Lifestyle Behaviors and Health-Related Quality of Life in Long-Term Survivors of Acute Myeloid Leukemia: An International Survivorship Study By the Gimema, EORTC Quality of Life and Leukemia Groups
Authors: Efficace Fabio , Cannella Laura , Thomas Xavier , Yuksel Meltem Kurt , Trisolini Silvia Maria , Saveria Capria , Brini Alberto , Audisio Ernesta , Maurillo Luca , Lemoli Roberto Massimo , Imovilli Annalisa , Panovska Stavridis Irina , Quattrone Martina , Ciccone Maria , Filardi Nunzio , Fracchiolla Nicola , Vallisa Daniele , Crugnola Monica , Melillo Lorella Maria Antonia , Skerget Matevz , Vignetti Marco , Baron Frederic 
Published: December 2023

Background
Major advances have been made in the treatment of acute myeloid leukemia (AML), and the number of survivors is expected to rise over the coming years. Therefore, a better understanding of the relationships between lifestyle behaviors and health-related quality of life (HRQoL) is important to better inform survivorship care programs. Although valuable evidence exists in this area of research for survivors of solid tumors, little data is available on patients with AML.
Objective
We aimed to investigate the prevalence of lifestyle behaviors of long-term AML survivors and to identify associations with HRQoL profile. A secondary objective was to describe the prevalence of clinically important functional problems and symptoms by level of physical activity (PA).
Methods:
In this international AML survivorship study, patients were eligible if they were diagnosed at least 5 years before and were disease-free at study entry. Patients were invited to participate by their treating hematologist and all consenting patients were requested to complete a survey booklet. Clinical data were retrieved via hospital medical records. The following lifestyle behaviors were assessed: PA, maintaining a healthy weight, eating pattern, smoking status, and alcohol consumption. PA was assessed by the Godin Leisure-Time Exercise questionnaire. Using only moderate and strenuous scores, those with a leisure score index≥24 were classified as active and those with a score≤23 were classified as insufficiently active. Maintaining a healthy weight was evaluated by the BMI and patients were categorized into: non-overweight/obese (BMI &lt;25) and overweight/obese (BMI ≥25). HRQoL profile was assessed by the EORTC QLQ-C30 questionnaire. Univariable and multivariable linear regression analyses were used to investigate the associations of lifestyle behaviors and HRQoL. The summary score of the EORTC QLQ-C30 was used as outcome variable in regression analyses and the following covariates were considered: sex, age at study entry, time since AML diagnosis, ECOG performance status at diagnosis, education, living arrangements, hematopoietic stem cell transplantation history, being treated within a randomized controlled trial (RCT), and current comorbidity. Prevalence of clinically important problems and symptoms, by PA, was assessed based on recently developed thresholds for the EORTC QLQ-C30.
Results
Overall, 225 AML survivors with a median time from diagnosis to study entry of 8.8 years (IQR 6.4-11.9) were enrolled across 24 centers in 6 countries (Italy, France, Turkey, North Macedonia, Belgium, Slovenia). Median age at study entry was 58.0 years (IQR 47.3-66.9) and 119 (52.9%) were women. Overall, there were 165 (73.7%) patients who received at least one stem cell hematopoietic transplantation, and 70 (31.1%) patients treated in the setting of a RCT as first line therapy. One hundred ninety-five survivors (88.6%) reported at least one comorbidity and 103 (46.8%) reported four or more comorbidities. Overall, 74 (33.8%) patients were considered physically active, 121 (55.3%) were considered as overweight/obese, and 43 (19.8%) reported healthy eating habits. The majority of patients were non-smoker (n=184, 83.6%) and reported low alcohol consumption (n=209, 95.9%).
In univariable analyses, no comorbidity (p=.046), no smoking habits (p=.035), higher level of education (p=.017), and being physically active (p&lt;.001) were associated with a higher EORTC QLQ-C30 summary score. However, in multivariable analysis, only being physically active (p=.005) remained independently associated with a higher EORTC QLQ-C30 summary score.
Marked differences were observed in the prevalence of clinically important functional problems and symptoms between the two groups. For example, the prevalence of patients reporting clinically important fatigue and dyspnea in patients who were physically active versus those who were not, was: 8.1% vs. 23.6% and 23% vs 43.1%, respectively. Likewise, patients who were physically active tended to report a lower prevalence of clinically important functional problems (Figure 1).
Conclusion: We found an independent association between being physically active and reporting a better HRQoL profile in long-term survivors of AML. Our findings suggest that interventions aimed to increase PA in survivors of AML may be critical to improve their functional outcomes and reduce symptom burden.