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Myers AM, Barlow RC, Baldini G, Campbell AM, Carli F, Carr EJ, Collyer T, Danjoux G, Davis JF, Denehy L, Durrand J, Gillis C, Greenfield DM, Griffiths SP, Grocott M, Humphreys L, Jack S, Keen C, Levett DZH, Merchant Z, Moore J, Moug S, Ricketts W, Santa Mina D, Saxton JM, Shaw CE, Tew GA, Thelwell M, West MA, Copeland RJ. International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research. Br J Anaesth 2024; 132:851-856. [PMID: 38522964 DOI: 10.1016/j.bja.2024.02.021] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/31/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.
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Affiliation(s)
- Anna M Myers
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK.
| | - Rachael C Barlow
- Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Gabriele Baldini
- Anaesthesiology and Intensive Care Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | | | - Franco Carli
- Department of Anaesthesia, McGill University Health Center, Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Esther J Carr
- South Tees NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Tom Collyer
- Anaesthetic Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Gerard Danjoux
- North Yorkshire Academic Alliance of Perioperative Medicine, James Cook University Hospital, Middlesbrough, UK
| | - June F Davis
- Macmillan Cancer Support, London, UK; Allied Health Solutions, Hadlow, Kent, UK
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - James Durrand
- Department of Anaesthesia and Perioperative Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, QC, Canada
| | - Diana M Greenfield
- Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Mike Grocott
- Faculty of Medicine, University of Southampton, Southampton, UK; Acute Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Trust, University of Southampton, Southampton, UK
| | - Liam Humphreys
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Sandy Jack
- Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Biomedical Research Centre, University Hospital Southampton NHS Trusts, Southampton, UK
| | - Carol Keen
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Trust, University of Southampton, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Zoe Merchant
- Greater Manchester Cancer Alliance, Manchester, UK
| | - John Moore
- Department of Anaesthesia and Peri-operative Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Susan Moug
- Departments of Colorectal Surgery, Royal Alexandra Hospital, Paisley, Scotland, UK
| | - William Ricketts
- Respiratory Medicine, Barts Health NHS Trust, St Bartholomew's Hospital, London, UK
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada; Department of Anaesthesiology and Pain Management, University Health Network, Toronto, ON, Canada
| | - John M Saxton
- School of Sport, Exercise and Rehabilitation Sciences, University of Hull, Hull, UK
| | - Clare E Shaw
- NIHR Biomedical Research Centre at The Royal Marsden and the Institute of Cancer Research, London, UK
| | | | - Michael Thelwell
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Malcolm A West
- University of Southampton, Faculty of Medicine, Cancer Sciences, University Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Robert J Copeland
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
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Bates A, West MA, Jack S, Grocott MPW. Preparing for and Not Waiting for Surgery. Curr Oncol 2024; 31:629-648. [PMID: 38392040 PMCID: PMC10887937 DOI: 10.3390/curroncol31020046] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.
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Affiliation(s)
- Andrew Bates
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Malcolm A. West
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Sandy Jack
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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West CT, West MA, Mirnezami AH, Drami I, Denys A, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Pape E, van Ramshorst GH, Aalbers AGJ, Abdul AN, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Angenete E, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brown K, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelen W, Chan KKL, Chang GJ, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Denost QD, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Egger E, Eglinton T, Enrique-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Flatmark K, Fleming F, Flor B, Folkesson J, Foskett K, Frizelle FA, Funder J, Gallego MA, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther N, Glover T, Goffredo P, Golda T, Gomez CM, Griffiths B, Gwenaël F, Harris C, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kaufman M, Kazi M, Kelley SR, Keller DS, Kelly ME, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Kusters M, Lago V, Lakkis Z, Lampe B, Langheinrich MC, Larach T, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Mackintosh M, Mann C, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McDermott FD, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Monson JRT, Morton JR, Mullaney TG, Navarro AS, Neeff H, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock A, Pellino G, Peterson AC, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Quyn A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Smith T, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor C, Taylor D, Tejedor P, Tekin A, Tekkis PP, Teras J, Thanapal MR, Thaysen HV, Thorgersen E, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg 2023; 110:1730-1731. [PMID: 37757457 PMCID: PMC10805575 DOI: 10.1093/bjs/znad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
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Sibley D, Chen M, West MA, Matthew AG, Santa Mina D, Randall I. Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review. Appl Physiol Nutr Metab 2023; 48:639-656. [PMID: 37224570 DOI: 10.1139/apnm-2022-0272] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.
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Affiliation(s)
- Daniel Sibley
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maggie Chen
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Malcolm A West
- Faculty of Medicine, Cancer Sciences, University of Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew G Matthew
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Drami I, Fletcher JA, Corr A, West MA, Aston W, Hellawell G, Burns EM, Jenkins JT. Total pelvic exenteration with 'high and wide' sacrectomy for recurrent rectal cancer: A video vignette. Colorectal Dis 2022; 24:1625-1626. [PMID: 35730692 DOI: 10.1111/codi.16230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/04/2022] [Accepted: 06/11/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Jordan A Fletcher
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Alison Corr
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Malcolm A West
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK.,School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Will Aston
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Giles Hellawell
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Elaine M Burns
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - John T Jenkins
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
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Ha SM, Sheehan D, Shalabi A, West MA, Ilangovan R, Moorghen M, Jenkins JT, Thomas-Gibson S. Should you trust the radiologist? Gut 2022; 71:2193-2299. [PMID: 34145044 DOI: 10.1136/gutjnl-2021-325129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/02/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Sun Mi Ha
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Donal Sheehan
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Ahmed Shalabi
- St Mark's Hospital and Academic Institute, Harrow, UK
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Fletcher J, Drami I, Burns E, Mughal M, West MA, Corr A, Jenkins JT. Open sidewall excision for recurrent rectal cancer with gluteal flap reconstruction - a video vignette. Colorectal Dis 2022; 24:1252-1253. [PMID: 35490346 DOI: 10.1111/codi.16162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jordan Fletcher
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Elaine Burns
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Maleeha Mughal
- Department of Plastic and Reconstructive Surgery, Guy's and St Thomas Hospital, London, UK
| | - Malcolm A West
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK.,School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Alison Corr
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - John T Jenkins
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 455] [Impact Index Per Article: 227.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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9
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Fletcher JA, Drami I, West MA, Burns EM, Ross D, Northover J, Jenkins JT. Inferior gluteal artery perforator flap reconstruction of the perineum: A Video Vignette. Colorectal Dis 2022; 24:1098. [PMID: 35426969 DOI: 10.1111/codi.16152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jordan A Fletcher
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Malcolm A West
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK.,School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Elaine M Burns
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - David Ross
- Department of Plastic and Reconstructive Surgery, Guy's and St Thomas Hospital, London, UK
| | - John Northover
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
| | - John T Jenkins
- Complex Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, UK
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10
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Johnson YL, West MA, Gould LE, Drami I, Behrenbruch C, Burns EM, Mirnezami AH, Jenkins JT. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24:16-26. [PMID: 34653292 DOI: 10.1111/codi.15956] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/12/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
AIM Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. METHOD The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. RESULTS Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). CONCLUSION The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.
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Affiliation(s)
- Yanika L Johnson
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Malcolm A West
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Laura E Gould
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | | | | | - Alexander H Mirnezami
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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11
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West MA, Baker WC, Rahman S, Munro A, Jack S, Grocott MP, Underwood TJ, Levett DZ. Cardiopulmonary exercise testing has greater prognostic value than sarcopenia in oesophago-gastric cancer patients undergoing neoadjuvant therapy and surgical resection. J Surg Oncol 2021; 124:1306-1316. [PMID: 34463378 DOI: 10.1002/jso.26652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/10/2021] [Revised: 07/07/2021] [Accepted: 08/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sarcopenia (low skeletal muscle mass), myosteatosis (low skeletal muscle radiation-attenuation) and fitness are independently associated with postoperative outcomes in oesophago-gastric cancer. This study aimed to investigate (1) the effect of neoadjuvant therapy (NAT) on sarcopenia, myosteatosis and cardiopulmonary exercise testing (CPET), (2) the relationship between these parameters, and (3) their association with postoperative morbidity and survival. METHODS Body composition analysis used single slice computed tomography (CT) images from chest (superior to aortic arch) and abdominal CT scans (third lumbar vertebrae). Oxygen uptake at anaerobic threshold (VO2 at AT) and at peak exercise (VO2 Peak) were measured using CPET. Measurements were performed before and after NAT and an adjusted regression model assessed their association. RESULTS Of the 184 patients recruited, 100 underwent surgical resection. Following NAT skeletal muscle mass, radiation-attenuation and fitness reduced significantly (p < 0.001). When adjusted for age, sex, and body mass index, only pectoralis muscle mass was associated with VO2 Peak (p = 0.001). VO2 at AT and Peak were associated with 1-year survival, while neither sarcopenia nor myosteatosis were associated with morbidity or survival. CONCLUSION Skeletal muscle and CPET variables reduced following NAT and were positively associated with each other. Cardiorespiratory function significantly contributes to short-term survival after oesophago-gastric cancer surgery.
