Implement exercise in the oncological setting

Over the past 20 years, the understanding of the role of physical activity in cancer has been increased. Traditionally, patients were advised to rest, recovery, and save energy during and after anticancer treatments. Nevertheless, it is now clear that physical activity may help alleviate some side effects caused by therapies and a sedentary lifestyle; consequently, cancer patients should be encouraged to perform exercise. Epidemiological evidence shows that post-diagnosis physical activity is associated with enhancing patients \u2018survival, especially in breast, colon, and prostate cancer. In cancer patients, exercise acts by improving health-related skills, particularly cardiorespiratory fitness, strength, and body composition. Moreover, several trials demonstrated that a regular exercise program effectively relieves some cancer and treatments \u2018side effects, such as fatigue, nausea, and vomiting, thereby improving patients\u2019 quality of life. The last update of the American College of Sports Medicine\u2019 guidelines recommends that patients perform 90 minutes per week of aerobic exercise at moderate intensity, with strength activities twice a week. Despite these important benefits, in Italy, the spread of exercise-oncology programs and the research in the exercise oncology field are still poor, negatively impacting patients and producing a gap in the literature. The purpose of this thesis is trying to fill this gap, increasing the available literature, and proposing an exercise program based on patients\u2019 needs and the current guidelines. Chapter one is dedicated to a brief introduction about physical activity in cancer. In chapters two, three, four, and five, the experimental studies that led to the development of patient-centred exercise program are presented. Chapters six and seven report two other studies investigating exercise as part of the multimodal approach in counteracting cancer cachexia. The last chapter is dedicated to a summary of the main thesis results

Multidisciplinary lifestyle intervention to manage pancreatic cancer-related cachexia: a case report

Pancreatic cancer remains an aggressive disease, with a poor prognosis and a high risk of incurring into cachexia. Supportive care, such as exercise, nutritional and psychological support, may be effective in reducing functional loss, psychological distress and improving nutritional status. We report the effect of 12 weeks of multimodal lifestyle intervention in a 55-year-old female, diagnosed with unresectable body/tail pancreatic cancer and metastasis in the liver, bone, lymph node and lung, to counteract cachexia. The multimodal program resulted safe and feasible. Over 12 weeks, considerable improvements were found in body weight, health-related physical fitness, nutritional status, distress scores, anxiety and depression levels. These findings highlight the potential role of integrated supportive interventions to manage metastatic cancer and cancer-induced cachexia

Physical activity guidelines in oncology: a systematic review of the current recommendations

This review aims to summarize the recommendations endorsed by scientific societies regarding physical activity for patients with cancer. A systematic search was conducted to identify guidelines endorsed by scientific societies and published in the last 15 years dedicated to physical activity for cancer patients. The AGREE II instrument was used to assess the methodological quality of the guidelines. Results are presented as qualitative synthesis. A total of 11 guidelines met the inclusion criteria. Seven were considered high quality, scoring ≥60% in the AGREE II tool. All the guidelines recommended to include aerobic and resistance training as types of activities. Regarding the physical activity dosage, most suggested a generic 150minutes/week of moderate-intensity activity plus resistance training twice a week. Three guidelines reported instructions for exercise prescription, including frequency, intensity, and duration of training sessions. Six guidelines reported exercise testing/medical clearance instructions, 9 provided considerations regarding adaptation/precautions, and 7 detailed the specialists for referral. Four guidelines considered motivational aspects related to physical activity and cancer. Although important steps have been made in the more recent recommendations, effort is needed to produce high-quality research in the exercise-oncology field, with the ultimate aim of developing more tailored guidelines

Factors influencing physical activity in cancer patients during oncological treatments: a qualitative study

