Exercise training as part of multidisciplinary rehabilitation in cancer survivors: an observational study on changes in physical performance and patient-reported outcomes

Determinants of physical activity maintenance and the acceptability of a remote coaching intervention following supervised exercise oncology rehabilitation: a qualitative study

PURPOSE

The purpose of the study was to investigate perceived determinants of physical activity (PA) maintenance following supervised exercise oncology rehabilitation and the acceptability of a remote coaching intervention during this period.

METHODS

A phenomenological qualitative study with semi-structured interviews was conducted. Nineteen participants (16 women, 3 men) were recruited from the intervention (n = 12) and control group (n = 7) of a randomized controlled trial on the effectiveness of remote coaching following hospital-based, supervised exercise oncology rehabilitation. Participants in the intervention group received a 6-month remote coaching intervention after completing the exercise program, aimed at stimulating PA maintenance. The interviews were based on the Capability, Opportunity, and Motivation model of Behaviour (COM-B model) and the framework of acceptability (TFA) and were coded using template analysis.

RESULTS

Key themes regarding determinants of PA maintenance were self-efficacy, PA habits, accountability, physical complaints, and facilities. Remote coaching was perceived acceptable because it stimulated PA maintenance by offering a source of structure and social support and thereby increased accountability. Moreover, it improved confidence to perform PA, leading to increased levels of self-efficacy. The remote nature of the intervention was perceived as convenient by some of the participants, while others would have preferred additional physical appointments.

CONCLUSIONS

Cancer survivors considered remote coaching acceptable to stimulate PA maintenance following supervised rehabilitation. Interventions should focus on increasing accountability, self-efficacy, forming habits, and helping cancer survivors to overcome barriers.

IMPLICATIONS FOR CANCER SURVIVORS

The ability to maintain PA beyond supervised exercise oncology programs depends on many determinants. Remote coaching interventions have potential to target individually relevant determinants following exercise programs in cancer survivors.

Postcancer rehabilitation: multidisciplinary exercise - programme organisation and feasibility

BACKGROUND

Although the benefit of supportive care in the postcancer period is now well demonstrated, its implementation in the patient journey remains challenging. This article describes the development, since 2015 and in routine care, of supportive postcancer care comprising a multidisciplinary rehabilitation programme (MRP) based on exercise for patients with early breast cancer.

METHODS

As part of quality control, we reviewed all patient files since the programme was implemented. Patient data regarding the type of cancer, clinical and pathological factors, and treatment were recorded in a computerised database.

RESULTS

From April 2015 to January 2024, 655 patients participated in the MRP. The programme lasts for 14 weeks, totalling 126 hours of face-to-face programme, with a maximum of 8 patients per group, in 5 different centres. A multidisciplinary professional team provide supportive care. The MRP is mainly based on supervised physical exercise and patients also participate in social, psychological, dietary support and educational sessions. Supervised physical exercise includes cardiorespiratory endurance work through specific sessions on ergometers or outdoor walking and adapted physical activity sessions to improve muscular capacities (endurance, strength and flexibility).

CONCLUSION

We describe here the practical implementation of a routine multidisciplinary supportive care programme, based mainly on physical activity, for post-treatment breast cancer patients. We report almost 9 years of experience with the programme. We show that offering this programme in the postcancer setting and in clinical routine practice is feasible and can be maintained in the long term.

Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review

OBJECTIVE

Providing an overview of the clinimetric properties of the steep ramp test (SRT)-a short-term maximal exercise test-to assess cardiorespiratory fitness (CRF), describing its underlying physiological responses, and summarizing its applications in current clinical and research practice.

DATA SOURCES

MEDLINE (through PubMed), CINAHL Complete, Cochrane Library, EMBASE, and PsycINFO were searched for studies published up to July 2023, using keywords for SRT and CRF.

STUDY SELECTION

Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch.

DATA EXTRACTION

Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated.

