Cardiorespiratory fitness in breast cancer patients undergoing adjuvant therapy

Timing of cardio-oncological rehabilitation and cardiorespiratory fitness in patients receiving cardiotoxic chemotherapy: a longitudinal observational study

AIMS

Anthracycline-based chemotherapy has well-known cardiotoxic effects, butmay also cause skeletal muscle myopathy and negatively affect cardiorespiratory fitness and quality of life. The effectiveness of exercise training in improving cardiorespiratory fitness and quality of life during chemotherapy is highly variable. We set out to determine how the effect of exercise training on cardiorespiratory fitness (primary outcome) and quality of life (secondary outcome) in cancer patients is affected by the type of therapy they receive (cardiotoxic therapy with or without anthracyclines; non-cardiotoxic therapy) and the timing of the exercise training (during or after therapy).

METHODS

Consecutive patients with cancer who participated in an exercise-based cardio-oncology rehabilitation programme at a university hospital in Switzerland between January 2014 and February 2022 were eligible. Patients were grouped based on chemotherapy (anthracycline vs non-anthracycline) and timing of exercise training (during vs after chemotherapy). Peak oxygen uptake (VO2) was assessed with cardiopulmonary exercise testing (n = 200), and quality of life with the Functional Assessment of Cancer Therapies questionnaire (n = 77). Robust linear models were performed for change in peak VO2 including type and timing of cardiotoxic therapies, age, training impulse and baseline peak VO2; change in quality of life was analysed with cumulative linked models.

RESULTS

In all patients with valid VO2 (n = 164), median change in peak VO2 from before to after exercise training was 2.3 ml/kg/min (range: -10.1-15.9). The highest median change in peak VO2 was 4.1 ml/kg/min (interquartile range [IQR]: 0.7-7.7) in patients who completed exercise training during non-anthracycline cardiotoxic or non-cardiotoxic therapies, followed by 2.8 ml/kg/min (IQR: 1.2-5.3) and 2.3 ml/kg/min (IQR: 0.1-4.6) in patients who completed exercise training after anthracycline and after non-anthracycline cardiotoxic or non-cardiotoxic therapies, respectively. In patients who completed exercise training during anthracycline therapy, peak VO2 decreased by a median of -2.1 ml/kg/min (IQR: -4.7-2.0). In the robust linear model, there was a significant interaction between type and timing of cancer treatment for anthracycline therapy, with greater increases in peak VO2 when exercise training was performed after anthracycline therapy. For quality of life, higher baseline scores were negatively associated with changes in quality of life.

CONCLUSION

In our cohort, the increase in cardiorespiratory fitness was diminished when exercise training was performed concurrently with anthracyclines. For patients with cardiotoxic treatments other than anthracyclines, cardiorespiratory fitness and quality of life was not associated with timing of exercise training.

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

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

The Benefit of Exercise in Patients With Cancer Who Are Receiving Chemotherapy: A Systematic Review and Network Meta-Analysis

OBJECTIVE

This study aimed to determine which therapeutic exercise-based intervention is most effective in improving cardiorespiratory fitness (CRF) in patients with cancer receiving chemotherapy.

METHODS

The authors conducted a systematic review with network meta-analysis in MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, SPORTDiscus, and Web of Science. The authors employed the Physiotherapy Evidence Database and the Revised Cochrane Risk of Bias Tool for Randomized Trials to assess the methodological quality and risk of bias, respectively.

RESULTS

A total of 27 studies were included. Data were pooled using a random-effects model. Adding aerobic training (moderate to high intensity), with or without resistance training, to usual care versus usual care was statistically significant, with a small beneficial effect (aerobic training: standardized mean difference = 0.46; 95% CI= 0.17 to 0.75; aerobic and resistance training: standardized mean difference = 0.26; 95% CI = 0.00 to 0.52) for peak oxygen consumption at the postintervention assessment.

CONCLUSION

Therapeutic exercise-based interventions to improve short-term CRF in patients with cancer receiving chemotherapy should include moderate- to high-intensity aerobic exercise, with or without resistance training.

IMPACT

It is important to improve CRF in the oncological population due to its relationship with mortality. The results showed the benefit of exercise to improve cardiorespiratory fitness in the oncology population receiving chemotherapy treatment.

Moderate Intensity Exercise Reduces Side Effects of Cancer Therapy and Maintains Cardiorespiratory Fitness in Male Breast Cancer Patients: Findings from the BRECA Male Crossover Study

Introduction

There is growing evidence that aerobic exercise mitigates cancer therapy-related side effects and improves cardiorespiratory fitness (CRF). However, to the best of our knowledge, no exercise study has been conducted in male breast cancer (MBC) patients. The aim of this study was to investigate the feasibility and efficacy of different exercise intensities on CRF and self-reported questionnaire items in MBC patients.

Methods

Twenty-two MBC patients (60 ± 9 years) participated in this randomized crossover study. After completion of medical treatment, MBC patients were randomly assigned to either moderate (40-50% of heart rate [HR] max. and self-perceived exertion: 11) or vigorous (70-80% of HR max. and self-perceived exertion: 15) exercise intensity during the first 3 months of the study. After a 1-month washout period, participants switched group assignments. Primary endpoints were CRF and questionnaire items.

Results

We observed a dropout rate of 36% over 7 months, with the number of participants decreasing from 22 to 14. The results showed significant improvements in "Physical Function" (p = 0.037) and "Social Function" (p = 0.016) after moderate training. A non-significant improvement was also observed in "Breast Symptoms" (p = 0.095), but there was no change in "Fatigue" (p = 0.306). There were no differences observed in cardiovascular fitness (V̇O2 peak) between the treatment groups.

Conclusion

This study emphasizes the effectiveness of exercise intervention for an exceedingly rare cancer, highlighting the vital role of moderate intensity aerobic exercise in mitigating treatment side effects. Despite minimal peak V̇O2 differences, both exercise protocols adequately sustain CRF. Future studies are imperative to design optimized, sex-specific rehabilitation strategies tailored to the unique requirements of MBC patients, advancing our understanding of this under explored realm.

Comparison of the effects of high-intensity interval and moderate-intensity continuous training on inflammatory markers, cardiorespiratory fitness, and quality of life in breast cancer patients

BACKGROUND

As the effectiveness of breast cancer treatment has improved, a growing number of long-term breast cancer survivors are seeking help for unique health problems. These patients may be at increased risk of cardiovascular disease due to the side effects of treatment. The positive impact of most types of exercise has been repeatedly reported in people with cancer, but the most effective exercise approaches for maximum beneficial adaptations remain controversial. Thus, this study aimed to compare the effects of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) on inflammatory indices, adipokines, metabolic markers, body composition, cardiorespiratory fitness, and quality of life in breast cancer patients during adjuvant endocrine therapy.

METHODS

Thirty non-metastatic breast cancer patients during adjuvant endocrine therapy who had been treated with chemotherapy and/or radiotherapy were recruited from Iran and randomized to HIIT, MICT, or control groups for a supervised exercise intervention that took place 3 times a week for 12 weeks. The training intensity was determined based on the peak oxygen uptake (VO2peak), and the volume of training was matched in HIIT and MICT based on the VO2peak. Body composition, functional capacity, cardiorespiratory fitness, metabolic indices, sex hormones, adipokines, and inflammatory markers were assessed before and after the intervention.

RESULTS

The VO2peak increased by 16.8% in the HIIT group in comparison to baseline values (mean difference = 3.61 mL/kg/min). HIIT significantly improved the VO2peak compared to control (mean difference = 3.609 mL/kg/min) and MICT (mean differences = 2.974 mL/kg/min) groups. Both HIIT (mean difference = 9.172 mg/dL) and MICT (mean difference = 7.879 mg/dL) interventions significantly increased high-density lipoprotein cholesterol levels compared to the control group. The analysis of covariance showed that physical well-being significantly improved in MICT compared to control group (mean difference = 3.268). HIIT significantly improved the social well-being compared to the control group (mean difference = 4.412). Emotional well-being subscale was significantly improved in both MICT (mean difference = 4.248) and HIIT (mean difference = 4.412) compared to the control group. Functional well-being scores significantly increased in HIIT group compared with control group (mean difference = 3.35) . Significant increase were also observed in total functional assessment of cancer therapy-General scores in both HIIT (mean difference = 14.204) and MICT groups (mean difference = 10.036) compared with control group. The serum level of suppressor of cytokine signaling 3 increased significantly (mean difference = 0.09 pg/mL) in the HIIT group compared to the baseline. There were no significant differences between groups for body weight, body mass index, fasting blood glucose, insulin resistance, sex hormone binding globulin, total cholesterol, low-density lipoprotein cholesterol, adipokines, interleukin-6, tumor necrosis factor-α, or interleukin-10.

