Physical exercise for cancer patients with advanced disease: a randomized controlled trial

Variability in physical function for patients living with breast cancer during a 12-week exercise program

PURPOSE

To describe the variability during weekly performance on physical function tests during a 12-week individualized exercise program for patients with breast cancer and to test if the expected improvements in physical function surpass the minimally clinically important difference (MCID), after accounting for week-to-week variance.

METHODS

Twenty-five participants, 19 years and older living with breast cancer within 2 years of their initial diagnosis, were recruited. Some participants were undergoing active treatment, while others completed their treatment. The intervention was an individualized exercise session twice a week, for 1 h each session, for a total of 12 weeks. Main outcomes tested included the 6-min walk test and chair stand test.

RESULTS

A significant average improvement was observed in the 6MWT (p < .01) and the chair stand test (p < .001) following the intervention. Individual confidence intervals were wide across all testing measures with only 28% and 8% of participants meeting or surpassing the MCID for the 6MWT and chair stand test, respectively.

CONCLUSION

Despite a significant improvement in physical function during the program, the majority of patients did not reach the MCID, which could be due to large variability resulting from treatment-related side effects or measurement error.

Demographic, Symptom, and Lifestyle Factors Associated With Cancer-Related Fatigue in Men With Prostate Cancer

OBJECTIVES

To identify potential demographic, symptom, and lifestyle factors associated with cancer-related fatigue (CRF) in men with prostate cancer.

SAMPLE & SETTING

Data were retrieved from men with prostate cancer across the disease trajectory who were enrolled in the Genitourinary Cancer Collaborative Registry-Prostate Cancer.

METHODS & VARIABLES

Self-reported data on demographic characteristics, lifestyle habits (smoking history, alcohol consumption, physical activity/exercise, dietary habits, and vitamins/supplements), and symptom experiences (measured using the Brief Fatigue Inventory, European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Prostate Cancer and -Bone Metastasis, and Pittsburgh Sleep Quality Index) were included in the registry.

RESULTS

Demographic (younger age) and symptom (sleep quality, urinary, bowel, hormone-related, and sexual activity) correlates of CRF were identified. Higher levels of moderate to vigorous exercise and activities were associated with lower CRF in the sample as a whole. However, there was no association between CRF and physical activity in men with bone metastasis.

IMPLICATIONS FOR NURSING

CRF is a common and burdensome symptom among individuals with cancer and survivors. Identification of demographic, symptom, and lifestyle factors associated with CRF can enhance understanding of this symptom and contribute to early risk assessment and intervention.

Molecular and Neural Mechanism of Dysphagia Due to Cancer

Cancer is one of the most common causes of death worldwide. Along with the advances in diagnostic technology achieved through industry–academia partnerships, the survival rate of cancer patients has improved dramatically through treatments that include surgery, radiation therapy, and pharmacotherapy. This has increased the population of cancer “survivors” and made cancer survivorship an important part of life for patients. The senses of taste and smell during swallowing and cachexia play important roles in dysphagia associated with nutritional disorders in cancer patients. Cancerous lesions in the brain can cause dysphagia. Taste and smell disorders that contribute to swallowing can worsen or develop because of pharmacotherapy or radiation therapy; metabolic or central nervous system damage due to cachexia, sarcopenia, or inflammation can also cause dysphagia. As the causes of eating disorders in cancer patients are complex and involve multiple factors, cancer patients require a multifaceted and long-term approach by the medical care team.

Barriers and facilitators related to undertaking physical activities among men with prostate cancer: a scoping review

BACKGROUND

Prostate cancer (PC) and its treatments lead to significant acute, chronic, or latent adverse effects that result in declines in patients' physical functions, quality of life and reduced sense of masculinities. Robust evidence shows that physical activity (PA) can improve many health outcomes in men with PC; however, less is known about the facilitators, preferences, and barriers to PA engagement in this population. The purpose of this scoping review is to document the nature and extent of literature related to these aspects of PA participation among men with PC.

METHODS

We conducted a scoping review of PA among men with PC. Databases searched included Medline, CINAHL, Embase, Rehabilitation & Sports Medicine Source, and SportDiscus from inception to June 30, 2020. Multiple reviewers were used in all screening and data abstractions.

RESULTS

The search yielded 2788 individual citations after duplicates were removed. Following title and abstract screening, 129 underwent full-text review, and 46 articles were included. Quantitative data related to our research question showed that structured group exercise was the most commonly reported facilitator/preference among men with PC, whereas treatment-related effects and lack of time are the most common barriers. In terms of qualitative data, the most prominent theme noted related to masculinities and gender-specific needs within the context of having PC.

CONCLUSION

Men with PC have unique facilitators and barriers concerning PA. More work is needed from the research and clinical practice perspectives to enable this population to engage and remain in regular PA.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments

BACKGROUND

Fatigue is a common complaint reported by patients with advanced disease, impacting their daily activities and quality of life. The pathophysiology is incompletely understood, and evidence-based treatment approaches are needed.

AIM

This systematic review aims to evaluate the efficacy of non-pharmacological interventions as treatment for fatigue in advanced disease.

DESIGN

The review design follows the Cochrane guidelines for systematic reviews of interventions.

DATA SOURCES

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, ClinicalTrials.gov and a selection of journals up to February 28th 2019, for randomised controlled trials (RCTs) investigating the effect of non-pharmacological treatments for fatigue in advanced disease associated with palliative care. Further potentially relevant studies were identified from the reference lists in relevant reviews, and in studies considered for this review.

RESULTS

We screened 579 publications; 15 met the inclusion criteria, with data from 1179 participants: 815 were treated with physical exercise, 309 with psycho-educational therapy and 55 with an energy restoration approach. Sources of potential bias included lack of description of blinding and allocation concealment methods, and small study sizes. Physical exercise as treatment for fatigue in patients with advanced cancer was supported by moderate-quality evidence.

CONCLUSION

Physical exercise should be considered as a measure to reduce fatigue in patients with advanced cancer, but data on other advanced diseases is lacking. Due to the differences between studies, no clear recommendations can be made with respect to the best type of physical therapy. Restoration exercise and psycho-educational therapy are promising treatment options, although further research is needed.

Exercise for cancer cachexia in adults

BACKGROUND

Cancer cachexia is a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass, with or without a loss of fat mass, leading to progressive functional impairment. Physical exercise may attenuate cancer cachexia and its impact on patient function. This is the first update of an original Cochrane Review published in Issue 11, 2014, which found no studies to include.

OBJECTIVES

To determine the effectiveness, acceptability and safety of exercise, compared with usual care, no treatment or active control, for cancer cachexia in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to March 2020. We searched for ongoing studies in trial registries, checked reference lists and contacted experts to seek relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials in adults with cancer cachexia, that compared a programme of exercise alone or in combination with another intervention, with usual care, no treatment or an active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for relevance and extracted data on study design, participants, interventions and outcomes from potentially relevant articles. We used standard methodological procedures expected by Cochrane. Our primary outcome was lean body mass and secondary outcomes were adherence to exercise programme, adverse events, muscle strength and endurance, exercise capacity, fatigue and health-related quality of life. We assessed the certainty of evidence using GRADE and included two Summary of findings tables.

