THE IMPACT OF OBESITY AND PHYSICAL ACTIVITY ON BREAST
CANCER SURVIVORS’ HEALTH AND WELLBEING
Anneli Elme1, Meri Utriainen1, Tiina Palva2, Riitta Luoto 3,5 , Kellokumpu-Lehtinen
P6, Huovinen R7, Kautiainen H8, Järvenpää S9, Penttinen HM1, Vehmanen L1,
Jääskeläinen AS1, Johanna Ruohola7, Carl Blomqvist1, Tiina Saarto1
Jani Raitanen 3, Leena Moilanen4, Kati Valtola 4,
Helsinki University Central Hospital, Department of Oncology, Helsinki, Finland1
Pirkanmaa Cancer Societies, Tampere, Finland2
UKK Institute for Health Promotion, Tampere, Finland3
National Institutes for Health and Welfare, Helsinki, Finland5
Tampere University Central Hospital, Department of Oncology6 Tampere, Finland
Turku University Central Hospital, Department of Oncology 7 Turku, Finland
Central Finland Central Hospital, Unit of Family Practice8, Jyväskylä, Finland
The Medcare Foundation, Finland 9 Äänekoski, Finland
Key words: breast cancer, exercise intervention, cardiovascular disease,
cardiovascular risk factors, health behaviour, obesity, physical activity.
Tiina Saarto, MD, Ph.D.
Dept. of Oncology
Helsinki University Central Hospital
Tel:+358 50 427 0256
Fax:+358 9 471 74247
Passive lifestyle and obesity are one of the greatest health risks in the western world.
The prevalence of obesity is increasing worldwide. Europe has the highest number of
overweight and obese people in the world. According to the latest obesity statistics
over 130 million out of the 730 million Europeans are obese defined as body mass
index (BMI) ≥30 kg/m2. In addition, 400 million Europeans are overweight, defined
as BMI >25 kg/m2 (http://www.healthfirsteurope.org). In the US, 40 million people
are obese and 58 million overweight. Eight out of ten over 25’s are overweight or
obese. 78% of the Americans are not meeting basic activity level recommendations,
25% are completely sedentary (http://www.annecollins.com/obesity/statistics-
obesity.htm). Obesity and sedentary lifestyle are major risk factors of several diseases,
such as diabetes, cardiovascular diseases and cancer, which are the leading causes of
death in western world.
Breast cancer is the most common cancer among women. Currently, approximately
421 000 women are diagnosed with breast cancer in Europe and 207 000 in the US
(www.cancer.org) and the numbers are increasing. However, the survival in breast
cancer has improved significantly during the last few decades thanks to earlier
diagnosis and better therapeutic results. In Finland almost 90% of the women
diagnosed with breast cancer survive more than five years, three out of four are cured
permanently. Therefore, the number of breast cancer survivors has increased
significantly. Even in Finland there live currently more than 52 000 women with
history of breast cancer (www.cancer.fi).
Despite the improved survival, the adjuvant treatments cause many long-term adverse
effects, which could compromise the health benefit of the treatments. Weight gain is
one of the well known consequences of adjuvant breast cancer treatments. Obesity
increases the risk of insulin resistance and dyslipidemia, which increase the risk of
type 2 diabetes and cardiovascular diseases. In addition, weight gain and obesity may
have a negative impact on breast cancer outcome .
Compared with the physical activity before the diagnosis, the physical activity level of
breast cancer patients markedly decreases after the diagnosis and adjuvant treatments .
Epidemiologic studies have demonstrated that physically active women have a lower
risk of breast cancer compared to sedentary . Furthermore, four observational studies
have suggested that physically active women have better breast cancer specific and
overall survival compared with inactive women . The relation of physical inactivity
and obesity is well known, but in those studies physical activity seemed also to reduce
breast cancer risk and improve survival of breast cancer patients independently of
obesity as physical activity also improves insulin sensitivity and glucose tolerance. In
addition, physical activity has a positive effect on cholesterol- and blood sugar
indicators, decreases blood pressure, and therefore, reduces the risk for cardiovascular
disease and diabetes, and mortality in general (.
