The effect of a pre- and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): Study protocol for a randomised controlled trial

Impact of nutrition risk index, prognostic nutritional index and skeletal muscle index on early myelosuppression of first-line chemotherapy in stage IV gastric cancer patients

BACKGROUND

In gastric cancer (GC) patients, malnutrition is common and has a negative impact on treatment tolerance, survival, and prognosis. The purpose of this study was to explore the relationship between prechemotherapy nutritional state and early myelosuppression in stage IV GC patients treated with first-line chemotherapy.

METHODS

This retrospective study included patients with stage IV GC who received first-line chemotherapy between July 2012 and December 2021. Clinical and laboratory data were collected within 1 week before chemotherapy to calculate nutrition risk index, prognostic nutritional index. Pretreatment abdominal computed tomography scans were used to quantify skeletal muscle index (SMI). The main measurable outcome was the incidence of grade ≥ 2 early myelosuppression after chemotherapy.

RESULTS

Among 102 patients eligible for analysis, 50% were malnourished, 50% were poor prognoses and 49% were sarcopenic at baseline.The side effects were generally well managed, with a 26.5% occurrence of grade 3/4 side effects. Pre-chemotherapy patients with low Nutrition Risk Index (NRI) (p = 0.002), low prognostic nutritional index (PNI) (p = 0.001), and low SMI (p = 0.001) had significantly higher incidences of grade ≥ 2 myelosuppression occurred after the first cycle of chemotherapy. Moreover, the high level of PNI was associated with higher completion rate of chemotherapy (p = 0.01). Multivariate logistic regression analysis revealed that SMI at baseline (p = 0.006) and hemoglobin level (p = < 0.001) were prognostic factors for grade ≥ 2 early myelosuppression.

CONCLUSION

Stage IV GC patients with low NRI, low PNI and low SMI experienced significantly more grade ≥ 2 early myelosuppression during the first line of chemotherapy.

The effect of a pre- and post-operative exercise program versus standard care on physical activity and sedentary behavior of patients with esophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (the PERIOP-OG Trial): a randomized controlled trial†

Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged ≥18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey.

The effect of a pre-operative and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (the PERIOP-OG trial): a randomized controlled trial

INTRODUCTION

Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise programme on patient fitness during and after the neoadjuvant window.

METHODS

A pragmatic, randomized controlled multicentre trial was undertaken in three centres. Inclusion criteria were patients aged at least 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery time point using the 6-minute walk test (MVT). Secondary endpoints included a hand dynamometer, 10-s sit-to-stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing the quality of life, surgical fear, general self-efficacy and mastery.

RESULTS

Between March 2019 and December 2020, 71 participants were recruited: EX ( n =36) or UC ( n =35). From baseline to pre-surgery, the difference-in-difference (DID) for EX showed a significant improvement in 6MWT of 50.7 m ( P =0.05) compared to UC [mean (SD): 522.1 m (+/-104.3) to 582.1 m (+/-108) vs. 497.5 m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures.

CONCLUSIONS

This community exercise prehabilitation programme significantly improves physical fitness for surgery, is feasible and provides a standardized framework for the prescription of exercise in oesophagogastric cancer patients undergoing NCT.

Exercise as a Promising Agent against Cancer: Evaluating Its Anti-Cancer Molecular Mechanisms

BACKGROUND

Cancer cases are continuously increasing, while the prevalence rates of physical inactivity are also continuously increasing. Physical inactivity is a causative factor in non-communicable diseases, including cancer. However, the potential beneficial effects of exercise on cancer treatment have not received much attention so far. The aim of this study was to highlight the relationship between cancer and exercise on a molecular basis.

METHODS

Comprehensive and in-depth research was conducted in the most accurate scientific databases by using relevant and effective keywords.

RESULTS

The mechanisms by which exercise may reduce cancer risk and/or progression may include the metabolic profile of hormones, systemic inflammation reduction, insulin sensitivity increase, antioxidant capacity augmentation, the boost to the immune system, and the direct effect on the tumor. There is currently substantial evidence that the effect of exercise may predict a stronger association with cancer and could supplementarily be embedded in cancer clinical practice to improve disease progression and prognosis.

CONCLUSION

The field of this study requires interconnecting the overall knowledge of exercise physiology with cancer biology and cancer clinical oncology to provide the basis for personalized targeting strategies that can be merged with training as a component of a holistic co-treatment approach to optimize cancer healthcare.

Value of sarcopenia in the resection of colorectal liver metastases-a systematic review and meta-analysis

Introduction

Sarcopenia is defined as a decline in muscle function as well as muscle mass. Sarcopenia itself and sarcopenic obesity, defined as sarcopenia in obese patients, have been used as surrogates for a worse prognosis in colorectal cancer. This review aims to determine if there is evidence for sarcopenia as a prognostic parameter in colorectal liver metastases (CRLM).

