Physical activity preferences of ovarian cancer survivors

Psycho-Oncology Psycho-Oncology 18: 422–428 (2009) Published online 26 February 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1396

Physical activity preferences of ovarian cancer survivors Clare Stevinson1, Valerie Capstick2, Alexandra Schepansky2, Katia Tonkin3, Jeffrey K. Vallance1, Aliya B. Ladha1, Helen Steed2, Wylam Faught2 and Kerry S. Courneya1, 1

Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB, Canada 3 Department of Oncology, University of Alberta, Edmonton, AB, Canada 2

* Correspondence to: Faculty of Physical Education and Recreation, University of Alberta, E-488 Van Vliet Center, Edmonton, AB, Canada T6G 2H9. E-mail: kerry.courneya@ ualberta.ca

Received: 26 October 2007 Revised: 11 April 2008 Accepted: 25 April 2008

Abstract Objective: Regular physical activity is positively associated with quality of life in ovarian cancer survivors, but no data exist on how best to promote activity in this population. This study investigated the interests and preferences of ovarian cancer survivors with regard to physical activity participation. Methods: A provincial, population-based postal survey of ovarian cancer survivors in Alberta, Canada, was performed including measures of self-reported physical activity, medical and demographic variables, and physical activity preferences. Results: A total of 359 women participated (51.4% response rate). Over half expressed interest in participating in a physical activity program (53.8%), with a further 32.9% maybe interested. The most common preferences were for programs to be home-based (48.9%), start post-treatment (69.5%), and involve walking (62.7%). There were differences in preferences based on demographic, but not medical, factors. Conclusion: The majority of ovarian cancer survivors expressed interest in participating in physical activity programs; however, some preferences varied by demographic factors. Designing physical activity interventions according to these preferences may optimize adherence and outcomes in ovarian cancer survivors. Copyright r 2009 John Wiley & Sons, Ltd. Keywords: gynecologic cancers; ovarian neoplasms; survivorship; exercise; cancer; oncology

Ovarian cancer is the eighth most common cancer among women, and ranks second among gynecologic cancers. An estimated 21 650 cases will be diagnosed in the United States during 2008 [1]. Treatment typically involves surgical debulking and adjuvant chemotherapy, with the goal of increasing survival or disease-free intervals. Although prognosis is generally poor, and the chance of recurrence is high, survival rates have significantly improved in the last decade. Overall, 5-year survival is currently estimated at 45%, compared with 37% in 1976 [1]. As survival rates improve, the importance of promoting healthy lifestyle choices among ovarian cancer survivors increases. Although the direct impact of physical activity on ovarian cancer survival is unknown, it may have an important role through weight control, since obesity is negatively associated with survival [2]. Furthermore, we have previously reported a positive association between physical activity and quality of life in ovarian cancer survivors [3]. Although a strong body of evidence exists for the functional and quality of life benefits of physical activity for cancer survivors [4,5], studies of physical activity participation rates have consistently reported low levels of activity [6–8]. We have

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previously reported [3] that only 31% of ovarian cancer survivors were meeting current physical activity guidelines. The equivalent figure for women aged 45–64 years in the general population is 46%, and for those aged 65 years or above, 36% [9]. In order to design optimal health promotion interventions aimed at increasing physical activity, it is important to be aware of the preferences of the target population. Although some data are available for other cancer populations such as brain [10], endometrial [11], bladder [12], and non-Hodgkin lymphoma [13], there are no published data on the preferences regarding physical activity of women with ovarian cancer. The specific objectives of the present study were to ascertain the interest and identify the preferences of ovarian cancer survivors regarding participating in a physical activity program, and to examine any associations between demographic and medical variables and physical activity preferences. On the basis of the results of similar research in other cancer survivor groups, we hypothesized that interest in physical activity would be high, and preferences would be strongest for home-based physical activity, particularly walking, and a post-treatment start date. Comparisons based on different demographic and medical variables were considered exploratory.

