Exercise-based multimodal programming : A treatment gap for older adults with advanced cancer [Commentary]

[Extract] Approximately 60% of new cancer diagnoses occur in patients aged 65 years and older.1 Normal aging is associated with a decline in health and physical function.2 A cancer diagnosis and subsequent treatment can accelerate this age-related physical decline, increasing the risk of adverse health events and mortality.1 Aerobic and resistance exercise is an effective therapy to improve physical fitness and quality of life and to reduce cancer-related fatigue in individuals diagnosed with cancer, including advanced cancer.3 The American College of Sports Medicine guidelines recommend maintenance of physical activity during active cancer treatment,3 but guidelines specific to advanced cancer or elderly populations are lacking. Older patients with cancer are vastly underrepresented in clinical trials, including exercise-based trials,4 due in part to the challenges introduced by the observed heterogeneity among older adults with respect to comorbid conditions, functional status, motivation, and safety-related concerns of the treating health care professionals.4 Older adults are more likely to fear physical activity due to potential injury and to lack of guidance regarding how to start exercising.5,

Evaluating the role of exercise as a management strategy to counteract the burden of cancer cachexia

Cancer cachexia is a multifactorial syndrome characterised by progressive, involuntary body weight loss and skeletal muscle wasting. Cachexia disproportionately affects patients with advanced or incurable cancers and significantly contributes to cancer morbidity and mortality. The physical and psychosocial burden of cancer cachexia is extensive and includes reductions in physical function, a greater number of and more severe cancer symptoms, increased patient-reported distress (i.e., anxiety and depression), and lower overall quality of life (QOL). Despite the burden of cancer cachexia, no universal therapies exist for its treatment and management. Moreover, supportive care options for cancer cachexia are limited and understudied. Many patients do not feel their cachexia receives enough attention and particularly in its early stages, cancer cachexia often goes clinically unnoticed. Exercise is safe, accessible, and inexpensive relative to other pharmaceutical and medical interventions. Exercise also has established health and QOL benefits in people with cancer, although this is principally established among patients with early-stage disease who do not have cachexia. There is both a strong rationale and preliminary evidence in people with more advanced disease to suggest exercise may be an important addition to cancer cachexia management strategies to address unmet patient needs. The current thesis aims to evaluate the role of exercise as a management strategy to counteract the burden of cancer cachexia in a series of carefully designed studies. The primary findings are: 1) an existing multidisciplinary clinical service for cancer cachexia that prescribes combined medical, pharmaceutical, dietary, and exercise-based support is associated with significant improvements in patient-reported QOL and symptoms, but not clinically-assessed physical function and muscular strength; 2) people with advanced cancer and cachexia perceive exercise as important for their physical and psychosocial health and wellbeing and prefer exercise options with greater support (e.g., professionally supervised and structured exercise) and access (e.g., convenient exercise options) to overcome multifaceted exercise barriers and maximise the potential benefits of exercise; and 3) a virtually supervised exercise intervention delivered using an internet-based videoconference platform is safe and feasible in people with advanced cancer and cachexia and has benefits on physical function and patient-reported outcomes. Overall, findings from the current thesis help fill critical research gaps on the potential role of exercise for people with advanced cancer and cachexia. The current thesis contributes important new knowledge underscoring that exercise is valued by patients with cancer cachexia and has the potential to be a meaningful intervention. Further, a virtually supervised, structured exercise intervention is feasible in patients with advanced cancer and cachexia and may be a critical new way to provide convenient high-quality exercise-based support to higher risk patients. Altogether, results from the current thesis lay the much-needed groundwork for future high-impact studies in the emerging field of exercise and cancer cachexia research

Exercise influence on taxane side effects in women with breast cancer

Taxane-based chemotherapy is frequently administered to treat breast cancer. However, side effects of taxanes include chemotherapy-induced peripheral neuropathy (CIPN) and cardiovascular complications, which negatively impact patient quality of life and long-term health. Exercise can significantly reduce cancer treatment side effects. However, information on exercise’s influence on taxane-specific side effects is limited. The primary aim of this dissertation was to evaluate the effect of exercise on taxane side effects, including CIPN and cardiovascular outcomes, in women with breast cancer. METHODS: Women with early-stage breast cancer were randomized to thrice-weekly exercise (EX) or usual care (UC) during taxane chemotherapy (4 cycles, 2-3 weeks apart). Patient-reported CIPN symptoms and quality of life (EORTC QLQ-C30 + CIPN20 subscale), clinical CIPN tests (vibration sensation and pinprick), patient-reported pain (Brief Pain Inventory) and cardiovascular outcomes, including heart rate and blood pressure at rest, and during and after submaximal exercise testing, were evaluated at baseline (pre-taxane chemotherapy) and end of chemotherapy. CIPN symptoms and quality of life were also evaluated at 0-3 days pre-chemotherapy cycle 4. RESULTS: Twenty-four women enrolled (EX: n=11, UC: n=13). Patient-reported CIPN symptoms were significantly worse by the end of chemotherapy in both groups for sensory (p<0.01) and motor symptoms (p=0.04), with a trend towards reduced sensory symptom progression among exercisers (p=0.08). Significantly more participants in the usual care group had impaired vibration sensation at 0-3 days pre-chemotherapy cycle 4 at the left interphalangeal joint (UC: 80%, EX: 10%, p<0.01), with a similar trend for the right interphalangeal joint (UC: 60%, EX: 10% p=0.06). Resting heart rate was significantly lower by the end of chemotherapy in the exercise group (EX: 71±2, UC: 77±2 bpm, p<0.05). The exercise group also had significantly lower heart rates during submaximal exercise testing (p<0.01) and significantly faster heart rate recovery (p=0.02) by the end of chemotherapy. Lastly, a non-significant trend towards higher blood pressure during submaximal exercise testing was observed among the usual care group by the end of chemotherapy. CONCLUSION: This study provides preliminary evidence supporting the positive influence of exercise on CIPN and cardiovascular outcomes in early-stage breast cancer patients undergoing taxane chemotherapy.Medicine, Faculty ofGraduat

