Pedometer-facilitated walking intervention shows promising effectiveness for reducing cancer fatigue: a pilot randomized trial

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.

What Do Older Canadians Think They Need to Walk Well?

Purpose

To identify older Canadians' perception of the importance of expert-generated elements of walking quality, and the contributors to and consequences of perceived walking quality.

Method

Cross-sectional survey of 649 adults was conducted through a commercial participant panel, Hosted in Canada Surveys.

Results

Of the 649 respondents, 75% were between 65 and 74 years old (25% ≥ 75) and 49% were women. The most important elements were foot, ankle, hip, and knee mobility with little difference in ranks across walking perception (Fr χ12 = 5.0, p > 0.05). People who were older by a decade were more likely to report poorer walking (POR: 1.4; 95% CI: 1.0, 1.7), as were women compared to men, and people who used a walking aid compared to none. Lung disease showed the highest association with a perception of not walking well (POR: 7.2; 95% CI: 3.7, 14.2). The odds of being willing to pay more for a technology to improve walking were always greater for those with a lower perception of their walking quality.

Conclusions

People who perceived their walking quality as poor were more likely to report poorer health and were willing to pay more for a technology to improve walking. This supports the opportunity of leveraging wearable technologies to improve walking.

Association of patient activity bio-profiles with health-related quality of life in patients with newly diagnosed multiple myeloma: a prospective observational cohort study

Background

Due to the nature of their disease, patients with multiple myeloma (MM) often have bone disease-related pain that limits physical activity and diminishes health-related quality of life (HRQOL). Digital health technology with wearables and electronic patient reported outcome (ePRO) tools can provide insights into MM HRQoL.

Methods

In this prospective observational cohort study conducted at Memorial Sloan Kettering Cancer in NY, NY, USA, patients with newly diagnosed MM (n = 40) in two cohorts (Cohort A - patients <65 years; Cohort B - patients ≥65 years) were passively remote-monitored for physical activity at baseline and continuously for up to 6 cycles of induction therapy from Feb 20, 2017 to Sep 10, 2019. The primary endpoint of the study was to determine feasibility of continuous data capture, defined as 13 or more patients of each 20-patient cohort compliant with capturing data for ≥16 h of a 24-hr period in ≥60% of days of ≥4 induction cycles. Secondary aims explored activity trends with treatment and association to ePRO outcomes. Patients completed ePRO surveys (EORTC - QLQC30 and MY20) at baseline and after each cycle. Associations between physical activity measurements, QLQC30 and MY20 scores, and time from the start of treatment were estimated using a linear mixed model with a random intercept.

Findings

Forty patients were enrolled onto study, and activity bioprofiles were compiled among 24/40 (60%) wearable user participants (wearing the device for at least one cycle). In an intention to treat feasibility analysis, 21/40 (53%) patients [12/20 (60%) Cohort A; 9/20 (45%) Cohort B] had continuous data capture. Among data captured, overall activity trended upward cycle over cycle for the entire study cohort (+179 steps/24 h per cycle; p = 0.0014, 95% CI: 68-289). Older patients (age ≥65 years) had higher increases in activity (+260 steps/24 h per cycle; p < 0.0001, 95% CI: -154 to 366) compared to younger patients (+116 steps/24 h per cycle; p = 0.21, 95% CI: -60 to 293). Activity trends associated with improvement of ePRO domains, including physical functioning scores (p < 0.0001), global health scores (p = 0.02), and declining disease burden symptom scores (p = 0.042).

Interpretation

Our study demonstrates that feasibility of passive wearable monitoring is challenging in a newly diagnosed MM patient population due to patient use. However, overall continuous data capture monitoring remains high among willing user participants. As therapy is initiated, we show improving activity trends, mainly in older patients, and that activity bioprofiles correlate with traditional HRQOL measurements.

Funding

Grants -National Institutes of HealthP30 CA 008748, Awards - Kroll Award 2019.

Development of a Frailty Ladder Using Rasch Analysis: If the Shoe Fits

Background

The current measurement approach to frailty is to create an index of frailty status, rather than measure it. The purpose of this study is to test the extent to which a set of items identified within the frailty concept fit a hierarchical linear model (e.g., Rasch model) and form a true measure reflective of the frailty construct.

Methods

A sample was assembled from three sources: community organization for at-risk seniors (n=141); colorectal surgery group assessed post-surgery (n=47); and hip fracture assessed post-rehabilitation (n=46). The 234 individuals (age 57 to 97) contributed 348 measurements. The frailty construct was defined according to the named domains within commonly used frailty indices, and items drawn to reflect the frailty came from self-report measures. Performance tests were tested for the extent to which they fit the Rasch model.

