Exercise Therapy in Oncology—the Impact on Quality of Life and Side Effects

BACKGROUND

The diagnosis and treatment of cancer are highly stressful. Exercise therapy is often used to mitigate the adverse effects of treatment. But how good is the evidence base, and what has changed in recent years? In this narrative review, we present the current data and what it implies for the care of adults with cancer.

METHODS

This review is based on data from meta-analyses and systematic reviews concerning 16 relevant clinical endpoints (outcomes) of exercise therapy for cancer patients

RESULTS

The literature evaluated for this paper reveals that targeted exercise therapy is feasible and safe under appropriate supervision. It is highly effective for improving eight of the sixteen endpoints (anxiety, depression, fatigue, quality of life, physical function, secondary lymphedema after breast cancer, urinary incontinence, post-mastectomy pain syndrome in breast cancer) and may also have a beneficial effect on sleep quality, cardiotoxicity, and cognitive function. Less conclusive studies are currently available with respect to chemotherapy-induced polyneuropathy, nausea/vomiting, and bone health. There is currently insufficient data to suggest any benefit with respect to sexual function and risk factors for falling.

CONCLUSION

The data situation shows that exercise therapy for cancer patients is safe and has manifold effects on selected clinically relevant parameters. Further studies should be performed regarding the possible utility of exercise therapy against treatment-related side effects for which the evidence is currently insufficient. On the basis of the currently available and already existing recommendations, quality-assured exercise therapy can be recommended to cancer patients suffering from a wide range of neoplastic conditions.

Eight weeks of exercise intervention improves visuomotor and functional capacity, performance, and physiological profile in a patient with choroidal melanoma

The aim of this case study was to investigate the effects of an 8-wk combined exercise intervention, consisting of visual-coordinative and high-intensity interval training (HIIT), on the physical and visuomotor-functional capacity, performance, and physiological profile of a moderately active 29-yr-old man diagnosed with choroidal melanoma of the left eye. Data were collected on three occasions: at the initial diagnosis (T0), after hospitalization and radiotherapy treatment (T1), and following the recovery through the exercise intervention (T2), spanning a total of 17 wk. The primary outcome variables consisted of visuomotor and functional tests (VFTs), cardiorespiratory fitness (CRF), and microvascular circulation measured via flicker light-induced dilation (FiD). For visuomotor tests in general, a significant decline was observed between baseline T0 and T1 (by 6%-22%), followed by significant improvements at T2 (by 11%-36%), surpassing the initially observed T0 values. The cardiopulmonary exercise testing (CPET)-derived parameters exhibited a similar pattern, declining from T0 to T1 [by 8%-12% for peak V̇o2, peak power output (PO), and CPET duration, respectively], with a subsequent recovery observed in response to 8 wk of exercise training (T2), resulting in increases of 11%-25% for V̇o2, peak PO, and CPET duration. Interestingly, the dilation of both arteries and veins in response to the FiD stimulus exhibited a twofold increase compared with baseline levels. Our results suggest that the 8-wk exercise intervention improved patients' VFT and CRF profiles and exceeded baseline values. Additional investigation, particularly through randomized controlled trials, is needed to comprehensively explain changes in FiD.NEW & NOTEWORTHY Results presented here suggest that combined visual-coordinative and HIIT training improves the visual-functional capacity, performance, and physiological profile of choroidal melanoma patients during treatment recovery. This case study lays the groundwork for further research concerning exercise therapy in this unique patient population. In addition, further investigation is required to fully comprehend the combined effects of exercise and radiation therapy on vasculature and oxygenation in patients with choroidal melanoma.

A Multimodal Lifestyle Psychosocial Survivorship Program in Young Cancer Survivors: The CARE for CAYA Program-A Randomized Clinical Trial Embedded in a Longitudinal Cohort Study

Importance

There is a lack of trials examining the effect of counseling interventions for child, adolescent, and younger adult (CAYA) cancer survivors.

Objective

To assess lifestyle habits and the psychosocial situation of CAYAs to determine the efficacy of needs-based interventions in the CARE for CAYA program (CFC-P).

Design, Setting, and Participants

The CFC-P was conducted as a multicenter program in 14 German outpatient clinics, mainly university cancer centers. Recruitment began January 1, 2018; a randomized clinical trial was conducted until July 15, 2019; and intervention was continued as a longitudinal cohort study until March 31, 2021. Data preparation was conducted from April 1, 2021, and analysis was conducted from August 14, 2021, to May 31, 2022. Herein, predefined confirmatory analyses pertain to the RCT and descriptive results relate to the overall longitudinal study. Data analysis was based on the full analysis set, which is as close as possible to the intention-to-treat principle.

Intervention

A comprehensive assessment determined needs in physical activity, nutrition and psychooncology. Those with high needs participated in 1 to 3 modules. In the RCT, the IG received 5 counseling sessions plus newsletters, while the control group CG received 1 counseling session.

Main Outcomes and Measures

The primary outcome was the change in the rate of CAYAs with high needs at 52 weeks. Secondary outcomes were feasibility, modular-specific end points, satisfaction, quality of life, and fatigue.

Results

Of 1502 approached CAYAs aged 15 to 39 years, 692 declined participation. Another 22 CAYAs were excluded, resulting in 788 participants. In the randomized clinical trial, 359 CAYAs were randomized (intervention group [IG], n = 183; control group [CG], n = 176), and 274 were followed up. In the RCT, the median age was 25.0 (IQR, 19.9-32.2) years; 226 were female (63.0%) and 133 male (37.0%). After 52 weeks, 120 CAYAs (87.0%) in the IG and 115 (86.5%) in the CG still had a high need in at least 1 module (odds ratio, 1.04; 95% CI, 0.51-2.11; P = .91). Both groups reported reduced needs, improved quality of life, reduced fatigue, and high satisfaction with the CFC-P.

Conclusions and Relevance

In this randomized clinical trial, the implementation of a lifestyle program in this cohort was deemed necessary, despite not meeting the primary outcome. The interventions did not alter the rate of high needs. The results may provide guidance for the development of multimodal interventions in the follow-up care of CAYAs.

Trial Registration

German Clinical Trial Register: DRKS00012504.

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.

[Exercise therapy in prehabilitation : Current findings in urology]

BACKGROUND

Prehabilitation refers to interventions that take place before starting medical treatment. Prehabilitation exercise therapy aims to increase functional physical capacities to improve recovery and reduce side effects.

OBJECTIVES

To present the evidence and potential of prehabilitation exercise therapy in urological oncology.

METHODS

Compilation and explanation of study results.

RESULTS

Studies are limited and primarily focused on prostate and bladder cancer. Current data show positive effects on physical functioning and cardiorespiratory capacity. The majority of prehabilitation studies in prostate cancer focus on specific goals of physical functioning, particularly maintenance and recovery of urinary continence with inconsistent results.

CONCLUSIONS

There is preliminary evidence to improve cardiorespiratory fitness and overall physical functioning in urinary bladder and prostate cancer. Further in-depth research is needed to map the potential spectrum of prehabilitation exercise therapy in uro-oncology.

Assessing Osteolytic Lesion Size on Sequential CT Scans Is a Reliable Study Endpoint for Bone Remineralization in Newly Diagnosed Multiple Myeloma

Multiple myeloma (MM) frequently induces persisting osteolytic manifestations despite hematologic treatment response. This study aimed to establish a biometrically valid study endpoint for bone remineralization through quantitative and qualitative analyses in sequential CT scans. Twenty patients (seven women, 58 ± 8 years) with newly diagnosed MM received standardized induction therapy comprising the anti-SLAMF7 antibody elotuzumab, carfilzomib, lenalidomide, and dexamethasone (E-KRd). All patients underwent whole-body low-dose CT scans before and after six cycles of E-KRd. Two radiologists independently recorded osteolytic lesion sizes, as well as the presence of cortical destruction, pathologic fractures, rim and trabecular sclerosis. Bland-Altman analyses and Krippendorff's α were employed to assess inter-reader reliability, which was high for lesion size measurement (standard error 1.2 mm) and all qualitative criteria assessed (α ≥ 0.74). After six cycles of E-KRd induction, osteolytic lesion size decreased by 22% (p < 0.001). While lesion size response did not correlate with the initial lesion size at baseline imaging (Pearson's r = 0.144), logistic regression analysis revealed that the majority of responding osteolyses exhibited trabecular sclerosis (p < 0.001). The sum of osteolytic lesion sizes on sequential CT scans defines a reliable study endpoint to characterize bone remineralization. Patient level response is strongly associated with the presence of trabecular sclerosis.

