Feasibility and preliminary efficacy of progressive resistance exercise training in lung cancer survivors

Maximal Number of Repetitions at Percentages of the One Repetition Maximum: A Meta-Regression and Moderator Analysis of Sex, Age, Training Status, and Exercise

The maximal number of repetitions that can be completed at various percentages of the one repetition maximum (1RM) [REPS ~ %1RM relationship] is foundational knowledge in resistance exercise programming. The current REPS ~ %1RM relationship is based on few studies and has not incorporated uncertainty into estimations or accounted for between-individuals variation. Therefore, we conducted a meta-regression to estimate the mean and between-individuals standard deviation of the number of repetitions that can be completed at various percentages of 1RM. We also explored if the REPS ~ %1RM relationship is moderated by sex, age, training status, and/or exercise. A total of 952 repetitions-to-failure tests, completed by 7289 individuals in 452 groups from 269 studies, were identified. Study groups were predominantly male (66%), healthy (97%), < 59 years of age (92%), and resistance trained (60%). The bench press (42%) and leg press (14%) were the most commonly studied exercises. The REPS ~ %1RM relationship for mean repetitions and standard deviation of repetitions were best described using natural cubic splines and a linear model, respectively, with mean and standard deviation for repetitions decreasing with increasing %1RM. More repetitions were evident in the leg press than bench press across the loading spectrum, thus separate REPS ~ %1RM tables were developed for these two exercises. Analysis of moderators suggested little influences of sex, age, or training status on the REPS ~ %1RM relationship, thus the general main model REPS ~ %1RM table can be applied to all individuals and to all exercises other than the bench press and leg press. More data are needed to develop REPS ~ %1RM tables for other exercises.

Nurse navigation, symptom monitoring and exercise in vulnerable patients with lung cancer: feasibility of the NAVIGATE intervention

We developed the Navigate intervention to improve survival among vulnerable lung cancer patients. In this intervention-only study, we examined feasibility in terms of recruitment, retention, attendance, adherence, and acceptability to specify adjustments to study procedures and intervention components prior to a randomized trial. The Navigate intervention includes nurse navigation, patient-reported outcomes, and physical exercise. Patients ≥ 18 years old, diagnosed with non-small cell lung cancer at any stage, with performance status ≤ 2, eligible for cancer treatment and vulnerable according to a screening instrument were included. The recruitment goal of eligible patients was 40% while the retention goal was 85%. The predefined cut-offs for sufficient attendance and adherence were ≥ 75%. Acceptability was evaluated by semi-structured interviews with participants, nurse navigators, and physiotherapists. Seventeen (56%) out of 30 screened patients were considered vulnerable and eligible for the study, 14 (82%) accepted participation, and 3 (21%) were subsequently excluded due to ineligibility, leaving 11 patients. Four patients dropped out (36%) and four patients died (36%) during follow-up and 3 (27%) were retained. All 11 patients participated in nurse sessions (mean 16, range 1-36) with 88% attendance and dialogue tools being applied in 68% of sessions. Ninety-one percent of patients responded to PROs (mean of 9 PROs, range 1-24) with 76% of the PRO questionnaires used (attendance) and 100% adherence (completion of all questions in PRO questionnaires), and 55% participated in exercise sessions with 58% attendance and 85% adherence. We identified important barriers primarily related to transportation, but overall acceptability was high. The Navigate intervention was feasible with high participation, acceptability and satisfactory adherence. Retention and exercise attendance were low, which resulted in adjustments.Trial registration: The feasibility study was initiated prior to the multicenter randomized controlled trial registered by ClinicalTrials.gov (number: NCT05053997; date 23/09/2021).

Cancer-associated cachexia - understanding the tumour macroenvironment and microenvironment to improve management

Cachexia is a devastating, multifactorial and often irreversible systemic syndrome characterized by substantial weight loss (mainly of skeletal muscle and adipose tissue) that occurs in around 50-80% of patients with cancer. Although this condition mainly affects skeletal muscle (which accounts for approximately 40% of total body weight), cachexia is a multi-organ syndrome that also involves white and brown adipose tissue, and organs including the bones, brain, liver, gut and heart. Notably, cachexia accounts for up to 20% of cancer-related deaths. Cancer-associated cachexia is invariably associated with systemic inflammation, anorexia and increased energy expenditure. Understanding these mechanisms is essential, and the progress achieved in this area over the past decade could help to develop new therapeutic approaches. In this Review, we examine the currently available evidence on the roles of both the tumour macroenvironment and microenvironment in cancer-associated cachexia, and provide an overview of the novel therapeutic strategies developed to manage this syndrome.

Is physical activity effective against cancer-related fatigue in lung cancer patients? An umbrella review of systematic reviews and meta-analyses

OBJECTIVES

To discuss the effects of physical activity on cancer-related fatigue (CRF) in lung cancer patients, summarize the types of physical activity in the published reviews, assess the quality of the evidence, and provide suggestions for the clinical selection of exercise intervention.

METHODS

PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews were searched through 8 November 2021 to identify relevant systematic reviews and meta-analyses. We also performed a manual search of the reference lists of included articles as supplements. Two researchers independently performed literature screening, data extraction, and quality assessment. The umbrella review has been registered in the International Prospective Register of Systematic Review (PROSPERO) registry (CRD42021292548).

RESULTS

From the 13 systematic reviews or meta-analyses identified, 10 physical activity interventions were included. The most mentioned intervention was aerobic combined with resistance exercise; however, no reduction of the symptoms of CRF was observed in lung cancer patients by this exercise intervention. Most of the patients who performed aerobic exercises alone showed improvement in CRF after the intervention. In addition, Tai Chi and breathing exercises have been shown to improve fatigue, but more high-quality research is still needed to support its effectiveness.

CONCLUSIONS

Aerobic exercise, respiratory muscle training, aerobic combined with balance training, and other exercise interventions have been shown to improve CRF in lung cancer patients. But it should be noted that according to the different treatment methods and disease stages of patients, individualized rehabilitation programs should be developed for patients. Due to the low methodological quality and evidence quality of some systematic reviews and meta-analyses included in this study, more high-quality clinical studies and systematic reviews are still needed for validation in the future. This umbrella review helps to identify effective ways of exercise to improve fatigue in lung cancer patients before dedicated evidence-based medical guidelines are established.

Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients

BACKGROUND

Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps.

METHODS

A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines.

RESULTS

One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea.

CONCLUSION

Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.

Nonpharmacological Interventions for Pain Management in Lung Cancer Patients: A Systematic Review

Background:

The presence of lung cancer is almost always associated with pain, a symptom that causes severe distress in patients. Although many pharmacological methods are available to manage pain in this oncologic population, the medications often cause undesirable sideeffects and inadequate relief. Nonpharmacological interventions can be used as adjuvants to pharmacological interventions in reducing pain and increasing quality of life.

Objectives:

The purpose of this review is to compare the efficacy of nonpharmacological interventions in reducing pain in lung cancer patients.

