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Koevoets EW, Petr J, Monninkhof EM, Geerlings MI, Witlox L, van der Wall E, Stuiver MM, Sonke GS, Velthuis MJ, Jobsen JJ, van der Palen J, Mutsaerts HJMM, de Ruiter MB, May AM, Schagen SB. Effect of Physical Exercise on MRI-Assessed Brain Perfusion in Chemotherapy-Treated Breast Cancer Patients: A Randomized Controlled Trial. J Magn Reson Imaging 2024; 59:1667-1680. [PMID: 37801027 DOI: 10.1002/jmri.28967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Exercise is a promising intervention to alleviate cognitive problems in breast cancer patients, but studies on mechanisms underlying these effects are lacking. PURPOSE Investigating whether an exercise intervention can affect cerebral blood flow (CBF) in cognitively impaired breast cancer patients and to determine if CBF changes relate to memory function. STUDY TYPE Prospective. POPULATION A total of 181 chemotherapy-treated stage I-III breast cancer patients with cognitive problems and relatively low physical activity levels (≤150 minutes moderate to vigorous physical activity per week), divided into an exercise (N = 91) or control group (N = 90). FIELD STRENGTH/SEQUENCE Two-dimensional echo planar pseudo-continuous arterial spin labeling CBF sequence at 3 T. ASSESSMENT The 6-month long intervention consisted of (supervised) aerobic and strength training, 4 × 1 hour/week. Measurements at baseline (2-4 years post-diagnosis) and after 6 months included gray matter CBF in the whole brain, hippocampus, anterior cingulate cortex, and posterior cingulate cortex. Physical fitness and memory function were also assessed. Subgroup analyses were performed in patients with high fatigue levels at baseline. STATISTICAL TESTS Multiple regression analyses with a two-sided alpha of 0.05 for all analyses. RESULTS There was a significant improvement in physical fitness (VO2peak in mL/minute/kg) in the intervention group (N = 53) compared to controls (N = 51, β = 1.47 mL/minute/kg, 95% CI: 0.44-2.50). However, no intervention effects on CBF were found (eg, whole brain: P = 0.565). Highly fatigued patients showed larger but insignificant treatment effects on CBF (eg, whole brain: P = 0.098). Additionally, irrespective of group, a change in physical fitness was positively associated with changes in CBF (eg, whole brain: β = 0.75, 95% CI: 0.07-1.43). There was no significant relation between CBF changes and changes in memory performance. DATA CONCLUSION The exercise intervention did not affect CBF of cognitively affected breast cancer patients. A change in physical fitness was associated with changes in CBF, but changes in CBF were not associated with memory functioning. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 5.
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Affiliation(s)
- Emmie W Koevoets
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan Petr
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mirjam I Geerlings
- Department of General Practice, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging & Later Life and Personalized Medicine, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration and Mood, Anxiety, Psychosis, Stress, and Sleep, Amsterdam, The Netherlands
| | - Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martijn M Stuiver
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Jan J Jobsen
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
- Section Cognition, Data and Education, Universiteit Twente, Enschede, The Netherlands
| | - Henk J M M Mutsaerts
- Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Brain Imaging, Amsterdam, The Netherlands
| | - Michiel B de Ruiter
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sanne B Schagen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Brain and Cognition Group, University of Amsterdam, Amsterdam, The Netherlands
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2
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Hiensch AE, Beckhaus J, Witlox L, Monninkhof EM, Schagen SB, van Vulpen JK, Sweegers MG, Newton RU, Aaronson NK, Galvão DA, Steindorf K, Stuiver MM, Mesters I, Knoop H, Goedendorp MM, Bohus M, Thorsen L, Schulz KH, Schmidt ME, Ulrich CM, Sonke GS, van Harten WH, Winters-Stone KM, Velthuis MJ, Taaffe DR, van Mechelen W, Kersten MJ, Nollet F, Wiskemann J, Buffart LM, May AM. Moderators of exercise effects on self-reported cognitive functioning in cancer survivors: an individual participant data meta-analysis. J Cancer Surviv 2023:10.1007/s11764-023-01392-3. [PMID: 37160571 DOI: 10.1007/s11764-023-01392-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE This individual participant data meta-analysis (IPD-MA) assesses exercise effects on self-reported cognitive functioning (CF) and investigates whether effects differ by