Initial observations on sexual dysfunction as a symptom of chemotherapy-induced peripheral neuropathy

Introduction

Peripheral neuropathy (PNP) in feet and/or hands and sexual dysfunction are common side effects of cancer therapies. In patients with other diseases, there is evidence of an association between peripheral nervous system disorders and sexual dysfunction due to the impact of impaired neuronal control on genital organ sensitivity. In cancer patient interviews, it has now been observed that PNP and sexual dysfunction may be related. The aim of the study was to investigate the potential association between PNP, sexual dysfunction, and physical activity behavior.

Methods

Ninety-three patients with PNP of the feet and/or hands were interviewed in August/September 2020 in a cross-sectional study regarding medical history, sexual dysfunction and functionality of the genital organs.

Results

Thirty-one persons who participated in the survey provided seventeen evaluable questionnaires (four men, thirteen women). Nine women (69%) and three men (75%) reported sensory disorders of the genital organs. Three men (75%) had erectile dysfunction. All men who had sensory symptoms of the genital organs received chemotherapy, and one man also received immunotherapy. Eight women were sexually active. Five (63%) of them reported genital organ symptoms and mainly lubrication disorders. Four (80%) of the five sexually inactive women reported genital organ symptoms. Eight of the nine women with sensory symptoms of the genital organs received chemotherapy, and one woman received immunotherapy.

Discussion

Our limited data suggest genital organ sensory symptoms in chemotherapy and immunotherapy patients. Genital organ symptoms do not appear to be directly related to sexual dysfunction, and the association between PNP and genital organ symptoms appears to be more pronounced in sexually inactive women. Chemotherapy could cause sensory symptoms of the genital organs and sexual dysfunction by damaging genital organ nerve fibers. Chemotherapy and anti-hormone therapy (AHT) could trigger a disturbance of the hormone balance, which in turn could be causative for sexual dysfunction. It remains open whether the cause of these disorders is the symptomatology of the genital organs or the altered hormone balance. The significance of the results is limited due to the small number of cases. To our knowledge, this study is the first of its kind in cancer patients and allows a better understanding of the association between PNP, sensory symptoms of the genital organs, and sexual dysfunction.

Conclusion

In order to be able to narrow down the cause of these initial observations in cancer patients more precisely, larger studies are needed that can relate the influence of cancer therapy-induced PNP, physical activity level and hormone balance to sensory symptoms of the genital organs and sexual dysfunction. The methodology of further studies should take into account the frequent problem of low response rates in surveys on sexuality.

Exercise interventions for adults with cancer receiving radiation therapy alone

BACKGROUND

Radiation therapy (RT) is given to about half of all people with cancer. RT alone is used to treat various cancers at different stages. Although it is a local treatment, systemic symptoms may occur. Cancer- or treatment-related side effects can lead to a reduction in physical activity, physical performance, and quality of life (QoL). The literature suggests that physical exercise can reduce the risk of various side effects of cancer and cancer treatments, cancer-specific mortality, recurrence of cancer, and all-cause mortality.

OBJECTIVES

To evaluate the benefits and harms of exercise plus standard care compared with standard care alone in adults with cancer receiving RT alone.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL, conference proceedings and trial registries up to 26 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people who were receiving RT without adjuvant systemic treatment for any type or stage of cancer. We considered any type of exercise intervention, defined as a planned, structured, repetitive, objective-oriented physical activity programme in addition to standard care. We excluded exercise interventions that involved physiotherapy alone, relaxation programmes, and multimodal approaches that combined exercise with other non-standard interventions such as nutritional restriction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the GRADE approach for assessing the certainty of the evidence. Our primary outcome was fatigue and the secondary outcomes were QoL, physical performance, psychosocial effects, overall survival, return to work, anthropometric measurements, and adverse events.

MAIN RESULTS

Database searching identified 5875 records, of which 430 were duplicates. We excluded 5324 records and the remaining 121 references were assessed for eligibility. We included three two-arm RCTs with 130 participants. Cancer types were breast and prostate cancer. Both treatment groups received the same standard care, but the exercise groups also participated in supervised exercise programmes several times per week while undergoing RT. Exercise interventions included warm-up, treadmill walking (in addition to cycling and stretching and strengthening exercises in one study), and cool-down. In some analysed endpoints (fatigue, physical performance, QoL), there were baseline differences between exercise and control groups. We were unable to pool the results of the different studies owing to substantial clinical heterogeneity. All three studies measured fatigue. Our analyses, presented below, showed that exercise may reduce fatigue (positive SMD values signify less fatigue; low certainty). • Standardised mean difference (SMD) 0.96, 95% confidence interval (CI) 0.27 to 1.64; 37 participants (fatigue measured with Brief Fatigue Inventory (BFI)) • SMD 2.42, 95% CI 1.71 to 3.13; 54 participants (fatigue measured with BFI) • SMD 1.44, 95% CI 0.46 to 2.42; 21 participants (fatigue measured with revised Piper Fatigue Scale) All three studies measured QoL, although one provided insufficient data for analysis. Our analyses, presented below, showed that exercise may have little or no effect on QoL (positive SMD values signify better QoL; low certainty). • SMD 0.40, 95% CI -0.26 to 1.05; 37 participants (QoL measured with Functional Assessment of Cancer Therapy-Prostate) • SMD 0.47, 95% CI -0.40 to 1.34; 21 participants (QoL measured with World Health Organization QoL questionnaire (WHOQOL-BREF)) All three studies measured physical performance. Our analyses of two studies, presented below, showed that exercise may improve physical performance, but we are very unsure about the results (positive SMD values signify better physical performance; very low certainty) • SMD 1.25, 95% CI 0.54 to 1.97; 37 participants (shoulder mobility and pain measured on a visual analogue scale) • SMD⁠⁠⁠⁠⁠⁠ 3.13 (95% CI 2.32 to 3.95; 54 participants (physical performance measured with the six-minute walk test) Our analyses of data from the third study showed that exercise may have little or no effect on physical performance measured with the stand-and-sit test, but we are very unsure about the results (SMD 0.00, 95% CI -0.86 to 0.86, positive SMD values signify better physical performance; 21 participants; very low certainty). Two studies measured psychosocial effects. Our analyses (presented below) showed that exercise may have little or no effect on psychosocial effects, but we are very unsure about the results (positive SMD values signify better psychosocial well-being; very low certainty). • SMD 0.48, 95% CI -0.18 to 1.13; 37 participants (psychosocial effects measured on the WHOQOL-BREF social subscale) • SMD 0.29, 95% CI -0.57 to 1.15; 21 participants (psychosocial effects measured with the Beck Depression Inventory) Two studies recorded adverse events related to the exercise programmes and reported no events. We estimated the certainty of the evidence as very low. No studies reported adverse events unrelated to exercise. No studies reported the other outcomes we intended to analyse (overall survival, anthropometric measurements, return to work).

AUTHORS' CONCLUSIONS

There is little evidence on the effects of exercise interventions in people with cancer who are receiving RT alone. While all included studies reported benefits for the exercise intervention groups in all assessed outcomes, our analyses did not consistently support this evidence. There was low-certainty evidence that exercise improved fatigue in all three studies. Regarding physical performance, our analysis showed very low-certainty evidence of a difference favouring exercise in two studies, and very low-certainty evidence of no difference in one study. We found very low-certainty evidence of little or no difference between the effects of exercise and no exercise on quality of life or psychosocial effects. We downgraded the certainty of the evidence for possible outcome reporting bias, imprecision due to small sample sizes in a small number of studies, and indirectness of outcomes. In summary, exercise may have some beneficial outcomes in people with cancer who are receiving RT alone, but the evidence supporting this statement is of low certainty. There is a need for high-quality research on this topic.