Materials and Methods:

This is a systematic review study guided by the Preferred Reporting Items of Systematic reviews and Meta-Analysis Protocol. Interventions identified in the present systematic review have been categorized as physical treatment, technologybased, cognitive behavioral, coping, and coaching.

Results:

Results indicate that the nonpharmacological interventions such as physical treatment interventions, selfmanagement and coaching interventions, cognitive behavioral interventions, and technologybased interventions or coping skills interventions had limited and shortterm effects on alleviating pain among the patients. However, previous studies have provided limited evidence regarding nonpharmacologic therapy due to the lack of a comparison group, small sample sizes, and lack of longterm followup periods to determine whether sustained effects are feasible.

Conclusion:

Healthcare professionals should consider additional research on the added advantage of utilizing the nonpharmacological interventions as an adjunct option while managing pain in lung cancer patients.

Resistance Training Impact on Mobility, Muscle Strength and Lean Mass in Pancreatic Cancer Cachexia: A Randomized Controlled Trial

Objective:

To determine the efficacy of a three-month resistance training programme on the mobility, muscle strength and lean body mass of patients with pancreatic cancer-induced cachexia.

Design:

Randomized controlled trial.

Setting:

Elsahel Teaching Hospital, outpatient clinic of the Faculty of Physical Therapy, Cairo, Egypt.

Participants:

Patients with pancreatic cancer-induced cachexia.

Interventions:

Participants were randomized to the resistance training group ( n = 20) and control group ( n = 20).

Main measures:

Outcomes including mobility, muscle strength and lean body mass were measured at baseline, three months after surgical resection and 12 weeks after intervention.

Results:

The mean (SD) age was 51.9 (5.03) years and body mass index was 21.1 (1.13) kg/m²; 65% of patients were male. Compared to the control group, the resistance training group showed significant improvement in mobility: 400-m walk performance (270.3–256.9 seconds vs 266.4–264.2 seconds, respectively) and chair rise (13.82–12.53 seconds vs 13.77–13.46 seconds, respectively). Similarly, muscle strength was also significantly improved in the resistance training group than in the control group; we observed increase in peak torque of knee extensors ( P = 0.004), elbow flexors ( P = 0.001) and elbow extensors, improvement in lean mass of the upper limb (6.28–6.46 kg vs 6.31–6.23 kg, respectively) and lower limb (16.31–16.58 kg vs 16.4–16.31 kg, respectively).

Conclusion:

A three-month resistance training improved the mobility of patients with pancreatic cancer-induced cachexia. Muscle strength and lean body mass also improved.

Cancer cachexia, a clinical challenge

PURPOSE OF REVIEW

The aim of this article is to review the metabolic background of the cachectic syndrome and to analyze the recent therapeutic approaches designed to counteract the wasting suffered by the cancer patient with cachexia.

RECENT FINDINGS

The main changes associated with the development of this multiorganic syndrome are glucose intolerance, fat depletion and muscle protein hypercatabolism. Among the most promising approaches for the treatment of cachexia include the use of ghrelin agonists, beta-blockers, beta-adrenergic agonists, androgen receptor agonists and antimyostatin peptides. The multitargeted approach seems essential in these treatments, which should include the combination of both nutritional support, drugs and a suitable program of physical exercise, in order to ameliorate both anorexia and the metabolic changes associated with cachexia. In addition, another very important aspect for the design of clinical trials for the treatment of cancer cachexia is to staging cancer patients in relation with the degree of cachexia, in order to start as early as possible, this triple approach in the course of the disease, even before weight loss can be detected.

SUMMARY

Cancer cachexia has two main components: anorexia and metabolic alterations and both have to be taken into consideration for the treatment of the syndrome.

Cancer-Associated Cachexia: A Systemic Consequence of Cancer Progression

Cancer is a life-threatening disease that has plagued humans for centuries. The vast majority of cancer-related mortality results from metastasis. Indeed, the invasive growth of metastatic cancer cells in vital organs causes fatal organ dysfunction, but metastasis-related deaths also result from cachexia, a debilitating wasting syndrome characterized by an involuntary loss of skeletal muscle mass and function. In fact, about 80% of metastatic cancer patients suffer from cachexia, which often renders them too weak to tolerate standard doses of anticancer therapies and makes them susceptible to death from cardiac and respiratory failure. The goals of this review are to highlight important findings that help explain how cancer-induced systemic changes drive the development of cachexia and to discuss unmet challenges and potential therapeutic strategies targeting cachexia to improve the quality of life and survival of cancer patients.

Exploring the feasibility, sustainability and the benefits of the GrACE + GAIT exercise programme in the residential aged care setting

Background

The feasibility and benefits of a 24-week targeted progressive supervised resistance and weight-bearing exercise programme (Group Aged Care Exercise + GAIT (GrACE + GAIT)) in the residential aged care (RAC) setting was investigated as very little peer-reviewed research has been conducted in relation to exercise programmes of this duration in this cohort.

Methods

A quasi-experimental study design consisting of two groups (control and exercise) explored a 24-week targeted progressive supervised resistance and weight-bearing exercise programme (GrACE + GAIT) in two RAC facilities in Northern New South Wales, Australia. A total of 42 adults consented to participate from a total of 68 eligible residents (61.7%). The primary outcome measures were feasibility and sustainability of the exercise programme via intervention uptake, session adherence, attrition, acceptability and adverse events. Secondary measures included gait speed and the spatio-temporal parameters of gait, handgrip muscle strength and sit to stand performance.

Results

Twenty-three residents participated in the exercise intervention (mean (SD) 85.4 (8.1) years, 15 females) and 19 in the control group (87.4 (6.6) years 13 females). Exercise adherence was 79.3%, with 65% of exercise participants attending ≥70% of the sessions; 100% of those originally enrolled completed the programme and strongly agreed with the programme acceptability. Zero exercise-related adverse events were reported. ANCOVA results indicated that post-intervention gait speed significantly increased (p < 0.001) with an 18.8% increase in gait speed (m/s).

Discussion

The GrACE + GAIT programme was shown to be feasible and significantly improve adults living in RAC facilities gait speed, handgrip strength and sit to stand performance. These results suggest that the GrACE + GAIT programme is suitable for use in the RAC sector and that it has the potential to reduce disability and improve function and quality of life of the residents.

Therapeutic strategies against cancer cachexia

Cancer cachexia has two main components: anorexia and metabolic alterations. The main changes associated with the development of this multi-organic syndrome are glucose intolerance, fat depletion and muscle protein hypercatabolism. The aim of this paper is to review the more recent therapeutic approaches designed to counteract the wasting suffered by the cancer patient with cachexia. Among the most promising approaches we can include the use of ghrelin agonists, beta-blockers, beta-adrenergic agonists, androgen receptor agonists and anti-myostatin peptides. The multi-targeted approach seems essential in these treatments, which should include the combination of both nutritional support, drugs and a suitable program of physical exercise, in order to ameliorate both anorexia and the metabolic changes associated with cachexia. In addition, another very important and crucial aspect to be taken into consideration in the design of clinical trials for the treatment of cancer cachexia is to staging cancer patients in relation with the degree of cachexia, in order to start as early as possible this triple approach in the course of the disease, even before the weight loss can be detected.

Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial

INTRODUCTION

Lung cancer is a significant burden on societies worldwide, and the most common cause of death in patients with cancer overall. Exercise intervention studies in patients with lung cancer have consistently shown benefits with respect to physical and emotional functioning. However, to date, exercise training has not been consistently implemented into clinical practice given that interventions have been costly and not aligned with clinical care.

METHODS/DESIGN

The Precision-Exercise-Prescription (PEP) study is a prospective randomised controlled trial comparing the effectiveness and feasibility of a personalised intervention exercise programme among patients with lung cancer undergoing surgery. Two-hundred patients who are diagnosed with stage primary or secondary lung cancer and are eligible to undergo surgical treatment at Huntsman Cancer Institute comprise the target population. Patients are randomised to either the (1) outpatient precision-exercise intervention group or (2) delayed intervention group. The intervention approach uses Motivation and Problem Solving, a hybrid behavioural treatment based on motivational interviewing and practical problem solving. The dosage of the exercise intervention is personalised based on the individual's Activity Measure for Post-Acute-Care outpatient basic mobility score, and incorporates four exercise modes: mobility, callisthenics, aerobic and resistance. Exercise is implemented by physical therapists at study visits from presurgery until 6 months postsurgery. The primary endpoint is the level of physical function assessed by 6 min walk distance at 2 months postsurgery. Secondary outcomes include patient-reported outcomes (eg, quality of life, fatigue and self-efficacy) and other clinical outcomes, including length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months postsurgery.

ETHICS/DISSEMINATION

The PEP study will test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery. Outcomes of this clinical trial will be presented at national and international conferences and symposia and will be published in international, peer-reviewed journals. Ethics approval was obtained at the University of Utah (IRB 00104671).

TRIAL REGISTRATION NUMBER

NCT03306992.

Novel targeted therapies for cancer cachexia

Anorexia and metabolic alterations are the main components of the cachectic syndrome. Glucose intolerance, fat depletion, muscle protein catabolism and other alterations are involved in the development of cancer cachexia, a multi-organ syndrome. Nutritional approach strategies are not satisfactory in reversing the cachectic syndrome. The aim of the present review is to deal with the recent therapeutic targeted approaches that have been designed to fight and counteract wasting in cancer patients. Indeed, some promising targeted therapeutic approaches include ghrelin agonists, selective androgen receptor agonists, β-blockers and antimyostatin peptides. However, a multi-targeted approach seems absolutely essential to treat patients affected by cancer cachexia. This approach should not only involve combinations of drugs but also nutrition and an adequate program of physical exercise, factors that may lead to a synergy, essential to overcome the syndrome. This may efficiently reverse the metabolic changes described above and, at the same time, ameliorate the anorexia. Defining this therapeutic combination of drugs/nutrients/exercise is an exciting project that will stimulate many scientific efforts. Other aspects that will, no doubt, be very important for successful treatment of cancer wasting will be an optimized design of future clinical trials, together with a protocol for staging cancer patients in relation to their degree of cachexia. This will permit that nutritional/metabolic/pharmacological support can be started early in the course of the disease, before severe weight loss occurs. Indeed, timing is crucial and has to be taken very seriously when applying the therapeutic approach.

The feasibility of a pragmatic distance-based intervention to increase physical activity in lung cancer survivors

The purpose of this study was to investigate the feasibility and preliminary efficacy of a pragmatic distance-based intervention designed to increase physical activity (PA) participation in lung cancer survivors. Fourteen lung cancer survivors were recruited via invitation from the State Cancer Registry to join a 12-week PA intervention of print materials paired with brief telephone follow-up. Outcome measures of feasibility, PA participation and quality of life (QoL) were assessed at baseline, post-intervention and follow-up via telephone interview. Eligibility, recruitment and attrition rates were 16%, 58% and 29% respectively. No adverse events were reported; however, pain scores worsened following the intervention (median change -3.6, IQR -8.0, 0.0). Average intervention adherence was 91% with low median ratings of participation burden (i.e., all items 1/7) and high trial evaluation (i.e., all items 7/7). Post-intervention, median change in self-reported moderate and vigorous PA was 84 min (IQR -22, 188), and several domains of QoL improved. However, for both of these outcomes, improvements were not maintained at follow-up. Our findings suggest that this pragmatic distance-based intervention was safe, had good adherence rates, and indicate potential for improving short-term PA and QoL in lung cancer survivors. Additional strategies are needed to improve other indicators of feasibility, particularly recruitment, retention and long-term maintenance of improvements. Australian New Zealand Clinical Trials Registration: ACTRN12612000085875.

Preoperative exercise training prevents functional decline after lung resection surgery: a randomized, single-blind controlled trial

OBJECTIVES

To investigate the effects of a preoperative pulmonary rehabilitation programme in patients with lung cancer undergoing video-assisted thoracic surgery.

DESIGN

Randomized, single-blind controlled trial.

SETTING

Teaching hospital.

SUBJECTS

Patients with suspected or confirmed lung cancer undergoing video-assisted thoracic surgery.

INTERVENTION

Participants were randomized to either a prehabilitation group or a control group. Participants in the prehabilitation group underwent a combination of moderate endurance and resistance training plus breathing exercises three to five times per week.

MAIN MEASURES

The primary outcome of the study was exercise capacity. Secondary outcomes were muscle strength (Senior Fitness Test), health-related quality of life (Short-Form 36) and the postoperative outcomes. Patients were evaluated at baseline (before randomization), presurgery (only the prehabilitation group), after surgery and three months post-operatively.

RESULTS

A total of 40 patients were randomized and 22 finished the study (10 in the prehabilitation group and 12 in the control group). Three patients were lost to follow-up at three months. After the training, there was a statistically significant improvement in exercise tolerance (+397 seconds, p = 0.0001), the physical summary component of the SF-36 (+4.4 points, p = 0.008) and muscle strength ( p < 0.01). There were no significant differences between groups after surgery. However, three months postoperatively, significant differences were found in the mean change of exercise capacity ( p = 0.005), physical summary component ( p = 0.001) and upper and lower body strength ( p = 0.045 and p = 0.002).

CONCLUSIONS

A pulmonary rehabilitation programme before video-assisted thoracic surgery seems to improve patients' preoperative condition and may prevent functional decline after surgery. Clinical Registration Number: NCT01963923 (Registration date 10/10/2013).

Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA): A Feasibility Study

Introduction Surgical resection in patients with non-small cell lung cancer (NSCLC) may be associated with significant morbidity, functional limitations, and decreased quality of life. Objectives The safety and feasibility of a preoperative and early postoperative rehabilitation program in patients operated for NSCLC was determined in a nonhospital setting, with focus on high-intensity interval exercise. Methods Forty patients with biopsy-proven NSCLC stages I to IIIa referred for surgical resection at the Department of Cardiothoracic Surgery RT, Rigshospitalet, University of Copenhagen, were randomly assigned to 1 of 4 groups (3 intervention groups and 1 control group). The preoperative intervention consisted of a home-based exercise program, while the postoperative exercise program comprised a supervised group exercise program involving resistance and high-intensity interval cardiorespiratory exercise 2 hours weekly for 12 weeks combined with individual counseling. The study endpoints were inclusion rate, adherence, and number of adverse events. Results Forty patients (of 124 screened; 32%) were included and randomized into the 4 groups. The postoperative exercise was completed by 73% of the patients randomized to this intervention. No adverse events were observed, indicating that the early postoperative exercise program is safe. The preoperative home-based exercise program was not feasible due to interfering diagnostic procedures and fast-track surgery that left only 1 to 2 weeks between diagnosis and surgery. Conclusion The early postoperative exercise program for patients with NSCLC was safe and feasible, but in a fast-track set up, a preoperative home-based exercise program was not feasible for this population.

POSITIVE study: physical exercise program in non-operable lung cancer patients undergoing palliative treatment

Background

Patients with advanced stage non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC) often experience multidimensional impairments, affecting quality of life during their course of disease. In lung cancer patients with operable disease, several studies have shown that exercise has a positive impact on quality of life and physical functioning. There is limited evidence regarding efficacy for advanced lung cancer patients undergoing palliative treatment. Therefore, the POSITIVE study aims to evaluate the benefit of a 24-week exercise intervention during palliative treatment in a randomized controlled setting.

Methods/design

The POSITIVE study is a randomized, controlled trial investigating the effects of a 24-week exercise intervention during palliative treatment on quality of life, physical performance and immune function in advanced, non-operable lung cancer patients. 250 patients will be recruited in the Clinic for Thoracic Diseases in Heidelberg, enrolment begun in November 2013. Main inclusion criterion is histologically confirmed NSCLC (stage IIIa, IIIb, IV) or SCLC (Limited Disease-SCLC, Extensive Disease-SCLC) not amenable to surgery. Patients are randomized into two groups. Both groups receive weekly care management phone calls (CMPCs) with the goal to assess symptoms and side effects. Additionally, one group receives a combined resistance and endurance training (3x/week). Primary endpoints are quality of life assessed by the Functional Assessment of Cancer Therapy for patients with lung cancer (FACT-L, subcategory Physical Well-Being) and General Fatigue measured by the Multidimensional Fatigue Inventory (MFI-20). Secondary endpoints are physical performance (maximal voluntary isometric contraction, 6-min walk distance), psychosocial (depression and anxiety) and immunological parameters and overall survival.

Discussion

The aim of the POSITIVE trial is the evaluation of effects of a 24-week structured and guided exercise intervention during palliative treatment stages. Analysis of various outcomes (such as quality of life, physical performance, self-efficacy, psychosocial and immunological parameters) will contribute to a better understanding of the potential of exercise in advanced lung cancer patients. In contrast to other studies with advanced oncological patients the POSITIVE trial provides weekly phone calls to support patients both in the intervention and control group and to segregate the impact of physical activity on quality of life.

Trial registration

ClinicalTrials.gov NCT02055508 (Date: December 12, 2013)

Exercise and Prostate Cancer: Evidence and Proposed Mechanisms for Disease Modification

Exercise has many potential benefits in relation to cancer. Apart from primary prevention, these include improvement of nonspecific cancer-related symptoms, amelioration of symptoms and cardiovascular risk factors related to cancer treatment, and improvements in various quality-of-life-related factors. Increasing evidence also points toward improved cancer-free and overall survival in cancer patients who undertake regular exercise, findings which should encourage further research in this area. Obesity is known to be associated with a proinflammatory, prothrombotic humoral milieu, which may promote aggressiveness in prostate cancer through interactions with NK-cell-mediated killing of circulating tumor cells, through platelet-circulating tumor cell interactions, and through alterations in adipokine and myokine profile among others. Physical activity reduces levels of systemic inflammatory mediators and so exercise may represent an accessible and cost-effective means of ameliorating the proinflammatory effects of obesity in cancer patients. This review outlines the evidence for the benefits of exercise in these patients, focusing on prostate cancer, and delineates current theories of the underlying biological mechanisms. Cancer Epidemiol Biomarkers Prev; 25(9); 1281-8. ©2016 AACR.

Feasibility and benefits of group-based exercise in residential aged care adults: a pilot study for the GrACE programme

The objective of the study was to examine the feasibility and benefits of a group resistance training exercise programme for improving muscle function in institutionalised older adults. A feasibility and acceptability study was designed for a residential aged care (RAC) facility, based on the Gold Coast, Australia. Thirty-seven adults, mean age 86.8 ± 6.1 years (30 females) living in a RAC facility. Participants were allocated into an exercise (n = 20) or control (n = 17) group. The exercise group, the Group Aged Care Exercise (GrACE) programme, performed 12 weeks of twice weekly resistance exercises. Feasibility was measured via recruitment rate, measurement (physiological and surveys) completion rate, loss-to-follow-up, exercise session adherence, adverse events, and ratings of burden and acceptability. Muscle function was assessed using gait speed, sit-to-stand and handgrip strength assessments. All intervention participants completed pre- and post-assessments, and the exercise intervention, with 85% (n = 17) of the group attending ≥ 18 of the 24 sessions and 15% (n = 3) attending all sessions. Acceptability was 100% with exercise participants, and staff who had been involved with the programme strongly agreed that the participants "Benefited from the programme." There were no adverse events reported by any participants during the exercise sessions. When compared to the control group, the exercise group experienced significant improvements in gait speed (F(4.078) = 8.265, p = 0.007), sit to stand performance (F(3.24) = 11.033, p = 0.002) and handgrip strength (F(3.697) = 26.359, p < 0.001). Resistance training via the GrACE programme is feasible, safe and significantly improves gait speed, sit-to-stand performance and handgrip strength in RAC adults.

Exercise Training for Patients Pre- and Postsurgically Treated for Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis

BACKGROUND

This meta-analysis examined the effects of exercise training on length of hospital stay, postoperative complications, exercise capacity, 6-minute walking distance (6MWD), and health-related quality of life (HRQoL) in patients following resection of non-small cell lung cancer (NSCLC).

METHODS

This review searched PubMed, EMBASE, and the Cochrane Collaboration data base up to August 16, 2015. It includes 15 studies comparing exercise endurance and quality of life before versus after exercise training in patients undergoing lung resection for NSCLC.

RESULTS

This review identified 15 studies, 8 of which are randomized controlled trials including 350 patients. Preoperative exercise training shortened length of hospital stay; mean difference (MD): -4.98 days (95% CI = -6.22 to -3.74, P < .00001) and also decreased postoperative complications for which the odds ratio was 0.33 (95% CI = 0.15 to 0.74, P = .007). Four weeks of preoperative exercise training improved exercise capacity; 6MWD was increased to 39.95 m (95% CI = 5.31 to 74.6, P = .02) .While postoperative exercise training can also effectively improve exercise capacity, it required a longer training period; 6MWD was increased to 62.83 m (95% CI = 57.94 to 67.72) after 12 weeks of training ( P < .00001). For HRQoL, on the EORTC-QLQ-30, there were no differences in patients' global health after exercise, but dyspnea score was decreased -14.31 points (95% CI = -20.03 to -8.58, P < .00001). On the SF-36 score, physical health was better after exercise training (MD = 3 points, 95% CI = 0.81 to 5.2, P = .007) while there was no difference with regard to mental health. The I² statistics of all statistically pooled data were lower than 30%. There was a low amount of heterogeneity among these studies.

