Actigraphic assessment of daily sleep-activity pattern abnormalities reflects self-assessed depression and anxiety in outpatients with advanced non-small cell lung cancer

Effects of mind-body exercise on body constitution and circadian rhythm in people with suboptimal health status

BACKGROUND

Suboptimal health status (SHS) is a dynamic state in which people have not been diagnosed with a disease but tend to develop diseases. People with SHS are more prone to conditions such as cardiovascular disease and metabolic syndrome. Suitable interventions in people with SHS can prevent disease development. SHS is correlated with traditional Chinese medicine (TCM)-based constitutions, including Yang-Xu (yang deficiency), Yin-Xu (yin deficiency), and stasis types. The circadian rhythm is a potential biomarker of health and metabolism. Baduanjin exercise, a kind of mind-body exercise, has been regarded to adjust body constitution and metabolism, but few studies have evaluated the effects of Baduanjin exercise on body constitution and circadian rhythms. Therefore, this randomized controlled trial investigated the effects of Baduanjin exercise on body constitution and circadian rhythms in people with SHS.

METHODS

Seventy-six participants with SHS were divided into the Baduanjin exercise and control groups (watching a Baduanjin video), with the interventions lasting 12 weeks. The Body Constitution Questionnaire (BCQ), SHS Questionnaire-25 (SHSQ-25), and actigraphy for circadian rhythm measurement were conducted.

RESULTS

The scores of SHSQ-25, Yang-Xu, Yin-Xu, and BCQ stasis decreased significantly after 12 weeks in the Baduanjin exercise group, but not in the control group. Interdaily stability of the circadian rhythm increased significantly in the Baduanjin exercise group but not in the control group.

CONCLUSION

This is the first report of improved health status, modulated body constitution, and increased interdaily stability of the circadian rhythm in participants with SHS who practiced Baduanjin exercise.

Circadian rhythm disorders in patients with advanced cancer: a scoping review

Circadian rhythms can be demonstrated in several biomarkers and behavioural activities, with rhythmical patterns occurring roughly over a 24-h period. Circadian disorders occur in patients with cancer and may be associated with poor clinical outcomes. This scoping review aimed to identify circadian rhythm research and reporting practices, circadian rhythm patterns, circadian rhythm disorders, and relevant associations of circadian rhythm disorders in patients with advanced cancer. Studies involved adult patients with locally advanced or metastatic cancer and used objective measures of circadian rhythmicity. Two independent authors completed initial screening of title and abstracts, full text reviews, data extraction, and data checking. A total of 98 articles were highlighted in the scoping review, which utilised physical activity measures (actigraphy and polysomnography), biomarkers (cortisol and melatonin), or a combination. Several circadian rhythms are commonly disordered amongst patients with advanced cancer and have significant implications for symptom burden, quality of life, and survival. It remains unclear which patients are most at risk of a circadian rhythm disorder. Significant heterogeneity exists in research and reporting practices. Standardising this approach may address discrepancies in the current literature and allow for research to focus on the most relevant parameters and approaches to improving circadian rhythmicity.

Data-Driven Personalized Care in Lung Cancer: Scoping Review and Clinical Recommendations on Performance Status and Activity Level of Patients With Lung Cancer Using Wearable Devices

PURPOSE

Performance status (PS) is a crucial assessment for research and clinical practice in lung cancer (LC), including its usage for the assessment of the suitability and toxicity of treatment or eligibility for clinical trials of patients with LC. These PS assessments are subjective and lead to substantial discrepancies between observers. To improve the objectivity of PS assessments, Electronic Activity Monitoring devices (EAMs) are increasingly used in oncology, but how these devices are used for PS assessments in LC is an issue that remains unclear. The goal of this study is to address the challenges and opportunities of the use of digital tools to support PS assessments in patients with LC.

METHODS

The literature review followed PRISMA-ScR methodology. Searches were performed in the ScienceDirect, PsycInfo, ACM, IEEE Xplore, and PubMed databases. Furthermore, a panel discussion was performed to address the clinical use cases.

RESULTS

Thirty-two publications were found. Most of the studies used wrist accelerometry-based wearables (59%) and monitored sleep activity (SA; 28%) or physical activity (PA; 72%). Critical findings include positive usefulness of the use of wearables to categorize moderate-to-vigorous/light PA, which was associated with better sleep and health. In addition, steps and time awake immobile were found to be associated with risk of hospitalization and survival. Use cases identified included the health assessment of patients and clinical research.

CONCLUSION

There are positive experiences in the use of EAM to complement PS assessment in LC. However, there is a need for adapting thresholds to the particularities of patients with LC, for example, differentiating moderate-to-vigorous and light. Moreover, developing methodologies combining PS assessments and the use of EAM adapted to clinical and research practice is needed.

International e-Delphi Consensus Recommendations for the Assessment and Diagnosis of Circadian rest-Activity Rhythm Disorders (CARDs) in Patients with Cancer

PURPOSE

Circadian rest-Activity Rhythm Disorders (CARDs) are common in patients with cancer, particularly in advanced disease. CARDs are associated with increased symptom burden, poorer quality of life, and shorter survival. Research and reporting practices lack standardization, and formal diagnostic criteria do not exist. This electronic Delphi (e-Delphi) study aimed to formulate international recommendations for the assessment and diagnosis of CARDs in patients with cancer.

METHODS

An international e-Delphi was performed using an online platform (Welphi). Round 1 developed statements regarding circadian rest-activity rhythms, diagnostic criteria, and assessment techniques. Rounds 2 and 3 involved participants rating their level of agreement with the statements and providing comments until consensus (defined internally as 67%) and stability between rounds were achieved. Recommendations were then created and distributed to participants for comments before being finalized.

RESULTS

Sixteen participants from nine different clinical specialties and seven different countries, with 5-35 years of relevant research experience, were recruited, and thirteen participants completed all three rounds. Of the 164 generated statements, 66% achieved consensus, and responses were stable between the final two rounds.