MAIN RESULTS

We included four new studies in this update which overall randomised 178 adults with a mean age of 58 (standard deviation (SD) 8.2) years. Study sample size ranged from 20 to 60 participants and in three studies the proportion of men ranged from 52% to 82% (the fourth study was only available in abstract form). Three studies were from Europe: one in the UK and Norway; one in Belgium and one in Germany. The remaining study was in Canada. The types of primary cancer were head and neck (two studies), lung and pancreas (one study), and mixed (one study). We found two comparisons: exercise alone (strength-based exercise) compared to usual care (one study; 20 participants); and exercise (strength-based exercise/endurance exercise) as a component of a multimodal intervention (pharmacological, nutritional or educational (or a combination) interventions) compared with usual care (three studies, 158 participants). Studies had unclear and high risk of bias for most domains. Exercise plus usual care compared with usual care We found one study (20 participants). There was no clear evidence of a difference for lean body mass (8 weeks: MD 6.40 kg, 95% CI -2.30 to 15.10; very low-certainty evidence). For our secondary outcomes, all participants adhered to the exercise programme and no participant reported any adverse event during the study. There were no data for muscle strength and endurance, or maximal and submaximal exercise capacity. There was no clear evidence of a difference for either fatigue (4 to 20 scale, lower score was better) (8 weeks: MD -0.10, 95% CI -4.00 to 3.80; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score was better) (8 weeks: MD 4.90, 95% CI -15.10 to 24.90; very low-certainty evidence). Multimodal intervention (exercise plus other interventions) plus usual care compared with usual care We found three studies but outcome data were only available for two studies. There was no clear evidence of a difference for lean body mass (6 weeks: MD 7.89 kg, 95% CI -9.57 to 25.35; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -2.00, 95% CI -8.00 to 4.00; one study, 60 participants; very low-certainty evidence). For our secondary outcomes, there were no data reported on adherence to the exercise programme, endurance, or maximal exercise capacity. In one study (44 participants) there was no clear evidence of a difference for adverse events (patient episode report) (6 weeks: risk ratio (RR) 1.18, 95% CI 0.67 to 2.07; very low-certainty evidence). Another study assessed adverse events but reported no data and the third study did not assess this outcome. There was no clear evidence of a difference in muscle strength (6 weeks: MD 3.80 kg, 95% CI -2.87 to 10.47; 1 study, 44 participants; very low-certainty evidence; 12 weeks MD -5.00 kg, 95% CI -14.00 to 4.00; 1 study, 60 participants; very low-certainty evidence), submaximal exercise capacity (6 weeks: MD -16.10 m walked, 95% CI -76.53 to 44.33; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -62.60 m walked, 95% CI -145.87 to 20.67; 1 study, 60 participants; very low-certainty evidence), fatigue (0 to 10 scale, lower score better) (6 weeks: MD 0.12, 95% CI -1.00 to 1.24; 1 study, 44 participants; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score better) (12 weeks: MD -2.20, 95% CI -13.99 to 9.59; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The previous review identified no studies. For this update, our conclusions have changed with the inclusion of four studies. However, we are uncertain of the effectiveness, acceptability and safety of exercise for adults with cancer cachexia. Further high-quality randomised controlled trials are still required to test exercise alone or as part of a multimodal intervention to improve people's well-being throughout all phases of cancer care. We assessed the certainty of the body of evidence as very low, downgraded due to serious study limitations, imprecision and indirectness. We have very little confidence in the results and the true effect is likely to be substantially different from these. The findings of at least three more studies (one awaiting classification and two ongoing) are expected in the next review update.

ESPEN practical guideline: Clinical Nutrition in cancer

BACKGROUND

This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients.

METHODS

ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer.

RESULTS

A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care.

The effects of physical activity on overall survival among advanced cancer patients: a systematic review and meta-analysis

Background

The survival rates of advanced cancer patients remain low despite clinical therapy advancements. However, physical activity showed promising effects in improving cancer outcomes. This review aimed to systematically evaluate and synthesize the effects on overall mortality of post-diagnosis physical activity in advanced cancer patients.

Methods

A systematic search of six English databases (PubMed, EMBASE, CINAHL, PsycINFO, The Cochrane Central Register of Controlled Trials, and SPORTDiscus) was conducted from their inception up to 3 February 2021. The association of physical activity with survival was evaluated by combining study-specific hazard ratios with random-effects meta-analysis models.

Results

Eleven studies were identified. Compared with the reference group, higher-level physical activity was not significantly associated with a lower risk of earlier mortality in advanced cancer patients (InHR = − 0.18, 95% CI, − 0.36 to 0.01). When separated by study type, a higher level of physical activity in non-randomised trials was significantly associated with reduced mortality risk (InHR = − 0.25, 95% CI: − 0.44, − 0.06). However, in randomised trials, engaging in exercise was not significantly associated with a lower mortality risk compared with the control group (InHR = 0.08, 95%CI: − 0.17, 0.32).

Conclusions

Discrepancies were uncovered in the effect of physical activity on overall survival in randomised and non-randomised trials. In non-randomised trials, a higher level of physical activity was significantly associated with a lower risk of mortality, whereas no significant effect on survival was observed during exercise interventions compared to the control in randomised trials. Considering the wider benefits of physical activity, exercise can still be recommended to improve outcomes for advanced cancer patients. Nevertheless, it might be too late for advanced cancer patients to start exercising for survival improvements, based on findings from randomised controlled trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07988-1.

Psychoeducational and rehabilitative intervention to manage cancer cachexia (PRICC) for patients and their caregivers: protocol for a single-arm feasibility trial

INTRODUCTION

Half of all patients with cancer experience cachexia, with the prevalence rising above 80% in the last weeks of life. Cancer cachexia (CC) is a complex relational experience that involves the patient-family dyad. There are no studies on the association between the psychoeducational component and the rehabilitative component of dyads for supporting more functional relationships in the management of CC.The primary objective of this study is to evaluate the feasibility of a psychoeducational intervention combined with a rehabilitative intervention on dyads.The secondary objective is to improve the quality of life (QoL) and acceptability of the intervention.

METHODS AND ANALYSIS

This mixed-methods study with a nonpharmacological interventional prospective includes 30 consecutive cancer patients with cachexia and refractory cachexia and their caregivers, assisted by the Specialised Palliative Care Team. The recruitment will last 1 year. The intervention involves two components: (1) psychoeducational intervention: 3 weekly face-to-face consultations between dyads and trained nurses to help the dyads cope with involuntary weight loss and strengthening dyadic coping resources and (2) rehabilitation intervention: 3 biweekly educational sessions between dyads and trained physiotherapists focused on self-management, goal-setting, physical activity with three home exercise sessions per week.The primary endpoint will be in adherence to the intervention, indicated by a level of completion greater than or equal to 50% in both components. The secondary endpoints will be QoL (Functional Assessment of Anorexia-Cachexia Therapy), caregiver burden (Zarit Burden), physical performance (Hand-Grip strength and 30 seconds sit-to-stand test), and the acceptability of the intervention (ad hoc semi-structured interviews with the dyads and the healthcare professionals).

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee Area Vasta Emilia Nord, Azienda USL-IRCSS Reggio Emilia, Italy, number: 73/2019/SPER/IRCCSRE. The authors will provide the dissemination of the results through publication in international scientific journals.

TRIAL REGISTRATION NUMBER

NCT04153019.

The effects of physical activity, fast-mimicking diet and psychological interventions on cancer survival: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Health professionals are often asked if non-pharmacological interventions prolong life. This review aims to evaluate the effects of physical activity, fast-mimicking diet (FMD) and psychological interventions on survival in all cancers.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs). Only RCTs of physical activity, FMD and psychological interventions (including counselling, cognitive and other psychotherapies) in cancer patients that reported survival outcomes were included.

DATA SOURCES

CENTRAL, MEDLINE, Embase, CINAHL, APA PsycINFO, Web of Science, ICTRP and ClinicalTrials.gov from inception to January 2020 were searched without language restrictions. The protocol was prospectively registered at PROSPERO (CRD42019160944).

RESULTS

Thirty-one RCTs (9 on physical activity and 22 on psychological interventions) were included in the final analysis after evaluation of 60,207 records from our initial search. No eligible RCT on FMD was reported. RCTs on group psychological interventions (41.9 %) and in patients with breast cancer (38.7 %) were the most common. Most evaluated short-term interventions and in primary or adjuvant settings. Only one of 9 (11 %) RCTs on physical activity and 8 of 22 (36 %) RCTs on psychological interventions were associated with improved overall survival. Only group psychological interventions in breast cancer had adequate number of RCTs to allow a meta-analysis to be performed. It demonstrated a trend towards improved overall survival (HR -0.20, 95 %CI -0.49 to 0.10), particularly in RCTs that evaluated long-term (>6 months) therapies (HR -0.29, 95 %CI -0.59 to 0.01).

CONCLUSION

Longer term interventions starting early in the patients' care journey in primary and adjuvant settings have shown the most promise for improving survival. Better designed RCTs including survival outcomes are particularly needed in non-breast cancers.