CONCLUSIONS

Evidence from this review suggests that preoperative exercise training may shorten length of hospital stay, decrease postoperative complications and increase 6MWD. Postoperative exercise training can also effectively improve both the 6MWD and quality of life in surgical patients with NSCLC, but requiring a longer training period.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Cardiometabolic Health Among Cancer Survivors: A 13-Week Pilot Study of a Combined Aerobic and Resistance Training Program

PURPOSE/OBJECTIVES

To explore the feasibility of combined aerobic and resistance training (CART) as a safe method of improving cardiometabolic health among cancer survivors.
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DESIGN

Descriptive and longitudinal pilot study for exercise intervention.
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SETTING

University campus in Los Angeles, California.
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SAMPLE

A multiethnic population of cancer survivors (N = 11) was recruited by convenience sampling and physician referral. 
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METHODS

Consenting participants were prescribed CART for one hour per day, three days per week for 13 weeks.
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MAIN RESEARCH VARIABLES

Components of cardiometabolic health were measured, including resting heart rate (HRrest), blood pressure, body mass index, waist circumference, body fat percentage, and android fat percentage at baseline and after 13 weeks of training. Fasting blood glucose, insulin, adiponectin, leptin, tumor necrosis factor alpha, and C-reactive protein (CRP) also were assessed at baseline and after 13 weeks of training.
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FINDINGS

More than half of the participants reported living with at least two other chronic diseases or conditions in addition to a cancer diagnosis. Five of six African American and Hispanic participants reported the presence of at least two risk factors for metabolic syndrome, compared to one of five Caucasian participants. After 13 weeks of training, participants experienced an average decrease in waist circumference. Decrease in waist circumference was associated with a decrease in CRP. A relationship also was suggested between number of exercise sessions attended and improvement in HRrest. 
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CONCLUSIONS

A CART intervention among cancer survivors should continue to be explored in a larger sample to establish efficacy and effectiveness at improving cardiometabolic health. Because of the higher risk of comorbidity among cancer survivors in comparison to cancer-free adults, improving cardiometabolic health is as important as monitoring cancer recurrence. A need exists for increased attention to the post-treatment cardiometabolic health of cancer survivors and also for examining potential cardiometabolic health disparities among non-Caucasian cancer survivors.
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IMPLICATIONS FOR NURSING

CART may be a plausible alternative to reduce the risk of metabolic syndrome and improve cardiometabolic health among cancer survivors. Additional studies that continue to explore the efficacy and effectiveness of CART may provide more information to help nurses and physicians determine whether the cancer survivorship care plan should include an exercise-based alternative to intervene on cardiometabolic health.

Longitudinal study on the impact of physical activity on the symptoms of lung cancer survivors

PURPOSE

To examine the effect of physical activity on the physical and psychosocial symptoms of lung cancer survivors.

METHODS

A longitudinal design was used in this study. Participants were recruited from the chest and surgical departments of medical centers in Taiwan. The instruments used were the Godin Leisure-Time Exercise Questionnaire and the Taiwanese version of the M.D. Anderson Symptom Inventory.

RESULTS

In total, 185 survivors were followed up for 6 months (response rate 66%). Disturbed sleep was the most prevalent symptom in the participants. A generalized estimating equation (GEE) method was employed to analyze the relationships among intensity of physical activity, symptom severity, and symptom interference in the daily life of the participants. Regarding symptom severity, significant differences were observed in fatigue, drowsiness, and disturbed sleep between the participants who engaged in moderate physical activity and those who did not engage in any physical activity. Regarding symptom interference, the participants who engaged in light physical activity experienced a significantly lower level of symptom interference than did those with a sedentary lifestyle.

CONCLUSION

This is the first study to explore the role of physical activity in alleviating symptoms in lung cancer survivors by using the GEE method. The results suggest that physical activity plays an essential role in alleviating the physical and psychological symptoms of lung cancer survivors.

Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is an important therapeutic intervention that should no longer be considered suitable only for patients with chronic obstructive pulmonary disease (COPD). A strong rationale exists for providing PR to persons with a broad range of respiratory disorders other than COPD. Evidence shows that PR for these patients is feasible, safe and effective. A disease-relevant approach should be undertaken, based on individual patients' needs. Further research is needed to better understand the optimal program content, duration and outcomes measures, to enable diverse patients to achieve maximal benefits of PR.

Impact of resistance training in cancer survivors: a meta-analysis

PURPOSE

Current evidence suggests many health benefits from physical activity during and after cancer treatment. However, the optimal exercise program for cancer survivors has not yet been established. The purpose of this meta-analysis was to summarize evidence for the efficacy of resistance training (RT) interventions to improve muscle strength and body composition among adult cancer survivors. We also investigate potential dose-response relationships between intensity, duration, and frequency of RT and assessed outcomes.

METHODS

A systematic literature review of the Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE literature databases was undertaken. Studies were included if they were randomized controlled trials (RCT) comparing RT with an exercise or nonexercise control group in cancer survivors during and after treatment. Thirteen articles from 11 RCT met our inclusion criteria. We performed a random-effects meta-analysis to determine weighted mean differences (WMD) with 95% confidence intervals using the Cochrane Review Manager 5.0.25. A random-effects metaregression model was performed to examine dose-response relationships between RT variables and assessed outcomes.

RESULTS

Quantitative evidence shows a large effect of RT on lower-limb and upper-limb muscle strength (WMD: +14.57 kg, P = 0.0005 and +6.90 kg, P < 0.00001, respectively) and moderate effects on lean body mass and percentage of body fat (WMD: +1.07 kg, P < 0.0001 and -2.08%, P = 0.003, respectively). A small positive effect of RT was noted on Functional Assessment of Cancer Therapy-Fatigue (P = 0.05). Upper-limb muscle strength and percentage of body fat improved to a greater extent when RT interventions were of low to moderate intensity (≤ 75% one-repetition maximum, P = 0.042).

CONCLUSIONS

RT was shown to be associated with clinically important positive effects on muscular function and body composition in patients during treatment or in long-term follow-up.

Psychometric properties of the Late-Life Function and Disability Instrument: a systematic review

Background

The choice of measure for use as a primary outcome in geriatric research is contingent upon the construct of interest and evidence for its psychometric properties. The Late-Life Function and Disability Instrument (LLFDI) has been widely used to assess functional limitations and disability in studies with older adults. The primary aim of this systematic review was to evaluate the current available evidence for the psychometric properties of the LLFDI.

Methods

Published studies of any design reporting results based on administration of the original version of the LLFDI in community-dwelling older adults were identified after searches of 9 electronic databases. Data related to construct validity (convergent/divergent and known-groups validity), test-retest reliability and sensitivity to change were extracted. Effect sizes were calculated for within-group changes and summarized graphically.

