UNIVERSITY OF CALGARY

UNIVERSITY OF CALGARY
The Association of Physical Activity and Quality of Life in Gastric and Esophageal Cancers
by
Kaitlin Anne Krenz
A THESIS
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF SCIENCE
GRADUATE PROGRAM IN KINESIOLOGY
CALGARY, ALBERTA
JUNE, 2014
© Kaitlin Anne Krenz 2014
Abstract
Patients with esophageal and gastric cancer typically present with an advanced tumour
formation and severe symptoms such as progressive dysphagia, nausea, and weight loss (J.
Lagergren & Lagergren, 2010; Zali, Rezaei-tavirani, & Azodi, 2011). Surgical treatment is the
preference for both diagnoses, however often results in functional digestive complications
(Bhargava & Chasen, 2010). Given the myriad of symptoms pre and post treatment, it is clear
that health related quality of life (HRQL) is affected for these patients. PA has consistently and
repeatedly improved HRQL in cancer patients (Ferrer, Huedo-Medina, Johnson, Ryan, &
Pescatello, 2011). Only a few studies have identified potential PA effects in gastric and/or
esophageal cancers, with inconsistent results (Bhargava & Chasen, 2010; Feeney, Reynolds, &
Hussey, 2011; Lee et al., 2010; Na, Kim, Kim, Ha, & Yoon, 2000; Tatematsu, Park, Tanaka,
Sakai, & Tsuboyama, 2013; Tatematsu, Ezoe, et al., 2013; Zalina, Lee, & Kandiah, 2012). To
further explore the relationship between PA and HRQL in gastric and esophageal cancers, a
cross-sectional one-time survey was completed in a GI outpatient clinic in Calgary, AB. Pearson
correlations revealed a positive moderate association between total PA minutes and HRQL
(r=.40, p=.03). Future research should consider interventions (education or programming) that
promote PA participation in this unique population.
ii
Acknowledgements
I would like to acknowledge my supervisor, Dr. Nicole Culos-Reed, and my committee members
Dr. Jeff Vallance, and Dr. Guy Pelletier for their continued support and guidance. I would also
like to acknowledge all of the support staff at the TBCC GI outpatient clinic, Dr. Scot Dowden,
Colleen Cuthbert, and all of the administrative staff that made this research possible. Finally, I
would like to thank all of the Health and Wellness students and staff members for their
encouragement, and my family and friends who helped me maintain balance throughout this
journey.
iii
Dedication
To Thomas Hauck (Uncle Tom)…
…Who continues to inspire me.
iv
Table of Contents
Abstract ............................................................................................................................... ii
Acknowledgements ............................................................................................................ iii
Dedication .......................................................................................................................... iv
Table of Contents .................................................................................................................v
List of Symbols, Abbreviations and Nomenclature ......................................................... viii
CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW ..............................9
1.1 Gastric Cancer..........................................................................................................10
1.1.1 Treatments .......................................................................................................12
1.1.2 Health Related Quality of Life ........................................................................13
1.2 Esophageal Cancer ...................................................................................................14
1.2.1 Treatments .......................................................................................................16
1.2.2 Health Related Quality of Life ........................................................................17
1.3 Physical Activity in Cancer .....................................................................................20
1.3.1 Physical activity in gastric cancer ...................................................................21
1.3.2 Physical activity in esophageal cancer ............................................................24
1.3.3 Physical activity in combined upper GI cancers .............................................26
1.4 PA Barriers and Preferences in Cancer....................................................................28
CHAPTER TWO: : METHODOLOGY ............................................................................32
2.1 Participants...............................................................................................................32
2.1.1 Sample Size .....................................................................................................32
2.1.2 Recruitment .....................................................................................................33
2.2 Design and Procedure ..............................................................................................33
2.3 Outcome Measures ..................................................................................................34
2.3.1 Demographic and medical records ..................................................................34
2.3.2 Physical activity...............................................................................................34
2.3.3 Health-related quality of life ...........................................................................35
2.3.4 Barriers to PA ..................................................................................................36
2.3.5 Preferences for PA ...........................................................................................36
2.3.6 Social support for being physically active.......................................................37
2.3.7 Nutritional assessment .....................................................................................38
2.4 Data Analysis ...........................................................................................................39
CHAPTER THREE: RESULTS ........................................................................................40
3.1 Participant Characteristics .......................................................................................40
3.2 Preliminary Analysis ................................................................................................44
3.3 Primary Analysis......................................................................................................44
3.3.1 Objective 1.......................................................................................................44
3.3.1.1 PA Outcomes .........................................................................................44
3.3.1.2 HRQL Outcomes ...................................................................................45
3.3.1.3 PA and HRQL Associations and Analyses ............................................45
3.3.2 Objective 2.......................................................................................................46
3.3.2.1 Exercise Preferences ..............................................................................46
3.3.2.2 PA Barriers ............................................................................................47
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3.3.2.3 Social Support for being Physically Active ...........................................47
3.3.2.4 Nutritional Assessment ..........................................................................47
3.4 Exploratory Analysis ...............................................................................................48
CHAPTER FOUR: DISCUSSION ....................................................................................50
4.1 Limitations ...............................................................................................................56
4.2 Conclusions ..............................................................................................................56
REFERENCES ..................................................................................................................58
APPENDIX A: LITERATURE REVIEW TABLE ...........................................................81
APPENDIX B: SURVEY ..................................................................................................88
B.1. Demographic Variables Survey .............................................................................88
B.2. Medical Variables Survey ......................................................................................90
B.3. Modified Godin-Leisure Score Survey ..................................................................91
B.4. Health-Related Quality of Life Survey (FACT) ....................................................92
B.4.1. FACT-G .........................................................................................................92
B.4.2. FACT-E Additional Concerns .......................................................................94
B.4.3. FACT-Ga Additional Concerns .....................................................................95
B.5. Barriers to PA Survey ............................................................................................96
B.6. Preferences for PA Survey ...................................................................................104
B.7. Social Support for Being Physically Active Survey ............................................106
B.8. Nutritional Assessment Survey (PG-SGA) ..........................................................107
APPENDIX C: RECRUITMENT DIAGRAM ...............................................................108
APPENDIX D: TABLES .................................................................................................109
D.1. Table 3 Godin leisure-time exercise questionnaire results in a sample of gastric and
esophageal cancer patients. .................................................................................109
D.2. Table 4 Functional assessment of cancer therapy (FACT) results in a sample of
gastric and esophageal cancer patients. ..............................................................110
D.3. Table 5 Pearson correlation results and correlation coefficients for outcome variable
HRQL (FACT-G) (N=25). ...................................................................................111
D.4. Table 6 Exercise preference frequencies from a sample of gastric and esophageal
cancer patients. ....................................................................................................112
D.5. Table 7 Reported PA barrier frequencies among a sample of gastric and esophageal
cancer patients. ....................................................................................................114
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List of Tables
Table 1 Patient demographic frequencies for a sample of gastric and esophageal cancer
patients. ................................................................................................................................. 41
Table 2 Medical information for a sample of gastric and esophageal cancer patients. .............. 43
Table 3 Godin leisure-time exercise questionnaire results in a sample of gastric and
esophageal cancer patients. ................................................................................................ 109
Table 4 Functional assessment of cancer therapy (FACT) results in a sample of gastric and
esophageal cancer patients. ................................................................................................ 110
Table 5 Pearson correlation results and correlation coefficients for outcome variable HRQL
(FACT-G). ........................................................................................................................... 111
Table 6 Exercise preference frequencies from a sample of gastric and esophageal cancer
patients. ............................................................................................................................... 112
Table 7 Reported PA barrier frequencies among a sample of gastric and esophageal cancer
patients. ............................................................................................................................... 114
vii
List of Symbols, Abbreviations and Nomenclature
Symbol
Definition
BMI
Body mass index
CC
Cardiopulmonary complications
EWB
Emotional well-being
FWB
Functional well-being
HRQL
Health related quality of life
LSI
Leisure score index
METS
Metabolic equivalent
MID
Clinically meaningful important difference
MIE
Minimally invasive esophagectomy
NAC
Neo-adjuvant chemotherapy
NKCA
Natural killer cell cytotoxic activity
PA
Physical activity
PPC
Postoperative pulmonary complications
POD
Post-operative days
PWB
Physical well-being
RCT
Randomized controlled trial
ROM
Range of motion
SWT
Shuttle walk test
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9
Chapter One: Introduction and Literature Review
With an estimated 7.6 million deaths in 2008, cancer is the leading cause of
premature mortality on a global scale. It is projected that the incidence of cancer-related
deaths will continue to rise to 13.1 million by the year 2030 (Jemal et al., 2011).
Although improved screening and reduced exposure to common risk factors, such as
smoking has reduced the incidence rates in developed countries, the incidence rates and
mortality rates remain high in developing countries with low to middle income. Of the
most deadly cancers, stomach (or gastric) cancer alone accounted for 723,000 deaths
worldwide in 2012 (WHO | Cancer, 2014) which translated to 8% of total cancer cases
and 10% of total cancer deaths (Jemal et al., 2011). Esophageal cancer accounted for
400,000 cancer related deaths worldwide in 2012, which translated to 3.2% of total
cancer cases and 4.9% of total cancer deaths (GLOBOCAN, 2012)
Gastric and esophageal cancers are both part of the upper gastrointestinal tract and
therefore present with tumours that block food ingestion, which produces similar
symptoms. These symptoms are often only present in advanced tumour formation, which
results in poor prognosis and a reduced lifespan. The epidemiology of these two diseases
has shifted in the past decade, with the incidence of the adenocarcinomas in the lower
third of the esophagus and esophago-gastric junction on the rise (Allum et al., 2011) as
well as an increase in proximal gastric cancers in Caucasian males (Ahmed, Goodman,
Kosary, & Ruiz, 2006). This shift in epidemiology is related to regional differences in
diagnosis, with Western countries presenting primarily with proximal tumours of the
gastric cardia, fundus and esophagus, as opposed to primarily distal diagnoses in regions
10
of Japan and Korea (Yamaoka, Kato, & Asaka, 2008). While the symptoms, prognosis
and treatment unite these two diagnoses, the risk factors, histology, and total global
burden vary between gastric and esophageal cancers.
1.1 Gastric Cancer
Gastric cancer is the fourth most common cancer worldwide for men and fifth
most common for women, with incidence rates of 640,000 and 350,000 in 2011
respectively (Jemal et al., 2011). The estimated gastric cancer deaths for men were
464,000 and 273,000 for women in 2011 (Jemal et al., 2011). Overall, there is a mortality
rate of 70% for the gastric cancer population, which is significantly greater than the
mortality rates of other more common cancers such as prostate and breast cancers (3033%) (Guggenheim & Shah, 2013).
The global burden of gastric cancer resides mainly in developing countries such
as Eastern Asia, South America, Central and Eastern Europe. These areas account for
70% of gastric cancer cases in the world (Jemal et al., 2011). Demographic
considerations can be attributed to some common environmental and behavioural risk
factors such as salt intake, alcohol consumption and smoking. Research indicates an
increased risk of gastric cancer with a salt intake of >10 g per day (Shikata et al., 2006).
Incidence rates have decreased significantly with the improvement of food preservation
and refrigeration (Guggenheim & Shah, 2013). Environmental or ‘sporadic’ gastric
diagnosis occurs in 80-90% of total gastric incidence, 10-20% appear in a familial
cluster, and 1-3% are confirmed inherited genetic susceptibility (Corso, Roncalli, &
Marrelli, 2012).
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In Canada, the estimated new cases for gastric cancer in 2012 were 3,076 and the
estimated cancer-related deaths was 1,911 (Canadian Cancer Statistics, 2013). Males
account for approximately two thirds of the total diagnosed gastric cancer cases in
Canada (1,960 M: 1,116 F) (Canadian Cancer Statistics, 2013). Both incidence rates for
males and females have reduced by 2.0% and 1.6% respectively per year between 19982007 (Canadian Cancer Statistics, 2013). Reduced incidence can be attributed to diet
changes, decreases in alcohol consumption and smoking, as well as the identification of
the bacterium Helicobacter Pylori which has recently been identified as a risk factor for
gastric cancer (Canadian Cancer Statistics, 2013). Decreased mortality (-2.0% per year
since 1998) and increased long-term survival rates have also been attributed to early
detection as well as the improvements in treatment options, such as perioperative
chemotherapy and curative gastrectomy surgeries (Bae, Kim, Kim, Ryu, & Lee, 2006;
Jentschura, Winkler, Strohmeier, Rumstadt, & Hagmüller, 1996; Kaptein, Morita, &
Sakamoto, 2005). With increased long-term survival, attention has begun to focus on
health related quality of life (HRQL) post-treatment (Fayers & Machin, 2007; Gotay,
Korn, McCabe, Moore, & Cheson, 1992).
Although incidence and mortality rates have improved in Canada, survival rate is
still low in gastric cancer overall, and is most commonly attributed to late diagnosis (Zali
et al., 2011). Preliminary symptoms of gastric cancer are similar to that of common
digestive disorders such as bloating, gas, heartburn and sense of fullness, all of which are
self-diagnosed (Torpy, 2010). Most cases are not formally diagnosed until severe
symptoms occur, such as epigastric pain, a palpable epigastric mass, nausea and vomiting
due to gastric obstruction, early satiety, dysphagia, signs and symptoms of upper GI
12
bleeding, anorexia, weight loss, jaundice, ascites (the accumulation of fluid in the
peritoneal cavity, causing abdominal swelling), and hepatic enlargement (Zali et al.,
2011).
1.1.1 Treatments
Gastric cancer symptoms can be severe and often vary significantly between
patients. Heterogeneity within the disease has been cited as a contributor to the varying
symptomatology. It is suggested that gastric cancer should not be considered a single
disease, but individual diseases with unique epidemiology and biology (Guggenheim &
Shah, 2013). Subsequently, treatment plans often vary between surgery, chemotherapy
and radiation, or a combination thereof (Zali et al., 2011). Gastric cancer remains difficult
to cure, with a 5-year survival rate of only 20% due to disease recurrence after curative
surgical resection (Saghier, Kabanja, Afreen, & Sagar, 2013). Currently in early
diagnosis, curative surgery can be completed for non-metastatic gastric cancer. A
gastrectomy (partial or full stomach removal) and systemic lymph node dissection can be
paired with chemotherapy and radiation to improve the chance of survival (Jiang &
Ajani, 2010; Yokota et al., 2003; Zali et al., 2011). Currently, chemotherapeutic
treatments alone are not profoundly effective due to detection at advanced stages (van de
Velde, 2008). However, in advanced tumour formation, perioperative chemotherapy
should be considered because of a statistically significant improvement in survival by 46% (Meyer & Wilke, 2011).
