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Associations between exercise and quality of life in adult survivors of non-Hodgkin's lymphoma and colorectal cancer

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Associations between exercise and quality of life in adult survivors of non-Hodgkin's lymphoma and colorectal cancer

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ASSOCIATIONS BETWEEN EXERCISE AND QUALITY OF LIFE IN ADULT
SURVIVORS OF NON-HODGKIN’S LYMPHOMA AND COLORECTAL CANCER

by

Matthew C. Parker

A Thesis Presented to the
FACULTY OF THE KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(BIOSTATISTICS)

May 2009

Copyright 2009 Matthew C. Parker

ii
Dedication

To Mom, Dad, and Brad for your support and guidance, and to Ken and Sue,
whose strength and courage have been a consistent motivation.

iii
Table of Contents

Dedication ii

List of Tables iv

List of Figures v

Abstract vi

Associations Between Exercise and Quality of Life in Adult 1
Survivors of Non-Hodgkin’s Lymphoma and Colorectal Cancer

References 24

iv
List of Tables

Table 1: Percent Distribution of Respondent Response 10
Rate by Cancer Site

Table 2: Percent Distribution of Respondents and Eligible 11
Nonrespondents

Table 3: Proportion of Cancer Survivors With Insufficiant 13
Exercise by Selected Characteristic

Table 4: Adjusted Odds Rations for Insufficient Exercise by 14
Selected Characteristics of Adult Survivors of NHL or
Colorectal Cancer

Table 5: Adjusted Odds Ratios for Factors Related to Lower General 18
and Mental Health in Adult Survivors of NHL or Colorectal Cancer

v
List of Figures

Figure 1: SF-12 Raw Score Differences 16
Figure 2: SF-12 Score Differences Between Physical Symptoms 17

vi
Abstract

Purpose: The number of cancer survivors has been increasing and research on factors
associated with health-related quality of life (HRQoL) is needed. Exercise has been
shown to affect HRQoL, but few studies have included Non-Hodgkin’s Lymphoma
(NHL) and colorectal cancer (CRC) patients.

Methods: 507 cancer survivors with NHL or CRC completed a survey about lifestyle
factors and HRQoL. Univariate and multivariable methods were used to assess factors
associated with receiving sufficient exercise and the effect that exercise had on HRQoL.

Results: NonWhite race/ethnicity, symptoms likely to impede exercise, NHL, low
education, and high BMI were all independently associated with lower exercise
participation. After controlling for other factors, insufficient exercise was associated
with lower HRQoL (OR= 2.19, 95% CL=1.33 to 3.61).

Conclusions: The identification of factors likely to hinder exercise participation among
cancer survivors is of importance in designing interventions that may improve HRQoL by
increasing exercise in this population.

1
Introduction

In the past 30 years, the prevalence of cancer survivors has more than tripled from
3 million in 1971 to over 11 million in 2004 (Horner et al., 2009). As this figure
continues to increase, researchers have begun to assess cancer survivors’ health related
quality of life (HRQoL), information needs, and follow-up care in order to develop
possible strategies to improve these factors following cancer treatment, especially in the
most commonly diagnosed cancers in the United States (Courneya & Kristina, 2007).
Recent goals identified by the National Cancer Institute (NCI) include enhancing registry
data with outcome information (Clauser, 2004). As cancers continue to become diseases
that people live with as opposed to die from, outcomes research will prove to be an
invaluable tool for improved survivorship and long-term health management.
Recent studies have shown that, as a result of the often intensive treatments given
to Non Hodgkin’s Lymphoma (NHL) and colorectal cancer (CRC) patients, which
include chemotherapy, radiation, and bone-marrow transplantation, it is not uncommon
for these survivors to experience a loss of HRQoL (Bellizzi, Miller, Arora, & Rowland,
2007; Fernsler & Fanuele, 1998). The incidence of NHL has more than doubled in the
past two decades in the United States, and, according to the NCI, there were
approximately 66,120 new cases of NHL in 2006 and 19,160 deaths (Horner et al., 2009).
As of 2005, there were approximately 401,697 prevalent cases of NHL (207,821 men and
193,876 women respectively) in the United States (Horner et al.). Although the five-year
relative survival rate of NHL is high (68.7%) (Horner et al.), survivors often experience
such morbidities as fatigue, loss of sexual functioning, and psychological distress.