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Effects of In-Hospital Exercise on Frailty in Patients with Hepatocellular Carcinoma

Frailty including physical inactivity is associated with the survival of patients with hepatocellular carcinoma (HCC). We aimed to investigate the effects of in-hospital exercise on frailty in patients with HCC. This was a multi-center observational study. Patients with HCC were classified into exercise (n = 114) and non-exercise (n = 67) groups. The exercise group was treated with a mixture of aerobic and resistance exercises (20-40 min/day, median four days). Frailty was assessed using the liver frailty index (LFI). Factors for changes in LFI were examined by multivariate and decision-tree analyses. The factors were also examined after propensity score matching. During hospitalization, LFI was significantly improved in the exercise group compared to the non-exercise group (ΔLFI -0.17 vs. -0.02, p = 0.0119). In multivariate analysis, exercise (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.240-4.570, p = 0.0091) and females (OR 2.09; 95%CI, 1.062-4.109; p = 0.0328) were identified as independent factors for the improvement of LFI. In the decision-tree analysis, exercise was identified as an initial classifier associated with the improvement of LFI. Similar findings were also seen in the propensity score matching analyses. We demonstrated that in-hospital exercise improved frailty in patients with HCC. Thus, in-hospital exercise may be beneficial for improving physical function in patients with HCC.

The pre-efficacy phase testing for PAfitME™-A behavioral physical activity intervention to manage moderate and severe symptoms among advanced stage cancer patients

Fatigue and pain are the most frequently reported symptoms among advanced-stage cancer patients. Although physical activity (PA) is known to improve the aforementioned symptoms, few patients demonstrate the physically active behavior that adheres to the clinical guidelines regarding PA. The current article presents an exemplar that used the National Institute of Health's Obesity-Related Behavioral Intervention Trial (ORBIT) model and developed a behavioral intervention known as the personalized Physical Activity intervention with fitness graded Motion Exergames (PAfitME™). There were two phases of testing in the ORBIT model presented in the current paper. In Phase I testing, a standardized exergame prescription was evaluated by an advisory board and a single-case study was used to evaluate the personalized exergame prescription with personalization of the fitness levels. In Phase IIa, a within-group pre- and posttest design was used to evaluate the personalized exergame prescriptions with personalization of the fitness levels, self-efficacy, and variation in fatigue/pain. Subsequently, a complete intervention package was developed in accordance with a logic model, driven from the result of the Phase IIa testing with clinically significant findings. Currently, PAfitME™ is under Phase IIb testing in a randomized clinical trial with a control group. PAfitME™ employs a personalized approach to initiate and promote physically active behavior, to facilitate the management of fatigue and pain in cancer patients. Positive results from an efficacy trial would support the use of PAfitME™ in the management of fatigue and pain in advanced-stage cancer patients.

Physical activity in the context of advanced breast cancer: An integrative review

AIMS

To describe and synthesize diverse empirical evidence regarding physical activity (PA) in the context of advanced breast cancer (ABC).

DESIGN

Integrative review guided by the work of Whittemore and Knafl (2005).

DATA SOURCES

Six electronic databases were systematically searched to identify relevant literature published between January 2007-June 2019.

REVIEW METHODS

Abstracts of papers that met the inclusion criteria were reviewed by two researchers and full texts of eligible papers were assessed. Data were extracted by two independent researchers and inter-rater reliability of data extraction established. Quality of papers was evaluated using the Mixed Methods Appraisal Tool. Data were organized according to comprehensive thematic analysis and the biobehavioural model for the study of exercise interventions.

RESULTS

Of the 532 abstracts, 18 studies met the inclusion criteria which included six randomized controlled trials, one quantitative non-randomized study, seven quantitative descriptive studies, three mixed method studies and one qualitative study. Results from studies enrolled fell into four domains: PA performance and its influence on survival; barriers and preferences for PA; interventions to enhance PA; perceived benefits of PA from qualitative feedback.

CONCLUSION

Evidence suggests that ABC patients are physically inactive. Main barriers of PA are less aerobic fitness and heavy symptom burden. Simple, tailored and specialist-supervised PA is preferred by ABC patients. Form of joint self-instructed and group accompanying is advocated as well. PA intervention programmes identified in this review vary on type, intensity, duration and frequency, while generally, are found to be feasible, safe and beneficial to patients' physical and psychosocial well-being.

IMPACT

The results propose tailored, supervised, group-based PA programmes are in urgent need for ABC patients. Clinical professionals should manage more feasible and safer PA interventions to help improve patients' overall health. More research with rigorous methodology design is warranted to explore PA's effect on long-term health outcomes.

Cancer cachexia and skeletal muscle atrophy in clinical studies: what do we really know?

Research investigators have shown a growing interest in investigating alterations underlying skeletal muscle wasting in patients with cancer. However, skeletal muscle dysfunctions associated with cancer cachexia have mainly been studied in preclinical models. In the present review, we summarize the results of clinical studies in which skeletal muscle biopsies were collected from cachectic vs. non-cachectic cancer patients. Most of these studies suggest the presence of significant physiological alterations in skeletal muscle from cachectic cancer patients. We suggest a hypothesis, which connects structural and metabolic parameters that may, at least in part, be responsible for the skeletal muscle atrophy characteristic of cancer cachexia. Finally, we discuss the importance of a better standardization of the diagnostic criteria for cancer cachexia, as well as the requirement for additional clinical studies to improve the robustness of these conclusions.

Feasibility and preliminary efficacy of a hypopressive exercise program on postmenopausal cancer survivors: A pilot study

BACKGROUND

Cancer-related fatigue (CRF) is a common symptom during and after cancer treatment that negatively affects the patient's quality of life. Exercise is one of the most effective non-pharmacological treatments for CRF. Multimodal exercise therapy programs that include hypopressive exercises, relaxation and myofascial release may be beneficial for CRF. The aim of this pilot study was to evaluate the feasibility and efficacy of a multimodal program on CRF and lower limb functional strength in postmenopausal women diagnosed with cancer.

METHODS

7 postmenopausal women (age = 55.28 years; BMI = 26.05 kg/m2) who had a cancer diagnosis participated in a supervised and progressive 55-min class once per week for 12-weeks. CRF was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cancer Related Fatigue 12 and lower limb strength was assessed with the sit and stand test.

RESULTS

No adverse events were reported during the training period and all participants completed the exercise protocol. There was a significant increase (p = 0.01) in lower limb functional strength (pre: 19.60 (SD = 2.19) vs post: 24.60(SD = 2.19)) with an effect size of d = 2.28 and a decrease in CRF (p = 0.245) (pre: 29.36 ± 24.42; post: 17.85 ± 14.23) with a trivial effect size (d < 0.5).

CONCLUSIONS

These preliminary findings indicate that a supervised once per week multimodal program that includes hypopressive exercises for postmenopausal cancer survivors increased lower limb functional strength without exacerbating their CRF. These findings support further randomized trials of hypopressive training programs on patients with cancer.

The efficacy of specialised rehabilitation using the Op-reha Guide for cancer patients in palliative care units: protocol of a multicentre, randomised controlled trial (JORTC-RHB02)

BACKGROUND

Although rehabilitation is recommended for terminal cancer patients, the specific components and methods of such programs are poorly documented. No studies to date have examined the effectiveness of rehabilitation for terminal cancer patients. This study aims to evaluate the efficacy of a new intervention for rehabilitation therapists, using the Op-reha Guide (Guide to Optimal and Patient-Centred Rehabilitation Practice for Patients in Palliative Care Units [PCUs]) in rehabilitation practice. This guide consists of recommended actions and attitudes for rehabilitation therapists and aims to optimise therapists' actions according to the patient's needs and condition. It shares goals with terminal cancer patients to maintain their activities of daily living (ADL).