CONCLUSION

HIIT can be used as a safe, feasible, and time-efficient intervention to improve cardiovascular fitness in breast cancer patients. Both HIIT and MICT modalities enhance quality of life. Further large-scale studies will help determine whether these promising results translate into improved clinical and oncological outcomes.

Cardiotoxicity is mitigated after a supervised exercise program in HER2-positive breast cancer undergoing adjuvant trastuzumab

Background

Trastuzumab is used, alone or in conjunction with standard chemotherapy, to treat HER2-positive breast cancer (BC). Although it improves cancer outcomes, trastuzumab. can lead to cardiotoxicity. Physical exercise is a safe and effective supportive therapy in the management of side effects, but the cardioprotective effects of exercise are still unclear.

Objectives

The primary aim of this study was to test whether trastuzumab-induced cardiotoxicity [left ventricular ejection fraction (LVEF) under 50%, or an absolute drop in LVEF of 10%] was reduced after a supervised exercise program of 3 months in patients with HER2-positive breast cancer. Secondary endpoints were to evaluate (i) cardiotoxicity rates using other criteria, (ii) cardiac parameters, (iii) cardiorespiratory fitness and (iv) whether a change in LVEF influences the cardiorespiratory fitness.

Methods

89 women were randomized to receive adjuvant trastuzumab in combination with a training program (training group: TG; n = 46) or trastuzumab alone (control group: CG; n = 43). The primary and secondary endpoints were evaluated at the end of the supervised exercise program of 3 months (T3).

Results

After exercise program, 90.5 % of TG patients and 81.8% of CG patients did not exhibit cardiotoxicity. Furthermore, whatever the used criterion, percentage of patients without cardiotoxicity were greater in TG (97.6 and 100% respectively) than in CG (90.9 and 93.9% respectively). LVEF and GLS values remained stable in both groups without any difference between the groups. In contrast, at T3, peak VO2 (+2.6 mL.min−1.kg−1; 95%CI, 1.8 to 3.4) and maximal power (+21.3 W; 95%CI, 17.3 to 25.3) increased significantly in TG, whereas they were unchanged in CG (peak VO2: +0.2 mL.min−1.kg−1; 95%CI, −0.5 to 0.9 and maximal power: +0.7 W, 95%CI, −3.6 to 5.1) compared to values measured at T0. No correlation between LVEF changes and peak VO2 or maximal power was observed.

Conclusion

A 12-week supervised exercise regimen was safe and improved the cardiopulmonary fitness in particular peak VO2, in HER2-positive BC patients treated with adjuvant trastuzumab therapy. The study is under powered to come to any conclusion regarding the effect on cardiotoxicity.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT02433067.

Thirty-second sit-to-stand test as an alternative for estimating peak oxygen uptake and 6-min walking distance in women with breast cancer: a cross-sectional study

Purpose

To determine whether the 30-s sit-to-stand (30STS) test can be a valid tool for estimating and stratifying peak oxygen uptake (VO2peak) and 6-min walking distance (6MWD) in women with breast cancer.

Methods

This cross-sectional study uses data from the ONCORE randomized controlled trial, including 120 women aged 18–70 years with early-stage breast cancer under treatment with anthracycline and/or anti-HER2 antibodies. Participant characteristics were collected at baseline and pooled data from functional assessment (30STS test, relative and absolute VO2peak, and 6MWD) were collected at baseline and post-intervention (comprehensive cardio-oncology rehabilitation program vs. usual care). Bivariate correlations and multivariate linear regression analyses were performed to study the relationship between functional test variables.

Results

The number of repetitions in the 30STS test showed (i) a moderate correlation with relative VO2peak (ml/kg/min) (r = 0.419; p < 0.001; n = 126), (ii) a weak correlation with absolute VO2peak (ml/min) (r = 0.241; p = 0.008; n = 120), and (iii) a moderate correlation with the 6MWD (r = 0.440; p < 0.001; n = 85). The ONCORE equations obtained from the multivariate regression models allowed the estimation of VO2peak and 6MWD (r² = 0.390; r² = 0.261, respectively) based on the 30STS test, and its stratification into tertiles (low, moderate, and high).

Conclusion

The 30STS test was found to be a useful tool to estimate VO2peak and/or 6MWD in women with early-stage breast cancer. Its use may facilitate the assessment and stratification of functional capacity in this population for the implementation of therapeutic exercise programs if cardiopulmonary exercise testing (CPET) or 6MWT are not available.

Trial registration

ClinicalTrials.gov Identifier: NCT03964142. Registered on 28 May 2019. Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT03964142

Novel Therapeutics for Anthracycline Induced Cardiotoxicity

Anthracyclines remain an essential component of the treatment of many hematologic and solid organ malignancies, but has important implications on cardiovascular disease. Anthracycline induced cardiotoxicity (AIC) ranges from asymptomatic LV dysfunction to highly morbid end- stage heart failure. As cancer survivorship improves, the detection and treatment of AIC becomes more crucial to improve patient outcomes. Current treatment modalities for AIC have been largely extrapolated from treatment of conventional heart failure, but developing effective therapies specific to AIC is an area of growing research interest. This review summarizes the current evidence behind the use of neurohormonal agents, dexrazoxane, and resynchronization therapy in AIC, evaluates the clinical outcomes of advanced therapy and heart transplantation in AIC, and explores future horizons for treatment utilizing gene therapy, stem cell therapy, and mechanism-specific targets.

Real-time exercise reduces impaired cardiac function in breast cancer patients undergoing chemotherapy: A randomized controlled trial

BACKGROUND

Previous studies have reported that chemotherapy results in substantial long-term risk of heart failure. Exercise ameliorates exercise responses and exercise tolerance in patients receiving chemotherapy. The cardioprotective effect of real-time exercise in breast cancer is still unclear.

OBJECTIVES

The aim of the present study was to determine the effect of real-time moderate-to-high-intensity exercise training in women with breast cancer undergoing chemotherapy and to follow up on parameters of cardiac function and exercise capacity at different times. We hypothesized that early moderate-to-high-intensity exercise training has beneficial effects on cardiac function in women with breast cancer undergoing chemotherapy.

METHODS

This was a randomized controlled study that included 32 women randomly allocated into the control or exercise group. Exercise began with the first cycle of chemotherapy, and the training program was maintained during chemotherapy with 2 to 3 sessions per week for 3 months. Patients were instructed to perform moderate-to-high-intensity training with aerobic and resistance training. Outcome measurements were echocardiography and cardiopulmonary exercise test. The primary outcome was the change in left ventricle ejection fraction (LVEF). The secondary outcome was peak oxygen consumption (peak VO2).

RESULTS

The control group showed lower cardiac systolic function than the exercise group [mean (SD) LVEF 62% (2) and 70% (5), P<0.05], reduced cardiac diastolic function, and cardiac hypertrophy at 3, 6 and 12 months after chemotherapy. At 6 months after chemotherapy, the exercise group exhibited relatively higher exercise capacity than controls [mean (SD) VO2 12.1 (2.2) and 13.6 (2.2) mL/kg/min, P<0.05]. The main effect size of the study based on echocardiography outcomes was 0.25 (95% confidence interval 0.23 to 0.27), a medium effect size.

CONCLUSIONS

Moderate-to-high-intensity exercise training in breast cancer patients undergoing chemotherapy may prevent impaired cardiac function.

CLINICAL TRIAL REGISTRATION

https://www.

CLINICALTRIALS

in.th (Identifier TCTR20190330002).

Predictors of cardiopulmonary fitness in cancer-affected and -unaffected women with a pathogenic germline variant in the genes BRCA1/2 (LIBRE-1)

Physical activity (PA) helps prevention and aftercare of sporadic breast cancer (BC), cardiopulmonary fitness (CPF) being an age-independent predictor of tumor-specific mortality. Therefore, we wanted to identify predictors of CPF (represented by peak oxygen uptake: VO_2peak) in BRCA1/2 mutation carriers whose risk of developing BC is high. We used cross-sectional data from 68 BRCA1/2 germline mutation carrying women participating in the randomized, prospective, controlled clinical study LIBRE-1. Assessments included cardiopulmonary exercise testing, medical and lifestyle history plus socioeconomic status. Additionally, the participants completed a psychological questionnaire regarding their attitude, subjective norms, perceived behavior control and intention towards PA. A multivariate logistic regression model was used to identify predictors for participants reaching their age- and sex-adjusted VO_2peak reference values. 22 participants (median age: 40 years, interquartile range (IQR) 33–46) were cancer-unaffected and 46 cancer-affected (median age: 44 years, IQR 35–50). The strongest predictor for reaching the reference VO_2peak value was attitude towards PA (Odds Ratio 3.0; 95% Confidence Interval 1.3–8.4; p = 0.021). None of the other predictors showed a significant association. A positive attitude towards PA seems to be associated with VO_2peak, which should be considered in developing therapeutic and preventive strategies.

