Reply to W. Hryniuk et al
Authors: Cheryl L. Rock, Wendy Demark-Wahnefried, Tim E. Byers, Graham A. Colditz, Jingxia Liu, Bilgé Pakiz, Rebecca L. Sedjo, Patricia A. Ganz
Journal: Journal of Clinical Oncology (2016)

We appreciate the interest that Hryniuk et al have expressed in our article that described the results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) trial, a behavioral weight-loss intervention in overweight or obese breast cancer survivors. As we noted in our article, we concur that women who have been diagnosed and treated for breast cancer often have special issues, such as treatment-related musculoskeletal problems, enduring psychosocial symptoms (especially fatigue and depression), and changes in body composition associated with cancer treatment, which can complicate weight management efforts. Moreover, breast cancer survivors also may have more foodrelated concerns and body image issues that must be addressed to promote adherence to weight loss efforts. The ENERGY intervention was tailored to breast cancer survivors and, hence, addressed their preferences and the challenges specific to breast cancer-related symptoms, including fatigue, symptoms of estrogen withdrawal, body image concerns, and lymphedema. Details about the screening process and specific medical and psychiatric exclusion criteria for the ENERGYtrial have been previously published. Similar to Hryniuk et al, we excluded women who were bipolar or schizophrenic, but we also screened out individuals with other psychoses, bulimia nervosa, and anorexia nervosa, as well as serious personality disorders and serious depression. Several psychosocial measures were conducted at baseline and regular intervals, including risk for depression, using the Center for Epidemiologic Studies Depression Scale (CES-D). In addition, we queried whether participants were currently being treated for depression. As we have previously reported, 137 of the 692 participants (approximately 20%) were considered at risk for depression (CES-D score $16) at study entry, and 21% reported that they were currently being treated for depression. These two measures were strongly associated (P , .001). In response to the suggestion of Hryniuk et al that depression might be an important determinant of weight loss, we conducted an exploratory analysis of the relationship between depression and subsequent study outcomes in the ENERGY trial. There were no differences in weight loss, drop-out rate, or attendance at group or individual intervention sessions at any follow-up time point by depression status based on the CES-D score or diagnosis and treatment of depression. Thus, our data from a relatively large population of overweight and obese breast cancer survivors are not in agreement with those reported by Hryniuk et al. However, it must be noted that our population could have differed because we screened out individuals with severe depression and other disorders that may have been included in the Hryniuk et al sample. Nonetheless, based on our extensive experience with diet and weight-loss interventions in this population, we believe any weight control interventions in cancer survivors need to also address enduring psychosocial symptoms such as cancer-related fatigue and depression.