1
|
Kuehl R, Feyer J, Limbach M, Pahl A, Stoelzel F, Beck H, Wegner A, Rosenberger F, Dreger P, Luft T, Wiskemann J. Prehabilitative high-intensity interval training and resistance exercise in patients prior allogeneic stem cell transplantation. Sci Rep 2023; 13:22069. [PMID: 38086868 PMCID: PMC10716116 DOI: 10.1038/s41598-023-49420-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
Physical capacity prior allogeneic stem cell transplantation (allo-HCT) has been shown as a relevant prognostic factor for survival after transplant. Therefore, we evaluated feasibility and preliminary efficacy of a high-intensity interval training (HIIT) and moderate to high-intensity resistance exercise (RE) to increase physical capacity in patient's prior allo-HCT. In this multicentre single arm pilot study, a supervised exercise program was performed twice weekly for 4-12 weeks prior allo-HCT, depending on the individual time remaining. Outcomes were feasibility (recruitment, adherence, safety), physical capacity (cardiorespiratory fitness [VO2peak], muscle strength) and patient reported outcomes (physical functioning, fatigue). Thirty patients were intended, 16 could be included, and 14 completed post intervention assessment (75% male, 55 ± 11 years). The study was stopped early due to a low recruitment rate. Nine patients (64%) reached the initial minimum planned number of eight exercise sessions. Individual adherence was high with 92% for HIIT and 85% for RE. 87% of all performed exercise sessions were completed without complaints and VO2peak increased significantly from 20.4 to 23.4 ml/kg/min. The low recruitment rate suggests that initiation of the intervention concept immediately before allo-HCT is feasible only in a small number of patients. In particular, the timeframe directly prior allo-HCT seems too short for exercise interventions, although the exercise program was designed to improve outcomes in a very short time frame. HIIT and RE were feasible, effective and well accepted by the included patients.
Collapse
Affiliation(s)
- Rea Kuehl
- Working Group Exercise Oncology, Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Jule Feyer
- Working Group Exercise Oncology, Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Matthias Limbach
- Working Group Exercise Oncology, Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Antonia Pahl
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Center -University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friederike Stoelzel
- Prevention Center of the National Center for Tumor Diseases Dresden (NCT/UCC), Dresden, Germany
| | - Heidrun Beck
- Department of Sports Medicine, University Center for Orthopedics, Trauma and Plastic Surgery, Dresden, Germany
| | - Annika Wegner
- Medical Clinic II, Hematology-Oncology, University Clinic Frankfurt, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Friederike Rosenberger
- Working Group Exercise Oncology, Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
- Division of Health Sciences, German University of Applied Sciences for Prevention and Health Management, Saarbrucken, Germany
| | - Peter Dreger
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Luft
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Joachim Wiskemann
- Working Group Exercise Oncology, Division of Medical Oncology, National Center for Tumor Diseases (NCT) Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| |
Collapse
|
2
|
Artese AL, Winthrop HM, Bohannon L, Lew MV, Johnson E, MacDonald G, Ren Y, Pastva AM, Hall KS, Wischmeyer PE, Macleod D, Molinger J, Barth S, Jung SH, Cohen HJ, Bartlett DB, Sung AD. A pilot study to assess the feasibility of a remotely monitored high-intensity interval training program prior to allogeneic hematopoietic stem cell transplantation. PLoS One 2023; 18:e0293171. [PMID: 38032994 PMCID: PMC10688680 DOI: 10.1371/journal.pone.0293171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 10/05/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Although allogeneic hematopoietic stem cell transplantation (HCT) can be a curative therapy for hematologic disorders, it is associated with treatment-related complications and losses in cardiorespiratory fitness and physical function. High-intensity interval training (HIIT) may be a practical way to rapidly improve cardiorespiratory fitness and physical function in the weeks prior to HCT. The primary aim of this study was to assess the feasibility of implementing a pre-HCT home-based HIIT intervention. The secondary aim was to evaluate pre to post changes in cardiorespiratory fitness and physical function following the intervention. METHODS This was a single-arm pilot study with patients who were scheduled to undergo allogeneic HCT within six months. Patients were instructed to complete three 30-minute home-based HIIT sessions/week between the time of study enrollment and sign-off for HCT. Sessions consisted of a 5-minute warm-up, 10 high and low intervals performed for one minute each, and a 5-minute cool-down. Prescribed target heart rates (HR) for the high- and low-intensity intervals were 80-90% and 50-60% of HR reserve, respectively. Heart rates during HIIT were captured via an Apple Watch and were remotely monitored. Feasibility was assessed via retention, session adherence, and adherence to prescribed interval number and intensities. Paired t-tests were used to compare changes in fitness (VO2peak) and physical function [Short Physical Performance Battery (SPPB), 30-second sit to stand, and six-minute walk test (6MWT)] between baseline and sign-off. Pearson correlations were used to determine the relationship between intervention length and changes in cardiorespiratory fitness or functional measures. RESULTS Thirteen patients (58.8±11.6 years) participated in the study, and nine (69.2%) recorded their training sessions throughout the study. Median session adherence for those nine participants was 100% (IQR: 87-107). Adherence to intervals was 92% and participants met or exceeded prescribed high-intensity HR on 68.8±34.8% of intervals. VO2peak improved from baseline to sign-off (14.6±3.1 mL/kg/min to 17.9±3.3 mL/kg/min; p<0.001). 30-second sit to stand and SPPB chair stand scores significantly improved in adherent participants. Improvements in 30-second sit to stand (13.8±1.5 to 18.3±3.3 seconds) and 6MWT (514.4±43.2 to 564.6±19.3) exceeded minimal clinically important improvements established in other chronic disease populations, representing the minimum improvement considered meaningful to patients. CONCLUSIONS Findings demonstrate that implementing a pre-HCT home-based remotely monitored HIIT program is feasible and may provide benefits to cardiorespiratory fitness and physical function.
Collapse
Affiliation(s)
- Ashley L. Artese
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Exercise Science and Health Promotion, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - Hilary M. Winthrop
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Lauren Bohannon
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Meagan V. Lew
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Ernaya Johnson
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Grace MacDonald
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina, United States of America
- Division of Medical Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Yi Ren
- Duke Cancer Institute Biostatistics Shared Resources, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Amy M. Pastva
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Katherine S. Hall
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina, United States of America
| | - Paul E. Wischmeyer
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
| | - David Macleod
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Jeroen Molinger
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Stratton Barth
- Duke University Hospital, Department of Anesthesiology and Surgery, Durham North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - David B. Bartlett
- Division of Medical Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| |
Collapse
|
3
|
Reilly M, Dandapani SV, Kumar KA, Constine L, Fogh SE, Roberts KB, Small W, Schechter NR. ACR-ARS Practice Parameter for the Performance of Total Body Irradiation. Am J Clin Oncol 2023; 46:185-192. [PMID: 36907934 DOI: 10.1097/coc.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVES This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter provides updated reference literature regarding both clinical-based conventional total body irradiation and evolving volumetric modulated total body irradiation. METHODS This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. RESULTS This practice parameter provides a comprehensive update to the reference literature regarding conventional total body irradiation and modulated total body irradiation. Dependence on dose rate remains an active area of ongoing investigation in both the conventional setting (where instantaneous dose rate can be varied) and in more modern rotational techniques, in which average dose rate is the relevant variable. The role of imaging during patient setup and the role of inhomogeneity corrections due to computer-based treatment planning systems are included as evolving areas of clinical interest notably surrounding the overall dose inhomogeneity. There is increasing emphasis on the importance of evaluating mean lung dose as it relates to toxicity during high-dose total body irradiation regimens. CONCLUSIONS This practice parameter can be used as an effective tool in designing and evaluating a total body irradiation program that successfully incorporates the close interaction and coordination among the radiation oncologists, medical physicists, dosimetrists, nurses, and radiation therapists.
Collapse
Affiliation(s)
| | | | - Kiran A Kumar
- UT Southwestern Medical Center 5323 Harry Hines Blvd, Dallas, TX
| | - Louis Constine
- University of Rochester Medical Center 601 Elmwood Ave, Rochester, NY
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco, CA
| | | | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Loyola University Medical Center Department of Radiation Oncology Maguire Center - Room 2944 2160 S. 1st Ave. Maywood, IL
| | - Naomi R Schechter
- South Florida Proton Therapy Institute and Rakuten-Medical, Inc., Delray Beach, FL
| |
Collapse
|
4
|
Dillon HT, Foulkes S, Horne-Okano YA, Kliman D, Dunstan DW, Daly RM, Fraser SF, Avery S, Kingwell BA, La Gerche A, Howden EJ. Reduced cardiovascular reserve capacity in long-term allogeneic stem cell transplant survivors. Sci Rep 2023; 13:2112. [PMID: 36747066 PMCID: PMC9902607 DOI: 10.1038/s41598-023-28320-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023] Open
Abstract
Premature cardiovascular mortality is increased in long-term allogeneic stem cell transplant (allo-SCT) survivors, but little information exists regarding subclinical cardiovascular dysfunction in this population. We compared peak oxygen uptake ([Formula: see text]O2peak), a prognostic cardiovascular marker, and its determinants between long-term allo-SCT survivors and non-cancer controls. Fourteen allo-SCT survivors (mean ± SD, 44 ± 15 years, 50% male, median time since allo-SCT: 6.5 years [range 2-20]) and 14 age- and sex-matched controls (46 ± 13 years, 50% male) underwent cardiopulmonary exercise testing to quantify [Formula: see text]O2peak. Resting echocardiography (left-ventricular ejection fraction and strain), exercise cardiac MRI (peak cardiac and stroke volume index [CIpeak, SVIpeak]), biochemistry (hemoglobin, troponin-I, B-natriuretic peptide), dual-energy x-ray absorptiometry (lean [LM] and fat [FM] mass, percent body fat [%BF]) and Fick-principal calculation (arteriovenous oxygen difference) were also performed. Survivors exhibited impaired [Formula: see text]O2peak as compared with controls (25.9 ± 5.1 vs. 33.7 ± 6.5 ml kg-1 min-1, p = 0.002), which coincided with reduced CIpeak (6.6 ± 0.8 vs. 8.6 ± 1.9 L min-1 m-2; p = 0.001) secondary to reduced SVIpeak (48 ± 4 vs. 61 ± 8 ml m-2; p < 0.001) rather than chronotropic impairment, and higher %BF (difference, 7.9%, p = 0.007) due to greater FM (5.8 kg; p = 0.069) and lower LM (4.3 kg, p = 0.25). All other measures were similar between groups. Despite comparable resting cardiac function and biomarker profiles, survivors exhibited reduced [Formula: see text]O2peak and exercise cardiac function and increased %BF relative to controls. These results highlight potential therapeutic avenues and the utility of exercise-based cardiovascular assessment in unmasking cardiovascular dysfunction in allo-SCT survivors.
