The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): Study protocol for a randomised controlled trial

Background: The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging. Methods/Design: The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ( V · o 2 at δ L ) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading. Discussion: The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes

copying

copying vbl n[PT] Jumping from one pan of ice to anotherYesJWUsed I and SupUsed I and SupNot Usedcobbying*, cockeying, conkying*, coodying*, coonying*, COPYChecked by Jordyn Hughes Tue 21 Jun 201

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): study protocol for a randomised controlled trial.

BackgroundThe standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging.Methods/designThe EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ([Formula: see text] at [Formula: see text]) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading.DiscussionThe EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes.Trial registrationClinicalTrials.gov NCT01914068 (received: 7 June 2013).SponsorUniversity Hospital Southampton NHS Foundation Trust

Showing flow of patients through the study protocol.

<p>Post-NACRT tests carried out within 48±5 hours of finishing NACRT period.</p

Patient characteristics at Baseline and post-NACRT.

<p>Patient characteristics at Baseline and post-NACRT.</p

Averaged number of steps at Baseline (before NACRT)) and at 48±5 hours post-NACRT: lines link data-points (closed circles) for individual patients, and open circles show overall mean±SEM. Mean change (SEM) between baseline and post-NACRT is −1627(712) steps, p = 0.039.

<p>Averaged number of steps at Baseline (before NACRT)) and at 48±5 hours post-NACRT: lines link data-points (closed circles) for individual patients, and open circles show overall mean±SEM. Mean change (SEM) between baseline and post-NACRT is −1627(712) steps, p = 0.039.</p

³¹P MRS (k_PCr) and CPET (o₂ at _L and o₂ at Peak) data at Baseline (before NACRT)) and at 48±5 hours post-NACRT: lines link data-points (closed circles) for individual patients, and open circles show overall mean±SEM. Mean changes (SEM) between baseline and post-NACRT are for k_PCr −0.4(0.1) min⁻¹, p = 0.001; for o₂ at _L −2.4(0.7) ml.kg⁻¹.min⁻¹, p = 0.004; and for o₂ Peak −4.0(1.3) ml.kg⁻¹.min⁻¹, p = 0.011.

<p>³¹P MRS (k_PCr) and CPET (o₂ at _L and o₂ at Peak) data at Baseline (before NACRT)) and at 48±5 hours post-NACRT: lines link data-points (closed circles) for individual patients, and open circles show overall mean±SEM. Mean changes (SEM) between baseline and post-NACRT are for k_PCr −0.4(0.1) min⁻¹, p = 0.001; for o₂ at _L −2.4(0.7) ml.kg⁻¹.min⁻¹, p = 0.004; and for o₂ Peak −4.0(1.3) ml.kg⁻¹.min⁻¹, p = 0.011.</p

Patient data at Baseline and post-NACRT.

<p>Abbreviations: k_PCr, post-exercise phosphocreatine recovery rate constant; o₂ at _L, oxygen uptake at estimated anaerobic threshold; o₂ Peak, oxygen uptake at peak exercise; O₂ pulse at _L, oxygen pulse at estimated anaerobic threshold; O₂ pulse at Peak, oxygen pulse at peak exercise; _E/co₂ at _L, ventilatory equivalents for carbon dioxide at estimated anaerobic threshold; _E/co₂ at _L, ventilatory equivalents for carbon dioxide at peak exercise; Work rate at _L, work rate at estimated anaerobic threshold; Work rate at Peak, work rate at peak exercise.</p><p>Patient data at Baseline and post-NACRT.</p