The impact of physical activity on health-related fitness and quality of life for patients with head and neck cancer: a systematic review

Quality of Life and Respiratory Performance in the Laryngectomized Patient: Role of the HME Filters during Physical Activity

Background: Permanent tracheostomy because of total laryngectomy surgery entails significant consequences for patients regarding respiratory physiopathology, such as the loss of the filtering, humidifying, and heating of air by the nose. The use of special stomal filters can provide adequate protection of the tracheal-bronchopulmonary system with a reduction in respiratory pathologies. In fact, in most cases, laryngectomy patients are first cigarette smokers who for this reason also already have respiratory diseases such as chronic obstructive pulmonary disease (COPD). Despite the availability of tracheal filters, as reported in the literature, patients often tend to limit their use due to reported breathing difficulties, especially in conditions of intense breathing. Methods: The objective of this clinical study was to evaluate the most suitable stomal filter for laryngectomy patients during physical activity. The filters studied were an INHEALTH device (Blom-Singer SpeakFree HME); two ATOS devices (Provox® Life™ Energy HME and Provox® Life™ Home HME); and an FAHL device (Laryvox HME Sport). Results: For this purpose, the performances of 31 laryngectomy patients, subjected to medium-high physical effort, were analyzed through a standardized pneumological test, the Six Minute Walking Test (6MWT), which involves a sustained walk lasting six minutes, with an evaluation of heart rate, oxygen saturation, and meters traveled every 60 s; furthermore, we examined two subjective indices, namely, the basal and final dyspnea index and the initial and final muscular fatigue index. Conclusions: The multidisciplinary approach of the laryngectomee patient must also take pulmonary rehabilitation into consideration. It is the task of the medical team and speech therapy support to help the patient in the correct choice of HME filters taking into account daily needs.

A perspective on a precision approach to pain in cancer; moving beyond opioid therapy

PURPOSE

Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use.

CONCLUSIONS

Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.

Lifestyle changes after cancer treatment in patients and their partners: a qualitative study

PURPOSE

Oncologists nowadays promote healthy lifestyle choices more often, focusing on diet, physical activity, smoking, alcohol consumption, and sleep, but the question is whether this is enough to establish actual change. As patients will have to achieve a healthy lifestyle at home in daily life, it is important to understand barriers and facilitators for lifestyle change for both patients and their partners.

METHODS

A qualitative interview study was done among patients who received chemotherapy for testicular (n = 10) or breast cancer (n = 7) and their partners (n = 17). The interview focused on how much they remembered the lifestyle advice given in hospital, whether and what they had adapted since diagnosis, and what they deemed as facilitators and barriers in maintaining lifestyle change.

RESULTS

Results showed that many patients and partners recalled that some advice was given in hospital but experienced this as too general and only at the start of treatment. Social contacts and the entire cancer experience helped facilitate change but were also seen as barriers. Other barriers were not considering healthy behaviors a priority or experiencing unhealthy choices as something nice after a trying time.

CONCLUSIONS

Oncologists and hospitals that provide lifestyle advice should provide cancer- and person-specific lifestyle advice, should offer this advice repeatedly into survivorship, and include the partner, as they are dedicated to improving lifestyle as well.

IMPLICATION FOR CANCER SURVIVORS

Staying healthy after cancer is important to both patients and their partners, and both experience their own facilitators and barriers to achieving this. Seeing a healthy lifestyle as a joint goal might facilitate change.

Exploring the use of rehabilitation in individuals with head and neck cancer undergoing treatment: a scoping review

Explore the use, characteristics, feasibility, and functional outcomes of rehabilitation interventions used for individuals with head and neck cancer (HNC) during treatment.

Searches were conducted in four databases from Jan 2011 to Dec 31, 2022. Included studies had to include adults with HNC undergoing treatment, a rehabilitation intervention, an assessment of functional outcome(s) addressed by the International Classification of Functioning Framework (ICF) and be published in English language. Title and abstract screening, full-text review, and data extraction were completed independently, in duplicate. Descriptive statistics and a qualitative synthesis summarized findings.

Twenty-seven studies were included in this review. The majority of studies were randomized controlled trials (70%). Most individuals represented in the included studies were males (92% of all participants) between 50 and 60 years of age. Interventions led by a speech language pathologist (33%) were most commonly described. Sixteen studies (59%) described primary outcomes that fit the ICF "impairment" domain.

We identified few studies that explored the use, feasibility, and effectiveness of rehabilitation interventions for individuals with HNC during treatment. Future research should assess the effectiveness of rehabilitation interventions on functional outcomes beyond the ICF body function and structure domain.

Effectiveness of Comprehensive Intervention Programme on Quality of life, fatigue, self-efficacy, and psychosocial distress among head and neck cancer patients receiving radiotherapy

PURPOSE

The study aimed at evaluating the Effectiveness of Comprehensive Intervention Programme (CIP) on Quality of life (QOL), fatigue, self-efficacy, and psychosocial distress among Head and Neck Cancer (HNC) patients receiving radiotherapy treatment.

METHODS

Single-centre non-RCT time series study was conducted among 134 HNC patients (67 observed, followed by 67 subjected to CIP). FACT- H&N, FACT-F, Cancer Behavior Inventory and psychosocial distress scales were used to assess QOL, fatigue, self-efficacy, and psychosocial distress respectively. CIP was provided to the intervention arm twice a week during the course of radiation therapy along with the standard care; the control arm received only standard care. Data were collected before commencing radiotherapy, and post-test assessments were carried out at the end of radiotherapy treatment, and at 3 and 6 months after completion of radiotherapy.

RESULTS

Repeated measures ANOVA revealed a statistically significant improvement with CIP in QOL (F (1.917) = 454.103, p = 0.001), fatigue (F (2.106) = 183.775, p = 0.001), self-efficacy (F (2.429) = 190.861, p = 0.001), and psychosocial distress (F (2.288) = 290.105, p = 0.001) in the intervention arm.

CONCLUSION

The CIP implemented to address multitude of issues in HNC patients receiving radiotherapy, proved to be effective in reducing the impact of treatment on QOL, fatigue, self-efficacy and psychosocial distress in HNC patients receiving radiotherapy.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

Associations Between Health Behaviors, Gastrointestinal Symptoms, and Gut Microbiota in a Cross-Sectional Sample of Cancer Survivors: Secondary Analysis from the Chemo-Gut Study

BACKGROUND

Health behaviors, such as diet and exercise, are actions individuals take that can potentially impact gastrointestinal (GI) symptoms and the gut microbiota. Little is known about how health behaviors impact GI symptoms and the gut microbiota after anti-cancer therapies.

METHODS

This is a secondary analysis of a cross-sectional study that investigated relationships between GI symptoms, gut microbiota, and patient-reported outcomes in adult cancer survivors. Gut microbiota was assessed from stool samples using 16 S rRNA gene sequencing. GI symptoms and health behaviors were measured via self-report. Descriptive statistics, multiple regression, and correlation analyses are reported.

RESULTS

A total of 334 cancer survivors participated, and a subsample of 17 provided stool samples. Most survivors rated their diet as moderately healthy (55.7%) and reported engaging in low intensity exercise (53.9%) for ≤5 h/week (69.1%). Antibiotic use was associated with more belly pain, constipation, and diarrhea (P < .05). Survivors consuming a healthier diet had fewer symptoms of belly pain (P = .03), gas/bloating (P = .01), while higher protein consumption was associated with less belly pain (P = .03). Better diet health was positively correlated with Lachnospiraceae abundance, and negatively with Bacteroides abundance (P < .05). Greater exercise frequency positively correlated with abundance of Lachnospiraceae, Faecalibacterium, Bacteroides, Anaerostipes, Alistipes, and Subdoligranulum (P < .05).

