A Preliminary Study on the Efficacy of a Community-Based Physical Activity Intervention on Physical Function-Related Risk Factors for Falls Among Breast Cancer Survivors

Exploring the reliability and validity of clinically-relevant outcome measures for chemotherapy-induced peripheral neuropathy

PURPOSE

To explore the reliability and validity of clinically-relevant outcome measures for balance (i.e., The Short Physical Performance Battery [SPPB] - Balance Subscale) and sensation (i.e., monofilament threshold testing) for use in clinical trials of chemotherapy-induced peripheral neuropathy (CIPN).

METHODS

Adult, post-treatment cancer survivors (N = 142) who had reported ≥ 4/10 CIPN symptom severity following neurotoxic chemotherapy were recruited from six National Cancer Institute Community Oncology Research Program (NCORP) sites associated with the University of Rochester Cancer Center NCORP Research Base. Participants completed the monofilament threshold test at the screening and baseline time points (i.e., one week apart), while the Quality of Life Questionnaire-CIPN20, Treatment-Induced Neuropathy Assessment Scale, and SPPB - Balance Subscale were completed at baseline. Test-retest reliability of the monofilament threshold testing scores was assessed using the Intraclass Correlation Coefficient (ICC). The convergent validity among monofilament threshold testing, SPPB - Balance Subscale, and CIPN patient-reported outcome (PRO) scores at baseline was assessed using Spearman's correlation.

RESULTS

Ceiling effects were observed for SPPB-Balance Subscale scores as 113 (79.6%) respondents reported the highest score. Agreement between the screening and baseline monofilament threshold testing scores was moderate (ICC = 0.65). Monofilament threshold testing (rs Range: 0.14 - 0.21) and SPPB Balance Subscale scores (rs Range: -0.36 - -0.22) showed largely low correlations with all PRO measures.

CONCLUSIONS

Monofilament threshold testing demonstrated moderate test-retest reliability, but low convergent validity with CIPN PROs, while the SPPB - Balance Subscale demonstrated low convergent validity with CIPN PROs and ceiling effects (i.e., highest possible score) among post-treatment cancer survivors with CIPN. Future research is needed to identify promising measures of balance and sensation loss for use in clinical trials that complement CIPN PROs to aid in the identification of clinically relevant treatments for CIPN.

TRIAL REGISTRATION

NCT04367490 [April 29, 2020].

Falls experienced by adult cancer survivors: a scoping review

PURPOSE

Accidental falls among adult cancer survivors are a health concern. Falls impose economic burdens and detrimental consequences to cancer survivors. This review aimed to synthesize findings from published research to explore the relationship between falls and cancer diagnosis and treatment among cancer survivors.

MATERIALS AND METHODS

A scoping review was conducted using four databases (Medline, EMBASE, CINAHL, and Scopus) for the years 2001-2021. A total of 425 abstracts were identified after removing duplicates. A second search for the years 2022-2023 was completed where 80 abstracts were identified. Abstract screening, full-text review, and data extraction were conducted. Study characteristics and key findings were extracted from full texts. Descriptive numerical summaries were presented, and narrative analyses were performed.

RESULTS AND CONCLUSIONS

A total of 42 articles were included in the scoping review which demonstrated (1) an increased prevalence of falls among cancer survivors, (2) the presence of cancer-specific fall risk factors, (3) a lack of cancer-specific fall prediction tools, and (4) few fall prevention interventions as part of usual care among cancer survivors. Younger cancer survivors were underrepresented. Cancer survivors should be aware of their risk of falls, and health professionals should ensure that fall prevention is part of usual care.

Effect of Physical Activity on Static and Dynamic Postural Balance in Women Treated for Breast Cancer: A Systematic Review

BACKGROUND

Therapies against breast cancer (BC) frequently involve complications that impair patients' daily function and quality of life, the most common of which are motor coordination and balance disorders, increasing the risk of falls and injuries. In such cases, physical activity is recommended. Designed following the PRISMA guidelines, this study presents a systematic review of randomised and pilot clinical trials investigating the effect of physical exercises on postural balance in women treated for BC.

METHODS

Scientific databases (PubMed, EBSCO) and the online resources of grey publications were searched for trial reports published between January 2002 and February 2022. The inclusion criteria necessitated full-text, English-language reports from randomised clinical trials (RCTs) or pilot clinical trials (pilot CTs), whose authors used physical exercises to treat women with BC and the experimental and control groups consisted of at least 10 women. The methodological quality of the RCTs and pilot CTs were measured using the Physiotherapy Evidence Database (PEDro) scale and the Methodological Index for Non-Randomized Studies (MINORS), respectively. Data were extracted on the effect of exercise on the women's static and dynamic balance.

RESULTS

Seven reports, five RCTs and two pilot CTs involving a total of 575 women (aged 18-83 years) were included in the systematic review. Their training protocols utilised a variety of aerobic, strength, endurance, sensorimotor, Pilates exercises, and fitness exercises with elements of soccer. The experimental groups usually worked out in fitness or rehabilitation centres under the supervision of physiotherapists or trainers. Training sessions of 30-150 min were held 2 or 3 times a week for 1.5-24 months. Most trials reported that static and dynamic balance in the experimental groups improved significantly more compared with the control groups.

