Quality of life and fatigue of patients with spinal bone metastases under combined treatment with resistance training and radiation therapy- a randomized pilot trial

Exercise in newly diagnosed patients with multiple myeloma: A randomized controlled trial of effects on physical function, physical activity, lean body mass, bone mineral density, pain, and quality of life

Reduced physical function caused by bone destruction, pain, anemia, infections, and weight loss is common in multiple myeloma (MM). Myeloma bone disease challenges physical exercise. Knowledge on the effects and safety of physical exercise in newly diagnosed patients with MM is limited. In a randomized, controlled trial, we studied the effect of a 10-week individualized physical exercise program on physical function, physical activity, lean body mass (LBM), bone mineral density (BMD), quality of life (QoL), and pain in patients newly diagnosed with MM. Lytic bone disease was assessed, and exercise was adjusted accordingly. Primary outcome: knee extension strength. Secondary outcomes: Six-Minute-Walk-Test, 30-s Sit-to-Stand-Test (SST), grip strength, level of physical activity, LBM, BMD, QoL, and pain. Measurements were conducted pre- and post-intervention, and after 6 and 12 months. We included 100 patients, 86 were evaluable; 44 in the intervention group (IG) and 42 in the control group (CG). No statistically significant differences between groups were observed. Knee extension strength declined in the IG (p = .02). SST, aerobic capacity, and global QoL improved in both groups. Pain decreased consistently in the IG regardless of pain outcome. No significant safety concerns of physical exercise in newly diagnosed patients with MM were observed.

Physical Activity in Patients with Advanced Cancer: Sociodemographic, Clinical, and Psychological Correlates

As cancer progresses, patients may experience physical decline, which can impair their ability to carry out essential daily tasks. The aim of this study was to analyze the levels of physical activity in patients with advanced cancer undergoing systemic treatment and its relationship with sociodemographic, clinical, and psychological factors. A prospective, cross-sectional, multicenter study was carried out in 15 oncology departments in Spain. Patients with locally advanced, unresectable, or metastatic cancer who were candidates for systemic treatment were included. Participants completed demographic information and psychological scales. In total, 508 patients were included in the study, the majority of whom were male, over the age of 65, and diagnosed with bronchopulmonary tumors (36%) and metastatic disease. Based on their physical activity levels, participants were categorized as sedentary (20%, n = 190), engaging in light physical activity (43%, n = 412), or demonstrating moderate physical activity (37%, n = 351). Patients who were over 65 years old; had a worse baseline status (ECOG ≥ 1); lacked a partner; had a lower educational level; or were retired or unemployed were found to have lower levels of physical activity. Those with sedentary physical activity reported higher levels of psychological distress, anxiety, depression, somatization, and physical symptoms, as well as worse functional status, global health status, and well-being. Understanding the complex interplay between physical activity and sociodemographic, clinical, and psychological factors can help neuroscientists develop tailored exercise interventions that address the unique needs of advanced cancer patients.

Efficacy of aerobic and resistance exercises on cancer pain: A meta-analysis of randomised controlled trials

Purpose

To evaluate effects of aerobic and resistance exercises for cancer-related pain in adults with and surviving cancer. Secondary objectives were to a) evaluate the effect of exercise on fatigue, psychological function, physical function, b) assess fidelity to exercise.

Design

A systematic search of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Central Register of Controlled Trials was conducted to identify randomised controlled trials (RCTs) comparing aerobic and/or resistance exercise to control groups. The primary endpoint were changes in cancer-related pain intensity from baseline to post intervention. Meta-regression analysis evaluated predictors for heterogeneity between study findings. Tolerability was defined as reporting of exercise-induced adverse events while fidelity evaluated by reported intervention dropout.

Results

Twenty-three RCTs including 1954 patients (age 58 ± 8.5 years; 78 % women); 1087 (56 %) and 867 (44 %) allocated to aerobic/resistance exercise therapy and control group, respectively. Exercise therapy was associated with small to moderate decreases in cancer-related pain compared to controls (SMD = 0.38, 95 % CI: 0.17, 0.58). Although there was significant heterogeneity between individual and pooled study effects (Q = 205.25, p < 0.0001), there was no publication bias. Meta-regression including supervision, age, duration and exercise type as moderators showed no significant differences in reported outcomes. Analysis of secondary outcomes revealed a moderate effect for improvements in physical function, fatigue and psychological symptoms.

Conclusions

Aerobic and resistance exercises are tolerable and effective adjunct therapies to reduce cancer-related pain while also improving physical function, fatigue and mood. Future RCTs of dose, frequency, compliance and exercise type in specific cancer settings are required.

