Exploring the relationship between physical well-being and healthy lifestyle changes among European- and Latina-American breast and cervical cancer survivors

Psycho-OncologyPsycho-Oncology 19: 1161–1170 (2010)Published online 25 January 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.1687

Exploring the relationship between physical well-beingand healthy lifestyle changes among European- andLatina-American breast and cervical cancer survivors

Kimlin T. Ashing-Giwa�, Jung-Won Lim and Patricia GonzalezCenter of Community Alliance for Research and Education (CCARE), Department of Population Sciences, City of Hope, Duarte, CA, USA

Abstract

Background: Cancer and its treatments have a lingering and often negative impact on survivors’

physical well-being. The physical sequelae impinge on daily functioning and overall HRQOL,

and perhaps influence lifestyle changes post-cancer. This study aims to examine: (1) physical

well-being items that are associated with low overall health-related quality of life; and (2) the

relationship between physical well-being outcomes and healthy lifestyle changes by cancer type.

Methods: This study employed a cross-sectional design with mixed sampling methods. In

total 922 European- (n5 452) and Latina-American (n5 470) breast (BCS) or cervical cancer

survivors (CCS) were recruited from the California Cancer Surveillance Program and Los

Angeles area hospital registries. Item responses from survivors in the lowest quartile of total

quality of life scores and percentages reflecting low physical well-being levels were calculated.

Results: A statistical approach to individual items provides unique and valuable measurement

and clinical information above and beyond physical well-being total scores. Physical well-being

item responses varied according to ethnicity, income, and education. BCS and CCS showed

different patterns in the relationship between physical well-being items and lifestyle changes.

Specifically, exercise was significantly related to physical well-being items for BCS, while diet

changes were significantly associated with physical well-being for CCS.

Conclusions: Results reveal unique correlates of physical well-being items by cancer type,

ethnicity, and lifestyle changes. Clinically, this study highlights the need for greater

consideration of individual and medical characteristics in developing culturally sensitive and

patient responsive interventions to promote healthy lifestyles and improve survivorship

outcomes.

Copyright r 2010 John Wiley & Sons, Ltd.

Keywords: cancer; breast and cervical cancer survivorship; oncology; physical well-being; lifestyle

change; item analysis

Introduction

Breast and cervical cancer represent two of the mostcommon cancers among women in the United States[1, 2]. In 2009, 192 370 women were expected tobe diagnosed with breast cancer and 11 270 areexpected to be diagnosed with cervical cancer [3].With advances in health care, the survival ratesfor breast and cervical cancer have significantlyincreased [3]. As a result, health-related quality oflife (HRQOL) for the growing number of breast(BCS) and cervical cancer survivors (CCS) has beenof great concern.Of all the multidimensional components of

HRQOL, physical well-being may most directlyinfluence overall cancer survivorship and even survi-val outcomes [4]. Approximately 30% of survivorsreport decreased HRQOL due to physical concernsafter a cancer diagnosis and its treatment [5]. Physicalsymptoms are among the most burdensome and

persistent cancer sequelae including fatigue [6, 7], pain[8], lymphedema [9–11], menopausal symptoms[12–16], and sleep disturbance [17–19]. Among cancersurvivors, physical well-being differs by medicalcharacteristics as well as socio-demographic charac-teristics including age [7, 8, 20–23], income [24, 25],education [21, 26], and ethnicity [27]. One study foundthat older cancer survivors reported poorer physicalquality of life outcomes [23]. Another study demon-strated that individuals with higher education andwealth enjoyed better physical well-being [24]. More-over, ethnic minority survivors are more likely toreport unfavorable physical well-being outcomescomparedwith European-Americans [28–30]. A bodyof research documents that Spanish-speaking Latina-Americans endorse the poorest physical well-beingoutcomes in multi-ethnic cohort studies [29, 31, 32].Despite these disparities, demographic, socioecologic,and ethnic considerations are inadequately addressedin the literature [33]. Specifically, there is a dearth of

* Correspondence to: Centerof Community Alliance forResearch and Education,Department of PopulationsSciences, City of Hope, 1500East Duarte Road, Duarte,CA 91010-3000, USA.E-mail: [email protected]

Received: 28 July 2009

Revised: 16 November 2009

Accepted: 20 November 2009

Copyright r 2010 John Wiley & Sons, Ltd.

