Differential effects of cardiovascular and resistance exercise on functional mobility in individuals with advanced cancer: a randomized trial

Effects of Exercise in Adults With Cancer Pain: A Systematic Review and Network Meta-Analysis

CONTEXT

Pain is one of the most common symptoms of cancer patients, affecting the patient's physical, psychological, behavioral, social relations and other aspects. Previous studies have demonstrated that exercise is effective for cancer pain, and the optimal exercise is still unknown.

OBJECTIVES

This study aimed to compare the effects of different exercise interventions on cancer pain in adults.

METHODS

Randomized control trials identified from medical literature databases that reported effects of exercise in adults with cancer pain were included in this study. Literature screening and data extraction were conducted independently by 2 researchers. Cochrane Bias Assessment 2.0 was used to assess the quality of the literature, and Stata 15.0 software was used for Network meta-analysis.

RESULTS

Forty-one studies were included, involving 3537 patients with cancer pain. The types of exercise involved included aerobic exercise, medium intensity continuous training, high-intensity interval training, resistance exercise, mind-body exercise and comprehensive exercise program (CEP). The results suggested that CEP was more effective than the usual care in relieving pain intensity in cancer patients [SMD = -1.96,95% CI (-3.47, -0.44)] (SUCRA = 97.9%). Mind-body exercise outperformed usual care in reducing pain interference in cancer patients [SMD = -0.65, 95% CI (-1.21, -0.09)] (SUCRA = 83.8%).

CONCLUSION

Current evidence shows that CEP is the best way to relieve the pain intensity of cancer patients, and mind-body exercise is the best way to reduce pain interference of cancer patients. Due to the limited number and quality of the included studies, the above conclusions need to be further verified by more high-quality studies.

Living well with advanced cancer: a scoping review of non-pharmacological supportive care interventions

PURPOSE

The increasing number of people living longer with advanced cancer presents unique physical, psychosocial, financial, legal, practical and complex care needs. Supportive care interventions aim to address these needs by improving symptom management, promoting wellbeing, enhancing quality of life and potentially improving prognosis. To integrate supportive care interventions into clinical practice, a comprehensive review of existing studies is needed. This scoping review maps the evidence on non-pharmacological supportive care interventions for people with advanced cancer and identifies gaps to inform future research.

METHODS

We systematically searched four electronic databases-CINAHL, Medline, Cochrane and PsycINFO-for peer-reviewed original research on non-pharmacological supportive care interventions for adults with advanced cancer, published from January 1, 2013, to July 1, 2024.

RESULTS

Out of 3716 studies, 84 publications met the inclusion criteria. These studies were categorised into key supportive care domains: physical activity, psychosocial support, patient care and autonomy, multimodal approaches and others. Most publications focused on interventions addressing physical and psychosocial needs, showing benefits such as reduced fatigue, pain and improved mood. However, significant gaps were found in research on interventions addressing practical needs essential to autonomy, including health system and information needs, patient care and support and financial needs.

CONCLUSION

Mapping the studies to the needs of the advanced cancer population showed that domains with greatest unmet needs have the fewest interventions available. Our scoping review suggests that non-pharmacological supportive care interventions can improve the wellbeing and quality of life of people living with advanced cancer. However, addressing methodological limitations requires further large-scale, multi-centre studies focusing on the identified gaps to inform the implementation of suitable supportive care programs.

IMPLICATIONS FOR CANCER SURVIVORS

Non-pharmacological interventions can boost wellbeing and quality of life for advanced cancer survivors, but addressing gaps in practical and systemic support is crucial.

Non-pharmacological interventions targeting mobility among people with advanced cancer: a systematic review

PURPOSE

To synthesise evidence evaluating non-pharmacological interventions targeting mobility among people with advanced cancer, considering the type, efficacy and contextual factors that may influence outcome.

METHODS

Systematic review of studies of non-pharmacological interventions in adults (≥ 18 years) with advanced (stage III-IV) cancer, and assessing mobility using clinical or patient-reported outcome measures. Searches were conducted across three electronic databases (MEDLINE, EMBASE and CINAHL) up to June 2024. Methodological quality was assessed using Joanna Briggs Institute tools and contextual factors were evaluated through the Context and Implementation of Complex Interventions framework. A narrative synthesis was conducted due to clinical heterogeneity of included studies.

RESULTS

38 studies encompassing 2,464 participants were included. The most frequent mobility outcome measure was the 6-min walk test (26/38 studies). Exercise was the most common intervention, (33 studies: 27 aerobic and resistance, 5 aerobic, 1 resistance versus aerobic training) and improvements in mobility were found in 21/33 outcomes. Electrotherapy interventions led to significant improvements in mobility in 3/5 studies. Geographical factors (e.g. distance, transport, parking requirements) potentially limited participation in 18/38 studies. A lack of ethnic diversity among populations was evident and language proficiency was an inclusion criterion in 12 studies.

CONCLUSION

Exercise and neuromuscular electrical stimulation appear to improve mobility outcomes in advanced cancer. The evaluation of other non-pharmacological interventions targeting mobility should consider access and inclusivity, and be adaptable to the needs of this population.

Physical activity and pain in people with cancer: a systematic review and meta-analysis

PURPOSE

Physical activity can provide analgesic benefit but its effect on cancer-related pain is unclear. This review synthesised and appraised the evidence for the effect of physical activity on pain in people living with or beyond cancer.

METHODS

A systematic search of Ovid Medline and Embase was performed to identify randomised controlled trials (RCTs), randomised cross-over studies (RXTs), and prospective observational studies that examined physical activity and pain outcomes in adults living with or beyond cancer. Meta-analyses were performed to generate effect estimates. Risk of bias was assessed, and the GRADE system was used to assess evidence quality.

RESULTS

One hundred twenty-one studies (n = 13,806), including 102 RCTs, 6 RXTs, and 13 observational studies, met the criteria for inclusion. Meta-analyses of RCTs identified a decrease in pain intensity (n = 3734; standardised mean difference (SMD) - 0.30; 95% confidence interval (CI) - 0.45, - 0.15) and bodily pain (n = 1170; SMD 0.28; 95% CI 0.01, 0.56) but not pain interference (n = 207; SMD - 0.13, 95% CI - 0.42, 0.15) following physical activity interventions. Individual studies also identified a reduction in pain sensitivity but not analgesic use, although meta-analysis was not possible for these outcomes. High heterogeneity between studies, low certainty in some effect estimates, and possible publication bias meant that evidence quality was graded as very low to low.

