domingo, 12 de julio de 2015

Adaptation of an Evidence-Based Arthritis Program for Breast Cancer Survivors on Aromatase Inhibitor Therapy Who Experience Joint Pain

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Adaptation of an Evidence-Based Arthritis Program for Breast Cancer Survivors on Aromatase Inhibitor Therapy Who Experience Joint Pain

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Adaptation of an Evidence-Based Arthritis Program for Breast Cancer Survivors on Aromatase Inhibitor Therapy Who Experience Joint Pain

Kirsten A. Nyrop, PhD; Leigh F. Callahan, PhD; Christine Rini, PhD; Mary Altpeter, PhD; Betsy Hackney; Arielle Schecher; Anne Wilson; Hyman B. Muss, MD

Suggested citation for this article: Nyrop KA, Callahan LF, Rini C, Altpeter M, Hackney B, Schecher A, et al. Adaptation of an Evidence-Based Arthritis Program for Breast Cancer Survivors on Aromatase Inhibitor Therapy Who Experience Joint Pain. Prev Chronic Dis 2015;12:140535. DOI:


Adding aromatase inhibitors (AIs) to adjuvant treatment of postmenopausal women with hormone-receptor–positive breast cancer significantly reduces cancer recurrence. A common side effect of AIs is noninflammatory joint pain and stiffness (arthralgia) similar to arthritis symptoms. An evidence-based walking program developed by the Arthritis Foundation — Walk With Ease (WWE) — reduces arthritis-related joint symptoms. We hypothesized that WWE may also reduce AI-associated arthralgia. However, the potential for different barriers and facilitators to physical activity for these 2 patient populations suggested a need to adapt WWE before testing it with breast cancer survivors. We conducted qualitative research with 46 breast cancer survivors to explore program modification and inform the development of materials for an adapted program (Walk With Ease-Breast Cancer). Our process parallels the National Cancer Institute’s Research-Tested Intervention Programs (RTIPs) guidelines for adapting evidence-based programs for cancer populations. Findings resulted in a customized 8-page brochure to supplement existing WWE materials.


In 2014, an estimated 232,670 women in the United States received a breast cancer diagnosis (1). Most cancers will be diagnosed in postmenopausal women at an early, highly treatable stage, and most tumors will be hormone receptor–positive (2,3). For women with this tumor type, standard adjuvant (postsurgery chemotherapy and/or radiation) treatment generally includes an aromatase inhibitor (AI) to reduce the chances for cancer recurrence (4,5). Third generation AIs — exemestane (Aromasin), letrozole (Femara), and anastrozole (Arimidex) — are pills taken daily for 5 years, with ongoing scientific consideration of additional years (4,5). Musculoskeletal symptoms — noninflammatory joint pain, stiffness, or achiness (arthralgia) — are common side effects of AIs, with an estimated 33% to 61% of women reporting these symptoms (6–9). When joint symptoms are moderate or severe, they interfere with engagement in physical activity, reduce overall quality of life, and can lead to AI discontinuation or not taking the AI dose as prescribed (7,9,10).
The number of women who are likely to experience these symptoms is substantial. In 2012, there were an estimated 2.97 million female breast cancer survivors, 75% of whom had tumors diagnosed as being hormone receptor–positive; most of these patients were likely to have been prescribed an AI (10). In an aging US population — and breast cancer being largely a disease of aging with 61 years the median age at diagnosis (1) — the number of survivors coping with AI-associated arthralgia will continue to grow. Their quality of life and ability to be physically active during adjuvant treatment may depend on the development of effective behavioral interventions to reduce these musculoskeletal symptoms.
Because AI-associated arthralgia symptoms are similar to those caused by arthritis, we hypothesized that a physical activity program developed by the Arthritis Foundation — Walk With Ease (WWE) (11–14) — could have similar benefits for women on AI therapy. However, the potential for unique psychosocial or medical concerns warranted an investigation of the need to adapt WWE for breast cancer survivors. We describe our process for developing and pilot testing materials to adapt WWE as a precursor to program testing in a randomized controlled trial (currently under way). Our adaptation process parallels guidelines developed by the National Cancer Institute’s (NCI’s) Research-Tested Intervention Programs (RTIPs) (15). We offer this description of our adaptation process as an example of how evidence-based physical activity interventions developed for 1 patient population can be adapted for a new patient population.


This research is supported by NCI, National Institutes of Health, under award no. R21CA169492 and a pilot grant from the UNC Institute on Aging. We thank the Arthritis Foundation, UNC Thurston Arthritis Research Center, and the North Carolina Cancer Hospital oncology physicians and clinical staff for their interest and support throughout the study as well as the breast cancer survivors who participated in this study.
The research presented in this article is in full compliance with current laws of the United States of America.
The authors declare that they have no conflict of interest.

Author Information

Corresponding Author: Kirsten A. Nyrop, PhD, Division of Hematology/Oncology, CB 7305, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7305. Telephone: 919-962-5139. Email:
Author Affiliations: Leigh F. Callahan, Christine Rini, Mary Altpeter, Betsy Hackney, Hyman B. Muss, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Arielle Schecher, Anne Wilson, patient advisors, Chapel Hill, North Carolina.


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