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Affiliation(s)
- Malcolm A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia, Perioperative, and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - William Ca Baker
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Saqib Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Alicia Munro
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia, Perioperative, and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Pw Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia, Perioperative, and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Timothy J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Upper Gastro-intestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Denny Zh Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia, Perioperative, and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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12
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Abstract
PURPOSE To evaluate the role of prehabilitation interventions in adult patients before elective major surgery. RECENT FINDINGS Exercise training before elective adult major surgery is feasible and safe. Efficacy has been determined but the clinical effectiveness remains uncertain. Early data suggest a reduction in morbidity, length of stay, and an improvement in the quality of life. Nutritional and psychological interventions are less well evaluated, and when they are, it is often in combination with exercise interventions as part of multimodal prehabilitation. SUMMARY Studies evaluating multimodal prehabilitation interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical effectiveness is currently very limited. Future research should focus on refining interventions, exploring mechanisms, establishing minimum dosage, interrogating interactions between therapies, and urgent implementation of large-scale clinical effectiveness studies.
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Affiliation(s)
- Malcolm A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Sandy Jack
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Michael P W Grocott
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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13
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Gillis C, Hasil L, Kasvis P, Bibby N, Davies SJ, Prado CM, West MA, Shaw C. Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology. Front Nutr 2021; 8:644706. [PMID: 34249985 PMCID: PMC8264148 DOI: 10.3389/fnut.2021.644706] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/26/2021] [Indexed: 12/21/2022] Open
Abstract
The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Leslee Hasil
- Department of Nutrition Services, Alberta Health Services, Calgary, AB, Canada
| | - Popi Kasvis
- Department of Nutrition, McGill University Health Center, Montreal, QC, Canada
| | - Neil Bibby
- Manchester Royal Infirmary, Dietetics Department, Manchester University National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Sarah J Davies
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton National Health Service (NHS) Foundation Trust, Southampton, United Kingdom
| | - Carla M Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | - Malcolm A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,University Hospital Southampton National Health Service (NHS) Foundation Trust, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust, Southampton, United Kingdom.,Anaesthesia, Perioperative and Critical Care Research Group, National Institute for Health Research (NIHR) Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust, University of Southampton, Southampton, United Kingdom
| | - Clare Shaw
- Department of Nutrition and Dietetics, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
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14
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Loughney L, West MA, Moyses H, Bates A, Kemp GJ, Hawkins L, Varkonyi-Sepp J, Burke S, Barben CP, Calverley PM, Cox T, Palmer DH, Mythen MG, Grocott MPW, Jack S. The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial). Perioper Med (Lond) 2021; 10:23. [PMID: 34154675 PMCID: PMC8216760 DOI: 10.1186/s13741-021-00190-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/22/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health. METHODS Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling. RESULTS Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011. CONCLUSION A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.
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Affiliation(s)
- Lisa Loughney
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- ExWell Medical, Dublin, Ireland
| | - Malcolm A West
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen Moyses
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
| | - Andrew Bates
- Departments of Anaesthesia and Critical Care, Royal Bournemouth NHS Foundation Trust, Bournemouth, UK
| | - Graham J Kemp
- Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Lesley Hawkins
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Judit Varkonyi-Sepp
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
| | - Shaunna Burke
- Faculty of Biological Sciences, School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Christopher P Barben
- Department of Colorectal Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter M Calverley
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Trevor Cox
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Daniel H Palmer
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Michael G Mythen
- Anaesthesia and Critical Care, University College London, London, UK
| | - Michael P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Sandy Jack
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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15
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West MA, Anastasiou Z, Ambler G, Loughney L, Mythen MG, Owen T, Danjoux G, Levett DZ, Calverley PM, Kelly JJ, Jack S, Grocott MP. The effects of cancer therapies on physical fitness before oesophagogastric cancer surgery: a prospective, blinded, multi-centre, observational, cohort study. NIHR Open Res 2021; 1:1. [PMID: 35106479 PMCID: PMC7612293 DOI: 10.3310/nihropenres.13217.1] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 12/05/2022]
Abstract
Background Neoadjuvant cancer treatment is associated with improved survival following major oesophagogastric cancer surgery. The impact of neoadjuvant chemo/chemoradiotherapy on physical fitness and operative outcomes is however unclear. This study aims to investigate the impact of neoadjuvant chemo/chemoradiotherapy on fitness and post-operative mortality. Methods Patients with oesophagogastric cancer scheduled for chemo/chemoradiotherapy and surgery were recruited to a prospective, blinded, multi-centre, observational cohort study. Primary outcomes were changes in fitness with chemo/chemoradiotherapy, measured using cardiopulmonary exercise testing and its association with mortality one-year after surgery. Patients were followed up for re-admission at 30-days, in-hospital morbidity and quality of life (exploratory outcomes). Results In total, 384 patients were screened, 217 met the inclusion criteria, 160 consented and 159 were included (72% male, mean age 65 years). A total of 132 patients (83%) underwent chemo/chemoradiotherapy, 109 (71%) underwent chemo/chemoradiotherapy and two exercise tests, 100 (63%) completed surgery and follow-up. A significant decline in oxygen uptake at anaerobic threshold and oxygen uptake peak was observed following chemo/chemoradiotherapy: -1.25ml.kg -1.min -1 (-1.80 to -0.69) and -3.02ml.kg -1.min -1 (-3.85 to -2.20); p<0.0001). Baseline chemo/chemoradiotherapy anaerobic threshold and peak were associated with one-year mortality (HR=0.72, 95%CI 0.59 to 0.88; p=0.001 and HR=0.85, 0.76 to 0.95; p=0.005). The change in physical fitness was not associated with one-year mortality. Conclusions Chemo/chemoradiotherapy prior to oesophagogastric cancer surgery reduced physical fitness. Lower baseline fitness was associated with reduced overall survival at one-year. Careful consideration of fitness prior to chemo/chemoradiotherapy and surgery is urgently needed.
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Affiliation(s)
- Malcolm A. West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Zachos Anastasiou
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
| | - Lisa Loughney
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Michael G. Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, W1T 7HA, UK
| | - Thomas Owen
- Department of Critical Care and Anaesthesia, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, PR7 1PP, UK
| | - Gerard Danjoux
- Department of Critical Care and Anaesthesia, The James Cook University Hospital, Middlesborough, TS4 3BW, UK
| | - Denny Z.H. Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Peter M.A. Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Liverpool, L9 7AL, UK
| | - Jamie J. Kelly
- Department of Upper Gastro-intestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Michael P.W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fit4Surgery Consortium
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, W1T 7HA, UK
- Department of Critical Care and Anaesthesia, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, PR7 1PP, UK
- Department of Critical Care and Anaesthesia, The James Cook University Hospital, Middlesborough, TS4 3BW, UK
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Liverpool, L9 7AL, UK
- Department of Upper Gastro-intestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
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16
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Gillis C, Davies SJ, Carli F, Wischmeyer PE, Wootton SA, Jackson AA, Riedel B, Marino LV, Levett DZH, West MA. Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review. Front Nutr 2021; 8:644723. [PMID: 33898499 PMCID: PMC8062858 DOI: 10.3389/fnut.2021.644723] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Sarah J. Davies
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Paul E. Wischmeyer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Stephen A. Wootton
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Alan A. Jackson
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Anaethesia, Pain and Perioperative Medicine Unit, The University of Melbourne, Melbourne, VIC, Australia
- Centre for Integrated Critical Care Medicine and The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Luise V. Marino
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Nutrition and Dietetics, Faculty of Health and Well Being, University of Winchester, Winchester, United Kingdom
| | - Denny Z. H. Levett
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Anaesthesia, Perioperative and Critical Care Research Group, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, University of Southampton, Southampton, United Kingdom
| | - Malcolm A. West
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Anaesthesia, Perioperative and Critical Care Research Group, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, University of Southampton, Southampton, United Kingdom
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, United Kingdom
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17
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Davies SJ, West MA, Rahman SA, Underwood TJ, Marino LV. Oesophageal cancer: The effect of early nutrition support on clinical outcomes. Clin Nutr ESPEN 2021; 42:117-123. [PMID: 33745564 DOI: 10.1016/j.clnesp.2021.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 09/02/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is prevalent in oesophageal cancer. Evidence for the use of nutrition support and prehabilitation in this cohort is variable. The aim of this study was to examine the effect of early nutrition support and functional measures of nutritional status on post-operative outcomes in adult patients with oesophageal cancer. METHODS Retrospective review of adults with oesophageal cancer undergoing oesophagectomy (n = 151). Early nutrition support was defined as: oral or enteral nutrition supplementation during neoadjuvant treatment. Late nutrition support defined as: oral or enteral nutrition supplementation prescribed post-operatively. Nutrition outcome measures were; percentage weight loss from 3 to 6 months prior to diagnosis, peri- and post-operatively, and pre-operative assessment of handgrip-strength (HGS). RESULTS Pre-operative weight loss ≥10% was a significant predictor of mortality at 1 year (OR 2.84, 95%CI 1.03-7.83, p = 0.04) independent of tumour stage, adjuvant treatment, age and gender. Adults prescribed early nutrition support during neoadjuvant treatment experienced less weight loss at 12-months post-oesophagectomy compared to adults prescribed late oral nutrition support (p=<0.05). Pre-operative HGS measurements were not a useful predictor of postoperative complications (p = 0.2), length of stay (p = 0.9) or 90-day mortality (p = 0.6). CONCLUSIONS Pre-operative weight loss ≥10% was associated with mortality. Early nutrition support was associated with less weight loss at 12-months post-operatively. Pre-operative HGS measures did not have prognostic value as a stand-alone measure. Future work should investigate the efficacy of early nutrition support in reducing both pre- and post-operative weight loss to improve nutritional status and surgical outcomes as part of a multimodal prehabilitation programme in adults with oesophageal cancer.
