Effects of exercise interventions on quality of life in patients with breast cancer: A systematic review and network meta-analysis

OBJECTIVE

To compare and rank the effectiveness of four primary categories of exercise modalities (aerobic, resistance, mind-body, and combined exercise [CE]) in improving the Quality of life (QoL) of women with breast cancer in a network meta-analysis (NMA).

METHODS

Articles published in English and indexed in the PubMed (MEDLINE), EBSCO, Web of Science, SPORTDiscus, The Cochrane Library, Google Scholar, PsycINFO, EMBASE, and CINAHL Plus databases were identified from inception to 12 October 2023. Studies that met the eligibility criteria were assessed for risk of bias. A frequentist NMA was conducted to appraise the efficacy of different exercise types.

RESULTS

This study included 56 studies with 3904 participants. Aerobic, mind-body, and combined exercises effectively improved QoL compared to controls. The surface under the cumulative ranking curve (SUCRA) indicated that CE best improved patients' QoL (SUCRA = 96.7%). Analysis of the secondary outcomes suggests that exercise reduced patients' depression (standardized mean difference [SMD] = -0.38, 95% confidence interval [CI] = -0.70 to -0.06, p < 0.001; I2 = 79%) and anxiety (SMD = -0.50, 95% CI = -0.69 to -0.31, p < 0.001; I2 = 27.4%) but did not affect self-esteem.

CONCLUSION

All exercise types but resistance were effective in improving the QoL of women with breast cancer, CE (the combination of aerobic and resistance exercise) had the highest likelihood of being optimal for improving QoL.

The efficacy of exercise training for improving body composition in patients with breast cancer: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the efficacy of exercise in improving body composition in patients with breast cancer; the effects of exercise on weight and BMI were evaluated as secondary outcomes.

DATA SOURCES

Cochrane Library, EMBASE, PubMed and Web of Science were searched for randomized controlled trials published in English from database inception to 29 November 2023.

METHODS

The effects of exercise on body composition in patients with breast cancer were explored. After separately extracting the data, two reviewers assessed the overall quality of the evidence as well as the methodological quality of the included studies.

RESULTS

Fourteen studies with 1241 participants were included, of which 12 studies were eligible for meta-analysis. Exercise significantly reduced body fat (mean difference [MD], -0.33; 95% CI, -0.37 to -0.29; P < 0.00001) and increased lean mass (MD, 0.42; 95% CI, 0.34 to 0.49; P < 0.00001) in patients with breast cancer. Further, exercise intervention was associated with increased BMI of patients with breast cancer (MD, 0.03; 95% CI, 0.01 to 0.06; P = 0.01), while no significant difference in weight was detected between the exercise and the non-exercise groups. Subgroup analysis results showed that only resistance exercise reduced fat mass (MD, -0.22; 95% CI, -0.27 to -0.16; P < 0.00001).

CONCLUSIONS

Exercise effectively improves body composition in patients with breast cancer. Clinicians should encourage patients to engage in exercise and develop optimized exercise prescriptions.

Effect of a Long-Term Online Home-Based Supervised Exercise Program on Physical Fitness and Adherence in Breast Cancer Patients: A Randomized Clinical Trial

The purpose of the present study was to analyze the effect of a synchronous-supervised online home-based exercise program (HBG) during 24 weeks on body composition, physical fitness and adherence compared to an exercise recommendation group (ERG) without supervision with patients undergoing breast cancer treatment. Fifty-nine female breast cancer patients (31 in HBG and 28 in the ERG) undergoing cancer treatments participated in the present randomized clinical trial. The exercise program consisted of a 60 min combined resistance and aerobic supervised exercise session (6-8 points on Borg Scale CR-10, moderate intensity), twice a week during 24 weeks. The exercise recommendation group only received general recommendations to comply with the current ACSM guidelines. Body composition and physical fitness were assessed at baseline, 12 weeks and 24 weeks of the program. Adherence to the intervention was measured according to the minutes of exercise completed per session during each week. A general linear model of two-way repeated measures showed significant improvements (p < 0.05) in physical fitness that were observed in the home-based exercise group at the baseline, 12-week and 24-week assessments compared to the exercise recommendation group. Adherence was also higher in the home-based exercise group. However, no changes (p > 0.05) in body composition between groups and moments were observed. In this sense, supervised home-based exercise interventions can be an interesting strategy to improve physical fitness and adherence rates in breast cancer patients undergoing treatment.

