Exercise Training in Elderly Cancer Patients: A Systematic Review

Multicomponent rehabilitation to improve independence and functioning in elderly patients with common age-associated diseases: a scoping review

OBJECTIVE

Multicomponent rehabilitation (MR) could restore functioning in elderly patients after hospitalisation, even beyond geriatrics, but specific evidence seems lacking. This review mapped the evidence on MR in elderly patients following hospitalisation for age-related conditions regarding functioning-related outcomes.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Cochrane Library, International Clinical Trials Registry Platform and ClinicalTrials.gov (searched through 24 June 2024).

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCT) and controlled cohort studies (CCS) comparing centre-based MR with usual care (medical care excluding exercise training) in patients ≥75 years, hospitalised for age-related cardiac, neurological, oncological and orthopaedic diseases. MR was defined as exercise training and at least one additional component (eg, nutritional counselling), starting within 3 months after hospital discharge. RCTs and CCS were included from inception, without language restriction. Care dependency, physical function, health-related quality of life (HRQL) and activities of daily living (ADL) after ≥6 months follow-up were the outcomes of interest.

DATA EXTRACTION AND SYNTHESIS

Four reviewers independently screened titles, abstracts and full texts for inclusion and extracted data. MR components and the typology of outcome assessments used were mapped at the final data synthesis level.

RESULTS

Out of 20 409 records, nine studies were investigated in the final data synthesis. Throughout these studies, disease education was the most frequent MR component besides exercise training, while physical function, HRQL and ADL were commonly assessed outcomes. One RCT (cardiac rehabilitation, 80±0.3 years, MR/usual care n=24/23) fully met the inclusion criteria and reported improvements in physical function (2 months) and in HRQL (2, 8, 14 months post intervention) in MR patients.

CONCLUSIONS

Evidence on MR regarding functioning-related outcomes in ≥75-year-old patients is sparse beyond geriatrics. There is an essential need for studies investigating the capabilities of MR in this growing and under-represented patient population.

TRIAL REGISTRATION NUMBER

OSF (https://doi.org/10.17605/OSF.IO/GFK5C).

The impact of multidisciplinary geriatric follow-up on quality of life in older, non-surgical prefrail and frail patients with cancer A randomized controlled trial

INTRODUCTION

Cancer management in older frail patients can be complex, given the high decline in functional status, comorbidity, and limited life expectancy affecting this group of patients. Therefore, this study aimed to investigate whether oncological treatment combined with comprehensive geriatric assessment (CGA) and tailored follow-up interventions improved or maintained quality of life (QoL) in older prefrail and frail patients with cancer.

MATERIALS AND METHODS

A single-center randomized controlled trial included participants aged 70 or older with head, neck, lung, upper gastrointestinal tract, colon, or rectum cancer referred to non-surgical treatment. All participants underwent CGA conducted by a multidisciplinary geriatric team in an outpatient oncological clinic. The team consisted of a geriatrician and a specialized nurse who provided tailored follow-up visits and phone calls within 90 days after randomization. Exclusion criteria were fit patients, referral for specialized palliative care, or participating in another geriatric research program. In patients with well-functioning cognition, QoL was assessed using the EORTC QLQ-C30 and QlQ-ELD-14 questionnaires before and after the intervention. In patients with cognitive impairment, the Overall QoL-Depression List was used. Changes in QoL were dichotomized into improved/unchanged or worsened and analyzed in a logistic regression model.

RESULTS

In total, 363 participants were included with a mean age of 76 years (SD 4.6) and 45 % were female. Sixty percent in the intervention group had improved or unchanged QoL compared to 66 % in the control group (odds ratio: 0.75 [95 % confidence interval(CI): 0.45-1.23]). Overall, clinically important changes were found in fatigue and reduced worries about the future. The intervention showed improvements in insomnia symptoms and reported decreased role functioning. Discrepancies were found in the burden of illness without a clinically important difference, where the intervention group experienced an increased burden while the control group had a decreased burden (coefficient: 9.02 [95 % CI, 0.49-17.5]).