[Physical activity and exercise therapy in oncology]

Optimized and individualized treatment options in oncology significantly improve the prognosis of patients. Accordingly, the management of side effects and the avoidance of long-term consequences is becoming increasingly more important. Numerous studies have shown a positive impact of physical activity and targeted exercise therapy on certain patient-related outcomes. Ideally, patients are introduced to exercise therapy directly after the diagnosis is made in order to enable adequate supportive monitoring and to sustainably reduce therapy-associated side effects. Meanwhile, scientific findings have resulted in concrete recommendations for action to effectively improve the main patient-related outcomes, such as fatigue or depression. A moderate endurance training in combination with individualized strength training seems to be of particular importance. In principle, oncological training and exercise therapy can be recommended to every cancer patient regardless of the form of cancer and the timing of therapy but taking the contraindications into account. Therefore, the aim of communal as well as national efforts should be to implement a comprehensive offer of professional exercise therapy to facilitate access of cancer patients to these services as well as to ensure adequate care during and after treatment.

Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations

BACKGROUND

Pediatric cancer leads to reduced participation in exercise and only few patients comply with national physical activity recommendations. Physically inactive behavior hinders motor development and increases physical and psychological adverse effects of therapy and incidence of sequelae. Currently, there is neither nationwide coverage nor uniform level of knowledge regarding exercise promotion. The objective of the guideline is to facilitate qualified exercise interventions through standardized procedures in addition to regular physiotherapy and overall avoid physical inactivity in pediatric cancer patients.

METHODS

This guideline addresses the multidisciplinary treatment team and informs physiotherapists and decision-makers in tertiary care hospitals and health insurance companies. The requirements of the Association of the Scientific Medical Societies in Germany were followed. Contents were based on best practice experience of experts, patient advocates, as well as on scientific evidence.

RESULTS

The guideline includes 11 recommendations. Recommendations 1-4 declare the relevance of implementing exercise interventions and address general framework conditions. Recommendations 5-11 focus on the design of exercise programs, prevention and safety issues, relative contraindications for specific training loads, and options to overcome barriers to exercise.

CONCLUSION

This guideline summarizes existing and established structures and evidence in the context of movement and exercise in pediatric oncology. It takes into consideration the rights, varying needs, and characteristics of children and adolescents as well as national and international experience in this field. In the future, relevant research gaps need to be addressed by high-quality intervention studies to provide the scientific background for a stronger evidence-based guideline.

[Physical activity in cancer - effectiveness of exercise therapy approaches]

The positive effects of oncological exercise therapy are sufficiently proven according to scientific studies. International evidence-based guidelines confirm this importance and recommend physical exercise as part of the standard therapy for cancer. The effects of physical activity on cancer-specific deficits are versatile ranging from positive impact on fatigue syndrome, mortality, incontinence, lymphoedema, CIPN, anxiety, depression to reduction of pain. According to current knowledge, sensorimotor training is recommended for the treatment of polyneuropathy. The actual effectiveness of vibration training in reducing symptom burden is undetermined. There are more than 100 randomized, controlled studies with the highest evidence rating for the management of CrF available. In this regard, exercise therapy is more effective than drug therapy in alleviating the symptomatology of CrF. In addition to the movement-therapeutic approach, a coordinated diet is necessary to avoid nutrition shortages.The evidence on physical activity in oncology must be considered not only in theory, but also in practice and be accepted as a general recommendation for oncology patients. The personalized OTT treatment concept represents a practical implementation and offers a targeted treatment option with low side effects.

Resistance Exercise for Breast Cancer Patients? Evidence from the Last Decade

Background

Breast cancer is associated with many therapy-induced side effects that impact patients' lives from diagnosis to long-term survivorship. Physical activity has become an important and proven supportive measure in treating side effects like loss of muscle strength, fatigue, chemotherapy-induced peripheral neuropathy, lymphedema, and loss of quality of life. Resistance training (RT) is an established exercise intervention for breast cancer patients, but the correct type, timing, intensity, and duration of exercise remain unclear. It is necessary to investigate different resistance training interventions and their effects on breast cancer patients by covering all stages of treatment, beginning with prehabilitation, through the period of acute therapy, to long-term survivorship.

Conclusion

Upon evaluation of randomized controlled trials (RCTs) from the past decade, RT was found to be feasible and safe. Furthermore, there is evidence on the impact of RT on muscle strength, CRF and QoL amongst other factors. Studies implementing mixes of aerobic and strength exercises are rather common, but RCTs of RT-only protocols remain scarce. Different strength training protocols at distinct stages of breast cancer treatment have been conducted, but with the complexity of treatments and the variety of training styles, a large field of study remains.

Key Messages

Although the overall data on RT for breast cancer patients has increased, there are many different methodological approaches and testing measures as well as gaps in study documentation. There is still very little of the evidence that would facilitate the compilation of standardized and individualized guidelines.

Effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy-a pilot study

PURPOSE

Colorectal cancer and its treatment are associated with debilitating side effects. Exercise may improve the physical and psychological wellbeing of cancer patients; however, evidence in colorectal cancer patients undergoing adjuvant chemotherapy is limited. This pilot study aimed to explore the effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy.

METHODS

Patients who had undergone curative resection for colorectal cancer (stages II-III) and were scheduled to receive adjuvant chemotherapy were enrolled into this non-randomized controlled trial. Patients in the intervention group (IG) took part in a 6-month supervised aerobic exercise program, while the control group (CG) received usual care. Cardiorespiratory fitness (measured by peak oxygen consumption) was assessed at baseline and 6 months. Fatigue, quality of life, and physical activity levels were additionally assessed at 3 months.

RESULTS

In total, 59 patients (33 in IG vs. 26 in CG) were enrolled into this study. Eighteen patients (9 in IG vs. 9 in CG) dropped out of the study prior to the 6-month follow-up. Significant improvements in cardiorespiratory fitness (p = .002) and selected patient-reported health outcomes, such as reduced motivation (p = .015) and mental fatigue (p = .018), were observed in the IG when compared to the CG.

CONCLUSION

To our knowledge, this is the first study to investigate the effects of a supervised aerobic exercise program in colorectal cancer patients undergoing adjuvant chemotherapy. The significant and clinically meaningful improvements in CRF warrant further randomized controlled trials to confirm these findings.

TRIALS REGISTRATION

German Clinical Trials Register Identifier: DRKS00005793, 11/03/2014, retrospectively registered.

A Randomized Controlled Pilot Trial About the Influence of Kyusho Jitsu Exercise on Self-efficacy, Fear, Depression, and Distress of Breast Cancer Patients within Follow-up Care

Introduction

Breast cancer survivors are faced with several psychological issues. We report the influence on self-efficacy by a holistic orientated training schedule based on the “Kyusho Jitsu” martial art and explore the effects on self-efficacy, distress, fear, and depression.

Methods

Breast cancer survivors (N = 51) were randomly assigned to an intervention (n = 30) or control group (n = 21). The intervention group participated in a Kyusho Jitsu intervention twice a week over a period of 6 months, the control group received no intervention. Patients from both groups were measured at baseline, 3 and 6 months on level of self-efficacy (German General-Self-Efficacy Scale, SWE), stress (Perceived Stress Questionnaire, PSQ20), and fear and depression (Hospital Anxiety and Depression Scale, HADS).

Results

Analysis of the original data showed a significant difference between both groups regarding the subscale “joy” (P = .018). Several significant results within the intervention group were seen in self-efficacy (P = .014), fear (P = .009) and the overall score for fear and depression (P = .043). Both groups improved significantly within “worries” (intervention P = .006, control P = .019) and the PSQ20 overall score (both P = .005). The control group also significantly improved in the subscale for “demands” (P = .019).

Conclusion

To summarize, our pilot study showed that Kyusho Jitsu training is safe and feasible. Though, the intervention alone cannot be considered as being effective enough to help breast cancer survivors regarding relevant psychological issues, but might be an important supplement offer within follow-up care.

Supervised pelvic floor muscle exercise is more effective than unsupervised pelvic floor muscle exercise at improving urinary incontinence in prostate cancer patients following radical prostatectomy - a systematic review and meta-analysis

BACKGROUND

Urinary incontinence is one of the most clinically relevant side effects in the treatment of prostate cancer patients. The aim of this systematic review and meta-analysis was to analyze the specific exercise effects of supervised versus unsupervised pelvic floor muscle exercise (PFME) and exercise volume on urinary incontinence status after radical prostatectomy.

METHODS

A systematic data search was performed for studies published from January 2000 to December 2020 using the following databases: PubMed, Embase, SciSearch, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews and Effects. The review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A random-effects meta-analysis of urinary incontinence remission was performed. The relation between time since surgery and urinary incontinence remission was analyzed using a non-linear dose-response meta-analysis.