CONCLUSIONS

The e-Delphi resulted in international recommendations for assessing and diagnosing CARDs in patients with cancer. These recommendations should ensure standardized research and reporting practices in future studies.

Circadian disruption and cancer- and treatment-related symptoms

Cancer patients experience a number of co-occurring side- and late-effects due to cancer and its treatment including fatigue, sleep difficulties, depressive symptoms, and cognitive impairment. These symptoms can impair quality of life and may persist long after treatment completion. Furthermore, they may exacerbate each other's intensity and development over time. The co-occurrence and interdependent nature of these symptoms suggests a possible shared underlying mechanism. Thus far, hypothesized mechanisms that have been purported to underlie these symptoms include disruptions to the immune and endocrine systems. Recently circadian rhythm disruption has emerged as a related pathophysiological mechanism underlying cancer- and cancer-treatment related symptoms. Circadian rhythms are endogenous biobehavioral cycles lasting approximately 24 hours in humans and generated by the circadian master clock - the hypothalamic suprachiasmatic nucleus. The suprachiasmatic nucleus orchestrates rhythmicity in a wide range of bodily functions including hormone levels, body temperature, immune response, and rest-activity behaviors. In this review, we describe four common approaches to the measurement of circadian rhythms, highlight key research findings on the presence of circadian disruption in cancer patients, and provide a review of the literature on associations between circadian rhythm disruption and cancer- and treatment-related symptoms. Implications for future research and interventions will be discussed.

Exploration of a Novel Circadian miRNA Pair Signature for Predicting Prognosis of Lung Adenocarcinoma

Lung adenocarcinoma (LUAD) is the primary histological subtype of lung cancer with a markedly heterogeneous prognosis. Therefore, there is an urgent need to identify optimal prognostic biomarkers. We aimed to explore the value of the circadian miRNA (cmiRNA) pair in predicting prognosis and guiding the treatment of LUAD. We first retrieved circadian genes (Cgenes) from the CGDB database, based on which cmiRNAs were predicted using the miRDB and mirDIP databases. The sequencing data of Cgenes and cmiRNAs were retrieved from TCGA and GEO databases. Two random cmiRNAs were matched to a single cmiRNA pair. Finally, univariate Cox proportional hazard analysis, LASSO regression, and multivariate Cox proportional hazard analysis were performed to develop a prognostic signature consisting of seven cmiRNA pairs. The signature exhibited good performance in predicting the overall and progression-free survival. Patients in the high-risk group also showed lower IC50 values for several common chemotherapy and targeted medicines. In addition, we constructed a cmiRNA–Cgenes network and performed a corresponding Gene Ontology and Gene Set enrichment analysis. In conclusion, the novel circadian-related miRNA pair signature could provide a precise prognostic evaluation with the potential capacity to guide individualized treatment regimens for LUAD.

Preventing Sleep Disruption With Bright Light Therapy During Chemotherapy for Breast Cancer: A Phase II Randomized Controlled Trial

Purpose

The goal of this study was to examine whether daily increased morning light exposure would maintain or improve sleep and the circadian pattern of relatively more activity in the day and less during the night in women undergoing chemotherapy for breast cancer.

Patients and Methods

Participants were 39 women with newly diagnosed breast cancer, randomized to either 30-mins of daily morning bright white light (BWL) or dim red light (DRL). Sleep/wake was measured objectively for 72-h with wrist actigraphy and subjectively with the Pittsburgh Sleep Quality Index (PSQI) prior to and during chemotherapy cycles 1 and 4. The study was registered with the National Institutes of Health ClinicalTrials.gov (Clinical Trials number: NCT00478257).

Results

Results from actigraphy suggested that compared to the DRL group, women in the BWL group had longer night-time sleep, fewer sleep disturbances during the night, and had fewer and shorter daytime naps at the end of cycle 4 of chemotherapy as well as exhibiting less activity at night and more activity during the day by the end of cycle 4. Results from PSQI indicated that components of sleep quality improved but daytime dysfunction deteriorated during cycle 4 treatment in the BWL group; meanwhile the DRL group used more sleep medications in the treatment weeks which might have led to the improved sleep quality during the recovery weeks of both cycles.

Conclusion

These results suggest that bright white light therapy administered every morning on awakening may protect women undergoing chemotherapy for breast cancer from nighttime sleep and daytime wake disruption. Randomized clinical trials in larger samples are needed to confirm these findings.

Genetic Liability to Insomnia and Lung Cancer Risk: A Mendelian Randomization Analysis

Lung cancer is the second most frequently diagnosed cancer and the leading cause of cancer death worldwide, making its prevention an urgent issue. Meanwhile, the estimated prevalence of insomnia was as high as 30% globally. Research on the causal effect of insomnia on lung cancer incidence is still lacking. In this study, we aimed to assess the causality between the genetic liability to insomnia and lung cancer. We performed a two-sample Mendelian randomization analysis (inverse variance weighted) to determine the causality between the genetic liability to insomnia and lung cancer. Subgroup analysis was conducted, which included lung adenocarcinoma and lung squamous cell carcinoma. In the sensitivity analysis, we conducted heterogeneity test, MR Egger, single SNP analysis, leave-one-out analysis, and MR PRESSO. There were causalities between the genetic susceptibility to insomnia and increased incidence of lung cancer [odds ratio (95% confidence interval), 1.35 (1.14-1.59); P, < 0.001], lung adenocarcinoma [odds ratio (95% confidence interval), 1.35 (1.07-1.70); P, 0.01], and lung squamous cell carcinoma [odds ratio (95% confidence interval), 1.35 (1.06-1.72), P, 0.02]. No violation of Mendelian randomization assumptions was observed in the sensitivity analysis. There was a causal relationship between the genetic susceptibility to insomnia and the lung cancer, which was also observed in lung adenocarcinoma and lung squamous cell carcinoma. The underlying mechanism remains unknown. Effective intervention and management for insomnia were recommended to improve the sleep quality and to prevent lung cancer. Moreover, regular screening for lung cancer may be beneficial for patients with insomnia.

