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

Feasibility of a 12-Month Exercise Intervention in Postsurgical Colorectal Cancer Patients

Background

Extensive physical activity (PA; ≥18 MET∗h/week, MET metabolic equivalent of tasks hours) postcancer diagnosis has shown favorable effects on colorectal cancer disease-free survival. However, the feasibility of introducing this high volume of PA in this patient group is unclear. Therefore, the aim of the F-PROTECT study was to evaluate the feasibility of extensive and prolonged PA (≥18 MET∗h/week over 12 months) in colorectal cancer patients with the primary objectives to (1) recruit 50 patients within 12 months and (2) reach an attendance rate of ≥70%.

Methods

Single-armed, bicentric, prospective intervention study in colorectal cancer patients (≤80 years; UICC II/III Union for International Cancer Control) after histopathological confirmed R0-resection who were consecutively recruited from visceral surgery units of 10 clinics in Germany. Recruitment rates were calculated using screening logs. Intervention was a 12-month endurance-focused exercise program with supervised and home-based training. Attendance rates defined as ≥70% participation in training sessions were calculated by training diaries.

Results

Out of 521 patients who were screened for eligibility, 50 (23 female; 59 ± 10 years, UICC 44% II, 56% III; adjuvant chemotherapy 60%) were recruited within 15 months. Mean duration between surgery and first training was 103 ± 57 days. Training attendance rate was 64% (including 9 dropouts). Six (12%) participants reached ≥18 MET∗h/week in ≥70% of training sessions between 4-12 months. 28 adverse events (n = 9 serious) occurred, however, were not assessed as training related.

Conclusions

The present intervention involving a combination of supervised and home-based exercise training in postsurgical colorectal cancer patients was not feasible. Strategies specifically designed for this patient group must be developed and investigated to motivate long-term PA. Registration. The study was prospectively registered at clinicaltrials.gov (NCT01991847).

The Impact of Surgical Techniques in Patients with Rectal Cancer on Spine Mobility and Abdominal Muscle Strength-A Prospective Study

The aim of this non-randomized study was to evaluate the impact of spine joint mobility and chest mobility on inhalation and exhalation, and to assess the abdominal muscle strength in patients undergoing surgery for colorectal cancer with one of the following methods: anterior resection, laparoscopic anterior resection or abdominoperineal resection. In patients who were successively admitted to the Department of Surgical Oncology at the Oncology Center in Bydgoszcz, the impact of spine joint mobility, muscle strength and chest mobility on inhalation and exhalation wasassessed three times, i.e., at their admission and three and six months after surgery. The analysis included 72 patients (18 undergoing abdominoperineal resection, the APR group; 23 undergoing laparoscopic anterior resection, the LAR group; and 31 undergoing anterior resection, the AR group). The study groups did not differ in terms of age, weight, height, BMIor hospitalization time (p > 0.05). Three months after surgery, reductions in spine joint mobility regarding flexion, extension and lateral flexion, as well asreductions in the strength of the rectus abdominis and oblique muscles, were noted in all study groups (p < 0.05). In comparison between the groups, the lowest values suggesting the greatest reduction in the range of mobility were recorded in the APR group. Surgical treatment and postoperative management in colorectal cancer patients caused a reduction in spine mobility, abdominal muscle strength and chest mobility. The patients who experienced those changes most rapidly and intensively werethose undergoing abdominoperineal resection.

Exercise and colorectal cancer: prevention and molecular mechanisms

Exercise and physical activity have been shown to be strongly associated with a decreased incidence rate of various chronic diseases especially numerous human malignancies. A huge number of clinical trials and meta-analysis have demonstrated that exercise is significantly effective in lowering the risk of colorectal cancer. In addition, it is suggested as an effective therapeutic modality against this cancer type. Therefore, in this review, we will review comprehensibly the effects of exercise in preventing, treating, and alleviating the adverse effects of conventional therapeutic options in colorectal cancer. Moreover, the possible mechanisms underlying the positive effects of exercise and physical activity in colorectal cancer, including regulation of inflammation, apoptosis, growth factor axis, immunity, epigenetic, etc. will be also discussed.