CONCLUSION

Results provide evidence for associations between antibiotic use, probiotic use, dietary health behaviors, and GI symptoms. Diet and exercise behaviors are related to certain types of bacteria, but the direction of causality is unknown. Dietary-based interventions may be optimally suited to address survivors' GI symptoms by influencing the gut microbiota. Larger trials are needed.

Effects of Multimodal Exercise on Health-related Physical Fitness and Quality of Life in Patients with Nasopharyngeal Carcinoma during Radiotherapy

BACKGROUND

The health-related physical fitness of patients with nasopharyngeal carcinoma can decrease significantly during radiotherapy, which can adversely affect their quality of life.

AIM

This study was designed to evaluate the potential influence of a multimodal exercise program on the health-related physical fitness and quality of life of patients with nasopharyngeal carcinoma during radiotherapy.

METHODS

Forty patients with nasopharyngeal carcinoma undergoing radiotherapy in the First Affiliated Hospital of Fujian Medical University from May to November 2019 were included. The participants in the control group (N=20) received routine nursing, while those in the intervention group (N=20) were also subjected to the multimodal exercise program during radiotherapy.

RESULTS

The multimodal exercise program had a positive effect on participants. The step test index in the intervention group was significantly higher as compared to the control group (p < .05). The participants were subjected to 5 times slow speed (60°/s) and 10 times fast (180°/s) speed, and function of some extensor and flexor muscles of the elbow, shoulder, and knee joints in the intervention group was markedly improved (p < .05). In the intervention group, the grip strength of the right hand was observed to be significantly improved (p < .01). Furthermore, the upper limb scratch dorsal test of intervention group was significantly better than that of the control group (p < .05). The scores of physical, emotional, and social functions in the intervention group were found to be significantly higher as compared to the control group (p < .05).

CONCLUSIONS

The multimodal exercise program significantly improved the health-related physical fitness and life quality of the patients with nasopharyngeal carcinoma during radiotherapy, though its long-term effects remain to be further analyzed.

Multiphasic exercise prehabilitation for patients undergoing surgery for head and neck cancer: a hybrid effectiveness-implementation study protocol

Head and neck cancer (HNC) treatment often consists of major surgery followed by adjuvant therapy, which can result in treatment-related side effects, decreased physical function, and diminished quality of life. Perioperative nutrition interventions and early mobilization improve recovery after HNC treatment. However, there are few studies on prehabilitation that include exercise within the HNC surgical care pathway. We have designed a multiphasic exercise prehabilitation intervention for HNC patients undergoing surgical resection with free flap reconstruction. We will use a hybrid effectiveness-implementation study design guided by the RE-AIM framework to address the following objectives: (1) to evaluate intervention benefits through physical function and patient-reported outcome assessments; (2) to determine the safety and feasibility of the prehabilitation intervention; (3) to evaluate the implementation of exercise within the HNC surgical care pathway; and (4) to establish a post-operative screening and referral pathway to exercise oncology resources. The results of this study will provide evidence for the benefits and costs of a multiphasic exercise prehabilitation intervention embedded within the HNC surgical care pathway. This paper describes the study protocol design, multiphasic exercise prehabilitation intervention, planned analyses, and dissemination of findings. Trial registration: https://clinicaltrials.gov/NCT04598087.

ACTivity as medicine In Oncology for Head and Neck (ACTIOHN): Protocol for a feasibility study investigating a patient-centred approach to exercise for people with head and neck cancer

BACKGROUND AND AIM

Attempts at personalisation of exercise programmes in head and neck cancer (HaNC) have been limited. The main aim of the present study is to investigate the feasibility and acceptability of introducing a remotely delivered, fully personalised, collaborative, and flexible approach to prescribing and delivering exercise programmes into the HaNC usual care pathway.

METHODS

This is a single arm, feasibility study. Seventy patients diagnosed with HaNC will be recruited from two regional HaNC centres in the United Kingdom. Patients will undertake an 8-week exercise programme designed and delivered by cancer exercise specialists. The exercise programme will start any time between the time of diagnosis and up to 8 weeks after completing treatment, depending on patient preference. The content of the exercise programme will be primarily based on patient needs, preferences, and goals, but guided by current physical activity guidelines for people with cancer. The primary outcome measure is retention to the study. Secondary quantitative outcomes are uptake to the exercise programme, different measures of exercise adherence, pre- and post-intervention assessments of fatigue (Multidimensional Fatigue Symptom Inventory-Short Form), quality of life (SF-36), physical activity levels (International Physical Activity Questionnaire-Short Form), and various components of physical fitness. The outcomes of the nested qualitative study are acceptability and feasibility of the intervention evaluated via interviews with patients, health care professionals, and the cancer exercise specialists. Intervention and participant fidelity will be determined using checklists and scrutiny of each patient's logbook and the cancer exercise specialists' meeting notes. Analysis of quantitative data will be via standard summary statistics. Qualitative data will be analysed using thematic analysis.

EXPECTED RESULTS

This feasibility study will inform the design and conduct of a future randomised controlled trial. Success will be defined according to a traffic light system for identifying the appropriateness of progression to a randomised controlled trial.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number registry (ISRCTN82505455).

Investigating sarcopenia, physical activity, and inflammation biomarkers in newly diagnosed oral cancer patients during curative treatment: A prospective longitudinal study

Objective

This prospective longitudinal study aimed to investigate changes in sarcopenia, physical activity, and inflammation biomarkers in patients with oral cavity cancer during curative treatment and explore their association with treatment outcomes.

Methods

Patients newly diagnosed with oral cavity cancer who underwent primary surgery with (chemo)radiation therapy were included. Along with physical activity and inflammatory markers, sarcopenia was assessed using a 5-time chair stand test, hand grip strength, and skeletal muscle index (SMI). Data were collected before operation and after 3 months (T₂) and 6 months after operation. Logistic regression and Cox proportional hazards models were used to identify predictors of treatment outcomes.

Results

Out of 56 patients, 21 (37.5%) had sarcopenia. SMI score, physical activity, and neutrophil-to-lymphocyte ratio (NLR) showed significant changes after surgery, with exacerbation at T₂. Patients with sarcopenia exhibited a significant decrease in SMI scores at T₂. Advanced cancer stage and sarcopenia were associated with treatment-related dysphagia (odds ratio [OR] ​= ​3.01, P ​= ​0.034; OR ​= ​7.62, P ​= ​0.018). Sarcopenia (OR ​= ​3.02, P ​= ​0.002) and NLR (OR ​= ​5.38, P ​< ​0.001) were significantly associated with infections. Pretreatment SMI independently predicted poor survival outcomes (hazard ratio ​= ​7.00, P ​= ​0.005).

Conclusions

Identifying patients with oral cavity cancer, sarcopenia, and high NLR levels can ensure prompt education and vigilant monitoring, potentially improving treatment outcomes and patient well-being during curative treatment.

Sport in the Laryngectomized Patient: A Literature Review and Single Case Presentation

BACKGROUND

Total laryngectomy is an operation that involves numerous problems for the patient, especially in daily life: loss of the fact, loss of voice, evident scars and persistence of the tracheostoma. Much is known about rehabilitation programs involving the voice, swallowing, shoulder girdle rehabilitation; less explored is the field of sport and sports rehabilitation in the laryngectomized patient.

METHODS

We conduced systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement in order to evaluate the possibilities of practicing sports for the patient after total laryngectomy.

RESULTS

From an initial search of 4191 papers, we have come to include six papers for this literature review. We have also reported one of our clinical cases referring to a laryngectomized patient who swims competitively at an amateur level even after surgery with a particular device. The purpose of this work is to understand the role and importance of sport in rehabilitation and the possibilities that a frail patient like the laryngectomized patient has in practicing sport. Surely the best results are obtained in subjects who practiced sports before surgery.