research examining physical well-being in Latina-American cancer survivors. Given their survivorshipchallenges, as well as their increasing number in thegeneral and cancer survivor population, the inclusionof ethnic minority cancer survivors in outcomesresearch is crucial.In addition, there is increasing evidence that

healthy lifestyle changes may benefit survivors byproviding relief from the physical sequelae due tocancer and its treatments and in turn improve over-all HRQOL and perhaps survival [34–36]. Healthylifestyle changes during treatment and through-out survivorship are significantly associated withimproved physical and psychosocial well-being,reduced treatment side effects, enhanced self-esteem,and reduced relapse incidence [37–39]. Particularly,physical activity is linked to increased functionalcapacity, improved mood, decreased nausea,increased immune function, decreased fatigue,improved health perceptions, and HRQOL [40–43].Associations between fat intake and survival aftera cancer diagnosis have also been reported. Onestudy [44] found a 24% relative risk reduction forrecurrence in the low-fat diet group compared withthe control group. Furthermore, approximately 60%of adult cancer survivors use complementary therapyand 69% perceive such therapies as healthy practicescapable of improving well-being [45].These recent reports linking healthy lifestyle

changes to a reduction in cancer side effects,recurrence and mortality [34, 46, 47] warrants closerexamination of factors influencing health practices.Our study advances health behavior change researchby exploring the relationship between physical well-being and the adoption of healthy lifestyle prac-tices post-cancer treatments. Specifically, this studyexamines: (1) physical well-being items associatedwith low total HRQOL scores by medical (cancertype and years of survivorship) and demographiccharacteristics (ethnicity, age, income, and educa-tion); and (2) the relationship between physical well-being items and lifestyle changes by cancer type(breast and cervical cancer). Based on the limitedliterature, the following hypotheses were formulated:Of survivors whose overall HRQOL scores are in

the lowest quartile (p25%):

1 Survivors, who are older, socioeconomicallychallenged and Spanish-speaking Latina-Americans will report low physical well-beinglevels.

2 BCS and CCS will show different relationshippatterns between physical well-being items andlifestyle changes.

Methods

This study utilized data derived from BCS [29, 48]and CCS HRQOL studies [30, 49]. These two

studies employed a multi-ethnic, population-basedsampling and cross-sectional design that generatedparticipation rates of 58 and 64% for the breastcancer and cervical cancer studies, respectively.The current study focuses on European- andLatina-American survivors. Protocols and recruit-ment procedures were similar across the twostudies. Female BCS and CCS were recruited fromthe California Cancer Surveillance Program andLos Angeles area hospital cancer registries. Parti-cipants were within six months to five years of abreast or cervical cancer diagnosis and currentlycancer free. Participants experiencing other can-cers, major psychological or other major medicalconditions were excluded. Eligible survivors parti-cipated in the interview or questionnaire in theirpreferred language (English or Spanish). Ques-tionnaires were translated and back-translated intoSpanish. Internal consistency for the scales wasassessed using Cronbach’s alpha (a), and nolanguage differences were found. Studies wereapproved by the UCLA Institutional ReviewBoard. Details regarding subject identificationand recruitment are described elsewhere [48, 49].

Measures

HRQOL and physical well-being

The Functional Assessment of Cancer Therapy—General (FACT-G) is a standardized HRQOLinstrument composed of 27 general cancer concernitems including physical, functional, emotional,and social/family well-being [50]. The physical well-being subscale includes seven items: (1) I have alack of energy; (2) I have nausea; (3) Because of myphysical condition, I have trouble meeting theneeds of my family; (4) I have pain; (5) I ambothered by side effects of treatment; (6) I feel ill;and (7) I am forced to spend time in bed. Itemsare rated on a 5-point Likert scale: 0 (not at all), 1(a little bit), 2 (somewhat), 3 (quite a bit), and4 (very much). Items were reverse scored withhigher scores indicating better physical status.Total standardized HRQOL and physical well-being scores were obtained in accordance with theFACT-G scoring instructions [51]. Subscale relia-bility coefficients ranged from 0.79 to 0.88 accord-ing to ethnicity and cancer type.

