American College of Sports Medicine roundtable on exercise guidelines for cancer survivors

A Bayesian-adaptive decision-theoretic approach can reduce the sample sizes for multiarm exercise oncology trials

OBJECTIVES

Adaptive designs may reduce trial sample sizes and costs. This study illustrates a Bayesian-adaptive decision-theoretic design applied to a multiarm exercise oncology trial.

STUDY DESIGN AND SETTING

In the Physical exercise during Adjuvant Chemotherapy Effectiveness Study (PACES) trial, 230 breast cancer patients receiving chemotherapy were randomized to supervised resistance and aerobic exercise (OnTrack), home-based physical activity (OncoMove) or usual care (UC). Data were reanalyzed as an adaptive trial using both Bayesian decision-theoretic and a frequentist group-sequential approach incorporating interim analyses after every 36 patients. Endpoint was chemotherapy treatment modifications (any vs. none). Bayesian analyses were performed for different continuation thresholds and settings with and without arm dropping and both in a 'pick-the-winner' and a 'pick-all-treatments-superior-to-control' setting.

RESULTS

Treatment modifications occurred in 34% of patients in UC and OncoMove vs. 12% in OnTrack (P = 0.002). Using a Bayesian-adaptive decision-theoretic design, OnTrack was identified as most effective after 72 patients in the 'pick-the-winner' setting and after 72-180 patients in the 'pick-all-treatments-superior-to-control' setting. In a frequentist setting, the trial would have been stopped after 180 patients, and the proportion of patients with treatment modifications was significantly lower for OnTrack than UC.

CONCLUSION

A Bayesian-adaptive decision-theoretic approach substantially reduced the sample size required for this three-arm exercise trial, especially in the 'pick-the-winner' setting.

Randomized trial of exercise on cancer-related blood biomarkers and survival in women with ovarian cancer

BACKGROUND

In randomized trials in women with breast cancer, exercise has been shown to have beneficial effects on cancer-related circulating biomarkers that may impact survival. Such studies are lacking for ovarian cancer.

METHODS

This secondary analysis of a published randomized controlled trial examined the impact of a 6-month exercise intervention versus attention-control on change in prespecified circulating biomarkers (cancer antigen 125 (CA-125), C-reactive protein (CRP), insulin-like growth factor-1(IGF-1), insulin and leptin) in a subset of participants who provided a fasting blood draw (N = 104/144) at enrollment and at 6 months. Change in biomarkers between study arms was compared using a linear mixed effects model analysis. An exploratory analysis of the exercise intervention versus attention-control on all-cause mortality included all (N = 144) participants. All statistical tests were two-sided.

RESULTS

Participants included in the biomarker analysis were 57.0 ± 8.8 (mean ± SD) years old and 1.6 ± 0.9 years post-diagnosis. Adherence to the exercise intervention was 176.4 ± 63.5 min/week. Post intervention IGF-1 (group difference in change: -14.2 (-26.1 to -2.3) ng/mL (least squared means (95% CI))) and leptin (-8.9 (-16.5 to -1.4) ng/mL) were significantly reduced in the exercise group (N = 53) compared to those in attention-control (N = 51). No group difference in change was seen for CA-125 (p = 0.54), CRP (p = 0.95), or insulin (p = 0.37). With median follow-up of 70 months [range 6.6-105.4 months], 50/144 (34.7%) (exercise group; 24/74 (32.4%) versus attention-control group; 26/70 (37.1%)) participants died with no between group difference in overall survival (p = 0.99).

CONCLUSIONS

Further studies are needed to determine the clinical significance of exercise-induced changes in cancer-related circulating biomarkers in women with ovarian cancer.

Effects of a Pragmatic Home-based Exercise Program Concurrent With Neoadjuvant Therapy on Physical Function of Patients With Pancreatic Cancer: The PancFit Randomized Clinical Trial

OBJECTIVE

To determine the effects of a preoperative, home-based exercise program on fitness and physical function in patients with pancreatic cancer.

BACKGROUND

We previously established a well-tolerated preoperative exercise program after finding a high frequency of sarcopenia and frailty in patients with pancreatic cancer.

METHODS

In this randomized, controlled trial (NCT03187951), patients with pancreatic cancer were randomized to Arm A: enhanced usual care or Arm B: prescribed aerobic and resistance exercise during neoadjuvant therapy. Patients received nutrition counseling and activity trackers. The primary endpoint was a 6-minute walk distance (6MWD; ≥14 meters improvement was clinically meaningful). Secondary endpoints included additional physical function tests, health-related quality of life, and clinical outcomes.

RESULTS

One hundred fifty-one patients were randomized. Objectively measured weekly activity (153.2±135.6 and 159.8±122.8 min in Arm A and B, respectively, P =0.62) and self-reported weekly moderate-to-strenuous physical activity (107.4±160.4 and 129.6±161.6 min in Arm A and Arm B, respectively, P =0.49) were similar, but weekly strength training sessions increased more in Arm B (by 1.8±1.8 vs 0.1±2.4 sessions, P <0.001). 6MWD improved in both Arm A (mean change 18.6±56.8 m, P =0.01) and Arm B (27.3±68.1 m, P =0.002). Quality of life and clinical outcomes did not significantly differ between arms. Pooling patients in both study groups, exercise, and physical activity was favorably associated with physical performance and clinical outcomes.

CONCLUSIONS

In this randomized trial of prescribed exercise versus enhanced usual care during neoadjuvant therapy for pancreatic cancer, a high volume of physical activity and increased exercise capacity were observed in both arms, highlighting the importance of activity among patients preparing for surgery.

A multi-site trial of an electronic health integrated physical activity promotion intervention in breast and endometrial cancers survivors: MyActivity study protocol

Despite the known benefits of moderate-to-vigorous physical activity (MVPA) for breast and endometrial cancer survivors, most are insufficiently active, interventions response is heterogeneous, and MVPA programming integration into cancer care is limited. A stepped care approach, in which the least resource-intensive intervention is delivered first and additional components are added based on individual response, is one strategy to enhance uptake of physical activity programming. However, the most effective intervention augmentation strategies are unknown. In this singly randomized trial of post-treatment, inactive breast and endometrial cancer survivors (n = 323), participants receive a minimal intervention including a Fitbit linked with their clinic's patient portal and, in turn, the electronic health record (EHR) with weekly feedback delivered via the portal. MVPA progress summaries are sent to participants' oncology team via the EHR. MVPA adherence is evaluated at 4, 8, 12, 16 and 20 weeks; non-responders (those meeting ≤80% of the MVPA goal over previous 4 weeks) at each timepoint are randomized once for the remainder of the 24-week intervention to one of two "step-up" conditions: (1) online gym or (2) coaching calls, while responders continue with the minimal Fitbit+EHR intervention. The primary outcome is ActiGraph-measured MVPA at 24 and 48 weeks. Secondary outcomes include symptom burden and functional performance at 24 and 48 weeks. This trial will inform development of an effective, scalable, and tailored intervention for survivors by identifying non-responders and providing them with the intervention augmentations necessary to increase MVPA and improve health outcomes. Clinical Trials Registration # NCT04262180.

Conceptual development of an intensive exercise program for glioma patients (ActiNO): summary of clinical experience

PURPOSE

Exercise proved to reduce cancer-related symptoms and prolong survival in some cancer types. However, brain tumor patients are often advised against strenuous exercise. Here, we summarize our experience with a submaximal exercise program for glioma patients: ActiNO (Active in Neuro-Oncology).

METHODS

Glioma patients were invited to participate in the program. Since 2011, a sports scientist individualized two one-hour sessions per week adapted to the patients' symptoms. One session consisted of bicycle ergometry (average workload: 75% of maximum heart rate), the other of whole-body resistance training. Both sessions were further complimented by coordinative elements. Cardiorespiratory fitness was assessed using the "Physical Work Capacity" procedure. Patients were followed up regularly to assess adherence to the program and disease activity.

RESULTS

Until December 2019, 45 glioma patients, median-aged 49 years (IQR 42-59), were included in the analysis. Most patients suffered from glioblastoma (58%), followed by diffuse lower-grade astrocytoma (29%). In overall 1828 training sessions, two minor epileptic events occurred (1 speech arrest; 1 focal seizure). During fitness assessment, all patients achieved at least 75% of their age-adjusted maximum heart rate. Peak workload averaged 172 W (95% CI 156-187). Median survival of participating glioblastoma patients was 24.1 months (95% CI 8.6-39.5).

CONCLUSION

This supervised training program with submaximal exertion was feasible and safe in glioma regardless of WHO grading. Based on these experiences, we initiated a prospective multicenter study to objectify improvements in physical performance and quality of life in patients with glioblastoma.

