Pre- and post-diagnosis physical activity is associated with survival benefits of colorectal cancer patients: a systematic review and meta-analysis

The sustainability of exercise following colorectal surgery: A qualitative study of participants in the PREPARE-ABC trial

OBJECTIVE

This study aimed to explore perceptions regarding the sustainability of exercise following participation in a pre- and post-colorectal surgery exercise intervention trial (PREPARE-ABC).

DESIGN

Qualitative interview study. Data were analysed using framework analysis and independently coded by two researchers.

SETTING

Six United Kingdom National Health Service Trusts.

PARTICIPANTS

Eighteen interviews (hospital-based exercise n = 9, home-based exercise n = 3, standard care n = 6) were conducted with patients 12-15 months after being randomised in the trial, after their 12 month appointment.

INTERVENTION

Individuals who participated in one of two exercise intervention groups (hospital-supervised or home-supported exercise) or a standard care control group of the PREPARE-ABC trial were invited to interview.

RESULTS

The exercise interventions were reported to influence participants' recovery and future sustainability of exercise behaviour change. Several participants continued to engage in exercise over a year after their surgery. Reasons for this included being engaged with exercise prior to diagnosis, psychological benefits of exercise and wanting to be engaged with something to help recovery. Perceptions about the sustainability of active lifestyles were influenced by confidence to engage in structured exercise or physical activity and beliefs about its potential to promote future wellness.

CONCLUSIONS

Sustainability varies among individuals and early assessment of physical activity engagement could be beneficial. Physical activity interventions immediately following surgery may be important for future engagement.

Physical activity maintenance in colorectal cancer survivors after an exercise intervention applying behaviour change techniques: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review and meta-analysis is to determine the long-term effect of combined physical activity (PA) and behaviour change techniques (BCT) interventions in PA maintenance of colorectal cancer survivors (CRCS) and identify the most frequent BCT implemented in them.

METHODS

PRISMA recommendations were followed. Databases were searched for randomized controlled trials up to October 2023. Studies in which CRCS completed a PA intervention based on any Theoretical Model of Behaviour Change (TMBC) and a subsequent follow-up period were included. Between-group differences at baseline and after follow-up were pooled for meta-analysis. BCT codification was performed using the BCT taxonomy v1. Methodological quality and evidence certainty were also assessed.

RESULTS

Five studies involving 906 CRCS met the inclusion criteria. PA interventions applying BCT showed a significant change with a small positive effect (pooled SMD = 0.22 (0.09, 0.35)) on the PA after a follow-up period between 3 and 12 months. Twenty-two different BCTs were identified (mean 17.2, range 15-19) of which 12 were common across all interventions.

CONCLUSIONS

PA and BCT interventions have been found to be effective in improving the long-term maintenance of PA in CRCS. Further studies with higher methodological quality are needed to confirm these findings.

IMPLICATIONS FOR CANCER SURVIVORS

Aerobic exercise, pedometers, PA diaries and educational materials seem to be important aspects to achieve sustainable adherence to an active lifestyle over time. Supervision, access to fitness areas and applying some BCT appear to be differentiating features to obtain more successful PA maintenance.

Post-diagnosis physical activity and sedentary behaviour and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

Low physical activity and high sedentary behaviour have been clearly linked with colorectal cancer development, yet data on their potential role in colorectal cancer survival is limited. Better characterisation of these relationships is needed for the development of post-diagnosis physical activity and sedentary behaviour guidance for colorectal cancer survivors. We searched PubMed and Embase through 28 February 2022 for studies assessing post-diagnosis physical activity, and/or sedentary behaviour in relation to all-cause and cause-specific mortality and recurrence after colorectal cancer diagnosis. Total and recreational physical activity were assessed overall and by frequency, duration, intensity, and volume using categorical, linear, and non-linear dose-response random-effects meta-analyses. The Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel interpreted and graded the likelihood of causality. We identified 16 observational studies on 82,220 non-overlapping patients from six countries. Physical activity was consistently inversely associated with colorectal cancer morbidity and mortality outcomes, with 13%-60% estimated reductions in risk. Sedentary behaviour was positively associated with all-cause mortality. The evidence had methodological limitations including potential confounding, selection bias and reverse causation, coupled with a limited number of studies for most associations. The CUP Global Expert panel concluded limited-suggestive evidence for recreational physical activity with all-cause mortality and cancer recurrence. Total physical activity and its specific domains and dimensions, and sedentary behaviour were all graded as limited-no conclusion for all outcomes. Future research should focus on randomised trials, while observational studies should obtain objective and repeated physical activity measures and better adjustment for confounders.

The impact of high intensity interval training in a diverse group of cancer survivors: CAPABLE, a pilot study

Purpose

Given the well-documented benefits of regular exercise to cancer survivors, current American Cancer Society guidelines recommend that patients engage in a minimum of 150 min per week of moderate-to-vigorous physical activity with a minimum of two days of strength training. However, few survivors meet this goal, particularly among minorities.

Methods

The CAPABLE study is a single-arm, pilot exercise intervention that introduced 48 cancer survivors to a high intensity interval and strength training program three days a week for 12 weeks. We evaluated the impact of this unique training method on bodyweight, % body fat, serum markers correlated with an adverse cardiometabolic profile and health-related quality of life (HRQoL). Measures were summarized at baseline and program exit. Paired t-tests were used to assess change in each of these measures over time.

Results

We observed losses in weight, body mass index, and % body fat, and glycosylated hemoglobin (HbA1c) levels over 12-weeks. There were also clinically meaningful improvements in reported overall HRQoL (FACTG total change +9.5 (95% CI, 4.6, 14.4)) and in each one of the individual domains (physical, social, emotional, and functional well-being).

Conclusions

We observed meaningful improvements in body composition, HbA1c and quality of life over 12 weeks among cancer survivors participating in a high-intensity interval training program. Future work will include a control arm for comparison and address barriers to participation and adherence which will be important in using this intervention and others like it to improve outcomes and reduce cancer health disparities.

Impact of home-based training and nutritional behavior on body composition and metabolic markers in cancer patients: data from the CRBP-TS study

Introduction

Obesity and physical inactivity are known to affect cancer's development and prognosis. In this context, physical aerobic and resistance training as well as a Mediterranean nutrition have been proven to have many positive health effects. The aim of this study was therefore to investigate the effect of home-based training on body composition and certain metabolic laboratory parameters.

Methods

Patients with breast, colorectal and prostate cancer who underwent curative surgery at stages T1N0M0-T3N3M0 were eligible for this trial and randomized to an intervention and control group. In the intervention group the patients carried out online-based strength-endurance home training during the 6-month study period. Body composition was assessed via bioelectrical impedance analysis (baseline, 3 months and 6 months). Metabolic blood parameters were also analyzed and nutrition behavior determined using the Mediterranean Diet Adherence Screener (MEDAS).

Results

The intervention group's fat mass decreased while their lean body mass increased (time effect p = 0.001 and p = 0.001, respectively). We found no interaction effect in body weight (p = 0.19), fat mass [p = 0.06, 6-months estimates -0.9 (95% CI -1.8 to -0.1)] and lean body mass (p = 0.92). Blood samples also failed to show a statistically significant interaction effect between time × group for HbA1c% (p = 0.64), Insulin (p = 0.33), Adiponectin (p = 0.87), Leptin (p = 0.52) and Triglycerides (p = 0.43). Only Adiponectin revealed significance in the time effect (p < 0.001) and Leptin in the group effect (p = 0.03). Dietary behavior during the study period was similar in patients in the intervention and control groups (interaction p = 0.81; group p = 0.09 and time p = 0.03).

Discussion

Individualized online-based home training in postoperative cancer patients revealed only minor changes, with no group differences in body composition or metabolic laboratory parameters, which were predominantly in the reference range at baseline. More studies investigating effects of online-based home training on body composition and nutrition behavior are needed.

Trial registration

https://drks.de/search/en/trial/DRKS00020499, DRKS-ID: DRKS00020499.