patient-, intervention-, and exercise-related characteristics. METHODS IPD from 16 exercise RCTs, including 1987 patients across multiple types of non-metastatic cancer, was pooled. A one-stage IPD-MA using linear mixed-effect models was performed to assess exercise effects on self-reported CF (z-score) and to identify whether the effect was moderated by sociodemographic, clinical, intervention- and exercise-related characteristics, or fatigue, depression, anxiety, and self-reported CF levels at start of the intervention (i.e., baseline). Models were adjusted for baseline CF and included a random intercept at study level to account for clustering of patients within studies. A sensitivity analysis was performed in patients who reported cognitive problems at baseline. RESULTS Minimal significant beneficial exercise effects on self-reported CF (β=-0.09 [-0.16; -0.02]) were observed, with slightly larger effects when the intervention was delivered post-treatment (n=745, β=-0.13 [-0.24; -0.02]), and no significant effect during cancer treatment (n=1,162, β=-0.08 [-0.18; 0.02]). Larger effects were observed in interventions of 12 weeks or shorter (β=-0.14 [-0.25; -0.04]) or 24 weeks or longer (β=-0.18 [-0.32; -0.02]), whereas no effects were observed in interventions of 12-24 weeks (β=0.01 [-0.13; 0.15]). Exercise interventions were most beneficial when provided to patients without anxiety symptoms (β=-0.10 [-0.19; -0.02]) or after completion of treatment in patients with cognitive problems (β=-0.19 [-0.31; -0.06]). No other significant moderators were identified. CONCLUSIONS This cross-cancer IPD meta-analysis observed small beneficial exercise effects on self-reported CF when the intervention was delivered post-treatment, especially in patients who reported cognitive problems at baseline. IMPLICATIONS FOR CANCER SURVIVORS This study provides some evidence to support the prescription of exercise to improve cognitive functioning. Sufficiently powered trials are warranted to make more definitive recommendations and include these in the exercise guidelines for cancer survivors.
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Affiliation(s)
- Anouk E Hiensch
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Julia Beckhaus
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sanne B Schagen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jonna K van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maike G Sweegers
- Division of Psychosocial Research and Epidemiology & Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
| | - Karen Steindorf
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Martijn M Stuiver
- Division of Psychosocial Research and Epidemiology & Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ilse Mesters
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Martine M Goedendorp
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Martin Bohus
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health, Mannheim, Heidelberg University, Heidelberg, Germany
- Faculty of Health, University of Antwerp, Antwerp, Belgium
| | - Lene Thorsen
- National Advisory Unit on Late Effects after Cancer, Department of Oncology, Oslo University Hospital, Oslo, Norway
- Department of Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Karl-Heinz Schulz
- Athleticum - Competence Center for Sports- and Exercise Medicine and Institute for Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina E Schmidt
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Cornelia M Ulrich
- Huntsman Cancer Institute and Department of Population Health Sciences, University of Utah, Salt Lake City, USA
| | - Gabe S Sonke
- Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Kerri M Winters-Stone
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Miranda J Velthuis
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
| | - Willem van Mechelen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, location: Vrije Universiteit, Amsterdam, The Netherlands
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Australia
- Division of Exercise Science and Sports Medicine (ESSM), Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Public Health, Physiotherapy and Population Sciences, University College Dublin, Dublin, Ireland
| | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Centers, Location University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frans Nollet
- Department of Rehabilitation Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
| | - Joachim Wiskemann
- Working Group Exercise Oncology, Division of Medical Oncology, University Clinic Heidelberg and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laurien M Buffart
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia.
- Department of Physiology, Radboudumc, Nijmegen, The Netherlands.
