Meta-analysis of Exercise Training on Vascular Endothelial Function in Cancer Survivors

Cardio-oncology rehabilitation and exercise: evidence, priorities, and research standards from the ICOS-CORE working group

The aim of this whitepaper is to review the current state of the literature on the effects of cardio-oncology rehabilitation and exercise (CORE) programmes and provide a roadmap for improving the evidence-based to support the implementation of CORE. There is an urgent need to reinforce and extend the evidence informing the cardiovascular care of cancer survivors. CORE is an attractive model that is potentially scalable to improve the cardiovascular health of cancer survivors as it leverages many of the existing frameworks developed through decades of delivery of cardiac rehabilitation. However, there are several challenges within this burgeoning field, including limited evidence of the efficacy of this approach in patients with cancer. In this paper, a multidisciplinary team of international experts highlights priorities for future research in this field and recommends standards for the conduct of research.

Efficacy of exercise training for improving vascular dysfunction in people with cancer: a systematic review with meta-analyses

PURPOSE

Cancer treatments exert vascular toxic effects that can lead to the development of cardiovascular disease. Exercise training has the potential to prevent or reduce cancer treatment-induced damage to vascular structure and function. This systematic review with meta-analyses aimed to determine the isolated effects of exercise training on vascular outcomes in people with cancer.

METHODS

Seven electronic databases were searched on 20 September 2021 to identify randomised controlled trials, quasi-randomised trials, pilot and cohort studies. Included studies implemented a structured exercise intervention and assessed vascular structure and/or function in people during or following cancer treatment. Meta-analyses examined the effects of exercise training on endothelial function (via brachial artery flow-mediated dilation) and arterial stiffness (via pulse wave velocity). Methodological quality was assessed using the Cochrane Quality Assessment tool and modified Newcastle-Ottawa Quality Appraisal tool. Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence.

RESULTS

Ten studies (discussed across 11 articles) met the inclusion criteria. Methodological quality of the included studies was moderate (71% average). Exercise improved vascular function when compared to control (standardised mean difference = 0.34, 95% CI (0.01, 0.67); p = 0.044: studies = 5, participants = 171), but not pulse wave velocity (standardised mean difference = - 0.64, 95% CI (- 1.29, 0.02); p = 0.056: studies = 4, participants = 333). The certainty of evidence was moderate for flow-mediated dilation and low for pulse wave velocity.

CONCLUSIONS

Compared to usual care, exercise training significantly improves flow-mediated dilation (endothelial function) but not pulse wave analysis, in people treated for cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise may improve vascular health in individuals during and following cancer treatment.

[Influence of cardiorespiratory training program on the intercellular adhesion molecule level in patients with postmastectomy syndrome]

Postmastectomy syndrome (PMS) is a complex neurovascular set of symptoms that develops in most patients after breast cancer (BC) treatment and significantly reduces the quality of life. One of the potential mechanisms of its occurrence is considered to be an endothelial dysfunction. The possible method of reducing manifestation of endothelial dysfunction is systematic aerobic dynamic training.

OBJECTIVE

To evaluate the influence of 12-week aerobic dynamic training program of moderate intensity on the endothelial dysfunction laboratory markers and life quality in patients with PMS.

MATERIAL AND METHODS

Single-center prospective randomized trial included 40 patients with PMS divided into study (20 patients) and comparative (20 patients) groups, as well as 20 healthy female volunteers. The expression level of soluble intercellular adhesion molecule-1 (ICAM-1) and platelet endothelial cell adhesion molecule-1 (PECAM-1) were evaluated in all participants at baseline by enzyme-linked immunosorbent assay method, and additionally psychological and physical component of health by SF-36 questionnaire were assessed in patients with PMS.

Patients of study group received a course of 12-week partially controlled aerobic dynamic training of moderate intensity lasting 45 minutes with frequency equal 5 times per week. Patients with PMS were re-evaluated for ICAM-1 and PECAM-1, as well as for life quality.

RESULTS

The group of patients with PMS after BC treatment had increased level of ICAM-1 in long-term period, that may indicate endothelial dysfunction. Statistically significant decrease of endothelial dysfunction laboratory markers was revealed in patients with PMS, who underwent the course of cardiorespiratory training. In the same time, the dynamics of changes in ICAM-1 was higher in the study group than in comparative group. Further, improvement of physical and psychological components of health by SF-36 questionnaire was found.