The treatment options become more limited as the tumour formation progresses,
however surgical options are still preferred when preventing further advancement of the
disease or treating functional digestive concerns in palliation. Unfortunately, there are
13
implications with surgical treatment. Gastric surgeries often create functional
complications such as gastric dumping syndrome, gastric emptying and gastro esophageal
reflux; all of which affect not only the physical act of digestion, but also the social aspect
of eating (Bhargava & Chasen, 2010). Digestive dysfunction can make eating
troublesome both physiologically, and psychologically, with the result being a loss in
appetite and weight loss (Bhargava & Chasen, 2010). Gastric disease progression often
leads to severe weight loss conditions such as cachexia. Cachexia is characterized as
progressive weight loss, anorexia, metabolic alterations, asthenia (loss of strength),
reduced lipid stores and severe muscle protein loss (Bossola, Pacelli, & Rosa, 2012).
1.1.2 Health Related Quality of Life
Quality of life (QOL) is the subjective evaluation of a patient’s own physical,
emotional, social and functional well-being along with their perceived symptom burden
(Conroy, Marchal, & Blazeby, 2007). Health related quality of life (HRQL) is used in
health care to report physical and mental health determinants and the effect disease,
disability or disorder have on QOL at a given time (Taylor, 2000). While both terms are
used in the literature, this document will refer to reported QOL outcomes as HRQL.
Given the myriad of treatments, and the subsequent side effects involved in a
gastric or esophageal cancer diagnosis, it is apparent that facets of HRQL are affected.
With the majority of patients in low-incidence countries presenting in advanced stages,
HRQL outcomes post-diagnosis to alleviate physical symptoms is a priority in treatment
related research (Mahar, Coburn, Karanicolas, Viola, & Helyer, 2012).
Prospective research on HRQL outcome measures for gastric and gastro
esophageal adenocarcinoma patients post-surgery indicated that HRQL was impaired
14
during and after radiation and chemotherapy treatments, and did not return to baseline for
6-12 months. It should also be noted that for a significant number of patients, there were
some HRQL subscales that did not return to baseline measures even after 12 months
(Kassam et al., 2010). Examining the effects surgery had on HRQL revealed that a
significant reduction in HRQL was still present 3 months post-surgery, and in some cases
was reduced for up to 6 months (Munene et al., 2012). Both of these studies highlight the
significant decrease in HRQL for gastric cancer patients during and post treatment. They
also highlighted the elongated length of time HRQL remained below baseline.
While HRQL was not affected by tumour location, there were large differences
reported in HRQL and symptom indices as cancer stages increased (McKernan,
McMillan, Anderson, Angerson, & Stuart, 2008). HRQL measures such as social
functioning, fatigue, appetite loss and global HRQL were all reduced as the tumour stage
increased (McKernan et al., 2008). With each increasing stage, gastric cancer patients
are at greater risk for functional eating and digestive issues, which can cause social
concerns at meal times and a lack of calorie intake that is related to fatigue and appetite
loss. Overall, it is apparent that the greater the stage upon diagnosis, the greater the
reduction in HRQL. Specific HRQL outcomes, such as appetite loss, have presented as
an independent significant prognostic factor in gastric cancer survival rates, even after
adjustment for stage, treatment, clinical-pathological variables, HRQL and symptom
scores (McKernan et al., 2008).
1.2 Esophageal Cancer
Estimated new cases of esophageal cancer in Canada were 2,000 in 2013, with
estimated cancer-related deaths of 1,900 (Canadian Cancer Statistics, 2013). Esophageal
15
cancer rates in Canada mainly occur in males, with incidence rates 3-4 times greater than
in females (1,550 M: 460 F) (Canadian Cancer Statistics, 2013). Esophageal cancer rates
vary significantly by region globally with the highest incidence rates in Southern and
Eastern Africa as well as Eastern Asia. The region from Northern Iran continuing into
Central Asia and onto North-Central China is referred to as the ‘Esophageal belt’, with
squamous-cell carcinoma being the majority of diagnosed cases (90%) (Gholipour,
Shalchi, & Abbasi, 2008; Tran et al., 2005).
Esophageal cancer is broken down into two main histological types; squamouscell carcinoma which presents in the upper one-third of the esophagus, and
adenocarcinoma, which generally presents in the lower one-third and/or the junction of
the esophagus and the stomach (Fritz, 2000; Jemal et al., 2011). In contrast to gastric
cancer, adenocarcinoma incidence rates in esophageal cancer have steadily increased in
previously low risk areas in Western Countries (Bosetti, Levi, & Ferlay, 2008; Cook,
Chow, & Devesa, 2009; Lepage, Rachet, Jooste, Faivre, & Coleman, 2008). In order to
better understand this increase, risk factors by histological type are further explored.
Risk factors for esophageal cancer are separated by histological type and region.
Risk factors in squamous-cell carcinoma are somewhat unclear in the ‘Esophageal belt’
region, however it is suggested that contributing factors may include low nutritional
status, low fruits and vegetable intake, and high temperature drinks. Conversely, smoking
and excessive alcohol are probable risk factors for squamous-cell carcinoma in Western
countries (Engel et al., 2003; Islami, Boffetta, et al., 2009; Islami, Pourshams, et al.,
2009; M. Wu et al., 2009). Esophageal adenocarcinoma has been linked with smoking,
obesity or overweight, and chronic gastro esophageal reflux disease that promotes a
16
condition called Barrett’s esophagus (Engel et al., 2003; Kamangar, Chow, Abnet, &
Dawsey, 2009). It is hypothesized that obesity is the greatest risk factor in Western
countries; hence the recent increase in adenocarcinoma incidence rates (El–Serag, 2007;
Post, Siersema, & Van Dekken, 2007).
Esophageal cancer presents with similar symptoms and also similar prognosis to
gastric cancer. The 5-year survival rate is approximately 13% due to late stage diagnosis
(Eloubeidi, Mason, Desmond, & El-Serag, 2003). Patients typically present with severe
symptoms such as progressive dysphagia leading to vomiting of undigested food and
weight loss (Lagergren & Lagergren, 2010). Elasticity in the esophagus contributes to the
late presentation of symptoms, and often the identification of late stage tumours by
allowing tumour growth to escalate without detection (Lagergren & Lagergren, 2010).
1.2.1 Treatments
Treatment in esophageal cancer is highly dependent on the stage of disease and
location of tumour, as well as histological type, medical condition and patient preference
(Lagergren & Lagergren, 2010; Mawhinney & Glasgow, 2011; Stahl, Budach, Meyer, &
Cervantes, 2010). Surgical treatment is preferred in patients with localized tumours,
however low exercise tolerance has been attributed to peri-operative complications and is
taken into consideration prior to surgery (Allum et al., 2011). Typically, those with the
ability to complete two flights of stairs without stopping should be able to complete
surgical treatment options (Allum et al., 2011). If caught early, squamous cell carcinoma
can be treated with chemotherapy alone or chemotherapy plus surgery (Allum et al.,
2011). In esophageal adenocarcinoma, pre-treatment chemo radiation has been shown to
improve long-term survival compared to surgery alone (Allum et al., 2011). Those who
17
have advanced tumour formation or are unable to tolerate surgery are provided palliative
care that consists of chemotherapy and/or radiation (Lagergren & Lagergren, 2010; Stahl
et al., 2010).
Although prognostic factors have improved in esophageal cancer, the 5-year
survival rate is still low (17%) (Mawhinney & Glasgow, 2011). Those with curative
surgery typically have an improved 5-year survival of 30-35% (Lagergren & Lagergren,
2010). However, recurrence is common and those who have undergone surgery and have
a tumour recurrence have limited treatment options due to lack of second-line treatment
(Lagergren & Lagergren, 2010).
1.2.2 Health Related Quality of Life
Invasive surgical treatments in esophageal cancer create similar outcomes to
gastric cancer treatments, with HRQL reports remaining below baseline for up to oneyear post treatment (Blazeby, Farndon, Donovan, & Alderson, 2000; Brooks, Kesler,
Johnson, Ciaccia, & Brown, 2002; de Boer et al., 2000; Safieddine et al., 2009; Zieren,
Jacobi, Zieren, & Müller, 1996). Surgical treatment provides limited improvement in
lifespan, and serious complications are a considerable risk (Enzinger & Mayer, 2003;
Viklund, Wengström, Rouvelas, Lindblad, & Lagergren, 2006; Wu & Posner, 2003).
With approximately 50% of all esophageal patients experiencing a postoperative
complication in the first 30 days post-surgery, a sustained reduction in HRQL postsurgery is often inevitable (Daly et al., 2000; Viklund et al., 2006).
HRQL has been consistently measured as a means of improving surgical
treatments and verifying the self-reported recovery of patients who have undergone
invasive treatments. HRQL in esophageal patients is generally measured pre-treatment,
18
and several times post-treatment to determine change. Pre-treatment reports for those
who are scheduled for curative surgery include symptom concerns such as dysphagia
(Daly et al., 2000; Enzinger & Mayer, 2003; Massey, 2011), eating difficulties
(Verschuur et al., 2006; Viklund et al., 2006; Watt & Whyte, 2003), and fatigue. Despite
these reported concerns, pre-treatment functional scores are generally normal (>70 points
out of 100).
During the first 6 weeks post-operation, individuals report the greatest reduction
in HRQL (Avery & Metcalfe, 2007; Blazeby & Metcalfe, 2005; Lagergren et al., 2007).
Common symptoms of fatigue, nausea, vomiting, dry mouth, diarrhea, dyspnea, taste
problems and coughing are reported (Avery & Metcalfe, 2007; Parameswaran et al.,
2008; Stahl et al., 2010). Reductions in physical function, role function, and social
function are also significant (Avery & Metcalfe, 2007; Parameswaran et al., 2008; Stahl
et al., 2010). Similar to gastric cancer, dumping syndrome is a major concern and is more
commonly reported in female and younger esophageal patients (Djärv, Lagergren,
Blazeby, & Lagergren, 2008; McLarty et al., 1997; Viklund et al., 2006).
The loss in HRQL during the first weeks post curative surgery are typically not
regained for a minimum of 6-12 months (Avery & Metcalfe, 2007; Blazeby et al., 2000;
Blazeby & Metcalfe, 2005; Brooks et al., 2002; Lagergren et al., 2007; Parameswaran et
al., 2008) Global HRQL, physical function, social function and fatigue tend to take the
longest time to recover, while some symptoms such as dyspnea, reflux and diarrhea are
never recovered to baseline measures (Lagergren et al., 2007). Studies that report longer
follow-up protocols have had mixed results, with some suggesting that HRQL returns to
general population levels within 2-5 years of survival (Boer, 2004; de Boer et al., 2000;
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Derogar & Lagergren, 2012; Deschamps, Nichols III, Cassivi, Allen, & Pairolero, 2005;
Gockel, Gönner, Domeyer, Lang, & Junginger, 2010; McLarty et al., 1997; Moraca &
Low, 2006), while some revealed that HRQL did not return to general population levels
even after 1 and 3 year follow ups (Courrech Staal, van Sandick, van Tinteren, Cats, &
Aaronson, 2010; Djärv et al., 2008; Donohoe, McGillycuddy, & Reynolds, 2011)..
Surgery type is often a factor involved in HRQL recovery. Those who undergo
open esophagectomy have a slightly longer HRQL recovery time compared to those with
minimally invasive esophagectomy (MIE). MIE candidates generally start to see
improvement 3 months later, and are generally back to baseline by about 6 months, with
the exception of reflux and diarrhea reports (Parameswaran et al., 2008). It is not clear if
these differences are related to the particular treatment or if those who have more
minimal treatment are generally at an earlier disease stage (Djärv & Lagergren, 2012).
However, overall tumour type, stage and location all affect HRQL outcomes. Those with
squamous cell carcinoma or a tumour location higher up on the esophagus are more likely
to report a lower HRQL. Also, those who have a more advanced tumour report lower
HRQL. Comorbidities can reduce HRQL outcomes further, especially in the physical
function and role function, as well as reporting greater fatigue and diarrhea (Djärv et al.,
2008). Other treatments such as neo-adjuvant chemotherapy (NAC) do not affect global
health status or HRQL outcomes further, except in the social functioning category, where
there was a significant reduction after NAC (Tatematsu, Ezoe, et al., 2013).
Interventions to enhance HRQL and decrease the duration of reduction should be
considered for esophageal cancer. Exercise and PA are documented lifestyle behaviour
20
strategies that can improve HRQL in cancer survivors pre, during and post treatment
(Schmitz et al., 2010).
1.3 Physical Activity in Cancer
Research in the cancer field has produced improved prognoses due to early
detection and improved treatments. The effect has been a continual decrease in cancer
mortality rates (1.8% per year in males, 1.6% in females between 2004-2008) (Siegel,
Naishadham, & Jemal, 2012). With survivors living longer, research related to HRQL
outcomes has increasingly become a focus. A universally accepted definition for HRQL
has not yet been established, however the components that have been most tested in
cancer populations include physiological, psychological and social functioning domains
(Fong et al., 2012).
Physical activity and exercise interventions for those on treatment and those who
have completed treatment have been deemed safe (Schmitz et al., 2010). Physical activity
(PA) has been defined as ‘any bodily movement produced by skeletal muscle that results
in energy expenditure’, while exercise is ‘a subset of PA defined as planned, structured,
and repetitive bodily movement done to improve or maintain one or more components of
physical fitness’ (Caspersen, Powell, & Christenson, 1985). Although there are some
relevant differences between PA and exercise in definition, PA and exercise were both
used in the literature review to ensure a thorough search was completed. In the present
paper, PA will be used for both terms.