Assessment of Integrative Therapeutic Methods for Improving the Quality of Life and Functioning in Cancer Patients-A Systematic Review

Background: Cancer rehabilitation represents a series of measures adopted for the recovery of psychological, emotional, social, and financial functioning in the case of cancer patients. The purpose of this study is to identify the main elements of therapeutic management in the field of medical rehabilitation, as well as integrative, complementary medicine and holistic approaches that can be performed on the oncological patient. Methods: This systematic literature review follows the methodology outlined in the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" ("PRISMA") statement, which is an internationally recognized and widely accepted standard. Results: Active rehabilitative therapies offer therapeutic options for improving the functioning and quality of life of oncological patients; these therapies comprehensively address both the physical and psychological aspects of the disease. This review also includes the latest novelties and nanotechnologies applied in oncological rehabilitation, for example, drugs (or supplements) inspired by nature. Conclusions: Physical and rehabilitation medicine, mostly using stimulating therapeutic methods, was recently added to the list of contraindications in the management of oncological patients, both as an approach to the pathological concept itself and as an approach to the main clinical consequences and functional aspects of oncological therapies. Integrative, complementary medicine presents an important therapeutic resource in the case of oncological patients. Advanced studies are needed in the future to further ascertain the role of these therapies.

Exercise Intervention for Bone Metastasis: Safety, Efficacy and Method of Delivery

Background: The benefits of exercise for patients with cancer are well-established, however, for patients with bone metastases, exercise as adjuvant therapy is underutilised due to concerns for safety, efficacy and other barriers such as the method of delivery. This scoping review explores these barriers by reviewing the results of clinical trials conducted on participants with bone metastases. Methods: A thorough literature search was undertaken using PubMed, Scopus, NIH Clinical Trials and Google Scholar databases. Articles that involved an exercise intervention and patients with bone metastases were included. Data were pooled, charted, analysed and reported according to PRISMA-ScR standards. Results: A total of 26 trials were reviewed with interventions that included aerobic and resistance training. Only three serious adverse events occurred, not likely related to bone metastases. Nine trials (34.6%) involved unsupervised exercise sessions. Remote exercise delivery had an average of 80.3% compliance, rivalling in-person and mixed supervision. The results of this review reaffirm that exercise helps improve functional capacity, muscle strength, lean mass and cardiovascular function, and is safe in patients with bone metastases irrespective of in-person or remote delivery. Conclusions: Exercise therapy, whether delivered in person or remotely, is safe and efficacious for patients with bone metastases.

Exercise interventions for adults with cancer receiving radiation therapy alone

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Exercise and Bone Health in Cancer: Enemy or Ally?

Bone health is often threatened in cancer patients. Bone metastasis and osteoporosis frequently occur in patients with cancer and may lead to different skeletal-related events, which may negatively affect patients' quality of life and are associated with high mortality risk. Physical exercise has been recognized as a potential adjunctive strategy in the cancer setting to improve physical function as well as treatment-related side effects. Nevertheless, exercise is often not recommended to patients with bone health impairments due to safety concerns. In the current review, we aimed, through a comprehensive review of the evidence, to explore the impact of exercise in terms of safety profile, bone outcomes, and the effects on other outcomes in patients with cancer affected by bone metastasis or at high risk of losing bone. Additionally, we explored the potential mechanisms by which exercise may act on bone, particularly the impact of mechanical load on bone remodeling. Finally, considerations about exercise prescription and programming in these populations are also discussed.

Physical Activity as the Best Supportive Care in Cancer: The Clinician's and the Researcher's Perspectives

Multidisciplinary supportive care, integrating the dimensions of exercise alongside oncological treatments, is now regarded as a new paradigm to improve patient survival and quality of life. Its impact is important on the factors that control tumor development, such as the immune system, inflammation, tissue perfusion, hypoxia, insulin resistance, metabolism, glucocorticoid levels, and cachexia. An increasing amount of research has been published in the last years on the effects of physical activity within the framework of oncology, marking the appearance of a new medical field, commonly known as "exercise oncology". This emerging research field is trying to determine the biological mechanisms by which, aerobic exercise affects the incidence of cancer, the progression and/or the appearance of metastases. We propose an overview of the current state of the art physical exercise interventions in the management of cancer patients, including a pragmatic perspective with tips for routine practice. We then develop the emerging mechanistic views about physical exercise and their potential clinical applications. Moving toward a more personalized, integrated, patient-centered, and multidisciplinary management, by trying to understand the different interactions between the cancer and the host, as well as the impact of the disease and the treatments on the different organs, this seems to be the most promising method to improve the care of cancer patients.

