Frailty in older breast cancer survivors: age, prevalence, and associated factors

Can strength training or tai ji quan training reduce frailty in postmenopausal women treated with chemotherapy? A secondary data analysis of the GET FIT trial

PURPOSE

To determine whether strength training or tai ji quan can reduce frailty in older, postmenopausal women treated with chemotherapy for cancer.

METHODS

We conducted a secondary data analysis from a 3-arm, single-blind, randomized controlled trial where older (50-75 years), postmenopausal women cancer survivors were randomized to supervised group exercise programs: tai ji quan, strength training, or stretching control for 6 months. We assessed frailty using a 4-criteria model consisting of weakness, fatigue, inactivity, and slowness. Using logistic regression, we determined whether the frailty phenotype (pre-frailty or frailty) decreased post-intervention, how many and which frailty criteria decreased, and what characteristics identified women most likely to reduce frailty.

RESULTS

Data from 386 women who completed baseline and 6-month testing were used (mean age of 62.0 ± 6.4 years). The odds of reducing overall frailty over 6 months were significantly higher in the strength training group compared to controls (OR [95%CI] 1.86 [1.09, 3.17]) but not for tai ji quan (1.44 [0.84, 2.50]). Both strength training (OR 1.99 [1.10, 3.65]) and tai ji quan (OR 2.10 [1.16, 3.84]) led to significantly higher odds of reducing ≥ 1 frailty criterion compared to controls. Strength training led to a three-fold reduction in inactivity (p < 0.01) and tai ji quan to a two-fold reduction in fatigue (p = 0.08) versus control. Higher baseline BMI, comorbidity score, and frailty status characterized women were more likely to reduce frailty than other women.

CONCLUSIONS

Strength training appears superior to tai ji quan and stretching with respect to reducing overall frailty phenotype among postmenopausal women treated with chemotherapy for cancer, but tai ji quan favorably reduced the number of frailty criteria.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: GET FIT was registered as a clinical trial in clinicaltrials.gov: NCT01635413.

IMPLICATIONS FOR CANCER SURVIVORS

Supervised, group exercise training that emphasizes strength training and/or tai ji quan may help combat accelerated aging and reduce frailty after cancer treatment.

Functional decline in older breast cancer survivors treated with and without chemotherapy and non-cancer controls: results from the Hurria Older PatiEnts (HOPE) prospective study

PURPOSE

This study aimed to assess whether physical functional decline in older women with early-stage breast cancer is driven by cancer, chemotherapy, or a combination of both.

METHODS

We prospectively sampled three groups of women aged ≥ 65: 444 with early-stage breast cancer receiving chemotherapy (BC Chemo), 98 with early-stage breast cancer not receiving chemotherapy (BC Control), and 100 non-cancer controls (NC Control). Physical function was assessed at two timepoints (T1 [baseline] and T2 [3, 4, or 6 months]) using the Physical Functioning Subscale (PF-10) of the RAND 36-item Short Form. The primary endpoint was the change in PF-10 scores from T1 to T2, analyzed continuously and dichotomously (Yes/No, with "yes" indicating a PF-10 decline > 10 points, i.e., a substantial and clinically meaningful difference).

RESULTS

Baseline PF-10 scores were similar across all groups. The BC Chemo group experienced a significant decline at T2, with a median change in PF-10 of -5 (interquartile range [IQR], -20, 0), while BC Control and NC Control groups showed a median change of 0 (IQR, -5, 5; p < 0.001). Over 30% of BC Chemo participants had a substantial decline in PF-10 vs. 8% in the BC Control and 5% in the NC Control groups (p < 0.001).

CONCLUSION

In this cohort of older adults with early-stage breast cancer, the combination of breast cancer and chemotherapy contributes to accelerated functional decline. Our findings reinforce the need to develop interventions aimed at preserving physical function, particularly during and after chemotherapy.

IMPLICATIONS FOR CANCER SURVIVORS

The high prevalence of accelerated functional decline in older women undergoing breast cancer chemotherapy underscores the urgency to develop interventions aimed at preserving physical function and improving health outcomes.

CLINICAL TRIAL

NCT01472094, Hurria Older PatiEnts (HOPE) with Breast Cancer Study.

Identifying pre-habilitation targets for the mitigation of long-term side effects of chemotherapy in patients with early breast cancer

BACKGROUND

Pre-treatment characteristics of women with early breast cancer that are associated with persistent fatigue or suboptimal health-related quality of life (HRQOL) post-chemotherapy need to be identified as potential targets for pre-habilitation.

PATIENTS AND METHODS

Ancillary analysis of previously collected data from patients with newly diagnosed Stage I-III breast cancer scheduled to receive chemotherapy. The objective was to identify baseline (pre-chemotherapy) variables associated with meaningful deteriorations in fatigue and other measures of HRQOL from pre-treatment to 6 months after chemotherapy completion. Percentages are reported along with unadjusted and adjusted relative risks.

RESULTS

In a sample of 249 women post-chemotherapy, 32% reported worsening fatigue (FACIT-F), 35% worsening Physical Well-Being (PWB), 16% worsening Functional Well-Being (FWB), 8% worsening Emotional Well-Being (EWB), and 30% worsening Social Well-Being (SWB). In multivariable (MV) analysis, variables that were significant in univariate analysis - Black race, high BMI, and baseline poorer EWB - remained significant for worsening post-chemotherapy fatigue (FACIT-F). In MV analysis that included race, education, falls, and baseline EWB, Black race and a positive falls history remained significant for worsening PWB. In MV analysis inclusive of race, Short Physical Performance Battery (SPPB) and FWB, lower SPPB and FWB remained significant predictors of worsening FWB. In MV analysis that included baseline Mental Health Index-Anxiety, EWB and SWB, a higher SWB and lower EWB remained significant for worsening SWB.

CONCLUSION

Pre-chemotherapy characteristics in women with early-stage breast cancer that are associated with increased fatigue and reduced HRQOL post-treatment could be used to identify patients who may benefit from pre-habilitation interventions.

Daily life mobility detects frailty, falls, and functioning in ADT-treated prostate cancer survivors

Background

Androgen deprivation therapy (ADT) increases the risk of frailty, falls, and, poor physical functioning in prostate cancer survivors. Detection of frailty is limited to self-report instruments and performance measures, so unbiased tools are needed. We investigated relationships between an unbiased measure - daily life mobility - and ADT history, frailty, falls, and functioning in ADT-treated prostate cancer survivors.

Methods

ADT-treated prostate cancer survivors (N=99) were recruited from an exercise clinical trial, an academic medical center, and the community. Participants completed performance measures and surveys to assess frailty, fall history, and physical functioning, then wore instrumented socks to continuously monitor daily life mobility. We performed a principal component analysis on daily life mobility metrics and used regression analyses to investigate relationships between domains of daily life mobility and frailty, fall history, and physical functioning.

Results

Daily life mobility metrics clustered into four domains: Gait Pace, Rhythm, Activity, and Balance. Worse scores on Rhythm and Activity were associated with increased odds of frailty (OR 1.59, 95% CI: 1.04, 2.49 and OR 1.81, 95% CI: 1.19, 2.83, respectively). A worse score on Rhythm was associated with increased odds of ≥1 falls in the previous year (OR 1.60, 95% CI: 1.05, 2.47). Worse scores on Gait Pace, Rhythm, and Activity were associated with worse physical functioning. Mobility metrics were similar between current and past users of ADT.