Upon review of the literature at the American College of Sport Medicine (ASCM)
roundtable discussion, it was suggested that exercise-induced improvements are expected
in aerobic fitness, muscular strength and HRQL in cancer patients during and after
21
treatment (Schmitz et al., 2010). HRQL measures have been utilized in PA and cancer
research consistently and repeatedly across intervention types (i.e., aerobic, resistant
training, mixed). The impact of PA on HRQL has not yet been reported in gastric and
esophageal cancers, however research in other cancer groups have been explored. A
systematic review and meta-analysis identified effect sizes of PA in cancer from high
quality control trials (Speck, Courneya, & Mâsse, 2010) It was concluded that there was a
small to moderate effect on overall HRQL in interventions post-treatment, and a small to
moderate effect on functional HRQL in interventions during treatment (Speck et al.,
2010). Similar results were reported in a recent HRQL and PA meta-analysis stating that
overall, exercise interventions had a positive and significant effect on HRQL outcomes
and were maintained at follow up (Ferrer et al., 2011).
The majority of research that explored the effects of PA has been predominantly
breast or prostate cancer specific (Schmitz et al., 2010), which affects the external
generalizability of these findings for other cancer populations. Smaller cancer
populations have very little research, with cancers of the upper GI being almost nonexistent in the literature. Only a select few studies have looked at the possible effects of
PA in gastric and esophageal cancers.
1.3.1 Physical activity in gastric cancer
While PA can help attenuate treatment effects in breast cancer and subsequently
increase HRQL in cancer survivors during and post treatment (Schmitz et al., 2010) only
two studies have reported potential PA effects in gastric cancer (Lee et al., 2010; Na et
al., 2000) (see APPENDIX A). These studies were included because they identified PA
interventions or evaluations for those with a diagnosis of gastric cancer. There are several
22
studies that evaluated or reviewed PA in relation to gastric cancer risk, however these
were excluded.
A number of studies (Choi & Kang, 2012; Kim, 2005; Lee et al., 2010; Na et al.,
2000) were conducted in Korea, but some of the research could not be considered here
because it is not published in English or remains unpublished. Most notably, these
include an unpublished doctoral dissertation: Effects of an individualized exercise
program on cancer-related fatigue, physical and cognitive function, and emotional status
in patients with gastric cancer during chemotherapy (Kim, 2005) and Effects of a Homebased Exercise Program for Patients with Stomach Cancer Receiving Oral
Chemotherapy after Surgery (Choi & Kang, 2012) which was not completed in English.
Finally, one study described a pre-operative protocol but did not publish results (Cho et
al., 2008).
The first intervention study by Na et al. (2000) was a randomized controlled trial
(RCT) with stomach cancer patients who had just completed curative resection of the
stomach. Exercise therapy was conducted for 2 weeks post-surgery starting with in bed
exercise on day one with active range of motion (ROM), pelvic tilting exercise and
isometric quadriceps-setting exercise for 30 minutes, three times a day. Patients were
encouraged to start walking as soon as possible, and when able to, their exercise program
was progressed to 30 minutes of supervised aerobic activity using an arm and bicycle
ergometer two times a day, five times a week for the 2 weeks. Blood samples were taken
on postoperative days (POD) 1, 7 and 14 to determine natural killer cell cytotoxic activity
(NKCA) with exercise therapy. Mean sequential change of NKCA decreased until day 7,
then increased in both exercise group and control. POD 14 means of difference for blood
23
samples showed a significant increase in NKCA in the exercise group compared to the
control group, suggesting that a 2-week exercise therapy program could increase the
immunity levels of stomach cancer patients post-surgery. A limitation to this study was
the length of the exercise intervention. The determination of long-lasting effects with
only a 2-week follow-up is impossible. Clinical significance was also not mentioned, and
with some of the control group seeing improvement by POD 14, it is unclear whether the
improvement in 14 days post-surgery would significantly improve health status over a
longer period of time.
The second intervention study examined a Tai-Chi intervention paired with an
educational self-help program in gastric cancer (Lee et al., 2010). The study was an
intervention with pre and post measures. The Tai-Chi portion was conducted 1 time per
week for 24 weeks and included a take home CD for at home practice. The self-help
education sessions were bi-weekly for 12 weeks. Blood samples were taken to examine
immune markers, and questionnaires were conducted to determine depression and HRQL.
All measures were taken at baseline and one week prior to completion of study. Overall,
no significant improvements were seen in immune markers, HRQL or depression from
baseline to completion. A limitation to this study was attrition; the dropout rate was 36%,
which could have been due to the length of program. Also, the baseline measures for
immunity were already within normal ranges, meaning there was little room for
improvement. Finally, the frequency of the Tai Chi sessions (one time per week) was
likely inadequate to acquire a training effect given what is known about PA guidelines,
and therefore did not produce measurable changes.
24
1.3.2 Physical activity in esophageal cancer
Four prospective studies were completed specifically in esophageal cancer
(Feeney et al., 2011; Murray et al., 2007; Tatematsu, Park, et al., 2013; Tatematsu, Ezoe,
et al., 2013) (APPENDIX A). The first two studies were conducted at the same facility
during the same time period. Both of these studies included only those with squamous
cell carcinoma. The first one explored the possible association between self-reported PA,
physical fitness and postoperative complications after esophagectomy. It was determined
that those with a low level of PA were independently associated with greater
postoperative complications (p=0.002, CI 3.5-227.7), meaning that a lesser number of
postoperative complications were reported in those with higher levels of PA. These
findings suggest that increasing activity prior to surgical treatment may benefit the patient
(Tatematsu, Park, et al., 2013).
The second Tatematsu publication explored the impact of neo-adjuvant
chemotherapy on physical fitness, PA and HRQL. Individuals reported their current PA
levels and HRQL. All participants completed a knee extensor strength test and a 6-minute
walk test. Overall, no association was determined and it was concluded that neo-adjuvant
chemotherapy did not have an effect on physical fitness, PA or HRQL (Tatematsu, Ezoe,
et al., 2013).
Another study identified the pre-operative PA levels of esophageal cancer patients
in relation to postoperative pulmonary complications (PPC) (Feeney et al., 2011).
Individuals recruited in the study were provided an accelerometer for four days leading
up to the surgery to determine quantity and intensity of PA. After surgery, patients were
monitored and it was reported that 10 out of the 37 participants developed a PPC. Those
25
who developed a PPC spent a significantly longer time period in inactivity compared to
those who did not. It was also determined that those in the non-PPC group spent
significantly longer time in moderate intensity activity than those who developed a PPC.
A second study with a similar outcome goal, measured the cardiovascular fitness of
esophageal patients prior to surgery with a shuttle walk test (SWT) (Murray et al., 2007).
It was determined that 5/8 participants who completed <340m on the SWT died within
the study time frame. The results of these studies support the theory that an increase in
pre-treatment PA and fitness level decreases the incidence of post-surgery morbidity and
mortality rates in esophageal cancer (Feeney et al., 2011; Murray et al., 2007).
The limitations to these studies are population based. Specifically, all participants
in the first two esophageal studies were squamous-cell carcinoma, which is not a
prevalent type of esophageal cancer in Western countries. Histology was not reported in
the third or fourth studies so it is unknown which types of esophageal cancer were
included. No study was identified that looked at adenocarcinoma exclusively, and as such
results could vary in other histological populations. The limitations for the esophageal
cancer and PA literature as a whole are that the research is exclusively in those who
completed surgery, which typically only includes earlier stage cancers. The literature fails
to identify the effects of PA at a later stage in treatment (into recovery) and also in those
in an advanced stage who do not qualify for surgical treatment. Therefore, since a large
majority of patients present in advanced stages, the literature is missing a large proportion
of the relevant population.
26
1.3.3 Physical activity in combined upper GI cancers
The final three studies identified in Table 3 included mixed samples of gastric
cancer and esophageal (Bhargava & Chasen, 2010), or included a population of
‘gastrointestinal’ cancers (Zalina et al., 2012) (APPENDIX A). One study included PA in
a rehabilitation program that included psychological counselling (Bhargava & Chasen,
2010), another study conducted survey work about current levels of PA as well as
nutritional status (Zalina et al., 2012), and one final study identified the risk of
cardiopulmonary complication after surgical treatment (Moyes et al., 2013). All three of
these studies were included because they had populations inclusive of gastric and
esophageal cancers, and had specific measurement tools for PA. Study designs ranged
substantially, some had small sample sizes and one study had an extraordinarily high
drop-out rate (58%) (Bhargava & Chasen, 2010).
All PA intervention studies were conducted in early stage gastric and/or
esophageal cancer patients who had undergone surgery or were about to, however due to
the drastic difference in exercise type, length of study, study type and outcomes, it is
difficult to discern any firm conclusions. We can however establish that exercise at this
stage (pre/post-curative surgery) of the gastric and esophageal cancer populations is
feasible. The mixed population studies generally did not isolate each diagnosis, which
eliminated the possibility of the generalization of PA results to specific cancer diagnoses.
It was also unclear if PA was responsible for any reported outcome improvement, such as
in the rehabilitation program for gastric and esophageal patients (Bhargava & Chasen,
2010). In this study a comprehensive 8-week rehabilitation program was completed,
which included psychological counselling, nutritional counselling and therapeutic
27
exercises to maintain ROM. The results did show improvement in a variety of measures
however, given the protocol it is not possible to relate any of these improvements to PA
alone. The program also reported poor adherence due to disease progression and
geographical location (Bhargava & Chasen, 2010).
The second study included all gastrointestinal diagnoses (Zalina et al., 2012), and
did further separate into upper (n=8) and lower (n=62) gastrointestinal diagnoses
however the results were not separate. This lack of result separation, lack of diagnosis
separation and the small sample size overall made the outcomes of this study impossible
to apply or generalize to gastric and esophageal cancers.
The final study that was identified utilized an incremental cardiovascular test to
determine the probability of cardiopulmonary complications (CC) post-surgery (Moyes et
al., 2013). The results of this study displayed that an anaerobic threshold of 9 ml/kg/min
or lower was associated with the development of postoperative CC. With CC being a
major postoperative morbidity concern among these diagnoses, this result (as well as
those displayed in the esophageal literature) suggests a promising first step into PA
recommendations and encouragement for those upon initial diagnosis pre-treatment.
Some limitations to this study include lack of long-term follow up and a small sample
size, making it difficult to translate these findings to all patients in this population.
With the lack of research in these populations, further investigation is necessary
and essential to determine if PA is feasible at various stages and during different
treatment types. It is documented that gastric and esophageal cancer patients have a
reduced HRQL during various treatments, and that PA has improved HRQL in other
cancer populations. In order to better understand the potential for future PA research
28
designs in gastric and esophageal cancer, PA preferences, possible PA barriers, levels of
social support for engaging in PA, and potential improvements in HRQL must be
identified and documented.
1.4 PA Barriers and Preferences in Cancer
Preferences for PA have been collected to inform future exercise interventions in
cancer. Preferences have been dichotomised and collected in terms of PA counselling and
PA programming (Demark‐ Wahnefried, Peterson, McBride, Lipkus, & Clipp, 2000).
Preferences for PA counselling and PA programming have been explored in many
specific patient populations such as: breast (Rogers, Courneya, Verhulst, Markwell, &
McAuley, 2008; Rogers, Markwell, Verhulst, McAuley, & Courneya, 2009), endometrial
(Karvinen et al., 2006), non-Hodgkin’s lymphoma (Vallance, Courneya, Jones, &
Reiman, 2006), bladder (Karvinen et al., 2006), primary brain cancer (Jones et al., 2007),
head and neck (Rogers, Malone, & Rao, 2009), ovarian (Stevinson et al., 2009), kidney
(Trinh, Plotnikoff, Rhodes, North, & Courneya, 2012), and a group of mixed cancer
patients (Jones & Courneya, 2002). Given the apparent diversity among these diagnoses,
it is interesting to note that there were some distinct trends reported across all or most
cancer groups. Specifically, all reported that the majority of patients in their samples
were ‘definitely’ interested in PA counselling and programming or ‘maybe’ interested.
The majority of these populations reported that they preferred to speak face –to-face with
an exercise specialist at a cancer centre about PA, with the exception of one study that
reported patients preferred mailed literature (Demark‐ Wahnefried et al., 2000). The
most commonly reported programming preferences were home-based exercise that was
alone, in the morning, and consisted of walking. Only one population reported a
29
relatively equal preference for alone and group based exercise (Vallance et al., 2006).
The majority of patient groups reported that post-treatment was the preferred timing of a
PA program, with the exception of the mixed cancer population which preferred to start a
program before treatment (Jones & Courneya, 2002). The most commonly reported
moderators of exercise preferences were stage, months since diagnosis, treatment,
meeting PA guidelines, income, education, and age. The majority of these studies
recruited participants through a cancer registry, either in Alberta Canada or in a midsize
Midwestern state in the USA. These studies also consisted of primarily stage I and II
patients, or those who were classified as in remission or ‘disease-free’, with the exception
of the sample collected in head and neck cancer that reported their patients were 81%
stage III or IV cancer (Rogers et al., 2009), and a sample collected in primary brain
cancer (75.5% were III/IV) (Jones et al., 2007).
The literature on barriers in PA are more limited, and a survey method has not
been validated, but there is some literature that has been surmised and recommendations
were made for future collection of perceived PA barriers, which suggested grouping
barriers into treatment-related, life-related and motivation-related barriers (Brawley &
Culos-Reed, 2002). The few studies that have reported PA barriers with either an openended question or a survey, were in colorectal (Courneya, Friedenreich, et al., 2005),
breast (Courneya et al., 2008), head and neck (Rogers et al., 2008), multiple myeloma
(Craike, Hose, & Livingston, 2013), and a mixed cancer group (Blaney, Lowe-Strong,
Rankin-Watt, Campbell, & Gracey, 2011). There were again a wide array of population
and methodological discrepancies, which makes it challenging to draw generalized
conclusions. However, in all of these studies, a clear distinction was made between
30
treatment-related barriers and life/motivation-related barriers. Patients with head and
neck cancer most commonly reported life/motivation-related barriers, however treatmentrelated barriers were significantly associated with PA levels (Rogers et al., 2008). In
other patient populations, both barrier categories were commonly reported, such as in
colorectal cancer where the most common barriers to exercise were ‘lack of time/too
busy’, ‘nonspecific treatment side effects’, and ‘fatigue’. These 3 barriers accounted for
45% of all missed exercise weeks (Courneya, Friedenreich, et al., 2005). Similarly in
breast cancer, exercise barriers that accounted for the most missed exercise sessions
were: ‘feeling sick’ (12%), ‘fatigue’ (11%), ‘lost interest’ (9%), ‘vacation’ (7%), and
‘nausea/vomiting’ (5%) (Courneya et al., 2008). In the mixed cancer population patients
reported that the top ten barriers that interfered ‘often/very often’ with exercise were
illness/other health problems (37.3%), joint stiffness (36.9%), fatigue (35.7%), pain
(30.1%), lack of motivation (26.5%), weakness (21.5%), lack of interest (20.7%) and fear
of falling (19.5%) (Blaney et al., 2011). Whereas patients with multiple myeloma mainly
reported treatment related barriers and barriers related to confidence in knowledge and
ability. The strongest perceived barriers were ‘fatigue’ (37.8%), followed by ‘injuries’
(34.2%), ‘pain’ (28.1%), ‘other health conditions’ (21.1%), ‘age-related decline in
physical ability’ (18.5%), ‘lack of knowledge about physical activities that are safe’
(19.7%), ‘lack of confidence in physical ability (17.1%), and ‘fear of injury’ (16.2%)
(Craike et al., 2013).