CONCLUSIONS

The program of cardiorespiratory trainings of moderate intensity in patients, who had BC treatment a year ago, decreases intercellular adhesion molecules level that may show an improvement of endothelial dysfunction.

Physical exercise in patients with testicular cancer treated with bleomycin, etoposide and cisplatin chemotherapy: pulmonary and vascular endothelial function-an exploratory analysis

PURPOSE

Bleomycin, etoposide, and cisplatin combination chemotherapy (BEP) improves the survival of patients with testicular cancer, but is associated with potentially life-threatening toxicities like pneumonitis and thromboembolic events. This study explored the effects of physical exercise in patients with testicular cancer during or after BEP-chemotherapy on pulmonary and vascular endothelial toxicity.

METHODS

In this post hoc analysis of a multicenter randomized clinical trial (NCT01642680), patients with metastatic testicular cancer scheduled to receive BEP-chemotherapy were randomized to a 24-week exercise intervention, initiated during (group A) or after BEP-chemotherapy (group B). Endpoints were pulmonary function (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), lung transfer-coefficient and transfer factor for carbon monoxide (KCO, DLCO) and markers of vascular endothelial dysfunction (von Willebrand factor (vWF) and factor VIII).

RESULTS

Thirty patients were included. Post-chemotherapy, patients declined less in FVC, FEV1 and DLCO in group A compared to group B. Post-chemotherapy, vWF and factor VIII were significantly lower in group A compared to group B. After completion of exercise, started either during BEP-chemotherapy or thereafter, no between-group differences were found. At 1-year post-intervention, significant between-group differences were found in favour of group A in DLCO and KCO.

CONCLUSIONS

Patients who exercised during BEP-chemotherapy better preserved FVC, FEV1 and DLCO, measured directly post-chemotherapy and 1-year post-intervention (DLCO, KCO). This coincided with less increase in vWF and factor VIII measured directly post-chemotherapy. These data support a beneficial role of a physical exercise intervention during BEP-chemotherapy on pulmonary and vascular damage in patients with testicular cancer.

TRIAL REGISTRY

Optimal Timing of Physical Activity in Cancer Treatment (ACT) Registry URL: https://clinicaltrials.gov/ct2/show/NCT01642680 .

TRIAL REGISTRATION NUMBER

NCT01642680.

Updated systematic review of the effects of exercise on understudied health outcomes in cancer survivors

INTRODUCTION

The American College of Sports Medicine provided guidelines for exercise prescriptions in cancer survivors for specific cancer- and treatment-related health outcomes. However, there was insufficient evidence to generate exercise prescriptions for 10 health outcomes of cancer treatment. We sought to update the state of evidence.

METHODS

We conducted a systematic review of these 10 understudied health outcomes (bone health, sleep, cardiovascular function, chemotherapy-induced peripheral neuropathy (CIPN), cognitive function, falls and balance, nausea, pain, sexual function, and treatment tolerance) and provided an update of evidence.

RESULTS

While the evidence base for each outcome has increased, there remains insufficient evidence to generate exercise prescriptions. Common limitations observed across outcomes included: variability in type and quality of outcome measurement tools, variability in definitions of the health outcomes, a lack of phase III trials, and a majority of trials investigating breast or prostate cancer survivors only.

CONCLUSION

We identified progress in the field of exercise oncology for several understudied cancer- and treatment-related health outcomes. However, we were not able to generate exercise prescriptions due to continued insufficient evidence base. More work is needed to prescribe exercise as medicine for these understudied health outcomes, and our review highlights several strategies to aid in research acceleration within these areas of exercise oncology.