Exercise is an effective post-treatment management program in colorectal cancer survivals

Exercise improves muscle strength, cardiorespiratory fitness, emotional distress, physical activity, fatigue, and sleep quality in colorectal patients undergoing chemotherapy

Targeting and modulating insulin-like growth factor (IGF) system, inflammation, apoptosis, immunity, epigenetic, Leptin and Ghrelin, and signaling pathways are major underlying mechanisms for preventive effects of exercise in colorectal cancer

Physical activity interventions for disease-related physical and mental health during and following treatment in people with non-advanced colorectal cancer

BACKGROUND

Colorectal cancer is the third most commonly diagnosed cancer worldwide. A diagnosis of colorectal cancer and subsequent treatment can adversely affect an individuals physical and mental health. Benefits of physical activity interventions in alleviating treatment side effects have been demonstrated in other cancer populations. Given that regular physical activity can decrease the risk of colorectal cancer, and cardiovascular fitness is a strong predictor of all-cause and cancer mortality risk, physical activity interventions may have a role to play in the colorectal cancer control continuum. Evidence of the efficacy of physical activity interventions in this population remains unclear.

OBJECTIVES

To assess the effectiveness and safety of physical activity interventions on the disease-related physical and mental health of individuals diagnosed with non-advanced colorectal cancer, staged as T1-4 N0-2 M0, treated surgically or with neoadjuvant or adjuvant therapy (i.e. chemotherapy, radiotherapy or chemoradiotherapy), or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), along with OVID MEDLINE, six other databases and four trial registries with no language or date restrictions. We screened reference lists of relevant publications and handsearched meeting abstracts and conference proceedings of relevant organisations for additional relevant studies. All searches were completed between 6 June and 14 June 2019.

SELECTION CRITERIA

We included randomised control trials (RCTs) and cluster-RCTs comparing physical activity interventions, to usual care or no physical activity intervention in adults with non-advanced colorectal cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, performed the data extraction, assessed the risk of bias and rated the quality of the studies using GRADE criteria. We pooled data for meta-analyses by length of follow-up, reported as mean differences (MDs) or standardised mean differences (SMDs) using random-effects wherever possible, or the fixed-effect model, where appropriate. If a meta-analysis was not possible, we synthesised studies narratively.

MAIN RESULTS

We identified 16 RCTs, involving 992 participants; 524 were allocated to a physical activity intervention group and 468 to a usual care control group. The mean age of participants ranged between 51 and 69 years. Ten studies included participants who had finished active treatment, two studies included participants who were receiving active treatment, two studies included both those receiving and finished active treatment. It was unclear whether participants were receiving or finished treatment in two studies. Type, setting and duration of physical activity intervention varied between trials. Three studies opted for supervised interventions, five for home-based self-directed interventions and seven studies opted for a combination of supervised and self-directed programmes. One study did not report the intervention setting. The most common intervention duration was 12 weeks (7 studies). Type of physical activity included walking, cycling, resistance exercise, yoga and core stabilisation exercise. Most of the uncertainty in judging study bias came from a lack of clarity around allocation concealment and blinding of outcome assessors. Blinding of participants and personnel was not possible. The quality of the evidence ranged from very low to moderate overall. We did not pool physical function results at immediate-term follow-up due to considerable variation in results and inconsistency of direction of effect. We are uncertain whether physical activity interventions improve physical function compared with usual care. We found no evidence of effect of physical activity interventions compared to usual care on disease-related mental health (anxiety: SMD -0.11, 95% confidence interval (CI) -0.40 to 0.18; 4 studies, 198 participants; I2 = 0%; and depression: SMD -0.21, 95% CI -0.50 to 0.08; 4 studies, 198 participants; I2 = 0%; moderate-quality evidence) at short- or medium-term follow-up. Seven studies reported on adverse events. We did not pool adverse events due to inconsistency in reporting and measurement. We found no evidence of serious adverse events in the intervention or usual care groups. Minor adverse events, such as neck, back and muscle pain were most commonly reported. No studies reported on overall survival or recurrence-free survival and no studies assessed outcomes at long-term follow-up We found evidence of positive effects of physical activity interventions on the aerobic fitness component of physical fitness (SMD 0.82, 95% CI 0.34 to 1.29; 7 studies, 295; I2 = 68%; low-quality evidence), cancer-related fatigue (MD 2.16, 95% CI 0.18 to 4.15; 6 studies, 230 participants; I2 = 18%; low-quality evidence) and health-related quality of life (SMD 0.36, 95% CI 0.10 to 0.62; 6 studies, 230 participants; I2 = 0%; moderate-quality evidence) at immediate-term follow-up. These positive effects were also observed at short-term follow-up but not medium-term follow-up. Only three studies reported medium-term follow-up for cancer-related fatigue and health-related quality of life.