METHODS

This study uses a multicentre, prospective, randomised controlled trial (RCT) design with two parallel groups in PCUs where specialised rehabilitation will be routinely performed for terminal cancer patients by rehabilitation therapists. Participants will be randomised (1:1) to intervention (the Op-reha Guide) and control groups (usual rehabilitation). We will then conduct an observational study in PCUs that do not perform specialised rehabilitation for terminal cancer patients; this will be considered the usual care group, and the efficacy of usual rehabilitation will be quantitatively evaluated. Inclusion criteria are hospitalisation in PCU, European Cooperative Oncology Group Performance Status of 2 or 3, and clinical estimation of life expectancy of 3 weeks or more. Patients with severe symptom burden will be excluded. We hypothesise that the Op-reha Guide will be more effective in maintaining the ADL of terminal cancer patients hospitalised in PCUs than usual rehabilitation. The primary endpoint is defined as the change in (total) modified Barthel Index from baseline to Day 22. Quality of life will be a secondary endpoint. In total, 135 patients will be recruited from 16 Japanese sites between July 2019 and December 2021.

DISCUSSION

This will be the first trial to evaluate the efficacy of specialised rehabilitation for terminal cancer patients hospitalised in PCUs, and will contribute to the evidence on the efficacy of implementing rehabilitation for terminal cancer patients.

TRIAL REGISTRATION

UMIN-CTR, UMIN000037298 R000042525 (date of registration 7 July 2019).

Exercise in older women with breast cancer during systemic therapy: study protocol of a randomised controlled trial (BREACE)

INTRODUCTION

Exercise interventions have been widely investigated in patients with cancer and demonstrate beneficial effects. However, intervention studies that include older women with breast cancer exercising during medical treatment are scarce. Hence, the aim of this study is to investigate the effect of a 12-week exercise-based intervention in older women (≥65 years) with breast cancer receiving (neo)adjuvant or first-line or second-line systemic therapy.

METHODS AND ANALYSIS

This is a single-centre, two-armed randomised controlled trial. We anticipate including 100 patients, who will be randomised 1:1 to exercise-based intervention or control stratified by treatment setting ((neo)adjuvant or metastatic) and treatment (chemotherapy or endocrine therapy + cyclin-dependent kinase (CDK) 4/6 inhibitors). The intervention group will receive standard oncological treatment and a 12-week supervised exercise-based intervention comprising a progressive resistance exercise programme two times per week, a protein supplement after exercise and a home-based walking programme based on daily step counts. The control group will receive standard oncological treatment. Assessments will be performed at baseline and 6, 12 and 24 weeks after start of the intervention. Primary outcome is physical function, measured by the 30-second Chair Stand Test. Secondary outcomes are feasibility (compliance and adherence to intervention), objective and patient-reported functional measures (6-meter and 10-meter gait speed; 6-min Walk Test; Handgrip Strength; Stair Climb Test; Physical Activity Questionnaire), symptom burden and well-being (MD Anderson Symptom Inventory; Hospital Anxiety and Depression Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and B23), body composition (dual-energy X-ray absorptiometry scan), side effects, inflammatory biomarkers, hospitalisation and survival.

ETHICS AND DISSEMINATION

The protocol was reviewed and accepted by the Scientific Ethics Review Committee of the Capital Region of Denmark, 17 June 2018 (VEK ref.: H-18021013). Trial results will be submitted for publication in a peer-reviewed journal and presented on conferences, in oncology wards, exercise centres in municipalities and patient organisations, ensuring dissemination to relevant stakeholders.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ on 3 September 2018. Identifier: NCT03656731.

Postoperative muscle mass restoration as a prognostic factor in patients with resected pancreatic cancer

Background

Recent studies have found that muscle depletion may be a prognostic predictor in patients with pancreatic cancer (PC). However, in these studies, limited data were used to assess the relationship between the serial change in body composition and outcomes after PC resection. Hence, we evaluated the changes in body composition during the perioperative period in patients with PC and their association with the overall survival (OS).

Methods

A total of 89 patients with PC who received surgery with curative intent between 2006 and 2015 were included in this study retrospectively. These patients underwent serial computed tomography (CT) scans: preoperatively, immediately after surgery (4 weeks), and 12 and 24 weeks after resection. The muscle and visceral fat areas were measured at the third lumbar vertebra level on cross-sectional CT images using sliceOmatic V5.0 program (TomoVision, Canada). The body composition ratio was determined by dividing the post-resection body composition at each point (4, 12, and 24 weeks) by the pre-resection body composition. Patients were divided into two groups—higher and lower groups—based on this body composition ratio (skeletal muscle mass ratio [SMR], visceral fat mass ratio [VFR]). The OS was compared between the two groups using the log-rank test.

Results

The median age of patients was 63 (27–84) years, and the baseline body mass index was 23.0 (17.0–35.8) kg/m². In the comparison of the SMR, there was no significant difference in the OS between the two groups at 4 and 12 weeks (4 weeks, P = 0.488; 12 weeks, P = 0.397). However, the higher group showed a longer OS than the lower group at 24 weeks (39 vs. 20 months, P = 0.008). Similarly, in the VFR, there was no significant difference in the OS between the two groups at 4 and 12 weeks (4 weeks, P = 0.732; 12 weeks, P = 0.060). However, the OS was longer in the higher group at 24 weeks (35 vs. 22 months, P = 0.023). When we analyzed the effect of muscle restoration at 24 weeks after resection on the OS by gender, there was no significant difference between the OS and SMR in the male group (P = 0.213), but a significant difference was noted in the female group (P = 0.002). In the multivariate Cox regression analysis, the SMR at 24 weeks after resection was significantly associated with the OS (P = 0.023) but not VFR at 24 weeks. In 69 patients without recurrence at 6 months, the SMR at 24 weeks was related to longer OS but without statistical significance (P = 0.07).

Conclusions

This study suggests that the restoration of muscle mass at 24 weeks after resection may be an independent prognostic factor for survival in patients with resected PC.

Patient-centred, self-administered acupressure for Chinese advanced cancer patients experiencing fatigue and co-occurring symptoms: A pilot randomised controlled trial

OBJECTIVES

To evaluate the feasibility and potential effects of patient-centred self-administered acupressure for alleviating fatigue and co-occurring symptoms among Chinese advanced cancer patients receiving treatment.

METHODS

Thirty advanced cancer patients who screened positive for moderate/severe fatigue with symptoms of insomnia and/or pain were recruited from a hospital in Hong Kong. They were randomly assigned (1:1) to receive a 4-week patient-centred self-administered acupressure intervention or health education. Fatigue (primary outcome) and secondary outcomes (sleep quality, pain, fatigue-sleep disturbance-pain symptom cluster severity, anxiety, depression and quality of life) were measured by questionnaires and actigraphy.

RESULTS

Twenty-four participants (80%) completed the study. Adherence to self-administered acupressure practice was satisfactory, with all retained participants attending all sessions and 90.9% practising acupressure daily. All completers rated the class as very enjoyable or quite enjoyable. Fatigue, pain, symptom cluster severity, anxiety, depression and quality of life appeared to improve from baseline to post-intervention in the intervention group. Among these outcomes, only the between-group difference in anxiety post-intervention was significant. The group × time interaction effect was nonsignificant for all outcomes.

CONCLUSIONS

Patient-centred self-administered acupressure appears to be feasible and acceptable among advanced cancer patients. A fully powered trial is warranted to confirm the intervention effect.

Resistance training in advanced cancer: a phase II safety and feasibility trial—home versus hospital

Background

Resistance training (RT) is an effective way to increase muscle mass but little is known about its role to prevent sarcopenia in advanced cancer. Furthermore, the preferred setting for this training is not known. Considering home is frequently the place of care and death preferred by cancer patients, it is important to find out whether this would also be the best training setting as opposed to the most common one, hospital.

Objectives

We aimed to test if RT at home and in hospital is feasible (primary outcome) and safe in advanced cancer, with a view to inform a phase III trial.

Methods

Phase II randomised controlled trial including adults (≥18 years) with incurable solid tumours, randomised into one of three arms: (1) supervised RT at home; (2) supervised RT in hospital; (3) standard care with information leaflet. Both training programmes were similar, ran one-to-one with therapists and planned to last 12 weeks (three sessions/week). Feasibility included adherence (proportion of completed sessions) and acceptability (proportion of completed exercises), compared using Fisher’s test.