Introduction: Although the literature supports the importance of physical activity in the oncological context, in Italy a large number of patients are not sufficiently active. Methods: The present study aimed to explore factors influencing an active lifestyle in cancer patients during oncological treatments. Semi-structured focus groups, including 18 patients with different cancer types, were conducted at the Oncology Unit in the University Hospital Trust of Verona (Italy). The interviews were audio-recorded, transcribed verbatim, and analyzed with content analysis. Results: According to the Health Belief Model, transcripts were categorized into the following themes: benefits, barriers, and cues to action. Patients reported a series of physical, physiological, and psychological benefits deriving from an active lifestyle. The main barriers hampering the physical activity participation were represented by treatment-related side effects, advanced disease, and some medical procedures, for example, ileostomy. Several strategies that can trigger patients to exercise were identified. Medical advice, social support from family and friends, features such as enjoyment, setting goals, and owning an animal can motivate patients to perform physical activity. At the same time, an individualized program based on patients' characteristics, an available physical activity specialist to consult, more detailed information regarding physical activity in the oncological setting, and having accessible structures were found important facilitators to implementing active behavior. Conclusions: Overall, patients have a positive view regarding physical activity, and a variety of obstacles and cues to action were recognized. Considering this information may help to improve adherence to a physical activity program over time, consequently increasing the expected benefits

Feasibility of a novel exercise program for patients with breast cancer offering different modalities and based on patient preference

Purpose: Exercise improves quality of life and reduces the side effects of cancer therapies. Nevertheless, attendance to exercise programs remains a challenge for patients. This study explored the feasibility of an exercise program in which women with breast cancer may be allowed to choose among three exercise delivery modalities. Methods: Forty-seven patients with breast cancer (stage I-IV) participated in a 12-week combined aerobic and resistance training program. The exercise modality was chosen by patients according to their preferences and needs among three options: the personal training program, the home-based program, or the group-based program. Exercise prescription was similar between the three modalities. Whereas the primary endpoint was feasibility, assessed through recruitment rate, attendance, adherence, dropout rate, tolerability, and safety, secondary endpoints included health-related skills and quality of life. Results: Out of 47 recruited patients, 24 chose the home-based program, 19 the personal training program, and four the group-based program. Six dropouts (13%) were registered, and no severe adverse events were recorded. The median program attendance was 98% for personal training programs, 96% for home-based programs, and 100% for group-based programs, whereas compliance resulted in more than 90% in each modality. At postintervention, a significant increase in cardiorespiratory fitness, lower body flexibility, and body weight was observed. Different quality-of-life domains were improved following the intervention, including physical and social functioning, fatigue, and appetite loss. No significant changes in other parameters were detected. Conclusions: An exercise prescription based on a patient-preferred delivery modality showed high feasibility in women with breast cancer

Exercise levels and preferences in cancer patients: a cross-sectional study

Background: Despite the benefits related to physical exercise, large numbers of cancer patients are not sufficiently active. Methods: To investigate exercise levels and preferences in cancer patients, a cross-sectional study was conducted on a random sample of 392 cancer outpatients who anonymously completed a questionnaire investigating general and medical characteristics, and expressed willingness to participate in exercise programs. Current exercise levels were estimated with the Leisure Score Index (LSI). Results: Most patients (93%) were insufficiently active but 80% declared an interest in exercise programs. Patients preferred oncologist-instructed programs and specified particular exercise needs. Multivariate logistic regression showed that willingness to exercise was associated with education (OR: 1.87; 95% CI: 1.15-3.04 beyond age 14 years vs. up to 14 years) and current physical activity (OR: 1.92; 95% CI: 1.92-3.63 for sweat-inducing activity >2 times/week vs. <1 time/week). Patients given chemotherapy were less inclined to exercise (OR: 0.45; 95% CI: 0.23-0.86) than those who did not. LSI was lower if cancer stage was advanced (β: -0.36; 95% CI: -0.75 to -0.02) than if it was in remission. High LSI was also associated with longer education, lower BMI, and longer time after diagnosis. Conclusion: Cancer patients are insufficiently active but are willing to participate in personalized exercise programs. Information from this survey may help in designing personalized interventions so these patients will achieve sufficient exercise

What is the role of physical exercise in the era of cancer prehabilitation? A systematic review

Purpose: Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding. Methods: A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included. Results: A total of 97 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported. Conclusion: Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies

Exploring the feasibility of a combined exercise program for patients with advanced lung or pancreatic cancer