AUTHORS' CONCLUSIONS

The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. We are uncertain whether physical activity interventions improve physical function. Physical activity interventions may have no effect on disease-related mental health. Physical activity interventions may be beneficial for aerobic fitness, cancer-related fatigue and health-related quality of life up to six months follow-up. Where reported, adverse events were generally minor. Adequately powered RCTs of high methodological quality with longer-term follow-up are required to assess the effect of physical activity interventions on the disease-related physical and mental health and on survival of people with non-advanced colorectal cancer. Adverse events should be adequately reported.

Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial

Background and objectives: Performing physical exercise after a colorectal cancer diagnosis is associated with lower mortality related to the tumor itself. In order to improve physical recovery after elective surgery, there are no specific exercise protocols after discharge from the hospital. The purpose of this study is to show the preliminary results of an exercise program after colorectal cancer surgery. Materials and Methods: Six patients with non-metastatic colorectal adenocarcinoma addressed to respective laparoscopic were randomly assigned to a mixed supervised/home-based exercise program for six months and compared to a control group without exercise. To assess the effectiveness of the program, functional and body composition parameters were evaluated. Results: Three months after surgery, the exercise group increased flexibility (p <0.01, ES = 0.33), strength of lower limbs (p <0.01, ES = 0.42) and aerobic capacity (p <0.01, ES = 0.28). After surgery, the six patients experienced a significant reduction in body mass index (BMI) and free fat mass. More specifically, fat mass reached the lowest values, with a concomitant increase in cell mass after six months (p <0.01, ES = 0.33). This did not occur in the control group. Conclusions: Colorectal cancer treatment induces a reduction in physical function, particularly during the first six months after treatment. A mixed exercise approach appears promising in countering this process after colorectal cancer surgery.

Motivational Interviewing to Increase Physical Activity Behavior in Cancer Patients: A Pilot Randomized Controlled Trials

OBJECTIVE

This pilot randomized controlled trial (RCT) aimed at evaluating the feasibility and potential efficacy of a motivational interviewing (MI) intervention to increase physical activity (PA) behavior in cancer patients.

METHODS

Participants were randomly assigned to an experimental group with standard care plus 12 MI sessions within 12 weeks or a control group with standard care only. The number of recruited participants and the modality of recruitment were recorded to describe the reach of the study. The acceptability of the study was estimated using the attrition rate during the intervention phase. The potential efficacy of the intervention was evaluated by analyzing the PA behavior.

RESULTS

Twenty-five participants were recruited within the 16-month recruitment period (1.6 participants per month). Five participants (38.5%) from the experimental group (n = 13) and one participant (8.3%) from the control group (n = 12) dropped out of the study before the end of the intervention phase. No group by time interaction effect for PA behavior was observed at the end of the intervention.

CONCLUSION

Due to the low recruitment rate and compliance, no conclusion can be drawn regarding the efficacy of MI to increase PA behavior in cancer patients. Moreover, the current literature cannot provide any evidence on the effectiveness of MI to increase PA in cancer survivors. Future RCTs should consider that the percentage of uninterested patients to join the study may be as high as 60%. Overrecruitment (30% to 40%) is also recommended to accommodate the elevated attrition rate.

