Sarcopenia during neoadjuvant therapy for oesophageal cancer: characterising the impact on muscle strength and physical performance. Support Care Cancer. 2018;26:1569-1576. [PMID: 29197960 DOI: 10.1007/s00520-017-3993-0]

Association of Preoperative Sarcopenia with the Risk of Anastomotic Leakage in Surgical Esophageal Cancer Patients: A Meta-Analysis

BACKGROUND

Whether preoperative sarcopenia predicts increased risk of anastomotic leakage in operated esophageal cancer patients remains unclear. This study aimed to identify the relationship between preoperative sarcopenia and the incidence of anastomotic leakage in surgical esophageal cancer.

METHODS

PubMed, EMBASE, CNKI and Web of Science databases were searched up to October 11, 2024. Odds ratios (ORs) and 95% confidence intervals (CIs) were combined and subgroup analysis based on the pathological type, definition of sarcopenia and history of neoadjuvant therapy were performed.

RESULTS

Fifteen studies with 3,785 patients were included and 368 patients developed the anastomotic leakage (9.72%). Pooled results demonstrated that preoperative sarcopenia was significantly associated with the occurrence of anastomotic leakage among surgical esophageal cancer patients (OR = 1.57, 95% CI: 1.29-1.90, p < 0.001). Subgroup analysis by the pathological type and definition of sarcopenia revealed similar results. However, subgroup analysis by the neoadjuvant therapy indicated that preoperative sarcopenia was only related to anastomotic leakage among patients without the history of neoadjuvant therapy (OR = 2.40. 95% CI: 1.61-3.58, p < 0.001), and sarcopenia was not a significant risk factor for anastomotic leakage in neoadjuvant therapy treated patients (OR = 1.06, p = 0.845).

CONCLUSION

Preoperative sarcopenia could serve as a risk indicator in surgical esophageal cancer patients without neoadjuvant therapy.

The course of physical fitness and nutritional status in patients following prehabilitation before esophageal cancer surgery: Results from the PRIOR study

INTRODUCTION

This study evaluates the course of physical fitness and nutritional status during curative therapy for esophageal cancer, after implementation of a prehabilitation program. Additionally, the impact of baseline physical fitness level and severe postoperative complications on the course of individual patients were explored.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients with esophageal cancer following curative treatment. Prehabilitation, consisting of supervised exercise training and nutritional counseling was offered as standard care to patients after neoadjuvant therapy, prior to surgery. Primary outcome measures included change of exercise capacity, hand grip strength, self-reported physical functioning, Body Mass Index, and malnutrition risk from diagnosis to 2-6 months postoperatively. Analyses over time were performed using linear mixed models, and linear mixed regression models to investigate the impact of baseline level and severe postoperative complications.

RESULTS

Hundred sixty-eight patients were included (mean age 65.9 ± 8.6 years; 78.0 % male). All parameters (except for malnutrition risk) showed a decline during neoadjuvant therapy (p < .05), an improvement during prehabilitation (p < .005) and a decline postoperatively (p < .001), with a high heterogeneity between patients. Change in the outcomes from baseline to postoperatively was not different for patients with or without a severe complication. Better baseline physical fitness and nutritional status were significantly associated with a greater decline postoperatively (p < .001).

CONCLUSION

This study demonstrates a notable decline during neoadjuvant therapy, that fully recovers during prehabilitation, and a subsequent long lasting decline postoperatively. The heterogeneity in the course of physical fitness and nutritional status underlines the importance of individualized monitoring.

Development and Initial Implementation of a Clinical Monitoring Strategy in a Non-regulated Trial: a research note from the ReStOre II Trial

Background

Data and Safety Monitoring is integral to quality assurance of clinical trials. Although monitoring is a core legal component of regulated clinical trials, non-regulated trials are not mandated to incorporate monitoring. Consequently, the monitoring process has been underutilised and underreported in this setting. This research report outlines the development and plans for implementing a bespoke Clinical Monitoring Strategy within the ' Rehabilitation Strategies Following Oesophagogastric and Hepatopancreaticobiliary Cancer (ReStOre II) Trial', a non-regulated trial comparing a 12-week multidisciplinary programme of rehabilitation to standard care in a cohort of 120 cancer survivors.

Methods

This research note provides a detailed overview of the ReStOre II Clinical Monitoring Strategy and describes the development of the strategy pre and post awarding of the grant. The strategy consists of the establishment and implementation of a comprehensive trial governance structure, inclusive of a Trial Management Group, Trial Steering Committee Meeting, and Independent Data Monitoring Committee. In addition, external trial monitoring by the Clinical Research Facility at St James's Hospital. Three monitoring visits will be conducted during the trial; i) site initiation visit, ii) interim monitoring visit, and iii) close our visit.

Results

The Clinical Monitoring Strategy has been finalised and is currently being implemented within the ReStOre II Trial. Two site initiation visits and one interim monitoring visit have been completed to date.

Conclusion

This research note provides a template for implementation of a Clinical Monitoring Strategy in a non-regulated clinical trial.

Registration

ReStOre II Trial: https://clinicaltrials.gov/ct2/show/NCT03958019.

Prevention of Sarcopenia and Maintenance of Exercise Tolerance by Individualized Prehabilitation in a Patient With Esophageal Cancer During Preoperative Adjuvant Therapy: A Case Report

Preoperative adjuvant therapy for esophageal cancer increases sarcopenia and decreases exercise tolerance, which are risk factors for postoperative pneumonia. Preoperative rehabilitation for patients undergoing esophagectomy effectively reduces the incidence of postoperative pneumonia. Therefore, the risk factors should be optimized by preoperative rehabilitation. Our patient had several risk factors for postoperative pneumonia, including low exercise tolerance, presarcopenia, and low respiratory muscle strength. However, because of the patient's advanced age, multiple comorbidities, and poor nutritional status, we struggled to determine the appropriate exercise intensity. Furthermore, there was a concern that chemotherapy-related adverse events could prevent adequate exercise from being performed. However, with individualized measures such as adjustable exercise intensity settings based on treatment status and nutritional management through multidisciplinary collaboration, it was possible to prevent sarcopenia and maintain exercise tolerance during preoperative adjuvant therapy. Individualized support in preoperative rehabilitation was suggested to contribute to the prevention of sarcopenia and maintenance of exercise tolerance during preoperative adjuvant therapy.

Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Case-control study of the correlation between the five times sit to stand and 6-min walk distance in patients with pancreatic cancer

PURPOSE

Cases of pancreatic cancer are increasing, and the risk of developing this disease reportedly increases with age. In recent years, there has been an increasing number of reports on physical function in patients with pancreatic cancer. Methods such as the 6-min walk distance (6 MWD) should be established to evaluate physical function, as a decline in exercise capacity is an important index in these patients. Recently, the 6 MWD has also been used to evaluate physical function in patients with pancreatic cancer. In healthy older adults, a decrease in 6 MWD is reportedly associated with intrinsic capacity and health status. Such factors make assessing 6 MWD important. However, the measurement of 6 MWD requires a sizable measurement environment. The five times sit to stand (FTSTS) test is a simple method that can be performed using a chair. FTSTS is hypothesized to be a useful assessment scale in patients with pancreatic cancer because it is easy to estimate the decline in physical function in clinical practice if the decline in 6 MWD can be estimated by evaluating FTSTS. The study's purpose was to clarify this hypothesis and ascertain the cutoff required to determine the decrease in 6 MWD in clinical practice.

METHODS

Sixty consecutive patients with preoperative pancreatic cancer who were assessed for physical function were studied. 6 MWD (< 400 m) was the objective variable, and binary logistic regression analysis was performed, with age, BMI, sex, FTSTS, and HGS as explanatory variables. Receiver-operating characteristic (ROC) curve analysis was performed for the explanatory variables, which were found to be significant based on logistic regression analysis. The area under the curve (AUC) was also calculated. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were evaluated. This study was approved by Hiroshima University Hospital's ethics committee (approval number: E808-1).

RESULTS

Fifty-seven of the 60 patients were included in the analysis. Logistic regression analysis showed that FTSTS was a significant explanatory variable; ROC curve analysis showed an AUC of 0.872 and a cutoff value of 8.98 s. The sensitivity, specificity, PPV, and NPV were 82.4%, 80.0%, 63.6%, and 91.4%, respectively.

CONCLUSIONS

A decrease in 6 MWD in preoperative pancreatic cancer patients can be identified by performing FTSTS.

Progress in Research on Antitumor Drugs and Dynamic Changes in Skeletal Muscles

Objective: To review the research progress of reltionship between antitumor drugs and the dynamic changes of the skeletal muscles during treatment phase.

Background: Sarcopenia is a common disease in patients with tumors, and it has been agreed that patients with tumors and sarcopenia experience more serious adverse reactions and have a shorter long-term survival after antitumor therapy than patients without sarcopenia. Antitumor drugs whilst beneficial for tumor regression, interferes and synergizes with cancer-induced muscle wasting/sarcopenia, induced myodemia or intramuscular fat and the two conditions often overlap making it difficult to drive conclusions. In recent years, increasing attention has been paid to the dynamic changes in skeletal muscles during antitumor drug therapy. Dynamic changes refer not only measurement skeletal muscle quantity at baseline level, but give more emphasis on the increasing or decreasing level during or end of the whole treatment course.

Methods: We retrievaled published English-language original research articles via pubmed, those studies mainly focused on repeated measurements of skeletal muscle index using computed tomography (CT) in cancer patients who received antitumor drug treatment but not received interventions that produced muscle mass change (such as exercise and nutritional interventions).

Conclusion: This article will summarize the research progress to date. Most of antineoplastic drug cause skeletal muscle loss during the treatment course, loss of L3 skeletal muscle index is always associated with poor clinical outcomes.

Skeletal Muscle Change During Neoadjuvant Therapy and Its Impact on Prognosis in Patients With Gastrointestinal Cancers: A Systematic Review and Meta-Analysis

Background

Gastrointestinal cancers are the most common malignant tumors worldwide. As the improvement of survival by surgical resection alone for cancers is close to the bottleneck, recent neoadjuvant therapy has been emphasized and applied in the treatment. Despite the advantage on improving the prognosis, some studies have reported neoadjuvant therapy could reduce skeletal muscle and therefore affect postoperative outcomes. However, the conclusions are still controversial.

Methods

PubMed, CINAHL, Embase, and Cochrane Library were searched from inception to September 2, 2021. The inclusion criteria were observational studies, published in English, of individuals aged ≥18 years who underwent neoadjuvant therapy with gastrointestinal cancers and were assessed skeletal muscle mass before and after neoadjuvant therapy, with sufficient data on skeletal muscle change or the association with clinical outcomes. Meta-analysis was conducted by using the STATA 12.0 package when more than two studies reported the same outcome.

Results

A total of 268 articles were identified, and 19 studies (1,954 patients) were included in the review. The fixed effects model showed that the risk of sarcopenia increased 22% after receiving neoadjuvant therapy (HR=1.22, 95% CI 1.14, 1.31, Z=4.286, P&lt;0.001). In the random effects model, neoadjuvant therapy was associated with skeletal muscle loss, with a standardized mean difference of -0.20 (95% CI -0.31, -0.09, Z=3.49, P&lt;0.001) and a significant heterogeneity (I2 =62.2%, P&lt;0.001). Multiple meta regression indicated that population, neoadjuvant therapy type, and measuring tool were the potential sources of heterogeneity. The funnel plot revealed that there was no high publication bias in these studies (Begg’s test, P=0.544) and the sensitivity analysis showed stable results when separately excluding studies. For the postoperative outcomes, the results revealed that muscle loss during neoadjuvant therapy was significantly related to overall survival (HR=2,08, 95% CI =1.47, 2.95, Z=4.12, P&lt;0.001, I2 = 0.0%), but not related to disease-free survival and other short-term outcomes.

Conclusions

This systematic review and meta-analysis revealed that skeletal muscle decreased significantly during neoadjuvant therapy in patients with gastrointestinal cancers and skeletal muscle loss was strongly associated with worse overall survival. More high-quality studies are needed to update and valid these conclusions in a more specific or stratified way.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier PROSPERO (CRD42021292118)

Effect of Body Composition Change during Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma

Effects of changes in body composition during neoadjuvant chemotherapy (NAC) on perioperative complications and prognosis are unknown in patients with esophageal squamous cell carcinoma (ESCC). A total of 175 patients who underwent surgery for ESCC in our hospital between 2016 and 2019 were examined. The psoas muscle index (PMI) was calculated from the total psoas muscle area, and the visceral fat mass (VFM) at the umbilical level was measured. We defined body composition change (BCC) group as those with increased VFM of ≥ 3% and decreased PMI of ≥ 3% during NAC. Sarcopenia (S) was defined as PMI < 5.89 (male) and <4.06 (female). Nutritional assessment using the Subjective Global Assessment tool was performed upon admission. The percentages of BCC group, pre-NAC S, and post-NAC S was 32.5%, 79.4%, and 80.0%, respectively. BCC group had significantly more postoperative complications (p < 0.01) and longer hospital stays (p = 0.03) than groups pre-NAC S and post-NAC S. Overall survival (OS) analysis using the Cox hazard model showed that stage III (p < 0.01) and post-NAC S (p = 0.03) were poor prognostic factors. Changes in body composition during NAC affected perioperative complications and prognosis of patients with ESCC.