Methods

PubMed, Embase, Cochrane Central, Web of Science, SCOPUS, and CINAHL databases were searched for articles that were selected in accordance with the PRISMA guidelines. The primary outcomes were overall survival (OS) and disease-free survival (DFS). A random effects meta-analysis was conducted.

Results

After eliminating duplicates and screening abstracts (n = 111), 949 studies were screened, and 33 publications met the inclusion criteria. Of them, 15 were selected after close paper review, and 10 were incorporated into the meta-analysis, which comprised 825 patients. No significant influence of sarcopenia for OS (odds ratio (OR), 2.802 (95% confidence interval (CI), 1.094-1.11); p = 0.4) or DFS (OR, 1.203 (95% CI, 1.162-1.208); p = 0.5) was found, although a trend was defined toward sarcopenia. Sarcopenia significantly influenced postoperative complication rates (OR, 7.905 (95% CI, 1.876-3.32); p = 0.001) in two studies where data were available.

Conclusion

Existing evidence on the influence of sarcopenia on postoperative OS as well as DFS in patients undergoing resection for CRLM exists. We were not able to confirm that sarcopenic patients have a significantly worse OS and DFS in our analysis, although a trend toward this hypothesis was visible. Sarcopenia seems to influence complication rates but prospective studies are needed.

Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know

As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.

An Irish Multi-Centre Study of Behaviours, Attitudes and Barriers to Exercise in Inflammatory Bowel Disease, a Survey from the Patient’s Perspective

Background: Physical activity (PA) in inflammatory bowel disease (IBD) has many potential favourable outcomes including anti-inflammatory effects, improvement in quality of life and improvements in patient body composition. It is recognised that patients with IBD have a significantly decreased exercise tolerance. Aim: 1. To assess physical activity levels, behaviours and barriers to PA in IBD. 2. To assess the likelihood of patients with IBD to engage in a community-based exercise programme. 3. To examine the presence of body image concerns in IBD. Method: Patient surveys were distributed in Beaumont and Connolly Hospitals between October and December 2021. Descriptive statistics, Chi-squared testing and Pearson’s correlations were completed using Minitab. p < 0.05 denoted statistical significance. Results: Data were recorded for a total of 203 patients. Out of all patients, 62% (n = 126) had Crohn’s disease (CD). Over half of the cohort were male (n = 115). Mean weight among females was 75 kg and 83 kg among males. Exercise behaviours: Out of all patients, 71% exercise regularly, on average for 59 min, 3.2 days/week. Walking was the most common form of PA (74%). A post-diagnosis change in exercise behaviour was found in 66% with three-quarters exercising less. The primary barrier to exercise was fatigue (54%). Female gender (p = 0.007) and age < 45 years (p = 0.02) were associated with body image dissatisfaction reported in 62% of patients. Conclusion: These data demonstrate the patient-reported impact of IBD on patient participation in PA. Concerns regarding body image were common and associated with gender and age. A feasibility study of a physician-derived exercise programme in patients with active IBD is underway in Beaumont Hospital to determine the effect on patient response to therapy, inflammation and body composition outcomes (NCT05174754).

Impact of a physician-led exercise programme on quality of life, muscle mass and clinical response in inflammatory bowel disease patients during induction with disease-modifying therapy: a study protocol

Introduction

Biologic and small-molecule therapies have revolutionised the treatment of moderate-to-severe inflammatory bowel disease (IBD). A significant proportion of patients experience early or delayed treatment failure. Patients with IBD with greater visceral obesity are less likely to respond to biologics. Sarcopenia has been identified as a predictor of disease severity and need for rescue therapy in acute severe ulcerative colitis. The aim of this study is to assess the feasibility of a physician-derived exercise programme in patients with IBD commencing biologic or small-molecule therapy in addition to the effect on physical fitness, body composition and objective measures of quality of life, fatigue scores and disease activity.

Methods and analysis

This is a randomised controlled feasibility study comparing the effects of a physician-derived exercise programme and standard medical care (biologic/small-molecule therapy) with standard care alone in patients with moderate to severe IBD. Patients with IBD in the intervention group will undergo a structured exercise programme for 20 weeks. Both IBD groups will carry out body composition, disease activity and quality-of-life assessments at baseline, week 12 and week 26. The primary objective is to assess the feasibility of the physician-derived exercise programme in patients with IBD commencing disease-modifying therapies. Secondary endpoints include a change in cardiorespiratory fitness, disease activity/inflammation, fatigue, health-related quality of life outcomes and body composition between the two IBD groups. Exploratory endpoints include validation of anterior thigh ultrasound for sarcopenia screening, assessment of proinflammatory cytokines and markers of immunometabolism.

Ethics and dissemination

This study has received ethical approval from the Beaumont Hospital Ethics committee on 22 October 2021 (reference number 21/21). Data generated or analysed during this study will be published as an article and supplementary appendix in relevant medical journals. The data will also be presented at national and international conferences.

