The effect of training during treatment with chemotherapy on muscle strength and endurance capacity: A systematic review

Mouse skeletal muscle adaptations to different durations of treadmill exercise after the cessation of FOLFOX chemotherapy

FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) chemotherapy is a treatment for colorectal cancer that can induce persistent fatigue and metabolic dysfunction. Regular exercise after chemotherapy cessation is widely recommended for cancer patients and has been shown to improve fatigue resistance in mice. However, gaps remain in understanding whether the early systemic and skeletal muscle adaptations to regular exercise are altered by prior FOLFOX chemotherapy treatment. Furthermore, the effects of exercise duration on early metabolic and skeletal muscle transcriptional adaptations are not fully established. Purpose: Investigate the effects of prior FOLFOX chemotherapy treatment on the early adaptations to repeated short- or long-duration treadmill exercise, including the fasting regulation of circulating metabolic regulators, skeletal muscle COXIV activity and myokine/exerkine gene expression in male mice. Methods: Male C57BL6/J mice completed 4 cycles of FOLFOX or PBS and were allowed to recover for 4-weeks. Subsets of mice performed 14 sessions (6 d/wk, 18 m/min, 5% grade) of short- (10 min/d) or long-duration (55 min/d) treadmill exercise. Blood plasma and muscle tissues were collected 48-72 h after the last exercise bout for biochemical analyses. Results: Long-duration exercise increased fasting plasma osteocalcin, LIF, and IL-6 in healthy PBS mice, and these changes were ablated by prior FOLFOX treatment. Slow-oxidative soleus muscle COXIV activity increased in response to long-duration exercise in PBS mice, which was blocked by prior FOLFOX treatment. Fast-glycolytic plantaris muscle COXIV activity increased with short-duration exercise independent of FOLFOX administration. There was a main effect for long-duration exercise to increase fasting muscle IL-6 and COXIV mRNA expression independent of FOLFOX. FOLFOX administration reduced muscle IL-6, LIF, and BDNF mRNA expression irrespective of long-duration exercise. Interestingly, short-duration exercise suppressed the FOLXOX induction of muscle myostatin mRNA expression. Conclusion: FOLFOX attenuated early exercise adaptations related to fasting circulating osteocalcin, LIF, and IL-6. However, prior FOLFOX treatment did not alter the exercise adaptations of plantaris muscle COXIV activity and plasma adiponectin. An improved understanding of mechanisms underlying exercise adaptations after chemotherapy will provide the basis for successfully treating fatigue and metabolic dysfunction in cancer survivors.

Effect of a 1-year tailored exercise program according to cancer trajectories in patients with breast cancer: study protocol for a randomized controlled trial

BACKGROUND

Patients with breast cancer undergo various treatments according to their tumor subtype and cancer stages within 1 year after being diagnosed. Each treatment may cause treatment-related symptoms that have negative impacts on patients' health and quality of life (QoL) The symptoms can be mitigated when exercise interventions are appropriately applied to patients' physical and mental conditions. Although many exercise programs were developed and implemented during this period, the effects of tailored exercise programs according to symptoms and cancer trajectories on patients' long-term health outcomes have not yet been fully elucidated. Therefore, this randomized controlled trial (RCT) aims to investigate the effect of tailored home-based exercise programs on short-term and long-term physiological outcomes in patients with breast cancer.

METHODS

This 12-month RCT includes 96 patients with (stages 1-3) breast cancer randomly assigned to the exercise or control groups. Participants in the exercise group will receive an exercise program tailored to their phase of treatment, type of surgery, and physical function. During post-operative recovery, exercise interventions will be emphasized to improve shoulder range of motion (ROM) and strength. During chemoradiation therapy, exercise intervention will focus on improving physical function and preventing loss of muscle mass. Once chemoradiation therapy is completed, exercise intervention will focus on improving cardiopulmonary fitness and insulin resistance. All interventions will be home-based exercise programs supplemented with once-monthly exercise education and counseling sessions. The main outcome of the study is fasting insulin level at baseline, 6 months, and 1 year post-intervention. Our secondary outcomes include shoulder ROM and strength at 1 month and 3 months, body composition, inflammatory markers, microbiome, QoL, and physical activity levels at 1 month, 6 months, and 1 year post-intervention.

CONCLUSION

This trial is the first tailored home-based exercise oncology trial to better understand the comprehensive phase-dependent short- and long-term effects of exercise on shoulder function, body composition, fasting insulin, biomarkers, and microbiome. The results of this study will inform the development of effective exercise programs tailored to the needs of patients with breast cancer post-operatively.