Degradation of skeletal mass in locally advanced oesophageal cancer between initial diagnosis and recurrence

BACKGROUND

The prognostic value of a low skeletal mass index (SMI) has been investigated in locally advanced oesophageal (LAE) cancer at diagnosis. However, nothing is known about its evolution and clinical impact between initial diagnosis and recurrence.

METHODS

A total of 89 patients treated for LAE cancer between January 2009 and December 2019 were included in this study. Computed tomography (CT) scans before treatment and at recurrence were evaluated. SMI and other body composition parameters were analysed by the L3 scan method.

RESULTS

Participants were aged 66.0 (36.0-86) years. The incidence of low SMI increased by 12.3% between diagnosis and recurrence (70.7% vs. 83.0%, respectively) over a median follow-up of 16.9 (1.7-101.6) months. Patients with high SMI at diagnosis showed loss of muscle mass (58.0 vs. 55.2 cm²/m², respectively; P < 0.001) and decreased body mass index (BMI) (27.9 vs. 26.3 kg/m², respectively; P = 0.05), but fat mass was increased (68.9 vs. 72.0 cm²/m², respectively; P = 0.01). Patients with low SMI at diagnosis showed no significant changes in body composition parameters and no improvement of SMI, even with nutritional support. Low SMI (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.02-3.16) was an independent predictor (P = 0.041) of high nutritional risk index (HR: 1.79; 95% CI: 1.03-3.11; P = 0.039) at diagnosis.

CONCLUSIONS

The percentage of patients with a low SMI increased during follow-up. Our data suggest that an assessment of skeletal muscle parameters and nutrition support may be more useful in patients with a high SMI.

Opposing Immune-Metabolic Signature in Visceral Versus Subcutaneous Adipose Tissue in Patients with Adenocarcinoma of the Oesophagus and the Oesophagogastric Junction

Oesophageal adenocarcinoma (OAC) is an exemplar model of obesity-associated cancer. Previous work in our group has demonstrated that overweight/obese OAC patients have better responses to neoadjuvant therapy, but the underlying mechanisms are unknown. Unravelling the immune-metabolic signatures of adipose tissue may provide insight for this observation. We hypothesised that different metabolic pathways predominate in visceral (VAT) and subcutaneous adipose tissue (SAT) and inflammatory secretions will differ between the fat depots. Real-time ex vivo metabolic profiles of VAT and SAT from 12 OAC patients were analysed. These samples were screened for the secretion of 54 inflammatory mediators, and data were correlated with patient body composition. Oxidative phosphorylation (OXPHOS) was significantly higher in VAT when compared to SAT. OXPHOS was significantly higher in the SAT of patients receiving neoadjuvant treatment. VEGF-A, VEGF-C, P1GF, Flt-1, bFGF, IL-15, IL-16, IL-17A, CRP, SAA, ICAM-1, VCAM-1, IL-2, IL-13, IFN-γ, and MIP-1β secretions were significantly higher from VAT than SAT. Higher levels of bFGF, Eotaxin-3, and TNF-α were secreted from the VAT of obese patients, while higher levels of IL-23 and TARC were secreted from the SAT of obese patients. The angiogenic factors, bFGF and VEGF-C, correlated with visceral fat area. Levels of OXPHOS are higher in VAT than SAT. Angiogenic, vascular injury and inflammatory cytokines are elevated in VAT versus SAT, indicating that VAT may promote inflammation, linked to regulating treatment response.

Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis

BACKGROUND

Esophageal cancer and curative treatment have a significant impact on the physical fitness of patients. Knowledge about the course of physical fitness during neoadjuvant therapy and esophagectomy is helpful to determine the needs for interventions during and after curative treatment. This study aims to review the current evidence on the impact of curative treatment on the physical fitness of patients with esophageal cancer.

METHODS

A systematic literature search of PubMed, Embase, Cinahl and the Cochrane Library was conducted up to March 29, 2021. We included observational studies investigating the change of physical fitness (including exercise capacity, muscle strength, physical activity and activities of daily living) from pre-to post-neoadjuvant therapy and/or from pre-to post-esophagectomy. Quality of the studies was assessed and a meta-analysis was performed using standardized mean differences.

RESULTS

Twenty-seven articles were included. After neoadjuvant therapy, physical fitness decreased significantly. In the first three months after surgery, physical fitness was also significantly decreased compared to preoperative values. Subgroup analysis showed a restore in exercise capacity three months after surgery in patients who followed an exercise program. Six months after surgery, there was limited evidence that exercise capacity restored to preoperative values.

CONCLUSION

Curative treatment seems to result in a decrease of physical fitness in patients with esophageal cancer, up to three months postoperatively. Six months postoperatively, results were conflicting. In patients who followed a pre- or postoperative exercise program, the postoperative impact of curative treatment seems to be less.

Targeting cancer via ribosome biogenesis: the cachexia perspective

Cancer cachexia afflicts many advanced cancer patients with many progressing to death. While there have been many advancements in understanding the molecular mechanisms that contribute to the development of cancer cachexia, substantial gaps still exist. Chemotherapy drugs often target ribosome biogenesis to slow or blunt tumor cell growth and proliferation. Some of the most frequent side-effects of chemotherapy are loss of skeletal muscle mass, muscular strength and an increase in fatigue. Given that ribosome biogenesis has emerged as a main mechanism regulating muscle hypertrophy, and more recently, also implicated in muscle atrophy, we propose that some chemotherapy drugs can cause further muscle wasting via its effect on skeletal muscle cells. Many chemotherapy drugs, including the most prescribed drugs such as doxorubicin and cisplatin, affect ribosomal DNA transcription, or other pathways related to ribosome biogenesis. Furthermore, middle-aged and older individuals are the most affected population with cancer, and advanced cancer patients often show reduced levels of physical inactivity. Thus, aging and inactivity can themselves affect muscle ribosome biogenesis, which can further worsen the effect of chemotherapy on skeletal muscle ribosome biogenesis and, ultimately, muscle mass and function. We propose that chemotherapy can accelerate the onset or worsen cancer cachexia via its inhibitory effects on skeletal muscle ribosome biogenesis. We end our review by providing recommendations that could be used to ameliorate the negative effects of chemotherapy on skeletal muscle ribosome biogenesis.