CONCLUSION

Physical activity may decrease pain in people living with and beyond cancer; however, high heterogeneity limits the ability to generalise this finding to all people with cancer or to specific types of cancer-related pain.

Nurse-Supervised Exercise for People with Stage IV Cancer: The EFICANCER Randomized Clinical Trial

OBJECTIVES

To assess the effectiveness of the EFICANCER individualized and supervised exercise program for people with gastrointestinal, breast, or non-small cell lung stage IV cancer, in terms of quality of life and functional capacity.

DATA SOURCES

Randomized controlled clinical trial with two parallel groups: EFICANCER (n = 47) and control (n = 43). Both groups received standard oncological care. In addition, the EFICANCER group participated in a nurse-supervised exercise program. Primary outcome was cancer-specific (EORTC QLQ-C30 questionnaire) and general quality of life (SF-36) at baseline and after 2, 6, and 12 months. Secondary outcomes were functional capacity (6-minute walking test), strength, and fatigue. The evolution in both groups was compared over 12 months using mixed-effect longitudinal models; 74.47% of patients completed at least one session of the program. At 12 months, EFICANCER group had better scores in cancer-related quality of life, with a difference between groups of 15.7 points (95% confidence interval 4.4 to 25.9) and in functional capacity, with a difference of 4.5 points (95% confidence interval -0.5 to 9.5). No significant differences in any other secondary variables were observed.

CONCLUSION

The EFICANCER primary care nurse supervised exercise program is safe and feasible and improves cancer patient's outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Providing the best care and trying to improve the quality of life of cancer patients are essential parts of nursing practice. Eficancer adds a new dimension to nursing practice by providing greater attention and care to patients during treatment through the supervision of physical exercise, thereby contributing to improve the quality of life of this population.

The role of exercise for pain management in adults living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

Pain is a common side effect of cancer or cancer treatment that negatively impacts biopsychosocial wellbeing and quality of life. Exercise is a potential intervention to manage pain that is safe and has multiple benefits. The objective was to determine the role of exercise in cancer pain management.

METHODS

We completed a systematic review and meta-analysis of exercise interventions in adults with any type or stage of cancer by searching Ovid MEDLINE®, Embase, APA PsycInfo, the Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus. We included experimental and quasi-experimental designs where pain was measured as an outcome. Data synthesis included narrative and tabular summary. A meta-analysis was performed on studies powered to detect the effect of exercise on pain. Study quality was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the GRADE tool.

RESULTS

Seventy-six studies were included. Studies were predominantly conducted in breast cancer and exercise usually included a combination of aerobic and strength training. Ten studies were included in the meta-analysis demonstrating a significant effect for exercise in decreasing pain (estimated average standard mean difference (SMD) was g =  - 0.73 (95% CI: - 1.16 to - 0.30)); however, the overall effect prediction interval was large. Overall risk of bias for most studies was rated as some concerns and the grading of evidence certainty was low.

CONCLUSION

There are limitations in the evidence for exercise to manage cancer-related pain. Further research is needed to understand the role of exercise in a multimodal pain management strategy.

Exercise Intervention for Bone Metastasis: Safety, Efficacy and Method of Delivery

Background: The benefits of exercise for patients with cancer are well-established, however, for patients with bone metastases, exercise as adjuvant therapy is underutilised due to concerns for safety, efficacy and other barriers such as the method of delivery. This scoping review explores these barriers by reviewing the results of clinical trials conducted on participants with bone metastases. Methods: A thorough literature search was undertaken using PubMed, Scopus, NIH Clinical Trials and Google Scholar databases. Articles that involved an exercise intervention and patients with bone metastases were included. Data were pooled, charted, analysed and reported according to PRISMA-ScR standards. Results: A total of 26 trials were reviewed with interventions that included aerobic and resistance training. Only three serious adverse events occurred, not likely related to bone metastases. Nine trials (34.6%) involved unsupervised exercise sessions. Remote exercise delivery had an average of 80.3% compliance, rivalling in-person and mixed supervision. The results of this review reaffirm that exercise helps improve functional capacity, muscle strength, lean mass and cardiovascular function, and is safe in patients with bone metastases irrespective of in-person or remote delivery. Conclusions: Exercise therapy, whether delivered in person or remotely, is safe and efficacious for patients with bone metastases.

Exercise and Bone Health in Cancer: Enemy or Ally?

Bone health is often threatened in cancer patients. Bone metastasis and osteoporosis frequently occur in patients with cancer and may lead to different skeletal-related events, which may negatively affect patients' quality of life and are associated with high mortality risk. Physical exercise has been recognized as a potential adjunctive strategy in the cancer setting to improve physical function as well as treatment-related side effects. Nevertheless, exercise is often not recommended to patients with bone health impairments due to safety concerns. In the current review, we aimed, through a comprehensive review of the evidence, to explore the impact of exercise in terms of safety profile, bone outcomes, and the effects on other outcomes in patients with cancer affected by bone metastasis or at high risk of losing bone. Additionally, we explored the potential mechanisms by which exercise may act on bone, particularly the impact of mechanical load on bone remodeling. Finally, considerations about exercise prescription and programming in these populations are also discussed.

Efeitos de Abordagens não Farmacológicas nos Sintomas Físicos de Indivíduos com Câncer Avançado: Revisão Sistemática

Introdução: O câncer e um problema de saúde publica que, em estágios avançados, pode ocasionar desconfortos físicos, psicossociais e espirituais. Assim, abordagens fisioterapêuticas e as Práticas Integrativas e Complementares em Saúde (PICS) surgem como ferramentas importantes para o controle e melhora de sintomas físicos nesses indivíduos. Objetivo: Descrever os efeitos de abordagens não farmacológicas, envolvendo técnicas fisioterapêuticas e PICS, nos sintomas físicos de indivíduos com câncer avançado. Método: Revisão sistemática da literatura composta por ensaios clínicos randomizados que abordassem os efeitos de abordagens fisioterapêuticas ou PICS nos sintomas físicos de indivíduos diagnosticados com câncer avançado. Foram selecionadas as bases de dados PubMed, LILACS, PEDro, Cochrane, SciELO, e a última busca ocorreu em abril de 2021. A avaliação da qualidade metodológica dos estudos foi realizada por meio da escala PEDro. Resultados: Vinte e dois estudos foram incluídos, e demonstraram que ambas as abordagens tem efeitos positivos para os sintomas físicos, como fadiga e dor, na população estudada. Conclusão: A fisioterapia e as PICS tem efeitos positivos nos sintomas físicos em indivíduos com diagnostico de câncer avançado. No entanto, existem poucos estudos com qualidade metodológica suficiente para confirmar a eficácia das duas abordagens nos desfechos estudados para essa população.