Conclusions

Continuous passive monitoring of daily life mobility may identify prostate cancer survivors who have or are developing risk for frailty, falls, and declines in physical functioning.

Development and validation of a prediction model for frailty in breast cancer patients with extended survival

BACKGROUND

Breast cancer (BC) patients with extended survival show a higher incidence of frailty. This study aimed to develop and validate a novel model combining sociodemographic factors (SF) and disease-related factors (DRF) to identify frailty in BC patients with extended survival.

METHODS

This cross-sectional study examined data from 1167 patients admitted to a large urban academic medical centre. Three types of predictive models were constructed in the training set (817 patients): the SF model, the DRF model, and the SF + DRF model (combined model). The model performance and effectiveness were assessed using receiver operating characteristic (ROC) curves, calibration plots and decision curves analysis (DCA). Then the model was subsequently validated on the validation set.

RESULTS

The incidence of frailty in BC patients with extended survival was 35.8%. We identified six independent risk factors including age, health status, chemotherapy, endocrine therapy, number of comorbidities and oral medications. Ultimately, we constructed an optimal model (combined model C) for frailty. The predictive model showed significantly high discriminative accuracy in the training set AUC: 0.754, (95% CI, 0.719-0.789; sensitivity: 76.8%, specificity: 62.2%) and validation set AUC: 0.805, (95% CI, 0.76-0.85), sensitivity: 60.8%, specificity: 87.1%) respectively. A prediction nomogram was constructed for the training and validation sets. Calibration and DCA were performed, which indicated that the clinical model presented satisfactory calibration and clinical utility. Ultimately, we implemented the prediction model into a mobile-friendly web application that provides an accurate and individualized prediction for BC.

CONCLUSIONS

The present study demonstrated that the prevalence of frailty in BC patients with extended survival was 35.8%. We developed a novel model for screening frailty, which may provide evidence for frailty screening and prevention.

Effect of complex decongestive therapy on frailty and quality of life in women with breast cancer-related lymphedema: the before-and-after treatment study

Objective

To investigate the impact of Complex Decongestive Therapy (CDT) on the severity of frailty and quality of life in individuals suffering from postmastectomy lymphedema syndrome.

Methods

Participants who met the inclusion criteria were informed about CDT and informed consent was obtained. Edmonton Frailty Scale (EFS), extremity volüme (EV), lymphedema stage(LS), EQ-5D General Quality of Life Scale (EQ-5D-5L), and Quick Disabilities of Arm, Shoulder, and Hand (DASH) scores were evaluated by the same physician before and after treatment. A total of 15 sessions of CDT were performed for 3 weeks, five days a week. During the treatment period, hospitalized patients received guidance from a nurse on protecting the affected arm in their daily routine.

Results

Eighty patients with breast cancer-related lymphedema who met the inclusion criteria were included in the study. Following a period of 3 weeks of practice and training, the specialist physician conducted the final evaluation and assessments. All patients showed a statistically significant reduction in EV, and regression in LS, EFS, and Quick DASH score (p<0.001). Statistically significant improvement was also observed in quality of life and general health status. (p<0.001).

Conclusion

The application of 15 sessions of CDT and educational interventions to women with postmastectomy lymphedema syndrome due to breast cancer yielded positive outcomes. This approach led to an enhancement in patients' functional capacity, improving their quality of life and a subsequent reduction in the severity of frailty.

The Influencing Factors of Frailty and Quality of Life in Elderly Patients After Spinal Surgery

Background

To study the related factors of frailty and quality of life in elderly patients after spinal surgery.

Methods

The anxiety, depression, frailty, and quality of life of all patients were assessed by the Anxiety screening scale (GAD-7), Depression screening scale (PHQ-9), Frailty screening scale (FRAIL), and European five-dimensional health scale (EQ-5D-5L) 1 day before surgery (DAY-0). A numeric rating scale (NRS) was used to evaluate patients' pain during activities on the 1st day (POD-1), 3rd day (POD-3), and 30th day (POD-30) after operation. FRAIL scale and EQ-5D-5L were used to evaluate patients' frailty and quality of life on POD-30 and 90th day (POD-90) after the operation.

Results

There were significant differences in age, body mass index (BMI), preoperative serum albumin level (ALB), and NRS score on POD-1 between the two groups (P<0.05). Age and PHQ-9 score were positively correlated with EQ-5D-5L score (P<0.05, r Age=0.245, rPHQ-9=0.217), and preoperative ALB level was negatively correlated with EQ-5D-5L score (P<0.05, r ALB=-0.274).

Conclusion

The older the age, the larger the BMI and the higher the NRS score on the first day after surgery, the more prone to frailty in elderly patients after spinal surgery; The older age and the lower the preoperative ALB level, the worse the quality of life in elderly patients after spinal surgery.

Upper Limb Morbidity in Newly Diagnosed Individuals After Unilateral Surgery for Breast Cancer: Baseline Results from the AMBER Cohort Study

PURPOSE

We aimed to examine potential associations between post-surgical upper limb morbidity and demographic, medical, surgical, and health-related fitness variables in newly diagnosed individuals with breast cancer.

METHODS

Participants were recruited between 2012 and 2019. Objective measures of health-related fitness, body composition, shoulder range of motion, axillary web syndrome, and lymphedema were performed within 3 months of breast cancer surgery, and prior to or at the start of adjuvant cancer treatment.

RESULTS

Upper limb morbidity was identified in 54% of participants and was associated with poorer upper limb function and higher pain. Multivariable logistic regression analysis identified mastectomy versus breast-conserving surgery (odds ratio [OR] 3.51, 95% confidence interval [CI] 2.65-4.65), axillary lymph node dissection versus sentinel lymph node dissection (OR 2.67, 95% CI 1.73-4.10), earlier versus later time from surgery (OR 1.58, 95% CI 1.15-2.18), and younger versus older age (OR 1.01, 95% CI 1.00-1.03) as significantly associated with a higher odds of upper limb morbidity, while mastectomy (OR 1.57, 95% CI 1.10-2.25), axillary lymph node dissection (OR 2.20, 95% CI 1.34-3.60), lower muscular endurance (OR 1.10, 95% CI 1.01-1.16) and higher percentage body fat (OR 1.04, 95% CI 1.00-1.07) were significantly associated with higher odds of moderate or greater morbidity severity.

CONCLUSIONS

Upper limb morbidity is common in individuals after breast cancer surgery prior to adjuvant cancer treatment. Health-related fitness variables were associated with severity of upper limb morbidity. Findings may facilitate prospective surveillance of individuals at higher risk of developing upper limb morbidity.

Can strength training or tai ji quan training reduce frailty in postmenopausal women treated with chemotherapy? A secondary data analysis of the GET FIT trial

Purpose

To determine whether strength training or tai ji quan can reduce frailty in older, postmenopausal women treated with chemotherapy for cancer.

Methods

We conducted a secondary data analysis from a 3-arm, single-blind, randomized controlled trial where older (50+ years), postmenopausal women cancer survivors were randomized to supervised group exercise programs: tai ji quan, strength training, or stretching control for 6 months. We assessed frailty using a 4-criteria model consisting of weakness, fatigue, inactivity, and slowness. Using logistic regression, we determined whether the frailty phenotype (pre-frailty or frailty) decreased post-intervention, how many and which frailty criteria decreased, and what characteristics identified women most likely to reduce frailty.