Maintenance of Muscle Mass and Cardiorespiratory Fitness to Cancer Patients During COVID-19 Era and After SARS-CoV-2 Vaccine

There is emerging evidence that decreased muscle mass and cardiorespiratory fitness (CRF) are associated with increased risk of cancer-related mortality. This paper aimed to present recommendations to prescribe effective and safe exercise protocols to minimize losses, maintain or even improve muscle mass, strength, and CRF of the cancer patients who are undergoing or beyond treatment during the COVID-19 era. Overall, we recommend performing exercises with bodyweight, elastic bands, or suspension bands to voluntary interruption (i.e., interrupt the exercise set voluntarily, according to their perception of fatigue, before concentric muscular failure) to maintain or increase muscle strength and mass and CRF during COVID-19 physical distancing. Additionally, rest intervals between sets and exercises (i.e., long or short) should favor maintaining exercise intensities between 50 and 80% of maxHR and/or RPE of 12. In an exercise program with these characteristics, the progression of the stimulus must be carried out by increasing exercise complexity, number of sets, and weekly frequency. With feasible exercises attainable anywhere, modulating only the work-to-rest ratio and using voluntary interruption, it is possible to prescribe exercise for a wide range of patients with cancer as well as training goals. Exercise must be encouraged; however, exercise professionals must be aware of the patient's health condition even at a physical distance to provide a safe and efficient exercise program. Exercise professionals should adjust the exercise prescription throughout home confinement whenever necessary, keeping in mind that minimal exercise stimuli are beneficial to patients in poor physical condition.

The Impact of Preoperative Sarcopenia on Survival Prognosis in Patients Receiving Neoadjuvant Therapy for Esophageal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Sarcopenia is a poor prognostic factor in patients with esophageal cancer (EC). It can be aggravated by neoadjuvant therapy (NAT) that improves the prognosis of patients with EC. Until now, the impact of preoperative sarcopenia on survival prognosis in patients receiving NAT for EC remains unclear.

METHODS

We systematically researched relevant studies in the PubMed, EMBASE, Web of Science, the Cochrane Library databases up to March 8, 2020. Prevalence of sarcopenia before and after NAT, overall survival (OS) and disease-free survival (DFS) were collected for analysis. Finally, eleven cohort studies were included.

RESULTS

Pooled analysis indicated that preoperative sarcopenia was negatively associated with OS. (HR = 1.290; 95% CI [1.078-1.543]; P = 0.005; I 2 = 0.0%) and DFS (HR = 1.554; 95% CI [1.177-2.052]; P = 0.002; I 2 = 0.0%) in the patients with EC receiving NAT. The prevalence of sarcopenia increased by 15.4% following NAT (95%CI [12.9%-17.9%]). Further subgroup analysis indicated that sarcopenia diagnosed following NAT (HR = 1.359; 95% CI [1.036-1.739]; P = 0.015; I 2 = 6.9%) and age >65 years (HR = 1.381; 95% CI [1.090- 1.749]; P = 0.007; I 2 = 0.0%) were the independent risk factors for decreased OS.

CONCLUSIONS

Clinicians should strengthen the screening of preoperative sarcopenia in patients of EC both receiving NAT and older than 65 years and give active nutritional support to improve the prognosis of patients.

SYSTEMATIC REVIEW REGISTRATION

International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY), identifier INPLASY202050057.

Addressing the changing rehabilitation needs of patients undergoing thoracic surgery

The rehabilitation needs of individuals undergoing thoracic surgery are changing, especially as surgical management is increasingly being offered to patients who are at risk of developing functional limitations during and after hospital discharge. In the past rehabilitative management of these patients was frequently limited to specific respiratory physiotherapy interventions in the immediate postoperative setting with the aim to prevent postoperative pulmonary complications. In the past two decades, this focus has shifted toward pulmonary rehabilitation interventions that aim to improve functional status of individuals, both in the pre- and (longer-term) postoperative period. While there is increased interest in (p)rehabilitation interventions the majority of thoracic surgery patients are however currently on their own with respect to progression of their exercise and physical activity regimens after they have been discharged from hospital. There are also no formal guidelines supporting the referral of these patients to outpatient rehabilitation programs. The current evidence regarding rehabilitation interventions initiated before, during, and after the hospitalization period will be briefly reviewed with special focus on patients undergoing surgery for lung cancer treatment and patients undergoing lung transplantation. More research will be necessary in the coming years to modify or change clinical rehabilitation practice beyond the acute admission phase in patients undergoing thoracic surgery. Tele rehabilitation or web-based activity counseling programs might also be interesting emerging alternatives in the (long-term) postoperative rehabilitative treatment of these patients.

Perspectives of Esophageal Cancer Survivors on Diagnosis, Treatment, and Recovery

Simple Summary

An esophageal cancer diagnosis signals the start of a difficult period of health-related physical, psychological, and social challenges. To date, relatively few studies have explored the diagnosis, treatment, and recovery experiences of esophageal cancer survivors. Esophageal cancer diagnosis and treatment pose challenges to all aspects of wellbeing, and necessitate an extended period of recovery. As such, supportive education and rehabilitative interventions must encompass a range of strategies to help survivors maintain an adequate quality of life during treatment and recovery. This study aimed to examine patient experiences of esophageal cancer diagnosis, treatment, and recovery, to enable researchers and health professionals to better understand the education and rehabilitative needs of esophageal cancer survivors.

Abstract

Esophageal cancer poses challenges to all domains of wellbeing. This qualitative study aimed to explore the experiences of esophageal cancer diagnosis, treatment, and recovery, with a view to informing the health education needs of this group. Eighteen persons who had undergone an esophagectomy participated in one of four audio-taped focus groups in a specialist hospital for cancer care. Transcriptions were analyzed thematically. Fear and uncertainty underpinned all stages of diagnosis, treatment, and recovery. Participants emphasized: (a) a lack of understanding over what to expect throughout treatment and recovery; (b) the demanding and traumatic period of adjustment required as a result of changes to their physical, psychological, and social functioning; and, (c) that support provided by family, friends, and acquaintances was variable and uninformed, often to the point of being counterproductive to physical and psychosocial recovery. Tailored education is needed to enable patients to prepare for each stage of their cancer journey. Equally, families and wider social networks should receive education that enables them to provide esophageal cancer survivors with appropriate support. Education should be provided at intervals that enable patients, survivors, and support networks to prepare for the physical, emotional, and social challenges experienced during diagnosis, treatment, and recovery.

