The effect of exercise on bone mineral density in adult cancer survivors: a systematic review and meta-analysis

Updated systematic review of the effects of exercise on understudied health outcomes in cancer survivors

INTRODUCTION

The American College of Sports Medicine provided guidelines for exercise prescriptions in cancer survivors for specific cancer- and treatment-related health outcomes. However, there was insufficient evidence to generate exercise prescriptions for 10 health outcomes of cancer treatment. We sought to update the state of evidence.

METHODS

We conducted a systematic review of these 10 understudied health outcomes (bone health, sleep, cardiovascular function, chemotherapy-induced peripheral neuropathy (CIPN), cognitive function, falls and balance, nausea, pain, sexual function, and treatment tolerance) and provided an update of evidence.

RESULTS

While the evidence base for each outcome has increased, there remains insufficient evidence to generate exercise prescriptions. Common limitations observed across outcomes included: variability in type and quality of outcome measurement tools, variability in definitions of the health outcomes, a lack of phase III trials, and a majority of trials investigating breast or prostate cancer survivors only.

CONCLUSION

We identified progress in the field of exercise oncology for several understudied cancer- and treatment-related health outcomes. However, we were not able to generate exercise prescriptions due to continued insufficient evidence base. More work is needed to prescribe exercise as medicine for these understudied health outcomes, and our review highlights several strategies to aid in research acceleration within these areas of exercise oncology.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Management of cancer treatment-induced bone loss (CTIBL) in patients with breast cancer or prostate cancer

Breast cancer and prostate cancer are sex hormone-dependent cancers, and estrogen or androgen suppression therapy is the standard treatment. Cancer treatment-induced bone loss (CTIBL): bone loss and osteoporosis have become important side effects of these therapies. To summarize the current evidences, (1) Endocrine therapy for breast cancer and prostate cancer is associated with a significant decrease in bone mineral density. (2) Aromatase inhibitors (AI) for breast cancer are associated with a significant increase in fractures, and androgen deprivation therapy (ADT) for prostate cancer is likely to be associated with an increase in fractures. (3) Administration of bisphosphonates and denosumab increases bone mass in patients undergoing endocrine therapy for breast cancer. Administration of bisphosphonates, denosumab, and SERMs increased bone mass in patients undergoing ADT therapy for prostate cancer. (4) Bisphosphonates and denosumab reduce fracture risk in patients on AI for breast cancer, and toremifene and denosumab in patients on ADT for prostate cancer.

Effect of Combining Impact-Aerobic and Strength Exercise, and Dietary Habits on Body Composition in Breast Cancer Survivors Treated with Aromatase Inhibitors

This study examines both the effect of a twice-weekly combined exercise-1 h session of strength and 1 h session of impact-aerobic-on body composition and dietary habits after one year of treatment with aromatase inhibitors (AI) in breast cancer survivors. Overall, forty-three postmenopausal women with a BMI ≤ 35 kg/m², breast cancer survivors treated with AI, were randomized into two groups: a control group (CG) (n = 22) and a training group (IG) (n = 21). Body composition, i.e., abdominal, visceral, and subcutaneous adipose tissue) was measured by magnetic resonance. In addition, some questionnaires were used to gather dietary data and to measure adherence to the Mediterranean diet. After one year, women in the IG showed a significant improvement in body composition, indicated by decreases in subcutaneous and visceral adipose tissue, and total fat tissue. Furthermore, the dietary habits were compatible with moderate adherence to the Mediterranean diet pattern and a low dietary intake of Ca, Zn, Folic Ac, and vitamins D, A, and E. A twice-weekly training program combining impact aerobic exercise and resistance exercise may be effective in improving the body composition for postmenopausal women who have breast cancer treated with AI, and the results suggest the need for nutritional counselling for this population.

Factors predicting long-term physical activity of breast cancer survivors. 5-year-follow-up of the BREX exercise intervention study

BACKGROUND

The benefits of exercise training are well documented among breast cancer (BC) survivors. Patients decrease their physical activity during treatment, and many fail to regain their previous exercise levels. There is therefore a need to define factors supporting long-term physical activity behavior in this patient group, to target supporting interventions aimed at preventing the decline in physical activity (PA).