Trial registrations: NCT02087592; DRKS00005736.

Evidence of Better Autonomic, Metabolic and Psychological Profile in Breast Cancer Survivors Meeting Current Physical Activity Recommendations: An Observational Study

The increased cardiometabolic risk observed in breast cancer survivors (BCS) is due to multiple mechanisms: Hormonal and immunological dysfunction are well-identified ones, while cardiac autonomic regulation (CAR) is less recognized but may play a new complementary role particularly relevant when considering conditions and behaviors associated with a better prognosis in BCS, such as physical training. This observational study investigated a group of consecutive (172) BCS subdivided in two groups: those who reached the physical activity goals above 600 (MET·min/week) and those who did not. We assessed CAR by autoregressive spectral analysis of cardiovascular variabilities (considering in particular the unitary autonomic nervous system index—ANSI), body mass composition, stress perception and lifestyle in order to verify possible differences due to execution of physical activity. Subjects who spontaneously met physical activity recommendations presented a better autonomic, metabolic and psychological profile compared to those who did not. Lower physical activity volume, poor metabolic parameters, increased stress and fatigue perception may cluster together, leading to worsened CAR. This control mechanism may play a complementary role in determining the increased cardiometabolic risk observed in BCS. Furthermore, it may also explain, albeit in part, the better prognosis observed in patients following interventions aiming to improve the sympathetic–parasympathetic balance, such as physical training, using a personalized medicine approach.

Cardio-Oncology Rehabilitation and Telehealth: Rationale for Future Integration in Supportive Care of Cancer Survivors

The direct toxicity of cancer treatment threatens patients and survivors with an increased risk of cardiovascular disease or adverse functional changes with subsequent progression of cardiovascular complications. An accumulation of cardiovascular risk factors combined with an unhealthy lifestyle has recently become more common in cancer patients and survivors. It has been recommended to integrate a comprehensive cardiac rehabilitation model called cardio-oncology rehabilitation to mitigate cardiovascular risk. Nevertheless, cardiac rehabilitation interventions limit barriers in low utilization, further exacerbated by the restrictions associated with the COVID-19 pandemic. Therefore, it is essential to integrate alternative interventions such as telehealth, which can overcome several barriers. This literature review was designed as a framework for developing and evaluating telehealth interventions and mobile applications for comprehensive cardio-oncology rehabilitation. We identify knowledge gaps and propose strategies to facilitate the development and integration of cardio-oncology rehabilitation telehealth as an alternative approach to the standard of care for cancer patients and survivors. Despite the limited evidence, the pilot results from included studies support the feasibility and acceptability of telehealth and mobile technologies in cardio-oncology rehabilitation. This new area suggests that telehealth interventions are feasible and induce physiological and psychological benefits for cancer patients and survivors. There is an assumption that telehealth interventions and exercise may be an effective future alternative approach in supportive cancer care.

Can the Six-Minute Walk Test Be Used to Individualize Physical Activity Intensity in Patients with Breast Cancer?

Simple Summary

Physical activity has proven to be effective in breast cancer patients. Appropriate exercise intensity for each patient is necessary to maintain this practice in patients with possible comorbidities and potential adverse events of specific treatments. These programs should be proposed to many patients so to prescribe the adapted program; this will necessitate easy and cost-effective tests. It is useful to use an adapted target heart rate (HR) to prescribe exercise intensity. In this work, we assessed the potential equivalence of the ventilatory threshold HR obtained during a cardiopulmonary exercise test and the HR measured over the last 3 min of the six-minute walk test (6MWT-HR). At baseline, the 6MWT-HR was in good agreement and showed moderate but statistical correlation with the VT-HR in breast cancer patients. The best correlation between these two tests was obtained after the APA program and chemotherapy. These results were independent of body mass index. The 6MWT is useful to prescribe APA programs before and also after chemotherapy concomitant with physical activity.

Abstract

Background: Adapted physical activity (APA) aids breast cancer patients. It is necessary to use an adapted target heart rate (HR) when prescribing exercise intensity. Methods: In total, 138 patients previously included in two published randomized clinical trials underwent the CPET and 6MWT before and after adjuvant therapy. Of these patients, 85 had performed APA, and 53 had received only the usual therapy. HRs were recorded during the two tests. Results: Before starting chemotherapy, good agreement (intraclass correlation (ICC) 0.69; confidence interval at 95% IC_0.95 (0.591–0.769); p < 0.001) and a moderate correlation were evident between the 6MWT-HR and ventilatory threshold HR of the CPET (r = 0.70; p < 0.001). Good agreement and a high positive correlation were noted only in the group who engaged in APA (ICC 0.77; IC_0.95 (0.659–0.848); p < 0.001; r = 0.8; p < 0.01); moderate agreement and a moderate positive correlation were apparent in the control group (ICC 0.57; IC_0.95 (0.329–0.74); p < 0.001; r = 0.6; p < 0.01). The correlations were independent of age and body mass index. Conclusions: The 6MWT-HR can be used to prescribe exercise intensity for breast cancer patients both before and after specific treatment with concomitant APA.

Exercise to Reduce Anthracycline-Mediated Cardiovascular Complications in Breast Cancer Survivors

While developments in cancer therapeutics have greatly reduced morbidity and mortality in females with breast cancer, it comes at a cost of an increased risk of cardiovascular complications. In particular, anthracyclines, like doxorubicin, which are a mainstay of current chemotherapy regimens, are associated with dose-dependent cardiotoxicity. Exercise has been widely accepted as an effective intervention in reducing cardiovascular risk in a variety of different clinical conditions. However, the benefits of exercise in anthracycline-mediated cardiotoxicity are not clearly understood. First, this review discusses the pre-clinical studies which have elucidated the cardioprotective mechanisms of aerobic and resistance exercise in improving cardiovascular function in the setting of anthracycline treatment. Next, it aims to summarize the results of aerobic and resistance exercise clinical trials conducted in females with breast cancer who received anthracycline-based chemotherapy. The review further discusses the current exercise guidelines for women undergoing chemotherapy and contraindications for exercise. Finally, the review addresses gaps in research, specifically the need for further clinical trials to establish a recommended exercise prescription within this patient population.

Cardiac and skeletal muscle predictors of impaired cardiorespiratory fitness post-anthracycline chemotherapy for breast cancer

This study aimed to characterize peak exercise cardiac function and thigh muscle fatty infiltration and their relationships with VO2peak among anthracycline-treated breast cancer survivors (BCS). BCS who received anthracycline chemotherapy ~ 1 year earlier (n = 16) and matched controls (matched-CON, n = 16) were enrolled. Resting and peak exercise cardiac function, myocardial T1 mapping (marker of fibrosis), and thigh muscle fat infiltration were assessed by magnetic resonance imaging, and VO2peak by cycle test. Compared to matched-CON, BCS had lower peak SV (64 ± 9 vs 57 ± 10 mL/m2, p = 0.038), GLS (- 30.4 ± 2.2 vs - 28.0 ± 2.5%, p = 0.008), and arteriovenous oxygen difference (16.4 ± 3.6 vs 15.2 ± 3.9 mL/100 mL, p = 0.054). Mediation analysis showed: (1) greater myocardial T1 time (fibrosis) is inversely related to cardiac output and end-systolic volume exercise reserve; (2) greater thigh muscle fatty infiltration is inversely related to arteriovenous oxygen difference; both of which negatively influence VO2peak. Peak SV (R2 = 65%) and thigh muscle fat fraction (R2 = 68%) were similarly strong independent predictors of VO2peak in BCS and matched-CON combined. Post-anthracyclines, myocardial fibrosis is associated with impaired cardiac reserve, and thigh muscle fatty infiltration is associated with impaired oxygen extraction, which both contribute to VO2peak.

Patterns of Sequelae in Women with a History of Localized Breast Cancer: Results from the French VICAN Survey

Breast cancer (BC) remains complex for women both physically and psychologically. The objectives of this study were to (1) assess the evolution of the main sequelae and treatment two and five years after diagnosis in women with early-stage breast cancer, (2) explore patterns of sequelae associated with given sociodemographic, clinical, and lifestyle factors. The current analysis was based on 654 localized BC patients enrolled in the French nationwide longitudinal survey "vie après cancer" VICAN (January-June 2010). Information about study participants was collected at enrollment, two and five years after diagnosis. Changes over time of the main sequelae were analyzed and latent class analysis was performed to identify patterns of sequelae related to BC five years after diagnosis. The mean age (±SD) of study participants at inclusion was 49.7 (±10.5) years old. Six main classes of sequelae were identified two years and five years post-diagnosis (functional, pain, esthetic, fatigue, psychological, and gynecological). A significant decrease was observed for fatigue (p = 0.03) and an increase in cognitive sequelae was reported (p = 0.03). Two latent classes were identified-functional and esthetic patterns. Substantial sequelae remain up to five years after BC diagnosis. Changes in patient care pathways are needed to identify BC patients at a high risk.

