Rehabilitation strategies following oesophagogastric and Hepatopancreaticobiliary cancer (ReStOre II): a protocol for a randomized controlled trial

BACKGROUND

Curative treatment for upper gastrointestinal (UGI) and hepatopancreaticobiliary (HPB) cancers, involves complex surgical resection often in combination with neoadjuvant/adjuvant chemo/chemoradiotherapy. With advancing survival rates, there is an emergent cohort of UGI and HPB cancer survivors with physical and nutritional deficits, resultant from both the cancer and its treatments. Therefore, rehabilitation to counteract these impairments is required to maximise health related quality of life (HRQOL) in survivorship. The initial feasibility of a multidisciplinary rehabilitation programme for UGI survivors was established in the Rehabilitation Strategies following Oesophago-gastric Cancer (ReStOre) feasibility study and pilot randomised controlled trial (RCT). ReStOre II will now further investigate the efficacy of that programme as it applies to a wider cohort of UGI and HPB cancer survivors, namely survivors of cancer of the oesophagus, stomach, pancreas, and liver.

METHODS

The ReStOre II RCT will compare a 12-week multidisciplinary rehabilitation programme of supervised and self-managed exercise, dietary counselling, and education to standard survivorship care in a cohort of UGI and HPB cancer survivors who are > 3-months post-oesophagectomy/ gastrectomy/ pancreaticoduodenectomy, or major liver resection. One hundred twenty participants (60 per study arm) will be recruited to establish a mean increase in the primary outcome (cardiorespiratory fitness) of 3.5 ml/min/kg with 90% power, 5% significance allowing for 20% drop out. Study outcomes of physical function, body composition, nutritional status, HRQOL, and fatigue will be measured at baseline (T0), post-intervention (T1), and 3-months follow-up (T2). At 1-year follow-up (T3), HRQOL alone will be measured. The impact of ReStOre II on well-being will be examined qualitatively with focus groups/interviews (T1, T2). Bio-samples will be collected from T0-T2 to establish a national UGI and HPB cancer survivorship biobank. The cost effectiveness of ReStOre II will also be analysed.

DISCUSSION

This RCT will investigate the efficacy of a 12-week multidisciplinary rehabilitation programme for survivors of UGI and HPB cancer compared to standard survivorship care. If effective, ReStOre II will provide an exemplar model of rehabilitation for UGI and HPB cancer survivors.

TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov, registration number: NCT03958019, date registered: 21/05/2019.

Supports and Barriers to Home-Based Physical Activity During Preoperative Treatment of Pancreatic Cancer: A Mixed-Methods Study

BACKGROUND

Physical activity and exercise appear to benefit patients receiving preoperative treatment for cancer. Supports and barriers must be considered to increase compliance with home-based exercise prescriptions in this setting. Such influences have not been previously examined.

METHODS

The authors used quantitative and qualitative methods to examine potential physical activity influences among patients who were prescribed home-based aerobic and strengthening exercises concurrent with preoperative chemotherapy or chemoradiation for pancreatic cancer. Physical activity was measured using exercise logs and accelerometers. Social support for exercise and perceived neighborhood walkability were measured using validated surveys. Relationships between influences and physical activity were evaluated using linear regression analyses and qualitative interviews.

RESULTS

Fifty patients received treatment for a mean of 16 (9) weeks prior to planned surgical resection. Social support from friends and neighborhood esthetics were positively associated with physical activity (P < .05). In interviews, patients confirmed the importance of these influences and cited encouragement from health care providers and desire to complete and recover from treatment as additional motivators.

CONCLUSIONS

Interpersonal and environmental motivators of exercise and physical activity must be considered in the design of future home-based exercise interventions designed for patients receiving preoperative therapy for cancer.

Pain palliation by endoscopic ultrasound-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer

BACKGROUND

Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) represents an alternative approach to pain palliation in patients with advanced pancreatic cancer.

AIM

to evaluate the safety and initial efficacy of EUS-CPN in patients with painful unresectable pancreatic cancer.

METHODS

Patients with inoperable body-tail pancreatic adenocarcinoma without prior chemotherapy and pain requiring opioid analgesia were included prospectively in this cohort study in a tertiary medical center. Central EUS-CPN was performed and the brief pain inventory and the Functional Assessment of Cancer Therapy measurement were applied before and 2 weeks after the procedure.

RESULTS

Thirty-two patients underwent the procedure in one session without complications. Follow-up revealed overall pain relief in 24 patients (75%) and significant improvement in pain scores. Ratings of pain interfering with general activity, walking, work, mood, enjoyment of life, relations with others, and sleep improved significantly. Physical, functional, and emotional well-being improved significantly, except for acceptance of illness and enjoyment of life.

CONCLUSION

Central EUS-CPN was an efficient and safe method for palliative pain management in our patients with inoperable pancreatic body-tail adenocarcinoma. The pain alleviation improved the patients' functional status, sleep, and quality of life, although other variables could also be involved, but acceptance of the illness and enjoyment of life did not change after treatment.

[Palliative rehabilitation of two patients with terminal stage cancer: a visit to patient's home and the provision of advice by a nurse and rehabilitation staff members before discharge--from physical therapist's perspective]

We report two patients with terminal stage cancer who spent some days at their home after a physical therapist, occupational therapist, nurse, and medical social worker all visited the patients' homes and advised the patients' family in regard to the appropriate care before the patients were discharged as a strategy for palliative rehabilitation. Case 1: A patient suffering from terminal stage cancer was bed-ridden because of a pathological fracture of the femur. After palliative rehabilitation, the patient was able to get out of the bed and improved her daily living activity level through physical therapy. She spent some days at home according to the results of the pre-discharge home visit guidance to her family. Case 2: A patient suffering from terminal stage cancer manifested symptoms of fatigue and generalized muscular weakness. After palliative rehabilitation, her muscle strength and physical endurance were improved by physical therapy and adjustment of the bed height. Because she was eager to go home, we took her to her home before being discharged, and she was able to spend a few hours at home. Pre-discharge home visit guidance by a nurse and rehabilitation staff members to the patient' s family in regard to appropriate home care may therefore be a good means of satisfying such patients' desire to see their home once more and thereby improve their quality of life.

Anxiety symptoms and panic attacks preceding pancreatic cancer diagnosis

Cancer of the pancreas is a highly malignant disease with a very poor prognosis. Depression and anxiety occur more frequently in cancer of the pancreas than they do in other forms of intra-abdominal malignancies and other cancers in general. Yet, the etiology of psychiatric symptoms in patients with cancer of the pancreas may not be traced solely to poor prognosis, pain, or existential issues related to death and dying. In as many as half of patients that go on to be diagnosed with the disease, symptoms of depression and anxiety precede knowledge of the diagnosis. This observation has raised speculation that mood and anxiety syndromes are related to disruption in one of the physiologic functions of the pancreas. In this paper, we present a patient who had no prior psychiatric history and developed panic attacks just prior to diagnosis of her cancer. To our knowledge, this is the first report in the literature where panic attacks, not simply anxiety, presented prior to a pancreatic cancer diagnosis. Her symptoms resolved following resection of the tumor. Implications of such phenomena for the diagnosis and treatment of anxiety and depression in pancreas cancer are discussed.