In summary, the current literature reporting PA preferences and barriers in cancer
have shown relatively consistent PA preferences in terms of counselling and
programming, however the PA barriers have been unique in each cancer type with only
31
limited consistency in reports of treatment-related barriers, such as fatigue. To better
understand how cancer specific barriers may impact PA levels, it is important that
individual cancer groups are examined so that further exploration of individual treatmentrelated barriers in particular can be addressed. It is also important that individual PA
preferences are included and taken into consideration to further explore their impact on
long term PA adherence (Trinh et al., 2012).
The purpose of this investigation was to report the PA levels in a clinical sample
of gastric and esophageal cancer patients, and to examine the relationship between PA
and HRQL. The secondary objective was to report the PA preferences, barriers, social
support for being physically active as well as nutritional assessment results to further
explore potential barriers to PA. Finally, exploratory linear regression models were
completed to investigate potential demographic and medical influences on HRQL.
It was hypothesized that the majority of gastric and esophageal patients would be
inactive and that there would be a significant positive association between PA levels and
HRQL. It was also hypothesized that patients would be generally interested in PA
counselling and programming, with preferences similar to those reported for other patient
populations. In terms of barriers, it was hypothesized that patients would rate
‘disease/treatment’ related barriers higher than ‘life-related’ or ‘motivational’ barriers. As
nutrition is a potential barrier, it was also hypothesized that the majority of patients
would show preliminary signs and symptoms of malnutrition. Finally, it was
hypothesized that stage, age, months since diagnosis, and treatment type would be
identified as demographic and medical variables that effect HRQL in the linear regression
modeling.
32
Chapter Two: : Methodology
2.1 Participants
Participants were recruited from the Tom Baker Cancer Centre Outpatient
Gastrointestinal Tumour clinic. Eligible participants were recruited from the active
tumour group clinic by a qualified research staff member after presentation of the study
by clinic staff. Inclusion criteria included: (I) a current diagnosis of gastric, esophageal or
gastroesophageal junction cancer; (II) be over 18 years of age; (III) must not have any
cognition-altering comorbidities (physiological, psychological or social) that may affect
the survey response accuracy; and (IV) participants had to be English speaking. Any
patient who did not fulfill the inclusion criteria were excluded from the study.
Participants were also excluded upon oncologist recommendation. Participants of varying
stages and treatments were captured in this sample.
2.1.1 Sample Size
Given the lack of literature regarding PA in gastro esophageal cancer, the primary
objective of the study was the preliminary exploration and recruitment of gastric and
esophageal cancer patients to determine PA prevalence in these populations and examine
the association between PA and HRQL. A review of annual clinic records revealed that
approximately 200 new gastric and esophageal cancer patients were initiated into the
TBCC GI tumour clinic from March 2013-September 2014. In order to effectively
analyze the tertiary objective (predictive regression model) a preliminary power
calculation on the primary outcome of interest (PA levels) using the GLTEQ, a sample
size of 38 was required (GPower 3.1) (Faul, Erdfelder, Lang, & Buchner, 2007; Franz
33
Faul, Erdfelder, Buchner, & Lang, 2009). An a priori clinically significant effect size of
0.3 (Rogers et al., 2006), an α of 0.05 and a power of 0.80 were utilized.
2.1.2 Recruitment
Patients were flagged through a historical retrieval of new patients to the TBCC,
and identified through the AHS scheduling system (ARIA) by the student co-investigator
(KK). Historical records dated back one and one half years prior to recruitment start date.
Individuals who returned with scheduled appointments in the upcoming 1-2 weeks were
identified. The student would then email the appropriate oncologist about the potential
participant. Upon oncologist approval and verification of inclusion criteria, the student
attended the appropriate clinic time. The oncologist introduced the study to the potential
participant and gained consent for the student to approach the patient. Once this verbal
consent was obtained, the student co-investigator entered the clinic room, provided
further details about the study and obtained written consent as well as provided a hard
copy or online access to the survey for completion. The participants then either
completed the self-administered questionnaire in the clinic and returned it the study coinvestigator, or completed the on-line version from home. If study completion was
declined, research staff attempted to record why they declined (ie- lack of time, lack of
interest).
2.2 Design and Procedure
In this cross-sectional design, all patients in the gastrointestinal outpatient clinic
eligible to participate in the current study, and who completed an informed consent, were
provided with the questionnaire. Individuals from varying diagnoses and disease stages
were included. The one-time questionnaire was self-administered and completed during
34
clinic time. If the participant did not wish to complete the survey in clinic, two options
were provided: (i) a hard copy version with a pre-addressed, stamped envelope or (ii) a
document containing information about the online version of the questionnaire. If the
participant chose one of the ‘take-home’ alternatives, telephone information was gathered
and the participant was informed that a reminder phone call would be made after 2
weeks. If the questionnaire package was still not returned after the reminder call, it was
assumed that the participant no longer wished to participate.
2.3 Outcome Measures
2.3.1 Demographic and medical records
General demographics were self-reported in the questionnaire package and
included: age, sex, education level, income, marital status, height and weight (to
determine BMI), smoker/non-smoker, and weekly alcoholic beverage intake
(APPENDIX B.1). Self-reported medical records were collected as well, and included
stage or grade of disease, completed and present treatment types, disease recurrence
(Y/N), and present disease prognosis. Comorbidities were recorded by Y/N response for a
number of cardiovascular (i.e.-hypertension) and metabolic conditions (i.e.-diabetes) (see
APPENDIX B.2).
2.3.2 Physical activity
PA was reported with the Leisure Score Index (LSI) of the Godin Leisure Time
Exercise Questionnaire (GLTEQ) (Godin, Jobin, & Bouillon, 1985; Godin & Shephard,
1997) (see APPENDIX B.3). The questionnaire is broken down into categories of
reported intensity: mild effort (minimal effort), moderate exercise (not exhausting), and
strenuous exercise (heart beats rapidly) on a per week basis. Activity breakdown is
35
reported in a ‘typical 7-day period’. Questionnaires were modified to include duration of
PA at each intensity. The final portion was reported with an ‘often/sometimes/rarely’
response of how frequently the individual increased their heart rate in a typical 7 day
period. Results of this questionnaire were calculated for both frequency and duration
separately. Each intensity category was multiplied by the estimated METs exerted for
that intensity, (IE- Mild effort x 3, Moderate effort x 5, Strenuous effort x 9) and summed
to compile an estimated MET/week output. This final value was evaluated for both
reported frequency and duration. This method of reporting PA levels has been previously
validated, and has a test-retest reliability of 0.64 (Godin et al., 1985).
2.3.3 Health-related quality of life
HRQL was collected with the gastric and esophageal cancer specific QOL survey
Functional Assessment of Cancer Therapy, Gastric or Esophageal cancer specific
questionnaire (FACT-Ga) (Garland et al., 2011). (FACT-E) (Darling, Eton, Sulman,
Casson, & Celia, 2006). These surveys contained 5 sections: Physical Wellbeing (PWB),
Social/family Wellbeing (SWB), Emotional Wellbeing (EWB), Functional Wellbeing
(FWB), (see APPENDIX B.4.1) and Additional Concerns, which was a collection of
esophageal (see APPENDIX B.4.2) or gastric cancer (see APPENDIX B.4.3) specific
symptoms and concerns. Each category had a collection of statements and participants
were encouraged to respond with one of the following predetermined responses: not at
all/a little bit/somewhat/quite a bit/very much. All subscales were scored as well as a
collaborative total score. FACT-Ga has been validated, and all portions of the survey
have been determined to have a high internal consistency score (Cronbach α >0.70) and a
high test-rest reliability score (ICC = 0.885 for total scored survey). The FACT-E has
36
also been validated, and has good internal consistency and stability (test-retest) reliability
(Cronbach α >0.70).
2.3.4 Barriers to PA
Barriers to PA were collected with a questionnaire based on perceived barriers
guidelines for cancer patients (Brawley & Culos-Reed, 2002) (see APPENDIX B.5.).
Guidelines for disease and treatment-related barriers suggested that potential barriers
should be tailored to the population at hand. It was also suggested that treatment side
effects related to the disease should be included. In cancer-related treatments, common
side effects and potential perceived barriers included: fatigue, nausea/vomiting, hair loss,
weight loss/gain, dizziness, diarrhea, muscle weakness and shortness of breath. Other
categories of barrier assessment included: (1) life-related barriers: family concern, too
busy, not belonging to exercise class or gym, cost, lack of equipment, lack of access, no
one to exercise with, weather and lack of knowledge; (2) motivational barriers: preferring
to do other activities, not a priority, lack of self-discipline, lack of interest,
discouragement, body image, and overall lack of motivation. Scales will be provided for
each of the above barriers, with two numeric ranges (1-7). Two responses were provided
for each barrier (i) the influence it had on exercise (did not influence-influenced exercise
completely) and (ii) how often the individual barrier affected their exercise output (neverdaily). The questionnaire scores were reported, and averaged across all participants to
determine the significant individual barriers.
2.3.5 Preferences for PA
PA preferences were collected on exercise counselling and programming.
Participants were encouraged to answer the questions even if they were not currently
37
active. Questions regarding preferences in exercise counselling (Demark‐ Wahnefried et
al., 2000; Jones & Courneya, 2002) included the preference for counselling at some point
during their cancer journey (yes/no/maybe), the preferred time of counselling (pretreatment, during treatment, post treatment, 3-6 months post, at least 1 year post), the
preferred method of PA counselling (face-to-face, telephone, videotape, audiotape,
pamphlet/brochure, internet), and the preferred source of exercise counselling
(oncologist, nurse, exercise specialist affiliated with the cancer centre, exercise specialist
from a community fitness centre, a fellow cancer patient or survivor) (see APPENDIX
B.6.).
PA programming preference questions were modified similar to those described
in the literature (Courneya & Hellsten, 1998; Jones & Courneya, 2002) and included
preferred exercise company (alone, with 1 or 2 other survivors, with 1 or 2 other nonsurvivors, group of cancer survivors, group of non-survivors, no preference), the
preferred start of an exercise program (before treatment, during treatment, post treatment,
3-6 months post treatment, at least one year post treatment), preferred exercise location
(at home, community fitness centre, outdoors, fitness centre located at cancer centre, no
preference), preferred structure of exercise program (supervised/instructed, or
unsupervised, competitive or recreational, spontaneous or structured time, same activity
or varied activity), and preferred intensity of exercise (low, moderate, vigorous).
2.3.6 Social support for being physically active
A modified short version of a validated PA social support scale was used (Sallis,
Grossman, Pinski, Patterson, & Nader, 1987) (see APPENDIX B.7.). The participants
were asked to complete two versions of the same questionnaire, one in regards to family
38
members and one for friends and acquaintances. Questions asked whether their
family/friends engaged in PA, whether they offered to do PA with them, or whether they
gave them encouragement to do PA. Scoring was on a four-point score range, from 0
(never) to 4 (very often).
2.3.7 Nutritional assessment
Malnutrition has been a commonly reported concern for gastric and esophageal
cancers due to varying levels of dysphagia both pre and post treatment. Malnutrition was
identified with 3 variables: A body mass index (BMI) of <18.5kg/m2, unintentional
weight loss >10% within the last 3-6 months, and a BMI <20kg/m2 and unintentional
weight loss >5% within the last 3-6 months. Nutritional assessment tools can also be used
to identify malnutrition.
Nutritional assessment was completed with the modified Patient-Generated
Subjective Global Assessment (PG-SGA) (see APPENDIX B.8.). This survey was a
modified version of the validated Subjective Global Assessment (SGA) (Detsky et al.,
1987). The PG-SGA was specifically created for cancer populations in hospital where
clinical assessments would be compared to the responses (Bauer, Capra, & Ferguson,
2002). However, because client records were not accessed during this study, the initial
survey portion only was used to provide a more thorough presentation of their change in
nutritional status as opposed to the current 7-day reports administered in the FACT
survey. There were four questions with answer options in a ‘check off’ format. Questions
involved current weight, and self-reported weight one month ago, food intake currently
and one month ago, symptoms checklist for the past two weeks, and activities and
function over the past month.
39
2.4 Data Analysis
The data was analyzed on IBM SPSS statistical software. Descriptive statistics
were completed for demographics, medical record reports, and questionnaire outcomes.
Box-plots were utilized to determine any outliers. Descriptive statistics provided the
preliminary results of the primary objective and purpose.
Pearson correlations were completed between PA levels and HRQL, PA barriers,
social support and PA preferences. Pearson correlation coefficient was analyzed to
determine if a linear relationship existed between the given variables, and to address the
secondary objectives.
A multiple linear regression was completed on all measures as a predictive model,
and to adjust for demographic and medical variables.
40
Chapter Three: Results
3.1 Participant Characteristics
Patients were identified through historic review of the Tom Baker Cancer Centre
initial appointment lists, and by reviewing the Gastrointestinal Tumour Group weekly
initial and follow-up appointments. Fifty-seven patients had appointments during the
study timeline. The study representative was unable to make contact with eleven patients
due to either patient no-show at clinic appointment (n=4), oncologist non-responsive
(n=2), or the representative was unable to make the appointment time provided (n=5).
Two patients were deemed ineligible by oncologists because they did not speak English.
Upon study introduction by the oncologist, two further patients declined participation
with no reason recorded. Four patients agreed to speak with the study representative,
however later declined participation citing they were unable to participate ‘not at this
time’ (n=2), or ‘not interested’ (n=2). Thirty-eight patients consented to participate in the
study, and thirty-two patients submitted a completed survey (84% response rate) (see
APPENDIX C—Recruitment Diagram).