Impact of physical exercise in advanced-stage cancer patients: Systematic review and meta-analysis

Health professionals predict that the number of people who will suffer and die from oncological diseases will continue to increase. It is vitally important to provide comprehensive care to these patients and prescribe physical exercise programs as adjuvant therapy. The objective of this systematic review was to determine the impact of physical exercise on advanced‐stage cancer patients. A literature search was performed in eight different databases. This search focused on randomized controlled trials (RCTs) published during the last 10 years. To assess the methodological quality of the sample of 15 RCTs finally obtained, the PEDro scale was used. Aerobic and strength training methods were used. The combination of both aerobic and strength training methods was the most frequently reported. Likewise, different physical and psychological variables were recorded, from which improvements were seen in fatigue, independence, quality of life and sleep, among others. The participation in physical exercise programs by advanced‐stage cancer patients has a positive impact on health. Providing these programs serves as adjuvant therapy, facilitating the comprehensive care of patients. Similarly, aerobic, strength or mixed training programs increase the muscle mass of patients and therefore reduce hypotonia, the main side effect during the advanced‐stages of cancer.

Effects of a 12-Week Multimodal Exercise Intervention Among Older Patients with Advanced Cancer: Results from a Randomized Controlled Trial

BACKGROUND

Older patients with cancer are at risk of physical decline and impaired quality of life during oncological treatment. Exercise training has the potential to reduce these challenges. The study aim was to investigate the feasibility and effect of a multimodal exercise intervention in older patients with advanced cancer (stages III/IV).

PATIENTS AND METHODS

Eighty-four older adults (≥65 years) with advanced pancreatic, biliary tract, or non-small cell lung cancer who received systemic oncological treatment were randomized 1:1 to an intervention group or a control group. The intervention was a 12-week multimodal exercise-based program including supervised exercise twice weekly followed by a protein supplement, a home-based walking program, and nurse-led support and counseling. The primary endpoint was change in physical function (30-second chair stand test) at 13 weeks.

RESULTS

Median age of the participants was 72 years (interquartile range [IQR] 68-75). Median adherence to the exercise sessions was 69% (IQR 21-88) and 75% (IQR 33-100) for the walking program. At 13 weeks, there was a significant difference in change scores of 2.4 repetitions in the chair stand test, favoring the intervention group (p < .0001). Furthermore, significant beneficial effects were seen for physical endurance (6-minute walk test), hand grip strength, physical activity, symptom burden, symptoms of depression and anxiety, global health status (quality of life), and lean body mass. No effects were seen for dose intensity, hospitalizations, or survival.

CONCLUSION

A 12-week multimodal exercise intervention with targeted support proved effective in improving physical function in older patients with advanced cancer during oncological treatment.

Exercise for individuals with bone metastases: A systematic review

BACKGROUND

Exercise has the potential to improve physical function and quality of life in individuals with bone metastases but is often avoided due to safety concerns. This systematic review summarizes the safety, feasibility and efficacy of exercise in controlled trials that include individuals with bone metastases.

METHODS

MEDLINE, Embase, Pubmed, CINAHL, PEDro and CENTRAL databases were searched up to July 16, 2020.

RESULTS

A total of 17 trials were included incorporating aerobic exercise, resistance exercise or soccer interventions. Few (n = 4, 0.5%) serious adverse events were attributed to exercise participation, with none related to bone metastases. Mixed efficacy results were found, with exercise eliciting positive changes or no change. The majority of trials included an element of supervised exercise instruction (n = 16, 94%) and were delivered by qualified exercise professionals (n = 13, 76%).

CONCLUSIONS

Exercise appears safe and feasible for individuals with bone metastases when it includes an element of supervised exercise instruction.

Sarcopenia versus cancer cachexia: the muscle wasting continuum in healthy and diseased aging

Muscle wasting is one of the major health problems in older adults and is traditionally associated to sarcopenia. Nonetheless, muscle loss may also occur in older adults in the presence of cancer, and in this case, it is associated to cancer cachexia. The clinical management of these conditions is a challenge due to, at least in part, the difficulties in their differential diagnosis. Thus, efforts have been made to better comprehend the pathogenesis of sarcopenia and cancer cachexia, envisioning the improvement of their clinical discrimination and treatment. To add insights on this topic, this review discusses the current knowledge on key molecular players underlying sarcopenia and cancer cachexia in a comparative perspective. Data retrieved from this analysis highlight that while sarcopenia is characterized by the atrophy of fast-twitch muscle fibers, in cancer cachexia an increase in the proportion of fast-twitch fibers appears to happen. The molecular drivers for these specificmuscle remodeling patterns are still unknown; however, among the predominant contributors to sarcopenia is the age-induced neuromuscular denervation, and in cancer cachexia, the muscle disuse experienced by cancer patients seems to play an important role. Moreover, inflammation appears to be more severe in cancer cachexia. Impairment of nutrition-related mediators may also contribute to sarcopenia and cancer cachexia, being distinctly modulated in each condition.

Physical Activity for Individuals Living with Advanced Cancer: Evidence and Recommendations

OBJECTIVES

To provide health and fitness professionals with screening, triage, prescription, and physical activity recommendations to better serve individuals living with advanced cancer. A call to action regarding next steps to improve research and knowledge translation is also outlined, ensuring the growing number of those with advanced cancers are supported in their efforts to adopt and adhere to active lifestyles.

DATA SOURCES

Sources include published literature, physical activity guidelines, and expert opinion from physical medicine and rehabilitation physicians, exercise physiologists, and health and exercise psychology researchers.

CONCLUSION

Individuals with advanced cancer who engage in regular physical activity report improved function, fatigue management, and quality of life, while objective testing shows improvements in fitness and physical function. Although there are no clear activity guidelines or recommendations for this population, patients must avoid inactivity to gain health benefits and minimize deconditioning. For most patients with advanced cancer, physical activity prescriptions should focus on maintaining fitness and functional independence, and specific modifications based on common comorbidities must be considered.

IMPLICATIONS FOR NURSING PRACTICE

Evidence supports the use of physical activity for the management of symptoms experienced by those with advanced cancers. Understanding the benefits of physical activity for patients with advanced cancer is important because health care providers play a key role in the adoption and adherence of physical activity among patients.

Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments

BACKGROUND

Fatigue is a common complaint reported by patients with advanced disease, impacting their daily activities and quality of life. The pathophysiology is incompletely understood, and evidence-based treatment approaches are needed.