AIM

The aim of this study was to determine physical and psychosocial factors explaining long-term physical activity after the adjuvant treatments in BC survivors.

METHODS

Four-hundred forty-six BC survivors followed for 5-years within a randomized exercise trial participated. Factors explaining (1) physical activity after the adjuvant treatments and (2) changes in physical activity in long-term were analyzed using linear regression models and general estimating equation models. Pretreatment leisure-time physical activity (LTPA), demographic, and treatment factors, physical fitness, and quality of life (Qol) at baseline were independent factors.

RESULTS

Exercise levels increased during the first year, and thereafter remained mostly stable. Higher LTPA, higher fitness level, better Qol and older age at baseline were associated with higher physical activity level after adjuvant treatments (p < .001) in multivariate analysis. Higher levels of fatigue (p < .008) and better emotional functioning (p = .017) at baseline were the main factors associated with increased physical activity during the follow-up.

CONCLUSION

Previous exercise habits and Qol after adjuvant chemo-, and radiotherapy were the strongest determinants of long-term physical activity levels in breast cancer survivors. Patients with better emotional functioning increased their exercise activity most as did those patients with higher fatigue levels at baseline. Patients suffering from fatigue after adjuvant treatment managed to increase their exercise levels, in contrast to patients with low emotional functioning, and may benefit from physical exercise interventions. Emotionally deprived patients may benefit from psychosocial support to regain their previous exercise levels.

Bone loss induced by cancer treatments in breast and prostate cancer patients

Cancer and cancer therapies are a major factor risk for osteoporosis due to bone loss and deterioration of bone microarchitecture. Both factors contribute to a decrease in bone strength and, consequently, increased bone fragility and risk of fracture. Cancer-associated bone loss is a multifactorial process, and optimal interdisciplinary management of skeletal health, accurate assessment of bone density, and early diagnosis are essential when making decisions aimed at reducing bone loss and fracture risk in patients who have received or are receiving treatment for cancer. In this document, a multidisciplinary group of experts collected the latest evidence on the pathophysiology of osteoporosis and its prevention, diagnosis, and treatment with the support of the Spanish scientific society SEOM. The aim was to provide an up-to-date and in-depth view of osteoporotic risk and its consequences, and to present a series of recommendations aimed at optimizing the management of bone health in the context of cancer.

The effects of exercise on the bone health of people with cancer: a systematic review and meta-analysis

PURPOSE

To determine the pooled effect of exercise on the bone health of people diagnosed with cancer.

METHODS

Four electronic databases were systematically searched. Controlled trials that assessed the effect of exercise on the bone mineral density (BMD) or content (BMC) measured by dual-energy x-ray absorptiometry or peripheral quantitative computed tomography in people who had been diagnosed with cancer were included in the study. Random-effect meta-analyses of effect size (ES) were conducted. Sub-group analyses were performed to explore the influence of intervention duration, prescription and participant characteristics.

RESULTS

Of 66 full-text articles screened, 22 studies, from 21 interventions, were included (primarily breast/prostate cancer, sample range n = 36-498). When all interventions were grouped, a significant pooled ES was observed for exercise on hip (ES = 0.112, 95% CI: 0.026 to 0.198; p = 0.011) and lumbar spine BMD (ES = 0.269, 95% CI: 0.036 to 0.501; p = 0.024) compared to control. There was also an influence of sex, where females had greater improvements in hip (ES = 0.120, 95% CI: 0.017 to 0.223; p = 0.022) and spine BMD (ES = 0.415, 95% CI: 0.056 to 0.774; p = 0.23) compared to males.

CONCLUSION

Overall, exercise regimens of studies included in this review appear to improve bone health at the hip and spine in people diagnosed with cancer. Sub-analyses suggest some influence of sex, where females had greater improvements in BMD compared to males. It is essential that future studies evaluate the dose-response of exercise training on bone health and create exercise protocols that better align with the laws of bone modelling to enhance osteogenic potential.