CONCLUSION

It is evident that sport is important in the psychological and motor recovery of the laryngectomized patient. There is still a lack of clear rehabilitation protocols, especially for water sports, which allow all laryngectomized patients to return to sports. We believe that early resumption of physical activity makes the experience of the disease less dramatic.

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

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

Feasibility and safety of Heavy Lifting Strength Training in Head and Neck Cancer survivors post-surgical neck dissection (the LIFTING trial)

BACKGROUND

Light-to-moderate intensity strength training (LMST) improves muscular strength, physical functioning, and some side effects in head and neck cancer survivors (HNCS). Heavy lifting strength training (HLST) may further improve these outcomes; however, it has not been studied in HNCS. The primary aim of the LIFTING trial was to examine the feasibility and safety of a HLST program in HNCS ≥1-year post-surgical neck dissection.

METHODS

In this single-arm feasibility study, HNCS were asked to complete a twice weekly, 12-week, supervised HLST program, gradually progressing to lifting heavy loads of 80-90% of 1 repetition maximum (1RM) for barbell squat, bench press, and deadlift. The feasibility outcomes included recruitment rate, 1RM completion rate, program adherence, barriers, and motivation. The preliminary efficacy outcomes included changes in upper and lower body strength.

RESULTS

Nine HNCS were recruited over an 8-month period during the COVID-19 pandemic. All 9 (100%) completed the 1RM tests and successfully progressed to heavy loads at approximately 5 weeks. The median attendance was 95.8% (range 71-100%), and few barriers were reported. Weight lifted increased for squat/leg press (median change: +34kg; 95% CI +25 to +47), bench press (median change: +6kg; 95% CI +2 to +10), and deadlift (median change: +12kg; 95% CI +7 to +24). No adverse events were reported and participants were motivated to continue HLST after the study.

CONCLUSIONS

HLST appears feasible and safe for HNCS and may result in meaningful improvements in muscular strength. Future research should consider additional recruitment strategies and compare HLST to LMST in this understudied survivor population.

TRIAL REGISTRATION

NCT04554667.

EffEx-HN trial: study protocol for a randomized controlled trial on the EFFectiveness and feasibility of a comprehensive supervised EXercise program during radiotherapy in Head and Neck cancer patients on health-related quality of life

BACKGROUND

With over 500,000 annually reported cases worldwide, head and neck cancer (HNC) is the seventh most common type of cancer worldwide. Treatment of HNC with chemoradiotherapy frequently results in serious impairments in physical and psychosocial functioning. Besides, HNC patients typically start their cancer treatment already with poor physical and psychosocial health. It has been shown that a sufficient level of physical activity (PA) before, during, and after cancer treatment is associated with fewer negative treatment-related side effects and a better quality of life (QOL). In order to prevent worsening of functioning and limit the physical impact of the HNC treatment, a comprehensive supervised exercise program (CSEP) may be beneficial during early cancer treatment. However, up to now, the feasibility and effectiveness of such a program are not yet investigated thoroughly in HNC. Therefore, the primary objective of this study is to examine the effectiveness of a CSEP during HNC treatment, in addition to usual supportive care, compared to usual supportive care alone, on health-related QOL up to 1 year post-diagnosis. Secondary objectives entail gathering information on (1) the effectiveness of a CSEP on secondary outcomes such as physical and mental function, activities of daily life, and participation in society and (2) the feasibility, possible barriers, and facilitators for participation in a CSEP during HNC treatment.

METHODS

To investigate the effectiveness of the CSEP, a parallel, open-label randomized controlled trial will be performed. To study the feasibility of the CSEP, a mixed-method study will be performed in a subgroup of participants. HNC patients are eligible if they receive radiotherapy at the Radiation-Oncology department of the University Hospital of Leuven. A 4-size permuted block randomization will be used. The control group receives the current standard of supportive care. The intervention group receives a CSEP, additional to the same usual supportive care. The CSEP consists of a 12-week intensive phase with 3 exercise sessions of 1 h per week, where supervision is gradually reduced after 6 weeks. During the maintenance phase (from week 13), patients exercise at home with monthly tele-consultations with a physiotherapist. The CSEP contains supervised aerobic and resistance training. In both groups, outcomes of interest are evaluated through self-reported questionnaires and clinical assessments, at baseline, 6 weeks, 12 weeks, 6 months, and 12 months post-diagnosis. The primary endpoint is health-related QOL, measured with the EORTC QLQ-C30 at 6 months post-diagnosis.

DISCUSSION

The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the ethical committee of the University Hospitals Leuven (s65549). Recruitment started in January 2022. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses.

TRIAL REGISTRATION

Trial Registration: ClinicalTrials.gov Identifier: NCT05256238 Date of registration: February 25, 2022.

Exercise interventions for adults with cancer receiving radiation therapy alone

BACKGROUND

Radiation therapy (RT) is given to about half of all people with cancer. RT alone is used to treat various cancers at different stages. Although it is a local treatment, systemic symptoms may occur. Cancer- or treatment-related side effects can lead to a reduction in physical activity, physical performance, and quality of life (QoL). The literature suggests that physical exercise can reduce the risk of various side effects of cancer and cancer treatments, cancer-specific mortality, recurrence of cancer, and all-cause mortality.

OBJECTIVES

To evaluate the benefits and harms of exercise plus standard care compared with standard care alone in adults with cancer receiving RT alone.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL, conference proceedings and trial registries up to 26 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people who were receiving RT without adjuvant systemic treatment for any type or stage of cancer. We considered any type of exercise intervention, defined as a planned, structured, repetitive, objective-oriented physical activity programme in addition to standard care. We excluded exercise interventions that involved physiotherapy alone, relaxation programmes, and multimodal approaches that combined exercise with other non-standard interventions such as nutritional restriction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the GRADE approach for assessing the certainty of the evidence. Our primary outcome was fatigue and the secondary outcomes were QoL, physical performance, psychosocial effects, overall survival, return to work, anthropometric measurements, and adverse events.

MAIN RESULTS

Database searching identified 5875 records, of which 430 were duplicates. We excluded 5324 records and the remaining 121 references were assessed for eligibility. We included three two-arm RCTs with 130 participants. Cancer types were breast and prostate cancer. Both treatment groups received the same standard care, but the exercise groups also participated in supervised exercise programmes several times per week while undergoing RT. Exercise interventions included warm-up, treadmill walking (in addition to cycling and stretching and strengthening exercises in one study), and cool-down. In some analysed endpoints (fatigue, physical performance, QoL), there were baseline differences between exercise and control groups. We were unable to pool the results of the different studies owing to substantial clinical heterogeneity. All three studies measured fatigue. Our analyses, presented below, showed that exercise may reduce fatigue (positive SMD values signify less fatigue; low certainty). • Standardised mean difference (SMD) 0.96, 95% confidence interval (CI) 0.27 to 1.64; 37 participants (fatigue measured with Brief Fatigue Inventory (BFI)) • SMD 2.42, 95% CI 1.71 to 3.13; 54 participants (fatigue measured with BFI) • SMD 1.44, 95% CI 0.46 to 2.42; 21 participants (fatigue measured with revised Piper Fatigue Scale) All three studies measured QoL, although one provided insufficient data for analysis. Our analyses, presented below, showed that exercise may have little or no effect on QoL (positive SMD values signify better QoL; low certainty). • SMD 0.40, 95% CI -0.26 to 1.05; 37 participants (QoL measured with Functional Assessment of Cancer Therapy-Prostate) • SMD 0.47, 95% CI -0.40 to 1.34; 21 participants (QoL measured with World Health Organization QoL questionnaire (WHOQOL-BREF)) All three studies measured physical performance. Our analyses of two studies, presented below, showed that exercise may improve physical performance, but we are very unsure about the results (positive SMD values signify better physical performance; very low certainty) • SMD 1.25, 95% CI 0.54 to 1.97; 37 participants (shoulder mobility and pain measured on a visual analogue scale) • SMD⁠⁠⁠⁠⁠⁠ 3.13 (95% CI 2.32 to 3.95; 54 participants (physical performance measured with the six-minute walk test) Our analyses of data from the third study showed that exercise may have little or no effect on physical performance measured with the stand-and-sit test, but we are very unsure about the results (SMD 0.00, 95% CI -0.86 to 0.86, positive SMD values signify better physical performance; 21 participants; very low certainty). Two studies measured psychosocial effects. Our analyses (presented below) showed that exercise may have little or no effect on psychosocial effects, but we are very unsure about the results (positive SMD values signify better psychosocial well-being; very low certainty). • SMD 0.48, 95% CI -0.18 to 1.13; 37 participants (psychosocial effects measured on the WHOQOL-BREF social subscale) • SMD 0.29, 95% CI -0.57 to 1.15; 21 participants (psychosocial effects measured with the Beck Depression Inventory) Two studies recorded adverse events related to the exercise programmes and reported no events. We estimated the certainty of the evidence as very low. No studies reported adverse events unrelated to exercise. No studies reported the other outcomes we intended to analyse (overall survival, anthropometric measurements, return to work).