Results

Of the 68 items, 29 fit the Rasch model: 19 self-report items on physical function and 10 performance tests, including one for cognition; patient reports of pain, fatigue, mood, and health did not fit; nor did body mass index (BMI) nor any item representing participation.

Conclusion

Items that are typically identified as reflecting the frailty concept fit the Rasch model. The Frailty Ladder would be an efficient and statistically robust way of combining results of different tests into one outcome measure. It would also be a way of identifying which outcomes to target in a personalized intervention. The rungs of the ladder, the hierarchy, could be used to guide treatment goals.

Fatigue self-management led by occupational therapists and/or physiotherapists for chronic conditions: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to investigate the effectiveness of occupational therapist-/physiotherapist-guided fatigue self-management for individuals with chronic conditions.

METHODS

Eight databases, including MEDLINE and EMBASE, were searched until September 2019 to identify relevant studies. Randomised controlled trials and quasi-experimental studies of self-management interventions specifically developed or delivered by occupational therapists/physiotherapists to improve fatigue symptoms of individuals with chronic conditions were included. A narrative synthesis and meta-analysis were conducted to determine the effectiveness of fatigue self-management.

RESULTS

Thirty-eight studies were included, and fatigue self-management approaches led by occupational therapists/physiotherapists were divided into six categories based on the intervention focus: exercise, energy conservation, multimodal programmes, activity pacing, cognitive-behavioural therapy, and comprehensive fatigue management. While all exercise programmes reported significant improvement in fatigue, other categories showed both significant improvement and no improvement in fatigue. Meta-analysis yielded a standardised mean difference of the overall 13 studies: 0.42 (95% confidence interval:-0.62 to - 0.21); standardised mean difference of the seven exercise studies was -0.55 (95% confidence interval: -0.78 to -0.31).

DISCUSSION

Physical exercises inspired by the self-management principles may have positive impacts on fatigue symptoms, quality of life, and other functional abilities.

Effect and feasibility of wearable physical activity trackers and pedometers for increasing physical activity and improving health outcomes in cancer survivors: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the effect of wearable devices for improving physical activity and health-related outcomes in cancer survivors.

METHODS

CINAHL, Cochrane, Ebscohost, MEDLINE, Pubmed, ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, ScienceDirect, and SPORTDiscus databases were searched for randomized controlled trials published before September 1, 2020, that evaluated interventions involving wearable devices in cancer survivors. Standardized mean differences (SMDs) were calculated to assess effects on physical activity and health-related outcomes. Subgroup analyses were conducted to assess whether the effects differed by interventions and cancer characteristics. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

Thirty-five trials were included (breast cancer, n = 15, 43%). Intervention durations ranged between 4 weeks and 1 year. Most trials (n = 25, 71%) involved pedometer-based physical activity interventions. Seven (20%) involved Fitbit-based interventions, and 3 (9%) involved other wearable physical activity trackers (e.g., Polar, Garmin). Compared to usual care, wearable devices had moderate-to-large effects (SMD range 0.54-0.87, p < 0.001) on moderate-intensity physical activity, moderate-to-vigorous-intensity physical activity, total physical activity, and daily steps. Compared to usual care, those in the intervention had higher quality of life, aerobic fitness, physical function, and reduced fatigue (SMD range = 0.18-0.66, all p < 0.05).

CONCLUSION

Wearable physical activity trackers and pedometers are effective tools that increase physical activity and improve health-related outcomes in individuals with cancer. Identifying how these devices can be implemented for longer-term use with other intervention components remains an area for future research.

Practice review: Evidence-based and effective management of fatigue in patients with advanced cancer

BACKGROUND

Fatigue affects most patients living with advanced cancer and is a symptom that healthcare professionals can find difficult to manage.

AIM

To provide healthcare professionals with a pragmatic overview of approaches to management of fatigue in patients with advanced cancer that are commonly recommended by guidelines and to evaluate evidence underpinning them.

DESIGN

Scoping review methodology was used to determine the strength of evidence supporting use of interventions recommended in management of fatigue in patients with advanced cancer.

DATA SOURCES

National or international guidelines were examined if they described the management of fatigue in adult cancer patients and were written within the last 6 years (2015-2021) in English. The Cochrane Database of Systematic Reviews (January 2011-December 2021) was searched for 'cancer' AND 'fatigue' in title, abstract or keywords. A PubMed search was also made.