AIM

This systematic review aims to evaluate the efficacy of non-pharmacological interventions as treatment for fatigue in advanced disease.

DESIGN

The review design follows the Cochrane guidelines for systematic reviews of interventions.

DATA SOURCES

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, ClinicalTrials.gov and a selection of journals up to February 28th 2019, for randomised controlled trials (RCTs) investigating the effect of non-pharmacological treatments for fatigue in advanced disease associated with palliative care. Further potentially relevant studies were identified from the reference lists in relevant reviews, and in studies considered for this review.

RESULTS

We screened 579 publications; 15 met the inclusion criteria, with data from 1179 participants: 815 were treated with physical exercise, 309 with psycho-educational therapy and 55 with an energy restoration approach. Sources of potential bias included lack of description of blinding and allocation concealment methods, and small study sizes. Physical exercise as treatment for fatigue in patients with advanced cancer was supported by moderate-quality evidence.

CONCLUSION

Physical exercise should be considered as a measure to reduce fatigue in patients with advanced cancer, but data on other advanced diseases is lacking. Due to the differences between studies, no clear recommendations can be made with respect to the best type of physical therapy. Restoration exercise and psycho-educational therapy are promising treatment options, although further research is needed.

Exercise for cancer cachexia in adults

BACKGROUND

Cancer cachexia is a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass, with or without a loss of fat mass, leading to progressive functional impairment. Physical exercise may attenuate cancer cachexia and its impact on patient function. This is the first update of an original Cochrane Review published in Issue 11, 2014, which found no studies to include.

OBJECTIVES

To determine the effectiveness, acceptability and safety of exercise, compared with usual care, no treatment or active control, for cancer cachexia in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to March 2020. We searched for ongoing studies in trial registries, checked reference lists and contacted experts to seek relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials in adults with cancer cachexia, that compared a programme of exercise alone or in combination with another intervention, with usual care, no treatment or an active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for relevance and extracted data on study design, participants, interventions and outcomes from potentially relevant articles. We used standard methodological procedures expected by Cochrane. Our primary outcome was lean body mass and secondary outcomes were adherence to exercise programme, adverse events, muscle strength and endurance, exercise capacity, fatigue and health-related quality of life. We assessed the certainty of evidence using GRADE and included two Summary of findings tables.

MAIN RESULTS

We included four new studies in this update which overall randomised 178 adults with a mean age of 58 (standard deviation (SD) 8.2) years. Study sample size ranged from 20 to 60 participants and in three studies the proportion of men ranged from 52% to 82% (the fourth study was only available in abstract form). Three studies were from Europe: one in the UK and Norway; one in Belgium and one in Germany. The remaining study was in Canada. The types of primary cancer were head and neck (two studies), lung and pancreas (one study), and mixed (one study). We found two comparisons: exercise alone (strength-based exercise) compared to usual care (one study; 20 participants); and exercise (strength-based exercise/endurance exercise) as a component of a multimodal intervention (pharmacological, nutritional or educational (or a combination) interventions) compared with usual care (three studies, 158 participants). Studies had unclear and high risk of bias for most domains. Exercise plus usual care compared with usual care We found one study (20 participants). There was no clear evidence of a difference for lean body mass (8 weeks: MD 6.40 kg, 95% CI -2.30 to 15.10; very low-certainty evidence). For our secondary outcomes, all participants adhered to the exercise programme and no participant reported any adverse event during the study. There were no data for muscle strength and endurance, or maximal and submaximal exercise capacity. There was no clear evidence of a difference for either fatigue (4 to 20 scale, lower score was better) (8 weeks: MD -0.10, 95% CI -4.00 to 3.80; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score was better) (8 weeks: MD 4.90, 95% CI -15.10 to 24.90; very low-certainty evidence). Multimodal intervention (exercise plus other interventions) plus usual care compared with usual care We found three studies but outcome data were only available for two studies. There was no clear evidence of a difference for lean body mass (6 weeks: MD 7.89 kg, 95% CI -9.57 to 25.35; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -2.00, 95% CI -8.00 to 4.00; one study, 60 participants; very low-certainty evidence). For our secondary outcomes, there were no data reported on adherence to the exercise programme, endurance, or maximal exercise capacity. In one study (44 participants) there was no clear evidence of a difference for adverse events (patient episode report) (6 weeks: risk ratio (RR) 1.18, 95% CI 0.67 to 2.07; very low-certainty evidence). Another study assessed adverse events but reported no data and the third study did not assess this outcome. There was no clear evidence of a difference in muscle strength (6 weeks: MD 3.80 kg, 95% CI -2.87 to 10.47; 1 study, 44 participants; very low-certainty evidence; 12 weeks MD -5.00 kg, 95% CI -14.00 to 4.00; 1 study, 60 participants; very low-certainty evidence), submaximal exercise capacity (6 weeks: MD -16.10 m walked, 95% CI -76.53 to 44.33; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -62.60 m walked, 95% CI -145.87 to 20.67; 1 study, 60 participants; very low-certainty evidence), fatigue (0 to 10 scale, lower score better) (6 weeks: MD 0.12, 95% CI -1.00 to 1.24; 1 study, 44 participants; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score better) (12 weeks: MD -2.20, 95% CI -13.99 to 9.59; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The previous review identified no studies. For this update, our conclusions have changed with the inclusion of four studies. However, we are uncertain of the effectiveness, acceptability and safety of exercise for adults with cancer cachexia. Further high-quality randomised controlled trials are still required to test exercise alone or as part of a multimodal intervention to improve people's well-being throughout all phases of cancer care. We assessed the certainty of the body of evidence as very low, downgraded due to serious study limitations, imprecision and indirectness. We have very little confidence in the results and the true effect is likely to be substantially different from these. The findings of at least three more studies (one awaiting classification and two ongoing) are expected in the next review update.

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Spinal Stabilization Exercises for Cancer Patients with Spinal Metastases of High Fracture Risk: Feasibility of the DISPO-II Training Program

Simple Summary

Previous research indicates that the outcomes of irradiation of spinal metastases can be improved through exercise. After this was demonstrated for metastases of low fracture risk, we conducted the first study in patients with spinal metastases of high fracture risk to investigate exercise feasibility. An exercise group performed four spinal stabilization exercises daily over two weeks of radiotherapy, while a control group received relaxation. Patients in the exercise group attended 90% of training sessions, compared to 80% in the control group. No injuries occurred. However, about half of the patients could not perform two out of the four exercises due to pain, weakness or immobility. Nevertheless, they increased exercise time and training-specific strength. Altogether, exercise is well accepted and enhances muscle strength in these patients, but frequent individual adaptations of the training program are needed. This knowledge is a prerequisite for larger studies addressing exercise effects on health.