Effect of home-based online training and activity feedback on oxygen uptake in patients after surgical cancer therapy: a randomized controlled trial

BACKGROUND

Exercise training is beneficial in enhancing physical function and quality of life in cancer patients. Its comprehensive implementation remains challenging, and underlying cardiopulmonary adaptations are poorly investigated. This randomized controlled trial examines the implementation and effects of home-based online training on cardiopulmonary variables and physical activity.

METHODS

Of screened post-surgical patients with breast, prostate, or colorectal cancer, 148 were randomly assigned (1:1) to an intervention (2 × 30 min/week of strength-endurance training using video presentations) and a control group. All patients received activity feedback during the 6-month intervention period. Primary endpoint was change in oxygen uptake after 6 months. Secondary endpoints included changes in cardiac output, rate pressure product, quality of life (EORTC QoL-C30), C-reactive protein, and activity behavior.

RESULTS

One hundred twenty-two patients (62 intervention and 60 control group) completed the study period. Change in oxygen uptake between intervention and control patients was 1.8 vs. 0.66 ml/kg/min (estimated difference after 6 months: 1.24; 95% CI 0.23 to 2.55; p = 0.017). Rate pressure product was reduced in IG (estimated difference after 6 months: - 1079; 95% CI - 2157 to - 1; p = 0.05). Physical activity per week was not different in IG and CG. There were no significant interaction effects in body composition, cardiac output, C-reactive protein, or quality of life.

CONCLUSIONS

Home-based online training among post-surgery cancer patients revealed an increase of oxygen uptake and a decrease of myocardial workload during exercise. The implementation of area-wide home-based training and activity feedback as an integral component in cancer care and studies investigating long-term effects are needed.

TRIAL REGISTRATION

DRKS-ID: DRKS00020499 ; Registered 17 March 2020.

Feasibility and acceptability of an mHealth, home-based exercise intervention in colorectal cancer survivors: A pilot randomized controlled trial

OBJECTIVE

To determine the feasibility and acceptability of an mHealth, home-based exercise intervention among stage II-III colorectal cancer (CRC) survivors within 5-years post-resection and adjuvant therapy.

METHODS

This pilot randomized controlled trial of a 12-week mHealth, home-based exercise intervention, randomly assigned CRC survivors to a high-intensity interval training (HIIT) or moderate-intensity continuous exercise (MICE) prescription. The following assessments were carried out at baseline and end-of-study (EOS): handgrip strength, short physical performance battery (SPPB), PROMIS physical function, neuropathy total symptom score-6 (NTSS-6), Utah early neuropathy scale (UENS), cardiopulmonary exercise testing, anthropometrics, and body composition via BOD POD, modified Godin leisure-time activity questionnaire. Feasibility, as defined by number of completed prescribed workouts and rate of adherence to individualized heart rate (HR) training zones, was evaluated at EOS. Acceptability was assessed by open-ended surveys at EOS. Descriptive statistics were generated for participant characteristics and assessment data.

RESULTS

Seven participants were included in this pilot study (MICE: n = 5, HIIT: n = 2). Median age was 39 years (1st quartile: 36, 3rd quartile: 50). BMI was 27.4 kg/m2 (1st quartile: 24.5, 3rd quartile: 29.7). Most participants had stage III CRC (71%, n = 5). We observed an 88.6% workout completion rate, 100% retention rate, no adverse events, and qualitative data indicating improved quality of life and positive feedback related to ease of use, accountability, motivation, and autonomy. Mean adherence to HR training zones was 95.7% in MICE, and 28.9% for the high-intensity intervals and 51.0% for the active recovery intervals in HIIT; qualitative results revealed that participants wanted to do more/work-out harder.

CONCLUSION

An mHealth, home-based delivered exercise intervention, including a HIIT prescription, among stage II-III CRC survivors' post-resection and adjuvant therapy was tolerable and showed trends towards acceptability.

Comparison of Pre-Diagnosis Physical Activity and Its Correlates between Lung and Other Cancer Patients: Accelerometer Data from the UK Biobank Prospective Cohort

Purpose: Physical activity (PA) plays an important role in health outcomes for people with cancer, and pre-diagnosis PA influences PA behaviors after cancer treatment. Less is known about the PA of lung cancer patients, and the strong history of smoking could influence pre-diagnosis levels of PA and place them at risk for health problems. This study aimed to compare pre-diagnosis PA and its correlates in patients with lung cancer and other types of cancer (female breast, colorectal, and prostate cancer) and examine the relationship between pre-diagnosis PA and all-cause mortality. Methods: This study used data from the UK Biobank, which is a national cohort study with accelerometry data. We included 2662 participants and used adjusted linear regressions and survival analyses. Results: Male and female lung cancer groups spent a mean of 78 and 91 min/day in pre-diagnosis moderate to vigorous PA (MVPA), respectively; this is lower than the 3 other types of cancer (p < 0.001). Younger age and faster walking pace had a strong association with PA in all the four types of cancer (p < 0.01). Smoking status had a strong association with PA in the lung cancer group, while obesity had a strong association with PA in female breast, colorectal, and prostate cancer (p < 0.01). Higher levels of pre-diagnosis MVPA (≥1.5 h/day) were associated with a significantly lower all-cause mortality risk. Conclusions: The present study suggests that lung cancer patients are the most inactive population before diagnosis. The identified difference in correlates of PA suggest that cancer-specific approaches are needed in PA research and practices. This study also highlights the importance of high PA for individuals with high cancer risk.

Designing, analyzing, and interpreting observational studies of physical activity and cancer outcomes from a clinical oncology perspective

Observational studies may play an important role in evaluating physical activity (PA) as a cancer treatment; however, few studies have been designed, analyzed, or interpreted from a clinical oncology perspective. The purpose of the present paper is to apply the Exercise as Cancer Treatment (EXACT) Framework to assess current observational studies of PA and cancer outcomes from a clinical oncology perspective and provide recommendations to improve their clinical utility. Recent systematic reviews and meta-analyses of over 130 observational studies have concluded that higher prediagnosis and postdiagnosis PA are associated with lower risks of cancer-specific and all-cause mortality. Most of these studies, however, have: (a) included cancer patients receiving heterogeneous treatment protocols, (b) provided minimal details about those cancer treatments, (c) assessed PA prediagnosis and/or postdiagnosis without reference to those cancer treatments, (d) reported mainly mortality outcomes, and (e) examined subgroups based on demographic and disease variables but not cancer treatments. As a result, current observational studies on PA and cancer outcomes have played a modest role in informing clinical exercise trials and clinical oncology practice. To improve their clinical utility, we recommend that future observational studies of PA and cancer outcomes: (a) recruit cancer patients receiving the same or similar first-line treatment protocols, (b) collect detailed data on all planned and unplanned cancer treatments beyond whether or not cancer treatments were received, (c) assess PA in relation to cancer treatments (i.e., before, during, between, after) rather than in relation to the cancer diagnosis (i.e., various time periods before and after diagnosis), (d) collect data on cancer-specific outcomes (e.g., disease response, progression, recurrence) in addition to mortality, (e) conduct subgroup analyses based on cancer treatments received in addition to demographic and disease variables, and (f) interpret mechanisms for any associations between PA and cancer-specific outcomes based on the clinical oncology scenario that is recapitulated rather than referencing generic mechanisms or discordant preclinical models. In conclusion, observational studies are well-suited to contribute important knowledge regarding the role of PA as a cancer treatment; however, modifications to study design and analysis are necessary if they are to inform clinical research and practice.

Physical Activity and Sedentary Behavior in Relation to Cancer Survival: A Narrative Review

Simple Summary

Globally, cancer is a major issue and an increasing number of people live with cancer. Lifestyle-associated factors play a major role in cancer prevention. Being physically active and limiting the amount of time spent sitting reduce the risk of developing several types of cancer. Furthermore, physical activity before, during, and after cancer diagnosis has been found to improve cancer outcomes. In addition, reduced levels of time spent sedentary may lead to improved outcomes in cancer survivors as well. This narrative review summarizes the existing evidence on the relationship of physical activity and sedentary behavior to cancer survival and other health outcomes in cancer survivors. The review provides an overview on the barriers, facilitators, and other factors that determine the levels of physical activity and sedentary behavior in cancer survivors as well as on the current recommendations on physical activity and sedentary behavior for cancer survivors.