2
Currently, NHL is the fifth most common cancer in the United States (Horner et al.).
CRC is the second leading cause of cancer-related deaths in the United States.(Horner et
al.). In 2006, there were approximately 148,810 new cases and an estimated 49,960
deaths (Horner et al.). As of 2005, there were an estimated 1,095,283 men and women
alive who had a history of colorectal cancer (531,875 men and 563,408 women), and, of
those individuals, 112,100 (54,700 men and 57,400 women) were in the state of
California (Horner et al.). Similar to NHL, the five-year relative survival rates for CRC is
66.2%, but survivors may experience pelvic pain, constipation, and anxiety (Horner et
al.). While the incidence of CRC decreased by 2.3% from 1998-2004, it remains the
third most common cancer in the United States (Horner et al.).
Physical activity and other lifestyle factors have been studied to determine their
impact on cancer survivor’s HRQoL. National exercise guidelines recommend that adults
should receive 150 minutes of exercise/week (Haskell, Lee, & Pate, 2007). Recent
cross-sectional studies have shown that prostate, breast, and CRC survivors who met the
physical activity recommendations for exercise had significantly higher HRQoL scores
compared to those who did not (Alfano et al., 2007; Wilder Smith et al., 2009; Courneya
et al., 2003; Snyder et al., 2008; Bellizzi et al., 2009). Despite the potential benefits of
regular exercise after cancer treatment, however, only 20-24% of cancer survivors report
meeting national exercise guidelines (Blanchard, Kerry, & Stein, 2008; Courneya et al.,
2003).
In addition to examining the effects of exercise on HRQoL, it is also important to
identify potential subgroups of survivors who may be less likely to be getting exercise

3
and factors that influence their activity level. For example, previous studies have shown
decreased levels of exercise in survivors of breast cancer who had lower levels of
education, as well as in African American women compared to other racial and ethnic
groups (Bellizzi et al., 2009; Wilder Smith et al., 2009). Additional factors that may
predict physical activity and quality of life include the identification and severity of
symptoms, both physical and mental, experienced by the survivor.
This study was performed to test the feasibility of conducting outcomes
surveillance within a registry by enhancing cancer registry data with self-reported data on
selected outcome measures. The goals of this study were to describe exercise levels in
cancer survivors by administering a questionnaire to a subset of cancer survivors and to
identify factors that were associated with insufficient exercise, as well as to determine
how insufficient exercise levels affects quality of life in cancer survivors.

Study Design and Methods
Description of the Sample
Subjects in this study included both men and women who participated in the
Cancer Outcomes and Patient Experience (COPE) study, a population-based cross-
sectional study that was designed to evaluate the outcomes related to NHL and CRC
survivorship. The study obtained a National Cancer Institute (NCI) clinical exemption,
and was approved by the University of Southern California Institutional Review Board.

4
Patient Contact Methods
The participants were five-year cancer survivors identified from the Cancer
Surveillance Program (CSP), the SEER (Surveillance, Epidemiology, and End Result)
registry for Los Angeles County. A total of 1,421 cases with NHL (635) and colorectal
cancer (786, excluding carcinoids) were selected who had been diagnosed in 2002 and
were not known to be deceased at the time of sample selection in Nov. 2006. The case
eligibility requirements for this study included: site colorectal (C18, C199, C209, C218),
NHL (all); year of diagnosis (2002); age at diagnosis (20-79); race (all for NHL;
excluding African American and Japanese from CRC); and first primary.
Prior to contacting the patients, a courtesy letter was mailed to one physician per
patient notifying them of our intent to contact the patient and allowing two weeks for
them to respond if they had objections. If no response (or no objections) were received,
we proceeded to mail the introductory letter to the patient along with a copy of the
questionnaire, and a postage-paid return envelope. The surveys were mailed between
3/07—6/07 with telephone follow-up, re-mailing of questionnaires, and extensive tracing,
continuing through February, 2008.

Definition of Variables
HRQoL
Health Related Quality of Life (HRQoL) was measured using summary scores
from the Short Form-12 (SF-12 v2 Standard), a short subset questionnaire of the original
SF-36. The values included both a physical component score (PCS) and a mental

5
component score (MCS) formulated from the 1999 US population norms. The PCS and
MCS had a mean value of 50 that represented US population norms and a standard
deviation of 10 (Bellizzi et al., 2009). Additional SF-12 measures examined included:
physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH),
vitality (V), social functioning (SF), role emotional (RE), and mental health (MH).

Physical Activity
Study participants completed survey questions regarding how many days per
week they participated in at least moderate leisure-time physical activities (exercise,
sports, physically active hobbies) for 10 minutes or more that caused sweating or an
increase in breathing or heart rate (never, 1 day, 2 days, 3 days, 4 days 5 days, 6 days, or
7 days), and the average minutes per session in which they were active (<10 minutes, 10-
19 minutes, 20-29 minutes, 30-59 minutes, 60 minutes or more). We calculated the
number of exercise minutes per week by multiplying the amount of days the subjects
reported exercising by the number of minutes per day. The activity level of the
respondents was coded as insufficient if they either had performed no physical activity
per week, or if their minutes per week were ≤149, and sufficient if their minutes per week
were ≥150. The parameters for this estimate are based on nationally recognized public
health exercise guidelines (Haskell, Lee, & Pate, 2007).