Lifestyle changes

Lifestyle changes were measured by asking partici-pants whether they had made lifestyle changes sincetheir cancer treatments, and if yes, which positivechange they made: (1) eating healthier; (2) moreexercise; (3) use of complementary/alternative medi-cine; and (4) stress reduction. Thus, this measureincludes one broad question and four addi-tional selections. All items involve a simple ‘yes’ or‘no’ answer.

Copyright r 2010 John Wiley & Sons, Ltd. Psycho-Oncology 19: 1161–1170 (2010)

DOI: 10.1002/pon

1162 K. T. Ashing-Giwa et al.

Demographic characteristics

Demographic questions assessed participants’ age,income, education, language, and ethnicity. Cancer-related factors included: years of cancer survivor-ship (time since diagnosis) and cancer type.

Analytical approach

HRQOL studies generally use the overall scalescore(s) of specific scale dimension(s) to generatemeaning [52]. Such approaches may not capture theunique and clinically sensitive data that each itemindependently communicates. Indeed, two items‘I have a lack of energy’ and ‘I have pain’ from theFACT-G physical well-being subscale reflect differ-ent physical quality of life dimensions. Therefore, astatistical approach to individual items may offerfurther insight into cancer survivors’ lived experi-ence [53, 54]. Decrements in individual itemsinfluence subscale and overall HRQOL scores[55–57], and offers some measurement of theimpairment experienced by the survivor; thus anunderstanding of these items may serve to informinterventions to improve HRQOL. Specifically, astudy found that survivors in the lowest HRQOLquartile differ from women in the upper quartile,indicating that patients scoring in the lowestHRQOL quartile experience a greater death rate[57]. Other studies also demonstrated that HRQOLscores can be predictive of survival in patientsscoring in the lowest HRQOL quartile [58–61].These studies provided an appropriate analyticalmodel to address this study’s goal. Hence, percen-tages of survivors endorsing low physical well-beinglevels (item response: ‘not at all’ or ‘a little bit’; meanscore:p50) from participants scoring in the lowestHRQOL quartile (p25%) were calculated toaccomplish the study’s specific aims.

Data analyses

Descriptive analyses were calculated to examineparticipant and response characteristics. For hypo-theses 1 and 2, first, the lowest quartile scores (the25th percentiles of the distribution) were calculatedfrom standardized FACT-G scores by cancer typeand demographic characteristics; thus each 25%cut-off score of the FACT-G varied by cancer typeand demographic characteristics (52–58). Next, thepercentage of survivors endorsing low physicalwell-being levels from participants scoring in thelowest HRQOL quartile ((N with low physicalwell-being levelsCN with p25% in the overallHRQOL scores)�100) was calculated. Womenwho responded ‘not at all’ or ‘a little bit’ to eachphysical well-being item were classified as a lowphysical well-being level. For the total standardizedphysical well-being score (0–100), we defined scoresless than or equal to 50 as a low total physical

well-being level [51]. Chi-square tests comparedproportions of low physical well-being levelsamong patients scoring in the lowest HRQOLquartile according to medical and demographiccharacteristics, and lifestyle changes. Thus, thisstudy identifies the level of physical well-beingamong survivors reporting low scores in overallHRQOL. Data were analyzed using SPSS 15.0and hypotheses tested with a po0.05 significancecriterion for a two-sided test.

Results

This study included 922 European- (N5 452) andLatina-American (N5 470) survivors. Approxi-mately 61% of Latinas (n5 285) preferred toparticipate in English, and about 39% of Latinas(n5 185) preferred Spanish. A total of 362 partici-pants were diagnosed with breast cancer and 560were diagnosed with cervical cancer. The meanyears of cancer survivorship for BCS were signifi-cantly shorter (M5 3.0; SD5 1.7) compared withCCS (M5 3.3; SD5 1.5) (t5 4.84; po0.001); how-ever, there were no differences by ethnicity. BCSwere relatively older (M5 55, SD5 11.3), comparedwith CCS (M5 49; SD5 12.2) (t5 53.81; po0.001).BCS reported higher income (t5 12.26; po0.01)and educational levels (t5 25.12; po0.001) com-pared to CCS. Moreover, BCS were more likelyto report English proficiency (t5 14.28; po0.001)and lifestyle changes (t5 9.82; po0.01). Overall,European-Americans’ income (t5 269.36; po0.001)and educational levels (t5 298.12; po0.001) werehigher than Latina-Americans (Table 1).