Benefícios e Segurança dos Exercícios Físicos em Pacientes com Metástases Ósseas: Revisão Sistemática da Literatura e Metanálise

Introdução: A expectativa de vida de pessoas com câncer metastático está aumentando, mas esse grupo de pacientes corre um risco considerável de apresentar problemas psicológicos e de saúde física. Nesse sentido, o exercício físico tem sido um aliado no tratamento de pacientes com metástases ósseas. Objetivo: Realizar uma revisão sistemática e metanálise sobre a segurança e os benefícios do exercício físico em pacientes com metástases ósseas. Método: Metanálise com pesquisa bibliográfica realizada nas bases eletrônicas: PubMed, LILACS, PEDro e Embase. Resultados: Dos 396 estudos, somente dez foram incluídos, com um total de 531 indivíduos. Não foi observado nenhum efeito adverso musculoesquelético durante a intervenção, sendo significativamente seguro o exercício em indivíduos com metástases ósseas. Não houve melhora considerável na capacidade aeróbica, progressão da doença, qualidade de vida, massa magra e gordura corporal. Três dos estudos incluídos avaliaram a dor durante e após a intervenção, demonstrando melhora no escore de dor, assim como a diminuição do uso do analgésico no grupo intervenção. Conclusão: A terapia com exercícios aeróbicos e isométricos e segura para pacientes com metástases ósseas, além de apresentar melhora da dor, mas sem evolução relevante na capacidade aeróbica, na progressão da doença, na massa corporal e na qualidade de vida.

Fracture risk in breast cancer: Does obesity have an effect? A scoping review

Background

Metastasis from breast cancer (BC) has a predilection for the skeleton. Due to its osteolytic nature, breast cancer bone metastasis (BCBM) appears to increase fracture risk. The association between obesity and its effect on bone seems to be skeletal site-specific. The incidence of pathological fractures often involves the axial skeleton even though the most debilitating effects of fractures are caused in the appendicular skeleton. Whether obesity increases fracture risk in BCBM remains inconclusive, however. At present, there is no literature that examines the effects of obesity on BCBM, and fracture risk are as such we sought to determine the effect of obesity on fracture risk in BC. This is the focus of the review.

Objectives

This scoping review aims to examine the link between fracture outcomes of women with BC and obesity as reported by Body Mass Index (BMI). The purpose of this study is to determine if current literature suggests obesity increases fracture risk in women with BC.

Design

We conducted a comprehensive literature search for breast cancer bone metastasis, obesity, and fracture risk in PubMed, Cochrane Library, NIH Clinical Trials, and OpenGrey. Articles that included BC, obesity, and fracture risk were included for analysis. Data were pooled, charted, analysed, and reported according to PRISMA-ScR standards.

Data synthesis and results

Each outcome was stratified by BMI (obese or non-obese) status in women with breast cancer. Five studies were eligible for analysis and relevant data was charted to allow results to be synthesised. We found four out of five studies reported a positive association between BMI and fracture risk in females with breast cancer.

Conclusions

We found a potential association of obesity and fracture risk in breast cancer. However, as we conducted this study it was evident that there is limited literature available on this topic and none for breast cancer bone metastasis. This poses an important direction for future research. Larger and robust pre-clinical and clinical randomized control trials are needed to better understand the relation between obesity and metastatic breast cancer.

Efeitos de Abordagens não Farmacológicas nos Sintomas Físicos de Indivíduos com Câncer Avançado: Revisão Sistemática

Introdução: O câncer e um problema de saúde publica que, em estágios avançados, pode ocasionar desconfortos físicos, psicossociais e espirituais. Assim, abordagens fisioterapêuticas e as Práticas Integrativas e Complementares em Saúde (PICS) surgem como ferramentas importantes para o controle e melhora de sintomas físicos nesses indivíduos. Objetivo: Descrever os efeitos de abordagens não farmacológicas, envolvendo técnicas fisioterapêuticas e PICS, nos sintomas físicos de indivíduos com câncer avançado. Método: Revisão sistemática da literatura composta por ensaios clínicos randomizados que abordassem os efeitos de abordagens fisioterapêuticas ou PICS nos sintomas físicos de indivíduos diagnosticados com câncer avançado. Foram selecionadas as bases de dados PubMed, LILACS, PEDro, Cochrane, SciELO, e a última busca ocorreu em abril de 2021. A avaliação da qualidade metodológica dos estudos foi realizada por meio da escala PEDro. Resultados: Vinte e dois estudos foram incluídos, e demonstraram que ambas as abordagens tem efeitos positivos para os sintomas físicos, como fadiga e dor, na população estudada. Conclusão: A fisioterapia e as PICS tem efeitos positivos nos sintomas físicos em indivíduos com diagnostico de câncer avançado. No entanto, existem poucos estudos com qualidade metodológica suficiente para confirmar a eficácia das duas abordagens nos desfechos estudados para essa população.

