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Originally published as JCO Early Release 10.1200/JCO.2008.20.2317 on November 17 2008 © 2008 American Society of Clinical Oncology.
In Reply:
Behavioral Research Center, American Cancer Society, Atlanta, GA
Department of Medicine, Dalhousie University, Halifax, Canada
Department of Physical Education and Recreation, University of Alberta, Edmonton, Canada
Nutrition and Physical Activity, American Cancer Society, Atlanta, GA We thank Cai et al for their response to our article regarding the relationship between compliance with American Cancer Society (ACS) lifestyle recommendations and health-related quality of life (HRQoL) among survivors of six cancers,1 and for raising several interesting and important considerations. As reported previously, the major findings of our study were two-fold. First, cancer survivors demonstrated good compliance with the recommendation to avoid tobacco products (82.6% to 91.6%), but had relatively poor compliance with guidelines in the areas of physical activity (29.6% to 47.3%) and consumption of fruits and vegetables (14.8% to 19.1%). Second, there was an additive effect of compliance, such that the more recommendations a survivor met, the better was his or her HRQoL. The first consideration Cai et al raised addressed the poorer compliance of the bladder cancer survivors (relative to survivors of other cancers) with the recommendation against smoking cigarettes. A related comment had to do with the potential role of physician-patient communication in this finding. Because bladder cancer has the strongest association with smoking (average relative risk = 3.0) of the six cancer types included in this study,2 it is not surprising that survivors of bladder cancer also reported the highest smoking rates. We did not assess the accuracy or clarity of information provided by physicians regarding risk of recurrence or second cancers. Thus, the impact of such communication on differences in smoking rates across survivors of different cancers cannot be determined with our data. However, there is evidence that some bladder cancer survivors (males, in particular) do perceive deficits in the overall quality of the cancer information they receive from their health care providers, compared with survivors of other cancers.3 Clearly, it is important that physicians discuss with their patients the adverse health outcomes associated with smoking, and use evidence-based guidelines for smoking cessation in providing care to patients who smoke. With respect to the second consideration, it is indeed possible that the (poor) rates of compliance with ACS nutrition guidelines among cancer survivors in our study simply reflect prevailing dietary patterns in the United States. We recognize that the Mediterranean diet, which is high in fruit and vegetable consumption and unsaturated fats, and low in processed and high-calorie foods, is generally regarded as healthier than the Western diet common in the United States. Indeed, the ACS nutrition guidelines overlap in many ways with the Mediterranean diet, and include eating a well-balanced diet that focuses on increasing intake of fruits, vegetables, and whole grains as well as limiting consumption of processed and red meats.4 However, it would perhaps be more interesting to compare fruit and vegetable consumption among cancer survivors in the United States with that of survivors in other countries in which dietary patterns differ. Such cross-cultural comparisons would help establish whether the level of compliance with dietary guidelines is attributable to the Western diet or to the cancer experience. In addressing the third consideration, we propose that although consumption of any alcoholic beverage (including red wine) is inversely associated with risk of coronary heart disease, individuals need to weigh the risks and benefits of such behavior, and this decision should be made with their health care providers. This is particularly true for cancer survivors, who are at increased risk for second cancers, and must consider the role that alcohol may play in the development of cancer recurrence or new primary diagnoses. Stated clearly, ACS recommends that cancer survivors limit consumption of any alcohol. If a survivor does drink alcohol, ACS suggests no more than one drink per day for women or two per day for men.5 It should also be noted that the beneficial impact of alcohol on risk of coronary heart disease can be achieved via other health behaviors (such as physical activity and diet) that are not linked with the negative outcomes associated with alcohol use and abuse. As for whether the consumption of red wine, even in moderate amounts, can modify cancer survivors’ HRQoL, we did not directly address this issue in our study, nor could we find any published studies related to this question. The final consideration relates to the potential relationship between smoking habits and sex among bladder cancer survivors. Cai et al ask about the correlation between sex, age at which patients started smoking, and length of smoking exposure among bladder cancer survivors. Although this may be of interest, perhaps the more important questions are: What is the impact of smoking cessation on bladder cancer recurrence and survival, and does this vary by sex, age at which patients started smoking, and length of smoking exposure? Data have shown that for people with no personal history of cancer, stopping smoking does result in a reduction of smoking-related health problems, including cancer risk, even among long-term smokers.6 Conversely, research has also demonstrated that continued smoking among lung cancer patients increases the incidence of secondary tumors, minimizes the effectiveness of cancer treatment, and decreases the odds of overall survival.7-10 Female lung cancer survivors have been found to be more likely to try to quit smoking and maintain abstinence.11 However, the extent to which this holds true among bladder cancer survivors deserves more attention. Better understanding is needed of the sociodemographic factors (including sex) and psychosocial variables associated with smoking behavior among cancer survivors. In summary, our original publication and the response it elicited highlight the important and often challenging issues faced by those who study, work directly with, or provide information to cancer survivors. Understanding the determinants of compliance with health recommendations is an important goal for researchers, clinicians, and public health officials alike. Our data, as well as the ever-growing body of literature on the HRQoL of cancer survivors, clearly demonstrate the need for evidence-based interventions to help cancer survivors achieve and maintain optimal health. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. NOTES published online ahead of print at www.jco.org on November 17, 2008. REFERENCES
1. Blanchard CM, Courneya KS, Stein KD: Cancer survivors’ compliance with lifestyle behavior recommendations and their relationship with health-related quality of life: Results from the American Cancer Society's SCS-II. J Clin Oncol 26:2198-2204, 2008 2. Office of the Surgeon General: The Health Consequences of Smoking: A Report of the Surgeon General. Rockville, MD, Office of the Surgeon General, US Department of Health and Human Services, 2004 3. McInnes DK, Cleary PD, Stein KD, et al: Perceptions of cancer-related information among cancer survivors: A report from the American Cancer Society's studies of cancer survivors. Cancer 113:1471-1479, 2008[CrossRef][Medline] 4. Kushi LH, Byers T, Doyle C, et al: American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 56:254-281, 2006 5. Doyle C, Kushi LH, Byers T, et al: Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA Cancer J Clin 56:323-353, 2006 6. International Agency for Research on Cancer: Handbook of Cancer Prevention: Tobacco Control—Reversal of Risk After Quitting Smoking (Vol 11). Geneva, Switzerland, WHO Press, 2007, pp 139-306 7. Fox JL, Rosenzweig KE, Ostroff JS: The effect of smoking status on survival following radiation therapy for non-small cell lung cancer. Lung Cancer 44:287-293, 2004[CrossRef][Medline] 8. Yu GP, Ostroff JS, Zhang ZF, et al: Smoking history and cancer patient survival: A hospital cancer registry study. Cancer Detect Prev 21:497-509, 1997[Medline] 9. Barrera R, Shi W, Amar D, et al: Smoking and timing of cessation: Impact on pulmonary complications after thoracotomy. Chest 127:1973-1975, 2005 10. Ostroff JS, Jacobsen PB, Moadel AB, et al: Prevalence and predictors of continued tobacco use after treatment of patients with head and neck cancer. Cancer 75:569-576, 1995[CrossRef][Medline] 11. Gritz ER, Nisenbaum R, Elashoff RE, et al: Smoking behavior following diagnosis in patients with stage I non-small cell lung cancer. Cancer Causes Control 2:105-112, 1991[CrossRef][Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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