Results

Data from 386 women who completed baseline and 6-month testing were used (mean age of 62.0 ± 6.4 years). The odds of improving overall frailty phenotype over 6 months was significantly higher in the strength training group compared to controls (OR [95%CI]: 1.86 [1.09, 3.17]), but not for for tai ji quan (1.44 [0.84, 2.50]). Both strength training (OR 1.99 [1.10, 3.65]) and tai ji quan (OR 2.10 [1.16, 3.84]) led to significantly higher odds of reducing ≥1 frailty criterion compared to controls. Strength training led to a three-fold reduction in inactivity (p <0.01), and tai ji quan to a two-fold reduction in fatigue (p=0.08) versus control. Higher baseline BMI, comorbidity score, and frailty status characterized women more likely to reduce frailty than other women.

Conclusions

Strength training appears superior to tai ji quan and stretching with respect to reducing overall frailty phenotype among postmenopausal women treated with chemotherapy for cancer, but tai ji quan favorably impacted the number of frailty criteria.

Implications for Cancer Survivors

Supervised, group exercise training that emphasizes strength training and/or tai ji quan may help combat accelerated aging and reduce frailty after cancer treatment.

Frailty Among Breast Cancer Survivors: Evidence From Swedish Population Data

Incidence and survival of breast cancer, the most common cancer among women, have been increasing, leaving survivors at risk of aging-related health conditions. In this matched cohort study, we examined frailty risk with the Hospital Frailty Risk Score among breast cancer survivors (n = 34,900) and age-matched comparison subjects (n = 290,063). Women born in 1935-1975, registered in the Swedish Total Population Register (1991-2015), were eligible for inclusion. Survivors had a first breast cancer diagnosis in 1991-2005 and survived ≥5 years after initial diagnosis. Death date was determined by linkage to the National Cause of Death Registry (through 2015). Cancer survivorship was weakly associated with frailty (subdistribution hazard ratio (SHR) = 1.04, 95% confidence interval (CI): 1.00, 1.07). In age-stratified models, those diagnosed at younger ages (<50 years) had higher risk of frailty (SHR = 1.12, 95% CI: 1.00, 1.24) than those diagnosed at ages 50-65 (SHR = 1.03, 95% CI: 0.98, 1.07) or >65 (SHR = 1.09, 95% CI: 1.02, 1.17) years. Additionally, there was increased risk of frailty for diagnoses in 2000 or later (SHR = 1.15, 95% CI: 1.09, 1.21) compared with before 2000 (SHR = 0.97, 95% CI: 0.93, 1.17). This supports work from smaller samples showing that breast cancer survivors have increased frailty risk, particularly when diagnosed at younger ages.

Premature aging in childhood cancer survivors

Progress in medicine has increased the survival time of children suffering from cancer; >80% of patients survive for at least 5 years from the end of treatment. However, there are late effects of anticancer therapy, which accompany this success. Two-thirds of childhood cancer survivors (CCSs) have at least one late effect (any side effects or complications of anticancer treatment that appear months to years after the completion of treatment), e.g. endocrinopathies, cardiovascular diseases or subsequent cancers, and half of these late effects are serious or life threatening. These late consequences of childhood cancer treatment pose a serious health, social and economic problem. A common mechanism for developing a number of late effects is the onset of premature biological aging, which is associated with the early onset of chronic diseases and death. Cellular senescence in cancer survivors is caused by therapy that can induce chromosomal aberrations, mutations, telomere shortening, epigenetic alterations and mitochondrial dysfunctions. The mechanisms of accelerated aging in cancer survivors have not yet been fully clarified. The measurement of biological age in survivors can help improve the understanding of aging mechanisms and identify risk factors for premature aging. However, to the best of our knowledge, no single marker for the evaluation of biological or functional age is known, so it is therefore necessary to measure the consequences of anticancer treatment using complex assessments. The present review presents an overview of premature aging in CCSs and of the mechanisms involved in its development, focusing on the association of senescence and late effects.

Functional Decline in the Cancer Patient: A Review

A decline in functional status, an individual's ability to perform the normal activities required to maintain adequate health and meet basic needs, is part of normal ageing. Functional decline, however, appears to be accelerated in older patients with cancer. Such decline can occur as a result of a cancer itself, cancer treatment-related factors, or a combination of the two. The accelerated decline in function seen in older patients with cancer can be slowed, or even partly mitigated through routine assessments of functional status and timely interventions where appropriate. This is particularly important given the link between functional decline and impaired quality of life, increased mortality, comorbidity burden, and carer dependency. However, a routine assessment of and the use of interventions for functional decline do not typically feature in the long-term care of cancer survivors. This review outlines the link between cancer and subsequent functional decline, as well as potential underlying mechanisms, the tools that can be used to assess functional status, and strategies for its prevention and management in older patients with cancer.

Cancer-related accelerated ageing and biobehavioural modifiers: a framework for research and clinical care

A growing body of evidence indicates that patients with cancer who receive cytotoxic treatments (such as chemotherapy or radiotherapy) have an increased risk of accelerated physical and cognitive ageing. Furthermore, accelerated biological ageing is a suspected driving force behind many of these observed effects. In this Review, we describe the mechanisms of biological ageing and how they apply to patients with cancer. We highlight the important role of specific behavioural factors, namely stress, sleep and lifestyle-related factors such as physical activity, weight management, diet and substance use, in the accelerated ageing of patients with cancer and cancer survivors. We also present a framework of how modifiable behaviours could operate to either increase the risk of accelerated ageing, provide protection, or promote resilience at both the biological level and in terms of patient-reported outcomes.

Delivering exercise medicine to cancer survivors: has COVID-19 shifted the landscape for how and who can be reached with supervised group exercise?

PURPOSE

Due to stay-at-home orders during COVID-19, we transitioned supervised, group, in-person resistance training interventions in two clinical trials in cancer survivors to live, online delivery using video-conferencing technology. We describe the feasibility, preliminary efficacy, and safety of live online group training and compare to in-person training.

METHODS

Adherence (% sessions attended), retention (% participants completing intervention), and safety (# adverse events) data of resistance training groups from two randomized controlled trials in cancer survivors that participated before or during the COVID-19 pandemic were collated. Participants were post-treatment breast cancer survivors and their spouses (n = 62) and prostate cancer survivors (n = 32) (age range: 38-82 years). During COVID-19, delivery of supervised, group resistance exercise sessions was delivered live online via video-conference. Preliminary evidence for training efficacy was assessed by chair stand performance over the 6-month intervention.

RESULTS

Feasibility of online resistance training was better than in-person for both studies (adherence: 86% vs 82% and 91% vs. 81% and retention 95% vs. 80% and 92% vs. 84% for online and in-person classes). Improvements in chair stand time were similar in prostate cancer and spouse groups that trained online vs. in-person, except for breast cancer survivors who improved more with in-person training (7% vs. 14% for online vs. in-person). Safety was similar between formats (12 vs. 11 adverse events for online vs. in-person).

CONCLUSION

Supervised, in-person group resistance training can be feasibly adapted for live, online delivery and could help broaden approaches to exercise delivery in cancer survivors, including older adults.

TRIAL REGISTRATION

The studies described in this commentary were registered on ClinicalTrials.gov on August 3, 2018 (NCT03630354) and on October 30, 2018 (NCT03741335).