Reliability and reproducibility of cardiac MRI quantification of peak exercise function with long-axis views

The conventional approach to cardiac magnetic resonance (CMR) involving breath holds, electrocardiography-gating, and acquisition of a short-axis (SAX) image stack, introduces technical and logistical challenges for assessing exercise left ventricular (LV) function. Real-time, free-breathing CMR acquisition of long-axis (LAX) images overcomes these issues and also enables assessment of global longitudinal strain (GLS). We evaluated the reliability of a free-breathing LAX approach compared to the standard SAX approach and the reproducibility of free-breathing LAX. LV SAX (contiguous stack) and LAX (two-chamber and four-chamber) 3T CMR cine images were acquired four times within one scan in 32 women with cardiovascular risk factors (56±10 years, 28±4 kg/m2) as follows: 1) resting, gated-segmented, end-expiration breath-hold; 2) resting, real-time, free-breathing; 3) test-retest set of resting, real-time, free-breathing; 4) peak exercise (incremental-to-maximum, in-magnet, stepper test), real-time, free-breathing. A second scan was performed within one week in a subset (n = 5) to determine reproducibility of peak exercise measures. Reliability and agreement of the free-breathing LAX approach with the conventional SAX approach were assessed by intraclass correlation coefficient (ICC) and Bland-Altman plots, respectively. Normal control GLS reserve was also acquired in a separate set of 12 young, healthy control women (25±4 years, 22±2 kg/m2) for comparison. Comparisons of LV volumes and function among all techniques at rest had good-to-excellent reliability (ICC = 0.80-0.96), and excellent reliability between peak exercise free-breathing LAX and SAX evaluations (ICC = 0.92-0.96). Higher resting heart rates with free-breathing acquisitions compared to breath-hold (mean difference, limits of agreement: 5, 1-12 beats per minute) reduced reliability for cardiac output (ICC = 0.67-0.79). Reproducibility of the free-breathing LAX approach was good-to-excellent at rest and peak exercise (ICC = 0.74-0.99). GLS exercise reserve was impaired in older women at cardiovascular risk compared to young healthy women (-4.7±2.3% vs -7.4±2.1%, p = 0.001). Real-time, free-breathing CMR with LAX evaluation provides a reliable and reproducible method to assess rest and peak exercise cardiac function, including GLS.

Aerobic Fitness Is Related to Myocardial Fibrosis Post-Anthracycline Therapy

PURPOSE

We evaluated the impact of anthracyclines on left ventricular function and myocardial tissue characteristics using cardiovascular magnetic resonance (CMR) imaging to determine their relationship with V˙O2peak.

METHODS

Women with breast cancer who had not yet received treatment (No-AT, n = 16) and had received anthracycline treatment ~1 yr earlier (Post-AT, n = 16) and controls without cancer (CON, n = 16) performed a maximal exercise test and a comprehensive 3T CMR examination, including native myocardial T1 mapping, where elevated T1 times are indicative of myocardial fibrosis. ANOVA and linear regression were used to compare CMR variables between groups and to determine associations with V˙O2peak. Subgroup analysis was performed by categorizing participants as "fit" or "unfit" based on whether their V˙O2peak value was greater or less than 100% of reference value for age, respectively.

RESULTS

Left ventricular end-diastolic volume, ejection fraction, and mass were similar between groups. Post-AT, T1 times were elevated (1534 ± 32 vs 1503 ± 28 ms, P < 0.01), and V˙O2peak was reduced (23.1 ± 7.5 vs 29.5 ± 7.7 mL·kg-1⋅min-1, P = 0.02) compared with CON. In No-AT, T1 times and V˙O2peak were similar to CON. In the Post-AT group, T1 time was associated with V˙O2peak (R2 = 64%), whereas in the absence of anthracyclines (i.e., No-AT and CON groups), T1 time was not associated with V˙O2peak. Regardless of group, all fit women had similar T1 times, whereas unfit women Post-AT had higher T1 than unfit CON (1546 ± 22 vs 1500 ± 33 ms, P < 0.01).

CONCLUSIONS

After anthracycline chemotherapy, an elevated T1 time suggesting greater extent of myocardial fibrosis, was associated with lower V˙O2peak. However, those who were fit did not have evidence of myocardial fibrosis after anthracycline treatment.

Long-term Cardiopulmonary Consequences of Treatment-Induced Cardiotoxicity in Survivors of ERBB2-Positive Breast Cancer

Importance

Trastuzumab improves outcomes in patients with ERBB2-positive (formerly HER2) breast cancer but is associated with treatment-induced cardiotoxicity, most commonly manifest by an asymptomatic decline in left ventricular ejection fraction (LVEF). Little is known to date regarding the long-term effects of treatment-induced cardiotoxicity on cardiopulmonary function in patients who survive trastuzumab-treated breast cancer.

Objective

To determine whether treatment-induced cardiotoxicity recovers or is associated with long-term cardiopulmonary dysfunction in survivors of ERBB2-positive breast cancer.

Design, Setting, and Participants

This cross-sectional case-control study enrolled patients with nonmetastatic ERBB2-positive breast cancer after completion of trastuzumab-based therapy (median, 7.0 [interquartile range (IQR), 6.2-8.7] years after therapy) who met 1 of 2 criteria: (1) cardiotoxicity (TOX group) developed during trastuzumab treatment (ie, asymptomatic decrease of LVEF≥10% from baseline to <55% [n = 22]) or (2) no evidence of cardiotoxicity during trastuzumab treatment (NOTOX group [n = 20]). Patients were treated at the Memorial Sloan Kettering Cancer Center. Fifteen healthy control participants (HC group) were also enrolled for comparison purposes. All groups were frequency matched by age strata (<55, 55-64, and ≥65 years). Data were collected from September 9, 2016, to August 10, 2018, and analyzed from November 20, 2018, to August 12, 2019.

Main Outcomes and Measures

Speckle-tracking echocardiography and maximal cardiopulmonary exercise testing were performed to measure indices of left ventricular function (including LVEF and global longitudinal strain [GLS]) and peak oxygen consumption (peak VO2).

Results

A total of 57 participants (median age, 60.8 [IQR, 52.7-65.7] years) were included in the analysis. Overall, 38 of 42 patients with breast cancer (90%) were treated with anthracyclines before trastuzumab. Resting mean (SD) LVEF was significantly lower in the TOX group (56.9% [5.2%]) compared with the NOTOX (62.4% [4.0%]) and HC (65.3% [2.9%]) groups; similar results were found for GLS (TOX group, -17.8% [2.2%]; NOTOX group, -19.8% [2.2%]; HC group, -21.3% [1.8%]) (P < .001). Mean peak VO2 in the TOX group (22.9 [4.4] mL/kg/min) was 15% lower compared with the NOTOX group (27.0 [5.3] mL/kg/min; P = .03) and 25% lower compared with the HC group (30.5 [3.4] mL/ kg/min; P < .001). In patients with breast cancer, GLS was significantly associated with peak VO2 (β coefficient, -0.75; 95% CI, -1.32 to -0.18).

Conclusions and Relevance

Treatment-induced cardiotoxicity appears to be associated with long-term marked impairment of cardiopulmonary function and may contribute to increased risk of late-occurring cardiovascular disease in survivors of ERBB2-positive breast cancer.

[Cardiovascular fitness in oncology : Exercise and sport]

BACKGROUND

Malignant diseases lead to a decline in physical performance in a large number of patients. This includes a reduction of the musculoskeletal system, restrictions in cardiovascular fitness and psychogenically influenced syndromes such as fatigue and asthenia. It is not yet clear to what extent physical training can counteract these limitations or undesirable side effects and how this training needs to be designed in the individual situation.

AIM OF THIS ARTICLE

The aim of this article is to find out whether physical training can be performed in cancer patients, how this training should be designed and which physical disorders can be influenced favorably.

MATERIALS AND METHODS

In this review, the currently available work on this topic was evaluated and classified with regard to its feasibility and effects in cancer patients.

RESULTS AND DISCUSSION

Physical training can be performed without complications in most patients even under treatment for the underlying malignant disease. It has a positive effect on physical performance, cardiovascular function, the perception of one's own cancer and overall well-being. Ideally, physical training for cancer patients should include a mixture of strength and endurance training. It should be carried out regularly and its intensity should be slowly increased. The type of physical activity should be adapted to the individual needs of the patient, take into account the particularities of the malignant disease and exclude any risk to the patient.

