Physical activity and fitness in women with metastatic breast cancer

Feasibility and preliminary effects of the Fit2ThriveMB pilot physical activity promotion intervention on physical activity and patient reported outcomes in individuals with metastatic breast cancer

PURPOSE

Physical activity research among patients with metastatic breast cancer (MBC) is limited. This study examined the feasibility and potential benefits of Fit2ThriveMB, a tailored mHealth intervention.

METHODS

Insufficiently active individuals with MBC (n = 49) were randomized 1:1 to Fit2ThriveMB (Fit2ThriveMB app, Fitbit, and weekly coaching calls) or Healthy Lifestyle attention control (Cancer.Net app and weekly calls) for 12 weeks. Fit2ThriveMB aimed to increase daily steps via an algorithm tailored to daily symptom rating and step goal attainment. The primary outcome was feasibility defined as ≥ 80% completion rate. Secondary feasibility metrics included meeting daily step goal and wearing the Fitbit ≥ 70% of study days, fidelity, adherence to intervention features and safety. Secondary outcomes included physical activity, sedentary time, patient reported outcomes (PROs), health-related quality of life (QOL) and social cognitive theory constructs. A subsample (n = 25) completed functional performance tests via video conferencing.

RESULTS

The completion rate was 98% (n = 1 died). No related adverse events were reported. Fit2ThriveMB participants (n = 24) wore the Fitbit 92.7%, met their step goal 53.1%, set a step goal 84.6% and used the app 94.1% of 84 study days. Intent-to-treat analyses indicated trends toward improvements in activity, QOL, and some PROs, social cognitive theory constructs, and functional performance tests favoring the Fit2ThriveMB group. Significant effects favoring Fit2ThriveMB were observed for self-efficacy and goal-setting. However, some PROs and functional performance improvements favored the control group (p-values > 0.05).

CONCLUSIONS

Fit2ThriveMB is feasible and safe for patients with MBC and warrants further evaluation in randomized controlled trials with larger sample sizes. Registration Clinicaltrials.gov NCT04129346, https://clinicaltrials.gov/ct2/show/NCT04129346.

Exercise as part of survivorship care in metastatic breast cancer: protocol for the randomized EMBody trial

BACKGROUND

Exercise is associated with improved survival, physical functioning, treatment tolerability, and quality of life in early-stage breast cancer. These same endpoints matter in metastatic breast cancer (MBC). Prior trials in MBC have found exercise to be not feasible or of limited benefit, possibly due to inclusion of patients with heterogeneous disease trajectories. Patients with MBC have variable disease trajectories and supportive care needs; those with indolent MBC have longer life expectancy, lower symptom burden and distinct priorities, and are well-positioned to participate in and benefit from an exercise program. The EMBody trial aims to determine the impact of a multimodal exercise intervention on cardiorespiratory fitness, physical function, body composition, and patient-reported outcomes, specifically in patients with stable, indolent MBC.

METHODS

Eligible patients have MBC with no evidence of disease progression on current therapy in the prior 12 months and cannot be receiving cytotoxic chemotherapy. The trial aims to enroll 100 patients, randomized 1:1 to the exercise intervention versus usual care, stratified by baseline function. The virtually-delivered exercise intervention arm achieves moderate intensity exercise with exercise physiologists 3 days/week for 16 weeks. The 60-minute sessions include aerobic, resistance, balance and stretching exercises. The exercise arm receives informational sessions on the role of exercise in cancer and principles of habit and self-efficacy. The primary endpoint is 16 week change in fitness on a ramp treadmill test between the exercise and control arms. Secondary endpoints include change in a physical function, muscle mass assessed by CT scans, and PROs of fatigue and quality of life. Exploratory analysis includes behavioral modifiers of exercise adherence and effectiveness and serologic measures of inflammatory, metabolic, and immune pathway biomarkers.

DISCUSSION

The EMBody trial evaluates exercise in a unique patient population with indolent, non-progressive MBC. Patients living with MBC experience similar symptom burden to those undergoing therapy for early-stage disease and the benefits achieved with exercise could be similarly impactful. This trial will contribute evidence to support expansion of exercise recommendations, among other survivorship care efforts, to those living with metastatic disease.

CLINICAL TRIAL INFORMATION

NCT05468034.

TRIAL REGISTRATION

NCT05468034. Date of registration: 7/12/2022.

Canadian oncology physiotherapists' perspectives of physical activity in people with advanced cancer: a mixed-methods study

BACKGROUND

Individuals with advanced cancer can benefit from physical activity (PA), but face barriers to PA participation. Physiotherapists can be well-positioned to support this patient population.

OBJECTIVE

Our objective was to describe the perspectives, practices, knowledge, and skills of oncology physiotherapists related to PA in people with advanced cancer.

METHODS

In this mixed-methods study, we recruited Canadian physiotherapists with current or recent clinical experience with advanced cancer. Phase I consisted of an online survey about views toward PA in advanced cancer and activity-related recommendations and concerns for two case scenarios. Phase II involved individual, semi-structured interviews about perspectives related to working with advanced cancer.

RESULTS

Sixty-two physiotherapists participated in the survey, of which 13 participated in interviews. Most respondents (> 85%) agreed or strongly agreed PA is important and safe for individuals with advanced cancer. Case responses highlighted cancer-related considerations (e.g. bone metastases) tailored activity recommendations, and patient-centered, interprofessional care. Interview themes included: 1) situating PA within individually meaningful goals; 2) tailored strategies to promote PA; 3) overarching roles in functional optimization and symptom management; and 4) generalized lack of awareness regarding physiotherapy.

CONCLUSION

Our findings indicate Canadian oncology physiotherapists describe knowledge of the safety and importance of PA, as well as key considerations in advanced cancer. Moreover, they highlight the importance of a patient-centered approach to support this population, particularly in facilitating safe and meaningful PA, as well as optimizing function and alleviating symptom burden. Further efforts are needed to investigate the development and integration of physiotherapy within cancer care.

PERSPECTIVEs on supervised exercise programs in people with metastatic breast cancer- a qualitative study in four European countries

PURPOSE

Supervised exercise is a potentially promising supportive care intervention for people with metastatic breast cancer (MBC), but research on the patients' perspective is limited. The aim of the current focus group study was to gain an in-depth understanding of MBC patients' perceived barriers, facilitators, and preferences for supervised exercise programs.

METHODS

Eleven online focus groups with, in total, 44 MBC patients were conducted in four European countries (Germany, Poland, Spain, Sweden). Main topics of the semi-structured discussions covered attitudes towards participation in supervised exercise programs, perceived facilitators, experienced barriers, and exercise preferences. Interviews were transcribed verbatim, translated into English, and coded based on a preliminary coding framework, supplemented by themes emerging during the sessions. The codes were subsequently examined for interrelations and re-organized into overarching clusters.

RESULTS

Participants had positive attitudes towards exercise, but experienced physical limitations and insecurities that inhibited their participation. They expressed a strong desire for exercise tailored to their needs, and supervision by an exercise professional. Participants also highlighted the social nature of group training as an important facilitator. They had no clear preference for exercise type, but rather favored a mixture of different activities. Flexible training modules were considered helpful to increase exercise program adherence.

CONCLUSIONS

MBC patients were generally interested in supervised exercise programs. They preferred group exercise that facilitates social interaction, but also expressed a need for individualized exercise programs. This suggests the relevance to develop flexible exercise programs that are adjusted to the individual's needs, abilities, and preferences.

Change in four measures of physical function among older adults during lung cancer treatment: A mixed methods cohort study

INTRODUCTION

Functional outcomes during non-small cell lung cancer (NSCLC) treatment are critically important to older adults. Yet, data on physical function and which measures best capture functional change remain limited.