Collapse
Affiliation(s)
- Hayley T Dillon
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Stephen Foulkes
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia.,University of Melbourne, Melbourne, Australia
| | | | - David Kliman
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, Australia
| | - David W Dunstan
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Sharon Avery
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, Australia
| | - Bronwyn A Kingwell
- Baker Heart and Diabetes Institute, Melbourne, Australia.,CSL Ltd, Melbourne, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Erin J Howden
- Baker Heart and Diabetes Institute, Melbourne, Australia. .,University of Melbourne, Melbourne, Australia.
| |
Collapse
|
5
|
Gavotto A, Dubard V, Avesani M, Huguet H, Picot MC, Abassi H, Guillaumont S, De La Villeon G, Haouy S, Sirvent N, Sirvent A, Theron A, Requirand A, Matecki S, Amedro P. Impaired aerobic capacity in adolescents and young adults after treatment for cancer or non-malignant haematological disease. Pediatr Res 2023:10.1038/s41390-023-02477-6. [PMID: 36709386 DOI: 10.1038/s41390-023-02477-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE Childhood cancer survivors are at increased risk for cardiovascular disease. Maximal oxygen uptake (VO2max) is a major determinant of cardiovascular morbidity. The aim of this study was to compare aerobic capacity, measured by cardiopulmonary exercise test (CPET), of adolescents and young adults in remission with that of healthy controls and to identify the predictors of aerobic capacity in this population. METHOD This is a controlled cross-sectional study. RESULTS A total of 477 subjects (77 in remission and 400 controls), aged from 6 to 25 years, were included, with a mean delay between end of treatment and CPET of 2.9 ± 2.3 years in the remission group. In this group, the mean VO2max was significantly lower than in controls (37.3 ± 7.6 vs. 43.3 ± 13.1 mL/kg/min, P < 0.01, respectively), without any clinical or echocardiographic evidence of heart failure. The VAT was significantly lower in the remission group (26.9 ± 6.0 mL/kg/min vs. 31.0 ± 9.9 mL/kg/min, P < 0.01, respectively). A lower VO2max was associated with female sex, older age, higher BMI, radiotherapy, and hematopoietic stem cell transplantation. CONCLUSION Impaired aerobic capacity had a higher prevalence in adolescents and young adults in cancer remission. This impairment was primarily related to physical deconditioning and not to heart failure. TRIAL REGISTRY NCT04815447. IMPACT In childhood cancer survivors, aerobic capacity is five times more impaired than in healthy subjects. This impairment mostly reflects early onset of physical deconditioning. No evidence of heart failure was observed in this population.
Collapse
Affiliation(s)
- Arthur Gavotto
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France.,PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Vincent Dubard
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Martina Avesani
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France
| | - Helena Huguet
- Epidemiology and Clinical Research Department, Clinical Investigation Centre, INSERM-CIC 1411, University of Montpellier, Montpellier University Hospital, Montpellier, France
| | - Marie-Christine Picot
- Epidemiology and Clinical Research Department, Clinical Investigation Centre, INSERM-CIC 1411, University of Montpellier, Montpellier University Hospital, Montpellier, France
| | - Hamouda Abassi
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Sophie Guillaumont
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France.,Paediatric Cardiology and Rehabilitation Centre, Saint-Pierre Institute, Palavas-Les-Flots, France
| | - Gregoire De La Villeon
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France.,Paediatric Cardiology and Rehabilitation Centre, Saint-Pierre Institute, Palavas-Les-Flots, France
| | - Stephanie Haouy
- Paediatric Cancer Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Nicolas Sirvent
- Paediatric Cancer Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Anne Sirvent
- Paediatric Cancer Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Alexandre Theron
- Paediatric Cancer Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Anne Requirand
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France
| | - Stefan Matecki
- Paediatric Cardiology and Pulmonology Unit, Department of Paediatrics, Montpellier University Hospital, Montpellier, France.,PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France. .,IHU Liryc, INSERM 1045, Bordeaux University, Bordeaux, France.
| |
Collapse
|
6
|
Dillon HT, Foulkes S, Horne-Okano YA, Kliman D, Dunstan DW, Daly RM, Fraser SF, Avery S, Kingwell BA, La Gerche A, Howden EJ. Rapid cardiovascular aging following allogeneic hematopoietic cell transplantation for hematological malignancy. Front Cardiovasc Med 2022; 9:926064. [PMID: 36588564 PMCID: PMC9797839 DOI: 10.3389/fcvm.2022.926064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Allogeneic hematopoietic cell transplantation (allo-HCT) offers a potential cure for high-risk hematological malignancy; however, long-term survivors experience increased cardiovascular morbidity and mortality. It is unclear how allo-HCT impacts cardiovascular function in the short-term. Thus, this 3-month prospective study sought to evaluate the short-term cardiovascular impact of allo-HCT in hematological cancer patients, compared to an age-matched non-cancer control group. Methods Before and ~3-months following allo-HCT, 17 hematological cancer patients (45 ± 18 years) underwent cardiopulmonary exercise testing to quantify peak oxygen uptake (VO2peak)-a measure of integrative cardiovascular function. Then, to determine the degree to which changes in VO2peak are mediated by cardiac vs. non-cardiac factors, participants underwent exercise cardiac MRI (cardiac reserve), resting echocardiography (left-ventricular ejection fraction [LVEF], global longitudinal strain [GLS]), dual-energy x-ray absorptiometry (lean [LM] and fat mass [FM]), blood pressure (BP) assessment, hemoglobin sampling, and arteriovenous oxygen difference (a-vO2diff) estimation via the Fick equation. Twelve controls (43 ± 13 years) underwent identical testing at equivalent baseline and 3-month time intervals. Results Significant group-by-time interactions were observed for absolute VO2peak (p = 0.006), bodyweight-indexed VO2peak (p = 0.015), LM (p = 0.001) and cardiac reserve (p = 0.019), which were driven by 26, 24, 6, and 26% reductions in the allo-HCT group (all p ≤ 0.001), respectively, as no significant changes were observed in the age-matched control group. No significant group-by-time interactions were observed for LVEF, GLS, FM, hemoglobin, BP or a-vO2diff, though a-vO2diff declined 12% in allo-HCT (p = 0.028). Conclusion In summary, allo-HCT severely impairs VO2peak, reflecting central and peripheral dysfunction. These results indicate allo-HCT rapidly accelerates cardiovascular aging and reinforces the need for early preventive cardiovascular intervention in this high-risk group.
Collapse
Affiliation(s)
- Hayley T. Dillon
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia,Institute of Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Stephen Foulkes
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia,Institute of Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Yuki A. Horne-Okano
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - David Kliman
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, VIC, Australia
| | - David W. Dunstan
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia,Institute of Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Robin M. Daly
- Institute of Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Steve F. Fraser
- Institute of Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Sharon Avery
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, VIC, Australia
| | - Bronwyn A. Kingwell
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia,CSL Ltd, Melbourne, VIC, Australia
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Erin J. Howden
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia,*Correspondence: Erin J. Howden
| |
Collapse
|
7
|
Gent DG, Saif M, Lee J, Tóth AG, Tholouli E, Dobson R, Wright DJ. Cardiovascular screening prior to stem cell transplantation in the United Kingdom. EJHAEM 2022; 3:1455-1458. [PMID: 36467825 PMCID: PMC9713214 DOI: 10.1002/jha2.599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 06/17/2023]
Affiliation(s)
- David G. Gent
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
| | | | - Julia Lee
- British Society of Blood and Marrow Transplantation and Cellular Therapy Data RegistryLondonUK
| | | | - Eleni Tholouli
- Department of HaematologyManchester University NHS Foundation TrustManchesterUK
| | - Rebecca Dobson
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
| | - David J. Wright
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
| |
Collapse
|
8
|
Dillon HT, Saner NJ, Ilsley T, Kliman D, Spencer A, Avery S, Dunstan DW, Daly RM, Fraser SF, Owen N, Lynch BM, Kingwell BA, La Gerche A, Howden EJ. Preventing the adverse cardiovascular consequences of allogeneic stem cell transplantation with a multi-faceted exercise intervention: the ALLO-Active trial protocol. BMC Cancer 2022; 22:898. [PMID: 35978289 PMCID: PMC9383666 DOI: 10.1186/s12885-022-09793-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/17/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Allogeneic stem cell transplantation (allo-SCT) is a potentially lifesaving treatment for high-risk hematological malignancy, but survivors experience markedly elevated rates of cardiovascular disease and associated functional impairment. Mounting evidence suggests regular exercise, combined with a reduction in sedentary time through replacement with light exercise may be a useful therapeutic strategy for the prevention of cardiovascular comorbidities. However, this type of intervention has yet to be evaluated in patients undergoing allo-SCT. The ALLO-Active study will evaluate the efficacy of a ~ 4 month multi-faceted exercise intervention, commenced upon admission for allo-SCT, to preserve peak oxygen uptake (VO2peak) and peak cardiac output, compared with usual care. The study will also evaluate the effect of the intervention on functional independence, quality of life, and symptoms of fatigue. METHODS Sixty adults with hematological malignancy scheduled for allo-SCT will be randomly assigned to usual care (n = 30) or the exercise and sedentary behaviour intervention (n = 30). Participants assigned to the intervention will complete a thrice weekly aerobic and progressive resistance training program and concomitantly aim to reduce daily sedentary time by 30 min with short, frequent, light-intensity exercise bouts. Participants will undergo testing prior to, immediately after inpatient discharge, and 12 weeks after discharge. To address aim 1, VO2peak and peak cardiac output (multiple primary outcomes, p < 0.025) will be assessed via cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, respectively. Secondary outcomes include functional independence (defined as VO2peak ≥ 18.mL.kg-1.min-1), quality of life, and fatigue (assessed via validated questionnaire). Exploratory outcomes will include indices of resting cardiac, vascular, and skeletal muscle structure and function, cardiovascular biomarkers, anxiety and depression, transplant outcomes (e.g., engraftment, graft-versus-host disease), and habitual physical activity, sedentary time, and sleep. DISCUSSION Multi-faceted exercise programs are a promising approach for ameliorating the cardiovascular consequences of allo-SCT. If this intervention proves to be effective, it will contribute to the development of evidence-based exercise guidelines for patients undergoing allo-SCT and assist with optimising the balance between acute cancer management and long-term health. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR), ID: 12619000741189 . Registered 17 May 2019.
Collapse
Affiliation(s)
- Hayley T Dillon
- Baker Heart and Diabetes Institute, Melbourne, Australia.