Genetically predicted insomnia and lung cancer risk: a Mendelian randomization study

BACKGROUND

The relationship between insomnia and lung cancer is scanty. The Mendelian randomization approach provides the rationale for evaluating the potential causality between genetically-predicted insomnia and lung cancer risk.

METHODS

We extracted 148 insomnia-related single-nucleotide polymorphisms (SNPs) as instrumental variables (IVs) from published genome-wide association studies (GWASs). Summary data of individual-level genetic information of participants were obtained from the International Lung Cancer Consortium (ILCCO) (29,266 cases and 56,450 controls). MR analyses were performed using the inverse-variance-weighted approach, MR pleiotropy residual sum and outlier (MR-PRESSO) test, weighted median estimator, and MR-Egger regression. Sensitivity analyses were further performed using Egger intercept analysis, leave-one-out analysis, MR-PRESSO global test, and Cochran's Q test to verify the robustness of our findings.

RESULTS

The results of the MR analysis indicated an increased risk of lung cancer in insomnia patients (OR = 1.1671; 95% CI 1.0754-1.2666, p = 0.0002). The subgroup analyses showed increased risks of lung adenocarcinoma (OR = 1.1878; 95% CI 1.0594-1.3317, p = 0.0032) and squamous cell lung cancer (OR = 1.1595; 95% CI 1.0248-1.3119, p = 0.0188).

CONCLUSION

Our study indicated that insomnia is a causal risk factor in the development of lung cancer. Due to the lack of evidence on both the epidemiology and the mechanism level, more studies are needed to better elucidate the results of the study.

Actigraphy-measured rest-activity circadian rhythm disruption in patients with advanced cancer: a scoping review

PURPOSE

Patients with later-stage cancer have been reported to demonstrate more disrupted rest-activity circadian rhythms (RACR) than those with earlier-stage cancer, but consolidated evidence of this is lacking. The aim of this review was to examine and map the existing evidence on actigraphy-measured RACR in terms of their (1) pattern, (2) prevalence, (3) related factors, and (4) outcomes in advanced cancer patients.

METHODS

A comprehensive scoping review was conducted using Arksey and O'Malley's framework. A literature search was performed using nine databases: MEDLINE, Embase, PsycINFO, CINAHL, British Nursing Index, Cochrane Library, Scopus, Web of Science, and SINTA.

RESULTS

Twenty-one studies were included in the review. Compared with the healthy population, advanced cancer patients were more likely to display weaker RACR, manifesting as lower activity levels during the day, more frequent and longer daytime naps, and fragmented nighttime sleep. The prevalence of RACR disruption among advanced cancer patients ranged from 31.3 to 54.9%. It was found to be linked to the presence of physical and psychological symptoms (fatigue, appetite loss, pain, dyspnoea, sleep disturbance, depression, and anxiety), chemotherapy, male sex, and also predict the lower quality of life and survival.

CONCLUSION

Disruption of the RACR is prevalent in advanced cancer patients and is associated with a set of physical and psychological symptoms. It was also found to be a predictor of the quality of life and survival among these patients. These results indicate the importance of interventions to restabilise the disrupted RACR among advance cancer patients to improve their health outcomes.

Pregnancy rest-activity patterns are related to salivary cortisol rhythms and maternal-fetal health indicators in women from a disadvantaged population

Irregular rest-activity patterns can disrupt metabolic and hormonal physiology and potentially lead to disease. Little is known regarding rest-activity patterns during gestation and their association with hormonal rhythms and health in pregnant women. We conducted a pilot study to determine if 24 h rest-activity was related to saliva cortisol rhythms and maternal-fetal health in an economically disadvantaged population. Primiparous women wore a wrist actigraphy device for a week to record activity during gestational weeks 22 (G22; n = 50) and 32 (G32; n = 46) and postpartum week one (PPW1; n = 39). Participants collected saliva samples every 4 hr over a 24 hr period during G22 (n = 22), G32 (n = 20) and 24–48 hr postnatal (n = 20), and cortisol concentrations were measured with ELISA. Circadian rhythmicity was assessed using autocorrelation coefficient (r24) and cosinor analysis. Blood glucose levels, body mass index (BMI), gestational disease data, and gestational age of infant at birth were abstracted from medical charts. Time of cortisol peak (acrophase) during G22 was related with acrophase of activity (r = 0.66; p = 0.001) and blood glucose levels (r = 0.58; p = 0.006). During G22, minutes of wake after sleep onset was positively related to cortisol mesor and AUC (p <0.05). Rest-activity r24, R², and mesor during G32 were positively (p<0.05) associated with gestational age of infant at birth. Across all three time points r24 of activity was related with cortisol amplitude (r = 0.33; p = 0.01). Findings support a relationship between rest-activity patterns and saliva cortisol rhythms during pregnancy. The association of less robust activity rhythms with earlier gestational age of infant at birth indicates a potential link between circadian system disruption and maternal-fetal health outcomes.

Pulmonary Rehabilitation does not Improve Objective Measures of Sleep Quality in People with Chronic Obstructive Pulmonary Disease

Abnormal sleep duration is associated with poor health. Upwards of 50% of people with chronic obstructive pulmonary disease (COPD) report poor sleep quality. The effect of pulmonary rehabilitation on self-reported sleep quality is variable. The aim of this study was to assess the effect of pulmonary rehabilitation on objectively measured sleep quality (via actigraphy) in people with COPD. Sleep quality was assessed objectively using the SenseWear Armband (SWA, BodyMedia, Pittsburgh, PA), worn for ≥4 days before and immediately after completing an 8-week pulmonary rehabilitation program. Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined from energy expenditure. Forty-eight participants (n = 21 male) with COPD (mean (SD), age 70 (10) years, mean FEV₁ 55 (20) % predicted, mean 45 (24) pack year smoking history) contributed pre and post pulmonary rehabilitation sleep data to this analysis. No significant differences were seen in any sleep parameters after pulmonary rehabilitation (p = 0.07-0.70). There were no associations between sleep parameters and measures of quality of life or function (all p > 0.30). Sleep quality, measured objectively using actigraphy, did not improve after an 8-week pulmonary rehabilitation program in individuals with COPD. Whether on-going participation in regular exercise training beyond the duration of pulmonary rehabilitation may influence sleep quality, or whether improving sleep quality could enhance rehabilitation outcomes, is yet to be determined.