The effect of strength and endurance training on SSTR2 and SSTR5 in patients with colorectal cancer

The roots of apoptosis caused by the use of certain drugs in patients with colorectal cancer and certain drugs could be induced the change in genes SSTR2 and SSTR5. SSTRs play a role in colorectal cancer and it’s also known that exercise training has similar effects to certain drugs. Therefore, this study aims to evaluate the effects of a combined training program on hormonal and physiological changes in patients with colorectal cancer. Twenty patients with colorectal cancer were included in this study and divided into two groups as experimental (n=10) and control (n=10). The experimental group performed an exercise training program 5 days a week for 14 weeks. Blood samples were taken from the patients before and after the training program, and analyzed for somatostatin and its receptors. When the pretest effect excluded as statistical, there were no significant differences in SSRT2 (P>0.05) and SSRT5 (P>0.05) between the experimental and control groups. The hypothesis for this study was “SSTR2 and SSTR5 will improve after combined training program” however, in accordance with the results it was rejected. It seems that the determined training program for these patients need to be extended and performed for at least 3 months in a gradual incremental structure so that it could affect their health indicators significantly.

Impact of physical activity and diet on colorectal cancer survivors' quality of life: a systematic review

Background

Post-treatment management is essential for improving the health and quality of life of colorectal cancer (CRC) survivors. The number of cancer survivors is continually increasing, which is causing a corresponding growth in the need for effective post-treatment management programs. Current research on the topic indicates that such programs should include aspects such as physical activity and a proper diet, which would form the basis of lifestyle change among CRC survivors. Therefore, this study aimed to identify the impact of physical activity and diet on the quality of life of CRC survivors.

Methods

We performed a systematic literature review regarding CRC survivors. We searched the Embase, PubMed, and EBSCOhost databases, considering papers published between January 2000 and May 2017 in any language, using a combination of the following subject headings: “colorectal cancer,” “colorectal carcinoma survivor,” “survivorship plan,” “survivorship care plan,” “survivorship program,” “lifestyle,” “activities,” “exercise,” “diet program,” and “nutrition.”

Results

A total of 14,036 articles were identified, with 35 satisfying the eligibility criteria for the systematic review. These articles were grouped by the study questions into physical activity and diet: 24 articles were included in the physical activity group and 11 in the diet group.

Conclusions

The research showed that an effective survivorship program can significantly help CRC survivors maintain good health and quality of life for long periods. However, there is a lack of consensus and conclusive evidence regarding how the guidelines for such a program should be designed, in terms of both its form and content.

Effect of exercise on colorectal cancer prevention and treatment

In recent years, because of improved cancer screening, detection and treatment modalities, a rapid increase in the population of colorectal and other cancer survivors has been observed. The increasing population has justified the requirement of preventive strategies such as lifestyle modifications with regard to obesity, physical activity, diet and smoking. Physical activity may prevent approximately 15% of the colon cancers. Furthermore, several observational studies have demonstrated the efficacy and dose-dependent and anti-cancer effects of exercise on decreasing the mortality and risk of recurrence before and after the colorectal cancer (CRC) diagnosis. However, the required exercise dose, type and intensity are yet unclear. The results of randomised prospective studies are expected to determine the optimal amount, type and intensity of exercise and formulate the most appropriate exercise plan and guidelines, according to the requirements and comorbidities of the patients. In addition, recent studies have focused on the molecular and genetic mechanisms underlying the effect of physical activity on disease outcomes and recurrence rates. This review aimed to investigate the effects of physical activity and the biological basis of these effects in preventing the risk and recurrence of CRC and decreasing the hazards of cancer and cancer treatment.

Exercise in African American and White Colorectal Cancer Survivors: A Mixed Methods Approach

Background

African-American (AA) colorectal cancer (CRC) survivors tend to be more obese and less physically active compared to white survivors.