6
Categorization of Symptoms
The Memorial Symptom list was included in the survey (Chang, Hwang,
Feuerman , Basil, & Thaler, 2009). In response to a list of 32 symptoms, the respondent
was asked to categorize how much the symptom bothered them in five levels, as follows:
1) not at all, 2) a little bit, 3)somewhat, 4) quite a bit, or 5) very much. We considered a
symptom to be having an impact on daily life if the patient was bothered by it quite a bit
or very much.
In order to assess the impact of symptoms on the participation in physical
exercise, we categorized them into three groups based on likely impact on exercise
participation and created an index by summing the number of symptoms in each group
that the patient said affected them quite a bit or very much. The three symptoms groups
are as follows:

1) Minimal impact on exercise symptoms:
difficulty concentrating, dry mouth, difficulty sleeping, feeling bloated, problems with
urination, sweats, mouth sores, problems with sexual activity, itching, lack of appetite,
difficulty swallowing, change in the way food tastes, and hair loss.

2) Moderate impact on exercise symptoms:
lack of energy, cough, feeling drowsy, numbness, weight loss, and constipation;

7
3) Definite impact on exercise symptoms:
pain, nausea, vomiting, shortness of breath, diarrhea, dizziness, and swelling of arms and
legs.

For each of these categories, we dichotomized symptom index variables into being
affected by none of these symptoms versus being affected by one or more. If a patient
had symptoms more than one category (minimal, moderate, or definite impact on
exercise) we included them in the more severe category only.

Depression:
The 32-item Memorial Symptom List (MSL) also included symptoms related to
mental health. In the same manner as described above for the physical symptoms, an
index based on the number of symptoms that caused quite a bit or very much bother was
created. The symptoms included were: 1) “I don’t look like myself;” 2) Feeling sad; 3)
Worrying; 4) Feeling irritable; and 5) Feeling nervous.
In addition we had a separate variable on depression which was included on a list
of 13 conditions. Patients coded as having had depression if they indicated that they had
ever experienced it.

Statistical Methods
We calculated response rates based on the proportion of eligible patients who
responded. Ineligible patients were categorized as those whose physician refused

8
permission to contact, who did not speak English, denied having cancer, were too ill to
respond or who were deceased. Using demographic and clinical data from the Cancer
Surveillance Program (CSP), we assessed characteristics of respondents and non-
respondents to identify biases in the respondent group using the chi-square statistic.
The association of exercise (sufficient/insufficient) with “other characteristics”
was assessed using Chi-square statistics. We also used multivariable analyses to
determine adjusted odds ratios and 95% confidence limits for variables independently
associated with getting insufficient exercise. The variables in this model included age,
sex, race, marital status, education, depression, adequate financial resources, body mass
index (BMI), definite physical symptom, cancer site, cancer recurrence, and currently
receiving cancer treatment.
We calculated the mean SF-12 scores for physical functioning (PF), role physical
(RP), bodily pain (BP), general health (GH), vitality (V), social functioning (SF), role
emotional (RE), mental health (MH), physical component score (PCS), and mental
component score (MCS) using a standard algorithm, and adjusted them to compare to the
general population (mean of 50). This is done by examining the frequency distributions
for each variable, and adding together the respective percentages. We compared the
means for these measures for categories of exercise (sufficient and insufficient) and for
the three symptoms indices (minimal, moderate, and definite). In order to examine the
independent effect of exercise on both physical and emotional well-being as measured by
the SF-12 scores, we dichotomized the mean scores from the general health (GH) and
mental health (MH) indices into the lower 25% and upper 75% as our outcome

9
measures—<45 and ≥45 for general health, and <47 ≥47 for mental health—and used
multivariable logistic regression to obtain adjusted odds ratio’s and 95% confidence
limits. The variables included in these models were: age, sex, race, marital status,
education, adequate financial resources, BMI, depression, definite physical symptom,
cancer site, exercise, cancer recurrence, and currently receiving cancer treatment.

Results
Response Rates and Sample Characteristics
After the extensive follow-up efforts, the final response rate among eligible
respondents was 44.1%, with little difference between the CRC and NHL cases (Table 1).
A total of 1,151 ( 81% ) of the of s sample was considered to be eligible A total of 310
individuals were determined to be ineligible because 116 were deceased (not known at
the time of sample selection), 40 were too ill or incompetent, 30 denied having cancer, 3
had physicians refuse permission, and 81 did not speak English or Spanish.
Approximately 35% of 1,151 who were eligible were subsequently coded as lost to
follow-up after multiple tracing efforts with made to contact them with no response.
Among the 747 eligible respondents contacted our response rate was 67.9%.