Abstract

Exercise concomitant to radiotherapy for stable spinal metastases was demonstrated to increase bone density and reduce pain. In the DISPO-II study, the feasibility of exercise concomitant to radiotherapy for unstable spinal metastases was investigated. Here, a detailed analysis of the training program is presented. Cancer patients with spinal metastases (Taneichi score ≥ D) were randomly assigned to an intervention group (INT, n = 27, 62 ± 9 years) or control group (CON, n = 29, 61 ± 9 years). INT performed spinal stabilization exercises (“all fours”/“plank”/“swimmer”/“band exercise”), and CON received relaxation, daily concomitant to radiotherapy. Exercise attendance rate was 90% in INT and 80% in CON (p = 0.126). Within INT, exercise dose increased significantly (p < 0.001). 54% of patients could not perform “swimmer” in some or all sessions. 42% could not perform “plank” in some or all sessions. 13 and 25% could not perform “all fours” and “band exercise” in some sessions. “Plank” holding time increased in INT and remained unchanged in CON with different development between groups (p = 0.022). Handgrip strength did not develop differently between groups (p = 0.397). The exercise intervention demonstrated high acceptability but required frequent modifications due to pain, weakness and immobility to be feasible for the majority of participants. It enhanced specific muscle strength. Larger trials should now investigate exercise effects on health.

Exercise in older women with breast cancer during systemic therapy: study protocol of a randomised controlled trial (BREACE)

INTRODUCTION

Exercise interventions have been widely investigated in patients with cancer and demonstrate beneficial effects. However, intervention studies that include older women with breast cancer exercising during medical treatment are scarce. Hence, the aim of this study is to investigate the effect of a 12-week exercise-based intervention in older women (≥65 years) with breast cancer receiving (neo)adjuvant or first-line or second-line systemic therapy.

METHODS AND ANALYSIS

This is a single-centre, two-armed randomised controlled trial. We anticipate including 100 patients, who will be randomised 1:1 to exercise-based intervention or control stratified by treatment setting ((neo)adjuvant or metastatic) and treatment (chemotherapy or endocrine therapy + cyclin-dependent kinase (CDK) 4/6 inhibitors). The intervention group will receive standard oncological treatment and a 12-week supervised exercise-based intervention comprising a progressive resistance exercise programme two times per week, a protein supplement after exercise and a home-based walking programme based on daily step counts. The control group will receive standard oncological treatment. Assessments will be performed at baseline and 6, 12 and 24 weeks after start of the intervention. Primary outcome is physical function, measured by the 30-second Chair Stand Test. Secondary outcomes are feasibility (compliance and adherence to intervention), objective and patient-reported functional measures (6-meter and 10-meter gait speed; 6-min Walk Test; Handgrip Strength; Stair Climb Test; Physical Activity Questionnaire), symptom burden and well-being (MD Anderson Symptom Inventory; Hospital Anxiety and Depression Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and B23), body composition (dual-energy X-ray absorptiometry scan), side effects, inflammatory biomarkers, hospitalisation and survival.

ETHICS AND DISSEMINATION

The protocol was reviewed and accepted by the Scientific Ethics Review Committee of the Capital Region of Denmark, 17 June 2018 (VEK ref.: H-18021013). Trial results will be submitted for publication in a peer-reviewed journal and presented on conferences, in oncology wards, exercise centres in municipalities and patient organisations, ensuring dissemination to relevant stakeholders.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ on 3 September 2018. Identifier: NCT03656731.

Role of Physiotherapy in Hospice Care of Patients with Advanced Cancer: A Systematic Review

OBJECTIVE

To review the role of physiotherapy and its effects in hospice care of patients with advanced cancer.

METHODS

A comprehensive literature search was performed in PubMed, Scopus, Web of Science, CINAHL and PEDro. The search strategy was devised, articles were screened, and 2 independent reviewers conducted data extraction. Eligible studies were methodologically assessed for quality rating using modified Downs and Black's checklist. The extracted data was summarized according to site/stage of cancer, details of intervention, outcome measures and the results.

RESULT

The total number of screened articles were 2102, out of which 9 were identified as suitable for the purposes of comprehensive review. The studies included exercise therapy, massage therapy, relaxation therapy, compression bandaging and use of TENS as the various physiotherapy interventions under consideration. Studies were generally of low to moderate quality. A broad range of outcomes were employed including physical symptoms like loss of function, pain, fatigue, edema, sleep disturbances and quality of life. The findings of the studies supported the benefits of the interventions.

CONCLUSION

A structured exercise protocol, massage therapy, TENS and compression bandaging are useful in alleviating the symptoms experienced by patients with advanced cancer in hospice care. The reduced symptom burden has reflected as an improvement in their quality of life. However, there is a further need for high quality studies to strengthen the findings of this review.

Supervised Physical Rehabilitation in the Treatment of Patients with Advanced Cancer: a Systematic Review and Meta-analysis

BACKGROUND

As the survival rate of cancer patients increases, the clinical importance of rehabilitation provided by healthcare professionals also increases. However, the evidence supporting the relevance of rehabilitation programs is insufficient. This study aimed to review the literature on effectiveness in physical function, quality of life (QOL) or fatigue of supervised physical rehabilitation in patients with advanced cancer.

METHODS

A systematic review and meta-analysis was conducted following the Cochrane guidelines. We narratively described the results when meta-analysis was not applicable or appropriate. Literature databases including Ovid-MEDLINE, Ovid-EMBASE, and the Cochrane Library, as well as several Korean domestic databases, were searched up to June 2017 for studies that investigated the effectiveness of supervised physical rehabilitation programs on physical function, QOL or fatigue in patients with advanced cancer. The quality of the selected studies was evaluated independently by paired reviewers.

RESULTS

Eleven studies with 922 participants were finally selected among 2,459 articles. The meta-analysis revealed that after physical exercise, the physical activity level and strength of patients with advanced cancer increased significantly. The QOL showed a statistically significant improvement after physical rehabilitation according to the European Organization for Research and Treatment of Cancer version C30. Though some of measurements about cardiovascular endurance or strength in several studies were not able to be synthesized, each study reported that they were significantly improved after receiving rehabilitation.