Depressive symptoms and actigraphy-measured circadian disruption predict head and neck cancer survival

OBJECTIVE

Depressive symptoms have demonstrated prognostic significance among head and neck cancer patients. Depression is associated with circadian disruption, which is prognostic in multiple other cancer types. We hypothesized that depressive symptoms would be associated with circadian disruption in head and neck cancer, that each would be related to poorer 2-year overall survival, and that relationships would be mediated by tumor response to treatment.

METHODS

Patients (N = 55) reported on cognitive/affective and somatic depressive symptoms (PHQ-9) and wore an actigraph for 6 days to continuously record rest and activity cycles prior to chemoradiation. Records review documented treatment response and 2-year survival. Spearman correlations tested depressive symptoms and circadian disruption relationships. Cox proportional hazard models tested the predictive capability of depressive symptoms and circadian disruption, separately, on survival.

RESULTS

Depressive symptoms were significantly associated with circadian disruption, and both were significantly associated with shorter survival (somatic: hazard ratio [HR] = 1.325, 95% confidence interval [CI] = 1.089-1.611, P = .005; rest/activity rhythm: HR = 0.073, 95% CI = 0.009-0.563, P = .012; nighttime restfulness: HR = 0.910, 95% CI = 0.848-0.977, P = .009). Tumor response to treatment appeared to partly mediate the nighttime restfulness-survival relationship.

CONCLUSIONS

This study replicates and extends prior work with new evidence linking a subjective measure of depression and an objective measure of circadian disruption-2 known prognostic indicators-to shortened overall survival among head and neck cancer patients. Continued examination should elucidate mechanisms by which depressive symptomatology and circadian disruption translate to head and neck cancer progression and mortality.

Associations of objectively assessed physical activity and sedentary time with health-related quality of life among lung cancer survivors: A quantile regression approach

OBJECTIVES

No studies have examined objectively assessed physical activity, sedentary time, and patient-reported outcomes among lung cancer survivors. The objective of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) and sedentary time with health-related quality of life (HRQoL) and fatigue among lung cancer survivors.

MATERIALS AND METHOD

Lung cancer survivors in Southern Alberta (N = 540) were invited to complete a mailed survey that assessed HRQoL [Functional Assessment of Cancer Therapy-Lung (FACT-L)], physical and functional well-being [Trial Outcome Index (TOI)], and fatigue [Fatigue Scale (FS)]. Physical activity and sedentary time data was collected using an Actigraph^® GT3X+ accelerometer that was worn on the hip for seven consecutive days. Quantile regression was used to examine associations of HRQoL and fatigue with physical activity and sedentary time at the 25th, 50th, and 75th HRQoL and fatigue percentiles.

RESULTS

A total of 127 lung cancer survivors participated for a 24% response rate (Mean age = 71 years; Mean time since diagnosis = 75 months). Total MVPA minutes was positively associated with fewer fatigue symptoms at the 25th percentile (β = 0.16, p = 0.046). Total sedentary time was inversely associated with HRQoL at the 75th percentile (β = -0.07, p = 0.014) and inversely associated with fatigue symptoms at the 50th percentile (β = -0.04, p = 0.009). Total sedentary time was also inversely associated with physical and functional well-being scores at the 25th (β = -0.07, p = 0.045), 50th (β = -0.07, p = 0.004) and 75th (β = -0.04, p = 0.035) percentiles.

CONCLUSION

Across the HRQoL, fatigue, and physical and functional well-being distributions, sedentary time was inversely associated with HRQoL, fatigue, and physical and functional well-being in lung cancer survivors. Small associations were observed between MVPA and fatigue, but no associations emerged with HRQoL or physical and functional well-being.

How is physical activity measured in lung cancer?A systematic review of outcome measures and their psychometric properties

Physical activity (PA) levels are low in patients with lung cancer. Emerging evidence supports the use of interventions to increase PA in this population. We aimed to (1) identify and synthesize outcome measures which assess PA levels in patients with lung cancer and (2) to evaluate, synthesize and compare the psychometric properties of these measures. A systematic review of articles from searches was conducted of five electronic databases and personal records. Eligible studies were those which assessed PA using either performance-based or patient-reported measures. For aim 2, studies identified in aim 1 reporting on at least one psychometric property (validity, reliability, responsiveness or measurement error) were included. Two independent reviewers assessed eligibility and risk of bias with the COnsensus-based Standards for the selection of health status Measurement INstruments. Thirty-four studies using 21 different measures of PA were identified. Seventeen studies used performance-based measures. The Godin Leisure Time Exercise Questionnaire (GLTEQ) was the most frequently used patient-reported measure. Psychometric properties were reported for 13 of these measures and most frequently for movement sensors. Two studies reported on properties of the GLTEQ. Quality ratings for risk of bias were low. There is significant heterogeneity amongst studies regarding method of PA measurement along the lung cancer continuum. Greater consensus could be achieved by using a consensus approach such as a Delphi process. Future studies should include assessment of psychometric properties of the measurement tool being used. Currently, it is recommended where feasible, both performance-based and patient-reported measurements of PA should be undertaken.

