Janice J. Twiss

Bone mineral density in postmenopausal breast cancer survivors.

Purpose The overall purpose of this longitudinal 18‐month study was to test the feasibility and effectiveness of a multicomponent intervention for prevention and treatment of osteoporosis. The purpose of this article is to describe the baseline bone mineral density (BMD) findings for 30 postmenopausal women and to compare these BMD findings to time since menopause, body mass index, and tamoxifen use. Data Sources Baseline data of BMD findings for 30 post‐menopausal women, who have had a variety of treatments including surgery, adjuvant chemotherapy and or tamoxifen, and are enrolled in the 18‐month longitudinal study. A demographic questionnaire and a three day dietary record were used to collect baseline data. Conclusions Eighty percent of the women with breast cancer history had abnormal BMDs at baseline (t‐scores below ‐1.00 SD). Thinner women showed a greater risk for accelerated trabecular bone loss at the spine and hip. Implications for Practice These findings suggest the need for early BMD assessments and for aggressive health promotion intervention strategies that include a multifaceted protocol of drug therapy for bone remodeling, 1500 mg of daily calcium, 400 IU vitamin D and a strength weight training program that is implemented immediately following chemotherapy treatment and menopause in this high risk population of women.

Vitamin D Insufficiency and Musculoskeletal Symptoms In Breast Cancer Survivors on Aromatase Inhibitor Therapy

Breast cancer survivors (BCSs) on aromatase inhibitor (AI) therapy often experience musculoskeletal symptoms (joint pain and stiffness, bone and muscle pain, and muscle weakness), and these musculoskeletal symptoms may be related to low serum levels of vitamin D. The primary purpose of this pilot exploratory study was to determine whether serum levels of 25-hydroxyvitamin D (25[OH]D) concentration were below normal (<30 ng/mL) in 29 BCSs on AI therapy and if musculoskeletal symptoms were related to these low vitamin D levels. The mean (SD) serum 25(OH)D level was 25.62 (4.93) ng/mL; 86% (n = 25) had levels below 30 ng/mL. Patients reported muscle pain in the neck and back, and there was a significant inverse correlation between pain intensity and serum 25(OH)D levels (r = −0.422; P < .05 [2 tailed]). This sample of BCSs taking AIs had below normal levels of serum 25(OH)D despite vitamin D supplements. This is one of the few studies to document a significant relationship between vitamin D levels and muscle pain in BCSs on AI therapy. Findings from this pilot study can be used to inform future studies examining musculoskeletal symptoms in BCSs on AI therapy and relationships with low serum levels of vitamin D.

Challenges of Recruitment of Breast Cancer Survivors to a Randomized Clinical Trial for Osteoporosis Prevention

Recruitment of participants was a challenging issue for a statewide, 4-site, randomized, longitudinal trial for osteoporosis prevention. The accrual goal was 273 healthy breast cancer survivors. This federally funded study included a home-based followed by a fitness center-based 24-month intervention with follow-up at 36 months. In this report, recruitment planning, monitoring, and modifications are described, and the cost per enrolled participant is identified. Monthly monitoring of accrual numbers per recruitment strategy at each of 4 catchment areas allowed for early identification of necessary changes in recruitment strategies. Modifications were necessary when only 39% of the overall accrual goal had been attained at the 66% time point into the 18-month recruitment phase. Successful recruitment strategies were intensified, and new strategies were implemented, addressing motivators and deterrents for participation in clinical trials. Because approximately 81% of women were demonstrating bone loss via free dual energy x-ray absorptiometry screening, prevalence of the bone loss problem in survivors was incorporated into the recruitment information. Of 708 women screened via telephone and laboratory/dual energy x-ray absorptiometry testing, 249 were enrolled with 67% at 2 metropolitan sites and 33% at 2 rural sites. Recruitment media costs were approximately US

Perimenopausal symptoms, quality of life, and health behaviors in users and nonusers of hormone therapy

35 per enrolled participant. When combined with skeletal and laboratory screening, costs were approximately US

Facilitative strategies, psychological factors, and strength/weight training behaviors in breast cancer survivors who are at risk for osteoporosis.