As mentioned above, a non-favourable metabolic profile due to weight gain and
obesity and physical inactivity are, apart from risk factors for cardiovascular diseases
and diabetes, recently quite well established breast cancer risk factors, and also may
influence breast cancer survival. Therefore, as modifiable factors, metabolic
parameters may become important targets for interventions among breast cancer
The present study is part of an open prospective randomised multicenter phase III trial
(BREX) in Finland conducted in order to investigate whether supervised exercise
training shortly after adjuvant treatment of breast cancer could prevent osteoporosis
and improve quality of life. The secondary end points were physical fitness, co-
morbidities, cancer recurrence and health economy. The primary outcome of the
present paper was to investigate the impact of obesity and physical activity on breast
cancer patient’s health and wellbeing at the beginning of the trial i.e. shortly after the
PATIENTS AND METHODS
537 pre- and postmenopausal women aged from 35 to 68 years with histologically
proven newly diagnosed invasive breast cancer (pT1-4 pN0-3 M0) were enrolled in to
the one year controlled prospective aerobic exercise intervention study (BREX)
between September 2005 and September 2007 from Helsinki, Tampere and Turku
University Hospitals, Departments of Oncology. Eligible were pre- or postmenopausal
breast cancer patients who were treated with adjuvant chemotherapy and/or
radiotherapy within four months or who have started endocrine therapy no more than
four months earlier. The adjuvant treatment was carried out according to clinical
guidelines. Chemotherapy regimen used were six cycles of FE75C, three cycles of
docetaxel 80 mg/m2 and three cycles of FE75C or according to FinXX trial three
cycles of docetaxel 80 mg/m2 iv with oral cabesitabin (X) 1800 mg/m2 per day for
two weeks and three cycles of XE75C . Endocrine therapy for premenopausal women
was antiestrogen tamoxifen for five years and for postmenopausal women aromatase
inhibitor, tamoxifen or sequentially both agents. Radiotherapy was given after breast
conservative operation to the remaining breast tissue. Locoregional lymph nodes and
operative scar after mastectomy were treated when needed. The randomisation took
place in median 33 weeks from the surgery (IQR 27, 40), 12 weeks (IQR 5, 17) from
the end of the chemotherapy, 4 weeks from the radiotherapy (IQR -2, 10) and 9 weeks
(IQR ( 3,16) from the start of endocrine therapy.
Exclusion criteria were severe cardiac disease (NYHA class III or more), myocardial
infarction within 12 months, uncontrolled hypertension, verified osteoporosis, other
serious illness or medical condition which could be contraindication for exercise,
patients not capable of training (severe knee arthrosis, ligament or cartilage injuries at
lower extremities). The screening process of the patients has been reported in detail
previously . The recruitment rate of the patients considered eligible for the study was
78 %, which is 54 % from the potentially eligible patients and 31 % from all those
screened. The main reasons to exclude patients were age (over 68 years) and health
problems that contraindicated physical training, e.g. musculoskeletal disorders. The
members of the exercise group were planned to participate into supervised training
once a week and to perform a home based exercise program three times a week, and
the controls to maintain their physical activity and exercise habits throughout the
The local ethical committee of Helsinki University Hospital has approved the study
protocol and written informed consent was sign by all participants before the study
entry. The trial has been registered in the Helsinki and Uusimaa Hospital District
Clinical Trials Register (www.hus.fi) (trial number 210590) and on the website,
http://www.clinicaltrials.gov/ (identifier number NCT00639210).
Cardiometabolic risk factors
The baseline measurements were performed during the inclusion visit before the
randomisation. Patients height, weight, waistline, blood pressure, pulse and body mass
index (BMI) were measured. Blood glucose and insulin, plasma lipoproteins (total
cholesterol, LDL- and HDL cholesterol and triglyceride) were determined. Serum
triglyceride and cholesterol were determined with an automated Cobas Mira analyzer
(Hoffman-LaRoche, Basel, Switzerland) by enzymatic methods. The concentration of
HDL cholesterol was measured by the phosphotungstic acid/magnesium chloride
precipitation method using a commercially available kit (Hoffman-LaRoche, Basel,
Switzerland). LDL cholesterol was calculated according to the Friedewald equation.
Body weight was measured to the nearest 0,1 kg using balance-beam hospital scale.
