Etiology, assessment, and management of aromatase inhibitor-related musculoskeletal symptoms

The influence of mat Pilates training adherence on strength and flexibility parameters in breast cancer survivors undergoing hormone therapy

The aim of this study was to evaluate the influence of adherence to mat Pilates training on lower and upper body strength and flexibility in breast cancer survivors. Breast cancer survivors ( ≥ 40 years) with cancer stages 0–III undergoing hormone therapy participated in this study. For this secondary investigation only the intervention group was analyzed, divided into low and high training adherence. Participants performed a 60-min session of mat Pilates, 3 times/wk, for 24 weeks. Concentric, eccentric, and isometric hip flexor-extensor muscle peak torque, and isometric maximal strength parameters of the shoulder abductors, trunk extensors, and handgrip were assessed. Physical activity level was analyzed as a control variable. The results showed that high training adherence improved (<i>P</i>< 0.05) left shoulder abductor strength parameters and lower and upper body flexibility compared to baseline. The low training adherence group improved (<i>P</i>< 0.05) trunk extensors, right and left shoulder abductor strength parameters, handgrip strength, and extensor-flexor peak torque compared to baseline. There were no differences (<i>P</i>> 0.05) between high and low adherence for physical activity level before and after the intervention. Therefore, it appears that higher training adherence most influences some strength parameters and flexibility, while fewer sessions enable the achievement of significant results for shoulder abductor and hip extensor-flexor muscle strength parameters.

Feasibility Trial to Evaluate Tendon Stiffness Obtained from Shear Wave Elastography Imaging as a Biomarker of Aromatase Inhibitor-Induced Arthralgias

Aromatase inhibitor-induced arthralgia (AIA) comprises significant, activity-limiting musculoskeletal symptoms, including joint pain, myalgia, and joint stiffness. We conducted a prospective feasibility study in postmenopausal women diagnosed with early-stage (0–3) hormone receptor positive (HR+) breast cancer who were candidates for treatment with adjuvant AI therapy (n = 16). Tendons of the hands and wrists and the median nerve were imaged using gray-scale and power Doppler ultrasound (US) and US SWE. Arthralgia symptoms were evaluated using the Breast Cancer Prevention Trial (BCPT) Symptom Checklist musculoskeletal subscale (MS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and stiffness subscales. At baseline, there were significant differences in the SW velocities of tendons between dominant and nondominant hands. Increased velocity in 2 of 6 tendons and the median nerve was associated with greater pain at baseline, whereas slower velocity of the extensor digitorum tendon (suggesting decreased stiffness) was associated with a higher WOMAC stiffness score. Increased SW velocity (suggestive of increased stiffness) at baseline in the abductor pollicis longus tendon was associated with a worsening of all three pain and stiffness measures by 6 months. Future studies should evaluate SWE scores related to AIA outcomes in a larger sample size.

Shear wave elastography detects novel imaging biomarkers of aromatase inhibitor-induced joint pain: a pilot study

Aim

To determine whether differences in joint and tendon stiffness as measured by ultrasound shear wave elastography are present in breast cancer patients with aromatase inhibitor-associated arthralgias compared to age-comparable healthy control women.

Methods

Postmenopausal women with stage I–III breast cancer who were taking adjuvant aromatase inhibitors and complained of joint pain were enrolled (n = 6). Postmenopausal women with no history of breast cancer, hormone treatment, or joint pain served as controls (n = 7). All subjects had bilateral hands and wrists evaluated by gray-scale and power Doppler ultrasound, and shear wave elastography ultrasound.

Results

Patients with AI-associated arthralgias had significantly stiffer tendons than controls in the 1^st extensor compartment (long axis; p = 0.001), 4^th extensor compartment (long axis; p = 0.014), 3^rd metacarpophalangeal joint (p = 0.002), the pooled values of the extensor compartments, both long (p = 0.044) and short axes (p = 0.035), and the pooled values for the metacarpophalangeal joints (p = 0.002). On ultrasound, the patients (but not controls) presented with hyperemia and increased tenosynovial fluid in the flexor and extensor tendon sheaths, and the median nerves were symptomatic and bifid; however, these differences were not statistically significant.