480 per enrolled participant. Tracking recruitment efforts in large clinical trials should be ongoing, site-specific, and cost-effective. Changes incorporated early in the recruitment phase addressed unique aspects of rural versus metropolitan areas and resulted in near achievement of accrual goals.

Postmenopausal survivors of breast cancer at risk for osteoporosis: nutritional intake and body size.

Purpose: This pilot study was designed to determine the difference in frequency and distress related to perimenopausal symptoms in users and nonusers of hormone therapy (HT), to identify the difference in quality of life (QoL) indicators, and to determine if there is a relationship between QoL and frequency and distress of symptoms for users and nonusers of HT between the ages of 40 and 55 years. Data source: Self‐reported responses to the Perimenopause Assessment Questionnaire with five QoL indicators imbedded, the Women’s Health Assessment Scale, height, weight, and body mass index from 77 users and 89 nonusers of HT. Conclusions: More users reported using HT to control perimenopausal symptoms than for birth control or gynecological problems. Nonusers reported a higher percentage of a variety of symptoms compared to users, with more psychosomatic symptoms being reported. Both groups identified lack of energy as the most frequent and distressful symptom. There was a significant difference in frequency of symptoms between groups and a significant difference in distress of symptoms. There were significant negative correlations with the five QoL indicators and frequency and distress of symptoms for users and nonusers of HT, with exception of stress and frequency of symptoms for users. More psychosomatic symptoms were correlated with QoL for nonusers. Cold sweats, loss of interest, miserable and sad, and life not worth living were highly significant for nonusers with QoL, while feeling unattractive, decreased well‐being, and lack of enjoyment for users was highly significant. Implications for practice: Perimenopause is more than hot flashes and abnormal menses. A checklist of perimenopausal symptoms should be used as an assessment tool at each annual visit or more frequently to determine the significance of the symptoms a woman might be experiencing. Assessing the perimenopausal knowledge base is very important. Most importantly, there is a need for perimenopausal educational programs to be developed and implemented.

Bone mineral density and bone turnover in postmenopausal women treated for breast cancer.

INTRODUCTION/PURPOSE Many women who have been treated for breast cancer are at increased risk for bone loss. Strength/weight training exercises (SWTE) may be effective in preventing bone loss and subsequent fractures. The purpose of this exploratory study was to examine psychological factors (self-efficacy, perceived benefits vs. costs, and processes of change) and their relationship to adherence and progression in use of heavier weights in breast cancer survivors (BCS). SAMPLE Twenty-three BCS with mean age of 54.8 (SD = 7.2) years, mean time since menopause of 5.8 (SD = 5.3) years, and mean time since cancer treatment completion of 4.1 (SD = 3.0) years. METHODS Exploratory one-group design with multicomponent intervention inclusive of medication, calcium with vitamin D supplement, and home-based SWTE with facilitative strategies by nurses and personal exercise trainers based on the Transtheoretical Model. FINDINGS BCS doing SWTE for 6 months: (1) maintain a high level of self-efficacy, (2) perceive increasing benefits for 6 months, (3) use cognitive processes more frequently than behavioral ones, (4) were highly adherent to the SWTE, and (5) demonstrate that behavioral processes are positively related to increase in pounds lifted. DISCUSSION/CLINICAL IMPLICATIONS Larger randomized trials studies are needed to determine the most effective strategies for assuring adherence to and progression of SWTE in this population at risk for osteoporosis.

Health behaviors in breast cancer survivors experiencing bone loss.

Postmenopausal survivors of breast cancer for whom hormone replacement therapy is contraindicated are at risk for development of osteoporosis. The primary purpose of this article is to describe, in a sample of 30 postmenopausal survivors of breast cancer, their calcium and vitamin D intake compared with recommended dietary guidelines for those nutrients for postmenopausal women not taking hormone replacement therapy and the body mass index of these women as nutritional status risk factors for development of osteoporosis. Bone health and presence of osteoporosis were determined by bone mineral density testing of the spine, hip, and forearm. To obtain calcium and vitamin D intake, including supplements, 3-day diet records were completed; height and weight measures were used to calculate body mass index. The sample participants ranged in age from 42 to 65 years; the majority (56%) had been menopausal or off hormone replacement therapy for 5 years or less, and 70% had completed breast cancer treatment for 5 years or less (except tamoxifen). The majority (63%) were of medium body frame size; 30% were of small frame size. The mean body mass index (27.3) and mean weight (160 lbs) indicate that these women, as a group, were overweight. Although a large percent (63%) were taking calcium supplements, the mean daily intake (diet and supplements) of calcium (1,353 mg) and vitamin D (403 IU) was less than the recommended dietary guidelines for these nutrients in this population. At study entry, 80% of the women were osteopenic (60%) or osteoporotic (20%) and none was receiving treatment/prevention for osteoporosis; only 1 had a previous known osteoporosis diagnosis. This is a special group of women for whom screening and preventive strategies for osteoporosis are imperative.

