Perspectives of patients with metastatic breast cancer on physical exercise programs: results from a survey in five European countries

BACKGROUND

To successfully implement exercise programs for patients with metastatic breast cancer (MBC), services and patient education should consider patients' knowledge, preferences, values, and goals. Hence, gaining insight into their perspectives on exercise and exercise programming is important.

METHOD

In this cross-sectional survey, we recruited patients with MBC from the Netherlands, Germany, Poland, Spain, and Sweden. We collected data on patients' knowledge and skills about exercise and outcome expectations. We identified barriers to and facilitators of participation in exercise programs, and patients' preferences for program content and modes of exercise delivery.

RESULTS

A total of 420 patients participated in the survey. Respondents were, on average, 56.5 years old (SD 10.8) and 70% had bone metastases. Sixty-eight percent reported sufficient skills to engage in aerobic exercise, but only 35% did so for resistance exercise. Respondents expected exercise to have multiple physical benefits, but a few patients expected exercise to worsen their pain (5%). Not having access to an exercise program for cancer patients (27%), feeling too tired (23%), and/or weak (23%) were the most often reported barriers. Facilitators for exercising regularly were previous positive physical (72%) and emotional (68%) experiences with exercising, and receiving personalized advice from a physiotherapist or sport/fitness instructor (62%). Patients were most interested in walking and preferred exercising at a public gym, although there were differences by country. Fifty-seven percent did not know whether their insurance company reimburses exercise programs and only 9% would be willing to pay more than €50 per month to participate.

CONCLUSION

A large percentage of patients with MBC lack the skills to engage in regular exercise as recommended by exercise guidelines for people with cancer. Patients may benefit from personalized advice and appropriate training facilities to overcome barriers. When implementing exercise interventions, attention should be given to reimbursement and the relatively low willingness-to-pay.

PERSPECTIVEs on supervised exercise programs in people with metastatic breast cancer- a qualitative study in four European countries

PURPOSE

Supervised exercise is a potentially promising supportive care intervention for people with metastatic breast cancer (MBC), but research on the patients' perspective is limited. The aim of the current focus group study was to gain an in-depth understanding of MBC patients' perceived barriers, facilitators, and preferences for supervised exercise programs.

METHODS

Eleven online focus groups with, in total, 44 MBC patients were conducted in four European countries (Germany, Poland, Spain, Sweden). Main topics of the semi-structured discussions covered attitudes towards participation in supervised exercise programs, perceived facilitators, experienced barriers, and exercise preferences. Interviews were transcribed verbatim, translated into English, and coded based on a preliminary coding framework, supplemented by themes emerging during the sessions. The codes were subsequently examined for interrelations and re-organized into overarching clusters.

RESULTS

Participants had positive attitudes towards exercise, but experienced physical limitations and insecurities that inhibited their participation. They expressed a strong desire for exercise tailored to their needs, and supervision by an exercise professional. Participants also highlighted the social nature of group training as an important facilitator. They had no clear preference for exercise type, but rather favored a mixture of different activities. Flexible training modules were considered helpful to increase exercise program adherence.

CONCLUSIONS

MBC patients were generally interested in supervised exercise programs. They preferred group exercise that facilitates social interaction, but also expressed a need for individualized exercise programs. This suggests the relevance to develop flexible exercise programs that are adjusted to the individual's needs, abilities, and preferences.

OptiBra study, a randomized controlled trial on optimal postoperative bra support after breast cancer surgery

AIM

This randomized controlled trial aimed to compare two different postoperative bras after breast cancer surgery and evaluate their impact on primary outcome pain.

METHOD

The study included 201 patients scheduled for primary surgery (breast conserving surgery with sentinel node biopsy or axillary clearance, mastectomy, or mastectomy with primary implant reconstruction with sentinel node biopsy or axillary clearance). Participants were randomized to either a soft bra or stable bra with compression. The patients were recommended to use the bra 24 h/day for 3 weeks, record daily pain (NRS), analgesic use and hours of bra use.