10
Table 1: Percent Distribution of Respondent Response Rate by Cancer Site
Response Colorectal
Cancer
NHL* Total (%)

Eligible 612 539 1,151
Completed quest (total)
269 (44.0)†
238 (44.2) 507 (44.1)

Refused 129 (21.0) 111 (20.6) 240 (20.8)
Lost to follow-up/out of
country
214 (35.0) 190 (35.2) 404 (35.1)
Total eligible 612 (100.0) 539 (100.0) 1,151 (100.0)
% Response based on
located patient
67.5 68.2 67.9
*NHL= Non-Hodgkin's Lymphoma
† N(%)

As shown in Table 2, there was no significant difference by age group at
diagnosis between the 507 respondents and 644 eligible nonrespondents. However,
respondents were significantly more likely to be non-Spanish surnamed White and less
likely to belong to a minority group (Hispanic, African-American, and Other) compared
to non-respondents. They were also less likely to reside in a lower socio-economic status
(SES) census tracts compared to non-respondents. No differences between respondents
and non-respondents were seen for chemotherapy, hormone therapy, or radiation therapy
(data not shown).

11
Table 2: Percent Distribution of Respondents and Eligible Nonrespondents
Selected Demographic
Characteristics N % N %
Total 507 100 644 100
Age at diagnosis (in years)
<45 63 12.4 109 16.9
45-49 53 10.4 52 8.1
50-54 77 15.2 103 16.0
55-59 68 13.4 94 14.6
60-64 70 13.8 67 10.4
65-69 46 9.1 47 7.3
70+ 130 25.6 172 26.7
P value =.12*
Race/ethnicity
Hispanic 94 18.5 162 25.2
African-American 15 3.0 38 5.9
Non-Spanish Surname White 353 69.6 353 54.8
Other 45 8.9 91 14.1
P value <.0001*
Socio-economic Status of
Census Tract
High (1) 197 39.3 151 24.0
(2) 129 25.8 141 22.4
(3) 86 17.2 143 22.8
(4) 59 11.8 113 18.0
Low (5) 30 6.0 80 12.7
P value <.0001*
*Chi-square analyses
Respondents Nonrespondents
Table 2: Percent Distribution of Respondents and Eligible Non-respondents

Exercise Behavior in Survivors of NHL and Colorectal Cancer
70.7% of the sample did not meet public health guidelines of 150 minutes or more
of moderate to vigorous exercise per week (defined as sufficient). Results from the
univariate analysis (Table 3) indicate that physical symptoms and education were the
most significant variables associated with insufficient exercise levels. 81% of those who

12
reported having a high school education or less engaged in insufficient amounts of
exercise, while only 56.8% of those who reported having some graduate school or a
graduate school education had insufficient levels. Similarly, 100% of those who reported
having two or more definite physical symptoms had insufficient levels of exercise,
compared to 68.1% who reported no definite symptoms. Results from the multinomial
logistic regression model predicting insufficient exercise as the outcome measure (Table
4) illustrate that African Americans, Asians, and those who marked “other” on the
questionnaire were over twice as likely to have insufficient exercise levels compared to
Whites (OR= 2.39, 95% CI = 1.10 to 5.20). Respondents who indicated having one or
more symptoms that would likely impede their exercise capabilities were more than three
times as likely to report insufficient levels of exercise compared to those who reported
having no definite symptoms (OR=3.10, 95% CI = 1.43 to 6.70). In addition, those with
NHL were also more likely to be getting insufficient amounts of exercise (OR=1.65, 95%
CI = 1.00-2.74), although the OR was of borderline significance. On the other hand,
several variables were protective against insufficient levels of exercise. For example,
respondents who received some graduate school or a graduate school degree were 0.36
(95% CI = 0.16 to 0.81) times as likely to receive insufficient exercise compared to those
who received some high school education or less. Participants who reported having a
normal body mass index (BMI<25) were 0.35 times as likely to have insufficient exercise
levels compared to those who were obese (bmi>30) and those who were reported as being
overweight (BMI = 25-30) were 0.49 times as likely to have insufficient levels of
exercise (95% CI = 0.17 to 0.73 and 95% C.L 0.24 to 0.99, respectively).