DISCUSSION

Multidisciplinary geriatric follow-up did not universally improve QoL in older frail patients with cancer. However, positive changes in specific aspects of QoL revealed nuanced impacts, warranting further exploration and larger studies to validate these observations. Tailored interventions targeting fatigue, insomnia, and emotional well-being are crucial for improving QoL in this population.

TRIAL REGISTRATION

Registered in January 2016 at ClinicalTrials.gov (ID: NCT02837679).

Integrative Geriatric Oncology: A Review of Current Practices

PURPOSE OF REVIEW

This article aims to offer a comprehensive review of optimal integrative medicine practices for geriatric oncology patients. Given the aging population and the global rise in cancer incidence, it is crucial to identify evidence-based modalities and employ an integrated approach to enhance cancer outcomes and quality of life in older adults.

RECENT FINDINGS

It has been predicted that 20.5% (6.9 million) of new cancer cases in 2050 will occur in adults over 80 years old.1 The increasing focus on lifestyle factors in healthy aging has shed light on various overlooked areas of significance. Notably, anti-inflammatory diets and the promotion of a healthy gut microbiome have demonstrated significant impacts on overall health outcomes, bolstering the body's innate capacity to combat disease. This review delves into further evidence and extrapolation concerning integrative approaches and their influence on cancer outcomes and older adults quality of life. The complexity and unique nature of cancer in older adults requires a wide range of support from medical providers. Incorporating various integrative techniques as part of cancer treatment and side effect support can improve health outcomes and patient's quality of life. Familiarity with the lifestyle interventions and other topics explored in this review equips healthcare providers to offer tailored and holistic care to geriatric patients navigating cancer.

A physiotherapists perspective of a geriatric clinic in a tertiary oncology centre

Aims and objectives

To analyse various domains amongst the geriatric population such as age, gender, body mass index (BMI), comorbidities, type of cancer and use of assistive devices, and find a correlation between the outcome measures such as short physical performance battery (SPPB) and performance-oriented mobility assessment (POMA).

Methodology

Patients above 60 years were screened and further referred to the physiotherapy department. A brief history was recorded to retrieve the demographic data such as name, age, gender, height, weight, BMI, hand dominance, diagnosis, previous investigations are done, comorbidities if any present, use of assistive devices if required and in case any previous oncological treatment has been delivered. Various outcome measures were administered such as POMA, SPPB, 6 minutes walk test (6 MWT) and numerical rating for fatigue. The interpretations were noted on a case report sheet and the appropriate interventions for the deficits were delivered to the patient. Also, the patients were asked to carry on the necessary investigation (if required) and get back to the physiotherapy OPD. No follow-up is required by the patients as this was a retrospective single-endpoint study.

Results and analysis

The descriptive analysis was done by using R software (version 4.2.3). The main objective was to analyse the variables descriptively using numbers and percentages. The correlation between 2 outcome measures: SPPB and POMA was assessed using Spearman's rank correlation.All the 100 patients had solid tumour malignancies, commonly GI (37%), thoracic (18%), breast (17%), H and N (13%), uro-oncology (11%) and gynecology (4%). The median age was 70 years (range, 60-88). The median BMI was 22.10 (IQR, 19.40-24.77). Among 100 patients, comorbidities were found in most of the patients, most commonly hypertension (35%), diabetes mellitus (20%), heart disease (9%) and other diseases (8%). Out of 100 patients, 15% of them used assistive devices but the remaining 85% of patients did not require any assistive devices. Different outcome measures were also assessed for understanding the patients' risk in different categories. On assessing POMA, most of the patients had a medium risk of fall (49%), followed by high risk (31%) and low risk (14%). On assessing SPPB, most of the patients had low risk (41%), followed by medium risk (31%) and high risk (28%). The aerobic capacity of patients was assessed using 6 MWT (walking capacity) which showed that most of them had a severe reduction in aerobic capacity (37%) followed by moderation reduction (28%), good aerobic capacity (25%) and mild reduction (10%). The treatment required by the patients involved most commonly LL strengthening (71; 30.6%) and aerobic conditioning (67; 28.9%) and the least was brisk walking (4; 1.72%) and UL strengthening (2; 0.86%).