A Comprehensive Review of Cancer Drug-Induced Cardiotoxicity in Blood Cancer Patients: Current Perspectives and Therapeutic Strategies

OPINION STATEMENT

Cardiotoxicity has emerged as a serious outcome catalyzed by various therapeutic targets in the field of cancer treatment, which includes chemotherapy, radiation, and targeted therapies. The growing significance of cancer drug-induced cardiotoxicity (CDIC) and radiation-induced cardiotoxicity (CRIC) necessitates immediate attention. This article intricately unveils how cancer treatments cause cardiotoxicity, which is exacerbated by patient-specific risks. In particular, drugs like anthracyclines, alkylating agents, and tyrosine kinase inhibitors pose a risk, along with factors such as hypertension and diabetes. Mechanistic insights into oxidative stress and topoisomerase-II-B inhibition are crucial, while cardiac biomarkers show early damage. Timely intervention and prompt treatment, especially with specific agents like dexrazoxane and beta-blockers, are pivotal in the proactive management of CDIC.

Prehabilitation for Patients with Cancer Undergoing Radiation Therapy: a Scoping Review

AIMS

Prehabilitation is a process of identifying and assessing factors that could compromise the physical and psychological health of patients undergoing cancer treatment and implementing an intervention to combat such concerns. The use of prehabilitation in cancer surgery has yielded positive outcomes in rectal, lung and abdominal cancers. Prehabilitation strategies have potential to improve the management of patients receiving radiation therapy or chemoradiation. The aim of the present study was to map the evidence of the assessment and evaluation of prehabilitation for radiation therapy patients.

MATERIALS AND METHODS

A database search using EMBASE and PubMed was conducted. The PRISMA guidelines were adhered to. Keywords included prehabilitation, radiation therapy/radiotherapy, chemoradiotherapy/chemoradiation, intervention and exercise. Types of prehabilitation strategy, their purposes and impact, according to cancer site, were analysed.

RESULTS

Prehabilitation is most commonly evaluated in head and neck cancer, whereby unimodal, physical interventions manage dysphagia. Prehabilitation for lung cancer demonstrated its ability to widen treatment options for patients. Physical prehabilitation is administered to combat adverse effects of neoadjuvant chemoradiation therapy in patients with rectal cancer.

CONCLUSION

Prehabilitation is adaptive and tailored to specific patient and site needs; thus it is applied across a wide range of cancer sites. More interventions by which radiation therapy is the definitive treatment modality and larger sample sizes within these studies are warranted to increase prehabilitation utilisation for patients undergoing radiation therapy.

Comparing the effects of various β-blockers on cardiovascular mortality in breast cancer patients

BACKGROUND

Cardiovascular (CV) disease is a leading cause of death in breast cancer (BC) patients due to the increased age and treatments. While individual β-blockers have been investigated to manage CV complications, various β-blockers have not been compared for their effects on CV death in this population. We aimed to compare CV mortality in older BC patients taking one of the commonly used β-blockers.

METHODS

This retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results (SEER) - Medicare data (2010-2015). Patients of age 66 years or older at BC diagnosis receiving metoprolol, atenolol, or carvedilol monotherapy were included. The competing risk regression model was used to determine the risk of CV mortality in the three β-blocker groups. The multivariable model was adjusted for demographic and clinical covariates. The adjusted hazard ratio (HR) and 95% confidence intervals (CI) were reported for the risk of CV mortality.

RESULTS

The study cohort included 6,540 patients of which 55% were metoprolol users, 30% were atenolol users, and 15% were carvedilol users. Metoprolol was associated with a 37% reduced risk of CV mortality (P = 0.03) compared to carvedilol after adjusting for the covariates (HR = 0.63; 95% CI 0.41-0.96). No significant difference in the risk of CV mortality between atenolol and carvedilol users was observed (HR = 0.74; 95% CI 0.44-1.22).

CONCLUSIONS

Our findings suggest that metoprolol is associated with a reduced risk of CV mortality in BC patients. Future studies are needed to confirm these findings and understand the mechanism of action.

Racial disparities in treatment-related cardiovascular toxicities amongst women with breast cancer: a scoping review

PURPOSE

Black women often experience poorer breast cancer-related outcomes and higher mortality than white women. A contributor to this disparity may relate to the disproportionate burden of cancer treatment-related cardiovascular (CV) toxicities. The objective of this review is to identify studies that report racial differences in CV toxicity risk.

METHODS

Medline and Embase were searched for studies that assessed CV toxicities as the outcome(s) and included Black and White women with breast cancer. Studies were selected based on inclusion/exclusion criteria and through the use of multiple reviewers.

RESULTS

The review included 13 studies following a review of 409 citations and 49 full-text articles. All studies were retrospective and 8/13 utilized data from the Surveillance, Epidemiology, and End Results-Medicare linked database. Trastuzumab was the most frequently studied treatment. The proportion of Black women in these studies ranged from 5.5 to 63%. A majority of studies reported a higher risk of CV toxicity amongst Black women when compared to white women (93%). Black women had up to a two times higher risk of CV toxicity (HR, 2.73 (CI, 1.24 to 6.01)) compared to white women. Only one study evaluated the role of socioeconomic factors in explaining racial differences in CV toxicity; however, the disparity remained even after adjusting for these factors.