Results

Seventy-one studies including 17,301 older adults met inclusion criteria. Data supporting the convergent/divergent and known-groups validity for both the Function and Disability components were extracted from 30 and 18 studies, respectively. High test-retest reliability was found for the Function component, while results for the Disability component were more variable. Sensitivity to change of the LLFDI was confirmed based on findings from 25 studies. The basic lower extremity subscale and overall summary score of the Function component and limitation dimension of the Disability component were associated with the strongest relative effect sizes.

Conclusions

There is extensive evidence to support the construct validity and sensitivity to change of the LLFDI among various clinical populations of community-dwelling older adults. Further work is needed on predictive validity and values for clinically important change. Findings from this review can be used to guide the selection of the most appropriate LLFDI subscale for use an outcome measure in geriatric research and practice.

The effect of radical treatment and rehabilitation on muscle mass and strength: a randomized trial in stages I-III lung cancer patients

OBJECTIVES

Little is known about the impact of an oncological treatment on muscle mass and strength in patients with lung cancer and the impact of a subsequent rehabilitation program. This study investigates the effect of radical treatment and post-treatment pulmonary rehabilitation on muscle mass and strength in patients with lung cancer and the relationship between muscle mass and strength.

METHODS

Lung cancer patients, candidate for radical treatment, were randomly (2:1) allocated after radical treatment to either standard follow up (CON) or a 12-week rehabilitation training program (RT). Muscle mass was estimated by bioelectric impedance and CT-scan. Muscle strength was estimated by measuring quadriceps force (QF) with a hand held dynamometer. All variables were measured before (M1) and after radical treatment (M2), and at the earliest 12 weeks after randomization (M3). Data are presented as means with standard deviation.

RESULTS

45 lung cancer patients (age: 65 years (9)) participated in the study. At M2, both muscle cross sectional area (MCSA) and QF were significantly decreased (p<0.05). 28 patients were randomized. 13/18 RT and 9/10 CON patients ended the trial. At M3, RT-patients improved significantly their MCSA compared to CON-patients (ΔMCSA: 6 cm(2) (6) (p=0.003) vs. 1cm(2) (11) (p=0.8)).

CONCLUSION

Muscle mass and strength: (1) are decreased at presentation in a substantial part of lung cancer patients; (2) are significantly negatively affected by radical treatment and (3) completely recover after a 12 week structured rehabilitation program, whereas a further decline was observed in CON-patients.

The assessment and impact of sarcopenia in lung cancer: a systematic literature review

OBJECTIVES

There is growing awareness of the relationship between sarcopenia (loss of muscle mass and function), and outcomes in cancer, making it a potential target for future therapies. In order to inform future research and practice, we undertook a systematic review of factors associated with loss of muscle mass, and the relationship between muscle function and muscle mass in lung cancer, a common condition associated with poor outcomes.

DESIGN

We conducted a computerised systematic literature search on five databases. Studies were included if they explored muscle mass as an outcome measure in patients with lung cancer, and were published in English.

SETTING

Secondary care.

PARTICIPANTS

Patients with lung cancer.

PRIMARY OUTCOME

Factors associated with loss of muscle mass and muscle function, or sarcopenia, and the clinical impact thereof in patients with lung cancer.

RESULTS

We reviewed 5726 citations, and 35 articles were selected for analysis. Sarcopenia, as defined by reduced muscle mass alone, was found to be very prevalent in patients with lung cancer, regardless of body mass index, and where present was associated with poorer functional status and overall survival. There were diverse studies exploring molecular and metabolic factors in the development of loss of muscle mass; however, the precise mechanisms that contribute to sarcopenia and cachexia remain uncertain. The effect of nutritional supplements and ATP infusions on muscle mass showed conflicting results. There are very limited data on the correlation between degree of sarcopenia and muscle function, which has a non-linear relationship in older non-cancer populations.

CONCLUSIONS

Loss of muscle mass is a significant contributor to morbidity in patients with lung cancer. Loss of muscle mass and function may predate clinically overt cachexia, underlining the importance of evaluating sarcopenia, rather than weight loss alone. Understanding this relationship and its associated factors will provide opportunities for focused intervention to improve clinical outcomes.

Changes in motivational outcomes after a supervised resistance exercise training intervention in lung cancer survivors

BACKGROUND

Short-term supervised exercise interventions improve health-related fitness in lung cancer survivors; however, sustained exercise is required to maintain the health benefits. The impact of exercise interventions on motivational outcomes may be important for long-term exercise adoption.

OBJECTIVE

The objective of this study was to examine the effects of a 10-week supervised progressive resistance exercise training program on lung cancer survivors' motivational outcomes based on the Theory of Planned Behavior (TPB).

METHODS

Posttreatment lung cancer survivors were recruited to undergo a 10-week supervised resistance exercise training intervention. The 2-component model of the TPB was measured at baseline and after intervention.

RESULTS

Fifteen participants completed assessments of TPB measures. Significant increases in self-efficacy (P = .022) and perceived controllability (P = .032) and a nonsignificant increase in affective attitude (P = .090) were observed after intervention. Intention was significantly lower at postintervention (P = .044). Significant correlates of postintervention intention were instrumental attitude (P = .001), self-efficacy (P = .004), perceived behavioral control (P = .009), and affective attitude (P = .044). At postintervention, self-efficacy was significantly correlated with planning (P < .046).

CONCLUSIONS

Short-term supervised resistance exercise training may improve some motivational outcomes for lung cancer survivors. Intentions appeared to be weakened after the intervention, but there are methodological explanations for this finding.

IMPLICATIONS FOR PRACTICE

Participation in short-term supervised resistance exercise may be an effective method to improve some motivational factors related to exercise in lung cancer survivors. More research is needed to examine the long-term effects of supervised resistance exercise on motivational outcomes in lung cancer survivors. Strategies to maintain motivational changes that occur following a supervised resistance exercise intervention need to be investigated.

Feasibility and efficacy of a 12-week supervised exercise intervention for colorectal cancer survivors

Exercise training improves health-related physical fitness and patient-reported outcomes in cancer survivors, but few interventions have targeted colorectal cancer (CRC) survivors. This investigation aimed to determine the feasibility and efficacy of a 12-week supervised exercise training program for CRC survivors. Feasibility was assessed by tracking participant recruitment, loss to follow-up, assessment completion rates, participant evaluation, and adherence to the intervention. Efficacy was determined by changes in health-related physical fitness. Over a 1-year period, 72 of 351 (21%) CRC survivors screened were eligible for the study and 29 of the 72 (40%) were enrolled. Two participants were lost to follow-up (7%) and the completion rate for all study assessments was ≥93%. Mean adherence to the exercise intervention was 91% (standard deviation = ±18%), with a median of 98%. Participants rated the intervention positively (all items ≥ 6.6/7) and burden of testing low (all tests ≤ 2.4/7). Compared with baseline, CRC survivors showed improvements in peak oxygen uptake (mean change (MC) = +0.24 L·min(-1), p < 0.001), upper (MC = +7.0 kg, p < 0.001) and lower (MC = +26.5 kg, p < 0.001) body strength, waist circumference (MC = -2.1 cm, p = 0.005), sum of skinfolds (MC = -7.9 mm, p = 0.006), and trunk forward flexion (MC = +2.5 cm, p = 0.019). Exercise training was found to be feasible and improved many aspects of health-related physical fitness in CRC survivors that may be associated with improved quality of life and survival in these individuals.

