A Retrospective, Cross-Sectional Study of Self-Reported Physical Activity and Depression Among Breast, Gynecologic, and Thoracic Cancer Survivors

According to the American Cancer Society (ACS, 2019), there were more than 16.9 million cancer survivors in the United States in 2019, and that number is projected to exceed 22.1 million by 2030. Cancer survivors have an increased prevalence of physiologic and psychological distress compared to the general population for multiple reasons, including fear of death, disease recurrence, pain, fatigue, memory issues, and poor sleep quality (ACS, 2019; Iadeluca et al., 2017; Syrowatka et al., 2017). A growing body of evidence suggests that this population is at elevated risk for mood disorders, such as depression, for years following diagnosis. Synthesis of the data regarding the overall prevalence of depression among people with cancer during and after treatment is complicated by differences in the type and stage of cancer, as well as time since diagnosis and treatment completion (Krebber et al., 2014). Previous multicenter studies and meta-analyses describing depression in the population of patients with cancer reported overall mean depression prevalence from 8% to 24%, but noted that prevalence was highest during treatment (27%) and decreased to 19%–21% one year postdiagnosis and 12%–15% when measured more than one year postdiagnosis (Eichler et al., 2018; Krebber et al., 2014; Mitchell et al., 2013). Among longer-term survivors who have completed treatment and are without metastatic disease, reports of depression prevalence also varied by tumor type. In a systematic review of 42 studies, depression was prevalent in 4%–26% of breast cancer survivors who were 6–10 years postdiagnosis (Syrowatka et al., 2017). Fewer reports focused on long-term survivors of other cancers, with depression prevalence of 19%–20% and 13% among lung and ovarian cancer survivors who were more than five years postdiagnosis, respectively (Eichler et al., 2018; Watts et al., 2015).

The second edition of the U.S. Physical Activity Guidelines for Americans (Piercy et al., 2018) was developed through the scientific review and consensus of an expert panel appointed by the U.S. Department of Health and Human Services. Their findings are reflected in oncology-specific guidelines and recommendations from ACS, the National Comprehensive Cancer Network, and the American College of Sports Medicine (Campbell et al., 2019; El-Shami et al., 2015; National Comprehensive Cancer Network, 2020; Schmitz et al., 2010). These guidelines are consistent in recommending that adults, including cancer survivors, participate in a minimum of 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity plus two sessions of muscle-strengthening exercise per week.

Cancer survivors who are physically active may decrease their risk of mortality and disease recurrence and enjoy improved quality of life, as well as less fatigue and pain, and fewer depressive symptoms (Levin et al., 2018; Loprinzi & Lee, 2014; Piercy et al., 2018). Several studies noted that as many as 50% of cancer survivors do not meet national exercise recommendations of participation in sufficient activity to accrue health benefits, including lowered rates of depression (Hyland et al., 2018; Loprinzi & Lee, 2014). Evidence suggests that engagement in physical activity varies by tumor type. In a secondary analysis of the ACS Cancer Prevention Study (N = 9,105), 30% of uterine cancer survivors met the U.S. Physical Activity Guidelines for Americans’ recommended level of activity as compared to 37% of breast cancer survivors and 47% of melanoma survivors (Blanchard et al., 2008).

Oncology nurses are well positioned to ask cancer survivors about their participation in physical activity and to encourage engagement in physical activity for physical and emotional health promotion. Because less is known about the frequency and intensity at which longer-term cancer survivors of varied tumor types engage in exercise and report depressive symptoms, the purpose of this study was to describe patient responses to an annual self-assessment tool completed at an advanced practice provider (APP)–run survivorship clinic at an urban comprehensive cancer center.

Methods

Sample and Setting

The survivorship clinic at Memorial Sloan Kettering Cancer Center in New York, New York, annually sees about 15,000 patients who have completed treatment, including chemotherapy, radiation therapy, surgical procedures, and bone marrow/stem cell transplantations. Patients with solid tumors are referred to the clinic from two to five years postdiagnosis and are seen annually by APPs. Prior to each appointment, patients are asked to complete a survivorship patient self-assessment form (SPSA) to elicit information about recent symptoms, sociodemographic changes, and health maintenance activities, which is then reviewed in detail by the APP during their visit.