MATERIALS AND METHODS

This multisite, mixed methods cohort study recruited adults ≥65 years with advanced NSCLC starting systemic treatment (i.e., chemotherapy, immunotherapy, and/or targeted therapy) with non-curative intent. Participants underwent serial geriatric assessments prior to starting treatment and at one, two, four, and six months, which included the Karnofsky Performance Scale (KPS, range: 0-100%), instrumental activities of daily living (IADL, range: 0-14), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Physical Functioning subscale (EORTC QLQ-C30 PF, range: 0-100), and Life-Space Assessment (LSA, range: 0-120). For all measures, higher scores represent better functioning. In a qualitative substudy, 20 patients completed semi-structured interviews prior to starting treatment and at two and six months to explore how treatment affected their daily functioning. We created joint displays for each interview participant that integrated their longitudinal KPS, IADL, EORTC QLQ-C30 PF, and LSA scores with patient quotes describing their function.

RESULTS

Among 87 patients, median age was 73 years (range 65-96). Mean pretreatment KPS score was 79% (standard deviation [SD] 13), EORTC QLQ-C30 PF was 69 (SD 23), and LSA was 67 (SD 28); median IADL was 13 (interquartile range [IQR] 10-14). At two months after treatment initiation, 70% of patients experienced functional decline on at least one measure, with only 13% of these patients recovering at six months. At two and six months, decline in LSA was the most common (48% and 35%, respectively). Joint displays revealed heterogeneity in how well each quantitative measure of physical function captured the qualitative patient experience.

DISCUSSION

Functional decline during NSCLC treatment is common among older adults. LSA is a useful measure to detect subtle functional decline that may be missed by other measures. Given heterogeneity in how well each quantitative measure captures changes in physical function, there is value to including more than one functional measure in geriatric oncology research studies.

Impact of obesity, lifestyle factors and health interventions on breast cancer survivors

The incidences of both breast cancer and obesity are rising in the UK. Obesity increases the risk of developing breast cancer in the postmenopausal population and leads to worse outcomes in those of all ages treated for early-stage breast cancer. In this review we explore the multifactorial reasons behind this association and the clinical trial evidence for the benefits of physical activity and dietary interventions in the early and metastatic patient groups. As more people with breast cancer are cured, and those with metastatic disease are living longer, cancer survivorship is becoming increasingly important. Therefore, ensuring the long-term implications of cancer and cancer treatment are addressed is vital. Although there remains a lack of definitive evidence that deliberate weight loss after a diagnosis of breast cancer reduces disease recurrence, a number of studies have reported benefits of weight loss and of physical activity. However, the limited data currently available mean that clinicians remain unclear on the optimal lifestyle advice to give their patients. Further high-quality research is needed to provide this evidence base, which will be required to optimise clinical care and for the commissioning of lifestyle interventions in the UK in breast cancer survivors.

Implementation of a Standard Care Program of Therapeutic Exercise in Metastatic Breast Cancer Patients

BACKGROUND

There is little information on the feasibility and benefit of therapeutic exercise (TE) in women with metastatic breast cancer (MBC). The aim of this article is to describe the implementation of a TE intervention in MBC patients, and to determine the recruitment, compliance and improvement in outcomes after its completion.

METHODS

The "Therapeutic Exercise program in MBC" (TEP-MBC) consists of 1 h of individualized TE supervised by a physiotherapist in a group format, consisting of four groups of seven to eight participants. TEP-MBC was delivered twice a week, lasting 12 weeks (22 sessions), with patients considered to have completed the program when attending at least 17 sessions (>75% attendance). After referral, patients underwent a clinical interview and a physical and functional assessment. This information was complemented with patient-reported outcomes. Data about referral, compliance and assessment were collected.

RESULTS

Only 11 of the 30 patients completed the program. Drop-out was mainly related to personal issues and symptoms arising from the disease or treatment. All patients who completed the program improved cancer-related fatigue and increased their functional parameters.

CONCLUSIONS

The TEP-MBC was safe and feasible in patients with MBC, although with low compliance. The high variability in baseline measures reflects the heterogeneous level of function.

Application of the theory of planned behavior to understand physical activity intentions and behavior among Korean breast cancer survivors

PURPOSE

The purpose of this study was to apply the theory of planned behavior (TPB) to understand physical activity intentions and behaviors among Korean breast cancer survivors.

METHODS

A total of 286 Korean breast cancer survivors (M_age52.3 ± 8.3) completed a self-reported survey administered face to face by a trained interviewer. The survey assessed the physical activity frequency and intensity in a typical week after breast cancer diagnosis, demographic factors, and theory of planned behavior variables including attitude, subjective norm, perceived behavioral control (PBC), planning, and intentions to participate in physical activity. We used structural equation modeling to examine the direct and indirect effects of the TPB variables on physical activity intentions and behavior. Covariates included age, cancer stage, and clinical treatment.

RESULTS

Confirmatory factor analyses indicated a satisfactory model fit. We observed direct effects for instrumental attitude (ß = 0.34, p < 0.001), subjective norm (ß = 0.12, p < 0.05), and PBC (ß = 0.57, p < 0.001) on physical activity intentions. PBC (ß = .17, p < 0.01) and physical activity intentions (ß = 0.46, p < 0.01) had direct effects on planning. PBC (ß = 0.28, p < 0.01) and planning (ß = 0.22, p < 0.01) had direct effects on physical activity behavior.

CONCLUSION

The TPB was a useful model for understanding Korean breast cancer survivors' physical activity intentions and behavior. Interventions that can enhance attitudes, subjective norm, PBC, intention, and planning may facilitate physical activity intentions and behaviors in this population.

Development of a functional assessment task in metastatic breast cancer patients: the 30-second lie-to-sit test

PURPOSE

To develop a physical function test based on lie-to-sit transition and to study its feasibility in patients suffering from metastatic breast cancer (MBC).

MATERIALS AND METHODS

This cross-sectional study recruited 90 women diagnosed with MBC. Patients were asked to transfer from lying to sitting position as fast as possible during 30 s, performing the 30-second lie-to-sit test (30-LTS). Heart rate (HR), rate of perceived exertion (RPE) and number of repetitions were measured. An assessment included the 30-second sit-to-stand test (30-STS), handgrip strength, Upper Limb Functional Index (ULFI) and Lower Limb Functional Index (LLFI). Pearson correlation was calculated between 30-LTS and independent outcomes. A linear regression model explaining the 30-LTS results was further constructed with variables that had a significant correlation.

RESULTS

About 72 patients were measured, of which 65 were able to perform 30-LTS. Subjects performed 8.13 repetitions on average, with a mean RPE of 4.78 (0-10), reaching 63.08% of maximal HR. 30-LTS was significantly correlated with 30-STS (r = 0.567), handgrip (p = 0.26) and LLFI (r = 0.348). The regression model was significant (F = 4.742; p = 0.00), and these variables explained 32% of the variance of the 30-LTS.

CONCLUSION

The 30-LTS showed to be a feasible functional and submaximal test in a sample of MBC. IMPLICATIONS FOR REHABILITATIONThe 30-second lie-to-sit (30-LTS) developed does not require the patient to acquire a standing position and therefore it is an alternative to other more biomechanically demanding tests such as a 30 second sit-to-stand test or Timed up-and-go.30-LTS involves both a functional and energy system assessment tool that can be implemented by allied health professionals in oncology rehabilitation to individualize exercise prescription, as well as for functional screening purposes.The present study adds value to current research focused on individualizing exercise prescription in the oncology field and provides reference values of function in metastatic breast cancer patients.

Feasibility of a Digital Therapeutic Program for Cancer Patients During Active Treatment: Analysis of Engagement, Retention and Quality of Life (Preprint)

Background

Increasing evidence shows that lifestyle interventions can improve the symptoms, quality of life (QoL), and even overall survival of patients with cancer. Digital therapeutics (DTx) can help implement behavioral modifications and empower patients through education, lifestyle support, and remote symptom monitoring.

Objective

We aimed to test the feasibility of a DTx program for patients with cancer, as measured by engagement, retention, and acceptability. In addition, we explored the effects of the program on cancer-related QoL.

Methods

We conducted a 4-week single-arm trial in Iceland, where DTx was delivered through a smartphone app. The intervention consisted of patient education about mindfulness, sleep, stress, and nutrition; lifestyle coaching; and the completion of daily missions for tracking physical activity and exercise, reporting patient-reported outcomes (PROs), practicing mindfulness, and logging healthy food intake. Information on program engagement and retention, step goal attainment, as well as PROs were collected throughout the study. QoL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 at baseline and follow-up.