TRIAL REGISTRATION

The protocol for this study is registered with the Korean Clinical Trials Registry (KCT0007853).

The lasting effects of resistance and endurance exercise interventions on breast cancer patient mental wellbeing and physical fitness

Breast cancer is a persisting global burden for health services with cases and deaths projected to rise in future years. Surgery complemented by adjuvant therapy is commonly used to treat breast cancer, however comes with detrimental side effects to physical fitness and mental wellbeing. The aim of this systematic review and meta-analysis is to determine whether resistance and endurance interventions performed during adjuvant treatment can lastingly ameliorate these side effects. A systematic literature search was performed in various electronic databases. Papers were assessed for bias and grouped based on intervention design. RStudio was used to perform the meta-analyses for each group using the ‘meta’ package. Publication bias and power analyses were also conducted. These methods conform to PRISMA guidelines. Combined resistance and endurance interventions elicited significant long-lasting improvements in global fatigue and were beneficial to the remaining side effects. Individually, resistance and endurance interventions non-significantly improved these side effects. Resistance interventions elicited higher benefits overall. Exercise interventions have lasting clinical benefits in ameliorating adjuvant therapy side effects, which negatively impact physical fitness and mental wellbeing. These interventions are of clinical value to enhance adherence rates and avoid comorbidities such as sarcopenia, thus improving disease prognosis.

Efficacy of resistance training during adjuvant chemotherapy and radiation therapy in cancer care: a systematic review and meta-analysis

PURPOSE

To determine the effect of resistance training during adjuvant chemotherapy and radiation therapy in cancer patients on measures of lean mass and muscle strength. Secondary aims were to analyse the prescription and tolerability of supervised resistance training in this population.

METHODS

EMBASE, Medline, CINAHL, Cochrane Library and Web of Science were searched from inception until 29 March 2021. Eligible randomised controlled trials (RCTs) examining supervised resistance training > 6 weeks duration during adjuvant chemotherapy and/or radiation therapy in cancer patients with objective measurement of muscle strength and/or lean mass were included. The meta-analysis was performed using Revman 5.4.

RESULTS

A total of 1910 participants from 20 articles were included (mean age: 54 years, SD = 10) and the majority were female (76.5%). Resistance training was associated with a significant increase in upper body strength (standardised mean difference (SMD) = 0.57, 95% CI 0.36 to 0.79, I2 = 64%, P < 0.0001), lower body strength (SMD = 0.58, 95% CI 0.18 to 0.98, I2 = 91%, P = 0.005), grip strength (mean difference (MD) = 1.32, 95% CI 0.37 to 2.27, I2 = 0%, P < 0.01) and lean mass (SMD = 0.23, 95% CI 0.03 to 0.42, I2 = 0%, P = 0.02). A P value of < 0.05 was considered statistically significant. The quality of the studies included was moderate to high with low risk of bias as per the PEDro scale.

CONCLUSION

Resistance training is an effective adjunct therapy to improve muscle strength and lean mass in cancer patients undergoing chemotherapy and/or radiation therapy.

PROSPERO REGISTRATION NUMBER

CRD42020180643.

Cancer Rehabilitation Provided by Designated Cancer Hospitals in Japan: The Current State of Outpatient Setting and Coordination after Discharge

Objectives:

The aim of the present study was to clarify the current state of outpatient cancer rehabilitation and coordination systems provided by designated cancer hospitals in Japan.

Methods:

A questionnaire was sent to 427 designated cancer hospitals in Japan to investigate the status of outpatient cancer rehabilitation and whether it was sufficiently conducted. The status of regional coordination with post-discharge rehabilitation facilities was surveyed.

Results:

Responses were received from 235/427 facilities (55.0%). Outpatient cancer rehabilitation was implemented in 92 (39.1% of responding facilities), and of these facilities, 83.7% answered that the provision of rehabilitation was insufficient. The reasons were ineligibility for reimbursement of medical fees, a lack of human resources, a lack of awareness of the need, and a lack of education. Regional coordination was conducted by 39.1% of responding facilities, yet a regional alliance path had been established in only 9.8% of centers. The absence of coordination was associated with large facility size, the absence of physiatrists, and few rehabilitation professionals who had completed the training program; an insufficient framework for regional coordination was also given as a reason.

