Exercise interventions for adults with cancer receiving radiation therapy alone

Cardiovascular training for fatigue in people with cancer

RATIONALE

Cancer-related fatigue (CRF) is the most prevalent and severe symptom among people with cancer. It can be attributed to the cancer itself or to anticancer therapies. CRF affects the individual physically and mentally, and cannot be alleviated by rest. Studies show a positive effect of exercise on CRF.

OBJECTIVES

To evaluate the effects of cardiovascular training on cancer-related fatigue (CRF), quality of life (QoL), adverse events, anxiety, and depression in people with cancer, with regard to their stage of anticancer therapy (before, during, or after), up to 12 weeks, up to six months, or longer, postintervention.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and World Health Organization ICTRP to identify studies that are included in the review. The latest search date was October 2023.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) evaluating cardiovascular training for CRF or QoL, or both, in people with cancer. Trials were eligible if training was structured, included at least five sessions, and instruction was face-to-face (via video tools or in person). We excluded studies with fewer than 20 randomised participants per group and where only an abstract was available.

OUTCOMES

Our critical outcomes were: short-, medium-, long-term CRF and QoL. Important outcomes were adverse events, and short-, medium-, long-term anxiety and depression.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess bias in RCTs.

SYNTHESIS METHODS

We used standard Cochrane methodology. We synthesised results for each outcome using meta-analysis where possible (inverse variance or Mantel-Haenszel; random-effects model). We pooled data for the respective assessment periods above. We used GRADE to assess certainty of evidence for each outcome.

INCLUDED STUDIES

We included 23 RCTs with 2135 participants, of whom 96.6% originated from high-income countries; 1101 participants were randomised to cardiovascular training and 1034 to no training. Studies included mostly females who were diagnosed with breast cancer. We also identified 36 ongoing and 12 completed studies that have not yet published (awaiting assessment). We only present findings on CRF, QoL and adverse events. For details regarding anxiety and depression, see full text.

SYNTHESIS OF RESULTS

Cardiovascular training before anticancer therapy versus no training for people with cancer We identified no studies for inclusion in this comparison. Cardiovascular training during anticancer therapy versus no training for people with cancer We included 10 studies (1026 participants); eight studies contributed data to quantitative analyses (860 participants). Cardiovascular training probably reduces short-term CRF slightly (mean difference (MD) 2.85, 95% confidence interval (CI) 1.16 to 4.55, on the Functional Assessment of Cancer Therapy - Fatigue (FACT-F), scale 0 to 52, higher values mean better outcome; minimally important difference (MID) 3; 6 studies, 593 participants) and probably results in little to no difference in short-term QoL (MD 3.56, 95% CI 0.21 to 6.90, on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ C-30), scale 0 to 100, higher values mean better outcome, MID 10; 6 studies, 612 participants) (both moderate-certainty evidence). We are uncertain about the effects on medium-term CRF (MD 2.67, 95% CI -2.58 to 7.92, on FACT-F; MID 3; 1 study, 62 participants), long-term CRF (MD 0.41, 95% CI -2.24 to 3.05, on FACT-F; MID 3; 2 studies, 230 participants), medium-term QoL (MD 6.79, 95% CI -4.39 to 17.97, on EORTC QLQ C-30; MID 10; 1 study, 62 participants), and long-term QoL (MD 1.51, 95% CI -3.40 to 6.42, on EORTC QLQ C-30; MID 10; 2 studies, 230 participants) (all very low-certainty evidence). For adverse events (any grade and follow-up), we did not perform meta-analysis due to heterogeneous definitions, reporting, and measurement (9 RCTs, 955 participants; very low-certainty evidence). Cardiovascular training after anticancer therapy versus no training for people with cancer We included 13 studies (1109 participants); nine studies contributed data to quantitative analyses (756 participants). We are uncertain about the effects of cardiovascular training on short-term CRF (MD 3.62, 95% CI 0 to 7.13, on FACT-F; MID 3; 6 studies, 497 participants), long-term CRF (MD -0.80, 95% CI -1.72 to 0.13, on the Fatigue Symptom Inventory (FSI), scale 1 to 10, higher values mean worse outcome; MID 1; 2 studies, 262 participants), short-term QoL (MD 3.70, 95% CI -0.14 to 7.41, on the Functional Assessment of Cancer Therapy - General (FACT-G), scale 0 to 108, higher values mean better outcome; MID 4; 8 studies, 642 participants), long-term QoL (MD 3.10, 95% CI -1.12 to 7.32, on FACT-G; MID 4; 1 study, 201 participants), and adverse events (risk ratio (RR) 2.71, 95% CI 0.58 to 12.67; 1 study, 50 participants) (all very low-certainty evidence). There were no data for medium-term CRF and QoL.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that cardiovascular training by people with cancer during their anticancer therapy slightly reduces short-term CRF and results in little to no difference in short-term QoL. We do not know whether cardiovascular training increases or decreases medium-term CRF/QoL, and long-term CRF/QoL. There is very low-certainty evidence (due to heterogeneous definitions, reporting and measurement) evaluating whether the training increases or decreases adverse events. In people with cancer who perform cardiovascular training after anticancer therapy, we are uncertain about the effects on short-term CRF/QoL, long-term CRF/QoL, and adverse events. We identified a lack of evidence concerning cardiovascular training before anticancer therapy and on safety outcomes. The 36 ongoing and 12 completed, but unpublished, studies could help close this gap, and could contribute to improving the effect estimates and certainty.