13
Table 3: Proportion of Cancer Survivors With Insufficient
Exercise by Selected Characteristic

Characteristic Insufficient
Proportion (%) Chi-Sq
All Patients 70.7
345
Demographic
Age (in years) 0.33
<50 67.5
50-59 66.4
60-69 74.8
70+ 74.2
Gender 0.14
Male 68.3
Female 74.5
Race 0.14
White 67.1
Hispanic 74.4
Black/Asian/Other 77.5
Marital Status 0.06
Never Married 74.1
Married 66.9
Separated/Divorced/Widowed 78.3
Education 0.003*
HS or less 81.0
Some College 69.5
College Graduate 69.2
Some Grad or Grad Degree 56.8
Adequate Financial Resources 0.25
Yes 76.0
No 69.4
Clinical
BMI 0.23
<25 68.8
25-30 68.2
>30 77.1
Depression 0.42
Yes 75.0
No 70.1
Cancer Site 0.70
Colorectal 70.0
Non-Hodgkin's Lymphoma 71.6
Cancer Returned 0.36
Yes 70.3
No 75.7
Definite Physical Symptom 0.003*
0 68.1
1 77.8
2+ 100.0
Moderate Physical Symptom 0.0007*
0 66.5
1 81.7
2+ 90.9
Minimal Physical Symptom 0.06
0 67.5
1 76.7
2+ 79.4
Mental Distress 0.12
0 69.1
1 85.7
2+ 76.9
Currently Receiving Cancer Treatment 0.20
Yes 76.5
No 69.5
*Statistically Significant
Table 3- Proportion of Cancer Survivors With Insufficient Exercise by Selected Characteristics

14
Table 4: Adjusted Odds Rations for Insufficient Exercise by Selected
Characteristics of Adult Survivors of NHL or Colorectal Cancer

Charactertistic OR 95% CI
Age, years‡
<50 1.00 --
50-59 0.90 0.47 to 1.74
60-69 2.12 0.99 to 4.55
70+ 1.46 0.69 to 3.09
Sex
Male 1.00 --
Female 1.11 0.67 to 1.84
Race
White 1.00 --
Hispanic 0.81 0.43 to 1.53
Black/Asian/Other 2.39* 1.10 to 5.20
Marital Status
Married 1.00 --
Never Married 1.54 0.69 to 3.42
Separated/Widowed/Divorced 1.18 0.63 to 2.19
Education‡
High School or Less 1.00 --
Some College 0.54 0.26 to 1.12
College Graduate 0.57 0.26 to 1.24
Some Graduate School or Graduate Degree 0.36* 0.16 to 0.81
Adequete Financial Resource
Yes 1.00 --
No 0.81 0.39 to 1.68
BMI†
Obese (>30) 1.00 --
Overweight (25-30) 0.49* 0.24 to 0.99
Normal (<25) 0.35* 0.17 to 0.73
Depression
No 1.00 --
Yes 0.90 0.43 to 1.88
Definite Physical Symptom
0 1.00 --
1+ 3.10* 1.43 to 6.70
Cancersite
Colon 1.00 --
NHL 1.65 1.00 to 2.74
Cancer Returned
No 1.00 --
Yes 0.91 0.41 to 2.01
Currently Receiving Cancer Treatment
No 1.00 --
Yes 1.06 0.48 to 2.34
Abbreviations: OR, Odds Ratio; CI, Confidence Interval;
BMI, Body Mass Index; NHL, Non-Hodgkin's Lymphoma
* Statistically Significant
†Normal Body Mass Index is 18.5-24.9 kg/m
2
;
overweight is 25.0-29.9 kg/m
2
; and obese is >= 30
‡Test for trend in age was not significant (p=0.1532); test for trend in education was significant (p=0.0270)
Insufficient Exercise
Table 4- Adjusted Odds Ratios for Insufficient Exercise by Selected Characteristics of Adult Survivors of
NHL or Colorectal Cancer

15

HRQoL Differences in Survivors of NHL and CRC by Exercise Participation and
Physical Symptoms
We investigated the association between exercise and health related quality of life
(HRQoL). Those engaging in insufficient amounts of physical activity reported
consistently lower scores for many of the SF-12 components than did those with
sufficient exercises. Specifically, for the Mental Component Score (MCS) the insufficient
exercisers had a mean score of 48.9 (95% CI = 47.5 to 50.2) compared to 51.9 (95% CI =
50.3 to 53.5) for those getting sufficient exercises. The means for the Physical
Component Score (PCS) were 45.2 (95% CI = 43.8 to 46.6) for those with insufficient
exercise compared to 51.3 (95% CI = 49.5 to 53.0) for the sufficient exercisers. As
illustrated in Figure 1, those who engaged in sufficient amounts of exercise reported
statistically significantly higher SF-12 scores on every measure compared to those who
did engaged in insufficient amounts of exercise (p<0.05), with the exception of mental
health (MH) and MCS.