Abstract

From a public health perspective, cancer is a major issue, and it contributes to a high economic and societal burden. Lifestyle-associated risk factors play a crucial role in cancer prevention. The present narrative review aims to summarize the existing evidence on the relationship of physical activity and sedentary behavior to cancer survival, including the evidence on mortality and other health-related outcomes. There is strong evidence that physical activity before, during, and after cancer diagnosis improves outcomes for breast and colorectal cancers. In addition, there is emerging evidence that reduced levels of sedentary behavior in cancer survivors are associated with improved outcomes. Future studies are needed to strengthen the evidence and to provide details on additional cancer sites. In the meantime, existing recommendations for physical activity and sedentary behavior in cancer survivors should be followed to improve the health status of cancer survivors.

A Smartphone Remote Monitoring App to Follow Up Colorectal Cancer Survivors: Requirement Analysis

BACKGROUND

Colorectal cancer survivors face multiple challenges after discharge. eHealth may potentially support them by providing tools such as smartphone apps. They have lots of capabilities to exchange information and could be used for remote monitoring of these patients.

OBJECTIVE

In this study, we addressed the required features for apps designed to follow up colorectal cancer patients based on survivors' and clinical experts' views.

METHODS

A mixed methods study was conducted. Features of related apps were extracted through the literature; the features were categorized, and then, they were modified. A questionnaire was designed containing the features listed and prioritized based on the MoSCoW (Must have, Should have, Could have, Won't have) technique and an open question for each category. The link to the questionnaire was shared among clinical experts in Iran. The answers were analyzed using the content validity ratio (CVR), and based on the value of this measure, the minimum feature set of a monitoring app to follow up patients with colorectal cancer was addressed. In addition, a telephone interview with colorectal cancer survivors was conducted to collect their viewpoints regarding a remote monitoring system for colorectal cancer cases.

RESULTS

The questionnaire contained 10 sections evaluating 9 categories of features. The questionnaire was completed by 18 experts. The minimum set of features in the app was identified as patient information registration, sign and symptom monitoring, education, reminders, and patient evaluation (0.42 < CVR < 0.85). Features including physical activity, personalized advice, and social network did not achieve the minimum score (-0.11 < CVR < 0.39). We interviewed 9 colorectal cancer survivors. Information registration, sign and symptom monitoring, education, and personalized advice were the features with high priority from the survivors' perspectives. Scheduling, shopping, and financial support features were emphasized by survivors in the interview.

CONCLUSIONS

The requirement set could be used to design an app for the targeted population or patients affected by other cancers. As the views from both survivors and clinical experts were considered in this study, the remote system may more adequately fulfill the need for follow-up of survivors. This eases the patients' and health care providers' communication and interaction.

Attitudes to and Experiences of Physical Activity After Colon Cancer Diagnosis Amongst Physically Active Individuals - A Qualitative Study

BACKGROUND

Physical activity improves survival, reduces postoperative complications, and reduces the risk of developing colon cancer. It is important to maintain physical activity after receiving a diagnosis of colon cancer to improve postoperative recovery. Individuals who are physically active and diagnosed with colon cancer presumably have different motivations to maintain physical activity compared to their sedentary counterparts.

OBJECTIVE

Enlighten how the diagnosis of colon cancer might affect physically active individuals in their attitude and experiences towards physical activity.

METHODS

A qualitative study using content analysis was conducted in northern Sweden based on semi-structured telephone interviews of twenty patients diagnosed with colon cancer. All participants met the recommendations for physical activity issued by the World Health Organization.

RESULTS

Participants were between 50 and 88 years and 50% were male. Three main categories were identified: I'll fight the cancer and come out stronger; The diagnosis makes no difference; and The diagnosis is an obstacle for physical activity. These main categories represent the ways the individuals reacted to the diagnosis of colon cancer regarding their physical activity.

CONCLUSION

Attitudes to and experience of physical activity after colon cancer diagnosis varied from a will to increase physical activity and fight the cancer, to the diagnosis putting a stop to physical activity. It is important that healthcare professionals recommend physical activity even in already physically active individuals, to encourage continued physical activity after diagnosis of colon cancer.

Density of CD3+ and CD8+ Cells in the Microenvironment of Colorectal Cancer according to Prediagnostic Physical Activity

BACKGROUND

Physical activity is associated not only with a decreased risk of developing colorectal cancer but also with improved survival. One putative mechanism is the infiltration of immune cells in the tumor microenvironment. Experimental findings suggest that physical activity may mobilize immune cells to the tumor. We hypothesized that higher levels of physical activity prior to colorectal cancer diagnosis are associated with higher densities of tumor-infiltrating T-lymphocytes in colorectal cancer patients.

METHODS

The study setting was a northern Swedish population-based cohort, including 109,792 participants with prospectively collected health- and lifestyle-related data. For 592 participants who later developed colorectal cancer, archival tumor tissue samples were used to assess the density of CD3⁺ and CD8⁺ cytotoxic T cells by IHC. Odds ratios for associations between self-reported, prediagnostic recreational physical activity and immune cell infiltration were estimated by ordinal logistic regression.

RESULTS

Recreational physical activity >3 times per week was associated with a higher density of CD8⁺ T cells in the tumor front and center compared with participants reporting no recreational physical activity. Odds ratios were 2.77 (95% CI, 1.21-6.35) and 2.85 (95% CI, 1.28-6.33) for the tumor front and center, respectively, after adjustment for sex, age at diagnosis, and tumor stage. The risk estimates were consistent after additional adjustment for several potential confounders. For CD3, no clear associations were found.

CONCLUSIONS

Physical activity may promote the infiltration of CD8⁺ immune cells in the tumor microenvironment of colorectal cancer.

IMPACT

The study provides some evidence on how physical activity may alter the prognosis in colorectal cancer.

Physical Activity after Colorectal Cancer Diagnosis and Mortality in a Nationwide Retrospective Cohort Study

Simple Summary

Physical activity can help to prevent colorectal cancer, but its importance after cancer diagnosis has not been validated. In this nationwide insurance data-based study of 43,596 colorectal cancer patients, a high level of physical activity after colorectal cancer diagnosis was negatively associated with a risk of death in both colon and rectal cancer patients, particularly in the surgically treated group. Our findings support the importance of the physical activity among colorectal cancer patients.

Abstract

Physical activity reduces the risk of colon cancer, but its prognostic impact after cancer diagnosis remains unclear. To evaluate the association between post-diagnosis activity and cause-specific mortality, we reconstructed a colorectal cancer patient cohort from the 2009–16 Korean National Health Insurance Service (NHIS) database. Subgroup analyses were performed by treatment group. In total, 27,143 colon cancer patients and 16,453 rectal cancer patients were included in the analysis (mean follow-up, 4.3 years; median 4.0 years). In the surgically treated group, a high level of activity (the weighted sum of the frequencies for walking, moderate, and vigorous activity greater than or equal to 3 times/week) was inversely associated with all-cause mortality (colon cancer: HR, 0.79; 95% CI, 0.72 to 0.88; rectal cancer: HR, 0.75; 95% CI, 0.66 to 0.86) and colorectal cancer-specific mortality (colon cancer: HR, 0.85; 95% CI, 0.76 to 0.97; rectal cancer: HR, 0.77; 95% CI, 0.66 to 0.90). No significant results were shown for cardiovascular disease-specific mortality. No association was shown in patients who received chemoradiotherapy without surgery. The present study may provide evidence for post-diagnosis physical activity as a prognostic factor in colorectal cancer, particularly in surgically treated early-stage patients.