Physical Activity in Oncology: To Do, Not to Do, and How to Do It? An Announcement of an Educational Program

The National Cancer Institute of Aviano, Italy, recently launched a new program to educate the cancer population, bringing patients as close as possible to the world of physical activity during the cancer rehabilitation phase. A personalized assessment of the patient using the latest technologies allows to create a personalized electronic record of the state of physical performance to be shared among the patient, the staff at the institute (including the medical doctors and physiotherapists in charge), and the fitness instructors, who deal with of the recovery tasks. The outcome of the program can allow the development of a personalized rehabilitation path that includes physical fitness to be monitored remotely.

Physical activity behaviour change in people living with and beyond cancer following an exercise intervention: a systematic review

PURPOSE

Exercise interventions can increase physical activity and wellbeing of people living with/beyond cancer. However, little is known about maintenance of physical activity in this population ≥ 6 months post-exercise intervention, when theoretical evidence suggests behaviour maintenance occurs. Study aims are to (i) systematically review maintenance of physical activity ≥ 6-month post-exercise intervention, and (ii) investigate the influence of behaviour change techniques (BCTs) on physical activity maintenance in people living with/beyond cancer.

METHODS

CINAHL, CENTRAL, EMBASE and PubMed databases were searched for randomised controlled trials up to August 2021. Trials including adults diagnosed with cancer that assessed physical activity ≥ 6 months post-exercise intervention were included.

RESULTS

Of 142 articles assessed, 21 reporting on 18 trials involving 3538 participants were eligible. Five (21%) reported significantly higher physical activity ≥ 6 months post-exercise intervention versus a control/comparison group. Total number of BCTs (M = 8, range 2-13) did not influence intervention effectiveness. The BCTs Social support, Goal setting (behaviour), and Action planning, alongside supervised exercise, were important, but not sufficient, components for long-term physical activity maintenance.

CONCLUSIONS

Evidence for long-term physical activity maintenance post-exercise intervention for people living with/beyond cancer is limited and inconclusive. Further research is required to ensure the physical activity and health benefits of exercise interventions do not quickly become obsolete.

IMPLICATIONS FOR CANCER SURVIVORS

Implementation of the BCTs Social support, Goal setting (behaviour), and Action planning, alongside supervised exercise, may enhance physical activity maintenance and subsequent health outcomes in people living with/beyond cancer.

Pediatric oncohematological exercise program in hospital: clinical trial study protocol

Leukemias are the most common types of hematological cancers in children, and negatively impact functional capacity. There is evidence in the literature that therapeutic exercises can have a positive impact on functions. The aim of this study is to evaluate functional capacity, muscle strength, fatigue and quality of life through the application of a protocol of therapeutic exercises during pediatric leukemia hospitalization. Children will be allocated into two groups: one will carry out a protocol of therapeutic exercises, while the other will undergo conventional respiratory physiotherapy. The protocol is approved by the ethics and research committee of the host institution (No. 5.439.594). Results will be disseminated through peer-reviewed journal articles and conferences. Clinical trial registration: RBR-8sxnfyd (https://ensaiosclinicos.gov.br).

Active for Life after Cancer: Association of Physical Activity with Cancer Patients' Interpersonal Competence, Quality of Life, and Survival Beliefs

This study aimed to examine the relationship between physical activity and cancer patients' survival beliefs and constructed a mediation model involving the mediating effects of interpersonal competence and quality of life. We conducted 252 questionnaire surveys on multiple chat groups for cancer patients using the WeChat software, and assessed physical activity, survival beliefs, interpersonal competence, and quality of life using standard scales. Data were analyzed using SPSS and AMOS. There were positive correlations between physical activity and quality of life (β = 0.393, p < 0.001), physical activity and interpersonal competence (β = 0.385, p < 0.001), interpersonal competence and quality of life (β = 0.455, p < 0.001), and quality of life and survival beliefs (β = 0.478, p < 0.001). In addition, a significant mediating effect between physical activity and survival beliefs was observed between interpersonal competence and quality of life (standardized indirect effect = 0.384, p < 0.001). The study revealed that effective physical activity led to higher interpersonal competence, more excellent quality of life, and improved survival beliefs in cancer patients, and that the association of physical activity with improved survival beliefs was fully mediated through interpersonal competence and quality of life. The findings suggest that the relevant government should increase policy support and publicity to improve cancer patients' participation in physical activity.

A Decomposition Analysis of Racial Disparities in Physical Activity Among Cancer Survivors: National Health Interview Survey 2009-2018

PURPOSE

In light of the known benefits of physical activity (PA) for cancer survivors, this exploratory study sought to investigate the uptake of PA among this population in the United States.

METHODS

Using the National Health Interview Survey data from 2009 to 2018, lung, breast, colorectal, prostate, ovarian, and lymphoma cancer survivors were identified, and their PA adherence measured per the standards of the American College of Sports Medicine. Logistic regression and the Fairlie decomposition were used, respectively, to identify correlates of PA and to explain the difference in PA adherence between races.

RESULTS

Uptake of PA was significantly different between Whites and minorities. Blacks had lower odds than Whites (adjusted odds ratio: 0.77; 95% confidence interval, 0.66-0.93), whereas Mixed Race had twice the odds of Whites (adjusted odds ratio: 1.94; 95% confidence interval, 0.27-0.98) of adhering to PA recommendations. Decomposition identified education, family income-to-poverty ratio, body mass index, number of chronic conditions, alcohol use, and general health as key factors accounting for the PA disparity between cancer survivors of White and Black or Multiple/Mixed racial group.

CONCLUSION

These findings could help inform behavioral PA interventions to improve their design and targeting to different racial groups of cancer survivors.

Does participation in therapeutic exercise programs after finishing oncology treatment still ensure an adequate health status for long-term breast cancer survivors? A ≥ 5 years follow-up study

PURPOSE

The aims of this study were to evaluate whether the effects of two therapeutic exercise programs are sustained over time (≥ 5 years) in long-term breast cancer survivors (LTBCS). Second, to determine the influence of the current level of physical activity (PA) performed on cancer-related fatigue (CRF) that these patients may present ≥5 years later.

METHODS

A prospective observational study was conducted with a cohort of 80 LTBCS in Granada during 2018. Firstly, considering their participation in one of the programs, they were allocated into two groups: usual care and therapeutic exercise program, to assess CRF, pain and pressure pain sensitivity, muscle strength, functional capacity, and quality of life. Secondly, they were also classified into 3 groups according to current level of weekly PA performed: ≤ 3, 3.1-7.4, and ≥ 7.5 (MET-hour/week) respectively, to assess its impact over CRF.

RESULTS

Although the positive effects of the programs are not sustained over time, a trend toward significance can be observed for a greater reduction in overall CRF levels, lower intensity of pain in the affected arm and cervical region, and greater functional capacity and quality of life in the group that underwent therapeutic exercise. Additionally, 66.25% of LTBCS are inactive ≥ 5 years after completion of the program and furthermore, such inactivity is accompanied by higher CRF levels (P .013 to .046).

CONCLUSION

The positive effects of therapeutic exercise programs are not maintained over time for LTBCS. Additionally, more than half of these women (66.25%) are inactive ≥ 5 years after completion of the program, this inactivity being accompanied by higher levels of CRF.

The Streaming Web-Based Exercise at Home Study for Breast and Prostate Cancer Survivors: A Feasibility Study Protocol

BACKGROUND

Despite the known benefits of physical activity in cancer survivors, adherence to exercise guidelines remains low. Known barriers to adhering to guidelines include a lack of time and an unwillingness to return to treatment facilities. Virtual exercise programming could assist in mitigating these barriers. This protocol presents a single arm pilot study exploring the feasibility of personalized Zoom-delivered exercise training for breast and prostate cancer survivors. A secondary objective is to determine the preliminary efficacy of participation on body composition, estimated VO_2max, hand grip, one repetition maximum leg press, resting heart rate, resting blood pressure, exercise self-efficacy, and intentions to remain active.

METHODS

Breast (n = 10) and prostate (n = 10) cancer survivors will participate in a 24-week feasibility study, including (1) 12 weeks of one-on-one virtual personal training with an exercise physiologist (EP) via Zoom, and (2) individual exercise for a 12-week follow-up period using recordings of Zoom sessions for guidance. Physical assessments and surveys will be implemented at baseline, 12 weeks, and at the end of the study (24 weeks from baseline).

CONCLUSIONS

While virtual exercise programming became popularized during the pandemic, evidence is still required to understand whether it can successfully address barriers and promote participation.