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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van Vulpen JK, Witlox L, Methorst-de Haan AC, Hiensch AE, van Hillegersberg R, Ruurda JP, Nieuwenhuijzen GAP, Kouwenhoven EA, Siersema PD, May AM. Perceived facilitators and barriers by esophageal cancer survivors participating in a post-treatment exercise program. Support Care Cancer 2023; 31:320. [PMID: 37148366 PMCID: PMC10164010 DOI: 10.1007/s00520-023-07769-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/17/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE Participation in a post-treatment exercise program improves cardiorespiratory fitness and aspects of quality of life for esophageal cancer survivors. For optimal effects, high adherence to the exercise intervention is important. We assessed which facilitators and barriers to exercise adherence are perceived by esophageal cancer survivors, who participate in a post-treatment exercise program. METHODS The current qualitative study was performed within the randomized controlled PERFECT trial, in which we investigated effects of a 12-week supervised exercise program with moderate-to-high intensity and daily physical activity advice. Semi-structured interviews were conducted with patients randomized to the exercise group. A thematic content approach was used to derive perceived facilitators and barriers. RESULTS Thematic saturation was reached after inclusion of sixteen patients. Median session attendance was 97.9% (IQR 91.7-100%), and relative dose intensity (compliance) to all exercises was ≥90.0%. Adherence to the activity advice was 50.0% (16.7-60.4%). Facilitators and barriers were captured in seven themes. The most important facilitators were patients' own intention to engage in exercise and supervision by a physiotherapist. Barriers were mainly experienced in completion of the activity advice, and included logistic factors and physical complaints. CONCLUSIONS Esophageal cancer survivors are well capable to attend a moderate-to-high intensity post-treatment exercise program, and to fulfill the exercises according to protocol. This is facilitated by patients' own intention to engage in exercise and supervision of the physiotherapist, and only minimally affected by barriers as logistic factors and physical complaints. IMPLICATIONS FOR CANCER SURVIVORS When implementing postoperative exercise programs in clinical care, it can be useful to be aware of perceived facilitators and barriers of cancer survivors in order to achieve optimal exercise adherence and maximize beneficial exercise effects. TRIAL REGISTRATION Dutch Trial Register NTR 5045.
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Affiliation(s)
- Jonna K van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CG, Utrecht, The Netherlands
| | - Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, STR 6.131, 3508, GA, Utrecht, The Netherlands
| | | | - Anouk E Hiensch
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, STR 6.131, 3508, GA, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CG, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CG, Utrecht, The Netherlands
| | - Grard A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, ZGT Hospital, Zilvermeeuw 1, 7609, PP, Almelo, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, STR 6.131, 3508, GA, Utrecht, The Netherlands.
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4
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Koevoets EW, Geerlings MI, Monninkhof EM, Mandl R, Witlox L, van der Wall E, Stuiver MM, Sonke GS, Velthuis MJ, Jobsen JJ, van der Palen J, Bos MEMM, Göker E, Menke-Pluijmers MBE, Sommeijer DW, May AM, de Ruiter MB, Schagen SB. Effect of physical exercise on the hippocampus and global grey matter volume in breast cancer patients: A randomized controlled trial (PAM study). Neuroimage Clin 2023; 37:103292. [PMID: 36565574 PMCID: PMC9800528 DOI: 10.1016/j.nicl.2022.103292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Physical exercise in cancer patients is a promising intervention to improve cognition and increase brain volume, including hippocampal volume. We investigated whether a 6-month exercise intervention primarily impacts total hippocampal volume and additionally hippocampal subfield volumes, cortical thickness and grey matter volume in previously physically