Purpose/Objective

To test the feasibility of an aerobic exercise program as well as explore perceptions about supervised exercise among AA CRC survivors.

Methods

A prospective supervised exercise intervention performed on a cycle ergometer 2 days/week for 12 weeks. Peak (VO_2peak) and sub-maximal exercise (6MWT) along with questionnaires (SF-36, Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI), Functional Assessment of Cancer Therapy Scale-Colorectal (FACT-C) and Fatigue (FACIT-F), Brief Symptom Inventory (BSI). A second group of survivors participated in an interview evaluating perceptions regarding exercise.

Design

Prospective case series and qualitative interview.

Setting

Research university and academic medical center.

Patients

African American and white colorectal cancer survivors.

Results

Quantitative: A total of 237 letters were mailed to CRC survivors (112 white, 126 AAs). From the letters, 25 white and 15 AAs expressed interest; only five white (4.5%) and four AAs (3.2%) enrolled. Two AAs and five white survivors (7/9) finished the program. There was an improvement in peak exercise (p=0.011) and quality of life (QoL) (SF-36 total, p=0.035) post-training. Qualitative: 30 CRC survivors (12 AA and 18 white) participated in qualitative interviews and selected co-morbidity, motivation and location as primary barriers to exercise.

Limitations

Small sample size.

Conclusions

Recruiting CRC survivors (regardless of race) into an exercise program is challenging, however, there are exercise and QoL benefits associated with participation. Barriers to exercise are similar between AA and white CRC survivors.

Feasibility and Effects of a Postoperative Recovery Exercise Program Developed Specifically for Gastric Cancer Patients (PREP-GC) Undergoing Minimally Invasive Gastrectomy

PURPOSE

Exercise intervention after surgery has been found to improve physical fitness and quality of life (QOL). The purpose of this study was to investigate the feasibility and effects of a postoperative recovery exercise program developed specifically for gastric cancer patients (PREP-GC) undergoing minimally invasive gastrectomy.

MATERIALS AND METHODS

Twenty-four patients treated surgically for early gastric cancer were enrolled in the PREP-GC. The exercise program comprised sessions of In-hospital Exercise (1 week), Home Exercise (1 week), and Fitness Improvement Exercise (8 weeks). Adherence and compliance to PREP-GC were evaluated. In addition, body composition, physical fitness, and QOL were assessed during the preoperative period, after the postoperative recovery (2 weeks after surgery), and upon completing the PREP-GC (10 weeks after surgery).

RESULTS

Of the 24 enrolled patients, 20 completed the study without any adverse events related to the PREP-GC. Adherence and compliance rates to the Fitness Improvement Exercise were 79.4% and 99.4%, respectively. Upon completing the PREP-GC, patients also exhibited restored cardiopulmonary function and muscular strength, with improved muscular endurance and flexibility (P<0.05). Compared to those in the preoperative period, no differences were found in symptom scale scores measured using the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and Quality of Life Questionnaire-Stomach Cancer-Specific Module (QLQ-STO22); however, higher scores for global health status and emotional functioning were observed after completing the PREP-GC (P<0.05).

CONCLUSIONS

In gastric cancer patients undergoing minimally invasive gastrectomy, PREP-GC was found to be feasible and safe, with high adherence and compliance. Although randomized studies evaluating the benefits of exercise intervention during postoperative recovery are needed, surgeons should encourage patients to participate in systematic exercise intervention programs in the early postoperative period (Registered at the ClinicalTrials.gov NCT01751880).

Cardiorespiratory Fitness and Body Composition Responses to Different Intensities and Frequencies of Exercise Training in Colorectal Cancer Survivors

INTRODUCTION

Deteriorations in cardiorespiratory fitness (V˙o_2peak) and body composition are associated with poor prognosis after colorectal cancer treatment. However, the optimal intensity and frequency of aerobic exercise training to improve these outcomes in colorectal cancer survivors is unknown.