Rehabilitation in Advanced Cancer Patients with Bone Metastases and Neural Compromise: Current Status and Future Directions

PURPOSE OF REVIEW

This review aimed to increase the understanding of oncologists and physiatrists about the necessity, efficacy, and safety of rehabilitation in advanced cancer patients with bone metastases and neural compromise.

RECENT FINDINGS

Recently, there are growing evidence supporting the safety and efficacy of rehabilitation in patients with bone metastases and neural compromise. Despite the potential benefits of rehabilitation, however, rehabilitative services are considerably underutilized in clinical practice. Many oncologists are not familiar with functional issues and have limited understanding of the available rehabilitative services. Moreover, medical professionals, even physiatrists, have uncertainties and concerns about skeletal complications and often regard rehabilitation as a contraindication in this patient group. This review aimed to raise awareness on the role of rehabilitation in the continuum of cancer treatment, to improve its use in clinical practice. A multidisciplinary team approach involving physiatrist may facilitate integration of relevant clinicians.

A Systematic Review of the Safety, Feasibility and Benefits of Exercise for Patients with Advanced Cancer

Simple Summary

Most advanced cancer patients suffer from severe symptoms due to cancer and medical treatment. Common symptoms are physical weakness, mental problems, and tiredness. Research has shown that exercise positively influences cancer-related side effects during and after treatment and longevity in cancer survivorship. However, exercise as a supportive therapy in advanced cancer patients is still not recommended in oncological guidelines. Therefore, the aim of this systematic review was to assess the safety, feasibility, and benefits of exercise for patients with advanced cancer. Based on the results of 14 included exercise intervention studies, we conclude that exercise is safe and feasible, seems to improve physical performance, and may lower symptoms like chronic tiredness. Early integration of exercise for advanced cancer patients should be considered as usual care as a supportive strategy.

Abstract

Exercise therapy is a common supportive strategy in curative cancer treatment with strong evidence regarding its positive effects on, for example, cancer-related fatigue, health- related quality of life, and physical function. In the field of advanced cancer patients, knowledge about exercise as a useful supportive strategy is missing. The aim of this systematic review was to evaluate the feasibility and safety of exercise interventions as well as its effects on lowering the symptom burden. We included randomized controlled trials and nonrandomized controlled trials with advanced cancer patients receiving any type of exercise intervention. After an extensive literature search (in accordance to PRIMSA guidelines) in PubMed, Cochrane Library, and SPORTDiscus, 14 studies including 940 participants with different cancer entities were eligible. The results indicated the safety of exercise. In total, 493 participants received exercise interventions, with nine adverse events and no severe adverse events. The median recruitment rate was 68.33%, and adherence to exercise intervention was 86%. Further research with a high-quality and larger sample size is needed to clarify the potential of exercise with advanced cancer patients. Different advanced cancer entities have distinguished symptoms, and future research should construct entities-specific trial populations to figure out the best supportive exercise interventions.

Exercise for individuals with bone metastases: A systematic review

BACKGROUND

Exercise has the potential to improve physical function and quality of life in individuals with bone metastases but is often avoided due to safety concerns. This systematic review summarizes the safety, feasibility and efficacy of exercise in controlled trials that include individuals with bone metastases.

METHODS

MEDLINE, Embase, Pubmed, CINAHL, PEDro and CENTRAL databases were searched up to July 16, 2020.

RESULTS

A total of 17 trials were included incorporating aerobic exercise, resistance exercise or soccer interventions. Few (n = 4, 0.5%) serious adverse events were attributed to exercise participation, with none related to bone metastases. Mixed efficacy results were found, with exercise eliciting positive changes or no change. The majority of trials included an element of supervised exercise instruction (n = 16, 94%) and were delivered by qualified exercise professionals (n = 13, 76%).

CONCLUSIONS

Exercise appears safe and feasible for individuals with bone metastases when it includes an element of supervised exercise instruction.