Results

In total, 30 patients with cancer undergoing active therapy were enrolled, and 29 registered in the app (23 female, 18 with breast cancer; mean age 52.6, SD 11.5 years). Overall, 97% (28/29) of participants were active in 3 of the 4 weeks and completed the pre- and postprogram questionnaires. The weekly active days (median) were 6.8 (IQR 5.8-6.8), and 72% (21/29) of participants were active at least 5 days a week. Users interacted with the app on average 7.7 (SD 1.9) times per day. On week 1, all 29 participants used the step counter and logged an average of 20,306 steps; 21 (72%) participants reached their step goals of at least 3000 steps per day. On week 4, of the 28 active users, 27 (96%) were still logging their steps, with 19 (68%) reaching their step goals. Of the 28 participants who completed the satisfaction questionnaire, 25 (89%) were likely to recommend the program, 23 (82%) said the program helped them deal with the disease, and 24 (86%) said it helped them remember their medication. QoL assessment showed that the average global health status, functioning, and symptom burden remained stable from baseline to follow-up. In all, 50% (14/28) of participants reported less pain, and the average pain score decreased from 31 (SD 20.1) to 22.6 (SD 23.2; P=.16). There was no significant change in PROs on the quality of sleep, energy, and stress levels from the first to the last week.

Conclusions

The high retention, engagement, and acceptability found in this study demonstrate that multidisciplinary DTx is feasible for patients with cancer. A longer, full-scale randomized controlled trial is currently being planned to evaluate the efficacy of the intervention.

The Effect of Exercise and Nutritional Interventions on Body Composition in Patients with Advanced or Metastatic Cancer: A Systematic Review

Advanced and metastatic cancers significantly alter body composition, leading to decreased lean mass and variable effects on fat mass. These effects on body composition are associated with significant physical dysfunction and poor prognosis in patients with cancer. Whilst exercise and nutritional interventions are likely to be of benefit in counteracting these effects, relatively little is known about using such interventions in patients with advanced or metastatic cancer. Therefore, in this systematic review we examine the effect of exercise and combined exercise and nutritional interventions on lean mass and fat mass among patients diagnosed with advanced or metastatic cancer. Following PRISMA guidelines, we identified 20 articles from PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PEDro, SPORTDiscus, and REHABDATA. Overall, advanced or metastatic cancer populations comprising of mixed cancer types were most commonly examined (n = 8) with exercise or combined exercise and nutritional interventions being well-tolerated with few adverse effects. Both intervention approaches may preserve lean mass, while only combined interventions may lead to alterations in fat mass. However, further exercise and nutritional studies are needed to definitively understand their effects on body composition. As exercise and nutrition-related research continues in this understudied population, the knowledge gained will help guide supportive clinical treatments.

Systemic effects of abnormal bone resorption on muscle, metabolism, and cognition

Skeletal tissue is dynamic, undergoing constant remodeling to maintain musculoskeletal integrity and balance in the human body. Recent evidence shows that apart from maintaining homeostasis in the local microenvironment, the skeleton systemically affects other tissues. Several cancer-associated and noncancer-associated bone disorders can disrupt the physiological homeostasis locally in the bone microenvironment and indirectly contribute to dysregulation of systemic body function. The systemic effects of bone on the regulation of distant organ function have not been widely explored. Recent evidence suggests that bone can interact with skeletal muscle, pancreas, and brain by releasing factors from mineralized bone matrix. Currently available bone-targeting therapies such as bisphosphonates and denosumab inhibit bone resorption, decrease morbidity associated with bone destruction, and improve survival. Bisphosphonates have been a standard treatment for bone metastases, osteoporosis, and cancer treatment-induced bone diseases. The extraskeletal effects of bisphosphonates on inhibition of tumor growth are known. However, our knowledge of the effects of bisphosphonates on muscle weakness, hyperglycemia, and cognitive defects is currently evolving. To be able to identify the molecular link between bone and distant organs during abnormal bone resorption and then treat these abnormalities and prevent their systemic effects could improve survival benefits. The current review highlights the link between bone resorption and its systemic effects on muscle, pancreas, and brain.

Changes in older adults' life space during lung cancer treatment: A mixed methods cohort study

BACKGROUND

Maintenance of function during cancer treatment is important to older adults. Characteristics associated with pretreatment life-space mobility and changes during non-small cell lung cancer (NSCLC) treatment remain unknown.

METHODS

This mixed methods cohort study recruited adults age ≥65 with advanced NSCLC starting palliative chemotherapy, immunotherapy, and/or targeted therapy from a Comprehensive Cancer Center, Veterans Affairs, and safety-net clinic. Patients completed geriatric assessments including Life-Space Assessment (LSA) pretreatment and at 1, 2, 4, and 6 months after treatment initiation. LSA scores range from 0 to 120 (greater mobility); LSA <60 is considered restricted. We used mixed-effects models to examine pretreatment LSA, change from 0 to 1 month, and change from 1 to 6 months. A subgroup participated in semistructured interviews pretreatment and at 2 and 6 months to understand the patient experience of life-space change. For each interview participant, we created joint displays of longitudinal LSA scores juxtaposed with illustrative quotes.

RESULTS

Among 93 patients, median age was 73 (range 65-94). Mean pretreatment LSA score was 67.1. On average, LSA declined 10.1 points from pretreatment to 1 month and remained stable at 6 months. Pretreatment LSA score was associated with several demographic, clinical, geriatric assessment, and symptom characteristics. LSA decline at 1 month was greater among patients with high anxiety (slope = -12.6 vs. -2.3, p = 0.048). Pretreatment body mass index <21 kg/m2 was associated with LSA improvement from 1 to 6 months (slope = 4.1 vs. -0.04, p = 0.003). Joint displays illustrated the impact of different life-space trajectories on patients' lives in their words.

CONCLUSION

Older adults with NSCLC have low pretreatment life space with many developing restricted life space during treatment. Incorporating life-space assessments into clinical cancer care may help older adults concretely visualize how treatment might impact their daily function to allow for informed decision making and identify early changes in mobility to implement supportive interventions.

Absolute and Relative Handgrip Strength as Indicators of Self-Reported Physical Function and Quality of Life in Breast Cancer Survivors: The EFICAN Study

Simple Summary

Breast cancer is the most diagnosed type of cancer worldwide and it has a high survival rate. Thus, side effects related to breast cancer and treatments compromise lots of people’s physical functions and health-related quality of life. For this reason, it is important to manage these side effects in the follow up after treatments. The handgrip strength and the handgrip strength relative to body mass index may constitute useful, simple, quick and economically feasible tools that may help clinicians detecting these side effects, which is key to undertake actions for improving the physical function and health-related quality of life of breast cancer survivors.

Abstract

Background: Although breast cancer (BC) is the most prevalent type of cancer in the world, its high survival rate implies that many people live long after the treatments and face their side effects. The physical function (PF) and health-related quality of life (HRQoL) of people surviving BC decreases significantly, which makes important to identify markers that may be associated with a better health status and prognosis. Previous studies suggest that handgrip strength (HGS) and HGS relative to the body mass index (rHGS) are good indicators of PF and HRQoL in different populations. However, it is unknown whether this applies to BC survivors. This study aimed to evaluate the association of HGS and rHGS with PF and HRQoL in this population. Methods: Sixty female BC survivors participated. Handgrip strength was assessed with a dynamometer. Arm volume was estimated and upper limb impairments, as well as cancer-related fatigue, depression, life satisfaction and HRQoL, were assessed using standardized questionnaires. Results: Higher levels of HGS and rHGS were associated with higher levels of HRQoL, lower cancer-related fatigue, and fewer problems with the affected arm. Conclusions: These results suggest that HGS may be a good indicator of self-reported PF and HRQoL in female BC survivors.

