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Introduction: Physical activity interventions can improve sleep quality in breast cancer survivors. This paper examines the effects of the ACTIVATE Trial, a wearable-based physical activity intervention (Garmin Vivofit2® coupled with behavioral feedback, goal setting, and health coaching) on sleep outcomes. Methods: Post-primary treatment, inactive, postmenopausal breast cancer survivors were recruited and randomized to primary intervention or waitlist. Wrist-worn actigraphy (sleep onset latency, SOL; total sleep time, TST; sleep efficiency, SE; wake after sleep onset, WASO; and number of awakenings, NWAKE) and questionnaire-derived sleep measures (Pittsburgh Sleep Quality Index) were assessed at baseline (T1), 12 weeks (end of primary intervention and start of waitlist intervention, T2), and at 24 weeks (T3). Results: Eighty-three women (mean age = 62 years) were randomized; trial retention was 94% at T2 and 87% at T3. At T2, primary intervention participants had greater improvements in WASO (− 5.7 min, 95% CI − 11.7 to − 0.2) and NWAKE compared with the waitlist arm (− 2.0, 95% CI − 3.6 to − 0.4). At T3, within-group improvements were observed for SE (both groups), WASO (both groups), NWAKE (primary intervention group only), total PSQI score (primary intervention group), and sleep efficacy (primary intervention group). Conclusions: The intervention reduced actigraphy-measured sleep disturbances. Within-group analyses suggest that improvements in sleep quality are sustained over a longer duration, and there may be similar benefits from an abridged intervention (wearable device only). Actigraphy-measured effects appeared stronger in participants who were poor sleepers at study entry. Implications for Cancer Survivors: Wearable technology can increase physical activity and improve sleep for breast cancer survivors Refereed/Peer-reviewed

Background: It is not always clear whether physical activity is causally related to health outcomes, or whether the associations are induced through confounding or other biases. Randomized controlled trials of physical activity are not feasible when outcomes of interest are rare or develop over many years. Thus, we need methods to improve causal inference in observational physical activity studies. Methods: We outline a range of approaches that can improve causal inference in observational physical activity research, and also discuss the impact of measurement error on results and methods to minimize this. Results: Key concepts and methods described include directed acyclic graphs, quantitative bias analysis, Mendelian randomization, and potential outcomes approaches which include propensity scores, g methods, and causal mediation. Conclusions: We provide a brief overview of some contemporary epidemiological methods that are beginning to be used in physical activity research. Adoption of these methods will help build a stronger body of evidence for the health benefits of physical activity.

Background: Physical activity is positively associated with survival and quality of life among breast cancer survivors. Despite these benefits, the majority of breast cancer survivors are insufficiently active. The potential health benefits of reducing sedentary behaviour (sitting time) in this population have not been extensively investigated. The ACTIVATE Trial will evaluate the efficacy of an intervention that combines wearable technology (the Garmin Vivofit2®) with traditional behavioural change approaches to increase physical activity and reduce sedentary behaviour performed by breast cancer survivors. Methods/design: This randomised controlled trial includes inactive, postmenopausal women diagnosed with stage I-III breast cancer who have completed their primary treatment. Participants are randomly assigned to the primary intervention group (Garmin Vivofit2®; behavioural feedback and goal setting session; and, five telephone-delivered health coaching sessions) or to the wait-list control group. The primary intervention is delivered over a 12-week period. The second 12-week period comprises a maintenance phase for the primary intervention group, and an abridged intervention (Garmin Vivofit2® only) for the wait-list control group. Moderate- to vigorous-intensity physical activity (MVPA) and sedentary behaviour are assessed by accelerometry at baseline (T1), end of intervention (T2), and end of maintenance phase (T3). Discussion: The ACTIVATE Trial is one of the first studies to incorporate wearable technology into an intervention for cancer survivors. If the use of wearable technology (in combination with behaviour change strategies, or alone) proves efficacious, it may become an inexpensive and sustainable addition to the health promotion strategies available to health care providers in the cancer survivorship context. Trial registration: ACTRN12616000175471. Refereed/Peer-reviewed

