Abstract ES9-3: Balancing Risks of Deconditioning vs. Weight-Lifting for Breast Cancer Survivors

Background: Clinical guidelines for breast cancer survivors with and at-risk for lymphedema have advised against upper body exercise, preventing them from obtaining established health benefits of weight-lifting. The primary hypotheses of the Physical Activity and Lymphedema Trial were that lymphedema onset and worsening would not differ after a one-year weightlifting intervention compared to no exercise among survivors at risk for and with breast cancer-related lymphedema.

Methods: We performed a randomized controlled trial of a twice-weekly progressive weight-lifting intervention involving 141 breast cancer survivors with stable arm lymphedema at study entry and 154 survivors at-risk for lymphedema at study entry. Treatment group participants were provided a gym membership and 13 weeks of supervised instruction; the remaining nine months were unsupervised. Control group participants were provided the intervention after study completion. The primary outcome was the change in arm swelling at one year, as measured by water volumetry of the affected and unaffected arms. Secondary outcomes included the clinician defined incidence of onset and exacerbations of lymphedema, lymphedema symptoms, and muscle strength. Participants with lymphedema were required to wear a well-fitted compression garment while weight-lifting.

Results: Among the women who entered the study with lymphedema, the proportion who experienced a 5% or greater increase in arm swelling (interlimb difference) was similar in the treatment and control groups (11% versus 12%; cumulative incidence ratio [95% confidence interval], 1.00 (0.88 to 1.13) As compared with the control group, the women in the intervention group with lymphedema had greater improvements in self-reported lymphedema symptom severity (p=0.03), and a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14% versus 29% in the control group, p= 0.04). Among the women who entered the study without lymphedema, more control than treatment group women experienced lymphedema onset defined by 5% increase in interlimb difference (17 versus 11%, p = 0.35). Among higher risk women (5+ lymph nodes removed), this comparison was statistically significant (22 versus 7%, p=0.04). Clinician-defined BCRL onset occurred in 1 treatment and 3 control group women (p=0.62).

Conclusions: Slowly progressive weight-lifting had no significant impact on arm swelling among breast cancer survivors with lymphedema, and resulted in a reduced incidence of lymphedema flares and improvement in symptoms. In breast cancer survivors at risk for lymphedema, a program of slowly progressive weight-lifting, compared with no intervention, did not result in increased incidence of lymphedema. In secondary analyses, women with 5+ nodes removed who did weight-lifting were less likely to experience increases in arm swelling.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr ES9-3.

Functional assessment of performance status in patients with myelofibrosis (MF): Utility and feasibility of the 6-minute walk test (6MWT)

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Background: Patients with Myelofibrosis (MF) suffer from significant fatigue, constitutional symptoms and splenomegaly (Mesa et. al. Cancer 2007) not improved by current therapy. The 6MWT measures functional status in cardio-pulmonary clinical trials. We undertook a prospective feasibility study of the 6MWT in MF patients for use in therapeutic clinical trials. Methods: MF patients (able to walk, normal vitals, not on a JAK2 inhibitor) were eligible. Baseline features and the MF symptom assessment form (MFSAF: Mesa et. al. Blood 2008) was administered. The 6MWT was administered in standardized fashion (American Thoracic Society: observed laps of a 30 - 35 meter long course, indoors, level, without encouragement), and then repeated for further validation. Results: Safety of the 6MWT: Fifty five MF patients were enrolled with only 2 patients (3%) stopping the 6MWT early secondary to fatigue. There were no adverse events attributable to undergoing the 6MWT in test subjects. Results of the 6MWT: Current results of our ongoing study demonstrate compared to age matched healthy volunteer controls, males with MF walk approximately 90 meters less and females with MF walk approximately 60 meters less (Table). Correlation of 6MWT Results to Patient Reported Symptoms (MFSAF): Results from the MFSAF demonstrated the fatigue (as assessed by the brief fatigue inventory (Medoza et. al. Cancer 1999) embedded in the MFSAF) showed patients with a higher BFI (i.e., more fatigued) had more impairment in the 6MWT than those with low BFI scores. Symptomatic burden as assessed by the MFSAF were typical for MF, correlation of individual symptom severity with 6MWT will require a larger trial for adequate power. Conclusions: The 6MWT can be safely performed in un-selected MF patients, and demonstrates a functional deficit compared to published controls. Validation of the ability of the 6MWT to measure functional improvements in MF patients as a response to novel therapy trials is planned.

[Table: see text]

No significant financial relationships to disclose.

Minimal arm lymphedema after breast conservation therapy

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Background: Arm lymphedema (ALE) is a serious consequence of the treatment for breast carcinoma. The objective of the current retrospective study was to analyze the time-course of minimal ALE after breast conservation treatment for early stage breast cancer. Methods: The study cohort was drawn from consecutive stage I or II patients who underwent breast conservation therapy including axillary staging followed by radiation. During follow up assessments after treatment, measurements of arm circumference were frequently performed at regular intervals, for clinically evident swelling of the arm or for complaints of swelling of the arm. ALE was documented in 274 of 1861 (15%) patients. 109 patients, 6% of overall group, and 40% of the patients with lymphedema, presented with minimal ALE, defined as a difference of 2 cm or less between the affected and unaffected arms. Results: The median age of patients was 54 years. The median interval to develop ALE was 1 year. The median follow up was 11 years. Among all 109 patients with minimal grade ALE at the time of ALE diagnosis, 21%, 13% and 14% of the patients progressed to more severe grades of lymphedema after 1,3 and 5 years of follow-up, respectively (See table). 40% of the patients with minimal grade ALE received therapy for lymphedema. Despite treatment for minimal grade ALE, 37% of treated patients progressed to more severe grades of lymphedema at 1 year follow up, and 24% progressed at 3 and 5 years follow up. Conclusions: Minimal ALE after breast conservation therapy, including axillary staging, developed in 6% of stage I or II breast cancer patients. Minimal ALE has the potential to progress to more severe grade of ALE. Despite treatment for lymphedema for minimal grade ALE, some patients still progressed to more severe grades of lymphedema.