A systematic review of exercise protocols applied to athymic mice in tumor-related experiments

Athymic mice are unable to produce T-cells and are then characterized as immunodeficient. This characteristic makes these animals ideal for tumor biology and xenograft research. New non-pharmacological therapeutics are required owing to the exponential increase in global oncology costs over the last 10 years and the high cancer mortality rate. In this sense, physical exercise is regarded as a relevant component of cancer treatment. However, the scientific community lacks information regarding the effect of manipulating training variables on cancer in humans, and experiments with athymic mice. Therefore, this systematic review aimed to address the exercise protocols used in tumor-related experiments using athymic mice. The PubMed, Web of Science, and Scopus databases were searched without restrictions on published data. A combination of key terms such as athymic mice, nude mice, physical activity, physical exercise, and training was used. The database search retrieved 852 studies (PubMed, 245; Web of Science, 390; and Scopus, 217). After title, abstract, and full-text screening, 10 articles were eligible. Based on the included studies, this report highlights the considerable divergences in the training variables adopted for this animal model. No studies have reported the determination of a physiological marker for intensity individualization. Future studies are recommended to explore whether invasive procedures can result in pathogenic infections in athymic mice. Moreover, time-consuming tests cannot be applied to experiments with specific characteristics such as tumor implantation. In summary, non-invasive, low-cost, and time-saving approaches can suppress these limitations and improve the welfare of these animals during experiments.

Effects of Digital Physical Activity Interventions for Breast Cancer Patients and Survivors: A Systematic Review and Meta-Analysis

OBJECTIVES

The benefits of physical activity (PA) for breast cancer (BC) patients and survivors are well documented. With the widespread use of the internet and mobile phones, along with the recent coronavirus disease 2019 pandemic, there has been a growing interest in digital health interventions. This study conducted a systematic review and meta-analysis to evaluate the effects of digital PA interventions for BC patients and survivors in improving PA and quality of life (QoL).

METHODS

We searched eight databases, including PubMed, CINAHL, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials in the Cochrane Library, RISS, and DBpia. Studies were included if they provided digital PA interventions, assessed PA and QoL among BC patients and survivors, and were published from inception to December 31, 2022.

RESULTS

In total, 18 studies were identified. The meta-analysis showed significant improvement in the total PA duration (five studies; standardized mean difference [SMD] = 0.71; 95% confidence interval [CI], 0.25-1.18; I2 = 86.64%), functional capacity (three studies; SMD = 0.38; 95% CI, 0.10-0.66; I2 = 14.36%), and QoL (nine studies; SMD = 0.45; 95% CI, 0.22-0.69; I2 = 65.55%).

CONCLUSIONS

Digital PA interventions for BC patients and survivors may significantly improve PA, functional capacity, and QoL. Future research should focus on the long-term effects of digital PA interventions, using objective outcome measures.

Anthracycline chemotherapy, vascular dysfunction and cognitive impairment: burgeoning topics and future directions

Anthracyclines, chemotherapeutic agents used to treat common forms of cancer, increase cardiovascular (CV) complications, thereby necessitating research regarding interventions to improve the health of cancer survivors. Vascular dysfunction, which is induced by anthracycline chemotherapy, is an established antecedent to overt CV diseases. Potential treatment options for ameliorating vascular dysfunction have largely been understudied. Furthermore, patients treated with anthracyclines have impaired cognitive function and vascular dysfunction is an independent risk factor for the development of mild cognitive impairment. Here, we will focus on: anthracycline chemotherapy associated CV diseases risk; how targeting mechanisms underlying vascular dysfunction may be a means to improve both CV and cognitive health; and research gaps and potential future directions for the field of cardio-oncology.

Home-Based Buddhist Walking Meditation Mitigates Cardiotoxicity of Anthracycline Chemotherapy in Breast Cancer Patients: A Randomized Controlled Trial

Purpose: To investigate the effect of walking meditation on vascular function, aerobic fitness, and quality of life in breast cancer patients receiving anthracycline chemotherapy and compare with the nonexercising control group. Methods: Patients aged 40-60 years with newly diagnosed, histologically confirmed resected stage I-II breast cancer were studied in a parallel randomized controlled trial. The participants were randomly assigned to either the nonexercising control group (n = 15) or the Buddhist walking meditation group (n = 15). All participants received four cycles of anthracycline chemotherapy every 3 weeks starting at 2 weeks before the start of the exercise intervention. The walking meditation group performed home-based mindfulness walking exercises at a moderate exercise intensity for 30 min/session, 3 times/week for 12 weeks. The primary outcome measures were vascular reactivity (flow-mediated dilation [FMD]) and arterial stiffness (brachial-ankle pulse wave velocity [baPWV]). Results: Eleven participants from each group completed the entire study. Analysis of variance with repeated measures indicated that FMD and peak oxygen consumption (VO2peak) decreased in both groups after the initiation of anthracycline chemotherapy (all p < 0.05). After the exercise intervention, FMD, VO2peak, peak stroke volume, and peak cardiac output remained lower in the controls, but improved in the walking meditation group (all p < 0.05). baPWV increased in the control group, while no such change was observed in the walking meditation group. There were no significant changes in blood cortisol, malondialdehyde, and interleukin-6 concentrations in both groups. Overall quality of life decreased after 2 weeks of anthracycline chemotherapy in both groups (all p < 0.05). However, the walking meditation group improved many of these symptoms significantly (all p < 0.05), while no such changes were observed in the control group. Conclusions: Buddhist walking meditation exercise was effective in mitigating cardiotoxicity of anthracycline chemotherapy on vascular function, aerobic fitness, and quality of life in breast cancer patients. Clinical trial registration number: NCT02676531.