Dietary Intake and Energy Expenditure in Breast Cancer Survivors: A Review

Many breast cancer survivors (BCS) gain fat mass and lose fat-free mass during treatment (chemotherapy, radiation, surgery) and estrogen suppression therapy, which increases the risk of developing comorbidities. Whether these body composition alterations are a result of changes in dietary intake, energy expenditure, or both is unclear. Thus, we reviewed studies that have measured components of energy balance in BCS who have completed treatment. Longitudinal studies suggest that BCS reduce self-reported energy intake and increase fruit and vegetable consumption. Although some evidence suggests that resting metabolic rate is higher in BCS than in age-matched controls, no study has measured total daily energy expenditure (TDEE) in this population. Whether physical activity levels are altered in BCS is unclear, but evidence suggests that light-intensity physical activity is lower in BCS compared to age-matched controls. We also discuss the mechanisms through which estrogen suppression may impact energy balance and develop a theoretical framework of dietary intake and TDEE interactions in BCS. Preclinical and human experimental studies indicate that estrogen suppression likely elicits increased energy intake and decreased TDEE, although this has not been systematically investigated in BCS specifically. Estrogen suppression may modulate energy balance via alterations in appetite, fat-free mass, resting metabolic rate, and physical activity. There are several potential areas for future mechanistic energetic research in BCS (e.g., characterizing predictors of intervention response, appetite, dynamic changes in energy balance, and differences in cancer sub-types) that would ultimately support the development of more targeted and personalized behavioral interventions.

Continuous, objective measurement of physical activity during chemotherapy for breast cancer: the Activity in Treatment pilot study

Despite many potential benefits of physical activity during and after breast cancer treatment, activity levels typically decline from pre- to posttreatment. Most previous research has relied on self-reported activity. The purpose of this study were to assess patterns of daily, to objectively measured physical activity throughout chemotherapy for breast cancer, and to identify predictors of physical activity patterns. Participants were given a Fitbit before starting chemotherapy and asked to wear it throughout chemotherapy. Restricted cubic splines assessed nonlinear patterns of Fitbit measured total physical activity (TPA) and moderate-to-vigorous physical activity (MVPA) throughout the duration of chemotherapy (mean = 17 weeks, standard deviation [SD] = 6.3). Mixed-effects regression models assessed the rate of physical activity decline. Regressions of subject-level random slope assessed predictors of the rate of physical activity decline on participant and cancer characteristics and self-reported physical and cognitive functioning. Participants (n = 32) were on average 50 years old; the majority had stage II breast cancer. MVPA declined linearly at a mean rate of 1.4 min/day (p = .002) for every 10% of chemotherapy completed, whereas TPA declined linearly at an average rate of 13.4 min/day (p = .0007) for every 10% of chemotherapy completed, until around halfway through chemotherapy, when activity rates leveled off. HER+ receptor status was associated with a greater rate of MVPA decline, β = 13.3, p = .04. This novel study of objectively measured daily MVPA throughout chemotherapy showed that most reductions in activity occurred during the first half of a course of chemotherapy. Targeting this early period of chemotherapy may be important for preventing declines in activity levels throughout chemotherapy.

Myosteatosis at diagnosis is adversely associated with 2-year survival in women with estrogen receptor-negative metastatic breast cancer

PURPOSE

To examine the relationship between skeletal muscle (SM) and cancer-specific outcomes for women with estrogen receptor-negative (ER-) metastatic breast cancer (MBC).

METHODS

For this retrospective cohort, females (≥ 18 years) with histologically confirmed ER- MBC and computerized tomography (CT) imaging were screened. Demographic, anthropometric, and clinical data were collected uniformly from the electronic medical record. CT images inclusive of the third lumbar region (L3) at diagnosis, 6 and 12 months, were used to classify sarcopenia (≤ 41 cm²/m²) and myosteatosis (< 41 or 33 Hounsfield Units, adjusted for body mass index (BMI)) and to evaluate changes in SM and total adipose tissue (TAT) over time. Kaplan-Meier curves, Cox Proportional Hazards (PH), and restricted mean survival time (RMST) estimates were generated to examine the relationship between sarcopenia and myosteatosis and time to tumor progression (TTP), treatment toxicity and 2-year survival, adjusting for covariates.

RESULTS

Participants were 58.0 (15.0) years of age, ethnically diverse (55% non-Hispanic white, 31% Black, 11% Hispanic), post-menopausal (73%, n = 111), and classified as overweight (BMI 29.4 (7.6)). At diagnosis, 40% (n = 61) were sarcopenic, 49% had myosteatosis, and 28% (n = 42) had both. While Cox PH modeling and RMST analysis reveal no significant relationship between sarcopenia at diagnosis and 2-year survival (RMST difference - 1.6 (1.4) months, HR 1.35 (0.88-2.08)), these analyses support a significant, adverse association between myosteatosis at diagnosis and 2-year survival (RMST difference - 2.4 (1.5) months, HR 1.72 (1.09-2.72)). Incident sarcopenia was 11% (n = 5/45) and 2.5% (n = 1/40), respectively, while incident myosteatosis was 19% (n = 8/42) and 15% (n = 5/34) at 6 and 12 months, respectively. TTP and treatment toxicities did not appear to be related to diagnostic SM or body composition changes over time.

CONCLUSION

Targeted interventions initiated within the first year of diagnosis to preserve or improve SM quality seem warranted for women with ER-MBC.

Cancer Survivors with Low Hand Grip Strength Have Decreased Quality of Life Compared with Healthy Controls: The Korea National Health and Nutrition Examination Survey 2014-2017

BACKGROUND

Cancer survivors experience decreased physical function and reduced muscle strength, which leads to lower quality of life (QOL). The hand grip strength (HGS) can be a predictor of poor health-related QOL as a parameter of sarcopenia. The purpose of this study was to investigate the relationship between low HGS and QOL in cancer survivors and healthy controls.

METHODS

We analyzed 392 cancer survivors and 1,176 healthy controls from the Korea National Health and Nutrition Examination Survey, 2014-2017. We defined low HGS as 2 standard deviation values for healthy young Korean adults from a previous study. QOL was evaluated using the European Quality of Life Scale-Five Dimensions. A complex sample logistic regression model was used to assess the relationship between each dimension of low HGS and QOL.

RESULTS

The odds ratios (ORs) for decreased QOL were significantly higher in male cancer survivors with low HGS on self-care (OR, 8.51; 95% confidence interval [CI], 1.69-42.83) and usual activities (OR, 6.63; 95% CI, 1.22-36.03). The ORs for problems in mobility (OR, 5.87; 95% CI, 2.04-16.91), usual activities (OR, 14.46; 95% CI, 3.84-54.44), pain/discomfort (OR, 4.90; 95% CI, 2.00-12.01), and anxiety/depression (OR, 6.43; 95% CI, 2.16-19.12) were significantly high in female cancer survivors with low HGS. However, healthy controls showed no significant relationship between low HGS and QOL.

CONCLUSION

For cancer survivors, low HGS was associated with poor QOL in some domains. Strategies to increase muscle strength must be considered to improve the QOL of cancer survivors.

A Technology-Based Physical Activity Intervention for Patients With Metastatic Breast Cancer (Fit2ThriveMB): Protocol for a Randomized Controlled Trial

Background

Increased incidence and life expectancy have resulted in a growing population of patients with metastatic breast cancer, and these patients experience high rates of morbidity and premature mortality. Increased physical activity (PA) is consistently associated with improved health and disease outcomes among early-stage survivors. However, there is a paucity of research on PA in patients with metastatic breast cancer, and existing PA interventions have exhibited low feasibility because of their focus on intense PA and/or requirement of on-site visits. Mobile health (mHealth)–based PA interventions may be particularly useful for patients with metastatic breast cancer because they allow for remote monitoring, which facilitates individual tailoring of PA recommendations to patients’ abilities and may minimize participant burden. However, no studies have examined mHealth PA interventions in patients with metastatic breast cancer.

Objective

We aim to address these critical research gaps by testing a highly tailored technology-based intervention to promote PA of any intensity (ie, light, moderate, or vigorous) by increasing daily steps in patients with metastatic breast cancer. The primary aim of this study is to test the feasibility and acceptability of the Fit2ThriveMB intervention. We will also examine outcome patterns suggesting the efficacy of Fit2ThriveMB on symptom burden, quality of life, and functional performance.