RESULTS

Follow up was completed by 184 patients. No significant differences between the arms were found considering pain score over time, neither day 1-14, nor after 3 weeks. Sixty-eight percent of all patients, regardless of randomization, reported pain during the first 14 days. After 3 weeks 46% still reported pain in the operated breast. Among these, patients randomized to the stable bra with compression reported significantly lower pain score than those randomized to the soft bra. Patients who used the stable bra with compression reported significantly higher levels of comfort, sense of security during activity, less difficulty moving the arm, as well as support and stability for the operated breast compared to those using the soft bra.

CONCLUSION

Using a stable bra with compression is the optimal evidence-based choice after breast cancer surgery to reduce remaining pain 3 weeks after surgery, increasing mobility, comfort, and sense of security.

TRIAL REGISTRATION NUMBER

NCT04059835 at www.

CLINICALTRIALS

gov.

A pedagogical model to enhance nurses' ability to support patient learning: an educational design research study

OBJECTIVES

To design, apply, evaluate, and analyse a pedagogical model to enhance nurses' ability to create pedagogical encounters to support patients' learning.

METHODS

The study relies on an educational design research approach. A pedagogical model based on learning theories was designed, applied, evaluated, and analysed in a specialist nursing programme in cancer care. All students (n=28) who attended the programme accepted to participate in the evaluation of the model. Their perception of the learning activities was evaluated in a questionnaire, and 16 (57%) students responded. The students' learning was assessed in written assignments, including all students. Descriptive statistics, content analysis and theoretical reasoning, were used to analyse data and interpret the usefulness and shortcomings of the model.

RESULTS

The most appreciated learning activities were to study learning theories, observe pedagogical encounters, act as a critical friend, and document one's own pedagogical encounters. The written assignments about observing and performing their own pedagogical encounters with patients showed students' increased awareness of how to support patients' learning. The clinical supervisors' lack of pedagogical knowledge inhibited the feedback on students' performances.

CONCLUSIONS

The theoretical analysis of the evaluation identified strengths and needs for further development. The strengths tend to be the ongoing learning process created by learning activities supporting students to continuously study, experience, and apply their knowledge. Nurse supervisors and other stakeholders at the clinics are suggested to be involved in improving the design and require pedagogical competence. Further research should include observational and interview studies related to students' performance in pedagogical encounters.

Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial

Background

Advanced therapeutic strategies are often accompanied by significant adverse effects, which warrant equally progressive countermeasures. Physical exercise has proven an effective intervention to improve physical function and reduce fatigue in patients undergoing chemotherapy. Effects of high-intensity interval training (HIIT) in this population are not well established although HIIT has proven effective in other clinical populations. The aim of the OptiTrain trial was to examine the effects of concurrent resistance and high-intensity interval training (RT-HIIT) or concurrent moderate-intensity aerobic and high-intensity interval training (AT-HIIT), to usual care (UC) on pain sensitivity and physiological outcomes in patients with breast cancer during chemotherapy.

Methods

Two hundred and forty women were randomized to 16 weeks of RT-HIIT, AT-HIIT, or UC. Outcomes: cardiorespiratory fitness, muscle strength, body mass, hemoglobin levels, and pressure-pain threshold.

Results

Pre- to post-intervention, RT-HIIT (ES = 0.41) and AT-HIIT (ES = 0.42) prevented the reduced cardiorespiratory fitness found with UC. Handgrip strength (surgery side: RT-HIIT vs. UC: ES = 0.41, RT-HIIT vs. AT-HIIT: ES = 0.28; non-surgery side: RT-HIIT vs. UC: ES = 0.35, RT-HIIT vs. AT-HIIT: ES = 0.22) and lower-limb muscle strength (RT-HIIT vs. UC: ES = 0.66, RT-HIIT vs. AT-HIIT: ES = 0.23) were significantly improved in the RT-HIIT. Increases in body mass were smaller in RT-HIIT (ES = − 0.16) and AT-HIIT (ES = − 0.16) versus UC. RT-HIIT reported higher pressure-pain thresholds than UC (trapezius: ES = 0.46, gluteus: ES = 0.53) and AT-HIIT (trapezius: ES = 0.30).