Disruptions in sleep-wake cycles in community-dwelling cancer patients receiving palliative care and their correlates

Significant disruptions in sleep-wake cycles have been found in advanced cancer patients in prior research. However, much remains to be known about specific sleep-wake cycle variables that are impaired in patients with a significantly altered performance status. More studies are also needed to explore the extent to which disrupted sleep-wake cycles are related to physical and psychological symptoms, time to death, maladaptive sleep behaviors, quality of life and 24-h light exposure. This study conducted in palliative cancer patients was aimed at characterizing patients' sleep-wake cycles using various circadian parameters (i.e. amplitude, acrophase, mesor, up-mesor, down-mesor, rhythmicity coefficient). It also aimed to compare rest-activity rhythm variables of participants with a performance status of 2 vs. 3 on the Eastern Cooperative Oncology Group scale (ECOG) and to evaluate the relationships of sleep-wake cycle parameters with several possible correlates. The sample was composed of 55 community-dwelling cancer patients receiving palliative care with an ECOG of 2 or 3. Circadian parameters were assessed using an actigraphic device for seven consecutive 24-h periods. A light recording and a daily pain diary were completed for the same period. A battery of self-report scales was also administered. A dampened circadian rhythm, a low mean activity level, an early mean time of peak activity during the day, a late starting time of activity during the morning and an early time of decline of activity during the evening were observed. In addition, a less rhythmic sleep-wake cycle was associated with a shorter time to death (from the first home visit) and with a lower 24-h light exposure. Sleep-wake cycles are markedly disrupted in palliative cancer patients, especially, near the end of life. Effective non-pharmacological interventions are needed to improve patients' circadian rhythms, including perhaps bright light therapy.

Deterioration in physical activity and function differs according to treatment type in non-small cell lung cancer - future directions for physiotherapy management

OBJECTIVES

To investigate in non-surgically and surgically treated non-small cell lung cancer (NSCLC): (1) changes in physical activity, function, health-related quality of life (HRQoL) and symptoms after diagnosis; and (2) the association between physical activity and outcomes.

DESIGN

Prospective observational study.

SETTING

Three acute tertiary hospitals.

PARTICIPANTS

Sixty-nine individuals (43 male, median [IQR] age 68 [61 to 74] years) with stage I-IV NSCLC.

MAIN OUTCOME MEASURES

The primary outcome (Physical Activity Scale for the Elderly) and secondary outcome (six-minute walk test and questionnaires assessing HRQoL, function, symptoms, mood) were measured at diagnosis (pre-treatment), and eight to ten weeks post-diagnosis (post-operative and/or during chemotherapy/radiotherapy).

RESULTS

Individuals treated surgically (n=27) experienced a deterioration in physical activity levels (baseline median [IQR]=74 [51 to 135]; follow-up median [IQR]=29 [24 to 73]; median difference=45, effect size=0.3). At follow-up physical activity was inversely related to depression, pain and appetite loss (rho>0.5, p<0.05). In contrast non-surgical individuals (n=42) did not experience a change in physical activity, however did experience deterioration in function, functional capacity, global HRQoL, fatigue and dyspnoea. Physical activity levels were low in this group and at follow-up the strongest relationships with physical activity levels were global HRQoL, function, fatigue and mood (inverse, rho>0.5, p<0.05).

CONCLUSIONS

Surgically treated individuals experienced a reduction in physical activity levels after diagnosis, which was not seen in the non-surgical group. Lower physical activity levels were associated with poorer outcomes, particularly in non-surgically treated individuals. Further research is required to establish the optimal intervention to improve physical activity levels in these cohorts.

Circadian actigraphic rest-activity rhythms following surgery for endometrial cancer: A prospective, longitudinal study

OBJECTIVE

To investigate (1) circadian rest-activity rhythm disturbances among endometrial cancer patients as they recover from surgery in comparison to a historical reference group of women with no cancer history and (2) health- and treatment-related predictors of dysregulated rest-activity rhythms in endometrial cancer patients.

METHODS

60 endometrial cancer patients participated in a prospective, longitudinal study with actigraphic assessment at 1week, 1month, and 4months post-surgery. 60 women without cancer from an epidemiological sample completed one actigraphic assessment, acting as a reference group.

RESULTS

On average, results revealed initial significant rest-activity dysregulation at 1week and 1month post-surgery for the endometrial cancer group and then significant recovery in rest-activity patterns at 4months post-surgery. Similarly, the cancer group had significantly more impaired rhythms than the reference group at 1week post-surgery, but demonstrated comparable rhythms by 4months post-surgery. Among the health- and treatment-related variables examined, obesity and receipt of more invasive surgery were found to predict more impaired rhythms at all time points.

CONCLUSION(S)

The current study highlights significant disturbances in rest-activity patterns for endometrial cancer patients initially during surgical recovery followed by improvement in these patterns by 4months post-surgery; however, obese patients and those having more invasive surgery demonstrated more impaired rest-activity patterns throughout the 4-month recovery period. Further research is warranted to understand how more impaired rest-activity patterns relate to health and quality of life outcomes.

Impairment in circadian activity rhythms occurs during dexamethasone therapy in children with leukemia

BACKGROUND

Circadian rhythm disturbances in adults with cancer are associated with fatigue, time to relapse, and death. This study of circadian activity rhythms (CAR) of children with acute lymphoblastic leukemia (ALL) on continuation chemotherapy aimed to describe CAR before and after starting dexamethasone, and to determine whether fatigue was associated with less robust CAR.

PROCEDURE

This was a secondary analysis of data from a multi-institutional study in which children with ALL aged 5-18 years wore an actigraph for 10 consecutive 24-hour periods, five before and five during dexamethasone therapy. CAR parameters measured by actigraphy were calculated for each 5-day period, including peak activity, MESOR, amplitude, acrophase, and circadian quotient. Fatigue was measured on study days 2, 5, 7, and 10 by parent-report and self-report for children ≥ 7 years.

RESULTS

Eighty-two children qualified for CAR analysis, and 87 for analysis of daily peak activity patterns and fatigue. Mean age was 8.8 ± 3.3 years. Peak activity, MESOR, and amplitude significantly decreased during dexamethasone therapy. Children on high-dose dexamethasone (8 or 12 mg/m(2)/d) had significantly higher (better, or more robust) values of several CAR parameters than those on low-dose (6 mg/m(2)/d). There was a significant trend of decreasing daily pattern of peak activity during dexamethasone therapy only. Fatigue increased across the study and was associated with decreasing CAR peak activity, MESOR, and amplitude.