PATIENTS AND METHODS

This trial compared 8 weeks of moderate-intensity continuous exercise (MICE; 50 minutes; 70% peak heart rate [HR_peak]; 24 sessions), with high-intensity interval exercise (HIIE; 4 × 4 minutes; 85%-95% HR_peak) at an equivalent (HIIE; 24 sessions) and tapered frequency (HIIE-T; 16 sessions) on V˙o_2peak and on lean and fat mass, measured at baseline, 4, 8, and 12 weeks.

RESULTS

Increases in V˙o_2peak were significantly greater after both 4 (+3.0 mL·kg^-1·min^-1, P = .008) and 8 (+2.3 mL·kg^-1·min^-1, P = .049) weeks of HIIE compared to MICE. After 8 weeks, there was a significantly greater reduction in fat mass after HIIE compared to MICE (-0.7 kg, P = .038). Four weeks after training, the HIIE group maintained elevated V˙o_2peak (+3.3 mL·kg^-1·min^-1, P = .006) and reduced fat mass (-0.7 kg, P = .045) compared to the MICE group, with V˙o_2peak in the HIIE-T also being superior to the MICE group (+2.8 mL·kg^-1·min^-1, P = .013).

CONCLUSION

Compared to MICE, HIIE promotes superior improvements and short-term maintenance of V˙o_2peak and fat mass improvements. HIIE training at a reduced frequency also promotes maintainable cardiorespiratory fitness improvements. In addition to promoting accelerated and superior benefits to the current aerobic exercise guidelines, HIIE promotes clinically relevant improvements even with a substantial reduction in exercise training and for a period after withdrawal.

Effectiveness of Lumbopelvic Exercise in Colon Cancer Survivors: A Randomized Controlled Clinical Trial

INTRODUCTION

This study evaluated the effectiveness of lumbopelvic exercise in improving health-related fitness, anthropometric measurements, and body composition in colon cancer survivors (CCS).

METHODS

Forty-six CCS (35% female, n = 14) were assigned to two groups for this randomized controlled clinical trial: a trunk muscle stabilization exercise program group (CO-CUIDATE) and a usual-care group. The CO-CUIDATE program was conducted for 8 wk (three times per week). The primary end point was isometric abdominal strength measured using the trunk curl test. The secondary end points used were isometric back strength, functional capacity, lower-body flexibility, weight, and anthropometric measurements evaluated at baseline, after the physical exercise program and after 6 months of follow-up. A trained member of the research group with 5 yr of experience working with cancer patients and who was blinded to the patient group assessed the variables. All physical tests were conducted with multiple observations.

RESULTS

The adherence to intervention was 88.36%, and two dropouts (10.5%) were recorded. Minor side effects, including discomfort with the exercises in the first sessions, were reported by the participants. ANOVA demonstrated significant differences in group-time interactions for isometric abdominal strength (F = 7.7; P = 0.001), functional capacity (F = 4.6; P = 0.015), lower-body flexibility (right, F = 4.3, P = 0.021 and left, F = 3.6, P = 0.034), and waist circumference (F = 5.7; P = 0.07), which were the best values for the CO-CUIDATE group. No significant changes in isometric back strength, weight, hip circumference or body composition were observed.

CONCLUSION

An 8-wk program based on stabilization exercises is a promising strategy to increase health-related fitness and to reduce waist circumference in CCS. An exercise program based on lumbopelvic exercise is a feasible intervention to improve the control of deep abdominal muscles and health-related fitness.

Impact of physical activity in group versus individual physical activity on fatigue in patients with breast cancer: A pilot study

BACKGROUND

Physical activity improves the quality of life of cancer survivors, but whether there is a difference between individual vs. group physical activity is unknown.

OBJECTIVES

To compare fatigue at 12 weeks in breast cancer survivors after participation in a program of group vs. individual video-assisted physical activity.

METHODS

This was a randomized phase II pilot study carried out in breast cancer survivors at a tertiary breast cancer center. Eligible patients were randomized to individual or group 12-week physical activity program. The primary outcome was fatigue (FACT-F). Aerobic capacity (6-min walk test), muscular strength, and quality-of-life (FACT-G and FACT-B) were assessed. Because of poor accrual, 200 consecutive breast cancer patients were surveyed about their physical activity habits to assess reasons for low recruitment.