Objective: This study aims to assess the safety, feasibility, and potential benefits of a combined aerobic and resistance exercise intervention for patients diagnosed with advanced pancreatic or lung cancer. Methods: A prospective, single-arm study was conducted, enrolling patients with advanced lung or pancreatic cancer. Participants engaged in a 12-week exercise intervention comprising personalized bi-weekly aerobic and resistance training tailored to individual baseline conditions. The primary study outcomes focused on safety (absence of serious adverse events) and feasibility. Secondary outcomes included assessments of functional capacity using the "Six minutes walking test", strength measured through handgrip and leg press tests, anthropometric measures including body mass index and waist-hip ratio, quality of life (QoL), and changes in blood parameters. Results: The study involved twelve patients (mean age 57.66 ​± ​7.40 years), with seven having pancreatic cancer and five having lung cancer. The recruitment rate was 50%, and assessment adherence was 100%, with an 84% adherence to the exercise program and no dropouts. No exercise-related adverse events were recorded, while three non-severe, non-exercise-related adverse events were observed: treatment-related dermatitis (Grade 2), axillary lymphadenopathy (Grade 2), and migraine (Grade 1). Significant enhancements in functional capacity, emotional well-being, and social functioning within the QoL domains were observed. Anthropometric measures, specifically waist-hip ratio and body mass index, remained stable. Conclusions: The findings suggest that a tailored 12-week exercise intervention is both feasible and safe for patients with advanced lung or pancreatic cancer. This intervention appears to enhance functional capacity, specific aspects of QoL, and contribute to maintaining body weight

Combining a 9-month tailored physical exercise program with osimertinib and denosumab in a patient affected by advanced NSCLC with multiple osteolytic bone lesions: A case report

A 55-year-old female patient affected by an EGFR mutant NSCLC with multiple lytic bone metastases and two prior pathological fractures, undergoing treatment with osimertinib and denosumab, participated in a 9-month physical exercise program. The exercise program was performed twice a week and consisted of aerobic and strength training. Aerobic training was composed of moderate-intensity continuous training for the first 3 months and then high-intensity interval training. Strength training was performed through body-weight/elastic band exercises for the first 6 months and isotonic machines from months 6-9. Assessments, performed every 3 months, included physical fitness parameters, such as functional capacity, muscle strength, anthropometric measures, body composition, and quality of life. Functional capacity progressively improved by 80 m at month 6 and slightly decreased by 22 m at month 9. At the end of the intervention, grip strength increased in both arms, whereas the body composition showed a progressive decrease in fat mass (-3.39 kg) and an increase in muscle mass (+3.89 kg) until month 6 and then stabilization. Quality of life exhibits a great improvement in the first 3 months, especially in the physical role, emotional functioning, fatigue, pain, dyspnoea, insomnia, appetite loss, constipation, and diarrhea, and then maintained with little variations. This case suggests that a highly structured physical exercise program may be feasible, safe, and effective in patients with lung cancer and bone metastases if performed under the supervision of trained experts

How a physical exercise program performed by patients may impact caregiver burden in cancer: a qualitative study

Purpose: Caregivers of patients with metastatic cancer may be exposed to an overwhelming sense of burden. Physical exercise may help patients improve their physical condition, manage symptoms, and enhance their quality of life. Nevertheless, it is unclear if these interventions may also likely affect caregivers. Methods: Five focus group (n = 20 participants) were conducted to explore the caregivers' experiences/perspectives of patients affected by metastatic cancer and performing a supervised physical exercise intervention. Thematic analysis using an inductive approach was performed. Theme, sub-themes, and illustrative quotes are displayed. Results: Four themes were identified. Theme 1 captured, with two sub-themes, the impact of the diagnosis on caregivers' emotional status and daily routines. Theme 2 was related to the perceived benefits of patients' engagement in the physical exercise program, enclosing three sub-themes (physical advantages, management of side effects, psychological well-being) and how this has helped caregivers enhance their emotional well-being. Theme 3 reported how caregivers have felt supported by the physical exercise program for the care of their loved ones (three-sub-themes: supervised by specialists, tailored and flexible program). Finally, theme 4 explained that caregivers, thanks to the patient's participation in the exercise, were able to take back control of their own lives, having more time available and enhancing their relationship with the patient. Conclusion: Participation of patients with metastatic cancer in a structured physical exercise program may be effective in reducing caregiver's burden. This study may serve as a trailblazer to guide future investigations and consolidate the present findings