Current Evidence on the Benefit of Exercise in Cancer Patients: Effects on Cardiovascular Mortality, Cardiotoxicity, and Quality of Life

Cancer and its treatments affect cardiovascular (CV) health, including an increased risk of CV death, decreased cardiorespiratory fitness (CRF), and cardiac dysfunction. Moreover, cancer-related fatigue and worse quality of life (QoL) are highly prevalent adverse effects experienced by patients during treatment and can persist years after therapy ends. Physical exercise has been proposed as a strategy to improve different aspects of life of cancer patients, and is recommended as a therapy in cardio-oncology guidelines. Exercise interventions reduce fatigue and improve QoL in patients with both solid tumors and hematological malignancies, although there is a lack of awareness of exercise recommendations, timing, and referral to such programs. New evidence indicates that physical activities improve CRF, which can lead to a reduction in CV mortality. Furthermore, cardiac dysfunction is a side effect of many oncological treatments, which may be mitigated by exercise interventions according to preclinical studies and recent publications. Nevertheless, specific physical exercise programs are not widely used in cancer patients. Thus, the goal of this review was to describe the current evidence on the benefits of exercise in cancer patients, the gaps that remain, and an approach to exercise prescription.

Impact of Exercise Training Interventions on Flow-Mediated Dilation in Adults: An Umbrella Review

BACKGROUND

Dysfunction of the endothelium is a key precursor of cardiovascular disease. Endothelial function, as assessed via the flow-mediated dilation test, is attenuated with chronic disease (e.g., type 2 diabetes mellitus, hypertension). Exercise training may mitigate this dysfunction and promote better vascular health.

OBJECTIVE

The main objective of this umbrella review was to determine the impact of exercise training on flow-mediated dilation in healthy adults and those with chronic disease.

METHODS

Studies were included if they conducted a systematic review and/or meta-analysis on flow-mediated dilation responses to exercise interventions in adults. Sources were searched in January 2022 and included Scopus, EMBASE, MEDLINE, CINAHL, and Academic Search Premier. National Institutes of Health quality assessment tools were used. The results were presented narratively.

RESULTS

Twenty-seven systematic reviews, including 19 meta-analyses, (total: 5464 unique participants, 2181 reported unique female individuals) met the inclusion criteria. The average overall quality of included reviews was 8.8/11. The quality of studies within each included review varied from low to moderate using a variety of quality assessment scales. Reviews were conducted in healthy adults (n = 9, meta-analyses = 6), as well as those with type 2 diabetes (n = 5, meta-analyses = 4), cardiovascular conditions [i.e., conditions that impact the cardiovascular system, but excluding samples of only type 2 diabetes] (n = 11, meta-analyses = 7), and other chronic conditions (n = 2, meta-analyses = 2). Overall, the included reviews provided evidence that the type of training to optimally improve FMD may vary based on disease condition. Specifically, the evidence suggests that healthy adults benefitted most from higher intensity aerobic training and/or more frequent low-to-moderate resistance training. In addition, adults with type 2 diabetes benefitted most from low-intensity resistance or aerobic exercise training, whereas those with cardiovascular conditions should consider engaging in high-intensity aerobic training to improve endothelial function.

CONCLUSIONS

This information may help guide the design of specific exercise programs or recommendations for adults with chronic conditions.