Physical well-being items by medical anddemographic characteristics

Figure 1 depicts percentages of survivors endorsinglow total physical well-being levels (low vs moder-ate to high total physical well-being) among thosein the lowest HRQOL quartile according tomedical and demographic characteristics. Overall,survivors endorsing low total physical well-beinglevels ranged from 12.7 to 46.8%. Survivors atgreater than 40% tended to be Spanish-speakingLatinas (46.8%), women with low educationallevels (ohigh school:45.8%) and low income levels(o$25K:41.6%). Specifically, significant differ-ences by ethnicity, income, and education insurvivors endorsing low total physical well-beinglevels were found. European-American cancersurvivors (12.7%), and those with higher income(4$75K:14%) and higher educational levels(4high school:20.7%) were less likely to expresslow physical well-being symptoms. Differences bycancer type (X2 5 0.013; p40.05), years of cancersurvivorship (X2 5 1.336; p40.05), and age(X2 5 5.289; p40.05) were not found.

Physical well-being and lifestyle changes 1163


DOI: 10.1002/pon

Table 2 shows the percentages of survivorsendorsing low physical well-being item scores(low vs moderate to high physical well-being items)among those in the lowest HRQOL quartile

according to medical and demographic characteris-tics. Overall, survivors endorsing low physicalwell-being levels ranged from 2.1 (nausea item forEuropean-Americans) to 64.2% (energy item for

Table 1. Study participants characteristics

Variables Breast cancer Cervical cancer

Total

(n 5 362)

European

(n 5 179)

Latina

(n 5 183)

Total

(n 5 560)

European

(n 5 273)

Latina

(n 5 287)

By cancer

type

By ethni-

city

Frequency (%) Chi-square

Years since diagnosis

p2 years 124 (34) 64 (36) 60 (33) 178 (32) 89 (33) 89 (31)

2–3 years 158 (44) 83 (46) 75 (41) 267 (48) 129 (48) 138 (48) 1.72 2.80

X4 years 80 (22) 32 (18) 48 (26) 111 (20) 51 (19) 60 (21)

Age

p49 124 (34) 53 (30) 71 (39) 313 (57) 152 (57) 161 (56) 53.81�� 2.51

50–59 104 (29) 53 (30) 51 (28) 140 (25) 64 (24) 76 (27)

X60 134 (37) 73 (40) 61 (33) 101 (18) 52 (19) 49 (17)

Income

o$25K 199 (30) 24 (14) 87 (50) 239 (43) 40 (15) 199 (71) 12.26�� 269.36��

$25K–$45K 147 (22) 38 (22) 36 (21) 89 (16) 41 (15) 48 (17)

4$45K–$75K 146 (22) 43 (25) 27 (16) 91 (17) 70 (26) 21 (7)

4$75K 182 (27) 68 (39) 23 (13) 132 (24) 119 (44) 13 (5)

Education

oHigh school 101 (14) 5 (3) 9 (7) 188 (34) 9 (3) 179 (64) 25.12�� 298.12��

High school 76 (11) 13 (7) 17 (13) 75 (14) 47 (17) 28 (10)

4High school 524 (75) 161 (90) 108 (80) 287 (51) 215 (80) 72 (26)

Language

English 550 (78) 179 (100) 97 (53) 361 (64) 273 (100) 88 (31) 14.28�� —

Spanish 153 (22) — 86 (47) 199 (36) — 199 (69)

Lifestyle changes (Yes): 240 (67) 125 (70) 115 (63) 312 (56) 153 (57) 159 (56) 9.82�� 1.09

Diet 205 (85) 101 (81) 104 (90) 254 (81) 121 (79) 133 (84) 1.47 4.26�

Exercise 142 (59) 82 (66) 60 (52) 156 (50) 90 (58) 66 (42) 4.36� 13.65��

Alternative Medicine 91 (38) 53 (42) 38 (33) 79 (25) 48 (31) 31 (20) 9.88�� 7.88��

Stress Management 143 (59) 84 (67) 59 (51) 121 (39) 77 (50) 44 (28) 23.02�� 22.42��

�po0.05; ��po0.01; ��po0.001.