Conclusions

This is the first study to identify increased tendon stiffness as a putative physiological characteristic of aromatase inhibitor–associated arthralgias. Future studies should determine whether increased tendon stiffness is a risk factor for the development of aromatase inhibitor–associated arthralgias, or a result of aromatase inhibitor treatment.

Original Research: Arthritis-Related Functional Limitations and Inadequate Physical Activity Among Female Adult Cancer Survivors

BACKGROUND

The American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity for Cancer Prevention recommend an adequate level of physical activity for cancer prevention and survivorship. Many adults have been diagnosed with arthritis, with a significantly higher rate in women. People with arthritis tend to be less physically active than those without arthritis, and are less likely to engage in moderate or vigorous activity. The proportion of adults meeting ACS physical activity guidelines is especially low among those with arthritis.

OBJECTIVE

We wanted to explore the extent to which arthritis-related functional limitations are predictive of inadequate physical activity in female adult cancer survivors after accounting for other known predictors.

METHODS

Data included in the analyses were from a sample of 729 adult women diagnosed with cancer who participated in the U.S. National Health and Nutrition Examination Survey between 2011 and 2016. Inadequate physical activity was defined as not meeting ACS physical activity guidelines. Bivariate and multivariate logistic regression analyses were conducted to identify correlates of inadequate physical activity.

RESULTS

Being age 65 years or older, having no more than a high school education, being overweight or obese, being clinically depressed, and having arthritis-related functional limitations were found to be significant correlates of inadequate physical activity in the study population.

CONCLUSIONS

Our results indicate that, in addition to previously identified predictors of inadequate physical activity in cancer survivors, having arthritis-related functional limitations is a significant predictor of inadequate physical activity in female adult cancer survivors. Assessment and management of arthritis-related functional limitations by health care providers are needed to facilitate successful adherence to physical activity guidelines.

Musculoskeletal Effects of Antineoplastic Agents

Cancer remains a common disease with approximately 40% of Americans diagnosed with cancer in their lifetime. Medical advances in the field of oncology have led to an increased life expectancy and a decreased mortality rate. Antineoplastic agents such as taxanes and targeted therapies are indicated in the treatment of many cancers, and their use can be associated with various musculoskeletal complaints and adverse effects. Orthopaedic Surgeons are trained to identify primary bone tumors and metastasis to bones. It is also important for them to have an understanding of the profile of musculoskeletal adverse effects associated with the treatment of the more common neoplasms. This article reviews the current literature on the commonly used chemotherapeutic agents and their associated musculoskeletal effects.

Endocrine Therapy-Related Symptoms and Quality of Life in Female Cancer Survivors in the Yale Fitness Intervention Trial

PURPOSE

The aim of the current study was to describe and compare endocrine therapy-related symptoms and quality of life in female cancer survivors taking aromatase inhibitors, tamoxifen, and no endocrine therapy, and to evaluate the effect of an exercise intervention on these symptoms and quality of life.

DESIGN

Randomized controlled trial. An aerobic resistance exercise intervention group was compared with a home-based exercise control group over 1 year. The exercise intervention was supervised for the first 6 months, followed by 6 unsupervised months.

METHODS

Perimenopausal and early postmenopausal female cancer survivors within 3 years of completing primary or adjuvant chemotherapy were selected. A total of 154 women were enrolled in the study. Type of endocrine or hormonal therapy was documented. Symptoms were measured by the Breast Cancer Prevention Trial Symptom Checklist and the Functional Assessment of Cancer Therapy-Endocrine Subscale. Quality of life was measured by the Functional Assessment of Cancer Therapy-General. Data were collected at baseline, and at 6 and 12 months.