The purpose of this study was to examine potential effects of reallocating time between sleep, sedentary and active behaviours on fatigue symptoms and quality of life in a sample of non-Hodgkin lymphoma survivors. Non-Hodgkin lymphoma survivors identified from the Western Australian Cancer Registry (N = 149) (response rate = 36%; median age = 64 years) wore an ActigraphA (R) GT3X+ accelerometer for 7 days and completed the Fatigue Scale, the Functional Assessment of Cancer Therapy-General and the Pittsburgh Sleep Quality Index. We used isotemporal substitution methods in linear regression models to examine the potential effects of reallocating time between sleep, sedentary and activity behaviours on fatigue and quality of life. Data collection was conducted in Western Australia in 2013. Significant differences were observed for fatigue symptoms when 30 min per day of bouted moderate-to-vigorous physical activity (10 min) was reallocated from 30 min per day of sleep (5.7 points, 95% CI = 1.8, 9.7), sedentary time bouts (20 min) (5.7 points, 95% CI = 1.6, 9.7), sedentary time non-bouts (5.1 points, 95% CI = 1.0, 9.3) or light intensity activity (5.5 points, 95% CI = 1.5, 9.5). Isotemporal substitution effects of reallocating sedentary time, sleep and light physical activity with bouted physical activity was significantly associated with fatigue, but not quality of life. Findings from the present study may aid in the development and delivery of health behaviour interventions that are more likely to influence the health outcome of interest. Refereed/Peer-reviewed

Background: High levels of sedentary behavior may negatively affect health outcomes in cancer survivors. A systematic review and meta‐analysis was performed to clarify whether postdiagnosis sedentary behavior is related to survival, patient‐reported outcomes, and anthropometric outcomes in cancer survivors. Methods: The Ovid MEDLINE, EMBASE, CINAHL (The Cumulative Index to Nursing and Allied Health Literature), and SPORTDiscus databases were searched from study inception to June 2019. Studies of adults who had been diagnosed with cancer that examined the association between sedentary behavior and mortality, patient‐reported outcomes (eg, fatigue, depression), or anthropometric outcomes (eg, body mass index, waist circumference) were eligible for inclusion. Meta‐analyses were performed to estimate hazard ratios for the highest compared with the lowest levels of sedentary behavior for all‐cause and colorectal cancer‐specific mortality outcomes. The ROBINS‐E (Risk of Bias in Nonrandomized Studies‐of Exposures tool) and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system were used to assess the risk of bias and the strength of evidence, respectively. Results: Thirty‐three eligible publications from a total of 3569 identified articles were included in the review. A higher level of postdiagnosis sedentary behavior was associated with an increased risk of all‐cause mortality (hazard ratio, 1.22; 95% CI, 1.06‐1.41; heterogeneity [I2 statistic], 33.8%) as well as colorectal cancer‐specific mortality (hazard ratio, 1.53; 95% CI, 1.14‐2.06; I2, 0%). No clear or consistent associations between sedentary behavior and patient‐reported or anthropometric outcomes were identified. The risk of bias in individual studies ranged from moderate to serious, and the strength of evidence ranged from very low to low. Conclusions: Although avoiding high levels of sedentary behavior after a cancer diagnosis may improve survival, further research is required to help clarify whether the association is causal. Refereed/Peer-reviewed

Background:The ACTIVATE Trial examined the efficacy of a wearable-based intervention to increase physical activity and reduce sedentary behavior in breast cancer survivors. This paper examines the effects of the intervention on health-related quality of life (HRQoL) and fatigue at 12 weeks (T2; end of intervention) and 24 weeks(T3; follow-up). Methods:Inactive and postmenopausal women who had completed primary treatment for stage I-III breast cancer were randomized to intervention or wait list control.Physical activity and sedentary behavior were measured by Actigraph and activPAL accelerometers at baseline (T1), end of the intervention (T2), and 12 weeks follow-up(T3). HRQoL and fatigue were measured using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue). Primary intervention effects were evaluated comparing intervention and wait list group at T2 using repeated measures mixed effects models. Results:Overall, 83 women were randomized and trial retention was high (94%). A4.6-point difference in fatigue score was observed between groups at T2 (95% CI:1.3, 7.8) indicating improvement in fatigue profiles in the intervention group. In within groups analyses, the intervention group reported a 5.1-point increase in fatigue from baseline to T2 (95% CI: 2.0, 8.2) and a 3.3-point increase from baseline to T3 (95%CI: 0.1, 6.41). Conclusions:Despite small improvements in fatigue profiles, no effects on HRQoL were observed. While the ACTIVATE Trial was associated with improvements in physical activity and sedentary behavior, more intensive or longer duration interventions may be needed to facilitate changes in HRQoL Refereed/Peer-reviewed