CONCLUSIONS

There is a critical need for more longitudinal studies that evaluate multilevel factors (e.g., psychosocial, biological) that may help to explain this disparity.

IMPLICATIONS FOR CANCER SURVIVORS

Black cancer survivors may require additional surveillance and mitigation strategies to decrease disproportionate burden of CV toxicities.

The "home-based exercise for breast and prostate cancer patients during treatment-a feasibility trial" (BENEFIT CA trial): rationale and methodological protocol

BACKGROUND

Physical activity has been shown to benefit patients undergoing adjuvant cancer therapy. Although exercise interventions may be applied in several settings, most trials have focused on specialized facilities for their interventions. While these approaches benefit the access for individuals living near exercise centers, it hampers the assessment of real-world effectiveness. Therefore, evaluating the feasibility and implementation of home-based models of exercise training, especially in low-to-middle-income settings, may inform future physical activity trials and programs. In this article, we present the protocol for the BENEFIT CA trial, which aims to assess the implementation of a remote exercise intervention for patients with breast cancer or prostate cancer, primarily quantifying adherence to an exercise program.

METHODS

This is a 12-week study, utilizing a non-randomized, single-arm design to assess the feasibility of a home-based exercise training. The intervention is remotely guided, and participants also receive an educational component about cancer and exercise. The study aims to recruit 40 patients diagnosed with breast cancer and 40 patients diagnosed with prostate cancer, all of whom undergoing active hormonal treatment. The primary outcome is the level of adherence, indicated as the proportion of performed exercise episodes. Secondary outcomes include recruitment rates, fatigue, quality of life, and functional capacity. Adverse events will be monitored throughout the study. Because this is a feasibility trial, the statistical analysis plan is based on descriptive statistics, which encompasses an intention-to-treat analysis and a plan for handling missing data.

DISCUSSION

This is a low-cost feasibility study to orient the design of a wide-range, pragmatic phase 3 trial based on remote exercise intervention. With this study, we aim to better understand the adherence and implementation strategies regarding home-based exercise for the proposed population and, in the near future, move forward to a randomized clinical trial. In addition, this trial may contribute to engage patients with cancer in exercise programs throughout their treatment and beyond.

TRIAL REGISTRATION

This trial has been approved by the Hospital de Clínicas de Porto Alegre Ethics Committee/IRB (48,869,621.9.0000.5327), and it is registered at Clinicaltrials.gov (NCT05258526), registered on February 25, 2022, prior to the beginning of the study.

Nonlinear, Multicomponent Physical Exercise With Heart Rate Variability-Guided Prescription in Women With Breast Cancer During Treatment: Feasibility and Preliminary Results (ATOPE Study)

OBJECTIVE

The purpose of this study was to examine the feasibility, safety, adherence, and preliminary efficacy of the ATOPE program during radiotherapy (RT) or chemotherapy (CT) for women with breast cancer.

METHODS

This single-blind, pretest-posttest feasibility study included 38 women with breast cancer at the beginning of their treatment. The ATOPE program consisted of 12 to 18 sessions of a multimodal physical exercise program, prescribed based on daily heart rate variability and clinimetric assessments using the ATOPE+ mHealth system. Overall health was assessed with quality of life, autonomous balance, and body composition, whereas health-related fitness was measured through functional capacity, physical activity levels, and upper and lower limb strength.

RESULTS

The rates of recruitment, retention, and adherence were 52.35, 73.68, and 84.37%, respectively, and the satisfaction rating was 9.2 out of a possible 10 points. The perceived health status change score was 3.83 points, scored on a -5 to 5 point scale. No adverse effects were found. Compliance results showed that the ATOPE+ mHealth system was used on 73.38% of the days, and the Fitbit bracelet (Google, Mountain View, CA, USA) was used on 84.91% of the days. Women stayed physically active 55% of days. Regarding preliminary results, for overall health, the percentage of body fat in the RT group decreased by 1.93%, whereas it increased by 5.03% in the CT group. Lower limb strength increased in the RT group, specifically knee extensor isometric strength (6.07%), isokinetic knee flexors 180 degree/second (1.53%), and isokinetic knee extensors 300 degree/second (4.53%), in contrast with the reductions found in the CT group (11.07, 18.67, and 14.89%, respectively).

CONCLUSION

The ATOPE program, through nonlinear prescription based on daily monitoring with the ATOPE+ mHealth system, is feasible and safe for application during breast cancer treatment. The results suggest that the overall health can be maintained or even improved regarding most variables.

IMPACT

This study focused on the feasibility, safety, and completion of a physical therapist-led program at early diagnosis for adults with breast cancer. The multimodal, supervised, tailored, nonlinear physical exercise program is feasible and safe, showed a good completion rate, and was able to prevent the quality-of-life deficits that are often triggered by systemic breast cancer treatment. This study highlights the importance of daily morning assessments using the ATOPE+ mHealth system in patients with breast cancer to prescribe nonlinear physical exercise.