Results

We included 15 patients (53% men, median age 68), 5 per arm. The home intervention had higher adherence (49% vs 9% in hospital; p<0.001). Acceptability was similar (93% in home and 95% in hospital; p=0.179). No adverse events were recorded.

Conclusions

RT is a safe intervention, more feasible at home than in hospital in advanced cancer. Ways to increase adherence to the home intervention could further improve its potential benefit.

Trial registration number

NCT02930876.

Supervised Physical Rehabilitation in the Treatment of Patients with Advanced Cancer: a Systematic Review and Meta-analysis

BACKGROUND

As the survival rate of cancer patients increases, the clinical importance of rehabilitation provided by healthcare professionals also increases. However, the evidence supporting the relevance of rehabilitation programs is insufficient. This study aimed to review the literature on effectiveness in physical function, quality of life (QOL) or fatigue of supervised physical rehabilitation in patients with advanced cancer.

METHODS

A systematic review and meta-analysis was conducted following the Cochrane guidelines. We narratively described the results when meta-analysis was not applicable or appropriate. Literature databases including Ovid-MEDLINE, Ovid-EMBASE, and the Cochrane Library, as well as several Korean domestic databases, were searched up to June 2017 for studies that investigated the effectiveness of supervised physical rehabilitation programs on physical function, QOL or fatigue in patients with advanced cancer. The quality of the selected studies was evaluated independently by paired reviewers.

RESULTS

Eleven studies with 922 participants were finally selected among 2,459 articles. The meta-analysis revealed that after physical exercise, the physical activity level and strength of patients with advanced cancer increased significantly. The QOL showed a statistically significant improvement after physical rehabilitation according to the European Organization for Research and Treatment of Cancer version C30. Though some of measurements about cardiovascular endurance or strength in several studies were not able to be synthesized, each study reported that they were significantly improved after receiving rehabilitation.

CONCLUSION

Supervised physical rehabilitation for patients with advanced cancer is effective in improving physical activity, strength, and QOL. However, more trials are needed to prove the effectiveness of supervised exercise and to strengthen the evidence.

Resistance Training Impact on Mobility, Muscle Strength and Lean Mass in Pancreatic Cancer Cachexia: A Randomized Controlled Trial

Objective:

To determine the efficacy of a three-month resistance training programme on the mobility, muscle strength and lean body mass of patients with pancreatic cancer-induced cachexia.

Design:

Randomized controlled trial.

Setting:

Elsahel Teaching Hospital, outpatient clinic of the Faculty of Physical Therapy, Cairo, Egypt.

Participants:

Patients with pancreatic cancer-induced cachexia.

Interventions:

Participants were randomized to the resistance training group ( n = 20) and control group ( n = 20).

Main measures:

Outcomes including mobility, muscle strength and lean body mass were measured at baseline, three months after surgical resection and 12 weeks after intervention.

Results:

The mean (SD) age was 51.9 (5.03) years and body mass index was 21.1 (1.13) kg/m²; 65% of patients were male. Compared to the control group, the resistance training group showed significant improvement in mobility: 400-m walk performance (270.3–256.9 seconds vs 266.4–264.2 seconds, respectively) and chair rise (13.82–12.53 seconds vs 13.77–13.46 seconds, respectively). Similarly, muscle strength was also significantly improved in the resistance training group than in the control group; we observed increase in peak torque of knee extensors ( P = 0.004), elbow flexors ( P = 0.001) and elbow extensors, improvement in lean mass of the upper limb (6.28–6.46 kg vs 6.31–6.23 kg, respectively) and lower limb (16.31–16.58 kg vs 16.4–16.31 kg, respectively).

Conclusion:

A three-month resistance training improved the mobility of patients with pancreatic cancer-induced cachexia. Muscle strength and lean body mass also improved.

Analysis of the StoRM cohort reveals physical activity to be associated with survival in metastatic breast cancer

Benefits of physical activity are widely demonstrated for early stage cancers but few studies have focused on metastatic disease. The purpose of this study was to determine the impact of physical activity on survival in patients with metastatic breast cancer. We conducted a secondary analysis of the national, multicentric, non-randomized, prospective cohort SNPs to Risk of Metastasis (StoRM) study. The level of physical activity was self-reported at inclusion and divided into three categories of physical activity: light level, moderate level, and vigorous level. Overall, 833 patients (56.2%) completed the physical activity questionnaire at baseline on average physical activity during the previous year: 11.6% had a light level of physical activity, 69.0% achieved moderate levels of physical activity and 19.3% reported vigorous levels of physical activity. After adjustment for confounding, physical activity was not statistically significantly associated with overall survival in the whole population. Subgroup analysis identified that both vigorous and moderate physical activity were associated with statistically significantly improved overall survival compared to light physical activity level only in the HER2 positive subgroup (HR 0.23; 95% CI 0.07-0.70, p = 0.01 and HR 0.38; 95% CI 0.15-0.96, p = 0.04). Physical activity done during the previous year was associated with survival in HER2 positive metastatic breast cancer patients. These results suggest that overall survival in metastatic breast cancer patients could be improved through physical activity which should be considered as a complementary intervention for these individuals. The study showed that moderate/vigorous levels of physical activity were associated with better overall survival, and that these associations remained statistically significant in multivariate analysis in the HER2 positive subgroup. These results have clinical relevance and justify the recommendations for physical activity interventions in metastatic breast cancer.

Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.

Effects of a Multicomponent Exercise Program in Older Adults with Non-Small-Cell Lung Cancer during Adjuvant/Palliative Treatment: An Intervention Study

Clinical intervention studies support the efficacy and safety of exercise programs as a treatment modality for non-small-cell lung cancer (NSCLC) during adjuvant/palliative treatment, but the effectiveness of real-world oncogeriatric services is yet to be established. We aimed to examine the effects of a 10-week structured and individualized multicomponent exercise program on physical/cognitive functioning and mental wellness in elderly patients with NSCLC under adjuvant therapy or palliative treatment. A non-randomized, opportunistic control, longitudinal-design trial was conducted on 26 patients with NSCLC stage I-IV. Of 34 eligible participants, 21 were allocated into two groups: (i) control group (n = 7) received usual medical care; and (ii) intervention group (n =19) received multicomponent program sessions, including endurance, strength, balance, coordination and stretching exercises. Tests included the Short Physical Performance Battery (SPPB), 5-m habitual Gait Velocity Test (GVT), Timed Up & Go Test (TUG), 6-Min Walk Test (6MWT), independence of activities in daily living (IADL), muscular performance, cognitive function, and quality of life, which were measured at baseline and after 10 weeks of the program. Results revealed a significant group×time interaction for SPPB (p = 0.004), 5-m GVT (p = 0.036), TUG (p = 0.007), and muscular performance (chest and leg power; p < 0.001). Similarly, significant changes were observed between groups for cognitive functioning (p = 0.021) and quality of life for EUROQoL 5D (p = 0.006). Our findings confirm that a multicomponent exercise program improves measures of physical/cognitive functioning and quality of life in the elderly with NSCLC under adjuvant therapy or palliative treatment. This is an interesting and important study that adds to our current body of knowledge on the safety of exercise interventions, especially in the elderly with solid tumors.

Exercise Training for Improving Patient-Reported Outcomes in Patients With Advanced-Stage Cancer: A Systematic Review and Meta-Analysis

CONTEXT

Patients with advanced-stage cancer often suffer many physical and psychological symptoms. Exercise has been shown to improve quality of life (QoL), decrease cancer-related symptoms, and maintain or improve functional status in cancer survivors or patients with early stage cancer. However, the effect of exercise on these outcomes in patients with advanced-stage cancer is unclear.

OBJECTIVES

This meta-analysis aimed to assess the effectiveness of exercise interventions for patients with advanced-stage cancer in improving cancer-related symptoms and functional status outcomes.

METHODS

We conducted a comprehensive literature search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science from their inception to February 3, 2019, to include randomized controlled trials (RCTs) comparing exercise and usual care for improving outcomes in patients with advanced-stage cancer. Two reviewers independently screened the studies, extracted data of interest, and assessed the risk of bias of individual RCTs using the Cochrane Handbook, Version 5.1.0.

