Decision Sciences

National Institute On Minority Health And Health Disparities

Investigators

Linked publications, trials & patents

Abstract

The following manuscripts were developed by the staff of this research program: 1) Summarizing the Effects of Exercise Communication on Exercise Participation among Breast Cancer Survivors Exercise offers various clinical benefits to breast cancer survivors. However, exercise participation among survivors is low. Discussions about exercise can increase participation, but details regarding implementation of exercise communication for breast cancer survivors are unclear. In this project, we examined the development and implementation of explicitly reported exercise communication for breast cancer survivors. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-Scoping Reviews) to conduct this study. Six databases (PubMed/MEDLINE, Cochrane Library, Embase, Web of Science, Communication and Mass Media Complete, and PsycINFO) were searched for articles describing exercise communication for female breast cancer survivors in any geographical location or setting published up to April 2024. Information about study and participant characteristics, exercise communication, and intervention components and effects were extracted. Thirty-nine studies were included. Information consistent with exercise guidelines was communicated in 32 studies for aerobic exercise (82.1%) and 7 studies for muscle-strengthening exercise (17.9%). Most interventions reported an increase in exercise (19 of 21 [90.4%]) among breast cancer survivors. However, data were limited about the development and implementation of these interventions among breast cancer survivors in communities with limited access to healthcare resources. 2) Examining Disparities in Physical Activity Participation and Communication among Breast Cancer Survivors There are limited data on population-level patterns of exercise among breast cancer survivors in the U.S. In this study, we aimed to quantify adherence to exercise guidelines in breast cancer survivors and female adults without cancer based on race, ethnicity, and socioeconomic characteristics. The overarching goal was to provide information to support the development of targeted interventions to improve breast cancer survivorship care in the U.S. Data for female aged ≥35 years with and without breast cancer (at time of the survey) were obtained from the 2004-2018 National Health Interview Survey (NHIS). Female adults met aerobic exercise guidelines if they participated in ≥150 minutes of moderate intensity physical activity per week; and muscle strengthening exercise guidelines if they participated in ≥2 strength training sessions per week. We used NHIS survey weights to generate national-level estimates and absolute differences in the percentage of breast cancer survivors and female adults without cancer meeting aerobic, and muscle strengthening guidelines stratified by age, race, ethnicity, marital status, insurance status, and socioeconomic characteristics. Absolute (between-group variance) and relative (mean log deviation) indices of disparity were generated using the National Cancer Institute's health disparities calculator (HD*Calc). The study included 5,485 breast cancer survivors and 160,162 female adults without cancer. The percentage of breast cancer survivors meeting aerobic guidelines was 37.7% compared to 40.9% of female adults without cancer. A lower proportion of female adults met muscle strengthening guidelines (17.6% breast cancer survivors; 18.6% of female adults without cancer). The proportion of breast cancer survivors meeting aerobic or muscle strengthening exercise recommendations were lower compared to female adults without cancer across younger ages (35-49; 50-64), race/ethnicity (non-Hispanic Asian, non-Hispanic American Indian/Alaska Native, non-Hispanic Black, Hispanic), education (<high school), employment, income (<1.5 ratio of imputed family income to poverty threshold), and homeownership (rented). For example, the percentage of Hispanic female adults meeting aerobic exercise guidelines was 4.2% (95% CI: 3.2-5.5%) among breast cancer survivors compared to 11.2% (95% CI: 10.7-11.7%) of female adults without cancer, for an absolute difference of 7% (95% CI: 5.7-8.2%). The absolute and relative disparity indices indicated that the most severe disparities for both aerobic and muscle strengthening exercise exist across race and ethnicity. Exercise offers various clinical benefits to older breast cancer survivors. However, studies report that healthcare providers may not regularly discuss exercise with their patients. We evaluated clinical and sociodemographic factors associated with receiving advice about exercise from healthcare providers among older breast cancer survivors (aged ≥65 years). We used data from the Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare Health Outcomes Survey (MHOS) from 2008-2015. We included female breast cancer survivors, aged ≥65 years, who completed the MHOS survey ≥2 years after a breast cancer diagnosis in a modified Poisson regression to identify clinical and sociodemographic determinants of reportedly receiving advice about exercise from healthcare providers. The sample included 1,836 breast cancer survivors. The median age of the sample was 76 years (range:72-81). Overall, 10.7% of the survivors were non-Hispanic Black, 10.1% were Hispanic, and 67.8% were non-Hispanic White. Only 52.3% reported receiving advice about exercise from a healthcare provider. Higher body mass index (BMI) and comorbid medical history that included diabetes, cardiovascular, or musculoskeletal disease were associated with a higher likelihood of receiving exercise advice. Lower education levels, lower BMI, and never having been married were associated with a lower likelihood of receiving exercise advice. The findings suggest that interventions are needed to improve exercise counseling between providers and survivors, especially with female adults with lower educational attainment who have never been married. 3) Evaluating the Impact of Exercise on Quality of Life and Cardiovascular Events among Breast Cancer Survivors Breast cancer survivors are at increased risk of poor health-related quality of life (HRQOL). Clinical trials suggest that physical activity may improve HRQOL among cancer survivors. However, there is limited evidence to confirm if these benefits translate to the broader population of patients seen in real-world settings. We aimed to fill this gap by evaluating the observational literature on post-diagnosis recreational physical activity and HRQOL among breast cancer survivors. The observational findings were compared with clinical trial data. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted using MEDLINE/PubMed and six other databases to identify studies from January 2003 to October 2024. Study characteristics and adjusted analyses of the association between physical activity and HRQOL were extracted. A qualitative synthesis was performed, categorizing HRQOL outcomes into global, physical, emotional, social, and breast cancer-specific domains. Clinically meaningful differences were assessed by comparing adjusted mean differences to established minimally important differences. We compared key study design features and findings between observational studies and clinical trials. The search identified 5,831 sources, with 11 observational studies meeting inclusion criteria across the U.S. and internationally. Most studies reported positive associations between physical activity and HRQOL. For breast cancer survivors meeting aerobic physical activity guidelines, five studies found clinically meaningful improvements in global HRQOL, two found clinically meaningful improvements in physical HRQOL, and one found clinically meaningful improvement in the breast cancer-specific subscale of HRQOL. There were also improvements in emotional and social well-being associated with aerobic activity. However, only a few studies reported these domains, and none met minimally important difference threshold. Only one study reported on muscle-strengthening exercise and found that meeting muscle-strengthening guidelines was associated with improved global and physical HRQOL, however, the estimates did not meet minimally important difference threshold. There was no evidence on effective dosage or types of physical activity for optimal HRQOL outcomes. The observational findings were consistent with clinical trial findings among breast cancer survivors. Breast cancer survivors are at increased risk of cardiovascular events due to the cardiotoxic effects of cancer treatment. Exercise participation can lower the risk of various adverse cardiovascular health outcomes. We critically evaluated the observational literature describing the direction and strength of the relationship between post-diagnosis leisure-time exercise (aerobic and muscle-strengthening) and cardiovascular health (cardiovascular disease, cardiac function, and related physiological risk factors) among diverse breast cancer survivors; and identify variations in this relationship based on race, ethnicity, and/or socioeconomic status. A scoping review was conducted in accordance with established guidelines and frameworks. Seven databases were searched. Participant characteristics, findings regarding the relationship between exercise and cardiovascular health, and any variations in this relationship were extracted. Fourteen sources were identified, and study quality varied. Two adjusted analyses found aerobic exercise may lower the risk of cardiovascular disease. There was limited data found on the direction and strength of an adjusted relationship between exercise (aerobic or muscle-strengthening) and other cardiovascular outcomes or possible variations in the relationship across racial, ethnic, or socioeconomic groups. 4) Needs Assessment Studies: Healthcare Provider and Breast Cancer Survivor Perspectives on a Clinical Decision Tool to Support Individualized Exercise Prescriptions Current cancer exercise guidelines recommend clinicians provide individualized ‘exercise prescriptions’ for cancer survivors. However, the guidelines themselves provide limited information on the optimal frequency, intensity, duration, and type of exercise a healthcare provider may need to consider in an exercise prescription given the survivor’s individual characteristics. This is important as studies suggest that individual demographic (e.g., age), clinical (e.g., comorbidities), and contextual (e.g., neighborhood safety) factors could determine exercise participation and health outcomes among breast cancer survivors in the US. Moreover, individualized exercise prescriptions may require healthcare providers to conduct comprehensive assessments of needs, values, and preferences of female adults diagnosed with breast cancer. However, it is unclear how ‘exercise prescriptions’ would be implemented practically as a part of survivorship care. To address these knowledge gaps, we evaluated breast cancer survivors’ and healthcare providers’ current knowledge and practices regarding exercise discussions with breast cancer survivors. We also gathered survivor’s and provider’s perspectives on a beta version of a clinical decision tool that could provide individualized exercise prescriptions. Finally, we also examined any differences in knowledge, practices, and perspectives on the tool across survivor and provider characteristics. The overarching goal of this project was to inform the development of an individualized clinical decision tool to support discussions and exercise prescriptions for breast cancer survivors in clinical settings. We had complete survey responses from 177 healthcare providers including clinicians (38.4%), exercise specialists (19.8%), occupational/physical therapists (18.1%), advanced care providers, nurses, navigators, and social workers (23.7%). Median years of experience was 8-years (range: 5-13). Overall, 62.1% (n=110) reported that they were knowledgeable about counseling survivors based on exercise guidelines. Among clinicians (n=68), only 39.7% reported that they were knowledgeable about identifying patients for exercise referrals. The majority agreed that they would find the tool offering individualized information useful (n=148, 83.6%) and would use it regularly to inform practice (82.5%). ‘Exercise Readiness’, ‘Exercise Resources at Home’, and ‘Quality-of-Life’ were the highest rated items for inclusion in the tool for exercise prescriptions. Similar results were observed among breast cancer survivors. 5) Developing a Simulation Model-based Clinical Decision Tool to Support Individualized Exercise Prescriptions for Breast Cancer Survivors Clinical decision tools considering patient characteristics, treatment, and breast cancer outcomes associated with exercise could increase clinician’s confidence to discuss, educate, encourage, and provide exercise prescriptions for breast cancer survivors. However, to our knowledge, currently there are no tools that provide individualized outcomes associated with different amounts and types of exercise for breast cancer survivors seen in clinical practice. In this project, we adapted an established discrete-event simulation modeling approach to generate individualized survival outcomes and absolute benefits associated with exercise for US female adults with breast cancer. We aimed to provide simulation model-based estimates for a clinical tool that could help clinicians discuss the benefits of exercise considering patient's characteristics, breast cancer treatment, and survival. The overarching goal of this study was to support patient-provider discussions to gradually increase post-diagnosis exercise and improve overall survival among breast cancer survivors.