BMI was calculated as a measure of body mass relative to height (kg/m2). The revised
definition for metabolic syndrome provided by the National Cholesterol Education
Program (NCEP) was used to identify the patients having metabolic syndrome. The
criteria in women are waist circumference ≥ 88 cm, elevated triglyserides (≥ 1.7
mmol/l), reduced HDL cholesterol (< 1,3 mmol/l in women), elevated blood pressure
(130/85 mm Hg or use of antihypertensive medication) and elevated fasting glucose
( > 5.5 mmol/l or use of medication for hyperglycemia). .
Quality of life
The data of quality of life of the study population has been reported elsewhere . The
quality of life was measured by the EORTC QLQ-C30 (Version 3) . The symptoms of
fatigue were assessed by using the FACIT-Fatigue scale . Depressive symptoms were
assessed using the Finnish modified version of Beck's 13-item depression scale
Physical activity and performance
The leisure-time physical activity of the patients was studied both before and after the
breast cancer diagnosis using questionnaires. The history of leisure time physical
activity before the diagnoses of breast cancer was classified as low (e.g. mostly
watching TV, reading), moderate (e.g. walking or cycling at least 4 hours per week) or
vigorous intensity (e.g. gym, ball games, swimming or jogging at least 3 hours per
week). The current (after the diagnosis and treatment) intensity of leisure-time
physical activity and the time spent was measured by a prospective two-week diary
using metabolic equivalent of task (MET) hours . One metabolic equivalent (MET)
accounts for the amount of oxygen consumed when resting in a seated position. One
MET is equal to 3.5 ml oxygen consumption per kilogram per minute. Each reported
activity was categorized as light intensity (< 3 METs), moderate (3 to 6 METs),
vigorous (6 to 9 METs) or very vigorous intensity (> 9 METs). MET hours (METh)
represent the amount of physical activity defined by multiplying the intensity of the
activity by the time spent with the activity. For the analyses the amount of physical
activity was calculated as mean METh/week using the two-week diary. The
cardiovascular performance of the patients was tested by a two-kilometre walking test
(UKK walk test, Tampere, Finland), where the participants were asked to walk the 2-
km distance as quickly as possible. The results are divided into five categories based
on age and walking time according to reference values of the general population in
Finland . For women aged 31 to 40, 41 to 50, and ≥50 years of age, category 3 average
2-km walking times are 16:08-16:23 (min:sec), 16:15-16:59, and 17:34-18:31
Staging investigations were performed before the adjuvant treatments. Clinical
investigations, including basic laboratory safety tests and radiological examinations,
were repeated according to the usual follow-up practice. The medical history of the
patients was surveyed at baseline visit, which also included a medical examination.
The patients filled in QoL questionnaires, a questionnaire covering basic
demographics and lifestyle issues, and a two-week exercise diary before the
intervention. The tests of physical performance (2-km walking test) were performed
before the intervention.
Main characteristics of the study population
The mean age of the patients was 52.4 years (35-68 y). 284 (52.9%) of the patients
were postmenopausal and 253 (47.1%) premenopausal. 306 (57%) were overweight
or obese and 293 (54.6%) had at least one chronic disease. The most common co-
morbidity was hypertension which was reported on 108 (20.1%) cases. Only 12
(2.2%) of the patients had diabetes requiring medication. 64 (12%) were smokers at
the moment of randomisation. The sociodemographic distribution characterise urban
population with the domination of lower- or upper-level employees (61.1 %). The
mean length of education was 14 years. The majority of the patients were treated after
surgery with chemotherapy (91.9%), endocrine therapy (82.9%) and postoperative
Body mass index (BMI)
231 (43.0%) patients had normal or lean weight (BMI < 25 ), 204 (38.0%) were
overweight (BMI 25-30) and 102 (19%) were obese (BMI ≥ 30). The mean weight
and BMI of the patients was significantly higher at the entry of study (after adjuvant
treatments) compared with the self reported weight and BMI in the beginning of
chemotherapy. The weight gain correlated positively to starting weight: the higher the
starting weight the greater the weight gain during chemotherapy.