AUTHORS' CONCLUSIONS

There is little evidence on the effects of exercise interventions in people with cancer who are receiving RT alone. While all included studies reported benefits for the exercise intervention groups in all assessed outcomes, our analyses did not consistently support this evidence. There was low-certainty evidence that exercise improved fatigue in all three studies. Regarding physical performance, our analysis showed very low-certainty evidence of a difference favouring exercise in two studies, and very low-certainty evidence of no difference in one study. We found very low-certainty evidence of little or no difference between the effects of exercise and no exercise on quality of life or psychosocial effects. We downgraded the certainty of the evidence for possible outcome reporting bias, imprecision due to small sample sizes in a small number of studies, and indirectness of outcomes. In summary, exercise may have some beneficial outcomes in people with cancer who are receiving RT alone, but the evidence supporting this statement is of low certainty. There is a need for high-quality research on this topic.

The effects of myofascial induction therapy in survivors of head and neck cancer: a randomized, controlled clinical trial

PURPOSE

We aim to evaluate the effects of myofascial induction therapy (MIT) on the sequelae suffered by the survivors of HNC (sHNC).

METHODS

We enrolled 46 sHNC in a randomized controlled trial (RCT), of whom 20 received a MIT protocol and 23 were placed on a waitlist while receiving the recommended treatment for 6 weeks. The MIT protocol included a total of 18 sessions, 3 days a week on alternate days for 6 weeks. Maximal mouth opening, the presence of temporomandibular dysfunction, cervical endurance, active range of motion (AROM), shoulder AROM, handgrip strength, and perceived physical fitness were assessed.

RESULTS

Maximal mouth opening, temporomandibular dysfunction, cervical endurance, and AROM, affected shoulder abduction and unaffected shoulder flexion and external rotation significantly improved (p < .05) after an MIT protocol, but only cervical AROM and affected shoulder abduction changes were clinically meaningful. No statistically significant changes were observed in the other shoulder AROM, handgrip strength, or physical fitness perception (p > .05).

CONCLUSION

A 6-week MIT protocol improves mouth opening, TMD, cervical function (endurance and AROM), affected shoulder abduction and unaffected shoulder flexion, and external rotation AROM in the sHNC. However, no changes were observed in most of the shoulder AROM, muscular strength, or perceived physical fitness. Future studies should perform longer follow-up designs, increase the sample size, and include multimodal treatments to address these sequelae in the sHNC.

Neck and Shoulder Morbidity in Patients with Oral Cancer and Clinically Negative Node Neck Status: A Comparison between the Elective Neck Dissection and Sentinel Lymph Node Biopsy Strategies

The choice for the most optimal strategy for patients with a cT_1-2N₀ carcinoma of the oral cavity, sentinel lymph node biopsy (SLNB) or elective neck dissection (END), is still open for debate in many head and neck cancer (HNC) treatment centers. One of the possible benefits of the less invasive SLNB could be reduced neck and shoulder morbidity. Recent studies have shown a benefit in favor of SLNB the first year after intervention, but the long-term consequences and differences in neck morbidity remain unclear. This cross-sectional study aimed to research differences in neck and shoulder morbidity and Health-Related Quality of Life (HR-QoL) in patients with a cT_1-2N₀ carcinoma of the oral cavity, treated with either END or SLNB. Neck and shoulder morbidity and HR-QOL were measured with patient-reported questionnaires (SDQ, SPADI, NDI, NDII, EORTC-QLQ-C30, EORTC-QLQ-HN35) and active range of motion (AROM) measurements. In total 18 patients with END and 20 patients with SLNB were included. We found no differences between END and SLNB for long-term neck morbidity, shoulder morbidity, and HR-QOL. The significant differences found in the rotation of the neck are small and not clinically relevant.

Nutritional prehabilitation in head and neck cancer: a systematic review

PURPOSE

Prehabilitation affords an opportunity to support the management of malnutrition that is strongly associated with head and neck cancer. The purpose of this systematic review was to identify the components of nutritional prehabilitation interventions and their effects on nutritional and health outcomes in head and neck cancer patients.

METHODS

A comprehensive search was completed within Medline (including PubMed), CINHAL, Cochrane database, EMBASE, PRoQUEST, clinical trials registries, and grey literature to identify studies involving a nutritional intervention pre-treatment in head and neck cancer patients receiving any form of curative therapy. Nutritional intervention was defined as a specified period pre-treatment and outcome measures had to include assessment of nutritional status or body composition. Quality of included studies was assessed using Cochrane risk of bias 2.

RESULTS

From 557 identified studies, two met the inclusion criteria. Due to the low number of studies, a meta-analysis was not indicated. Both studies conducted a nutritional intervention using an "enriched formula" in malnourished patients prior to surgery. Neither study reported the intervention was effective for reducing weight loss, physical function, surgical complications, or length of stay versus the comparison.

CONCLUSION

There is limited nutritional prehabilitation research within head and neck cancer. An "enriched formula" provided in the prehabilitation period appears no more advantageous than routine standard nutritional formula in mitigating against the weight loss experienced in malnourished head and neck patient. Due to the malnutrition risks on diagnosis and the negative impact of poor nutritional status on clinical and functional outcomes, robust nutritional prehabilitation research is required to inform clinical practice.

Barriers and facilitators to physical activity participation in patients with head and neck cancer: a scoping review

BACKGROUND

Patients with head and neck cancer (HNC) usually experienced disfigurement, dysfunction, and psychosocial distress, leading to a decline in their quality of life. Physical activity (PA) is recommended for such patients. Despite the proven benefits of participating in PA, the compliance of patients with HNC is still poor. Hence, the factors influencing PA participation and adherence in patients with HNC need to be explored.

OBJECTIVES

This study aimed to (1) identify barriers and enablers of PA in adult patients living with HNC and (2) map barriers and facilitators to the Capability-Opportunity-Motivation-Behavior (COM-B) model.

ELIGIBILITY CRITERIA

Types of studies: Studies with qualitative, quantitative, and mixed designs were included in this review.

TYPES OF PARTICIPANTS

The current review takes into account patients with HNC aged 18 years or above. Types of interventions: This review considered all studies focusing on full-body PA.

TYPES OF OUTCOMES

This scoping review focused on studies examining health behavior, patients' compliance, and facilitators and/or barriers to PA engagement. Five databases (Ovid Medline, Ovid Embase, CINAHL, Cochrane Library, and PsycINFO) were searched following the methodology for scoping reviews from inception to July 2021.

DATA EXTRACTION

The extracted data included author(s)/year of publication, country, main purpose of the study, sample size/disease site and stage, methodology and methods, type of treatment, and main findings/barriers, or facilitators.