FUNDING

This Cochrane review was funded by the Federal Ministry of Education and Research of Germany, grant number: FKZ 01KG2017.

REGISTRATION

Protocol available via DOI: 10.1002/14651858.CD015211.

An integrated framework for the study of exercise across the postdiagnosis cancer continuum

Exercise plays many important roles across the entire cancer continuum that have been described in previous frameworks. These frameworks, however, have generally provided a simplified description of the roles of exercise postdiagnosis. The modern cancer treatment landscape has become complex and often consists of multiple lines of multimodal treatments combined concurrently and/or sequentially and delivered over many months or years. This complexity requires a more multifaceted and targeted approach to the study of exercise after a cancer diagnosis. Here, we propose a new integrated framework-Exercise Across the Postdiagnosis Cancer Continuum (EPiCC)-that highlights the distinct roles of exercise for disease treatment and supportive care from diagnosis until death. We also propose new terminology to clarify the distinct roles of exercise that emerge in the context of the modern cancer treatment landscape. The EPiCC Framework is structured around multiple sequential cancer treatments that highlight six distinct cancer treatment-related time periods for exercise-before treatments, during treatments, between treatments, immediately after successful treatments, during longer term survivorship after successful treatments, and during end of life after unsuccessful treatments. The EPiCC Framework proposes that the specific roles of exercise as a disease treatment and supportive care intervention will vary depending on its positioning within different cancer treatment combinations. As a cancer treatment, exercise may serve as a "priming therapy", primary therapy, neoadjuvant therapy, induction therapy, "bridging therapy", adjuvant therapy, consolidation therapy, maintenance therapy, and/or salvage therapy. As a supportive care intervention, exercise may serve as prehabilitation, intrahabilitation, interhabilitation, rehabilitation, "perihabilitation", health promotion/disease prevention, and/or palliation. To date, exercise has been studied during all of the cancer treatment-related time periods but only in relation to some cancer treatments and combinations. Moreover, fewer studies have examined exercise across multiple cancer treatment-related time periods within any cancer treatment combination. Future research is needed to study exercise as a disease treatment and supportive care intervention within and across the distinct cancer treatment-related time periods contained within different cancer treatment combinations. The aim of the EPiCC Framework is to stimulate a more targeted, integrated, and clinically-informed approach to the study of exercise after a cancer diagnosis.

Long-term quality of life of testicular cancer survivors differs according to applied adjuvant treatment and tumour type

PURPOSE

To evaluate the quality of life (QoL) in long-term testicular cancer (TC) survivors.