(Table 1, Figure 1)
Overweight and obesity was associated to age and menopausal status: more common
among older postmenopausal women as compared to younger premenopausal women
(p < 0.001 and p < 0.001, respectively. (Table 1)
No significant difference was found in smoking or alcohol consumption between the
BMI groups, but leisure time physical activity before the diagnosis and current
physical activity measured by METh/wk were significantly reduced in overweight and
obese patients as compared to normal weight patients (p < 0.001 and p = 0.021,
respectively). (Table 1)
Physical performance measured with 2-km walking test was significantly impaired in
overweight and obese patients, from 17.8 (SD 1.6) minutes for normal weight, to 18.6
(SD 1.7) minutes for overweight and to 20.4 (SD 2.2) minutes for obese patients (p <
0.001). (Table 1)
Tumour characteristics and treatments
No significant difference was found in tumour characteristics or treatments between
the study groups, except more mastectomies were performed in women with BMI less
than 25 (p = 0.008), which could be related to a clinical practise favouring a
mastectomy in younger patients. The number of nodal metastases and number of
investigated lymph nodes were slightly, but not statistically significantly higher in
obese patients (0.089 and 0.067, respectively. (Table 2)
Cardiometabolic risk factors
The patients with BMI over 25 had more co-morbidities (p < 0.001), particularly
hypertension (p = 0.02) and diabetes (p < 0.001), than normal weight patients. In
addition, metabolic syndrome was significantly more frequent in obese and
overweight than in normal weight patients (p < 0.001) (Table 3, Figure 2).
Quality of life
Quality of life (EORTC-QLQ-C30) was significantly impaired in obese and
overweight patients as compared to normal weight patients [Global health score ,
respectively, adjusted p < 0.001]. Also the prevalence of depression measured by
RBDI [33 (34.4%), 47 (35.0%) and 50 patients (22.5%), respectively, adjusted p =
0.025] and fatigue measured by FACIT-B [27 (27.6%), 40 (21.0%) and 40 patients
(17.7%), respectively, adjusted p = 0.033] were significantly higher in obese and
overweight patients than in normal weight patients (Figure 3).
Table 4. Figure 2.
Factors associated to physical performance
Factors associated to physical performance tested by 2-km walking test were
investigated using age adjusted ordered logistic regressions (Table 5). In univariate
analyses leisure time physical activity before diagnosis (p < 0.001) current physical
activity measured by METh/wk (p < 0.001) and longer education (p < 0.001) were
associated to better walking test result; while, high BMI, depression and co-
morbidities impaired it (p < 0.001, p < 0.001 and p = 0.002, respectively). In
multivariate analyses leisure time physical activity before the diagnoses, current
physical activity and BMI were the most important determinants of physical
performance ( p < 0.001 and p < 0.001, respectively).
We found that the overweight and obesity of breast cancer survivors were
significantly associated to sedentary lifestyle and poor physical performance, which
seem to make a vicious circle impairing physical health and quality of life of the
survivors. In the present population 57 % were overweight or obese reflecting the
significancy of the problem.
The physical activity level after breast cancer diagnosis often diminishes . Irwin et. al.
demonstrated in 812 breast cancer patients that the total physical activity decreased on
average by 2 hours per week from the level before the cancer diagnosis within one
year after the diagnoses. The greatest declines in physical activity were observed
among obese patients and in vigorous intensity physical activity among all patients .
In the present study physical inactivity was the most common among the obese
patients with a very low level of high intensity activity. The proportion of physically
inactive obese patients was three times higher and the proportion of vigorous active
obese subjects three times lower than that of normal weight subjects. Diminished
physical activity in turn, is one of the primary factors responsible for further weight
gain during adjuvant chemotherapy . According to previous literature, weight gain
ranges from 2.5 to 6.0 kg during the first year after breast cancer diagnosis, however,
greater gains are not unusual . After the first year further weight gain still occurs, most
in women who receive chemotherapy followed by endocrine therapy . In the present
study, along with the highest level of physical inactivity the weight gain during the
chemotherapy also seemed to be the highest among the obese patients. As BMI and
physical activity were the only independent factors associated to physical
performance, obesity concurrent with physical inactivity seemed to make a vicious
circle that future impaired physical performance.In the present study, not only adverse
health behavioural profile was associated to obesity and overweight, but also the
profile of cardiovascular risk factors was impaired. Prevalence of metabolic syndrome
was significantly higher in obese and overweight patients as compared to normal
weight patients. Metabolic syndrome was present in over two thirds of the obese
patients as compared to one third in overweight and 10 % of normal weight patients.
