Feasibility and promise of a 6-week program to encourage physical activity and reduce joint symptoms among elderly breast cancer survivors on aromatase inhibitor therapy

https://doi.org/10.1016/j.jgo.2013.12.002Get rights and content

Abstract

Background

National guidelines suggest that women with hormone receptor positive breast cancer be considered for adjuvant endocrine treatment with an aromatase inhibitor (AI). Joint symptoms (arthralgia) are a common AI side-effect. There is a need for effective approaches to arthralgia management that enable survivors to remain on AI therapy while optimizing as pain-free a life as possible. This feasibility study investigates a 6-week self-directed walking program in a sample of elderly female breast cancer survivors on AIs reporting joint pain.

Methods

Intervention: Walk With Ease (WWE) goal—minimum 30 min of walking 5 days a week (150 min per week). Eligibility: age > 65; Stage I–III breast cancer; ≥ 3 months of AI therapy; self-reported joint pain/stiffness. Measures: (1) walking—number of days/week and number of minutes/walk, (2) visual analog scales (VAS) for joint pain, fatigue and stiffness, and (3) arthritis self-efficacy (ASE) to manage joint pain and fatigue. Statistics: t-tests, correlation coefficients and effect sizes.

Results

Sample target of 20 was achieved—mean age 71 (65–87), 85% Caucasian, mean BMI 29. Proportion walking 150 min/week increased from 21% at baseline to 50% at 6 weeks (p < 0.001). Mean joint pain at baseline (39.7 + 26.9) decreased 10% (p = 0.63), fatigue (37.4 + 33.3) decreased 19% (p = 0.31), joint stiffness (46.1 + 27.2) decreased 32% (p = 0.07).

Conclusions

A self-directed walking program among elderly breast cancer survivors on AI therapy significantly increased total time of walking per week over a 6 week period. Joint pain, stiffness, and fatigue also decreased, although not significantly. Testing within a larger sample is warranted.

Introduction

Breast cancer is the most common cancer among women in the U.S., with estimated 232,340 new diagnoses in 2013 and a lifetime risk among women born today of 1 in 8.1 Most new diagnoses are made in postmenopausal women, generally at an early and curable stage, with hormone receptor positive (HR +) tumors, and where there is a significant survival benefit from adjuvant endocrine therapy.[2], [3], [4], [5] For such patients, the American Society of Clinical Oncology Clinical Practice Guideline: Update on Adjuvant Endocrine Therapy for Women with Hormone Receptor-Positive Breast Cancer and the International Society of Geriatric Oncology recommend that adjuvant endocrine therapy include a third generation aromatase inhibitor (AI) – anastrozole, exemestane, or letrozole – as part of treatment.[6], [7]

Non-inflammatory joint pain, stiffness or achiness – known as AI-associated arthralgia (AIA) – is a common and troublesome side-effect.[8], [9], [10], [11] In clinical trials, estimates of AIA range from 5% to 36%[12], [13], [14], [15]; however, reporting of musculoskeletal events was inconsistent in these trials and did not include patient-reported symptom questionnaires inquiring specifically about musculoskeletal symptoms.[9], [16] In clinical practice, by contrast, estimates of adverse joint symptoms are estimated as high as 33% to 74% among patients on AI therapy.[17], [18], [19], [20], [21], [22], [23], [24] Of those who report AIA, almost 70% rate their symptoms as moderate to severe.[18], [21] Sites most often affected include knees, feet, pelvic and hip bones, back, hands (fingers, wrists), and arms.[16], [23], [25] Symptoms can appear anywhere from 6 weeks to 12 months of starting AI therapy, increase over time, cease upon discontinuation of AI therapy, and range from minor to moderate or severe.[18], [26], [27]

For survivors whose symptoms are moderate to severe, there are growing concerns that AIA can undermine full adherence with doctor-recommended AI dosage[17], [18], [23], [28], [29] and thereby compromise treatment efficacy.[3], [28], [30] Complete discontinuation due to side-effects ranges from 20% to 32%.[18], [23], [31], [32] Both self-medication at lower-than-recommended doses and complete discontinuation of AI due to side effects are important survivorship concerns for oncologists treating patients with breast cancer.[28], [33] Switching among AIs is a common AIA management option,[34], [35] and pharmaceutical treatment options include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), pain modifiers, and sleep aids.[3], [8], [10], [36], [37] However, to date, there have been no formal assessments of these symptom management options in clinical trials.[3], [9] More importantly, for too many survivors on AI therapy, pharmacological remedies provide little or no relief18 and have their own adverse side effects.38 There is a need for effective, easy-to-use, and sustainable adjunctive approaches to AIA management,30 to minimize or ameliorate symptoms so that survivors remain on AI therapy to maximize breast cancer specific survival.

We conducted a pilot study to investigate whether a scalable (easy to implement) physical activity intervention – a self-directed walking program – is feasible and potentially effective in providing relief for survivors on AI therapy who report joint pain or other joint symptoms. The general benefits of physical activity for overall survival, quality of life and cardiovascular health are already well-established through randomized controlled trials (RCTs) and observational studies conducted over the past several decades[39], [40], [41], [42], [43], [44], [45], [46]; in fact, guidelines encourage persons diagnosed with cancer to participate in physical activity.[47], [48], [49] The physical activity intervention evaluated in this pilot study – the Arthritis Foundation's self-directed walk with ease (WWE) program – is evidence-based for reducing self-reported arthritis or joint pain among adults. The primary outcomes of interest are the feasibility of (a) recruiting and retaining our target population for the intervention study and2 increasing walking among study participants during the 6-week WWE program. Secondary outcomes of interest were preliminary evidence of positive program impacts (promise) on patient-reported outcome measures related to joint pain, stiffness and fatigue and self-efficacy to manage joint symptoms.

Section snippets

Setting and Participants

Target enrollment was 20 breast cancer survivors. Participants were recruited on a consecutive basis between June and October 2012 through breast cancer clinics at the North Carolina Cancer Hospital (NCCH). The study team identified potential participants – female breast cancer survivors age 65 or older and on AI therapy for three months or more – through a review of medical records of patients scheduled for an NCCH clinic visit. For each potential participant identified through this process,

Results

A review of medical records for scheduled patients identified 61 potential participants—female patients with breast cancer, age 65 or older on AI therapy for 3 months or more. Treating clinicians determined that: (a) 7 patients (11%) had medical conditions that were too complex for a physical activity program, (b) 10 patients (16%) were not AI compliant (stopped or never started), and (c) 13 patients (21%) were not experiencing joint pain. Of the remaining 31 patients approached by the study

Discussion

The purpose of our pilot study was to investigate whether a self-directed walking program was feasible and potentially effective in providing relief for elderly breast cancer survivors on AI therapy who report joint pain or other joint symptoms. Our findings show that a self-directed walking program is feasible from two perspectives. First, it is feasible to identify and recruit study participants by working collaboratively with breast cancer oncologists and nursing staff in a busy clinic

Disclosures and Conflict of Interest Statements

There is no conflict of interest.

Author Contributions

Study concepts and design: L.F. Callahan, H.B. Muss, K.A. Nyrop, M. Altpeter

Data acquisition: K.A. Nyrop, B. Hackney

Data analysis and interpretation: K.A. Nyrop, R. Cleveland

Manuscript preparation: K.A. Nyrop

Manuscript editing and review: L.F. Callahan, H.B. Muss, K.A. Nyrop, M. Altpeter

Final approval of manuscript: All authors

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