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Affiliation(s)
- S J Davies
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - S A Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - T J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - L V Marino
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK; NIHR Biomedical Research Centre Southampton, University Hospital NHS Foundation Trust Southampton, UK; Nutrition and Dietetics, Faculty of Health and Well Being, University of Winchester, UK
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18
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Abstract
A video abstract is available at https://youtu.be/LYJPmWunnKE
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Affiliation(s)
- A Bates
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - M A West
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - S Jack
- Anaesthesia and Critical Care Research Area, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, and Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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19
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Thomas G, West MA, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW, Levett DZH. Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing. Perioper Med (Lond) 2020; 9:18. [PMID: 32518637 PMCID: PMC7271469 DOI: 10.1186/s13741-020-00148-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET. Aim We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice. Methods We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET. Results Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male. Conclusion To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.
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Affiliation(s)
- G Thomas
- Department of Intensive Care, Spaarne Hospital, Haarlem, The Netherlands
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone, Kent, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, 9th Floor Terence Lewis Building, Plymouth, UK.,Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- STRAPH Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, East Ayrshire, Scotland, UK
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - M P W Grocott
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - D Z H Levett
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
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20
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West MA, van Dijk DP, Gleadowe F, Reeves T, Primrose JN, Abu Hilal M, Edwards MR, Jack S, Rensen SS, Grocott MP, Levett DZ, Olde Damink SW. Myosteatosis is associated with poor physical fitness in patients undergoing hepatopancreatobiliary surgery. J Cachexia Sarcopenia Muscle 2019; 10:860-871. [PMID: 31115169 PMCID: PMC6711456 DOI: 10.1002/jcsm.12433] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Body composition assessment, measured using single-slice computed tomography (CT) image at L3 level, and aerobic physical fitness, objectively measured using cardiopulmonary exercise testing (CPET), are each independently used for perioperative risk assessment. Sarcopenia (i.e. low skeletal muscle mass), myosteatosis [i.e. low skeletal muscle radiation attenuation (SM-RA)], and impaired objectively measured aerobic fitness (reduced oxygen uptake) have been associated with poor post-operative outcomes and survival in various cancer types. However, the association between CT body composition and physical fitness has not been explored. In this study, we assessed the association of CT body composition with selected CPET variables in patients undergoing hepatobiliary and pancreatic surgery. METHODS A pragmatic prospective cohort of 123 patients undergoing hepatobiliary and pancreatic surgery were recruited. All patients underwent preoperative CPET. Preoperative CT scans were analysed using a single-slice CT image at L3 level to assess skeletal muscle mass, adipose tissue mass, and muscle radiation attenuation. Multivariate linear regression was used to test the association between CPET variables and body composition. Main outcomes were oxygen uptake at anaerobic threshold ( V̇ O2 at AT), oxygen uptake at peak exercise ( V̇ O2 peak), skeletal muscle mass, and SM-RA. RESULTS Of 123 patients recruited [77 men (63%), median age 66.9 ± 11.7, median body mass index 27.3 ± 5.2], 113 patients had good-quality abdominal CT scans available and were included. Of the CT body composition variables, SM-RA had the strongest correlation with V̇ O2 peak (r = 0.57, P < 0.001) and V̇ O2 at AT (r = 0.45, P < 0.001) while skeletal muscle mass was only weakly associated with V̇ O2 peak (r = 0.24, P < 0.010). In the multivariate analysis, only SM-RA was associated with V̇ O2 peak (B = 0.25, 95% CI 0.15-0.34, P < 0.001, R2 = 0.42) and V̇ O2 at AT (B = 0.13, 95% CI 0.06-0.18, P < 0.001, R2 = 0.26). CONCLUSIONS There is a positive association between preoperative CT SM-RA and preoperative physical fitness ( V̇ O2 at AT and at peak). This study demonstrates that myosteatosis, and not sarcopenia, is associated with reduced aerobic physical fitness. Combining both myosteatosis and physical fitness variables may provide additive risk stratification accuracy and guide interventions during the perioperative period.
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Affiliation(s)
- Malcolm A. West
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - David P.J. van Dijk
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Fredrick Gleadowe
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Thomas Reeves
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - John N. Primrose
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Mohammed Abu Hilal
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Mark R. Edwards
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Sander S.S. Rensen
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Michael P.W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Denny Z.H. Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Steven W.M. Olde Damink
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
- Departments of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
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21
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Abstract
BACKGROUND People undergoing multimodal cancer treatment are at an increased risk of adverse events. Physical fitness significantly reduces following cancer treatment, which is related to poor postoperative outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity may contribute to improved physical fitness. OBJECTIVES To determine the effects of exercise interventions for people undergoing multimodal treatment for cancer, including surgery, on physical fitness, safety, health-related quality of life (HRQoL), fatigue, and postoperative outcomes. SEARCH METHODS We searched electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, SPORTDiscus, and trial registries up to October 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared the effects of exercise training with usual care, on physical fitness, safety, HRQoL, fatigue, and postoperative outcomes in people undergoing multimodal cancer treatment, including surgery. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, performed the data extraction, assessed the risk of bias, and rated the quality of the studies using Grading of Recommendation Assessment, Development, and Evaluation (GRADE) criteria. We pooled data for meta-analyses, where possible, and reported these as mean differences using the random-effects model. MAIN RESULTS Eleven RCTs were identified involving 1067 participants; 568 were randomly allocated to an exercise intervention and 499 to a usual care control group. The majority of participants received treatment for breast cancer (73%). Due to the nature of the intervention, it was not possible to blind the participants or personnel delivering the intervention. The risk of detection bias was either high or unclear in some cases, whilst most other domains were rated as low risk. The included studies were of moderate to very low-certainty evidence. Pooled data demonstrated that exercise training may have little or no difference on physical fitness (VO2 max) compared to usual care (mean difference (MD) 0.05 L/min-1, 95% confidence interval (CI) -0.03 to 0.13; I2 = 0%; 2 studies, 381 participants; low-certainty evidence). Included studies also showed in terms of adverse effects (safety), that it may be of benefit to exercise (8 studies, 507 participants; low-certainty evidence). Furthermore, exercise training probably made little or no difference on HRQoL (EORTC global health status subscale) compared to usual care (MD 2.29, 95% CI -1.06 to 5.65; I2 = 0%; 3 studies, 472 participants; moderate-certainty evidence). However, exercise training probably reduces fatigue (multidimensional fatigue inventory) compared to usual care (MD -1.05, 95% CI -1.83 to -0.28; I2 = 0%; 3 studies, 449 participants moderate-certainty evidence). No studies reported postoperative outcomes. AUTHORS' CONCLUSIONS The findings should be interpreted with caution in view of the low number of studies, the overall low-certainty of the combined evidence, and the variation in included cancer types (mainly people with breast cancer), treatments, exercise interventions, and outcomes. Exercise training may, or may not, confer modest benefit on physical fitness and HRQoL. Limited evidence suggests that exercise training is probably not harmful and probably reduces fatigue. These findings highlight the need for more RCTs, particularly in the neoadjuvant setting.
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Affiliation(s)
- Lisa A Loughney
- Dublin City UniversitySchool of Health and Human PerformanceDublin 9Ireland
- University of Southampton NHS Foundation Trust / University of SouthamptonRespiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreSouthamptonUKSO16 6YD
| | - Malcolm A West
- University of Southampton NHS Foundation Trust / University of SouthamptonRespiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreSouthamptonUKSO16 6YD
- University of SouthamptonAcademic Unit of Cancer Sciences, Faculty of MedicineSouth Academic BlockTremona RoadSouthamptonUKSO16 6YD
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUKSO16 6YD
| | - Graham J Kemp
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUKSO16 6YD
- University of LiverpoolDepartment of Musculoskeletal Biology and MRC – Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life SciencesLiverpoolUK
| | - Michael PW Grocott
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUKSO16 6YD
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
| | - Sandy Jack
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUKSO16 6YD
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
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22
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Curtis NJ, West MA, Salib E, Ockrim J, Allison AS, Dalton R, Francis NK. Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation? Int J Colorectal Dis 2018; 33:979-983. [PMID: 29574506 DOI: 10.1007/s00384-018-3016-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes. METHODS An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method. RESULTS Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2-3.1], p = 0.008), age ≤ 65 (OR 1.9 [1.2-3], p = 0.01), higher ASA scores (p = 0.01) stoma formation (OR 6.9 [4.1-11], p < 0.001) and neoadjuvant treatment (OR 5.06 [3.1-8.3], p < 0.001). There was no association between time to surgery and BMI (p = 0.36), conversion (16.3%, p = 0.5), length of stay (p = 0.33) and readmission or reoperation (p = 0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p = 0.397, p = 0.962 and p = 0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p = 0.52). CONCLUSION Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.
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Affiliation(s)
- N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK.,Department of Surgery and Cancer, Imperial College London, Level 10, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - E Salib
- Faculty of Health and Life Sciences, Brownlow Hill, University of Liverpool, Liverpool, L69 7ZX, UK
| | - J Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - A S Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - R Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
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23
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Abstract
PURPOSE OF REVIEW The purpose of this study is to evaluate the role of physical exercise and nutrition interventions in adult patients before elective major surgery. RECENT FINDINGS Exercise training before elective adult major surgery is feasible, safe, and efficacious, but the clinical effectiveness remains uncertain. Early data suggests a reduction in morbidity, length of stay, and quality of life, but the results of larger definitive studies are awaited. Nutritional interventions are less well evaluated and when they are, it is often in combination with exercise interventions as part of a prehabilitation package. SUMMARY Studies evaluating exercise and nutrition interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical evidence is currently very limited. Future research should focus on refining interventions, exploring mechanism, and evaluating the interactions between therapies and large-scale clinical effectiveness studies.