"EXHALE": exercise as a strategy for rehabilitation in advanced stage lung cancer patients: a randomized clinical trial comparing the effects of 12 weeks supervised exercise intervention versus usual care for advanced stage lung cancer patients

Background

Lung cancer is the leading cause of cancer death in North America and Western Europe. Patients with lung cancer in general have reduced physical capacity, functional capacity, poor quality of life and increased levels of anxiety and depression. Intervention studies indicate that physical training can address these issues. However, there is a lack of decisive evidence regarding the effect of physical exercise in patients with advanced lung cancer. The aim of this study is to evaluate the effects of a twelve weeks, twice weekly program consisting of: supervised, structured training in a group of advanced lung cancer patients (cardiovascular and strength training, relaxation).

Methods/Design

A randomized controlled trial will test the effects of the exercise intervention in 216 patients with advanced lung cancer (non-small cell lung cancer (NSCLC) stage IIIb - IV and small cell lung cancer (SCLC) extensive disease (ED)). Primary outcome is maximal oxygen uptake (VO₂peak). Secondary outcomes are muscle strength (1RM), functional capacity (6MWD), lung capacity (Fev1) and patient reported outcome (including anxiety, depression (HADS) and quality of life (HRQOL)).

Discussion

The present randomized controlled study will provide data on the effectiveness of a supervised exercise intervention in patients receiving systemic therapy for advanced lung cancer. It is hoped that the intervention can improve physical capacity and functional level, during rehabilitation of cancer patients with complex symptom burden and help them to maintain independent function for as long as possible.

Trial registration

http://ClinicalTrials.gov, NCT01881906

Lung cancer: what are the links with oxidative stress, physical activity and nutrition

Oxidative stress appears to play an essential role as a secondary messenger in the normal regulation of a variety of physiological processes, such as apoptosis, survival, and proliferative signaling pathways. Oxidative stress also plays important roles in the pathogenesis of many diseases, including aging, degenerative disease, and cancer. Among cancers, lung cancer is the leading cause of cancer in the Western world. Lung cancer is the commonest fatal cancer whose risk is dependent on the number of cigarettes smoked per day as well as the number of years smoking, some components of cigarette smoke inducing oxidative stress by transmitting or generating oxidative stress. It can be subdivided into two broad categories, small cell lung cancer and non-small-cell lung cancer, the latter is the most common type. Distinct measures of primary and secondary prevention have been investigated to reduce the risk of morbidity and mortality caused by lung cancer. Among them, it seems that physical activity and nutrition have some beneficial effects. However, physical activity can have different influences on carcinogenesis, depending on energy supply, strength and frequency of exercise loads as well as the degree of exercise-mediated oxidative stress. Micronutrient supplementation seems to have a positive impact in lung surgery, particularly as an antioxidant, even if the role of micronutrients in lung cancer remains controversial. The purpose of this review is to examine lung cancer in relation to oxidative stress, physical activity, and nutrition.

The effect of progressive resistance training on lean body mass in post-treatment cancer patients - a systematic review

Loss of lean body mass is a common problem in many post-treatment cancer patients and may negatively affect physical capacity in terms of maximal muscle strength and functional performance. The purpose of this study was to systematically review the scientific evidence on the effect of progressive resistance training on lean body mass in post-treatment cancer patients. A comprehensive literature search was conducted and ultimately 12 studies were included. Methodological quality of the included studies was evaluated using the PEDro scale and the effect of progressive resistance training was reported as the range of mean changes among RCTs and non-RCTs. Six RCTs and six non-RCTs were included in the study. In the RCTs the change in lean body mass in the progressive resistance training groups relative to control groups ranged from -0.4% to 3.9%, and in four of six trials the training effect was significantly larger than the change in the control groups. In the six non-RCTs, the mean change in lean body mass over time ranged from -0.01 to 11.8% which was significant in two of the trials. The included studies reported no or very limited adverse events following progressive resistance training. Based on 12 heterogenic studies there is moderate evidence supporting a positive effect of progressive resistance training on lean body mass in post-treatment cancer patients.

CanWell: meeting the psychosocial and exercise needs of cancer survivors by translating evidence into practice

BACKGROUND

As more evidence emerges to support the incorporation of exercise for cancer survivors to positively affect physical, emotional, and social health, it is imperative that health-care providers use current knowledge to develop evidence-based exercise programs for these patients. Our purpose is to describe the development, implementation, and effectiveness of the CanWell program, an evidence-based, community and partnership-based, exercise, and education program for all people with cancer.

METHODS

Exercise and cancer research was reviewed, summarized, and utilized to develop CanWell. A 12-week, supervised, community-based, exercise, and education program established in collaboration between an acute care hospital, academic center, and a not-for-profit YMCA facility. CanWell participants completed physical and health-related quality of life measures prior to initiating the program and repeated them at 6 and 12 weeks.

RESULTS

Following the exercise program, participants reported significant improvements in health-related quality of life, recorded distance ambulated during a 6-min walk test, and total minutes on a treadmill recorded using the standardized exponential exercise protocol treadmill test. Furthermore, no increases in disease burden were identified using the Edmonton Symptom Assessment System. In addition, no exercise related injuries were reported by CanWell participants.

CONCLUSIONS

As the body of evidence supporting the incorporation of exercise as a standard of care for cancer survivors, it is imperative that care providers use current knowledge to provide opportunities for their patients to exercise in effective exercise programs. CanWell is an example on how collaboration between hospital, university, and community institutions can be used to move research into practice and meet the needs of cancer survivors.

Exercise and nutrition interventions in advanced lung cancer: a systematic review

In this systematic review, we sought to evaluate the effect of physical activity or nutrition interventions (or both) in adults with advanced non-small-cell lung cancer (nsclc).

METHODS

A systematic search for relevant clinical trials was conducted in 6 electronic databases, by hand searching, and by contacting key investigators. No limits were placed on study language. Information about recruitment rates, protocol adherence, patient-reported and clinical outcome measures, and study conclusions was extracted. Methodologic quality and risk of bias in each study was assessed using validated tools.

MAIN RESULTS

Six papers detailing five studies involving 203 participants met the inclusion criteria. Two of the studies were single-cohort physical activity studies (54 participants), and three were controlled nutrition studies (149 participants). All were conducted in an outpatient setting. None of the included studies combined physical activity with nutrition interventions.