Of note, pre-existing cardiovascular risk factors are known to predict the development
of therapy-induced cardiovascular injury among breast cancer patients . Obesity was
also related to co-morbidities, particularly hypertension and diabetes in our
observation. This is especially alarming, as breast cancer patients with co-morbidities,
such as cardiovascular problems or diabetes, are known to have poorer breast cancer
prognosis . Especially type 2 diabetes increases risk of death among breast cancer
patients . In a Norwegian study including 1364 breast cancer cases, obese women
(BMI>30), sedentary women and women in the highest tertile of total cholesterol had
30-50% increased risk of total and breast cancer specific mortality compared to
healthier women . Likewise in our observation, a profile of cardiovascular risk factors
was less favorable not only in obese women, but also in women with a lower level of
physical activity independently of BMI.
Obese patients appear to have higher risk for nodal metastasis and larger tumour size .
Concurrently, in the present study we found a trend, though not reaching statistically
significance, towards more advanced disease in overweight and obese breast cancer
patients especially in nodal status and grade.
Epidemiological studies have shown a clear dose response relation between physical
activity and breast cancer mortality. In a recent cohort study of 2987 breast cancer
patients, the risk of death from breast cancer decreased from up to 44 % with physical
activity in a dose-responsive fashion. Even a moderate amount of exercise seems to be
effective. . The association between physical inactivity and breast cancer risk has been
related to weight control and sex hormone regulation, but also to insulin-resistance .
According to Goodwin et al., high insulin levels cause up to two-fold increased risk of
distant recurrence and a three-fold increased risk of death compared with the lowest
levels of insulin in breast cancer patients . The impaired prognosis of obese breast
cancer patients has also been related to higher concentrations of mitogenic hormones,
e.g. oestradiol, due to the aromatising activity of adipose tissue and, on the other hand,
to hyperinsulinaemia as androgen adiposity is also related to insulin resistance.
Notably, in our observation obesity was significantly related to hyperinsulinemia and
in some extent to a low physical activity too.
We have earlier reported that quality of life of the breast cancer patients shortly after
the adjuvant treatments was significantly impaired as compared with general
population . Every fourth patient was depressive. In the current report we found a
strong association between high BMI and impaired quality of life, and more
specifically, increased prevalence of depression and fatigue in overweight and obese
breast cancer patients. Thus, obesity does not only halter physical health but also
psychosocial wellbeing and quality of life. Interestingly, as we have previously
reported, physical activity was the only factor positively correlating to quality of life
The current study had some limitations that should be considered when interpreting
the findings. The study population was selected from the exercise intervention trial.
Even though the recruitment rate was as high as 78 % from the eligible patients,
patients with major health problems were excluded. The study population represent
only 30 % of all screened patients. This, however, make our findings even more
worrying to see such a significant number of physical and psychosocial problems
among the participants. Both physical activity and weight before breast cancer
diagnosis was patient reported. Some patients might have reported overestimated
numbers of their physical activity rather than underestimates. According earlier
studies not only treatment but already the breast cancer diagnosis itself can lead to
diminished physical activity, increased calorie intake and weight gain, and therefore,
overestimates of weight before diagnosis might had happen. Therefore, we
hypothesize that possible inaccuracy in before diagnosis measures could have
diminished but not increased the after diagnosis changes in weight and physical
activity observed in the current study. The strength of this study lies in the large size
and comprehensive assessment of the physical and mental well-being including
quality of life, physical activity, physical performance and cardiometabolic risk
factors, which give a unique information of the interpretation of different factors to
In summary, overweight and obesity of breast cancer patients are related to sedentary
lifestyle and poor physical performance, increased risk of cardiovascular diseases and
impaired quality of life, in particular increasing the risk of depression and fatigue.
Obesity, decreaced physical activity and performance make a vicious circle, which
impair patients’ physical health and quality of life. More attention should be paid on
obesity and physical inactivity among breast cancer patients and survivors.