Mechanobiology of Bone Metastatic Cancer

PURPOSE OF REVIEW

In this review, we provide an overview of what is currently known about the impacts of mechanical stimuli on metastatic tumor-induced bone disease (TIBD). Further, we focus on the role of the osteocyte, the skeleton's primary mechanosensory cell, which is central to the skeleton's mechanoresponse, sensing and integrating local mechanical stimuli, and then controlling the downstream remodeling balance as appropriate.

RECENT FINDINGS

Exercise and controlled mechanical loading have anabolic effects on bone tissue in models of bone metastasis. They also have anti-tumorigenic properties, in part due to offsetting the vicious cycle of osteolytic bone loss as well as regulating inflammatory signals. The impacts of metastatic cancer on the mechanosensory function of osteocytes remains unclear. Increased mechanical stimuli are a potential method for mitigating TIBD.

Androgen Deprivation Therapy Differentially Impacts Bone and Muscle in the Short Term in Physically Active Men With Prostate Cancer

Androgen deprivation therapy (ADT) is a cornerstone of advanced prostate cancer (PCa) therapy. Its use is associated with a loss of bone mineral density (BMD) and a greater risk of falls and osteoporotic fractures. In this prospective cohort study, we examined the impact of ADT on muscle and bone strength in men initiating ADT for PCa. Participants were evaluated at three time points: immediately before (week 0), and 6 and 24 weeks after ADT initiation. Study measures included fasting blood levels (for markers of muscle and bone metabolic activity), MRI and QCT imaging (for muscle fat content, and bone density and architecture), and validated clinical tests of muscle strength and gait. Sixteen men completed all study visits. At baseline and throughout the study, participants exercised a median of four times/week, but still experienced weight gain (+2.0 kg at week 24 versus week 0, p = 0.004). Biochemically, all men sustained dramatic early and persistent reductions in sex hormones post-ADT, along with a progressive and significant increase in serum C-telopeptide of type I collagen (CTX, +84% at week 24 versus week 0). There was a trend for rise in serum sclerostin (p = 0.09) and interleukin 6 (IL-6) (p = 0.08), but no significant change in serum myostatin (p = 0.99). Volumetric BMD by QCT declined significantly at the femoral neck (-3.7% at week 24 versus week 0), particularly at the trabecular compartment. On MRI, there were no significant changes in thigh muscle fat fraction. On physical testing, men developed weaker grip strength, but experienced no worsening in lower extremity and lumbar spine muscle strength, or on functional tests of gait. In conclusion, in physically active men, ADT for 24 weeks results in a significant increase in bone resorption and reduction in BMD, but nonsignificant changes in thigh muscle quality (on imaging) or strength and gait (on functional testing). © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The effect of exercise for improving bone health in cancer survivors - A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of exercise for improving bone-related outcomes among cancer survivors.

DESIGN

Systematic review and meta-analysis.

METHODS

An electronic search using the following databases: SPORTDiscus, Science Direct, CINAHL, MEDLINE, Cochrane, Pubmed, Ebscohost, ProQuest Nursing and Allied Health Source. Randomised, controlled, exercise trials involving cancer survivors were eligible. Effect data on bone mineral content (BMC) and density (BMD) outcomes were extracted. Risk of bias was assessed using the Physiotherapy Evidence Database tool. Standardised mean differences (SMD) were calculated to compare differences between exercise and usual care. Subgroup analyses were conducted to assess whether effect differed by exercise mode, intervention length, supervision, treatment, cancer type and risk of bias.

RESULTS

Twenty-six trials were included, with intervention durations ranging between 12 weeks and 2 years. Most trials involved breast cancer (n = 13, 50%), and most interventions were supervised (n = 18, 69%) and evaluated mixed-mode (i.e., combined aerobic and resistance) exercise (n = 13, 50%). Significant effects in favour of exercise (aerobic, resistance, mixed-mode and other exercise) were observed for whole body BMD, hip BMD, trochanter BMD and femoral neck BMD (SMD range: 0.19-0.39, all p < 0.05) compared to usual care.