CONCLUSIONS

Dexamethasone initiation was associated with a decrease in several CAR parameters, and a significant decrease in the trend of daily peak activity. Fatigue was associated with less robust CAR.

How are patient populations characterized in studies investigating depression in advanced cancer? Results from a systematic literature review

CONTEXT

Prevalence rates of depression in patients with advanced cancer vary considerably. This may be because of heterogeneous samples and use of different assessment methods. Adequate sample descriptions and consistent use of measures are needed to be able to generalize research findings and apply them to clinical practice.

OBJECTIVES

Our objective was twofold: First, to investigate which clinically important variables were used to describe the samples in studies of depression in patients with advanced cancer; and second, to examine the methods used for assessing and classifying depression in these studies.

METHODS

PubMed, PsycINFO, Embase, and CINAHL were searched combining search term groups representing "depression," "palliative care," and "advanced cancer" covering 2007-2011. Titles and abstracts were screened, and relevant full-text articles were evaluated independently by two authors. Information on 32 predefined variables on cancer disease, treatment, sociodemographics, depression-related factors, and assessment methods was extracted from the articles.

RESULTS

After removing duplicates, 916 citations were screened of which 59 articles were retained. Age, gender, and stage of the cancer disease were the most frequently reported variables. Depression-related variables were rarely reported, for example, antidepressant use (17%) and previous depressive episodes (12%). Only 25% of the studies assessed and classified depression according to a validated diagnostic system.

CONCLUSION

Current practice for describing sample characteristics and assessing depression varies greatly between studies. A more standardized practice is recommended to enhance the generalizability and utility of findings. Stakeholders are encouraged to work toward a common standard for sample descriptions.

Can quality of life assessments differentiate heterogeneous cancer patients?

Purpose

This research conducted a face validation study of patient responses to the application of an HRQOL assessment research tool in a comprehensive community cancer program setting across a heterogeneous cohort of cancer patients throughout the natural history of diagnosed malignant disease, many of whom would not be considered candidates for clinical research trial participation.

Methods

Cancer registries at two regional cancer treatment centers identified 11072 cancer patients over a period of nine years. The EORTC QLQ-C30 was administered to patients at the time of their initial clinical presentation to these centers. To determine the significance of differences between patient subgroups, two analytic criteria were used. The Mann-Whitney test was used to determine statistical significance; clinical relevance defined a range of point differences that could be perceived by patients with different health states.

Results

Univariate analyses were conducted across stratification variables for population, disease severity and demographic characteristics. The largest differences were associated with cancer diagnosis and recurrence of disease. Large differences were also found for site of origin, mortality and stage; minimal differences were observed for gender and age. Consistently sensitive QoL scales were appetite loss, fatigue and pain symptoms, and role (work-related), social and physical functions.

Conclusions

1) The EORTC QLQ-C30 collected meaningful patient health assessments in the context of non-research based clinical care, 2) patient assessment differences are manifested disparately across 15 QoL domains, and 3) in addition to indicating how a patient may feel at a point in time, QoL indicators may also reveal information about underlying biological responses to disease progression, treatments, and prospective survival.

Examination of wrist and hip actigraphy using a novel sleep estimation procedure ☆

Objective

Improving and validating sleep scoring algorithms for actigraphs enhances their usefulness in clinical and research applications. The MTI^® device (ActiGraph, Pensacola, FL) had not been previously validated for sleep. The aims were to (1) compare the accuracy of sleep metrics obtained via wrist- and hip-mounted MTI^® actigraphs with polysomnographic (PSG) recordings in a sample that included both normal sleepers and individuals with presumed sleep disorders; and (2) develop a novel sleep scoring algorithm using spline regression to improve the correspondence between the actigraphs and PSG.

Methods

Original actigraphy data were amplified and their pattern was estimated using a penalized spline. The magnitude of amplification and the spline were estimated by minimizing the difference in sleep efficiency between wrist- (hip-) actigraphs and PSG recordings. Sleep measures using both the original and spline-modified actigraphy data were compared to PSG using the following: mean sleep summary measures; Spearman rank-order correlations of summary measures; percent of minute-by-minute agreement; sensitivity and specificity; and Bland–Altman plots.

Results

The original wrist actigraphy data showed modest correspondence with PSG, and much less correspondence was found between hip actigraphy and PSG. The spline-modified wrist actigraphy produced better approximations of interclass correlations, sensitivity, and mean sleep summary measures relative to PSG than the original wrist actigraphy data. The spline-modified hip actigraphy provided improved correspondence, but sleep measures were still not representative of PSG.

Discussion

The results indicate that with some refinement, the spline regression method has the potential to improve sleep estimates obtained using wrist actigraphy.

Prevalence and relationship between major depressive disorder and lung cancer: a cross-sectional study

Objective

The aims of this study were to estimate the prevalence and examine the factors associated with major depressive disorder (MDD) in lung cancer patients.

Materials and methods

This cross-sectional study was carried out in the oncology clinic of the University Hospital, Chiang Mai University, Thailand. Patients with all stages of lung cancer were included in this study. Demographic data of eligible patients were gathered. The Mini-International Neuropsychiatric Interview, Thai version 5.0.0 was used to identify MDD. The Thai version of the Personal Health Questionnaire Depression Scale was used to assess depression severity.

Results

A total of 146 lung cancer patients from the outpatient clinic from July to December 2012 were approached. The 104 patients were included and analyzed in this study. Based on the Mini-International Neuropsychiatric Interview, 14.4% of them were defined as having MDD. Multiple linear regression analysis revealed that Chalder Fatigue Scale, Functional Assessment of Cancer Therapy – Lung, and Pittsburgh Sleep Quality Index scores were significantly correlated with MDD in lung cancer patients.

Conclusion

The results suggest that MDD is more prevalent in lung cancer patients. In addition, fatigue, poor quality of life, and sleep disturbance may increase associated MDD. Because of the small sample size, further studies should be conducted to confirm these results.

