9.5%) differed from robust controls (83.7%) on deficits and self-reported cognition (P < .001). Within combined trajectories, frail survivors had more sleep disturbances than frail controls (48.6% [SD = 17.4%] vs 25.0% [SD = 8.2%]; P = .05). Most survivors and controls remained robust, and there were similar proportions on a frail trajectory. However, there were differences in deficit patterns between survivors and controls. Survivor deficit accumulation trajectory was associated with patient-reported outcomes. Additional research is needed to understand how breast cancer and its treatments affect deficit accumulation.

Regional and temporal variation in receipt of long-term opioid therapy among older breast, colorectal, lung, and prostate cancer survivors in the United States.

BackgroundOlder cancer survivors have high rates of long‐term opioid therapy (≥90 days/year). However, the geographical and temporal variation in long‐term opioid therapy rates for older cancer survivors is not known.MethodsA retrospective cohort study was conducted using SEER‐Medicare data. Persons aged ≥66 years, diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 2011, and alive ≥5 years after diagnosis were included. Persons were followed from 1/1/2008 until 12/31/2016. Persons were assigned to a census region in their state of residence each year. Individuals who were covered by an opioid prescription for at least 90 days in a calendar year were classified as having received long‐term opioid therapy. Multivariable analysis was conducted using generalized estimating equations.ResultsTemporal trends significantly varied by region (p < 0.0001) and opioid‐naïve status (p < 0.0001). Compared to 2013, opioid‐naïve cancer survivors in the south and non‐naïve survivors in the south and west experienced significant declines in long‐term opioid therapy in 2015 and 2016. Significant declines were observed in 2016 for opioid‐naïve and non‐naïve cancer survivors residing in the northeast and among opioid‐naïve cancer survivors living in the Midwest.ConclusionThe annual trends in the receipt of long‐term opioid therapy significantly varied by region among older cancer survivors. Variation in a clinical practice suggests the need for more research and interventions to improve efficiency, process, cost, and quality of care.

Risk of Cardiovascular Diseases Among Older Breast Cancer Survivors in the United States: A Matched Cohort Study.

It has been suggested that cardiovascular risks are increased in breast cancer survivors, but few studies have quantified the risks of a range of specific clinically important cardiovascular outcomes in detail. Women aged >65 years with incident breast cancer from 2004 to 2013 in the SEER-Medicare linked database were matched with 5 cancer-free female counterparts (5:1 ratio). Prevalence of specific cardiovascular outcomes at baseline was measured, then Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals for the risk of individual cardiovascular outcomes during follow-up. Modification of the effect was investigated by time since diagnosis, race/ethnicity, prior cardiovascular disease (CVD), and age. In all, 91,473 women with breast cancer and 454,197 without breast cancer were included. Women with breast cancer had lower baseline prevalence of all CVDs. Compared with cancer-free controls, breast cancer survivors had substantially increased risks of deep vein thrombosis (adjusted HR, 1.67; 95% CI, 1.62-1.73; 386,484 person-years of follow-up) and pericarditis (HR, 1.43; 95% CI, 1.38-1.49; 390,776 person-years of follow-up); evidence of smaller increased risks of sudden cardiac arrest, arrhythmia, heart failure, and valvular heart disease (adjusted HRs ranging from 1.05-1.09, lower CI limits all ≥1); and evidence of lower risk of incident angina, myocardial infarction, revascularization, peripheral vascular disease, and stroke (adjusted HRs ranging from 0.89-0.98, upper CI limits all ≤1). Increased risks of arrhythmia, heart failure, pericarditis, and deep vein thrombosis persisted >5 years after cancer diagnosis. Women with a history of breast cancer were at increased risk of several CVDs, persisting into survivorship. Monitoring and managing cardiovascular risk throughout the long-term follow-up of women diagnosed with breast cancer should be a priority.