CONCLUSION

Participation in various modes (aerobic, resistance, mixed-mode and other) of supervised and unsupervised exercise is associated with improvements in BMD. The present results provide evidence for clinicians and other health care professionals (e.g., exercise physiologists and physiotherapists) to recommend exercise for cancer survivors to prevent bone loss during and following treatment.

Charcot Reconstruction: Outcomes in Patients With and Without Diabetes

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.

Home-Based Telehealth Exercise Intervention in Early-On Survivors of Childhood Acute Lymphoblastic Leukemia: Feasibility Study

Background

Acute lymphoblastic leukemia is the most common type of pediatric cancer. Acute lymphoblastic leukemia causes an altered bone mineral homeostasis state, which can contribute to osteopenia, and bone fractures, most commonly vertebral fractures. With the increasing number of childhood cancer survivors, late adverse effects such as musculoskeletal comorbidities are often reported and are further influenced by inactive lifestyle habits. Physical activity has been shown to increase the mechanical workload of the bone, mitigating bone impairment in other cancer-specific populations.

Objective

This interventional pilot study aims to investigate the use of telehealth to deliver a home-based exercise intervention for early-on survivors of bone marrow–related hematological malignancies and to assess its impact on survivors’ musculoskeletal and functional health.

Methods

We aimed to recruit a group of 12 early-on survivors of acute lymphoblastic leukemia, within 6 months to 5 years of treatment, to participate in and complete the proposed telehealth intervention with a parent. The 16-week intervention included 40 potential home-based physical activity interventions supervised by a kinesiologist through a telehealth internet platform, with monthly progression. Patients were recruited to the cohort if they were able to participate in the intervention during the first month (minimum 12 weeks of intervention). Evaluation before and after the intervention protocol highlighted differences in functional capacities and musculoskeletal health of patients using mechanography, peripheral quantitative computed tomography, 6-minute walk test, and grip force test.

Results

The recruitment rate for the intervention was low (12/57, 21% of contacted patients). Of 12 patients, 3 were excluded (1=relapse, 1=failure to meet technical requirements, and 1=abandoned). The 9 patients who completed the intervention (6 girls; mean age 10.93, SD 2.83 years; mean BMI 21.58, SD 6.55 kg/m²; mean time since treatment completion 36.67, SD 16.37 months) had a mean adherence of 89% and a completion rate of 75%. In addition, these patients showed functional improvements in lower limb muscle force and power as well as in the 6-minute walk test distance. Participants also showed improved bone health after the intervention on the following parameters: bone mineral content, stress-strain index, total and cortical cross-sectional area at the 14% site (P=.03, P=.01, P=.01, and P=.001, respectively) and 38% site of the tibia (P=.003, P=.04, P=.001, and P=.003, respectively).

Conclusions

High adherence and participation rates suggest that telehealth is a feasible method to deliver exercise interventions to young early-on survivors of acute lymphoblastic leukemia. The proposed intervention seems promising in providing benefits to patients’ functional performance and bone health, but a large-scale study is needed to confirm this assumption.

Managing Common Estrogen Deprivation Side Effects in HR+ Breast Cancer: an Evidence-Based Review

PURPOSE OF REVIEW

The article reviews the consequences of estrogen deprivation during endocrine therapy for breast cancer and provides an update on alternative therapies for the management of symptoms.

RECENT FINDINGS

Endocrine therapy has progressed substantially in recent years, and its use is recommended for all breast cancer patients expressing hormone receptors. The main adverse events of this treatment can be controlled with medications and nonpharmacological measures. Antidepressants are effective in controlling vasomotor symptoms. Vaginal discomfort can be treated with local lubricants and pelvic floor physiotherapy, which may help in sexual dysfunction. Pathophysiological mechanisms of musculoskeletal symptoms during aromatase inhibitors treatment are not well understood, but some studies evaluating treatment with duloxetine, yoga, and acupuncture have shown some benefits. For prevention of bone loss, patients with risk factors should be offered bisphosphonates or denosumab. Individualization of treatment is crucial. Consideration should be given to therapy effects on quality of life, and strategies for controlling associated symptoms should be offered.