RESULTS

Evidence indicates physical exercise interventions are effective and patients may benefit from energy conservation tactics. Evidence does not support use of psychostimulants such as methylphenidate. Limited data were found on efficacy of corticosteroids, psychological interventions, nutritional intervention, sleep optimization or complementary therapies for management of fatigue in advanced cancer.

CONCLUSION

We recommend regular assessment, review and acknowledgement of the impact of fatigue. Exercise and energy conservation should be considered. Pharmacological interventions are not endorsed as a routine approach. Many interventions currently recommended by guidelines are not supported by a robust evidence base and further research on their efficacy is required.

Effects of Walking on Fatigue in Cancer Patients: A Systematic Review and Meta-analysis

BACKGROUND

Walking is a simple form of exercise that is easily accepted by patients. Exercise is one of the main ways to control cancer-related fatigue (CRF). However, there are conflicting data on the association between walking and severity of CRF.

OBJECTIVE

The aim of this study was to assess the overall effect of walking on CRF among adult cancer patients.

METHODS

Databases including PubMed, CINAHL, EMBASE, and Cochrane Library were systematically reviewed to identify suitable randomized controlled trials from inception to February 29, 2020. Two reviewers independently evaluated the risk of bias and extracted correlated data with Cochrane Handbook of Systematic Reviews on Interventions. The data analysis was performed by Review Manager 5.3.

RESULTS

A total of 12 studies with 1064 patients were identified. Integrated result analysis of walking yielded a statistically significant effect on CRF (standard mean difference [SMD], -0.66; 95% confidence interval [CI], -1.06 to -0.26). Subgroup analysis demonstrated that intervention time longer than 6 weeks (SMD, -0.89; 95% CI, -1.22 to -0.57) had a better effect on fatigue compared with that of less than 6 weeks (SMD, 0.03; 95% CI, -0.39 to 0.45). The study showed walking was statistically more effective than the control intervention in patients undergoing cancer treatment (SMD, -0.79; 95% CI, -1.16 to -0.42). Descriptive analysis also showed that walking was effective for cancer patients who completed treatment.

CONCLUSIONS

Walking is effective for CRF during and after cancer therapy.

IMPLICATIONS FOR PRACTICE

The results provide evidence for a general exercise form to relieve fatigue in cancer patients and facilitate support for future clinical trials and work.

Effectiveness of Self-Monitoring Approach Using Fitness Trackers to Improve Walking Ability in Rehabilitation Settings: A Systematic Review

Background: A self-monitoring approach utilizing fitness trackers that provide feedback regarding physical activities has been recently applied to rehabilitation patients to promote voluntary walking activities. Although this approach has been proven to increase physical activity, it is uncertain whether the intervention improves walking ability.

Aim: This review investigated whether the additional self-monitoring approach using activity trackers would improve walking ability in any type of rehabilitation setting.

Methods: A systematic search was performed in four databases [PubMed (MEDLINE), The Cochrane Library, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature] to identify studies that examined the self-monitoring approach combined with rehabilitative intervention vs. the same rehabilitative intervention only in participants with any unhealthy conditions. Two review authors independently assessed the eligibility of all the retrieved English literature published from 2009 to 2019, then discussed the final inclusion. The risk of bias was assessed referring to the criteria of the Cochrane Risk of Bias tool. The key findings were synthesized using narrative synthesis. In addition, a quantitative synthesis was conducted when more than two studies investigating the same disease were identified.

Results: Eleven randomized controlled trials satisfied the eligibility criteria, nine of which had a lower risk of bias. The types of diseases included stroke, chronic obstructive pulmonary disease (COPD), cancer, Parkinson's disease, hemophilia, peripheral artery disease, post-total knee arthroplasty, and geriatric rehabilitation. Eight studies reported measures of walking endurance and four reported measures of gait speed. In the quantitative synthesis of two studies investigating COPD, there was a significant between-group difference in terms of changes in the 6-min walking distance from the baseline, which was favorable to the additional self-monitoring intervention group (mean difference: 13.1 m; 95% confidence interval, 1.8–24.5; 2 studies, 124 participants; p = 0.02; I² = 0%). Other available data revealed no consistent evidence regarding effectiveness of the intervention.

Conclusions: The findings indicate that there is little evidence suggesting the effectiveness of the self-monitoring approach in improving walking ability in rehabilitation settings. However, a weak recommendation for patients with stable COPD was implicated in the quantitative synthesis. Further research would be required to explore the best indications for this self-monitoring approach.

Systematic Review Registration: CRD 42020157695.