Protocol for GET FIT Prostate: a randomized, controlled trial of group exercise training for fall prevention and functional improvements during and after treatment for prostate cancer

BACKGROUND

Many prostate cancer survivors are treated with androgen deprivation therapy (ADT), but these therapies may increase frailty, worsen physical functioning, and increase fall risk. While exercise may counter functional declines associated with ADT, no studies have tested whether and which type of exercise may reduce falls and frailty. The purpose of this trial is to compare the relative efficacy of strength training versus tai ji quan training against each other and to a stretching control group on falls, frailty, and physical functioning in men expose to ADT for prostate cancer.

METHODS

Prostate cancer survivors treated with ADT (N = 360) who have fallen in the past year or are at risk of a fall based on validated risk factors will be recruited to participate in this single-blind, parallel group, randomized trial. Participants will be randomized to one of three supervised, group training programs: (i) strength training, (ii) tai ji quan training, or (iii) stretching (control), that train 3×/week for 6 months. Outcomes are assessed at baseline, 3 (mid-intervention), 6 (immediately post-intervention), and 12 (follow-up) months. The primary outcome is falls assessed by monthly self-report. Secondary outcomes include the following: frailty (low lean body mass (by bioelectrical impedance analysis), exhaustion (by SF-36 vitality scale), low activity (by CHAMPS physical activity survey), slowness (by 4 m usual walk speed), and weakness (by chair stand time)); objective and subjective measures of physical function will also be collected. Negative binomial regression models will be used to assess differences in falls between groups, while mixed effects modeling will be used to compare the relative efficacy of training group on secondary outcomes.

DISCUSSION

Exercise represents a non-pharmacologic approach to mitigate the problem of falls experienced among men treated with ADT. By engaging in appropriate exercise, men may be able to avoid or delay falls, frailty, and disability associated with their cancer treatment. Findings of the trial are expected to inform clinical practice about how exercise could be prescribed as part of cancer care for prostate cancer survivors prescribed ADT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03741335 . Registered on November 18, 2018.

The prevalence of frailty among breast cancer patients: a systematic review and meta-analysis

PURPOSE

Coexistence of frailty and breast cancer (BC) is related to a higher risk of hospitalization, mortality, and falls. Given the potential reversibility of frailty, investigating its epidemiology in BC is of great importance. However, estimates of the prevalence of frailty in BC patients vary considerably. We synthesized the existing body of literature on the prevalence of frailty among BC patients.

METHODS

We searched English databases (Cochrane Library, PubMed, Medline, CINAHL, Embase, Scopus, and Web of Science) and Chinese databases (CNKI, WanFang, CBM, and VIP database) from the inception to April 15, 2021, and collected observational studies about the prevalence of frailty among BC patients. The robustness of the pooled estimates was validated by analysis of different subgroups, meta-regression, and sensitivity. All data were analyzed using Stata 15.1.

RESULTS

In total, 4645 articles were screened and data from 24 studies involving 13,510 subjects were used in the meta-analysis. The prevalence of frailty among BC patients in individual studies varied from 5 to 71%. The pooled prevalence of frailty was 43% (95% confidence intervals (CI): 36% to 50%, I² = 98.4%, P < 0.05). Subgroup analyses revealed that the therapeutic method, frailty scales, age, frailty stage, regions, publication years, and study quality were associated with the prevalence of frailty among BC patients.

CONCLUSIONS

The prevalence of frailty among BC patients was relatively high, and the conditions of BC treatment can increase the risk of frailty. Understanding the effects of frailty on BC, especially in elderly patients, can provide the healthcare personnel with the theoretical basis for patients' management and treatment.

Active Living After Cancer: Adaptation and evaluation of a community-based physical activity program for minority and medically underserved breast cancer survivors

Background

An expanding body of research documents the benefits of physical activity for cancer survivors' physical functioning and quality of life, but few successful models provide community‐based physical activity programs to cancer survivors. This report presents an evaluation of Active Living After Cancer, an evidence‐based physical activity program for breast cancer survivors, adapted for community delivery to minority and medically underserved survivors.

Methods

Survivors were recruited from health care and community settings. The program consisted of 12 weekly group sessions providing training in cognitive and behavioral skills for behavior change, brief physical activity, and cancer survivorship‐related content. At the baseline and follow‐up, participants completed assessments of their physical activity, quality of life, and physical functioning (6‐minute walk and 30‐second sit‐to‐stand test). At follow‐up, they also completed questionnaires to measure program content mastery and satisfaction.

Results

The outcome analysis included 127 participants. Physical activity and quality of life (mental and physical) improved from the baseline to follow‐up (all P < .01). Physical functioning improved, with increases in sit‐to‐stand repetitions (mean, 12.5 at the baseline vs 14.9 at the follow‐up; P < .01) and 6‐minute walk distances (mean, 428 m at the baseline vs 470 m at the follow‐up; P < .01).

Conclusions

The results highlight the effectiveness of an evidence‐based program adapted for community‐based delivery to minority and medically underserved breast cancer survivors. The program could be delivered to improve outcomes in diverse survivor populations.

Lay Summary

Physical activity in breast cancer survivors is related to better quality of life and longer cancer‐free survival. However, there are few community‐based programs to help breast cancer survivors to become more physically active.

The Active Living After Cancer program was adapted from an evidence‐based program and delivered in community‐based settings to minority and medically underserved breast cancer survivors. It consisted of 12 weekly group sessions in which participants learned skills to increase their physical activity.

The program participants increased their physical activity and improved their mental and physical well‐being and physical functioning.

The Active Living After Cancer Program has been adapted from an evidence‐based program and implemented in the community for minority and medically underserved breast cancer survivors. Participants increase their physical activity and improve their quality of life and physical functioning.

Correlates of Frailty in Community-Dwelling Older Adults with Cancer: 2017 Survey of Living Condition of Elderly Study in South Korea

Objective

Frailty is prevalent among community-dwelling older adults with cancer and is associated with increased mortality and complications of treatments. However, evidence on the multiple factors influencing frailty in this population is scarce. This paper aimed to identify the demographic, sociobehavioral, and health status-related correlates of frailty in community-dwelling older adults with cancer.

Methods

This was a descriptive cross-sectional study using data from the fourth wave of the Living Condition of Elderly Study in South Korea conducted in 2017. Among the 10,299 individuals aged ≥65 years who participated in the survey, data of 391 individuals with cancer were analyzed. Frailty status (robust, prefrailty, and frailty) was assessed using the Korean version of the 5-item: Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight scale. We performed descriptive statistical analysis to report summary measures, and bivariate (t-test, Chi-squared test, and analysis of variance) and multivariate regression analyses.

Results

Frailty and prefrailty were prevalent in 24.8% and 50.6% of the participants, respectively. The strongest correlate of frailty was a greater level of depression, followed by low levels of physical activity, dependency in instrumental activities of daily living, a greater number of comorbidities, an advanced age, a lower household income, and a widowed marital status.

Conclusions

Community-dwelling older adults who had cancer and depression had the highest risk of frailty. Given the adverse impact of frailty on health outcomes in this population, health-care providers need to provide interventions incorporating the management of depression, physical activity, and comorbidities to prevent or manage frailty.