Every Day Counts: a randomized pilot lifestyle intervention for women with metastatic breast cancer

PURPOSE

To explore the feasibility, adherence, safety and potential efficacy of Every Day Counts; a randomized pilot trial designed for women with metastatic breast cancer (MBC) framed by the American Cancer Society nutrition and physical activity (PA) guidelines METHODS: Women with clinically stable MBC were recruited to complete an interview, dual energy X-ray absorptiometry imaging and phlebotomy at baseline and post-intervention. Multidimensional quality of life, symptom burden, lifestyle behaviors (nutrition and PA) and biomarkers of prognosis were procured and quantified. Women were randomized to the immediate intervention or a waitlist control arm. The 12-week intervention included a curriculum binder, lifestyle coaching (in-person and telephone-based sessions) and intervention support (activity monitor, text messaging, cooking classes.) Women in the waitlist control were provided monthly text messaging.

RESULTS

Forty women were recruited within 9 months (feasibility). Women in the immediate intervention attended 86% of all 12 weekly coaching sessions (adherence) and showed significant improvements in general QOL (p = 0.001), and QOL related to breast cancer (p = 0.001), endocrine symptoms (p = 0.002) and fatigue (p = 0.037), whereas the waitlist control did not (all p values ≥ 0.05) (efficacy). PA significantly increased for women in the intervention compared to control (p < 0.0001), while dietary changes were less evident across groups due to high baseline adherence. No significant changes in biomarkers or lean mass were noted, yet visceral adipose tissue declined (p = 0.001). No intervention-related injuries were reported (safety). Qualitative feedback strongly supports the desire for a longer intervention with additional support.

CONCLUSIONS

Lifestyle interventions are of interest, safe and potentially beneficial for women with MBC. A larger trial is warranted.

Spinal Stabilization Exercises for Cancer Patients with Spinal Metastases of High Fracture Risk: Feasibility of the DISPO-II Training Program

Simple Summary

Previous research indicates that the outcomes of irradiation of spinal metastases can be improved through exercise. After this was demonstrated for metastases of low fracture risk, we conducted the first study in patients with spinal metastases of high fracture risk to investigate exercise feasibility. An exercise group performed four spinal stabilization exercises daily over two weeks of radiotherapy, while a control group received relaxation. Patients in the exercise group attended 90% of training sessions, compared to 80% in the control group. No injuries occurred. However, about half of the patients could not perform two out of the four exercises due to pain, weakness or immobility. Nevertheless, they increased exercise time and training-specific strength. Altogether, exercise is well accepted and enhances muscle strength in these patients, but frequent individual adaptations of the training program are needed. This knowledge is a prerequisite for larger studies addressing exercise effects on health.

Abstract

Exercise concomitant to radiotherapy for stable spinal metastases was demonstrated to increase bone density and reduce pain. In the DISPO-II study, the feasibility of exercise concomitant to radiotherapy for unstable spinal metastases was investigated. Here, a detailed analysis of the training program is presented. Cancer patients with spinal metastases (Taneichi score ≥ D) were randomly assigned to an intervention group (INT, n = 27, 62 ± 9 years) or control group (CON, n = 29, 61 ± 9 years). INT performed spinal stabilization exercises (“all fours”/“plank”/“swimmer”/“band exercise”), and CON received relaxation, daily concomitant to radiotherapy. Exercise attendance rate was 90% in INT and 80% in CON (p = 0.126). Within INT, exercise dose increased significantly (p < 0.001). 54% of patients could not perform “swimmer” in some or all sessions. 42% could not perform “plank” in some or all sessions. 13 and 25% could not perform “all fours” and “band exercise” in some sessions. “Plank” holding time increased in INT and remained unchanged in CON with different development between groups (p = 0.022). Handgrip strength did not develop differently between groups (p = 0.397). The exercise intervention demonstrated high acceptability but required frequent modifications due to pain, weakness and immobility to be feasible for the majority of participants. It enhanced specific muscle strength. Larger trials should now investigate exercise effects on health.

The Effect of Exercise on Quality of Life, Fatigue, Physical Function, and Safety in Advanced Solid Tumor Cancers: A Meta-analysis of Randomized Control Trials

BACKGROUND

People with metastatic cancers experience poor quality of life (QoL), fatigue, and decreased physical function. Exercise improves these symptoms in the curative setting, but the efficacy and safety of exercise in the metastatic setting is uncertain.