inactive breast cancer patients. Furthermore, we evaluated associations with verbal memory. METHODS Chemotherapy-exposed breast cancer patients (stage I-III, 2-4 years post diagnosis) with cognitive problems were included and randomized in an exercise intervention (n = 70, age = 52.5 ± 9.0 years) or control group (n = 72, age = 53.2 ± 8.6 years). The intervention consisted of 2x1 hours/week of supervised aerobic and strength training and 2x1 hours/week Nordic or power walking. At baseline and at 6-month follow-up, volumetric brain measures were derived from 3D T1-weighted 3T magnetic resonance imaging scans, including hippocampal (subfield) volume (FreeSurfer), cortical thickness (CAT12), and grey matter volume (voxel-based morphometry CAT12). Physical fitness was measured with a cardiopulmonary exercise test. Memory functioning was measured with the Hopkins Verbal Learning Test-Revised (HVLT-R total recall) and Wordlist Learning of an online cognitive test battery, the Amsterdam Cognition Scan (ACS Wordlist Learning). An explorative analysis was conducted in highly fatigued patients (score of ≥ 39 on the symptom scale 'fatigue' of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire), as previous research in this dataset has shown that the intervention improved cognition only in these patients. RESULTS Multiple regression analyses and voxel-based morphometry revealed no significant intervention effects on brain volume, although at baseline increased physical fitness was significantly related to larger brain volume (e.g., total hippocampal volume: R = 0.32, B = 21.7 mm3, 95 % CI = 3.0 - 40.4). Subgroup analyses showed an intervention effect in highly fatigued patients. Unexpectedly, these patients had significant reductions in hippocampal volume, compared to the control group (e.g., total hippocampal volume: B = -52.3 mm3, 95 % CI = -100.3 - -4.4)), which was related to improved memory functioning (HVLT-R total recall: B = -0.022, 95 % CI = -0.039 - -0.005; ACS Wordlist Learning: B = -0.039, 95 % CI = -0.062 - -0.015). CONCLUSIONS No exercise intervention effects were found on hippocampal volume, hippocampal subfield volumes, cortical thickness or grey matter volume for the entire intervention group. Contrary to what we expected, in highly fatigued patients a reduction in hippocampal volume was found after the intervention, which was related to improved memory functioning. These results suggest that physical fitness may benefit cognition in specific groups and stress the importance of further research into the biological basis of this finding.
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Affiliation(s)
- E W Koevoets
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands; Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands; Department of General Practice, Amsterdam UMC, Amsterdam, the Netherlands
| | - E M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - R Mandl
- Department of Psychiatry, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - L Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - E van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M M Stuiver
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands; Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, the Netherlands; Center of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences, Amsterdam, the Netherlands
| | - G S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M J Velthuis
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - J J Jobsen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - J van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Department of Research Methodology, Measurement, Universiteit Twente, Enschede, the Netherlands
| | - M E M M Bos
- Department of Medical Oncology, ErasmusMC Cancer Institute, Rotterdam, the Netherlands
| | - E Göker
- Department of Medical Oncology, Alexander Monro Hospital, Bilthoven, the Netherlands
| | | | - D W Sommeijer
- Department of Internal Medicine, Flevohospital, Almere, the Netherlands; Department of Medical Oncology, Amsterdam UMC, Amsterdam, the Netherlands
| | - A M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - M B de Ruiter
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - S B Schagen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Brain and Cognition Group, University of Amsterdam, Amsterdam, the Netherlands.