RESULTS

About 15 RCTs enrolling 1208 patients were included. Compared with usual care, exercise showed a significant improvement in QoL (standardized mean difference [SMD] 0.22; 95% CI 0.06-0.38; P = 0.009), fatigue (SMD -0.25; 95% CI -0.45 to -0.04; P = 0.02), insomnia (SMD -0.36; 95% CI -0.56 to -0.17; P = 0.0002), physical function (SMD 0.22; 95% CI 0.05-0.38; P = 0.009), social function (SMD 0.18; 95% CI 0.02-0.34; P = 0.03), and dyspnea reduction (SMD -0.18; 95% CI -0.34 to -0.01; P = 0.03).

CONCLUSION

Exercise serves as an effective intervention to improve QoL and alleviate fatigue, insomnia, dyspnea, and physical and social functions for patients with advanced-stage cancer.

Effect of Collaborative Telerehabilitation on Functional Impairment and Pain Among Patients With Advanced-Stage Cancer: A Randomized Clinical Trial

Importance

Most patients with advanced-stage cancer develop impairment and pain-driven functional losses that jeopardize their independence.

Objective

To determine whether collaborative telerehabilitation and pharmacological pain management improve function, lessen pain, and reduce requirements for inpatient care.

Design, Setting, and Patients

The Collaborative Care to Preserve Performance in Cancer (COPE) study was a 3-arm randomized clinical trial conducted at 3 academic medical centers within 1 health care system. Patient recruitment began in March 2013 and follow-up concluded in October 2016. Participants (N = 516) were low-level community or household ambulators with stage IIIC or IV solid or hematologic cancer.

Interventions

Participants were randomly assigned to the (1) control arm, (2) telerehabilitation arm, or (3) telerehabilitation with pharmacological pain management arm. All patients underwent automated function and pain monitoring with data reporting to their care teams. Participants in arms 2 and 3 received 6 months of centralized telerehabilitation provided by a physical therapist-physician team. Those in arm 3 also received nurse-coordinated pharmacological pain management.

Main Outcomes and Measures

Blinded assessment of function using the Activity Measure for Postacute Care computer adaptive test, pain interference and average intensity using the Brief Pain Inventory, and quality of life using the EQ-5D-3L was performed at baseline and months 3 and 6. Hospitalizations and discharges to postacute care facilities were recorded.

Results

The study included 516 participants (257 women and 259 men; mean [SD] age, 65.6 [11.1] years), with 172 randomized to 1 of 3 arms. Compared with the control group, the telerehabilitation arm 2 had improved function (difference, 1.3; 95% CI, 0.08-2.35; P = .03) and quality of life (difference, 0.04; 95% CI, 0.004-0.071; P = .01), while both telerehabilitation arms 2 and 3 had reduced pain interference (arm 2, -0.4; 95% CI, -0.78 to -0.09; P = .01 and arm 3, -0.4; 95% CI, -0.79 to -0.10; P = .01), and average intensity (arm 2, -0.4; 95% CI, -0.78 to -0.07; P = .02 and arm 3, -0.5; 95% CI, -0.84 to -0.11; P = .006). Telerehabilitation was associated with higher odds of home discharge in arms 2 (odds ratio [OR], 4.3; 95% CI, 1.3-14.3; P = .02) and 3 (OR, 3.8; 95% CI, 1.1-12.4; P = .03) and fewer days in the hospital in arm 2 (difference, -3.9 days; 95% CI, -2.4 to -4.6; P = .01).

Conclusions and Relevance

Collaborative telerehabilitation modestly improved function and pain, while decreasing hospital length of stay and the requirement for postacute care, but these outcomes were not enhanced with the addition of pharmacological pain management.

Trial Registration

ClinicalTrials.gov identifier: NCT01721343.

The effect of nutritional counseling on muscle mass and treatment outcome in patients with metastatic colorectal cancer undergoing chemotherapy: A randomized controlled trial

BACKGROUND & AIMS

A low muscle mass before start of treatment and loss of muscle mass during chemotherapy is related to adverse outcomes in patients with cancer. In this randomized controlled trial, the effect of nutritional counseling on change in muscle mass and treatment outcome in patients with metastatic colorectal cancer during first-line chemotherapy was studied.

METHODS

Patients scheduled for first-line chemotherapy (n = 107) were randomly assigned to individualized nutritional counseling by a dietitian (NC) or usual care (UC). NC was aimed at sufficient protein- and energy intake, supported by oral supplements or enteral feeding if indicated. Furthermore, physical activity was encouraged. Outcomes were assessed at baseline (T0) and the time of the first (T1) and second (T2) regular follow-up computed tomography scans. The proportion of patients with a clinically relevant decrease in skeletal muscle area of ≥6.0 cm², measured by computed tomography, was the primary outcome. Secondary outcomes included body weight, quality of life, treatment toxicity and progression free and overall survival.

RESULTS

A total of 107 patients were enrolled (mean age, 65 years (SD, 11 years), 63% male). Mean change in skeletal muscle area from T0 till T1 was -2.5 (SD, 9.5) cm², with no difference between NC versus UC (p = 0.891). The proportion of patients with a clinically relevant decrease in skeletal muscle area of ≥6.0 cm² did not differ (NC 30% versus UC 31%, p = 0.467). NC compared with UC had a significant positive effect on body weight (B coefficient 1.7, p = 0.045), progression free survival (p = 0.039) and overall survival (p = 0.046).

CONCLUSIONS

NC of patients undergoing chemotherapy for metastatic colorectal cancer had no effect on muscle mass. However, we found that NC may increase body weight and improve progression free survival and overall survival compared to UC in this group of patients. These findings need further evaluation in future clinical trials.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov NCT01998152; Netherlands Trial Register NTR4223.

Feasibility and Health Benefits of an Individualized Physical Activity Intervention in Women With Metastatic Breast Cancer: Intervention Study

BACKGROUND

There is limited knowledge regarding the potential benefits of physical activity in patients with metastatic breast cancer.

OBJECTIVE

The Advanced stage Breast cancer and Lifestyle Exercise (ABLE) Trial aimed to assess the feasibility of a physical activity intervention in women with metastatic breast cancer and to explore the effects of physical activity on functional, psychological, and clinical parameters.

METHODS

The ABLE Trial was a single-arm, 6-month intervention study with a home-based, unsupervised, and personalized walking program using an activity tracker. At baseline and 6 months, we assessed anthropometrics, functional fitness, physical activity level, sedentary behavior, quality of life, fatigue, and tumor progression. Paired proportions were compared using the McNemar test and changes of parameters during the intervention were analyzed using the Wilcoxon signed-rank test, the Mann-Whitney test, and Spearman rank correlations.

RESULTS

Overall, 49 participants (mean age 55 years; recruitment rate 94%) were enrolled and 96% adhered to the exercise prescription (attrition rate 2%). Statistically significant improvements in the 6-minute walking distance test (+7%, P<.001) and isometric quadriceps strength (+22%, P<.001), as well as decreases in body mass index (-2.5%, P=.03) and hip circumference (-4.0%, P<.001) were observed at 6 months. Quality of life remained stable and a nonstatistically significant decrease (-16%, P=.07) in fatigue was observed.

CONCLUSIONS

The high recruitment and adherence rates suggest the willingness of patients with metastatic breast cancer to participate in a physical activity program. The beneficial outcomes regarding physical fitness and anthropometry of this unsupervised physical activity program may encourage these patients to maintain a physically active lifestyle. Future randomized controlled trials with larger sample sizes are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03148886; https://clinicaltrials.gov/ct2/show/NCT03148886.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

The Effect of Exercise on Quality of Life, Fatigue, Physical Function, and Safety in Advanced Solid Tumor Cancers: A Meta-analysis of Randomized Control Trials

BACKGROUND

People with metastatic cancers experience poor quality of life (QoL), fatigue, and decreased physical function. Exercise improves these symptoms in the curative setting, but the efficacy and safety of exercise in the metastatic setting is uncertain.

METHODS

Prospective, randomized trials of moderate/high-intensity aerobic exercise or resistance training vs. control in patients with advanced/metastatic solid cancers were identified from prior reviews and updated using a search of PubMed. The mean and SD for validated outcome measures (QoL, physical function, and fatigue) were extracted for intervention and control groups at baseline and postintervention. The Mann-Whitney test was used to evaluate the effect of exercise on the pooled change between baseline and postintervention. Safety was evaluated qualitatively.