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Affiliation(s)
- Malcolm A. West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton NIHR Biomedical Research Centre, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul E. Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC USA
- Duke Clinical Research Institute, Durham, NC USA
| | - Michael P. W. Grocott
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton NIHR Biomedical Research Centre, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Anaesthesia and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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24
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Burke S, Wurz A, Bradshaw A, Saunders S, West MA, Brunet J. Physical Activity and Quality of Life in Cancer Survivors: A Meta-Synthesis of Qualitative Research. Cancers (Basel) 2017; 9:cancers9050053. [PMID: 28531109 PMCID: PMC5447963 DOI: 10.3390/cancers9050053] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 04/06/2017] [Accepted: 05/16/2017] [Indexed: 12/23/2022] Open
Abstract
Qualitative research on the impact of physical activity on quality of life (QoL) in adults diagnosed with cancer is accumulating. However, the field of physical activity and cancer survivorship lack a synthesis of this research to reliably understand the implications for future research and practice. The aim of this meta-synthesis was to identify, appraise, and synthesize qualitative research on cancer survivors’ perspectives of the impact of physical activity on their QoL. Seven electronic databases were searched for original studies published in English, and reference lists of relevant studies were hand-searched to identify additional studies. Forty studies met eligibility criteria and were included in this meta-synthesis. Study characteristics and major findings were extracted, and findings were summarized, compared, and synthesized. Themes identified in this review revealed that physical activity positively impacted four dimensions of cancer survivors’ QoL: physical (e.g., managing the physical consequences of cancer and its treatment), psychological (e.g., evoking positive self-perceptions), social (e.g., feeling understood by others), and spiritual (e.g., redefining life purpose). This meta-synthesis corroborates conclusions from reviews of quantitative research and illustrates that physical activity can be used to improve QoL in adult cancer survivors, regardless of diagnosis (i.e., stage, cancer type) and treatment status. It also provides detailed insight into specific aspects within each dimension of QoL impacted by physical activity from cancer survivors’ perspectives, which is important for understanding the meaning and utility of physical activity for them. However, more research is needed to further develop the qualitative evidence base in order to better understand how physical activity impacts on QoL experiences in men, young adults, and adults diagnosed with less common types of cancer at different points along cancer trajectory (i.e., diagnosis, treatment, post-treatment, palliation).
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Affiliation(s)
- Shaunna Burke
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS29JT, UK.
| | - Amanda Wurz
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa ON K1N6N5, Canada.
| | - Andrew Bradshaw
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS29JT, UK.
| | - Stephanie Saunders
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa ON K1N6N5, Canada.
| | - Malcolm A West
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK.
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton SO16 6YD, UK.
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK.
- Academic Unit of Cancer Sciences, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Jennifer Brunet
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa ON K1N6N5, Canada.
- Institut du Savoir de l'Hôpital Montfort (IRHM), Hôpital Montfort, Ottawa ON K1K 0T2, Canada.
- Cancer Therapeutic Program, Ottawa Hospital Research Institute (OHRI), Ottawa ON K1H 8L6, Canada.
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25
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Key A, Parry M, West MA, Asher R, Jack S, Duffy N, Torella F, Walker PP. Effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in people with arterial vascular disease with and without COPD. BMJ Open Respir Res 2017; 4:e000164. [PMID: 28409004 PMCID: PMC5387942 DOI: 10.1136/bmjresp-2016-000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/31/2017] [Indexed: 01/31/2023] Open
Abstract
Introduction β Blockers are important treatment for ischaemic heart disease and heart failure; however, there has long been concern about their use in people with chronic obstructive pulmonary disease (COPD) due to fear of symptomatic worsening of breathlessness. Despite growing evidence of safety and efficacy, they remain underused. We examined the effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in a group of vascular surgical patients, a high proportion of who were expected to have COPD. Methods People undergoing routine abdominal aortic aneurysm (AAA) surveillance were sequentially recruited from vascular surgery clinic. They completed plethysmographically measured lung function and incremental cardiopulmonary exercise testing with dynamic measurement of inspiratory capacity while taking and not taking β blocker. Results 48 participants completed tests while taking and not taking β blockers with 38 completing all assessments successfully. 15 participants (39%) were found to have, predominantly mild and undiagnosed, COPD. People with COPD had airflow obstruction, increased airway resistance (Raw) and specific conductance (sGaw), static hyperinflation and dynamically hyperinflated during exercise. In the whole group, β-blockade led to a small fall in FEV1 (0.1 L/2.8% predicted) but did not affect Raw, sGaw, static or dynamic hyperinflation. No difference in response to β-blockade was seen in those with and without COPD. Conclusions In people with AAA, β-blockade has little effect on lung function and dynamic hyperinflation in those with and without COPD. In this population, the prevalence of COPD is high and consideration should be given to case finding with spirometry. Trial registration number NCT02106286.
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Affiliation(s)
- Angela Key
- Respiratory Department, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Matthew Parry
- Respiratory Department, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Malcolm A West
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Faculty of Health and Life Sciences, School of Physical Sciences, University of Liverpool, Liverpool, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rebecca Asher
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Sandy Jack
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Integrative Physiology and Critical Illness Group, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Duffy
- Respiratory Department, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Francesco Torella
- Faculty of Health and Life Sciences, School of Physical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Vascular and Endovascular Service, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Paul P Walker
- Respiratory Department, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.,Faculty of Health and Life Sciences, School of Physical Sciences, University of Liverpool, Liverpool, UK
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26
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West MA, Roman A, Sayan E, Primrose JN, Wedge SR, Underwood TJ, Mirnezami AH. A minimum core outcome dataset for the reporting of preclinical chemotherapeutic drug studies: Lessons learned from multiple discordant methodologies in the setting of colorectal cancer. Crit Rev Oncol Hematol 2017; 112:80-102. [PMID: 28325268 DOI: 10.1016/j.critrevonc.2017.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 10/31/2016] [Revised: 01/11/2017] [Accepted: 02/13/2017] [Indexed: 12/27/2022] Open
Abstract
In vivo studies in animal models are critical tools necessary to study the fundamental complexity of carcinogenesis. A constant strive to improve animal models in cancer exists, especially those investigating the use of chemotherapeutic effectiveness. In the present systematic review, colorectal cancer (CRC) is used as an example to highlight and critically evaluate the range of reporting strategies used when investigating chemotherapeutic agents in the preclinical setting. A systematic review examining the methodology and reporting of preclinical chemotherapeutic drug studies using CRC murine models was conducted. A total of 45 studies were included in this systematic review. The literature was found to be highly heterogeneous with various cell lines, animal strains, animal ages and chemotherapeutic compounds/regimens tested, proving difficult to compare outcomes between similar studies or indeed gain any significant insight into which chemotherapeutic regimen caused adverse events. From this analysis we propose a minimum core outcome dataset that could be regarded as a standardised way of reporting results from in vivo experimentation.
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Affiliation(s)
- M A West
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK.
| | - A Roman
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - E Sayan
- Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - J N Primrose
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - S R Wedge
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - T J Underwood
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
| | - A H Mirnezami
- University Surgery, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK; Academic Unit of Cancer Sciences, Somers Cancer Research Building, University of Southampton, UK
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27
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Brunet J, Burke S, Grocott MPW, West MA, Jack S. The effects of exercise on pain, fatigue, insomnia, and health perceptions in patients with operable advanced stage rectal cancer prior to surgery: a pilot trial. BMC Cancer 2017; 17:153. [PMID: 28228123 PMCID: PMC5322650 DOI: 10.1186/s12885-017-3130-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/09/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Promoting quality of life (QoL) is a key priority in cancer care. We investigated the hypothesis that, in comparison to usual care, exercise post-neoadjuvant chemoradiation therapy/prior to surgical resection will reduce pain, fatigue, and insomnia, and will improve physical and mental health perceptions in patients with locally advanced stage rectal cancer. METHODS In this non-randomized controlled pilot trial, patients in the supervised exercise group (EG; M age = 64 years; 64% male) and in the control group (CG; M age = 72 years; 69% male) completed the European Organization for Research and Treatment of Cancer core Quality of Life questionnaire and the RAND 36-Item Health Survey three times: pre-neoadjuvant chemoradiation therapy (Time 1; n EC = 24; n CG = 11), post-neoadjuvant chemoradiation therapy/pre-exercise intervention (Time 2; n EC = 23; n CG = 10), and post-exercise intervention (Time 3; n EC = 22; n CG = 10). The 6-week exercise intervention was delivered in hospital and comprised of interval aerobic training. Patients trained in pairs three times per week for 30 to 40 min. Data were analyzed by Mann-Whitney tests and by Wilcoxon matched-pairs signed-rank tests. RESULTS No significant between-group differences in changes were found for any of the outcomes. In both groups, fatigue levels decreased and physical health perceptions increased from pre- to post-exercise intervention. Pain levels also decreased from pre- to post-exercise intervention, albeit not significantly. CONCLUSIONS The findings from this study can be used to guide a more definitive trial as they provide preliminary evidence regarding the potential effects of pre-operative exercise on self-reported pain, fatigue, insomnia, and health perceptions in patients with locally advanced rectal cancer. TRIAL REGISTRATION This study has been registered with clinicaltrials.gov (NCT01325909; March 29, 2011).