Strategies to Prevent or Remediate Cancer and Treatment-Related Aging

Up to 85% of adult cancer survivors and 99% of adult survivors of childhood cancer live with an accumulation of chronic conditions, frailty, and/or cognitive impairments resulting from cancer and its treatment. Thus, survivors often show an accelerated development of multiple geriatric syndromes and need therapeutic interventions. To advance progress in this area, the National Cancer Institute convened the second of 2 think tanks under the auspices of the Cancer and Accelerated Aging: Advancing Research for Healthy Survivors initiative. Experts assembled to share evidence of promising strategies to prevent, slow, or reverse the aging consequences of cancer and its treatment. The meeting identified research and resource needs, including geroscience-guided clinical trials; comprehensive assessments of functional, cognitive, and psychosocial vulnerabilities to assess and predict age-related outcomes; preclinical and clinical research to determine the optimal dosing for behavioral (eg, diet, exercise) and pharmacologic (eg, senolytic) therapies; health-care delivery research to evaluate the efficacy of integrated cancer care delivery models; optimization of intervention implementation, delivery, and uptake; and patient and provider education on cancer and treatment-related late and long-term adverse effects. Addressing these needs will expand knowledge of aging-related consequences of cancer and cancer treatment and inform strategies to promote healthy aging of cancer survivors.

Changes in Eating Habits in Breast Cancer Patients

Introduction

Receiving a cancer diagnosis is an important moment in anyone’s life. Consequently, many patients are prepared to change their everyday habits and begin to look for advice from a wide range of sources. Women with breast cancer are particularly motivated and committed to making changes to their lifestyle and diet. The purpose of this study was to elucidate the changes in nutritional and other lifestyle habits following breast cancer diagnosis in Slovenia. A further goal was to estimate the proportion of breast cancer patients using dietary supplements and alternative diets or ascertain their desire to attend a consultation with a dietician.

Methods

A link to an online questionnaire was sent to the email addresses of members of Europa Donna and posted on their website (www.europadonna-zdruzenje.si) and Facebook page.

Results

A total of 102 patients were included in the study. We found that a majority of breast cancer patients changed their eating habits (68.6%) and/or physical activity level (53.9%) following diagnosis. On average, they increased their fruit and vegetable intake and reduced their intake of sugar, red meat and fat. Alternative diets were used by 29.4% of patients, with a high proportion of patients (75.5%) consuming dietary supplements. More than a half of the patients (69.6%) expressed a desire for a consultation with a dietician.

Conclusions

Nutritional support during cancer treatment is part of medical treatment and has an important role to play in secondary and tertiary cancer prevention activities. More dieticians should therefore be incorporated into the health system.

The acceleration of ageing in older patients with cancer

Older cancer survivors may experience ageing at an accelerated rate when compared to their similar-aged, cancer-free counterparts. Ageing is undoubtedly a significant risk factor for cancer. There is evidence to suggest, however, that this relationship may in fact be bidirectional, with cancer and its treatments contributing to the ageing process. In this review, we outline the current literature linking cancer and anti-cancer therapy to adverse ageing outcomes and explore what additional research is needed in order to conclusively define cancer and its treatment as an accelerator of ageing.

Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment

PURPOSE

This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population?

METHODS

MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome.

RESULTS

A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified.

CONCLUSION

This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.

Frailty and aging in cancer survivors

There are over 15 million survivors of cancer in the United States whose rates of frailty, an aging phenotype, range from just under 10% to over 80%. Frailty impacts not only disease survival but also long-term function and quality of life in children, adolescents, and in all adults diagnosed and/or treated for cancer. This review explains frailty as a construct and model of physiologic well-being. It also describes how frailty at diagnosis impacts cancer outcomes in adult populations and enumerates the prevalence of frailty in different populations of cancer survivors. Biological mechanisms responsible for aging and potentially for frailty among individuals with or who have been treated for cancer are discussed. Finally, promising pharmaceutical and lifestyle interventions designed to impact aging rather than a specific disease, tested in other populations, but likely applicable in cancer patients and survivors, are discussed.

The acute effects of adjuvant radiation and chemotherapy on peripheral blood epigenetic age in early stage breast cancer patients

Survival has increased in early stage breast cancer (BC), and the late effects of treatment persist for decades. Molecular mechanisms underlying the acceleration of age-related diseases after chemotherapy and radiotherapy are poorly understood. We examined epigenetic changes in peripheral whole blood cells in early stage BC patients undergoing surgery followed by adjuvant radiotherapy, or surgery followed by adjuvant chemotherapy and radiotherapy. DNA methylation experiments were performed on whole blood samples collected before and after adjuvant therapy. Methylation profiles were used to estimate four measures of epigenetic age acceleration-intrinsic, extrinsic, phenotypic, and Grim-and cell counts. We found significant increases in extrinsic, phenotypic, and Grim epigenetic age acceleration and in estimated proportions of senescent T lymphocytes from pre- to post-treatment. When examining differential effects by treatment category, most of these increases were significant only in women undergoing radiation alone. Further studies are needed to examine whether these effects are related to the risk of cognitive and functional decline in BC survivors.

Associations of inflammation with frailty in patients with breast cancer aged 50 and over receiving chemotherapy

PURPOSE

Chronic inflammation is a significant physiologic feature of frailty; however, its role and clinical utility in cancer-related frailty remains unknown. We sought to determine if pre-chemotherapy inflammation is predictive of frailty after chemotherapy in patients with breast cancer.

METHODS

Female patients (N = 144; age ≥ 50) with stage I-III breast cancer scheduled to receive chemotherapy and age-matched non-cancer controls (N = 142) were included in this secondary analysis and assessed pre- and post-chemotherapy. Controls were assessed at equivalent time-points. Frailty was assessed using a modified Fried's score (0-4) using self-reported measures of weakness, exhaustion, walking speed, and physical activity. Serum levels of interleukin (IL) 6, and soluble tumor necrosis factor-alpha (sTNFR) I and II were measured. Associations between pre-chemotherapy cytokine and receptors level (median as cutoff) and post-chemotherapy frailty were evaluated using t-tests.

RESULTS

Pre-chemotherapy, patients with breast cancer were more frail than non-cancer controls (mean score: 1.17 vs 0.65; p < .01). Patients also became more frail post-chemotherapy (mean score: 1.17 vs 2.08; p < .01). Patients with pre-chemotherapy serum levels of IL-6, sTNFRI, and sTNFRII above the median were more frail after chemotherapy than those with levels below the median [IL-6 (2.31 vs. 1.86; p = .03), sTNFRI (2.30 vs. 1.88; p = .04), and sTNFRII (2.30 vs. 1.88; p = .04)]. No differences were observed in non-cancer controls within the same timeframe.

CONCLUSIONS

Both cancer and chemotherapy were associated with frailty. Higher pre-chemotherapy inflammatory cytokine levels were associated with post-chemotherapy frailty. This supports the utility of inflammatory cytokines to identify patients who develop worsening of frailty characteristics with chemotherapy.

Frailty and Multimorbidity: A Systematic Review and Meta-analysis

BACKGROUND

Multimorbidity and frailty are complex syndromes characteristics of aging. We reviewed the literature and provided pooled estimations of any evidence regarding (a) the coexistence of frailty and multimorbidity and (b) their association.

METHODS

We searched PubMed and Web of Science for relevant articles up to September 2017. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity (I2), risk of bias, and publication bias were assessed. PROSPERO registration: 57890.