The impact of a meditative movement practice intervention on short- and long-term changes in physical activity among breast cancer survivors

PURPOSE

Tai Chi Easy (TCE) is a low-impact, meditative movement practice that is feasible for breast cancer survivors, even in the face of post-treatment symptoms, and may even serve as a gateway into developing an active lifestyle and improving overall physical activity (PA). In the context of a randomized controlled trial testing effects of an 8-week TCE intervention on breast cancer survivors' symptoms, we examined the short- (8-week) and long-term (9-month) impact on total PA compared to an educational control group.

METHODS

Participants were recruited from two hospital systems, local community organizations, and different media platforms. Eligible participants were predominant non-Hispanic White (82%), college educated (92%), and middle- to high-income (65%), and most commonly reported stage 1 (40%) or 2 breast cancer (38%). After baseline assessments, participants were randomized to the 8-week TCE intervention (N=51) or education control (N=53). Weekly intervention TCE classes were led by a trained instructor. Weekly educational control classes focused on a series of readings and group discussions. Total PA and steps were objectively measured via accelerometry, and the international physical activity questionnaire was used to measure self-reported total PA.

RESULTS

Multilevel mixed-effects linear regression models revealed no significant short- or long-term changes in objectively measured total PA or steps in either group; however, participants in the intervention reported short- and long-term changes in self-reported total PA.

CONCLUSIONS

TCE is an appropriate PA strategy for survivors that may lead to modest improvements in PA; however, more research is needed to examine the long-term impact on PA as well as other physical and psychological outcomes (i.e., flexibility, mobility, stress).

IMPLICATIONS FOR CANCER SURVIVORS

Low-impact, low-intensity activities like meditative movement practices are needed to assist survivors in overcoming post-treatment physical and psychological limitations to initiate a more active lifestyle.

High-intensity exercise prescription guided by heart rate variability in breast cancer patients: a study protocol for a randomized controlled trial

BACKGROUND

Breast cancer is a chronic disease with a large growth in its treatments, prognosis, improvements, side effects and rehabilitation therapies research. These advances have also highlighted the need to use physical exercise as a countermeasure to reduce the cardiotoxicity of pharmacological treatments, increase patients' strength and quality of life and improve body composition, physical condition and mental health. However, new investigations show the need for a closed exercise individualisation to produce higher physiological, physical and psychological benefits in remote exercise programs. To this end, the present study will use, in a novel way in this population, heart rate variability (HRV) as a measure for prescribing high-intensity training. Thus, the primary objective of this randomised clinical trial is to analyse the effects of a high-intensity exercise program daily guided by HRV, a preplanned moderate to high-intensity exercise intervention and a usual care group, in breast cancer patients after chemotherapy and radiotherapy treatments.

METHODS

For this purpose, a 16-week intervention will be carried out with 90 breast cancer patients distributed in 3 groups (a control group, a moderate to high-intensity preplanned exercise group and a high-intensity exercise group guided by HRV). Both physical exercise interventions will be developed remotely and supervised including strength and cardiovascular exercises. Physiological variables, such as cardiotoxicity, biomarkers, lipid profile, glucose, heart rate and blood pressure; physical measures like cardiorespiratory capacity, strength, flexibility, agility, balance and body composition; and psychosocial variables, as health-related quality of life, fatigue, functionality, self-esteem, movement fear, physical exercise level, anxiety and depression will be measure before, after the intervention and 3 and 6 months follow up.

DISCUSSION

Personalized high-intensity exercise could be a promising exercise intervention in contrast to moderate-intensity or usual care in breast cancer patients to reach higher clinical, physical and mental effects. In addition, the novelty of controlling HRV measures daily may reflect exercise effects and patients' adaptation in the preplanned exercise group and a new opportunity to adjust intensity. Moreover, findings may support the effectiveness and security of physical exercise remotely supervised, although with high-intensity exercise, to reach cardiotoxicity improvements and increase physical and psychosocial variables after breast cancer treatments. Trial registration ClinicalTrials.gov nº NCT05040867 ( https://clinicaltrials.gov/ct2/show/record/NCT05040867 ).

Exercise interventions used along the continuum of cancer care: A scoping review protocol

Background

Cancer is one of the leading causes of death worldwide. Exercise is crucial for ameliorating the burden associated with cancer and its management. A broad review of exercise interventions for cancer patients is not available.

Objective

Our study aims to review the documented exercise interventions prescribed for adult cancer patients aimed at ameliorating cancer-related and cancer treatment-induced symptoms in patients along the continuum of care.

Methods

A three-step search strategy will be used, the research question was developed; the first step in the research process was identified and the search strategy was developed using the Participants-Concept-Context framework. English language publications from 15 electronic databases from 2011 to 2021 will be searched. The Joanna Briggs Institute methodology for scoping reviews will be to guide the review and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews will be used for the report. The search strategy incorporated terms relevant to the research question. The reference lists of articles included in the review will be screened for additional papers. Searched articles will be screened to determine their eligibility for inclusion and a pretested data extraction form will be used to chart the extracted evidence.

