Physical Activity and Survival after Diagnosis
of Invasive Breast Cancer
Crystal N. Holick,1Polly A. Newcomb,1Amy Trentham-Dietz,2,3Linda Titus-Ernstoff,4,5
Andrew J. Bersch,2Meir J. Stampfer,7,8John A. Baron,4,6Kathleen M. Egan,9
and Walter C. Willett7,8
1Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington;
and Family Medicine and Norris Cotton Cancer Center,
Medical School, Lebanon, New Hampshire;
Harvard Medical School;
2Paul P. Carbone Comprehensive Cancer
4Department of Community
6Department of Medicine, Dartmouth
3Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin;
5Department of Pediatrics, and
7Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital,
8Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston,
9Moffitt Cancer Center and Research Institute and University of South Florida, Tampa, Florida
Previous studies suggest that increased physical activ-
ity may lower the risk of breast cancer incidence, but
less is known about whether levels of physical activity
after breast cancer diagnosis can influence survival.
We prospectively examined the relation between post-
diagnosis recreational physical activity and risk of
breast cancer death in women who had a previous inva-
sive breast cancer diagnosed between 1988 and 2001
(at ages 20-79 years). All women completed a question-
naire on recent postdiagnosis physical activity and
other lifestyle factors. Among 4,482 women without
history of recurrence at the time of completing the
questionnaire, 109 died from breast cancer within 6
years of enrollment. Physical activity was expressed as
metabolic equivalent task-hours per week (MET-h/wk);
hazard ratios (HR) and 95% confidence intervals (95%
CI) were estimated using Cox proportional hazards
regression. After adjusting for age at diagnosis, stage
of disease, state of residence, interval between diag-
nosis and physical activity assessment, body mass
index, menopausal status, hormone therapy use, energy
intake, education, family history of breast cancer, and
treatment modality compared with women expend-
ing <2.8 MET-h/wk in physical activity, women who
engaged in greater levels of activity had a significantly
lower risk of dying from breast cancer (HR, 0.65;
95% CI, 0.39-1.08 for 2.8-7.9 MET-h/wk; HR, 0.59; 95%
CI, 0.35-1.01 for 8.0-20.9 MET-h/wk; and HR, 0.51; 95%
CI, 0.29-0.89 for z21.0 MET-h/wk; P for trend = 0.05).
Results were similar for overall survival (HR, 0.44;
95% CI, 0.32-0.60 for z21.0 versus <2.8 MET-h/wk;
P for trend <0.001) and were similar regardless of a
woman’s age, stage of disease, and body mass index.
This study provides support for reduced overall
mortality and mortality from breast cancer among
women who engage in physical activity after breast
(Cancer Epidemiol Biomarkers Prev
At present, f2 million U.S. women have a history of
breast cancer (1). For this large population of women,
factors that influence survival are of critical importance.
Even after accounting for stage at diagnosis and treat-
ment, survival varies greatly (2), a finding that suggests
an influence of modifiable lifestyle factors, such as phy-
Few studies have considered the influence of lifestyle,
such as physical activity, on breast cancer–specific sur-
vival. Postdiagnosis physical activity has been associated
with improved quality of life (3), but few observational
studies have examined whether lifestyle may affect sur-
vival. A recent prospective study found that women who
engaged in physical activity after a diagnosis of breast
cancer had a statistically significant 20% to 50% lower
risk of death from breast cancer (4). Hormonal changes
induced during exercise, such as lower blood estrogen
(5, 6) or insulin growth factor-I (7, 8) concentrations, or
lower levels of adiposity (9) may explain the relationship
between physical activity and survival among breast
There is an urgent need for information on factors
contributing to long-term survival given the advance-
ments of early detection and treatment modalities (10).
To determine whether postdiagnosis physical activity is
associated with survival among women with a breast
cancer diagnosis, we analyzed data from a large cohort
of breast cancer survivors enrolled in the Collaborative
Women’s Longevity Study (CWLS), a population-based
prospective study established to examine the contribu-
tion of lifestyle to longevity in women with breast cancer.
Materials and Methods
Study Participants. The CWLS is a cohort of women,
ages 20 to 79 years at breast cancer diagnosis, who were
Cancer Epidemiol Biomarkers Prev 2008;17(2). February 2008
Received 8/22/07; revised 11/6/07; accepted 11/19/07.
Grant support: The Susan G. Komen Breast Cancer Foundation grant POP0504234
and National Cancer Institute, NIH, Department of Health and Human Services
grants CA47147, CA47305, CA69664, and CA94880.
The costs of publication of this article were defrayed in part by the payment of page
charges. This article must therefore be hereby marked advertisement in accordance
with 18 U.S.C. Section 1734 solely to indicate this fact.
Requests for reprints: Crystal N. Holick, i3 Drug Safety, Suite 3800, 950 Winter Street,
Waltham, MA 02451. Phone: 203-417-1466. E-mail: firstname.lastname@example.org
Copyright D 2008 American Association for Cancer Research.
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Physical Activity and Breast Cancer Survival
Cancer Epidemiol Biomarkers Prev 2008;17(2). February 2008