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia.
| | | | - Tegan Ilsley
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - David Kliman
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, Australia
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, Australia
| | - Sharon Avery
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, Australia
| | - David W Dunstan
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Neville Owen
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Centre for Urban Transitions, Swinburne University of Technology, Melbourne, Australia
| | - Brigid M Lynch
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
| | - Bronwyn A Kingwell
- Baker Heart and Diabetes Institute, Melbourne, Australia
- CSL Ltd, Melbourne, Australia
| | | | - Erin J Howden
- Baker Heart and Diabetes Institute, Melbourne, Australia
| |
Collapse
|
9
|
Powell AW, Urbina EM, Madueme P, Rotz S, Chin C, Taylor MD, Mays WA, Davies SM, Lane A, Berger S, Jodele S, Dandoy CE, Ryan TD. Abnormal maximal and submaximal cardiopulmonary exercise capacity in pediatric stem cell transplant recipients despite normal standard echocardiographic parameters: a pilot study. Transplant Cell Ther 2022; 28:263.e1-263.e5. [PMID: 35219851 DOI: 10.1016/j.jtct.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/10/2022] [Accepted: 02/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Left ventricular systolic dysfunction is a known complication of stem cell transplant (SCT). There has been minimal research to determine if subclinical cardiac dysfunction exists in SCT patients utilizing tools other than standard echocardiography, such as maximal and submaximal effort cardiopulmonary exercise testing (CPET) and vascular function studies. OBJECTIVE The objective of this study was to determine the rate of subclinical cardiac dysfunction in patients with normal ejection fraction after SCT, identified by abnormal values by CPET, tissue-Doppler imaging, and arterial stiffness measurements and to further describe submaximal exercise test measures in this population. STUDY DESIGN A prospective cohort study of SCT survivors who were at least three years post-SCT without prior anthracycline or radiation exposure and with preserved systolic function (LV ejection fraction > 50%) was performed to evaluate for abnormalities in exercise, vascular function, and diastolic function in an effort to detect subclinical dysfunction in SCT patients. RESULTS There were 11 patients (12.4±3.8-years-old) included in the study. No patients had diastolic dysfunction. All patients completed a maximal effort exercise test, and 73% (8/11) had abnormal peak oxygen consumption (VO2peak), which is a measure of aerobic fitness. However, during submaximal effort CPET, 45% (5/11) had an abnormal VO2 at anaerobic threshold (i.e. the point in exercise where aerobic transitions to anaerobic metabolism and fatigue starts), and 64% (7/11) had an abnormal oxygen uptake efficiency slope (a measure that relates VO2peak to total ventilation). 86% (6/7) of the patients with an abnormal oxygen uptake efficiency slope ultimately had an abnormal VO2peak. There were no vascular function abnormalities. CONCLUSION Pediatric survivors of SCT often have abnormal maximal and submaximal exercise capacity without vascular or cardiac dysfunction.
Collapse
Affiliation(s)
- Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peace Madueme
- The Division of Pediatric Cardiology, Nemours Children's Hospital, Orlando, FL
| | - Seth Rotz
- The Division of Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael D Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adam Lane
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Suzanne Berger
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonata Jodele
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christopher E Dandoy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
10
|
Yeon SH, Lee MW, Duong TT, Kang S, Jee S, Ahn SY, Ryu H, Lee HJ, Kwon JH, Yun HJ, Jo DY, Song IC. Cardiopulmonary Exercise Test With Comorbidity Index Before Allogeneic Hematopoietic Stem Cell Transplantation. Integr Cancer Ther 2022; 21:15347354221134249. [DOI: 10.1177/15347354221134249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Purpose: To evaluate the role of the cardiopulmonary exercise test (CPET) with comorbidity index as a predictor of overall survival (OS) and non-relapse mortality (NRM) in patients with hematological malignancies who undergo allogeneic hematopoietic stem cell transplantation (HSCT). Methods: We retrospectively analyzed consecutive adult patients with hematological malignancies who underwent HLA-matched donor-HSCT at Chungnam National University Hospital (Daejeon, South Korea) between January 2014 and December 2020. Maximal oxygen consumption (VO2max) was classified using the recommendations of the Mayo Clinic database. Results: Of 72 patients, 38 (52.8%) had VO2max values lower than the 25th percentile (VO2max ≤ 25th) of an age- and sex-matched normal population. Patients with VO2max ≤ 25th had no significant differences both OS and NRM (30 month OS 29.8% vs 41%, P = .328; and 30 month NRM 16% vs 3.3%, P = .222), compared with other patients. VO2max ≤ 25th was assigned a weight of 1 when added to the Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) to form a composite comorbidity/CPET index (HCT-CI/CPET). Patients with HCT-CI/CPET scores of 0 to 1 demonstrated significantly better OS and NRM than did patients with HCT-CI/CPET scores ≥2 [median OS not reached vs 6 months, P < .001 and 30 month NRM 7.4% vs 33.3%, P = .006]. An HCT-CI/CPET score ≥2 was the only adverse risk factor for NRM on multivariate analysis [hazard ratio (HR) of NRM 10.36 (95% CI 1.486-2.25, P = .018)]. Conclusion: The composite HCT-CI/CPET score can predict the survival and mortality of patients with hematological malignancies who undergo allogeneic HSCT.
Collapse
Affiliation(s)
- Sang Hoon Yeon
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Myung-Won Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Thi Thuy Duong
- Department of Medical Science, College of Medicine, Chungnam National University, Daejeon, Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University, Daejeon, Korea
| | - Sora Kang
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Sungju Jee
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - So-Young Ahn
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyewon Ryu
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyo-Jin Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hwan-Jung Yun
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Deog-Yeon Jo
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Ik-Chan Song
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
- Department of Medical Science, College of Medicine, Chungnam National University, Daejeon, Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University, Daejeon, Korea
| |
Collapse
|
11
|
Lindman A, Handberg C, Olesen G, Duijts S. Health-related quality of life and physical functioning in patients participating in a rehabilitation programme, undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation: Outcomes from a single arm longitudinal study. Eur J Cancer Care (Engl) 2021; 30:e13478. [PMID: 34263492 DOI: 10.1111/ecc.13478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study aims to report HRQOL, patient activation and physical functioning of haematological patients, participating in a 6-month multimodal interdisciplinary rehabilitation programme HAPPY, when undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation (NMA-HSCT). METHODS A prospective single-arm longitudinal design. Outcomes were collected as part of a feasibility study and included: HRQOL (EORTC QLQ-C30), patient activation measure (PAM), cardiorespiratory capacity (VO2peak ), leg extensor power, lean body mass, measured pre-NMA-HSCT at 3-, 6- and 12-month follow-up. RESULTS Thirty (mean age (SD) 64.1 (6.5)) out of 34 patients participated and 18 completed HAPPY. Outcome measures showed large individual differences of decline and improvement during follow-up. Patients rated HRQOL as good (median 70.8; range 33.3-100). Fatigue, dyspnoea, insomnia and appetite loss mainly remained or worsened. PAM stayed in the upper half of range (median 55.6; range 20.5-84.8) with a trend towards improvement at 12-month follow-up. Physical functioning scores were low [i.e. baseline VO2peak , men median 1.5 L/min range (1.0-2.9), women 1.0 L/min (0.8-1.4), leg extensor power men 2.1 Watt/kg range (1.3-3.8), women 1.7 Watt/kg (1.3-2.4), lean body mass men 19.5% (17.6-24.9) and women 17.8% (15.3-21.7)]. CONCLUSION The sustained low level of physical functioning and symptoms 12-month after NMA-HSCT emphasise the need for pre-rehabilitation and long-lasting rehabilitation support in this frail patient group.
Collapse
Affiliation(s)
- Astrid Lindman
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark.,Department of Public Health, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Charlotte Handberg
- Department of Public Health, Faculty of Health, Aarhus University, Aarhus, Denmark.,National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Gitte Olesen
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Saskia Duijts
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
12
|
Herr MM, Rehman S, Zhang Y, Ho CM, Chen GL, Ross M, Hillengass J, Jacobson H, McKenzie R, Farrell K, Maqsood A, McCarthy PL, Hahn T. Replicated Risk Index of Patient Functional Status Prior to Allogeneic Hematopoietic Cell Transplantation Predicts Healthcare Utilization and Survival. Transplant Cell Ther 2021; 27:875.e1-875.e9. [PMID: 34216792 DOI: 10.1016/j.jtct.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/08/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
Poor physical functioning is associated with adverse outcomes after allogeneic hematopoietic cell transplantation (alloHCT). Analytic tools to predict mortality in alloHCT recipients include the HCT Comorbidity Index (HCT-CI) based on comorbidities and the Disease Risk Index (DRI) based on disease and disease status. We developed and replicated a risk model for overall survival (OS), early mortality (ie, death from any cause at or before day +100), initial hospital length of stay (LOS), and percentage of inpatient days within the first year post-alloHCT. In this study, we incorporated a physical therapy (PT) assessment with the HCT-CI and DRI to improve outcome predictions. The well-defined and feasible measure of functional status for assessing risk includes (1) the number of sit-to-stands performed in 30 seconds, (2) performance of 25 step-ups on the right/left side with (3) oxygen saturation recovery and (4) heart rate recovery, (5) weight-bearing ability, (6) assistance with ambulation, (7) motor and grip strength, (8) sensory and coordination impairment (eg, self-reported peripheral neuropathy, imbalance), (9) self-reported pain, and (10) limited endurance (ie, inability to complete step-ups and/or sit-to-stands). Our training cohort (TC) included 349 consecutive alloHCT recipients at Roswell Park treated between 2010 and 2016 and a subsequent replication cohort (RC; n = 163) treated between 2016 and 2019. Four of the 10 metrics-self-reported pain, limited endurance, self-reported neuropathy, and <10 sit-to-stands in 30 seconds-were identified as significant predictors and were included in the multivariable models with the HCT-CI and DRI to create a new risk index (HCT-PCDRI: HCT-physical, comorbidity, and DRI) for outcomes. Models were tested in the RC. Shorter OS was associated with self-reported pain, limited endurance, higher HCT-CI, and higher DRI. At a median follow-up of 34 months, the 3-year OS based on the HCT-PCDRI was 30% for the very-high-risk group, 54% for the high-risk group, 49% for the intermediate-risk group, and 80% for the low-risk group. The number of patients identified as very high risk increased from 55 using HCT-CI alone to 120 with the new HCT-PCDRI, whereas the number in the low-risk group decreased from 91 to 45. Early mortality and a higher percentage of inpatient days within the first year post-alloHCT (a proxy for poor quality of life and high healthcare utilization) were associated with self-reported pain, higher HCT-CI, and higher DRI. A shorter initial LOS (ie, initial low healthcare utilization) was associated with performance of >10 sit-to-stands in 30 seconds, no self-reported neuropathy, and lower HCT-CI. These PT metrics combined with the HCT-CI and DRI created the HCT-PCDRI, which resulted in more patients being categorized accurately as high risk versus low risk. The HCT-PCDRI results were replicated in an independent cohort. Pre-alloHCT PT metrics with self-reported symptoms (pain and neuropathy) were associated with survival post-alloHCT and prolonged hospital LOS. The HCT-PCDRI scoring system for risk stratification of alloHCT recipients more accurately identifies patients at potential risk of poor outcomes. The HCT-PCDRI can be tested in <15 minutes to identify patients for intervention before or during treatment to potentially improve outcomes.