RESULTS

A total of 48 studies involving 78,122 participants were selected, and 25 studies were included in one or more meta-analyses. Forty-five studies were cross-sectional and 3 longitudinal, with the majority of them including community-dwelling participants (n = 35). Forty-three studies presented a moderate risk of bias and five a low risk. Most of the articles defined multimorbidity as having two or more diseases and frailty according to the Cardiovascular Health Study criteria. In meta-analyses, the prevalence of multimorbidity in frail individual was 72% (95% confidence interval = 63%-81%; I2 = 91.3%), and the prevalence of frailty among multimorbid individuals was 16% (95% confidence interval = 12%-21%; I2 = 96.5%). Multimorbidity was associated with frailty in pooled analyses (odds ratio = 2.27; 95% confidence interval = 1.97-2.62; I2 = 47.7%). The three longitudinal studies suggest a bidirectional association between multimorbidity and frailty.

CONCLUSIONS

Frailty and multimorbidity are two related conditions in older adults. Most frail individuals are also multimorbid, but fewer multimorbid ones also present frailty. Our findings are not conclusive regarding the causal association between the two conditions. Further longitudinal and well-designed studies may help to untangle the relationship between frailty and multimorbidity.

Longitudinal Relationship Between Frailty and Cognition in Patients 50 Years and Older with Breast Cancer

OBJECTIVES

To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy.

DESIGN

Secondary analysis of a prospective longitudinal observational study.

SETTING

University of Rochester NCI Community Oncology Research Program community oncology clinics.

PARTICIPANTS

Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age-matched controls without cancer (n = 234).

MEASUREMENTS

Frailty was assessed using a modified frailty score from self-reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy-Cognition [FACT-Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates.

RESULTS

The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs .73; P < .001) and lower mean FACT-Cog score (158.4 vs 167.3; P < .001) compared with controls. Objective cognitive measures were not statistically different. Longitudinal decline in FACT-Cog between A1 and A2 (P < .05) and between A1 and A3 (P < .01) was associated with increased frailty score in patients compared with controls. Longitudinal worsening in Controlled Oral Word Association (P < .05) and Trail-Making Test (P < .01) were associated with an increase in frailty between A1 and A2 in patients compared with controls; longitudinal decline in the Delayed Match to Sample test was associated with an increase in frailty between A1 and A3 (P < .05) in patients compared with controls. This finding remained significant for a subset analysis of those aged 65 and older.

CONCLUSION

In patients with breast cancer aged 50 and older, longitudinal decline in FACT-Cog and objective measures of attention and memory were associated with increased frailty during treatment and up to 6 months posttreatment. Overall, our study suggests cognition and frailty are both important factors to assess in breast cancer patients. J Am Geriatr Soc 67:928-936, 2019.

Gait and Balance Impairments in Breast Cancer Survivors: A Systematic Review and Meta-analysis of Observational Studies

Objective

To systematically review and quantitatively synthesize gait and balance impairments in breast cancer survivors compared with age-matched controls or normative values for adults who never had breast cancer.

Data Sources

PubMed, Cumulative Index of Nursing and Allied Health, and Web of Science was searched using terms associated with breast cancer, mobility, and adult until November 2018.

Study Selection

Studies were included if they were randomized control trials, cross-sectional, prospective, pre-post, or case-control by design, included adult breast cancer survivors, reported gait and/or balance metrics as primary or secondary outcomes, were peer-reviewed publications, and were written in English. The search yielded 2117 results with 29 studies meeting the inclusion criteria.

Data Extraction

Two reviewers assessed study quality by the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to determine the strength of evidence for each study that met the inclusion criteria. Basic descriptors of each study, study protocol, and balance and gait measures were extracted. Meta-analysis was performed for the single leg stance, functional reach, center of pressure velocity, gait speed, and timed up and go.

Data Synthesis

For quality assessment, 3 studies were rated good, 16 fair, and 10 poor. The meta-analysis indicated that there were no significant differences in single leg stance between breast cancer survivors and those who never had breast cancer (P=.33). Pooled values of the functional reach task (22.16cm; 95% CI, 8.98-35.33) and center of pressure velocity (1.2cm/s; 95% CI, 0.87-1.55) suggest balance impairment in breast cancer survivors when compared with normative values. Breast cancer survivors also performed worse than those who never had breast cancer in challenging balance conditions that reduced sensory information or altered base of support. Pooled gait speed at a usual speed (0.91m/s; 95% CI, 0.2-1.6), fast speed across a short distance (1.2m/s; 95% CI, 0.31-2.1), and fast gait speed across a long distance (1.65m/s; 95% CI, 1.64-1.66) suggest gait impairments when compared with normative values.

Conclusions

Breast cancer survivors may demonstrate gait and balance impairments compared with normative values. Clinicians should consider assessing changes in balance and gait in breast cancer survivors to improve functional independence and prevent fall-related injuries.

[The post-cancer period in geriatric oncology]

The increase in life expectancy together with the increased survival of patients with cancer is resulting in the emergence of a new population: that of cancer survivors whose health status is inferior to that of people not affected by this disease. The interaction between the cancer, the sequelae of the different treatments and other ageing-related health problems requires joint reflection on the best way of caring for this emerging geriatric population.

Survivorship issues in older breast cancer survivors

PURPOSE

Almost half of breast cancer survivors are aged ≥ 65 years and the proportion is likely to increase due to the aging of the population. The objectives of this article were to review studies of health outcomes among older breast cancer survivors ≥ 65 years to identify gaps in the published literature and offer suggestions for future research.

METHODS

The present review is based upon bibliographic searches in PubMed and CINAHL and relevant search terms. Articles published in English from January 1, 1970 through October 1, 2018 were identified using the following MeSH search terms and Boolean algebra commands.

RESULTS

This review has revealed that older breast cancer survivors cope with health issues related to cancer treatment and the aging process, including comorbidities, osteoporosis, symptoms, physical functioning, cognitive functioning, nutrition, and physical activity.

CONCLUSIONS

Additional research is needed to examine therapeutic interventions to address the health conditions older breast cancer survivors are coping with. Particular focus of further research should be on the nutritional status and physical activity levels of older breast cancer survivors. Individualized nutrition plans and tailored physical activity programs for older survivors are needed that meet people where they are and that form habits.

Patient-reported and objectively measured physical function in older breast cancer survivors and cancer-free controls

OBJECTIVES

Older breast cancer survivors (BCS) consistently report more functional limitations than women without cancer, but whether or not these differences remain when using objective measures of physical functioning and the correlates of these measures is unknown.

METHODS

Cross-sectional study comparing older (≥60 years old) BCS (n = 84) to similarly aged women without cancer (n = 40). Patient-reported physical function was assessed by the SF-36 physical function (SF-36PF) subscale and the Late Life Function & Disability Instrument (LLFDI). Objective measures included the short Physical Performance Battery (sPPB), usual walk speed (m/s), chair stand time (sec) and, grip strength (kg). Potential predictors included age, comorbidities, symptom severity, fatigue and skeletal muscle index (SMI; kg/m²).