Methods

The Fit2ThriveMB trial is a two-arm pilot randomized controlled trial that will compare the effects of a smartphone-delivered, home-based PA intervention and an attention-control education condition on PA and quality of life in low-active female patients with metastatic breast cancer. A subsample (n=25) will also complete functional performance measures. This innovative trial will recruit 50 participants who will be randomized into the study’s intervention or control arm. The intervention will last 12 weeks. The Fit2ThriveMB intervention consists of a Fitbit, coaching calls, and the Fit2ThriveMB smartphone app that provides self-monitoring, a tailored goal-setting tool, real-time tailored feedback, app notifications, and a group message board. Assessments will occur at baseline and post intervention.

Results

The Fit2ThriveMB study is ongoing. Data collection ended in February 2021.

Conclusions

Data from this study will provide the preliminary effect sizes needed to assemble an intervention that is to be evaluated in a fully powered trial. In addition, these data will provide essential evidence to support the feasibility and acceptability of using a technology-based PA promotion intervention, a scalable strategy that could be easily integrated into care, among patients with metastatic breast cancer.

Trial Registration

ClinicalTrials.gov NCT04129346; https://clinicaltrials.gov/ct2/show/NCT04129346

International Registered Report Identifier (IRRID)

DERR1-10.2196/24254

Ultrasound use in metastatic breast cancer to measure body composition changes following an exercise intervention

Changes in body composition and muscle dysfunction are common in metastatic breast cancer (MBC). Ultrasound imaging (US) offers reliable information about muscle and fat tissue architecture (thickness) and quality (echo-intensity). This study aimed to analyze the responsiveness of thickness and echo-intensity and its possible relationship with functional and patient reported-outcomes (PRO) in MBC patients after an exercise intervention. A prospective study was conducted in 2019. A 12-week exercise program was performed, including aerobic exercise and strength training. Measurements were made at baseline and after intervention. Thickness and echo-intensity were obtained from the quadriceps and biceps brachii and brachialis (BB). Mean differences were calculated using the T-Student parametric test for dependent samples of the differences in the means before and after the intervention (p = 0.05; 95% CI). Data from 13 MBC patients showed that some US muscle variables had significant differences after intervention. Best correlations were found between the quality of life questionnaire (QLQ-BR23) PRO and variables from BB muscle thickness in contraction (r = 0.61, p < 0.01), and Non-contraction (r = 0.55, p < 0.01). BB Muscle Non-contraction Thickness also explained 70% of QLQ-BR23 variance. In conclusion, muscle architecture biomarkers showed great responsiveness and are correlated with PRO after an exercise intervention in MBC patients.

Every Day Counts: a randomized pilot lifestyle intervention for women with metastatic breast cancer

PURPOSE

To explore the feasibility, adherence, safety and potential efficacy of Every Day Counts; a randomized pilot trial designed for women with metastatic breast cancer (MBC) framed by the American Cancer Society nutrition and physical activity (PA) guidelines METHODS: Women with clinically stable MBC were recruited to complete an interview, dual energy X-ray absorptiometry imaging and phlebotomy at baseline and post-intervention. Multidimensional quality of life, symptom burden, lifestyle behaviors (nutrition and PA) and biomarkers of prognosis were procured and quantified. Women were randomized to the immediate intervention or a waitlist control arm. The 12-week intervention included a curriculum binder, lifestyle coaching (in-person and telephone-based sessions) and intervention support (activity monitor, text messaging, cooking classes.) Women in the waitlist control were provided monthly text messaging.

RESULTS

Forty women were recruited within 9 months (feasibility). Women in the immediate intervention attended 86% of all 12 weekly coaching sessions (adherence) and showed significant improvements in general QOL (p = 0.001), and QOL related to breast cancer (p = 0.001), endocrine symptoms (p = 0.002) and fatigue (p = 0.037), whereas the waitlist control did not (all p values ≥ 0.05) (efficacy). PA significantly increased for women in the intervention compared to control (p < 0.0001), while dietary changes were less evident across groups due to high baseline adherence. No significant changes in biomarkers or lean mass were noted, yet visceral adipose tissue declined (p = 0.001). No intervention-related injuries were reported (safety). Qualitative feedback strongly supports the desire for a longer intervention with additional support.

CONCLUSIONS

Lifestyle interventions are of interest, safe and potentially beneficial for women with MBC. A larger trial is warranted.

A scoping review of studies exploring leisure-time physical activity in adults diagnosed with advanced cancer

OBJECTIVES

Despite improving survival rates, people with advanced cancer face several physical and psychosocial concerns. Leisure-time physical activity (LPA) has been found to be beneficial after cancer diagnosis, but little is known about the current state of research exploring LPA in advanced cancer. Our objectives were to (a) map the literature examining LPA in people with advanced cancer, (b) report on the terms used to describe the advanced cancer population within the literature, and (c) examine how the concept of LPA is operationalized within the literature.

METHOD

Our scoping review followed Arksey and O'Malley's methodological framework. We performed a search of 11 electronic databases and supplementary sources (February 2018; database search updated January 2020). Two reviewers independently reviewed and selected articles according to the inclusion criteria: English-language journal articles on original primary research studies exploring LPA in adults diagnosed with advanced cancer. Descriptive and thematic analyses were performed.

RESULTS

Ninety-two articles met our criteria. Most included studies were published in the last decade (80%) and used quantitative methods (77%). Many study populations included mixed (40%), breast (21%), or lung (17%) cancers. Stages 3-4 or metastatic disease were frequently indicated to describe study populations (77%). Several studies (68%) described LPA programs or interventions. Of these, 78% involved structured aerobic/resistance exercise, while 16% explored other LPA types.

SIGNIFICANCE OF RESULTS

This review demonstrates a recent surge in research exploring LPA in advanced cancer, particularly studies examining exercise interventions with traditional quantitative methods. There remains insufficient knowledge about patient experiences and perceptions toward LPA. Moreover, little is known about other leisure activities (e.g., Tai Chi, dance, and sports) for this population. To optimize the benefits of LPA in people with advanced cancer, research is needed to address the gaps in the current literature and to develop personalized, evidence-based supportive care strategies in cancer care.

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

AIMS

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

DESIGN

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Feasibility and outcomes of a goal-directed physical therapy program for patients with metastatic breast cancer

PURPOSE

To evaluate the feasibility and outcomes of a tailored, goal-directed, and exercise-based physical therapy program for patients with metastatic breast cancer (MBC).

METHODS

This was an observational, uncontrolled feasibility study. The physical therapy intervention was highly tailored to the individual patient's goals, abilities, and preferences and could include functional, strength, aerobic, and relaxation exercises. Feasibility outcomes were participation rate (expected: 25%), safety, and adherence (percentage of attended sessions relative to scheduled sessions). Additional outcomes were goal attainment, self-reported physical functioning, fatigue, health-related quality of life, and patient and physical therapist satisfaction with the program.

RESULTS

Fifty-five patients (estimated participation rate: 34%) were enrolled. Three patients did not start the intervention due to early disease progression. An additional 22 patients discontinued the program prematurely, mainly due to disease progression. Median intervention adherence was 90% and no major intervention-related adverse events occurred. A goal attainment score was available for 42 patients (of whom 29 had completed the program and 13 had prematurely dropped out). Twenty-two (52%) of these patients achieved their main goal fully or largely and an additional 15 patients (36%) partially. Eighty-five percent would "definitely recommend" the program to other patients with MBC. We observed a modest improvement in patient satisfaction with physical activities (Cohen's d_z 0.33).

CONCLUSION

The tailored intervention program was feasible in terms of uptake, safety, and outcomes and was highly valued by patients and physical therapists. However, disease progression interfered with the program, leading to substantial dropout.

TRIAL REGISTRATION

NTR register: NTR6475.

Design and methods of a national, multicenter, randomized and controlled trial to assess the efficacy of a physical activity program to improve health-related quality of life and reduce fatigue in women with metastatic breast cancer: ABLE02 trial

BACKGROUND

Patients with a metastatic breast cancer suffer from a deteriorated health-related quality of life and numerous symptoms such as pain, severe fatigue and a decrease of their physical fitness. As the feasibility of a physical activity program has been demonstrated in this population, ABLE02 aims to assess the efficacy of a 6 month-physical activity program using connected devices to improve health-related quality of life and to reduce fatigue in women with metastatic breast cancer.