RESULTS

Sixteen trials were analyzed. Among patients with scores at the mean or 2SD above, exercise was not associated with significant or clinical difference in QoL or fatigue. In patients with baseline scores 2SD below mean, exercise was associated with nonsignificant difference meeting minimal clinical important difference in QoL (-2.8 vs. 4.6, P = 0.28). For function, patients at the mean had nonstatistically significant, but clinically meaningful difference in the six-minute walk test (6-MWT) (14.7 vs. 29.0 m, P = 0.44). In patients 2 SD below the mean, there was a clinically meaningful difference in two patient-reported functional subscales (0.1 vs. 5.3, P = 0.076 and 0.44 vs. 8.5, P = 0.465) and a clinically meaningful improvement in the 6-MWT (-7.5 vs. 27.0 m, P = 0.34), although none of these associations met statistical significance. There were no differences in falls, fractures, or pain.

DISCUSSION

Exercise is associated with clinically meaningful improvements in QoL, function, and 6-MWT in some patients with metastatic cancer. Despite poor reporting of safety, there was no signal of increased harm from exercise in this setting.

Muscle protein anabolism in advanced cancer patients: response to protein and amino acids support, and to physical activity

In the field of oncology, it is well recognized that a decrease in mass, density, strength, or function of skeletal muscle is associated to increased treatment toxicities and postoperative complications, as well as poor progression-free survival and overall survival. The ability of amino acids to stimulate protein synthesis in cancer patients is reduced. Considering nutritional intervention, this anabolic resistance could be in a part counteracted by increasing protein or by giving specific amino acids. In particular, Leucine might counteract this anabolic resistance not only by increasing substrate availability, but also by directly modulating the anabolic signal pathway. Few studies showed the possibility of increasing muscle protein synthesis by specific nutriments and/or by increasing amino acids or protein administration. In addition, whereas many studies provide evidence of a benefit of adapted physical activity in advanced cancer patients, it is difficult to specify the most appropriate type of exercise, and the optimum rhythm and intensity. Moreover, the benefits of physical activities and of protein support seem greater when it is started at the precachexia stage rather than at the cachexia stage, and their benefits are limited or nonexistent at the stage of refractory cachexia. Future approaches should integrate the combination of several complementary treatments in order to prevent (or improve) cachexia and/or sarcopenia in cancer patients.

Physical activity preferences before and after participation in a 6-month physical activity intervention among women with metastatic breast cancer

OBJECTIVE

This secondary analysis of the ABLE Trial (ClinicalTrials.gov NCT03148886) aimed to assess physical activity preferences before and after a 6-month physical activity intervention for women recently diagnosed with metastatic breast cancer and to investigate demographic and clinical correlates of these preferences.

METHODS

Forty-nine patients participated in the ABLE Trial, a single-arm, unsupervised 6-month physical activity intervention with activity trackers. At baseline and 6 months, physical activity preferences, physical activity level, clinical variables, demographics and social vulnerability were assessed.

RESULTS

At baseline, 49 participants were included, among whom 85% were interested in receiving physical activity counselling and 89% were interested in following a physical activity programme designed for metastatic breast cancer. At the end of the study, more participants preferred practising in a community fitness centre (66%) rather than at home (19% vs. 44% at baseline, p = .03). A higher social vulnerability score and not being treated by chemotherapy at baseline were significantly associated with lower desire to receive physical activity counselling (p = .01 and p = .04 respectively).

CONCLUSIONS

This study will help design future studies within patients with metastatic breast cancer in accordance with their preferences. Designing tailored physical activity interventions according to the participant's preferences may be one key to success for adherence.

Combining optimal nutrition and exercise in a multimodal approach for patients with active cancer and risk for losing weight: Rationale and practical approach

Weight loss and functional decline is a common and detrimental consequence of cancer. The interventions that are offered to patients with weight loss and functional decline often seem haphazard and varying from center to center. The lack of stringent management is probably based both on lack of knowledge of existing treatment guidelines and the current weak level of evidence of clinical effects of different nutritional and exercise interventions. Some studies evaluated multimodal interventions with various treatment combinations, including nutrition and exercise, that report clinically significant effects on cachexia outcomes. As of today, however, there is a paucity of large randomized controlled trials that incorporate both a fully structured exercise program and a well-described nutritional intervention. Studies investigating combinations of several interventions in patients with active cancer and risk for losing weight are too few and too heterogeneous to enable firm conclusions about effect, optimal dose, or timing of interventions. However, data presented in this review suggest an overall benefit, especially if interventions are started before weight loss and loss of function become too severe. Thus, the aim of this review was to examine the evidence for combined treatments targeting weight loss in cancer patients.

Exercise interventions for patients with advanced cancer: A systematic review of recruitment, attrition, and exercise adherence rates

Purpose

Patients with advanced cancer can experience debilitating physical symptoms, making participation in exercise programs difficult. This systematic review investigated the recruitment, adherence, and attrition rates of patients with advanced cancer participating in exercise interventions and examined components of exercise programs that may affect these rates.

Methods

Relevant studies were identified in a systematic search of CINAHL, PubMed, PsycINFO, and EMBASE to December 2017. Two quality assessment tools were used, and levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.

Results

The search identified 18 studies published between 2004 and 2017. Recruitment, adherence, and attrition rates varied widely among the studies reviewed. The mean recruitment rate was 49% (standard deviation [SD] = 17; range 15–74%). Patient-reported barriers to recruitment included time constraints and difficulties in traveling to exercise centers. Levels of adherence ranged from 44% to 95%; however, the definition of adherence varied substantially among trials. The average attrition rate was 24% (SD = 8; range 10–42%), with progression of disease status reported as the main cause for dropout during exercise interventions.

Significance of results

Concentrated efforts are needed to increase the numbers of patients with advanced disease recruited to exercise programs. Broadening the eligibility criteria for exercise interventions may improve accrual numbers of patients with advanced cancer to exercise trials and ensure patients recruited are representative of clinical practice.

Exercise training for advanced lung cancer

BACKGROUND

Patients with advanced lung cancer have a high symptom burden, which is often complicated by coexisting conditions. These issues, combined with the indirect effects of cancer treatment, can cumulatively lead patients to continued deconditioning and low exercise capacity. This is a concern as exercise capacity is considered a measure of whole body health, and is critical in a patient's ability to participate in life activities and tolerate difficult treatments. There is evidence that exercise training improves exercise capacity and other outcomes, such as muscle force and health-related quality of life (HRQoL), in cancer survivors. However, the effectiveness of exercise training on these outcomes in people with advanced lung cancer is currently unclear.

OBJECTIVES

The primary aim of this review was to investigate the effects of exercise training on exercise capacity in adults with advanced lung cancer. Exercise capacity was defined as the six-minute walk distance (6MWD; in meters) measured during a six-minute walk test (6MWT; i.e. how far an individual can walk in six minutes on a flat course), or the peak oxygen uptake (i.e. VO₂peak) measured during a maximal incremental cardiopulmonary exercise test (CPET).The secondary aims were to determine the effects of exercise training on the force-generating capacity of peripheral muscles, disease-specific global HRQoL, physical functioning component of HRQoL, dyspnoea, fatigue, feelings of anxiety and depression, lung function, level of physical activity, adverse events, performance status, body weight and overall survival in adults with advanced lung cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE (via PubMed), Embase (via Ovid), CINAHL, SPORTDiscus, PEDro, and SciELO on 7 July 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared exercise training versus no exercise training in adults with advanced lung cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies and selected those for inclusion. We performed meta-analyses for the following outcomes: exercise capacity, disease-specific global HRQoL, physical functioning HRQoL, dyspnoea, fatigue, feelings of anxiety and depression, and lung function (forced expiratory volume in one second (FEV1)). Two studies reported force-generating capacity of peripheral muscles, and we presented the results narratively. Limited data were available for level of physical activity, adverse events, performance status, body weight and overall survival.