Conclusion

Sixteen weeks of RT-HIIT significantly improved muscle strength and reduced pain sensitivity. Both exercise programs were well tolerated and were equally efficient in preventing increases in body mass and in preventing declines in cardiorespiratory fitness. These results highlight the importance of implementing a combination of resistance and high-intensity interval training during chemotherapy for women with breast cancer.

Adding high-intensity interval training to conventional training modalities: optimizing health-related outcomes during chemotherapy for breast cancer: the OptiTrain randomized controlled trial

Purpose

Exercise training is an effective and safe way to counteract cancer-related fatigue (CRF) and to improve health-related quality of life (HRQoL). High-intensity interval training has proven beneficial for the health of clinical populations. The aim of this randomized controlled trial was to compare the effects of resistance and high-intensity interval training (RT–HIIT), and moderate-intensity aerobic and high-intensity interval training (AT–HIIT) to usual care (UC) in women with breast cancer undergoing chemotherapy. The primary endpoint was CRF and the secondary endpoints were HRQoL and cancer treatment-related symptoms.

Methods

Two hundred and forty women planned to undergo chemotherapy were randomized to supervised RT–HIIT, AT–HIIT, or UC. Measurements were performed at baseline and at 16 weeks. Questionnaires included Piper Fatigue Scale, EORTC-QLQ-C30, and Memorial Symptom Assessment Scale.

Results

The RT–HIIT group was superior to UC for CRF: total CRF (p = 0.02), behavior/daily life (p = 0.01), and sensory/physical (p = 0.03) CRF. Role functioning significantly improved while cognitive functioning was unchanged for RT–HIIT compared to declines shown in the UC group (p = 0.04). AT–HIIT significantly improved emotional functioning versus UC (p = 0.01) and was superior to UC for pain symptoms (p = 0.03). RT–HIIT reported a reduced symptom burden, while AT–HIIT remained stable compared to deteriorations shown by UC (p < 0.01). Only RT–HIIT was superior to UC for total symptoms (p < 0.01).

Conclusions

16 weeks of resistance and HIIT was effective in preventing increases in CRF and in reducing symptom burden for patients during chemotherapy for breast cancer. These findings add to a growing body of evidence supporting the inclusion of structured exercise prescriptions, including HIIT, as a vital component of cancer rehabilitation.

Trial registration

Clinicaltrials.gov Registration Number: NCT02522260.

Optitrain: a randomised controlled exercise trial for women with breast cancer undergoing chemotherapy

BACKGROUND

Women with breast cancer undergoing chemotherapy suffer from a range of detrimental disease and treatment related side-effects. Exercise has shown to be able to counter some of these side-effects and improve physical function as well as quality of life. The primary aim of the study is to investigate and compare the effects of two different exercise regimens on the primary outcome cancer-related fatigue and the secondary outcomes muscle strength, function and structure, cardiovascular fitness, systemic inflammation, skeletal muscle gene activity, health related quality of life, pain, disease and treatment-related symptoms in women with breast cancer receiving chemotherapy. The second aim is to examine if any effects are sustained 1, 2, and 5 years following the completion of the intervention and to monitor return to work, recurrence and survival. The third aim of the study is to examine the effect of attendance and adherence rates on the effects of the exercise programme.

METHODS

This study is a randomised controlled trial including 240 women with breast cancer receiving chemotherapy in Stockholm, Sweden. The participants are randomly allocated to either: group 1: Aerobic training, group 2: Combined resistance and aerobic training, or group 3: usual care (control group). During the 5-year follow-up period, participants in the exercise groups will receive a physical activity prescription. Measurements for endpoints will take place at baseline, after 16 weeks (end of intervention) as well as after 1, 2 and 5 years.

DISCUSSION

This randomised controlled trial will generate substantial information regarding the effects of different types of exercise on the health of patients with breast cancer undergoing chemotherapy. We expect that dissemination of the knowledge gained from this study will contribute to developing effective long term strategies to improve the physical and psychosocial health of breast cancer survivors.