Since the 1990s, a range of new statistical approaches has been developed to improve causal inference in observational research. The last 2 decades has also seen the development of more sophisticated methods to quantitatively estimate the impact of measurement error, exposure misclassification, and selection bias on the results of observational studies. Physical activity epidemiology has not adopted these methodological advances as quickly as other disciplines.

How sedentary behaviour affects cancer risk is still largely unknown. This chapter summarizes the modest, but growing, body of evidence accrued to date. Based on the findings of 25 different studies that have examined 17 different cancer sites, all-cancer mortality, and site-specific mortality (colorectal and liver cancer), we conclude that sedentary behaviour is associated with increased risks of endometrial (36%) and ovarian cancers (32%). We cannot rule out an increased risk for breast, colorectal, and lung cancers, but there is a lack of consistency across findings. Sedentary behaviour increases risk for all-cancer mortality (13%) and colorectal cancer-specific mortality (38% for pre-diagnosis sitting time; 61% for post-diagnosis sitting time). The association between sedentary behaviour and cancer risk is biologically plausible. Postulated mechanisms underlying the association include: body composition (most evidence relates to adiposity), sex hormones, metabolic function, chronic inflammation, and immune function. Better mechanistic understanding will help strengthen causal inference from epidemiologic data. The adoption of contemporary epidemiologic methods and analytic techniques may also facilitate improved causal inference.

Purpose: The purpose of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) and sedentary time with psychological health outcomes including depression symptoms, anxiety symptoms, and overall satisfaction with life in colon cancer survivors. Methods: Colon cancer survivors (N = 180) from Alberta, Canada (n = 91), and Western Australia (n = 89) completed a mailed survey that assessed depression symptom severity, state anxiety, and satisfaction with life (SWL). Sedentary time and MVPA were assessed using the Actigraph ® GT3X+ accelerometer (60-s epochs) via a 7-day monitoring protocol. MVPA and sedentary time were corrected for wear time and then examined as quartiles (Q). Multivariate analysis of variance was used to examine associations of MVPA and sedentary time with psychological health. Results: There was a significant association between psychological health outcomes and objectively assessed MVPA [Wilks’ λ = 0.886, F(3382.2) = 2.156, p = 0.024] that suggested a small and significant association between MVPA and SWL (p = 0.032). A significant multivariate analysis of variance (MANOVA) [Wilks’ λ = 0.945, F(3159) = 3.1, p = 0.028] suggested participants meeting guidelines reported significantly fewer anxiety symptoms (M < inf > diff < /inf > = −1.23, p = 0.027) and higher perceptions of SWL (M < inf > diff < /inf > = 3.0, p = 0.008). No significant associations emerged for sedentary time [Wilks’ λ = 0.956, F(9382.3) = 0.788, p = 0.628]. Conclusions: Contrary to previously published research using self-reports, objectively assessed MVPA and sedentary time were not associated with depression symptoms. Objectively assessed MVPA was associated with SWL and anxiety outcomes in colon cancer survivors. Implications for Cancer Survivors: Colon cancer survivors should continue to engage in regular and sustained MVPA for the accrual of psychological health benefits. Refereed/Peer-reviewed

Objective: To assess differences in accelerometer-assessed moderate-to vigorous-intensity physical activity (MVPA), light-intensity physical activity, and sedentary time between cancer survivors and adults without cancer. Patients and Methods: Accelerometer data collected from 241 breast cancer survivors (ACCEL-Breast study, 2013) and 171 colon cancer survivors (ACCEL-Colon study, 2012-2013) were pooled with data collected from adults without cancer (Australian Diabetes, Obesity and Lifestyle accelerometer sub-study, 2011-2012). Linear regression was used to estimate differences in physical activity and sedentary behavior levels between cancer survivors and adults without cancer, adjusted for potential confounding factors. Results: The mean MVPA was significantly higher among breast cancer survivors than among females who had not had cancer (29 vs 22 min/d; P