RESULTS

Patient-reported physical function was significantly lower in BCS than controls using SF-36PF (47.3 ± 0.1 vs. 52.9 ± 4.0, p < 0.001) and LLFDI (68.2 ± 10.5 vs. 75.0 ± 8.9, p = 0.001). BCS had significantly lower sPPB scores (10.7 ± 0.1 vs. 11.7 ± 0.5, p < 0.001), longer chair stand times (12.6 ± 3.7 vs. 10.1 ± 1.4 s, p < 0.001), and lower handgrip strength (22.3 ± 5.0 vs. 24.3 ± 4.4 kg, p = 0.03) than controls, but similar walk speed (1.1+0.2 vs. 1.1+0.1 m/s, p = 0.75). Within BCS, age, comorbidities, SMI, symptom severity and fatigue explained 17.3%-33.1% of the variance across physical function measures. Fatigue was the variable most consistently associated with patient-reported physical functioning and age and comorbidities were the variables most consistently associated with objectively measured physical functioning.

CONCLUSION

Older BCS should be screened for functional limitations using simple standardized objective tests and interventions that focus on improving strength and reducing fatigue should be tested.

Identifying a Relationship Between Physical Frailty and Heart Failure Symptoms

BACKGROUND

Heart failure (HF) is a complex clinical syndrome associated with significant symptom burden; however, our understanding of the relationship between symptoms and physical frailty in HF is limited.

OBJECTIVE

The aim of this study was to quantify associations between symptoms and physical frailty in adults with HF.

METHODS

A sample of adults with symptomatic HF were enrolled in a cross-sectional study. Physical symptoms were measured with the HF Somatic Perception Scale-Dyspnea subscale, the Epworth Sleepiness Scale, and the Brief Pain Inventory short form. Affective symptoms were measured with the Patient Health Questionnaire-9 and the Brief Symptom Inventory-Anxiety scale. Physical frailty was assessed according to the Frailty Phenotype Criteria: shrinking, weakness, slowness, physical exhaustion, and low physical activity. Comparative statistics and generalized linear modeling were used to quantify associations between symptoms and physical frailty, controlling for Seattle HF Model projected 1-year survival.

RESULTS

The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were male, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physically frail participants had more than twice the level of dyspnea (P < .001), 75% worse wake disturbances (P < .001), and 76% worse depressive symptoms (P = .003) compared with those who were not physically frail. There were no differences in pain or anxiety.

CONCLUSIONS

Physically frail adults with HF have considerably worse dyspnea, wake disturbances, and depression. Targeting physical frailty may help identify and improve physical and affective symptoms in HF.

Mediating Effects of Frailty Indicators on the Risk of Sepsis After Cancer

BACKGROUND

Cancer survivors are at increased risk of sepsis, possibly attributed to weakened physiologic conditions. The aims of this study were to examine the mediation effect of indicators of frailty on the association between cancer survivorship and sepsis incidence and whether these differences varied by race.

METHODS

We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort from years 2003 to 2012. We categorized frailty as the presence of ≥2 frailty components (weakness, exhaustion, and low physical activity). We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer. We examined the mediation effect of frailty on the association between cancer survivorship and sepsis incidence using Cox regression. We repeated analysis stratified by race.

RESULTS

Among 28 062 eligible participants, 2773 (9.88%) were cancer survivors and 25 289 (90.03%) were no cancer history participants. Among a total 1315 sepsis cases, cancer survivors were more likely to develop sepsis (12.66% vs 3.81%, P < .01) when compared to participants with no cancer history (hazard ratios: 2.62, 95% confidence interval: 2.31-2.98, P < .01). The mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). Similar results were observed when stratified by race.

CONCLUSION

Cancer survivors had more than a 2-fold increased risk of sepsis, and indicators of frailty contributed to less than 1% of this disparity.

Effects of a Translational Community-Based Multimodal Exercise Program on Quality of Life and the Influence of Start Delay on Physical Function and Quality of Life in Breast Cancer Survivors: A Pilot Study

The purpose of this investigation was 2-fold: (1) to investigate the effects of a translational 12-week community-based multimodal exercise program on quality of life (QoL) in breast cancer survivors (BCS) and (2) to examine the influence of a start delay on physical function and QoL in BCS. Fifty-two female BCS completed a 12-week program consisting of 90-minute supervised exercise sessions at a frequency of 2 supervised sessions per week. Exercise sessions consisted of three 30-minute components: (1) aerobic conditioning, (2) resistance exercise training, and (3) balance and flexibility training. Significant ( P < .05) improvements in QoL were identified post-program completion. Cohort stratification comparison between the early start (<1 year since completion of oncologic treatment) and late start (>1 year since completion of oncologic treatment) revealed no significant ( P > .05) differences between the early start and late start groups on improvements in physical function. Regarding the influence of start delay on QoL, the early start group showed significant ( P < .05) improvement in emotional well-being. No other significant differences in improvement in QoL were detected between the early start and late start groups. Regardless of start delay, meaningful improvements in physical function and QoL were found after completing the community-based multimodal exercise program. Early participation in community-based exercise programming may benefit BCS' emotional well-being compared to later participation.

The Biology of Aging and Cancer: Frailty, Inflammation, and Immunity

The majority of patients with common malignancies are older adults. Intrinsic complex biological changes of aging along with inflammation, immunosenescence, age-associated chronic diseases, and extrinsic environmental and psychosocial factors have significant impact on not only development and behavior of individual malignancies, but also physiologic reserve and vulnerability of older patients who suffer from them. As a result, clinical practice of geriatric oncology demands integration of careful geriatric assessment and management. This article provides an overview of basic biology of aging and its relationship with cancer. After a brief introduction about the definition and mechanisms of aging, as well as age-related biological and physiological changes, the discussion mainly focuses on recent development and insights into the relationship of frailty, inflammation, and immunity with cancer, highlighting how the new knowledge can help further improve assessment and treatment of older patients with malignancies and promote cancer research.

Weight management and physical activity throughout the cancer care continuum

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

A Preliminary Study on the Efficacy of a Community-Based Physical Activity Intervention on Physical Function-Related Risk Factors for Falls Among Breast Cancer Survivors

OBJECTIVE

The aim of this study was to examine the effects of a 6-week community-based physical activity (PA) intervention on physical function-related risk factors for falls among 56 breast cancer survivors (BCS) who had completed treatments.

DESIGN

This was a single-group longitudinal study. The multimodal PA intervention included aerobic, strengthening, and balance components. Physical function outcomes based on the 4-meter walk, chair stand, one-leg stance, tandem walk, and dynamic muscular endurance tests were assessed at 6-week pre-intervention (T1), baseline (T2), and post-intervention (T3). T1 to T2 and T2 to T3 were the control and intervention periods, respectively.

RESULTS

All outcomes, except the tandem walk test, significantly improved after the intervention period (P < 0.05), with no change detected after the control period (P > 0.05). Based on the falls risk criterion in the one-leg stance test, the proportion at risk for falls was significantly lower after the intervention period (P = 0.04), but not after the control period.

CONCLUSIONS

A community-based multimodal PA intervention for BCS may be efficacious in improving physical function-related risk factors for falls, and lowering the proportion of BCS at risk for falls based on specific physical function-related falls criteria. Further larger trials are needed to confirm these preliminary findings.