Results

This article presents a protocol for a scoping review on exercise interventions to affect symptoms in cancer patients from diagnosis to end-of-life care.

Conclusion

A broad review of exercise interventions for cancer management in adult patients will elucidate the characteristics and context of exercises used along the cancer care continuum.

Clinical implications

Exercise interventions used as part of cancer management will be mapped out to provide an overview of such exercise interventions. This could enhance knowledge among exercise oncology experts regarding exercise interventions for different cancer patient populations.

Cardiotoxicity is mitigated after a supervised exercise program in HER2-positive breast cancer undergoing adjuvant trastuzumab

Background

Trastuzumab is used, alone or in conjunction with standard chemotherapy, to treat HER2-positive breast cancer (BC). Although it improves cancer outcomes, trastuzumab. can lead to cardiotoxicity. Physical exercise is a safe and effective supportive therapy in the management of side effects, but the cardioprotective effects of exercise are still unclear.

Objectives

The primary aim of this study was to test whether trastuzumab-induced cardiotoxicity [left ventricular ejection fraction (LVEF) under 50%, or an absolute drop in LVEF of 10%] was reduced after a supervised exercise program of 3 months in patients with HER2-positive breast cancer. Secondary endpoints were to evaluate (i) cardiotoxicity rates using other criteria, (ii) cardiac parameters, (iii) cardiorespiratory fitness and (iv) whether a change in LVEF influences the cardiorespiratory fitness.

Methods

89 women were randomized to receive adjuvant trastuzumab in combination with a training program (training group: TG; n = 46) or trastuzumab alone (control group: CG; n = 43). The primary and secondary endpoints were evaluated at the end of the supervised exercise program of 3 months (T3).

Results

After exercise program, 90.5 % of TG patients and 81.8% of CG patients did not exhibit cardiotoxicity. Furthermore, whatever the used criterion, percentage of patients without cardiotoxicity were greater in TG (97.6 and 100% respectively) than in CG (90.9 and 93.9% respectively). LVEF and GLS values remained stable in both groups without any difference between the groups. In contrast, at T3, peak VO2 (+2.6 mL.min−1.kg−1; 95%CI, 1.8 to 3.4) and maximal power (+21.3 W; 95%CI, 17.3 to 25.3) increased significantly in TG, whereas they were unchanged in CG (peak VO2: +0.2 mL.min−1.kg−1; 95%CI, −0.5 to 0.9 and maximal power: +0.7 W, 95%CI, −3.6 to 5.1) compared to values measured at T0. No correlation between LVEF changes and peak VO2 or maximal power was observed.

Conclusion

A 12-week supervised exercise regimen was safe and improved the cardiopulmonary fitness in particular peak VO2, in HER2-positive BC patients treated with adjuvant trastuzumab therapy. The study is under powered to come to any conclusion regarding the effect on cardiotoxicity.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT02433067.

Adapted Physical Activity for Breast Cancer Patients Treated with Neoadjuvant Chemotherapy and Trastuzumab Against HER2 (APACAN2): A Protocol for a Feasibility Study

Background

The standard care for HER2-positive breast cancer is chemotherapy plus a HER2-directed therapy. This can lead to treatment-induced cardiotoxicity. On the other hand, the practice of physical activity is known to improve cardiac function; thus HER2-positive breast cancer patients could draw particular benefit from physical activity during treatment. However, at the time of diagnosis for breast cancer, the majority of patients are insufficiently active according to physical activity recommendations of World Health Organisation, and it is difficult to remain or become active during the treatment. There is a lack of data in the literature on the optimal program to propose to patients to encourage them to be active during treatment. The aim of our study is to assess the feasibility of a home-based physical activity program during neoadjuvant chemotherapy and trastuzumab for HER2-positive breast cancer.

Methods

The APACAN2 study is a single-centre, non-randomized interventional trial. Patients with HER2-positive breast cancer treated with anthracycline-based neoadjuvant chemotherapy and trastuzumab are eligible for enrolment. The supervised home-based physical activity program takes place during neoadjuvant chemotherapy (NACT). It combines aerobic and strengthening exercises. The primary endpoint is the proportion of patients reaching the international physical activity recommendations, i.e. 150 minutes of moderate-intensity activity per week at the end of NACT. The study started in April 2018 and seventy patients are expected to be recruited.

Discussion

In the literature, the majority of studies on practice of physical activity in breast cancer focus on adjuvant chemotherapy or on the period after the end of treatment. To the best of our knowledge, the APACAN2 study is the first to evaluate a home-based physical activity program during neoadjuvant chemotherapy for HER2-positive breast cancer.