MAIN RESULTS

We identified six RCTs, involving 221 participants. The mean age of participants ranged from 59 to 70 years; the sample size ranged from 20 to 111 participants. Overall, we found that the risk of bias in the included studies was high, and the quality of evidence for all outcomes was low.Pooled data from four studies demonstrated that, on completion of the intervention period, exercise capacity (6MWD) was significantly higher in the intervention group than the control group (mean difference (MD) 63.33 m; 95% confidence interval (CI) 3.70 to 122.96). On completion of the intervention period, disease-specific global HRQoL was significantly better in the intervention group compared to the control group (standardised mean difference (SMD) 0.51; 95% CI 0.08 to 0.93). There was no significant difference between the intervention and control groups in physical functioning HRQoL (SMD 0.11; 95% CI -0.36 to 0.58), dyspnoea (SMD -0.27; 95% CI -0.64 to 0.10), fatigue (SMD 0.03; 95% CI -0.51 to 0.58), feelings of anxiety (MD -1.21 units on Hospital Anxiety and Depression Scale; 95% CI -5.88 to 3.45) and depression (SMD -1.26; 95% CI -4.68 to 2.17), and FEV1 (SMD 0.43; 95% CI -0.11 to 0.97).

AUTHORS' CONCLUSIONS

Exercise training may improve or avoid the decline in exercise capacity and disease-specific global HRQoL for adults with advanced lung cancer. We found no significant effects of exercise training on dyspnoea, fatigue, feelings of anxiety and depression, or lung function. The findings of this review should be viewed with caution because of the heterogeneity between studies, the small sample sizes, and the high risk of bias of included studies. Larger, high-quality RCTs are needed to confirm and expand knowledge on the effects of exercise training in this population.

Whole-Body Electromyostimulation Combined With Individualized Nutritional Support Improves Body Composition in Patients With Hematological Malignancies - A Pilot Study

Patients undergoing the complex treatment for hematological malignancies are exposed to a high physiological and psychological distress inducing fatigue and physical inactivity. In line with cancer-related metabolic changes patients are predisposed for skeletal muscle mass loss that leads to a functional decline, affects therapeutic success, and quality of life. Benefits of physical exercise and nutritional interventions on muscle maintenance are observed in solid cancer patients, but marginally investigated in patients with hematological cancer. We here studied the effects of a combined supportive exercise and nutrition intervention using whole-body electromyostimulation (WB-EMS) training and individualized nutritional support in patients actively treated for hematological malignancy. In a controlled pilot trial, 31 patients (67.7% male; 58.0 ± 16.7 years) with various hematological cancers were allocated to a control group (n = 9) receiving nutritional support of usual care regarding a high protein intake (>1.0 g/kg/d) or to a physical exercise group (n = 22) additionally performing WB-EMS training twice weekly for 12 weeks. Bodyweight and body composition assessed by bioelectrical impedance analysis were measured every 4 weeks. Physical function, blood parameters, quality of life and fatigue were assessed at baseline and after 12 weeks. No WB-EMS-related adverse effects occurred. Patients attending the exercise program presented a higher skeletal muscle mass than controls after 12-weeks (1.51 kg [0.41, 2.60]; p = 0.008). In contrast, patients of the control group showed a higher fat mass percentage than patients of the WB-EMS group (-4.46% [-7.15, -1.77]; p = 0.001) that was accompanied by an increase in serum triglycerides in contrast to a decrease in the WB-EMS group (change ± SD, control 36.3 ± 50.6 mg/dl; WB-EMS -31.8 ± 68.7 mg/dl; p = 0.064). No significant group differences for lower limb strength, quality of life, and fatigue were detected. However, compared to controls the WB-EMS group significantly improved in physical functioning indicated by a higher increase in the 6-min-walking distance (p = 0.046). A combined therapeutic intervention of WB-EMS and protein-rich nutritional support seems to be safe and effective in improving skeletal muscle mass and body composition in hematological cancer patients during active oncological treatment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02293239.

Engaging the older cancer patient; Patient Activation through Counseling, Exercise and Mobilization - Pancreatic, Biliary tract and Lung cancer (PACE-Mobil-PBL) - study protocol of a randomized controlled trial

Background

Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy.

Methods

PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks.

Discussion

The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field.

Trial registration

The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200).

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4835-2) contains supplementary material, which is available to authorized users.

The Role of Systemic Inflammation in Cancer-Associated Muscle Wasting and Rationale for Exercise as a Therapeutic Intervention

Progressive skeletal muscle wasting in cancer cachexia involves a process of dysregulated protein synthesis and breakdown.  This catabolism may be the result of mal-nutrition, and an upregulation of both pro-inflammatory cytokines and the ubiquitin proteasome pathway (UPP), which can subsequently increase myostatin and activin A release.  The skeletal muscle wasting associated with cancer cachexia is clinically significant, it can contribute to treatment toxicity or the premature discontinuation of treatments resulting in increases in morbidity and mortality.  Thus, there is a need for further investigation into the pathophysiology of muscle wasting in cancer cachexia to develop effective prophylactic and therapeutic interventions.  Several studies have identified a central role for chronic-systemic inflammation in initiating and perpetuating muscle wasting in patients with cancer.  Interestingly, while exercise has shown efficacy in improving muscle quality, only recently have investigators begun to assess the impact that exercise has on chronic-systemic inflammation.  To put this new information into context with established paradigms, here we review several biological pathways (e.g. dysfunctional inflammatory response, hypothalamus pituitary adrenal axis, and increased myostatin/activin A activity) that may be responsible for the muscle wasting in patients with cancer.  Additionally, we discuss the potential impact that exercise has on these pathways in the treatment of cancer cachexia.  Exercise is an attractive intervention for muscle wasting in this population, partially because it disrupts chronic-systemic inflammation mediated catabolism.  Most importantly, exercise is a potent stimulator of muscle synthesis, and therefore this therapy may reverse muscle damage caused by cancer cachexia. 

Effects of whole-body electromyostimulation combined with individualized nutritional support on body composition in patients with advanced cancer: a controlled pilot trial

BACKGROUND

Physical exercise and nutritional treatment are promising measures to prevent muscle wasting that is frequently observed in advanced-stage cancer patients. However, conventional exercise is not always suitable for these patients due to physical weakness and therapeutic side effects. In this pilot study, we examined the effect of a combined approach of the novel training method whole-body electromyostimulation (WB-EMS) and individualized nutritional support on body composition with primary focus on skeletal muscle mass in advanced cancer patients under oncological treatment.

METHODS

In a non-randomized controlled trial design patients (56.5% male; 59.9 ± 12.7 years) with advanced solid tumors (UICC III/IV, N = 131) undergoing anti-cancer therapy were allocated to a usual care control group (n = 35) receiving individualized nutritional support or to an intervention group (n = 96) that additionally performed a supervised physical exercise program in form of 20 min WB-EMS sessions (bipolar, 85 Hz) 2×/week for 12 weeks. The primary outcome of skeletal muscle mass and secondary outcomes of body composition, body weight and hand grip strength were measured at baseline, in weeks 4, 8 and 12 by bioelectrical impedance analysis and hand dynamometer. Effects of WB-EMS were estimated by linear mixed models. Secondary outcomes of physical function, hematological and blood chemistry parameters, quality of life and fatigue were assessed at baseline and week 12. Changes were analyzed by t-tests, Wilcoxon signed-rank or Mann-Whitney-U-tests.

RESULTS

Twenty-four patients of the control and 58 of the WB-EMS group completed the 12-week trial. Patients of the WB-EMS group had a significantly higher skeletal muscle mass (0.53 kg [0.08, 0.98]; p = 0.022) and body weight (1.02 kg [0.05, 1.98]; p = 0.039) compared to controls at the end of intervention. WB-EMS also significantly improved physical function and performance status (p < 0.05). No significant differences of changes in quality of life, fatigue and blood parameters were detected between the study groups after 12 weeks.

CONCLUSIONS

Supervised WB-EMS training is a safe strength training method and combined with nutritional support it shows promising effects against muscle wasting and on physical function in advanced-stage cancer patients undergoing treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02293239 (Date: November 18, 2014).