16
Figure 1: SF-12 Raw Score Differences
0
10
20
30
40
50
60
SF -12
PF*
SF -12
RP*
SF-12
BP*
SF-12
GH*
SF-12
V*
SF -12
SF*
SF -12
RE*
SF-12
MH
SF-12
PCS*
SF -12
MCS
SF-12 Raw Score Differences †
Insufficient
Sufficient
†Abbreviations: PF= Physical Function; RP= Role Physical; BP= Bodily Pain; GH= General Health; V=Vitality; SF= Social Functioning; RE= Role Emotional; MH= Mental
Health; PCS= Physical Component Score; MCS= Mental Component Score
*Statistically significant; p<0.05 between means of SF -12 subscales for those getting sufficient vs insufficient exercise

We also compared the SF-12 scores among patients with minimal, moderate, and
definite physical symptoms (Figure 2). Statistically significant differences between
definite symptoms and minimal symptoms were seen in the SF-12 measures of Physical
Functioning (PF), Bodily Pain (BP), General Health (GH), and PCS (p<0.05). For all the
SF-12 measures the scores declined as the severity of the symptoms increased. It should
be noted that all subjects who reported a physical symptom, regardless of severity, had
SF-12 scores lower than the population mean of 50.

17
Figure 2: SF-12 Score Differences Between Physical Symptoms
0
5
10
15
20
25
30
35
40
45
50
SF-12
PF*
SF-12
RP
SF-12
BP*
SF-12
GH*
SF-12 V SF-12
SF
SF-12
RE
SF-12
MH
SF-12
PCS*
SF-12
MCS
* Statistically significant; p<0.05 between means of SF -12 measures for those with minimal symptoms and those with definite symp toms
SF-12 Score Differences between Physical Symptoms †
Minimal Problem=1
Moderate Problem=1
Definite Problem=1
†Abbreviations: PF= Physical Function; RP= Role Physical; BP= Bodily Pain; GH= General Health; V=Vitality; SF= Social Functioning; RE= Role Emotional;
MH= Mental Health; PCS= Physical Component Score; MCS= Mental Component Score

Factors independently associated with SF-12 General and Mental Health Scores
In order to assess the independent role of exercise on HRQoL outcome measures,
we constructed multivariable models to adjust for physical symptoms and other variables
that may affect HRQoL. Using the SF-12 general health and mental health indices as the
outcome measures, we dichotomized the scores into <45 and ≥45 for general health and
<47 and ≥47 for mental health, corresponding to 25% in the lowest group and 75% in the
other. Results from the multivariable logistic regression on general health (Table 5)
illustrate that the factors independently associated with an increased risk for lower
general health were depression (OR=2.85, 95% CI = 1.38 to 5.88), NHL cancer site
(OR=1.85, 95% CI = 1.15 to 2.98), and insufficient exercise (OR=2.19, 95% CI = 1.33 to
3.61). The factors associated with a decreased risk for lower general health included only
education, as those with some graduate school or a graduate school degree were less than