The Benefits of Exercise in Breast Cancer

Breast cancer is the most prevalent cancer among women, accounting for nearly 30% of all cancers, while in men, it represents only 1% of cases. Breast cancer is the main cause of death for cancer, and its incidence and mortality vary according to patients' ethnicity, geographic region, and socioeconomic status. Due to the low prevalence of breast cancer among men and the scarcity of studies in the literature, exercises have been prescribed based on extrapolations from studies on female patients. Scientific evidence has suggested beneficial effects of physical exercises on breast cancer prevention, treatment, and post-treatment. In addition to combatting sedentary behavior, it is essential to maintain a healthy body weight, limit alcohol consumption, and follow a balanced diet, rich in fruit, vegetables, grains and fibers, and limited in red meat. The effects of exercises are not restricted to breast cancer, but extend to controlling modifiable risk factors, and reducing the incidence of cardiovascular diseases, and all-cause and cardiovascular mortality.

Acute effects of singing on cardiovascular biomarkers

Background

Singing is a physical activity involving components of the vagal nerves manifested as changes in cardiac autonomic regulation.

Aims

The aim of this pilot study is to investigate the acute effects of singing on biomarkers of cardiovascular health.

Methods

Adult subjects were recruited from cardiology clinics to participate in a single 90-min study visit. Vascular function was measured at the fingertips with peripheral arterial tonometry (PAT) before and after singing to a 14-min video led by a voice expert. Heart rate variability (HRV) was measured with a chest strap sensor at baseline, during, and after singing. PAT measurements were expressed as reactive hyperemia index (RHI) and Framingham reactive hyperemia index (fRHI). Measures of HRV included root mean square of successive RR interval differences (RMSSD) and standard deviation of NN (or RR) intervals (SDNN).

Results

Sixty subjects completed the study (68% female, mean age 61 ±13 years, mean BMI 32 ± 8). There was a significant increase in fRHI (1.88 ± 0.14 to 2.10 ± 0.14, p = 0.02) after singing with no significant change in the RHI (1.99 ± 0.10 to 2.12 ± 0.09, p = 0.22). There was a reduction in HRV during singing (compared to baseline) (RMSSD: 42.0 ± 5 to 32.6 ± 4, p = 0.004 and SDNN: 54 ± 4 to 33.5 ± 3, p = 0.009). HRV measures trended back toward baseline after singing.

Conclusions

A short duration of singing improved vascular function acutely. Improvements were more substantial in subjects with abnormal baseline endothelial function. HRV patterns were similar to that of light-intensity exercise. Future studies should confirm favorable vascular adaptation to more sustained singing interventions.

Clinical trial registration

ClinicalTrials.gov, identifer: NCT03805529.

A Contemporary Review of the Effects of Exercise Training on Cardiac Structure and Function and Cardiovascular Risk Profile: Insights From Imaging

Exercise is a commonly prescribed therapy for patients with established cardiovascular disease or those at high risk for de novo disease. Exercise-based, multidisciplinary programs have been associated with improved clinical outcomes post myocardial infarction and is now recommended for patients with cancer at elevated risk for cardiovascular complications. Imaging studies have documented numerous beneficial effects of exercise on cardiac structure and function, vascular function and more recently on the cardiovascular risk profile. In this contemporary review, we will discuss the effects of exercise training on imaging-derived cardiovascular outcomes. For cardiac imaging via echocardiography or magnetic resonance, we will review the effects of exercise on left ventricular function and remodeling in patients with established or at risk for cardiac disease (myocardial infarction, heart failure, cancer survivors), and the potential utility of exercise stress to assess cardiac reserve. Exercise training also has salient effects on vascular function and health including the attenuation of age-associated arterial stiffness and thickening as assessed by Doppler ultrasound. Finally, we will review recent data on the relationship between exercise training and regional adipose tissue deposition, an emerging marker of cardiovascular risk. Imaging provides comprehensive and accurate quantification of cardiac, vascular and cardiometabolic health, and may allow refinement of risk stratification in select patient populations. Future studies are needed to evaluate the clinical utility of novel imaging metrics following exercise training.

Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction

INTRODUCTION

Vascular erectile dysfunction (ED) is a burdensome condition, associated with increased cardiovascular risk. Peak systolic velocity (PSV) represents the maximum pulse velocity in the cavernous artery measured by a penile color doppler ultrasonography (PCDU) during a pharmacologically induced erection and is considered a reliable parameter for the diagnosis of vascular ED. However, the cut-off value of standard PSV (30 cm/s) provides high sensitivity only in the diagnosis of advanced arteriogenic disease. Thus, an age-adjusted PSV (6.73 + 0.7 x age cm/s) has been proposed to offer a more accurate diagnosis of vascular ED.