METHODS

Prospective, randomized trials of moderate/high-intensity aerobic exercise or resistance training vs. control in patients with advanced/metastatic solid cancers were identified from prior reviews and updated using a search of PubMed. The mean and SD for validated outcome measures (QoL, physical function, and fatigue) were extracted for intervention and control groups at baseline and postintervention. The Mann-Whitney test was used to evaluate the effect of exercise on the pooled change between baseline and postintervention. Safety was evaluated qualitatively.

RESULTS

Sixteen trials were analyzed. Among patients with scores at the mean or 2SD above, exercise was not associated with significant or clinical difference in QoL or fatigue. In patients with baseline scores 2SD below mean, exercise was associated with nonsignificant difference meeting minimal clinical important difference in QoL (-2.8 vs. 4.6, P = 0.28). For function, patients at the mean had nonstatistically significant, but clinically meaningful difference in the six-minute walk test (6-MWT) (14.7 vs. 29.0 m, P = 0.44). In patients 2 SD below the mean, there was a clinically meaningful difference in two patient-reported functional subscales (0.1 vs. 5.3, P = 0.076 and 0.44 vs. 8.5, P = 0.465) and a clinically meaningful improvement in the 6-MWT (-7.5 vs. 27.0 m, P = 0.34), although none of these associations met statistical significance. There were no differences in falls, fractures, or pain.

DISCUSSION

Exercise is associated with clinically meaningful improvements in QoL, function, and 6-MWT in some patients with metastatic cancer. Despite poor reporting of safety, there was no signal of increased harm from exercise in this setting.

Fatigue in the general population: German normative values of the EORTC QLQ-FA12

PURPOSE

Fatigue is a frequent symptom in patients suffering from chronic diseases, especially cancer patients. A new fatigue questionnaire was recently developed to better assess this condition, the EORTC QLQ-FA12. The aims of this study were to test the psychometric properties of this fatigue questionnaire and to provide normative values.

METHODS

A total of 2411 individuals (53.5% women), representatively selected from the German general population, responded to the EORTC QLQ-FA12 questionnaire.

RESULTS

Women reported more fatigue than men on all three scales of the EORTC QLQ-FA12 with the following effect sizes: d = 0.29 (physical fatigue), d = 0.22 (emotional fatigue), and d = 0.11 (cognitive fatigue). There were no linear age trends. Confirmatory factorial analysis confirmed the latent structure of the questionnaire. The correlations among the latent scales were between 0.71 and 0.84. The internal consistency coefficients were alpha = 0.92 (physical fatigue), 0.86 (emotional fatigue), 0.79 (cognitive fatigue), and 0.94 (sum score).

CONCLUSIONS

The study proved the psychometric quality of the EORTC QLQ-FA12 in the general population. Gender differences should be accounted for when comparing groups of patients. The normative scores can be used to qualify the assessment of the degree of patients' fatigue.

Psychometric Properties of the Fatigue Questionnaire EORTC QLQ-FA12 in a Sample of Female Cancer Patients

CONTEXT

Cancer patients frequently suffer from fatigue. Recently, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life group developed a new 12-item fatigue assessment instrument.

OBJECTIVES

The aim of this study was to psychometrically test this questionnaire in comparison with the three-item fatigue scale of the EORTC QLQ-C30.

METHODS

A sample of 354 patients who were being treated for breast cancer or gynecologic cancer were examined using the new fatigue questionnaire EORTC QLQ-FA12 and the EORTC QLQ-C30 during their hospital stay (t1) and three months after hospital discharge (t2). Confirmatory factorial analyses, item analyses, test-retest reliability analyses, and correlation analyses were performed.

RESULTS

The analyses roughly supported the three-factorial structure of the FA12, which comprised the subscales physical, emotional, and cognitive fatigue. The fit indices of the confirmatory factorial analysis were worse than those of the original article but nevertheless acceptable. Cronbach alpha of the total scale was 0.92; the coefficients of the subscales were between 0.79 and 0.93. The correlation between the EORTC QLQ-FA12 total scale and the fatigue scale of the EORTC QLQ-C30 was 0.69 and the correlation between the t1 and t2 scores was 0.45 for the EORTC QLQ-FA12 total scale and between 0.37 and 0.47 for the subscales.

CONCLUSION

The psychometric coefficients justify the calculation of a sum score, which can be used by clinicians to assess the general degree of fatigue. Although the three-item fatigue scale of the EORTC QLQ-C30 stresses the physical aspect of fatigue, the new EORTC QLQ-FA12 covers its emotional and cognitive aspects as well.