RESULTS

A total of 22 studies were finally selected. The top three barriers were physical-related issues, time pressures, and low motivation or interest. Most facilitators included perceived psychological, health, and social benefits and preference for the model of PA. The most frequent COM-B model components were physical capability, automatic motivation, and physical opportunity.

CONCLUSIONS

Patients with HNC have unique facilitators and barriers to participating in PA. Interventions must leverage facilitators and limit barriers to exercise so as to increase compliance with exercise. Future studies should test the effectiveness of behavioral change measures based on the factors influencing the COM-B model.

The feasibility of patient-reported outcomes, physical function, and mobilization in the care pathway for head and neck cancer surgical patients

BACKGROUND

Head and neck cancer (HNC) patients are an understudied population whose treatment often includes surgery, causing a wide range of side effects. Exercise prehabilitation is a promising tool to optimize patient outcomes and may confer additional benefits as a prehabilitation tool. The primary objective of this study was to assess the feasibility of measuring patient-reported outcomes (PROs), physical function, and in-hospital mobilization across the HNC surgical timeline in advance of a future prehabilitation trial. The secondary objective was to examine potential changes in these outcomes across the surgical timeline.

METHODS

HNC patients scheduled to undergo oncologic resection with free-flap reconstruction completed assessments of PROs and physical function at three timepoints across the surgical timeline (baseline, in-hospital, and postsurgical/outpatient). Mobilization was measured during the in-hospital period. The feasibility of recruitment and measurement completion was tracked, as were changes in both PROs and physical function.

RESULTS

Of 48 eligible patients, 16 enrolled (recruitment rate of 33%). The baseline and in-hospital PROs were completed by 88% of participants, while the outpatient assessments were completed by 81% of participants. The baseline and in-hospital assessment of physical function were completed by 56% of participants, and 38% completed the outpatient assessment. Measuring in-hospital mobilization was completed for 63% of participants.

CONCLUSION

Measuring PROs and in-hospital mobilization is feasible across the surgical timeline in HNC; however, the in-person assessment of physical function prior to surgery was not feasible. A multidisciplinary collaboration between exercise specialists and clinicians supported the development of new clinical workflows in HNC surgical care that will aid in the implementation of a future prehabilitation trial for this patient population.

Moving beyond Definitive Therapy: Increasing Physical Activity in Survivors of Cancers of the Head and Neck

As chemotherapeutic, radiation, and surgical techniques have improved, there has been a dramatic improvement in survival in patients diagnosed with cancers of the head and neck. As a result, a heightened focus on survivorship by clinicians will increasingly prove necessary. In particular, medical care teams will have to pay special attention to mitigating the long-term sequelae of definitive cancer treatments, many of which act as barriers to exercise. This is unfortunate, as the benefits of exercise in patients with cancer have become increasingly recognized. In this review, we discuss the potential benefits of and barriers to exercise in survivors of cancers of the head and neck. We also review existing exercise guidelines and strategies by which clinicians can promote exercise in this unique patient population.

Relationship between physical activity, objective sleep parameters, and circadian rhythm in patients with head and neck cancer receiving chemoradiotherapy: A longitudinal study

OBJECTIVES

This study was developed to assess the relationship between physical activity, sleep and circadian rhythm using accelerometer and urine melatonin levels in patients with head and neck cancer (HNC). Also, this study evaluated the changes in physical activity, sleep, and circadian rhythm during the seven-week course of chemoradiotherapy.

METHODS

This longitudinal study recruited 27 participants diagnosed with HNC who were planning to undergo chemoradiotherapy. Accelerometers worn for 3 days during the 1st, 3rd, and 7th weeks of chemoradiotherapy were used to assess physical activity levels (step count and metabolic equivalents [METs]) and sleep quality (total sleep time [TST], sleep onset latency [SOL], and sleep efficiency [SE]). Urine melatonin analysis was conducted using the morning void urine sample on 1st, 3rd, and 7th weeks. The change in variables during the seven weeks and the correlation between them were analyzed.

RESULTS

During the seven weeks, trends of reduction in variables of physical activity, sleep and circadian rhythm were observed with significant decrease in step count, TST and melatonin levels. SE was found to have strong negative correlation with physical activity. TST was found to have moderate correlation with SE and step count. The variables of physical activity also showed moderate correlation among them.

CONCLUSION

This study concludes that higher physical activity is associated with poor SE due to increased night-time activity. There was a significant reduction in physical activity and sleep observed during seven weeks with moderate association between them. The significant circadian rhythm deregulation however showed poor association with the other variables.Level of Evidence: 2b.

Association between neighborhood built environment and health-related fitness: a systematic review protocol

OBJECTIVE

The objective of this review is to summarize the current literature on the association between the neighborhood built environment and components of health-related fitness. The findings may be useful for policy-makers and health professionals to inform the development of health-supportive neighborhood built environments.

INTRODUCTION

There is accumulating evidence linking neighborhood built environments to health, including physical activity and chronic health conditions, yet little is known about the potential links between the built environment and health-related fitness. Although physical activity and health-related fitness are intimately linked, health-related fitness is thought to be a more proximate and stronger correlate of health. Understanding how the built environment influences health-related fitness will allow better health-promoting urban design and population-level interventions.

INCLUSION CRITERIA

Published and unpublished evidence will be included if it has a quantitative component and the sample includes adults aged 18 years or older, with no physical disabilities or health issues that may affect health-related fitness. The exposure of interest will be objectively measured and self-reported neighborhood built characteristics. The outcome of interest will be objectively measured and self-reported components of health-related fitness (ie, morphological, muscular, motor, and cardiorespiratory fitness).

METHODS

We will follow the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases used in the search will include MEDLINE, Embase, CINAHL, Web of Science, SPORTDiscus, Environment Complete, and Transport Research International Documentation with no date or language restrictions. Two independent reviewers will screen titles and abstracts, and assess full-text studies against the inclusion criteria. Study quality will be assessed by two independent reviewers using the critical appraisal tools from JBI. A narrative approach will be used to synthesize the study findings; if data permit, a meta-analysis will be completed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020179807.

Chronic Nutrition Impact Symptoms Are Associated with Decreased Functional Status, Quality of Life, and Diet Quality in a Pilot Study of Long-Term Post-Radiation Head and Neck Cancer Survivors

BACKGROUND

As a result of tumor location and treatment that is aggressive, head and neck cancer (HNC) survivors experience an array of symptoms impacting the ability and desire to eat termed nutrition impact symptoms (NISs). Despite increasing cancer survival time, the majority of research studies examining the impact of NISs have been based on clinical samples of HNC patients during the acute phase of treatment. NISs are often chronic and persist beyond the completion of treatment or may develop as late side effects. Therefore, our research team examined chronic NIS complications on HNC survivors' functional status, quality of life, and diet quality.

METHODS

This was a cross-sectional study of 42 HNC survivors who were at least 6 months post-radiation. Self-reported data on demographics, NISs, quality of life, and usual diet over the past year were obtained. Objective measures of functional status included the short physical performance battery and InBody© 270 body composition testing. NISs were coded so a lower score indicated lower symptom burden, (range 4-17) and dichotomized as ≤10 vs. >10, the median in the dataset. Wilcoxon rank sum tests were performed between the dichotomized NIS summary score and continuous quality of life and functional status outcomes. Diet quality for HNC survivors was calculated using the Healthy Eating Index 2015 (HEI-2015). Wilcoxon rank sum tests examined the difference between the HNC HEI-2015 as compared to the National Health and Nutrition Examination Survey (NHANES) data calculated using the population ratio method.

RESULTS

A lower NIS score was statistically associated with higher posttreatment lean muscle mass (p = 0.002). A lower NIS score was associated with higher functional (p = 0.0006), physical (p = 0.0007), emotional (p = 0.007), and total (p < 0.0001) quality of life. Compared to NHANES controls, HNC survivors reported a significantly lower HEI-2015 diet quality score (p = 0.0001).