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Affiliation(s)
- Jennifer Brunet
- Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, 125 University Private, Montpetit Hall Room 339, Ottawa, ON, K1N 6N5, Canada. .,Institut de Recherche de l'Hôpital Montfort (IRHM), Hôpital Montfort, Ottawa, ON, Canada. .,Cancer Therapeutic Program, Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
| | - Shaunna Burke
- Centre for Sport and Exercise Sciences, School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Malcolm A West
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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28
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Loughney L, West MA, Dimitrov BD, Kemp GJ, Grocott MP, Jack S. Physical activity levels in locally advanced rectal cancer patients following neoadjuvant chemoradiotherapy and an exercise training programme before surgery: a pilot study. Perioper Med (Lond) 2017; 6:3. [PMID: 28228938 PMCID: PMC5311720 DOI: 10.1186/s13741-017-0058-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/04/2017] [Indexed: 01/13/2023] Open
Abstract
Background The aim of this pilot study was to measure changes in physical activity level (PAL) variables, as well as sleep duration and efficiency in people with locally advanced rectal cancer (1) before and after neoadjuvant chemoradiotherapy (CRT) and (2) after participating in a pre-operative 6-week in-hospital exercise training programme, following neoadjuvant CRT prior to major surgery, compared to a usual care control group. Methods We prospectively studied 39 consecutive participants (27 males). All participants completed standardised neoadjuvant CRT: 23 undertook a 6-week in-hospital exercise training programme following neoadjuvant CRT. These were compared to 16 contemporaneous non-randomised participants (usual care control group). All participants underwent a continuous 72-h period of PA monitoring by SenseWear biaxial accelerometer at baseline, immediately following neoadjuvant CRT (week 0), and at week 6 (following the exercise training programme). Results Of 39 recruited participants, 23 out of 23 (exercise) and 10 out of 16 (usual care control) completed the study. In all participants (n = 33), there was a significant reduction from baseline (pre-CRT) to week 0 (post-CRT) in daily step count: median (IQR) 4966 (4435) vs. 3044 (3265); p < 0.0001, active energy expenditure (EE) (kcal): 264 (471) vs. 154 (164); p = 0.003, and metabolic equivalent (MET) (1.3 (0.6) vs. 1.2 (0.3); p = 0.010). There was a significant improvement in sleep efficiency (%) between week 0 and week 6 in the exercise group compared to the usual care control group (80 (13) vs. 78 (15) compared to (69 ((24) vs. 76 (20); p = 0.022), as well as in sleep duration and lying down time (p < 0.05) while those in active EE (kcal) (152 (154) vs. 434 (658) compared to (244 (198) vs. 392 (701) or in MET (1.3 (0.4) vs. 1.5 (0.5) compared to (1.1 (0.2) vs. 1.5 (0.5) were also of importance but did not reach statistical significance (p > 0.05). An apparent improvement in daily step count and overall PAL in the exercise group was not statistically significant. Conclusions PAL variables, daily step count, EE and MET significantly reduced following neoadjuvant CRT in all participants. A 6-week pre-operative in-hospital exercise training programme improved sleep efficiency, sleep duration and lying down time when compared to participants receiving usual care. Trial registration Clinicaltrials.gov NCT01325909 Electronic supplementary material The online version of this article (doi:10.1186/s13741-017-0058-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,MedEx Research Cluster, School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Malcolm A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Borislav D Dimitrov
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Graham J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Michael Pw Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK
| | - Sandy Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD UK
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29
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West MA, Loughney L, Ambler G, Dimitrov BD, Kelly JJ, Mythen MG, Sturgess R, Calverley PMA, Kendrick A, Grocott MPW, Jack S. The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study. BMC Cancer 2016; 16:710. [PMID: 27589870 PMCID: PMC5010720 DOI: 10.1186/s12885-016-2682-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/05/2016] [Indexed: 11/13/2022] Open
Abstract
Background In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery. Methods This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L). Discussion The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival. Trial registration ClinicalTrials.gov NCT01325883 - 29th March 2011.
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Affiliation(s)
- M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - B D Dimitrov
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - J J Kelly
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - M G Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - R Sturgess
- Department of Gastroenterology, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - P M A Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - A Kendrick
- Department of Physiological Sciences, University of Bristol, Bristol, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK. .,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
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Loughney LA, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise interventions for people undergoing multimodal cancer treatment that includes surgery. Hippokratia 2016. [DOI: 10.1002/14651858.cd012280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lisa A Loughney
- University Hospital Southampton NHS Foundation Trust; Anaesthesia and Critical Care Research Unit; Southampton UK
- University of Southampton; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences; Southampton UK SO16 6YD
| | - Malcolm A West
- University Hospital Southampton NHS Foundation Trust; Anaesthesia and Critical Care Research Unit; Southampton UK
- University of Southampton; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences; Southampton UK SO16 6YD
- University of Southampton; Academic Unit of Cancer Sciences, Faculty of Medicine; South Academic Block Tremona Road Southampton UK SO16 6YD
| | - Graham J Kemp
- University of Southampton; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences; Southampton UK SO16 6YD
- University of Liverpool; Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences; Liverpool UK
| | - Michael PW Grocott
- University Hospital Southampton NHS Foundation Trust; Anaesthesia and Critical Care Research Unit; Southampton UK
- University of Southampton; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences; Southampton UK SO16 6YD
| | - Sandy Jack
- University Hospital Southampton NHS Foundation Trust; Anaesthesia and Critical Care Research Unit; Southampton UK
- University of Southampton; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences; Southampton UK SO16 6YD
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016. [PMID: 26914526 DOI: 10.1002/bjs.10112)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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West MA, Dimitrov BD, Moyses HE, Kemp GJ, Loughney L, White D, Grocott MPW, Jack S, Brown G. Timing of surgery following neoadjuvant chemoradiotherapy in locally advanced rectal cancer - A comparison of magnetic resonance imaging at two time points and histopathological responses. Eur J Surg Oncol 2016; 42:1350-8. [PMID: 27160356 DOI: 10.1016/j.ejso.2016.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/17/2016] [Accepted: 04/07/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE There is wide inter-institutional variation in the interval between neoadjuvant chemoradiotherapy (NACRT) and surgery for locally advanced rectal cancer. We aimed to assess the association of magnetic resonance imaging (MRI) at 9 and 14 weeks post-NACRT; T-staging (ymrT) and post-NACRT tumour regression grading (ymrTRG) with histopathological outcomes; histopathological T-stage (ypT) and histopathological tumour regression grading (ypTRG) in order to inform decision-making about timing of surgery. PATIENTS AND METHODS We prospectively studied 35 consecutive patients (26 males) with MRI-defined resection margin threatened rectal cancer who had completed standardized NACRT. Patients underwent a MRI at Weeks 9 and 14 post-NACRT, and surgery at Week 15. Two readers independently assessed MRIs for ymrT, ymrTRG and volume change. ymrT and ymrTRG were analysed against histopathological ypT and ypTRG as predictors by logistic regression modelling and receiver operating characteristic (ROC) curve analyses. RESULTS Thirty-five patients were recruited. Inter-observer agreement was good for all MR variables (Kappa > 0.61). Considering ypT as an outcome variable, a stronger association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.064 vs. p = 0.010; Volume change - p = 0.062 vs. p = 0.007). Similarly, considering ypTRG as an outcome variable, a greater association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.005 vs. p = 0.042; Volume change - p = 0.004 vs. 0.055). CONCLUSION Following NACRT, greater tumour down-staging and volume reduction was observed at Week 14. Timing of surgery, in relation to NACRT, merits further investigation. TRIAL REGISTRATION NUMBER NCT01325909.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom.
| | - B D Dimitrov
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom.
| | - H E Moyses
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom; National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom.
| | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - L Loughney
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - D White
- Department of Radiology, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - G Brown
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom.
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016; 103:744-752. [PMID: 26914526 DOI: 10.1002/bjs.10112] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/28/2015] [Accepted: 12/16/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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West MA. Preoperative physical fitness assessment, prehabilitation and surgical outcome - a video vignette. Colorectal Dis 2016; 18:215-6. [PMID: 26467122 DOI: 10.1111/codi.13155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/04/2015] [Indexed: 02/08/2023]
Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, South Academic Block, Mail point 816, Southampton University Hospital, Southampton SO16 6YD, UK.
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Loughney L, West MA, Kemp GJ, Rossiter HB, Burke SM, Cox T, Barben CP, Mythen MG, Calverley P, Palmer DH, Grocott MPW, Jack S. The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): study protocol for a randomised controlled trial. Trials 2016; 17:24. [PMID: 26762365 PMCID: PMC4710998 DOI: 10.1186/s13063-015-1149-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 12/29/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging. METHODS/DESIGN The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ([Formula: see text] at [Formula: see text]) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading. DISCUSSION The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT01914068 (received: 7 June 2013). SPONSOR University Hospital Southampton NHS Foundation Trust.
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Affiliation(s)
- Lisa Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - Malcolm A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK.
| | - Graham J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
| | - Harry B Rossiter
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9JT, UK.