Impact of exercise on chemotherapy completion rate: A systematic review of the evidence and recommendations for future exercise oncology research

Receipt of full chemotherapy dose is associated with improved treatment efficacy and survival following a diagnosis of cancer. Exercise has emerged as a supportive care intervention that may improve chemotherapy completion rate by managing dose-limiting toxicities. We conducted a systematic review to evaluate the impact of exercise interventions on outcomes of chemotherapy completion rate in adult cancer patients. Relevant literature was retrieved from CINAHL, Medline (Ovid) and EMBASE based on subject headings and keywords pertaining to cancer, exercise and antineoplastic agents. Eligible articles were randomized control trials (RCTs) that prescribed aerobic or resistance exercise and included end-points relating to chemotherapy completion rate. Overall, eight RCTs were included in the final analysis. Only two RCTs (25%) that enrolled women with early-stage breast cancer reported a significant beneficial effect of exercise on chemotherapy completion rate, including higher mean relative dose intensity and fewer chemotherapy dose adjustments, relative to usual care. The remaining six studies reported no difference with exercise. Altogether, despite the growing number of exercise oncology trials to-date, information pertaining to the effect of exercise on chemotherapy completion rate is limited. Current data suggest exercise does not worsen chemotherapy tolerability. However, full interpretation of these findings is limited by the small number of trials. Future research involving rigorous study design is needed to confirm whether exercise can influence chemotherapy treatments

Exercising in isolation? The role of telehealth in exercise oncology during the COVID-19 pandemic and beyond

[Extract] The COVID-19 pandemic, affecting over 200 countries and territories worldwide, has abruptly altered how we carry out our daily lives. This includes adapting to physical distancing restrictions and varying degrees of isolating at home or quarantining. The sudden and lasting health impacts of this new normal are unknown. Recently reviewed psychological effects of quarantine included post-traumatic stress symptoms, confusion, and anger.1 The physical impact may include a loss in daily physical activity needed to maintain an adequate health status and to prevent and manage chronic disease.2 For people with cancer, the health impacts of our new normal may be intensified and continue for longer, even as physical distancing restrictions ease. Adults with cancer are commonly immunocompromised while receiving treatment and may be twice as likely to test positive for COVID-19 and have higher morbidity and mortality after contracting COVID-19.3 Medical advice, particularly for people receiving immunocompromising cancer treatments, may therefore include spending more time isolating or adopting stricter physical distancing practices to minimize the risk of COVID-19 infection

Updated systematic review of exercise studies in breast cancer survivors : Attention to the principles of exercise training

Abstract Objectives To update our previous evaluation of the exercise interventions used in randomised controlled trials of breast cancer survivors in relation to (1) the application of the principles of exercise training in the exercise prescription; (2) the reporting of the components of the exercise prescription; and (3) the reporting of adherence of participants to the prescribed interventions. Design Systematic review. Data sources The OVID Medline, Embase, CINAHL and SPORTDiscus electronic databases were searched from January 2010 to January 2017. Eligibility criteria Randomised controlled trials of at least 4 weeks of aerobic and/or resistance exercise in women diagnosed with breast cancer, reporting on physical fitness or body composition outcomes. Results Specificity was appropriately applied by 84%, progression by 29%, overload by 38% and initial values by 67% of newly identified studies. Reversibility was reported by 3% anddiminishing returns by 22% of newly identified studies. No studies reported all components of the exercise prescription in the methods, or adherence to the prescribed intervention in the results. Reporting of reversibility has increased from 2010, but no other improvements in reporting were noted from the previous review. Summary/Conclusion No studies of exercise in women with breast cancer attended to all principles of exercise training, or reported all components of the exercise prescription in the methods, or adherence to the prescription in the results. Full reporting of the exercise prescribed and completed is essential for study replication in research and translating research findings into the community, and should be prioritised in future trials

Clinically relevant physical benefits of exercise interventions in breast cancer survivors

