The association between post-diagnosis health behaviors and long-term quality of life in survivors of ductal carcinoma in situ: a population-based longitudinal cohort study
Women diagnosed with ductal carcinoma in situ (DCIS) often experience adverse changes in health-related behaviors following diagnosis. The impact of health behaviors on long-term quality of life (QoL) in DCIS survivors has not been investigated.
We examined the association of post-diagnosis body mass index (BMI), physical activity, alcohol, and smoking with QoL among 1448 DCIS survivors aged 20–74 enrolled in the population-based Wisconsin in situ Cohort from 1997 to 2006. Health behaviors and QoL were self-reported during biennial post-diagnosis interviews. Physical and mental QoL were measured using the validated SF-36 questionnaire. Generalized linear regression was used to determine the association between behaviors and QoL with adjustment for confounders. Lagged behavior variables were used to predict QoL during follow-up and avoid reverse causation.
Women reported 3,536 QoL observations over an average 7.9 years of follow-up. Women maintaining a healthy BMI had on average a significantly higher summary measure score of physical QoL than obese women (normal versus obese: β = 3.02; 2.18, 3.85). Physical QoL scores were also elevated among those who were physically active (5 + h/week vs. none: β = 1.96; 0.72, 3.20), those consuming at least seven drinks/week of alcohol (vs. none; β = 1.40; 0.39, 2.41), and nonsmokers (vs. current smokers: β = 1.80; 0.89, 2.71). Summary measures of mental QoL were significantly higher among women who were moderately physically active (up to 2 h/week vs. none: β = 1.11; 0.30, 1.92) and nonsmokers (vs. current smokers: β = 1.49;0.45, 2.53).
Our results demonstrate that maintaining healthy behaviors following DCIS treatment is associated with modest improvements in long-term QoL. These results inform interventions aimed at promoting healthy behaviors and optimizing QoL in DCIS survivors.
KeywordsBreast cancer Ductal carcinoma in situ Health-related behaviors Health-related quality of life Epidemiology Exercise Body mass index Alcohol drinking Smoking
Body mass index
Ductal carcinoma in situ
Quality of life
Wisconsin In Situ Cohort
This Project was supported by Grants from the National Institutes of Health (P20 GM103644, U54 CA163303, R01 CA067264, P30 CA014520). The authors would like to express their gratitude to Julie McGregor and Kathy Peck for their assistance with data collection and project management.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflicts of interest to report.
Informed consent was obtained from all individual participants included in the study.
Research involving human participants
The study was approved by the University of Wisconsin Health Sciences Institutional Review Board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- 3.Berkman, A., B, F. C., Ades, P. A., Dickey, S., Higgins, S. T., Trentham-Dietz, A., Sprague, B. L., & Lakoski, S. G. (2014). Racial differences in breast cancer, cardiovascular disease, and all-cause mortality among women with ductal carcinoma in situ of the breast. Breast Cancer Research and Treatment, 148(2), 407–413.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Olivotto, I., & Levine, M., Steering Committee on Clinical Practice Guidelines for the C, Treatment of Breast Cancer. (2001). Clinical practice guidelines for the care and treatment of breast cancer: the management of ductal carcinoma in situ (summary of the 2001 update). CMAJ, 165(7): 912–913.PubMedPubMedCentralGoogle Scholar
- 6.Rakovitch, E., Franssen, E., Kim, J., Ackerman, I., Pignol, J. P., Paszat, L., Pritchard, K. I., Ho, C., & Redelmeier, D. A. (2003). A comparison of risk perception and psychological morbidity in women with ductal carcinoma in situ and early invasive breast cancer. Breast Cancer Res Treat, 77(3), 285–293.CrossRefPubMedGoogle Scholar
- 8.Hart, V., Sprague, B. L., Lakoski, S. G., Hampton, J. M., Newcomb, P. A., Gangnon, R. E., & Trentham-Dietz, A.: Trends in health-related quality of life after a diagnosis of ductal carcinoma in situ. Journal of Clinical Oncology 2016.Google Scholar