Prognostic Markers of Overall Survival in Cancer Patients Attending a Cachexia Support Service: An Evaluation of Clinically Assessed Physical Function, Malnutrition and Inflammatory Status

BACKGROUND

Cancer cachexia is a muscle-wasting syndrome that results in physical function impairments and decreased survival. While body weight and muscle mass loss predict survival, the prognostic significance of physical function in this population is unclear. Thus, we evaluated the association between physical function, and other routine measures, and overall survival (OS) in cancer patients attending a cachexia support service.

METHODS

Physical function was clinically-assessed using the 30 s sit-to-stand test and handgrip strength. Six-month weight loss, the Patient-Generated Subjective Global Assessment (PG-SGA) total score, C-reactive protein (CRP), albumin, and quality of life were also evaluated.

RESULTS

Records from 203 patients (age: 68.6 ± 11.6 years) were included. Handgrip strength did not predict OS. Sit-to-stand repetitions predicted OS in the single variable, but not the multivariable analysis. Multivariable results suggested higher PG-SGA total scores (HR: 1.04, 95% CI: 1.01-1.07), six-month weight loss (HR: 1.02, 95% CI: 1.004-1.04), and elevated CRP (HR: 1.004, 95% CI: 1.0004-1.01) predicted shorter OS. Higher albumin predicted longer OS (HR: 0.93, 95% CI: 0.90-0.97).

CONCLUSION

Six-month weight loss, the PG-SGA total score, CRP, and albumin independently predicted survival, while physical function did not. Functional impairments remain a hallmark of cancer cachexia and the benefit of their routine assessment warrants further exploration, especially in relation to patient quality of life.

Influence of body composition and muscle strength on outcomes after multimodal oesophageal cancer treatment

BACKGROUND

Influence of sarcopenia in combination with other body composition parameters and muscle strength on outcomes after oesophageal surgery for oesophageal cancer remains unclear. The objectives were (i) to describe the incidence of sarcopenia in relation to adipose tissue quantity and distribution and muscle strength; (ii) to evaluate if neoadjuvant chemoradiation (nCRTx) influences body composition and muscle strength; and (iii) to evaluate the influence of body composition and muscle strength on post-operative morbidity and long-term survival.

METHODS

This retrospective study included patients with oesophageal cancer who received nCRTx followed by surgery between January 2011 and 2016. Skeletal muscle, visceral, and subcutaneous adipose tissue cross-sectional areas were calculated based on computed tomography scans, and muscle strength was measured using hand grip tests, 30 seconds chair stand tests, and maximal inspiratory and expiratory pressure tests prior to nCRTx and after nCRTx.

RESULTS

A total of 322 patients were included in this study. Sarcopenia was present in 55.6% of the patients prior to nCRTx and in 58.2% after nCRTx (P = 0.082). Patients with sarcopenia had a significantly lower muscle strength and higher fat percentage. The muscle strength and incidence of sarcopenia increased while the mean body mass index and fat percentage decreased during nCRTx. A body mass index above 25 kg/m2 was associated with anastomotic leakage (P = 0.032). Other body composition parameters were not associated with post-operative morbidity. A lower handgrip strength prior to nCRTx was associated with pulmonary and cardiac complications (P = 0.023 and P = 0.009, respectively). In multivariable analysis, a lower number of stands during the 30 seconds chair stand test prior to nCRTx (hazard ratio 0.93, 95% confidence interval 0.87-0.99, P = 0.017) and visceral adipose tissue of >128 cm2 after nCRTx (hazard ratio 1.81, 95% confidence interval 1.30-2.53, P = 0.001) were associated with worse overall survival.

CONCLUSIONS

Sarcopenia occurs frequently in patients with oesophageal cancer and is associated with less muscle strength and a higher fat percentage. Body composition changes during nCRTx did not influence survival. Impaired muscle strength and a high amount of visceral adipose tissue are associated with worse survival. Therefore, patients with poor fitness might benefit from preoperative nutritional and muscle strengthening guidance, aiming to increase muscle strength and decrease visceral adipose tissue. However, this should be confirmed in a large prospective study.

Prognostic Impact of Sarcopenia and Skeletal Muscle Loss During Neoadjuvant Chemoradiotherapy in Esophageal Cancer

BACKGROUNDS

The relationship between sarcopenia, characterized by loss of muscle mass and strength, and survival outcomes of esophageal cancer is controversial. This study aimed to assess the effect of sarcopenia and skeletal muscle loss on overall survival (OS) and recurrence-free survival (RFS) of esophageal cancer patients.

METHODS

We retrospectively collected the medical records of 248 male patients diagnosed with squamous cell esophageal cancer and who underwent neoadjuvant chemoradiotherapy (NACRT) followed by surgery. We measured the cross-sectional area of the skeletal muscle at the L3 vertebra level using computed tomography images and calculated the skeletal muscle index (SMI). Sarcopenia was defined as SMI <52.4 cm²/m², and excessive muscle loss was defined as SMI change <-10.0%/50 days during NACRT. Moreover, laboratory test results, such as albumin, prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) before and after NACRT, were collected.

RESULTS

In the univariable Cox analysis, pre- (p = 0.689) and post-radiotherapy (RT) sarcopenia (p = 0.669) were not associated with OS. However, excessive muscle loss had a significant association with OS in both the univariable and multivariable analyses (all p = 0.001). Excessive muscle loss was also related to RFS in both the univariable (p = 0.011) and multivariable (p = 0.022) Cox analysis. Patients with excessive muscle loss had significantly lower levels of post-RT albumin (p < 0.001) and PNI (p < 0.001), higher levels of post-RT NLR (p = 0.031) and PLR (p = 0.071), larger decrease in albumin (p < 0.001) and PNI (p < 0.001) after NACRT, and larger increase in NLR (p = 0.051) and PLR (p = 0.088) after NACRT than in those with non-excessive muscle loss.

CONCLUSION

Excessive muscle loss rather than pre- and post-RT sarcopenia was a significant prognostic factor for OS and RFS, and it was also related to nutritional and inflammatory markers.