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Koevoets E, Schagen SB, de Ruiter MB, Geerlings MI, Witlox L, Van Der Wall E, Stuiver MM, Sonke GS, Velthuis M, van der Palen J, Jobsen JJ, May AM, Monninkhof EM. Effect of physical exercise on cognitive function after chemotherapy in patients with breast cancer: A randomized controlled trial (PAM study). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12015 Background: Chemotherapy is associated with cognitive problems. Physical exercise is a promising intervention. We investigated whether exercise improves cognition in chemotherapy-exposed breast cancer (BC) patients 2-4 years after diagnosis. Methods: In the PAM study, we randomized chemotherapy-exposed BC patients with self-reported and test-confirmed cognitive problems to an exercise or control group. The 6-month exercise intervention consisted of 2 hours of supervised aerobic and resistance training and two hours of Nordic/power walking. Memory function measured with the Hopkins Verbal Learning Test-Revised (HVLT-R) was our primary outcome. Further measurements included online neuropsychological tests (Amsterdam Cognition Scan; ACS), self-reported cognitive complaints (MDASI-MM, EORTC QLQ C-30 cognitive functioning), physical fitness (VO2peak), fatigue (MFI, EORTC fatigue), quality of life (QoL; EORTC), anxiety (HADS) and depression (HADS, PHQ9). HVLT-R total recall was analyzed with a Fisher exact test for clinically relevant improvement of ≥5 words. Other outcomes were analyzed using multiple regression analyses adjusted for baseline and stratification factors. An hypothesis driven but not pre-specified analysis in patients with high baseline EORTC fatigue levels (≥39) was performed. Results: We randomized 181 patients to the exercise (n = 91) or control group (n = 90). Two-third of the patients attended ≥ 80% of the exercise program and physical fitness significantly improved compared to the control patients ( VO2peak1.4 ml/min/kg, 95% CI 0.6; 2.2). No difference in favor of the intervention group was seen on the primary cognitive outcome or other cognitive tests. However, significant beneficial intervention effects were found for self-reported cognition (MDASI-MM Severity (-0.7, -1.2;-0.1)), fatigue (general fatigue (-2.2, -3.3; -1.1), physical fatigue (-3.3, -4.4; -2.2), mental fatigue (-1.0, -2.0; 0.0), reduced motivation (-1.1, -2.0; -0.2) and reduced activity (-2.1, -3.2; -1.1)), QoL (summary score (4.0, 1.2; 6.7), global health status (5.8, 1.1; 10.6), role functioning (7.2, 1.3; 13.1) and social functioning (5.9, 0.2; 11.6)) and depression (PHQ9 (-1.16, -2.19; -0.13)). In high-fatigued patients, exercise did show significant positive effects on objective cognitive function (ACS Reaction Time (-26.8, -52.9; -0.6) and ACS Wordlist Learning (4.4, 0.5; 8.3)). Conclusions: A 6-month exercise intervention did not improve objectively measured cognitive function in chemotherapy-exposed BC patients with cognitive problems. However, self-reported cognitive function, physical fitness, fatigue, QoL and depression did improve. Unplanned analysis indicated a small positive effect of exercise on cognitive functioning in high-fatigued patients. Clinical trial information: NTR6104.
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Affiliation(s)
- Emmie Koevoets
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Sanne B. Schagen
- Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michiel B. de Ruiter
- Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | | | - Martijn M. Stuiver
- Center of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences, Amsterdam, Netherlands
| | - Gabe S. Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Miranda Velthuis
- Comprehensive Cancer Centre the Netherlands, Utrecht, Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - Jan J. Jobsen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - Anne Maria May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Evelyn M. Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
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Witlox L, Schagen SB, de Ruiter MB, Geerlings MI, Peeters PHM, Koevoets EW, van der Wall E, Stuiver M, Sonke G, Velthuis MJ, Palen JAMVD, Jobsen JJ, May AM, Monninkhof EM. Effect of physical exercise on cognitive function and brain measures after chemotherapy in patients with breast cancer (PAM study): protocol of a randomised controlled trial. BMJ Open 2019; 9:e028117. [PMID: 31227537 PMCID: PMC6597001 DOI: 10.1136/bmjopen-2018-028117] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION After treatment with chemotherapy, many patients with breast cancer experience cognitive problems. While limited interventions are available to improve cognitive functioning, physical exercise showed positive effects in healthy older adults and people with mild cognitive impairment. The Physical Activity and Memory study aims to investigate the effect of physical exercise on cognitive functioning and brain measures in chemotherapy-exposed patients with breast cancer with cognitive problems. METHODS AND ANALYTICS One hundred and eighty patients with breast cancer with cognitive problems 2-4 years after diagnosis are randomised (1:1) into an exercise intervention or a control group. The 6-month exercise intervention consists of twice a week 1-hour aerobic and strength exercises supervised by a physiotherapist and twice a week 1-hour Nordic or power walking. The control group is asked to maintain their habitual activity pattern during 6 months. The primary outcome (verbal learning) is measured at baseline and 6 months. Further measurements include online neuropsychological tests, self-reported cognitive complaints, a 3-tesla brain MRI, patient-reported outcomes (quality of life, fatigue, depression, anxiety, work performance), blood sampling and physical fitness. The MRI scans and blood sampling will be used to gain insight into underlying mechanisms. At 18 months online neuropsychological tests, self-reported cognitive complaints and patient-reported outcomes will be repeated. ETHICS AND DISSEMINATION Study results may impact usual care if physical exercise improves cognitive functioning for breast cancer survivors. TRIAL REGISTRATION NUMBER NTR6104.