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, Los Angles Biomedical Research Institute, 1124 W Carson St, Torrance, CA, 90502, USA.
| | - Shaunna M Burke
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Clarendon Way, Leeds, LS2 9JT, UK.
| | - Trevor Cox
- Departments of Molecular and Clinical Cancer Medicine and Biostatistics, University of Liverpool, Liverpool, UK.
| | - Christopher P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.
| | - Michael G Mythen
- Anaesthesia and Critical Care, University College London, London, UK.
| | - Peter Calverley
- Institute of Ageing and Chronic Disease, Aintree University Hospital, Liverpool, UK.
| | - Daniel H Palmer
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, UK and The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK.
| | - Michael P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - Sandy Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
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Loughney L, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise intervention in people with cancer undergoing neoadjuvant cancer treatment and surgery: A systematic review. Eur J Surg Oncol 2015; 42:28-38. [PMID: 26506862 DOI: 10.1016/j.ejso.2015.09.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/22/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Neoadjuvant cancer treatment decreases physical fitness. Low levels of physical fitness are associated with poor surgical outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity that may contribute to improving physical fitness. This systematic review evaluates the evidence in support of exercise training in people with cancer undergoing the "dual hit" of neoadjuvant cancer treatment and surgery. METHODS We conducted a systematic database search of Embase Ovid, Ovid Medline without Revisions, SPORTDiscus, Web of Science, Cochrane Central Register of Controlled Trials Library and ClinicalTrials.gov to identify trials addressing the effect of exercise training in people scheduled for neoadjuvant cancer treatment and surgery. Data extraction and analysis were based on a pre-defined plan. RESULTS The database search yielded 6489 candidate abstracts. Ninety-four references included the required terms. Four studies were eligible for inclusion (breast cancer, locally advanced rectal cancer). All studies reported that exercise training was safe and feasible and that adherence rates were acceptable (66-96%). In-hospital exercise training improves physical fitness however the impact on HRQoL and other clinical important outcomes was uncertain. CONCLUSION This is the first systematic review of the effects of exercise training in people scheduled for "dual-hit" treatment. This evidence synthesis indicates that this approach is safe and feasible but that there are insufficient controlled trials in this area to draw reliable conclusions about the efficacy of such an intervention, the optimal characteristics of the intervention, or the impact on clinical or patient reported outcomes.
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Affiliation(s)
- L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
| | - G J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
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Loughney L, West MA, Kemp GJ, Grocott MPW, Jack S. Exercise intervention in people with cancer undergoing adjuvant cancer treatment following surgery: A systematic review. Eur J Surg Oncol 2015; 41:1590-602. [PMID: 26358569 DOI: 10.1016/j.ejso.2015.08.153] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/30/2015] [Accepted: 08/04/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Remaining physically active during and after cancer treatment is known to improve associated adverse effects, improve overall survival and reduce the probability of relapse. This systematic review addresses the question: is an exercise training programme beneficial in people with cancer undergoing adjuvant cancer treatment following surgery. METHODS A systematic database search of Embase, Ovid, Medline without Revisions, SPORTDiscus, Web of Science, Cochrane Library and ClinicalTrials.gov for any randomised controlled trials (RCT) or non-RCT addressing the effect of an exercise training programme in those having adjuvant cancer treatment following surgery was conducted. RESULTS The database search yielded 6489 candidate abstracts of which 94 references included the required terms. A total of 17 articles were included in this review. Exercise training is safe and feasible in the adjuvant setting and furthermore may improve measures of physical fitness and health related quality of life (HRQoL). CONCLUSION This is the first systematic review on exercise training interventions in people with cancer undergoing adjuvant cancer treatment following surgery. Due to the lack of adequately powered RCTs in this area, it remains unclear whether exercise training in this context improves clinical outcomes other physical fitness and HRQoL. It remains unclear what is the optimal timing of initiation of an exercise programme and what are the best combinations of elements within an exercise training programme to optimise training efficacy. Furthermore, it is unclear if initiating such exercise programmes at cancer diagnosis may have a long-lasting effect on physically activity throughout the subsequent life course.
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Affiliation(s)
- L Loughney
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - G J Kemp
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Department of Musculoskeletal Biology and MRC, Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
| | - S Jack
- Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, CE93, MP24, Tremona Road, Southampton, SO16 6YD, UK
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West MA, Parry M, Asher R, Key A, Walker P, Loughney L, Pintus S, Duffy N, Jack S, Torella F. The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms--A blinded interventional study. Br J Anaesth 2015; 114:878-85. [PMID: 25716221 DOI: 10.1093/bja/aev026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group. METHODS We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. RESULTS Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ). CONCLUSIONS Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. CLINICAL TRIAL REGISTRATION NCT 02106286.
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Affiliation(s)
- M A West
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - M Parry
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Waterhouse Building, University of Liverpool, Liverpool, UK
| | - A Key
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - P Walker
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - L Loughney
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - S Pintus
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building
| | - N Duffy
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - S Jack
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - F Torella
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Liverpool Vascular & Endovascular Service, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
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West MA, Loughney L, Lythgoe D, Barben CP, Adams VL, Bimson WE, Grocott MPW, Jack S, Kemp GJ. The effect of neoadjuvant chemoradiotherapy on whole-body physical fitness and skeletal muscle mitochondrial oxidative phosphorylation in vivo in locally advanced rectal cancer patients--an observational pilot study. PLoS One 2014; 9:e111526. [PMID: 25478898 PMCID: PMC4257525 DOI: 10.1371/journal.pone.0111526] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/26/2014] [Indexed: 11/18/2022] Open
Abstract
Background In the United Kingdom, patients with locally advanced rectal cancer routinely receive neoadjuvant chemoradiotherapy. However, the effects of this on physical fitness are unclear. This pilot study is aimed to investigate the effect of neoadjuvant chemoradiotherapy on objectively measured in vivo muscle mitochondrial function and whole-body physical fitness. Methods We prospectively studied 12 patients with rectal cancer who completed standardized neoadjuvant chemoradiotherapy, recruited from a large tertiary cancer centre, between October 2012 and July 2013. All patients underwent a cardiopulmonary exercise test and a phosphorus magnetic resonance spectroscopy quadriceps muscle exercise-recovery study before and after neoadjuvant chemoradiotherapy. Data were analysed and reported blind to patient identity and clinical course. Primary variables of interest were the two physical fitness measures; oxygen uptake at estimated anaerobic threshold and oxygen uptake at Peak exercise (ml.kg−1.min−1), and the post-exercise phosphocreatine recovery rate constant (min−1), a measure of muscle mitochondrial capacity in vivo. Results Median age was 67 years (IQR 64–75). Differences (95%CI) in all three primary variables were significantly negative post-NACRT: Oxygen uptake at estimated anaerobic threshold −2.4 ml.kg−1.min−1 (−3.8, −0.9), p = 0.004; Oxygen uptake at Peak −4.0 ml.kg−1.min−1 (−6.8, −1.1), p = 0.011; and post-exercise phosphocreatine recovery rate constant −0.34 min−1 (−0.51, −0.17), p<0.001. Conclusion The significant decrease in both whole-body physical fitness and in vivo muscle mitochondrial function raises the possibility that muscle mitochondrial mechanisms, no doubt multifactorial, may be important in deterioration of physical fitness following neoadjuvant chemoradiotherapy. This may have implications for targeted interventions to improve physical fitness pre-surgery. Trial Registration Clinicaltrials.gov registration NCT01859442
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Affiliation(s)
- Malcolm A. West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Department of Musculoskeletal Biology and MRC – Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- Magnetic Resonance and Image Analysis Research Centre (MARIARC), University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Lisa Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Daniel Lythgoe
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, United Kingdom
| | - Christopher P. Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Valerie L. Adams
- Magnetic Resonance and Image Analysis Research Centre (MARIARC), University of Liverpool, Liverpool, United Kingdom
| | - William E. Bimson
- Magnetic Resonance and Image Analysis Research Centre (MARIARC), University of Liverpool, Liverpool, United Kingdom
| | - Michael P. W. Grocott
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Department of Musculoskeletal Biology and MRC – Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Sandy Jack
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Department of Musculoskeletal Biology and MRC – Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Graham J. Kemp
- Department of Musculoskeletal Biology and MRC – Arthritis Research UK Centre for Integrated Research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- Magnetic Resonance and Image Analysis Research Centre (MARIARC), University of Liverpool, Liverpool, United Kingdom
