Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer

Association between accelerometer-measured light-intensity physical activity and tumor regression for male patients with esophageal cancer receiving neoadjuvant therapy: a retrospective cohort study

BACKGROUND

Physical activity has the potential to promote tumor regression in patients with esophageal cancer receiving neoadjuvant chemotherapy (NAC); however, the benefits of light-intensity physical activity (LIPA) are unclear. This study aimed to investigate the impact of LIPA on tumor regression in male patients with esophageal cancer during NAC and its optimal cutoff value.

METHODS

This retrospective single-center observational study included all male patients who underwent NAC or curative esophagectomy. We assessed the physical activity of patients using an accelerometer and calculated the time spent on LIPA. Tumor regression was defined as grade ≥ 1b according to the Japanese classification of esophageal cancer. The impact of LIPA on tumor regression was analyzed using multivariate analysis, and the optimal cutoff value was identified using the receiver operating characteristic curve.

RESULTS

Sixty-nine male patients with esophageal cancer who underwent NAC were analyzed. The mean age was 68 years, mean body mass index was 22.4, and 80% of the patients were diagnosed with clinical stage 3 or 4 disease. Every extra 30-min increase in LIPA during the treatment phase was associated with tumor regression (adjusted OR 1.41 [1.02-2.04]). The optimal cutoff value of LIPA was 156.11 min/day, and patients with rich LIPA (≥ 156.11 min/day) were less likely to suffer from anorexia and malnutrition during NAC.

CONCLUSION

This study demonstrated that LIPA during NAC has a potential of promoting tumor regression with a cutoff value of 156.5 min/day. Further clinical research is required to determine the prognostic benefits of LIPA in patients receiving NAC.

Association of Preoperative Physical Fitness With Post-Esophagectomy Pneumonia in Older With Locally Advanced Esophageal Cancer: An Exploratory Prospective Study

BACKGROUNDS

Currently, there is a lack of evidence of prehabilitation during neoadjuvant chemotherapy (NAC) to prevent pneumonia of older patients. This study aimed to investigate the association of preoperative physical fitness after NAC with post-esophagectomy pneumonia in older patients with locally advanced esophageal cancer (LAEC).

METHODS

This single-center exploratory prospective cohort study included 80 patients aged ≥ 65 years with LAEC scheduled for curative esophagectomy after NAC between 2021 and 2023. The post-NAC short incremental shuttle walk test (ISWT) by sex was established using the Youden index. The association of the post-NAC short ISWT with postoperative pneumonia was investigated via Firth's penalized logistic regression model with statistical significance set as two-tailed p < 0.05.

RESULTS

A total of 69 patients were analyzed. The mean post-NAC ISWT values were 353.5 m. Short ISWT distance was defined as ≤ 395 and ≤ 195 m for men and women, respectively. Postoperative pneumonia developed in 17 (25%) patients. Short post-NAC ISWT distance was significantly associated with postoperative pneumonia (adjusted odds ratio: 1.840, 95%CI: 1.760-28.440, p = 0.004).

CONCLUSIONS

Decline in physical fitness was associated with post-esophagectomy pneumonia, which may be a key targeted factor of prehabilitation during NAC for older patients with LAEC.

Prehabilitation for patients undergoing neoadjuvant therapy prior to cancer resection: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of uni- or multimodal prehabilitation on several outcomes in patients undergoing neoadjuvant therapy before cancer surgery.

METHODS

A systematic search was carried on May 1, 2023, using four major databases (SCOPUS, Web of Science, Medline (Ovid and Pubmed)) and updated monthly until February 2024. Inclusion criteria included (i) any original articles (any design), (ii) adult patients undergoing neoadjuvant therapy (NAT) prior to surgical resection, (iii) participation in uni- or multimodal prehabilitation programs during NAT, and (iv) reporting on any functional, treatment-related, or perioperative outcome. Two reviewers independently conducted the search and screened all records. Risk of bias was assessed using the Johanna Briggs Institute Appraisal Tools independently by two reviewers. A random-effects meta-analysis was performed for all outcomes with two or more studies.