Attention to principles of exercise training: an updated systematic review of randomized controlled trials in cancers other than breast and prostate

BACKGROUND

The primary objective of this systematic review was to update our previous review on randomized controlled trials (RCTs) of exercise in cancers other than breast or prostate, evaluating: 1) the application of principles of exercise training within the exercise prescription; 2) reporting of the exercise prescription components (i.e., frequency, intensity, time, and type (FITT)); and 3) reporting of participant adherence to FITT. A secondary objective was to examine whether reporting of these interventions had improved over time.

METHODS

MEDLINE, EMBASE, CINAHL and SPORTDiscus databases were searched from 2012 to 2020. Eligible studies were RCTs of at least 4 weeks of aerobic and/or resistance exercise that reported on physiological outcomes relating to exercise (e.g., aerobic capacity, muscular strength) in people with cancer other than breast or prostate.

RESULTS

Eighty-six new studies were identified in the updated search, for a total of 107 studies included in this review. The principle of specificity was applied by 91%, progression by 32%, overload by 46%, initial values by 72%, reversibility by 7% and diminishing returns by 5%. A significant increase in the percentage of studies that appropriately reported initial values (46 to 80%, p < 0.001) and progression (15 to 37%, p = 0.039) was found for studies published after 2011 compared to older studies. All four FITT prescription components were fully reported in the methods in 58% of all studies, which was higher than the proportion that fully reported adherence to the FITT prescription components in the results (7% of studies). Reporting of the FITT exercise prescription components and FITT adherence did not improve in studies published after 2011 compared to older studies.

CONCLUSION

Full reporting of exercise prescription and adherence still needs improvement within exercise oncology RCTs. Some aspects of exercise intervention reporting have improved since 2011, including the reporting of the principles of progression and initial values. Enhancing the reporting of exercise prescriptions, particularly FITT adherence, may provide better context for interpreting study results and improve research to practice translation.

Current Evidence and Directions for Future Research in eHealth Physical Activity Interventions for Adults Affected by Cancer: Systematic Review

Background

Physical activity (PA) interventions can increase PA and improve well-being among adults affected by cancer; however, most adults do not meet cancer-specific PA recommendations. Lack of time, facility access, and travel distances are barriers to participation in PA interventions. eHealth technologies may address some of these barriers, serving as a viable way to promote PA behavior change in this population. However, no review from July 2018 has synthesized available evidence across eHealth and cancer types or examined the use of behavioral theory and behavior change techniques (BCTs), leaving important gaps in knowledge.

Objective

This review aims to provide a comprehensive, updated overview of evidence on eHealth PA interventions for adults with cancer by describing the current state of the literature, exploring associations between intervention characteristics and effectiveness, and identifying future research needs.

Methods

MEDLINE, Embase, CINAHL, SportDiscus, Scopus, and CENTRAL were searched for eHealth PA interventions for adults affected by cancer. Study selection and data extraction were performed in duplicate, with consultation from the senior author (NCR). BCT coding, risk of bias, and completeness of reporting were performed using standardized tools. Results were summarized via narrative synthesis and harvest plots. Weight analyses were conducted to explore the associations between intervention characteristics and effectiveness.

Results

A total of 71 articles (67 studies) involving 6655 participants (mean age 56.7 years, SD 8.2) were included. Nearly 50% (32/67) of the articles were published after July 2018. Significant postintervention PA increases were noted in 52% (35/67) of the studies, and PA maintenance was noted in 41% (5/12) of the studies that included a follow-up. Study duration, primary objectives, and eHealth modality (eg, websites, activity trackers, and SMS text messaging) varied widely. Social cognitive theory (23/67, 34%) was the most used theory. The mean number of BCTs used across the studies was 13.5 (SD 5.5), with self-monitoring, credible sources, and goal setting being used in >90% of studies. Weight analyses showed the greatest associations between increased PA levels and PA as a primary outcome (0.621), interventions using websites (0.656) or mobile apps (0.563), interventions integrating multiple behavioral theories (0.750), and interventions using BCTs of problem solving (0.657) and action planning (0.645). All studies had concerns with high risk of bias, mostly because of the risk of confounding, measurement bias, and incomplete reporting.

Conclusions

A range of eHealth PA interventions may increase PA levels among adults affected by cancer, and specific components (eg, websites, use of theory, and action planning) may be linked to greater effectiveness. However, more work is needed to ascertain and optimize effectiveness, measure long-term effects, and address concerns with bias and incomplete reporting. This evidence is required to support arguments for integrating eHealth within PA promotion in oncology.