Safety and feasibility of exercise interventions in patients with advanced cancer: a systematic review

GOALS OF WORK

The beneficial effects of exercise in cancer patients are reasonably well-established, although research in this field has predominantly investigated cancer patients in the earlier stages of disease. However, the most recent evidence surrounding exercise interventions in advanced cancer populations has yet to be systematically evaluated. This review critically analyses the safety and feasibility of exercise interventions in patients with advanced cancer.

METHODS

All randomised, non-randomised and prospective observational trials of exercise training interventions in patients with advanced cancer were included. 'Safety' was defined as the number and severity of reported adverse events during exercise training. 'Feasibility' was determined by participant adherence, attendance and/or study completion rates.

RESULTS

A total of 25 studies involving 1088 patients were included: 16 randomised controlled and nine prospective observational cohort trials. Seven studies included advanced lung cancer patients exclusively, while eight involved patients with various cancer diagnoses. Aerobic exercise was investigated in five studies, resistance training in two studies and combination training (aerobic and resistance) in 14 studies. Six minor adverse events were reported due to exercise. All of these were musculoskeletal in nature, resulting in two participants' withdrawal from the study. Exercise adherence ranged from 65 to 89% but was only described in nine studies. Attendance at each exercise session was described in a further nine studies, ranging from 59 to 100%.

CONCLUSIONS

Implementation of exercise interventions appears to be safe and feasible in advanced cancer clinical practice, although targeted studies are required to determine the optimal exercise dose for specific cancer diagnoses.

Differentiated resistance training of the paravertebral muscles in patients with unstable spinal bone metastasis under concomitant radiotherapy: study protocol for a randomized pilot trial

BACKGROUND

Metastatic bone disease is a common and severe complication in patients with advanced cancer. Radiotherapy (RT) has long been established as an effective local treatment for metastatic bone disorder. This study assesses the effects of RT combined with muscle-training exercises in patients with unstable bone metastases of the spinal column from solid tumors. The primary goal of this study is to evaluate the feasibility of muscle-training exercises concomitant to RT. Secondly, quality of life, fatigue, overall and bone survival, and local control will be assessed.

METHODS/DESIGN

This study is a single-center, prospective, randomized, controlled, explorative intervention study with a parallel-group design to determine multidimensional effects of a course of exercises concomitant to RT on patients who have unstable metastases of the vertebral column, first under therapeutic instruction and subsequently performed by the patients themselves independently for strengthening the paravertebral muscles. On the days of radiation treatment the patients will be given four different types of exercises to ensure even isometric muscle training of all the spinal muscles. In the control group progressive muscle relaxation will be carried out parallel to RT. The patients will be randomized into two groups: differentiated muscle training or progressive muscle relaxation with 30 patients in each group.

DISCUSSION

Despite the clinical experience that RT is an effective treatment for bone metastases, there is insufficient evidence for a positive effect of the combination with muscle-training exercises in patients with unstable bone metastases. Our previous DISPO-1 trial showed that adding muscle-training exercises to RT is feasible, whereas this was not proven in patients with an unstable spinal column. Although associated with several methodological and practical challenges, this randomized controlled trial is needed.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02847754 . Registered on 27 July 2016.

Evaluation of health-related quality of life and its main influencing factors in a Polish population of patients with bone metastases

PURPOSE

Regardless of cancer type, the skeleton is one of the most common sites for cancer spread. Health-related Quality of Life (HRQoL) can be considered a primary endpoint in clinical trials concerning cancer patients with palliative disease. The proper measurement of this endpoint requires valid and reliable instruments. The aim of this study was to evaluate HRQoL and its main influencing factors using validated EORTC tools - the QLQ-C30 and the QLQ-BM22 in Polish population of patients with skeletal metastases.

METHODS

Patients with bone metastases and histologically confirmed malignancy were qualified for the study. They filled out a personal questionnaire, the Polish version of the EORTC QLQ-C30 and its supplementary module QLQ-BM22. The influence of numerous socio-clinical factors such as age, gender, working status, level of education, performance status, primary location, and previous treatment received was assessed.

RESULTS

One hundred and ten patients (65 women) were enrolled into this study (mean age ±SD; 57.8±13.8). The most significant HRQoL issues were fatigue (59.29/100); pain (56.97/100) and insomnia (56.36/100). Men coped worse with pain (p=0.013), fatigue (p=0.050), nausea and vomiting (p=0.024) and financial difficulties (p=0.016) than women.

CONCLUSIONS

The main factors influencing HRQoL in Polish patients with bone metastases are fatigue, pain and insomnia, and as such should be a primary focus of patient-centered care in this group.

