Abstract CN09-04: Multiple behavior interventions among cancer survivors and their relatives
Authors: Lopez M. Luisa , Lana Alberto 
Published: May 2012

Abstract
The leitmotiv of an investigation should be important health problems, due either to their magnitude or their consequences for health, life, and resources. Epidemiological data confirm that cancer is the second cause of death in Spain and the incident rate has an upward trend. Most known cancer risk factors, around 70%, are environmental, behavioral, and related to lifestyle. The survival percentages of cancer are also growing, due to better diagnostic techniques and more effective treatments. The bad news is the increase in the percentage of multiple cancer in the total of cancer: from 1.7% to around 12% in Spain, in the last 30 years.
For the last decade, our team has been investigating the efficacy of interventions aimed to modify behavioral risk of cancer among cancer patients, cancer survivors, and their close relatives because there are now more and more survivors susceptible to multiple cancer and this is increasing sharply. Cancer patients' relatives may share genetic or lifestyle risk factors.
The percentage of childhood survivors is high (around 70%). They usually have a potentially long life expectancy and many of them have still not gone through adolescence. A lot of cancer risk behavior is initiated at this time. Our research approach has other important theoretical supports, such as the European Code against Cancer (ECC) that has been widely spread since 1987. The last revised version, includes behavior of primary cancer prevention. In addition, we use psychosocial models which try to explain human behavior. We usually work with the ASE model (now denominated I-Change Model), which integrates elements from Fishbein-Ajzen, Bandura and Prochaska, and Di Clemente's theories. It establishes that behavior is associated with attitude, social influence, and self-efficacy through intention. Presented is a summary of three studies carried out in different settings and focused on different risk groups. In this decade we have developed three different educational programs for cancer prevention: the FAPACAN, EPIFARGEN, and PREVENCANADOL programs.
The FAPACAN, a randomized clinical controlled trial, had as its setting primary care, with a focus group of 3,031 cancer patients and their close relatives (15–50 years old). There were four educational interventions (every 6 months) by doctors and nurses, based on the ECC and ASE models. Risk evaluation was performed at baseline and 18 months later by self-administered questionnaire. The FAPACAN was developed by trained doctors and nurses, capable of spreading the ECC in the theoretical framework of the ASE model and in primary care. First and second-degree relatives of patients with cancer were randomly assigned to the experimental and control group. The experimental group received four educational interventions (EI) focused on tobacco, alcohol, diet, weight, sun, and work, and based on the ASE model. The impact was calculated measuring: the percentage of people with each cancer risk behavior; the score reached in a total cancer behavioral risk (TCBR) index and the odds ratios at the post-test. Five risk behaviors decreased significantly more in the experimental group than in the control group, after controlling for differences at the baseline, and for sociodemographic and cancer history variables. The total cancer behavioral risk index (TCBR), which ranged from 0 to 74, also decreased an average of nearly 5 points, significantly more in the experimental group. In conclusion: families with cancer experiences changed cancer risk behavior when approached in primary care.
The EPIFARGEN, a descriptive study/randomized clinical controlled trial and case-control study, was performed by a cancer registry and oncologists in a university/hospital setting. The focus group of the descriptive and clinical trial included 241 multiple cancer patients and their close relatives. The case-control study consisted of 217 women with primary breast cancer and multiple cancer and 465 controls without multiple cancer. There was one educational intervention by university preventive medicine teachers based on ECC and ASE models.
Risk evaluation was: 1) genetic [BRCA 1 and 2 and TP53 mutations] and 2) behavioral [baseline and 6 months later by self-administered questionnaire]. Predictors of multiple cancer linked to host (lifestyle included), type of breast cancer, and treatment. The EPIFARGEN program was developed by professors of preventive medicine and genetics and by oncologists. Some strategies for prevention of multiple cancer in cancer survivors have been published from this program. Two hundred and forty-one patients suffering from multiple cancers (involving breast cancer) and their close relatives took part in the genetic study and the trial. The genetic and the behavioral risk of cancer, measured as in the previous FACAPAN program, and the impact of an educational intervention to reduce behavioral risk were measured. The mean of the score reached in the TCBR at baseline was 24.9 of 74 and less than 5% had genetic mutations, 10 of them in BRCA1 and none in TP53. However, more than half were overweight and the prevalence of risk linked to diet and tobacco was around 30%. We could not find significant differences due to the impact of the intervention, because of lack of statistical power, because the university professors were less effective educators than the Primary Care professionals, because the intensity of the intervention was lower (1 vs. 4) or because the patients started with a total cancer behavioral risk slightly lower than the FAPACAN patients. The aim of the case-control study was to detect and compare second primary cancer predictors (SCP) linked to the host, the first breast cancer, and its treatment. The result showed that obesity, OR = 7.48 (1.25–44.88), smoking, OR = 3.16 (1.23–8.15) and having first-degree relatives suffering from breast cancer, OR = 1.69 (1.05–2.72) were the best predictors. Lifestyle was a more important predictor than the characteristics of the first breast cancer and its treatment. The PREVENCANADOL has as its setting Spanish secondary schools, the internet, and SMS. The focus group comprises survivors of cancer and healthy students, their relatives, and teachers. Student scored points for inviting adults to take part, solving weekly challenges, and visiting the website. The higher the score the higher the probability of getting prizes. The design was quasi-experimental, with the classroom as the randomization unit. There was weekly intervention of 1 challenge based on school curriculum and cancer prevention plus 1 SMS (advantages of cancer prevention behavior) plus 1 very short video with cancer prevention advice. Risk evaluation was performed at baseline, 12 months, and 18 months by self-administered online questionnaire. Finally, the PREVENCANADOL project is being initiated as we are finishing this abstract. It is based on new technologies: Web and mobile phones. Its aim is to reduce cancer behavioral risk in secondary students, their relatives, and teachers. The Ministry of Education and the Federation of Children with Cancer have supported the program. We don't know the number of classrooms that will be randomly assigned to the experimental and the control group yet, or the total of students, relatives and teachers taking part in the study. The planned educational intervention is multiple and renewed every week of the academic course through the website. The protagonist is the student, who can enlist online in a pirate ship to learn how to prevent cancer. A “challenge” or problem is introduced into a treasure chest. The problem is based on activities focused on the school curriculum and cancer prevention and must be solved if the student wants to accumulate points and get the top score. The correct answer to the weekly problem and the number of visits to the website score points too. The students also receive a short weekly text message on their mobile phones with arguments for refusing tobacco, alcohol, etc., and a video is put on the website emphasizing the advantages of prevention behavior. Other sections of the website analyze diet and detect dietary risk, provide information on cancer prevention for adults, offer games, chats, and give the position of the student, classroom and school in the ranking, encouraging competition. Students can and should invite adults around them to enlist too. We want the student to feel important and carry out the so-called “upward education” (i.e., educating the educator instead of vice versa). Enlisting adults is one of the activities that scores points. The students with the highest scores will receive prizes at the end of the program.
Potential barriers to implement intervention programs are lack of support, lack of acceptability by focus group or professionals. To avoid the barriers following are important: support from the highest authority; a tailor-made intervention design; to train providers using recorded role-playing activities; the strictest process evaluation by means of qualitative and quantitative research.
Citation Information: Cancer Prev Res 2010;3(1 Suppl):CN09-04.