METHODS

ABLE02 is a prospective, national, multicenter, randomized, controlled and open-label study. A total of 244 patients with a metastatic breast cancer, with at least one positive hormone receptor and a first-line chemotherapy planned, will be randomly assigned (1:1 ratio) to: (i) the intervention arm to receive physical activity recommendations, an activity tracker to wear 24 h a day during the whole intervention (6 months) with at least three weekly walking sessions and quizzes each week on physical activity and nutrition (ii) the control arm to receive physical activity recommendations only. Health-related quality of life will be assessed every 6 weeks and main assessments will be conducted at baseline, M3, M6, M12 and M18 to evaluate the clinical, physical, biological and psychological parameters and survival of participants. All questionnaires will be completed on a dedicated application.

DISCUSSION

An activity program based on a smartphone application linked to an activity tracker may help to improve quality of life and reduce fatigue of patients with a metastatic breast cancer. The growth of e-health offers the opportunity to get real-time data as well as improving patient empowerment in order to change long-term behaviors.

TRIAL REGISTRATION

NCT number: NCT04354233 .

Reflexive Intervention Development: Using Qualitative Research to Inform the Development of an Intervention for Women With Metastatic Breast Cancer

There is growing consensus around the limited attention given to documenting the process of intervention development, specifically the role of qualitative research. In this article, we seek to describe a missing piece of this process: how qualitative research, and related methodologies and theories, informs intervention development. We use our research as a case study of "reflexive intervention development." We begin by describing our interview study, consisting of 23 in-depth interviews with women diagnosed with metastatic breast cancer, and go on to detail our methodological framework and research team. We then explain how this interview study directly informed our development of the intervention materials, allowing us to attend carefully to language and its potential implications for women. We conclude by inviting researchers to reflect on the knowledge production process that is inherent in intervention development to consider not only their role in this process but also the role of qualitative research.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Physical Activity for Symptom Management in Women With Metastatic Breast Cancer: A Randomized Feasibility Trial on Physical Activity and Breast Metastases

CONTEXT

Physical activity for women with early-stage breast cancer is well recognized for managing cancer-related symptoms and improving quality of life. While typically excluded from interventions, women with metastatic breast cancer may also benefit from physical activity.

OBJECTIVE

To 1) determine the safety and feasibility of a physical activity program for women with metastatic breast cancer and 2) explore the efficacy of the program.

METHODS

Fourteen women with metastatic breast cancer were randomized to either a control group or an 8-week home-based physical activity intervention comprising twice weekly supervised resistance training and an unsupervized walking program.

RESULTS

The recruitment rate was 93%. Adherence to the resistance and walking components of the program was 100% and 25%, respectively. No adverse events were reported. When mean change scores from baseline to postintervention were compared, trends in favor of the exercise group over the control group were observed for the Functional Assessment of Chronic Illness Therapy-Fatigue score (+5.6 ± 3.2 vs. -1.8 ± 3.9, respectively), VO_2max (+1.6 ml/kg/minute ±1.8 mL/kg/minute vs. -0.2 mL/kg/minute ±0.1 mL/kg/minute, respectively) and six-minute walk test (+40 m ± 23 m vs. -46 m ± 56 m, respectively).

CONCLUSION

A partially supervised home-based physical activity program for women with metastatic breast cancer is feasible and safe. The dose of the resistance training component was well tolerated and achievable in this population. In contrast, adherence and compliance to the walking program were poor. Preliminary data suggest a physical activity program, comprising predominantly resistance training, may lead to improvements in physical capacity and may help women to live well with their disease.

Ankle loading ameliorates bone loss from breast cancer-associated bone metastasis

Breast cancer is a serious health problem that preferentially metastasizes to bone. We have previously shown that bone loss can be prevented by mechanical loading, but the efficacy of ankle loading for metastasis-linked bone loss has not been investigated. This study showed that body weight was decreased after inoculation of tumor cells, but ankle loading restored a rapid weight loss. The nonloading group exhibited a decrease in bone volume/tissue volume (BV/TV), trabecular thickness, and trabecular number (all P < 0.01) as well as an increase in trabecular separation (P < 0.001). However, ankle loading improved those changes (all P < 0.05). Furthermore, although the nonloading group increased the tumor bearing as well as expression of IL-8 and matrix metalloproteinase 9, ankle loading decreased them. Induction of tumor in the bone elevated the osteoclast number (P < 0.05) as well as the levels of nuclear factor of activated T-cells cytoplasmic 1, NF-κB ligand, cathepsin K, and serum tartrate-resistant acid phosphatase type 5b, but ankle loading reduced osteoclast activity and those levels (all P < 0.05). Tumor bearing was positively correlated with the osteoclast number (P < 0.01) and negatively correlated with BV/TV and the osteoblast number (both P < 0.01). Collectively, these findings demonstrate that ankle loading suppresses tumor growth and osteolysis by inhibiting bone resorption and enhancing bone formation.-Yang, S., Liu, H., Zhu, L., Li, X., Liu, D., Song, X., Yokota, H., Zhang, P. Ankle loading ameliorates bone loss from breast cancer-associated bone metastasis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of the effectiveness of physiotherapy in patients after oncological breast cancer treatment based on spirometric indicators

Introduction

The aim of this study is to evaluate the effects of physiotherapy in patients who underwent oncological treatment including spirometric indicators: FEV1, VC, FVC, PEF, FEV1/FVC, FEF25, FEF50, FEF75. Moreover, the possible influence of duration of physiotherapy on ventilation activity of lungs was assessed.

Material and methods

The study considered 91 women after breast cancer therapy qualified for outpatient physiotherapy. All patients underwent radiation therapy, and more than half of the women received concurrent chemotherapy. To assess rates of respiratory disorders, the patients were subjected to spirometric tests. The clinical status of examined subjects was also taken into account.

Results

Statistical analysis showed that the duration of physiotherapy contributed to increased ventilation index FEV1% – with each treatment day corresponding to an average of 1.8 units. In contrast, the involvement of lymph nodes radically reduced the level of PEF by as much as 64 units. The results of linear modelling provided evidence of statistically significant effects of chemotherapy on spirometric indicators. What is more, a statistically significant impact of time of rehabilitation on FEV1 increase was estimated.

Conclusions

Physiotherapy leads to improvement of lung functions in patients with breast cancer after oncological treatment; progress is more evident in patients with advanced cancer after radical treatment.

Muscle mass loss in patients with metastatic breast cancer

PURPOSE

To assess the change of body mass index (BMI), muscle mass, visceral and subcutaneous fat in patients with metastatic breast cancer.

METHODS

In this retrospective chart analysis, patients with metastatic breast cancer as initial diagnosis between 2012 and 2016 were analyzed. Patients had received either chemotherapy (CTH) or endocrine therapy (ETH) according to the German S3 Guideline. BMI was calculated from the patients' weight and height. Change of muscle mass, visceral and subcutaneous fat was determined by comparing the surface area of these tissues on transverse CT images at the level of the third lumbar vertebrae (L3) at baseline and during treatment.

RESULTS

A total of 45 patients were included in the study, 29 on CTH and 16 on ETH. BMI, visceral and subcutaneous fat remained stable over time for both treatment groups. When taking both treatment groups together, muscle mass decreased significantly by 5.0 ± 2.5 cm² per year (p < 0.05).

CONCLUSION

In patients with metastatic breast cancer, a slight reduction of muscle mass was observed, independent of therapy regimes.

A Review of Accelerometer-based Activity Monitoring in Cancer Survivorship Research

BACKGROUND

In the cancer survivorship context, physical activity and sedentary behavior have been measured using different methods.

PURPOSE

To conduct a narrative review of published research in cancer survivor populations to summarize the quality and identify gaps in reporting on accelerometer data collection, data processing, and outcome measures in cancer survivors.

METHODS

An initial PubMed® search of articles published in English was conducted in January 2017, and a final search was conducted in May 2017. Variables extracted included study characteristics, methods for accelerometry data collection (e.g., device used), data processing (e.g., cut points used), and data reporting (e.g., time spent in different activity intensities).