RESULTS

The meta-analysis included 20 randomized controlled trials involving 2188 men (n = 1105 in intervention groups; n = 1083 in control groups). PFME versus no PFME had a beneficial effect on urinary incontinence remission at 3 months, 3-6 months, and more than 6 months post-surgery, with risk differences ranging from 12 to 25%. These effects were particularly evident for higher volume, supervised PFME in the first 6 months post-surgery. Additional biofeedback therapy appeared to be beneficial but only during the first 3 months post-surgery.

CONCLUSIONS

There is good evidence that the supervised PFME causes a decrease in short-term urinary incontinence rates. Unsupervised PFME has similar effects as no PFME in postoperative urinary incontinence. PFME programs should be implemented as an early rehabilitative measure to improve postoperative short-term urinary incontinence in patients with prostate cancer.IMPLICATIONS FOR REHABILITATIONProstate cancer, surgery, and urinary incontinenceThe surgical treatment of prostate cancer often leads to urinary incontinence.Pelvic floor training leads to a significant improvement of this situation.Exercise therapy support is very important in this context and is even more effective than unsupported training.

Efficacy of face-to-face behavior change counseling interventions on physical activity behavior in cancer survivors - a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis of randomized controlled trials determines the efficacy of face-to-face behavior change counseling (BCC) interventions on physical activity (PA) behavior in adult cancer survivors at least pre-and immediately post-intervention compared to usual care. Additionally, this review aims to answer the question which behavior change techniques (BCTs) are most effective.

MATERIALS AND METHODS

A structured search of the databases Medline, OTseeker, PEDro, the Cochrane Library, and article reference lists was conducted. All trials were critically appraised for methodological quality using the PEDro scale. The BCC interventions were coded using the BCT Taxonomy (v1). Random effect meta-analysis explored between group differences in PA behavior post intervention. Standardized mean differences (SMD) describe effect sizes.

RESULTS

Fourteen studies were included, 12 effect sizes within 11 trials were pooled in meta-analysis. The SMD between groups favored the intervention group with a small effect (SMD 0.22; 95% CI 0.11, 0.33; p < 0.0001). The BCTs "graded tasks", "self-monitoring of behavior", "action planning" and "habit reversal" were more frequently coded in more efficacious interventions.

CONCLUSION

BCC interventions are effective in increasing PA behavior in cancer survivors. Further research is needed providing details of fidelity assessment and structuring the intervention description by using a BCT taxonomy. Health care professionals should consider our results while awaiting further trial evaluation.Implications for RehabilitationFace-to-face behavior change counseling interventions can significantly increase physical activity behavior in cancer survivors.Although small differences are evident, included trials presented with a broad variety of study components, and characteristics, which limits the interpretation of effective components.The behavior change techniques "Graded tasks", "Action planning", "Habit reversal", and "Credible Source" were used in the trials with a positive effect, but not in the ineffective ones.

Impact of whole-body vibration exercise on physical performance and bone turnover in patients with monoclonal gammopathy of undetermined significance

OBJECTIVE

Monoclonal Gammopathy of Undetermined Significance (MGUS) is a risk factor for reduced physical performance, osteoporosis, and fractures due to compromised musculoskeletal metabolism. In this condition it is unknown whether whole-body vibration (WBV) exercise favorably alters physical performance and bone metabolism.

METHODS

To evaluate the effect of three-months WBV exercise (30 min; 2x/week) including an optional three-month extension on physical performance, bone metabolism and bone mineral density. Endpoints included functional assessments, bone turnover markers and bone mineral density assessed by peripheral quantitative computed tomography of the tibia.

RESULTS

Fifteen MGUS patients (median age 62.0, nine female) completed the first three months of which ten completed the three-month extension. Measures of physical functioning including chair rise test, timed up and go and 6-minute walk test improved (p = 0.007; p = 0.009; p = 0.005) after three and six months of WBV exercise. Total tibial bone mineral density remained unaltered (p > 0.05). WBV exercise tended to increase levels of sclerostin (p = 0.093) with a transient increase in osteoclast resorption markers (N-terminal telopeptide of collagen type 1, tartrate resistant acid phosphatase 5b) after three months while Dickkopf-1 (p = 0.093), procollagen I N-terminal propeptide (p = 0.074) and total alkaline phosphatase (p = 0.016) appeared to decline. No exercise-related adverse events were reported.

CONCLUSION

WBV exercise in MGUS patients improves indicators of physical performance. Observed trends in bone turnover markers and changes in distal tibial bone mineral density may indicate a regulatory effect of WBV exercise on bone metabolism and warrants further evaluation by large scale studies.

[From the Oncological Rehabilitation Clinic to the Place of Residence - Interface Analysis Considering Exercise Intervention]

PURPOSE

This study analyzes the transfer of knowledge and information of exercise and physical activity after cancer therapy in rehabilitation clinics and rehabilitative cancer sports groups in Germany. Moreover, the way of referral into rehabilitative cancer sports groups is evaluated. A possible cooperation between rehabilitation clinics and rehabilitative cancer sports groups is also examined.

METHODS

A survey concept including 2 successive cross sectional analyses was applied using self-designed questionnaires. According to defined inclusion criteria oncological rehabilitation clinics were selected for the first survey (2015). Based on the results, the second survey (2018) was conducted within rehabilitative cancer sports groups using an online survey.

RESULTS

33 rehabilitation clinics with 44,828 patients treated (in 2014) as well as 126 cancer sports groups with 1,896 rehabilitative cancer sports group participants were included. 99% of patients in rehabilitation clinics had been informed about exercise and physical activity in the aftercare. 18% of the rehabilitative cancer sports groups were cooperating/in contact with oncological rehabilitation clinics, while 57% of the rehabilitation clinics provided contact information of the rehabilitation sports groups leaders at the patients' hometown. 78% of rehabilitation clinic patients received individual exercise recommendations for home-based exercise, while only 23% of the rehabilitative cancer sports groups participants' had received those recommendations prior to participation in this groups, according to the cancer sports group leaders.

CONCLUSION

The results are diverse: The rehabilitative cancer sports groups participants present a lower level of information and opposing prescriptions compared to the patients in rehabilitation clinics, according to the responding clinics and groups. This could be due to the fact that most patients are referred to rehabilitative cancer sports groups by specialists and general practitioners, and only few of them attended a rehabilitation clinic before, where comprehensive information is available. The implementation of a nationwide network including rehabilitative cancer sports groups, rehabilitation clinics and specialists/general practitioners could optimize cancer care in terms of quality as well as quantity.

Benefits of Exercise Training for Children and Adolescents Undergoing Cancer Treatment: Results From the Randomized Controlled MUCKI Trial

Objective: In cancer patients, the impairment in muscle function is a frequently observed phenomenon. However, comprehensive evaluation of the effect of exercise training on muscle function in childhood cancer patients (CCPs) is sparse and therefore investigated in the MUCKI trial. Study Design: In the randomized controlled MUCKI trial, CCPs during intensive cancer treatment and aged 4-18 years were recruited. Eligible patients were enrolled soon after diagnosis as long as they were physically and mentally able to participate in exercise testing and training. Patients of the exercise group (n = 16) participated in average 2.7 ± 1.2 times per week in a combined resistance and endurance training with moderate exercise intensity, for a time period of 8.0 ± 2.1 weeks, while patients of the control group (n = 17) received usual care. Leg strength was evaluated as the primary endpoint. Secondary endpoints were 6-min walk performance, arm strength, body composition, fatigue, and health-related quality of life. Results: Comparisons of pre- and post-intervention results were evaluated by baseline and stratification criteria adjusted analysis and showed positive effects for the exercise group regarding leg strength [F _{(1, 20)} = 5.733; p = 0.027^*; η p 2 = 0.223], walking performance [F _{(1, 25)} = 4.270; p = 0.049^*; η p 2 = 0.146], fatigue [F _{(1, 13)} = 8.353; p = 0.013^*; η p 2 = 0.391], self-esteem [F _{(1, 6)} = 6.823; p = 0.040^*; η p 2 = 0.532], and self-reported strength and endurance capacity [F _{(1, 6)} = 6.273; p = 0.046^*; η p 2 = 0.511]. No significant differences were found for the other parameters. Conclusion: Within one of the first randomized controlled trials, the present study provides evidence for a positive effect of combined training in CCPs during intensive cancer treatment. Further research is needed to confirm these results and to evaluate their clinical impact. Clinical Trial Registration Number: NCT02612025.