CONCLUSION

In summary, a physical training program to accompany cancer therapy should be offered to virtually all patients with malignant disease.

The Phys-Can observational study: adjuvant chemotherapy is associated with a reduction whereas physical activity level before start of treatment is associated with maintenance of maximal oxygen uptake in patients with cancer

BACKGROUND

Adjuvant therapy may cause multiple sideeffects on long term health, including reduced cardiorespiratory fitness (CRF) in patients with breast cancer (1, 2). However, there is currently limited knowledge regarding the effect of different types of adjuvant cancer treatment on CRF in other cancer populations. The primary objective of the present study was to assess whether previously known correlates (age, diagnosis, initial CRF, physical activity level), type of adjuvant treatment and cancer-related fatigue were associated with changes in V ˙ O 2 max in patients with breast, prostate or colorectal cancer.

METHODS

Prospective study with two time points of assessment, 85 patients scheduled for adjuvant cancer treatment were included. Cardiorespiratory fitness was assessed byV ˙ O 2 max during a maximal incremental exercise test on a treadmill before start of adjuvant therapy and again six months later. Physical activity level was recorded with a physical activity monitor (Sense Wear™ Mini) at baseline as average minutes of moderate-to-vigorous intensity physical activity (MVPA) per day. Physical fatigue at baseline was reported using the Multidimensional Fatigue Inventory-20 questionaire.

RESULTS

In multivariate linear regression analysis, 30 min higher daily MVPA at baseline was associated with a 5% higher V ˙ O 2 max at six months follow up when adjusted for adjuvant treatment (P = 0.010). Patients receiving adjuvant chemotherapy had a mean decline in V ˙ O 2 max of 10% (- 19, - 1; 95% confidence interval) compared to patients receiving adjuvant endocrine treatment (P = 0.028). Adjuvant radiotherapy, fatigue, age and diagnosis were not significantly associated with changes in V ˙ O 2 max .

CONCLUSION

The results of the present study indicate that adjuvant chemotherapy is associated with a subsequent reduction in V ˙ O 2 max in patients with cancer whereas MVPA before start of adjuvant treatment is positively associated with a higher V ˙ O 2 max after end of adjuvant treatment.

Effects of exercise on physical outcomes of breast cancer survivors receiving hormone therapy - A systematic review and meta-analysis

BACKGROUND

Side-effects of hormone therapy can impair the physical health of breast cancer survivors. Exercise has been clearly shown to improve the quality of life of breast cancer survivors. Less is known about the effects of exercise on physical outcomes for breast cancer survivors receiving hormone therapy.

OBJECTIVE

To investigate the effects of exercise on physical outcomes of breast cancer survivors receiving hormone therapy.

METHODS

Five electronic databases were searched by two authors using the terms "Breast Neoplasms" [MeSH] and "Tamoxifen" [MeSH] and "Aromatase Inhibitors" [MeSH] and "Exercise" [MeSH]. Randomized and non-randomized clinical trials were included. Risk of bias was assessed by the Cochrane Collaboration tool and ROBINS-I, and the quality of evidence was evaluated using GRADE. Pooled effects were reported as standardized mean differences (SMDs) and 95 % confidence intervals (CIs) using a random effects model.

RESULTS

Eleven studies were included in the meta-analysis. Two hundred and fourteen breast cancer survivors receiving hormone therapy, tamoxifen, or aromatase inhibitors participated in interventions based on aerobic plus resistance exercise or walking activity. The physical outcomes reported in the articles were: cardiorespiratory fitness, pain, bone mineral density, grip strength, and body fat percentage. Exercise effects were found only for cardiorespiratory fitness (SMD = 0.37; 95 % CI: 0.11; 0.63; I² = 93 %) and pain (SMD = -0.55; IC95 % -1.11; -0.00; I² = 80 %), with low quality of evidence. No effects were observed for the other variables.

CONCLUSIONS

Aerobic plus resistance exercise had positive effects on cardiorespiratory fitness and pain in breast cancer survivors receiving hormone therapy. However, high-quality randomized clinical trials are required to confirm this finding.

Physical deterioration and adaptive recovery in physically inactive breast cancer patients during adjuvant chemotherapy: a randomised controlled trial

Cardiorespiratory fitness is an independent risk factor for cardiovascular disease and shortened life expectancy in breast cancer survivors. This randomised controlled trial (n = 153) was designed for patients with a physically inactive lifestyle prediagnosis and concurrently referred to adjuvant chemotherapy. We compared two 12-week exercise interventions aimed at physiological and patient-reported outcomes (cardiorespiratory fitness, muscle strength, metabolic markers, physical activity, pain, fatigue), including a 39-week follow-up. A supervised hospital-based moderate to high intensity group exercise intervention was compared to an instructed home-based individual pedometer intervention. The two 12-week interventions included oncologists’ recommendations and systematic health counselling. Outcomes were measured at baseline and week 6, 12 and 39. Primary outcome cardiorespiratory fitness declined significantly during chemotherapy and was restored in both interventions at follow-up. The interventions effectively engaged breast cancer patients in sustaining physical activities during and following adjuvant treatment. A composite metabolic score improved significantly. Positive cardiorespiratory fitness responders had improved clinical effects on fatigue, pain and dyspnoea versus negative responders. We conclude that a loss of cardiorespiratory fitness among physically inactive breast cancer patients may be restored by early initiated interventions and by adapting to physical activity recommendations, leading to a decreased cardiovascular risk profile in breast cancer survivors.

Criteria for the determination of maximal oxygen uptake in patients newly diagnosed with cancer: Baseline data from the randomized controlled trial of physical training and cancer (Phys-Can)

Introduction

Maximal oxygen uptake (V˙O2max) is a measure of cardiorespiratory fitness often used to monitor changes in fitness during and after treatment in cancer patients. There is, however, limited knowledge in how criteria verifying V˙O2max work for patients newly diagnosed with cancer. Therefore, the aim of this study was to describe the prevalence of fulfillment of typical criteria verifying V˙O2max and to investigate the associations between the criteria and the test leader’s evaluation whether a test was performed “to exhaustion”. An additional aim was to establish new cut-points within the associated criteria.

Methods

From the Phys-Can randomized controlled trial, 535 patients (59 ±12 years) newly diagnosed with breast (79%), prostate (17%) or colorectal cancer (4%) performed an incremental V˙O2max test on a treadmill. The test was performed before starting (neo-)adjuvant treatment and an exercise intervention. Fulfillment of different cut-points within typical criteria verifying V˙O2max was described. The dependent key variables included in the initial bivariate analysis were achievement of a V˙O2 plateau, peak values for maximal heart rate, respiratory exchange ratio (RER), the patients’ rating of perceived exertion on Borg’s scale_6-20 and peak breathing frequency (f_R). A receiver operating characteristic analysis was performed to establish cut-points for variables associated with the test leader’s evaluation. Last, a cross-validation of the cut-points found in the receiver operating characteristic analysis was performed on a comparable sample of cancer patients (n = 80).

Results

The criteria RERpeak (<0.001), Borg’s RPE (<0.001) and f_R peak (p = 0.018) were associated with the test leader’s evaluation of whether a test was defined as “to exhaustion”. The cut-points that best predicted the test leader’s evaluation were RER ≥ 1.14, RPE ≥ 18 and f_R ≥ 40. Maximal heart rate and V˙O2 plateau was not associated with the test leader’s evaluation.

Conclusion

We recommend a focus on RER (in the range between ≥1.1 and ≥1.15) and RPE (≥17 or ≥18) in addition to the test leader’s evaluation. Additionally, a f_R peak of ≥40 breaths/min may be a cut-point to help the test leader evaluate the degree of exhaustion. However, more research is needed to verify our findings, and to investigate how these criteria will work within a population that are undergoing or finished with cancer treatment.

A Longitudinal Study of a Multicomponent Exercise Intervention with Remote Guidance among Breast Cancer Patients

Purpose: Breast cancer patients in treatment suffer from long-term side effects that seriously influence their physical and mental health. The aim of this study was to examine effectiveness of a 12-week multicomponent exercise (ME) with remote guidance intervention on health-related outcomes after one year among breast cancer patients. Methods: In phases I–III, 60 patients (51.2 ± 7.9 years) with breast cancer (BC) who completed chemotherapy/postoperative radiotherapy within the previous four months to two years were randomly assigned to (1) multicomponent exercise with remote guidance (ME) and (2) usual care (UC). Eligible participants were approached to assess cancer-related quality of life (QOL), muscle strength, cardiorespiratory endurance, and physical activity (PA) barriers after one year. Results: The results demonstrated that, after one year, the ME group reported higher vitality-related QOL (5.776, 95% confidence interval [CI] 0.987, 10.565, effect size [ES] = 0.360), mental health-related QOL (9.938, 95% CI 4.146, 15.729, ES = 0.512), leg strength and endurance (2.880, CI 1.337, 4.423, ES = 0.557), and strength and endurance of upper extremities (2.745, 95% CI 1.076, 4.415, ES = 0.491) and lower physical activity (PA) hindrance (5.120, 95% CI 1.976, 8.264, ES = 0.486) than the UC group. Conclusions: The ME group observed significant differences from the UC group in QOL, muscle strength, cardiopulmonary endurance, and PA participation. These findings suggested that the multicomponent exercise intervention with remote guidance produced long-term health benefits for breast cancer patients.