A retrospective, cross-sectional study of 1,412 patients with breast (n = 375), gynecologic (n = 369), or thoracic (n = 668) cancer aged 18 years or older who completed a SPSA was conducted between July 2017 and December 2018. These tumor types were selected because of a change from paper and pencil to electronically collected SPSAs during these clinical services, making these data numerous and feasible to collect.

Variables

After institutional review board approval was obtained, the first SPSA completed by each patient during the study period was analyzed to assess attainment of the recommended level of physical activity (score of 24 or greater) using the Godin-Shepard Leisure-Time Physical Activity Questionnaire (GSLTPAQ). Depression prevalence and severity were assessed using the Patient Health Questionnaire (PHQ)-2 or PHQ-9. To describe the cohort, characteristics were abstracted, including age, sex, race, years since diagnosis, pain, and body mass index, as well as smoking, marital, and employment status (see Table 1). 

The GSLTPAQ is a three-item self-administered questionnaire, which asks the number of times an individual participates in mild, moderate, or strenuous exercise for more than 15 minutes during their free time in a typical seven-day period. Each intensity frequency is then multiplied by its categoric metabolic equivalent and summed for a GSLTPAQ score. The GSLTPAQ interprets a score of 24 units or greater as sufficiently active, 14–23 units as moderately active, and less than 14 units as insufficiently active or sedentary (Godin, 2011). Although mild-intensity exercise is valuable to avoid sedentary behavior, it does not contribute to attainment of weekly physical activity guidelines, which focus on moderate- and vigorous-intensity physical activity (Piercy et al., 2018). In 2011, the GSLTPAQ developer proposed an alternative scoring method to include only self-reported data from the moderate and strenuous responses to classify patients into active (score of 24 or greater) and insufficiently active (score of 23 or less) categories (Godin, 2011), which was the scoring method used in the current study. The GSLTPAQ was found to demonstrate good test-retest performance, with a correlation coefficient of 0.69 for the overall leisure score index and a range from 0.24 to 0.84 for the measurement of light, moderate, and strenuous activity. The correlation between leisure score index and maximum oxygen consumption was 0.56 (Jacobs et al., 1993).

Depression prevalence was measured using the PHQ-2 (all patients) or PHQ-9 (patients with a score of 3 or greater on PHQ-2). The PHQ-2 and PHQ-9 are validated screening tools that have been established as diagnostic and severity measures. Both tools use a two-week recall period, with four possible response selections (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day) for all questions. The PHQ-2 consists of the first two questions of the PHQ-9, which are listed as items 1 and 2 with the same stem (i.e., “In the past two weeks, has there been [1] little interest in doing things or [2] feeling down, depressed, or hopeless?”) as an initial screening test for depression, and, depending on the patient’s response, may be the only tool administered. Possible scores on the PHQ-2 range from 0 to 6, and patients who receive a score of 3 or greater are identified as needing further evaluation with the full PHQ-9. Possible scores on the PHQ-9 range from 0 to 27 (inclusive of the score from the PHQ-2). PHQ-9 scoring is broken down into five cutoff points to categorize depression: 5 (mild), 10 (moderate), 15 (moderately severe), and 20 (severe); scores of 0–4 represent no or nondiagnostically minimal depression (Kroenke et al., 2001). Among patients with cancer, internal consistency of the PHQ-9 is considered good, with a Cronbach’s alpha coefficient of 0.84 (Hinz et al., 2016), and receiver operating characteristic curve analysis to discriminate the power of the instrument to identify the presence or absence of major depressive disorder was 0.94 (95% confidence interval [0.93, 0.95]) (Thekkumpurath et al., 2011).

Data were analyzed descriptively. Categoric variables were summarized using absolute and relative frequencies, and continuous variables were summarized through calculation of mean, standard deviation, relative frequency, and range.