Resistance training concomitant to radiotherapy of spinal bone metastases - survival and prognostic factors of a randomized trial

Purpose

To compare the effects of resistance training versus passive physical therapy on bone survival in the metastatic bone during radiation therapy (RT) as combined treatment in patients with spinal bone metastases. Secondly, to evaluate overall survival and progression-free-survival (PFS) as well as to quantify prognostic factors of bone survival after combined treatment.

Methods

In this randomized trial 60 patients were allocated from September 2011 until March 2013 into one of the two groups: resistance training (group A) or passive physical therapy (group B) with thirty patients in each group during RT. We estimated patient survival using Kaplan-Meier survival method. The Wald-test was used to evaluate the prognostic importance of pathological fracture, primary site, Karnofsky performance status, localization of metastases, number of metastases, and cerebral metastases.

Results

Median follow-up was 10 months (range 2–35). Bone survival showed no significant difference between groups (p = .303). Additionally no difference between groups could be detected in overall survival (p = .688) and PFS (p = .295). Local bone progression was detected in 16.7 % in group B, no irradiated bone in group A showed a local progression over the course (p = 0.019). In univariate analysis breast cancer, prostate cancer, and the presence of cerebral metastases had a significant impact on bone survival in group B, while no impact could be demonstrated in group A.

Conclusions

In this group of patients with spinal bone metastases we were able to show that guided resistance training of the paravertebral muscles had no essential impact on survival concomitant to RT. Importantly, no local bone progression in group A was detected, nevertheless no prognostic factor for combined treatment could be evaluated.

Trial registration

Clinical trial identifier NCT 01409720. Registered 8 February 2011.

Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: a systematic review and meta-regression

QUESTION

Is there a dose-response effect of exercise on inflammation, fatigue and activity in cancer survivors?

DESIGN

Systematic review with meta-regression analysis of randomised trials.

PARTICIPANTS

Adults diagnosed with cancer, regardless of specific diagnosis or treatment.

INTERVENTION

Exercise interventions including aerobic and/or resistance as a key component.

OUTCOME MEASURES

The primary outcome measures were markers of inflammation (including C-reactive protein and interleukins) and various measures of fatigue. The secondary outcomes were: measures of activity, as defined by the World Health Organization's International Classification of Functioning, Disability and Health, including activities of daily living and measures of functional mobility (eg, 6-minute walk test, timed sit-to-stand and stair-climb tests). Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Forty-two trials involving 3816 participants were included. There was very low-quality to moderate-quality evidence that exercise results in significant reductions in fatigue (SMD 0.32, 95% CI 0.13 to 0.52) and increased walking endurance (SMD 0.77, 95% CI 0.26 to 1.28). A significant negative association was found between aerobic exercise intensity and fatigue reduction. A peak effect was found for moderate-intensity aerobic exercise for improving walking endurance. No dose-response relationship was found between exercise and markers of inflammation or exercise duration and outcomes. Rates of adherence were typically high and few adverse events were reported.

CONCLUSIONS

Exercise is safe, reduces fatigue and increases endurance in cancer survivors. The results support the recommendation of prescribing moderate-intensity aerobic exercise to reduce fatigue and improve activity in people with cancer.

REVIEW REGISTRATION

PROSPERO CRD42015019164.

Spinal bone metastases in gynecologic malignancies: a retrospective analysis of stability, prognostic factors and survival

Background

The aim of this retrospective study was to evaluate the stability of spinal metastases in gynecologic cancer patients (pts) on the basis of a validated scoring system after radiotherapy (RT), to define prognostic factors for stability and to calculate survival.

Methods

Fourty-four women with gynecologic malignancies and spinal bone metastases were treated at our department between January 2000 and January 2012. Out of those 34 were assessed regarding stability using the Taneichi score before, 3 and 6 months after RT. Additionally prognostic factors for stability, overall survival, and bone survival (time between first day of RT of bone metastases and death from any cause) were calculated.

Results

Before RT 47% of pts were unstable and 6 months after RT 85% of pts were stable. Karnofsky performance status (KPS) >70% (p = 0.037) and no chemotherapy (ChT) (p = 0.046) prior to RT were significantly predictive for response. 5-year overall survival was 69% and 1-year bone survival was 73%.

Conclusions

RT is capable of improving stability of osteolytic spinal metastases from gynecologic cancer by facilitating re-ossification in survivors. KPS may be a predictor for response. Pts who received ChT prior to RT may require additional bone supportive treatment to overcome bone remodeling imbalance. Survival in women with bone metastases from gynecologic cancer remains poor.