METHODS

QoL was assessed in TC survivors treated between March 1976 and December 2004 (n = 625) using the EORTC-QLQ-C30 questionnaire, including a TC module. The assessment was performed at two time points (2006: response rate: n = 201/625 (32.2%), median follow-up (FU): 12.9 years (range 1.1-30.9); 2017: response rate: n = 95/201 (47.3%), median FU: 26.2 years (range: 13.0-41.2)). TC survivors were grouped according to treatment strategy, tumour entity, clinical stage and prognosis group. Linear and multiple linear regression analyses were performed, with age and time of follow-up as possible confounders.

RESULTS

Radiation therapy (RT) compared to retroperitoneal lymph node dissection (RPLND) was associated with a higher impairment of physical function (2017: β =  - 9.038; t(84) =  - 2.03; p = 0.045), role function (2017: β =  - 12.764; t(84) =  - 2.00; p = 0.048), emotional function (2006: β =  - 9.501; t(183) =  - 2.09; p = 0.038) and nausea (2006: β = 6.679; t(185) = 2.70; p = 0.008). However, RT was associated with a lower impairment of sexual enjoyment (2017: symptoms: β = 26.831; t(64) = 2.66; p = 0.010; functional: β = 22.983; t(65) = 2.36; p = 0.021). Chemotherapy (CT), compared to RPLND was associated with a higher impairment of role (2017: β =  - 16.944; t(84) =  - 2.62; p = 0.011) and social function (2017: β =  - 19.160; t(79) =  - 2.56; p = 0.012), more insomnia (2017: β = 19.595; t(84) = 2.25; p = 0.027) and greater concerns about infertility (2017: β = 19.830; t(80) = 2.30; p = 0.024). In terms of tumour type, nonseminomatous germ cell tumour (NSGCT) compared to seminoma survivors had significantly lower impairment of nausea (2006: β =  - 4.659; t(187) =  - 2.17; p = 0.031), appetite loss (2006: β =  - 7.554; t(188) =  - 2.77; p = 0.006) and future perspective (2006: β =  - 12.146; t(175) =  - 2.08; p = 0.039). On the other hand, surviving NSGCT was associated with higher impairment in terms of sexual problems (2006: β = 16.759; t(145) = 3.51; p < 0.001; 2017: β = 21.207; t(63) = 2.73; p = 0.008) and sexual enjoyment (2017: β =  - 24.224; t(66) =  - 2.76; p = 0.008).

CONCLUSIONS

The applied adjuvant treatment and the tumour entity had a significant impact on the long-term QoL of TC survivors, even more than 25 years after the completion of therapy. Both RT and CT had a negative impact compared to survivors treated with RPLND, except for sexual concerns. NSGCT survivors had a lower impairment of QoL compared to seminoma survivors, except in terms of sexual concerns.

IMPLICATIONS FOR CANCER SURVIVORS

Implications for cancer survivors are to raise awareness of aspects of long-term and late effects on QoL in TC survivors; offer supportive care, such as psycho-oncological support or lifestyle modification, if a deterioration in QoL is noticed; and avoid toxic treatment without compromising a cure whenever possible.

Unraveling the "golden ratio": a pilot study investigating acute-to-chronic workload ratio in breast cancer patients undergoing active treatment