Sleep duration and incidence of lung cancer in ageing men

BACKGROUND

Previous studies have suggested an association between sleep duration and cancer. However, the information on sleep duration regard to risk of lung cancer is scanty.

METHODS

Analysed data comprised prospective population-based cohort of 2586 men (aged 42-60 years) from Eastern Finland. Baseline survey and clinical examinations took place 1984-1989, and diagnosed lung cancers were obtained until the end of 2011 through linkage with the Finnish Cancer Registry. Self-reported sleep was categorized as ≤6.5 h, 7-7.5 h, and ≥8 h. Subjects with prior history of cancer or psychotropic medication (hypnotics or sedatives) were excluded from the analyses. Cox proportional hazards models with adjustments for possible confounders were used to examine the association.

RESULTS

Significant association between sleep duration and increased lung cancer risk was observed after adjustments for age, examination years, cumulative smoking history, family cancer history and Human Population Laboratory Depression scale scores (HR 2.12, 95% CI 1.17-3.85 for ≤6.5 h sleep, and HR 1.88, 95% CI 1.09-3.22 for ≥8 h sleep). Associations were even stronger among current smokers (HR 2.23, 95% CI 1.14-4.34 for ≤6.5 h sleep, and HR 2.09, 95% CI 1.14-3.81 for ≥8 h sleep). After further adjustments for alcohol consumption, physical activity, body mass index, marital status, education years, night work, employment status, asthma and chronic bronchitis, the association remained significant both in the whole study population and among smokers. When cumulative smoking history was replaced by current smoking in the adjustments, the increased risk was limited to those who slept<6.5 h.

CONCLUSIONS

Sleep duration of less than 7-7.5 hours or more than 7-7.5 hours associates with increased lung cancer risk. The physiological factors underlying the association are complex, and they may relate to melatonin excretion patterns, low-grade inflammation in cancer development process or disruptions in circadian rhythmicity.

Low physical activity levels and functional decline in individuals with lung cancer

OBJECTIVES

Physical activity has been infrequently measured objectively in non-small cell lung cancer (NSCLC). We aimed to investigate levels of physical activity, functional and patient reported outcomes at diagnosis and over six months in participants with recently diagnosed NSCLC and compare results with both physical activity guidelines and outcomes of similar-aged healthy individuals.

METHODS

This prospective observational study assessed 50 individuals from three Australian tertiary hospitals with stage I-IIIB NSCLC at diagnosis, then 10 weeks and six months later. Thirty five healthy individuals without cancer were assessed once. Outcome measures included tri-axial accelerometery (number of steps per day), six minute walk distance (6MWD), muscle strength and questionnaires including health-related quality of life (HRQoL).

RESULTS

Individuals with NSCLC were engaged in significantly less physical activity than similar-aged healthy individuals, with 60% not meeting physical activity guidelines. At diagnosis they had worse quadriceps strength, nutritional status and HRQoL. Over six months, participants with NSCLC experienced decline in self-reported physical activity, 6MWD and muscle strength, and worsening symptoms.

CONCLUSION

At diagnosis individuals with NSCLC engage in less physical activity, are weaker and more depressed than healthy individuals and their self-reported physical activity declines over six months. Future studies are required to investigate the efficacy of interventions to increase physical activity.

Functional capacity, physical activity and muscle strength assessment of individuals with non-small cell lung cancer: a systematic review of instruments and their measurement properties

BACKGROUND

The measurement properties of instruments used to assess functional capacity, physical activity and muscle strength in participants with non-small cell lung cancer (NSCLC) have not been systematically reviewed.

METHOD

OBJECTIVES

To identify outcome measures used to assess these outcomes in participants with NSCLC; and to evaluate, synthesise and compare the measurement properties of the outcome measures identified.

DATA SOURCES

A systematic review of articles using electronic databases MEDLINE (1950-2012), CINAHL (1982-2012), EMBASE (1980-2012), Cochrane Library (2012), Expanded Academic ASAP (1994-2012), Health Collection Informit (1995-2012) and PEDRO (1999-2012). Additional studies were identified by searching personal files and cross referencing. Eligibility Criteria for Study Selection: Search one: studies which assessed functional capacity, physical activity or muscle strength in participants with NSCLC using non-laboratory objective tests were included. Search two: studies which evaluated a measurement property (inter- or intra-rater reliability; measurement error; criterion or construct validity; or responsiveness) in NSCLC for one of the outcome measures identified in search one. Studies published in English from 1980 were eligible. Data Extraction and Methodological Quality Assessment: data collection form was developed and data extracted. Methodological quality of studies was assessed by two independent reviewers using the 4-point COSMIN checklist.

RESULTS

Thirteen outcome measures were identified. Thirty-one studies evaluating measurement properties of the outcome measures in participants with NSCLC were included. Functional capacity was assessed using the six- and twelve-minute walk tests; incremental- and endurance-shuttle walk tests; and the stair-climbing test. Criterion validity for three of these measures was established in NSCLC but not the reliability or responsiveness. Physical activity was measured using accelerometers and pedometers. Only the construct validity for accelerometers and pedometers was reported. Muscle strength was measured using hand-held dynamometry, hand-grip dynamometry, manual muscle test, one-repetition maximum and the chair-stand test, however only two studies reported reliability and measurement error and one study reported construct validity.

CONCLUSION

Currently there is a gap in the literature regarding the measurement properties of commonly used outcome measures in NSCLC participants, particularly reliability, measurement error and responsiveness. Further research needs to be conducted to determine the most suitable outcome measures for use in trials involving NSCLC participants.

Evidence-Based Treatment of Anxiety in Patients With Cancer

Anxiety is a dynamic response to perceived threat that is common among patients with cancer and fluctuates at critical points in the disease trajectory. A substantial minority of patients may experience clinically significant anxiety resulting from a range of potential etiologic factors. This review summarizes evidence-based recommendations for treatment of anxiety in oncology settings. Recommendations are based on the nature and time course of anxiety and the results of meta-analyses, systematic reviews, and individual trials in cancer populations. The evidence-based literature supports the use of psychosocial and psychopharmacologic treatments to prevent or alleviate anxiety symptoms. Conclusions are tempered by study heterogeneity and methodologic limitations and a lack of trials that included patients with clinically significant anxiety. In oncology settings, accessibility and acceptability of evidence-based treatments vary, and patients may seek a variety of resources to manage cancer concerns. Treatment planning should incorporate contributing factors to anxiety and patient preferences for psychiatric care.