CONCLUSIONS

Our systematic review suggests that exercise and nutrition interventions are not harmful and may have beneficial effects on unintentional weight loss, physical strength, and functional performance in patients with advanced nsclc. However, the observed improvements must be interpreted with caution, because findings were not consistent across the included studies. Moreover, the included studies were small and at significant risk of bias. More research is required to ascertain the optimal physical activity and nutrition interventions in advanced inoperable nsclc. Specifically, the potential benefits of combining physical activity with nutrition counselling have yet to be adequately explored in this population.

Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer

BACKGROUND

Decreased exercise capacity and impairments in health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with cancers such as prostate and breast cancer. A programme of exercise training for people following lung resection for NSCLC may confer important gains in these outcomes. To date, evidence of its efficacy in this population is unclear.

OBJECTIVES

The primary aim of this study was to determine the effects of exercise training on exercise capacity in people following lung resection(with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects on other outcomes such as HRQoL,lung function (forced expiratory volume in one second (FEV1)), peripheral muscle force, dyspnoea and fatigue as well as feelings of anxiety and depression.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2 of 12), MEDLINE(via PubMed) (1966 to February 2013), EMBASE (via Ovid) (1974 to February 2013), SciELO (The Scientific Electronic Library Online) (1978 to February 2013) as well as PEDro (Physiotherapy Evidence Database) (1980 to February 2013).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which study participants withNSCLC, who had recently undergone lung resection,were allocated to receive either exercise training or no exercise training.

DATA COLLECTION AND ANALYSIS

Two review authors screened the studies and identified those for inclusion. Meta-analyses were performed using post-intervention datafor those studies in which no differences were reported between the exercise and control group either: (i) prior to lung resection, or(ii) following lung resection but prior to the commencement of the intervention period. Although two studies reported measures of quadriceps force on completion of the intervention period, meta-analysis was not performed on this outcome as one of the two studies demonstrated significant differences between the exercise and control group at baseline (following lung resection).

MAIN RESULTS

We identified three RCTs involving 178 participants. Three out of the seven domains included in the Cochrane Collaboration' s 'seven evidence-based domains' table were identical in their assessment across the three studies (random sequence generation, allocation concealment and blinding of participants and personnel). The domain which had the greatest variation was 'blinding of outcome assessment' where one study was rated at low risk of bias, one at unclear risk of bias and the remaining one at high risk of bias. On completion of the intervention period, exercise capacity as measured by the six-minute walk distance was statistically greater in the intervention group compared to the control group (mean difference (MD) 50.4 m; 95% confidence interval (CI) 15.4 to 85.2 m). No between-group differences were observed in HRQoL (standardised mean difference (SMD) 0.17; 95% CI -0.16 to 0.49) or FEV1 (MD-0.13 L; 95% CI -0.36 to 0.11 L). Differences in quadriceps force were not demonstrated on completion of the intervention period.

AUTHORS' CONCLUSIONS

The evidence summarised in our review suggests that exercise training may potentially increase the exercise capacity of people following lung resection for NSCLC. The findings of our systematic review should be interpreted with caution due to disparities between the studies, methodological limitations, some significant risks of bias and small sample sizes. This systematic review emphasises the need for larger RCTs..

Feasibility and efficacy of progressive resistance training and dietary supplements in radiotherapy treated head and neck cancer patients--the DAHANCA 25A study

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) often lose a considerable amount of muscle mass following the disease and treatment. This is an independent mortality predictor, lowering muscle strength and functional performance. Progressive resistance training (PRT) increases muscle mass among healthy individuals and groups of cancer patients, but it has not been investigated in HNSCC patients. Furthermore, studies in healthy subjects show an additive effect of protein and creatine supplementation following PRT.

OBJECTIVES

Firstly, to investigate the feasibility of 12 weeks of PRT ± protein and creatine supplementation among HNSCC patients. Secondly, to investigate group changes over time and group differences regarding lean body mass (LBM), muscle strength and functional performance following PRT ± dietary supplementation.

MATERIAL AND METHODS

Thirty patients were randomized into two groups: a PROCR group undergoing a seven-day pre-trial creatine loading protocol followed by 12 weeks of PRT with creatine and protein supplementation and a PLA group undergoing a seven-day pre-trial placebo ingestion protocol followed by an identical PRT protocol with placebo supplementation. Before the pre-trial and pre- and post-PRT evaluation of LBM, maximal isometric and isokinetic muscle strength and functional performance were performed.

RESULTS

Seventy percent of the patients completed the intervention and the PRT adherence rate was 97%. No significant group differences were found in any endpoints. From pre- to post-PRT, LBM increased significantly in the PROCR group by 2.6 ± 2.2 kg (p < 0.0001) and increased in the PLA group (1.3 ± 1.1 kg, p = 0.07). Maximal isometric and isokinetic muscle strength as well as functional performance increased significantly in both groups.

CONCLUSION

PRT is feasible in radiotherapy treated HNSCC patients. Following PRT, lean body mass, muscle strength and functional performance increased significantly in both groups (LBM only borderline significant in PLA group) with no significant group difference in any endpoint.

Effects of systematic rehabilitation programs on quality of life in patients undergoing lung resection

The aim of this study was to investigate the effects of systematic rehabilitation programs on the quality of life (QOL) in patients undergoing lung resection of malignant lung lesions. In this prospective population-based cohort study, QOL in patients prior to, as well as 3 and 6 months after surgery, was investigated. Using a single-group design, 48 patients (7 females and 41 males) with suspected operable lung cancer were included in this study. The demographic characteristics and the clinical history of the patients were recorded. QOL [assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 3.0 (EORTC QLQ-C30)] was evaluated at baseline (immediately before), and 3 and 6 months after surgical resection. The systematic rehabilitation program, including breathing control, breathing exercises, relaxation training, upper and lower extremity exercises, mobilization and additional incorporating physiotherapy programs, was designed to meet each patient's individual needs. The χ² and Fisher's tests showed no statistically significant difference in the two groups in terms of age, gender, behavior, clinical stage, adjuvant therapy and Karnofsky scores. QOL analysis of baseline was homogeneous between the experimental and control groups. Three months after the rehabilitation process, the experimental group demonstrated an increase in the general QOL functional scales and a decrease of symptom scales compared to the control group. These changes were statistically significant in the functional scales of global health (P<0.01), physical function (P<0.01), role function (P<0.01), emotional function (P<0.05), symptom scales of fatigue (P<0.01) and appetite loss (P=0.001). Six months after the intervention, the outcome was the same as 3 months after the intervention in functional scale domains. However, in the symptom scales, the symptoms in the experimental group were improved compared to the control group. The domains had been significant in the scales of fatigue (P<0.001), dyspnea (P<0.001), pain (P<0.001), insomnia (P<0.001), appetite loss (P<0.001) and constipation (P<0.001). Therefore, the two groups demonstrated a statistically significant difference in 10 domains. In addition, the experimental group demonstrated a significant recovery. In conclusion, systematic rehabilitation programs may be beneficial for lung cancer patients by reducing respiratory symptoms, pain, and improving health-related QOL. Consequently, the findings of this study suggest that systematic rehabilitation programs, prepared by taking into consideration the individual requirements of lung cancer patients, should be incorporated into lung cancer treatment.