Influencing factors of cardiorespiratory fitness in allogeneic stem cell transplant candidates prior to transplantation

PURPOSE

Cardiorespiratory fitness (CRF) seems to be prognostic prior to allogeneic stem cell transplantation (allo-HSCT). Influencing factors of CRF in allo-HSCT candidates have not been studied so far. Aim was to identify potentially influencing factors on CRF.

METHODS

To assess CRF, a maximal cardiopulmonary exercise test (CPET) was performed on average 2.6 ± 7.2 days prior to admission. A regression analysis was conducted, with the following predictors: gender, age, body mass index (BMI), time between last therapy and allo-HSCT (t_Therapies), number of cardiotoxic therapies (n_Cardiotox), number of transplantations (n_Transplantations), comorbidity index (HCT-CI), hemoglobin level of the last 3 months (area under the curve), and physical activity.

RESULTS

A total of 194 patients performed a CPET. VO_2peak was significantly reduced compared with reference data. In total, VO_2peak was 21.4 ml/min/kg (- 27.5%, p < 0.05). Men showed a significant larger percentage difference from reference value (- 29.1%, p < 0.05) than women (- 24.4%). VO_2peak was significantly (p < 0.05) influenced by age (β = - 0.11), female gender (β = - 3.01), BMI (β = - 0.44), n_Cardiotox (β = - 0.73), hemoglobin level (β = 0.56), and physical activity prior to diagnosis (β = 0.10).

CONCLUSIONS

Our study demonstrates a decreased CRF indicating the potential need of prehabilitative exercise. We revealed some influencing factors on CRF. Those patients could benefit the most from exercise.

The Cardiac Rehabilitation Model Improves Fitness, Quality of Life, and Depression in Breast Cancer Survivors

PURPOSE

Exercise is a demonstrated, therapeutic strategy for cancer survivors to minimize many treatment-induced side effects and may decrease risk of recurrence. Nonetheless, structured programs that combine exercise and education are not yet standardized within cancer care. The Health, Exercise, Active Living, Therapeutic lifestyle (HEALTh) program is a clinical exercise program based on the established cardiac rehabilitation model, but customized for female breast cancer survivors. This study assessed the effects of a cardiac rehabilitation program on cardiorespiratory fitness, quality of life, and depressive symptoms in breast cancer survivors.

METHODS

Charts were reviewed to evaluate the cardiac rehabilitation model. The program consisted of 1 weekly supervised session for 22 group sessions. Each patient was provided with personalized aerobic and resistance exercises plus 12 group educational sessions to encourage behavioral adoption to a healthy lifestyle. Cardiorespiratory fitness (direct (Equation is included in full-text article.)O2peak), quality of life (Short Form-36 Health Status [SF-36] and Functional Assessment of Cancer Therapy-Breast [FACT-B]), and depression (Centre of Epidemiological Studies Depression [CES-D]) were assessed at baseline and after program completion.

RESULTS

Two hundred seventy-four files were accessed with 152 eligible files analyzed. Baseline cardiorespiratory fitness and quality-of-life values were below population norms. Program adherence was 66.6%. Cardiorespiratory fitness improved by 14% (21 ± 6 to 24 ± 7 mL/kg/min, P < .001), with significant improvements in quality of life (P < .001) and depression scores (P = .019). Bodily pain was the only domain not significantly affected (P = .311).

CONCLUSION

The cardiac rehabilitation model improved physical and mental health in breast cancer survivors. These results provide support for the collaborative effort between cardiology and oncology to improve patient care across the cancer care continuum.

Do we underestimate maximal oxygen uptake in cancer survivors? Findings from a supramaximal verification test

Cancer survivors demonstrate a reduced maximal oxygen uptake, which is clinically relevant in terms of overall survival. However, it remains uncertain whether they attain their "true maximal oxygen uptake" in a cardiopulmonary exercise test (CPET). In the present study, a supramaximal verification bout (Verif) was applied in cancer survivors to confirm attainment of maximal oxygen uptake. Seventy-five participants (age, 61 ± 12 years; n = 43 females with breast cancer and n = 32 males with prostate cancer, 6-52 weeks after primary therapy) performed a CPET on a cycle ergometer and a Verif at 110% peak power output. As verification criterion, maximal oxygen uptake in Verif should not exceed maximal oxygen uptake in CPET by >3%. On average, maximal oxygen uptake was significantly lower in Verif compared with CPET (1.60 ± 0.38 L·min^-1 vs. 1.65 ± 0.36 L·min^-1, p = .023). On the individual level, n = 51 (68%) satisfied the verification criterion, whereas n = 24 (32%) demonstrated a higher maximal oxygen uptake in Verif. n = 69 (92%) fulfilled ≥2 secondary criteria for maximal exhaustion in the CPET. While maximal oxygen uptake was not underestimated in the CPET on average, one-third of cancer survivors did not attain their true maximal oxygen uptake. Verif appears feasible and beneficial to confirm true maximal oxygen uptake in this population. Furthermore, it might be more reliable than secondary criteria for maximal exhaustion. Novelty In about one-third of cancer survivors, maximal oxygen uptake is underestimated by a CPET. This underestimation of maximal oxygen uptake is not necessarily indicated by secondary criteria for maximal exhaustion. A supramaximal verification bout appears feasible and helpful for the determination of maximal oxygen uptake in cancer survivors.

Which exercise prescriptions optimize V̇O2 max during cancer treatment?-A systematic review and meta-analysis

The aims of the present systematic review and meta-analysis were to investigate the effect of exercise on maximal oxygen uptake ( V ˙ O 2 m a x ) and to investigate whether exercise frequency, intensity, duration, and volume are associated with changes in V ˙ O 2 m a x among adult patients with cancer undergoing treatment. Medline and Embase through OvidSP were searched to identify randomized controlled trials. Two reviewers extracted data and assessed the risk of bias. The overall effect size and differences in effects for different intensities and frequencies were calculated on change scores and post-intervention V ˙ O 2 m a x data, and the meta-regression of exercise duration and volumes was analyzed using the Comprehensive Meta-Analysis software. Fourteen randomized controlled trials were included in the systematic review, comprising 1332 patients with various cancer types receiving (neo-)adjuvant chemo-, radio-, and/or hormone therapy. Exercise induced beneficial changes in V ˙ O 2 m a x compared to usual care (effect size = 0.46, 95% Confidence Interval = 0.23-0.69). Longer session duration (P = 0.020), and weekly duration (P = 0.010), larger weekly volume (P < 0.001), and shorter intervention duration (P = 0.005) were significantly associated with more beneficial changes in V ˙ O 2 m a x . No differences in effects between subgroups with respect to frequency and intensity were found. In conclusion, exercise has beneficial effects on V ˙ O 2 m a x in patients with cancer undergoing (neo-)adjuvant treatment. As interventions with larger exercise volumes and longer session durations resulted in larger beneficial changes in V ˙ O 2 m a x , exercise frequency, intensity, and duration should be considered carefully for sufficient exercise volume to induce changes in V ˙ O 2 m a x for this patient group.

Quality of life, problems, and needs of disease-free breast cancer survivors 5 years after diagnosis

PURPOSE

After cancer treatment, it is desirable to maintain or regain a high quality of life (QoL) and the ability to accomplish everyday tasks well. Therefore, we substantiated the scarce knowledge regarding long-term QoL after breast cancer, burdensome problems, and unmet needs for more support.

METHODS

Disease-free breast cancer survivors (n = 190) who had participated in two randomized controlled exercise trials during primary treatment were followed up to 5 years post-diagnosis. QoL-related functions and symptoms (EORTC QLQ-C30/-BR23), health problems, and support needs were assessed. EORTC-QLQ scores were compared with age-matched normative values from the general population in Germany.