CONCLUSION

Supervised physical rehabilitation for patients with advanced cancer is effective in improving physical activity, strength, and QOL. However, more trials are needed to prove the effectiveness of supervised exercise and to strengthen the evidence.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

Assessment of gait parameters and physical function in patients with advanced cancer participating in a 12-week exercise and nutrition programme: A controlled clinical trial

OBJECTIVE

Gait is a sensitive marker for functional declines commonly seen in patients treated for advanced cancer. We tested the effect of a combined exercise and nutrition programme on gait parameters of advanced-stage cancer patients using a novel wearable gait analysis system.

METHODS

Eighty patients were allocated to a control group with nutritional support or to an intervention group additionally receiving whole-body electromyostimulation (WB-EMS) training (2×/week). At baseline and after 12 weeks, physical function was assessed by a biosensor-based gait analysis during a six-minute walk test, a 30-s sit-to-stand test, a hand grip strength test, the Karnofsky Index and EORTC QLQ-C30 questionnaire. Body composition was measured by bioelectrical impedance analysis and inflammation by blood analysis.

RESULTS

Final analysis included 41 patients (56.1% male; 60.0 ± 13.0 years). After 12 weeks, the WB-EMS group showed higher stride length, gait velocity (p < .05), six-minute walking distance (p < .01), bodyweight and skeletal muscle mass, and emotional functioning (p < .05) compared with controls. Correlations between changes in gait and in body composition, physical function and inflammation were detected.

CONCLUSION

Whole-body electromyostimulation combined with nutrition may help to improve gait and functional status of cancer patients. Sensor-based mobile gait analysis objectively reflects patients' physical status and could support treatment decisions.

What are the attitudes and beliefs of oncologists regarding potential cancer rehabilitation in a tertiary cancer center?

Cancer Rehabilitation (CR) is an emerging field in Physical Medicine & Rehabilitation. Current literature highlights the effectiveness of cancer rehabilitation in improving functional outcomes, shorter length of hospital stay, and improved quality of life. Despite this, there are very few formalized CR programs across all of North America. We conducted a survey at a tertiary cancer center without a formalized CR program to assess the perceived need of such a program and its potential development. This survey of medical, surgical, radiation and pediatric oncologists demonstrated that 92.3% of 39 respondents felt CR was somewhat to very important, particularly for their patients' issues of fatigue, deconditioning, pain management and disposition planning. These findings highlight the value seen by oncologists in the need for further cancer rehabilitation access and formalized program development in order to meet patient needs for improving functional deficits, activities of daily living and quality of life.

Muscle protein anabolism in advanced cancer patients: response to protein and amino acids support, and to physical activity

In the field of oncology, it is well recognized that a decrease in mass, density, strength, or function of skeletal muscle is associated to increased treatment toxicities and postoperative complications, as well as poor progression-free survival and overall survival. The ability of amino acids to stimulate protein synthesis in cancer patients is reduced. Considering nutritional intervention, this anabolic resistance could be in a part counteracted by increasing protein or by giving specific amino acids. In particular, Leucine might counteract this anabolic resistance not only by increasing substrate availability, but also by directly modulating the anabolic signal pathway. Few studies showed the possibility of increasing muscle protein synthesis by specific nutriments and/or by increasing amino acids or protein administration. In addition, whereas many studies provide evidence of a benefit of adapted physical activity in advanced cancer patients, it is difficult to specify the most appropriate type of exercise, and the optimum rhythm and intensity. Moreover, the benefits of physical activities and of protein support seem greater when it is started at the precachexia stage rather than at the cachexia stage, and their benefits are limited or nonexistent at the stage of refractory cachexia. Future approaches should integrate the combination of several complementary treatments in order to prevent (or improve) cachexia and/or sarcopenia in cancer patients.

Top Ten Tips Palliative Care Clinicians Should Know About Physical Medicine and Rehabilitation

Physical medicine and rehabilitation (PM&R) is a specialty of medicine focused on optimizing function and quality of life for individuals with physical impairments, injuries, or disabling illnesses. Given the sometimes acute nature of the loss of function and even loss of independence, there are significant palliative care (PC) needs within patients seen by PM&R. This article, written by a team of PM&R and PC specialists, aims to help the PC team better understand the world of postacute care, expand their toolkit for treating musculoskeletal and neurological symptoms, improve prognostication for patients with brain and spinal cord injuries, and decide when patients may benefit from PM&R consultation and support. There is significant overlap between the populations treated by PM&R and PC. Better integration between these specialties will help patients to maintain independence as well as advance excellent patient-centered care.

Typical aspects in the rehabilitation of cancer patients suffering from metastatic bone disease or multiple myeloma

Background

The aim of this study was to present a practical concept focusing on typical aspects of regular physical activity, exercise and physical modalities for patients suffering from metastatic bone disease or multiple myeloma.

Methods

A narrative review of the relevant scientific literature and presentation of clinical experiences.

Results

In cancer patients with metastatic bone disease or multiple myeloma, pain is treated in an interdisciplinary and multimodal setting by using medication, radiotherapy and physical medical modalities (e.g. transcutaneous electrical nerve stimulation); however, modalities increasing local blood flow, such as ultrasound therapy, thermotherapy, massage, various electrotherapy options, are not performed at the site of the tumor. For physical activity and exercise, a suitable indication of the static and dynamic capacity of the affected skeletal structures is essential. This process includes strategies to maintain and improve mobility and independence. Individually tailored and adapted physical activity and exercise concepts (programs) within a multidisciplinary and interdisciplinary setting (tumor board) are used to manage the condition and bone load-bearing capacity of the patient. Typical clinical features and complications, such as pathological fractures in patients suffering from metastatic bone disease and additionally hypercalcemia, monoclonal gammopathy with bone marrow aplasia and risk of renal failure in patients with multiple myeloma have to be considered when planning supportive strategies and rehabilitation.

Conclusion

In order to ensure the safety and effectiveness of regular physical activity, exercise, and physical modalities in patients with metastatic bone disease or multiple myeloma, typical contraindications and considerations should be noted.

Exercise interventions for patients with advanced cancer: A systematic review of recruitment, attrition, and exercise adherence rates

Purpose

Patients with advanced cancer can experience debilitating physical symptoms, making participation in exercise programs difficult. This systematic review investigated the recruitment, adherence, and attrition rates of patients with advanced cancer participating in exercise interventions and examined components of exercise programs that may affect these rates.

Methods

Relevant studies were identified in a systematic search of CINAHL, PubMed, PsycINFO, and EMBASE to December 2017. Two quality assessment tools were used, and levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.