A randomized trial to evaluate the effects of a supervised exercise program on insomnia in patients with non-metastatic breast cancer undergoing chemotherapy: design of the FATSOMCAN study

BACKGROUND

Up to 70% of breast cancer patients report symptoms of insomnia during and after treatment. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed and poorly managed in breast cancer patients. Sleep medications treat symptoms but are ineffective to cure insomnia. Other approaches such as cognitive behavioral therapy for insomnia, relaxation through yoga and mindfulness are often not available for patients and are complex to implement. An aerobic exercise program could be a promising treatment and a feasible option for insomnia management in breast cancer patients, but few studies have investigated the effects of such a program on insomnia.

METHODS

This multicenter, randomized clinical trial evaluate the effectiveness of a moderate to high intensity physical activity program (45 min, 3 times per week), lasting 12 weeks, in minimizing insomnia, sleep disturbances, anxiety/depression, fatigue, and pain, and in enhancing cardiorespiratory fitness. Patients with breast cancer be recruited from six hospitals in France and randomly allocated to either the "training" or the "control" group. Baseline assessments include questionnaires [Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index questionnaire (PSQI), Hospital Anxiety Depression Scale (HADS), Epworth Sleepiness Scale (ESS)], home polysomnography (PSG), and 7-day actigraphy coupled with completion of a sleep diary. Assessments are repeated at the end of training program and at six-month follow-up.

DISCUSSION

This clinical trial will provide additional evidence regarding the effectiveness of physical exercise in minimizing insomnia during and after chemotherapy. If shown to be effective, exercise intervention programs will be welcome addition to the standard program of care offered to patients with breast cancer receiving chemotherapy.

TRIAL REGISTRATION

National Clinical Trials Number (NCT04867096).

Feasibility of supervised telehealth exercise for patients with advanced melanoma receiving checkpoint inhibitor therapy

PURPOSE

To determine the feasibility, safety and preliminary efficacy of a telehealth supervised exercise programme in patients with advanced melanoma receiving checkpoint inhibitor therapy.

METHODS

A 8-week non-randomised feasibility pilot trial utilising a telehealth delivered multimodal exercise programme undertaken thrice weekly with assessments at baseline and post-intervention. The study was considered feasible if there were no severe or life-threatening adverse events as a result of exercise, and three or more of the following criteria were met: the recruitment rate was >50%, completion rate was >80%, median programme attendance was >75%, median exercise compliance >75%, and average tolerance was >70%. Preliminary efficacy was assessed for objective measures of physical function (2-min step test, repeated chair stand test, 30-s push-up test, and a modified static balance test) and quality of life (QoL), fatigue and other patient-reported outcomes were assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30.

RESULTS

Eleven patients (32-80 years) were included in the study (6 female, 5 male). The recruitment rate was 48%, completion rate 91%, programme attendance 88%, median exercise compliance 82.1% and 84.9% for resistance and aerobic exercise, respectively, and tolerance 88%, with no severe or life-threatening adverse events as a result of exercise. In terms of preliminary efficacy, physical function significantly improved while QoL was maintained following the intervention.

CONCLUSION

An 8-week telehealth exercise intervention is feasible and safe for patients with advanced melanoma and appears to improve physical function while preserving QoL during checkpoint inhibitor therapy.

Nonpharmacological interventions for cancer-related fatigue: A literature review

Cancer-related fatigue (CRF) is a prevalent and debilitating side effect of cancer treatment that can persist for years posttreatment, significantly impacting patients' quality of life. Given the limited efficacy of pharmacological treatments, nonpharmacological interventions are gaining attention as effective management strategies for CRF. This review aims to provide an overview of the most common nonpharmacological interventions for CRF management, including exercise therapies, psychosocial interventions, sensory art therapy, light therapy, nutritional management, traditional Chinese medicine therapies, sleep management, combination therapy, and health education. By synthesizing the findings of high-quality literature, this review presents the definition of each therapy, along with their advantages and disadvantages in treating patients with CRF. Additionally, it addresses the role of oncology nurses in the nonpharmacological management of CRF. In summary, this review aims to inform oncology nurses about the prevalent nonpharmacological interventions for CRF and explore their clinical application to facilitate the development of effective CRF management strategies in clinical practice.

Study protocol for two pilot randomised controlled trials aimed at increasing physical activity using electrically assisted bicycles to enhance prostate or breast cancer survival

BACKGROUND

In 2020, 1.4 and 2.3 million new cases of prostate cancer and breast cancer respectively were diagnosed globally. In the UK, prostate cancer is the most common male cancer, while breast cancer is the most common female cancer. Engaging in physical activity (PA) is a key component of treatment. However, rates of PA are low in these clinical populations. This paper describes the protocol of CRANK-P and CRANK-B, two pilot randomised controlled trials, involving an e-cycling intervention aimed at increasing PA in individuals with prostate cancer or breast cancer respectively.

METHODS

These two trials are single-centre, stratified, parallel-group, two-arm randomised waitlist-controlled pilot trials in which forty individuals with prostate cancer (CRANK-P) and forty individuals with breast cancer (CRANK-B) will be randomly assigned, in a 1:1 allocation ratio, to an e-cycling intervention or waitlist control. The intervention consists of e-bike training with a certified cycle instructor, followed by the provision of an e-bike for 12 weeks. Following the intervention period, participants in the e-bike condition will be directed to community-based initiatives through which they can access an e-bike. Data will be collected at baseline (T0), immediately post intervention (T1) and at 3-month follow-up (T2). In addition, in the intervention group, data will be collected during the intervention and follow-up periods. Quantitative and qualitative methods will be used. The primary objectives are to determine effective recruitment strategies, establish recruitment and consent rates, adherence and retention in the study, and determine the feasibility and acceptability of the study procedures and intervention. The potential impact of the intervention on clinical, physiological and behavioural outcomes will be assessed to examine intervention promise. Data analyses will be descriptive.

DISCUSSION

The findings from these trials will provide information on trial feasibility and highlight the potential of e-cycling as a strategy to positively impact the health and behaviour of individuals with prostate cancer and breast cancer. If appropriate, this information can be used to design and deliver a fully powered definitive trial.

TRIAL REGISTRATION

CRANK-B: [ISRCTN39112034]. CRANK-P [ISRCTN42852156]. Registered [08/04/2022] https://www.isrctn.com .

ExPeCT: a randomised trial examining the impact of exercise on quality of life in men with metastatic prostate cancer

PURPOSE

All patients living with cancer, including those with metastatic cancer, are encouraged to be physically active. This paper examines the secondary endpoints of an aerobic exercise intervention for men with metastatic prostate cancer.

METHODS

ExPeCT (Exercise, Prostate Cancer and Circulating Tumour Cells), was a multi-centre randomised control trial with a 6-month aerobic exercise intervention arm or a standard care control arm. Exercise adherence data was collected via heart rate monitors. Quality of life (FACT-P) and physical activity (self-administered questionnaire) assessments were completed at baseline, at 3 months and at 6 months.

RESULTS

A total of 61 patients were included (69.4 ± 7.3 yr, body mass index 29.2 ± 5.8 kg/m²). The median time since diagnosis was 34 months (IQR 7-54). A total of 35 (55%) of participants had > 1 region affected by metastatic disease. No adverse events were reported by participants. There was no effect of exercise on quality of life (Cohen's d =  - 0.082). Overall adherence to the supervised sessions was 83% (329 out of 396 possible sessions attended by participants). Overall adherence to the non-supervised home exercise sessions was 72% (months 1-3) and 67% (months 3-6). Modelling results for overall physical activity scores showed no significant main effect for the group (p-value = 0.25) or for time (p-value = 0.24).

CONCLUSION

In a group of patients with a high burden of metastatic prostate cancer, a 6-month aerobic exercise intervention did not lead to change in quality of life. Further exercise studies examining the role of exercise for people living with metastatic prostate cancer are needed.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (NCT02453139) on May 25th 2015.

Considering depression as a secondary outcome in the optimization of physical activity interventions for breast cancer survivors in the PACES trial: a factorial randomized controlled trial

BACKGROUND

Depressive symptoms result in considerable burden for breast cancer survivors. Increased physical activity may reduce these burdens but existing evidence from physical activity interventions in equivocal. Furthermore, physical activity intervention strategies may differentially impact depressive symptoms, which should be considered in designing and optimizing behavioral interventions for breast cancer survivors.

METHODS

The Physical Activity for Cancer Survivors (PACES) trial enrolled 336 participants breast cancer survivors, who were 3 months to 10 years post-treatment, and insufficiently active (< 150 min of moderate-to-vigorous physical activity per week). Participants were randomly assigned to a combination of 4 intervention strategies in a full-factorial design: 1) supervised exercise sessions, 2) facility access, 3) Active Living Every Day, and 4) Fitbit self-monitoring. Depressive symptoms were assessed at baseline, mid-intervention (3 months), and post-intervention (6 months) using the Quick Inventory for Depressive Symptoms. Change in depressive symptoms were analyzed using a linear mixed-effects model.