Exercise Preserves Physical Function in Prostate Cancer Patients with Bone Metastases

Purpose

The presence of bone metastases has excluded participation of cancer patients in exercise interventions and is a relative contraindication to supervised exercise in the community setting because of concerns of fragility fracture. We examined the efficacy and safety of a modular multimodal exercise program in prostate cancer patients with bone metastases.

Methods

Between 2012 and 2015, 57 prostate cancer patients (70.0 ± 8.4 yr; body mass index, 28.7 ± 4.0 kg·m⁻²) with bone metastases (pelvis, 75.4%; femur, 40.4%; rib/thoracic spine, 66.7%; lumbar spine, 43.9%; humerus, 24.6%; other sites, 70.2%) were randomized to multimodal supervised aerobic, resistance, and flexibility exercises undertaken thrice weekly (EX; n = 28) or usual care (CON; n = 29) for 3 months. Physical function subscale of the Medical Outcomes Study Short-Form 36 was the primary end point as an indicator of patient-rated physical functioning. Secondary end points included objective measures of physical function, lower body muscle strength, body composition, and fatigue. Safety was assessed by recording the incidence and severity of any adverse events, skeletal complications, and bone pain throughout the intervention.

Results

There was a significant difference between groups for self-reported physical functioning (3.2 points; 95% confidence interval, 0.4–6.0 points; P = 0.028) and lower body muscle strength (6.6 kg; 95% confidence interval, 0.6–12.7; P = 0.033) at 3 months favoring EX. However, there was no difference between groups for lean mass (P = 0.584), fat mass (P = 0.598), or fatigue (P = 0.964). There were no exercise-related adverse events or skeletal fractures and no differences in bone pain between EX and CON (P = 0.507).

Conclusions

Multimodal modular exercise in prostate cancer patients with bone metastases led to self-reported improvements in physical function and objectively measured lower body muscle strength with no skeletal complications or increased bone pain.

Trial Registration: ACTRN12611001158954.

Limited Walking Abilities and Impaired Ankle Dorsiflexion Function in Children After Intense Cancer Treatment

BACKGROUND

With improved survival rates in pediatric oncology, the detection of adverse side- and late-effects is gaining increased interest. This cross-sectional study investigated walking abilities and ankle dorsiflexion function in children with cancer.

PATIENTS

Study participants included 16 children with various cancers (4-20 years, patient group) after completion of the intense treatment and 16 age- and gender-matched healthy peers (comparison group).

METHOD

Walking speed (10-meter-walking-test, treadmill test assessing preferred transition speed), walking capacity (2-minute-walk-test), walking balance (Timed-Up-And-Go-Test), active/passive ankle dorsiflexion range of motion (ROM) (goniometer) and ankle dorsiflexion strength (hand-held dynamometer) were comprehensively assessed.

RESULTS

Significant lower values in the patient group were found for walking capacity, maximum walking speed, ankle dorsiflexion ROM and strength. No significant differences between the groups were found for preferred walking speed and walking balance.

DISCUSSION

Limited walking abilities and ankle dorsiflexion dysfunctions are prominent in children with cancer; having the potential to impact children's community mobility and physical activity.

CONCLUSIONS

To provide holistic care, the development of specific supportive strategies such as exercise interventions and its translation into clinical practice needs to be accelerated.

Sensorimotor training and whole-body vibration training have the potential to reduce motor and sensory symptoms of chemotherapy-induced peripheral neuropathy-a randomized controlled pilot trial

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent and clinically relevant side effect of chemotherapy. The symptoms diminish patients' quality of life and represent a decisive limiting factor for medical therapy. To date, effective treatment options are lacking. Specific exercise interventions have proven promising to target relevant symptoms. We conducted a prospective, four-armed, randomized, controlled trial, to evaluate the effects of sensorimotor training (SMT) and whole-body vibration training (WBV) on patients with CIPN. Participants (N = 40) were randomized to either one of two intervention groups (SMT N = 10 or WBV N = 10) or oncological control group (N = 10) and matched by gender and age with a healthy control (N = 10). The intervention groups exercised twice a week for 6 weeks. Primary endpoint was the reduction of CIPN-related symptoms (improve peripheral deep sensitivity, Achilles tendon reflex (ASR) and patellar tendon reflex (PSR), light-touch perception, sense of position, and lower leg strength). Secondary endpoints were nerve conduction velocity and amplitude, balance control, quality of life, and CIPN-related pain. Patients exercising improved sensory and associated motor symptoms. Significant intergroup differences were found for the tendon reflexes (ASR P = .017 and PSR P = .020), peripheral deep sensitivity (P = .010), and pain (P = .043). Furthermore, tendencies were found regarding the subjective improvement of symptoms (P = .075) and two subscales of the EORTC-QLQ-C30 questionnaire: pain (P = .054) and dyspnea (P = .054). The results for the SMT group were superior regarding the tendon reflexes, and a tendency regarding the subjective report of symptoms, while WBV was superior regarding pain. SMT and WBV behold a large potential to reduce CIPN-related symptoms and can be considered feasible and safe for patients with CIPN (compliance 97.5%, no adverse events).Registration: DRKS00013027.

Effects of Kyusho Jitsu on Physical Activity-levels and Quality of Life in Breast Cancer Patients

BACKGROUND/AIM

Breast cancer survivors often report a decrease in physical activity levels and quality of life. The aim of this study was to explore whether a "Kyusho Jitsu" martial arts intervention is feasible and can improve general well-being and physical activity levels in breast cancer survivors.

MATERIALS AND METHODS

Breast cancer survivors (N=51) were randomly assigned to the intervention or control group. The intervention group participated in a 24-week Kyusho Jitsu intervention. Both groups were assessed at baseline, 3, and 6 months.

RESULTS

Analysis of original data showed several significant improvements in favor of the intervention group, but also some of the control group. Sensitivity analysis supports these findings. No adverse events were observed.

CONCLUSION

To our knowledge this is the first study showing that a holistic Kyusho Jitsu martial arts intervention can be feasible and effective for breast cancer survivors.

Does Exercise Have a Preventive Effect on Secondary Lymphedema in Breast Cancer Patients Following Local Treatment? - A Systematic Review

Background

Secondary lymphedema (SL) is a possible side effect of breast cancer treatment. Current data describe a positive influence of exercise on upper lymphedema. This systematic review evaluates studies examining a potential preventive effect of exercise on SL incidence.

Methods

A systematic literature search of PubMed, LIVIVO, and the Cochrane Library was performed.

Results

8 randomized controlled trials were included in the review. 3 studies investigated the effect of strength training, and 5 the effect of combined exercise therapy. 5 studies included participants without lymphedema at study entry, and 3 studies included both patients with and without lymphedema. The partly significant results showed that progressive strength training as well as combined dynamic exercise therapies consisting of physiotherapy, physical therapy, and/or kinesiotherapy are safe and can prevent SL. Onset as well as diagnosis of lymphedema were significantly decreased in 5 studies in the exercise group.

Conclusion

All 8 studies included indicate a potential preventive effect of exercise on SL; however, further research is needed.

Physical Activity, Exercise and Breast Cancer - What Is the Evidence for Rehabilitation, Aftercare, and Survival? A Review

The current scientific field of exercise interventions in breast cancer is very large. Rehabilitation focuses on restoring or improving quality of life and thus on independence and participation in life. Hence, it is important to investigate exercise interventions in the setting of rehabilitation and aftercare. It is also necessary to determine the influence of physical activity or exercise therapy on the prevention of recurrence and mortality as well as on certain side effects of the disease and its medical treatment in rehabilitation. Physical activity in rehabilitation and aftercare is feasible and safe and can be used for various purposes. Against the background of reduced fatigue, chemotherapy-induced peripheral neuropathy, cancer-related cognitive impairment, arthralgia, lymphedema, recurrence, and mortality, as well as improved quality of life, different methodological approaches and evidence can be seen. Although the overall data availability has increased, there are gaps in study documentation as well as inadequate verification of scientific approaches in rehabilitation clinics and in everyday life.