Five-year follow-up results of aerobic and impact training on bone mineral density in early breast cancer patients

A 12-month exercise program reversibly prevented hip bone loss in premenopausal women with early breast cancer. The bone-protective effect was maintained for 2 years after the end of the program but was lost thereafter.

PURPOSE

Breast cancer survivors are at an increased risk for osteoporosis and fracture. This 5-year follow-up of a randomized impact exercise intervention trial evaluated the maintenance of training effects on bone among breast cancer patients.

METHODS

Five hundred seventy-three early breast cancer patients aged 35-68 years and treated with adjuvant therapy were allocated into a 12-month exercise program or a control group. Four hundred forty-four patients (77%) were included in the 5-year analysis. The exercise intervention comprised weekly supervised step aerobics, circuit exercises, and home training. Areal bone mineral density (aBMD) was measured by dual-energy X-ray absorptiometry. Physical activity was estimated in metabolic equivalent (MET) hours per week and physical performance assessed by 2-km walking and figure-8 running tests.

RESULTS

In premenopausal patients, the 12-month exercise program maintained femoral neck (FN) and total hip (TH) aBMD for 3 years, but the protective effect was lost thereafter. The mean FN aBMD change in the exercise and control groups was - 0.2% and - 1.5% 1 year, - 1.1% and - 2.1% 3 years and - 3.3% versus - 2.4% 5 years after the beginning of the intervention, respectively. Lumbar spine (LS) bone loss was not prevented in premenopausal women and no training effects on aBMD were seen in postmenopausal women. The main confounding element of the study was the unexpected rise in physical activity among patients in the control group. The physical performance improved among premenopausal women in the exercise group compared with the controls.

CONCLUSION

The 12-month exercise program prevented FN and TH bone loss in premenopausal breast cancer patients for 3 years. The bone-protective effect was reversible and lost thereafter.

The prognostic impact of skeletal muscle status and bone mineral density for resected distal cholangiocarcinoma

BACKGROUND & AIMS

The preoperative body composition and bone mineral density (BMD) have been reported as prognostic factors for several cancers. However, the prognostic impact of the preoperative body composition and BMD for resected distal cholangiocarcinoma (DCC) remains unclear.

METHODS

A total of 111 patients who underwent pancreatoduodenectomy for DCC between 2002 and 2017 were analyzed. The skeletal muscle index (SMI) and BMD were measured by preoperative computed tomography. The optimal cut-off value of the body composition and BMD were selected based on the minimum P-value obtained by the log-rank test. The prognostic significance of the preoperative body composition and BMD was investigated using multivariate analysis.

RESULTS

The median values of the SMI (45.7 vs. 36.7 cm²/m², P < 0.001) and BMD (128.5 vs. 101.0 Hounsfield units [HU], P = 0.005) in male and female were significantly different. The optimal cut-off values for the SMI were 55 cm²/m² in male and 36 cm²/m² in female, and those for the BMD were 75 HU in male and 74 HU in female. A multivariate analysis identified low SMI (hazard ratio [HR], 4.340; P = 0.044), low BMD (HR, 5.333; P < 0.001) and microscopic venous invasion (HR, 2.019; P = 0.026) as independent prognostic factors for the survival.

CONCLUSIONS

A preoperative low SMI and low BMD were independent prognostic factors for resected DCC.

Physical activity for people living with cancer: Knowledge, attitudes, and practices of general practitioners in Australia

Background

Healthcare professionals’ (Oncologists, doctors, and nurses) physical activity (PA) recommendations impact patients living with cancer PA levels. General practitioners (GPs) monitor the overall health of patients living with cancer throughout their treatment journey. This is the first study to explore GP’s knowledge, attitudes and practices of PA for patients living with cancer.