Usability testing of tablet-based cognitive behavioral intervention application to improve a simple walking activity for older adults with arthritis fatigue

The purpose of this study was to test usability of a tablet-based cognitive behavioral intervention ("Tab-CBI") application. Tab-CBI was designed to improve a simple walking activity for older adults with arthritis fatigue. Two phases of usability evaluation were conducted: phase I with 5 older adults to identify any initial design issues and phase II with 10 older adults to examine if Tab-CBI was seamlessly integrated into their daily living. Participants perceived that Tab-CBI was easy, light, and intuitive to use and helped them walking. They reported two key benefit as a motivator to make more active in walking and improved confidence of self-management of fatigue. They referred video recordings and videoconferencing communications as two preferable features. There were also comments for improvement, for example, a challenge for holding a tablet when videoconferencing communications. Participants comments were incorporated into a final version of Tab-CBI to prepare for a future pilot study.

Developing an Innovative Tablet-Based Walking Program to Improve Arthritis Fatigue

Fatigue associated with arthritis is highly prevalent and interferes with patients' daily routines. An interdisciplinary research team developed the Tablet-based Cognitive Behavioral Intervention (Tab-CBI) for older adults with arthritis fatigue. The goal of the Tab-CBI is to alleviate fatigue by promoting a simple walking activity. The Tab-CBI application used off-the-shelf technologies and was implemented on a mini-tablet computer. The four key components of Tab-CBI are: (a) multimedia cognitive-behavioral therapy (CBT)-based educational modules; (b) videoconferencing communication; (c) individualized goal setting; and (d) electronic data submission. Experts perceived that the Tab-CBI was engaging and user friendly, and effective in improving simple walking routines and alleviating fatigue. Experts' feedback was incorporated into refining the Tab-CBI. The current study demonstrated that the Tab-CBI has potential to be a useful innovation for fatigue management in older adults. [Journal of Gerontological Nursing, 46(10), 13-18.].

Systematic Review of Randomized Controlled Trials of Exercise Interventions Using Digital Activity Trackers in Patients With Cancer

Background: Exercise can ameliorate cancer- and treatment-related toxicities, but poor adherence to exercise regimens is a barrier. Exercise interventions using digital activity trackers (E-DATs) may improve exercise adherence, but data are limited for patients with cancer. We conducted a systematic review examining the feasibility of E-DATs in cancer survivors and effects on activity level, body composition, objective fitness outcomes, health-related quality of life (HRQoL), self-reported symptoms, and biomarkers. Methods: We identified randomized controlled trials (RCTs) of E-DATs in adult cancer survivors published in English between January 1, 2008, and July 27, 2017. Two authors independently reviewed article titles (n=160), removed duplicates (n=50), and reviewed the remaining 110 articles for eligibility. Results: A total of 12 RCTs met eligibility criteria, including 1,450 patients (mean age, 50-70 years) with the following cancers: breast (n=5), colon or breast (n=2), prostate (n=1), acute leukemia (n=1), or others (n=3). Duration of E-DATs ranged from 4 to 24 weeks, and the follow-up period ranged from 4 to 52 weeks, with retention rates of 54% to 95%. The technology component of E-DATs included pedometers (n=8); pedometers with smartphone application (n=1), Wii Fit (n=1), heart rate monitor (n=1); and a wireless sensor with accelerometer, gyroscope, and magnetometer (n=1). Adherence by at least one measure to E-DATs was >70% in 8 of 8 RCTs. Compared with controls, E-DATs significantly improved patients' step count in 3 of 5 RCTs, activity level in 6 of 9 RCTs, and HRQoL in 7 of 9 RCTs (all P≤05), with no significant changes in biomarkers (eg, interleukin 6, tumor necrosis factor α, C-reactive protein, c-peptide, lipid panel) in 3 RCTs. Duration of E-DAT was not significantly correlated with adherence or study retention. Conclusions: This systematic review shows that E-DATs are feasible to implement in cancer survivors. Future research should examine the optimal type, dose, and schedule of E-DATs for cancer survivors.

Aerobic physical exercise for adult patients with haematological malignancies

BACKGROUND

Although people with haematological malignancies have to endure long phases of therapy and immobility, which is known to diminish their physical performance level, the advice to rest and avoid intensive exercises is still common practice. This recommendation is partly due to the severe anaemia and thrombocytopenia from which many patients suffer. The inability to perform activities of daily living restricts them, diminishes their quality of life and can influence medical therapy.