Effects of physical exercise on breast cancer-related secondary lymphedema: a systematic review

PURPOSE

The aim of this systematic review is to assess the effect of different types of exercise on breast cancer-related lymphedema (BCRL) in order to elucidate the role of exercise in this patient group.

METHODS

A systematic data search was performed using PubMed (December 2016). The review is focused on the rehabilitative aspect of BCRL and undertaken according to the PRISMA statement with Levels of Evidence (LoE) assessed.

RESULTS

11 randomized controlled trials (9 with LoE 1a and 2 with LoE 1b) that included 458 women with breast cancer in aftercare were included. The different types of exercise consisted of aqua lymph training, swimming, resistance exercise, yoga, aerobic, and gravity-resistive exercise. Four of the studies measured a significant reduction in BCRL status based on arm volume and seven studies reported significant subjective improvements. No study showed adverse effects of exercise on BCRL.

CONCLUSION

The evidence indicates that exercise can improve subjective and objective parameters in BCRL patients, with dynamic, moderate, and high-frequency exercise appearing to provide the most positive effects.

The preventive effect of sensorimotor- and vibration exercises on the onset of Oxaliplatin- or vinca-alkaloid induced peripheral neuropathies - STOP

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and clinically relevant side effect of chemotherapy. Approximately 50% of all leukemia, lymphoma, colorectal- and breast cancer patients are affected. CIPN is induced by neurotoxic chemotherapeutic agents and can manifest with sensory and/or motor deficits. It is associated with significant disability and poor recovery. Common symptoms include pain, altered sensation, reduced or absent reflexes, muscle weakness, reduced balance control and insecure gait. These symptoms not only affect activities of daily living, subsequently reducing patients' quality of life, they have far more become a decisive limiting factor for medical therapy, causing treatment delays, dose reductions, or even discontinuation of therapy, which can affect the outcome and compromise survival. To date, CIPN cannot be prevented and its occurrence presents a diagnostic dilemma since approved and effective treatment options are lacking. Promising results have recently been achieved with exercise. We have revealed that sensorimotor training (SMT) or whole body vibration (WBV) can reduce the symptoms of CIPN and attenuate motor and sensory deficits. We furthermore detected a tendency that it may also have a preventive effect on the onset of CIPN.

METHODS

We are therefore conducting a prospective, multicentre, controlled clinical trial involving 236 oncological patients receiving either oxaliplatin (N = 118) or vinca-alkaloid (N = 118) who are randomized to one of two interventions (SMT or WBV) or a treatment as usual (TAU) group. Primary endpoint is the time to incidence of neurologically confirmed CIPN. Secondary endpoints are pain, maintenance of the functionality of sensory as well as motor nerve fibres as well as the level of physical activity. The baseline assessment is performed prior to the first cycle of chemotherapy. Subsequent follow-up assessments are conducted at 12 weeks, after completion of chemotherapy, and at a 3-month follow-up. Patients who develop CIPN receive an additional assessment at this time point, as it represents the primary endpoint.

DISCUSSION

We hypothesize that SMT and WBV prevent the onset or delay the progression of CIPN, decrease the likelihood of dose reductions or discontinuation of cancer treatment and improve patients' quality of life.

TRIAL REGISTRATION

Deutsche Register Klinischer Studien ( DRKS00006088 , registered 07.05.2014).

Exercise interventions for patients with pediatric cancer during inpatient acute care: A systematic review of literature

Physical inactivity has been shown to exacerbate negative side effects experienced by pediatric patients undergoing cancer therapy. Exercise interventions are being created in response. This review summarizes current exercise intervention data in the inpatient pediatric oncology setting. Two independent reviewers collected literature from three databases, and analyzed data following the PRISMA statement for systematic reviews and meta-analyses. Ten studies were included, representing 204 patients. Good adherence, positive trends in health status, and no adverse events were noted. Common strategies included individual, supervised, combination training with adaptability to meet fluctuating patient abilities. We recommend that general physical activity programming be offered to pediatric oncology inpatients.

Influence of Personalized Exercise Recommendations During Rehabilitation on the Sustainability of Objectively Measured Physical Activity Levels, Fatigue, and Fatigue-Related Biomarkers in Patients With Breast Cancer

Purpose. Only one-third of patients with breast cancer reach the recommended activity level of 15 to 25 MET h/wk. The aim of this study was to determine the influence of personalized exercise recommendations during rehabilitation on patients’ physical activity level, fatigue, and self-perceived cognitive function as well as on side effect–associated biomarkers. Methods. Total metabolic rate, physical activity level, mean MET and steps, fatigue, self-perceived cognitive functioning , and biomarkers (C-reactive protein [CRP], interleukin 6, macrophage migration inhibiting factor [MIF], tumor necrosis factor [TNF]-α, brain-derived neurotrophic factor [BDNF], insulin-like growth factor 1 [IGF1]) were assessed in 60 patients with breast cancer in the aftercare phase before (t₀) and 8 months after (t₁) the intervention. The rehabilitation program consisted of an initial 3-week period and a 1-week stay after 4 months. Results. Paired t-test indicated a statistically significant increase in all activity outcomes from t₀ to t₁. Patients’ mean activity level significantly increased from 14.89 to 17.88 MET h/wk. Fatigue and self-perceived cognitive functioning significantly improved from t₀ to t₁. CRP levels significantly decreased, and BDNF as well as IGF1 levels significantly increased over time. Correlation analysis revealed statistically significant negative associations between fatigue, physical activity, and markers of inflammation (TNF-α and MIF). Furthermore, significant positive correlations between subjective cognitive functioning and all dimensions of fatigue were observed. Conclusions. The results support the importance of personalized exercise recommendations to increase physical activity levels in patients with breast cancer. Furthermore, the results highlighti an association between physical activity, fatigue, and inflammation.

[Effects of a Four-Week Rehabilitation Program on Motor Performance, Quality of Life and Fatigue in Childhood Cancer Patients and Healthy Siblings]

Aim In Germany all childhood cancer patients and their families are offered the opportunity to participate in a four-week, family-oriented, inpatient rehabilitation program in order to facilitate (re-)integration into everyday life. The aim of this study is to evaluate the effect of this rehabilitation program on motor performance, quality of life (QoL) and fatigue. Methods Motor performance, QoL and fatigue were assessed in 22 childhood cancer patients and 20 healthy siblings at the beginning (t1) and the end (t2) of the four-week rehabilitation program, as well as 6 months later (t3). Results At t1 significant differences between groups were found in motor performance and physical well-being. Improvements in motor performance, QoL and fatigue were found in both groups. Conclusion Different preconditions must be considered. Childhood cancer patients as well as healthy siblings benefit from a family-oriented rehabilitation program.

Associations between aerobic exercise levels and physical and mental health outcomes in men with bone metastatic prostate cancer: a cross-sectional investigation

Cancer patients with bone metastases have previously been excluded from participation in physical activity programmes due to concerns of skeletal fractures. Our aim was to provide initial information on the association between physical activity levels and physical and mental health outcomes in prostate cancer patients with bone metastases. Between 2012 and 2015, 55 prostate cancer patients (mean age 69.7 ± 8.3; BMI 28.6 ± 4.0) with bone metastases (58.2% >2 regions affected) undertook assessments for self-reported physical activity, physical and mental health outcomes (SF-36), objective physical performance measures and body composition by DXA. Sixteen men (29%) met the current aerobic exercise guidelines for cancer survivors, while 39 (71%) reported lower aerobic exercise levels. Men not meeting aerobic exercise guidelines had lower physical functioning (p = .004), role functioning (physical and emotional) (p < .05), general health scores (p = .014) as well all lower measures of physical performance (p < .05). Lower levels of aerobic exercise are associated with reduced physical and mental health outcomes in prostate cancer patients with bone metastases. While previous research has focused primarily in those with non-metastatic disease, our initial results suggest that higher levels of aerobic exercise may preserve physical and mental health outcomes in prostate cancer patients with bone metastases. Clinical Trial Registry: Trial Registration: ACTRN12611001158954.

Effects of a 6-Month, Group-Based, Therapeutic Exercise Program for Childhood Cancer Outpatients on Motor Performance, Level of Activity, and Quality of Life

BACKGROUND

Exercise interventions in pediatric oncology are feasible and safe. However, scarce data are available with regard to the effectiveness of outpatient, group-based exercise interventions. As well, the potential role of exercise to improve motor performance has not been adequately explored despite being a meaningful outcome during childhood with important implications for physical activity behavior. No study has yet demonstrated significant changes in motor performance after an exercise intervention.