FINDINGS

Participants generally had mild symptom distress. There was no difference in symptoms by endocrine therapy group or by exercise group. Participants taking aromatase inhibitors in the aerobic resistance exercise intervention group reported significant improvement in social, family, and functional well-being and better quality of life compared to those in the control group at 6 months but not at 12 months.

CONCLUSIONS

Findings were similar to those of previous large clinical trials in that no significant differences were found for endocrine therapy-related symptoms and quality of life by type of endocrine therapy taken. However, exercise may improve quality of life outcomes for women taking aromatase inhibitors.

CLINICAL RELEVANCE

Exercise has established efficacy for patient outcomes such as cardiovascular fitness, fatigue, weight management, and quality of life and may provide better quality of life for women who take aromatase inhibitors as adjuvant therapy.

Efficacy of management strategies for aromatase inhibitor-induced arthralgia in breast cancer patients: a systematic review

Aromatase inhibitors are the gold standard in the treatment of hormone receptor-positive breast cancer, but lead to an arthralgia syndrome which is implicated in 13-22% of noncompliance. This is the first systematic review of the efficacy of existing management strategies for this side effect. Eligible studies were retrieved from computer searches of Medline, Cochrane and Embase and the significant intervention groups were identified. The risk of bias of selected studies was evaluated and the relevant data items were extracted, summarized and analyzed. A total of 21 studies were discussed in this review representing 12 different interventions. While several trials had positive findings, the major methodological limitations of the studies meant that no definitive evidence could be found supporting any of the interventions. Future trials are needed which address the methodological problems identified in this review. Exercise holds promise for future research based on its proven benefit in breast cancer.

The effect of a community-based exercise intervention on symptoms and quality of life

BACKGROUND

Moderate-intensity physical activity in women with breast cancer has been reported to improve physical and psychological outcomes. However, initiation and adherence to a routine physical activity program for cancer survivors after therapy may be challenging.

OBJECTIVE

The purpose of this study was to determine the feasibility and effect of a community-based exercise intervention on physical and psychological symptoms and quality of life in breast cancer survivors.

METHODS

A 1-group pretest-posttest design was used to evaluate a thrice weekly, 4- to 6-month supervised exercise intervention on symptoms and quality of life. Data were collected at baseline and end of the intervention, using the Breast Cancer Prevention Trial Checklist, the Symptom Distress Scale, the Centers for Epidemiology Scale for Depression, and the Medical Outcomes Short Form.

RESULTS

There were 26 participants, with a mean (SD) age of 51.3 (6.2) years; most were married, well educated, and employed. The intervention was delivered at 3 community fitness centers, and adherence ranged from 75% to 98%. Vasomotor, musculoskeletal, and cognitive symptoms were common, but only muscle stiffness, fatigue, and depression significantly changed over time (P = .04, .05, and .01, respectively). Quality of life improved significantly in the areas of physical, emotional, and social function; pain; vitality; and mental health.

CONCLUSIONS

Providing an exercise intervention in the community where women live and work is feasible and improves physical, psychological, and functional well-being.

IMPLICATIONS FOR PRACTICE

Exercise is a key component of cancer rehabilitation and needs to be integrated into our standard care.

Endocrine therapy in breast cancer: the neoadjuvant, adjuvant, and metastatic approach

OBJECTIVES

To review the rationale for endocrine therapy in the neoadjuvant, adjuvant, and metastatic breast cancer setting and to highlight clinical considerations unique to this treatment.

DATA SOURCES

Contemporary literature, clinical guidelines, and national statistics.

CONCLUSION

Endocrine therapy represents an important strategy in the management of both early and advanced hormone positive breast cancer. Additional research is required to better define the role of neoadjuvant therapy and the optimal duration of treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a pivotal role in the identification and management of endocrine therapy-associated symptoms. Prompt symptom intervention may improve therapy adherence and ultimately, may improve long-term disease outcomes.