Figure 1. Percentage of survivors with low total physical well-being scores (p50) among survivors in the lowest quartile bydemographic characteristics and cancer type. Percentages of survivors endorsing less than or equal to 50 in total standardizedphysical well-being scores were calculated. Higher percentages indicate that survivors were more likely to endorse negative physicalwell-being items (‘not at all’ or ‘a little’). aCancer type: X2 5 0.013; p40.05; bYears of survivorship: X2 5 1.336; p40.05; cEthnicity:X2 5 32.652; po0.001; dAge: X2 5 5.289; p40.05; eIncome: X2 5 24.879; po0.001; fEducation: X2 5 15.070; po0.01.



DOI: 10.1002/pon

English-speaking Latinas); such that European-Americans were less likely to report nauseasymptoms, while English-speaking Latinas weremore likely to experience energy concerns. Themajority of survivors in the lowest HRQOLquartile endorsed the energy item (26.9–64.2%).More specifically, ethnicity, income, and educationshowed significant differences in most physicalwell-being items. In terms of age, only one item(‘because of my physical condition, I have troublemeeting the needs of my family’) showed asignificant association, indicating that survivorsbetween 50 and 59 years of age in the lowestHRQOL quartile were more likely to endorse lowphysical well-being scores (X2 5 9.049; po0.05).Additionally, survivors endorsing the energy itemvaried by cancer type; thus BCS (50.5%) in thelowest HRQOL quartile were more likely toendorse low physical well-being levels comparedwith CCS (39.4%), (X2 5 3.172; po0.05). Mean-while, no physical well-being items showed signi-ficant differences by years of cancer survivorship.

Physical well-being items and lifestyle changes

Approximately 60% (n5552) of BCS and CCSreported positive lifestyle changes. Although, BCS(67%) were more likely than CCS (56%) to modifytheir lifestyles (t59.82; po0.01). Both BCS (85%)and CCS (81%) tended to positively change their diet.However, in terms of exercise, complementary medi-cine, and stress management, BCS were more likely toreport positive changes than CCS. Overall, European-Americans were more likely to report positive lifestylechanges compared with Latina-Americans. However,in terms of diet, Latina-Americans were more likelythan European-Americans to report positive lifestylechanges regardless of cancer type (t54.26; po0.05)(Table 1).

Breast cancer survivors

Of survivors in the lowest HRQOL quartileaccording to lifestyle change variables, the percen-tage endorsing low physical well-being levels didnot significantly vary by lifestyle changes. Once

Table 2. Percentage of survivors with low physical well-being item scores by demographic characteristics and cancer type