RESULTS

QoL-related functions and symptoms in patients during cancer treatment were worse compared to healthy references, but largely improved over time. Yet, cognitive function and sleep were still significantly impaired at 5-year follow-up. Other common long-term problems included sexual issues (45% of survivors), hot flashes (38%), pain (34%), fatigue (24%), and polyneuropathy (21%). Regression analyses indicated fatigue having the strongest impact on global QoL. Support needs were expressed mainly for menopausal disorders (43%), physical performance (39%), sleep problems (38%), arthralgia (37%), cognitive problems (36%), weight problems (32%), and fatigue (31%).

CONCLUSIONS

While QoL in disease-free breast cancer survivors 5 years post-diagnosis was largely comparable to the general population on average, still many survivors suffered from adverse effects. There appears to be a need for ongoing screening and support regarding fatigue, sleep problems, cognitive problems, arthralgia/pain, menopausal/sexual symptoms, physical performance, and weight problems during and several years following breast cancer therapy.

Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer

Background

Neoadjuvant chemotherapy may have a detrimental impact on cardiorespiratory reserve. Determination of oxygen uptake at the anaerobic threshold by cardiopulmonary exercise testing (CPET) provides an objective measure of cardiorespiratory reserve. Anaerobic threshold can be used to predict perioperative risk. A low anaerobic threshold is associated with increased morbidity after oesophagogastrectomy. The aim of this study was to establish whether neoadjuvant chemotherapy has an adverse effect on fitness, and whether there is recovery of fitness before surgery for oesophageal and gastric adenocarcinoma.

Methods

CPET was completed before, immediately after (week 0), and at 2 and 4 weeks after neoadjuvant chemotherapy. The ventilatory anaerobic threshold and peak oxygen uptake (Vo2 peak) were used as objective, reproducible measures of cardiorespiratory reserve. Anaerobic threshold and Vo2 peak were compared before and after neoadjuvant chemotherapy, and at the three time intervals.

Results

Some 31 patients were recruited. The mean anaerobic threshold was lower following neoadjuvant treatment: 15·3 ml per kg per min before chemotherapy versus 11·8, 12·1 and 12·6 ml per kg per min at week 0, 2 and 4 respectively (P &lt; 0·010). Measurements were also significantly different at each time point (P &lt; 0·010). The same pattern was noted for Vo2 peak between values before chemotherapy (21·7 ml per kg per min) and at weeks 0, 2 and 4 (17·5, 18·6 and 19·3 ml per kg per min respectively) (P &lt; 0·010). The reduction in anaerobic threshold and Vo2 peak did not improve during the time between completion of neoadjuvant chemotherapy and surgery.

Conclusion

There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.

Determinants of physical, affective, and cognitive fatigue during breast cancer therapy and 12 months follow-up

Fatigue is common in cancer survivors but often insufficiently treated. Due to its complexity a one-size-fits-all treatment seems not appropriate. To gain more information on influencing factors and sub-dimensions of fatigue we investigated potential determinants and correlates of physical, affective, and cognitive fatigue in breast cancer survivors during and after adjuvant therapy. Within the follow-up of two randomized controlled trials physical, affective, and cognitive fatigue were repeatedly assessed during and up to 12 months after cancer therapy with the 20-item Fatigue Assessment Questionnaire in 255 breast cancer survivors. Determinants of the different fatigue dimensions over time were explored with linear mixed models. Chemotherapy appeared as significant precipitating factor for physical fatigue. However, type of cancer therapy had no impact on fatigue one year post-treatment. Obesity was significantly associated with increased physical fatigue throughout all time points (Δ=15.5 at 12 months) whereas exercise appeared to be beneficial (Δ = -6.3). In contrast, affective fatigue was significantly associated with poor social support and worries about the future. In addition, poor sleep quality and previous use of psychopharmaceuticals were significantly associated with physical, affective, as well as cognitive fatigue. Further, hot flashes were associated with increased physical and cognitive fatigue. In conclusion, the broad diagnosis 'fatigue' in cancer survivors needs to be recognized as a diversity of symptoms determined by specific characteristics and likely different etiologies. Taking potential influencing factors such as obesity, physical inactivity, sleep problems, hot flashes, lack of social support, or psychological disorders into consideration might enable a better, individually-tailored fatigue treatment.

Cardiorespiratory fitness and muscle strength in pancreatic cancer patients

PURPOSE

Cancer patients frequently experience reduced physical fitness due to the disease itself as well as treatment-related side effects. However, studies on physical fitness in pancreatic cancer patients are missing. Therefore, we assessed cardiorespiratory fitness and muscle strength of pancreatic cancer patients.

METHODS

We included 65 pancreatic cancer patients, mostly after surgical resection. Cardiorespiratory fitness was assessed using cardiopulmonary exercise testing (CPET) and 6-min walk test (6MWT). Hand-held dynamometry was used to evaluate isometric muscle strength. Physical fitness values were compared to reference values of a healthy population. Associations between sociodemographic and clinical variables with patients' physical fitness were analyzed using multiple regression models.

RESULTS

Cardiorespiratory fitness (VO₂peak, 20.5 ± 6.9 ml/min/kg) was significantly lower (-24%) compared to healthy reference values. In the 6MWT pancreatic cancer patients nearly reached predicted values (555 vs. 562 m). Maximal voluntary isometric contraction (MVIC) of the upper (-4.3%) and lower extremities (-13.8%) were significantly lower compared to reference values. Overall differences were larger in men than those in women. Participating in regular exercise in the year before diagnosis was associated with greater VO₂peak (p < .05) and MVIC of the knee extensors (p < .05).

CONCLUSIONS

Pancreatic cancer patients had significantly impaired physical fitness with regard to both cardiorespiratory function and isometric muscle strength, already in the early treatment phase (median 95 days after surgical resection). Our findings underline the need to investigate exercise training in pancreatic cancer patients to counteract the loss of physical fitness.

Muscle strength in breast cancer patients receiving different treatment regimes

BACKGROUND

Muscle dysfunction and sarcopenia have been associated with poor performance status, an increased mortality risk, and greater side effects in oncologic patients. However, little is known about how performance is affected by cancer therapy. We investigated muscle strength in breast cancer patients in different adjuvant treatment settings and also compared it with data from healthy individuals.

METHODS

Breast cancer patients (N = 255) from two randomized controlled exercise trials, staged 0-III and aged 54.4 ± 9.4 years, were categorized into four groups according to their treatment status. In a cross-sectional design, muscle function was assessed bilaterally by isokinetic dynamometry (0°, 60°, 180°/s) as maximal voluntary isometric contraction (MVIC) and maximal isokinetic peak torque (MIPT) in shoulder rotators and knee flexors and extensors. Additionally, muscular fatigue index (FI%) and shoulder flexibility were evaluated. Healthy women (N = 26), aged 53.3 ± 9.8 years, were tested using the same method. Analysis of covariance was used to estimate the impact of different cancer treatments on skeletal muscle function with adjustment for various clinical and socio-demographic factors.

RESULTS

Consistently, lower muscle strength was measured in shoulder and knee strength in patients after chemotherapy. On average, patients had up to 25% lower strength in lower extremities and 12-16% in upper extremities in MVIC and MIPT during cancer treatment compared with healthy women. No substantial difference between patient groups in shoulder strength, but significantly lower shoulder flexibility in patients with radical mastectomy was measured. Chemotherapy-treated patients had consistently higher FI%. No serious adverse events were reported.

CONCLUSIONS

Breast cancer patients showed markedly impaired muscle strength and joint dysfunctions before and after anticancer treatment. The significant differences between patients and healthy individuals underline the need of exercise therapy as early as possible in order to prevent or counteract the loss of muscle function after curative surgery as well as the consequences of neo-/adjuvant chemotherapy.

Self-reported physical activity behavior of breast cancer survivors during and after adjuvant therapy: 12 months follow-up of two randomized exercise intervention trials

BACKGROUND

Exercise during and after breast cancer treatment has shown several health benefits. However, little is known about the courses, patterns, and determinants of physical activity of breast cancer patients, and the role of exercise interventions on their physical activity behavior in the long run.

MATERIAL AND METHODS

Self-reported physical activity was assessed in 227 breast cancer survivors before, during, and three, six, and 12 months post-intervention within two randomized resistance exercise trials performed during adjuvant chemo- or radiotherapy, respectively, with similar designs. Multiple ordinal logistic regression analyses were performed to identify determinants of physical activity at these time points.

RESULTS

While the intervention group exercised a median 1.8 h/week during adjuvant therapy (interquartile range 1.4-2.5), 68% of controls did not engage in any exercise. At 12-months follow-up 32% of patients did not engage in any exercise irrespective of the intervention. Of the patients who cycled for transportation pre-diagnosis about half stopped cycling in the long term in both groups. In contrast, walking was maintained over time. Major determinants of low levels of exercise at 12-months follow-up were low pre-diagnosis levels of exercise, lower education, being postmenopausal, and having breast problems or depressive symptoms. Further, the intervention appeared to influence the type of sports performed, with strength exercise being the most common type of exercise at follow-up in the exercise group, more frequently compared to the control group.