Collapse
Affiliation(s)
- Megan M Herr
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.
| | - Shabnam Rehman
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Yali Zhang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Christine M Ho
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - George L Chen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Maureen Ross
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Hillary Jacobson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Renee McKenzie
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kelly Farrell
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Anaum Maqsood
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Theresa Hahn
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| |
Collapse
|
13
|
Ezzatvar Y, Ramírez-Vélez R, Sáez de Asteasu ML, Martínez-Velilla N, Zambom-Ferraresi F, Lobelo F, Izquierdo M, García-Hermoso A. Cardiorespiratory fitness and all-cause mortality in adults diagnosed with cancer systematic review and meta-analysis. Scand J Med Sci Sports 2021; 31:1745-1752. [PMID: 33909308 DOI: 10.1111/sms.13980] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 04/23/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The inverse association between cardiorespiratory fitness and all-cause mortality in apparently healthy populations has been previously reported; however, the existence of this association among adults diagnosed with cancer is unclear. AIM To determine the association between cardiorespiratory fitness and all-cause mortality in adults diagnosed with cancer. METHODS Medline, Embase, and SPORTDiscus databases were searched. Eligible prospective cohort studies that examined the association of cardiorespiratory fitness with all-cause mortality in adults diagnosed with cancer were included. Hazard ratios (HRs) with associated 95% confidence intervals (CIs) were extracted from studies for all-cause mortality and pooled HRs were calculated using the random-effects inverse-variance model with the Hartung-Knapp-Sidik-Jonkman adjustment. RESULTS Data from 13 studies with 6,486 adults were included. Compared with lower levels of cardiorespiratory fitness, high levels were associated with a reduced risk of all-cause mortality among adults diagnosed with any cancer (HR = 0.52; 95% CI, 0.35-0.77), lung cancer (HR = 0.62; 95% CI, 0.46-0.83), and among those with cardiorespiratory fitness measurement via indirect calorimetry (HR = 0.47; 95% CI, 0.27-0.80). Pooled HRs for the reduction in all-cause mortality risk per 1-MET increase were also statistically significant (HR = 0.82; 95% CI, 0.69-0.99). Neither age at baseline nor the length of follow-up had a significant influence on the HR estimates for all-cause mortality risk. CONCLUSION Cardiorespiratory fitness may confer an independent protective benefit against all-cause mortality in adults diagnosed with cancer. The use of cardiorespiratory fitness as a prognostic parameter might help determine risk for future adverse clinical events and optimize therapeutic management strategies to reduce long-term treatment-related effects in adults diagnosed with cancer.
Collapse
Affiliation(s)
- Yasmin Ezzatvar
- Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, Universitat de València, Valencia, Spain
| | - Robinson Ramírez-Vélez
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Mikel L Sáez de Asteasu
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain.,CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Nicolás Martínez-Velilla
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain.,Geriatric Department, Complejo Hospitalario de Navarra (CHN), Pamplona, Spain
| | - Fabricio Zambom-Ferraresi
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain.,Geriatric Department, Complejo Hospitalario de Navarra (CHN), Pamplona, Spain
| | - Felipe Lobelo
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Exercise is Medicine Global Research and Collaboration Center, Atlanta, GA, USA
| | - Mikel Izquierdo
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain.,CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio García-Hermoso
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain.,CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain.,Universidad de Santiago de Chile (USACH), Escuela de Ciencias de la Actividad Física, el Deporte y la Salud, Santiago, Chile
| |
Collapse
|
14
|
Kirsten J, Wais V, Schulz SV, Sala E, Treff G, Bunjes D, Steinacker JM. Sarcopenia Screening Allows Identifying High-Risk Patients for Allogenic Stem Cell Transplantation. Cancers (Basel) 2021; 13:cancers13081771. [PMID: 33917738 PMCID: PMC8068111 DOI: 10.3390/cancers13081771] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Allogenic stem cell transplantation is a treatment option for various hematological diseases. Due to the intensity of the therapy regimes used, there is a substantial therapy associated mortality and morbidity. Therefore, it is crucial to identify patients with increased risk for treatment associated complications. Sarcopenia, defined as the loss of muscle mass and strength is a risk factor in various diseases. Aim of our study was to implement and evaluate the predictive power of a sarcopenia assessment, based on muscle mass, muscle strength and aerobic capacity (by measuring peak oxygen uptake), on all-cause and non-relapse mortality. A total of 178 patients were screened, with 28% suffering from sarcopenia before transplantation. Our results show a three-fold increase in all-cause and non-relapse mortality in this subpopulation compared to non-sarcopenic patients within a 12-month follow up. The importance of physical performance status demonstrated, raises the question, if exercise interventions might even allow to decrease mortality and morbidity. Abstract Allogenic stem cell transplantation (aSCT) is the only potentially curative treatment for high-risk hematological diseases. Despite advancements in supportive measures, aSCT outcome is still affected by considerable transplant-related mortality. We implemented a new sarcopenia assessment prior to aSCT to evaluate its predictive capability for all-cause and non-relapse mortality. Therefore all patients initially scheduled for aSCT within a 25-month period were screened during pre-transplantation-routine for muscle mass, grip strength, and aerobic capacity (AC) by measuring peak oxygen uptake (VO2peak). Patients were assigned to one of five groups adapted according current sarcopenia guidelines. Primary endpoints were all-cause and non-relapse mortality within a follow up time of up to 12 months. A total of 178 patients were included and rated as normal (n = 48), impaired aerobic capacity (n = 56), pre-sarcopenic (n = 26), sarcopenic (n = 27), and severe sarcopenic (n = 22) without significant age-differences between groups. Patients presenting with sarcopenia showed a significant three-fold increase in all-cause and non-relapse mortality compared to patients with normal screening results. AC showed to be the strongest single predictor with a more than two-fold increase of mortality for low AC. We conclude that risk stratification based on combination of muscle mass, grip strength, and AC allowed identifying a subgroup with increased risk for complications in patients undergoing aSCT.
Collapse
Affiliation(s)
- Johannes Kirsten
- Center for Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (S.V.W.S.); (G.T.); (J.M.S.)
- Correspondence:
| | - Verena Wais
- Unit for Allogenic Blood Stem Cell and Bone Marrow Transplants, Clinic for Internal Medicine III, Center for Internal Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (V.W.); (E.S.); (D.B.)
| | - Sebastian V.W. Schulz
- Center for Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (S.V.W.S.); (G.T.); (J.M.S.)
| | - Elisa Sala
- Unit for Allogenic Blood Stem Cell and Bone Marrow Transplants, Clinic for Internal Medicine III, Center for Internal Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (V.W.); (E.S.); (D.B.)
| | - Gunnar Treff
- Center for Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (S.V.W.S.); (G.T.); (J.M.S.)
| | - Donald Bunjes
- Unit for Allogenic Blood Stem Cell and Bone Marrow Transplants, Clinic for Internal Medicine III, Center for Internal Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (V.W.); (E.S.); (D.B.)
| | - Jürgen M. Steinacker
- Center for Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, 89073 Ulm, Germany; (S.V.W.S.); (G.T.); (J.M.S.)
| |
Collapse
|
15
|
Wood WA, Deal AM, Stover AM, Basch E. Comparing Clinician-Assessed and Patient-Reported Performance Status for Predicting Morbidity and Mortality in Patients With Advanced Cancer Receiving Chemotherapy. JCO Oncol Pract 2021; 17:e111-e118. [PMID: 33417484 DOI: 10.1200/op.20.00515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Performance status (PS) is assessed during cancer treatment to determine clinical trial eligibility, appropriateness for treatment, and need for supportive care. There is rising interest for patients to report this information directly. We determined whether clinician- and patient-reported PS were equally associated with mortality and service utilization in patients with cancer. METHODS A secondary analysis was conducted using data from an radiotherapy plus chemotherapy in which 441 patients with advanced cancer and clinicians reported PS using the Eastern Cooperative Oncology Group scale. Simple kappa statistics measured agreement between clinician-reported performance status (cPS) and patient-reported performance status (pPS). Associations of cPS and pPS with emergency department (ED) and hospital visits and overall survival were evaluated via Cox regression, competing risk regression, and Fisher's exact tests. RESULTS cPS and pPS correlated weakly (kappa = 0.27). Both pPS and cPS were associated with survival, ED visits, and hospitalizations, but only cPS remained associated after adjustment (survival: HR, 1.75; P < .0001). The first available cPS predicted mortality more strongly than the first available pPS (HR for death, comparing PS ≥ 1 v 0: 2.05 for cPS and 1.41 for pPS). When pPS questionnaires were repeated over time and averaged, associations with outcomes were stronger as measured by AIC model fit. Both pPS and cPS were associated with EQ-5D subcomponents (eg, 75%-77% with no usual activity deficits for PS 0, v 42%-51% for PS ≥ 1). CONCLUSION Both clinician-reported PS and patient-reported PS provide useful information and can be considered for clinical trials and routine care.
Collapse
Affiliation(s)
- William A Wood
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Allison M Deal
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Angela M Stover
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Ethan Basch
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| |
Collapse
|
16
|
Pahl A, Waibel S, Wehrle A, Ihorst G, Gollhofer A, Bertz H. Cardiopulmonary performance in allogeneic hematopoietic cell transplantation recipients-evaluation of pre-transplant risk assessments. Bone Marrow Transplant 2021; 56:1325-1334. [PMID: 33408382 PMCID: PMC8189913 DOI: 10.1038/s41409-020-01191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/09/2022]
Abstract
Cardiopulmonary performance reflects how well different organ systems interact. It is inter alia influenced by body composition, determines patients' quality of life and can also predict mortality. However, it is not yet used for risk prediction prior to allogeneic hematopoietic cell transplantations (alloHCT). Thus, we aimed to examine the predictive power of peak oxygen consumption (VO2peak) as a representative of cardiopulmonary performance and that of body composition before alloHCT to determine overall survival (OS) and non-relapse mortality (NRM) 2 years after transplantation. We also compared it with the predictive power of four commonly-used risk scores: revised Pretransplant Assessment of Mortality (rPAM), Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI), revised Disease Risk Index (rDRI), European Society for Blood and Marrow Transplantation (EBMT). Fifty-nine patients performed a cardiopulmonary exercise test and body composition assessments before alloHCT and were observed for 2 years. Sixteen patients died. VO2peak and most risk scores assessed pre-transplant revealed no association with OS or NRM. Body composition parameters only within univariable analyses. But higher rDRI and the male sex, were associated with shorter OS and higher NRM. We thus propose that the current risk assessments be reconsidered. The predictive value of VO2peak and body composition need further clarification, however.