RESULTS

Results from the linear mixed-effects model indicated that depressive symptoms decreased significantly across the entire study sample over the 6-month intervention (F = 4.09, p = 0.044). A significant ALED x time interaction indicated participants who received the ALED intervention experienced greater reductions in depressive symptoms (F = 5.29, p = 0.022). No other intervention strategy significantly impacted depressive symptoms.

CONCLUSIONS

The ALED intervention consists of strategies (i.e., goal setting, social support) that may have a beneficial impact on depressive symptoms above and beyond the effect of increased physical activity. Our findings highlight the need to consider secondary outcomes when designing and optimizing physical activity interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03060941. Posted February 23, 2017.

Effects and Moderators of Exercise Medicine on Cardiometabolic Outcomes in Men With Prostate Cancer Previously or Currently Undergoing Androgen Deprivation Therapy: An Individual Patient Data Meta-analysis

PURPOSE

To examine the effects and moderators of exercise effects on cardiometabolic outcomes in men with prostate cancer previously or currently undergoing androgen deprivation therapy (ADT).

RESULTS

Seven trials including 560 patients were examined. Exercise resulted in significant effects on whole-body and regional fat mass (P≤0.001). For whole-body fat mass, significant exercise effects were observed in patients who were unmarried (-1.4kg, P<0.05) and who presented with higher fat mass levels (-1.0kg, P<0.05). For diastolic blood pressure and low-density lipoprotein (LDL), younger (-4.7mmHg, P<0.05) and older patients (-0.2mmol.l^-1, P<0.10) achieved greater effects, respectively. Regarding high-density lipoprotein (HDL), patients undertaking ADT + prostatectomy + radiotherapy derived significant exercise effects (0.3mmol.l^-1, P<0.05).

CONCLUSIONS

Exercise effectively reduces fat mass across subgroups of men undergoing or following ADT with different characteristics. For diastolic blood pressure, HDL and LDL, groups based on age and treatment history could be specifically targeted with exercise medicine.

Restoring Balance: a physical activity intervention for Native American cancer survivors and their familial support persons

Introduction/Purpose

Exercise interventions among Native American cancer survivors are lacking, despite major cancer health disparities in survivorship. The purpose of this study was to evaluate a 12-week randomized controlled trial (RCT) of culturally tailored exercise on cancer risk biomarkers and quality of life among Native American cancer survivors and family members.

Methods

Participants were randomized to immediate start versus 6-week waitlist control at two rural and two urban sites. Participants enrolled in a small feasibility pilot study (only cancer survivors evaluated, n=18; cohort 1) or larger efficacy pilot study where cancer survivors (n=38; cohort 2) and familial supporters (n=25; cohort 3) were evaluated concurrently. Resistance, aerobic, flexibility, and balance exercises were tailored by cultural experts representing ten tribes. Exercises was supervised on-site one day per week and continued in home-based settings two to five days per week. Fat mass, blood pressure, hemoglobin A1c, 6-min walk, sit-to-stand test, and quality of life (Patient-Reported Outcomes Measurement Information System Global Health short form and isolation subscale) were measured. Mixed effects models evaluated differences between RCT arms from baseline to 6 weeks, and 12-week intervention effects in combined arms.

Results

There were no consistent differences at 6 weeks between randomized groups. Upon combining RCT arms, 6-min walk and sit-to-stand tests improved in all three cohorts by 12 weeks (both survivors and familial support persons, p<0.001); social isolation was reduced in all three cohorts (p≤0.05). Familial support persons additionally improved blood pressure and HbA1c (p≤0.05).

Conclusion

Exercise improved cardiorespiratory fitness and physical function among Native American cancer survivors and familial supporters. A longer intervention may influence other important health outcomes among Native American survivors. Additional improvements demonstrated among Native American family members may have a meaningful impact on cancer prevention in this underserved population with shared heritable and environmental risks.

Associations of combined physical activity and body mass index groups with colorectal cancer survival outcomes

BACKGROUND

Physical activity and BMI have been individually associated with cancer survivorship but have not yet been studied in combinations in colorectal cancer patients. Here, we investigate individual and combined associations of physical activity and BMI groups with colorectal cancer survival outcomes.

METHODS

Self-reported physical activity levels (MET hrs/wk) were assessed using an adapted version of the International Physical Activity Questionnaire (IPAQ) at baseline in 931 patients with stage I-III colorectal cancer and classified into 'highly active' and'not-highly active'(≥ / < 18 MET hrs/wk). BMI (kg/m2) was categorized into 'normal weight', 'overweight', and 'obese'. Patients were further classified into combined physical activity and BMI groups. Cox-proportional hazard models with Firth correction were computed to assess associations [hazard ratio (HR), 95% profile HR likelihood confidence interval (95% CI) between individual and combined physical activity and BMI groups with overall and disease-free survival in colorectal cancer patients.

RESULTS

'Not-highly active' compared to 'highly active' and 'overweight'/ 'obese' compared to 'normal weight' patients had a 40-50% increased risk of death or recurrence (HR: 1.41 (95% CI: 0.99-2.06), p = 0.03; HR: 1.49 (95% CI: 1.02-2.21) and HR: 1.51 (95% CI: 1.02-2.26), p = 0.04, respectively). 'Not-highly active' patients had worse disease-free survival outcomes, regardless of their BMI, compared to 'highly active/normal weight' patients. 'Not-highly active/obese' patients had a 3.66 times increased risk of death or recurrence compared to 'highly active/normal weight' patients (HR: 4.66 (95% CI: 1.75-9.10), p = 0.002). Lower activity thresholds yielded smaller effect sizes.

CONCLUSION

Physical activity and BMI were individually associated with disease-free survival among colorectal cancer patients. Physical activity seems to improve survival outcomes in patients regardless of their BMI.

The impact of motivational interviewing on behavioural change and health outcomes in cancer patients and survivors. A systematic review and meta-analysis

BACKGROUND

Cancer patients and survivors commonly have poorer health behaviours and subsequent outcomes, often as a result of negative impacts of diagnosis and treatment. Motivational interviewing is reported to be an effective psychological tool to produce a shift in one's behaviour resulting in improved outcomes. However, there is a lack of analyses investigating this tool's impact on healthy behaviours and health outcomes in cancer populations.

OBJECTIVE

To investigate the effect of motivational interviewing on behaviours and health outcomes in cancer populations.

METHODS

The studies were identified from four databases using variations of the terms "cancer" and "motivational interviewing". Randomised trials, non-randomised trials and quasi-experimental studies which contained control (or usual care) comparators were included. Risk of bias was assessed using the Cochrane Risk of Bias Version 5.1.0 and the Risk of Bias In Non-Randomised Studies of Interventions tools. The quality of evidence was assessed using the GRADE framework. Means difference and standardised mean differences and 95 % confidence intervals were used to report the pooled effects using a random effects model.

RESULTS

Twenty-one studies were included in the review and 17 studies were included in the meta-analysis. A total of 1752 cancer patients and survivors received MI as an intervention (or part thereof). Quality of life, anxiety, depression, functional tasks (6-minute walk test), body mass index and body weight (BMI/BW), physical activity (PA), self-efficacy and fatigue were outcomes measured in the selected studies. Effects were seen in functional tasks, physical activity, BMI/BW, depression and self-efficacy. All of these outcomes were from studies that were classed as very low-quality evidence except for BMI/BW and PA, which were from moderate-quality evidence.

CONCLUSION

Motivational interviewing had positive effects on functional tasks, PA, BMI/BW, depression and self-efficacy in people diagnosed with cancer. However, more higher-quality studies need to be conducted to further ascertain the effect of this intervention.

Effect of exercise on rehabilitation of breast cancer surgery patients: A systematic review and meta-analysis of randomized controlled trials

AIM

To determine the effective exercise methods for different complications of breast cancer patients after surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive electronic search was carried out with no time limit until May 2020. Studies must have been randomized controlled trials of patients after breast cancer surgery, without limit to the way of exercise. Literature quality was evaluated by the modified Jadad scale. The meta-analysis was conducted with CMA2.0 software.

RESULTS

Aerobic exercise reduced the intensity of the pain (MD = -1.043), improved shoulder flexion (MD = 3.398) and internal rotation range (MD = 3.868), lessened upper limb dysfunction (MD = -5.231) and improved muscle strength during flexion (MD = 1.076) and abduction (MD = 0.991). Shoulder elbow movement improved the range of shoulder external rotation (MD = 2.691) and reduced the incidence of arm lymphedema (RR = 0.343). Anti-resistance exercise also lessened upper limb dysfunction (MD = - 4.094).