Conclusions:

To provide adequate outpatient cancer rehabilitation, sufficient human resources, the reimbursement of medical fees in the outpatient setting, and education and a framework to promote regional coordination are necessary.

Impact of aerobic versus resistive training on functional capacity in acute myeloid leukemia survivors: a comparative study

Background. Cancer-related fatigue is a persistent symptom in acute myeloid leukemia survivors, with associated decreased functional capacity, which further deteriorates their quality of life. The current study aimed to compare between the impact of aerobic training and resistive training on functional capacity in acute myeloid leukemia (AML) survivors. Fifty nine patients with AML from both sexes aged between 35 and 45 years,were selected from hematology department in (BLINDED FOR PEER REVIEW), where the study was conducted. Patients were randomly assigned into two groups; Group (A) underwent aerobic training in the form of cycling within 50-60% of maximum heart rate. Group (B) underwent resistive training conducted in the form of a series of exercises using free weights, and dumbbells. Sessions were carried out three times per week, for a total of eight weeks period. Six minute walk test (6MWT), 10 repetitions maximum test (10 RM). Ventilatory functions test, fatigue severity assessment (FAS) and quality of life (QoL) scales were measured in both groups before and after the study period. Results. Significant improvement in 6MWT, maximum oxygen consumption (VO2 max) and vital capacity in group (A), significant improvement in fatigue and QoL in both groups and significant improvement in 10 RM test in group (B). Conclusion. Both aerobic and resistive training significantly improved functional capacity in acute myeloid leukemia survivors with a more significant improvement due to aerobic training.

[Sarcopenia and Cachexia-associated Risk in Surgery]

Cachexia is defined as a multifactorial syndrome characterised by involuntary progressive weight loss due to a decrease in skeletal muscle mass, with or without a reduction in adipose tissue. The breakdown of muscle tissue is known as sarcopenia. This is clinically defined as loss of muscle mass and/or muscle strength, with loss of muscle strength being more important than muscle mass. Cachexia is responsible for the death of at least 20% of all cancer patients. The incidence in these patients varies, depending on the type of disease, between 80% for patients with gastric and pancreatic cancer, 50% for patients with lung, colon and prostate cancer, and about 40% for patients with breast cancer or leukemia. It is often difficult to distinguish between tumour-associated cachexia and cachexia caused by side effects and complications of oncological therapy. The main clinical feature of cachexia is involuntary weight loss, but this does not always manifest itself clinically, making it much more difficult to identify patients at risk. Not only the long-term outcome of the patient is influenced by cachexia and sarcopenia. Immediate postoperative complication rates (morbidity) are also increased and have profound effects on the burden of disease and the suffering of patients after surgical treatment. Cachexia, sarcopenia and myosteatosis are therefore highly relevant parameters for everyday clinical practice, which have a significant influence on the postoperative outcome of the patient. Several tools have been developed to aid the identification of patients with nutritional risk, i.e. involuntary weight loss, reduced muscle strength and physical condition. Such measures should be a part of our daily clinical routine to ensure the identification of patients with the highest postoperative risk. Novel preconditioning treatment may be beneficial to certain patient groups to reduce postoperative morbidity.

Effects of aerobic, resistance, and mixed exercises on quality of life in patients with cancer: A systematic review and meta-analysis

BACKGROUND

Quality of life has multiple aspects, but little is known about the effects of exercise on each domain of it. This systematic review aimed to determine the effects of aerobic, resistance, and mixed exercise on multiple aspects of quality of life in patients with cancer through a meta-analysis.

METHODS

Randomized controlled trials with quality of life were collected, and 20 studies were analyzed. Subgroup analyses were performed according to exercise types.

RESULTS

Exercise improved global, physical, role, and emotional quality of life, but not cognitive and social quality of life. Aerobic, resistance, and mixed exercises improved global, physical, role, emotional, and social quality of life; global, physical and role quality of life; and only physical quality of life, respectively.

CONCLUSION

According to exercise type, aerobic and resistance exercises improved global, physical, and role quality of life, whereas aerobic exercise only improved emotional quality of life.

The challenge of timing: a qualitative study on clinician and patient perspectives about implementing exercise-based rehabilitation in an acute cancer treatment setting

OBJECTIVE

Assess the barriers and facilitators to implementing an exercise-based rehabilitation program in an acute setting for cancer survivors receiving treatment.

METHODS

A qualitative study using individual semi-structured interviews and focus groups was completed with 25 clinicians working in oncology and 9 patients receiving cancer treatment who were purposively sampled at a tertiary hospital. Interviews were audio-recorded and transcribed verbatim with coding completed independently by two reviewers and confirmed by a third reviewer, followed by thematic analysis.