RESULTS

A total of 30 records met the inclusion criteria and were analyzed. Studies showed that prehabilitation during NAT can be feasible in most settings and increase or prevent the loss of cardiorespiratory fitness (CRF), maintain or improve muscle mass, and improve pathological response and treatment completion compared to no prehabilitation, but the certainty of the evidence is low to moderate. However, according to our findings, prehabilitation has little to no effect on postoperative complications and length of hospital stay as well as in health-related quality of life.

CONCLUSIONS

Prehabilitation during NAT might be feasible and associated with improvements in cardiorespiratory fitness, muscle mass, and treatment response/completion with low-to-moderate certainty of evidence. Insufficient data on safety is available at this stage.

Perioperative gum-chewing training prevents a decrease in tongue pressure after esophagectomy in thoracic esophageal cancer patients: a nonrandomized trial

Tongue pressure (TP) decreases significantly after esophagectomy in esophageal cancer patients (ECPs). Meanwhile, 2 weeks of gum-chewing training (GCT) significantly increased TP in healthy university students. We examined whether perioperative GCT would decrease the proportion of patients exhibiting a decline in TP at 2 weeks postoperatively, and prevent postoperative complications, in thoracic ECPs (TECPs). This was a single-center interventional study, and nonrandomized study with a historical control group (HCG). TECPs who underwent first-stage radical esophagectomy were recruited. Thirty-two patients of 40 in the gum-chewing group (GCG) were completed perioperative GCT in 3 times daily. Propensity score matching was performed with covariates related to TP including preoperative age, sex, body mass index, and the repetitive saliva swallowing test result, and yielded a matched cohort of 25 case pairs. Eleven GCG patients [44.0%] exhibited significantly lower TP at 2 weeks postoperatively than before esophagectomy was significantly fewer than that of 19 patients [76.0%] in the HCG. The median number of fever days (> 38 °C) in the 2 weeks after esophagectomy in the GCG was significantly fewer than those in the HCG. Perioperative GCT may prevent postoperative TP decline and postoperative dysphagia-related complications after esophagectomy.

The implementation status of prehabilitation during neoadjuvant chemotherapy for patients with locally advanced esophageal cancer: a questionnaire survey to the board-certified facilities in Japan

BACKGROUND

Prehabilitation during neoadjuvant therapy has the potential to improve clinical outcomes. However, information on its global dissemination status is limited. This Japanese nationwide survey investigated the implementation status of and barriers to prehabilitation during neoadjuvant chemotherapy (NAC) for patients with locally advanced esophageal cancer in hospitals.

METHODS

This multicenter nationwide survey was conducted by post. The eligible facilities were 155 Japanese hospitals that had been certified within the last 10 years as authorized institutes for board-certified esophageal surgeons by the Japan Esophageal Society. We administered an original questionnaire to investigate the current status of prehabilitation during NAC.

RESULTS

The response rate was 75% (117/155 facilities). Forty-six facilities (39%) provided prehabilitation during NAC. The most frequently selected reasons for not providing or providing insufficient prehabilitation were lack of human resources, issues with the reimbursement of medical fees, difficulty in providing continuous prehabilitation during repeated inpatient and outpatient care, the lack of established standard prehabilitation programs, challenges in providing multidisciplinary prehabilitation, and difficulty in managing physical symptoms.

CONCLUSION

We observed that the implementation rate of prehabilitation during NAC was low. Critical reasons were not only the lack of medical resources but also the lack of evidence-based standard prehabilitation programs during NAC and the lack of evidence for how to continuously deliver prehabilitation during NAC to patients with physical symptoms.

Age-related and cancer-related sarcopenia: is there a difference?

PURPOSE OF REVIEW

The aim of this review is the attempt to differentiating the pathophysiologic and clinical features of the aging-related sarcopenia from cancer-related sarcopenia. In fact, there is some controversy among the experts mainly regarding two points: is always sarcopenia, even that aging-related one, the expression of a generalized disease or may exist independently and without major alteration of the muscle function? Are always aging-related and cancer-related sarcopenia completely separated entities?

RECENT FINDINGS

Literature shows that sarcopenia, defined as simple skeletal muscle mass loss, may range from a mainly focal problem which is common in many healthy elderly people, to a component of a complex multiorgan syndrome as cancer cachexia. Disuse, malnutrition and (neuro)degenerative processes can account for most of the aging-related sarcopenias while systemic inflammation and secretion of cancer-and immune-related molecules play an additional major role in cachexia.