Postmenopausal breast cancer survivors at risk for osteoporosis: physical activity, vigor, and vitality.

Chemotherapy and endocrine treatments for breast cancer are believed to increase risk of osteoporosis by causing early menopause in premenopausal women and by further depleting estrogen levels in postmenopausal women. Multivariate analyses were used to evaluate the contributions of 7 predictors (age, body mass index [BMI], family history of osteoporosis, months since menopause, past use of chemotherapy, and current use of tamoxifen or aromatase inhibitors) in explaining variability in bone mineral density (BMD) at the hip and the spine and bone turnover in 249 postmenopausal women who are breast cancer survivors. This report was an analysis of baseline data from a federally funded (1 R01 NR07743-01A1) intervention study on osteoporosis prevention. Mean age of the women was 58.5 years, and average BMI was 26.7 kg/m2; 98% were white. All had measurable bone loss, 167 had chemotherapy, 76 were on tamoxifen, and 21 were on aromatase inhibitors. Women with higher BMI had higher BMD at the hip (P < .001) and the spine (P = .004). Women on tamoxifen had lower measures of bone formation (Alkphase B) (P < .001), suggesting less bone turnover, and higher BMD at the hip (P = .035). There was a trend for women who had received chemotherapy to have lower BMD at the spine (P = .06). The implications of these findings are discussed in the article.

Cancer risk-reduction behaviors of breast cancer survivors.

Purpose: To describe the baseline healthy lifestyle behaviors (dietary, calcium, vitamin D, caffeine and alcohol intake, smoking history, and physical activity) of postmenopausal breast cancer survivors (BCS); and to identify any relationship of healthy lifestyle behaviors with bone mineral density (BMD) at the forearm, total hip and spine, L1‐L4. Data sources: Self‐reported responses to a demographic and health status questionnaire, to a 3‐day Diet Record, and to the 7‐Day Physical Activity Questionnaire‐Adapted provided data for the lifestyle behaviors. Baseline BMD (g/cm2) was determined with dual‐energy x‐ray absorptiometry (DEXA). Height, weight, and body mass index (BMI) were also measured in each of the 249 postmenopausal BCS. Conclusions: There was an imbalance between consumed kilocalories and expenditure of energy. The majority of BCS were overweight or obese. They consumed less fruit and vegetable servings than recommended by the new 2005 U.S. Department of Agriculture’s dietary guidelines, less dairy products, below average recommended grains and fiber, less protein and carbohydrate intake, and a slightly higher fat gram intake. Approximately, 43% did not take any supplemental calcium, with 46% taking less than 1000 mg a day. Likewise, 52.59% consumed less than 400 IU of vitamin D with both supplemental and dietary intake. This group of BCS consumed below accepted levels of caffeine and alcohol. Only 18 BCS continued to smoke. This group spent an average of 10.36 h in light (sedentary) activities on a daily basis. There were significant negative relationships with bone mass (g/cm2) at the total hip and daily intake of caffeine/mg and daily grams of alcohol. Weight and BMI both demonstrated a significant relationship with bone mass (g/cm2) at the total hip, spine L1‐L4, and the forearm. Implications for practice: The healthcare provider must incorporate appropriate teaching strategies, intensive counseling, and coaching, along with a support mechanism, to enable BCS to understand the importance of a healthy diet, calcium, and vitamin D supplement, and a regular strength/weight program that will be integrated into their daily lifestyle. Early DEXA screens should be part of the protocol with BCS, and there is a particular need for forearm DEXA screens to be included in the treatment protocol for BCS.