18
half as likely to report low general health scores compared to those with some high
school education or less (OR=0.46, 95% CI = 0.22 to 0.99).
Table 5: Adjusted Odds Ratios for Factors Related to Lower General and
Mental Health in Adult Survivors of NHL or Colorectal Cancer
Characteristic OR 95% CI OR 95% CI
Age, years**
<50 1.00 -- 1.00 --
50-59 0.76 0.40 to 1.45 0.79 0.42 to 1.51
60-69 0.72 0.36 to 1.44 0.62 0.30 to 1.27
70+ 1.51 0.73 to 3.10 0.50 0.24 to 1.03
Sex
Male 1.00 -- 1.00 --
Female 1.39 0.87 to 2.25 1.55 0.95 to 2.52
Race
White 1.00 -- 1.00 --
Hispanic 1.36 0.74 to 2.50 0.77 0.41 to 1.43
Black/Asian/Other 1.23 0.62 to 2.41 0.93 0.47 to 1.85
Marital Status
Married 1.00 -- 1.00 --
Never Married 0.51 0.24 to 1.05 1.10 0.52 to 2.34
Separated/Widowed/Divorced 1.20 0.68 to 2.14 1.46 0.83 to 2.59
Education**
High School or Less 1.00 -- 1.00 --
Some College 0.79 0.41 to 1.52 0.97 0.50 to 1.88
College Graduate 0.66 0.34 to 1.31 0.95 0.47 to 1.92
Some Graduate School or Graduate Degree 0.46* 0.22 to 0.99 0.70 0.32 to 1.55
Adequete Financial Resources
Yes 1.00 -- 1.00 --
No 1.70 0.85 to 3.37 1.59 0.81 to 3.09
BMI†
Obese (>30) 1.00 -- 1.00 --
Overweight (25-30) 0.75 0.40 to 1.38 0.94 0.50 to 1.75
Normal (<25) 0.68 0.36 to 1.29 0.64 0.33 to 1.24
Depression‡
No 1.00 -- -- --
Yes 2.85* 1.38 to 5.88 -- --
Definite Physical Symptom‡
0 -- -- 1.00 --
1+ -- -- 5.17* 2.73 to 9.79
Cancersite
Colon 1.00 -- 1.00 --
NHL 1.85* 1.15 to 2.98 1.27 0.78 to 2.05
Minutes per Week
Sufficient 1.00 -- 1.00 --
Insufficient 2.19* 1.33 to 3.61 0.8 0.48 to 1.34
Cancer Returned
No 1.00 -- 1.00 --
Yes 1.75 0.84 to 3.66 1.29 0.61 to 2.71
Currently Receiving Cancer Treatment
No 1.00 -- 1.00 --
Yes 1.40 0.67 to 2.91 0.65 0.30 to 1.39
* Statistically Significant
‡Variable left out in analysis because of a
probable relationship with outcome
†Normal Body Mass Index is 18.5-24.9 kg/m
2
; overweight is 25.0-29.9 kg/m
2
; and obese is >= 30
kg/m
2
**test for trend on age was significant (p=0.0346); test for trend on education was not significant (p=0.4051)
Table 5- Adjusted Odds Ratios for Factors related to Lower General and Mental Health in Adult Survivors of NHL or Colorectal Cancer
General Health: <45 vs. >=45 Mental Health: <47 vs. >=47
Abbreviations: OR, Odds Ratio; CI, Confidence Interval; BMI, Body Mass Index; NHL, Non-
Hodgkin's Lymphoma

19
In contrast to general health, there were fewer factors either positively or
negatively associated with the mental health score. The only significant variable was
having a definite physical symptom, as those with one or more of these symptoms were
over 5 times as likely to report lower mental health scores compared to those who
reported no symptoms (OR=5.17, 95% CI = 2.73 to 9.79). While age, taken
categorically, was not found to be significantly associated with mental health, the test for
trend was significant (p=0.0346), with older patients more likely to have a lower mental
health score.

Discussion
Similar to previous research on exercise and survivors of NHL and other cancers,
almost three fourths of the study population (71%) did not meet weekly public health
recommendations for physical activity. We found that nonWhite race and having a
definite physical symptom were significant predictors of insufficient exercise, with
cancer site serving as only a marginal predictor. In accordance with studies on breast
cancer, Black and Asian Americans were significantly more likely to report lower levels
of physical activity compared to White and Hispanic Americans (Wilder Smith et al.,
2009). To date, no other study has examined the effects of symptoms likely to impede
exercise participation on the physical activity of NHL and CRC survivors. We also
found education and BMI (add direction of these variables that are protective at this point
in sentence) to be significant protective factors against insufficient exercise, as those with
higher education—defined as those with some graduate school or a graduate school

20
degree—and lower BMI were less likely to report lower levels of insufficient exercise.
These findings support past results of the positive association between higher levels of
education and lower BMI on higher physical activity levels in endometrial, breast, and
colorectal cancer survivors (Basen-Engquist et al., 2009; DiPietro, 1995; Lynch, Cerin,
Newman, & Owen, 2007).
A second aim of this study was to explore the relationship of physical activity
levels and measures HRQoL as indicated by the general and mental health categories on
the SF-12 questionnaire. Numerous intervention studies and reviews have suggested that
physical activity after diagnosis can be significantly beneficial in reducing cancer-related
comorbidities and improving HRQoL (Friendenreich & Courneya, 1996; Johnson,
Trentham-Dietz, Koltyn, & Colbert, 2009; Knobf, Musanti, & Dorward, 2007; Korstjens
et al., 2009). For general health, higher levels of education was a significant protective
factor against lower HRQOL scores, as higher levels of education corresponded to higher
self-reported rates of quality of life. Cancer site, depression, and exercise were also
significant independent predictors of lower quality of life scores for general health.
These findings support current literature on the positive effects of exercise on the
physical and emotional quality of life in NHL and breast cancer survivors using summary
scores from the Short Form-36 (SF-36) (Bellizzi et al., 2009; Kendall, Carpenter, Ganz,
& Bernstein, 2005). For our mental health measure, we found that the most significant
predictor of lower quality of life scores was having a definite physical symptom. To
date, no other study has examined the effects of definite physical symptoms and their
associations with mental health in cancer survivors.