SUMMARY

A multimodal approach including physical exercise and optimized nutritional support are the key measures to offset sarcopenia with some contribution by the anti-inflammatory drugs in cancer patients. Results are more promising in elderly patients and are still pending for cancer patients where a more specific approach will only rely on the identification and contrast of the key mediators of the cachectic process.

Effectiveness of prehabilitation during neoadjuvant therapy for patients with esophageal or gastroesophageal junction cancer: a systematic review

Progression of the physical weakness during neoadjuvant therapy (NAT) in patients with esophageal or gastroesophageal junction cancer is a serious problem; however, prehabilitation during NAT has the potential to overcome the unmet need. Nevertheless, systematic reviews on this topic have not been summarized. Therefore, this systematic review aimed to determine prehabilitation's effectiveness, acceptability, and safety during NAT for patients with esophageal or gastroesophageal junction cancer. An electronic search was performed in the MEDLINE, Web of Science, CENTRAL, CINAHL, and PEDro databases. A meta-analysis was conducted to assess the effectiveness of prehabilitation during NAT, along with a descriptive analysis of acceptance and safety. This study analyzed data from three randomized controlled trials (RCTs) and nine non-RCTs involving 664 patients. The meta-analysis of two RCTs demonstrated that prehabilitation during NAT may be more effective than usual care in enhancing tolerance to NAT and grip strength; moreover, one RCT and three non-RCTs revealed that prehabilitation may reduce the risk of postoperative complications. The adherence rates for exercise programs in two RCTs and seven non-RCTs were 55-76%. Additionally, two studies reported a 76% adherence rate for multimodal prehabilitation programs, including exercise, dietary, and psychological care. Six studies reported no serious prehabilitation-related adverse events during NAT. Prehabilitation during NAT may be a safe and beneficial intervention strategy for patients with esophageal or gastroesophageal junction cancer. However, the investigation of strategies to enhance adherence is essential. Furthermore, additional high-quality RCTs are needed to examine the effect of prehabilitation during NAT.

Exercise Across the Phases of Cancer Survivorship: A Narrative Review

Exercise has long been recognized as an important component of treatment for various diseases. However, the benefits and risks of exercise interventions must be carefully evaluated to ensure the former outweighs the latter. As cancer patients undergo diverse treatment modalities with distinct objectives, a systematic approach partitioning the cancer journey into distinct phases is necessary to inform tailored exercise prescriptions. This narrative review summarizes exercise benefits and mechanisms for cancer patients and survivors across four distinct survivorship periods-before surgery, after surgery and before adjuvant treatment, during nonsurgical treatment (adjuvant and neoadjuvant), and during extended survival. In summary, exercise reduces the risks of complications and declines in physical functioning while improving fatigue, quality of life, and the ability to manage treatment effects. Although additional research is warranted, existing evidence is sufficient to integrate exercise into clinical oncology practice and cancer survivorship programs.

Effects of exercise training on cancer patients undergoing neoadjuvant treatment: A systematic review

OBJECTIVES

This systematic review aimed to analyze the effects of different exercise protocols on physical fitness (cardiorespiratory fitness, muscle strength, and body composition), quality of life, cancer-related fatigue, and sleep quality in patients with different types of cancer undergoing neoadjuvant treatment.

DESIGN

Systematic review.

METHOD

A comprehensive search of existing literature was carried out using four electronic databases: PubMed, Scopus, Web of Science, and Cochrane Library (published until October 19, 2022). All databases were searched for randomized controlled trials, quasi-experimental investigations, and pre-post investigations assessing the effects of exercise in cancer patients during neoadjuvant treatment. Excluded articles included multicomponent interventions, such as exercise plus diet or behavioral therapy, and investigations performed during adjuvant treatment or survivorship. The methodological quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Twenty-seven trials involving 999 cancer patients were included in this review. The interventions were conducted in cancer patients undergoing neoadjuvant treatment for rectal (n = 11), breast (n = 5), pancreatic (n = 4), esophageal (n = 3), gastro-esophageal (n = 2), and prostate (n = 1) cancers, and leukemia (n = 1). Among the investigations included, 14 utilized combined exercise protocols, 11 utilized aerobic exercise, and two utilized both aerobic and resistance training separately. Exercise interventions appeared to improve cardiorespiratory fitness, muscle strength, body composition, and quality of life, although many investigations lacked a between-group analysis.