OBJECTIVES

In this update of the original review (published in 2014) our main objective was to re-evaluate the efficacy, safety and feasibility of aerobic physical exercise for adults suffering from haematological malignancies considering the current state of knowledge.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 7) and MEDLINE (1950 to July 2018) trials registries (ISRCTN, EU clinical trials register and clinicaltrials.gov) and conference proceedings. We did not apply any language restrictions. Two review authors independently screened search results, disagreements were solved by discussion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing an aerobic physical exercise intervention, intending to improve the oxygen system, in addition to standard care with standard care only for adults suffering from haematological malignancies. We also included studies that evaluated aerobic exercise in addition to strength training. We excluded studies that investigated the effect of training programmes that were composed of yoga, tai chi chuan, qigong or similar types of exercise. We also excluded studies exploring the influence of strength training without additive aerobic exercise as well as studies assessing outcomes without any clinical impact.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed the quality of trials. We used risk ratios (RRs) for adverse events, mortality and 100-day survival, standardised mean differences (SMD) for quality of life (QoL), fatigue, and physical performance, and mean differences (MD) for anthropometric measurements.

MAIN RESULTS

In this update, nine trials could be added to the nine trials of the first version of the review, thus we included eighteen RCTs involving 1892 participants. Two of these studies (65 participants) did not provide data for our key outcomes (they analysed laboratory values only) and one study (40 patients) could not be included in the meta-analyses, as results were presented as changes scores only and not as endpoint scores. One trial (17 patients) did not report standard errors and could also not be included in meta-analyses. The overall potential risk of bias in the included trials is unclear, due to poor reporting.The majority of participants suffered from acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), malignant lymphoma and multiple myeloma, and eight trials randomised people receiving stem cell transplantation. Mostly, the exercise intervention consisted of various walking intervention programmes with different duration and intensity levels.Our primary endpoint overall survival (OS) was only reported in one of these studies. The study authors found no evidence for a difference between both arms (RR = 0.67; P = 0.112). Six trials (one trial with four arms, analysed as two sub-studies) reported numbers of deceased participants during the course of the study or during the first 100 to 180 days. For the outcome mortality, there is no evidence for a difference between participants exercising and those in the control group (RR 1.10; 95% CI 0.79 to 1.52; P = 0.59; 1172 participants, low-certainty evidence).For the following outcomes, higher numbers indicate better outcomes, with 1 being the best result for the standardised mean differences. Eight studies analysed the influence of exercise intervention on QoL. It remains unclear, whether physical exercise improves QoL (SMD 0.11; 95% CI -0.03 to 0.24; 1259 participants, low-certainty evidence). There is also no evidence for a difference for the subscales physical functioning (SMD 0.15; 95% CI -0.01 to 0.32; 8 trials, 1329 participants, low-certainty evidence) and anxiety (SMD 0.03; 95% CI -0.30 to 0.36; 6 trials, 445 participants, very low-certainty evidence). Depression might slightly be improved by exercising (SMD 0.19; 95% CI 0.0 to 0.38; 6 trials, 445 participants, low-certainty evidence). There is moderate-certainty evidence that exercise probably improves fatigue (SMD 0.31; 95% CI 0.13 to 0.48; 9 trials, 826 patients).Six trials (435 participants) investigated serious adverse events. We are very uncertain, whether additional exercise leads to more serious adverse events (RR 1.39; 95% CI 0.94 to 2.06), based on very low-certainty evidence.In addition, we are aware of four ongoing trials. However, none of these trials stated, how many patients they will recruit and when the studies will be completed, thus, potential influence of these trials for the current analyses remains unclear.

AUTHORS' CONCLUSIONS

Eighteen, mostly small RCTs did not identify evidence for a difference in terms of mortality. Physical exercise added to standard care might improve fatigue and depression. Currently, there is inconclusive evidence regarding QoL, physical functioning, anxiety and SAEs .We need further trials with more participants and longer follow-up periods to evaluate the effects of exercise intervention for people suffering from haematological malignancies. To enhance comparability of study data, development and implementation of core sets of measuring devices would be helpful.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

OBJECTIVES

To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

SEARCH METHODS

We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

MAIN RESULTS

We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

Tracking steps in oncology: the time is now

Purpose

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

Design

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

Results

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

Conclusion

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

The 'Cancer Home-Life Intervention': A randomised controlled trial evaluating the efficacy of an occupational therapy-based intervention in people with advanced cancer

BACKGROUND

People with advanced cancer face difficulties with their everyday activities at home that may reduce their health-related quality of life. To address these difficulties, we developed the 'Cancer Home-Life Intervention'.