DATA SYNTHESIS

In total, 370 studies were found, of which 39 were included in this study. In several healthy and patient populations, correlation coefficients between the work rate at peak exercise (WRpeak) attained at the SRT and oxygen uptake at peak exercise during cardiopulmonary exercise testing (CPET) ranged from .771-.958 (criterion validity). Repeated measurements showed intraclass correlation coefficients ranging from .908-.996 for WRpeak attained with the first and second SRT (test-retest reliability). Physiological parameters, like heart rate and minute ventilation at peak exercise, indicated that the SRT puts a lower burden on the cardiopulmonary system compared to CPET. The SRT is mostly used to assess CRF, among others as part of preoperative risk assessment, and to personalize interval training intensity.

CONCLUSIONS

The SRT is a practical short-term maximal exercise test that is valid for CRF assessment and to monitor changes in CRF over time in various healthy and patient populations. Its clinimetric properties and potential applications make the SRT of interest for a widespread implementation of CRF assessment in clinical and research practice and for personalizing training intensity and monitoring longitudinal changes in CRF.

Early reduction in cardiorespiratory fitness and diastolic reserve following radiation therapy for lung cancer

BACKGROUND

Contemporary radiotherapy for the treatment of lung cancer is effective in targeting tumor tissue while limiting heart exposure, yet cardiac toxicity still occurs, often becoming clinically apparent years later. Cardiorespiratory fitness (CRF) is an independent predictor of cardiovascular, cancer-related, and overall mortality and may serve as a sensitive measure of subclinical cardiac toxicity following anti-cancer treatments. Prior work has demonstrated a significant relationship between reduced CRF and impaired left-ventricular (LV) diastolic reserve in cancer survivors following thoracic radiotherapy. The purpose of this study was to assess early longitudinal changes in CRF and cardiac function in patients with lung cancer following radiotherapy.

METHODS

Ten patients (69 [61-76] years, 70% female) with lung cancer without known cardiovascular disease scheduled to receive radiotherapy involving a clinically-relevant heart dose (≥ 5 Gy to > 10% of heart volume) were evaluated prior to and following treatment. Changes in CRF (peak oxygen consumption [VO2peak], oxygen uptake efficiency slope [OUES]), cardiac function (LV ejection fraction [LVEF], rest and exercise diastolic function [diastolic functional reserve index (DFRI)]), cardiac biomarkers (N-terminal pro-brain natriuretic peptide [NT-proBNP], high-sensitivity C-reactive protein [hsCRP]), and health-related quality of life (HRQOL; Functional Assessment of Cancer Therapy-General-7 [FACT-G7]) were measured.

RESULTS

The VO2peak was reduced at baseline (1.245 [0.882-1.605] L·min- 1; 70 [62-86] %-predicted) and significantly declined (1.095 [0.810-1.448] L·min- 1, P = 0.047; 62 [56-76] %-predicted, P = 0.005) at 6.0 [3.0-6.0] months post-radiotherapy. Similarly, a significant decline in the OUES was observed (1.63 [1.27-1.88] to 1.57 [1.12-1.75], P = 0.032). Systolic cardiac function was normal at baseline and did not change following radiotherapy (LVEF; 62 [56-65]% to 66 [57-68]%, P = 0.475). The DFRI significantly declined following radiotherapy (34.9 [22.7-41.6] vs. 12.8 [3.1-35.9]). The hsCRP increased significantly from 4.4 [1.4-5.8] to 6.1 [3.7-20.7] g/L, P = 0.047 with a trend towards higher levels of NT-proBNP (65 [49-125] to 121 [88-191] pg/mL, P = 0.110). Health-related quality of life significantly decreased (FACT-G7; 21.5 [18.8-25] to 15.5 [11.5-20]; P = 0.021) post-radiotherapy.

CONCLUSIONS

Patients with lung cancer receiving radiotherapy with a clinically-significant heart dose experience reductions in CRF (VO2peak, OUES) as early as six months following treatment with concurrent reductions in diastolic reserve (DFRI), HRQOL, and increases in cardiac biomarkers (NT-proBNP, hsCRP).

Effects of remote coaching following supervised exercise oncology rehabilitation on physical activity levels, physical fitness, and patient-reported outcomes: a randomised controlled trial

BACKGROUND

Studies have shown that cancer survivors experience difficulties maintaining physical activity levels after participation in a supervised exercise rehabilitation program. This study aimed to assess the effectiveness of a six-month remote coaching intervention, following a supervised exercise oncology rehabilitation program on maintenance of PA levels; and improvement of aerobic capacity, muscle strength and patient-reported outcomes in cancer survivors.