Characterizing the Exercise Behaviour, Preferences, Barriers, and Facilitators of Cancer Survivors in a Rural Canadian Community: A Cross-Sectional Survey

Barriers, facilitators, and motivators to exercise for cancer survivors living in urban settings are well described in the literature. However, there is a lack of comparable information for cancer survivors living in rural communities. We describe the exercise behaviours, barriers, facilitators, and motivators to exercise participation of cancer survivors living in a rural Canadian community. Adult cancer survivors with a primary address in a rural region of Ontario, Canada, who had visited a community hospital in the previous five years were mailed a cross-sectional survey assessing current exercise volume (minutes of moderate-to-vigorous aerobic and resistance exercise), as well as exercise preferences, barriers, and facilitators. Seventy-two survivors (mean age 65 years) completed the survey (16% response rate). A majority of respondents were diagnosed with breast cancer (49%) in the last 5 years (61%). Aerobic- and resistance-training guidelines for cancer survivors were met by 38% and 10% of respondents, respectively. Physical side effects were the most common barrier to exercise during treatment (65%) and post-treatment (35%). Being unaware of available exercise programs, time for exercise, distance to exercise services, and cost were commonly reported barriers during and post-treatment (reported by 10–22%). Respondents reported needing information from a qualified exercise professional (46%), access to a gym (33%) and exercise equipment (26%), and social support (25%) to facilitate exercise participation. Consistent with urban-based cancer survivors, most rural survivors surveyed in this study were not meeting the physical-activity guidelines and reported numerous exercise barriers. These findings can serve as a resource for this and similar rural communities when developing community-based exercise-support services for cancer survivors.

A systematic review and meta-analysis of physical activity interventions among colorectal cancer survivors

With the growing number of colorectal cancer survivors (CRCS), theory-based, high-quality physical activity (PA) interventions are needed to promote quality and quantity of life. This systematic review and meta-analysis synthesized theory-based PA interventions among CRCS. Using PubMed, PsyINFO, CINAHL, MEDLINE, SportDiscus, and Cochrane databases, studies including CRCS participants, a PA outcome, a behavioral theory/model or behavior change techniques (BCTs), and randomized research design were identified. Two reviewers coded BCT, intervention reproducibility (Template for Intervention Description and Replication-TIDier), risk of bias, and quality of evidence. From an initial screen of 1,328 articles, 10 RCTs met our inclusion criteria. The Transtheoretical Model (n = 3), Social Cognitive Theory (n = 3), and Theory of Planned Behavior (n = 2) were the most used theories. "Goal setting (behavior)" (n = 10), "goal setting (outcome)" (n = 10), "action planning" (n = 9), and "problem solving" (n = 9) were the most commonly used BCTs. Intervention modalities were primarily print material based (n = 4) and telephone counseling (n = 4). Findings demonstrated that theory-based PA interventions are successful at increasing PA among CRCS as meta-analysis evidenced a small effect size of 0.26. TDier items 3, 9, and 12 hindered intervention replicability. Lack of blinding and bias in the measurement of outcomes by assessors resulted in serious bias. In-depth theoretical applications are needed for PA interventions that minimize bias and improve outcomes measurement. Intervention adherence and fidelity, as well as theoretical construct measurement pre- and post-intervention, will enhance the behavioral research enterprise. PROSPERO registration: CRD42019142816.

Physical activity and mortality in patients with colorectal cancer: a meta-analysis of prospective cohort studies

The association between physical activity (PA) and colorectal cancer (CRC) patients' survival is inconsistent. We conducted a systematic review and meta-analysis to summarize published articles on this issue. We performed a comprehensive search of the PubMed, Embase, and Web of Science databases for relevant articles through 28 February 2018. The summary hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a random-effects model. Eighteen prospective cohort studies were included in the meta-analysis, with a total of 9257 cases of total mortality (TM) and 4015 cases of colorectal cancer-specific mortality (CRCSM) among 31 873 CRC survivors and 557 150 general populations. Among CRC survivors, the highest versus the lowest levels of prediagnosis PA showed decreased risks of TM (summary HR = 0.81, 95% CI: 0.76-0.87, I = 1.8%) and CRCSM (summary HR = 0.85, 95% CI: 0.77-0.98, I = 0), respectively. Significant risk reductions for TM and CRCSM were also demonstrated for postdiagnosis PA (HR = 0.63, 95% CI: 0.54-0.74; and HR = 0.64, 95% CI: 0.47-0.88, respectively). The inverse association between prediagnosis PA and cancer mortality was more pronounced for colon cancer than that for rectal cancer (P = 0.08). The summary HRs (95% CIs) of TM were 0.89 (0.83-0.97) and 0.79 (0.69-0.90) per 10 metabolic equivalent task-h/week increase in prediagnosis and postdiagnosis PA, respectively. Our meta-analysis provides comprehensive evidence that PA performed before or after cancer diagnosis is related to reduced mortality risk among CRC survivors.

Identification of Lifestyle Behaviors Associated with Recurrence and Survival in Colorectal Cancer Patients Using Random Survival Forests

Current lifestyle recommendations for cancer survivors are the same as those for the general public to decrease their risk of cancer. However, it is unclear which lifestyle behaviors are most important for prognosis. We aimed to identify which lifestyle behaviors were most important regarding colorectal cancer (CRC) recurrence and all-cause mortality with a data-driven method. The study consisted of 1180 newly diagnosed stage I-III CRC patients from a prospective cohort study. Lifestyle behaviors included in the current recommendations, as well as additional lifestyle behaviors related to diet, physical activity, adiposity, alcohol use, and smoking were assessed six months after diagnosis. These behaviors were simultaneously analyzed as potential predictors of recurrence or all-cause mortality with Random Survival Forests (RSFs). We observed 148 recurrences during 2.6-year median follow-up and 152 deaths during 4.8-year median follow-up. Higher intakes of sugary drinks were associated with increased recurrence risk. For all-cause mortality, fruit and vegetable, liquid fat and oil, and animal protein intake were identified as the most important lifestyle behaviors. These behaviors showed non-linear associations with all-cause mortality. Our exploratory RSF findings give new ideas on potential associations between certain lifestyle behaviors and CRC prognosis that still need to be confirmed in other cohorts of CRC survivors.

Impact of exercise on the immune system and outcomes in hematologic malignancies

Exercise is increasingly recognized as important to cancer care. The biology of how exercise improves outcomes is not well understood, however. Studies show that exercise favorably influences the immune system in healthy individuals (neutrophils, monocytes, natural killer cells, T cells, and a number of cytokines). Thus, exercise in patients with hematologic cancer could significantly improve immune function and tumor microenvironment. We performed a literature search and identified 7 studies examining exercise and the immune environment in hematologic malignancies. This review focuses on the role of exercise and physical activity on the immune system in hematologic malignancies and healthy adults.

Interventions to improve physical activity in colorectal cancer survivors: protocol for a systematic review and meta-analysis of randomized controlled trials

AIM

To examine the effectiveness of physical activity (PA) interventions on changes in PA among colorectal cancer survivors, including an examination of theoretical versus atheoretical-driven approaches, with a special focus on their effectiveness across ethnic and racial minorities.

DESIGN

Systematic review with aggregated data meta-analyses.

DATA SOURCES

Using six databases (Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, CINAHL with full text, Scopus and Web of Science), we will screen for randomized controlled trials written in English from May 1, 1993 up to December 31, 2020.

REVIEW METHODS

Dual study-selection and data abstraction will be performed. The Behavior Change Technique Taxonomy (v1) will be used to examine behavior change techniques among selected studies, while the Theory Coding Scheme will be used to assess the extent of theory use. Risk of bias will be assessed using the revised Cochrane risk-of-bias tool for randomized trials, while the strength of the evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation instrument. In addition, intervention delivery will be appraised using the Template for Intervention Description and Replication. Changes in PA from each study will be calculated using the standardized mean difference effect size (Hedge's g). Results will be pooled using the inverse-variance heterogeneity model. Heterogeneity (Cochran's Q) and inconsistency (I² ) will be examined, while small-study effects (publication bias) will be evaluated using the Doi plot and LFK Index. Meta-regression will also be conducted to examine for potential associations between changes in physical activity and selected covariates (theoretical versus atheoretical-driven approaches, race/ethnicity).