CONCLUSIONS

Physical exercises are able to improve static and dynamic postural balance in women treated for BC. However, as all evidence in support of this conclusion comes from only two pilot CT and five RCTs whose methodologies varied widely, more high quality research is needed to validate their findings and determine which exercise protocols are the most effective in improving postural control in women with BC.

Influence of Complex Physical Therapy on Physical Fitness and Balance in Women After Unilateral Mastectomy Due to Cancer Treatment

Introduction: As a result of mastectomy, physical fitness deteriorates, balance disorders and lymphoedema of the upper limb occur, which undoubtedly affect the level of stability among women following this surgery. Complex physical therapy in this group of patients is one of the key aspects influencing the level of physical activity among women subjected to surgery. Research objective: The aim of the study was to assess the impact of complex physiotherapy on physical fitness and balance in women following unilateral mastectomy with lymphoedema of the upper limb. Additionally, it was analysed whether wearing an external breast prosthesis affects the postural stability of women after mastectomy. Materials and methods: The study group comprised 30 women post unilateral mastectomy, 51 to 78 years of age, with upper limb lymphoedema. Before starting and after completing the physical therapy programme, the examined women were asked to perform the Timed Up and Go (TUG) Test and the Static Postural Stability Test on the Biodex Balance System platform. The tests were performed at the Posturology Laboratory of the Collegium Medicum, Jan Kochanowski University in Kielce. Results: In the analysis of the results of the Timed Up and Go Test in women following unilateral mastectomy, better results were noted after completion of physiotherapy in all 3 trials (p=0.001, p=0.021, p=0.004), as well as in the Postural Stability Test for all test parameters. The Mann-Whitney U test allowed to indicate a statistically significant difference in the values of the general stability index (p=0.005) and the A/P stability index (p=0.004). Greater body sway dominated in the sagittal plane than in the frontal one (A/P > M/L). On the other hand, in posturographic examination, external prostheses did not affect the postural stability of post-mastectomy women. Conclusions: 1. Systematic motor exercises in women following unilateral mastectomy are an important element of maintaining required physical activity, and they also prevent posture-related disorders; 2. The use of an external breast prosthesis in women after unilateral mastectomy does not significantly cause a change to body posture.

Incidence and risk factors associated with falls among women with breast cancer during taxane-based chemotherapy

PURPOSE

This study aims to evaluate the falling incidence density and examine the potential risk factors associated with falling among women with breast cancer during taxane-based chemotherapy.

METHODS

One hundred and twenty-three women with breast cancer participated in this study. The fall incidence density, taxane-induced peripheral neuropathy (TIPN) symptoms, and physical performance tests were evaluated at five time points throughout chemotherapy treatment. A fall diary was used to record fall incidence during treatment. The fall incidence density was calculated by dividing the number of first fall occurrences by person-time at risk. The risk factors associated with time to first fall were analyzed using the Cox proportional hazards model. The Kaplan-Meier curve illustrated the probability of survival from a fall during chemotherapy treatment.

RESULTS

Over the course of treatment, 29 (23.58%) participants reported falls. The fall incidence density was 3 per 1000 person-day. This study discovered a significant link between age (adjusted HR (HR_adj) = 1.07; 95% CI: 1.02-1.13) and BMI (HR_adj = 1.11; 95% CI: 1.02-1.21) and falling.

CONCLUSIONS

Women with breast cancer could fall for the first time at any time after starting chemotherapy until the end of the follow-up period. Furthermore, time to first fall was associated with age and BMI. Early detection of falling in women with breast cancer, particularly among older persons and those with a high BMI, may be essential to preventing falls.

Community-based exercise programs for cancer survivors: A scoping review of program characteristics using the Consolidated Framework for Implementation Research

OBJECTIVE

To describe the characteristics of exercise programs for cancer survivors conducted outside of a research laboratory (i.e., home-based, or community-based settings).

DATA SOURCES

A systematic search of published literature was conducted using Medline, Pubmed, CINAHL, PsychINFO, SPORTdiscus, and Embase from 1980 to January 2021. Where conference abstracts were identified, authors were contacted for other articles.

STUDY SELECTION

Two independent reviewers screened titles and abstracts, and full texts of potentially relevant studies with discrepancies resolved by discussion. Included studies were reports of exercise programs or interventions in which participants exercise at home, or in a community-based setting, and including individuals diagnosed with cancer either undergoing treatment or who had completed treatment.

DATA EXTRACTION

Data were extracted using the Oxford Implementation Index and coded under the five domains of the Consolidated Framework for Implementation Research (CFIR). Extraction and coding were completed by two independent reviewers, with discrepancies resolved through discussion. Data were synthesized narratively according to CFIR.

DATA SYNTHESIS

A total of 58 publications describing 34 individual programs from around the world were included. Of these, only 14 publications had the specific goal of reporting on program implementation and development. A variety of intervention characteristics and characteristics of individuals involved in the intervention were described. Reporting of factors related to the CFIR domains of inner setting, outer setting and implementation process were minimal.