CONCLUSIONS

Lower NIS burden was associated with higher lean muscle mass and functional, physical, emotional, and total quality of life in post-radiation HNC survivors. HNC survivors reported a significantly lower total HEI-2015 as compared to healthy NHANES controls, providing support for the hypothesis that chronic NIS burden impacts the desire and ability to eat. The effects of this pilot study were strong enough to be detected by straight forward statistical approaches and warrant a larger longitudinal study. For survivors most impacted by NIS burden, multidisciplinary post-radiation exercise and nutrition-based interventions to manage NISs and improve functional status, quality of life, and diet quality in this survivor population are needed.

Low physical activity in patients diagnosed with head and neck cancer

BACKGROUND

This pilot study aimed to describe physical activity (PA) and self-perceived function, health and quality of life (QoL) prior to oncological treatment in patients with head and neck cancer (HNC).

METHODS

In a prospective study including 49 patients, self-perceived PA (Saltin-Grimby scale) and health-related QoL (European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 and EQ-5D) were assessed. Further, PA was also measured by an accelerometer attached to the thigh for eight consecutive days. The accelerometer PA was compared to the PA of a reference population assessed with the same method. Results presented are from data collected before start of oncological treatment.

RESULTS

The patients (44-79 years, 65% males) spent most of their time in sedentary behavior: a median of 555 minutes/day in bed (39% of total) and 606 minutes/day sitting (41%). Only 129 minutes/day were spent moving/walking. Patients with higher education, reduced physical function and higher fatigue were less physically active (P ≤ .01). Further, the different PA measures demonstrated a pattern of being less physically active compared to the reference population.

CONCLUSIONS

Patients diagnosed for HNC may have low PA level. Assessment of PA from accelerometer data may be an important component of oncological treatment to identify patients in need for PA intervention that may enhance treatment outcome.

Patients' views of physical activity whilst living with and beyond head and neck cancer

Exercise is an important component of recovery following cancer. Head and neck cancer (HNC) patients typically report low levels of engagement in exercise initiatives. The aim of this study was to give insight into HNC patients' reflections on how and why they would be interested in participating in an exercise programme. A stratified sample of 51 patients based on age, gender and initial interest in an exercise programme was selected from 430 postal survey respondents. Twenty-five took part in a semi-structured telephone interview. There was responder bias with females, younger patients, and those already participating in or interested in an exercise programme being over-represented. The responders in this study highlighted issues related to physical activity levels, perceived ability to meet physical activity guidelines for cancer survivors, perceived exercise benefits, perceived exercise barriers, and advice to others diagnosed with cancer. The findings support the premise of personalized interventions tailored towards the specific needs of the patient, supported by patient peers to emphasize the benefits and help motivate patients to take part. In order to promote engagement in exercise there needs to be collaborative, culturally sensitive and individualized approaches, in order to address the specific barriers experienced by HNC patients.

Physical activity and fitness in survivors of head and neck cancer

PURPOSE

The purposes of the study were (1) to assess the physical activity (PA) status, muscle strength (MS), and flexibility of survivors of head and neck cancer (HNC) and compare these findings with normative data from national labor fitness measures; (2) to examine the differences among PA subgroups, as categorized using Godin's scores; and (3) to examine the association between stretching exercises and cervical range of motion (CROM).

METHODS

A cross-sectional study with consecutive sampling was used to recruit HNC survivors from a medical center in Northern Taiwan who had completed either radiation therapy (RT) or multimodality treatments including RT within the current 5 years. The level of PA, daily function, fatigue, quality of life (QOL), MS (handgrip and hip flexor), BMI, and flexibility (CROM and fingertip-to-floor tests) of the participants were assessed.

RESULTS

A total of 108 participants completed the assessments from 135 eligible patients (80% response rate). Although 60.2% reported engaging in PA, only 16.7% met WHO guidelines. Compared to subjects in the normative data, the survivors of HNC in this study had poorer handgrip strength, BMI, and CROM, but better forward flexion. The participants who were consistent with WHO PA guidelines reported less fatigue, better right hip flexor MS, and better QOL than those who did not engage in any PA.

CONCLUSION

Lack of sufficient PA and generally poorer fitness were found in study subjects. Longitudinal research to explore changes in fitness and barriers to PA compliance is strongly suggested to better enhance HNC patients' PA and fitness.

Fatigue in Women with Fibromyalgia: A Gene-Physical Activity Interaction Study

Fatigue is a cardinal symptom in fibromyalgia. Fatigue is assumed to be the result of genetic susceptibility and environmental factors. We aimed at examining the role of genetic susceptibility for fatigue in southern Spanish women with fibromyalgia, by looking at single nucleotide polymorphisms in 34 fibromyalgia candidate-genes, at the interactions between genes, and at the gene-physical activity interactions. We extracted DNA from saliva of 276 fibromyalgia women to analyze gene-polymorphisms. Accelerometers registered physical activity and sedentary behavior. Fatigue was assessed with the Multidimensional Fatigue Inventory. Based on the Bonferroni’s and False Discovery Rate values, we found that the genotype of the rs4453709 polymorphism (sodium channel protein type 9 subunit alpha, SCN9A, gene) was related to reduced motivation (AT carriers showed the highest reduced motivation) and reduced activity (AA carriers showed the lowest reduced activity). Carriers of the heterozygous genotype of the rs1801133 (methylene tetrahydrofolate reductase, MTHFR, gene) or rs4597545 (SCN9A gene) polymorphisms who were physically active reported lower scores on fatigue compared to their inactive counterparts. Highly sedentary carriers of the homozygous genotype of the rs7607967 polymorphism (AA/GG genotype; SCN9A gene) presented more reduced activity (a dimension of fatigue) than those with lower levels of sedentary behavior. Collectively, findings from the present study suggest that the contribution of genetics and gene-physical activity interaction to fatigue in fibromyalgia is modest.

Promoting exercise in patients with cancers of the head and neck during COVID-19 and beyond

In recent years, the benefits of exercise in patients with cancer have increasingly been recognised. Unfortunately, patients with, and survivors of, cancers of the head and neck often face a constellation of symptomatic and nutritional obstacles that can interfere with their ability to adhere to structured exercise regimens. The spread of COVID-19 has only added to these challenges. In this Viewpoint, the authors detail the impediments faced by patients with cancers of the head and neck in obtaining sufficient exercise, review the evidence supporting the benefits of exercise in patients with cancer and discuss interventions to promote exercise in this patient population.

Change in Physical Performance Correlates with Decline in Quality of Life and Frailty Status in Head and Neck Cancer Patients Undergoing Radiation with and without Chemotherapy

Simple Summary

Quality of life (QoL) scores and frailty status are becoming increasingly important criterion with implications on both how patients are treated and survival in head and neck cancer (HNC). Despite this, physicians lack tools to identify patients who are at risk of suffering declines in QoL and becoming frail following treatment. Therefore, we investigated whether functional decline, as measured by a series of physical tests called the Short Physical Performance Battery (SPPB), correlated with a reduction in QoL and increased risk of frailty. In the current study, patients who experienced a decline in SPPB scores were significantly more likely to have changes in physical functioning QoL measures as well as transition to frail status following treatment. In conclusion, the SPPB may be a useful tool to identify patients who may benefit from additional rehabilitation in future studies.