RESULTS

A total of 46 articles were eligible for inclusion in the review. The majority of studies (34 of 46) targeted a single cancer group and 18 of these 34 studies were in survivors of breast cancer. Half (54%) of the studies used an ActiGraph® accelerometer. Methods of accelerometer data processing varied across studies. Definitions of non-wear time, vectors used during processing, and filters applied during processing were reported by 51%, 60%, and 8% of studies, respectively. Most studies reported moderate and vigorous physical activity (78%), 50% reported sedentary time, and 43% reported light-intensity activity. Cut points to categorize these activities varied between studies.

CONCLUSIONS

This narrative review highlights inconsistency in the methods used to collect, process, and report accelerometry data across cancer survivor studies. Accelerometry has potential to add detailed knowledge of the levels and patterns of physical activities and sedentary behaviors across the cancer spectrum. Recommendations are made to improve data processing and reporting methods to maximize the scientific validity of future accelerometer research in this field.

Body Composition, Serum Biomarkers of Inflammation and Quality of Life in Clinically Stable Women with Estrogen Receptor Positive Metastatic Breast Cancer

Limited data exist regarding body composition and associated patient-reported outcomes for women with metastatic BC. Demographic, clinical, blood, and questionnaire data were collected to quantify body composition and explore associations with symptoms, inflammation, and quality of life (QOL) in 41 women with ER + metastatic BC. Diagnostic/surveillance computed tomography (CT) images including the third lumbar region (L3) were obtained to evaluate skeletal muscle (SM) quantity and quality, and abdominal adipose tissue. Frequencies, medians and interquartile ranges are presented, stratified by sarcopenia and obesity (Body mass index (BMI) ≥ 30.0 kg/m²). Overall, 34% (n = 14/41), 49% (n = 20/41), and 34% (n = 14) of women had sarcopenia, myosteatosis, and obesity, respectively. Handgrip strength was compromised in 24% of subjects (n = 10/41). Women with sarcopenia had significantly lower body weight (P = 0.01), BMI (P ≤ 0.001), and whole body SM (P < 0.001), yet reported greater engagement in leisure time exercises (P = 0.05) vs. nonsarcopenic women. Women with obesity had significantly higher levels of abdominal obesity (all values P < 0.0001) and serum biomarkers of inflammation (P values <0.06), yet lower QOL (P = 0.02) vs. women without obesity. The abPGSGA did not differentiate women with sarcopenia. Future interventions should test if improvements in body composition are associated with better outcomes for this vulnerable, emerging population.

Cancer- and Chemotherapy-Induced Musculoskeletal Degradation

Mobility in advanced cancer patients is a major health care concern and is often lost in advanced metastatic cancers. Erosion of mobility is a major component in determining quality of life but also starts a process of loss of muscle and bone mass that further devastates patients. In addition, treatment options become limited in these advanced cancer patients. Loss of bone and muscle occurs concomitantly. Advanced cancers that are metastatic to bone often lead to bone loss (osteolytic lesions) but may also lead to abnormal deposition of new bone (osteoblastic lesions). However, in both cases there is a disruption to normal bone remodeling and radiologic evidence of bone loss. Many antitumor therapies can also lead to loss of bone in cancer survivors. Bone loss releases cytokines (TGFβ) stored in the mineralized matrix that can act on skeletal muscle and lead to weakness. Likewise, loss of skeletal muscle mass leads to reduced bone mass and quality via mechanical and endocrine signals. Collectively these interactions are termed bone-muscle cross-talk, which has garnered much attention recently as a prime target for musculoskeletal health. Pharmacological approaches as well as nutrition and exercise can improve muscle and bone but have fallen short in the context of advanced cancers and cachexia. This review highlights our current knowledge of these interventions and discusses the difficulties in treating severe musculoskeletal deficits with the emphasis on improving not only bone mass and muscle size but also functional outcomes. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Activity Behaviors and Physiological Characteristics of Women With Advanced-Stage Ovarian Cancer: A Preliminary Cross-sectional Investigation

OBJECTIVES

Ovarian cancer (OC) survivors experience many disease and treatment adverse effects. However, the impact of OC and its treatment on objective activity behaviors and physiological status have not been examined. The purpose of this study was to compare objectively measured activity behaviors and physiological characteristics of advanced-stage OC survivors to age-matched controls.

METHODS

Twenty stage III-IV OC survivors and 20 controls completed assessments of activity behaviors (7-day accelerometry), physical function (400-meter walk as indicator of cardiorespiratory fitness, repeated chair rise, 6-meter walking tests), muscle strength (1-repetition maximum and handgrip), body composition (dual-energy x-ray absorptiometry), and musculoskeletal morphology (peripheral quantitative computed tomography).

RESULTS

Compared with controls, OC survivors spent more time/day in prolonged sedentary bouts (P = 0.039, r = 0.32), had lower cardiorespiratory fitness (P = 0.041, r = 0.33) and upper body strength (P = 0.023, r = 0.37), had higher areal bone mineral content (P = 0.047, r = 0.33) and volumetric trabecular density (P = 0.048, r = 0.31), but were not different in other measures of body composition nor in muscle morphology (P > 0.050). Only 20% (n = 4) of OC survivors accrued 150 minutes/week or greater moderate and vigorous physical activity (MVPA) time in 10-minute bouts or greater. Moderate and vigorous physical activity time/day in 10-minute bouts or greater was strongly associated with cardiorespiratory fitness (P = 0.001, ρ = -0.702) and lower extremity function (P = 0.019, ρ = -0.519) and moderately associated with muscle cross-sectional area (P = 0.035, ρ = 0.473).

CONCLUSIONS

Posttreatment OC survivors spent more time in prolonged sedentary bouts and had lower cardiorespiratory fitness and upper body strength compared with controls. Moderate and vigorous physical activity was associated with physical function and muscle cross-sectional area. Future studies should test the efficacy of exercise interventions to increase MVPA, reduce sedentary behavior, and increase cardiorespiratory fitness and muscle strength in OC survivors.

Tracking steps in oncology: the time is now

Purpose

Accurate evaluation of patients’ health status is a key component of the workup, treatment, and follow-up of cancer patients. Assessments by clinicians (eg, performance status, toxicity grade) and patients (eg, quality of life) play a critical role in current practice but have significant limitations. Technological advances now provide an opportunity to track a new class of objective measures of patient activity, such as daily step counts. Here, we describe recent efforts to incorporate this technology into the field of oncology.

Design

We conducted a structured literature search using MEDLINE electronic database to identify published observational studies of tracking steps in cancer patients and trials of exercise programs for cancer survivors incorporating pedometers until February 2016.

Results

Data indicate that physical activity information may supplant existing scales for the assessment of cancer patients’ functional capacity.

Conclusion

Objective activity monitoring is poised to revolutionize the way health care providers assess cancer patients at the time of diagnosis, during treatment, and in the survivorship setting.

Metastatic Breast Cancer Collateral Damage Project (MBCCD): Scale development and preliminary results of the Survey of Health, Impact, Needs, and Experiences (SHINE)

PURPOSE

Until recently, people with metastatic breast cancer (MBC) had a very poor prognosis. New treatment approaches have prolonged the time that people with MBC live, but their quality of life has received less attention. Consequently, the needs and concerns across financial, vocational, psychological, social, and physical domains in MBC patients are poorly understood-particularly regarding the collateral damage or longer-term, life-altering impacts of MBC and its treatments. This study's aims were to characterize MBC-related collateral damage, identify groups most likely to experience collateral damage, and examine its associations with psychological health, illness management, and health behaviors.

METHODS

Participants (N = 515) with MBC were recruited from Dr. Susan Love Research Foundation's Army of Women® and other advocacy organizations. Participants completed questionnaires of MBC-related collateral damage, depressive symptoms, anxiety, self-efficacy for managing oncologic treatments and physical symptoms, sleep, and physical activity.

RESULTS

Eight domains of MBC-related collateral damage, as well as MBC-related benefit finding, were reliably characterized. Concerns about mortality/uncertainty were most prominent. Participants also endorsed high levels of benefit finding. Participants younger than 50 years, with limited financial resources, or with children under 18 at home reported the most collateral damage. Collateral damage was associated significantly with compromised psychological health, lower illness management efficacy, and poorer health behaviors, beyond sociodemographic and medical characteristics.