AIM

To evaluate the efficacy of the 'Cancer Home Life-Intervention' compared with usual care with regard to patients' performance of, and participation in, everyday activities, and their health-related quality of life.

DESIGN AND INTERVENTION

A randomised controlled trial ( ClinicalTrials.gov NCT02356627). The 'Cancer Home-Life Intervention' is a brief, tailored, occupational therapy-based and adaptive programme for people with advanced cancer targeting the performance of their prioritised everyday activities.

SETTING/PARTICIPANTS

Home-living adults diagnosed with advanced cancer experiencing functional limitations were recruited from two Danish hospitals. They were assessed at baseline, and at 6 and 12 weeks of follow-up. The primary outcome was activities of daily living motor ability. Secondary outcomes were activities of daily living process ability, difficulty performing prioritised everyday activities, participation restrictions and health-related quality of life.

RESULTS

A total of 242 participants were randomised either to the intervention group ( n = 121) or the control group ( n = 121). No effect was found on the primary outcome (between-group mean change: -0.04 logits (95% confidence interval: -0.23 to 0.15); p = 0.69). Nor was any effect on the secondary outcomes observed.

CONCLUSION

In most cases, the 'Cancer Home-Life Intervention' was delivered through only one home visit and one follow-up telephone contact, which not was effective in maintaining or improving participants' everyday activities and health-related quality of life. Future research should pay even more attention to intervention development and feasibility testing.

Cancer-associated cachexia

Cancer-associated cachexia is a disorder characterized by loss of body weight with specific losses of skeletal muscle and adipose tissue. Cachexia is driven by a variable combination of reduced food intake and metabolic changes, including elevated energy expenditure, excess catabolism and inflammation. Cachexia is highly associated with cancers of the pancreas, oesophagus, stomach, lung, liver and bowel; this group of malignancies is responsible for half of all cancer deaths worldwide. Cachexia involves diverse mediators derived from the cancer cells and cells within the tumour microenvironment, including inflammatory and immune cells. In addition, endocrine, metabolic and central nervous system perturbations combine with these mediators to elicit catabolic changes in skeletal and cardiac muscle and adipose tissue. At the tissue level, mechanisms include activation of inflammation, proteolysis, autophagy and lipolysis. Cachexia associates with a multitude of morbidities encompassing functional, metabolic and immune disorders as well as aggravated toxicity and complications of cancer therapy. Patients experience impaired quality of life, reduced physical, emotional and social well-being and increased use of healthcare resources. To date, no effective medical intervention completely reverses cachexia and there are no approved drug therapies. Adequate nutritional support remains a mainstay of cachexia therapy, whereas drugs that target overactivation of catabolic processes, cell injury and inflammation are currently under investigation.

Wearable activity monitors in oncology trials: Current use of an emerging technology

BACKGROUND

Physical activity is an important outcome in oncology trials. Physical activity is commonly assessed using self-reported questionnaires, which are limited by recall and response biases. Recent advancements in wearable technology have provided oncologists with new opportunities to obtain real-time, objective physical activity data. The purpose of this review was to describe current uses of wearable activity monitors in oncology trials.

METHODS

We searched Pubmed, Embase, and the Cochrane Central Register of Controlled Trials for oncology trials involving wearable activity monitors published between 2005 and 2016. We extracted details on study design, types of activity monitors used, and purpose for their use. We summarized activity monitor metrics including step counts, sleep and sedentary time, and time spent in moderate-to-vigorous activity.

RESULTS

We identified 41 trials of which 26 (63%) involved cancer survivors (post-treatment) and 15 trials (37%) involved patients with active cancer. Most trials (65%) involved breast cancer patients. Wearable activity monitors were commonly used in exercise (54%) or behavioral (29%) trials. Cancer survivors take between 4660 and 11,000 steps/day and those undergoing treatment take 2885 to 8300steps/day.

CONCLUSION

Wearable activity monitors are increasingly being used to obtain objective measures of physical activity in oncology trials. There is potential for their use to expand to evaluate and predict clinical outcomes such as survival, quality of life, and treatment tolerance in future studies. Currently, there remains a lack of standardization in the types of monitors being used and how their data are being collected, analyzed, and interpreted.

PRECIS

Recent advancements in wearable activity monitor technology have provided oncologists with new opportunities to monitor their patients' daily activity in real-world settings. The integration of wearable activity monitors into cancer care will help increase our understanding of the associations between physical activity and the prevention and management of the disease, in addition to other important cancer outcomes.

