Lifestyle, cancer recurrence, and survival after a cancer diagnosis Restricted; Files Only

Troeschel, Alyssa (Spring 2021)

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Several lifestyle factors, such as diet, physical activity, and body fatness, have a clear role in the development of some cancers; however, their role in cancer prognosis remains unclear. The overarching goal of this dissertation was to gain a better understanding of lifestyle factors and their role in cancer recurrence and survival. In Aim 1, we evaluated the one-year reproducibility and relative validity of a modified semi-quantitative food frequency questionnaire (FFQ) to assess food groups and diet quality in accordance with the American Cancer Society’s (ACS) dietary guidelines. Reproducibility was good (>0.50) for the diet quality score and most food groups analyzed. Validity was good for the diet score but varied substantially by food group. In Aim 2, we investigated associations of body mass index (BMI) and weight change on prostate cancer-specific mortality (PCSM) and all-cause mortality among men diagnosed with non-metastatic prostate cancer. Using Cox proportional hazards models, hazard ratios (HR) associated with BMI >30 kg/m2, compared to 18.5-<25.0 kg/m2, were 1.28 for PCSM (95% confidence interval (95%CI): 0.97, 1.69) and 1.23 for all-cause mortality (95%CI: 1.11, 1.36). Post-diagnosis weight gain (>5%), compared with stable weight (±<3%), was associated with a higher risk of PCSM (HR=1.64, 95%CI: 1.20, 2.24) and all-cause mortality (HR=1.27, 95%CI: 1.11, 1.44). In Aim 3, we investigated the separate and combined role of lifestyle factors on the risk of breast cancer recurrence and mortality due to breast cancer and all causes among women diagnosed with invasive breast cancer. Using Cox proportional hazards models, increasing concordance with lifestyle recommendations was inversely associated with all-cause mortality (HR per 2-point increase=0.89, 95%CI: 0.82, 0.98) and breast cancer mortality (HR=0.78, 95%CI: 0.65, 0.94), but not recurrence. In our model including all 9 lifestyle recommendations together in a multivariable model, higher intake of legumes and higher levels of aerobic physical activity appeared inversely related with all-cause mortality. The findings of this dissertation support the use of the modified FFQ to assess most major food groups and a diet quality score in future studies of diet and cancer survival, and suggest that lifestyle factors may play a role in cancer prognosis.

Table of Contents

Chapter 1 ꟷ Introduction and Background. 13

Overarching Goal and Specific Aims. 16

Chapter 2 ꟷ The American Cancer Society Cancer Prevention Study-3 food frequency questionnaire has reasonable validity and reproducibility for food groups and a diet quality score. 17

Abstract 17

Introduction. 18

Methods. 19

Study Design & Participants. 19

Food Frequency Questionnaire. 20

24-Hour Dietary Recalls. 21

Food Group Definitions. 21

Diet Quality. 22

Statistical Analysis. 22

Results. 24

Food Groups. 24

Diet Quality. 27

Discussion. 28

Acknowledgements and statement of authors’ contributions to manuscript 34

Chapter 3 ꟷ Post-diagnosis body mass index, weight change, and mortality due to prostate cancer, cardiovascular disease, and all causes among non-metastatic prostate cancer survivors in a large US cohort 83

Abstract 83

Introduction. 84

Methods. 84

Study Population. 84

Assessment of BMI and Weight Change. 85

Assessment of Outcomes. 85

Statistical Analyses. 85

Results. 86

Post-diagnosis BMI 87

Weight Change. 87

Supplemental Analyses. 87

Discussion. 88

Supplemental Text 91

Chapter 4 ꟷ Associations of post-diagnosis lifestyle with prognosis among women with invasive breast cancer. 119

Abstract 119

Introduction. 120

Methods. 120

Study Population. 120

Exposure Assessment 121

Outcome Assessment 122

Covariates. 122

Statistical Analyses. 122

Supplemental analyses – Addressing potential non-response bias. 123

Results. 124

Post-Diagnosis Lifestyle. 124

Behavior Change Models. 125

Supplemental Analyses. 126

Discussion. 126

Combined Lifestyle. 126

Physical Activity. 127

Diet 127

Body Weight 128

Strengths/Limitations. 128

Chapter 5 ꟷ Summary of Results, Future Research. 155

Review of Major Findings. 155

Implications for Public Health. 161

Future Directions. 162

Chapter 6 ꟷ References 164

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