CONCLUSIONS

Subgroups of MBC patients report long-term, life-altering consequences of MBC and its treatments, which relate to important health outcomes. Clinical implications and recommendations are discussed.

Differences in Balance Function Between Cancer Survivors and Healthy Subjects: A Pilot Study

Older adults who have survived cancer experience significantly more falls compared with healthy adults. Adult cancer survivors may also have a lower balance function than healthy adults. We examined muscle strength and balance function among 19 cancer survivors and 14 healthy subjects. The mean age of the cancer survivors was 51.5 ± 11.2 years; 6 men and 13 women. Cancer diagnoses included breast cancer, retroperitoneal sarcoma, acute leukemia, lung cancer, colorectal cancer, thyroid cancer, Ewing’s sarcoma, and tongue cancer. The mean age of healthy subjects was 47.4 ± 14 years; 3 men, 11 women. Muscle strength was assessed using hand grip and knee extensor strength tests. Balance function was evaluated using the Timed Up and Go (TUG) test, and body sway was tested using a force platform. No significant differences were found with respect to right and left grip strength or right and left knee extension strength between the 2 groups. A significantly higher TUG time was observed in cancer survivors than in healthy subjects (P < .05). With eyes open, the area of the center of pressure was significantly larger in cancer survivors than in healthy subjects (P < .05). Similarly, the length per area was significantly lower both with eyes open and closed for cancer survivors than for healthy subjects (P < .05). TUG was significantly correlated with muscle strength in both groups (P < .05). However, no body sway parameters were related to muscle strength in either group. Cancer survivors had lower balance function that might not have been related to muscle strength. Cancer survivors should be evaluated for balance function as there is a potential for impairment. The findings of this study will be relevant for planning the prevention of falls for cancer survivors.

Cancer survivors exhibit a different relationship between muscle strength and health-related quality of life/fatigue compared to healthy subjects

We investigated the difference in relationship between muscle strength and quality of life (QOL)/fatigue in long-term cancer survivors and healthy subjects. Thirty-six cancer survivors and 29 healthy subjects were assessed for body composition and bone status at the calcaneus using the Osteo Sono Assessment Index. Muscle strength was evaluated via handgrip and knee extensor strength. Health-related QOL was assessed using the Medical Outcome Study 36-item Short-Form Health Survey. Fatigue was measured using the brief fatigue inventory. Cancer survivors exhibited lower QOL scores in the physical functioning, physical role function, bodily pain and general health domains (p < .05). Grip and knee extension muscle strength in cancer survivors was positively correlated with the physical function and bodily pain of QOL (p < .05). The usual fatigue subscale score was only significantly higher in cancer survivors than in healthy subjects (p < .05). However, there were no correlations between muscle strength and fatigue in cancer survivors. Our results showed that muscle strength was an important factor for improving QOL in cancer survivors. We believe that the findings of this study will be relevant in the context of planning rehabilitation for cancer survivors.

Exercise interventions for individuals with advanced cancer: A systematic review

Despite improvements in therapy a large proportion of individuals with cancer will have a shortened life expectancy because of advanced or metastatic disease. Advances in therapy have however, extended life in those with advanced cancer thus heightening the importance of living well and preventing decline. The burdens of disease and cancer therapy impair aerobic fitness, strength, physical function and quality of life (QOL). Fatigue, the most common side effect of cancer and cancer therapy can further deteriorate QOL. Exercise has the potential to improve aerobic fitness, physical function, control fatigue and enhance QOL. However, exercise interventions are not routinely provided to those with advanced cancer. We present a systematic literature review of outcomes from interventions that include exercise for patients with advanced cancer. Studies were reviewed if they included an advanced cancer population and an intervention with a component of exercise. Overall, exercise containing interventions resulted in improvements in measures of aerobic capacity (14 of 19 studies) strength (11 of 12 studies), and components of physical function (9 of 9 studies). Fatigue and QOL were identified to improve in slightly over half of all evaluated studies (11 of 19 studies and 10 of 19 studies for fatigue and QOL respectively). The numbers of total participants reporting improvements in QOL (60%) were greater than fatigue (45%). Exercise provided to individuals with advanced cancer maintains or improves fitness and physical function and may diminish fatigue and enhance QOL and should be considered as an intervention to prevent further health complications.

Current challenges in optimizing systemic therapy for patients with pancreatic cancer: expert perspectives from the Australasian Gastrointestinal Trials Group (AGITG) with invited international faculty

INTRODUCTION

Despite recent progress, the outlook for most patients with pancreatic cancer remains poor. There is variation in how patients are managed globally due to differing interpretations of the evidence, partly because studies in this disease are challenging to undertake. This article collates the evidence upon which current best practice is based and offers an expert opinion from an international faculty on how latest developments should influence current treatment paradigms. Areas covered: Optimal chemotherapy for first and subsequent lines of therapy; optimal management of locally advanced, non-metastatic cancer including the role of neoadjuvant chemo(radio)therapy, current evidence for adjuvant chemotherapy, major advances in pancreatic cancer genomics and challenges in supportive care particularly relevant to patients with pancreatic cancer. For each section, literature was reviewed by comprehensive search techniques, including clinical trial websites and abstracts from international cancer meetings. Expert commentary: For each section, a commentary is provided. Overall the challenges identified were: difficulties in diagnosing pancreatic cancer early, challenges for performing randomised clinical trials in all stages of the disease, some progress in systemic therapy with new agents and in identifying molecular subtypes that may be clinically relevant and move towards personalized therapy, but still, pancreatic cancer remains a very poor prognosis cancer with significant palliative care needs.

Comparison between logbook-reported and objectively-assessed physical activity and sedentary time in breast cancer patients: an agreement study

Background

Increasing physical activity (PA) and decreasing sedentary time (ST) have important health effects among breast cancer patients, a growing population group. PA and sedentary behaviors are complex multi-dimensional behaviors and are challenging to monitor accurately. To date few studies have compared self-reports and objective measurement in assessing PA and ST in women undergoing breast cancer treatments. The aim of the present study was to compare self-reports and objective measures for assessing daily time spent in moderate-intensity physical activity (MPA), vigorous-intensity physical activity (VPA) and ST in women undergoing breast cancer treatments.

Methods

Baseline data from 65 women with breast cancer scheduled to undergo adjuvant treatment was included. Daily time spent in MPA, VPA and ST was assessed by a study-specific logbook and the SenseWear Armband mini (SWA). The level of agreement between the two measurement methods was then determined by performing Bland-Altman plots with limits of agreements, and calculating Spearman’s rank correlation coefficients.

Results

The mean difference between the logbook and SWA with limits of agreement was 14 (±102) minutes for MPA, 1 (±21) minute for VPA and −196 (±408) minutes for ST, respectively. The logbook reported an average of 34 and 50% higher values than the SWA for MPA and VPA, as well as an average of 27% lower values for ST (P < 0.05). The Spearman’s rank correlation coefficients showed that the differences between the methods increased as the average amount of time spent in PA and ST increased (P < 0.01).

Conclusions

The results imply that the two measurement methods have limited agreement and cannot be used interchangeably.

Is it time to address survivorship in advanced breast cancer? A review article

The outcome of advanced breast cancer has significantly improved over recent decades. As a consequence, the complex needs of patients living with the disease and their care-givers should be addressed not only in terms of supportive and palliative care but also of "survivorship" requirements. The multidisciplinary approach to advanced breast cancer should encompass - early in the history of the disease - not only physical but also functional, social, psychological and spiritual domains. It is important to clearly define the disease context with patients and families ("chronic" preferred to "incurable"), addressing the concept of uncertainty, and tailoring the treatment strategy according to both disease status and individual priorities. Specific psychosocial needs of young and elderly women and male patients - i.e. social security, job flexibility, rehabilitation (including sexuality), home and child care - should be recognized and supported. This review will address the key questions associated with survivorship in this disease context, recognizing the dearth of specific data and the urgent need for targeted clinical research and tailored interventions.