Patient demographics can be seen in Table 1. Mean age was 65±9 years and mean
BMI was 24.0±4.1kg/m2. The majority of patients were between the ages of 55-74 years
(68.8%). The majority of patients were male (71.9%) and married/common law (75%).
Most of the patients had completed high school (77.4%) and over half had started or
completed university (51.6%). The majority of patients had an income greater than
$80,000 (38.5%), and were retired (56.3%). Patients were mainly non-smokers (84.4%)
and reported drinking zero alcoholic beverages a week (61.3%).
41
Table 1 Patient demographic frequencies for a sample of gastric and esophageal cancer
patients.
Demographic Measure
N
Percent (%)
Marital Status
Married/Common Law
Divorced/Separated
Widowed
Never Married
n
24
5
2
1
32
75.0
15.6
6.3
3.1
Education Level
Some high school
Completed high school
Some university/college
Completed university/college
Some or completed grad school
n
3
8
8
8
4
31
9.7
25.8
25.8
25.8
12.9
3
4
5
4
10
26
11.5
15.4
19.2
15.4
38.5
8
18
1
5
32
25.0
56.3
3.1
15.6
23
9
32
71.9
28.1
Annual Income
<$20,000
$20,000-$39,999
$40,000-$59,999
$60,000-$79,999
>$80,000
n
Employment Status
Full time
Retired
Part time
Disability/sick leave
n
Gender
Male
Female
n
42
Age (yrs)
45-54
55-64
65-74
75-84
85+
Mean
n
5
10
12
4
1
65
32
15.6
31.3
37.5
12.5
3.1
Smoker
Yes
No
n
5
27
32
15.6
84.4
Weekly Alcohol Intake
0
1-3
4-6
7-9
>10
n
19
6
1
3
2
31
61.3
19.4
3.2
9.7
6.5
Most patients were diagnosed with esophageal cancer (68.8%; gastric cancer,
31.3%) with stage III (34.4%) or stage IV (28.1%) cancer. The majority of patients were
within ten months of diagnosis (74.2%), and reported having chemotherapy (84.4%) or
radiation (71.9%). Roughly half of the patients reported surgical treatment (53.1%). This
was a first cancer occurrence for 75.9%. Refer to Table 2 for further medical information.
43
Table 2 Medical information for a sample of gastric and esophageal cancer patients.
Gastric
Variable
Esophageal
N
Percent
(%)
N
Percent
(%)
10
31.3
22
68.8
0
1
5
2
0.0
12.5
62.5
25.0
0
3
6
7
0.0
18.8
37.5
43.8
4
4
1
0
1
40.0
40.0
10.0
0.0
10.0
10
5
3
1
2
47.6
23.8
14.2
4.8
4
9
6
40.0
90.0
60.0
19
18
11
86.4
81.8
50.0
1
3
4
12.5
37.5
50.0
6
5
6
35.3
29.4
35.3
7
3
70.0
30.0
15
4
78.9
21.1
1
3
0
0
0
0
10.0
30.0
0.0
0.0
0.0
0.0
4
4
0
2
1
1
18.2
18.2
0.0
9.1
4.5
4.5
Cancer Diagnosis
Stage
I
II
III
IV
Months Since Diagnosis
1-5
6-10
11-15
16-20
45+
Treatment
Radiation
Chemotherapy
Surgery
Metastatic
Yes
No
Unsure
First Occurrence with Cancer
Yes
No
Other Conditions
Diabetes
Hypertension
COPD
Coronary artery
disease
Liver disease
Other
44
3.2 Preliminary Analysis
Patient demographic and medical information were evaluated in relation to global
HRQL (FACT-G) and PA outcomes to examine preliminary relationships. The only
significant demographic or medical associations with HRQL was months since diagnosis
(r=.39, p=.04). Upon evaluation of PA and HRQL associations (Objective #1) it was
determined that continuous PA outcomes: LSI score and total active minutes, presented
with a positive skew (LSI= .77: Active Minutes=4.51) and positive kurtosis (LSI=.45:
Active Minutes=22.95) both approaching or surpassing one. Even with the removal of a
single outlier, PA minutes continued to have a positive skew (=1.1). Given these
descriptive outcomes, log transformed data was created for both total LSI score and total
PA minutes in order to address the assumption of normality (Field, 2013).
3.3 Primary Analysis
3.3.1 Objective 1
3.3.1.1 PA Outcomes
The Godin-leisure score index (LSI) total score was calculated (25.9±20.8 METS)
and total reported active minutes were 295.1±531.8. Strenuous (4.1±10.6 METS),
moderate (8.9±13.5 METS) and mild activities (12.9±11.1 METS) were compiled into
individual scores. The majority of patients reported that they ‘sometimes’ (46.9%) or
‘never/rarely’ (46.9%) participated in weekly activity that would produce sweat (see
APPENDIX D.1. Table 3). PA guidelines have been cited as 150 minutes of moderate to
vigorous activity (American College of Sport Medicine Recommendation) thus vigorous
PA minutes were combined with reported moderate activity minutes in order to better
represent the PA guidelines. It was determined that 15.6% of gastric and esophageal
45
patients were getting ≥ 150 minutes of moderate/vigorous PA in a typical week during
the past month.
3.3.1.2 HRQL Outcomes
HRQL, measured with the functional assessment of cancer therapy questionnaire
(FACT-G) had a mean score of 76±18.1, and ‘additional concerns’ category for gastric
and esophageal surveys were 52.4±12.1 and 44.1±11.8 respectively. The total survey
score was also calculated for each diagnosis (FACT-E: 118.8±27.4; FACT-Ga
133.7±24.7). The lowest scores were reported in the emotional wellbeing (EWB:
15.6±5.2) and functional wellbeing (FWB: 17.5±6.5) categories (APPENDIX D.2. Table
4). ANOVA results revealed that there was a significant difference in global HRQL
(FACT-G) between patient reported stages 2 (85.1±3.0), 3 (83.5±15.4) and 4 (63.9±20.1)
(p=.04). Pairwise comparisons revealed no significant differences between groups,
however the difference between stage 3 and 4 was closest to significance (p=.06).
3.3.1.3 PA and HRQL Associations and Analyses
Pearson correlations were completed with dependent outcome FACT-G
(APPENDIX D.3. Table 5). Global QOL (FACT-G) was moderately correlated with
leisure score total minutes (r=.40, p=.03). LSI and total leisure minutes were moderately
correlated with the subscale physical wellbeing (PWB) in the HRQL measure (r=0.39,
p=.03 and r=0.412 p=.02 respectively). To further explore a potential PA threshold in
relation to HRQL, patients were divided into two groups: Those achieving PA guidelines,
and those not. There was a significant difference in PA minutes between those achieving
the PA guidelines and those not (t=8.85, p<.001), however there was a non-significant
difference between HRQL scores between groups (t=1.22, p=.23). A similar analysis was
46
explored for HRQL outcome PWB between those achieving PA guidelines and those not.
Those who were achieving PA guidelines had significantly higher PWB (t=2.06, p=.049).
A clinically meaningful important difference (MID) was also explored between PA
groups. It has been reported that a change in FACT-G score of 3-7 points indicate a MID.
Patients who were achieving PA guidelines reported a score 10.8 points higher in global
HRQL than those not meeting PA guidelines (85.5±10.5 and 74.7±19.0, respectively).
Considering there is evidence that small improvements in levels of PA can produce
improvements in health, a lower threshold was also explored (Sugiura, Kajima, Mirbod,
Iwata, & Matsuoka, 2002; Tudor-Locke, Myers, Bell, Harris, & Wilson Rodger, 2002)
Patients were grouped into those who achieved a minimum of 150 minutes of total PA
minutes (sum of mild, moderate and vigorous minutes), and those who did not. Half of
the patients reported getting ≥150 minutes of total PA minutes (50%). A significant
difference existed between the two PA groups (t=2.67, p=0.01). However, there was a
non-significant difference in HRQL between the two PA groups (t=1.64, p= .11). MID
clinical significance was also explored between these groups, and those who completed
150 minutes of total PA also reported a score 10.8 points higher in global HRQL than
those not achieving the PA guidelines (81.4±15.7 and 70.6±19.7, respectively).
3.3.2 Objective 2
3.3.2.1 Exercise Preferences
Exercise preferences indicated that a majority of patients would not like to receive
exercise counselling during their cancer journey (51.1%). Of the patients who completed
the rest of the questionnaire (n=19), patients reported that they would like to receive
exercise counselling ‘during treatment’ (21.9%) or ‘immediately post-treatment’ (18.8%).
47
They would prefer that an ‘exercise specialist at a cancer centre’ provide the counselling
(65.0%), and that it was a ‘face-to-face’ interaction (42.1%). The majority reported that
they would prefer to start an exercise program ‘during treatment’ (42.1%), and that it was
‘home-based’ (47.8%), ‘alone’ (43.5%), and at a ‘moderate’ intensity (73.9%). It was
also reported that they would prefer ‘varied activity’ (68.8%), ‘unsupervised’ (70.0%),
‘recreational’ (100.0%) and ‘structured’ activity (60.0%) (APPENDIX D.4. Table 6).
3.3.2.2 PA Barriers
PA barriers were reported in terms of frequency and influence on PA engagement.
The highest reported barriers were ‘muscle weakness’, ‘fatigue’, and ‘pain’ (APPENDIX
D.5. Table 7). Those who were achieving the PA guidelines reported a significantly lower
score for influence of muscle weakness (p=.03).
3.3.2.3 Social Support for being Physically Active
The social support for being physically active survey revealed that family
members and friends typically did not engage in PA with the patient (34.6% and 37.0%
respectively). Out of the response options, more patients reported that their family
members encouraged them to do PA (28.6%). There were higher response rates that
reported neither family nor friends offered to be physically active with the patient (25.9%
and 34.6% respectively).
3.3.2.4 Nutritional Assessment
Nutritional assessment outcomes were calculated to produce a percent weight loss
score for one month (1.3±4.4%) and 6 months (7.7±1.2%). ANOVA results indicated a
significant difference between groups (p<.001). Pairwise comparisons revealed
significant differences between current weight and previous 6 month weight (p<.001),
48
and retrospective 1 month and 6 month weight (p<.001). A non-significant difference
occurred between current weight and retrospective 1 month (p=.06). The majority of
patients reported that their weight remained unchanged in the past two weeks (46.4%).
Food intake was generally reported as ‘unchanged’ (33.3%), or ‘normal food but a
smaller amount’ (23.3%). The majority of patients reported ‘no problems eating’ (33.3%)
however ‘no appetite’ (30.3%), ‘constipation’ (23.3%), and ‘pain’ (23.3%) were the most
commonly reported symptoms. Patients reported that their general activity and function
in the past month, and majority of patients reported that they were ‘not my normal self,
but able to do normal activities’ (53.3%).
3.4 Exploratory Analysis
Several multiple linear regression models were explored to see if PA significantly
predicted HRQL. After adjustment for age, annual income, and education level, LSI total
score did not produce a significant model (R2=.204, F(2, 20)=1.03, p=.40). Adjustments
for medical variables were also explored. After adjustment for stage, months since
diagnosis and BMI, the addition of LSI total score produced a significant model that
explained more variance in HRQL than the previous models (R2=.631, F(2, 17)=5.55,
p=.006), however individually LSI was not a significant contributing predictor (b=.287,
t(17)=1.51, p=.153). Finally, blocked entry of predictor variables displayed only one
significant model that did not include PA predictors. The results of the regression model
indicated that the two variables predicted 54.2% of the variance (R2=.542, F(1, 18)=9.48,
p=.002). Both BMI (b=.474, t(18)=2.80, p=.013) and stage (b=-.592, t(18)=-3.50,
p=.003) significantly predicted HRQL. Again, the addition of PA predictor LSI
49
accounted for more variance in this model (R2=.626, F(1, 17)=7.82, p=.003), but was not
a significant contributing predictor (b=.328, t(17)=1.84, p=.088).
50
Chapter Four: Discussion
It is well documented that PA levels in cancer patients are low across the cancer
spectrum. It is also recognized that HRQL is negatively affected during the cancer
experience. Studies have shown that PA can improve this reduction in HRQL and impact
some of the detrimental side effects that invasive treatments cause. However, only one
study has examined the exercise and HRQL relationship in a gastrointestinal population
that included gastric and esophageal cancer patients (Zalina et al., 2012). Therefore, the
primary objectives of this study were to examine PA levels among gastro esophageal
patients as well as the relationship between PA and HRQL. The secondary objectives
were to report the most common barriers to PA as well as PA preferences, social support
for being physically active and a preliminary nutritional assessment. Finally, exploratory
analyses were completed with demographic and medical variables to examine predictive
models of HRQL.
Gastric and esophageal cancer patients in this sample were representative of
population-based data in terms of stage, age and gender (Canadian Cancer Statistics,
2013). The majority of patients in this sample fell within the ‘normal’ range for body
mass index (BMI=24.0±4.1kg/m2), which is consistently lower than reports from other
cancer patient populations in similar studies (Jones et al., 2004; Karvinen, Courneya,
North, & Venner, 2007; Rogers et al., 2006; Stevinson et al., 2007; Trinh, Plotnikoff,
Rhodes, North, & Courneya, 2011; Vallance, Courneya, Jones, & Reiman, 2005), Overall
only 15.6% of gastric and esophageal patients were achieving the exercise guidelines of
150 minutes of moderate and vigorous PA. Not surprisingly, these values were lower
than the reported leisure time exercise for Canadians aged 65 years and over (46.1%)
51
(StatCan, 2013). However, gastric and esophageal patients reported lower PA than other
cancer patient groups (20-30%) (Courneya, Karvinen, et al., 2005; Jones et al., 2004;
Karvinen, Courneya, North, et al., 2007; Stevinson et al., 2007; Trinh et al., 2011;
Vallance et al., 2005).