Cyclophosphamide leads to persistent deficits in physical performance and in vivo mitochondria function in a mouse model of chemotherapy late effects

Fatigue is the symptom most commonly reported by long-term cancer survivors and is increasingly recognized as related to skeletal muscle dysfunction. Traditional chemotherapeutic agents can cause acute toxicities including cardiac and skeletal myopathies. To investigate the mechanism by which chemotherapy may lead to persistent skeletal muscle dysfunction, mature adult mice were injected with a single cyclophosphamide dose and evaluated for 6 weeks. We found that exposed mice developed a persistent decrease in treadmill running time compared to baseline (25.7±10.6 vs. 49.0±16.8 min, P = 0.0012). Further, 6 weeks after drug exposure, in vivo parameters of mitochondrial function remained below baseline including maximum ATP production (482.1 ± 48.6 vs. 696.2 ± 76.6, P = 0.029) and phosphocreatine to ATP ratio (3.243 ± 0.1 vs. 3.878 ± 0.1, P = 0.004). Immunoblotting of homogenized muscles from treated animals demonstrated a transient increase in HNE adducts 1 week after exposure that resolved by 6 weeks. However, there was no evidence of an oxidative stress response as measured by quantitation of SOD1, SOD2, and catalase protein levels. Examination of mtDNA demonstrated that the mutation frequency remained comparable between control and treated groups. Interestingly, there was evidence of a transient increase in NF-ĸB p65 protein 1 day after drug exposure as compared to saline controls (0.091±0.017 vs. 0.053±0.022, P = 0.033). These data suggest that continued impairment in muscle and mitochondria function in cyclophosphamide-treated animals is not linked to persistent oxidative stress and that alternative mechanisms need to be considered.

Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed.

DATA SOURCES

Five electronic databases-Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO-were searched from inception to March 2016 for relevant articles.

STUDY SELECTION

Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search.

DATA EXTRACTION

Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools-Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure.

DATA SYNTHESIS

Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07-.27) to medium (.45; 95% CI, .23-.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes.

CONCLUSIONS

Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Frequency of and Significance of Physical Frailty in Patients With Heart Failure

Physical frailty is an important prognostic indicator in heart failure (HF); however, few studies have examined the relation between physical frailty and invasive hemodynamics among adults with HF. The purpose of this study was to characterize physical frailty in HF in relation to invasive hemodynamics. We enrolled 49 patients with New York Heart Association class II to IV HF when participants were scheduled for a right-sided cardiac heart catheterization procedure. Physical frailty was measured according to the "frailty phenotype": shrinking, weakness, slowness, physical exhaustion, and low physical activity. Markers of invasive hemodynamics were derived from a formal review of right-sided cardiac catheterization tracings, and projected survival was calculated using the Seattle HF model. The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were men, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physical frailty was identified in 24 participants (49%) and was associated with worse Seattle HF model 1-year projected survival (p = 0.007). After adjusting for projected survival, physically frail participants had lower cardiac index (by both thermodilution and the Fick equation) and higher heart rates compared with those not physically frail (all p <0.05). In conclusion, physical frailty is highly prevalent in patients with HF and is associated with low-output HF.

Inflammatory Cytokines and Comorbidity Development in Breast Cancer Survivors Versus Noncancer Controls: Evidence for Accelerated Aging?

Purpose The sequelae of cancer treatment may increase systemic inflammation and create a phenotype at increased risk of functional decline and comorbidities, leading to premature mortality. Little is known about how this trajectory compares with natural aging among peers of the same age without cancer. This longitudinal study investigated proinflammatory cytokines and comorbidity development over time among breast cancer survivors and a noncancer control group. Methods Women (N = 315; 209 with breast cancer and 106 in the control group) were recruited at the time of their work-up for breast cancer; they completed the baseline questionnaire, interview, and blood draw (lipopolysaccharide-stimulated production of interleukin [IL] -6, tumor necrosis factor-α, and IL-1β). Measures were repeated 6 and 18 months after primary cancer treatment (cancer survivors) or within a comparable time frame (control group). Results There were no baseline differences in comorbidities or cytokines between survivors and the control group. Over time, breast cancer survivors had significantly higher tumor necrosis factor-α and IL-6 compared with the control group. Survivors treated with surgery, radiation, and chemotherapy accumulated a significantly greater burden of comorbid conditions and suffered greater pain associated with inflammation over time after cancer treatment than did the control group. Conclusion Survivors who had multimodal treatment had higher cytokines and comorbidities, suggestive of accelerated aging. Comorbidities were related to inflammation in this sample, which could increase the likelihood of premature mortality. Given that many comorbidities take years to develop, future research with extended follow-up beyond 18 months is necessary to examine the evidence of accelerated aging in cancer survivors and to determine the responsible mechanisms.

Symptoms, weight loss, and physical function in a lifestyle intervention study of older cancer survivors

OBJECTIVES

Many older cancer survivors are overweight or obese, with additional illness burden increasing functional decline, which may affect their ability to engage in lifestyle interventions. This study examined how overweight long-term survivors' symptom severity associated with comorbidity prior to a diet and exercise intervention was associated with post-intervention function and examined symptoms' effects on function through change in physical activity, diet quality, and weight status.

MATERIALS AND METHODS

This is a secondary data analysis of 514 breast, prostate, and colorectal cancer survivors who participated in the one-year home-based diet and exercise intervention Reach-Out to Enhance Wellness trial. Measures included symptoms, weight, physical activity, diet quality, overall physical function (PF), and basic and advanced lower extremity function (BLEF and ALEF). Simple and serial mediation analyses were conducted to examine direct effects of symptom severity on PF, BLEF, and ALEF and indirect effects of symptom severity through changes in diet quality, physical activity, and weight.

RESULTS

Symptom severity was directly associated with lower functioning scores for PF (b=-0.63 p<0.001), BLEF (b=-0.33, p<0.001), and ALEF (b=-0.22, p<0.001). Indirect effects of symptom severity through weight loss, physical activity, and diet were not significant. Weight loss and physical activity were associated with higher PF and ALEF and diet quality was associated with higher BLEF.

CONCLUSION

Symptom severity of older, overweight cancer survivors negatively affects physical function. However, greater weight loss and more physical activity were associated with higher functioning scores, regardless of symptom severity.

Weight Lifting and Physical Function Among Survivors of Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial

PURPOSE

Survivors of breast cancer may experience deterioration of physical function. This is important because poor physical function may be associated with premature mortality, injurious falls, bone fracture, and disability. We conducted a post hoc analysis to explore the potential efficacy of slowly progressive weight lifting to reduce the incidence of physical function deterioration among survivors of breast cancer.

METHODS

Between October 2005 and August 2008, we conducted a single-blind, 12-month, randomized controlled trial of twice-per-week slowly progressive weight lifting or standard care among 295 survivors of nonmetastatic breast cancer. In this post hoc analysis of data from the Physical Activity and Lymphedema Trial, we examined incident deterioration of physical function after 12 months, defined as a ≥ 10-point decrease in the physical function subscale of the Medical Outcomes Short-Form 36-item questionnaire.

RESULTS

The proportion of participants who experienced incident physical function deterioration after 12 months was 16.3% (24/147) in the control group and 8.1% (12/148) in the weight lifting group (relative risk, 0.49; 95% CI, 0.25 to 0.96; P = .04). No serious or unexpected adverse events occurred that were related to weight lifting.

CONCLUSION

Slowly progressive weight lifting compared with standard care reduced the incidence of physical function deterioration among survivors of breast cancer. These data are hypothesis generating. Future studies should directly compare the efficacy of weight lifting with other modalities of exercise, such as brisk walking, to appropriately inform the development of a confirmatory study designed to preserve physical function among survivors of breast cancer.