- 11.Irwin, M. L., Crumley, D., McTiernan, A., Bernstein, L., Baumgartner, R., Gilliland, F. D., Kriska, A., & Ballard-Barbash, R. (2003). Physical activity levels before and after a diagnosis of breast carcinoma: The health, eating, activity, and lifestyle (HEAL) study. Cancer, 97(7), 1746–1757.CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Berkman, A. M., Trentham-Dietz, A., Dittus, K., Hart, V., Vatovec, C. M., King, J. G., James, T. A., Lakoski, S. G., & Sprague, B. L. (2015). Health behavior change following a diagnosis of ductal carcinoma in situ: An opportunity to improve health outcomes. Preventive Medicine, 80, 53–59.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Penttinen, H. M., Saarto, T., Kellokumpu-Lehtinen, P., Blomqvist, C., Huovinen, R., Kautiainen, H., Jarvenpaa, S., Nikander, R., Idman, I., Luoto, R., et al. (2011). Quality of life and physical performance and activity of breast cancer patients after adjuvant treatments. Psychooncology, 20(11), 1211–1220.CrossRefPubMedGoogle Scholar
- 15.Voskuil, D. W., van Nes, J. G., Junggeburt, J. M., van de Velde, C. J., van Leeuwen, F. E., & de Haes, J. C. (2010). Maintenance of physical activity and body weight in relation to subsequent quality of life in postmenopausal breast cancer patients. Annals of Oncology, 21(10), 2094–2101.CrossRefPubMedGoogle Scholar
- 22.Fritz, A. G., & Jack, A., et al. (2000). International classification of diseases for oncology (3rd edn.). Geneva: World Health Organization.Google Scholar
- 23.Wolf, A. M., Hunter, D. J., Colditz, G. A., Manson, J. E., Stampfer, M. J., Corsano, K. A., Rosner, B., Kriska, A., & Willett, W. C. (1994). Reproducibility and validity of a self-administered physical activity questionnaire. International Journal of Epidemiology, 23(5), 991–999.CrossRefPubMedGoogle Scholar
- 26.Khadanga, S., Lakoski, S. G., Hart, V., Sprague, B. L., Ba, Y., Hampton, J. M., Higgins, S. T., Ades, P. A., Newcomb, P. A., & Trentham-Dietz, A. (2016). Partnership status and socioeconomic factors in relation to health behavior changes after a diagnosis of ductal carcinoma in situ. Cancer Epidemiology Biomarkers & Prevention, 25(1), 76–82.CrossRefGoogle Scholar
- 27.Veal, C. T., Hart, V., Lakoski, S. G., Hampton, J. M., Gangnon, R. E., Newcomb, P. A., Higgins, S. T., Trentham-Dietz, A., & Sprague, B. L. (2017) Health-related behaviors and mortality outcomes in women diagnosed with ductal carcinoma in situ. Journal of Cancer Survivorship, 11(3), 320–328Google Scholar
- 28.Ware, J., Jr., Kosinski, M., & Keller, S. (1994). SF-36 physical and mental health summary scales: a user’s manual. Boston, MA: Health Assessment Lab, New England Medical Center.Google Scholar
- 29.Ware, J., Jr., Snow, K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey manual and interpretation guide. Boston, MA: The Health Institute, New England Medical Center.Google Scholar
- 30.Ware, J. E., Jr. (1991) National Survey of Functional Health Status. In J. Ware, Jr (Ed.), Inter-University Consortium for Political and Social Research. Ann Arbor, MI.Google Scholar
- 31.Whelan, T. J., Goss, P. E., Ingle, J. N., Pater, J. L., Tu, D., Pritchard, K., Liu, S., Shepherd, L. E., Palmer, M., Robert, N. J., et al. (2005). Assessment of quality of life in MA.17: a randomized, placebo-controlled trial of letrozole after 5 years of tamoxifen in postmenopausal women. Journal of Clinical Oncology, 23(28), 6931–6940.CrossRefPubMedGoogle Scholar
- 33.Kosinski, M., Zhao, S. Z., Dedhiya, S., Osterhaus, J. T., & Ware, J. E. Jr. (2000). Determining minimally important changes in generic and disease-specific health-related quality of life questionnaires in clinical trials of rheumatoid arthritis. Arthritis & Rheumatism, 43(7), 1478–1487.CrossRefGoogle Scholar
- 36.Selig, J. P., & Little, T. D. (2012). Autoregressive and cross-lagged panel analysis for longitudinal data. In B. Laursen, T. D. Little & N. A. Card (Eds.), Handbook of developmental research methods. New York: The Guilford Press.Google Scholar