AIM

In this study it was aimed to answer the following question: "Is there any positive association between indexes of vascular erectile dysfunction and cardiorespiratory fitness?"

MAIN OUTCOME MEASURE AND METHODS

25 patients with a medical history of ED (median age 55.3 years) underwent PCDU after pharmacological stimulation. Subsequently, a functional evaluation with ECG-monitored, incremental, maximal cardiopulmonary exercise testing was performed.

RESULTS

Peak oxygen uptake (VO2 peak), peak oxygen uptake per body weight (VO2 peak/kg) and Watt/kg correlated with standard PSV, even when corrected for age and BMI (p < 0.05). No differences emerged in cardiopulmonary fitness between pathological and healthy patients (4 vs 21) identified using the standard PSV cut-off. Conversely, the age-adjusted PSV cut-off identified a greater number of patients as pathological (18 vs 7), presenting a significantly lower cardiopulmonary fitness, exercise capacity and efficiency when compared to patients with normal age-adjusted PSV (all p < 0.05).

CONCLUSION

Data showed an age and BMI independent association between vascular disfunction of cavernous artery and cardiopulmonary fitness, a known solid predictor of all-cause and disease-specific mortality. Moreover, the age-adjusted PSV better identified a subgroup of patients with vascular ED presenting impaired cardiorespiratory fitness and thus increased cardiovascular risk. De Rocco Ponce M, Vecchiato M, Neunhaeuserer D, et al. Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction. Sex Med 2021;9:100347.

Endothelial dysfunction in patients with lymphoproliferative disorders and its changes in the course of polychemotherapy

The article is dedicated to contemporary views on the change of endothelial function in the patients with lymphoproliferative disorders prior to, and in the process of, chemotherapeutic treatment. Considering that possibilities of standard examination do not always help identifying subclinical endothelial dysfunction, it is necessary to use specific methods, in particular, to determine the levels of endothelin-1 and vascular endothelial growth factor to monitor endothelial function. The objective of this review is to identify problems and prospects for recognizing early subclinical changes of endothelial function in the patients with lymphoproliferative disorders before and after chemotherapy. Assessing presence and severity of endothelial dysfunction may be useful for determining subclinical stages of cardiovascular damage, stratifying the risk of the patients with confirmed cardiovascular disease, and reducing the likelihood of cardio- and endotheliotoxic effects in patients long after chemotherapy. That is why early detection and immediate therapy of cardiovascular toxicity is currently the most important task in the patients with lymphoproliferative disorders, receiving chemotherapy.

Chronic fatigue in myelodysplastic syndromes: Looking beyond anemia

Chronic fatigue is the most common and severe symptom in myelodysplastic syndromes (MDS) and has a strong negative association with health-related quality of life (HRQoL). Despite anemia being the most common objective manifestation of MDS, and the associated link between anemia and fatigue, evidence on treatments which temporarily mitigate anemia is equivocal regarding the effects on fatigue. Furthermore, previous work has found weak associations between anemia and chronic fatigue in MDS. As such, given that improving HRQoL is one of the primary treatment aims in MDS, further work is required to identify other potential contributors to chronic fatigue in these patients. In addition to anemia, MDS is associated with numerous other deviations in physiological homeostasis and has negative psychological consequences with links to chronic fatigue. Accordingly, the present review provides several potential aetiologic agents relevant to chronic fatigue in MDS which can be used to guide future research in this field.

The role of exercise in the management of adverse effects of androgen deprivation therapy for prostate cancer: a rapid review

PURPOSE

Prostate cancer (PCa) is the most commonly diagnosed cancer in Australia, accounting for one quarter of all new cancer diagnoses for males. Androgen deprivation therapy (ADT) is the standard first-line therapy for metastatic PCa but is also used across much of the spectrum of disease. Unfortunately, debilitating adverse effects are a significant and largely unavoidable feature of ADT. A recent systematic review of adverse effects of ADT identified 19 sub-groups classified according to the Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. The potential for multiple simultaneous adverse effects, their associated management and the impact of adverse effects on cancer outcomes and quality of life are important considerations in the treatment and supportive care of men with PCa. Exercise is increasingly being recognized as an efficacious strategy in managing these adverse effects.