CONCLUSION

Despite limited evidence, exercise interventions applied during neoadjuvant treatment demonstrate promising potential in enhancing cardiorespiratory fitness, muscle strength, body composition, and overall quality of life. However, a scarcity of evidence remains on the effects of exercise on cancer-related fatigue and sleep quality. Further research with high-quality randomized controlled trials is warranted.

Skeletal Muscle Quality and Quantity Affect Prognosis after Neoadjuvant Chemotherapy with a Triple Regimen of Docetaxel/Cisplatin/5-FU in Patients with Esophageal Cancer

The purpose of this study was to identify factors associated with the prognosis after docetaxel, cisplatin, and 5-fluorouracil (DCF) neoadjuvant chemotherapy (NAC) in patients with advanced esophageal squamous cell carcinoma (ESCC) undergoing surgical resection. We retrospectively examined a total of 100 patients who received neoadjuvant DCF therapy for ESCC at our institution between 2011 and 2020. The psoas muscle index (PMI) was calculated from the psoas muscle area at the L3 vertebral level, and the intramuscular adipose tissue content (IMAC) was calculated from the mean CT value of the multifidus muscle and from four points of subcutaneous fat. The median PMI value was 6.11 cm2/m2 (range, 3.12-11.07 cm2/m2) in men and 3.65 cm2/m2 (range, 2.70-6.82 cm2/m2) in women. The median IMAC was -0.426 (range, -0.079--0.968) in men and -0.359 (range, -0.079--0.671) in women. Based on the PMI, IMAC, and other patient factors, factors associated with NAC-DCF postoperative survival were identified using multivariate Cox regression analysis. A high IMAC was significantly related to overall survival after surgery (p = 0.005, hazard ratio 2.699). A comparison of Kaplan-Meier curves showed that the 5-year survival rate was 76.5% in the low IMAC group and 42.7% in the high IMAC group (log-rank test; p = 0.001). A low IMAC was associated with good survival outcomes and was an independent prognostic factor in patients with cStage II/III ESCC who were treated with the NAC-DCF regimen and underwent surgical resection.

Current Therapeutic Targets in Cancer Cachexia: A Pathophysiologic Approach

Significant progress in our understanding of cancer cachexia has occurred in recent years. Despite these advances, no pharmacologic agent has achieved US Food and Drug Administration approval for this common and highly morbid syndrome. Fortunately, improved understanding of the molecular basis of cancer cachexia has led to novel targeted approaches that are in varying stages of drug development. This article reviews two major thematic areas that are driving these pharmacologic strategies, including those targeting signal mediators at the level of the CNS and skeletal muscle. Additionally, pharmacologic strategies are being tested in combination with targeted nutrients, nutrition therapy, and exercise to treat cancer cachexia. To this end, we highlight recently published and ongoing trials evaluating cancer cachexia therapies in these specific areas.

Adverse effects of systemic cancer therapy on skeletal muscle: myotoxicity comes out of the closet

PURPOSE OF REVIEW

Systemic cancer therapy-associated skeletal muscle wasting is emerging as a powerful impetus to the overall loss of skeletal muscle experienced by patients with cancer. This review explores the clinical magnitude and biological mechanisms of muscle wasting during systemic cancer therapy to illuminate this adverse effect. Emerging strategies for mitigation are also discussed.

RECENT FINDINGS

Clinical findings include precise, specific measures of muscle loss over the course of chemotherapy, targeted therapy and immunotherapy. All these therapeutic classes associate with quantitatively important muscle loss, independent of tumor response. Parallel experimental studies provide understanding of the specific molecular basis of wasting, which can include inhibition of protein synthesis, proliferation and differentiation, and activation of inflammation, reactive oxygen species, autophagy, mitophagy, apoptosis, protein catabolism, fibrosis and steatosis in muscle. Strategies to mitigate these muscle-specific adverse effects of cancer therapy remain in the earliest stages of development.

SUMMARY

The adverse side effect of cancer therapy on skeletal muscle has been largely ignored in the development of cancer therapeutics. Given the extent to which loss of muscle mass and function can bear on patients' function and quality of life, protection/mitigation of these side effects is a research priority.