Physical activity preferences

Methods Study procedures have been described fully elsewhere [3]. In summary, the Alberta Cancer Board Research Ethics Board and the University of Alberta Research Health Ethics Board provided ethical approval to conduct a postal survey of ovarian cancer survivors identified through the Alberta Cancer Registry. Eligibility criteria were (1) aged 18 years or over, (2) diagnosis of histologically confirmed ovarian cancer between 1985 and 2005, (3) approval of the treating oncologist or general practitioner, and (4) ability to understand English. Participants were asked to complete a consent form and questionnaire. Similar to elements of the tailored design method of survey implementation [14], a reminder postcard was sent to non-responders after 2 weeks, followed by a second questionnaire pack after 6 weeks.

Measurements Medical information (i.e. date of diagnosis, histologic sub-type, disease stage, grade, borderline vs invasive, and treatments received) was obtained from the cancer registry where available. Additional medical and demographic data (i.e. age, marital status, employment status, education level, family income, height, weight, medical comorbidities, current disease status, and current treatments) were obtained by self-report. Current physical activity participation was assessed by the Leisure Score Index (LSI) of the Godin Leisure Time Exercise Questionnaire [15], which requires participants to recall their average weekly frequency of mild (e.g. easy walking, bowling), moderate (e.g. fast walking, folk dancing), and strenuous (e.g. running, cross-country skiing) intensity activity during the past month. Participants were also asked to indicate the average duration of activities. Reliability and validity of the LSI have been shown to compare favorably with other measures of physical activity and fitness [16]. Moderate and strenuous minutes of physical activity per week were computed by multiplying the average frequency by the average duration. The physical activity guidelines of the American Cancer Society (ACS) [17] and the American College of Sports Medicine (ACSM)/American Heart Association (AHA) [18] were used to classify participants as meeting public health guidelines (Z150 min of moderate and strenuous intensity physical activity or Z60 min of strenuous intensity physical activity per week accumulated in bouts of at least 10 min). Interests and preferences for physical activity participation were assessed using nine closed-item questions and one open-ended question (favorite type of activity). These questions have been used in Copyright r 2009 John Wiley & Sons, Ltd.

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Table 1. Preferences regarding physical activity program participation of ovarian cancer survivors Preference variable

N (%)

Would have liked physical activity information after diagnosis (n 5 345) Yes 164 (47.5%) Maybe 102 (29.6%) No 79 (22.9%) Capable of participating in physical activity program (n 5 350) Yes 226 (64.6%) Maybe 101 (28.9%) No 23 (6.6%) Interested in participating in physical activity program (n 5 346) Yes 186 (53.8%) Maybe 114 (32.9%) No 46 (13.3%) Preferred time of commencing physical activity program (n 5 318) After diagnosis 57 (17.9%) During treatment 40 (12.6%) Immediately after treatment 81 (25.5%) 3–6 months after treatment 82 (25.8%) 1 year after treatment 58 (18.2%) Preferred company during physical activity program (n 5 334) Friends and family 102 (30.5%) Alone 97 (29.0%) Other cancer survivors 53 (15.9%) No preference 82 (24.6%) Preferred location of physical activity program (n 5 321) Home Fitness center Cancer center No preference

Preferred time of day of physical activity program (n 5 327) Morning Evening Afternoon

157 (48.9%) 67 (20.9%) 22 (6.9%) 75 (23.4%)

160 (48.9%) 57 (17.4%) 49 (15.0%)

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Table 1. (Continued ) Preference variable No preference

Preferred type of physical activity (n 5 300) Walking Swimming Yoga Cycling Aerobics Others

Current member of fitness centre (n 5 351) Yes No

Owned home exercise equipment (n 5 204) Stationary bike Treadmill Weights Stair stepper Elliptical trainer

N (%) 61 (18.7%)

188 (62.7%) 13 (4.3%) 12 (4.0%) 10 (3.3%) 9 (3.0%) 68 (22.7%)

Results 67 (19.1%) 284 (80.9%)

70 (34.3%) 52 (25.5%) 50 (24.5%) 18 (8.8%) 14 (6.9%)

previous studies of exercise preferences in other cancer populations [11,13,19], although reliability or validity testing has not been conducted. The questions and response choices are presented in Table 1.