METHODS

A rapid review was undertaken to examine the role of exercise in the management of the most commonly reported ADT adverse effects classified according to the CTCAE sub-groups. A systematic search was conducted in Medline, PsycINFO, Google Scholar and Google for the years 2010 to September 2019 to identify the benefits of exercise in managing the adverse effects of ADT for PCa.

RESULTS

There is strong evidence for exercise as medicine in addressing several of the adverse effects of PCa such as loss of muscle mass and strength, fatigue and declining physical function. Moderate level evidence for PCa exists for exercise-induced improvements in depression and anxiety, bone loss, and sexual dysfunction. While evidence of the effectiveness of exercise is lacking for many adverse effects of ADT for PCa, evidence in the cancer population as a whole or other clinical populations is strong, and many clinical guidelines recommend exercise as a fundamental part of their clinical management. With the exception of gynaecomastia and breast pain, there is increasing evidence (PCa, cancer or other clinical populations) to suggest that exercise has the potential to reduce and even prevent many of the adverse effects of ADT, thus improving survivorship outcomes for men with PCa.

CONCLUSION

Exercise has the potential to reduce and even prevent many of the adverse effects of ADT, thus improving survivorship outcomes for men with PCa. The use of exercise for PCa management has the potential to translate into health and economic benefits in improved quality of life and fewer complications, resulting in savings to the health care system, enhanced productivity and reduced patient and carer burden. Exercise thus has the potential to improve quality of life for this population as well as generate significant cost savings.

Exercise and cancer: a position statement from the Spanish Society of Medical Oncology

Due to improvements in the number of cancer survivors and survival time, there is a growing interest in healthy behaviors, such as physical activity (PA), and their potential impact on cancer- and non-cancer-related morbidity in individuals with cancer. Commissioned by the Spanish Society of Medical Oncology (SEOM), in this review, we sought to distill the most recent evidence on this topic, focusing on the mechanisms that underpin the effects of PA on cancer, the role of PA in cancer prevention and in the prognosis of cancer and practical recommendations for clinicians regarding PA counseling. Despite the available information, the introduction of exercise programs into the global management of cancer patients remains a challenge with several areas of uncertainty. Among others, the most effective behavioral interventions to achieve long-term changes in a patient’s lifestyle and the optimal intensity and duration of PA should be defined with more precision in future studies.

Nurse-Led Supportive Care Intervention for Men With Advanced Prostate Cancer: Healthcare Professionals' Perspectives

PURPOSE

To identify barriers and corresponding solutions for implementing a telephone-based, nurse-led supportive care intervention for men with advanced prostate cancer.

PARTICIPANTS & SETTING

21 healthcare professionals with an average 15.81 years of experience in diverse prostate cancer care settings.

METHODOLOGIC APPROACH

Data from semistructured interviews were coded into the Theoretical Domains Framework and mapped to behavior change techniques (BCTs) to inform the development of an implementation schema.

FINDINGS

Barriers included lack of knowledge about the effectiveness of survivorship interventions and how to deliver them, low referral rates to psychosocial oncology care, low help-seeking behavior among men with advanced prostate cancer, lack of care coordination skills, and inadequate service capacity.

IMPLICATIONS FOR NURSING

Interprofessional support exists for a nurse-led supportive care intervention. Causes of low engagement with supportive care among men with advanced prostate cancer extend beyond gendered patterns of response.

Artificial Neural Network Correlation and Biostatistics Evaluation of Physiological and Molecular Parameters in Healthy Young Individuals Performing Regular Exercise