Table1. Sociodemographic and lifestyle factors, and physical performance according
VariablesBMI < 25
N = 231
mean (SD) or
N = 204
101 (43.7 %)
Alcohol units per
23 (10.0 %) 25 (12.4)
4.3 (4.6) 0.45
Physical activity and performance
2-km walking time
24 (10.8 %)
Table 2. Tumour characteristics and treatments and BMI
mean (SD) or
BMI 25 -
T (mm) 23.5 24.0 (18.1)25.5
N metastatic2.19 (?)2.07 (3.56) 1.84 (3.02)0.089
13.4 (7.7)13.3 (7.9)0.067
4 (19.6 %)
157 (68.0 %)
197 (85.3 %)164 (80.4) 84 (82.4) 0.40
Her 2 positive
164 (71.0 %)
38 (16.9 %)
136 (58.9 %)90 (44.1)51 (50.0)0.0084
171 (74.0 %)
206 (89.2 %)
39 (16.9 %)
173 (74.9 %)
37 (16.0 %)
130 (56.3 %)
64 (27.7 %)
Table 3. Cardiometabolic risk factors and BMI
81 (39,7 %)
Any diseases 99 (42,9
2 (0,9 %)
6 (2,6 %)
71 (69,6 %) <0.001
4 (2 %)
3 (1,5 %)
6 (5,9 %)
1 (1 %)
42 (20,6 %)35 (34,3 %)<0,001
NCEP, n (%)
5.26 (1.01)5.36 (1.14) 0.0240.0900.098
2.05 (0.50) 1.75 (0.42)1.62 (0.46) <0.001<0.001<0.001
2.61 (1.08) 2.92 (0.91) 3.01 (1.06)<0.001 <0.001 <0.001
82 (10)87 (11) 90 (11)<0.001 <0.001<0.001
24 (10.4) 78 (39.0)72 (71.3) <0.001<0.001<0.001
Table 4. Association of physical activity to BMI, CMS and QoL.
CMS by NCEP
Weight change, kg
Figure 2. Cardiometabolic risk factors according to BMI and physical activity.
<2525 to <30 30+
<2525 to <3030+
<2525 to <30 30+
<2525 to <30 30+
<2525 to <30 30+
1. Ferlay J, Parkin DM, Steliarova-Foucher E: Estimates of cancer
incidence and mortality in Europe in 2008. Eur J Cancer, 46(4):765-781.
2.Lorincz AM, Sukumar S: Molecular links between obesity and breast
cancer. Endocr Relat Cancer 2006, 13(2):279-292.
3. Irwin ML, Crumley D, McTiernan A, Bernstein L, Baumgartner R,
Gilliland FD, Kriska A, Ballard-Barbash R: Physical activity levels before
and after a diagnosis of breast carcinoma: the Health, Eating, Activity,
and Lifestyle (HEAL) study. Cancer 2003, 97(7):1746-1757.
4. Gammon MD, John EM, Britton JA: Recreational and occupational
physical activities and risk of breast cancer. J Natl Cancer Inst 1998,
5. McTiernan A, Kooperberg C, White E, Wilcox S, Coates R, Adams-
Campbell LL, Woods N, Ockene J: Recreational physical activity and the
risk of breast cancer in postmenopausal women: the Women's Health
Initiative Cohort Study. JAMA 2003, 290(10):1331-1336.
6. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA: Physical
activity and survival after breast cancer diagnosis. JAMA 2005,
7.Holick CN, Newcomb PA, Trentham-Dietz A, Titus-Ernstoff L, Bersch
AJ, Stampfer MJ, Baron JA, Egan KM, Willett WC: Physical activity and
survival after diagnosis of invasive breast cancer. Cancer Epidemiol
Biomarkers Prev 2008, 17(2):379-386.
8. Sternfeld B, Weltzien E, Quesenberry CP, Jr., Castillo AL, Kwan M,
Slattery ML, Caan BJ: Physical activity and risk of recurrence and
mortality in breast cancer survivors: findings from the LACE study.
Cancer Epidemiol Biomarkers Prev 2009, 18(1):87-95.
9. Irwin ML, Smith AW, McTiernan A, Ballard-Barbash R, Cronin K,
Gilliland FD, Baumgartner RN, Baumgartner KB, Bernstein L: Influence
of pre- and postdiagnosis physical activity on mortality in breast cancer
survivors: the health, eating, activity, and lifestyle study. J Clin Oncol
10.Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS:
Randomized controlled trial of exercise training in postmenopausal breast
cancer survivors: cardiopulmonary and quality of life outcomes. J Clin
Oncol 2003, 21(9):1660-1668.