Actigraphic assessment of sleep in chronic obstructive pulmonary disease

PURPOSE

Previously, sleep in chronic obstructive pulmonary disease (COPD) has been objectively investigated only by lab-based polysomnography. The main purpose of this study was to evaluate sleep quality in COPD patients in their home environment using actigraphy. We also investigated the factors associated with sleep impairment and the relationship between objective and subjective sleep quality and daytime somnolence in these patients.

METHODS

Twenty-six patients with moderate to very severe COPD and 15 controls were studied by actigraphy for at least 5 days. Subjective sleep quality was evaluated by the Pittsburgh Sleep Quality Index and daytime sleepiness by the Epworth Sleepiness Scale (ESS). Dyspnea was quantified by the modified Medical Research Council (MMRC) scale.

RESULTS

COPD patients showed increased sleep latency (p = 0.003), mean activity (p = 0.003), and wake after sleep onset (p = 0.003) and reduced total sleep time (TST; p = 0.024) and sleep efficiency (p = 0.001), as compared to controls. In patients, severity of dyspnea was correlated with sleep activity (r = 0.41; p = 0.04) and TST (r = -0.46; p = 0.02) and multiple regression analysis showed that MMRC score was the best predictor of TST (p = 0.02) and sleep efficiency (p = 0.03). Actigraphy measures during daytime were not significantly different between patients and controls. Subjective sleep quality was poorer in patients than controls (p = 0.043). ESS scores were not significantly different between the two groups. Actigraphy measures were not correlated with subjective sleep quality or daytime somnolence in both groups.

CONCLUSIONS

Nocturnal sleep is markedly impaired in stable COPD patients studied by actigraphy in their home environment and this impairment is related to severity of dyspnea.

Wrist actigraphy

To record sleep, actigraph devices are worn on the wrist and record movements that can be used to estimate sleep parameters with specialized algorithms in computer software programs. With the recent establishment of a Current Procedural Terminology code for wrist actigraphy, this technology is being used increasingly in clinical settings as actigraphy has the advantage of providing objective information on sleep habits in the patient's natural sleep environment. Actigraphy has been well validated for the estimation of nighttime sleep parameters across age groups, but the validity of the estimation of sleep-onset latency and daytime sleeping is limited. Clinical guidelines and research suggest that wrist actigraphy is particularly useful in the documentation of sleep patterns prior to a multiple sleep latency test, in the evaluation of circadian rhythm sleep disorders, to evaluate treatment outcomes, and as an adjunct to home monitoring of sleep-disordered breathing. Actigraphy has also been well studied in the evaluation of sleep in the context of depression and dementia. Although actigraphy should not be viewed as a substitute for clinical interviews, sleep diaries, or overnight polysomnography when indicated, it can provide useful information about sleep in the natural sleep environment and/or when extended monitoring is clinically indicated.

Sleep-wake circadian activity rhythm parameters and fatigue in oncology patients before the initiation of radiation therapy

BACKGROUND

Little is known about the relationships between sleep parameters and fatigue in patients at the initiation of radiation therapy (RT).

OBJECTIVES

The objectives of this study were to describe values for nocturnal sleep/rest, daytime wake/activity, and circadian activity rhythm parameters measured using actigraphy and to evaluate the relationships between these objective parameters and subjective ratings of sleep disturbance and fatigue severity, in a sample of patients at the initiation of RT.

METHODS

Patients (n = 185) with breast, prostate, lung, or brain cancer completed self-report measures for sleep disturbance (ie, Pittsburgh Sleep Quality Index, General Sleep Disturbance Scale) and fatigue (Lee Fatigue Scale) and wore wrist actigraphs for a total of 48 hours prior to beginning RT. Actigraphy data were analyzed using the Cole-Kripke algorithm. Spearman rank correlations were calculated between variables.

RESULTS

Approximately 30% to 50% of patients experienced sleep disturbance, depending on whether clinically significant cutoffs for the subjective or objective measures were used to calculate occurrence rates. In addition, these patients reported moderate levels of fatigue. Only a limited number of significant correlations were found between the subjective and objective measures of sleep disturbance. Significant positive correlations were found between the subjective, but not the objective measures of sleep disturbance and fatigue.

CONCLUSIONS

A significant percentage of oncology patients experience significant disturbances in sleep-wake circadian activity rhythms at the initiation of RT. The disturbances occur in both sleep initiation and sleep maintenance.

IMPLICATIONS FOR PRACTICE

Patients need to be assessed at the initiation of RT for sleep disturbance, so appropriate treatment is initiated.

Altered circadian rhythms and cancer-related fatigue outcomes

Fatigue is one of the most frequent and distressing complaints reported by patients with cancer. Describing relationships among disrupted circadian rhythms and cancer-related fatigue is important to the design and testing of interventions that target specific underlying etiology of fatigue. The purpose of this article is to review the literature on whether evidence exists to support the notion that disrupted circadian rhythms provide a mechanism of cancer-related fatigue. Searches were conducted from January 1950 to January 2010, to locate pertinent articles using 4 electronic databases: PubMed, MEDLINE, CINAHL, and Scopus.

RESULTS

After reviewing the articles, 15 were selected as meeting the established criteria of the study and were critiqued. Statistical approaches varied across studies, which may influence generalizability of results. Although commonalities across studies did emerge, there was a lack of consistency in variables studied, and most studies did not identify a theoretical framework. More research needs to be conducted using consistent types and characteristics of disrupted circadian rhythms in relation to fatigue, including temporal relationships between circadian rhythms, fatigue, and cancer.