PROCEDURES

This explorative, prospective study was designed to evaluate the effects of a 6-month, group-based, therapeutic exercise program for a mixed childhood cancer population on motor performance, level of activity, and quality of life. After cessation of inpatient medical treatment, childhood cancer outpatients aged 4-17 years exercised once a week during a 6-month period (IG). Comparison groups included childhood cancer outpatients receiving care as usual (CG(1)), as well as healthy peers (matched to IG by age and gender) (CG(2)).

RESULTS

Overall motor performance, various motor dimensions, activity in sport clubs and school sports, as well as physical and emotional well-being were significantly reduced in the IG at baseline. Significant differences between the IG and CG(1) and/or CG(2) were identified in the change of overall motor performance, single motor dimensions, overall level of activity, and emotional well-being from baseline to post-intervention.

CONCLUSIONS

The exercise intervention was beneficial in terms of motor performance, level of activity, and emotional well-being. As such, this study provides support for group-based exercise as a potential strategy to improve these outcomes after inpatient medical treatment.

Effects of a 15-Month Supervised Exercise Program on Physical and Psychological Outcomes in Prostate Cancer Patients Following Prostatectomy

Purpose. Despite advanced medical treatment options, many prostate cancer patients are still confronted with unfavorable physical and psychological burdens. Physical exercise has proven to be beneficial for prostate cancer patients, yet specific exercise offers are rare. The ProRehab Study aimed to evaluate the exercise program offered in rehabilitative prostate cancer sports groups in Germany and determine whether it is beneficial for patients following prostatectomy. Methods. Eighty-five prostate cancer patients were recruited for a multicenter, 2-armed, nonrandomized controlled trial 6 to 12 weeks after prostatectomy. The intervention group (n = 56) took part in a 15-month supervised multimodal exercise program. Exercise sessions took place once a week for 60 minutes at a moderate intensity (3.84-4.84 MET-hour). The control group (n = 29) received no intervention. Outcomes included aerobic fitness, activity levels, quality of life, disease- and treatment-related adverse effects, such as urinary incontinence and erectile dysfunction, and relapse-relevant blood values. Intention-to-treat analysis was performed. Results. A significant between-group difference was observed in the urinary symptom score ( P = .027). Physical fitness, urinary incontinence, physical, role, emotional, and social functioning, as well as further disease- and treatment-related side effects (dyspnea, urinary, and bowel symptoms) significantly improved within the intervention group. Erectile dysfunction and physical activity levels improved similarly in both groups. Conclusions. The presented data hint at the potential of rehabilitative sports groups for prostate cancer patients. However, according to the current state of the art, exercise intensity and volume may need to be increased to enhance the effects. A number of shorter studies (8-24 weeks) have proven significant between-group differences in quality of life, incontinence, and fitness outcomes when patients exercised 2 to 3 times per week. This is the first exercise intervention study with prostate cancer patients that was conducted over 15 months. Further studies are necessary to investigate whether prostate cancer patients recover sooner when receiving a supervised exercise program.

Impact of a half marathon on cellular immune system, pro-inflammatory cytokine levels, and recovery behavior of breast cancer patients in the aftercare compared to healthy controls

INTRODUCTION

Exercise has beneficial effects on cancer prevention as well as on prognosis of patients with cancer. To optimize the outcomes of exercise programs, more knowledge about the underlying mechanisms is needed. This study investigates the short-term effects of a half marathon on immune cell proportions, pro-inflammatory cytokine levels, and recovery behavior of patients with breast cancer in the aftercare compared to healthy controls.

METHODS

Nine patients with breast cancer in the aftercare and 9 healthy age-matched controls participated in a half marathon. Blood samples were collected before, after, and 24 h after the run. Immune status was measured by flow cytometer analysis, while serum levels of the pro-inflammatory cytokines TNF-α, IL-6, and MIF were assessed using ELISA. Recovery behavior was determined using an ADL monitor.

RESULTS

Both groups showed a similar recovery behavior and time courses in changes of granulocytes, monocytes, lymphocytes, and cytokine serum levels. Patients revealed increased proportions of cytotoxic and memory T cells, whereas helper and naïve T cells were decreased compared to healthy controls. Naïve and memory T-cell proportions were not affected by the intervention.

CONCLUSIONS

Patients with breast cancer in the aftercare and healthy subjects show a similarly recovery behavior and immune response to the intervention. The detected differences in T-cell subsets need further investigation. Based on the results of the study, we hypothesize that immune cell subsets with known relevance in cancer were mobilized through the intervention. We confirm that the hypothesis of a midterm anti-inflammatory effect of exercise is also valid for patients with breast cancer in the aftercare.

Impact of exercise on pro inflammatory cytokine levels and epigenetic modulations of tumor-competitive lymphocytes in Non-Hodgkin-Lymphoma patients-randomized controlled trial

INTRODUCTION

Physical activity is associated with decreased cancer (recurrence) risk and a reduction in treatment-specific side effects. Exercise modulates cytokine expression and shows beneficial effects on cancer patients' immune system. We investigated the following: (i) whether Non-Hodgkin-Lymphoma patients have increased serum macrophage migration inhibiting factor (MIF) and Interleukin-6 (IL-6) levels after immunochemotherapy; (ii) whether physical activity influences cytokine serum levels; and (iii) whether serum cytokine levels are associated with histone modifications in tumor-competitive immune cells.

METHODS

Thirty patients and 10 healthy controls were randomised into an intervention and a control group. Participants of the intervention group exercised once for 30 min at moderate intensity on a bicycle ergometer. Blood samples were collected twice, before and after the intervention. MIF and IL-6 serum concentrations were detected by ELISA. Natural killer cells and CD8(+) T-lymphocytes were isolated by magnetic labeled cell sorting. Isolated cells were stained and analyzed for global histone acetylation at histone 4, lysine 5 and histone three, lysine 9.

RESULTS

Patients showed higher serum MIF and IL-6 baseline levels, and reduced NK-cell histone acetylation, indicating a reduced transcriptional activity of tumor-competitive lymphocytes. Changes in MIF correlated with altered NK-cell histone acetylation, leading to the hypothesis that MIF impacts NK-cells via epigenetic modifications. Further, the exercise intervention was associated with an increase in IL-6 and CD8(+) T-lymphocyte histone acetylation.

CONCLUSIONS

We conclude that exercise induces changes in cytokine levels, thereby possibly affecting epigenetic patterns and activity of tumor-competitive lymphocytes.

Physical Activity in Breast Cancer Patients during Medical Treatment and in the Aftercare - a Review

Most scientific studies regarding physical activity in cancer patients involve breast cancer patients. It is apparent that physical activity during medical treatment and aftercare is not only feasible and safe but also effective. Current studies clearly show that regular and specific endurance and/or resistance training can reduce a number of side effects caused by medical treatment. Among others, improvements in physical performance, body composition, and quality of life as well as a reduction in fatigue, have been observed. Since inactivity appears to exacerbate lymphedema, patients with lymphedema are also encouraged to exercise. Few studies have been carried out regarding physical exercise in metastatic patients. However, experts in the field also recommend regular physical activity for patients with advanced-stage breast cancer.

[Physical activity and exercise recommendations for cancer patients during rehabilitation]

AIM OF THE WORK

Cancer and its commonly required continuous and intensive medical treatment have a profound and lasting effect on patients' physical, functional, emotional and social wellbeing. In this context the positive comprehensive effects of physical exercise interventions increasingly prove to be promising. The aim of this review is to derive physical exercise recommendations for patients with cancer, especially concerning aerobic and resistance training during rehabilitation, based on the current literature. In a second step the 3 main cancer types breast cancer, prostate cancer and colon cancer and their distinctive features will be addressed briefly.

METHODS

A hierarchic literature research was conducted using the medical information portal Medpilot. The evaluation system of the "European Society of Cardiology" was applied in order to evaluate the evidence and compile evidence-based exercise recommendations for patients with cancer.

RESULTS

When summing up the current data, physical exercise proves to be efficient, safe and feasible for patients with cancer. Both aerobic and resistance training have a positive influence on a patient's physical, psychological and social level and should therefore be included in every exercise program.