DISCUSSION

This systematic review will identify specific racial/ethnic minorities for whom interventions are most effective and summarize the evidence of the effectiveness of theoretical vs. theoretical based intervention.

IMPACT

This systematic review can direct policymakers and practitioners towards actions that are likely to bring about positive physical activity behaviour change.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BACKGROUND

Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.

METHODS AND FINDINGS

We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.

CONCLUSIONS

In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

The effects of physical activity on overall survival among advanced cancer patients: a systematic review and meta-analysis

Background

The survival rates of advanced cancer patients remain low despite clinical therapy advancements. However, physical activity showed promising effects in improving cancer outcomes. This review aimed to systematically evaluate and synthesize the effects on overall mortality of post-diagnosis physical activity in advanced cancer patients.

Methods

A systematic search of six English databases (PubMed, EMBASE, CINAHL, PsycINFO, The Cochrane Central Register of Controlled Trials, and SPORTDiscus) was conducted from their inception up to 3 February 2021. The association of physical activity with survival was evaluated by combining study-specific hazard ratios with random-effects meta-analysis models.

Results

Eleven studies were identified. Compared with the reference group, higher-level physical activity was not significantly associated with a lower risk of earlier mortality in advanced cancer patients (InHR = − 0.18, 95% CI, − 0.36 to 0.01). When separated by study type, a higher level of physical activity in non-randomised trials was significantly associated with reduced mortality risk (InHR = − 0.25, 95% CI: − 0.44, − 0.06). However, in randomised trials, engaging in exercise was not significantly associated with a lower mortality risk compared with the control group (InHR = 0.08, 95%CI: − 0.17, 0.32).

Conclusions

Discrepancies were uncovered in the effect of physical activity on overall survival in randomised and non-randomised trials. In non-randomised trials, a higher level of physical activity was significantly associated with a lower risk of mortality, whereas no significant effect on survival was observed during exercise interventions compared to the control in randomised trials. Considering the wider benefits of physical activity, exercise can still be recommended to improve outcomes for advanced cancer patients. Nevertheless, it might be too late for advanced cancer patients to start exercising for survival improvements, based on findings from randomised controlled trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07988-1.

Exercise-mediated downregulation of MALAT1 expression and implications in primary and secondary cancer prevention

Long non-coding RNAs (lncRNAs) play critical roles in various biological functions and disease processes including cancer. The metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) was initially identified as a lncRNA with elevated expression in primary human non-small cell lung tumors with high propensity to metastasize, and subsequently shown to be highly expressed in numerous other human cancers including breast, ovarian, prostate, cervical, endometrial, gastric, pancreatic, sarcoma, colorectal, bladder, brain, multiple myeloma, and lymphoma. MALAT1 is deeply involved in several physiological processes, including alternative splicing, epigenetic modification of gene expression, cellular senescence, healthy aging, and redox homeostasis. The aim of this work was to investigate the modulation exerted by a single bout of endurance exercise on the level of MALAT1 expression in peripheral blood mononuclear cells (PBMCs) from healthy male donors displaying different training status and redox homeostasis features. Our findings show that MALAT1 is downregulated after acute endurance exercise in subjects whose fitness level guarantee a high expression of SOD1 and SOD2 antioxidant genes and low levels of endogenous oxidative damage. In vitro protocols in Jurkat lymphoblastoid cells exposed to pro-oxidant environment confirmed the link between MALAT1 expression and antioxidant gene modulation, documenting p53 phosphorylation and its recruitment to MALAT1 promoter. Remarkably, analyses of Microarray-Based Gene Expression Profiling revealed high MALAT1 expression in leukemia patients in comparison to healthy control and a significant negative correlation between MALAT1 and SOD1 expression. Collectively our results highlight the beneficial effect of a physically active lifestyle in counteracting aberrant cancer-related gene expression programs by improving the redox buffering capacity.

The effect of exercise-based interventions on health-related quality of life and physical function in older patients with cancer receiving medical antineoplastic treatments: a systematic review

Older patients with cancer are underrepresented in trials investigating the effect of exercise therapy. The aim of this systematic review was to investigate the effect of exercise therapy during medical antineoplastic treatment in older patients (≥ 65 years) with cancer. A systematic review following the Cochrane guidelines was performed. Randomized controlled trials were identified through a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL up to December 2019. Study selection was performed independently by two reviewers. Four randomized controlled trials published between 2014 and 2019 were included comprising a total of 412 participants. Most participants were diagnosed with breast, prostate or colorectal cancer. The studies were characterized by large differences in design, interventions and outcomes, which prevented meta-analyses. The interventions ranged from 4 weeks to 12 months and involved both supervised and unsupervised exercise programs. Some evidence of beneficial effects from the interventions were documented on physical function, muscle strength, physical activity and cognitive function. No evidence of effects was found for health-related quality of life, aerobic capacity, body composition, cancer-related symptoms and side effects, or for any clinical outcomes. No adverse events were reported. Exercise therapy seems to be safe and feasible in older patients with cancer. However, due to a limited number of studies, small sample sizes and heterogeneity across study design, the effects of exercise in older patients with cancer receiving medical antineoplastic treatment are inconclusive.

Determinants of adherence to physical cancer rehabilitation guidelines among cancer patients and cancer centers: a cross-sectional observational study

PURPOSE

To tailor implementation strategies that maximize adherence to physical cancer rehabilitation (PCR) guidelines, greater knowledge concerning determinants of adherence to those guidelines is needed. To this end, we assessed the determinants of adherence to PCR guidelines in the patient and cancer center.

METHODS

We investigated adherence variation of PCR guideline-based indicators regarding [1] screening with the Distress Thermometer (DT), [2] information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), [3] advice to take part in PA and PCRPs, [4] referral to PCRPs, [5] participation in PCRPs, and [6] PA uptake (PAU) in nine cancer centers. Furthermore, we assessed patient and cancer center characteristics as possible determinants of adherence. Regression analyses were used to determine associations between guideline adherence and patient and cancer center characteristics. In these analyses, we assumed the patient (level 1) nested within the cancer center (level 2).

RESULTS

Nine hundred and ninety-nine patients diagnosed with cancer between January 2014 and June 2015 were included. Of the 999 patients included in the study, 468 (47%) received screening with the DT and 427 (44%) received information provision concerning PA and PCRPs. Subsequently, 550 (56%) patients were advised to take part in PA and PCRPs, which resulted in 174 (18%) official referrals. Ultimately, 280 (29%) patients participated in PCRPs, and 446 (45%) started PAU. Screening with the DT was significantly associated with information provision concerning PA and PCRPs (OR 1.99, 95% CI 1.47-2.71), advice to take part in PA and PCRPs (OR 1.79, 95% CI 1.31-2.45), referral to PCRPs (OR 1.81, 95% CI 1.18-2.78), participation in PCRPs (OR 2.04, 95% CI 1.43-2.91), and PAU (OR 1.69, 95% CI 1.25-2.29). Younger age, male gender, breast cancer as the tumor type, ≥2 cancer treatments, post-cancer treatment weight gain/loss, employment, and fatigue were determinants of guideline adherence. Less variation in scores of the indicators between the different cancer centers was found. This variation between centers was too low to detect any association between center characteristics with the indicators.

CONCLUSIONS

The implementation of PCR guidelines is in need of improvement. We found determinants at the patient level associated with guideline-based PCR care.

IMPLICATIONS FOR CANCER SURVIVORS

Implementation strategies that deal with the determinants of adherence to PCR guidelines might improve the implementation of PCR guidelines and the quality of life of cancer survivors.