PA guidelines have been endorsed at a national and international level. The World
Health Organization has identified physical inactivity as the fourth leading risk factor for
global mortality (2010), and is the leading organization that encourages every adult to
attain 150 minutes of moderate and vigorous PA per week, or 30 minutes of moderatevigorous activity per day. Subsequently, it has been stated that ‘some PA is better than no
PA’ (WHO | Physical activity, 2014). The beneficial effects of accumulated PA that fall
below the PA guidelines have been explored in the PA ‘step’ research. It has been
suggested that 10,000 daily steps is comparable to the PA time guideline provided above
(Tudor-Locke & Bassett Jr, 2004), however the impact of baseline step increases have
also been explored. Studies have shown that increasing steps by as little as 2500 steps per
day can improve important health outcomes (Sugiura et al., 2002; Tudor-Locke & Bassett
Jr, 2004). This finding suggests that lower levels of PA can positively contribute to
health. In the current study, a lower threshold of activity was also explored along with the
above guideline. Patient’s total PA minutes were calculated (mild, moderate and
vigorous) and patients were divided into two groups: those who completed 150 minutes
of total PA and those who did not. 50% of patients in this sample were getting 150
minutes of total PA minutes.
To date, there are no published studies identifying PA and HRQL in gastric and
esophageal cancers. The current results indicate a moderate positive association between
52
total PA minutes and HRQL in gastric and esophageal cancer patients. This trend of
increased HRQL with increased PA, is consistent with other patient populations such as
breast (Courneya & Friedenreich, 1998), colorectal (Courneya, Friedenreich, Arthur, &
Bobick, 1999) multiple myeloma (Jones et al., 2004), endometrial (Courneya, Karvinen,
et al., 2005), ovarian (Stevinson et al., 2007), non-hodgkins lymphoma (Vallance et al.,
2005) kidney (Trinh et al., 2011), bladder (Karvinen, Courneya, North, et al., 2007), head
and neck (Rogers et al., 2006), and young adult cancer (Bélanger, Plotnikoff, Clark, &
Courneya, 2011). Statistically, there was no difference in HRQL between those who were
meeting PA guidelines and those who were not.
In previous PA cancer research, participants have been divided into further
groupings such as completely sedentary, insufficiently active, within guidelines, and
above guidelines to explore the possible associations with HRQL. The sample size of the
present study was not sufficient to divide into four groupings, however lower levels of
PA were explored in relation to HRQL. As previously mentioned, patients were divided
into those who completed 150 minutes of total activity (mild, moderate and vigorous
minutes combined), and those who did not. Statistically there was no difference between
these groups, however clinically meaningful important differences were explored (MID).
To establish clinical significance, a change in score of 3-7 points on the FACT-G HRQL
scale must occur (Yost & Eton, 2005). In this study, those who were achieving the PA
guidelines had a 10.8 point higher score on the global HRQL outcome (FACT-G) versus
those who did not. A similar finding occurred when patients were divided into those who
completed 150 minutes of total PA, and those who did not. A MID of 10.8 was also
found with the combined minute groupings. This finding suggests that patients who were
53
achieving PA guidelines reported a clinically higher HRQL, and this trend also occurred
at a lower PA threshold (i.e., including mild minutes).
The low levels of PA reported for this population could be partially related to
diagnosis and treatment related side-effects, given the late staging at diagnosis and
invasive treatment options (Zali et al., 2011). The barrier items in this study reveal further
insights into the potential explanations for low levels of PA in this population.
Specifically, the highest rated barriers were ‘muscle weakness’, ‘fatigue’ and ‘pain’
(APPENDIX D.4. Table 6), which were reported to have ‘influenced exercise somewhat’.
These top barriers were all ‘disease-related’ barriers, which supports this theory. This
finding was consistent with other patient populations which also found that barriers
related to disease were top-rated (Blaney et al., 2011; Craike et al., 2013). The second
highest reported barriers were ‘lack of interest’, ‘lack of motivation’, and ‘lack of
discipline’, which were all ‘motivation-related’ barriers.
Barriers to PA are important to consider prior to intervention. For example,
considering disease-related barriers were the highest ranked, it is important that patients
are educated on the specific benefits of exercise in relation to reducing disease-related
burdens/symptom management (i.e., role of exercise for fatigue), to potentially enhance
buy-in and adherence to PA programming. Also, since stage negatively affected HRQL,
it can be suggested that those who are later in stage may in fact benefit the most from PA.
Therefore, exercise specialists and intervention investigators should be informed of the
most salient disease-related barriers so that they can provide the appropriate prescription
that will afford the most potential benefits for each individual.
54
In addition to these reported barriers, the nutrition analysis was also explored, as
poor nutrition could be a barrier to PA involvement. A recent study reported that both PA
and HRQL were associated with poorer nutritional status in gastrointestinal cancer
patients (Zalina et al., 2012). The majority of patients in the current study reported that
they were eating less than what they normally would and often had modified their diet.
They also reported a mean weight loss of 7.7% in the past 6 months. This trend of
involuntary weight loss has been previously documented in gastrointestinal cancers
(Blum et al., 2011), and can be attributed to late staging at diagnosis and mechanical
digestive issues that inhibit appropriate digestion (Zali et al., 2011). Significant losses in
weight and nutritional status impact treatment and survival in gastrointestinal cancer
patients as well as reduce HRQL (Andreyev & Norman, 1998; Gavazzi, Colatruglio,
Sironi, Mazzaferro, & Miceli, 2011) therefore it is important that future PA interventions
consider this when prescribing exercise, so as to not significantly accelerate weight loss
and increase barriers to PA.
To further inform potential PA interventions, patient PA preferences were
collected. Somewhat surprising, the majority of patients reported that they did not want to
receive exercise counselling (51.7%), while just under half of the patients reported ‘yes’
or ‘maybe’ (48.3%). This finding is not consistent with other patient populations, where
the majority of patients reported either a definitive or possible interest (Bélanger,
Plotnikoff, Clark, & Courneya, 2012; Jones & Courneya, 2002; Jones et al., 2007;
Karvinen et al., 2006; Karvinen, Courneya, Venner, & North, 2007; Rogers et al., 2009;
Rogers et al., 2009; Stevinson et al., 2009; Trinh et al., 2012; Vallance et al., 2006). This
finding could be due to sampling bias, however other explanations are also possible.
55
Generally, patients in this study were at later stages of diagnosis, and were more
sedentary in comparison to patient populations in similar studies listed above. Finally, it
is possible that the wording of the document affected the patient’s perceptions and
ultimately biased the survey outcomes. For example, the preferences survey used the
word ‘exercise’ as opposed to ‘physical activity’. Exercise has been defined as a subset of
PA, and is usually planned, structured and repetitive (Caspersen et al., 1985). Given this
definition, patients could have perceived it as something that would occur at a gym in a
public setting, which may have contributed to this outcome.
The remaining preference item findings were similar to other patient populations,
with the exception of temporality in programming. Specifically, the majority of patients
in this sample preferred exercise counselling during treatment, which has been reported
elsewhere (Jones et al., 2007). However, most notably, patients preferred to start an
exercise program during treatment. This later finding is unique to this population, as
several other populations have reported their preference in starting a PA program posttreatment (Blaney et al., 2011; Karvinen et al., 2006; Vallance et al., 2006).
In terms of exercise counselling, patients in this sample preferred to speak with an
exercise specialist at a cancer center in a face-to-face encounter. Patients preferred to
exercise at home, alone, and at a moderate intensity, which was consistent with most
other patient populations. Although patients reported that would prefer to do PA alone,
social support has been cited to be a factor that positively influences exercise adherence
in older adults (Oka, King, & Young, 1994). Future interventions should consider both of
these outcomes, and pilot a program that would provide either home-based PA options
56
that are accessible for patients to complete with family, or an intervention that
incorporates both group and independent PA.
4.1 Limitations
Limitations to this study were primarily related to the nature of the sample – small
and self-selected. Although the sample size was sufficient to complete all proposed
statistical measures, future work with larger samples may be more representative of the
two populations. Also, because all of the data was collected through self-report
questionnaires, recall bias is a concern. It is expected that the measurement method can
affect the reported outcome, and self-report PA outcomes have been reported as both
higher and lower than direct measurements of PA (Prince et al., 2008). Another
limitation was survey validation: three surveys that were a part of this questionnaire were
not previously validated. Despite this, literature in other patient populations have used
these questionnaires with various modifications dependent on patient population
(Bélanger et al., 2012; Jones et al., 2007; Karvinen et al., 2006; Karvinen, Courneya,
Venner, et al., 2007; Rogers et al., 2009; Stevinson et al., 2009; Trinh et al., 2012;
Vallance et al., 2006).
4.2 Conclusions
To our understanding, this is the first investigation to explore reported PA in
relation to HRQL in this gastro esophageal population, indicating a positive relationship
between total PA and HRQL. More patients reported that they were interested in
receiving exercise counselling and programming during treatment. This may suggest that
there is an interest in early PA intervention in gastric and esophageal cancer patients, one
that is not currently met with patient education or programming. Early PA intervention is
57
currently being explored in head and neck cancers, which also have similar weight loss
concerns (Capozzi et al., 2012). Therefore, specific exercise programming must be
further investigated to counteract weight loss concerns in this population but that also line
up with the patients preference in timing. Forthcoming research should examine the
impact of PA education for gastro esophageal patients in relation to PA levels. The
potential benefits of PA both physically and psychologically, must ultimately be
completed in an intervention that determines a causal relationship between PA and
HRQL. However, given that this population has yielded inconsistent results in previous
PA interventions, a prospective cohort that would follow this population over time, or a
pilot exercise intervention is suggested to identify and address the unique disease and
treatment related concerns for this population. Quantitative and qualitative data from a
cohort and pilot will directly inform a future large-scale intervention.
58
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of life and persisting symptoms after oesophageal cancer surgery. European Journal
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81
APPENDIX A: LITERATURE REVIEW TABLE
Author:
Population:
Intervention Details:
Measures and Findings:
Na, Y-M., et al. (2000)
Stomach Cancer patients
after curative surgery
(n=35)
RCT: exercise and control.
-Blood drawn on days 1,7 and 14
post-operative, mean sequential
change of NKCA (natural killer
cell cytotoxic activity).
-Mean sequential change of
NKCA decreased until day 7 and
then increased in both groups.
-Day 14, exercise group had
significant increase of NKCA
compared to control group.
-No significant difference between
groups in BMI, protein, albumin,
or total lymphocyte count
(p>0.05).
Lee, E-O., et al. (2010)
Exercise Therapy: While in bed:
Active ROM, pelvic tilting,
isometric quadriceps setting. 30
min x 3/day.
Ambulatory: aerobic activity
using arm and cycle ergometers.
30min x 2/day x 5/week for 2
weeks.
Gastric Cancer patients after One-group intervention, pre/post
gastrectomy (n=33)
test design.
Exercise Therapy: Tai Chi
program paired with educational
self-help program.
1x/week tai chi for 24 weeks.
-Immune markers, HRQOL,
depression
-No significant improvement of
immune markers, HRQOL and
depression.
82
Chasen, MB & Bhargava, R.
(2010).
Gastro-Esophageal Cancer
post surgery (n=53) (30
with gastric cancer, 23 with
esophageal)
One group intervention, pre/post
test design:
Rehabilitation Program: 8 weeks
biweekly with Physiotherapist.
Pre-test: Physical therapist
evaluates muscle strength,
mobility and joint ROM. 6 minute
walk test, gait speed test, timed 2
minute sit to stand, Berg balance
test, arm girth and scar
assessment.
Treatment: therapeutic exercises
to maintain or increase ROM,
endurance and mobility training.
4 surveys were completed pre and
post test: Edmonton symptom
assessment scale (ESAS), PatientGenerated Subjective Global
Assessment (PG-SGA), Brief
Fatigue Inventory (BFI), and
Distress Thermometer (DT).
- 22 patients completed 8 week
program (58% drop out rate).
-Reasons were disease progression
(19), geographical inaccessibility
(12)
-Statistically significant
differences for (ESAS) appetite
(p=0.01), strength (p=0.01),
nervousness (p=0.02), pain
(p=0.02), depression (p=0.04),
constipation (p=0.05) and nausea
(p=0.05) from pre to post test.
-Statistically significant
differences for (BFI) enjoyment in
life (p=0.01), general activity
(p=0.01), usual fatigue (p=0.03)
and fatigue now (p=0.05).
-Distress thermometer showed
significant reduction in distress
pre and post (p=0.01).
-PG-SGA median decreased from
12.00 to 9.00 (p=0.05).
-Significant increase in 6 minute
median walk distance and range:
384m (173-570) to 435m (203630), (p=0.01).
83
Zalina, AZ, Lee VC &
Kandiah M (2012)
Gastrointestinal Cancer
Patients (Upper and Lower):
-Have completed primary
treatments for cancer.
(n=70: 8 Upper GI, 62
Lower GI)
Cross-Sectional Study. One-time
Survey
Exercise Questionnaire:
International Physical Activity
Questionnaire- Short Form
(IPAQ, 2005)
Nutritional Status: Scored Patient
Generated Subjective Global
Assessment (PG-SGA).
Quality of Life: Gastrointestinal
Quality of Life Index (GIQLI)
Cancer Characteristics: GI
cancer type, stage of cancer,
treatment received.
-More males survivors (33%) than
females (16.1%) were in highest
quartile of GIQLI score
distribution.
-More than one third (40%) were
classified with having low PA.
-More females were physically
active (41%) in the high physical
activity level.
-Both PA and QOL showed a
negative correlation with
nutritional status
-Strong significant negative
relationship between nutritional
status and QOL (r=-0.661,
p>0.001)
-Small sample size affects the
generalizability
84
Tatamatsu et al. (2013)
Esophageal cancer who
underwent esophagectomy
(n=51)
Single Centre, Prospective study.
Physical Fitness: Knee extensor
muscle strength and 6 minute
walk distance. Forced vital
capacity (FVC), forced expiratory
volume in one second percent
predicted (FEV1%) and BMI.
Physical Activity Questionnaire:
Last 7-days short version of the
International Physical Activity
Questionnaire (IPAQ).
-Squamous cell carcinoma in all
cases
-Neo-adjuvant chemotherapy was
given to 67% of patients.
-Low-level physical activity was
found to be independently
associated with postoperative
complications (p=0.002, CI 3.5227.7).
85
Tatamatsu et al. (2013)
Resectable Esophageal
Cancer (n=27)
Impact of Neoadjuvant
Chemotherapy on PF and
PA.
Single centre, prospective study.
Physical Fitness: Knee extensor
muscle strength and 6 minute
walk distance.