Data analysis The physical activity preferences of the sample were determined by calculating frequencies and percentages of responses. To examine potential associations between demographic and medical variables and physical activity preferences, a series of six logistic regression equations was performed. All variables were dichotomized to ensure adequate numbers of participants per cell and maximize statistical power. Dichotomization was based on the nearest median split and/or clinically relevant cut-points. The physical activity preference variables used were interest in participating in an exercise program (yes vs no/maybe), preferred location (home vs other), preferred company (alone vs other), preferred start time (at diagnosis/during treatment vs post-treatment), preferred time of day (morning vs other), and preferred activity (walking vs other). Demographic variables were age (o60 years vs Z60 years), education level (high school or below vs at least some post-secondary), employCopyright r 2009 John Wiley & Sons, Ltd.

ment status (working full/part time vs retired/ disability leave), annual family income (o$60 000 vs $60 000), and marital status (married/common law vs single/divorced/widowed). Medical variables were time since diagnosis (o60 months vs Z60 months), disease status (disease-free vs current disease), current chemotherapy (yes vs no), and body mass index (BMI) (healthy weight vs overweight/obese). Healthy weight was defined as a BMI of o25, overweight as 25–29.9, and obese as Z30. A probability value of o0.01 was used as the level of statistical significance.

A detailed flow diagram of the study and participant characteristics have been presented elsewhere [3]. In summary, a total of 359 ovarian cancer survivors returned completed questionnaires resulting in a 51.4% response rate. The mean age was 60.2712.6 years, 73.5% were married or had a common law partner, and 40.9% were working full or part time. The mean BMI was 27.175.4, with 37.0% overweight and 24.2% obese. One or more medical comorbidities were reported by 78.1% of the sample, most commonly arthritis (42.3%) and hypertension (35.1%). The mean number of months since diagnosis was 73.6752.6, with 82.7% of participants in remission. Overall, 97.8% had received surgery, 70.5% chemotherapy and 6.4% radiation therapy; 8.1% were still receiving chemotherapy. Based on the ACS and ACSM/AHA criteria, 112 (31.1%) participants were meeting public health physical activity guidelines. A total of 192 (53.4%) reported no moderate or strenuous intensity physical activity. To assess the representativeness of the sample, available medical variables for participants and non-participants were compared. Study participants were closer than non-participants to the date of diagnosis (73.6 vs 93.8 months; Po0.001), and were more likely to have received chemotherapy (70.5% vs 52.0%; Po0.001), and have invasive tumors (85.8% vs 75.3%; Po0.001). Table 1 summarizes the preferences of participants. Over half expressed interest in participating in a physical activity program (53.8%), with a further 32.9% maybe interested. Approximately half the sample had a preference for a program to be based at home (48.9%), during the morning (48.9%), and commencing within 6 months of treatment completion (51.3%). Similar numbers favored exercising alone (29.0%) or with friends/ family (30.5%). Walking was the preferred activity for 62.7%. Table 2 presents a summary of the significant associations between physical activity preferences and demographic and medical variables. The results of the logistic regression analyses suggested Psycho-Oncology 18: 422–428 (2009) DOI: 10.1002/pon

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Table 2. Associations between physical activity preferences and demographic variables Physical activity preference variable

Demographic variables with significant associations

Interested in participating in a program

Age: 69.8% vs 37.9%; OR 5 0.27 [95% CI: 0.17–0.41]; Po0.001 Education: 43.5% vs 61.3%; OR 5 2.10 [95% CI: 1.32–3.24]; P 5 0.001 Employment: 42.1% vs 70.1%; OR 5 3.23 [95% CI: 2.01–5.09]; Po0.001

Preferred location at home

Age: 40.1% vs 57.9%; OR 5 2.05 [95% CI: 1.31–3.20]; P 5 0.001 Education: 59.5% vs 41.6%; OR 5 0.48 [95% CI: 0.31–0.76]; P 5 0.001 Activity: 56.2% vs 33.3% OR 5 0.39 [95% CI: 0.24–0.64]; Po0.001

Preferred to exercise alone

Age: 22.9% vs 35.4%; OR 5 1.84 [95% CI: 1.14–2.97]; P 5 0.009 Education: 35.3% vs 24.7%; OR 5 0.60 [95% CI: 0.41–0.97]; P 5 0.001 Activity: 32.6% vs 21.5%; OR 5 0.57 [95% CI: 0.33–0.97]; Po0.001