Variables 25% Quartile

score of

HRQOL

Na Physical well-being itemsb

Energy Nausea Family

needs

Pain Side

effects

Feeling ill Spend time

in bed

Cancer type

Breast cancer 54 103 50.5% 8.9% 16.7% 30.0% 36.0% 22.3% 14.9%

Cervical cancer 55 165 39.4% 6.7% 19.8% 34.8% 36.5% 20.2% 9.7%

X2 3.172� 0.435 0.394 0.639 0.006 0.165 1.676

Years of survivorship

p2 year 54 89 51.7% 7.9% 18.4% 36.0% 39.5% 28.1% 11.2%

2–4 years 54 110 42.7% 10.3% 22.0% 36.4% 40.6% 22.9% 16.7%

X4 years 56 49 34.7% 4.1% 16.7% 31.3% 23.4% 12.5% 6.1%

X2 3.909 1.739 0.744 0.428 4.548 4.314 3.639

Ethnicity

European 58 142 31.7% 2.1% 12.7% 24.8% 26.1% 10.6% 7.0%

English-speaking Latina 54 53 64.2% 11.3% 25.0% 28.3% 31.4% 22.6% 19.2%

Spanish-speaking Latina 52 79 50.6% 11.8% 26.0% 39.2% 45.9% 34.2% 14.1%

X2 18.896�� 9.883�� 7.388� 4.862 8.803� 18.244�� 6.392�

Age

p49 55 129 38.8% 7.0% 11.6% 33.9% 32.8% 18.8% 7.8%

50–59 54 76 48.7% 6.8% 28.4% 33.3% 44.0% 25.3% 14.9%

X60 55 65 46.2% 9.4% 20.6% 32.8% 36.1% 20.0% 16.9%

X2 2.196 0.435 9.049� 0.022 2.546 1.282 4.289

Income

$25K 53 101 58.8% 10.0% 26.0% 50.0% 46.9% 33.3% 21.6%

$25K–45K 56 61 54.3% 4.4% 13.0% 30.4% 28.9% 21.7% 11.1%

445K–$75K 57 51 39.6% 1.9% 13.2% 18.9% 24.5% 9.4% 3.8%

4$75K 58 50 26.9% 3.8% 15.4% 28.0% 19.2% 3.8% 3.8%

X2 2.625 10.677� 7.936� 7.470 12.361�� 20.196�� 13.026��

Education

oHigh school 52 72 51.4% 12.7% 28.2% 41.8% 46.3% 33.3% 21.1%

Graduated high school 55 28 60.7% 10.7% 25.0% 46.4% 32.1% 17.9% 14.3%

4High school 56 145 43.4% 3.5% 13.2% 25.7% 32.9% 16.7% 9.7%

X2 3.344 6.698� 7.708� 8.133� 3.799 8.119� 5.283

�po0.05; ��po0.01; ��po0.001.aThe total number of participants in the low quartile (p25%) of overall HRQOL score.bFor each physical well-being item, the percentages of survivors who endorsed ‘not at all’ or ‘a little bit’ (negative responses) were calculated.



DOI: 10.1002/pon

survivors committed to changing their lifestyles(n5 241), however, exercise was an importantfactor related to physical well-being. HRQOLtotal scores as well as physical well-being items(i.e. energy, nausea, family needs, pain, and sideeffects) were significantly related to exercise initia-tion, indicating that BCS who reported not exer-cising were more likely to endorse low physicalwell-being levels. Meanwhile, diet, complementarymedicine, and stress management were not asso-ciated with physical well-being items (Table 3).

Cervical cancer survivors

In the percentage endorsing low physical well-beinglevels among women in the lowest HRQOL quartile,total physical well-being scores as well as twophysical well-being items (pain and spend time inbed) significantly differed according to lifestylechanges. Overall, CCS who reported better physicalwell-being were less likely to report positive lifestylechanges. Unlike BCS, diet changes among CCS(n5 312) were significantly associated with physicalwell-being. Survivors who reported healthier diets

Table 3. Percentage of survivors with low physical well-being item scores by lifestyle changes