Factors Associated with Time Intervals for Diagnosis of Colorectal Cancer: A Hospital Based Study in Khon Kaen, Thailand

Background:

Colorectal cancer (CRC) is among the five-leading cancers in Thailand. Delayed diagnosis is crucial for undermining the prognosis of the patients. This study aims to evaluate the factors associated with the time interval for diagnosis (TID).

Methods:

A cross-sectional analytical study of 191 CRC patients with histological confirmation who were undergoing treatment in the tertiary hospital in Khon Kaen Province was conducted. The data were obtained by interview and retrieving from medical records. The time interval in each diagnostic process is reported in geometric mean. The geometric mean ratio (GMR) used to interpret the results from multiple linear regressions that analyze the relationship between factors and log-transformed TID.

Results:

Most patients were males (61.78%) with mean age of 61.28±10.2 years old. The geometric mean of TID was 263.48 days. Two factors were significantly associated with longer TID: first visit at a tertiary hospital (GMR=7.77 relative to secondary hospital; 95%CI=1.95 to 30.57) and distance to tertiary healthcare. Two factors were significantly associated with shorter TID: officer/ state enterprise (GMR=0.53 relative to agriculture; 95%CI=0.28 to 0.98) and cost of traveling to secondary healthcare.

Conclusions:

The results showed the occupation, first health care visit, distance and cost were factors associated with TID. Improving the facilities at the secondary healthcare units for diagnosing CRC would be likely to help to reduce the wasted time in the healthcare system.

The effects of exercise on insulin, glucose, IGF-axis and CRP in cancer survivors: Meta-analysis and meta-regression of randomised controlled trials

BACKGROUND

The purpose of this study was to investigate the relationship between physical activity and biological mediators of cancer recurrence and survival.

METHODS

We conducted a comprehensive literature search of PubMed, ScienceDirect and Web of Science for randomised controlled trials examining the association between physical activity and C-reactive protein (CRP), glucose, insulin, insulin resistance and insulin growth factor-one (IGF-1) up to December 2017. Standardised mean difference (SMD) scores were calculated, and meta-regression was performed.

RESULTS

The meta-analysis indicated that survivors randomised to physical activity conditions experienced greater improvements in Insulin (SMD = -0.59; 95% CI, -1.05 to -0.14), CRP (SMD = -0.52; 95% CI, -0.87 to -0.17), insulin resistance (SMD = -0.20; 95% CI, -0.41 to -0.003) and glucose (SMD = -0.19; 95% CI, -0.35 to -0.02) than survivors randomised to control conditions. The meta-regression showed that study duration was positively, albeit marginally related (p = .056) to change in CRP levels among survivors in the physical activity conditions. Furthermore, higher baseline insulin levels in the physical activity conditions were associated with improving insulin levels throughout the intervention (p = .007).

CONCLUSIONS

Promoting physical activity throughout the survivorship continuum is an effective intervention strategy for improving levels of insulin, glucose control, insulin resistance and CRP among cancer survivors.

Competing mortality risks analysis of prediagnostic lifestyle and dietary factors in colorectal cancer survival: the Norwegian Women and Cancer Study

Background

It remains unclear whether or which prediagnostic lifestyle and dietary factors influence colorectal cancer (CRC) survival following diagnosis. This study used competing mortality risks analysis to evaluate the association between these factors and CRC survival.

Methods

A total of 96 889 cancer-free participants of the Norwegian Women and Cancer Study completed the study’s baseline questionnaire on lifestyle and dietary factors between 1996 and 2004. Of the 1861 women who subsequently developed CRC, 550 had CRC as the cause of death, while 110 had a non-CRC cause of death. We used multiple imputation to handle missing data. We performed multivariable competing mortality risks analyses to determine the associations between prediagnostic lifestyle and dietary factors and CRC survival. Cause-specific HRs were estimated by Cox regression and subdistribution HRs were estimated by the Fine-Gray regression with corresponding 95% CIs.

Results

Following multivariable adjustment, a prediagnostic vitamin D intake of >10 μg/day compared with ≤10 μg/day was associated with better CRC survival (HR=0.75, 95% CI 0.61 to 0.92). Other prediagnostic lifestyle and dietary factors showed no association with CRC survival. The corresponding results obtained from cause-specific Cox and Fine-Gray regressions were similar.

Conclusion

Our study shows that prediagnostic vitamin D intake could improve CRC survival.

Physical Activity and Mortality in Cancer Survivors: A Systematic Review and Meta-Analysis

Background

Recommendations for improved survival after cancer through physical activity (PA) exist, although the evidence is still emerging. Our primary objective was to conduct a systematic review and meta-analysis of the association between prediagnosis and postdiagnosis PA and survival (cancer-specific, all-cause, and cardiovascular disease mortality) for all cancers and by tumor site. Secondary objectives were to examine the associations within population subgroups, by PA domain, and to determine the optimal dose of PA related to survival.

Methods

PubMed, EMBASE, and SportsDiscus databases were searched from inception to November 1, 2018. DerSimonian-Laird random-effects models were used to estimate the summary hazard ratios (HRs) and 95% confidence intervals (CI) for primary and secondary analyses and to conduct dose-response analyses.

Results

Evidence from 136 studies showed improved survival outcomes with highest vs lowest levels of prediagnosis or postdiagnosis total or recreational PA for all-cancers combined (cancer specific mortality: HR = 0.82, 95% CI = 0.79 to 0.86, and HR = 0.63, 95% CI = 0.53 to 0.75, respectively) as well as for 11 specific cancer sites. For breast and colorectal cancers, greater reductions were observed for postdiagnosis PA (HR = 0.58–0.63) compared with prediagnosis PA (HR = 0.80–0.86) for cancer-specific and all-cause mortality. Survival benefits through PA were observed in most subgroups (within sex, body mass index, menopausal status, colorectal subtypes, and PA domain) examined. Inverse dose-response relationships between PA and breast cancer-specific and all-cause mortality were observed, with steep reductions in hazards to 10–15 metabolic equivalent hours per week.

Conclusion

Higher prediagnosis and postdiagnosis levels of PA were associated with improved survival outcomes for at least 11 cancer types, providing support for global promotion of PA guidelines following cancer.

Cancer specialist nurses' perspectives of physical activity promotion and the potential role of physical activity apps in cancer care

PURPOSE

The purpose of this study was to understand breast, prostate and colorectal cancer clinical nurse specialists' (CNSs) perspectives on physical activity (PA) promotion and the role of smartphone apps to support PA promotion in cancer care.

METHODS

CNSs working in breast, prostate or colorectal cancer were recruited via advertisements distributed by professional organizations. In-depth semi-structured telephone interviews were conducted and analysed using thematic analysis.

RESULTS

Nineteen CNSs participated. The analysis resulted in 4 themes regarding CNSs' perspectives of PA promotion within cancer care: (i) policy changes in survivorship care have influenced CNSs' promotion of PA; (ii) CNSs recognize their role in supporting PA but sit within a wider system necessary for effective PA promotion; (iii) CNSs use several techniques to promote PA within their consultations; (iv) remaining challenges in PA promotion. The analysis resulted in 3 themes regarding CNSs' perspectives on the use of apps to promote PA within cancer care: (i) the influence of apps on access to PA support; (ii) the role of apps in self-directed PA; (iii) implementing apps in cancer care.

CONCLUSIONS

The results of this study provide valuable insight into the CNS role and provide a number of important considerations for the development and implementation of PA interventions within cancer care, with a specific focus on smartphone-based interventions.

IMPLICATIONS FOR CANCER SURVIVORS

CNSs play an important role in PA promotion in cancer care and this research can inform the development of PA interventions delivered via smartphone app for people affected by cancer.