METHODS

Ninety-seven participants from a Dutch University Hospital's exercise rehabilitation program were randomised to the COACH group (n = 46), receiving 6 months of remote coaching after completing the exercise program, or the CONTROL group (n = 50), receiving no additional intervention. Assessment of PA levels; sedentary time; aerobic capacity; muscle strength; fatigue; health-related quality of life (HRQoL); level of anxiety and depression; and return to work (RTW) rates were conducted at baseline (T0) and six months later (T1). Multiple linear regression was used for between-group statistical comparisons of all outcomes measures. Mean differences at T1 were estimated with corresponding 95% confidence intervals (95%CI).

RESULTS

No significant between-group differences were observed for all outcomes at T1. An adjusted mean difference in weekly PA of 45 min (95%CI -50;140) was observed between the COACH group and the CONTROL group, favouring the COACH group, yet lacking statistical or clinical significance.

CONCLUSIONS

Our six-month remote coaching intervention did not notably improve PA levels; sedentary time; aerobic capacity; muscle strength; HRQoL; fatigue; anxiety and depression symptoms and RTW rates after participation in a supervised exercise oncology program. Although the participants who received coaching showed slightly higher levels of PA, these differences were not significant. More research is needed to identify patients in need for follow-up interventions following supervised exercise program and to investigate the effectiveness of remote coaching interventions in these patients.

TRIAL REGISTRATION

Dutch Trial Register NL7729, registered 13 may 2019, https://trialsearch.who.int/Trial2.aspx?TrialID=NL7729 .

Monitoring aerobic capacity in cancer survivors using self-reported questionnaires: criterion validity and responsiveness

BACKGROUND

Evaluating the criterion validity and responsiveness of the self-reported FitMáx©-questionnaire, Duke Activity Status Index (DASI) and Veterans Specific Activity Questionnaire (VSAQ) to monitor aerobic capacity in cancer survivors.

METHODS

Cancer survivors participating in a 10-week supervised exercise program were included. The FitMáx©-questionnaire, DASI, VSAQ and a cardiopulmonary exercise test (CPET) were completed before (T₀) and after (T₁) the program. Intraclass correlation coefficients (ICC) were calculated between VO_2peak estimated by the questionnaires (questionnaire-VO_2peak) and VO_2peak measured during CPET (CPET-VO_2peak), at T₀ to examine criterion validity, and between changes in questionnaire-VO_2peak and CPET-VO_2peak (ΔT₀-T₁) to determine responsiveness. Receiver operating characteristic (ROC) analyses were performed to examine the ability of the questionnaires to detect true improvements (≥ 6%) in CPET-VO_2peak.

RESULTS

Seventy participants were included. Outcomes at T₁ were available for 58 participants (83%). Mean CPET-VO_2peak significantly improved at T₁ (Δ1.6 mL·kg^- 1·min^- 1 or 8%). Agreement between questionnaire-VO_2peak and CPET-VO_2peak at T₀ was moderate for the FitMáx©-questionnaire (ICC = 0.69) and VSAQ (ICC = 0.53), and poor for DASI (ICC = 0.36). Poor agreement was found between ΔCPET-VO_2peak and Δquestionnaire-VO_2peak for all questionnaires (ICC 0.43, 0.19 and 0.18 for the FitMáx©-questionnaire, VSAQ and DASI, respectively). ROC analysis showed that the FitMáx©-questionnaire was able to detect improvements in CPET-VO_2peak (area under the curve, AUC = 0.77), when using a cut-off value of 1.0 mL·kg^- 1·min^- 1, while VSAQ (AUC = 0.66) and DASI (AUC = 0.64) could not.

CONCLUSION

The self-reported FitMáx©-questionnaire has sufficient validity to estimate aerobic capacity in cancer survivors at group level. The responsiveness of the FitMáx©-questionnaire for absolute change is limited, but the questionnaire is able to detect whether aerobic capacity improved. The FitMáx©-questionnaire showed substantial better values of validity and responsiveness compared to DASI and VSAQ.