Trial registration number

NCT05174754.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer

Radical cystectomy (RC) is the standard treatment for patients with advanced bladder cancer. Since RC is a highly invasive procedure, the surgical indications in an aging society must be carefully judged. In recent years, the concept of "frailty" has been attracting attention as a term used to describe fragility due to aging. We focused on the psoas muscle Hounsfield unit (PMHU) and analyzed its appropriateness as a prognostic factor together with other clinical factors in patients after RC. We retrospectively analyzed the preoperative prognostic factors in 177 patients with bladder cancer who underwent RC between 2008 and 2020. Preoperative non-contrast computed tomography axial image at the third lumbar vertebral level was used to measure the mean Hounsfield unit (HU) and cross-sectional area (mm²) of the psoas muscle. Univariate analysis showed significant differences in age, sex, clinical T stage, and PMHU. In multivariate analysis using the Cox proportional hazards model, age (hazard ratio (HR) = 1.734), sex (HR = 2.116), cT stage (HR = 1.665), and PMHU (HR = 1.758) were significant predictors for overall survival. Furthermore, using these four predictors, it was possible to stratify the prognosis of patients after RC. Finally, PMHU was useful as a simple and significant preoperative factor that correlated with prognosis after RC.

Perceptions of wellbeing and quality of life following participation in a community-based pre-operative exercise programme in men with newly diagnosed prostate cancer: A qualitative pilot study

Background

Men with a newly diagnosed prostate cancer are often treated by surgery. The time window between cancer diagnosis and surgery causes high levels of uncertainty and stress, which negatively impact quality of life (QoL). We previously reported a larger intervention pilot study which demonstrated that participation in a community-based pre-operative exercise programme significantly improved physical fitness and health-related quality of life in men with prostate cancer prior to surgery. The aim of the current pilot study was to get an insight into men’s perceptions of wellbeing and QoL following completion of the pre-operative exercise programme.

Methods

From November 2017 to June 2018, men scheduled for prostate cancer surgery were recruited and took part in a prescribed community-based pre-operative exercise programme in the time available between referral and surgery. Following completion of the pre-operative exercise programme (within 1 week before surgery), participants took part in one semi-structured interview which explored four broad QoL domains: physical, psychological, social, and spiritual wellbeing. Data were analysed using thematic analysis (a bottom up/inductive analysis).

Results

Eleven men were recruited: mean standard deviation (SD) age was 60 ± 7 years. Data supported four main themes. Participation in the community-based pre-operative exercise training programme (over a mean (SD) of 4 ± 2 weeks) provided participants with: 1) a teachable moment; 2) a journey of preparation; 3) a sense of optimism; and 4) social connectedness prior to surgery.

Conclusion

This study provides an insight into how the exercise programme impacted wellbeing and QoL in men preparing for prostate cancer surgery. These findings highlight the important role that exercise prehabilitation plays for men preparing for prostate cancer surgery. Such exercise programmes can be easily implemented into standard cancer pathways by establishing relationships between hospital teams and community exercise programmes.

Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review

Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.

Preoperative nutritional risk index and postoperative one-year skeletal muscle loss can predict the prognosis of patients with gastric adenocarcinoma: a registry-based study

Background

Patients with gastric cancer have an increased nutritional risk and experience a significant skeletal muscle loss after surgery. We aimed to determine whether muscle loss during the first postoperative year and preoperative nutritional status are indicators for predicting prognosis.

Methods

From a gastric cancer registry, a total of 958 patients who received curative gastrectomy followed by chemotherapy for stage 2 and 3 gastric cancer and survived longer than 1 year were investigated. Clinical and laboratory data were collected. Skeletal muscle index (SMI) was assessed based on the muscle area at the L3 level on abdominal computed tomography.

Results

Preoperative nutritional risk index (NRI) and postoperative decrement of SMI (dSMI) were significantly associated with overall survival (hazards ratio: 0.976 [95% CI: 0.962–0.991] and 1.060 [95% CI: 1.035–1.085], respectively) in a multivariate Cox regression analysis. Recurrence, tumor stage, comorbidity index were also significant prognostic indicators. Kaplan-Meier analyses exhibited that patients with higher NRI had a significantly longer survival than those with lower NRI (5-year overall survival: 75.8% vs. 63.0%, P <  0.001). In addition, a significantly better prognosis was observed in a patient group with less decrease of SMI (5-year overall survival: 75.7% vs. 66.2%, P = 0.009). A logistic regression analysis demonstrated that the performance of preoperative NRI and dSMI in mortality prediction was quite significant (AUC: 0.63, P <  0.001) and the combination of clinical factors enhanced the predictive accuracy to the AUC of 0.90 (P <  0.001). This prognostic relevance of NRI and dSMI was maintained in patients experiencing tumor recurrence and highlighted in those with stage 3 gastric adenocarcinoma.

Conclusions

Preoperative NRI is a predictor of overall survival in stage 2 or 3 gastric cancer patients and skeletal muscle loss during the first postoperative year was significantly associated with the prognosis regardless of relapse in stage 3 tumors. These factors could be valuable adjuncts for accurate prediction of prognosis in gastric cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07885-7.