Results

The search identified 18 studies published between 2004 and 2017. Recruitment, adherence, and attrition rates varied widely among the studies reviewed. The mean recruitment rate was 49% (standard deviation [SD] = 17; range 15–74%). Patient-reported barriers to recruitment included time constraints and difficulties in traveling to exercise centers. Levels of adherence ranged from 44% to 95%; however, the definition of adherence varied substantially among trials. The average attrition rate was 24% (SD = 8; range 10–42%), with progression of disease status reported as the main cause for dropout during exercise interventions.

Significance of results

Concentrated efforts are needed to increase the numbers of patients with advanced disease recruited to exercise programs. Broadening the eligibility criteria for exercise interventions may improve accrual numbers of patients with advanced cancer to exercise trials and ensure patients recruited are representative of clinical practice.

Combined exercise and nutritional rehabilitation in outpatients with incurable cancer: a systematic review

PURPOSE

The optimal components for rehabilitation in patients with incurable cancer are unclear. However, principles of exercise and nutrition-based interventions used in cancer cachexia may be applied usefully to this population of cancer patients. This systematic review examines current evidence for rehabilitation combining exercise and nutritional support in patients with incurable cancer.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched. Eligible studies included patients with incurable cancer and rehabilitation programmes combining exercise and nutritional interventions. Studies of cancer survivors, curative treatments, reviews, case note reviews, protocols and abstracts were excluded. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied to patient-important outcomes.

RESULTS

Of the 2424 search results, 67 abstracts were reviewed and 24 full texts examined. Eight studies (n = 685) were included comprising two randomised control trials, three prospective, one exploratory and two secondary analyses. All examined multi-modal outpatient programmes. GRADE analysis revealed moderate evidence (B) for improvements in depression and physical endurance, low-quality evidence (C) for quality of life and fatigue and very low-quality evidence (D) for overall function and nutritional status.

CONCLUSION

There are limited data for multi-modal rehabilitation programmes combining exercise and nutritional interventions in patients with incurable cancer. However, studies to date report improvements in multiple domains, most notably physical endurance and depression scores. This supports the concept that multi-modal rehabilitation incorporating principles of cachexia management may be appropriate for the wider group of patients with incurable cancer. Further, high-quality studies are needed to define the optimal approach and outcome measures.

Engaging the older cancer patient; Patient Activation through Counseling, Exercise and Mobilization - Pancreatic, Biliary tract and Lung cancer (PACE-Mobil-PBL) - study protocol of a randomized controlled trial

Background

Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy.

Methods

PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks.

Discussion

The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field.

Trial registration

The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200).

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4835-2) contains supplementary material, which is available to authorized users.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

OBJECTIVES

To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

SEARCH METHODS

We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

MAIN RESULTS

We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

The Role of Systemic Inflammation in Cancer-Associated Muscle Wasting and Rationale for Exercise as a Therapeutic Intervention

Progressive skeletal muscle wasting in cancer cachexia involves a process of dysregulated protein synthesis and breakdown.  This catabolism may be the result of mal-nutrition, and an upregulation of both pro-inflammatory cytokines and the ubiquitin proteasome pathway (UPP), which can subsequently increase myostatin and activin A release.  The skeletal muscle wasting associated with cancer cachexia is clinically significant, it can contribute to treatment toxicity or the premature discontinuation of treatments resulting in increases in morbidity and mortality.  Thus, there is a need for further investigation into the pathophysiology of muscle wasting in cancer cachexia to develop effective prophylactic and therapeutic interventions.  Several studies have identified a central role for chronic-systemic inflammation in initiating and perpetuating muscle wasting in patients with cancer.  Interestingly, while exercise has shown efficacy in improving muscle quality, only recently have investigators begun to assess the impact that exercise has on chronic-systemic inflammation.  To put this new information into context with established paradigms, here we review several biological pathways (e.g. dysfunctional inflammatory response, hypothalamus pituitary adrenal axis, and increased myostatin/activin A activity) that may be responsible for the muscle wasting in patients with cancer.  Additionally, we discuss the potential impact that exercise has on these pathways in the treatment of cancer cachexia.  Exercise is an attractive intervention for muscle wasting in this population, partially because it disrupts chronic-systemic inflammation mediated catabolism.  Most importantly, exercise is a potent stimulator of muscle synthesis, and therefore this therapy may reverse muscle damage caused by cancer cachexia. 

Nonpharmacologic Pain Interventions: A Review of Evidence-Based Practices for Reducing Chronic Cancer Pain

BACKGROUND

Pain is a common issue for patients with cancer and can be challenging to manage effectively. Healthcare professionals need to be knowledgeable about evidence-based nonpharmacologic interventions.
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OBJECTIVES

This systematic review critically appraises the strength and quality of the empirical evidence for nonpharmacologic interventions in reducing chronic cancer pain.
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METHODS

Intervention studies were critically appraised and summarized by an Oncology Nursing Society Putting Evidence Into Practice team of RNs, advanced practice nurses, and nurse scientists. A level of evidence and a practice recommendation was assigned to each intervention.
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FINDINGS

Based on evidence, recommended interventions to reduce chronic cancer pain are celiac plexus block for pain related to pancreatic and abdominal cancers and radiation therapy for bone pain. Although psychoeducational interventions are considered likely to be effective, the effective components of these interventions and their dose and duration need to be determined through additional research.

Physical Therapy and Exercise for Hospice Patients

Falls are a particular health issue for hospice patients with cancer. Studies have found that 50% of patients diagnosed with advanced cancer fall during the subsequent 6-month time frame. The impact of falls on hospice and cancer patients is costly both in terms of reduced functional quality of life, increased anxiety and resulting pain and suffering. Physical therapy (PT) and exercise have been shown to be effective in reducing falls among older adult populations in the community. The purpose of this article is to review studies that examined PT and exercise for hospice and terminally ill cancer patients. Although none of the five studies evaluated the effect of PT and exercise specifically on falls, outcomes included factors such as balance, strength, pain, sleep and fatigue, all of which can contribute to falls. All the studies reviewed found benefits such as improved health status, functional mobility, or muscle strength.