Abstract

Patient-reported quality of life (QoL) metrics, frailty status, and physical functioning are emerging concepts in head and neck cancer (HNC) with implications on both treatment decision-making and prognosis. The impact of treatment-related functional decline on QoL and frailty has not been well-characterized in HNC and was the focus of this investigation. Methods: Patients who underwent radiation therapy for HNC from 2018 to 2020 were evaluated as a prospective observational cohort. Functional decline, QoL, and the frailty phenotype were measured via the Short Physical Performance Battery (SPPB), European Organization for Research and Treatment of Cancer (EORTC) qlq-C30, and Fried Frailty index, respectively. Results: A total of 106 HNC patients were included, 75 of which received concurrent chemoradiation therapy (CCRT) and 31 received radiation alone, both with and without surgery. There was a decrease in SPPB overall (p < 0.001) from the beginning to the end of treatment in the CCRT group but not the radiation group (p = 0.43). Change in overall SPPB points following treatment correlated with the decline in physical QoL for both groups (p < 0.05) as well as transition frail status in the CCRT group (p < 0.001) with a trend in the radiation group (p = 0.08). Conclusions: Change in SPPB correlates with QoL and transition to frailty status in patients undergoing definitive CCRT for HNC with similar trends in those receiving radiation alone. Decline in SPPB could potentially be useful in identification of those who may benefit from rehabilitation in future studies.

Identifying unmet needs and limitations in physical health in survivors of Head and Neck Cancer

Objective

To gain insight into the level of unmet needs and limitations in physical health experienced by survivors of head and neck cancer, and to evaluate whether unmet needs in physical health and limitations in physical performance are associated.

Materials and methods

In this cross‐sectional study, unmet needs were measured with Supportive Care Needs Surveys (SCNS‐SF34, SCNS‐HNC). Limitations in physical health were measured for maximal mouth opening, neck and shoulder function, hand grip strength and lower body strength, level of mobility and walking ability.

Results

The SCNSs showed that 48% had a cancer generic unmet need and 46% had at least one HNC‐specific unmet need. In total, 76% of sHNC had a cancer generic limitation in physical health and that 58% had an HNC‐specific limitation in the mobility of neck and shoulders or maximum mouth opening. The domain of physical and daily living needs showed a weak association with lateral flexion of the neck to the left (R = −0.319; p = 0.024).

Conclusion

Survivors of HNC might benefit from the use of both SCNSs and physical performance measurements during usual care follow‐up for early and optimal identification of unmet needs and limitations in physical health.

Effects of Exercise Training during Concomitant Chemoradiation Therapy in Head-and-Neck Cancer Patients: A Systematic Review

Existing literature suggests that cancer survivors present with high rates of morbidity due to various treatment and disease-induced factors. Research has shown exercise to be beneficial in improving treatment outcomes and quality of life (QOL). This review was done to collect the current state of exercise-based interventions for cancer survivors in India. From the summarized data, exercise interventions were categorized into resistance training, aerobic training, and home-based walking program in head-and-neck cancers. A broad range of outcomes showed improvement in muscle strength, functional capacity, and QOL and hence supported the benefits of exercise-based interventions in this population. All the data retrieved, therefore, conclude that exercise-based interventions are safe, feasible, and beneficial in patients with head and neck cancer receiving chemoradiation therapy.

Research progress of radiation-induced hypothyroidism in head and neck cancer

This paper reviews the factors related to hypothyroidism after radiotherapy in patients with head and neck cancer to facilitate the prevention of radiation-induced hypothyroidism and reduce its incidence. Hypothyroidism is a common complication after radiotherapy in patients with head and neck cancer, wherein the higher the radiation dose to the thyroid and pituitary gland, the higher the incidence of hypothyroidism. With prolonged follow-up time, the incidence of hypothyroidism gradually increases. Intensity modulated radiotherapy should limit the dose to the thyroid, which would reduce the incidence of hypothyroidism. In addition, the risk factors for hypothyroidism include small thyroid volume size, female sex, and previous neck surgery. The incidence of radiation-induced hypothyroidism in head and neck cancer is related to the radiation dose, radiotherapy technique, thyroid volume, sex, and age. A prospective, large sample and long-term follow-up study should be carried out to establish a model of normal tissue complications that are likely to be related to radiation-induced hypothyroidism.

The pre-efficacy phase testing for PAfitME™-A behavioral physical activity intervention to manage moderate and severe symptoms among advanced stage cancer patients

Fatigue and pain are the most frequently reported symptoms among advanced-stage cancer patients. Although physical activity (PA) is known to improve the aforementioned symptoms, few patients demonstrate the physically active behavior that adheres to the clinical guidelines regarding PA. The current article presents an exemplar that used the National Institute of Health's Obesity-Related Behavioral Intervention Trial (ORBIT) model and developed a behavioral intervention known as the personalized Physical Activity intervention with fitness graded Motion Exergames (PAfitME™). There were two phases of testing in the ORBIT model presented in the current paper. In Phase I testing, a standardized exergame prescription was evaluated by an advisory board and a single-case study was used to evaluate the personalized exergame prescription with personalization of the fitness levels. In Phase IIa, a within-group pre- and posttest design was used to evaluate the personalized exergame prescriptions with personalization of the fitness levels, self-efficacy, and variation in fatigue/pain. Subsequently, a complete intervention package was developed in accordance with a logic model, driven from the result of the Phase IIa testing with clinically significant findings. Currently, PAfitME™ is under Phase IIb testing in a randomized clinical trial with a control group. PAfitME™ employs a personalized approach to initiate and promote physically active behavior, to facilitate the management of fatigue and pain in cancer patients. Positive results from an efficacy trial would support the use of PAfitME™ in the management of fatigue and pain in advanced-stage cancer patients.

Exercise and Nutrition Interventions in Patients with Head and Neck Cancer during Curative Treatment: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to examine the effects of nutritional and physical exercise interventions and interventions combining these interventions during radiotherapy treatment for patients with head and neck cancer on body composition, objectively measured physical function and nutritional status. Systematic electronic searches were conducted in MEDLINE (PubMed interface), EMBASE (Ovid interface), CINAHL (EBSCO interface) and Cochrane Library (Wiley interface). We identified 13 randomized controlled trials (RCTs) that included 858 patients. For body composition, using only nutrition as intervention, a significant difference between treatment and control group were observed (SMD 0.42 (95CI 0.23-0.62), p < 0.001). Only pilot RCTs investigated combination treatment and no significant difference between the treatment and control groups were found (SMD 0.21 (95CI -0.16-0.58), p = 0.259). For physical function, a significant difference between treatment and control group with a better outcome for the treatment group were observed (SMD 0.78 (95CI 0.51-1.04), p < 0.001). No effects on nutritional status were found. This meta-analysis found significantly positive effects of nutrition and physical exercise interventions alone in favor of the treatment groups. No effects in studies with combined interventions were observed. Future full-scaled RCTs combining nutrition and physical exercise is warranted.

Feasibility and Effects of a Supervised Exercise Program Suitable for Independent Training at Home on Physical Function and Quality of Life in Head and Neck Cancer Patients: A Pilot Study

Introduction: Head and neck cancer patients often suffer from physical and cognitive impairments after cancer treatment. During rehabilitation, exercise therapy can improve physical function and quality of life (QoL). Surveys demonstrated patients' preference for home training with low- to moderate-intensity. This study was conducted in order to develope a suitable home-based training program. Therefore, the feasibility and effects of a low- to moderate-intensity exercise intervention on physical functions and QoL were evaluated. Methods: Training was conducted as supervised group training and consisted of mobilization, coordination, resistance, stretching, and relaxation exercises. The intervention lasted 12 weeks with 2 training sessions per week. Feasibility, attendance rate, physical function (eg, range of motion, 6-minute walk test [6MWT]), and QoL (eg, EORTC QLQ-30) were analyzed. Results: Ten out of 12 participants completed the intervention (83%) with an average attendance rate of 83%. Participants showed significant improvements in selected physical functions. For example, head rotation increased by 11.2° (P = .042), walking distance in the 6MWT increased by an average of 43.3 m (P = .010), and the global QoL scale improved by 8.2 points (P = .059). Additionally, there were positive changes in the physical function scale (P = .008), cognitive function scale (P = .015), and social function scale (P = .031) of the EORTC QLQ-30. Conclusion: Data indicate that the exercise program was feasible and had positive effects on physical function and QoL. Future research will analyze the effects of a home-based exercise program on physical function and QoL in a large-scale study.