Collapse
Affiliation(s)
- Antonia Pahl
- Department of Medicine I, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.
| | - Sarah Waibel
- Department of Neurology and Neuroscience, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Anja Wehrle
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Albert Gollhofer
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department of Medicine I, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| |
Collapse
|
17
|
Dias ALM, Laterza MC, Mira PADC, Freitas IMG, Trevizan PF, Martinez DG, de Almeida LB. Exacerbated hemodynamic response during exercise in cancer patients prior to autologous hematopoietic stem cell transplantation. Support Care Cancer 2020; 29:3831-3838. [PMID: 33245409 DOI: 10.1007/s00520-020-05911-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Chemotherapy treatment can lead to cardiovascular toxicity and physical impairment prior to autologous hematopoietic stem cell transplantation (auto-HSCT). Cardiovascular adjustments during exercise and the exercise capacity remain unknown in patients prior to auto-HSCT. Thus, the hemodynamic responses during exercise and exercise capacity were evaluated using a novel effort test in patients prior to auto-HSCT. METHODS Thirty patients prior to auto-HSCT (BMT group: 44.6 ± 14.1 years) and 23 control participants (CON group: 43.9 ± 16.6 years) performed the 6-Minute Step Test (6MST) to assess their exercise capacity and the hemodynamic responses during exercise. Systolic and diastolic blood pressure (SBP and DBP), heart rate (HR), and oxygen saturation (SpO2) were measured during the test. Rate-pressure product (RPP) was calculated multiplying SBP by HR. The highest HR value recorded during the test was compared with the maximum HR predicted by age and was used as % of maximum HR (%HRmax). RESULTS The number of steps up and down performed by the BMT group was lower than CON (108.8 ± 25.3 vs. 127.5 ± 34.4 steps, P = 0.02). The BMT group showed a higher magnitude of increase in SBP and RPP during the 6MST when compared to CON (ΔSBP: 18.5 ± 11.45 vs. 8.30 ± 18.46 mmHg, P = 0.01; and ΔRPP: 8197.3 ± 3829.1 vs. 6170.9 ± 3568.9 mmHg beats min-1, P = 0.05). The BMT group exhibited higher SpO2 and HR values throughout the protocol (P < 0.05), reaching a higher %HRmax than CON group (76.9 ± 9.6 vs. 66.4 ± 8.9%, P < 0.01). CONCLUSIONS Patients with indication for auto-HSCT have exacerbated chronotropic and pressor responses during exercise and reduced exercise capacity in the 6MST.
Collapse
Affiliation(s)
- Ana Luiza Machado Dias
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Mateus Camaroti Laterza
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Pedro Augusto de Carvalho Mira
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil.,Laboratory of Exercise Sciences, Department of Physiology and Pharmacology, Fluminense Federal University, Niteroi, Brazil
| | | | - Patrícia Fernandes Trevizan
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Daniel Godoy Martinez
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Leonardo Barbosa de Almeida
- Cardiovascular Research Unit and Exercise Physiology, Federal University of Juiz de Fora, Juiz de Fora, Brazil.
| |
Collapse
|
18
|
Wood WA, Weaver M, Smith-Ryan AE, Hanson ED, Shea TC, Battaglini CL. Lessons learned from a pilot randomized clinical trial of home-based exercise prescription before allogeneic hematopoietic cell transplantation. Support Care Cancer 2020; 28:5291-5298. [PMID: 32112353 PMCID: PMC7483208 DOI: 10.1007/s00520-020-05369-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) is a life-saving technology that can cure otherwise incurable diseases, but imposes significant physiologic stress upon recipients. This stress leads to short-term toxicity and mid- to long-term physical function impairment in some recipients. Exercise interventions have demonstrated preliminary efficacy in preserving physical function in HCT recipients, but the role of these interventions prior to HCT (prehabilitative) is less known. We tested a 5- to 12-week, prehabilitative higher intensity home-based aerobic exercise intervention in a randomized study of alloHCT candidates. Of 113 patients screened, 34 were randomized to control or intervention groups, 16 underwent pre- and post-intervention peak oxygen consumption (VO2peak) testing, and 12 underwent pre- and post-intervention 6-min walk distance (6MWD) testing. No significant differences in VO2peak or 6MWD were seen pre- to post-intervention between intervention and control groups, but final numbers of evaluable participants in each group were too small to draw inferences regarding the efficacy of the intervention. We conclude that the design of our prehabilitative intervention was not feasible in this pilot randomized study, and make recommendations regarding the design of future exercise intervention studies in alloHCT.
Collapse
Affiliation(s)
- William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - M Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC, USA
| | - A E Smith-Ryan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - E D Hanson
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - T C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - C L Battaglini
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
19
|
Groarke JD, Payne DL, Claggett B, Mehra MR, Gong J, Caron J, Mahmood SS, Hainer J, Neilan TG, Partridge AH, Di Carli M, Jones LW, Nohria A. Association of post-diagnosis cardiorespiratory fitness with cause-specific mortality in cancer. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:315-322. [PMID: 32167560 PMCID: PMC9989596 DOI: 10.1093/ehjqcco/qcaa015] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
AIMS The prognostic importance of post-diagnosis assessment of cardiorespiratory fitness (CRF) in cancer patients is not well established. We sought to examine the association between CRF and mortality in cancer patients. METHODS AND RESULTS This was a single-centre cohort analysis of 1632 patients (58% male; 64 ± 12 years) with adult-onset cancer who were clinically referred for exercise treadmill testing a median of 7 [interquartile range (IQR): 3-12] years after primary diagnosis. Cardiorespiratory fitness was defined as peak metabolic equivalents (METs) achieved during standard Bruce protocol and categorized by tertiles. The association between CRF and all-cause and cause-specific mortality was assessed using multivariable Cox proportional hazard models adjusting for important covariates. Median follow-up was 4.6 (IQR: 2.6-7.0) years; a total of 411 deaths (229, 50, and 132 all-cause, cardiovascular (CV), and cancer related, respectively) occurred during this period. Compared with low CRF (range: 1.9-7.6 METs), the adjusted hazard ratio (HR) for all-cause mortality was 0.38 [95% confidence interval (CI): 0.28-0.52] for intermediate CRF (range: 7.7-10.6 METs) and 0.17 (95% CI: 0.11-0.27) for high CRF (range: 10.7-22.0 METs). The corresponding HRs were 0.40 (95% CI: 0.19-0.86) and 0.41 (95% CI: 0.16-1.05) for CV mortality and 0.40 (95% CI: 0.26-0.60) and 0.16 (95% CI: 0.09-0.28) for cancer mortality, respectively. The adjusted risk of all-cause, CV, and cancer mortality decreased by 26%, 14%, and 25%, respectively with each one MET increment in CRF. CONCLUSION Cardiorespiratory fitness is a strong, independent predictor of all-cause, CV, and cancer mortality, even after adjustment for important clinical covariates in patients with certain cancers.
Collapse
Affiliation(s)
- John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
| | - David L Payne
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jingyi Gong
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jesse Caron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Syed S Mahmood
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jon Hainer
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Ann H Partridge
- Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Marcelo Di Carli
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
| |
Collapse
|
20
|
Scott JM, Stene G, Edvardsen E, Jones LW. Performance Status in Cancer: Not Broken, But Time for an Upgrade? J Clin Oncol 2020; 38:2824-2829. [PMID: 32584631 DOI: 10.1200/jco.20.00721] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jessica M Scott
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | - Guro Stene
- Norwegian University of Science and Technology, Trondheim, Norway.,Trondheim University Hospital, Cancer Clinic, Trondheim, Norway
| | | | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| |
Collapse
|
21
|
Exercise before, during, and after Hospitalization for Allogeneic Hematological Stem Cell Transplant: A Feasibility Randomized Controlled Trial. J Clin Med 2020; 9:jcm9061854. [PMID: 32545872 PMCID: PMC7355733 DOI: 10.3390/jcm9061854] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/26/2020] [Accepted: 06/10/2020] [Indexed: 01/14/2023] Open
Abstract
People with cancer who undergo allogeneic hematological stem cell transplant (allo-HSCT) experience significant deconditioning that can compromise quality of life. Exercise has shown to be beneficial before or after allo-HSCT; however, little is known about exercise therapy delivered across the continuum of care. We conducted a feasibility randomized controlled trial of exercise delivered prior to admission, during the inpatient stay, and after discharge versus control in people with planned allo-HSCT. Feasibility was assessed via recruitment and retention rates, the incidence of adverse events, and adherence to the exercise prescription. Estimates of efficacy were measured at baseline, one week prior to hospital admission, and 100 days and one year after transplant. The recruitment and retention rates were 20% and 33%, respectively. One serious adverse event occurred during the baseline six-minute walk test that precluded participation in the study and no adverse events were associated with the intervention. From baseline to pre-transplant, the intervention group improved six-minute walk test distances by 45 m (95% CI: −18.0 to 108.7)—a finding that warrants further investigation with an adequately powered trial. Our study contributes important feasibility considerations and pilot data for future exercise intervention research in allo-HSCT recipients.
Collapse
|
22
|
Limbach M, Kuehl R, Dreger P, Luft T, Rosenberger F, Kleindienst N, Friedmann-Bette B, Bondong A, Bohus M, Wiskemann J. Influencing factors of cardiorespiratory fitness in allogeneic stem cell transplant candidates prior to transplantation. Support Care Cancer 2020; 29:359-367. [PMID: 32367227 PMCID: PMC7686174 DOI: 10.1007/s00520-020-05485-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Cardiorespiratory fitness (CRF) seems to be prognostic prior to allogeneic stem cell transplantation (allo-HSCT). Influencing factors of CRF in allo-HSCT candidates have not been studied so far. Aim was to identify potentially influencing factors on CRF. METHODS To assess CRF, a maximal cardiopulmonary exercise test (CPET) was performed on average 2.6 ± 7.2 days prior to admission. A regression analysis was conducted, with the following predictors: gender, age, body mass index (BMI), time between last therapy and allo-HSCT (t_Therapies), number of cardiotoxic therapies (n_Cardiotox), number of transplantations (n_Transplantations), comorbidity index (HCT-CI), hemoglobin level of the last 3 months (area under the curve), and physical activity. RESULTS A total of 194 patients performed a CPET. VO2peak was significantly reduced compared with reference data. In total, VO2peak was 21.4 ml/min/kg (- 27.5%, p < 0.05). Men showed a significant larger percentage difference from reference value (- 29.1%, p < 0.05) than women (- 24.4%). VO2peak was significantly (p < 0.05) influenced by age (β = - 0.11), female gender (β = - 3.01), BMI (β = - 0.44), n_Cardiotox (β = - 0.73), hemoglobin level (β = 0.56), and physical activity prior to diagnosis (β = 0.10). CONCLUSIONS Our study demonstrates a decreased CRF indicating the potential need of prehabilitative exercise. We revealed some influencing factors on CRF. Those patients could benefit the most from exercise.
Collapse
Affiliation(s)
- Matthias Limbach
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Rea Kuehl
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Peter Dreger
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Luft
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Friederike Rosenberger
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | | | - Birgit Friedmann-Bette
- Internal Medicine VII (Sports Medicine), Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea Bondong
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bohus
- Central Institute of Mental Health, Mannheim, Germany
| | - Joachim Wiskemann
- Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| |
Collapse
|
23
|
Jaques R, Xu S, Matsakas A. Evaluating Trastuzumab in the treatment of HER2 positive breast cancer. Histol Histopathol 2020; 35:1059-1075. [PMID: 32323293 DOI: 10.14670/hh-18-221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The transmembrane oncoprotein HER2 is encoded by ERBB2 gene and overexpressed in around 20% of invasive breast cancers. It can be specifically targeted by Trastuzumab (Herceptin®), a humanised IgG1 antibody. Trastuzumab has been regarded as one of the most effective therapeutic drugs targeted to HER2 positive cancers. However, there are drawbacks, notably cardiotoxicity and resistance, which have raised awareness in clinical use. Therefore, understanding the mechanism of action is vital to establish improved therapeutic strategies. Here we evaluate Trastuzumab application in the treatment of HER2 positive breast cancer, focusing on its mechanistic actions and clinical effectiveness. Alternative therapies targeting the HER2 receptor and its downstream anomalies will also be discussed, as these could highlight further targets that could be key to improving clinical outcomes.