Results

The full cohort (N = 1,412) was 81% female (n = 1,138) and 84% White (n = 1,189), with a mean age of 66.5 years. There were 673 never smokers and 683 former smokers (48% each). The majority of patients described themselves as married (n = 996, 71%) and not employed (n = 832, 59%). On average, the cohort was 7.7 years postdiagnosis, with a mean body mass index of 28.4. The mean pain score was 1.58 (on a scale ranging from 0 [no pain] to 10 [worst pain imaginable]). Sixty-two percent (n = 872) of patients were found to be insufficiently active, with a score of 23 or less on the GSLTPAQ. Seven percent (n = 105) of patients scored some level of depression per the PHQ-9, with 44 of those patients reporting levels of moderate to severe depression (3% of total cohort).

By tumor type, 165 patients with breast cancer (44%) met recommended activity levels, and 19 (5%) reported some level of depression. Among those with gynecologic cancers, 131 patients (36%) met recommended activity levels, and 25 (7%) had some degree of depression. In the thoracic group, 244 (37%) met recommended activity levels, and 61 (9%) reported depression. Physical activity levels by tumor type are presented in Table 2. Post-hoc comparison using Bonferroni correction indicated that breast cancer survivors were significantly more likely to meet recommended activity levels as compared to gynecologic or thoracic cancer survivors (chi-square = 7.27, p = 0.026), but there was no intergroup difference in incidence or severity of depression. 

Discussion

This study examined the responses of adult survivors with breast, gynecologic, and thoracic cancers on an SPSA form administered annually prior to visiting the APP-led survivorship clinic. The purpose of this study was to describe the self-reported frequency of exercise and depression among survivors in these groups. Consistent with the literature (Blanchard et al., 2008; Hyland et al., 2018; Loprinzi & Lee, 2014), survivors in the current study’s sample had low attainment of the recommended levels of physical activity, with only 36% (gynecologic) to 44% (breast) of patients meeting these recommendations. In part because of the low prevalence of depression in the current study’s sample compared to other studies (Eichler et al., 2018; Krebber et al., 2014; Mitchell et al., 2013; Syrowatka et al., 2017; Watts et al., 2015), the impact of the level of exercise or other variables on the occurrence or severity of depression was not analyzed, and this will be further evaluated in future studies.

However, the results of this study add to the body of knowledge highlighting the low achievement of recommended exercise by cancer survivors. It is notable that, of the three tumor types examined, breast cancer survivors were more likely to be sufficiently active as compared to gynecologic or thoracic cancer survivors. This may be because of more focused engagement by the breast cancer survivorship community, as well as by researchers in the literature, on health promotion following treatment. To illustrate, a PubMed^® search of the keywords physical activity or exercise, breast cancer, and survivorship yielded 402 citations. The same search for the keywords lung or gynecologic cancer yielded only 41 and 42 citations, respectively.

Implications for Nursing

Participation in physical activity is a cost-effective, nonpharmacologic intervention that is associated with numerous health benefits for cancer survivors, including potential improvements in the incidence and severity of depression. Clinically, nurses working with survivors should ask patients about their participation in routine physical activity and encourage them to work toward meeting weekly physical activity duration and intensity recommendations. Resources to increase knowledge for practicing nurses to make exercise recommendations to cancer survivors include the Oncology Nursing Society’s Get Up, Get Moving campaign and collaboration with physical activity or rehabilitation specialists in their institution or community. 

Conclusion

Overall, cancer survivors, like many other populations, are not consistently achieving the duration or intensity of weekly exercise recommended by clinical practice guidelines. There appear to be differences in these rates of achievement by tumor type, as breast cancer survivors in the current study’s sample were more likely to meet the recommended level of activity when compared to survivors of gynecologic and thoracic cancers. Oncology nurses are well positioned to educate patients about the importance of exercise to support achievement of many health benefits in this population.

About the Author(s)

Michelle D’Errico, MSN, RN, OCN^®, is a clinical nurse II and Kristen L. Fessele, PhD, RN, ANP-BC, AOCN^®, is a nurse scientist, both at Memorial Sloan Kettering Cancer Center in New York, NY. This research was funded, in part, through a grant (P30CA008748) from the National Institutes of Health, National Cancer Institute. D’Errico and Fessele contributed to the conceptualization and design, completed the data collection, provided statistical support, and contributed to the manuscript preparation. Fessele provided the analysis. Fessele can be reached at fesselek@mskcc.org, with copy to ONFEditor@ons.org. (Submitted April 2020. Accepted September 1, 2020.)