TRIAL REGISTRATION

OptiTrain - Optimal Training Women with Breast Cancer (OptiTrain), NCT02522260 ; Registration: June 9, 2015, Last updated version Feb 29, 2016. Retrospectively registered.

A randomized pilot study with daily walking during adjuvant chemotherapy for patients with breast and colorectal cancer

BACKGROUND

Physical activity during chemotherapy has been shown in several studies to reduce fatigue, improve symptoms and impact positively on health-related quality of life (HRQoL). Challenges associated with intervention studies on physical activity during cancer treatment relate to consistent adherence. The primary objective was to study feasibility and adherence of physical activity intervention among patients with cancer during adjuvant chemotherapy treatment. The secondary objective was to investigate the effects of physical activity on health aspects, including HRQoL, symptoms and surrogate markers for cardiovascular disease.

MATERIAL AND METHODS

This randomized controlled trial included patients with breast cancer (BRCA) and colorectal cancer (CRC) during adjuvant chemotherapy. The intervention continued for 10 weeks and included daily walks of 10 000 steps and a weekly supervised group walk. Adherence was assessed by a pedometer and the number of participants who reported step counts every week and percentage of participants who achieved the target steps every week.

RESULTS

Adherence average reached 91% during the intervention period; in total 74% completed the exercise intervention. The majority of the participants achieved an average of 83% of the target of 10 000 steps per day for 10 weeks. There was a significant increase in daily physical activity (p = 0.016) in the intervention group. Significant differences were also found for some breast cancer-specific symptoms [swelling, mobility and pain (p = 0.045)]. The study showed a relatively small weight gain an average of 0.9 kg in the intervention group and 1.3 kg in the control group.

CONCLUSION

Physical activity in the form of walking is feasible during adjuvant chemotherapy treatment despite increasing symptoms. The physical activity increased in the intervention group during the study time and had a positive impact on breast symptoms and the weight gain was lower in comparison to previous studies.

A longitudinal study on women?s experiences of life with breast cancer in anthroposophical (complementary) and conventional care

Earlier findings in different care settings have revealed that women with breast cancer admitted to anthroposophical clinics (complementary care) initially had lower quality of life scores compared with those in conventional care, but that the scores after 1 year increased significantly. The anthroposophical hospital in this study offers integrated conventional and anthroposophical healthcare therapies. The present study examines experiences of life among women with breast cancer during the 1-year follow-up of the original study. A second aim was to seek profiles of differences between 37 matched pairs of women with breast cancer. The mean age of the women was 48 years, and 17 of the 37 pairs had a local limited disease, whereas 20 pairs had an advanced disease. The findings highlight seven themes of described meaning. Important changes noticed after 1 year were an appreciation of the beauty of life, experiences of threat, introspection into self and meaning of life, and changes in the body. The experience of being stronger constitutes being existentially demanded, including weakness, vulnerability and strength. Some differences in profiles were noticed after 1 year, in that the group that received anthroposophical care seemed to be more orientated towards personal growth and meaning of life, whereas the matching group was more orientated towards external activities and bodily changes.

Long-term effects of eradication of Helicobacter pylori on relapse and histology in gastric ulcer patients: a two-year follow-up study

BACKGROUND

The main purpose of this study was to compare omeprazole (ome) plus two antibiotics (OMC) with omeprazole plus placebo (OP) with regard to gastric ulcer relapse for a period of 2 years in patients who were Helicobacter pylori-positive at inclusion.

METHODS

Using double-blind randomization 125 patients with gastric ulcer were treated with either OMC (ome 20 mg b.i.d., metronidazole 400 mg b.i.d., clarithromycin 250 mg b.i.d.) (n = 64) or OP (ome 20 mg and placebo) (n = 61) for 1 week, followed by ome 20-40 mg o.d. until healing was confirmed endoscopically after 4, 8 or 12 weeks. Endoscopy and H. pylori diagnostics using culture, histology and serology were performed 6, 12 and 24 months after treatment or at symptomatic relapse. At inclusion, 35% of the OMC group and 38% of the OP group were taking non-steroidal anti-inflammatory drugs (NSAIDs). Nine percent (11/125) of the ulcers were malignant.