11.Fairey AS, Courneya KS, Field CJ, Bell GJ, Jones LW, Mackey JR:
Effects of exercise training on fasting insulin, insulin resistance, insulin-
like growth factors, and insulin-like growth factor binding proteins in
postmenopausal breast cancer survivors: a randomized controlled trial.
Cancer Epidemiol Biomarkers Prev 2003, 12(8):721-727.
12. Joensuu H, Kellokumpu-Lehtinen PL, Huovinen R, Jukkola-Vuorinen A,
Tanner M, Asola R, Kokko R, Ahlgren J, Auvinen P, Hemminki A et al:
Adjuvant capecitabine in combination with docetaxel and
cyclophosphamide plus epirubicin for breast cancer: an open-label,
randomised controlled trial. Lancet Oncol 2009, 10(12):1145-1151.
13. Penttinen H, Nikander R, Blomqvist C, Luoto R, Saarto T: Recruitment
of breast cancer survivors into a 12-month supervised exercise
intervention is feasible. Contemp Clin Trials 2009, 30(5):457-463.
14. Grundy SM, Brewer HB, Jr., Cleeman JI, Smith SC, Jr., Lenfant C:
Definition of metabolic syndrome: Report of the National Heart, Lung,
and Blood Institute/American Heart Association conference on scientific
issues related to definition. Circulation 2004, 109(3):433-438.
Penttinen HM, Saarto T, Kellokumpu-Lehtinen P, Blomqvist C,
Huovinen R, Kautiainen H, Jarvenpaa S, Nikander R, Idman I, Luoto R
et al: Quality of life and physical performance and activity of breast
cancer patients after adjuvant treatments. Psychooncology 2010.
Kaasa S, Bjordal K, Aaronson N, Moum T, Wist E, Hagen S, Kvikstad A:
The EORTC core quality of life questionnaire (QLQ-C30): validity and
reliability when analysed with patients treated with palliative
radiotherapy. Eur J Cancer 1995, 31A(13-14):2260-2263.
Sprangers MA, Groenvold M, Arraras JI, Franklin J, te Velde A, Muller
M, Franzini L, Williams A, de Haes HC, Hopwood P et al: The European
Organization for Research and Treatment of Cancer breast cancer-
specific quality-of-life questionnaire module: first results from a three-
country field study. J Clin Oncol 1996, 14(10):2756-2768.
Yellen SB, Cella DF, Webster K, Blendowski C, Kaplan E: Measuring
fatigue and other anemia-related symptoms with the Functional
Assessment of Cancer Therapy (FACT) measurement system. J Pain
Symptom Manage 1997, 13(2):63-74.
Ritasalo R: Elämänhallinta sosiaalipolitiikan tavoitteena. In. Edited by
Kansaneläkelaitos. Helsinki; 1995: 113.
Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ,
O'Brien WL, Bassett DR, Jr., Schmitz KH, Emplaincourt PO et al:
Compendium of physical activities: an update of activity codes and MET
intensities. Med Sci Sports Exerc 2000, 32(9 Suppl):S498-504.
Suni JH, Oja P, Miilunpalo SI, Pasanen ME, Vuori IM, Bos K: Health-
related fitness test battery for adults: associations with perceived health,
mobility, and back function and symptoms. Arch Phys Med Rehabil 1998,
Suni JH, Miilunpalo SI, Asikainen TM, Laukkanen RT, Oja P, Pasanen
ME, Bos K, Vuori IM: Safety and feasibility of a health-related fitness test
battery for adults. Phys Ther 1998, 78(2):134-148.
Suni JH, Oja P, Miilunpalo SI, Pasanen ME, Vuori IM, Bos K: Health-
related fitness test battery for middle-aged adults: associations with
physical activity patterns. Int J Sports Med 1999, 20(3):183-191.
Suni JH, Oja P, Laukkanen RT, Miilunpalo SI, Pasanen ME, Vuori IM,
Vartiainen TM, Bos K: Health-related fitness test battery for adults:
aspects of reliability. Arch Phys Med Rehabil 1996, 77(4):399-405.