Exercise interventions for individuals with advanced cancer: A systematic review

Despite improvements in therapy a large proportion of individuals with cancer will have a shortened life expectancy because of advanced or metastatic disease. Advances in therapy have however, extended life in those with advanced cancer thus heightening the importance of living well and preventing decline. The burdens of disease and cancer therapy impair aerobic fitness, strength, physical function and quality of life (QOL). Fatigue, the most common side effect of cancer and cancer therapy can further deteriorate QOL. Exercise has the potential to improve aerobic fitness, physical function, control fatigue and enhance QOL. However, exercise interventions are not routinely provided to those with advanced cancer. We present a systematic literature review of outcomes from interventions that include exercise for patients with advanced cancer. Studies were reviewed if they included an advanced cancer population and an intervention with a component of exercise. Overall, exercise containing interventions resulted in improvements in measures of aerobic capacity (14 of 19 studies) strength (11 of 12 studies), and components of physical function (9 of 9 studies). Fatigue and QOL were identified to improve in slightly over half of all evaluated studies (11 of 19 studies and 10 of 19 studies for fatigue and QOL respectively). The numbers of total participants reporting improvements in QOL (60%) were greater than fatigue (45%). Exercise provided to individuals with advanced cancer maintains or improves fitness and physical function and may diminish fatigue and enhance QOL and should be considered as an intervention to prevent further health complications.

Safety and feasibility of exercise interventions in patients with advanced cancer: a systematic review

GOALS OF WORK

The beneficial effects of exercise in cancer patients are reasonably well-established, although research in this field has predominantly investigated cancer patients in the earlier stages of disease. However, the most recent evidence surrounding exercise interventions in advanced cancer populations has yet to be systematically evaluated. This review critically analyses the safety and feasibility of exercise interventions in patients with advanced cancer.

METHODS

All randomised, non-randomised and prospective observational trials of exercise training interventions in patients with advanced cancer were included. 'Safety' was defined as the number and severity of reported adverse events during exercise training. 'Feasibility' was determined by participant adherence, attendance and/or study completion rates.

RESULTS

A total of 25 studies involving 1088 patients were included: 16 randomised controlled and nine prospective observational cohort trials. Seven studies included advanced lung cancer patients exclusively, while eight involved patients with various cancer diagnoses. Aerobic exercise was investigated in five studies, resistance training in two studies and combination training (aerobic and resistance) in 14 studies. Six minor adverse events were reported due to exercise. All of these were musculoskeletal in nature, resulting in two participants' withdrawal from the study. Exercise adherence ranged from 65 to 89% but was only described in nine studies. Attendance at each exercise session was described in a further nine studies, ranging from 59 to 100%.

CONCLUSIONS

Implementation of exercise interventions appears to be safe and feasible in advanced cancer clinical practice, although targeted studies are required to determine the optimal exercise dose for specific cancer diagnoses.

Feasibility and Pilot Studies in Palliative Care Research: A Systematic Review

CONTEXT

Feasibility and pilot study designs are common in palliative care research. Finding standard guidelines on the structure and reporting of these study types is difficult.

OBJECTIVES

In feasibility and pilot studies in palliative care research, to determine 1) how commonly a priori feasibility are criteria reported and whether results are subsequently reported against these criteria? and 2) how commonly are participants' views on acceptability of burden of the study protocol assessed?

METHODS

Four databases (OVID Medline, EMBASE, CINAHL, and PubMed via caresearch.com.au.) were searched. Search terms included palliative care, terminal care, advance care planning, hospice, pilot, feasibility, with a publication date between January 1, 2012 and December 31, 2013. Articles were selected and appraised by two independent reviewers.

RESULTS

Fifty-six feasibility and/or pilot studies were included in this review. Only three studies had clear a priori criteria to measure success. Sixteen studies reported participant acceptability or burden with measures. Forty-eight studies concluded feasibility.

CONCLUSION

The terms "feasibility" and "pilot" are used synonymously in palliative care research when describing studies that test for feasibility. Few studies in palliative care research outline clear criteria for success. The assessment of participant acceptability and burden is uncommon. A gold standard for feasibility study design in palliative care research that includes both clear criteria for success and testing of the study protocol for participant acceptability and burden is needed. Such a standard would assist with consistency in the design, conduct and reporting of feasibility and pilot studies.

Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed.

DATA SOURCES

Five electronic databases-Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO-were searched from inception to March 2016 for relevant articles.

STUDY SELECTION

Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search.

DATA EXTRACTION

Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools-Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure.

DATA SYNTHESIS

Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07-.27) to medium (.45; 95% CI, .23-.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes.

CONCLUSIONS

Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Clinically Relevant Physical Benefits of Exercise Interventions in Breast Cancer Survivors

Evidence is currently limited for the effect of exercise on breast cancer clinical outcomes. However, several of the reported physical benefits of exercise, including peak oxygen consumption, functional capacity, muscle strength and lean mass, cardiovascular risk factors, and bone health, have established associations with disability, cardiovascular disease risk, morbidity, and mortality. This review will summarize the clinically relevant physical benefits of exercise interventions in breast cancer survivors and discuss recommendations for achieving these benefits. It will also describe potential differences in intervention delivery that may impact outcomes and, lastly, describe current physical activity guidelines for cancer survivors.

REHABILITATION IN PALLIATIVE CARE

ABSTRACT: The objective of this study was to describe the activities and effects of functional rehabilitation in patients receiving palliative care. It is an integrative review, in which LILACS, BDENF, Coleciona SUS (Brazil) and PUBMED were used, 20 articles were selected, subsequently characterized as having designs of medium and low impact, more than half ranked with evidence levels II, III and IV and with samples not always consistent with the research designs. However, the results revealed the potential of rehabilitation to improve the functional status, quality of life and symptoms like pain and anxiety in this population, through interventions that are many times undervalued in palliative care. The conclusion is that rehabilitation is a feasible strategy to combat functional decline and improve the quality of life of patients in palliative care.

Effects of rehabilitation among patients with advances cancer: a systematic review

BACKGROUND

In parallel with the rising incidence of cancer and improved treatment, there is a continuous increase in the number of patients living with cancer as a chronic condition. Many cancer patients experience long-term disability and require continuous oncological treatment, care and support. The aim of this review is to evaluate the most recent data on the effects of rehabilitation among patients with advanced cancer.

MATERIAL AND METHODS

A systematic review was conducted according to Fink's model. Only randomized controlled trials (RCTs) published in 2009-2014 were included. Medline/PubMed and Cochrane databases were searched; five groups of keywords were used. The articles were evaluated for outcome and methodological quality.

RESULTS

Thirteen RCTs (1169 participants) were evaluated. Most studies were on the effects of physical exercise in patients with advanced cancer (N = 7). Physical exercise was associated with a significant improvement in general wellbeing and quality of life. Rehabilitation had positive effects on fatigue, general condition, mood, and coping with cancer.

CONCLUSIONS

Rehabilitation is needed also among patients with advanced disease and in palliative care. Exercise improves physical performance and has positive effects on several other quality of life domains. More data and RCTs are needed, but current evidence gives an indication that rehabilitation is suitable and can be recommended for patients living with advanced cancer.