Studies support that regular physical activity (PA) decelerates senescence-related decline of physiological and molecular parameters in the elderly. We have addressed the other end of this spectrum: healthy and young, inactive individuals participated in a 6-month long personal trainer-guided lifestyle program. We have measured physiological and molecular parameters (differentiating high- and low responders) and their correlation with PA (sedentary status). Cluster analysis helped to distinguish individuals with high- or low PA and differentiate high- and low-responders of each parameter. The assessed cardiovascular parameters (heart rate, blood pressure, 6-min walking distance, relative VO₂max), body composition parameters (body fat and muscle mass percentage) metabolic parameters (glucose, insulin, HDL, LDL), immune parameters (cortisol, CRP, lymphocyte counts, hTREC) all showed improvement. Artificial neural network analysis (ANN) showed correlation efficiencies of physiological and molecular parameters using a concept-free approach. ANN analysis appointed PA as the mastermind of molecular level changes. Besides sedentary status, insulin and hTREC showed significant segregation. Biostatistics evaluation also supported the schism of participants for their sedentary status, insulin concentration and hTREC copy number. In the future ANN and biostatistics, may predict individual responses to regular exercise. Our program reveals that high responder individuals of certain parameters may be low responders of others. Our data show that moderate regular PA is essential to counteract senescence in young and healthy individuals, despite individual differences in responsiveness. Such PA may not seem important in the everyday life of young and healthy adults, but shall become the base for healthy aging.

Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable

PURPOSE

The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.

METHODS

A second Roundtable was convened in 2018 to advance exercise recommendations beyond public health guidelines and toward prescriptive programs specific to cancer type, treatments, and/or outcomes.

RESULTS

Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain.

CONCLUSIONS

The proposed recommendations should serve as a guide for the fitness and health care professional working with cancer survivors. More research is needed to fill remaining gaps in knowledge to better serve cancer survivors, as well as fitness and health care professionals, to improve clinical practice.

Breast Cancer and Heart Failure

Heart failure and breast cancer have shared risks and morbidities. Multimodality therapies for breast cancer, including conventional chemotherapy, targeted therapeutics, radiation therapy, and hormonal agents, may make patients more susceptible to asymptomatic left ventricular dysfunction and clinical heart failure during and after treatment. New or preexisting left ventricular dysfunction may lead to interruptions in cancer treatment and limit options of breast cancer systemic therapy, leading to adverse outcomes. Early recognition and management of cardiovascular risk factors before, during, and after cancer treatment are of utmost importance. This review presents advances, challenges, and opportunities for cardiovascular care in contemporary breast cancer treatment.

Exercise as a diagnostic and therapeutic tool for the prevention of cardiovascular dysfunction in breast cancer patients

BACKGROUND

Anthracycline chemotherapy may be associated with decreased cardiac function and functional capacity measured as the peak oxygen uptake during exercise ( V·O2 peak). We sought to determine (a) whether a structured exercise training program would attenuate reductions in V·O2 peak and (b) whether exercise cardiac imaging is a more sensitive marker of cardiac injury than the current standard of care resting left ventricular ejection fraction (LVEF).

METHODS

Twenty-eight patients with early stage breast cancer undergoing anthracycline chemotherapy were able to choose between exercise training (mean ± SD age 47 ± 9 years, n = 14) or usual care (mean ± SD age 53 ± 9 years, n = 14). Measurements performed before and after anthracycline chemotherapy included cardiopulmonary exercise testing to determine V·O2 peak and functional disability ( V·O2 peak < 18 ml/min/kg), resting echocardiography (LVEF and global longitudinal strain), cardiac biomarkers (troponin and B-type natriuretic peptide) and exercise cardiac magnetic resonance imaging to determine stroke volume and peak cardiac output. The exercise training group completed 2 × 60 minute supervised exercise sessions per week.

RESULTS

Decreases in V·O2 peak during chemotherapy were attenuated with exercise training (15 vs. 4% reduction, P = 0.010) and fewer participants in the exercise training group met the functional disability criteria after anthracycline chemotherapy compared with those in the usual care group (7 vs. 50%, P = 0.01). Compared with the baseline, the peak exercise heart rate was higher and the stroke volume was lower after chemotherapy ( P = 0.003 and P = 0.06, respectively). There was a reduction in resting LVEF (from 63 ± 5 to 60 ± 5%, P = 0.002) and an increase in troponin (from 2.9 ± 1.3 to 28.5 ± 22.4 ng/mL, P < 0.0001), but no difference was observed between the usual care and exercise training group. The baseline peak cardiac output was the strongest predictor of functional capacity after anthracycline chemotherapy in a model containing age and resting cardiac function (LVEF and global longitudinal strain).

CONCLUSIONS

The peak exercise cardiac output can identify patients at risk of chemotherapy-induced functional disability, whereas current clinical standards are unhelpful. Functional disability can be prevented with exercise training.