Collapse
Affiliation(s)
- Ryan Jaques
- Centre for Atherothrombotic and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK.
| | - Sam Xu
- Centre for Atherothrombotic and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
| | - Antonios Matsakas
- Centre for Atherothrombotic and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
| |
Collapse
|
24
|
Armenian SH, Gibson CJ, Rockne RC, Ness KK. Premature Aging in Young Cancer Survivors. J Natl Cancer Inst 2020; 111:226-232. [PMID: 30715446 DOI: 10.1093/jnci/djy229] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 12/23/2022] Open
Abstract
Advances in early detection, treatment, and supportive care have resulted in an estimated 16 million cancer survivors who are alive in the United States today. Outcomes have notably improved for children with cancer as well as young adults with hematologic malignancies due, in part, to the intensification of cancer treatment, including the use of hematopoietic cell transplantation. Emerging evidence suggests that these cancer survivors are at risk for premature aging, manifesting as early onset of chronic health conditions and a higher risk of mortality compared with the general population. Although the pathophysiology of premature aging in these survivors has not been fully elucidated, emerging concepts in aging research could help shed light on this phenomenon. Longitudinal studies are needed to better characterize aging in these survivors, setting the stage for much-needed interventions to halt the trajectory of accelerated aging. These efforts will be enhanced through collaborations between translational researchers, clinical oncologists, primary care providers, geriatricians, patient caretakers, and other stakeholders committed to improving the lives of the growing population of survivors.
Collapse
Affiliation(s)
| | | | | | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| |
Collapse
|
25
|
Foulkes S, Claessen G, Howden EJ, Daly RM, Fraser SF, La Gerche A. The Utility of Cardiac Reserve for the Early Detection of Cancer Treatment-Related Cardiac Dysfunction: A Comprehensive Overview. Front Cardiovasc Med 2020; 7:32. [PMID: 32211421 PMCID: PMC7076049 DOI: 10.3389/fcvm.2020.00032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022] Open
Abstract
With progressive advancements in cancer detection and treatment, cancer-specific survival has improved dramatically over the past decades. Consequently, long-term health outcomes are increasingly defined by comorbidities such as cardiovascular disease. Importantly, a number of well-established and emerging cancer treatments have been associated with varying degrees of cardiovascular injury that may not emerge until years following the completion of cancer treatment. Of particular concern is the development of cancer treatment related cardiac dysfunction (CTRCD) which is associated with an increased risk of heart failure and high risk of morbidity and mortality. Early detection of CTRCD appears critical for preventing long-term cardiovascular morbidity in cancer survivors. However, current clinical standards for the identification of CTRCD rely on assessments of cardiac function in the resting state. This provides incomplete information about the heart's reserve capacity and may reduce the sensitivity for detecting sub-clinical myocardial injury. Advances in non-invasive imaging techniques have enabled cardiac function to be quantified during exercise thereby providing a novel means of identifying early cardiac dysfunction that has proved useful in several cardiovascular pathologies. The purpose of this narrative review is (1) to discuss the different non-invasive imaging techniques that can be used for quantifying different aspects of cardiac reserve; (2) discuss the findings from studies of cancer patients that have measured cardiac reserve as a marker of CTRCD; and (3) highlight the future directions important knowledge gaps that need to be addressed for cardiac reserve to be effectively integrated into routine monitoring for cancer patients exposed to cardiotoxic therapies.
Collapse
Affiliation(s)
- Stephen Foulkes
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia.,Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Guido Claessen
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Erin J Howden
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Robin M Daly
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Steve F Fraser
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Andre La Gerche
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
26
|
Lenihan DJ, Fradley MG, Dent S, Brezden-Masley C, Carver J, Filho RK, Neilan TG, Blaes A, Melloni C, Herrmann J, Armenian S, Thavendiranathan P, Armstrong GT, Ky B, Hajjar L. Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology. JACC CardioOncol 2019; 1:256-272. [PMID: 34396188 PMCID: PMC8352295 DOI: 10.1016/j.jaccao.2019.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022] Open
Abstract
The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.
Collapse
Key Words
- CV, cardiovascular
- CVD, cardiovascular disease
- DOAC, direct oral anticoagulant
- GCOS, Global Cardio-Oncology Summit
- GLS, global longitudinal strain
- HCT, hematopoietic cell transplantation
- ICI, immune checkpoint inhibitor
- LVEF, left ventricular ejection fraction
- PD-1, programmed cell death 1 or its ligand
- PD-L1, programmed cell death ligand 1
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- anthracycline
- antiangiogenic therapy
- bone marrow transplantation
- breast cancer
- cancer survivorship
- immunotherapy
- thrombosis
- tyrosine kinase inhibitor
Collapse
Affiliation(s)
- Daniel J. Lenihan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael G. Fradley
- Cardio-Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Joseph Carver
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roberto Kalil Filho
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Saro Armenian
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, University of Toronto, Toronto, Canada
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Bonnie Ky
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ludhmila Hajjar
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| |
Collapse
|
27
|
Cardiopulmonary Aerobic Fitness Assessment During Maximal and Submaximal Exercise Testing in Pediatric Oncology Patients After Chemotherapy. Am J Clin Oncol 2018; 41:1058-1061. [PMID: 29356733 DOI: 10.1097/coc.0000000000000422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The cardiopulmonary exercise test (CPET) is a valuable tool to assess cardiopulmonary exercise capacity in pediatric oncology patients after chemotherapy. In addition, few studies on the utility of submaximal testing have been performed, which could be important as some patients are unable to complete a maximal effort test secondary to deconditioning by both disease and treatment. MATERIALS AND METHODS We performed a retrospective chart review of pediatric cancer patients exposed to chemotherapy from 1992 to 2013 who underwent CPET with cycle ergometry (n=27). The study patients were compared with age-matched, sex-matched, and size-matched normal controls. The submaximal measure recorded was the oxygen consumption (VO2)@respiratory exchange ratio (RER) 1.0 during a maximal effort test. RESULTS The chemotherapy group demonstrated significantly lower exercise time (9.2±3.6 vs. 11.4±3.8; P=0.008), total work capacity (4914.4±3290.3 vs. 7664.4±4289.5; P=0.004), systolic blood pressure at peak exercise (162.9±23.2 vs. 177.3±23.8; P=0.01), indexed peak VO2 (33.9±6.9 vs. 40.0±6.3; P=0.001), and indexed peak oxygen pulse (6.1±1.3 vs. 7.0±1.5; P=0.004)). For the submaximal outcome measured, 11/27 of the chemotherapy patients had VO2@RER 1.0 values <-2 SD from the mean compared with 0/27 control patients. CONCLUSIONS Pediatric patients exposed to chemotherapy have impaired cardiopulmonary exercise capacity. The VO2@RER 1.0 in chemotherapy patients suggests that this may be a reliable submaximal measure in this population. IMPLICATIONS FOR CANCER SURVIVORS This study demonstrates that the CPET can be used in pediatric cancer survivors with prior exposure to chemotherapy to demonstrate impaired cardiopulmonary exercise tolerance, which is demonstrated on submaximal and maximal effort testing.
Collapse
|
28
|
Yoshida S, Someya F, Yahata T. Cardiac output response to exercise in patients before allogenic hematopoietic stem cell transplantation. Int J Clin Oncol 2018; 23:1173-1177. [DOI: 10.1007/s10147-018-1315-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
|
29
|
Armenian SH, Ryan TD, Khouri MG. Cardiac Dysfunction and Heart Failure in Hematopoietic Cell Transplantation Survivors: Emerging Paradigms in Pathophysiology, Screening, and Prevention. Heart Fail Clin 2017; 13:337-345. [PMID: 28279419 DOI: 10.1016/j.hfc.2016.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hematopoietic cell transplantation (HCT) has been used for curative intent in patients with hematologic and nonhematologic malignancies, resulting in an increasing number of HCT survivors. These survivors are at risk for serious and life-threatening complications, including cardiovascular disease (CVD). This article provides an overview of CVD in HCT survivors, describing the pathophysiology of disease, with a special emphasis on therapeutic exposures and comorbidities unique to this population. This article also discusses novel screening and prevention strategies that have shown promise in non-HCT cancer populations, emphasizing opportunities for collaboration between cardiologists and hematologists to improve the cardiovascular health of HCT survivors.
Collapse
Affiliation(s)
- Saro H Armenian
- Division of Outcomes Research, Department of Population Sciences, Comprehensive Cancer Center, City of Hope, 1500 East Duarte Road, Duarte, CA 91010-3000, USA.
| | - Thomas D Ryan
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Michel G Khouri
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| |
Collapse
|
30
|
Kim S, Song IC, Jee S. Cardiopulmonary Exercise Test in Leukemia Patients After Chemotherapy: A Feasibility Study. Ann Rehabil Med 2017; 41:456-464. [PMID: 28758084 PMCID: PMC5532352 DOI: 10.5535/arm.2017.41.3.456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/24/2016] [Indexed: 11/06/2022] Open
Abstract
Objective To explore the feasibility of cardiopulmonary exercise test (CPET) in leukemia patients after chemotherapy. Methods Leukemia patients with histologically confirmed hematologic malignancies were reviewed. We evaluated for CPET, between receiving chemotherapy and undergoing stem cell transplantation after 2 weeks. We recorded exercise testing and physiologic parameters during CPET between January 2013 to May 2015. All patients were subjected to symptoms limited to exercise testing, according to the Modified Bruce Protocol. We considered that if respiratory exchange ratio achieved was over 1.10, participants had successfully completed CPET. We dichotomized all participants into two groups (normal group, normal range of resting heart rate; higher group, over 100 per minute of heart rate). Results 30 patients were finally enrolled. All participants had no adverse effects during the exercise test. Mean peak double product was 26,998.60 mmHg·beats/min (range, 15,481–41,004), and mean peak oxygen consumption (VO2 peak) was 22.52±4.56 mL/kg/min. Significant differences were observed in the normal group with VO2 peak (mean, 24.21 mL/kg/min; p=0.027) and number of prior intensive chemotherapy, compared to the higher group (mean, 1.95; p=0.006). Conclusion Our results indicate that CPET in leukemia patients before stem cell transplantation was very safe, and is an efficient method to screen for patients with poor cardiac functions. As CPET presents the parameters which reveal the cardiopulmonary functions, including VO2 peak, double product and exercise capacity, this exercise test would help to predict the physical performance or general condition of the leukemia patients.