Managing mobility outcomes in vulnerable seniors ( MMOVeS): a randomized controlled pilot study

OBJECTIVE

To estimate feasibility and potential for efficacy of an individualized, exercise-focused, self-management program (i.e. Managing Mobility Outcomes In Vulnerable Seniors ( MMOVeS)), in comparison to exercise information in improving mobility after six months among seniors recently discharged from hospital.

DESIGN

Randomized pilot study.

SETTING

Two McGill University-teaching hospitals.

SUBJECTS

Community dwelling seniors, aged 70 years and older, recently discharged from either participating hospitals.

INTERVENTIONS

The physiotherapy-facilitated intervention consisted of (1) evaluation of mobility capacity, (2) setting short- and long-term goals, (3) delineation of an exercise treatment plan, (4) an educational booklet to enhance mobility self-management skills, and (5) six monthly telephone calls. Control group received a booklet with information on exercises targeting mobility limitations in seniors.

MAIN MEASURES

Mobility, pain, and health status were assessed at baseline and at six months using multiple indicators drawn from Disabilities of the Arm, Shoulder, and Hand (DASH) Score, Lower Extremity Functional Scale (LEFS) and Short-Form (SF)-36.

RESULTS

In all, 26 people were randomized to the intervention (mean age: 81 ± 8; 39% women), and 23 were randomized to the control (mean age: 79 ± 7; 33% women). The odds ratio for the mobility outcomes combined was 3.08 and the 95% confidence interval excluded 1 (1.65-5.77). The odds ratio for pain and health perception favored the MMOVeS group, but the 95% confidence interval included the null value.

CONCLUSIONS

This feasibility study highlights the potential for efficacy of an individualized, exercise-focused, self-management program in comparison to exercise information in improving mobility outcome for seniors. Furthermore, a home-program combining self-management skills and exercise taught with minimal supervision prove to be feasible. Finally, data from this study can be used to estimate sample size for a confirmatory trial.

Where have all the pilot studies gone? A follow-up on 30 years of pilot studies in Clinical Rehabilitation

Introduction:

Pilot studies are meritorious for determining the feasibility of a definitive clinical trial in terms of conduct and potential for efficacy, but their possible applications for planning a future trial are not always fully realized. The purpose of this review was to estimate the extent to which pilot/feasibility studies: (i) addressed needed objectives; (ii) led to definitive trials; and (iii) whether the subsequent undertaking of a definitive trial was influenced by the strength of the evidence of outcome improvement.

Methods:

Trials published in the journal Clinical Rehabilitation, since its inception, were eligible if the word ‘pilot’ or ‘feasibility’ was specified somewhere in the article. A total of 191 studies were reviewed, results were summarized descriptively, and between-group effect sizes were computed.

Results:

The specific purposes of piloting were stated in only 58% (n = 110) of the studies. The most frequent purpose was to estimate the potential for efficacy (85%), followed by testing the feasibility of the intervention (60%). Only 12% of the studies were followed by a definitive trial; <4% of studies had a main study underway or a published study protocol. There was no relationship between observed effect size and follow-up of pilot studies, although the confidence intervals were very wide owing to small number of trials that followed on.

Discussion:

Labelling and reporting of pilot studies needs to be improved to be concordant with the recently issued CONSORT guidelines. Feasibility needs to be fully tested and demonstrated prior to committing considerable human and monetary resources.

Agreement between personally generated areas of quality of life concern and standard outcome measures in people with advanced cancer

PURPOSE

People with advanced cancer experience different sequelae which have unique effects on quality of life (QOL). The patient-generated index (PGI) is a personalized measure that allows patients to nominate, rate, and value areas that have the most impact on QOL. Fatigue, pain, and aspects of physical function are among the top 10 areas with QOL impact. An area of validation that is lacking for the PGI is the extent to which spontaneously nominated areas of QOL that patients are concerned with, agree with ratings obtained from standard patient reported outcomes (PROs).

METHODS

Data from 192 patients were used to compare ratings on fatigue, pain, and physical function obtained from PGI to those from standard outcome measures.

RESULTS

Within one severity rating, agreement ranged from 32.1 to 76.9 % within the fatigue domain, 34.2 to 95.24 % for pain, and between 84.2 and 94.7 % for physical function. Of the 10 items where the PGI had the highest agreement, 7 came from the RAND-36. At the domain level, people nominating an area scored in the more impaired range on standard measures than people who did not.

CONCLUSION

PGI gives comparable information as do standard measures.

IMPLICATIONS FOR CANCER

PGI provides important information to guide clinical care of the patient and also produces a legitimate total score suitable for research.