Preferred to start after treatment

Age: 54.9% vs 72.4%; OR 5 2.16 [95% CI: 1.28–3.64]; P 5 0.003

Preferred to exercise in the morning

Employment: 56.1% vs 39.3%; OR 5 0.50 [95% CI: 0.32–0.79]; P 5 0.003 Marital status: 62.8% vs 44.0%; OR 5 0.47 [0.28–0.77]; P 5 0.003 Income: 69.9% vs 52.3%; OR 5 0.47 [95% CI: 0.28–0.79]; P 5 0.004 Activity: 72.1% vs 44.7%; OR 5 0.31 [95% CI: 0.19–0.51]; Po0.001

Preferred activity being walking

Age (o60 vsZ60 years); Education (rhigh school vsZsome post-secondary); Employment (retired/disability leave vs working full/part time); Income (o$60 000 vsZ$60 000); Marital status (single/divorced/widowed vs married/common law); Activity level (not meeting guidelines vs meeting guidelines).

that age, education level, employment status, annual family income, and current physical activity level influenced the physical activity program preferences of participants. Specifically, interest in an exercise program was higher among participants who were aged o60 years, who had at least some post-secondary education, and who were working full or part time. Greater preference for activity based at home, and also for exercising alone, existed for participants who were agedZ60 years, who had no more than a high school education, and who were not currently meeting physical activity guidelines. Preference for walking was highest for participants with an annual family income of o60 000, and those not currently meeting physical activity guidelines. No differences based on medical variables were observed.

Discussion The majority of ovarian cancer survivors in this study expressed definite or possible interest in receiving physical activity information (77%), and participating in a program (87%), which is very encouraging given the wide range of potential benefits achievable through physical activity for cancer survivors [20,21]. Studies of other cancer populations have reported similar high levels of interest [10–13,19], and a body of evidence is accumulating that demonstrates a desire from cancer survivors for provision of physical activity services. Nonetheless, there was no interest in information or a program from 23 and 13% respectively, despite only 7% stating that they were not capable of exercising. This Copyright r 2009 John Wiley & Sons, Ltd.

provides an indication of the challenge that health promotion strategies must overcome with some cancer survivors who may be unaware, or unconvinced, of the importance of physical activity for general health. Some clear preferences regarding physical activity programs emerged from our sample. As hypothesized, a large majority of participants preferred to commence a program after completing treatment, rather than at the time of diagnosis or during cancer therapy. Evidence for the benefits of physical activity on quality of life and functional outcomes is in fact stronger for post-treatment interventions than for those during therapy [5], although encouraging results have been achieved while receiving treatment for breast cancer [22,23]. Similar numbers of participants had a preference for exercising alone (29%) or with friends and family (31%), and consistent with that, home was the preferred location for 48%. Very few participants preferred to exercise with other cancer survivors or at a cancer center. These findings are consistent with the preferences reported for survivors with endometrial [11] and bladder [12] cancers, brain tumors [10], and non-Hodgkin lymphoma [13]. Interestingly, there are several studies of group exercise programs where participants report that the opportunity to exercise with other people with cancer was highly valued [24], referring to a sense of comradeship like being ‘brothers in arms’ in the Army [25] and friendships with others who had ‘traveled the same road’ [26] or ‘fought your battle’ [27]. However, the data from population-based surveys suggest that the participants who chose to join group programs may not be representative of the majority of survivors in this respect. Psycho-Oncology 18: 422–428 (2009) DOI: 10.1002/pon