Collapse
Affiliation(s)
- Soojae Kim
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ik-Chan Song
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sungju Jee
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, Korea
| |
Collapse
|
31
|
Armenian SH, Chemaitilly W, Chen M, Chow EJ, Duncan CN, Jones LW, Pulsipher MA, Remaley AT, Rovo A, Salooja N, Battiwalla M. National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Cardiovascular Disease and Associated Risk Factors Working Group Report. Biol Blood Marrow Transplant 2017; 23:201-210. [PMID: 27590105 PMCID: PMC5526451 DOI: 10.1016/j.bbmt.2016.08.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Abstract
A number of studies have shown that autologous and allogeneic hematopoietic cell transplantation (HCT) contribute to an increased incidence of cardiovascular disease (CVD) and worsening of cardiovascular risk factors that could contribute to further CVD over time. These observations, combined with a notable increase in the number of survivors after HCT in recent years, highlight the need for studies aimed at modifying risk or preventing these outcomes by changing specific approaches and/or post-HCT interventions. To address these issues, the National Heart, Lung and Blood Institute and National Cancer Institute co-sponsored an international initiative on late effects after HCT. This report summarizes the major gaps in knowledge along with detailed recommendations regarding study priorities from the Cardiovascular Disease and Associated Risk Factors Committee, a multidisciplinary panel of international experts. The committee calls for specific studies aimed at understanding and preventing arterial disease and cardiac dysfunction (heart failure, valvular disease, and arrhythmias), as well as decreasing cardiovascular risk factors (hypertension, hyperglycemia, dyslipidemia, and sarcopenic obesity) after HCT.
Collapse
Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California.
| | - Wassim Chemaitilly
- Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcus Chen
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Christine N Duncan
- Pediatric Stem Cell Transplant Center, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Alan T Remaley
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Alicia Rovo
- Department of Hematology, University Hospital of Bern, Bern, Switzerland
| | - Nina Salooja
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Minoo Battiwalla
- Hematopoietic Transplantation Section, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| |
Collapse
|
32
|
Armenian SH, Horak D, Scott JM, Mills G, Siyahian A, Berano Teh J, Douglas PS, Forman SJ, Bhatia S, Jones LW. Cardiovascular Function in Long-Term Hematopoietic Cell Transplantation Survivors. Biol Blood Marrow Transplant 2017; 23:700-705. [PMID: 28065839 DOI: 10.1016/j.bbmt.2017.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/02/2017] [Indexed: 12/22/2022]
Abstract
Peak oxygen consumption (VO2peak), as measured by cardiopulmonary exercise testing (CPET), is a powerful independent predictor of cardiovascular disease (CVD) and all-cause mortality in a broad range of populations. We assessed the safety and feasibility of CPET in aging long-term hematopoietic cell transplantation (HCT) survivors, a population at high risk for premature onset of CVD. Next, we examined how organ-specific impairments (eg, cardiac, pulmonary, hematologic) impact VO2peak after HCT. Twenty consecutive HCT survivors underwent a comprehensive assessment of cardiopulmonary health that included CPET, echocardiography with strain, pulmonary function testing, 6-minute walk test, and timed up and go. Median age at assessment was 67.4 years (range, 42 to 75), and median time from HCT was 9.8 years (range, 3 to 20). No adverse events were observed during CPET procedures, and 95% of studies were considered to be at "peak" effort (respiratory exchange ratio ≥ 1.10). VO2peak was on average 22% less than predicted, and allogeneic HCT survivors had markedly lower VO2peak when compared with autologous HCT survivors (18.2 mL/kg/min versus 22.2 mL/kg/min; P = .05). Six participants (30%) had VO2peak ≤ 16 mL/kg/min, a threshold associated with a 9-foldrisk of death in patients undergoing HCT. Despite the presence of normal (>50%) resting left ventricular ejection fraction in all participants, 25% had markedly abnormal left ventricular longitudinal strain, an advanced echocardiographic measure of myocardial dysfunction. These findings highlight the role of stress-based measures and advanced myocardial imaging to characterize CVD risk in HCT survivors, setting the stage for tailored interventions to prevent CVD with its attendant morbidity and mortality.
Collapse
Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California.
| | - David Horak
- Pulmonary and Critical Care Medicine, City of Hope, Duarte, California
| | - Jessica M Scott
- University of Texas Medical Branch, NASA Johnson Space Center, Houston, Texas
| | - George Mills
- Department of Population Sciences, City of Hope, Duarte, California
| | - Aida Siyahian
- Department of Population Sciences, City of Hope, Duarte, California
| | | | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
33
|
Stephens SJ, Thomas S, Rizzieri DA, Horwitz ME, Chao NJ, Engemann AM, Lassiter M, Kelsey CR. Myeloablative conditioning with total body irradiation for AML: Balancing survival and pulmonary toxicity. Adv Radiat Oncol 2016; 1:272-280. [PMID: 28740897 PMCID: PMC5514157 DOI: 10.1016/j.adro.2016.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/06/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose The purpose of this study was to compare leukemia-free survival (LFS) and other clinical outcomes in patients with acute myelogenous leukemia who underwent a myeloablative allogeneic stem cell transplant with and without total body irradiation (TBI). Methods and materials Adult patients with acute myelogenous leukemia undergoing myeloablative allogeneic stem cell transplant at Duke University Medical Center between 1995 and 2012 were included. The primary endpoint was LFS. Secondary outcomes included overall survival (OS), nonrelapse mortality, and the risk of pulmonary toxicity. Kaplan-Meier survival estimates and Cox proportional hazards multivariate analyses were performed. Results A total of 206 patients were evaluated: 90 received TBI-based conditioning regimens and 116 received chemotherapy alone. Median follow-up was 36 months. For all patients, 2-year LFS and OS were 36% (95% confidence interval [CI], 29-43) and 39% (95% CI, 32-46), respectively. After adjusting for known prognostic factors using a multivariate analysis, TBI was associated with improved LFS (hazard ratio: 0.63; 95% CI: 0.44-0.91) and OS (hazard ratio: 0.63; 95% CI, 0.43-0.91). There was no difference in nonrelapse mortality between cohorts, but pulmonary toxicity was significantly more common with TBI (2-year incidence 42% vs 12%, P < .001). High-grade pulmonary toxicity predominated with both conditioning strategies (70% and 93% of cases were grade 3-5 with TBI and chemotherapy alone, respectively). Conclusions TBI-based regimens were associated with superior LFS and OS but at the cost of increased pulmonary toxicity.
Collapse
Affiliation(s)
- Sarah J. Stephens
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - David A. Rizzieri
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Mitchell E. Horwitz
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nelson J. Chao
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ashley M. Engemann
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Martha Lassiter
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chris R. Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Corresponding author: Duke University Medical Center, DUMC Box 3085, Durham, NC 27710Duke University Medical CenterDUMC Box 3085DurhamNC27710
| |
Collapse
|
34
|
The Value of Patient Reported Outcomes and Other Patient-Generated Health Data in Clinical Hematology. Curr Hematol Malig Rep 2016; 10:213-24. [PMID: 26040262 DOI: 10.1007/s11899-015-0261-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With cures and long-term survival rates increasing in hematologic malignancies, increased focus has been placed on gaining a better understanding of the patient experience from disease and treatment effects. This has been the basis for the utilization of patient reported outcomes (PRO) and other patient-generated health data (PGHD) in efforts to improve long-term health-related quality of life (HRQOL). This review will summarize the impact PROs have had on the evolving standard of care for patients with hematologic malignant conditions and will conclude with a template for the integration of PRO and PGHD to enhance the patient experience, using stem cell transplantation as an example.
Collapse
|
35
|
Scott JM, Adams SC, Koelwyn GJ, Jones LW. Cardiovascular Late Effects and Exercise Treatment in Breast Cancer: Current Evidence and Future Directions. Can J Cardiol 2016; 32:881-90. [PMID: 27343744 DOI: 10.1016/j.cjca.2016.03.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 01/10/2023] Open
Abstract
Advances in detection and supportive care strategies have led to improvements in cancer-specific and overall survival after a diagnosis of early-stage breast cancer. These improvements, however, are associated with an increase in competing forms of morbidity and mortality, particularly cardiovascular disease (CVD). Indeed, in certain subpopulations of patients, CVD is the leading cause of mortality after early breast cancer, and these women also have an increased risk of CVD-specific morbidity, including an elevated incidence of coronary artery disease and heart failure compared with their sex- and age-matched counterparts. Exercise treatment is established as the cornerstone of primary and secondary prevention of CVD in multiple clinical populations. The potential benefits of exercise treatment to modulate CVD or CVD risk factors before, immediately after, or in the months/years after adjuvant therapy for early-stage breast cancer have received limited attention. We discuss the risk and extent of CVD in patients with breast cancer, review the pathogenesis of CVD, and highlight existing evidence from select clinical trials investigating the efficacy of structured exercise treatment across the CVD continuum in early breast cancer.
Collapse
Affiliation(s)
- Jessica M Scott
- Universities Space Research Association, NASA Johnson Space Center, Houston, Texas, USA
| | | | - Graeme J Koelwyn
- New York University Langone Medical Center, New York, New York, USA
| | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| |
Collapse
|
36
|
Wood WA, Phillips B, Smith-Ryan AE, Wilson D, Deal AM, Bailey C, Meeneghan M, Reeve BB, Basch EM, Bennett AV, Shea TC, Battaglini CL. Personalized home-based interval exercise training may improve cardiorespiratory fitness in cancer patients preparing to undergo hematopoietic cell transplantation. Bone Marrow Transplant 2016; 51:967-72. [PMID: 26999467 PMCID: PMC4935591 DOI: 10.1038/bmt.2016.73] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 01/26/2016] [Accepted: 01/28/2016] [Indexed: 01/30/2023]
Abstract
Impaired cardiorespiratory fitness is associated with inferior survival in patients preparing to undergo hematopoietic cell transplantation (HCT). Exercise training based on short, higher-intensity intervals has the potential to efficiently improve cardiorespiratory fitness. We studied home-based interval exercise training (IET) in 40 patients prior to autologous (N=20) or allogeneic (N=20) HCT. Each session consisted of 5, three-minute intervals of walking, jogging, or cycling at 65-95% maximal heart rate (MHR) with 3 minutes of low intensity exercise (<65% MHR) between intervals. Participants were asked to perform sessions at least 3 times weekly. The duration of the intervention was at least 6 weeks, depending on each patient’s scheduled transplantation date. Cardiorespiratory fitness was assessed from a peak oxygen consumption test (VO2peak) and a 6 minute walk (6MWD) before and after the intervention period. For the autologous HCT cohort, improvements in VO2peak (p=0.12) and 6MWD (p=0.19) were not statistically significant. For the allogeneic cohort, the median VO2peak improvement was 3.7ml/kg*min (p=0.005) and the median 6MWD improvement was 34 meters (p=0.006). Home-based, interval exercise training can be performed prior to HCT and has the potential to improve cardiorespiratory fitness.