Health Insurance and Colorectal Cancer Survival in Khon Kaen, Thailand

Background: Evidence from healthcare studies demonstrates that patients’ health insurance affects service accessibility and the outcome of treatment. However, assessment on how colorectal cancer survival relates to health insurance is limited. Objective: The study examined the association between health insurance and colorectal cancer survival in Khon Kaen, Thailand. Methods: The retrospective cohort study was conducted with 1,931 colorectal cancer patients from Khon Kaen cancer registry between January 1, 2003 and December 31, 2012, and was followed-up until December 31, 2015. Relative survival was used to estimate the survival rate. Cox proportional hazard regression was used to estimate the relationship between health insurance and colorectal cancer survival, represented with the hazard ratio. Result: Most of the participants were males, and the median age was 62 years. The median survival time was 2.25 years (95% CI: 2.00-2.51). The five-year observed survival rate and relative survival rate were 36.87 (95% CI: 34.66-39.08) and, 42.28 (95% CI: 39.75-44.81), respectively. The factors that showed significant associations with poorer survival after adjustment for gender and age were non-surgical treatments (HRadj=1.88;95%CI=1.45-2.45), advanced stage (III+IV) (HRadj=2.50; 95%CI=2.00-3.12), histological grading in poorly differentiated (HRadj=1.84; 95%CI=1.32-2.56), and Universal Coverage Scheme (HRadj=1.37;95%CI=1.09-1.72). Conclusion: The survival of colorectal cancer patients in the Universal Coverage Scheme was likely to be poorer than in the Civil Servant Medical Benefit Scheme. This indicates an urgent need for a national program for colorectal cancer screening in the general population and access to health insurance.

Physical Activity in Cancer Prevention and Survival: A Systematic Review

PURPOSE

This article reviews and updates the evidence on the associations between physical activity and risk for cancer, and for mortality in persons with cancer, as presented in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report.

METHODS

Systematic reviews of meta-analyses, systematic reviews, and pooled analyses were conducted through December 2016. An updated systematic review of such reports plus original research through February 2018 was conducted. This article also identifies future research needs.

RESULTS

In reviewing 45 reports comprising hundreds of epidemiologic studies with several million study participants, the report found strong evidence for an association between highest versus lowest physical activity levels and reduced risks of bladder, breast, colon, endometrial, esophageal adenocarcinoma, renal, and gastric cancers. Relative risk reductions ranged from approximately 10% to 20%. Based on 18 systematic reviews and meta-analyses, the report also found moderate or limited associations between greater amounts of physical activity and decreased all-cause and cancer-specific mortality in individuals with a diagnosis of breast, colorectal, or prostate cancer, with relative risk reductions ranging almost up to 40% to 50%. The updated search, with five meta-analyses and 25 source articles reviewed, confirmed these findings.

CONCLUSIONS

Levels of physical activity recommended in the 2018 Guidelines are associated with reduced risk and improved survival for several cancers. More research is needed to determine the associations between physical activity and incidence for less common cancers and associations with survival for other cancers. Future studies of cancer incidence and mortality should consider these associations for population subgroups, to determine dose-response relationships between physical activity and cancer risk and prognosis, and to establish mechanisms to explain these associations.

Effect of exercise on colorectal cancer prevention and treatment

In recent years, because of improved cancer screening, detection and treatment modalities, a rapid increase in the population of colorectal and other cancer survivors has been observed. The increasing population has justified the requirement of preventive strategies such as lifestyle modifications with regard to obesity, physical activity, diet and smoking. Physical activity may prevent approximately 15% of the colon cancers. Furthermore, several observational studies have demonstrated the efficacy and dose-dependent and anti-cancer effects of exercise on decreasing the mortality and risk of recurrence before and after the colorectal cancer (CRC) diagnosis. However, the required exercise dose, type and intensity are yet unclear. The results of randomised prospective studies are expected to determine the optimal amount, type and intensity of exercise and formulate the most appropriate exercise plan and guidelines, according to the requirements and comorbidities of the patients. In addition, recent studies have focused on the molecular and genetic mechanisms underlying the effect of physical activity on disease outcomes and recurrence rates. This review aimed to investigate the effects of physical activity and the biological basis of these effects in preventing the risk and recurrence of CRC and decreasing the hazards of cancer and cancer treatment.

The effects of physical activity on cancer prevention, treatment and prognosis: A review of the literature

INTRODUCTION

The World Health Organization has reported that approximately 35% of cancer-related deaths are attributed to modifiable risk factors. Among the most important risk factors amenable to modification are obesity and lack of physical activity. The purpose of this article is to review the current evidence of the benefits of physical activity in various types of cancer.

METHODS

A PubMed search for the key words "physical activity and cancer" as well as "exercise and cancer" was used to identify all indexed publications on this topic for potential utilization in this review. One MET was defined as the amount of oxygen consumed while a person is sitting quietly and is about 3.5 mL O2/kg body weight/min. MET represents the ratio of the working metabolic rate to the resting metabolic rate.

RESULTS

Routine physical activity was found to be associated with a reduced incidence of several of the most common malignancies, including colon, breast, lung, and endometrial cancer as well as many others. Physical activity also appears to reduce all-cause mortality and cancer-related mortality among patients with breast and colon cancer, and may improve the functional status and quality of life for these patients during cancer therapy.

CONCLUSIONS

The benefits of physical activity in the prevention and progression of cancer patients are multiple. However, the strength of the available evidence is limited by the observational nature of most studies. Given the probable improvement in prevention, mortality, and quality of life with structured physical activity in different malignancies, it is important that healthcare providers discuss physical activity programs with their cancer patients. Larger randomized trials are recommended.

Cancer- and Chemotherapy-Induced Musculoskeletal Degradation

Mobility in advanced cancer patients is a major health care concern and is often lost in advanced metastatic cancers. Erosion of mobility is a major component in determining quality of life but also starts a process of loss of muscle and bone mass that further devastates patients. In addition, treatment options become limited in these advanced cancer patients. Loss of bone and muscle occurs concomitantly. Advanced cancers that are metastatic to bone often lead to bone loss (osteolytic lesions) but may also lead to abnormal deposition of new bone (osteoblastic lesions). However, in both cases there is a disruption to normal bone remodeling and radiologic evidence of bone loss. Many antitumor therapies can also lead to loss of bone in cancer survivors. Bone loss releases cytokines (TGFβ) stored in the mineralized matrix that can act on skeletal muscle and lead to weakness. Likewise, loss of skeletal muscle mass leads to reduced bone mass and quality via mechanical and endocrine signals. Collectively these interactions are termed bone-muscle cross-talk, which has garnered much attention recently as a prime target for musculoskeletal health. Pharmacological approaches as well as nutrition and exercise can improve muscle and bone but have fallen short in the context of advanced cancers and cachexia. This review highlights our current knowledge of these interventions and discusses the difficulties in treating severe musculoskeletal deficits with the emphasis on improving not only bone mass and muscle size but also functional outcomes. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Recommendations for follow-up of colorectal cancer survivors

Colorectal cancer (CRC) is one of the tumours with the highest incidence and mortality in the Spanish population. Nevertheless, the advances in prevention and treatment have contributed to an increased number of patients who survive for prolonged periods of time. In addition, despite recurrences, improved survival following metastasis resection is likewise on the rise. This underscores the importance of carrying out follow-up programmes even in low-risk patients for the early detection of recurrence. The main objective of this article is to provide a set of recommendations for optimising the follow-up of CRC survivors as well as for managing the sequelae that result from either pharmacological or surgical treatment.

Precancer diagnosis cardiorespiratory fitness, physical activity and cancer mortality in men

BACKGROUND

The preventive role of precancer diagnosis cardiorespiratory fitness (CRF) and physical activity (PA) in cancer mortality is poorly characterized. The aim of this study was to assess the association between CRF, PA at precancer-diagnosis and cancer mortality in men who diagnosed with cancer later in life.

METHODS

A total of 699 men (63±10 years) who were diagnosed with cancer during 7.5±4.9 years from a baseline treadmill exercise test and reported PA were analyzed. Multivariate Cox models for CRF and univariate model for PA were conducted. Population Attributable Risks (PARs%) and exposure impact number (EIN) of low CRF (<5 METs) and inactivity were determined.