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As hypothesized, the results clearly indicated an overall preference for home-based walking programs. It was notable that this preference was significantly stronger for participants who were not currently meeting physical activity guidelines than those who were meeting them. Preference for walking was also stronger for participants with lower incomes. Since walking involves little cost, equipment, or travel, and is an achievable activity for most individuals regardless of physical activity history, it is an ideal activity to promote to ovarian cancer survivors, and an effective way of achieving physical activity guidelines. Although there may be concerns over lower adherence and higher risk of adverse events with home-based programs compared with supervised interventions, several trials using this type of program [28,29] have demonstrated encouraging adherence and few adverse events that support the promotion of such interventions. Age, education level, and current physical activity level were the variables most consistently associated with physical activity interests and preferences in this study. Although age did not influence preferences in most other studies of cancer survivor populations [10,11,13,19], homebased programs were preferred by older bladder cancer survivors [12]. There was greater preference for home-based programs performed alone, from participants with less education. This is compatible with a study of survivors of various cancers, which also found lower education associated with preferring to exercise at home [19]. However, in a study of endometrial cancer, those with a lower education preferred to exercise away from home [11], while for bladder cancer survivors, higher education was associated with preferring to exercise alone [12]. As already discussed, participants who were not currently meeting physical activity guidelines had a greater preference for exercising at home and alone, with walking as the activity of choice. Interestingly, in the study of endometrial cancer survivors, it was the participants who were meeting guidelines who preferred to exercise at home [11]. Although it is not clear why women with ovarian and endometrial cancer would differ in this respect, it may relate to discrepancies in treatment, disease status, obesity rates, or ownership of home exercise equipment. Nonetheless, different results observed for specific populations serve to highlight the importance of investigating them separately, rather than generalizing findings across all cancer survivor groups.

Implications The majority of ovarian cancer survivors are receptive to physical activity promotion. However, women who are older, less educated, and retired/on sick leave, express the least interest, and may prove Copyright r 2009 John Wiley & Sons, Ltd.

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to be the most resistant to behavior change. In general, women favor exercise interventions that take place after treatment completion, that are based at home, and that can be performed alone or with friends or family. Walking is popular, particularly with low-income and currently inactive women. Developing interventions that enable survivors to build up to at least 30 min of brisk walking on 5 days of the week will help them achieve public health guidelines for physical activity. While considering the general implications of this research, there was sufficient variation among study participants to suggest that an optimal design of interventions will involve attempts to be flexible and tailor interventions to the personal preferences of individuals. From a research perspective, these results suggest that there is sufficient interest and perceived capability from ovarian cancer survivors to warrant intervention studies of physical activity. Although preference was greatest for starting an exercise program post-treatment, there was sufficient desire for commencing one before or during treatment to suggest that a trial at this time-point might also be well received. Recruitment may prove to be slower than with participants who have already completed treatment, but evidence from other populations indicates the potential benefits that may be demonstrated while undergoing treatment [22,23,29].

Strengths and limitations This study represents the first investigation of the preferences of ovarian cancer survivors with regard to physical activity, and provides useful data to assist in intervention planning. Strengths include the large provincial, population-based sample of ovarian cancer survivors, and the use of official registry data for recording medical variables. One limitation relates to the response rate of 51% and the transparent purpose of the study, which increases the likelihood of a self-selected sample. Another is the reliance on self-reported physical activity, which likely resulted in an overestimate of the amount of physical activity being performed. A third is the use of preference questions that have not been tested for reliability and validity although their face validity seems high. A further weakness is the dichotomization of variables for the analysis, which may have masked some potentially interesting findings. Future studies with larger sample sizes may be able to analyze even finer distinctions in physical activity preferences. Finally, the large number of analyses performed increases the probability that some significant results occurred by chance, although our focus in interpreting the results has been based on the overall pattern of findings. Psycho-Oncology 18: 422–428 (2009) DOI: 10.1002/pon

Physical activity preferences

In summary, the majority of ovarian cancer survivors express interest in receiving information and participating in physical activity programs. Post-treatment, home-based walking programs were most popular overall, but particularly with survivors who were currently inactive, and those who were older and less educated. Considering the preferences of ovarian cancer survivors in the design of interventions may optimize adherence and improve outcomes in this population.

Acknowledgements Sources of support: This study was funded by the University of Alberta and a Research Team Grant from the National Cancer Institute of Canada (NCIC), with funds from the Canadian Cancer Society (CCS) and the NCIC/CCS Sociobehavioral Cancer Research Network. Kerry S. Courneya is supported by the Canada Research Chairs Program. Clare Stevinson is now with the Macmillan Research Unit, University of Manchester, the United Kingdom. Jeffrey K. Vallance is now with the Centre for Nursing and Health Studies, Athabasca University, Canada. Aliya B. Ladya is now at the American University of the Caribbean School of Medicine, St Maarten, Netherlands Antilles. Wylam Faught is now with the Department of Obstetrics and Gynecology, University of Ottawa, Canada. Conflict of interest: None.

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