Physical rehabilitation in patients with head and neck cancer: Impact on health-related quality of life and suitability of a post-treatment program

OBJECTIVE

Physical rehabilitation programs hold the potential to mitigate deterioration in health-related quality of life (HRQoL) in patients with head and neck cancer. The objective was to assess development in relevant domains of HRQoL following a physical exercise and nutrition intervention administrated during or after treatment.

METHODS

In a pilot study, 41 patients were randomized to resistance training and oral nutritional supplements during (EN-DUR, n = 20) or after (EN-AF, n = 21) radiotherapy. Global health status/QoL (GHS) and physical functioning (PF) were measured by the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire at baseline, week 6, and week 14. Differences between the groups were assessed by analysis of covariance. A difference of ≥10 points in GHS and PF was interpreted as clinically relevant.

RESULTS

No statistically significant differences were detected between the groups; however, clinically relevant changes and differences in GHS and PF were observed. From baseline to week 6, GHS decreased 9 points in the EN-DUR group and 23 points in the EN-AF group and PF decreased 13 points and 21 points, respectively. From week 6 to week 14, GHS increased 14 points in the EN-DUR group and 26 points EN-AF group and PF did not change (0 points) in the EN-DUR group and increased 16 points in the EN-AF group.

CONCLUSION

The findings from the present pilot study are promising and indicate that a physical rehabilitation program may have a positive impact on HRQoL during treatment and enhance recovery after treatment. A definitive randomized trial is warranted.

LEVEL OF EVIDENCE

1b-Individual randomized controlled trial.

A randomized clinical trial on the efficacy of a patient-adapted autonomous exercise regime for patients with head and neck cancer

Patients undergoing surgical therapy of head and neck malignancies are known to exhibit a high number of comorbidities and frequently present a high nosocomial morbidity. Physiotherapy (PT) improves the clinical course of patients after extensive surgery. The aim of this study was to establish and then compare an additional individualized autonomous exercise plan with standard physiotherapy. 69 consecutive patients undergoing surgical treatment of head and neck cancer were randomized into two groups. The control group received standard clinical physiotherapy, the intervention group an additional autonomous exercise plan, adapted to the patient's performance profile. The patients randomized to the intervention group showed significantly fewer signs of fatigue (5.5 ± 3.5 vs. 3.7 ± 2.7, p = 0.048) and fewer digestive problems (4.7 ± 3.3 vs. 2.3 ± 2.7; p = 0.009) compared with the patients of the control group. In addition, a significantly shorter hospital stay was observed (17.7 ± 6.3 vs. 13.4 ± 3.4 days, p = 0.005), which was positively influenced by the early start of the exercises (r = 0.623, p = 0.001) and frequent practice (r = 0.432, p = 0.031). Patients with head and neck cancer therapy can benefit from an autonomous, individualized exercise plan. In coordination with the physiotherapists, mobilization should be as early and intensive as possible.

Physical activity and laryngeal cancer

Although an active lifestyle physical has been convincingly associated with a decreased risk of developing many forms of cancers, including neck and head malignancies, uncertainty surrounds the relationship between physical activity (PA) and laryngeal carcinogenesis. Epidemiologic evidence, garnered from some well-conducted cross-sectional, prospective and retrospective studies, seemingly attests that the impact of PA may be not so straightforward in lowering laryngeal cancer risk as for other malignancies. Reasonable consensus has been reached that moderate-intensity PA may generate the larger potential benefits, whilst the effect of high-intensity PA appears more controversial and even contradictory. This is mainly attributable to the fact that moderate PA may have more favorable effects than high-intensity exercise in decreasing the impact of some risk factors of laryngeal cancer such as metabolic syndrome, cigarette smoking, inflammation, and gastroesophageal reflux disease. Significant biological and psychological benefits from moderate-intensity exercise have also been described in patients surviving from primary laryngeal cancers. This would hence lead us to conclude that promotion of an active lifestyle, characterized by performance of moderate-intensity PA (e.g., between 3 and 6 metabolic equivalents, equaling short distance running), may be beneficial for lowering the risk of developing laryngeal cancer and for improving the quality of life of larynx cancer survivors.

Body Composition Evaluation in Head and Neck Cancer Patients: A Review

Introduction: Head and neck cancer (HNC) patients show a high risk of malnutrition due to the lifestyle habits adopted prior to the diagnosis as well as to the compromising impact of both the anatomical location of the tumor and the treatment modalities on food intake. Weight change, measurement of skinfold thickness, biochemical parameters, bioelectrical impedance analysis (BIA), computed tomography (CT), magnetic resonance (MRI), or dual-energy x-ray absorptiometry (DXA) are available techniques to evaluate nutritional status and/or body composition in the clinical practice. Evaluating body composition alterations in HNC patients is essential to be able to offer the best therapeutical interventions. In this paper, we review the existing literature regarding body composition evaluation in HNC patients to determine, which is the most suitable method for this population, regarding availability in the day-to-day practice, patient burden, cost, sensibility, and specificity.

Methodology: A literature search for relevant papers indexed in MEDLINE, Cochrane Library and Scielo was conducted, with no publication date restriction and for all published articles until the 31 January, 2019. All the papers written in English, with interventions in humans, exclusively considering HNC patients were selected.

Results: A total of 41 studies with different methodologies were included in this review. In 15 studies BIA was the used assessment method and three of them also evaluated skinfold thickness and one was a bioelectric impedance vector analysis (BIVA). Body composition assessment was made with DXA in eight studies, one of which also included muscle biopsies. In two studies the chosen method was both BIA and DXA. CT/ positron emission tomography-CT was applied in 11 studies and one also included MRI. In two studies body composition was assessed with skinfold measurements alone and one study only used BIVA.

Conclusions: Despite the different existing body composition assessment tools, it seems that skeletal muscle mass (SMM) measurement at the level of cervical spine C3 vertebra may be a reliable method for SMM assessment as it strongly correlates with cross-sectional area measures at the level of L3 and it allows a cost-effective body composition assessment without the need for additional radiation exposure.

Therapeutic effects of aerobic and resistance exercises for cancer survivors: a systematic review of meta-analyses of clinical trials

OBJECTIVE

To systematically appraise and summarise meta-analyses investigating the effect of exercise compared with a control condition on health outcomes in cancer survivors.

DESIGN

Umbrella review of intervention systematic reviews.

DATA SOURCES

Web of Science, Scopus, Cochrane Library, CINAHL and MEDLINE databases were searched using a predefined search strategy.

ELIGIBILITY CRITERIA

Eligible meta-analyses compared health outcomes between cancer survivors participating in an exercise intervention and a control condition. Health outcomes were cardiovascular fitness, muscle strength, health-related quality of life, cancer-related fatigue and depression. Pooled effect estimates from each meta-analysis were quantified using standardised mean differences and considered trivial (<0.20), small (0.20-0.49), moderate (0.50-0.79) and large (≥0.80). Findings were summarised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

There were 65 eligible articles that reported a total of 140 independent meta-analyses. 139/140 meta-analyses suggested a beneficial effect of exercise. The beneficial effect was statistically significant in 104 (75%) meta-analyses. Most effect sizes were moderate for cardiovascular fitness and muscle strength and small for cancer-related fatigue, health-related quality of life and depression. The quality of evidence was variable according to the GRADE scale, with most studies rated low or moderate quality. Median incidence of exercise-related adverse events was 3.5%.

CONCLUSION

Exercise likely has an important role in helping to manage physical function, mental health, general well-being and quality of life in people undergoing and recovering from cancer and side effects of treatment.

PROSPERO REGISTRATION NUMBER

CRD42015020194.