Established and Emerging Cancer Therapies and Cardiovascular System: Focus on Hypertension-Mechanisms and Mitigation

Cardiovascular disease and cancer are 2 of the leading causes of death worldwide. Although improvements in outcomes have been noted for both disease entities, the success of cancer therapies has come at the cost of at times very impactful adverse events such as cardiovascular events. Hypertension has been noted as both, a side effect as well as a risk factor for the cardiotoxicity of cancer therapies. Some of these dynamics are in keeping with the role of hypertension as a cardiovascular risk factor not only for heart failure, but also for the development of coronary and cerebrovascular disease, and kidney disease and its association with a higher morbidity and mortality overall. Other aspects such as the molecular mechanisms underlying the amplification of acute and long-term cardiotoxicity risk of anthracyclines and increase in blood pressure with various cancer therapeutics remain to be elucidated. In this review, we cover the latest clinical data regarding the risk of hypertension across a spectrum of novel anticancer therapies as well as the underlying known or postulated pathophysiological mechanisms. Furthermore, we review the acute and long-term implications for the amplification of the development of cardiotoxicity with drugs not commonly associated with hypertension such as anthracyclines. An outline of management strategies, including pharmacological and lifestyle interventions as well as models of care aimed to facilitate early detection and more timely management of hypertension in patients with cancer and survivors concludes this review, which overall aims to improve both cardiovascular and cancer-specific outcomes.

Psycho-Educational and Rehabilitative Intervention to Manage Cancer Cachexia (PRICC) for Advanced Patients and Their Caregivers: Lessons Learned from a Single-Arm Feasibility Trial

Background: Key elements in cancer cachexia (CC) management are personalized and multimodal interventions, but it is hard for some patients to follow programs based on several components. We examined the feasibility of a bimodal intervention, including a psycho-educational component and exercises, to support patients and their caregivers in managing CC; Methods: Prospective mixed-methods pilot study explored feasibility data, changes in patient-reported outcomes, and performance outcomes over time in a convenient sample of 30 consecutive CC patients and their caregivers. Results: Twenty-four dyads consented to participate. Twenty dyads received at least two psycho-educational sessions, so the psycho-educational component was feasible for 83.3% of the sample. Six dyads participated in at least fourteen out of twenty-seven rehabilitation sessions, so the exercise program was feasible for 25.0% of the sample. Six dyads showed compliance greater than 50% for both components of the bimodal intervention. Conclusions: While we did not meet our primary feasibility endpoint and had mixed acceptability, our experience provides insight into the challenges and lessons learned in implementing a primary palliative care intervention for CC. More robust studies are needed to help clinicians understand the best exercise program for CC patients, to be included in a multimodal intervention.

Protocol for the SEHNeCa randomised clinical trial assesing Supervised Exercise for Head and Neck Cancer patients

OBJECTIVES

To evaluate the effectiveness of an innovative supervised exercise programme to mitigate the loss of lean body mass, functional capacity and quality of life in people with head and neck cancer, as well as to identify the optimal moment to apply it, before or after radiotherapy treatment, compared with the prescription of a physical activity plan carried out autonomously.

METHODS

Patients with squamous cell carcinoma of the head and neck (n = 144), treated with radiotherapy, will be randomly assigned to one of 3 comparison groups: pre-radiotherapy supervised exercise, post-radiotherapy supervised exercise and autonomous exercise, stratifying by human papillomavirus infection and previous surgery. The exercise programme will be carried out in 36 sessions over 12 weeks, combining moderate and high intensity strength and aerobic exercises. The main outcome variable is the change in lean body mass at 6 months measured by bioimpedance, while secondary variables are functional capacity, symptoms, quality of life and adverse effects. Longitudinal generalised mixed models will be used for the analyses of the repeated measurements at 3, 6, and 12 months after baseline.

CONCLUSIONS

The pilot study supports the feasibility and safety of the project. However, as the programme progressed, attendance at the sessions decreased. Strategies will be necessary for increasing attendance, as well as involving the patient in their recovery and other incentives. Follow-up after treatment to assess acute/late toxicity will enable us to know the response to both the exercise programme and its adherence.

TRIAL REGISTRATION

NCT04658706 Date and version identifier: March 1, 2023. Version 1.1.

Recent Findings in Physical Exercise for Cancer Survivors

In recent years, the number of cancer survivors has been increasing each year due to advances in the early diagnosis and treatment of cancer. Cancer survivors present a variety of physical and psychological complications due to cancer and its treatment. Physical exercise is an effective nonpharmacological treatment for complications in cancer survivors. Furthermore, recent evidence has shown that physical exercise improves the prognosis of cancer survivors. The benefits of physical exercise have been widely reported, and guidelines for physical exercise for cancer survivors have been published. These guidelines recommend that cancer survivors engage in moderate- or vigorous-intensity aerobic exercises and/or resistance training. However, many cancer survivors have a poor commitment to physical exercise. In the future, it is necessary to promote physical exercise among cancer survivors through outpatient rehabilitation and community support.

Description of supportive care and feasibility of physical exercise program to improve quality of life in advanced melanoma patients

Physical activity is the first-line treatment of cancer-related fatigue. It has shown benefits on patient's quality of life (QoL) when practiced during and after treatment. New treatments have drastically changed the prognosis of melanoma. Still, few data are available about research program of supportive care in advanced melanoma. The primary outcome was to assess the feasibility of setting up a prospective study evaluating the benefits of Adapted Physical Activity (APA) on the QoL of patients with advanced melanoma. Feasibility was defined with a combination of five criteria including completion of questionnaire, recruitment, participant retention, patient adhesion to supportive care, and absence of adverse event. Between September 2019 and March 2021, 271 melanoma patients were questioned. Around 60% of stage IV melanoma patients were interested in support care. Patient retention at 3 months was sufficient. Only one patient could not be evaluated after 3 months of enrolment because of deterioration of the general state. Adhesion to exercise and sessions was good. Supervised APA program appeared to be safe and well tolerated as no adverse events or discontinuations were reported. Setting up a prospective research program evaluating the benefits of physical activity in advanced melanoma patients seems feasible. With melanoma becoming a chronic disease, supportive care may reduce fatigue, improve QoL and help maintain a healthy lifestyle. Data supporting its benefits on this survivor population are needed.

Multimodal Physical Exercise and Functional Rehabilitation Program in Oncological Patients with Cancer-Related Fatigue-A Randomized Clinical Trial

The increase in life expectancy and survival time implies an increase in the possible side-effects of pharmacological treatments in patients. Cancer-related fatigue is one of these side-effects. The main objective of this study was to evaluate the effects of a multimodal program of physical exercise and functional rehabilitation on asthenia, pain, functional capacity, and quality of life in cancer patients with cancer-related fatigue.

METHODS

This was a randomized, parallel-controlled clinical trial, with two arms (experimental and control group), and it was conducted over the course of a year in the Oncology Hospitalization Unit at the University Hospital of Salamanca, Spain. Participants (n = 48) were assessed at three points during the study. The first assessment was prior to hospital discharge, the second assessment was after 15 days, and the final assessment was at one month post-hospital follow-up. The intervention lasted one month. The main variables studied were the dependency levels (Barthel), cancer-related fatigue (FACT-An), health-related quality of life (EuroQoL-5D), functional capacity (SPPB), and kinesiophobia (TSK-F).

RESULTS

Sample size (n = 44). Mean age 63.46 ± 12.36 years. Significant differences between control and experimental group participants in Barthel, FACT-An, TSK-F, and SPPB scores at follow-up and final assessment.

CONCLUSIONS

There are beneficial effects of a multimodal physical exercise and functional rehabilitation program in improving the autonomy of cancer-related fatigue patients.

Physiotherapy and Exercise Management of People Undergoing Surgery for Lung Cancer: A Survey of Current Practice across Australia and New Zealand

Background: Moderate- to high-certainty evidence supports the benefits of pre- and post-operative exercise for people undergoing surgical resection for lung cancer. Despite this, exercise programs are not commonly provided. Previous data regarding exercise practices are a decade old. Therefore, this study aimed to understand current exercise practices in surgical lung cancer care in Australia and New Zealand. Methods: An online cross-sectional survey of Australian and New Zealand allied health professionals specialising in exercise-based interventions was carried out. Survey development and reporting adhered to CHERRIES and CROSS checklists. Institutions with thoracic surgery departments were invited to participate via email, and additional responses were sought via snowballing. Results: The response rate was 81%, with a total of 70 health services responding. A total of 18 (26%) pre-operative services, 59 (84%) inpatient post-operative services, and 39 (55%) community/outpatient post-operative services were identified. Only eight (11%) services provided a pre-operative exercise program. Half of the respondents referred less than 25% of patients to community/outpatient exercise programs on hospital discharge. Respondents reported that their clinical management was predominantly influenced by established workplace practices and personal experience rather than evidence. Conclusions: The availability and uptake of pre- and post-operative exercise remain low, and work should continue to make pre/post-operative exercise training usual practice.