RESULTS

For all participants (n = 26; n = 12 for group vs. n = 14 for individual), there were some improvement in FACT-F, FACT-G, FACT-B, physical activity level, aerobic capacity, and shoulder strength. Among the 200 patients surveyed, 58% were interested to increase their physical activity level, 15% declared that they were already exercising enough, 9% declared being unable to, 3% declared having no time, and 2% declared having no interest, and other reasons (13%). Among the 200 patients surveyed, 25% preferred in group, 57% preferred alone, and 18% had no preference.

CONCLUSION

Low recruitment precluded conclusions about the efficacy of physical activity practiced in group vs. individually, but both groups derived a benefit. Low willingness to change exercising habits could be the biggest barrier to physical activity in breast cancer survivors.

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.

The feasibility and acceptability of trial procedures for a pragmatic randomised controlled trial of a structured physical activity intervention for people diagnosed with colorectal cancer: findings from a pilot trial of cardiac rehabilitation versus usual care (no rehabilitation) with an embedded qualitative study

Background

Pilot and feasibility work is conducted to evaluate the operational feasibility and acceptability of the intervention itself and the feasibility and acceptability of a trials’ protocol design. The Cardiac Rehabilitation In Bowel cancer (CRIB) study was a pilot randomised controlled trial (RCT) of cardiac rehabilitation versus usual care (no rehabilitation) for post-surgical colorectal cancer patients. A key aim of the pilot trial was to test the feasibility and acceptability of the protocol design.

Methods

A pilot RCT with embedded qualitative work was conducted in three sites. Participants were randomly allocated to cardiac rehabilitation or usual care groups. Outcomes used to assess the feasibility and acceptability of key trial parameters were screening, eligibility, consent, randomisation, adverse events, retention, completion, missing data, and intervention adherence rates. Colorectal patients’ and clinicians’ perceptions and experiences of the main trial procedures were explored by interview.

Results

Quantitative study. Three sites were involved. Screening, eligibility, consent, and retention rates were 79 % (156/198), 67 % (133/198), 31 % (41/133), and 93 % (38/41), respectively. Questionnaire completion rates were 97.5 % (40/41), 75 % (31/41), and 61 % (25/41) at baseline, follow-up 1, and follow-up 2, respectively. Sixty-nine percent (40) of accelerometer datasets were collected from participants; 31 % (20) were removed for not meeting wear-time validation.

Qualitative study: Thirty-eight patients and eight clinicians participated. Key themes were benefits for people with colorectal cancer attending cardiac rehabilitation, barriers for people with colorectal cancer attending cardiac rehabilitation, generic versus disease-specific rehabilitation, key concerns about including people with cancer in cardiac rehabilitation, and barriers to involvement in a study about cardiac rehabilitation.

Conclusions

The study highlights where threats to internal and external validity are likely to arise in any future studies of similar structured physical activity interventions for colorectal cancer patients using similar methods being conducted in similar contexts. This study shows that there is likely to be potential recruitment bias and potential imprecision due to sub-optimal completion of outcome measures, missing data, and sub-optimal intervention adherence. Hence, strategies to manage these risks should be developed to stack the odds in favour of conducting successful future trials.

Trial registration

ISRCTN63510637

The use of cardiac rehabilitation services to aid the recovery of patients with bowel cancer: a pilot randomised controlled trial with embedded feasibility study

Background

Colorectal cancer (CRC) survivors are not meeting the recommended physical activity levels associated with improving their chances of survival and quality of life. Rehabilitation could address this problem.

Objectives

The aims of the Cardiac Rehabilitation In Bowel cancer study were to assess whether or not cardiac rehabilitation is a feasible and acceptable model to aid the recovery of people with CRC and to test the feasibility and acceptability of the protocol design.