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West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 2014. [PMID: 25274049 DOI: 10.1093/bja/aeu318.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients requiring surgery for locally advanced rectal cancer often additionally undergo neoadjuvant chemoradiotherapy (NACRT), of which the effects on physical fitness are unknown. The aim of this feasibility and pilot study was to investigate the effects of NACRT and a 6 week structured responsive exercise training programme (SRETP) on oxygen uptake [Formula: see text] at lactate threshold ([Formula: see text]) in such patients. METHODS We prospectively studied 39 consecutive subjects (27 males) with T3-4/N+ resection margin threatened rectal cancer who completed standardized NACRT. Subjects underwent cardiopulmonary exercise testing at baseline (pre-NACRT), at week 0 (post-NACRT), and week 6 (post-SRETP). Twenty-two subjects undertook a 6 week SRETP on a training bike (three sessions per week) between week 0 and week 6 (exercise group). These were compared with 17 contemporaneous non-randomized subjects (control group). Changes in [Formula: see text] at [Formula: see text] over time and between the groups were compared using a compound symmetry covariance linear mixed model. RESULTS Of 39 recruited subjects, 22 out of 22 (exercise) and 13 out of 17 (control) completed the study. There were differences between the exercise and control groups at baseline [age, ASA score physical status, World Health Organisation performance status, and Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) predicted mortality]. In all subjects, [Formula: see text] at [Formula: see text] significantly reduced between baseline and week 0 [-1.9 ml kg(-1) min(-1); 95% confidence interval (CI) -1.3, -2.6; P<0.0001]. In the exercise group, [Formula: see text] at [Formula: see text] significantly improved between week 0 and week 6 (+2.1 ml kg(-1) min(-1); 95% CI +1.3, +2.9; P<0.0001), whereas the control group values were unchanged (-0.7 ml kg(-1) min(-1); 95% CI -1.66, +0.37; P=0.204). CONCLUSIONS NACRT before rectal cancer surgery reduces physical fitness. A structured exercise intervention is feasible post-NACRT and returns fitness to baseline levels within 6 weeks. CLINICAL TRIAL REGISTRATION NCT 01325909.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Lythgoe
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Waterhouse Building, Liverpool, UK
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK
| | | | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S Jack
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
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Jack S, West MA, Raw D, Marwood S, Ambler G, Cope TM, Shrotri M, Sturgess RP, Calverley PMA, Ottensmeier CH, Grocott MPW. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol 2014. [PMID: 24731268 DOI: 10.1016/j.ejso.2014.03.010)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) followed by surgery for resectable oesophageal or gastric cancer improves outcome when compared with surgery alone. However NAC has adverse effects. We assess here whether NAC adversely affects physical fitness and whether such an effect is associated with impaired survival following surgery. METHODS We prospectively studied 116 patients with oesophageal or gastric cancer to assess the effect of NAC on physical fitness, of whom 89 underwent cardiopulmonary exercise testing (CPET) before NAC and proceeded to surgery. 39 patients were tested after all cycles of NAC but prior to surgery. Physical fitness was assessed by measuring oxygen uptake (VO₂ in ml kg(-1) min(-1)) at the estimated lactate threshold (θL) and at peak exercise (VO₂ peak in ml kg(-1) min(-1)). RESULTS VO₂ at θL and at peak were significantly lower after NAC compared to pre-NAC values: VO₂ at θL 14.5 ± 3.8 (baseline) vs. 12.3 ± 3.0 (post-NAC) ml kg(-1) min(-1); p ≤ 0.001; VO₂ peak 20.8 ± 6.0 vs. 18.3 ± 5.1 ml kg(-1) min(-1); p ≤ 0.001; absolute VO₂ (ml min(-1)) at θL and peak were also lower post-NAC; p ≤ 0.001. Decreased baseline VO₂ at θL and peak were associated with increased one year mortality in patients who completed a full course of NAC and had surgery; p = 0.014. CONCLUSION NAC before cancer surgery significantly reduced physical fitness in the overall cohort. Lower baseline fitness was associated with reduced one-year-survival in patients completing NAC and surgery, but not in patients who did not complete NAC. It is possible that in some patients the harms of NAC may outweigh the benefits. Trials Registry Number: NCT01335555.
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Affiliation(s)
- S Jack
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - M A West
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - D Raw
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - S Marwood
- Liverpool Hope University, Hope Park, Liverpool, United Kingdom.
| | - G Ambler
- Statistical Science, University College London, Torrington Place, London, United Kingdom.
| | - T M Cope
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - M Shrotri
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - R P Sturgess
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - P M A Calverley
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - C H Ottensmeier
- Cancer Sciences Division and Department of Medical Oncology, University Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR/CR-UK Experimental Cancer Medicine Centre, Southampton, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
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West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 2014; 114:244-51. [PMID: 25274049 DOI: 10.1093/bja/aeu318] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients requiring surgery for locally advanced rectal cancer often additionally undergo neoadjuvant chemoradiotherapy (NACRT), of which the effects on physical fitness are unknown. The aim of this feasibility and pilot study was to investigate the effects of NACRT and a 6 week structured responsive exercise training programme (SRETP) on oxygen uptake [Formula: see text] at lactate threshold ([Formula: see text]) in such patients. METHODS We prospectively studied 39 consecutive subjects (27 males) with T3-4/N+ resection margin threatened rectal cancer who completed standardized NACRT. Subjects underwent cardiopulmonary exercise testing at baseline (pre-NACRT), at week 0 (post-NACRT), and week 6 (post-SRETP). Twenty-two subjects undertook a 6 week SRETP on a training bike (three sessions per week) between week 0 and week 6 (exercise group). These were compared with 17 contemporaneous non-randomized subjects (control group). Changes in [Formula: see text] at [Formula: see text] over time and between the groups were compared using a compound symmetry covariance linear mixed model. RESULTS Of 39 recruited subjects, 22 out of 22 (exercise) and 13 out of 17 (control) completed the study. There were differences between the exercise and control groups at baseline [age, ASA score physical status, World Health Organisation performance status, and Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) predicted mortality]. In all subjects, [Formula: see text] at [Formula: see text] significantly reduced between baseline and week 0 [-1.9 ml kg(-1) min(-1); 95% confidence interval (CI) -1.3, -2.6; P<0.0001]. In the exercise group, [Formula: see text] at [Formula: see text] significantly improved between week 0 and week 6 (+2.1 ml kg(-1) min(-1); 95% CI +1.3, +2.9; P<0.0001), whereas the control group values were unchanged (-0.7 ml kg(-1) min(-1); 95% CI -1.66, +0.37; P=0.204). CONCLUSIONS NACRT before rectal cancer surgery reduces physical fitness. A structured exercise intervention is feasible post-NACRT and returns fitness to baseline levels within 6 weeks. CLINICAL TRIAL REGISTRATION NCT 01325909.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Lythgoe
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Waterhouse Building, Liverpool, UK
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK
| | | | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - M P W Grocott
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S Jack
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, 3rd Floor Clinical Sciences Building, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
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West MA, Parry MG, Lythgoe D, Barben CP, Kemp GJ, Grocott MPW, Jack S. Cardiopulmonary exercise testing for the prediction of morbidity risk after rectal cancer surgery. Br J Surg 2014; 101:1166-72. [PMID: 24916313 DOI: 10.1002/bjs.9551] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 03/15/2014] [Accepted: 04/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study investigated the relationship between objectively measured physical fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after rectal cancer surgery. METHODS Patients scheduled for rectal cancer surgery underwent preoperative CPET (reported blind to patient characteristics) with recording of morbidity (recorded blind to CPET variables). Non-parametric receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Of 105 patients assessed, 95 (72 men) were included; ten patients had no surgery and were excluded (3 by choice, 7 owing to unresectable metastasis). Sixty-eight patients had received neoadjuvant treatment. ROC curve analysis of oxygen uptake (V˙o2 ) at estimated lactate threshold (θ^L ) and peak V˙o2 gave an area under the ROC curve of 0·87 (95 per cent confidence interval 0·78 to 0·95; P < 0·001) and 0·85 (0·77 to 0·93; P < 0·001) respectively, indicating that they can help discriminate patients at risk of postoperative morbidity. The optimal cut-off points identified were 10·6 and 18·6 ml per kg per min for V˙o2 at θ^L and peak respectively. CONCLUSION CPET can help predict morbidity after rectal cancer surgery.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Department of Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK; Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, Liverpool, UK; Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK
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West MA, Loughney L, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S. The effects of neoadjuvant chemoradiotherapy on physical fitness and morbidity in rectal cancer surgery patients. Eur J Surg Oncol 2014; 40:1421-8. [PMID: 24784775 DOI: 10.1016/j.ejso.2014.03.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/15/2014] [Accepted: 03/22/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NACRT) followed by surgery for resectable locally advanced rectal cancer improves outcome compared with surgery alone. Our primary hypothesis was that NACRT impairs objectively-measured physical fitness. We also wished to explore the relationship between fitness and postoperative outcome. METHOD In an observational study, we prospectively studied 27 consecutive patients, of whom 25 undertook cardiopulmonary exercise testing (CPET) 2 weeks before and 7 weeks after standardized NACRT, then underwent surgery. In-hospital post-operative morbidity and mortality were recorded. Patients were followed up to 1 year for mortality. Data was analysed blind to clinical details. Receiver-operating characteristic (ROC) analysis defined the predictive value of CPET for in-hospital morbidity at day 5. RESULTS Oxygen uptake ( [Formula: see text] in ml kg(-1) min(-1)) at estimated lactate threshold (θˆL) and at peak exercise ( [Formula: see text] at peak in ml kg(-1) min(-1)) both significantly decreased post-NACRT: [Formula: see text] at θˆL 12.1 (pre-NACRT) vs. 10.6 (post-NACRT), p < 0.001 (95%CI -1.7, -1.2); [Formula: see text] at peak 18.1 vs. 16.7, p < 0.001 (95%CI -3.1, -1.0). Optimal [Formula: see text] at θˆL and peak pre-NACRT for predicting postoperative morbidity were 12.0 and 18.1 ( [Formula: see text] at θˆL - AUC = 0.71, 77% sensitive and 75% specific; [Formula: see text] at peak - AUC = 0.75, 78% sensitive and 76% specific). Optimal [Formula: see text] at θˆL and peak post-NACRT for predicting postoperative morbidity were 10.7 and 16.7 ( [Formula: see text] at θˆL - AUC = 0.72, 77% sensitive and 83% specific; [Formula: see text] at peak - AUC = 0.80, 85% sensitive and 83% specific). CONCLUSION NACRT before major rectal cancer surgery significantly decreased physical fitness as assessed by CPET. TRIALS REGISTRY NUMBER NCT01334593.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - L Loughney
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - C P Barben
- Colorectal Surgery Research Group, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.