Trial Registration Number

Clinicaltrials.gov: NCT02963363, registered on July 11, 2016. Identifier with the French National Agency for the Safety of Medicines and Health Products N°ID RCB 2016-A01344-47, registered in August 2016. Protocol: version 8, 24 February 2021.

Traditional Chinese Medicine for adjuvant treatment of breast cancer: Taohong Siwu Decoction

The high incidence of breast cancer is the greastest threat to women' health all over the world. Among them, HER-2 positive breast cancer has the characteristics of high malignancy, easy recurrence and metastasis, and poor prognosis. Traditional Chinese medicine (TCM) has a rich theoretical basis and clinical application for breast cancer. TCM believes that blood stasis syndrome is one of the important pathogenesis of breast formation and development. Taohong Siwu Decoction (TSHWD) is based on the "First Prescription of Gynecology" Siwu Decoction. It is widely used in various blood stasis and blood deficiency syndromes, mainly in gynecological blood stasis. Clinical studies have found that THSWD can treat breast cancer by reducing blood vessel and lymphangiogenesis with auxiliary chemotherapy. In this study, we aim to explore the material basis and mechanism of THSWD in the treatment of HER-2 positive breast cancer through literature review and network pharmacology studies. Through a literature review of the traditional application, chemical composition of Chinese herbal medicine of THSWD, as well as its clinical reports and pharmacological research on breast cancer treatment. Meanwhile, we conducted "component-pathway-target" network through network pharmacology reveals the main material basis, possible targets and pathways of THSWD in inhibiting HER-2 positive breast cancer. Literature review and network pharmacology research results had predicted that, baicalein, kaempferol, caffeic acid, amygdalin, quercetin, ferulic acid, gallic acid, catalpol, hydroxysafflor yellow A, paeoniflorin in THSWD are the main effective chemical composition. THSWD regulates 386 protein targets and 166 pathways related to breast cancer. The molecular mechanism is mainly to improve the microenvironment of tumor cells, regulate the process of tumor cell EMT, and inhibit tumor cell proliferation and metastasis. This study revealed the mechanism of action of THSWD in the treatment of HER-2 positive breast cancer through literature review and network pharmacology studies, providing a scientific basis for clinical application.

An update of the molecular mechanisms underlying doxorubicin plus trastuzumab induced cardiotoxicity

Cardiotoxicity is a major side effect of the chemotherapeutic drug doxorubicin (Dox), which is further exacerbated when it is combined with trastuzumab, a standard care approach for Human Epidermal growth factor Receptor-type 2 (HER2) positive cancer patients. However, the molecular mechanisms of the underlying cardiotoxicity of this combination are still mostly elusive. Increased oxidative stress, impaired energetic substrate uses and topoisomerase IIB inhibition are among the biological processes proposed to explain Dox-induced cardiomyocyte dysfunction. Since cardiomyocytes express HER2, trastuzumab can also damage these cells by interfering with neuroregulin-1 signaling and mitogen-activated protein kinase (MAPK), phosphoinositide 3-kinase (PI3K)/Akt and focal adhesion kinase (FAK)-dependent pathways. Nevertheless, Dox and trastuzumab target other cardiac cell types, such as endothelial cells, fibroblasts, cardiac progenitor cells and leukocytes, which can contribute to the clinical cardiotoxicity observed. This review aims to summarize the current knowledge on the cardiac signaling pathways modulated by these two antineoplastic drugs highly used in the management of breast cancer, not only focusing on cardiomyocytes but also to broaden the knowledge of the potential impact on other cells found in the heart.

Effectiveness of physical exercise on the cardiovascular system in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The primary purpose of this study is to structure the available evidence relating to physical exercise programs and their impact on patients' cardiovascular system during the convalescence for breast cancer.

METHODS

We searched six English databases and four Chinese databases from inception to May 19, 2021. Two reviewers independently screened literature, extracted data. They assessed the risk of bias according to the eligibility criteria, and the Cochrane Collaboration RevMan 5.3.0 version software and STATA 15.0 software were used for this meta-analysis. This study has been registered in the International Prospective Register of Systematic Reviews (CRD42021226319).

RESULTS

In total, 3483 articles were screened and data from 11 randomized controlled trials (RCTs) involving 666 breast cancer patients were used in this meta-analysis. The results showed that exercise could decrease systolic blood pressure (SBP) (P = 0.006), diastolic blood pressure (DBP) (P = 0.0003), triglycerides (TG) levels (P < 0.00001), body mass index (BMI) (P = 0.009). Results also showed that exercise could significantly increase peak oxygen uptake (VO2peak) (P = 0.009), maximal oxygen consumption (VO2max) (P = 0.01), and High-density leptin cholesterol (HDL-C) levels (P < 0.0001). However, compared with the control group, there was no significant changes of mean arterial pressure (MAP), peak heart rate (HRpeak), and peak respiratory exchange ratio (PERpeak) (P > 0.05).