Sarcopenia and myosteatosis at presentation adversely affect survival after esophagectomy for esophageal cancer

Background Esophageal cancer remains a disease with poor survival and many complications. Measuring muscle mass and quality can identify patients with diminished muscle mass (sarcopenia) and muscle fat infiltration (myosteatosis). We studied the impact of sarcopenia and myosteatosis in resectable esophageal cancer on overall survival and complications. Patients and methods 139 patients received a radical esophagectomy. Skeletal muscle area (SMA) and muscle attenuation (MA) in CT images at L3 level were recorded and groups with and without sarcopenia and myosteatosis were compared for overall survival (OS), perioperative mortality, conduit complications, pleuropulmonary complications, respiratory failure requiring mechanical ventilation and other significant complications. Results Prevalence of sarcopenia and myosteatosis at presentation was 16.5% and 51.8%, respectively. Both were associated with decreased OS. Median survival was 18.3 months (CI 5.4-31.1) vs 31.0 months (CI 7.4-54.6) for sarcopenia/no sarcopenia (log rank p = 0.042) and 19.0 months (CI 13.3-24.7) vs 57.1 months (CI 15.2-99.0) for myosteatosis (log rank p = 0.044), respectively. A relationship between sarcopenia and myosteatosis and other negative outcomes after esophagectomy could not be established. Conclusions Sarcopenia and myosteatosis before esophagectomy are associated with decreased overall survival but not with more frequent perioperative complications. Identification of patients at risk can guide therapeutic decisions and interventions aimed at replenishing muscle reserves.

Early intravenous administration of nutritional support (IVANS) in metastatic gastric cancer patients at nutritional risk, undergoing first-line chemotherapy: study protocol of a pragmatic, randomized, multicenter, clinical trial

Background

Malnutrition is common in cancer patients, particularly in those affected by gastrointestinal malignancies, and negatively affects treatment tolerance, survival, functional status, and quality of life (QoL). Nutritional support, including supplemental parenteral nutrition (SPN), has been recommended at the earliest opportunity in malnourished cancer patients. The limited available evidence on the efficacy of SPN in gastrointestinal cancer patients is positive, particularly with regards to QoL, body composition, and energy intake, but the evidence on survival is still scanty. Furthermore, studies regarding the early administration of SPN in combination with nutritional counseling from the beginning of first-line chemotherapy (CT) are lacking. We hypothesize that early systematic SPN in combination with nutritional counseling (NC), compared with NC alone, can benefit patients with previously untreated metastatic gastric cancer at nutritional risk undergoing first-line CT.

Methods

The aim of this pragmatic, multicenter, randomized (1:1), parallel-group, open-label, controlled clinical trial is to evaluate the efficacy in terms of survival, weight maintenance, body composition, QoL and feasibility of cancer therapy of early systematic SNP. This is in combination with NC, compared with NC alone, in treatment-naïve metastatic gastric cancer patients at nutritional risk undergoing first-line CT.

Discussion

Malnutrition in oncology remains an overlooked problem. Although the importance of SPN in gastrointestinal cancer patients has been acknowledged, no studies have yet evaluated the efficacy of early SPN in metastatic gastric patients undergoing CT. The present study, which guarantees the early provision of nutritional assessment and support to all the enrolled patients in accordance with the recent guidelines and recommendations, could represent one of the first proofs of the clinical effectiveness of early intensive nutritional support in cancer patients undergoing CT. This study could stimulate further large randomized trials in different cancer types, potentially resulting in the improvement of supportive care quality.

Trial registration

This study is registered on ClinicalTrials.gov: NCT03949907.

Chemotherapy-Induced Sarcopenia

OPINION STATEMENT

Sarcopenia is being consistently recognized as a condition not only associated with the presence of a malignancy but also induced by the oncologic therapies. Due to its negative impact on tolerance to chemotherapy and final outcome in both medical and surgical cancer patients, sarcopenia should be always considered and prevented, and, if recognized, should be appropriately treated. A CT scan at the level of the third lumbar vertebra, using an appropriate software, is the more common and easily available way to diagnose sarcopenia. It is now acknowledged that mechanisms involved in iatrogenic sarcopenia are several and depending on the type of molecule included in the regimen of chemotherapy, different pharmacologic antidotes will be required in the future. However, progression of the disease and the associated malnutrition per se are able to progressively erode the muscle mass and since sarcopenia is the hallmark of cachexia, the therapeutic approach to chemotherapy-induced sarcopenia parallels that of cachexia. This approach mainly relies on those strategies which are able to increase the lean body mass and include the use of anabolic/anti-inflammatory agents, nutritional interventions, physical exercise and, even better, a combination of different therapies. There are some phase II studies and some small controlled randomized trials which have validated these treatments using single agents or combined multimodal approaches. While these approaches may require the cooperation of some specialists (nutritionists with a specific knowledge on pathophysiology of catabolic states, accredited exercise physiologists and physiotherapists), the oncologist too should directly enter these issues to coordinate the choice and priority of the treatments. Who better than the oncologist knows the natural history of the disease, its evolution, and the probability of tolerance and response to the oncologic therapy? Only the oncologist knows when it is essential to potentiate any effort to better achieve a control of the disease, using all the available armamentarium, and when the condition is too advanced and hence requires a more palliative than supporting care. The oncologist also knows when to expect a gastrointestinal toxicity (mucositis, nausea, vomiting, and diarrhea) and hence it is more convenient using a parenteral than an enteral nutritional intervention or, on the contrary, when patient is suitable for discharge from hospital and oral supplements should be promptly tested for compliance and then prescribed. When patients are at high risk for malnutrition or if, regardless of their nutritional status, they are candidate to aggressive and potentially toxic treatments, they should undergo a jointed evaluation by the oncologist and the nutritionist and physical therapist to assess together a combined approach. In conclusion, the treatment of both cancer- or chemotherapy-related sarcopenia represents a challenge for the modern oncologist who must be able to coordinate a new panel of specialists with the same skill necessary to decide the priority of different oncologic treatments within a complex multidisciplinary context.

Impact of regular enteral feeding via jejunostomy during neo-adjuvant chemotherapy on body composition in patients with oesophageal cancer

BACKGROUND

Malnourishment and sarcopenia are well documented phenomena in oesophageal cancer. Patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy have complex nutritional needs.

AIM

To examine the effect of regular nutritional support via feeding jejunostomy on overall body composition in patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy for oesophageal cancer.