RESULTS

The prevalence of H. pylori was 82% and the eradication rate 88% in the OMC group and 3% in the OP group. More than 90% of the ulcers were healed after 12 weeks. After 2 years, 76% of patients in the OMC group were in remission compared with 28% in the OP group (ITT) (P < 0.001). Sixty percent of patients in the OMC group that continued to take NSAIDs were in remission after 2 years compared with none in the OP group. Atrophy but not intestinal metaplasia decreased after treatment.

CONCLUSIONS

Gastric ulcers are mainly caused by H. pylori, and relapse is effectively prevented by H. pylori eradication, even in patients on NSAIDs.

Role of β-catenin in the developing cortical and hippocampal neuroepithelium

beta-Catenin plays a pivotal role in Wnt signaling during embryogenesis and is a component of adherens junctions. Since targeted disruption of the beta-catenin gene is lethal at gastrulation we have used a D6-Cre mouse line for conditional inactivation of beta-catenin in the mouse cerebral cortex and hippocampus after embryonic day (E) 10.5. In D6-Cre floxed beta-catenin mice, hippocampal CA1-CA2 fields are disrupted in similar manner as in Wnt-3a and LEF-1 mutants. The cortex of D6-Cre floxed beta-catenin mutants is strongly affected which contrasts with the normal cortex observed in Wnt-3a and LEF-1 mutants. Severe abnormalities in the organization of the neuroepithelium are observed that include disrupted interkinetic nuclear migration, loss of adherens junctions, impaired radial migration of neurons toward superficial layers and decreased cell proliferation after E15.5. At newborn stage, a premature disassembly of the radial glial scaffold and increased numbers of astrocytes are found in the cortex.

Forebrain-specific promoter/enhancer D6 derived from the mouse Dach1 gene controls expression in neural stem cells

Drosophila dachshund is involved in development of eye and limbs and in the development of mushroom bodies, a brain structure required for learning and memory in flies. Its mouse homologue mDach1 is expressed in various embryonic tissues, including limbs, the eye, the dorsal spinal cord and the forebrain. We have isolated a forebrain-specific 2.5-kb enhancer element termed D6 from the mouse mDach1 gene and created D6-LacZ and D6-green fluorescent protein (GFP) reporter gene mouse lines. In embryonic stages, the D6 enhancer activity is first detected at embryonic day 10.5 in scattered cells of the outbuldging cortical vesicles. By embryonic day 12.5, D6 activity expands throughout the developing neocortex and the hippocampus. In the adult mouse brain, D6 enhancer is active in neurons of the cortical plate, in the CA1 layer of the hippocampus and in cells of the subventricular zone and the ventricular ependymal zone. Adult mice also show D6 activity in the olfactory bulb and in the mamillary nucleus. Cultured D6-positive cells, which were derived from embryonic and postnatal brains, show characteristics of neural stem cells. They form primary and secondary neurospheres that differentiate into neurons and astrocytes as examined by cell-specific markers.Our results show that D6 enhancer exerts highly tissue-specific activity in the neurons of the neocortex and hippocampus and in neural stem cells. Moreover, the fluorescence cell sorting of D6-GFP cells from embryonic and postnatal stages allows specific selection of primary neural progenitors and their analysis.

Immunogenicity and reactogenicity of a new measles, mumps and rubella vaccine when administered as a second dose at 12 y of age