Goodwin PJ, Ennis M, Pritchard KI, McCready D, Koo J, Sidlofsky S,
Trudeau M, Hood N, Redwood S: Adjuvant treatment and onset of
menopause predict weight gain after breast cancer diagnosis. J Clin Oncol
Goodwin P, Esplen MJ, Butler K, Winocur J, Pritchard K, Brazel S, Gao
J, Miller A: Multidisciplinary weight management in locoregional breast
cancer: results of a phase II study. Breast Cancer Res Treat 1998, 48(1):53-
Rock CL, Flatt SW, Newman V, Caan BJ, Haan MN, Stefanick ML,
Faerber S, Pierce JP: Factors associated with weight gain in women after
diagnosis of breast cancer. Women's Healthy Eating and Living Study
Group. J Am Diet Assoc 1999, 99(10):1212-1221.
Demark-Wahnefried W, Peterson BL, Winer EP, Marks L, Aziz N,
Marcom PK, Blackwell K, Rimer BK: Changes in weight, body
composition, and factors influencing energy balance among
premenopausal breast cancer patients receiving adjuvant chemotherapy.
J Clin Oncol 2001, 19(9):2381-2389.
McInnes JA, Knobf MT: Weight gain and quality of life in women treated
with adjuvant chemotherapy for early-stage breast cancer. Oncol Nurs
Forum 2001, 28(4):675-684.
Irwin ML, McTiernan A, Baumgartner RN, Baumgartner KB, Bernstein
L, Gilliland FD, Ballard-Barbash R: Changes in body fat and weight after
a breast cancer diagnosis: influence of demographic, prognostic, and
lifestyle factors. J Clin Oncol 2005, 23(4):774-782.
Demark-Wahnefried W, Rimer BK, Winer EP: Weight gain in women
diagnosed with breast cancer. J Am Diet Assoc 1997, 97(5):519-526, 529;
Heideman WH, Russell NS, Gundy C, Rookus MA, Voskuil DW: The
frequency, magnitude and timing of post-diagnosis body weight gain in
Dutch breast cancer survivors. Eur J Cancer 2009, 45(1):119-126.
Jones LW, Haykowsky MJ, Swartz JJ, Douglas PS, Mackey JR: Early
breast cancer therapy and cardiovascular injury. J Am Coll Cardiol 2007,
Patterson RE, Flatt SW, Saquib N, Rock CL, Caan BJ, Parker BA,
Laughlin GA, Erickson K, Thomson CA, Bardwell WA et al: Medical
comorbidities predict mortality in women with a history of early stage
breast cancer. Breast Cancer Res Treat 2010, 122(3):859-865.
Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin JR, Hux JE: The
impact of diabetes on survival following breast cancer. Breast Cancer Res
Treat 2008, 109(2):389-395.
Emaus A, Veierod MB, Tretli S, Finstad SE, Selmer R, Furberg AS,
Bernstein L, Schlichting E, Thune I: Metabolic profile, physical activity,
and mortality in breast cancer patients. Breast Cancer Res Treat 2009,
Dirat B, Bochet L, Escourrou G, Valet P, Muller C: Unraveling the
obesity and breast cancer links: a role for cancer-associated adipocytes?
Endocr Dev 2010, 19:45-52.
Tymchuk CN, Tessler SB, Barnard RJ: Changes in sex hormone-binding
globulin, insulin, and serum lipids in postmenopausal women on a low-fat,
high-fiber diet combined with exercise. Nutr Cancer 2000, 38(2):158-162.
Schmitz KH, Ahmed RL, Yee D: Effects of a 9-month strength training
intervention on insulin, insulin-like growth factor (IGF)-I, IGF-binding
protein (IGFBP)-1, and IGFBP-3 in 30-50-year-old women. Cancer
Epidemiol Biomarkers Prev 2002, 11(12):1597-1604.
Goodwin PJ, Ennis M, Pritchard KI, Trudeau ME, Koo J, Madarnas Y,
Hartwick W, Hoffman B, Hood N: Fasting insulin and outcome in early-
stage breast cancer: results of a prospective cohort study. J Clin Oncol
McTiernan A, Rajan KB, Tworoger SS, Irwin M, Bernstein L,
Baumgartner R, Gilliland F, Stanczyk FZ, Yasui Y, Ballard-Barbash R:
Adiposity and sex hormones in postmenopausal breast cancer survivors. J
Clin Oncol 2003, 21(10):1961-1966.