- 39.Paxton, R. J., Phillips, K. L., Jones, L. A., Chang, S., Taylor, W. C., Courneya, K. S., & Pierce, J. P. (2012). Associations among physical activity, body mass index, and health-related quality of life by race/ethnicity in a diverse sample of breast cancer survivors. Cancer, 118(16), 4024–4031.CrossRefPubMedPubMedCentralGoogle Scholar
- 40.Mosher, C. E., Sloane, R., Morey, M. C., Snyder, D. C., Cohen, H. J., Miller, P. E., & Demark-Wahnefried, W. (2009). Associations between lifestyle factors and quality of life among older long-term breast, prostate, and colorectal cancer survivors. Cancer, 115(17), 4001–4009.CrossRefPubMedPubMedCentralGoogle Scholar
- 42.Heinrich, K. M., Becker, C., Carlisle, T., Gilmore, K., Hauser, J., Frye, J., & Harms, C. A. (2015). High-intensity functional training improves functional movement and body composition among cancer survivors: A pilot study. European Journal of Cancer Care, 24(6), 812–817 (Engl).CrossRefPubMedGoogle Scholar
- 43.Inoue-Choi, M., Lazovich, D., Prizment, A. E., & Robien, K. (2013). Adherence to the World Cancer Research Fund/American Institute for Cancer Research recommendations for cancer prevention is associated with better health-related quality of life among elderly female cancer survivors. Journal of Clinical Oncology, 31(14), 1758–1766.CrossRefPubMedPubMedCentralGoogle Scholar
- 45.Gothe, N. P., Kramer, A. F., & McAuley, E. (2014). The effects of an 8-week Hatha yoga intervention on executive function in older adults. Journal of Gerontology: Series A Biological Sciences and Medical Sciences, 69(9), 1109–1116.Google Scholar
- 47.Petrick, J. L., Reeve, B. B., Kucharska-Newton, A. M., Foraker, R. E., Platz, E. A., Stearns, S. C., Han, X., Windham, B. G., & Irwin, D. E. (2014). Functional status declines among cancer survivors: Trajectory and contributing factors. Journal of Geriatric Oncology, 5(4), 359–367.CrossRefPubMedPubMedCentralGoogle Scholar
- 49.Coste, J., Quinquis, L., D’Almeida, S., & Audureau, E. (2014). Smoking and health-related quality of life in the general population. Independent relationships and large differences according to patterns and quantity of smoking and to gender. PLoS ONE, 9(3), e91562.CrossRefPubMedPubMedCentralGoogle Scholar
- 52.Kaplan, M. S., Huguet, N., Feeny, D., McFarland, B. H., Caetano, R., Bernier, J., Giesbrecht, N., Oliver, L., & Ross, N. (2012). Alcohol use patterns and trajectories of health-related quality of life in middle-aged and older adults: A 14-year population-based study. Journal of Studies on Alcohol and Drugs, 73(4), 581–590.CrossRefPubMedPubMedCentralGoogle Scholar
- 54.Rehm, J., Baliunas, D., Borges, G. L., Graham, K., Irving, H., Kehoe, T., Parry, C. D., Patra, J., Popova, S., Poznyak, V., et al. (2010). The relation between different dimensions of alcohol consumption and burden of disease: An overview. Addiction, 105(5), 817–843.CrossRefPubMedPubMedCentralGoogle Scholar
- 55.Schrieks, I. C., Wei, M. Y., Rimm, E. B., Okereke, O. I., Kawachi, I., Hendriks, H. F., & Mukamal, K. J. (2016). Bidirectional associations between alcohol consumption and health-related quality of life amongst young and middle-aged women. Journal of Internal Medicine, 279(4), 376–387.CrossRefPubMedGoogle Scholar
- 56.Wyrwich, K. W., Tierney, W. M., Babu, A. N., Kroenke, K., & Wolinsky, F. D. (2005). A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease. Health Services Research, 40(2), 577–591.CrossRefPubMedPubMedCentralGoogle Scholar
- 59.Mozaffarian, D., Afshin, A., Benowitz, N. L., Bittner, V., Daniels, S. R., Franch, H. A., Jacobs, D. R. Jr., Kraus, W. E., Kris-Etherton, P. M., Krummel, D. A., et al. (2012). Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association. Circulation, 126(12), 1514–1563.CrossRefPubMedGoogle Scholar
- 60.Taylor, R. S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., Skidmore, B., Stone, J. A., Thompson, D. R., & Oldridge, N. (2004). Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. American Journal of Medicine, 116(10), 682–692.CrossRefPubMedGoogle Scholar
- 63.Adams, S. A., Matthews, C. E., Ebbeling, C. B., Moore, C. G., Cunningham, J. E., Fulton, J., & Hebert, J. R. (2005). The effect of social desirability and social approval on self-reports of physical activity. American Journal of Epidemiology, 161(4), 389–398.CrossRefPubMedPubMedCentralGoogle Scholar