[Table: see text]

No significant financial relationships to disclose.

Rehabilitation of patients with advanced cancer

Despite growing interest in advanced cancer patients' quality of life, little attention has been directed toward preservation or recovery of their function. Although there is a dearth of supportive literature, extensive experience with other advanced disease populations suggests that standard, widely available rehabilitation strategies can enhance function in cancer. Logistic challenges to the provision of adequate rehabilitation to advanced cancer patients is discussed in this article, based on the author's experience and discussions in the literature. Common sources of functional impairment are reviewed with elucidation of rehabilitation approaches likely to benefit affected patients. Appropriate physical and occupational therapy techniques, as well as appropriate orthotics, assistive devices, and environmental modifications, are outlined for each of these impairments. In the author's view, rehabilitation should be considered for all advanced cancer patients experiencing functional decline. Pathways and referral patterns need to be established so that timely and appropriate functional restoration may occur.

Rehabilitation of patients with advanced cancer

Despite growing interest in advanced cancer patients' quality of life, little attention has been directed toward preservation or recovery of their function. Although there is a dearth of supportive literature, extensive experience with other advanced disease populations suggests that standard, widely available rehabilitation strategies can enhance function in cancer. Logistic challenges to the provision of adequate rehabilitation to advanced cancer patients is discussed in this article, based on the author's experience and discussions in the literature. Common sources of functional impairment are reviewed with elucidation of rehabilitation approaches likely to benefit affected patients. Appropriate physical and occupational therapy techniques, as well as appropriate orthotics, assistive devices, and environmental modifications, are outlined for each of these impairments. In the author's view, rehabilitation should be considered for all advanced cancer patients experiencing functional decline. Pathways and referral patterns need to be established so that timely and appropriate functional restoration may occur.

A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty

BACKGROUND

Reliance on "as-needed" analgesia following total knee arthroplasty may lead to inadequate control of pain and delayed recovery of function. Preemptive use of controlled-release opioids may improve pain control, accelerate recovery, and reduce the need for inpatient rehabilitative services. This study was designed to determine whether controlled-release opioids enhance post-arthroplasty pain control and facilitate functional recovery during rehabilitation.

METHODS

Fifty-nine patients admitted for inpatient rehabilitation following unilateral total knee arthroplasty were randomized to receive OxyContin (controlled-release oxycodone) (twenty-nine patients) or a placebo (thirty patients) every twelve hours. Both groups could receive on-request, immediate-release oxycodone (5 mg every four hours). The dose of study medication was increased on the basis of the frequency of requests for immediate-release oxycodone. Measures of interest included pain ratings as determined with a visual-analog scale, changes in the range of motion of the knee and quadriceps strength, and improvements in selected Functional Independence Measure scores during the first eight physical therapy sessions. The duration of the hospital stay for rehabilitation also was compared between the two groups.

RESULTS

Baseline demographic, clinical, and functional characteristics were similar between the OxyContin and placebo groups. Compared with the placebo group, the patients who received OxyContin reported significantly less pain as well as significantly greater range of motion of the knee (passive motion, p = 0.036; active motion, p< 0.001) and quadriceps strength (p = 0.001) by the eighth physical therapy session. The patients who received OxyContin also were discharged from the rehabilitation hospital at an average of 2.3 days earlier than the patients in the placebo group (p = 0.013).

CONCLUSIONS

Preemptive use of controlled-release oxycodone during rehabilitation following total knee arthroplasty leads to improved pain control, more rapid functional recovery, and a reduced need for inpatient rehabilitative services.

Alterations in phosphoinositide metabolism associated with 17 beta-estradiol and growth factor treatment of MCF-7 breast cancer cells

Steady-state levels of phosphatidyl inositol (PtdIns) turnover are examined in MCF-7 human breast cancer cells in response to estradiol treatment. Elevated levels of PtdIns are observed 12-24 h after estradiol treatment, occur at estradiol concentrations as low as 10(-12) M, and are competitively blocked by the antiestrogen LY117018. MCF-7 cells secrete a transforming growth factor (TGF) alpha-like material which can partly replace estradiol in conferring tumorgenicity in nude mice. We show that acute or chronic treatment of MCF-7 cells with TGF alpha results in elevated PtdIns turnover and that chronic treatment increases growth rate. In contrast TGF beta is growth inhibitory and blocks estradiol-induced increases in PtdIns turnover. A phosphatidyl inositol 4,5-bisphosphate specific phospholipase-C activity has been identified and is elevated in association with estradiol treatment. These data are consistent with estradiol-induced autocrine growth factors, including TGF alpha, acting through the PtdIns turnover pathway as part of their mechanism of action.