Evidence is currently limited for the effect of exercise on breast cancer clinical outcomes. However, several of the reported physical benefits of exercise, including peak oxygen consumption, functional capacity, muscle strength and lean mass, cardiovascular risk factors, and bone health, have established associations with disability, cardiovascular disease risk, morbidity, and mortality. This review will summarize the clinically relevant physical benefits of exercise interventions in breast cancer survivors and discuss recommendations for achieving these benefits. It will also describe potential differences in intervention delivery that may impact outcomes and, lastly, describe current physical activity guidelines for cancer survivors

The effect of exercise on cancer-related cognitive impairment and applications for physical therapy : Systematic review of randomized controlled trials

Background Cancer-related cognitive impairment (CRCI), often called “chemo-brain” or “chemo-fog,” is a common side effect among adults with cancer, which can persist well after treatment completion. Accumulating evidence demonstrates exercise can improve cognitive function in healthy older adults and adults with cognitive impairments, suggesting exercise may play a role in managing CRCI. Purpose The purpose was to perform a systematic review of randomized controlled trials (RCTs) to understand the effect of exercise on CRCI. Data Sources Relevant literature was retrieved from CINAHL, Medline (Ovid), and EMBASE. Study Selection Eligible articles were RCTs that prescribed aerobic, resistance, combined aerobic/resistance, or mind-body (eg, yoga or Qigong) exercise during or following cancer treatment and included cognitive function outcome measures. Data Extraction Descriptive information and Cohen d effect sizes were directly extracted or calculated for included trials. Data Synthesis Twenty-nine trials were included in the final analysis. A statistically significant effect of exercise on self-reported cognitive function, both during and postadjuvant treatment, was reported in 12 trials (41%) (Cohen d range: 0.24–1.14), most commonly using the EORTC QLQ-C30. Ten trials (34%) performed neuropsychological testing to evaluate cognitive function; however, only 3 trials in women with breast cancer reported a significant effect of exercise (Cohen d range: 0.41–1.47). Limitations Few RCTs to date have evaluated the effect of exercise on CRCI as a primary outcome. Twenty-six trials (90%) in this review evaluated CRCI as secondary analyses. Conclusions Evidence supporting exercise as a strategy to address CRCI is limited. Future research evaluating CRCI as a primary outcome, including self-reported and objective measures, is needed to confirm the possible role of exercise in preventing and managing cognitive impairments in adults with cancer

Attention to the principles of exercise training in exercise studies on prostate cancer survivors: a systematic review

Background: The purpose of this review is to update previously published reviews on exercise programming in exercise trials in prostate cancer survivors. We evaluated: 1) the application of the principles of exercise training in prescribed programs; 2) the reporting of the components of the exercise prescription; and 3) the reporting of adherence of participants to the prescribed programs. Methods: Building upon a previous review, a systematic review was conducted searching OVID Medline, Embase, CINAHL, and SPORTDiscus databases from 2012-2017. Randomized controlled trials of at least four weeks of aerobic and/or resistance exercise in men diagnosed with prostate cancer that reported physical fitness outcomes, including body composition were eligible for inclusion. Results: Specificity was appropriately applied by 93%, progression by 55%, overload by 48%, initial values by 55%, and diminishing returns by 28% of eligible studies. No study adequately applied the principle of reversibility. Most (79%) studies reported all components of the exercise prescription in the study methods, but no study reported all components of adherence to the prescribed intervention in the study results. Conclusions: Application of standard exercise training principles is inadequate in exercise trials in men with prostate cancer and could possibly lead to an inadequate exercise stimulus. While many studies report the basic components of the exercise prescription in their study methods, full reporting of actual exercise completed is needed to advance our understanding of the optimal exercise dose for men with prostate cancer and promote translation of controlled trials to practice.Medicine, Faculty ofNon UBCPhysical Therapy, Department ofReviewedFacult

Exercise-based interventions to counteract skeletal muscle mass loss in people with cancer : Can we overcome the odds?

Addressing skeletal muscle mass loss is an important focus in oncology research to improve clinical outcomes, including cancer treatment tolerability and survival. Exercise is likely a necessary component of muscle-mass-preserving interventions for people with cancer. However, randomized controlled trials with exercise that include people with cancer with increased susceptibility to more rapid and severe muscle mass loss are limited. The aim of the current review is to highlight features of cancer-related skeletal muscle mass loss, discuss the impact in patients most at risk, and describe the possible role of exercise as a management strategy. We present current gaps within the exercise oncology literature and offer several recommendations for future studies to support research translation, including (1) utilizing accurate and reliable body composition techniques to assess changes in skeletal muscle mass, (2) incorporating comprehensive assessments of patient health status to allow personalized exercise prescription, (3) coupling exercise with robust nutritional recommendations to maximize the impact on skeletal muscle outcomes, and (4) considering key exercise intervention features that may improve exercise efficacy and adherence. Ultimately, the driving forces behind skeletal muscle mass loss are complex and may impede exercise tolerability and efficacy. Our recommendations are intended to foster the design of high-quality patient-centred research studies to determine whether exercise can counteract muscle mass loss in people with cancer and, as such, improve knowledge on this topic