Exercise Training in Elderly Cancer Patients: A Systematic Review

Due to the aging of the population, in 70% of cases, a new cancer diagnosis equals a cancer diagnosis in a geriatric patient. In this population, beyond the concept of mortality and morbidity, functional capacity, disability, and quality of life remain crucial. In fact, when the functional status is preserved, the pathogenetic curve towards disability will stop or even regress. The present systematic review investigated the effectiveness of physical exercise, as part of a holistic assessment of the patient, for preventing disability and improving the patient’s quality of life, and partially reducing all-cause mortality. This evidence must point towards decentralization of care by implementing the development of rehabilitation programs for elderly cancer patients either before or after anti-cancer therapy.

The minimal clinically important difference in the treadmill six-minute walk test in active women with breast cancer during and after oncological treatments

PURPOSE

To examine the minimal clinically important difference (MCID) in the treadmill 6-minute walk test (6MWT) in women with breast cancer.

MATERIALS AND METHODS

A secondary analysis of cross-sectional data from 112 women who were undergoing chemotherapy or had undergone anticancer treatment was conducted. Participants completed the 6MWT on a treadmill and the European Organization for Research and Treatment of Cancer Questionnaire (EORTC-QLQ-C30) twice, eight weeks apart. Change in the physical function domain of the EORTC-QLQ-C30 was used to classify the "positive change" subgroup (≥5 points difference) and the "unchanged" subgroup (<5 points difference). This was combined with the distance difference from the 6MWTs, determining the MCID as the cut-off from the area under the receiver operating characteristic (AUROC) curve (anchor-based determination). The MCID was also determined from (1) the effect size and (2) the difference in standard error (SEM) of the results of the first and second 6MWT (distribution-based determination).

RESULTS

The MCIDs in the during-chemotherapy group was 66.5 and 41.5 m and those in the after-treatment group to be 41.4 and 40.5 m (SEM and effect size based respectively).

CONCLUSIONS

The MCID in the treadmill 6MWT distance could be used to interpret changes in the physical health status of women with breast cancer.IMPLICATIONS FOR REHABILITATIONThe MCID for the 6MWT on treadmill in active women with breast cancer is of approximately 54 m during chemotherapy, and 41.6 m after treatment.The MCID on treadmill 6MWT distance could be used to interpret a decline in the physical health status of women with breast cancer.The 6MWT on treadmill could be an easy, feasible, performed under controlled conditions, alternative to the 6MWT to obtain valuable information in this population.

Early postoperative gain in activity levels of lower extremity sarcoma survivors positively affects long-term physical activity and performance

PURPOSE

Little is known about the effect of sports activity levels on health-related quality of life (HRQOL) in long-term survivors of lower-extremity sarcoma.

METHODS

Eighty-three long-term survivors of bone and soft tissue sarcoma of the lower extremities with a median follow-up of 14 (range: 5-35) years completed the University of California and Los Angeles (UCLA) activity scores before tumor resection, 1 year after surgery and at the latest follow-up, as well as a Short Form 36 (SF-36) health survey at the latest follow-up. Simple linear regression models as well as stepwise variable selection with Akaike information criterion (AIC) were undertaken.

RESULTS

The preoperative UCLA activity level (median: 9, range: 2-10) dropped to a median of 4 (range: 1-10) 1 year after surgery before increasing to a score of 6 (range: 2-10) 5 years after surgery. The long-term SF-36 physical health component summary score (PCS) was 49 (SD: 9), and the mental health component summary score (MCS) was 54 (SD: 7). A linear model with stepwise variable selection identified a negative correlation of PCS with age at surgery (estimate: -0.2; p = 0.02), UCLA score at the last follow-up (estimate: 1.4; p = 0.02) and UCLA score 1 year after surgery (estimate: 1.0; p = 0.02).

CONCLUSION

As not only the final activity levels but also the status immediately after surgery affect the PCS, higher early activity levels should be a goal of modern rehabilitation after sarcoma treatment. Further studies are needed to weigh the potential postoperative risks of higher sport activity levels against the benefits described in this study.

LEVEL OF EVIDENCE

Level 4.

Reporting Attendance and Resistance Exercise Compliance in Men with Localized Prostate Cancer

PURPOSE

Resistance exercise is a well-established intervention to counteract musculoskeletal and metabolic toxicities from prostate cancer treatment. In this study, we reported resistance exercise attendance and compliance, and examined if these variables can influence changes in outcomes of interest in men with localized or locally advanced prostate cancer.

METHODS

A total of 83 prostate cancer patients (age, 68.2 ± 7.0 yr; body mass index, 27.7 ± 3.8 kg·m -2 ) who had undergone 6 months of resistance-based exercise and had data available on exercise training from logbook records were examined. Attendance outcomes such as missed sessions, interruptions and permanent discontinuation, and metrics such as dosage completed (sessions × number of exercises × sets × repetitions × external load), compliance, tolerance, reductions, and escalations were assessed. Outcomes assessed were body composition, physical function, and muscle strength.

RESULTS

Median resistance exercise attendance was 80.6%, with a median resistance exercise compliance of 88.5% (interquartile range [IQR], 61.1%-107.1%) per participant. A median of 11 (IQR, 1-26) and 0 (IQR, 0-2) sessions were escalated or reduced, respectively. Significant improvements were observed in whole-body lean mass, 400-m walk, repeated chair rise, leg press, and chest press strength after 6 months of intervention ( P < 0.05) regardless of resistance exercise compliance ( Ptrend = 0.199-0.950). Participants with higher levels of resistance exercise compliance presented greater improvements in trunk fat mass ( Ptrend = 0.026) and appendicular lean mass ( Ptrend = 0.047).

CONCLUSIONS

A higher resistance exercise compliance led to greater improvements in regional fat and lean mass, whereas physical function and muscle strength improvements were achieved with lower compliance. In addition, patients experienced a high number of dose escalations during the intervention. These findings are important to improve the reproducibility/precision of exercise medicine prescription.

Movement and health beyond care, MoviS: study protocol for a randomized clinical trial on nutrition and exercise educational programs for breast cancer survivors

BACKGROUND

Breast cancer (BC) is the most common invasive cancer in women, and exercise can significantly improve the outcomes of BC survivors. MoviS (Movement and Health Beyond Care) is a randomized controlled trial aimed to evaluate the potential health benefits of exercise and proper nutritional habits. This study aims to assess the efficacy of aerobic exercise training in improving quality of life (QoL) and health-related factors in high-risk BC.

METHODS

One hundred seventy-two BC survivor women, aged 30-70 years, non-metastatic, stage 0-III, non-physically active, 6-12 months post-surgery, and post chemo- or radiotherapy, will be recruited in this study. Women will be randomly allocated to the intervention arm (lifestyle recommendations and MoviS Training) or control arm (lifestyle recommendations). The MoviS training consists of 12 weeks of aerobic exercise training (2 days/week of supervised and 1 day/week of unsupervised exercise) with a progressive increase in exercise intensity (40-70% of heart rate reserve) and duration (20-60 min). Both arms will receive counseling on healthy lifestyle habits (nutrition and exercise) based on the World Cancer Research Fund International (WCRF) 2018 guidelines. The primary outcome is the improvement of the QoL. The secondary outcomes are improvement of health-related parameters such as Mediterranean diet adherence, physical activity level, flexibility, muscular fitness, fatigue, cardiorespiratory fitness (estimated maximal oxygen uptake), echocardiographic parameters, heart rate variability (average of the standard deviations of all 5 min normal to normal intervals (ASDNN/5 min) and 24 h very low and low frequency), and metabolic, endocrine, and inflammatory serum biomarkers (glycemia, insulin resistance, progesterone, testosterone, and high-sensitivity C-reactive protein).

DISCUSSION

This trial aims to evaluate if supervised exercise may improve QoL and health-related factors of BC survivors with a high risk of recurrence. Findings from this project could provide knowledge improvement in the field of exercise oncology through the participation of a multidisciplinary team that will provide a coordinated program of cancer care to improve healthcare quality, improve prognosis, increase survival times and QoL, and reduce the risk of BC recurrence.

TRIAL REGISTRATION

ClinicalTrials.gov  NCT04818359 . Retrospectively registered on March 26, 2021.

Safety, Feasibility and Efficacy of Lokomat® and Armeo®Spring Training in Deconditioned Paediatric, Adolescent and Young Adult Cancer Patients

BACKGROUND

Rehabilitation robotics is a field of study which aims to understand and augment rehabilitation through the use of robotics devices.