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Affiliation(s)
- Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sanne B Schagen
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel B de Ruiter
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra H M Peeters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Emmie W Koevoets
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Stuiver
- Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, The Netherlands
- ACHIEVE Center of Applied Research, Faculty of Health, University of Applied Sciences, Amsterdam, The Netherlands
| | - Gabe Sonke
- Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Miranda J Velthuis
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Job A M van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Research Methodology, Measurement, Universiteit Twente, Enschede, The Netherlands
| | - Jan J Jobsen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Witlox L, Velthuis MJ, Boer JH, Steins Bisschop CN, van der Wall E, van der Meulen WJTM, Schröder CD, Peeters PHM, May AM. Attendance and compliance with an exercise program during localized breast cancer treatment in a randomized controlled trial: The PACT study. PLoS One 2019; 14:e0215517. [PMID: 31067223 PMCID: PMC6505930 DOI: 10.1371/journal.pone.0215517] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 04/02/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Maintaining high adherence rates (session attendance and compliance) in exercise programs during breast cancer treatment can be challenging. We aimed to identify adherence rates and predictors to an exercise program during adjuvant breast cancer treatment. METHODS Ninety-two patients with localized breast cancer undergoing chemotherapy were randomly assigned to an 18-week supervised moderate-to-high intensity aerobic and resistance exercise program, including two 1-hour sessions/week. Additionally, participants were asked to be physically active for at least 30 minutes/day on at least three other days. We report median percentages for attendance, compliance with the prescribed duration and intensity of aerobic and muscle strength exercises, and the exercise advice given. Predictors included in univariate and multivariable linear regression models were demographical, tumor- and treatment-related factors, constructs of the theory of planned behavior, psychological and physical factors. RESULTS Patients attended 83% (interquartile range: 69-91%) of the supervised sessions. Compliance with the duration of aerobic exercise, high-intensity aerobic exercise (cycling at the ventilatory threshold), muscle strength exercises and the exercise advice were 88%(64-97%), 50%(22-82%), 84%(65-94%) and 61%(33%-79%), respectively. Education, radiotherapy, BMI and physical fatigue were important predictors of adherence to supervised exercise. Beliefs about planned behaviors were important predictors, especially for compliance with the exercise advice. CONCLUSIONS Attendance to and compliance with an 18-week aerobic and strength exercise program were high. The lowest compliance was found for high-intensity supervised aerobic exercise. The identified predictors should be considered when designing or adapting exercise programs for patients with localized breast cancer to increase adherence. TRIAL REGISTRATION Current Controlled Trials ISRCTN43801571 Dutch Trial Register NTR2138.