Conclusion

Commonly deranged domains included fatigue (97%), risk of fall (80%), reduced aerobic capacity (75%) and comorbidities (73%). The correlation between SPPB and POMA was assessed using Spearman's rank correlation method which obtained a correlation coefficient of 0.79 which implies that there is a strong positive association between SPPB and POMA.

Application value of laparoscopic surgery in elderly patients (≥ 75 years) with colorectal cancer and prognostic factors influencing 5-year overall survival

OBJECTIVE

To investigate the application value of laparoscopic surgery in elderly patients (≥ 75 years) with colorectal cancer, and to identify the prognostic factors influencing the long-term survival in this demographic, and to establish a predictive nomogram model.

METHODS

A retrospective analysis was conducted on 146 elderly (≥ 75 years old) colorectal cancer patients who underwent radical surgery in Baoji People's Hospital from August 2016 to February 2018, including 55 patients who underwent laparotomy and 91 patients who underwent laparoscopic surgery. Survival curves were plotted using the Kaplan-Meier method, and differences in prognosis were assessed using the Log-rank test. Prognostic impacts of various factors on 5-year survival were analyzed using a Cox proportional hazards model. Significant predictors identified in the Cox model were used to construct a nomogram for predicting survival, which was then validated for accuracy and clinical utility.

RESULTS

Laparoscopic surgery was associated with shorter hospital stays (P = 0.022), although at a higher cost (P = 0.011). The laparoscopic group also had less intraoperative bleeding (P < 0.001), incision length (P < 0.001), time to first postoperative expectoration (P < 0.001), time to first postoperative feeding (P = 0.002), and time to postoperative peritoneal drainage (P = 0.003) compared to the open surgery group. Additionally, the rate of postoperative wound complications was also lower in the laparoscopic group (P = 0.014). There was no significant difference in the 5-year post-treatment survival between the two groups (P = 0.150). Multifactorial Cox regression analysis revealed that a history of diabetes mellitus (P = 0.037), vascular infiltration (P = 0.026), nerve bundle invasion (P = 0.001), and TNM stage (P = 0.001) were independent prognostic factors affecting the 5-year survival of patients with advanced colorectal cancer. The constructed nomogram showed high predictive accuracy for 1-, 3-, and 5-year survival, with AUC values of 0.91, 0.87, and 0.79, respectively. Calibration curves and decision curve analysis confirmed the model's clinical utility. Risk formula: History of diabetes mellitus * -0.696194503 + Vascular infiltration * -0.769736513 + Nerve bundle invasion * -1.1709777 + TNM staging * 1.201933691.

CONCLUSION

Laparoscopic surgery can reduce intraoperative trauma and accelerate postoperative recovery in elderly colorectal cancer patients (≥ 75 years) compared to open surgery. The developed nomogram model based on independent prognostic factors such as diabetes history, vascular infiltration, nerve bundle invasion, and TNM staging, facilitates tailored prognostic assessment, enhancing individual patient management.

Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial

BACKGROUND

Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery.

METHODS

The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses.

DISCUSSION

The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population.

TRIAL REGISTRATION

PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).

Exercise interventions for frail older adults with cancer

PURPOSE OF REVIEW

Frailty is prevalent in older adults with cancer and can lead to complications during cancer treatment and poor health outcomes. Exercise has been shown to be a promising strategy to mitigate frailty and slow the accumulation of functional impairment in the general geriatric population. In this review, we present a discussion on the state of the science of exercise interventions for frail older adults with cancer. This review is timely and relevant given the aging of the population and corresponding increase in proportion of older adults living with cancer.

RECENT FINDINGS

Existing research related to exercise interventions for frail older adults with cancer appear to show some promise in feasibility and efficacy in both surgical and systemic treatment settings.

SUMMARY

More research on this topic and testing rigorously structured exercise interventions for older adults with cancer may help inform cancer-specific guidelines and create a foundation of evidence to enable implementation of exercise interventions. These interventions can support cancer care to attenuate frailty-related outcomes while extending its benefit to overall health of this population.

Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways

Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.