Collapse
Affiliation(s)
- W A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - B Phillips
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - A E Smith-Ryan
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - D Wilson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - A M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - C Bailey
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - B B Reeve
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - E M Basch
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - A V Bennett
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - T C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - C L Battaglini
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
37
|
Scott JM, Armenian S, Giralt S, Moslehi J, Wang T, Jones LW. Cardiovascular disease following hematopoietic stem cell transplantation: Pathogenesis, detection, and the cardioprotective role of aerobic training. Crit Rev Oncol Hematol 2016; 98:222-34. [PMID: 26643524 PMCID: PMC5003053 DOI: 10.1016/j.critrevonc.2015.11.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 01/02/2023] Open
Abstract
Advances in hematopoietic cell transplantation (HCT) techniques and supportive care strategies have led to dramatic improvements in relapse mortality in patients with high-risk hematological malignancies. These improvements, however, conversely increase the risk of late-occurring non-cancer competing causes, mostly cardiovascular disease (CVD). HCT recipients have a significantly increased risk of CVD-specific mortality, including elevated incidence of coronary artery disease (CAD), cerebrovascular disease, and heart failure (HF) compared to age-matched counterparts. Accordingly, there is an urgent need to identify techniques for the detection of early CVD in HCT patients to inform early prevention strategies. Aerobic training (AT) is established as the cornerstone of primary and secondary disease prevention in multiple clinical settings, and may confer similar benefits in HCT patients at high-risk of CVD. The potential benefits of AT either before, immediately after, or in the months/years following HCT have received limited attention. Here, we discuss the risk and extent of CVD in adult HCT patients, highlight novel tools for early detection of CVD, and review existing evidence in oncology and non-oncology populations supporting the efficacy of AT to attenuate HCT-induced CVD. This knowledge can be utilized to optimize treatment, while minimizing CVD risk in individuals with hematological malignancies undergoing HCT.
Collapse
Affiliation(s)
- Jessica M Scott
- Universities Space Research Association NASA Johnson Space Center, Houston, TX, USA
| | - Saro Armenian
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
38
|
Jones LW, Devlin SM, Maloy MA, Wood WA, Tuohy S, Espiritu N, Aquino J, Kendig T, Michalski MG, Gyurkocza B, Schaffer WL, Ali B, Giralt S, Jakubowski AA. Prognostic Importance of Pretransplant Functional Capacity After Allogeneic Hematopoietic Cell Transplantation. Oncologist 2015; 20:1290-7. [PMID: 26446235 DOI: 10.1634/theoncologist.2015-0200] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/18/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the prognostic importance of functional capacity in patients undergoing allogeneic hematopoietic cell transplantation (HCT) for hematological malignancies. PATIENTS AND METHODS Using a retrospective design, 407 patients completed a 6-minute walk distance (6 MWD) test to assess functional capacity before HCT; 193 (47%) completed a 6 MWD test after hospital discharge. Cox proportional hazards regression was used to estimate the risk of nonrelapse mortality (NRM) and overall survival (OS) according to the 6 MWD category (<400 m vs. ≥ 400 m) and the change in 6 MWD (before HCT to discharge) with or without adjustment for Karnofsky performance status (KPS), age, and other prognostic markers. RESULTS Compared with <400 m, the unadjusted hazard ratio for NRM was 0.65 (95% confidence interval, 0.44-0.96) for a 6 MWD ≥ 400 m. A 6 MWD of ≥ 400 m provided incremental information on the prediction of NRM with adjustment for age (p = .032) but not KPS alone (p = .062) or adjustment for other prognostic markers (p = .099). A significant association was found between the 6 MWD and OS (p = .027). A 6 MWD of ≥ 400 m provided incremental information on the prediction of OS with adjustment for age (p = .032) but not for other prognostic markers (p > .05 for all). Patients presenting with a pre-HCT 6 MWD of <400 m and experiencing a decline in 6 MWD had the highest risk of NRM. CONCLUSION The 6 MWD is a significant univariate predictor of clinical outcomes but did not provide prognostic information beyond that of traditional prognostic markers in HCT. IMPLICATIONS FOR PRACTICE The pretransplant 6-minute walk test is a significant univariate predictor of clinical outcomes in hematological patients beyond age but not beyond that of performance status. On this basis, 6-minute walk distance testing should not be considered part of the standard battery of assessments for risk stratification before hematopoietic cell transplantation.
Collapse
Affiliation(s)
- Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Sean M Devlin
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Molly A Maloy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sharlynn Tuohy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Noel Espiritu
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Jennifer Aquino
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Tiffany Kendig
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Meghan G Michalski
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Boglarka Gyurkocza
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Wendy L Schaffer
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Benzar Ali
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | | |
Collapse
|
39
|
Wood WA, Le-Rademacher J, Syrjala KL, Jim H, Jacobsen PB, Knight JM, Abidi MH, Wingard JR, Majhail NS, Geller NL, Rizzo JD, Fei M, Wu J, Horowitz MM, Lee SJ. Patient-reported physical functioning predicts the success of hematopoietic cell transplantation (BMT CTN 0902). Cancer 2015; 122:91-8. [PMID: 26439325 DOI: 10.1002/cncr.29717] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/19/2015] [Accepted: 09/03/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND In hematopoietic cell transplantation (HCT), current risk adjustment strategies are based on clinical and disease-related variables. Although patient-reported outcomes (PROs) predict mortality in multiple cancers, they have been less well studied within HCT. Improvements in risk adjustment strategies in HCT would inform patient selection, patient counseling, and quality reporting. The objective of the current study was to determine whether pre-HCT PROs, in particular physical health, predict survival among patients undergoing autologous or allogeneic transplantation. METHODS In this secondary analysis, the authors studied pre-HCT PROs that were reported by 336 allogeneic and 310 autologous HCT recipients enrolled in the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0902 protocol, a study with broad representation of patients who underwent transplantation in the United States. RESULTS Among allogeneic HCT recipients, the pre-HCT Medical Outcomes Study Short Form-36 Health Survey (SF-36) physical component summary (PCS) scale independently predicted overall mortality (hazards ratio, 1.40 per 10-point decrease; P<.001) and performed at least as well as currently used, non-PRO risk indices. Survival probability estimates at 1 year for the first, second, third, and fourth quartiles of the baseline PCS were 50%, 65%, 75%, and 83%, respectively. Early post-HCT decreases in PCS were associated with higher overall and treatment-related mortality. When adjusted for patient variables included in the US Stem Cell Therapeutic Outcomes Database model for transplant center-specific reporting, the SF-36 PCS retained independent prognostic value. CONCLUSIONS PROs have the potential to improve prognostication in HCT. The authors recommend the routine collection of PROs before HCT, and consideration of the incorporation of PROs into risk adjustment for quality reporting.
Collapse
Affiliation(s)
- William A Wood
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer Le-Rademacher
- Division of Biostatistics, Psychiatry and Behavioral Medicine,Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen L Syrjala
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Heather Jim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Paul B Jacobsen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jennifer M Knight
- Division of Biostatistics, Psychiatry and Behavioral Medicine,Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Muneer H Abidi
- Department of Medical Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - John R Wingard
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Navneet S Majhail
- Taussig Cancer Institute, Cleveland Clinic, Blood and Marrow Transplant Program, Cleveland, Ohio
| | - Nancy L Geller
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - J Douglas Rizzo
- Division of Biostatistics, Psychiatry and Behavioral Medicine,Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mingwei Fei
- Division of Biostatistics, Psychiatry and Behavioral Medicine,Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Juan Wu
- Blood and Marrow Transplant Clinical Trials Network, Milwaukee, Wisconsin
| | - Mary M Horowitz
- Division of Biostatistics, Psychiatry and Behavioral Medicine,Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
40
|
Wiskemann J, Kuehl R, Dreger P, Huber G, Kleindienst N, Ulrich CM, Bohus M. Physical Exercise Training versus Relaxation in Allogeneic stem cell transplantation (PETRA Study) - Rationale and design of a randomized trial to evaluate a yearlong exercise intervention on overall survival and side-effects after allogeneic stem cell transplantation. BMC Cancer 2015; 15:619. [PMID: 26345187 PMCID: PMC4562345 DOI: 10.1186/s12885-015-1631-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/28/2015] [Indexed: 12/25/2022] Open
Abstract
Background Allogeneic stem cell transplantation (allo-HCT) is associated with high treatment-related mortality and innumerable physical and psychosocial complications and side-effects, such as high fatigue levels, loss of physical performance, infections, graft-versus-host disease (GvHD) and distress. This leads to a reduced quality of life, not only during and after transplantation, but also in the long term. Exercise interventions have been shown to be beneficial in allo-HCT patients. However, to date, no study has focused on long-term effects and survival. Previous exercise studies used ‘usual care’ control groups, leaving it unclear to what extent the observed effects are based on the physical effects of exercise itself, or rather on psychosocial factors such as personal attention. Furthermore, effects of exercise on and severity of GvHD have not been examined so far. We therefore aim to investigate the effects and biological mechanisms of exercise on side-effects, complications and survival in allo-HCT patients during and after transplantation. Methods/design The PETRA study is a randomized, controlled intervention trial investigating the effects of a yearlong partly supervised mixed exercise intervention (endurance and resistance exercises, 3–5 times per week) in 256 patients during and after allogeneic stem cell transplantation. Patients in the control group perform progressive muscle relaxation training (Jacobsen method) with the same frequency. Main inclusion criterion is planned allo-HCT. Main exclusion criteria are increased fracture risk, no walking capability or severe cardiorespiratory problems. Primary endpoint is overall survival after two years; secondary endpoints are non-relapse mortality, median survival, patient reported outcomes including cancer related fatigue and quality of life, physical performance, body composition, haematological/immunological reconstitution, inflammatory parameters, severity of complications and side-effects (e.g. GvHD and infections), and cognitive capacity. Discussion The PETRA study will contribute to a better understanding of the physiological and psychological effects of exercise training and their biological mechanisms in cancer patients after allo-HCT. The ultimate goal is the implementation of optimized intervention programs to reduce side-effects and improve quality of life and potentially prognosis after allogeneic stem cell transplantation. Trial registration ClinicalTrials.gov Identifier: NCT01374399.
Collapse
Affiliation(s)
- Joachim Wiskemann
- National Center for Tumor Diseases (NCT) and Heidelberg University Hospital, Heidelberg, Germany. .,National Center for Tumor Diseases (NCT) and German Cancer Research Center, Heidelberg, Germany. .,Central Institute of Mental Health, Mannheim, Germany.
| | - Rea Kuehl
- National Center for Tumor Diseases (NCT) and Heidelberg University Hospital, Heidelberg, Germany. .,National Center for Tumor Diseases (NCT) and German Cancer Research Center, Heidelberg, Germany.
| | - Peter Dreger
- Department of Medicine V, Heidelberg University, Heidelberg, Germany.
| | - Gerhard Huber
- Institute of Sports and Sport Science, Heidelberg University, Heidelberg, Germany.
| | | | | | - Martin Bohus
- Central Institute of Mental Health, Mannheim, Germany. .,Faculty of Health, University of Antwerp, Antwerp, Belgium.
| |
Collapse
|
41
|
Perioperative Implications of Neoadjuvant Therapies and Optimization Strategies for Cancer Surgery. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
42
|
|