Variables Na Total physical

well-being

Physical well-being itemsb

Energy Nausea Family

needs

Pain Side

effects

Feeling

ill

Spend time

in bed

Breast cancer

Lifestyle changes

Yes 240 7.6% 18.8% 3.0% 5.9% 11.5% 13.6% 7.2% 4.2%

No 121 9.9% 18.2% 1.7% 5.0% 14.0% 13.6% 5.8% 6.7%

X2 0.581 0.022 0.545 0.130 0.483 0.000 0.257 0.997

Eating

Yes 205 8.4% 18.6% 3.5% 6.4% 11.9% 14.0% 8.5% 4.5%

No 36 2.8% 19.4% 0% 2.8% 8.8% 11.1% 0% 2.8%

X2 1.375 0.013 1.292 0.729 0.269 0.217 3.280 0.214

Exercise

Yes 142 4.3% 14.1% 0.7% 2.1% 7.8% 9.3% 5.0% 2.1%

No 99 12.2% 25.5% 6.3% 11.3% 16.8% 19.8% 10.3% 7.1%

X2 5.299� 4.969� 6.117� 8.899�� 4.579� 5.363� 2.426 3.580

Complementary medicine

Yes 91 9.9% 15.4% 2.2% 6.7% 14.4% 14.4% 8.8% 5.6%

No 150 6.1% 20.8% 3.4% 5.4% 9.6% 13.0% 6.2% 3.4%

X2 1.174 1.090 0.271 0.171 1.296 0.097 0.581 0.659

Stress management

Yes 143 5.6% 18.2% 1.4% 6.3% 9.2% 11.3% 5.7% 2.8%

No 98 10.4% 19.6% 5.3% 5.2% 14.7% 17.0% 9.4% 6.3%

X2 1.918 0.075 2.951 0.123 1.705 1.597 1.175 1.677

Cervical cancer

Lifestyle changes

Yes 312 11.3% 17.4% 1.9% 6.2% 15.3% 15.4% 7.5% 4.8%

No 244 5.7% 17.6% 3.3% 4.9% 8.7% 12.0% 4.1% 1.6%

X2 5.169� 0.004 0.988 0.387 5.339� 1.324 2.749 4.220�

Eating

Yes 254 9.5% 14.2% 1.2% 4.8% 13.5% 13.8% 6.8% 3.6%

No 58 18.6% 31.0% 5.1% 11.9% 22.4% 22.0% 10.3% 10.3%

X2 4.029� 9.287�� 3.808 4.128� 2.873 2.505 0.873 4.735�

Exercise

Yes 156 10.3% 16.8% 1.9% 5.2% 10.3% 11.8% 8.3% 5.1%

No 156 12.3% 18.1% 1.9% 7.1% 19.6% 18.3% 6.6% 4.5%

X2 0.312 0.090 0.000 0.505 5.225� 2.483 0.343 0.057

Complementary medicine

Yes 79 10.1% 10.1% 1.3% 9.0% 10.4% 14.1% 7.6% 3.8%

No 233 11.6% 18.8% 2.2% 5.2% 16.5% 15.4% 7.4% 5.2%

X2 0.135 3.920� 0.238 1.420 1.670 0.078 0.002 0.250

Stress management

Yes 121 9.9% 10.9% 0.8% 5.0% 10.9% 12.8% 5.0% 3.3%

No 191 12.1% 21.5% 2.6% 6.9% 17.5% 16.5% 9.1% 5.8%

X2 0.354 5.664� 1.233 0.425 2.455 0.758 1.815 1.013

�po0.05; ��po0.01.aFor each physical well-being item, the percentages of survivors who endorsed ‘not at all’ or ‘a little bit’ (negative responses) were calculated.bIn the total standardized physical well-being score, the percentages of survivors who endorsed less than or equal to 50 were calculated.



DOI: 10.1002/pon

were less likely to endorse low physical well-beinglevels. Specifically, items that assessed ‘energy’,‘meeting the family needs’, and ‘spend time inbed’, as well as total physical well-being scoressignificantly differed by whether survivors positivelychanged their diet. Meanwhile, in terms of exercise,complementary medicine, and stress management,no significant findings were observed in totalphysical well-being scores. However, the ‘energy’item significantly differed according to complemen-tary medicine (10.1 vs 18.8%; po0.05) and stressmanagement (10.9 vs 21.5%; po0.05). Thus amongCCS in the lowest HRQOL quartile, those whoreported not using complementary medicine norstress reduction strategies were more likely toendorse low energy levels. Additionally, the ‘pain’item significantly differed according to exercise use(10.3 vs 19.6%; po0.05), indicating that CCS whoreported exercise use were less likely to endorsegreater pain levels (Table 3).

Discussion

This study investigated the relationship betweenphysical well-being items and lifestyle changes forEuropean- and Latina-American BCS and CCSwhose overall HRQOL scores are in the lowestquartile, specifically. Findings demonstrate that(1) physical well-being items varied according toethnicity, income, and education, such that lowerincome and educational levels and being Latina-American were associated with less favorableoutcomes; (2) BCS and CCS showed differentpatterns between physical well-being items andlifestyle changes; exercise was related to physicalwell-being for BCS, while diet was related tophysical well-being for CCS. Thus, support forthe study hypotheses was found.Specifically, this study assumed that ethnic dis-

parities exist in physical well-being items. TheInstitute of Medicine (IOM) report on unequalburden concluded that ‘ethnic disparities in health-care exist and, because they are associated withworse outcomes in many cases, are unacceptable’[62]. Our study demonstrated that Latina-Americansshowed unfavorable outcomes in most physicalwell-being items. If Latina-Americans receive lowerquality of care, have difficulties accessing state-of-the-art health care, and have greater languagechallenges in medical settings [63, 64], such barriersmay contribute to poorer physical outcomes. Ithighlights the need for navigational services (i.e.translation services, patient advocacy and assistance)to improve overall survivorship outcomes forLatina-American survivors.The study’s analytic approach contributes to the

identification of specific physical well-being itemsthat can inform culturally and clinically responsiveinterventions to increase healthy lifestyles among