CONCLUSIONS

This review summarizes the characteristics of existing programs that have been reported in the literature and finds that partnerships and collaboration in the inner and outer setting, and as part of the process of implementation. This review highlights key knowledge gaps to be answered in order to support the development of future community-based interventions.

Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment

PURPOSE

This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population?

METHODS

MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome.

RESULTS

A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified.

CONCLUSION

This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.

The Cumulative Complexity Model and Repeat Falls: A Quality Improvement Project

PURPOSE OF PROJECT

The purpose of this article is to demonstrate the effectiveness of the Cumulative Complexity Model as a framework to build an Excel tool and a Pareto tool that will enable inpatient case managers to predict the increased risk for and prevent repeat falls. The Excel tool is based on work explained in a previous article by and uses a macro to analyze the factors causing the repeat falls and then calculate the probability of it happening again. This enables the case manager to identify trends in how the patient is transitioning toward goals of care and identify problems before they become barriers to the smooth transition to other levels of care. Thus, the case manager will save the facility money by avoiding unneeded days of care and avoiding the costs that result from rendering medical care for the patient who has fallen.

PRIMARY PRACTICE SETTINGS

In July 2015, a group of nurses at a small Veterans Health Administration Hospital in the Northwest collaborated to find ways to reverse a trend of increasing falls and repeat falls.

METHODOLOGY AND SAMPLE

A retrospective chart review of all falls and repeat falls (N = 73) that happened between January 2013 and July 2015 was used to generate a list of top 11 contributing variables that enabled evaluation of the data. A bundle of 3 interventions was instituted in October 2015: (1) development of a dedicated charge nurse/resource nurse, (2) use of a standardized method of rounding, and (3) use of a noncontact patient monitoring system ("virtual nurses"). Falls pre- and postimplementation (N = 109) were analyzed using linear and logistic regression analyses. Data were entered into an Excel sheet and analyzed to identify the major contributing factors to falls and repeat falls and to identify trends. These data were also evaluated to find out whether length of stay and nurse workload contributed to falls.

RESULTS

Fifteen months after implementation of the aforementioned interventions, falls on the unit went down from 30 aggregate falls in 2015 to 17 aggregate falls in 2016. Repeat falls in 2015 went from 9 repeat falls after admission to the unit down to 2 repeat falls in 2016. Each additional extrinsic variable that was present added an additional 1.43 to the odds ratio (OR) for a fall. Similarly, each additional intrinsic variable present added 2.08 to the OR for a fall. The linear regression of length of stay and falls demonstrated that 17.5% of falls correlated with length of stay, F(1,36) = 7.63, p = .009, R = .175, adjusted R = .152. Workload correlated with work 17% of the time, as measured by using ward days of care, F(1,100) = 20.84, p = .00001, R = .17, adjusted R = .16.

IMPLICATIONS FOR CASE MANAGERS

Two examples of the how to use these tools are located in the "Discussion" section of the article.

Mortality in tongue cancer patients treated by curative surgery: a retrospective cohort study from CGRD

BACKGROUND

Our study aimed to compare the outcomes of surgical treatment of tongue cancer patients in three different age groups.

METHODS

From 2004 to 2013, we retrospectively analyzed the clinical data of 1,712 patients who were treated in the four institutions constituting the Chang Gung Memorial Hospitals (CGMH). We divided and studied the patients in three age groups: Group 1, younger (<65 years); Group 2, young old (65 to <75); and Group 3, older old patients (≥75 years).

RESULTS

Multivariate analyses determined the unfavorable, independent prognostic factors of overall survival to be male sex, older age, advanced stage, advanced T, N classifications, and surgery plus chemotherapy. No significant differences were found in adjusted hazard ratios (HR) of death in early-stage disease (stage I-II) among Group 1 (HR 1.0), Group 2 (HR 1.43, 95% confidence interval (CI) [0.87-2.34], p = 0.158), and Group 3 (HR 1.22, 95% CI [0.49-3.03], p = 0.664) patients. However, amongst advanced-stage patients (stage (III-IV)), Group 3 (HR 2.53, 95% CI [1.46-4.38], p  = 0.001) showed significantly worse survival than the other two groups after other variables were adjusted for. Fourteen out of 21 older old, advanced-staged patients finally died, and most of the mortalities were non-cancerogenic (9/14, 64.3%), and mostly occurred within one year (12/14, 85%) after cancer diagnosis. These non-cancer cause of death included underlying diseases in combination with infection, pneumonia, poor nutrition status, and trauma.

CONCLUSIONS

Our study showed that advanced T classification (T3-4), positive nodal metastasis (N1-3) and poorly differentiated tumor predicted poor survival for all patients. Outcome of early-stage patients (stage I-II) among three age groups were not significantly different. However, for advanced-stage patients (stage III-IV), the older old patients (≥75) had significantly worse survival than the other two patient groups. Therefore, for early-stage patients, age should not deny them to receive optimal treatments. However, older old patients (≥75) with advanced cancer should be comprehensively assessed by geriatric tools before surgical treatment and combined with intensive postoperative care to improve outcome, especially the unfavorable non-cancerogenic mortalities within one year after cancer diagnosis.