CONCLUSIONS

Physical exercise could improve the cardiovascular system function associated with decreased the levels of SBP, DBP, TG, and increased the levels of VO2peak, VO2max, and HDL-C in breast cancer patients. These findings reveal that exercise may be a promising means for cardiovascular nursing.

A randomized trial to evaluate the impact of exercise-based cardiac rehabilitation for the prevention of chemotherapy-induced cardiotoxicity in patients with breast cancer: ONCORE study protocol

Background

Anthracyclines and monoclonal antibodies against human epidermal growth factor receptor-2 (HER2) are frequently used to treat breast cancer but they are associated with risk of developing cardiotoxicity. Implementation of cardioprotective strategies as part of breast cancer treatment are needed. To date, a limited number of studies have examined the effectiveness of cardiac rehabilitation programs or exercise programs in the prevention of cardiotoxicity through an integral assessment of cardiac function. The ONCORE study proposes an exercise-based cardiac rehabilitation program as a non-pharmacological tool for the management of chemotherapy-induced cardiotoxicity.

Methods

The study protocol describes a prospective, randomized controlled trial aimed to determine whether an intervention through an exercise-based CR program can effectively prevent cardiotoxicity induced by anthracyclines and/or anti-HER2 antibodies in women with breast cancer. Three hundred and forty women with breast cancer at early stages scheduled to receive cardiotoxic chemotherapy will be randomly assigned (1:1) to participation in an exercise-based CR program (intervention group) or to usual care and physical activity recommendation (control group). Primary outcomes include changes in left ventricular ejection fraction and global longitudinal strain as markers of cardiac dysfunction assessed by transthoracic echocardiography. Secondary outcomes comprise levels of cardiovascular biomarkers and cardiopulmonary function through peak oxygen uptake determination, physical performance and psychosocial status. Supervised exercise program-related outcomes including safety, adherence/compliance, expectations and physical exercise in- and out-of-hospital are studied as exploratory outcomes. Transthoracic echocardiography, clinical test and questionnaires will be performed at the beginning and two weeks after completion of chemotherapy.

Discussion

The growing incidence of breast cancer and the risk of cardiotoxicity derived from cancer treatments demand adjuvant cardioprotective strategies. The proposed study may determine if an exercise-based CR program is effective in minimizing chemotherapy-induced cardiotoxicity in this population of women with early-stage breast cancer. The proposed research question is concrete, with relevant clinical implications, transferable to clinical practice and achievable with low risk.

Trial registration ClinicalTrials.gov Identifier: NCT03964142. Registered on 28 May 2019. Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT03964142

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01970-2.

Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review

BACKGROUND

It has been posited that physical activity (PA) has the potential to improve health outcomes and the health-related quality of life of people living with or beyond cancer. Despite the well-documented health benefits of PA, there is a low level of PA among cancer patients. A systematic scoping review was conducted to investigate attitudes, perceptions, preferences and barriers vs. facilitators to cancer patients' PA participation.

METHODS

A systematic search was performed across four automated databases (PubMed, Embase, PsycINFO and Medline) in keeping with the PRISMA guideline. All cancer types were included, and any age/gender groups were eligible. Both qualitative and quantitative studies were included. The Health Belief Model provided a conceptual framework for the conduct of the scoping review as well as guiding thinking to inform evidence-based interventions.

RESULTS

Ninety-eight articles were included in this review. Nearly half of the studies focused on mixed cancer sites; breast cancer was the most commonly examined cancer type (19%). Post-treatment was the most commonly investigated stage (33%), followed by studies of mixed stages of the cancer trajectory (27%), the acute treatment stage (23%) and pre-treatment stage (1%). Patient treatment stage was not reported in 16% of studies. Cancer patients reported positive attitudes to PA and recognized its benefits for health and wellbeing. Cancer-related side effects (e.g. fatigue) were a leading physiological barrier to PA participation, whereas effective symptom management techniques/tools acted as a powerful facilitator. Psychosocial barriers included low motivation and kinesiophobia, and perceived health benefits and social support/guidance by healthcare providers were significant facilitators. Inaccessible fitness facilities hindered cancer patients' PA engagement though the availability of tailored amenities appeared to be a strong facilitator. PA preferences varied in terms of type, place, time, company and source of information and pointed to the need for individualized PA programs.

CONCLUSIONS

There is a need for further research to identify barriers and facilitators to PA that are faced by patients with particular cancer types. Recommended PA promoting-strategies involve including exercise science professionals in healthcare teams and ensuring that fitness facilities are accessible.

Attenuating Treatment-Related Cardiotoxicity in Women Recently Diagnosed With Breast Cancer via a Tailored Therapeutic Exercise Program: Protocol of the ATOPE Trial

OBJECTIVE

Therapeutic exercise is already used to ameliorate some of the side effects of cancer treatment. Recent studies examined its preventive potential regarding treatment-related toxicity, which can increase the risk of functional decline and lead to disease recurrence and death. This trial will examine whether the Tailored Therapeutic Exercise and Recovery Strategies (ATOPE) program, performed before treatment, can mitigate the onset and extent of cardiotoxicity beyond that achieved when the program is followed during treatment in recently diagnosed breast cancer patients.