| | - R Sripadam
- Clatterbridge Cancer Centre, Wirral, United Kingdom.
| | - G J Kemp
- Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - M P W Grocott
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - S Jack
- Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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Jack S, West MA, Raw D, Marwood S, Ambler G, Cope TM, Shrotri M, Sturgess RP, Calverley PMA, Ottensmeier CH, Grocott MPW. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol 2014; 40:1313-20. [PMID: 24731268 DOI: 10.1016/j.ejso.2014.03.010] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) followed by surgery for resectable oesophageal or gastric cancer improves outcome when compared with surgery alone. However NAC has adverse effects. We assess here whether NAC adversely affects physical fitness and whether such an effect is associated with impaired survival following surgery. METHODS We prospectively studied 116 patients with oesophageal or gastric cancer to assess the effect of NAC on physical fitness, of whom 89 underwent cardiopulmonary exercise testing (CPET) before NAC and proceeded to surgery. 39 patients were tested after all cycles of NAC but prior to surgery. Physical fitness was assessed by measuring oxygen uptake (VO₂ in ml kg(-1) min(-1)) at the estimated lactate threshold (θL) and at peak exercise (VO₂ peak in ml kg(-1) min(-1)). RESULTS VO₂ at θL and at peak were significantly lower after NAC compared to pre-NAC values: VO₂ at θL 14.5 ± 3.8 (baseline) vs. 12.3 ± 3.0 (post-NAC) ml kg(-1) min(-1); p ≤ 0.001; VO₂ peak 20.8 ± 6.0 vs. 18.3 ± 5.1 ml kg(-1) min(-1); p ≤ 0.001; absolute VO₂ (ml min(-1)) at θL and peak were also lower post-NAC; p ≤ 0.001. Decreased baseline VO₂ at θL and peak were associated with increased one year mortality in patients who completed a full course of NAC and had surgery; p = 0.014. CONCLUSION NAC before cancer surgery significantly reduced physical fitness in the overall cohort. Lower baseline fitness was associated with reduced one-year-survival in patients completing NAC and surgery, but not in patients who did not complete NAC. It is possible that in some patients the harms of NAC may outweigh the benefits. Trials Registry Number: NCT01335555.
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Affiliation(s)
- S Jack
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - M A West
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - D Raw
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - S Marwood
- Liverpool Hope University, Hope Park, Liverpool, United Kingdom.
| | - G Ambler
- Statistical Science, University College London, Torrington Place, London, United Kingdom.
| | - T M Cope
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - M Shrotri
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - R P Sturgess
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom.
| | - P M A Calverley
- Respiratory Research Group, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, United Kingdom; Department of Musculoskeletal Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.
| | - C H Ottensmeier
- Cancer Sciences Division and Department of Medical Oncology, University Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR/CR-UK Experimental Cancer Medicine Centre, Southampton, United Kingdom.
| | - M P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, United Kingdom; Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom; Anaesthesia and Critical Care Research Unit, University Southampton NHS Foundation Trust, Southampton, United Kingdom.
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West MA, Lythgoe D, Barben CP, Noble L, Kemp GJ, Jack S, Grocott MPW. Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 2013; 112:665-71. [PMID: 24322573 DOI: 10.1093/bja/aet408] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative complications are associated with reduced fitness. Cardiopulmonary exercise testing (CPET) has been used in risk stratification. We investigated the relationship between preoperative CPET and in-hospital morbidity in major colonic surgery. METHODS We prospectively studied 198 patients undergoing major colonic surgery (excluding neoadjuvant cancer therapy), performing preoperative CPET (reported blind to clinical state), and recording morbidity (assessed blind to CPET), postoperative outcome, and length of stay. RESULTS Of 198 patients, 62 were excluded: 11 had emergency surgery, 25 had no surgery, 23 had incomplete data, and three were unable to perform CPET. One hundred and thirty-six (89 males, 47 females) were available for analysis. The median age was 71 [inter-quartile range (IQR) 62-77] yr. Sixty-five patients (48%) had a complication at day 5 after operation. Measurements significantly lower in patients with complications than those without were O2 uptake (VO₂) at estimated lactate threshold (θ(L)) [median 9.9 (IQR 8.3-12.7) vs 11.2 (9.5-14.2) ml kg(-1) min(-1), P<0.01], VO₂ at peak [15.2 (12.6-18.1) vs 17.2 (13.7-22.5) ml kg(-1) min(-1), P=0.01], and ventilatory equivalent for CO2 (V(E)/VCO₂) at θ(L) [31.3 (28.0-34.8) vs 33.9 (30.0-39.1), P<0.01]. A final multivariable logistic regression model contained VO₂ at θ(L) {one-point change odds ratio (OR) 0.77 [95% confidence interval (CI) 0.66-0.89], P<0.0005; two-point change OR 0.61 (0.46-0.81) and gender [OR 4.42 (1.78-9.88), P=0.001]}, and was reasonably able to discriminate those with and without complications (AUC 0.71, CI 0.62-0.80, 68% sensitivity, 65% specificity). CONCLUSIONS CPET variables are associated with postoperative morbidity. A multivariable model with VO₂ at θ(L) and gender discriminates those with complications after colonic surgery.
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Affiliation(s)
- M A West
- Colorectal Surgery Research Group, 3rd Floor Clinical Sciences Building, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK
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West MA, Horwood JF, Staves S, Jones C, Goulden MR, Minford J, Lamont G, Baillie CT, Rooney PS. Potential benefits of fast-track concepts in paediatric colorectal surgery. J Pediatr Surg 2013; 48:1924-30. [PMID: 24074669 DOI: 10.1016/j.jpedsurg.2013.02.063] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/20/2013] [Accepted: 02/05/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Structured care pathways optimising peri-operative care have been shown to significantly enhance post-operative recovery. We aim to determine if enhanced recovery after surgery (ERAS) principles could provide benefit for paediatric patients undergoing major colorectal resection for inflammatory bowel disease (IBD). METHODS Children undergoing elective bowel resection for IBD at a regional paediatric unit using standard methods of peri-operative care were matched to adult cases from an associated tertiary referral university hospital already using an ERAS program. Cases were matched for disease type, gender, operative procedure, and ASA grade. RESULTS Forty-four children undergoing fifty procedures were identified. Thirty-four were matched to adult cases. Total length of stay in the paediatric group was significantly longer than in the adult group (6 vs. 9 days; P=0.001). Paediatric patients were slower to start solid diet (1 vs. 4 days; P<0.0001) and were slower to mobilize post-operatively (1 vs. 4 days; P<0.0001). No difference was seen in time to restoration of bowel function (2 vs. 3 days; P=0.49). Thirty day readmissions and total in-hospital morbidity were not significantly different between the groups. CONCLUSION Potentially, application of ERAS in paediatric surgery could accelerate recovery and reduce length of post-operative stay thereby improving quality and efficiency of care.
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Affiliation(s)
- Malcolm A West
- Department of Colorectal Surgery, Royal Liverpool and Broadgreen University Teaching Hospitals, Liverpool, Merseyside, UK.
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Ekwueme KC, West MA, Rooney PS. Emergency first presentation of colorectal cancer following air travel: a case series. JRSM Short Rep 2011; 2:36. [PMID: 21637397 PMCID: PMC3105456 DOI: 10.1258/shorts.2011.011002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kingsley C Ekwueme
- Department of Surgery, Royal Liverpool and Broadgreen University Hospitals , Liverpool , UK
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West MA, Sangani C, Toh E. Tibialis posterior tendon rupture associated with a closed medial malleolar fracture: a case report and review of the literature. J Foot Ankle Surg 2010; 49:565.e9-12. [PMID: 20829074 DOI: 10.1053/j.jfas.2010.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 07/19/2010] [Indexed: 02/03/2023]
Abstract
We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient's progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.
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Affiliation(s)
- Malcolm A West
- Department of Trauma and Orthopaedics, Southport and Ormskirk NHS Hospital Trust, Southport, UK.
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Marusak RA, Guy JS, Abdul-Aziz TA, West MA, Fletcher OJ, Day JM, Zsak L, Barnes HJ. Parvovirus-associated cerebellar hypoplasia and hydrocephalus in day old broiler chickens. Avian Dis 2010; 54:156-60. [PMID: 20408417 DOI: 10.1637/8976-070709-case.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cerebellar hypoplasia and hydrocephalus were identified in day old broiler chickens showing nervous signs, impaired mobility, and diarrhea. At postmortem examination, brains of chickens were misshapen and cerebellums were smaller than normal. Microscopically, cerebellar folia were reduced in size and irregularly shaped, and the ventricles were widely distended. Affected cerebellums had focal areas along the base of folia where the internal granular cell layer had been lost, and Purkinje cells were disorganized and located within the molecular layer. Parvovirus DNA was detected by polymerase chain reaction in three of nine brains with oligonucleotide primers designed for amplification of chicken and turkey parvoviruses. On the basis of phylogenetic analyses, the detected virus was most closely related to chicken parvoviruses. These findings suggest that a chicken parvovirus might cause a neurologic disease of young chickens characterized by cerebellar hypoplasia and hydrocephalus; however, its role as the cause of the disease remains to be confirmed.
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Affiliation(s)
- R A Marusak
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough Street, Raleigh, NC 27606, USA
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