Methods

GPs who see patients living with cancer regularly (n = 111) completed a survey based on The Theory of Planned Behaviour (TPB). Participants (GP’s) reported knowledge, attitudes, perceived behaviour control and subjective norms of PA within the cancer population. GP recommendation and referral rates of PA were reported. Principal component analysis was conducted to establish a set of survey items aligned to TPB constructs (attitude, subjective norms, perceived control), and multiple regression analyses characterised associations between these predictor variables and (a) recommendation; and (b) referral–of PA to cancer patients.

Results

GPs (n = 111) recommended PA to 41–60% of their patients and referred 1–20% to PA programs. Multiple regression models significantly predicted the percent of patients recommended PA, p < .0005 adj. R² = 0.40 and referred PA, p < .0005, adj. R² = 0.21. GP attitudes and perceived behavioural control and GP’s own activity levels were significant predictors of whether patients were recommended and referred for PA, p<0.05.

Conclusion

GPs reported positive attitudes and perceptions towards promoting PA for their patients living with cancer. Despite having a positive correlation between PA recommendations and referral rates, a gap was evident between GP’s PA beliefs and their individual referral practices. More GP’s willing to promote and refer their patients for PA, would improve the physical and mental health outcomes of the cancer population.

Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable

PURPOSE

The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.

METHODS

A second Roundtable was convened in 2018 to advance exercise recommendations beyond public health guidelines and toward prescriptive programs specific to cancer type, treatments, and/or outcomes.

RESULTS

Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain.

CONCLUSIONS

The proposed recommendations should serve as a guide for the fitness and health care professional working with cancer survivors. More research is needed to fill remaining gaps in knowledge to better serve cancer survivors, as well as fitness and health care professionals, to improve clinical practice.

Exercise and Nutritional Approaches to Combat Cancer-Related Bone and Muscle Loss

PURPOSE OF REVIEW

The aim of this narrative review is to summarise recent literature on the effects of exercise and nutrition interventions alone or in combination on muscle and bone loss in people with cancer.

RECENT FINDINGS

There is emerging evidence to support the inclusion of targeted exercise and nutrition strategies to counter loss of muscle and bone associated with cancer treatments. Although research in this field is advancing, the optimal exercise and nutrition prescription to combat cancer-related bone and muscle loss remain unknown. This review identifies specific components of nutrition and exercise interventions that are promising although require further exploration through studies designed to determine the effect on muscle and bone. A focused research effort is required to elucidate the full potential of exercise and nutrition intervention for people with cancer at risk of bone and muscle loss.

Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline

PURPOSE

The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer.

METHODS

ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature.

RESULTS

The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline.

RECOMMENDATIONS

Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.

The time course and mechanisms of change in biomarkers of joint metabolism in response to acute exercise and chronic training in physiologic and pathological conditions

PURPOSE

The benefits of exercise across the lifespan and for a wide spectrum of health and diseases are well known. However, there remains less clarity as to the effects of both acute and chronic exercise on joint health. Serum biomarkers of joint metabolism are sensitive to change and have the potential to differentiate between normal and adverse adaptations to acute and chronic load. Therefore, the primary objective of this review is to evaluate how serum biomarkers can inform our understanding of how exercise affects joint metabolism.

METHODS

A comprehensive literature search was completed to identify joint biomarkers previously used to investigate acute and chronic exercise training.

RESULTS

Identified biomarkers included those related to joint cartilage, bone, synovium, synovial fluid, and inflammation. However, current research has largely focused on the response of serum cartilage oligomeric matrix protein (COMP) to acute loading in healthy young individuals. Studies demonstrate how acute loading transiently increases serum COMP (i.e., cartilage metabolism), which is mostly dependent on the duration of exercise. This response does not appear to be associated with any lasting deleterious changes, cartilage degradation, or osteoarthritis.

CONCLUSION

Several promising biomarkers for assessing joint metabolism exist and may in future enhance our understanding of the physiological response to acute and chronic exercise. Defining 'normal' and 'abnormal' biomarker responses to exercise and methodological standardisation would greatly improve the potential of research in this area to understand mechanisms and inform practice.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Adherence to multiple health behaviours in cancer survivors: a systematic review and meta-analysis

PURPOSE

Multiple health behaviours (not smoking, minimal alcohol consumption, and maintaining a healthy weight by having a healthy diet and regular physical activity) improve quality of life and longevity of cancer survivors. Despite international guidelines, there are no existing reviews that synthesise cancer survivors' adherence to healthy lifestyle recommendations.