CONCLUSION

The exercise intervention effectively countervailed the decrease in physical activity during cancer therapy and boosted strength exercise in the months following the intervention, but in the longer term many survivors were insufficiently active. Breast cancer survivors may need continued motivation and practical support tailored to their individual characteristics and physical activity history to incorporate exercise in everyday routine in the long term.

Age- and treatment-related associations with health behavior change among breast cancer survivors

OBJECTIVE

The aim of this study was to identify demographic and treatment-related factors associated with health-promoting behavior changes after a breast cancer diagnosis. Changes in health behaviors were also evaluated according to weight, exercise, diet and alcohol consumption patterns before breast cancer diagnosis.

MATERIALS AND METHODS

We examined self-reported behavior changes among 1415 women diagnosed with breast cancer in the NIEHS Sister Study cohort. Women reported changes in exercising, eating healthy foods, maintaining a healthy body weight, drinking alcohol, smoking, getting enough sleep, spending time with family and friends, and participating in breast cancer awareness events.

RESULTS

On average, women were 3.7 years from their breast cancer diagnosis. Overall, 20-36% reported positive changes in exercise, eating healthy foods, maintaining a healthy weight, or alcohol consumption. However, 17% exercised less. With each 5-year increase in diagnosis age, women were 11-16% less likely to report positive change in each of these behaviors (OR = 0.84-0.89; p < 0.05), except alcohol consumption (OR = 0.97; CI: 0.81, 1.17). Women who underwent chemotherapy were more likely to report eating more healthy foods (OR = 1.47; 95% CI 1.16-1.86), drinking less alcohol (OR = 2.01; 95% CI: 1.01, 4.06), and sleeping enough (OR = 1.41; 95% CI: 1.04, 1.91). The majority of women (50-84%) reported no change in exercise, eating healthy foods, efforts to maintain a healthy weight, alcohol consumption, sleep patterns, or time spent with family or friends.

CONCLUSIONS

Many women reported no change in cancer survivorship guideline-supported behaviors after diagnosis. Positive changes were more common among younger women or those who underwent chemotherapy.

The clinical picture of cachexia: a mosaic of different parameters (experience of 503 patients)

BACKGROUND

Despite our growing knowledge about the pathomechanisms of cancer cachexia, a whole clinical picture of the cachectic patient is still missing. Our objective was to evaluate the clinical characteristics in cancer patients with and without cachexia to get the whole picture of a cachectic patient.

METHODS

Cancer patients of the University Clinic "Klinikum rechts der Isar" with gastrointestinal, gynecological, hematopoietic, lung and some other tumors were offered the possibility to take part in the treatment concept including a nutrition intervention and an individual training program according to their capability. We now report on the first 503 patients at the time of inclusion in the program between March 2011 and October 2015. We described clinical characteristics such as physical activity, quality of life, clinical dates and food intake.

RESULTS

Of 503 patients with cancer, 131 patients (26.0%) were identified as cachectic, 369 (73.4%) as non-cachectic. The change in cachexia were 23% reduced capacity performance (108 Watt for non-cachectic-patients and 83 Watt for cachectic patients) and 12% reduced relative performance (1.53 Watt/kg for non-cachectic and 1.34 Watt/kg for cachectic patients) in ergometry test. 75.6% of non-cachectic and 54.3% of cachectic patients still received curative treatment.

CONCLUSION

Cancer cachectic patients have multiple symptoms such as anemia, impaired kidney function and impaired liver function with elements of mild cholestasis, lower performance and a poorer quality of life in the EORTC questionnaire. Our study reveals biochemical and clinical specific features of cancer cachectic patients.

Impact of chemotherapy on medium-term physical function and activity of older breast cancer survivors, and associated biomarkers

OBJECTIVE

Chemotherapy is less often prescribed in older individuals due to concerns about post-treatment morbidity and quality of life. We evaluated the physical performance of breast cancer survivors treated with and without adjuvant chemotherapy.

MATERIALS AND METHODS

We conducted a case-control study in 56 estrogen receptor positive breast cancer survivors (BCS) on adjuvant aromatase inhibitors 1-2years after definitive surgery. Cases had received adjuvant chemotherapy (n=27; age 70.5±3.6years) versus age-matched controls who had not (n=29; age 70.0±4.3years). Measures of grip strength, physical activity and performance, walking speed, fatigue, and self-reported physical function were collected. Biological correlates of inflammation, frailty and markers of DNA and RNA oxidation were compared.

RESULTS

Grip strength (controls: 21±7.4 vs.

CASES

29.7±5.0kg, p=0.20), physical activity (5403±3204 vs. 6801±9320steps/day, p=0.45), physical performance (short physical performance battery score: 10.1±1.8 vs. 10.4±1.1, p=0.52) and long-distance walking speed (1.2±0.21 vs. 1.3±0.41m/s, p=0.17) were similar between the two groups. Self-reported physical function was marginally lower in cases than controls (controls: 72±24 vs.

CASES

57±34AU, p=0.07). Fatigue disruptiveness was not different between groups (controls: 11.1±13.0 vs.

CASES

15.7±16.2AU, p=0.24). Similarly, the inflammation, oxidation, and frailty markers did not present a significant difference between groups, except for vitamin D levels (p=0.04).

CONCLUSION

Older women who received chemotherapy reported having slightly lower physical function, but a similar physical performance compared to women who did not. These data suggest that older BCS treated with chemotherapy recover to an extent similar to survivors who only received hormonal therapy.

The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma

Introduction Operable oesophagogastric adenocarcinoma management in the UK includes three cycles of neoadjuvant chemotherapy (NAC) followed by resection. Determination of oxygen uptake at the anaerobic threshold (AT) with cardiopulmonary exercise testing (CPET) is used to objectively measure cardiorespiratory reserve. Oxygen uptake at AT predicts perioperative risk, with low values associated with increased morbidity. Previous studies indicate NAC may have a detrimental impact on cardiorespiratory reserve. Methods CPET was completed by 30 patients before and after a standardised NAC protocol. The ventilatory AT was determined using the V-slope method, and the peak oxygen uptake and ventilatory equivalents for carbon dioxide measured. Median AT before and after chemotherapy was compared using a paired Student's t-test. Results Median oxygen uptake at AT pre- and post-NAC was 13.9±3.1 ml/kg/min and 11.5±2.0 ml/kg/min, respectively. The mean decrease was 2.4 ml/kg/min (95% confidence interval [CI] 1.3-3.85; p<0.001). Median peak oxygen delivery also decreased by 2.17 ml/kg/min (95% CI 1.02-3.84; p=0.001) after NAC. Ventilatory equivalents were unchanged. Conclusions This reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after NAC. Patients with lower cardiorespiratory reserve have increased postoperative morbidity and mortality. Preventing this decrease in cardiorespiratory reserve during chemotherapy, or optimising the timing of surgical resection after recovery of AT, may allow perioperative risk-reduction.

The challenge of preserving cardiorespiratory fitness in physically inactive patients with colon or breast cancer during adjuvant chemotherapy: a randomised feasibility study

Introduction

Anti-neoplastic treatment is synonymous with an inactive daily life for a substantial number of patients. It remains unclear what is the optimal setting, dosage and combination of exercise and health promoting components that best facilitate patient adherence and symptom management in order to support cardio-respiratory fitness and lifestyle changes in an at-risk population of pre-illness physically inactive cancer patients.

Methods

Patients with breast or colon cancer referred to adjuvant chemotherapy and by the oncologists pre-screening verified as physically inactive were eligible to enter a randomised three-armed feasibility study comparing a 12-week supervised hospital-based moderate to high intensity exercise intervention or alternate an instructive home-based12-week pedometer intervention, with usual care.

Results

Using a recommendation based physical activity screening instrument in order to correspond with cardio-respiratory fitness (VO2 peak) proved to be an applicable method to identify pre-illness physically inactive breast and colon cancer patients. The study demonstrated convincing recruitment (67%), safety and intervention adherence among breast cancer patients; while the attendance rate for colon cancer patients was notably lower (33%). VO2-peak declined on average 12% across study groups from baseline to 12 weeks though indices towards sustaining watt performance and reduce fat mass favoured the hospital-based intervention. Pedometer use was well adapted in both breast and colon cancer patients.

Conclusions

Despite a fair adherence and safety, the current study calls into question whether aerobic exercise, regardless of intensity, is able to increase VO2-peak during texane-based chemotherapy in combination with Neulasta in physically inactive breast cancer patients.

Trial Registration:

ISRCTN24901641