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Affiliation(s)
- Lenja Witlox
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | | | - Jennifer H. Boer
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Charlotte N. Steins Bisschop
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wout J. T. M. van der Meulen
- Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carin D. Schröder
- Brain Center Rudolf Magnus and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- De Hoogstraat Rehabilitation, Utrecht, the Netherlands
| | - Petra H. M. Peeters
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
- School of Public Health, Imperial College London, London, United Kingdom
| | - Anne M. May
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
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Witlox L, Hiensch AE, Velthuis MJ, Steins Bisschop CN, Los M, Erdkamp FLG, Bloemendal HJ, Verhaar M, Ten Bokkel Huinink D, van der Wall E, Peeters PHM, May AM. Four-year effects of exercise on fatigue and physical activity in patients with cancer. BMC Med 2018; 16:86. [PMID: 29879968 PMCID: PMC5992660 DOI: 10.1186/s12916-018-1075-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In the earlier randomized controlled Physical Activity during Cancer Treatment (PACT) study, we found beneficial effects of an 18-week supervised exercise program on fatigue in patients with newly diagnosed breast or colon cancer undergoing adjuvant treatment. The present study assessed long-term effects of the exercise program on levels of fatigue and physical activity 4 years after participation in the PACT study. METHODS The original study was a two-armed, multicenter randomized controlled trial comparing an 18-week supervised exercise program to usual care among 204 breast cancer patients and 33 colon cancer patients undergoing adjuvant treatment. Of the 237 PACT participants, 197 participants were eligible and approached to participate in the 4-year post-baseline measurements, and 128 patients responded. We assessed fatigue and physical activity levels at 4 years post-baseline and compared this to levels at baseline, post-intervention (18 weeks post-baseline), and at 36 weeks post-baseline. RESULTS Intention-to-treat mixed linear effects model analyses showed that cancer patients in the intervention group reported significantly higher moderate-to-vigorous total physical activity levels (141.46 min/week (95% confidence interval (CI) 1.31, 281.61, effect size (ES) = 0.22) after 4 years compared to the usual care group. Furthermore, cancer patients in the intervention group tended to experience less physical fatigue at 4 years post-baseline compared to the usual care group (- 1.13, 95% CI -2.45, 0.20, ES = 0.22), although the result was not statistically significant. CONCLUSION Patients with breast or colon cancer who participated in the 18-week exercise intervention showed significant higher levels of moderate-to-vigorous total physical activity levels and a tendency towards lower physical fatigue levels 4 years post-baseline. Our result indicate that exercising during chemotherapy is a promising strategy for minimizing treatment-related side effects, both short and long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN43801571 , Dutch Trial Register NTR2138 . Trial registered on 9 December 2009.
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Affiliation(s)
- Lenja Witlox
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, STR 6.131, 3508 GA, Utrecht, The Netherlands
| | - Anouk E Hiensch
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, STR 6.131, 3508 GA, Utrecht, The Netherlands
| | - Miranda J Velthuis
- Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Charlotte N Steins Bisschop
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, STR 6.131, 3508 GA, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Frans L G Erdkamp
- Department of Internal Medicine - Medical Oncology, Obis Medisch Centrum, Dr van der Hoffplein 1, 6166 BG, Sittard-Geleen, The Netherlands
| | - Haiko J Bloemendal
- Department of Internal Medicine, Meander Medical Center, Maatweg 3, 3818 TZ, Amersfoort, The Netherlands
| | - Marlies Verhaar
- Department of Internal Medicine, Hofpoort Ziekenhuis, Polanerbaan 2, 3447 GN, Woerden, The Netherlands
| | - Daan Ten Bokkel Huinink
- Department of Internal Medicine, Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Petra H M Peeters
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, STR 6.131, 3508 GA, Utrecht, The Netherlands
| | - Anne M May
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, STR 6.131, 3508 GA, Utrecht, The Netherlands.