RESULTS

During 6.5±5.2 years from cancer diagnosis, 56% died from cancer. CRF was inversely, graded and independently associated with cancer death. A 1-MET increase and categories of moderate and high CRF were associated with 7%, 28% and 51% reductions in risk of cancer death, respectively. Active compared to inactive individuals had a 23% reduced risk of cancer mortality (HR=0.77, 95% CI [0.63-0.94], P=0.01). PARs% of low CRF and inactivity were 4.8% and 9.4%, respectively, while the respective EIN were 3 and 9.

CONCLUSIONS

Higher CRF and being active at precancer-diagnosis were associated with lower cancer mortality and longer survival time in men who developed cancer later in life. Screening and intervening for low CRF and inactivity as risk factors during middle-age and maintaining at least moderate CRF and activity levels may be effective strategies for prevention of cancer mortality.

STAT3 induces colorectal carcinoma progression through a novel miR-572-MOAP-1 pathway

Purpose

Colorectal carcinoma (CRC) is among the most common causes of death. Recent studies have shown that both STAT3 and miR-572 contribute to CRC progression. STAT3 plays an important role in miRNA expression. Moreover, MOAP-1, which is a pro-apoptotic protein that induces cell death or apoptosis, has a direct correlation with miRNA. Therefore, the current study is designed to explore whether miR-572 and STAT3 are involved in a common pathway and the role of MOAP-1 in this process.

Patients and methods

The expressions of STAT3, miR-572, and MOAP-1 in human CRC tissues and multiple cell lines were estimated by qRT-PCR or Western blot. MTT, transwell migration, and invasion assays were used to assess cell growth, migration, and invasion, respectively. Dual-luciferase reporter assay was applied to examine the association between miR-572 and MOAP-1.

Results

Elevated STAT3 levels were accompanied by increased miR-572 and decreased MOAP-1 levels in primary CRC specimens and cell lines. STAT3 promoted CRC cell growth, migration, and invasion via the upregulated expression of miR-572. Subsequently, miR-572 inhibited MOAP-1 protein expression through an interaction with its 3′UTR.

Conclusion

Our study proposes a novel STAT3-miR-572-MOAP-1 pathway involved in the process of CRC progression, which might be a potential target for the development of new preventive and therapeutic approaches against human colorectal cancer.

Health Care Professionals' Perception of Contraindications for Physical Activity During Cancer Treatment

Introduction

Suggested medical contraindications for physical activity (PA) during cancer therapy might have an influence on PA recommendation behavior of Health Care Professionals (HCP). The purpose of the present study was to examine perceptions of physicians and oncology nurses (ON) toward specific medical conditions as contraindications for PA during cancer treatment.

Materials and methods

A total of 539 physicians and 386 ON were enrolled in this cross-sectional survey. HCP judged 13 medical conditions as to whether they are contraindications for PA during cancer treatment. Answering format was "no contraindication"/"potentially a contraindication"/"yes, a contraindication."

Results

χ² analyses revealed significant differences between general practitioners, specialized physicians, and ON in their perception of 10 medical conditions. Approximately half of the medical conditions were answered cautiously, showing high numbers on the response option potentially (36-72%). Moreover, physicians' ratings differed significantly depending on their practical experience with particular medical conditions. Those being familiar with a specific medical condition was more permissive to PA during treatment, with effect sizes (Cramer's V) ranging from 0.13 to 0.27.

Conclusion

Results indicate high cautiousness among HCP in judging medical conditions and their impact on PA during cancer treatment. However, group comparisons show that familiarity and clinical experience with potential contraindications facilitate a confident handling of safety issues, which at best leads to higher levels of PA recommendations during cancer treatment.

The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects

The combination of an increasing number of new cancer cases and improving survival rates has led to a large and rapidly growing population with unique health-care requirements. Exercise has been proposed as a strategy to help address the issues faced by cancer patients. Supported by a growing body of research, major health organizations commonly identify the importance of incorporating exercise in cancer care and advise patients to be physically active. This systematic review comprehensively summarizes the available epidemiologic and randomized controlled trial evidence investigating the role of exercise in the management of cancer. Literature searches focused on determining the potential impact of exercise on 1) cancer mortality and recurrence and 2) adverse effects of cancer and its treatment. A total of 100 studies were reviewed involving thousands of individual patients whose exercise behavior was assessed following the diagnosis of any type of cancer. Compared with patients who performed no/less exercise, patients who exercised following a diagnosis of cancer were observed to have a lower relative risk of cancer mortality and recurrence and experienced fewer/less severe adverse effects. The findings of this review support the view that exercise is an important adjunct therapy in the management of cancer. Implications on cancer care policy and practice are discussed.

Physical Activity and Outcomes in Patients with Stage III Colon Cancer: A Correlative Analysis of Phase III Trial NCCTG N0147 (Alliance)

Background: Prior studies have supported an inverse association between physical activity and colon cancer risk and suggest that higher physical activity may also improve cancer survival. Among participants in a phase III adjuvant trial for stage III colon cancer, we assessed the association of physical activity around the time of cancer diagnosis with subsequent outcomes.Methods: Before treatment arm randomization (FOLFOX or FOLFOX + cetuximab), study participants completed a questionnaire including items regarding usual daily activity level and frequency of participation in recreational physical activity (N = 1,992). Using multivariable Cox models, we calculated HRs for associations of aspects of physical activity with disease-free (DFS) and overall survival (OS).Results: Over follow-up, 505 participants died and 541 experienced a recurrence. Overall, 75% of participants reported recreational physical activity at least several times a month; for participants who reported physical activity at least that often (vs. once a month or less), the HRs for DFS and OS were 0.82 [95% confidence interval (CI), 0.69-0.99] and 0.76 (95% CI, 0.63-0.93), respectively. There was no evidence of material effect modification in these associations by patient or tumor attributes, except that physical activity was more strongly inversely associated with OS in patients with stage T3 versus T4 tumors (P_interaction = 0.03).Conclusions: These findings suggest that higher physical activity around the time of colon cancer diagnosis may be associated with more favorable colon cancer outcomes.Impact: Our findings support further research on whether colon cancer survival may be enhanced by physical activity. Cancer Epidemiol Biomarkers Prev; 27(6); 696-703. ©2018 AACR.

Critical research gaps and recommendations to inform research prioritisation for more effective prevention and improved outcomes in colorectal cancer

OBJECTIVE

Colorectal cancer (CRC) leads to significant morbidity/mortality worldwide. Defining critical research gaps (RG), their prioritisation and resolution, could improve patient outcomes.

DESIGN

RG analysis was conducted by a multidisciplinary panel of patients, clinicians and researchers (n=71). Eight working groups (WG) were constituted: discovery science; risk; prevention; early diagnosis and screening; pathology; curative treatment; stage IV disease; and living with and beyond CRC. A series of discussions led to development of draft papers by each WG, which were evaluated by a 20-strong patient panel. A final list of RGs and research recommendations (RR) was endorsed by all participants.

RESULTS

Fifteen critical RGs are summarised below: RG1: Lack of realistic models that recapitulate tumour/tumour micro/macroenvironment; RG2: Insufficient evidence on precise contributions of genetic/environmental/lifestyle factors to CRC risk; RG3: Pressing need for prevention trials; RG4: Lack of integration of different prevention approaches; RG5: Lack of optimal strategies for CRC screening; RG6: Lack of effective triage systems for invasive investigations; RG7: Imprecise pathological assessment of CRC; RG8: Lack of qualified personnel in genomics, data sciences and digital pathology; RG9: Inadequate assessment/communication of risk, benefit and uncertainty of treatment choices; RG10: Need for novel technologies/interventions to improve curative outcomes; RG11: Lack of approaches that recognise molecular interplay between metastasising tumours and their microenvironment; RG12: Lack of reliable biomarkers to guide stage IV treatment; RG13: Need to increase understanding of health related quality of life (HRQOL) and promote residual symptom resolution; RG14: Lack of coordination of CRC research/funding; RG15: Lack of effective communication between relevant stakeholders.

CONCLUSION

Prioritising research activity and funding could have a significant impact on reducing CRC disease burden over the next 5 years.