RESULTS

The main theme was finding the 'right time' for rehabilitation. Exercise-based rehabilitation was seen as important to deliver in the acute cancer treatment setting but challenging due to patient factors such as feeling overwhelmed and health service constraints. Barriers and facilitators to acute exercise-based rehabilitation were raised under four sub-themes: attitudes, knowledge, convenience and resources. There was agreement among both patients and clinicians around the main themes.

CONCLUSION

Implementing exercise-based rehabilitation in the acute cancer treatment setting is viewed as necessary but challenging to implement. Positive attitudes towards exercise-based cancer rehabilitation services from staff and patients in this study are at odds with current levels of service delivery. This study provides evidence for why this might be the case, and can be used to inform the design of future models of rehabilitation in the acute treatment setting to meet the needs of this patient group.

Effect of different types of exercise on health-related quality of life during and after cancer treatment: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Cancer (and survival) is known to affect the quality of life. Strategies as physical activity and exercise during and after cancer may improve health-related qualify of life (HRQOL) outcomes and are, therefore, of clinical and public health importance. To the best of our knowledge, comparative evidence of the effect of the different types of exercise on improving HRQOL in cancer patients has not been synthesised thus far. We aim to conduct a systematic review and network meta-analysis in order to synthesise all available evidence regarding the effect of different types of exercise interventions on HRQOL during and after cancer treatment.

METHODS AND ANALYSIS

MEDLINE (via PubMed), Web of Science, Embase, The Cochrane Library and SPORTDiscus will be searched from inception to December 2018 for relevant randomised controlled trials (RCTs) and non-RCTs. Studies assessing physical activity and exercise interventions in cancer patients (during treatment) and survivors (after treatment) will be selected. Two independent reviewers will identify eligible studies. After quality appraisal and data extraction, we will conduct meta-analyses for outcomes of interest, including data from mental and physical dimensions of cancer-specific and/or generic HRQOL questionnaires. Risk of bias assessments will be completed using the Quality Assessment Tool for Quantitative Studies. Study heterogeneity will be measured by the I² statistic. Bayesian (and traditional approach) network meta-analysis will be performed when possible to determine the comparative effect of the different physical activity or exercise interventions.

ETHICS AND DISSEMINATION

This systematic review and network meta-analysis will synthesise evidence on the effect of different types of exercise interventions on HRQOL during and after cancer treatment. The results will be disseminated by publication in a peer-reviewed journal and through scientific conferences and symposia. Ethical approval will not be required because the data used for this work will be exclusively extracted from published studies.

PROSPERO REGISTRATION NUMBER

CRD42019125028.

The association of resistance training with mortality: A systematic review and meta-analysis

BACKGROUND

The benefits of aerobic exercise are well-studied; there is no consensus on the association between resistance training and major adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to address this issue.

DESIGN AND METHODS

We searched for randomized trials and cohort studies that evaluated the association between resistance training and mortality and cardiovascular events. Two investigators screened the identified abstracts and full-texts independently and in duplicate. Cochrane tools were used to assess the risk of bias. We calculated hazard ratios and 95% confidence intervals using random effect models.

RESULTS

From the 1430 studies identified, 11 (one randomized trial and 10 cohort studies) met the inclusion criteria, totaling 370,256 participants with mean follow-up of 8.85 years. The meta-analysis showed that, compared with no exercise, resistance training was associated with 21% (hazard ratio (95% confidence interval (CI)), 0.79 (0.69-0.91)) and 40% (hazard ratio (95% CI), 0.60 (0.49-0.72)) lower all-cause mortality alone and when combined with aerobic exercise, respectively. Furthermore, resistance training had a borderline association with lower cardiovascular mortality (hazard ratio (95% CI), 0.83 (0.67-1.03)). In addition, resistance training showed no significant association with cancer mortality. Risk of bias was low to intermediate in the included studies. One cohort study looked at the effect of resistance training on coronary heart disease events in men and found a 23% risk reduction (risk ratio, 0.77, CI: 0.61-0.98).

CONCLUSION

Resistance training is associated with lower mortality and appears to have an additive effect when combined with aerobic exercise. There are insufficient data to determine the potential beneficial effect of resistance training on non-fatal events or the effect of substituting aerobic exercise with resistance training.

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.

Systematic review of exercise training in colorectal cancer patients during treatment

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.