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van Vulpen J, Witlox L, Methorst - de Haan A, Peeters PH, van Hillegersberg R, Nieuwenhuijzen GAP, Kouwenhoven E, Siersema P, May AM. Perceived facilitators and barriers to physical exercise adherence in esophageal cancer patients after surgery. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.7_suppl.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
94 Background: To achieve optimal effects of exercise interventions in esophageal cancer patients, high adherence is needed. Knowledge on facilitators and barriers can help improving exercise adherence. Hence, the aim of this study is to evaluate perceived facilitators and barriers to physical exercise adherence in esophageal cancer patients in the first year after surgery. Methods: Semi-structured interviews were conducted with patients (n = 16) who were randomised to the exercise group of the Physical ExeRcise Following Esophageal Cancer Treatment (PERFECT) Study. Patients participated in a 12-week supervised combined aerobic and resistance exercise program twice weekly, and were advised to be physically active at least 30 minutes each day. Physiotherapists registered attendance at the supervised sessions and compliance (i.e., performing the exercises according to protocol). Transcribed interviews were analysed using a thematic content approach. Results: Median attendance was 97.9%, interquartile range (IQR): 91.7 – 100%. Median compliance to both components of the exercise program was high: 89.6% (IQR 75.5 – 95.8%) for aerobic exercise and 88.0% (IQR 73.8 – 93.6%) for resistance exercise. The most important perceived facilitators were patients’ own attitudes towards exercise (i.e. motivation, commitment and personal goals) and supervision by a physiotherapist. There were only few perceived barriers, of which the most frequently mentioned were logistic factors (i.e. holidays, conflicting activities and weather circumstances) and impaired physical condition due to regular endoscopic esophageal dilation therapy or general physical complaints, such as fatigue. Conclusions: Esophageal cancer patients after surgery are well capable to perform physical exercise with moderate-to-high intensity. The most important perceived facilitators for the high adherence rates are patients’ own attitudes towards exercise and supervision by a physiotherapist. Completion of the exercise program was only minimally affected by perceived barriers as logistic factors and physical complaints. This information can help in designing future exercise programs for clinical practice.
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Affiliation(s)
| | - Lenja Witlox
- University Medical Center Utrecht, Julius Center, Utrecht, Netherlands
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May AM, Hiensch AE, Witlox L, Velthuis M, Van Der Wall E, Peeters PH. Four-year effects of physical exercise during adjuvant treatment on fatigue and physical activity in breast and colon cancer patients. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.7_suppl.99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
99 Background: A recent randomized trial, the PACT study, showed beneficial effects on fatigue and physical fitness after an 18-week supervised exercise program in breast and colon cancer patients undergoing adjuvant treatment. So far, little is known on long-term effects of exercising during adjuvant treatment on fatigue and whether physical activity levels could be maintained. The latter is important to preserve achieved beneficial health effects. The present study assessed effects of the exercise intervention on fatigue and physical activity on average 4 years after participation in the PACT study. Methods: The PACT study was a 2-armed, multicenter randomized controlled trial comparing an 18-week supervised exercise program to usual care among 204 breast cancer patients and 33 colon cancer patients undergoing adjuvant treatment including chemotherapy. Of the 237 participants, 197 patients were eligible and approached to participate in the 4-year follow-up measurements, and finally 128 patients responded (intervention (n = 70), usual care (n = 58)). Fatigue (MFI) and physical activity levels (SQUASH) was assessed at baseline, post-intervention (at 18 weeks), 36-week post-baseline and 4 years post-baseline. Results: Intention-to-treat mixed linear model analyses showed that cancer patients in the intervention group experienced less physical fatigue at 4-year post-baseline compared to the usual care group (-1.13, 95% CI -2.45;0.20, effect size (ES) = 0.22), although not statistically significant. Furthermore, cancer patients in the intervention group reported significantly higher moderate-to-vigorous total physical activity levels (141.77 min/week (CI 95% 1.31;281.61, ES = 0.22) after 4 years compared to the usual care group. Conclusions: Breast and colon cancer patients, who participated in an 18-week exercise intervention during adjuvant treatment, showed significant higher levels of moderate-to-vigorous total physical activity levels and a tendency towards lower physical fatigue levels 4-year post-baseline. Exercise during chemotherapy might be a promising strategy for minimizing treatment-related side-effects both in the short- and long-term. Clinical trial information: NTR2138.
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Affiliation(s)
| | - Anouk E Hiensch
- University Medical Center Utrecht, Julius Center, Utrecht, Netherlands
| | - Lenja Witlox
- University Medical Center Utrecht, Julius Center, Utrecht, Netherlands
| | - Miranda Velthuis
- Comprehensive Cancer Centre the Netherlands, Utrecht, Netherlands
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