An open randomized trial involving 301 subjects was conducted in order to compare the reactogenicity and immunogenicity of a new measles, mumps and rubella (MMR) vaccine, SB MMR, with those of a commercial MMR vaccine, Merck MMR, when given as a second dose to children at 11-12 y of age. All subjects had previously received Merck MMR in the first year of life. In initially seronegative subjects, all subjects receiving the Merck MMR vaccine had seroconverted with respect to measles (10/10 subjects), mumps (38/38) and rubella (4/4). Of the subjects receiving SB MMR, 6/7 seroconverted with respect to measles, 29/31 with respect to mumps and 3/3 with respect to rubella. No difference was seen in seroconversion rates or geometric mean values (GMVs) between groups. In initially seropositive subjects, a higher anti-mumps immune response rate was observed in the SB MMR group (59.3%) compared with the Merck MMR group (24.1%). Higher post-vaccination anti-mumps and anti-rubella GMVs were observed in the group receiving SB MMR (p < 0.007), whereas higher anti-measles GMVs were observed in the Merck MMR group (p = 0.0013). There was a lower (p = 0.013) incidence of pain at the injection site in subjects receiving SB MMR (20.1%) compared with Merck MMR (33.3%). Incidences of systemic reactions were similar between groups.

Perceived quality of life and coping for Swedish women with breast cancer who choose complementary medicine

The aim of the present study, which is part of a major clinical controlled study of the life situation of women with breast cancer, was to compare two groups of women concerning perceived quality of life and coping. The women were treated in two different cancer treatment programs: complementary treatment, which included anthroposophic therapy, and conventional cancer treatment. A total of 120 women were included, 60 women treated with anthroposophic medicine, and 60 individually matched women treated with conventional medicine only. Quality of life was measured by the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Core 30, and the Life Satisfaction Questionnaire. Coping was measured by the Mental Adjustment to Cancer scale. The results showed that the women who chose anthroposophic therapy perceived their quality of life to be lower on admission to the hospital and showed more anxious preoccupation than the women in conventional medicine. It can be concluded that, due to the careful matching procedure, the women in the two groups are comparable in a medical sense but not from the perspective of quality of life and coping.

Yeast two-hybrid system identifies the ubiquitin-conjugating enzyme mUbc9 as a potential partner of mouse Dac

Using a yeast two hybrid system and pull-down assays we demonstrate that mouse Dac (mDac) specifically binds to mouse ubiquitin-conjugating enzyme mUbc9. In contrast to a direct interaction between Drosophila dachshund (dac) and eyes absent (eya)gene products, we cannot detect by the same methods that mDac binds to mEya2, a functional mouse homologue of the Drosophila Eya. Immunostaining of various cell lines that were transfected with mDac reveals that mDac protein is found predominantly in the nucleus but translocates to the cytoplasm and condensates along the nuclear membrane in a cell-cycle dependent manner. Deletion analysis of mDac show the intracellular localization and protein stability correlates with the binding to mUbc9. The C-terminal half of mDac, which associates with mUbc9, remains cytoplasmic and is degraded in proteasome whereas the non-interacting N-terminus is exclusively nuclear and more stable than the full-length mDac or its C-terminal portion. In situ hybridization on whole-mount embryos or tissue sections detects mUbc9 transcripts in complementary and overlapping areas with mDac expression, particularly in the proliferation zone of the limb buds, the spinal cord and forebrain. Mouse embryos stained with an anti-mDac antibody document that mDac is localized both in the nucleus and the cytoplasm with a cytoplasmic predominance in migrating neural crest cells. In the proliferation zone, visible nuclear envelopes are not formed and mDac is detected throughout the cells.

[Patients' perception of surgical care. A study at HUCH, Surgical Hospital in 1994 and a comparison of study results from 1990]

The purpose of this study was to assess patient satisfaction with care in HUCH, Surgical Hospital 1994 and to compare the results to the results of a-study done with the same questionnaire in 1990. The data were collected using SPRI:s (Sjukvårdens och socialvårdens planerings- och rationaliseringsinsitut) questionnaire from patients (N = 215) at seven wards. The response rate was 72. The structured questions were analysed by using the SOLO calculating program and the open-ended questions by using content analyses method. The results are presented in percentages and cross tabulations in the article. According to the results the patients were elder, suffered from more serious diseases and stayed for a longer time in the hospital than 1990. Patients' satisfaction was improved with information and nursing. However, even if the information was improved, most patients wanted more written information. On the whole, patients were satisfied with nursing care but some criticism was expressed concerning environment.