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McIsaac DI, Neilipovitz N, Bryson GL, Gagne S, Huang A, Lalu M, Lavallée LT, Moloo H, Power B, Scheede-Bergdahl C, van Walraven C, McCartney CJL, Taljaard M, Hladkowicz E. Home-based exercise prehabilitation to improve disease-free survival and return to intended oncologic treatment after cancer surgery in older adults with frailty: a secondary analysis of a randomized trial. Can J Anaesth 2024; 71:1525-1534. [PMID: 39237725 DOI: 10.1007/s12630-024-02835-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/02/2024] [Accepted: 05/13/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Improving survivorship for patients with cancer and frailty is a priority. We aimed to estimate whether exercise prehabilitation improves disease-free survival and return to intended oncologic treatment for older adults with frailty undergoing cancer surgery. METHODS We conducted a secondary analysis of the oncologic outcomes of a randomized trial of patients ≥ 60 yr of age with frailty undergoing elective cancer surgery. Participants were randomized either to a supported, home-based exercise program plus nutritional guidance or to usual care. Outcomes for this analysis were one-year disease-free survival and return to intended oncologic treatment. We estimated complier average causal effects to account for intervention adherence. RESULTS We randomized 204 participants (102 per arm); 182 were included in our modified intention-to-treat population and, of these participants, 171/182 (94%) had complete one-year follow up. In the prehabilitation group, 18/94 (11%) died or experienced cancer recurrence, compared with 19/88 (11%) in the control group (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.66 to 2.34; P = 0.49). Return to intended oncologic treatment occurred in 24/94 (29%) patients the prehabilitation group vs 20/88 (23%) in the usual care group (HR, 1.53; 95% CI, 0.84 to 2.77; P = 0.16). Complier average causal effects directionally diverged for disease-free survival (HR, 0.91; 95% CI, 0.20 to 4.08; P = 0.90) and increased the point estimate for return to treatment (HR, 2.04; 95% CI, 0.52 to 7.97; P = 0.30), but in both cases the CIs included 1. CONCLUSIONS Randomization to home-based exercise prehabilitation did not lead to significantly better disease-free survival or earlier return to intended oncologic treatment in older adults with frailty undergoing cancer surgery. Our results could inform future trials powered for more plausible effect sizes, especially for the return to intended oncologic treatment outcome. STUDY REGISTRATION ClinicalTrials.gov ( NCT02934230 ); first submitted 22 August 2016.
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Affiliation(s)
- Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada.
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
- Department of Anesthesiology, The Ottawa Hospital Civic Campus, Room B311, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, Canada.
| | - Nathaniel Neilipovitz
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregory L Bryson
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sylvain Gagne
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Allen Huang
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Geriatric Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Manoj Lalu
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luke T Lavallée
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Urology, Department of Surgery, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Barbara Power
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Geriatric Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montreal, QC, Canada
| | - Carl van Walraven
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Emily Hladkowicz
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Gagnat G, Hobeika C, Modzelewski R, Collet CS, Di Fiore F, Druesne L, Tuech JJ, Schwarz L. Evaluation of sarcopenia biomarkers in older patients undergoing major surgery for digestive cancer. SAXO prospective cohort study. Eur J Surg Oncol 2023; 49:285-292. [PMID: 36167704 DOI: 10.1016/j.ejso.2022.08.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/12/2022] [Accepted: 08/31/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The aim of the study was to prospectively evaluate different biomarkers to identify the most reliable for anticipating complications after major abdominal surgery for digestive cancer in older patients and compare their performance to the existing definition and screening algorithm of sarcopenia from EWGSOP. METHODS Ninety-five consecutive patients aged over 65 years who underwent elective surgery for digestive cancer were prospectively included in the SAXO study. Sarcopenia was defined according to EWGSOP criteria (four level from no sarcopenia to severe sarcopenia). Strength and physical performance were evaluated with the handgrip test (HGT) and gait speed test (GST), respectively. CT scan analysis was used to calculate the skeletal muscle index (SMI), intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Measures were adjusted to body mass index (BMI). Complication grading was performed using the Clavien‒Dindo classification. A doubly robust estimator with multivariable regression was used to limit bias. RESULTS Sixteen patients presented with sarcopenia. Adjusted to BMI, sarcopenic patients had an increased IMATBMI (0.35 vs. 0.22; p = 0.003) and increased VATBMI (7.85 vs. 6.13; p = 0.048). In multivariable analysis, IMAT was an independent risk factor for minor and severe complications (OR = 1.298; 95% CI [1.031: 1.635] p = 0.027), while an increased SAT area was a protective factor (OR = 0.982; 95% CI [0.969: 0.995] p = 0.007). Twenty-two patients were obese (BMI ≥30 kg/m2). While no association was observed between obesity and sarcopenia (according to EWGSOP definition), obese patients had increased IMATBMI (0.31 vs. 0.23; p = 0.010) and VATBMI (8.40 vs. 6.49; p = 0.019). The combination of SAT, VAT and IMAT performed well to anticipate severe complication (AUC = 0.759) while AUC of EWGSOP 2010 and 2019 algorithm were 0.660 and 0.519, respectively. DISCUSSION Non-invasive and imaging related measures of IMAT, SAT and VAT seems to be valuable tools to refine risk-assessment of older patients in surgery and specially to detect myosteatosis in obese ones.
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Affiliation(s)
- Guillaume Gagnat
- Normandie Univ, UNIROUEN, Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Christian Hobeika
- Department of Hepatobiliary and Liver Transplantation Surgery, AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France
| | | | - Celine Savoye Collet
- Normandie Univ, UNIROUEN, Quantif-LITIS EA, 4108, Rouen Cedex, France; Normandie Univ, UNIROUEN, Department of Radiology, Rouen University Hospital, Rouen, France
| | - Frederic Di Fiore
- Normandie Univ, UNIROUEN, Department of Digestive Oncology, Rouen University Hospital, Rouen, France; Normandie Univ, UNIROUEN, Inserm, 1245, IRON Group, Rouen Cedex, France
| | - Laurent Druesne
- Normandie Univ, UNIROUEN, Department of Geriatrics, Rouen University Hospital, Rouen, France
| | - Jean Jacques Tuech
- Normandie Univ, UNIROUEN, Department of Digestive Surgery, Rouen University Hospital, Rouen, France; Normandie Univ, UNIROUEN, Inserm, 1245, IRON Group, Rouen Cedex, France
| | - Lilian Schwarz
- Normandie Univ, UNIROUEN, Department of Digestive Surgery, Rouen University Hospital, Rouen, France; Normandie Univ, UNIROUEN, Inserm, 1245, IRON Group, Rouen Cedex, France.
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