METHODS

Retrospective data were collected for 15 patients before and after neo-adjuvant chemotherapy. All patients had feeding jejunostomies inserted at staging laparoscopy prior to neo-adjuvant chemotherapy and underwent regular jejunostomy feeding. Changes in body composition were determined by analysis of computed tomography imaging.

RESULTS

Patient age was 61.3 ± 12.8 years, and 73% of patients were male. The time between start of chemotherapy and surgery was 107 ± 21.6 d. There was no change in weight (74.5 ± 14.1 kg to 74.8 ± 13.1 kg) and body mass index (26.0 ± 3.8 kg/m² to 26.1 ± 3.4 kg/m²). Body composition analysis revealed a statistically significant decrease in lumbar skeletal muscle index despite regular feeding (45.8 ± 8.0 cm²/m² to 43.5 ± 7.3 cm²/m²; P = 0.045). The proportion of sarcopenic patients increased (33.3% to 60%). Six patients (40%) experienced dose-limiting toxicity during chemotherapy.

CONCLUSION

Regular jejunostomy feeding during neo-adjuvant chemotherapy can maintain weight and adipose tissue. Feeding alone is not sufficient to maintain muscle mass. Further insight into the underlying processes causing reduced muscle mass in cancer patients may help to provide targeted interventions.

CT-assessed sarcopenia is a predictive factor for both long-term and short-term outcomes in gastrointestinal oncology patients: a systematic review and meta-analysis

BACKGROUND

The impact of sarcopenia on the outcome of gastrointestinal (GI) oncological patients is still controversial. We aim to discuss the prevalence of sarcopenia and its relation to the oncological outcome.

METHODS

Embase, Medline, PubMed, and the Cochrane library were systematically searched for related keywords. Studies using CT to assess sarcopenia and evaluate its relationship with the outcome of GI oncological patients were included. Long-term outcomes, including overall survival and disease-free survival, were compared by hazard ratios (HRs) with 95% confidence intervals (CIs). Short-term outcomes, including total complications and major complications (Clavien-Dindo ≥IIIa) after curable surgery, were compared by the risk ratio (RR) and 95% CI.

RESULTS

A total of 70 studies including 21,875 patients were included in our study. The median incidence of sarcopenia was 34.7% (range from 2.1 to 83.3%). A total of 88.4% of studies used skeletal muscle index (SMI) in the third lumbar level on CT to define sarcopenia, and a total of 19 cut-offs were used to define sarcopenia. An increasing trend was found in the prevalence of sarcopenia when the cut-off of SMI increased (β = 0.22, 95% CI = 0.12-0.33, p < 0.001). The preoperative incidence of sarcopenia was associated both with an increased risk of overall mortality (HR = 1.602, 95% CI = 1.369-1.873, P < 0.001) and with disease-free mortality (HR = 1.461, 95% CI = 1.297-1.646, P < 0.001). Moreover, preoperative sarcopenia was a risk factor for both total complications (RR = 1.188, 95% CI = 1.083-1.303, P < 0.001) and major complications (RR = 1.228, 95% CI = 1.042-1.448, P = 0.014).

CONCLUSION

The prevalence of sarcopenia depends mostly on the diagnostic cut-off points of different criteria. Preoperative sarcopenia is a risk factor for both long-term and short-term outcomes.

Measuring the impact of oesophagectomy on physical functioning and physical activity participation: a prospective study

BACKGROUND

Oesophagectomy remains the only curative intervention for oesophageal cancer, with defined nutritional and health-related quality of life (HR-QOL) consequences. It follows therefore that there is a significant risk of decline in physical wellbeing with oesophagectomy however this has been inadequately quantified. This study prospectively examines change in physical functioning and habitual physical activity participation, from pre-surgery through 6-months post-oesophagectomy.

METHODS

Patients scheduled for oesophagectomy with curative intent were recruited. Key domains of physical functioning including exercise tolerance (six-minute walk test (6MWT)) and muscle strength (hand-grip strength), and habitual physical activity participation, including sedentary behaviour (accelerometry) were measured pre-surgery (T0) and repeated at 1-month (T1) and 6-months (T2) post-surgery. HR-QOL was measured using the EORTC-QOL C30.

RESULTS

Thirty-six participants were studied (mean age 62.4 (8.8) years, n = 26 male, n = 26 transthoracic oesophagectomy). Mean 6MWT distance decreased significantly from T0 to T1 (p = 0.006) and returned to T0 levels between T1 and T2 (p < 0.001). Percentage time spent sedentary increased throughout recovery (p < 0.001) and remained significantly higher at T2 in comparison to T0 (p = 0.003). In contrast, percentage time spent engaged in either light or moderate-to-vigorous intensity activity, all reduced significantly (p < 0.001 for both) and remained significantly lower at T2 in comparison to T0 (p = 0.009 and p = 0.01 respectively). Patients reported deficits in multiple domains of HR-QOL during recovery including global health status (p = 0.04), physical functioning (p < 0.001) and role functioning (p < 0.001). Role functioning remained a clinically important 33-points lower than pre-operative values at T2.

CONCLUSION

Habitual physical activity participation remains significantly impaired at 6-months post-oesophagectomy. Physical activity is a measurable and modifiable target for physical rehabilitation, which is closely aligned with patient-reported deficits in role functioning. Rehabilitation aimed at optimising physical health in oesophageal cancer survivorship is warranted.

Effects of preoperative sarcopenia on postoperative complications of minimally invasive oesophagectomy for oesophageal squamous cell carcinoma

Background

Sarcopenia is closely associated with surgical complications in patients with certain cancers. In this study we assessed the relationship between sarcopenia and postoperative complications in patients with oesophageal squamous cell carcinoma.

Methods

We retrospectively analysed of patients who underwent thoracoscopic combined with laparoscopic radical resection of oesophageal cancer. Preoperative computed tomography to evaluate skeletal muscle mass to diagnose sarcopenia and to evaluate associations with age, body mass index (BMI), lung function and postoperative complications.

