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ALCOHOL USE AND ASSOCIATED HEALTH BEHAVIOURS OF WOMEN WHO HAVE BEEN TREATED FOR BREAST CANCER Sarah Balaam BHthSc(Nut&Diet)(Hons1), APD Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Nursing Faculty of Health Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology 2019 Alcohol use and associated health behaviours of women who have been treated for breast cancer i Keywords Alcohol consumption, breast cancer, health behaviours, health promotion, precede-proceed model, predisposing, reinforcing, enabling, survivorship. ii Alcohol use and associated health behaviours of women who have been treated for breast cancer Abstract Background Breast cancer is the most commonly diagnosed cancer in Australian women (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2017). Fortunately, advances in screening, early detection, and diagnosis, together with more effective treatments, are associated with recently-improved survival rates for these women, despite increased incidence (Potter, Collins, Brown, & Hure, 2014; Rock et al., 2012; World Cancer Research Fund/American Institute for Cancer Research, 2007). Better survival is clearly a positive outcome for this growing population; however, survival is also associated with negative outcomes, such as an increased risk of secondary primary cancers (Pollard, Eakin, Vardy, & Hawkes, 2009), co-morbidities (Eakin et al., 2007; Eakin et al., 2006; Pollard et al., 2009; Rock, Byers, et al., 2013), and the debilitating long-term effects of cancer treatment. Alcohol is a known carcinogen, with direct links to breast cancer development (Brooks, 2011; World Cancer Research Fund International/American Institute for Cancer Research, 2017a). Alcohol consumption after treatment for breast cancer amplifies the risk of secondary cancers (Rock, Byers, et al., 2013), adverse treatment-related effects (Gallicchio et al., 2015; Lydon et al., 2016; Mitchell & Woods, 2015; Smith, Gallicchio, Miller, Zacur, & Flaws, 2016; Tipples & Robinson, 2011), and comorbidities (Campbell et al., 2012; Rock, Byers, et al., 2013), while potentially increasing the risk of recurrence (Brooks, 2011; Kwan et al., 2013; Rock et al., 2012; Tan, Barber, & Shields, 2006; Winstanley et al., 2011). For example, the relative risk of breast cancer recurrence is increased by 20% for postmenopausal women who regularly consume more than three alcoholic drinks per week (Kwan et al., 2013). Unfortunately, national and international alcohol-related guidelines in this context are confusing, in that there is no consensus as to how many grams of alcohol constitute a standard drink (International Center for Alcohol Policies, 2007a) and there is little agreement regarding the precise intake that protects health (Winstanley et al., 2011). Adding to this ambiguity, the amount of alcohol consumed and the reasons for alcohol intake among the growing Australian population of women who Alcohol use and associated health behaviours of women who have been treated for breast cancer iii have been treated for breast cancer are largely unknown. However, the evidence indicates, that alcohol consumption is a chronic disease risk factor that can and should be modified to enhance the health of this cohort. Aims The aim of this PhD study was to determine the predisposing, enabling, and reinforcing factors associated with alcohol consumption in women previously treated for breast cancer. The objectives were to: 1) quantify alcohol consumption in women who have been treated for breast cancer compared to guidelines and Australian norms, 2) investigate the decision-making and psychosocial processes associated with alcohol consumption in this cohort and to highlight any physical or psychosocial outcomes associated with alcohol use, and 3) determine whether a tailored e-health lifestyle intervention changed alcohol-related health behaviours. Methods An independent component of the Women’s Wellness after Cancer Program (WWACP) (D. J. Anderson, McGuire, & Porter-Steele, 2014; D. J. Anderson et al., 2017), this PhD project utilised mixed methods. Study 1 of the PhD project combined secondary analysis of quantitative alcohol-related and socio-demographic data from the randomised controlled WWACP trial (N = 269). Study 2 comprised the collection and analysis of qualitative alcohol-related data from a sub-set of seventeen WWACP intervention and control participants. Results Quantitative analysis of 269 female breast cancer participants (N = 269, n = 138 intervention, n = 131 control) provided the following results. The baseline alcohol intake pattern (frequency, quantity, type, and place) of participants reflected that of women in the general Australian population and was similar to other breast cancer cohorts. Binary logistic regression modelling identified significant differences between non-drinkers and drinkers. Participants in this cohort who consumed alcohol at baseline were highly educated (p = .017), current or past smokers (p = .008), and reported better quality of life scores in the social and family wellbeing domain (p = .009). Significant findings that related to the odds of moving to a higher level of alcohol intake, assessed using ordinal logistic regression, were associated with being a current or past smoker (p = .004), greater physical activity levels (p = .049), and iv Alcohol use and associated health behaviours of women who have been treated for breast cancer better quality of life overall (p = .045). There was no quantifiable change to alcohol intake following participation in the WWACP intervention. Qualitative findings from the 17 sub-study participants indicated that, overall, participants viewed alcohol consumption favourably. Australian social norms and a family history of alcohol use appeared to influence pre-cancer behaviours and beliefs, and predisposed alcohol-related behaviours after diagnosis. Other predisposing factors identified in this phase of the study included age, tobacco use, health-related quality of life, physical activity, baseline knowledge, exposure to alcohol education, and socially-mediated beliefs about alcohol. WWACP-related behaviour change enablers identified in this cohort related to the WWACP intervention content, timing, and delivery method. The factors that reinforced change included the physical consequences of alcohol consumption and partner support. The qualitative data also suggested that alcohol intake changed during diagnosis, treatment, and into the period of survivorship, and was influenced by participation in the WWACP intervention. The data also suggested that health professionals provided inconsistent education about alcohol, and participants had varying levels of receptivity to education, depending on their position on the cancer trajectory. This resulted in some critical knowledge deficiencies and little knowledge among participants about the risk factors attendant on alcohol consumption before and after cancer treatment. Conclusions This PhD study makes a significant contribution to the currently sparse evidence base regarding alcohol consumption in Australia’s growing population of women who have received treatment for breast cancer. The study provides insights into the predisposing, enabling, and reinforcing factors that shape alcohol consumption. It also provides grounds for further research into interventions that target these behaviours to reduce the potential harms from alcohol consumption after breast cancer treatment. Alcohol use and associated health behaviours of women who have been treated for breast cancer v vi Alcohol use and associated health behaviours of women who have been treated for breast cancer Table of Contents Keywords .................................................................................................................................. ii Abstract .................................................................................................................................... iii Table of Contents .................................................................................................................... vii List of Figures ........................................................................................................................... x List of Tables ........................................................................................................................... xi List of Abbreviations .............................................................................................................. xii Statement of Original Authorship .......................................................................................... xiv PhD Supervisors ..................................................................................................................... xv Acknowledgements ............................................................................................................... xvi Chapter 1: Introduction ....................................................................................... 1 1.1 Context of the research project ........................................................................................ 1 1.2 Background ..................................................................................................................... 3 1.3 Study aim and research questions ................................................................................... 5 1.4 Design and methods overview .......................................................................................
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