women with low HRQOL scores. Generally,studies use the overall mean or sum scores forstandardized instruments to identify the meaningof specific dimensions. Even though such approa-ches provide a global survivorship perspective,they may be limited in the delivery of the uniquemeaning that each item contains. The current studysuggests that examination of individual itemsprovides new data above and beyond the compo-site score. For example, as illustrated in Table 2,for the relationship between age and physical well-being items, we anticipate that physical statusdimensions may show greater age variabilitycompared with sum scores. Additionally, the totalphysical well-being scores did not differ by cancertype; but the energy item performed differentlybetween BCS and CCS. Further, given that eachphysical well-being item is relatively concrete, astatistical approach to individual items providesreasonable and useful clinical data. As a result, itis important to utilize individual item approach toidentify specific physical symptoms, and such anapproach may better inform clinically responsive,patient centered interventions.Additionally, most physical well-being items

were found to vary by ethnicity, income, andeducation. Of survivors in the lowest HRQOLquartile, those who reported lower income andeducation levels and Latina-Americans were morelikely to report low physical well-being levels.Consistent with other reports [65, 66], this findingsuggests that ethnic and socio-economic variationsin physical well-being exist. Additionally, uniquefindings emerged for the energy item across groups.That is, of survivors in the lowest HRQOLquartile, a majority reported lower energy levelscompared with other physical well-being items suchas ‘nausea’; suggesting that low energy level is animportant risk factor for survivors with lowHRQOL score. On the methodological side, resultsindicate that skewed scores in the energy item maycontribute to a decrease in the overall physical well-being score. Clinically, our findings document thatdecreased energy is the most pervasive HRQOLconcern, suggesting the need for interventions toimprove energy levels.Our study revealed different patterns among BCS

and CCS between physical well-being items andlifestyle changes. For BCS, exercise seems tobe an important lifestyle behavior, which mayimprove physical well-being. Indeed, exercise playsa pivotal role in physical and emotional recovery forBCS, and may help prolong life [67, 68]. Specifically,lymphedema is a primary concern for BCS; andphysical therapy such as exercise is the mainstreamtherapy for treating lymphedema [68]. Hence, itwould be important to encourage BCS to commit toregular exercise to improve physical well-being andultimately HRQOL. In terms of CCS, diet wassignificantly related to several physical well-being



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items. There is little research investigating therelationship between diet and physical well-beingfor CCS. Yet, diets low in fruits and vegetables havelong been linked to cervical cancer risk [44].There are study limitations worth noting. First,

the cross-sectional study design does not assess thedynamic relationship of physical well-being andlifestyle changes. Second, findings may not general-ize to all populations, even though the sample waspopulation-based. Third, self-report was utilized;thus findings may have been influenced by recallbiases. Fourth, the statistical analyses performed onindividual items may have lowered reliability andvalidity; such that findings should be interpretedwith caution. Finally, the lifestyle questions utilizeda dichotomous (Yes/No) response format; thuslimiting our ability to fully estimate lifestyle change.The data reveal unique patterns relevant to

physical well-being items based on overall HRQOLscores according to ethnicity, cancer type, andlifestyle changes. Clinically, this study highlights theneed for greater attention to physical well-beingitems that considers individual and medical char-acteristics. Additionally, information regarding therelationship between physical well-being items andlifestyle changes should inform interventions tomatch appropriate lifestyle patterns to physicalstatus. Further, findings suggest that there areimportant barriers to healthy behavior uptakeamong cancer survivors, such that the BCS whocan best benefit from exercise (those with physicalchallenges) are the least likely to initiate suchtherapeutic activities on their own accord. Similarly,CCS who stand to gain from the immune systemboost through healthy eating are less likely to initiatedietary changes. Therefore, findings point to the needfor a targeted, comprehensive intervention groundedin a behavioral change model; such that readinessfor change and knowledge level of the benefits ofchange as well as other contextual factors (e.g. socialsupport) are considered. Finally, findings suggestthat the cancer experience may serve as a teachableperiod to reinforce healthy lifestyle changes and 60%of survivors reported some form of healthy behaviorchange. Moreover, Latina-Americans, lower incomeand less educated survivors are at greater risk forpoorer physical cancer-related outcomes and maystand to benefit the greatest from culturally andclinically responsive health behavior interventions.

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Documents

Exploring the relationship between physical well-being and healthy lifestyle changes among European- and Latina-American breast and cervical cancer survivors