METHODS

The intervention has a preparatory phase plus 12 to 18 sessions of tailored, high-intensity exercise, and post-exercise recovery strategies. A total of 120 women recently diagnosed with breast cancer, at risk of cardiotoxicity due to anticancer treatment awaiting surgery followed by chemotherapy and/or radiotherapy, will be randomized to either group. In a feasibility study, measurements related to recruitment rate, satisfaction with the program, adherence to them, the retention of participants, safety, and adverse effects will be explored. In the main trial, the efficacy of these interventions will be examined. The major outcome will be cardiotoxicity, assessed echocardiographically via the left ventricular ejection fraction. Other clinical, physical, and anthropometric outcomes and biological and hormonal variables will also be assessed after diagnosis, after treatment, 1 year after treatment ends, and 3 years after treatment ends.

CONCLUSION

Given its potential effect on patient survival, the mitigation of cardiotoxicity is a priority, and physical therapists have an important role in this mitigation. If the ATOPE intervention performed before treatment returns better cardioprotection results, it may be recommendable that patients recently diagnosed follow this program.

IMPACT

The ATOPE program will highlight the need for a physical therapist intervention from the moment of diagnosis, in the prevention or mitigation of cardiotoxicity, in women with breast cancer. It could help physical therapists to establish an adequate therapeutic exercise dose adapted to breast cancer patients and to propose correct therapeutic exercise prescription according to the assimilation of the sessions.

Roles and molecular mechanisms of physical exercise in cancer prevention and treatment

Exercise can enhance motivation to change lifestyle behaviors, improve aerobic fitness, improve physical function, control fatigue, and enhance quality of life. Studies have demonstrated the benefits to be gained from physical exercise, highlighting the importance of popularizing the concept of physical exercise for individuals and making professional exercise-treatment programs available to patients with cancer. However, the correlation between physical exercise and carcinogenesis is easily overlooked, and exercise interventions are not routinely provided to patients with cancer, especially those with advanced cancer. In this article, we present a literature review of the effects of exercise on cancer development and progression and give recent evidence for the type of exercise best suited for different types of cancer and in different disease stages. Moreover, the molecular mechanisms about regulating metabolism and systemic immune function in cancer are summarized and discussed. In conclusion, physical exercise should be considered as an important intervention for preventing and treating cancer and its complications.

Physical Activity as an Imperative Support in Breast Cancer Management

Breast cancer (BC) is the most common malignancy and the second cause of cancer-related death among women. It is estimated that 9 in 10 cases of BC are due to non-genetic factors, and approximately 25% to 30% of total breast cancer cases should be preventable only by lifestyle interventions. In this context, physical activity represents an excellent and accessible approach not only for the prevention, but also for being a potential support in the management of breast cancer. The present review will collect the current knowledge of physical activity in the background of breast cancer, exploring its systemic and molecular effects, considering important variables in the training of these women and the evidence regarding the benefits of exercise on breast cancer survival and prognosis. We will also summarize the various effects of physical activity as a co-adjuvant therapy in women receiving different treatments to deal with its adverse effects. Finally, we will reveal the impact of physical activity in the enhancement of quality of life of these patients, to conclude the central role that exercise must occupy in breast cancer management, in an adequate context of a healthy lifestyle.

Exercise Interventions in Cardio-oncology Populations: A Scoping Review of the Literature

BACKGROUND

Cardiac toxicity in patients with cancer results from treatment-related damage to the cardiovascular system by chemotherapy, targeted agents, or thoracic radiation. Cardio-oncology patients with co-occurring cancer and cardiovascular disease frequently experience fatigue. Exercise is recommended in clinical guidelines to manage fatigue during or after cancer treatment.

PURPOSE

The purpose of this article is to conduct a scoping review of the exercise randomized clinical trials in cardio-oncology patients, focusing on the components and effects of exercise interventions on patient cardiovascular and fatigue outcomes.

METHODS

A scoping review methodological framework was deemed appropriate and used. Key words for search included "cancer," "oncology," "cardio-oncology," "heart failure," "physical activity," and "exercise." Search involved systematic searches of large databases (PubMed, MEDLINE, Cochrane Review, and CINAHL) and hand searches of reference lists, key journals, webpages, and experts in the field using snowballing techniques.

RESULTS

There were 12 randomized clinical trials included in this review. Study characteristics, accordance of exercise protocols with recommendations, specific exercise training components, and cardiovascular and fatigue outcomes were mapped.

CONCLUSIONS

Recommendations for addressing the gaps included focusing on non-breast-cancer patients with cardiac toxicity risks, developing precision-based prescriptions based on various medical and physiological characteristics, and adding fatigue symptom experience as an outcome variable.