OBJECTIVE

This proof of concept study aimed to test the safety (no. adverse events, incidence of infection), feasibility (program demand, adherence, participant satisfaction) and efficacy (Peak Oxygen uptake (VO_2peak), 6-min walk test, gait speeds, Canadian Occupational Performance Measure, quality of life) of Lokomat^® and Armeo^®Spring training in children and adolescents and young adults (AYAs) during or soon after cancer treatment.

METHOD

This was a 6-week single arm pre-post study. Cancer patients with significant musculoskeletal, neurological, gait and/or upper limb deficiency aged 5 to 25 years were recruited. The rehabilitation program included access to two robotic orthoses: the Lokomat^® and/or Armeo^®Spring. Robotic devices utilised real-time biofeedback and computer games to engage and guide participants through a repetitive functional range of movement aimed at improving functional deficiencies. Progressive increases in exercise intensity and duration were encouraged.

RESULTS

Twentey-eight participants were approached for study; twenty-one consented. Seventy-six percent completed the six-week intervention with an overall adherence of 83%. The mean participant satisfaction score was 8.8/10. Forty-nine adverse events were recorded throughout the course of the study, forty-five grade 1, three grade 2 and one grade 3. No adverse events led to withdrawal from the study. Preliminary efficacy results indicate large beneficial effects on VO_2peak (r = 0.63), 10 m comfortable pace walk (r = 0.51) and maximal pace walk (r = 0.60), 6-min walk test (r = 0.60), maximal back and leg strength (r = 0.71), trunk flexibility (r = 0.60), The European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) (r = 0.61), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT F) r = 0.53 and the Canadian Occupational Performance Measure, satisfaction (r = 0.88) and performance scores (r = 0.83), and moderate beneficial effects on Leisure Score Index (LSI) (r = 0.30).

CONCLUSION

Our results suggest that Lokomat^® and Armeo^®Spring training is safe and feasible for use in children and AYAs who are currently undergoing or have recently completed cancer therapy. A larger controlled trial investigating the efficacy of robotics rehabilitation in this cohort is warranted.

Prescribing Exercise to Cancer Patients Suffering from Increased Bone Fracture Risk Due to Metastatic Bone Disease or Multiple Myeloma in Austria-An Inter- and Multidisciplinary Evaluation Measure

INTRODUCTION

In the current absence of specific functional fracture risk assessment technology, the planning of physical exercise interventions for cancer patients suffering from increased bone fracture risk remains a serious clinical challenge. Until a reliable, solely technical solution is available for the clinician, fracture risk assessment remains an inter- and multidisciplinary decision to be made by various medical experts. The aim of this short paper is depicting how this challenge should be approached in the clinical reality according to Austrian experts in cancer rehabilitation, presenting the best-practice model in Austria. Following referral from the specialist responsible for the primary cancer treatment (oncologist, surgeon, etc.), the physiatrist takes on the role of rehabilitation case manager for each individual patient. Fracture risk assessment is then undertaken by specialists in radiology, orthopedics, oncology, and radiation therapy, with the result that the affected bone regions are classified as being at highly/slightly/not increased fracture risk. Following internal clearance, exercise planning is undertaken by a specialist in exercise therapy together with the physiatrist based on the individual's fracture risk assessment. In the case in which the patient shows exercise limitations due to additional musculoskeletal impairments, adjuvant physical modalities such as physiotherapy should be prescribed to increase exercisability.

CONCLUSION

Exercise prescription for cancer patients suffering from increased fracture risk is an inter- and multidisciplinary team decision for each individual patient.

Exercise for the Prevention of Anthracycline-Induced Functional Disability and Cardiac Dysfunction: The BREXIT Study

BACKGROUND

Breast cancer survivors treated with anthracycline-based chemotherapy (AC) have increased risk of functional limitation and cardiac dysfunction. We conducted a 12-month randomized controlled trial in 104 patients with early-stage breast cancer scheduled for AC to determine whether 12 months of exercise training (ExT) could attenuate functional disability (primary end point), improve cardiorespiratory fitness (VO₂peak), and prevent cardiac dysfunction.

METHODS

Women 40 to 75 years of age with stage I to III breast cancer scheduled for AC were randomized to 3 to 4 days per week aerobic and resistance ExT for 12 months (n=52) or usual care (UC; n=52). Functional measures were performed at baseline, at 4 weeks after AC (4 months), and at 12 months, comprising: (1) cardiopulmonary exercise testing to quantify VO₂peak and functional disability (VO₂peak ≤18.0 mL·kg^-1·min^-1); (2) cardiac reserve (response from rest to peak exercise), quantified with exercise cardiac magnetic resonance measures to determine changes in left and right ventricular ejection fraction, cardiac output, and stroke volume; (3) standard-of-care echocardiography-derived resting left ventricular ejection fraction and global longitudinal strain; and (4) biochemistry (troponin and BNP [B-type natriuretic peptide]).

RESULTS

Among 104 participants randomized, greater study attrition was observed among UC participants (P=0.031), with 93 women assessed at 4 months (ExT, n=49; UC, n=44) and 87 women assessed at 12 months (ExT, n=49; UC, n=38). ExT attenuated functional disability at 4 months (odds ratio, 0.32 [95% CI, 0.11-0.94]; P=0.03) but not at 12 months (odds ratio, 0.27 [95% CI, 0.06-1.12]; P=0.07). In a per-protocol analysis, functional disability was prevented entirely at 12 months among participants adherent to ExT (ExT, 0% versus UC, 20%; P=0.005). Compared with UC at 12 months, ExT was associated with a net 3.5-mL·kg^-1·min^-1 improvement in VO₂peak that coincided with greater cardiac output, stroke volume, and left and right ventricular ejection fraction reserve (P<0.001 for all). There was no effect of ExT on resting measures of left ventricular function. Postchemotherapy troponin increased less in ExT than in UC (8-fold versus 16-fold increase; P=0.002). There were no changes in BNP in either group.

CONCLUSIONS

In women with early-stage breast cancer undergoing AC, 12 months of ExT did not attenuate functional disability, but provided large, clinically meaningful benefits on VO₂peak and cardiac reserve.

REGISTRATION

URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12617001408370.

Football training as a non-pharmacological treatment of the global aging population-A topical review

In the present topical mini-review, the beneficial impact of small-sided game football training for the increasing elderly global population is presented. As a multicomponent type of physical activity, football training executed on small pitched with 4-6 players in each team is targeting a myriad of physiological systems and causes positive adaptations of relevance for several non-communicable diseases, of which the incidence increases with advancing age. There is strong scientific evidence that this type of football training promotes cardiovascular, metabolic and musculo-skeletal health in elderly individuals. These positive adaptations can prevent cardiovascular disease, type 2 diabetes, sarcopenia and osteoporosis, and lower the risk of falls. Also, football training has been proven an efficient part of the treatment of several patient groups including men with prostate cancer and women after breast cancer. Finally, regular football training has an anti-inflammatory effect and may slow the biological aging. Overall, there is a growing body of evidence suggesting that recreational football training can promote health in the elderly.

Factors related to promotion of physical activity in clinical oncology practice: A scoping review

OBJECTIVES

To map which factors have been considered, explored, and found to influence physical activity (PA) promotion by oncology physicians and nurses (OPN).

METHODS

A scoping review of empirical studies was conducted using Arksey and O'Malley's framework and the PRISMA-ScR guideline. The quality of the studies was evaluated using the QATSDD tool.

RESULTS

Twenty-nine publications were included. The methodological quality of the studies was low to moderate. Studies have shown a positive attitude towards PA and recommending PA. PA knowledge seems to influence PA promotion by OPNs to some extent. Structural barriers for PA promotion are the most endorsed barriers but to what extent they influence PA promotion is unclear. The demographic and professional characteristics of OPNs and their PA behavior do not seem to influence PA promotion to a greater extent. Patients' PA interest, health characteristics, and medical conditions are additional factors. Their implications for PA promotion are not fully elucidated.

CONCLUSIONS

The varied results across the studies, together with the methodological limitations of the studies, make it unclear to what extent the explored factors influence PA promotion by OPNs.

PRACTICE IMPLICATIONS

More research into what influences OPNs' engagement in PA promotion is warranted to support clinical PA promotion.