Physical Activity Questionnaire:
Last 7-days short version of the
International Physical Activity
Questionnaire (IPAQ).
Health Related Quality of Life:
European Organization of the
research and Treatment of Cancer
Quality of Life Core
questionnaire with 30 items.
-Squamous cell carcinoma in all
patients.
-Occurrence of side effects: Grade
1 in 23 (85%), grade 2 in 16
(59%), grade 3 in 3 (11%) and
grade 4 in 1 (4%) of patients.
Grade 3 chemo-related toxicity
consisted of mucositis, abdominal
pain, thrombocytopenia. Grade 4
was related to hyponatremia.
-Statistically significant difference
in social functioning (p=0.04).
-Correlational analysis: the change
in PA demonstrated a significant
correlation with the change in 6minute walking distance but not
with change in knee extensor
muscle strength.
-NAC had no impact on PF, PA or
HRQOL
86
Feeney et al. (2011)
Esophageal cancer
scheduled for
esophagectomy (n=37)
Prospective cohort
Body Composition: BMI
Pulmonary Function: Micromedical spirometer, FVC, FEV
Physical Activity: RT3
Accelerometer for a period of 4
days
-10/37 individuals developed postoperative pulmonary complication
(PPC)
-Subjects who developed PPC
spent significantly longer in ICU
-Length of post operative stay in
those with PPC was significantly
longer
-6/10 in PPC group were
overweight compared to 15/27 in
the non PPC group
-Overall activity levels were low,
78.75% inactive, 18.75% in light
activity, 2% of the day in
moderate activity, and 0.42% in
vigorous activity
-Those with PPC spent
significantly longer time being
inactive per day compared to
those who did not.
-Subjects in non-PPC group spent
a significantly longer time in
moderate intensity activity
compared to PPC group
87
Moyes et al. (2012)
Gastric and esophageal
patients (n=108)
Prospective cohort
VO2Max and AnT: incremental
graded bicycle ergometer test.
Murray et al. (2007)
Patients after
oesophagogastrectomy
(n=51)
Prospective cohort
Cardiorespiratory reserve:
Shuttle walk test
-Mean VO2 peak was 15.2
ml/min/kg.
-Mean AT was 10.8 ml/min/kg.
-Post-operative complications
occurred in 57 patients (55%) with
29 (28%) developing noncardioplumonary complications.
-The mean AT in those with
cardiopulmonary complications
was 9.9 ml/kg/kg compared to
mean of non-cardiopulmonary
complications (p=.05).
-Majority of cardiopulmonary
complications occurred in those
with a low AT (p=.04).
-Reduced AT is a ‘progressive
marker for increasing risk’.
-Overall mortality in the group
was 10%.
-No patient who walked 350m or
more died within 30 days.
-5/8 patients who could not
achieve that distance died, and
two were in critical care at day 30.
88
APPENDIX B: SURVEY
B.1. Demographic Variables Survey
DEMOGRAPHICS: (Please answer in relation to your CURRENT status)
Please check only one option. If you do not wish to answer a question, please skip and go to the
next question. All information provided will be kept anonymous and confidential.
1. Marital Status
a. Married/Common Law:
b. Divorced/Separated:
c. Widowed:
d. Never Married:
☐
☐
☐
☐
2. Education Level (please check highest level attained)
a. Some high school
☐
b. Completed high school
☐
c. Some university/college
☐
d. Completed university/college ☐
e. Some or completed grad school ☐
3. Annual Family Income:
a. <20,000
☐
b. 20,000-39,999 ☐
c. 40,000-59,999 ☐
d. 60,000-79,999 ☐
e. >80,000
☐
4. Employment status:
a. Full-time
b. Homemaker
c. Retired
d. Part-time
e. Unemployed
f. Disability/sick leave
☐
☐
☐
☐
☐
☐
89
5. Gender
a. Male ☐
b. Female ☐
6. Age:____________
7. Smoker:
Yes
☐
No
☐
8. Weekly alcohol intake (drinks)
0 ☐
1-3 ☐
4-6 ☐
7-9 ☐
>10 ☐
90
B.2. Medical Variables Survey
MEDICAL INFORMATION:
Cancer Diagnosis (type and stage):____________________________________________
Date of Diagnosis (approximate):_____________________________________________
Is your diagnosis metastatic?
Yes ☐
Is this your first occurrence with cancer?:
No ☐
Yes ☐
Unsure ☐
No ☐
If no, please give details (date and type):______________________________________
_______________________________________________________________________
Type of Treatment:

Radiation

Chemotherapy ☐


Surgery ☐
Other (please specify): _______________________________________________
☐
If applicable, approximate date of treatment and treatment completion:
Other Health Conditions:






Diabetes (type 1 or 2) ☐
Hypertension (high blood pressure) ☐
COPD ☐
Coronary artery disease ☐
Liver disease
☐
Other:______________________________________
91
B.3. Modified Godin-Leisure Score Survey
Godin Leisure-Time Exercise Questionnaire
1. During a typical 7-day period (a week), how many times on the average do you do the
following kinds of exercise for more than 15 minutes during your free time (write on
each line the appropriate number).
a) STRENUOUS
EXERCISE (HEART
BEATS RAPIDLY)
(e.g., running, jogging,
hockey, football, soccer,
squash, basketball, cross
country skiing, judo, roller
skating, vigorous
swimming, vigorous long
distance bicycling)
Times Per Week
Minutes Per Week
___________
___________
b) MODERATE
EXERCISE (NOT
EXHAUSTING)
(e.g., fast walking, baseball,
tennis, easy bicycling,
volleyball, badminton, easy
swimming, alpine skiing,
popular and folk dancing)
Times Per Week
Minutes Per Week
___________
___________
c) MILD EXERCISE
(MINIMAL EFFORT)
(e.g., yoga, archery, fishing
from river bank, bowling,
horseshoes, golf, snowmobiling, easy walking)
Times Per Week
Minutes Per Week
___________
___________
2. During a typical 7-Day period (a week), in your leisure time, how often do you engage in any
regular activity long enough to work up a sweat (heart beats rapidly)?
Often
1.☐
Sometimes
2. ☐
Never/rarely
3.☐
92
B.4. Health-Related Quality of Life Survey (FACT)
B.4.1. FACT-G
FACT-E (Version 4)
Below is a list of statements that other people with your illness have said are important. Please circle
or mark one number per line to indicate your response as it applies to the past 7 days.
PHYSICAL WELL-BEING
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
GP1
I have a lack of energy .......................................................
0
1
2
3
4
GP2
I have nausea ......................................................................
0
1
2
3
4
GP3
Because of my physical condition, I have trouble
meeting the needs of my family .........................................
0
1
2
3
4
GP4
I have pain ..........................................................................
0
1
2
3
4
GP5
I am bothered by side effects of treatment .........................
0
1
2
3
4
GP6
I feel ill ...............................................................................
0
1
2
3
4
GP7
I am forced to spend time in bed ........................................
0
1
2
3
4
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
SOCIAL/FAMILY WELL-BEING
GS1
I feel close to my friends....................................................
0
1
2
3
4
GS2
I get emotional support from my family ............................
0
1
2
3
4
GS3
I get support from my friends.............................................
0
1
2
3
4
GS4
My family has accepted my illness ....................................
0
1
2
3
4
GS5
I am satisfied with family communication about my
illness..................................................................................
0
1
2
3
4
I feel close to my partner (or the person who is my main
support) ..............................................................................
0
1
2
3
4
0
1
2
3
4
GS6
Q1
GS7
Regardless of your current level of sexual activity, please
answer the following question. If you prefer not to answer it,
please mark this box
and go to the next section.
I am satisfied with my sex life ............................................
English (Universal)
Copyright 1987, 1997
16 November 2007
Page 1 of 3
93
FACT-E (Version 4)
Please circle or mark one number per line to indicate your response as it applies to the past 7
days.
EMOTIONAL WELL-BEING
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
GE1
I feel sad ..............................................................................
0
1
2
3
4
GE2
I am satisfied with how I am coping with my illness..........
0
1
2
3
4
GE3
I am losing hope in the fight against my illness..................
0
1
2
3
4
GE4
I feel nervous.......................................................................
0
1
2
3
4
GE5
I worry about dying .............................................................
0
1
2
3
4
GE6
I worry that my condition will get worse ............................
0
1
2
3
4
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
FUNCTIONAL WELL-BEING
GF1
I am able to work (include work at home) ..........................
0
1
2
3
4
GF2
My work (include work at home) is fulfilling.....................
0
1
2
3
4
GF3
I am able to enjoy life..........................................................
0
1
2
3
4
GF4
I have accepted my illness...................................................
0
1
2
3
4
GF5
I am sleeping well ...............................................................
0
1
2
3
4
GF6
I am enjoying the things I usually do for fun ......................
0
1
2
3
4
GF7
I am content with the quality of my life right now..............
0
1
2
3
4
English (Universal)
Copyright 1987, 1997
16 November 2007
Page 2 of 3
94
B.4.2. FACT-E Additional Concerns
FACT-E (Version 4)
Please circle or mark one number per line to indicate your response as it applies to the past 7
days.
ADDITIONAL CONCERNS
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
HN1
I am able to eat the foods that I like ....................................
0
1
2
3
4
HN2
My mouth is dry ..................................................................
0
1
2
3
4
HN3
I have trouble breathing.......................................................
0
1
2
3
4
HN4
My voice has its usual quality and strength ........................
0
1
2
3
4
HN5
I am able to eat as much food as I want ..............................
0
1
2
3
4
HN
10
I am able to communicate with others ................................
0
1
2
3
4
HN7
I can swallow naturally and easily ......................................
0
1
2
3
4
E1
I have difficulty swallowing solid foods ............................
0
1
2
3
4
E2
I have difficulty swallowing soft or mashed foods ............
0
1
2
3
4
E3
I have difficulty swallowing liquids....................................
0
1
2
3
4
E4
I have pain in my chest when I swallow .............................
0
1
2
3
4
E5
I choke when I swallow.......................................................
0
1
2
3
4
E6
I am able to enjoy meals with family or friends..................
0
1
2
3
4
C6
I have a good appetite..........................................................
0
1
2
3
4
E7
I wake at night because of coughing ...................................
0
1
2
3
4
ACT
11
I have pain in my stomach area...........................................
0
1
2
3
4
C2
I am losing weight ..............................................................
0
1
2
3
4
English (Universal)
Copyright 1987, 1997
16 November 2007
Page 3 of 3
95
B.4.3. FACT-Ga Additional Concerns
FACT-Ga (Version 4)
Please circle or mark one number per line to indi cate your response as it applies to the past 7
days.
ADDITIONAL CONCERNS
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
C2
I am losing weight ...............................................................
0
1
2
3
4
Ga1
I have a loss of appetite .......................................................
0
1
2
3
4
Ga2
I am bothered by reflux or heartburn ..................................
0
1
2
3
4
HN1
I am able to eat the foods that I like ....................................
0
1
2
3
4
Ga6
I have discomfort or pain when I eat...................................
0
1
2
3
4
Ga5
I have a feeling of fullness or heaviness in my stomach
area ..................................................................................... .
0
1
2
3
4
C1
I have swelling or cramps in my stomach area ...................
0
1
2
3
4
Ga
12
I have trouble swallowing food .......................................... .
0
1
2
3
4
Ga4
I am bothered by a change in my eating habits...................
0
1
2
3
4
E6
I am able to enjoy meals with family or friends..................
0
1
2
3
4
Ga
10
My digestive problems interfere with my usual activities ..
0
1
2
3
4
Ga9
I avoid going out to eat because of my illness ....................
0
1
2
3
4
Ga7
I have stomach problems that worry me .............................
0
1
2
3
4
Hep
8
I have discomfort or pain in my stomach area ....................
0
1
2
3
4
Ga
14
I am bothered by gas (flatulence)........................................
0
1
2
3
4
C5
I have diarrhea (diarrhoea) ..................................................
0
1
2
3
4
An2
I feel tired ............................................................................
0
1
2
3
4
HI
12
I feel weak all over ..............................................................
0
1
2
3
4
Leu4
Because of my illness, I have difficulty planning for the
future .................................................................................. .
0
1
2
3
4
English (Universal)
Copyright 1987, 1997
19 August 2009
Page 3 of 3
96
B.5. Barriers to PA Survey
Barriers Questionnaire
The following is a list of BARRIERS towards exercise that people might encounter. Please
circle the number that best reflects the influence the given barrier has on your exercise
using the following scale:
1
2
3
4
5
6
7
Didn’t Influence
Influenced
Influenced
Exercise
Exercise
Exercise Somewhat
Completely
The rate how often you experience the barrier, using the following scale:
1
2
3
4
5
6
Never
Sometimes
Disease Related Barriers
7
Daily
1. Shortness of breath
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
5
6
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
2. Fatigue
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
3. Muscle weakness
1
2
Didn’t Influence
Exercise
Exercise
3
4
Influenced
Exercise Somewhat
7
Influenced
Completely
97
1
Never
2
3
4
Sometimes
5
6
5
6
7
Daily
4. Other medical conditions
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
5. Pain
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
6. Nausea/ Vomiting
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
7. Diarrhea
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
5
7
Influenced
Completely
6
7
Daily
98
8. Surgical Complications
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
5
6
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
9. Dizziness
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
10. Numbness and tingling in hands and feet
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
11. Insomnia
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
7
Influenced
Completely
5
6
5
6
7
Daily
12. Central line catheter
1
2
Didn’t Influence
Exercise
Exercise
3
4
Influenced
Exercise Somewhat
7
Influenced
Completely
99
1
Never
2
3
4
Sometimes
5
6
5
6
7
Daily
13. Constipation
1
2
Didn’t Influence
Exercise
Exercise
3
1
Never
3
2
4
Influenced
Exercise Somewhat
4
Sometimes
5
Life related barriers:
1. Family worried you will be overtaxing yourself
1
2
3
4
5
Didn’t Influence
Influenced
Exercise
Exercise
Exercise Somewhat
1
Never
2
3
4
Sometimes
5
2. Patient (your) fear of overtaxing yourself
1
2
3
4
5
Didn’t Influence
Influenced
Exercise
Exercise
Exercise Somewhat
1
Never
2
3
4
Sometimes
5
2. Too busy (with family, work etc.)
1
2
3
4
5
Didn’t Influence
Influenced
Exercise
Exercise
Exercise Somewhat
1
Never
2
3
4
Sometimes
5
7
Influenced
Completely
6
6
7
Daily
7
Influenced
Completely
6
6
7
Daily
7
Influenced
Completely
6
6
7
Daily
7
Influenced
Completely
6
7
Daily
100
3. Not belonging to a current exercise class or gym
1
2
3
4
5
Didn’t Influence
Influenced
Exercise
Exercise
Exercise Somewhat
1
Never
2
4. Cost
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
5. Lack of equipment
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
6. Lack of access
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
3
3
2
4
Influenced
3
3
4
Sometimes
4
Influenced
5
6
5
6
3
4
Sometimes
4
Influenced
5
6
5
6
3
4
Sometimes
4
Influenced
5
6
5
6
5
6
5
6
5
7
Daily
7
Influenced
7
Daily
7
Influenced
Completely
Exercise Somewhat
4
7
Influenced
Completely
Exercise Somewhat
3
7
Daily
Completely
Exercise Somewhat
3
7
Influenced
Completely
Exercise Somewhat
7. Have no one to exercise with
1
2
3
Didn’t Influence
Exercise
Exercise
1
4
Sometimes
6
7
Daily
7
Influenced
Completely
6
7
101
Never
Sometimes
8. Weather
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
3
4
Influenced
Daily
5
Exercise Somewhat
3
4
Sometimes
5
9. Lack of knowledge of what to do
1
2
3
4
5
Didn’t Influence
Influenced
Exercise
Exercise
Exercise Somewhat
1
Never
2
3
Motivation Related Barriers
1. Preferring to do other activities
1
2
3
Didn’t Influence
Exercise
Exercise
1
Never
2
3
2. Don’t see it as a priority
1
2
3
Didn’t Influence
Exercise
Exercise
1
Never
2
6
3
4
Sometimes
4
Influenced
Completely
6
6
4
Influenced
5
6
5
6
5
6
5
6
5
7
Influenced
7
Daily
7
Influenced
Completely
Exercise Somewhat
4
Sometimes
7
Daily
Completely
Exercise Somewhat
4
Sometimes
7
Influenced
7
Daily
7
Influenced
Completely
6
7
Daily
102
3. Lack of self-discipline
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
4. Lack of interest
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
5. Discouragement
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
6. Body image
1
2
Didn’t Influence
Exercise
Exercise
1
Never
2
7. Lack of motivation
1
2
Didn’t Influence
Exercise
Exercise
3
4
Influenced
5
6
Exercise Somewhat
3
3
4
Sometimes
4
Influenced
Completely
5
6
5
6
Exercise Somewhat
3
3
4
Sometimes
4
Influenced
3
4
Sometimes
4
Influenced
5
6
5
6
3
4
Sometimes
4
Influenced
5
6
5
6
7
Daily
7
Influenced
7
Daily
7
Influenced
Completely
5
6
5
6
Exercise Somewhat
7
Influenced
Completely
Exercise Somewhat
3
7
Daily
Completely
Exercise Somewhat
3
7
Influenced
7
Daily
7
Influenced
Completely
103
1
Never
2
3
4
Sometimes
5
6
7
Daily
104
B.6. Preferences for PA Survey
PREFERENCES FOR PHYSICAL ACTIVITY: (Jones & Courneya, 2002)
Answer questions in terms of ‘preferred option’ if you are not currently active.
Exercise counseling:
1. Would you like to receive exercise counseling during your cancer journey?
a. Yes ☐
b. No ☐
c. Maybe ☐
2. When should exercise counseling be administered?
a. Pre-treatment ☐
b. During treatment ☐
c. Immediately post treatment ☐
d. 3-6 months post treatment ☐
e. At least one year post treatment ☐
3. What method of counseling would you prefer?
a. Face to face ☐
b. Telephone ☐
c. Videotape ☐
d. Audiotape ☐
e. Pamphlet/brochure ☐
f. Internet/email ☐
4. Who is your preferred counseling source?
a. Oncologist ☐
b. Nurse ☐
c. Exercise specialist affiliated with cancer centre ☐
d. Exercise specialist from community fitness centre ☐
e. Fellow cancer patient or survivor ☐
Exercise Programming:
1. Preferred exercise company:
a. Alone ☐
b. 1 or 2 other survivors ☐
c. 1 or 2 non-survivors ☐
d. Group of cancer survivors ☐
e. Group of non-survivors ☐
f. No preference ☐
105
2. What is your preferred exercise start time?
a. Before treatment ☐
b. During treatment ☐
c. Immediately post treatment ☐
d. 3-6 months post treatment ☐
e. At least one year post treatment ☐
3. Where would you prefer to do exercise?
a. At home ☐
b. Community fitness centre ☐
c. Outdoors ☐
d. Fitness centre located at cancer centre ☐
e. No preference ☐
4. How would you prefer your exercise structure? (circle one in each pair)
a. Supervised/instructed
or
Unsupervised
b. Competitive
or
Recreational
c. Spontaneous
or
Structured time
d. Same Activity
or
Varied activity
5. What is your preferred intensity of exercise?
a. Low ☐
b. Moderate ☐
c. Vigorous ☐
106
B.7. Social Support for Being Physically Active Survey
SOCIAL SUPPORT FOR BEING PHYSICALLY ACTIVE:
Please circle to best answer
Family Members:
1. Has a family member engaged in physical activity with you?
0
Never
1
2
3
4
Very Often
2. Has a family member offered to do physical activity with you?
0
Never
1
2
3
4
Very Often
3. Has a family member encouraged you to do physical activity?
0
Never
1
2
3
4
Very Often
Friend or Acquaintance:
1. Has a friend or acquaintance engaged in physical activity with you?
0
Never
1
2
3
4
Very Often
2. Has a friend or acquaintance offered to do physical activity with you?
0
Never
1
2
3
4
Very Often
3. Has a friend or acquaintance encouraged you to do physical activity?
0
Never
1
2
3
4
Very Often
107
B.8. Nutritional Assessment Survey (PG-SGA)
108
APPENDIX C: RECRUITMENT DIAGRAM
Historical Retrieval
Appointment Look up
•Approximately 250 Ga and Es patients
identified as patients in the last 1.5 years
at the TBCC
•Patient appointment times were flagged
1-2 weeks in advance
•57 total were identified during study
recruitment timeline.
Oncologist Approval
Oncologist Introduction
•Emails were sent to the corresponding
oncologist to determine elegibility.
•2 patients were deemed ineligible by
oncologists prior to recruitment.
•Upon approval, oncologist introduced the
study to participant.
•2 patients declined to oncologist, no
reason given
Patient Recruitment
Survey Completion
•11 patients either did not show up for
their appointment, or student was unable
to meet them at their clinic time.
•4 patients declined : 'not at this time', or
'uninterested'
•38 completed consent forms in clinic
•32 patients submitted a survey after
telephone and email follow up.
109
APPENDIX D: TABLES
D.1. Table 3 Godin leisure-time exercise questionnaire results in a sample of gastric and
esophageal cancer patients.
Questionnaire Item
Mean
SD
Strenuous activity per week (METS) (n=32)
Minutes per week (n=32)
4.1
8.6
10.6
22.9
Moderate activity per week (METS) (n=32)
Minutes per week (n=32)
8.9
51.0
13.5
96.9
Mild activity per week (METS) (n=32)
Minutes per week (n=32)
Total LSI score
Total minutes
12.9
235.5
25.9
295.1
11.1
531.6
20.8
531.8
N
Percent (%)
Questionnaire Item
Number of times engaged in PA per week (n=32)
Often
2
6.3
Sometimes
15
46.9
Never/rarely
15
46.9
Note. SD=standard deviation, LSI=leisure score index, METS=metabolic equivalents.
110
D.2. Table 4 Functional assessment of cancer therapy (FACT) results in a sample of gastric
and esophageal cancer patients.
Questionnaire Category
Mean Cumulative
Meeting PA
Not Meeting PA
Score
Guideline (n=5)
Guideline (n=25)
Physical wellbeing (PWB)
(n=30)
Social wellbeing (SWB) (n=30)
20.8±7.4
26.8±1.8
19.7±7.6
22.9±4.1
20.5±6.0
23.4±3.5
Emotional wellbeing (EWB)
(n=30)
Functional wellbeing (FWB)
(n=31)
Functional assessment of cancer
therapy-general (FACT-G)
(n=29)
15.6±5.2
16.4±3.7
15.5±5.5
17.5±6.5
21.8±4.9
16.7±6.6
76.0±18.1
85.5±10.5
74.7±19.0
44.1±11.8
N/A
N/A
Esophageal additional concerns
(ECS) (n=22)
Gastric additional concerns
(GACS) (n=9)
Total (FACT-E) (n=20)
52.4±12.1
N/A
N/A
118.8±27.4
N/A
N/A
Total (FACT-Ga) (n=9)
133.7±24.7
N/A
N/A
Note. Score ranges: PWB (0-28)+FWB (0-28)+SWB (0-28)+EWB (0-24)= FACT-G (0-108).
FACT-G + ECS (0-68)=FACT-E (0-176)
FACT-G + GACS (0-76)=FACT-Ga (0-184)
111
D.3. Table 5 Pearson correlation results and correlation coefficients for outcome variable
HRQL (FACT-G).
Correlation (r)
[CI]
R2
Total Leisure Score (n=32)
.32
[-.168, .747]
.10
Total Leisure Minutes (n=32)
.40*
[-.138, .775]
.16
Age (n=29)
.13
[-.254, .465]
.02
Percent Weight Change 6
months (n=27)
-.27
[-.546, .247]
.07
Months Since Diagnosis
(n=28)
.39*
[.027, .632]
.15
Independent Variable
BMI (n=25)
.39
[-.028, .761]
Note. * Significant at alpha p<0.05, CI=confidence interval.
.15
112
D.4. Table 6 Exercise preference frequencies from a sample of gastric and esophageal
cancer patients.
Questionnaire Item
Would you like to receive exercise
counselling? (n=29)
Yes
No
Maybe
Who would you prefer to receive exercise
counselling from? (n=20)
Oncologist
Nurse
Exercise Specialist at a cancer centre
Exercise Specialist at a community
centre
Cancer patient/survivor
Other (e.g. any specialist, yoga
instructor)
When would you like to receive exercise
counselling? (n=19)
Before treatment
During treatment
Immediately post-treatment
3-6 months post-treatment
At least 1 year post-treatment
Pre, during and immediately posttreatment
How would you like to receive exercise
counselling? (n=19)
Face to face
By telephone
DVD or videotape
Pamphlet/brochure
Internet
When would you prefer to start an exercise
program? (n=19)
Before treatment
During treatment
Immediately after treatment
3-6 months after treatment
At least 1 year after treatment
Where would you prefer to exercise? (n=23)
At home
Outcome
Percent
6
15
8
20.7
51.7
27.6
4
2
13
0
20.0
10.0
65.0
0.0
5.0
0.0
1
0
2
7
6
2
1
1
6.3
21.9
18.8
6.3
3.1
3.1
8
4
1
2
4
42.1
21.1
5.3
10.5
21.1
4
8
5
1
1
21.1
42.1
26.3
5.3
5.3
11
47.8
113
At a community centre
Outdoors
Cancer exercise centre
No preference
Who would you prefer exercise with? (n=23)
With 1 or 2 other cancer survivors
With 1 or 2 non-cancer survivors
In a group of cancer survivors
In a group of non-cancer survivors
Alone
No preference
More than one preference
What intensity would you prefer your
exercise? (n=23)
Low
Moderate
High
What type of activities would you like to
perform? (n=16)
Same activity
Varied activity
How would you prefer to perform these
exercises? (n=20)
Supervised
Unsupervised
What type of activities would you prefer?
(n=17)
Competitive
Recreational
What is your preferred exercise program
structure? (n=15)
Spontaneous
Structured
2
4
2
4
8.7
17.4
8.7
17.4
0
0
1
0
11
10
1
0.0
0.0
4.3
0.0
47.8
43.5
4.3
6
17
0
26.1
73.9
0.0
5
11
31.3
68.8
6
14
30.0
70.0
0
17
0.0
100.0
6
9
40.0
60.0
114
D.5. Table 7 Reported PA barrier frequencies among a sample of gastric and esophageal
cancer patients.
Questionnaire Item
Shortness of breath
n
Fatigue
n
Muscle weakness
n
Other medical condition
n
Pain
n
Nausea/vomiting
n
Diarrhea
n
Surgical complication
n
Dizziness
n
Family worried you will be
overtaxing yourself
n
Too busy
n
Not belonging to exercise class
n
Cost
n
Lack of equipment
n
Lack of access
n
Have no one to exercise with
n
Weather
n
Lack of knowledge of what to do
n
Preferring to do other activities
n
Don’t see it as a priority
Influence Rating
Mean Score
2.9±2.1
27
3.5±1.8
26
3.6±2.0
26
2.8±2.7
26
3.4±2.5
25
2.1±1.3
25
2.1±1.7
26
2.6±2.2
21
2.2±1.6
25
2.4±1.7
Frequency Rating Mean
Score
2.9±1.9
25
3.5±1.6
26
3.7±2.0
26
2.7±2.1
27
3.4±2.2
28
2.1±1.3
27
1.8±1.1
27
1.9±1.7
22
1.8±1.1
26
2.4±1.7
25
2.5±1.8
26
2.0±1.9
26
1.8±1.5
23
2.2±2.0
24
1.8±1.7
25
1.9±1.7
26
2.6±2.0
25
2.6±2.1
26
2.8±1.8
25
2.6±1.6
27
2.3±1.8
28
2.1±2.0
28
1.5±0.9
26
2.0±1.7
26
1.8±1.6
26
1.8±1.6
26
2.6±1.8
27
2.3±1.8
28
3.0±2.0
27
2.6±1.8
115
n
25
27
Lack of self-discipline
3.0±1.9
3.0±1.9
n
26
27
Lack of interest
3.1±1.7
3.0±1.9
n
26
26
Discouragement
2.3±1.7
2.3±1.6
n
24
26
Body image
2.2±1.5
1.9±1.5
n
25
27
Lack of motivation
3.1±2.1
2.9±1.8
n
24
28
Note. Too tired, feeling sick, numbness, central line catheter, constipation, patient fear were not
included due to low n.
Reported barrier influence (did not influence-influenced exercise completely) and frequency
(never-daily) likert score range was 1-7.