Results

Among 141 patients, 73 presented with sarcopenia (sarcopenia group) and 68 did not (non-sarcopenia group). The mean skeletal muscle index in all patients was 49.5±9.0 cm²/m²; median, 49.3 cm²/m². The sarcopenia group included a higher proportion of men (P=0.039) and had a lower BMI than the non-sarcopenia group (P=0.001). There were no significant differences in any other clinical and pathological features. The incidences of postoperative complications in the sarcopenia and non-sarcopenia groups were 63.0% and 36.8%, respectively (P=0.002). The incidences of pulmonary infections and postoperative pleural effusions were 28.8% vs. 11.8% (P=0.011) and 38.4% vs. 20.6% (P=0.020) in the sarcopenia and non-sarcopenia groups, respectively. The incidences of other complications were not significantly different between the two groups. Univariate and multivariate analyses of pulmonary infection-related clinical factors revealed that sarcopenia and forced expiratory volume in the first second as a percent of forced vital capacity (FEV1.0%) were independent risk factors for pulmonary infection after minimally invasive surgery.

Conclusions

Preoperative sarcopenia is an independent risk factor for pulmonary infection after minimally invasive oesophagectomy (MIE). Evaluation of preoperative sarcopenia will thus help to prevent postoperative complications.

Sarcopenia in patients with malignant pleural effusion: impact on symptoms, health status, and response to hospitalization

BACKGROUND

Malignant pleural effusion (MPE) refers to the presence of neoplastic cells in the pleural fluid and was previously associated with lung cancer, breast cancer, and lymphoma. Patients with MPE effusion have significant symptoms, diminishing their overall quality of life but little is known about the influence sarcopenia may have on their clinical presentation.

PURPOSE

To examine the prevalence of sarcopenia in patients with MPE and its relationship with symptoms, health status, and the response to hospitalization.

METHODS

Seventy-four patients with MPE underwent measurements of symptoms, health-related quality of life, and functional status upon admission, discharge, and 3 months after hospital discharge.

RESULTS

Patients with MPE and sarcopenia were symptomatic during hospitalization and at discharge. Additionally, health-related quality of life and functional status were worse in patients with MPE and sarcopenia. All measures of patients with MPE and sarcopenia were significantly poorer 3 months after hospital discharge.

CONCLUSIONS

Sarcopenia is a clinical characteristic with substantial negative effects in patients with MPE. Specific interventions may need to be provided, designed, and offered in the clinical setting.

Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective study

BACKGROUND

Chemotherapy is an effective treatment with good clinical response in patients with cancer. However, it can cause exacerbated toxicities in patients and consequently change the course of treatment. Some factors may interfere with this toxicity such as body composition, especially in gastrointestinal cancer. The aim of this study was to evaluate the effects of body composition, nutritional status, and functional capacity scale in predicting the occurrence of toxicities in gastrointestinal cancer patients during chemotherapy treatment.

METHODS

This is a prospective study with gastrointestinal cancer patients at the beginning of chemotherapy treatment. Sarcopenia and muscle attenuation were assessed using the skeletal muscle index from computerized tomography by measuring cross-sectional areas of the L3 tissue (cm² /m² ). Cachexia was graded according to involuntary weight loss associated with sarcopenia. Nutritional status was assessed by using anthropometric evaluation and Patient-Generated Subjective Global Assessment. Functional capacity was evaluated by handgrip strength and Eastern Cooperative Oncology Group (ECOG) Performance Status scale. Haematological gastrointestinal and dose-limiting toxicities (DLTs) were defined according to National Cancer Institute Common Toxicity Criteria. The associations among sarcopenia, cachexia, nutritional status, and functional capacity with DLT were assessed by univariate and multivariate Cox regression model.

RESULTS

A total of 60 patients were evaluated (55% male, 60.9 ± 14.0 years) and followed up for a mean of 55 days. Most patients had normal weight (44.2%) and good ECOG Performance Status (≤1) at baseline (78%). During the chemotherapy period, the most prevalent toxicities were diarrhoea, nausea, and anorexia, but the presence of DLT was similar between cycles (P > 0.05). Cachexia was associated with a higher toxicity manifested by diarrhoea (P = 0.02), nausea (P = 0.02), and anorexia (P < 0.01 and P = 0.03 at Cycles 1 and 2, respectively). Sarcopenic and cachetic individuals experienced more toxicities and DLT during chemotherapy. The only factors associated with DLT in the multivariate Cox regression analyses including the presence of metastasis and the chemotherapy protocol were cachexia and the ECOG scale (P < 0.001 for both).

CONCLUSIONS

Cachexia and ECOG score may identify patients with an increased risk for developing severe toxicity events during chemotherapy treatment for gastrointestinal cancer.

Home-Based Exercise Prehabilitation During Preoperative Treatment for Pancreatic Cancer Is Associated With Improvement in Physical Function and Quality of Life

Purpose: To investigate relationships among physical activity, changes in physical function, and health-related quality of life (HRQOL) among patients with pancreatic adenocarcinoma enrolled in a home-based exercise prehabilitation program. Methods: Patients with resectable pancreatic adenocarcinoma receiving preoperative chemotherapy and/or chemoradiation were enrolled on this prospective, single-arm trial and were advised to perform ≥60 minutes each of moderate-intensity aerobic exercise and strengthening exercise weekly. Activity was measured via self-report and accelerometers, including moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and sedentary activity (SA). Physical function measures at baseline and restaging follow-up included 6-minute walk test (6MWT), 5 times sit-to-stand (5×STS), handgrip strength (HGS), 3-m walk for gait speed (GS), and the PROMIS Physical Function Short Form. HRQOL was measured via the FACT-Hep questionnaire. Results: Fifty participants with mean age 66 years (standard deviation = 8 years) were enrolled. The 6MWT, 5×STS, and GS significantly improved from baseline to restaging follow-up (P=.001, P=.049, and P=.009, respectively). Increases in self-reported aerobic exercise, weekly MVPA, and LPA were associated with improvement in 6MWT (β=.19, P=.048; β=.18, P=.03; and β=.08, P=.03, respectively) and self-reported physical functioning (β=.02, P=.03; β=.03, P=.005; and β=.01, P=.02, respectively). Increased weekly LPA was associated with increased HRQOL (β=.03, P=.02). Increased SA was associated with decreased HRQOL (β=-.02,P=.01). Conclusions: Patients with potentially resectable pancreatic cancer exhibit meaningful improvement in physical function with prehabilitation; physical activity was associated with improved physical function and HRQOL. These data highlight the importance of physical activity during treatment for pancreatic cancer.

Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction

Background

Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro‐oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients.

Methods

Patients were allocated to a standard‐care control group or an exercise group, who were prescribed standard care plus twice‐weekly high‐intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient‐reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured.

Results

The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy — Esophageal (FACT‐E) total score compared with the baseline level.

Conclusion

Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.