CONCLUSION

While the evidence for breast cancer and increasingly also for prostate cancer is strong, research in colon cancer, for example, is still sparse. In order to create precise recommendations regarding the ideal exercise type and dose for the different cancer types during various treatment phases further high quality studies are necessary.

Relationship between cancer-related fatigue and physical activity in inpatient cancer rehabilitation

BACKGROUND

Fatigue is a serious problem for the majority of patients with cancer. In this context, several studies have shown benefits of physical activity during and following treatment. However, uncertainties remain regarding the optimal type and duration of physical activity. Therefore, this study examined the relationship between cancer-related fatigue and physical activity in the course of inpatient rehabilitation.

PATIENTS AND METHODS

Fatigue (Multidimensional Fatigue Inventory) and physical activity (Freiburg Questionnaire of Physical Activity) were assessed in a consecutive series of 35 patients with cancer attending oncological inpatient rehabilitation during a six-month study period. The three-week rehabilitation program included daily exercise therapy consisting of aerobic endurance training, moderate resistance training, coordination exercises, relaxation training and individual physiotherapy.

RESULTS

At discharge, a significant improvement in each dimension of cancer-related fatigue (p=0.001-0.003) and a significant increase of physical activity levels (p=0.001) were observed. A small, but significant negative correlation was found between cancer-related fatigue and the level of physical activity (R=-0.438, p=0.004). The largest effects were associated with a weekly energy expenditure of 3000 kcal through physical activity.

CONCLUSION

The results support a non-linear dose-response relationship between cancer-related fatigue and physical activity. Since this is the first study providing specific exercise recommendations for an effective treatment of cancer-related fatigue in the context of inpatient rehabilitation, further research is required to validate the observed trends.

Influence of a six month endurance exercise program on the immune function of prostate cancer patients undergoing Antiandrogen- or Chemotherapy: design and rationale of the ProImmun study

BACKGROUND

Exercise seems to minimize prostate cancer specific mortality risk and treatment related side effects like fatigue and incontinence. However the influence of physical activity on the immunological level remains uncertain. Even prostate cancer patients undergoing palliative treatment often have a relatively long life span compared to other cancer entities. To optimize exercise programs and their outcomes it is essential to investigate the underlying mechanisms. Further, it is important to discriminate between different exercise protocols and therapy regimes.

METHODS/DESIGN

The ProImmun study is a prospective multicenter patient preference randomized controlled trial investigating the influence of a 24 week endurance exercise program in 80-100 prostate cancer patients by comparing patients undergoing Antiandrogen therapy combined with exercise (AE), Antiandrogen therapy without exercise (A), Chemotherapy with exercise(CE) or Chemotherapy without exercise (C). The primary outcome of the study is a change in prostate cancer relevant cytokines and hormones (IL-6, MIF, IGF-1, Testosterone). Secondary endpoints are immune cell ratios, oxidative stress and antioxidative capacity levels, VO2 peak, fatigue and quality of life. Patients of the intervention group exercise five times per week, while two sessions are supervised. During the supervised sessions patients (AE and CE) exercise for 33 minutes on a bicycle ergometer at 70-75% of their VO2 peak. To assess long term effects and sustainability of the intervention two follow-up assessments are arranged 12 and 18 month after the intervention.

DISCUSSION

The ProImmun study is the first trial which primarily investigates immunological effects of a six month endurance exercise program in prostate cancer patients during palliative care. Separating patients treated with Antiandrogen therapy from those who are additionally treated with Chemotherapy might allow a more specific view on the influence of endurance training interventions and the impact of different therapy protocols on the immune function.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00004739.

Specific deficit analyses in motor performance and quality of life of pediatric cancer patients--a cross-sectional pilot study

Although survival rates in childhood cancer have distinctly improved, pediatric cancer patients often experience various disease- and treatment-related side effects with long-term consequences. Despite current studies investigating inactivity and limitations in physical functioning and quality of life in pediatric cancer patients, only little information regarding specific deficits in physical functioning and quality of life has been available until now. No study has yet analyzed these parameters from a global perspective and then identified specific deficits in a mixed childhood cancer population. Within this cross-sectional pilot study, motor performance and quality of life of 26 pediatric cancer patients were assessed after inpatient medical treatment, using standardized motor test batteries (MOT 4-6; DMT 6-18) and a quality of life questionnaire (KINDL®). Reference data have been mainly provided by the German "Children and Young People Health Survey" (KiGGS). Patients achieved lower motor performance scores (p = .000) (more than 27% below the average of healthy peers). Specific deficits were identified in motor speed and motor control (4-6 years), as well as in endurance, strength and coordination under time pressure (6-17 years). In terms of quality of life, no significant differences were examined compared to healthy children of the same age. The results of this study confirm that children with oncological diseases frequently have specific motor problems. Future research in pediatric oncology must investigate the impact of targeted, individualized exercise interventions addressing these specific deficits.

Feasibility of an Isometric Maximal Voluntary Contraction Test in Hematological Cancer Patients during Thrombocytopenia

Introduction. Resistance training is rarely offered to hemato-oncological patients in the daily clinical routine due to its potential harmful impact on the cardiovascular system and the long periods of thrombocytopenia experienced by these patients. Therefore, it is important to determine a valid assessment to define and control resistance training. In this study, the feasibility of a maximal voluntary contraction (MVC) test was investigated in hemato-oncological patients. This inexpensive assessment may be a practicable alternative to the one repetition maximum test which is currently described as the gold standard. Methods. 29 hemato-oncological patients with platelet counts between 30000/μL and 70000/μL were recruited for this pilot study. Complications like petechial bleedings, muscle convulsion, and pain were assessed using the Brief Pain Inventory before and 48 hours after the MVC test, which was performed unidirectionally for the quadriceps muscle. Results. We did not detect any statistically significant test-related exacerbations or pain development. Discussion. MVC testing seems to be a feasible method to control a resistance training program in hemato-oncological patients. Further studies need to extend their methods and, for example, compare the MVC test with the one repetition maximum test.

Role of physical activity in tumor patients and possible underlying mechanisms

A growing knowledge regarding the influence of exercise on adverse physiologic outcomes associated with cancer and its treatment exists. Aside from its effects on psychological behavior, quality of life, and cancer-related fatigue, physical exercise can target physical and cardio-respiratory fitness, insulin regulation and metabolic syndrome, body weight and composition, and immune function in tumor patients. The increasing number of study results for different cancer types, which prove the positive influences of physical activity in cancer patients, changed the contradictory opinions which existed until the end of the last century. Although an increasing number of studies showing the positive effects of physical activity and more specifically of endurance and resistance training in cancer patients have been published, the underlying mechanisms are mostly unknown. Thus, we summarized the current knowledge of the effects of physical activity and specific training in different tumor entities with specific respect to the possible underlying mechanisms. Especially, the association between physical activity and (1) the improvement of fatigue and the role of free radicals in this process, (2) the counterbalance of tumor-induced cachexia, (3) the improvement of the immune system for supportive tumor treatment, and (4) the possible role of epigenetic modulation against tumor and tumor treatment-dependent adverse physiologic outcomes is focused.

Influence of endurance exercise on the risk of pneumonia and Fever in leukemia and lymphoma patients undergoing high dose chemotherapy. A pilot study

Pneumonia and fever are common side effects of high dose chemotherapy (HDC). The positive influence of physical activity on physiological and psychological parameters in cancer patients has been demonstrated in several studies. In this non-randomized controlled pilot study we investigated the infection and pneumonia risk in 36 high dose chemotherapy patients undergoing a supervised endurance exercise program. 18 patients exercised for at least 3 weeks, starting with initiation of chemotherapy. These patients in the intervention group were compared with 18 patients who were matched by disease (leukemia/lymphoma), sex, age, risk factors, therapy protocols and did not take part in the exercise intervention. Leukemia and lymphoma groups were evaluated separately. In the leukemia group significant higher pneumonia rates could be observed in the control group (p = 0.040) when compared to the intervention group. Further an almost significantly higher risk (p = 0.061) of developing a pneumonia and fever was detected in the control group. In this pilot study, we gained first important positive experiences in possibly preventing pneumonias and fever through endurance training. Due to the non-randomized study design and small sample size the results are limited yet not irrelevant. RCTs with larger sample sizes are necessary to prove these findings.