Lower-Body Resistance Training Reduces Interleukin-1β and Transforming Growth Factor-β1 Levels and Fatigue and Increases Physical Performance in Breast Cancer Survivors

ABSTRACT

Martins, FM, Santagnello, SB, de Oliveira Junior, GN, de Sousa, JdFR, Michelin, MA, Nomelini, RS, Murta, EFC, and Orsatti, FL. Lower-body resistance training reduces interleukin-1β and transforming growth factor-β1 levels and fatigue and increases physical performance in breast cancer survivors. J Strength Cond Res 37(2): 439-451, 2023-This article ascertains whether resistance training (RT) improves inflammatory markers, fatigue (sensations and fatigability), and physical performance in breast cancer survivors (BCS) and investigates whether the changes in the inflammatory markers, fatigue, and physical performance are associated with each other. Volunteers were randomly divided into 2 groups: control group (n = 11) and RT group (n = 11). Resistance training (3 sets of 8-12 repetitions with 80% 1 repetition maximum (1RM) on 4 exercises-leg extension, leg curl, 45° leg press, and calf raise) was performed 3 times a week for 12 weeks. Self-reported fatigue (SRF), fatigability (critical torque [CT] and W prime [W']), muscle strength, and circulating inflammatory markers were assessed using the Brief Fatigue Inventory, iDXA, 1RM test, protocol of 60 maximal voluntary isometric contractions, and enzyme-linked immunosorbent assay, respectively. Resistance training reduced interleukin (IL)-1β, transforming growth factor (TGF)-β1, and SRF score and increased muscle strength, 6-minute walk test (6MWT), CT, and W'. In the RT group, the changes in SRF were positively associated with the changes in IL-1β. The changes in muscle strength were associated with the changes in CT and W', and the changes in the 6MWT were associated with the changes in CT, W', muscle strength, and SRF. Resistance training improved fatigue and physical performance and reduced IL-1β, and TGF-β1 in BCS. Although improvement in fatigability seems to be dependent on the increase in muscle strength, improvement in the sensation of fatigue seems to be dependent on the reduction in IL-1β after RT. Increase in physical performance seems to be dependent on improvement in muscle strength and fatigue.

Rehabilitation of patients after CAR T-cell therapy. Experiences on 5 patients

OBJECTIVE

CAR T-cell therapy is an effective treatment for various relapsed or refractory haemato-oncological diseases. However, this therapy results in significant immunosuppression that lasts for months. Whether these patients are at risk during a rehabilitation stay, e.g., due to infections, has not yet been answered.

METHODS

We describe the rehabilitation stay under special hygienic conditions of the five patients rehabilitated in our clinic after CAR T-cell therapy. Complications that occurred during rehabilitation are reported, as well as the positive effects of rehabilitation on physical performance, polyneuropathic complaints, anxiety and depression, and individual limitations.

RESULTS

One patient reported signs of infection already at the beginning of rehabilitation. This was treated with antibiotics, and rehabilitation could be continued. No complications occurred in any of the other patients. All patients reported having benefited physically and psychologically from the rehabilitation, and two expressed the intention to return to work.

CONCLUSIONS

As far as we know, this is the first report on several patients after CAR T-cell therapy. Based on the limited data, there is no reason to withhold a rehabilitation stay from patients after CAR T-cell therapy.

Safety, Feasibility, and Efficacy of Exercise Interventions for People With Multiple Myeloma: A Systematic Review

Bone lesions and other disease- and treatment-related side effects commonly experienced by people with multiple myeloma (MM) may impede their ability to exercise. This systematic review evaluated the safety, feasibility, and efficacy of exercise program participation on the physiological and/or psychological health of people with MM. Literature searches were conducted through five electronic databases and appraised using the Delphi list of criteria. Controlled trials that assessed the safety and feasibility of an exercise intervention and its effects on disease- or treatment-related symptoms in people with MM were included. Seven studies of varying quality involving 563 participants were included. All studies concluded that exercise was safe, reporting zero serious and 4 adverse events attributable to exercise testing or training. Attendance ranged from 58% to 96%, however no study reported adherence to the exercise prescription. Compared to a control group, exercise did not appear to affect fatigue, depression, anxiety, body composition, quality of life, or sleep. Isolated studies identified between-group differences favoring exercise in lower limb strength (+8.4 kg, 95% CI 0.5, 16.3, P= .04), peak oxygen uptake (+1.2 mL/kg/min, 95% CI 0.3, 3.7, P= .02), physical activity (+6.5MET-hs/wk, P< .001), stem cell collection attempts (1.1 ± 0.2 vs. 1.5 ± 0.9, P< .01), and red blood cell (1.8 ± 2.2 vs. 2.4 ± 2.6, P< .05) and platelet transfusions (2.3 ± 1.6 vs. 3.5 ± 3.4, P < .05) during transplantation. Exercise interventions appear safe and well attended by people with MM. The lack of improvements in disease- and treatment-related symptoms requires further exploration to determine whether exercise is a sufficient stimulus to elicit benefits in this unique population.

Adapting an Evidence-Based Exercise and Education Program for Older Breast Cancer Survivors for the REJOIN Trial

Physical activity (PA) promotes survival and mitigates symptoms in older breast cancer survivors (BCS), especially to reduce joint pain associated with adjuvant hormonal treatment. The purpose is to describe the adaptation process for an evidence-based exercise and education curriculum (i.e., Fit & Strong!) to support older BCS participating in the Using Exercise to Relieve Joint Pain and Improve Aromatase Inhibitor Adherence in Older Breast Cancer Survivors trial. We reviewed all educational materials with scientific/clinical experts to identify necessary content changes. Next, we conducted semistructured phone interviews with BCS to review all educational materials and conducted a real-time pretest for the trial. Overall, BCS found the adapted materials and experience acceptable (mean score of 9.2/10 for satisfaction). Content changes included simplifying exercise instructions, prioritizing content related to the trial goals, and updating photographs. Because of COVID, the pretest was conducted via Zoom. Our multistep adaptation process provided an acceptable intervention to meet the needs of older BCS. Lessons learned will be applied to the forthcoming pilot trial.

Metabolic Health, Mitochondrial Fitness, Physical Activity, and Cancer

Cancer continues to be a significant global health issue. Traditional genetic-based approaches to understanding and treating cancer have had limited success. Researchers are increasingly exploring the impact of the environment, specifically inflammation and metabolism, on cancer development. Examining the role of mitochondria in this context is crucial for understanding the connections between metabolic health, physical activity, and cancer. This study aimed to review the literature on this topic through a comprehensive narrative review of various databases including MedLine (PubMed), Cochrane (Wiley), Embase, PsychINFO, and CinAhl. The review highlighted the importance of mitochondrial function in overall health and in regulating key events in cancer development, such as apoptosis. The concept of "mitochondrial fitness" emphasizes the crucial role of mitochondria in cell metabolism, particularly their oxidative functions, and how proper function can prevent replication errors and regulate apoptosis. Engaging in high-energy-demanding movement, such as exercise, is a powerful intervention for improving mitochondrial function and increasing resistance to environmental stressors. These findings support the significance of considering the role of the environment, specifically inflammation and metabolism, in cancer development and treatment. Further research is required to fully understand the mechanisms by which physical activity improves mitochondrial function and potentially reduces the risk of cancer.

Long-term effects of exercise interventions on physical activity in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Benefits of exercise interventions for cancer patients are well established. This systematic review aimed to investigate the sustainability of exercise interventions with respect to physical activity behaviour of breast cancer patients in the longer term.

METHODS

The databases Pubmed, Cochrane, Embase, and Web of Science were systematically searched for randomized controlled trials (RCTs) investigating aerobic exercise, resistance exercise, or combined exercise interventions in breast cancer patients and assessing physical activity at least 2 months after the intervention. Random-effect models were used to calculate standardized mean differences (SMD).

RESULTS

A total of 27 RCTs with 4120 participants were included in the review, of which 11 RCTs with 1545 participants had appropriate data for the meta-analyses. Physical activity was mainly self-reported, and most exercise interventions were supervised. Exercise interventions tended to show a moderate significant effect up to 6 months for moderate to vigorous physical activity (SMD [95% CI] = 0.39 [0.07, 0.70]) and small, non-significant effects on total physical activity at 6 months (SMD [95% CI] = 0.14 [- 0.00, 0.28]) and up to 60 months after the intervention (SMD = 0.29 [-0.31, 0.90]). Differences between intervention characteristics, such as supervised versus unsupervised, were inconclusive due to the small number of RCTs.

CONCLUSIONS

The physical activity behaviour in breast cancer patients remained improved for several months beyond the end of exercise interventions, but effects were small to moderate and diminished over time. Future studies should clarify how to maintain a healthy level of physical activity after completion of an exercise intervention.

Feasibility and pilot testing of a personalized eHealth intervention for pain science education and self-management for breast cancer survivors with persistent pain: a mixed-method study

PURPOSE

Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention's acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy.

METHODS

A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks).

RESULTS

Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life.

CONCLUSION

A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.