21
An important aspect of these findings is the impact of having definite physical
symptoms on levels of exercise and mental well-being. This result is significant from
both a research-based and practical standpoint. Most studies of physical activity, mental
health, and quality of life have only examined categorical measures of comorbidities as a
factor influencing outcomes. None have classified the severity of the comorbid
conditions in order to examine their individual effects on exercise participation. Future
research should consider an examination of not only definite symptoms, but also minimal
and moderate symptoms as well, as the presence of just one symptom was associated
with decreased levels of quality of life across all measures in our sample. This finding
also presents a valuable insight to health care providers. If the symptoms of cancer
survivors can be identified early, then future interventions that promote physical activity
may be tailored according to the severity of their symptom. In light of the
overwhelmingly high amount of individuals not participating in the recommended
amount of physical activity, more complete health communication may play an
invaluable role in motivating the vast majority of inactive individuals to exercise.
The characteristics of those more likely to report insufficient exercise levels and
low health-related quality of life offer researchers and health care professionals
knowledge on how to construct future evaluations and recommendations. Black and
Asian Americans, those with a high school education or less, the obese and overweight,
and those reporting definite physical symptoms are at an increased risk for insufficient
exercise and low quality of life after cancer survivorship. Physicians are in the best
position to educate their patients on the risks of declining physical activity levels in light

22
of patient characteristics (Bellizzi et al., 2009). The benefits of physical activity far
outweigh the risks for cancer survivors, as insufficient physical activity may lead to
cardiovascular disease, second and recurring cancers, poor HRQoL, diabetes, and
reduced overall mortality (DiPietro, 1995).
Limitations of the study include the fact that the physical activity data were
obtained via brief self-report questionnaires, which often tend to overestimate actual
activity levels in comparison to objective measures such as heart-rate monitors,
pedometers, and accelerometers (Walsh, Hunter, Sirikul, & Gower, 2004). Another
limitation of this study was the cross-sectional design, which does not allow us to make
any inferences on causality between exercise and quality of life. The conclusions of our
data reflect an association between current exercise on HRQoL, however we can’t
determine if higher QoL leads to greater exercising or vice versa. However, randomized
controlled trials have found causal relationships between exercise and HRQoL
(Courneya, 2003). The response rate and representativeness of our sample, while
consistent with other population-based survivorship studies (Bellizzi et al. 2009; Alfano
et al., 2007; Coups et al., 2009), may lead to nonresponse bias in our estimates. Higher
response was obtained from white respondents compared to non-whites and from those in
higher SES census tracts compared to lower SES tracts. Thus our results may
underestimate problems faced by cancer survivors as these subgroups may be expected to
experience greater problems. Because this study included only NHL and CRC survivors,
we cannot generalize the findings to survivors of other cancers. Finally, since the study

23
attempted to contact patients five years after diagnosis, the results are only applicable to
patients surviving at least this long after diagnosis.
This study is the first to identify the effect of symptoms on exercise behavior and
quality of life in adult survivors of NHL and CRC, and confirms previous findings that
have shown the beneficial role that exercise may have on HRQoL (Bellizzi et al., 2009).
With more than 65% of cancer patients surviving >5 years beyond diagnosis (Demark-
Wahnefried, Aziz, Rowland, & Pinto, 2005), oncologists are continually challenged to
move beyond acute care and into long-term management of symptoms. The findings
from this study will assist in making this transition, through providing physicians the
insight into effects of symptoms and the importance of understanding the amount of
bother and distress that they cause.

24

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Abstract (if available)

Abstract Purpose: The number of cancer survivors has been increasing and research on factors associated with health-related quality of life (HRQoL) is needed. Exercise has been shown to affect HRQoL, but few studies have included Non-Hodgkin’s Lymphoma (NHL) and colorectal cancer (CRC) patients.

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Asset Metadata

Creator Parker, Matthew C. (author)

Core Title Associations between exercise and quality of life in adult survivors of non-Hodgkin's lymphoma and colorectal cancer

School Keck School of Medicine

Degree Master of Science

Degree Program Applied Biostatistics

Publication Date 07/07/2009

Defense Date 07/01/2009

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag colorectal cancer,Exercise,non-Hodgkin's lymphoma,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Azen, Stanley Paul (committee chair), Hamilton, Ann S. (committee member), Ingles, Sue A. (committee member), McKean-Cowdin, Roberta (committee member)

Creator Email matthew.c.parker@gmail.com,mcparker@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m2328

Unique identifier UC175900

Identifier etd-Parker-2904 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-251208 (legacy record id),usctheses-m2328 (legacy record id)

Legacy Identifier etd-Parker-2904.pdf

Dmrecord 251208

Document Type Thesis

Rights Parker, Matthew C.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

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