METHOD

Five databases (Embase, MEDLINE, PsycINFO, Web of Science, and Google Scholar) were searched for relevant articles published from 2007 until January 2018. Studies reporting adult cancer survivors' adherence to at least two lifestyle behaviours (body mass index, physical activity, smoking, fruit and vegetable intake, fiber intake, red meat intake, caloric intake, sodium intake, and alcohol consumption) based on the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations were included in the review. The pooled prevalence of adherence to single and multiple behaviours was calculated using a random-effects model. Subgroup analysis (mean years of survival and publication year) was undertaken.

RESULTS

A total of 3322 articles were identified. Of these, 51 studies matched the inclusion criteria, presenting data from 2,620,586 adult cancer survivors. Adherence to single behaviours, which was estimated from studies that assessed at least two health behaviours, was highest for not smoking (PE 87%; 95% CI, 85%, 88%) and low or no alcohol intake (PE 83%; 95% CI, 81%, 86%), and lowest for fiber intake (PE 31%; 95% CI, 21%, 40%). Adherence to multiple healthy behaviours (13 studies), ranged from 7 to 40% (pooled estimate (PE) 23%; 95% CI, 17%, 30%). Recent survivors (< 5-year survival time) had relatively better adherence to multiple behaviours (PE 31%; 95% CI, 27%, 35%) than long-term (> 5 years) survivors (PE 25%; 95% CI, 14%, 36%). Adherence to multiple behaviours improved over time since 2007.

CONCLUSION

Adherence to physical activity, dietary, and multiple lifestyle behaviours recommendations was low amongst cancer survivors. Recent cancer survivors were relatively more adherent to WCRF/AICR recommendations compared to long-term survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Health promotion programs help support healthy lifestyle behaviours of cancer survivors. PROSPERO registration number: CRD42018091663.

Immediate versus delayed exercise in men initiating androgen deprivation: effects on bone density and soft tissue composition

Objectives

To examine whether it is more efficacious to commence exercise medicine in men with prostate cancer at the onset of androgen‐deprivation therapy (ADT) rather than later on during treatment to preserve bone and soft‐tissue composition, as ADT results in adverse effects including: reduced bone mineral density (BMD), loss of muscle mass, and increased fat mass (FM).

Patients and methods

In all, 104 patients with prostate cancer, aged 48–84 years initiating ADT, were randomised to immediate exercise (IMEX, n = 54) or delayed exercise (DEL, n = 50) conditions. The former consisted of 6 months of supervised resistance/aerobic/impact exercise and the latter comprised 6 months of usual care followed by 6 months of the identical exercise programme. Regional and whole body BMD, lean mass (LM), whole body FM and trunk FM, and appendicular skeletal muscle (ASM) were assessed by dual X‐ray absorptiometry, and muscle density by peripheral quantitative computed tomography at baseline, and at 6 and 12 months.

Results

There was a significant time effect (P < 0.001) for whole body, spine and hip BMD with a progressive loss in the IMEX and DEL groups, although lumbar spine BMD was largely preserved in the IMEX group at 6 months compared with the DEL group (−0.4% vs −1.6%). LM, ASM, and muscle density were preserved in the IMEX group at 6 months, declined in the DEL group at 6 months (−1.4% to −2.5%) and then recovered at 12 months after training. FM and trunk FM increased (P < 0.001) over the 12‐month period in the IMEX (7.8% and 4.5%, respectively) and DEL groups (6.5% and 4.3%, respectively).

Conclusions

Commencing exercise at the onset of ADT preserves lumbar spine BMD, muscle mass, and muscle density. To avoid treatment‐related adverse musculoskeletal effects, exercise medicine should be prescribed and commenced at the onset of ADT.