Training load monitoring is a common practice in sports medicine for supporting athletes' health and performance. Despite progress in exercise oncology research for breast cancer patients, training load monitoring is underutilized. This study retrospectively investigated the relationship between maintained training load within a defined range and physical and health outcomes of ten breast cancer patients during active anticancer treatment who underwent a 12-week exercise program. Intervention consisted of endurance and resistance training, three times a week, with each session lasting 30-45 min. Assessments were conducted at baseline, 6 and 12 weeks after enrollment, evaluating physical function (6-min walk test-6MWT, and sit-to-stand), muscle strength, body composition, sleep quality (Pittsburgh Sleep Quality Index-Pittsburgh Sleep Quality Index), quality of life (EORTC-QLQ-C30), heart rate variability and physical activity levels (International Physical Activity Questionnaire-International Physical Activity Questionnaire). The Physiological Cost Index/Energy Expenditure Index (PCI/EEI) was estimated using the 6MWT and Heart rate. Training load monitoring was performed by session rating of perceived exertion (sRPE, relative intensity multiplying with session duration). Acute-to-Chronic Workload Ratio (ACWR) (7:28, rolling average) was calculated accordingly. Analyses were performed within-subjects across time points and between-subjects, comparing those who maintained from weeks 6-12 an ACWR of 0.8-1.3 with those who did not. Adherence rates were similar between groups. Physical function improved in the total sample with large effect sizes (Δ6MWT = 56.5 m [95%CI: 6-100 m], effect size [w] = 0.52, p = 0.006; ΔSit-to-Stand = 1.5 [95%CI: 1-5], effect size [w] = 0.681, p < 0.001), demonstrating greater changes in patients with higher ACWR. Sleep quality improvements were higher in the appropriate ACWR group (p = 0.016). A positive correlation was demonstrated between global health status and 6MWT change from baseline to 12 weeks (ρ = 0.689, p = 0.04). Despite a small sample size, patients maintaining sufficient relative training load presented greater physical fitness and sleep quality improvements. Thus, training load monitoring may enhance exercise program benefits in breast cancer patients under active treatment.

Prehabilitation in radiation therapy: a scoping review

PURPOSE/OBJECTIVES

Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT.

MATERIALS/METHODS

The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT.

RESULTS

A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity.

CONCLUSIONS

Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Exercise-based rehabilitation on functionality and quality of life in head and neck cancer survivors. A systematic review and meta-analysis

Head and Neck Cancer (HNC) is a globally rare cancer that includes a variety of tumors affecting the upper aerodigestive tract. It presents with difficulty breathing or swallowing and is mainly treated with radiation therapy, chemotherapy, or surgery for tumors that have spread locally or throughout the body. Alternatively, exercise can be used during cancer treatment to improve function, including pain relief, increase range of motion and muscle strength, and reduce cancer-related fatigue, thereby enhancing quality of life. Although existing evidence suggests the adjunctive use of exercise in other cancer types, no previous studies have examined the effects on HNC survivors. The aim of this meta-analysis was to quantify the effect of exercise-based rehabilitation on functionality and quality of life in HNC survivors who underwent surgery and/or chemoradiotherapy. A systematic review and meta-analysis were carried out following PRISMA statement and registered in PROSPERO (CRD42023390300). The search was performed in MEDLINE (PubMED), Cochrane Library, CINAHL and Web of Science (WOS) databases from inception to 31st December 2022 using the terms "cancer", "head and neck neoplasms", "exercise", "rehabilitation", "complications", "muscle contraction", "muscle stretching exercises" combining with booleans "AND"/"OR". PEDro scale, Cochrane Risk of Bias Tool and GRADE were used to assess methodological quality, risk of bias and grade of recommendation of included studies respectively. 18 studies (n = 1322) were finally included which 1039 (78.6%) were men and 283 (21.4%) were women. In patients who underwent radio-chemotherapy, overall pain [SMD = - 0.62 [- 4.07, 2.83] CI 95%, Z = 0.35, p = 0.72] and OP [SMD = - 0.07 [- 0.62, 0.48] CI 95%, Z = 0.25, p = 0.81] were slightly reduced with exercise in comparison to controls. Besides, lower limb muscle strength [SMD = - 0.10 [- 1.52, 1.32] CI 95%, Z = 0.14, p = 0.89] and fatigue [SMD = - 0.51 [- 0.97, - 0.057] CI 95%, Z = 2.15, p < 0.01] were also improved in those who receive radio-chemoradiation. In HNC survivors treated with neck dissection surgery, exercise was superior to controls in overall pain [SMD = - 1.04 [- 3.31, 1.23] CI 95%, Z = 0.90, p = 0.37] and, in mid-term, on shoulder pain SMD = - 2.81 [- 7.06, 1.43] CI 95%, Z = 1.76, p = 0.08]. No differences in quality of life were found at any of the follow-up periods. There is evidence of fair to good methodological quality, low to moderate risk of bias, and weak recommendations supporting the use of exercise-based rehabilitation to increase functionality. However, no evidence was found in favor of the use of this modality for improving the quality of life of HNC survivors who underwent chemoradiotherapy or surgery.