Design

Intervention testing and feasibility work (phase 1) and a pilot randomised controlled trial with embedded qualitative study (phase 2), supplemented with an economic evaluation. Randomisation was to cardiac rehabilitation or usual care. Outcomes were differences in objective measures of physical activity and sedentary behaviour, self-reported measures of quality of life, anxiety, depression and fatigue. Qualitative work involved patients and clinicians from both cancer and cardiac specialties.

Setting

Three colorectal cancer wards and three cardiac rehabilitation facilities.

Participants

Inclusion criteria were those who were aged > 18 years, had primary CRC and were post surgery.

Results

Phase 1 (single site) – of 34 patient admissions, 24 (70%) were eligible and 4 (17%) participated in cardiac rehabilitation. Sixteen clinicians participated in an interview/focus group. Modifications to trial procedures were made for further testing in phase 2. Additionally, 20 clinicians in all three sites were trained in cancer and exercise, rating it as excellent. Phase 2 (three sites) – screening, eligibility, consent and retention rates were 156 (79%), 133 (67%), 41 (31%) and 38 (93%), respectively. Questionnaire completion rates were 40 (97.5%), 31 (75%) and 25 (61%) at baseline, follow-up 1 and follow-up 2, respectively. Forty (69%) accelerometer data sets were analysed; 20 (31%) were removed owing to invalid data.

Qualitative study

CRC and cardiac patients and clinicians were interviewed. Key themes were benefits and barriers for people with CRC attending cardiac rehabilitation; generic versus disease-specific rehabilitation; key concerns of the intervention; and barriers to participation (CRC participants only).

Economic evaluation

The average out-of-pocket expenses of attending cardiac rehabilitation were £50. The costs of cardiac rehabilitation for people with cancer are highly dependent on whether it involves accommodating additional patients in an already existing service or setting up a completely new service.

Limitations and conclusions

The main limitation is that this is a small feasibility and pilot study. The main novel finding is that cardiac rehabilitation for cancer and cardiac patients together is feasible and acceptable, thereby challenging disease-specific rehabilitation models.

Future work

This study highlighted important challenges to doing a full-scale trial of cardiac rehabilitation but does not, we believe, provide sufficient evidence to reject the possibility of such a future trial. We recommend that any future trial must specifically address the challenges identified in this study, such as suboptimal consent, completion, missing data and intervention adherence rates and recruitment bias, and that an internal pilot trial be conducted. This should have clear ‘stop–proceed’ rules that are formally reviewed before proceeding to the full-scale trial.

Trial registration

Current Controlled Trials ISRCTN63510637.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 4, No. 24. See the NIHR Journals Library website for further project information.

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.

Exercise and cancer: return to work as a firefighter with ostomy after rectal carcinoma - a case report

BACKGROUND

Colorectal cancer survivors are deconditioned through anticancer therapy. Furthermore, about 10% of them have a permanent ostomy which is associated with weakened abdominal muscles and an increased risk of a hernia. This case study reports on how a firefighter with rectal carcinoma and ostomy was trained to regain operational fitness.

METHODS

A 44-year-old firefighter (178 cm, 82 kg) with an adenocarcinoma of the rectum (diagnosed 24 months prior) had been treated with neoadjuvant radiochemotherapy and surgery. After 2 temporary ileostomies, a permanent colostomy was performed 14 weeks before the start of a 9-months training program. The program included sensorimotor, endurance, and strength training of increasing volume and intensity. Endurance, strength, and patient reported outcomes were assessed every 2 to 3 months.

RESULTS

Training frequency varied from 1 to 3 sessions/week, although 3 to 5 sessions/week were prescribed. Peak power output was 150, 158, 167, 192, and 175 watts at baseline, 2, 4, 6, and 9 months. Maximal oxygen uptake increased from 1.56 L/min (19.0 mL/min/kg) to 2.39 L/min (28.8 mL/min/kg) after 6 months. Maximal isokinetic peak torque (MIPT) of the knee extensors were 138.0 and 196.5 Nm (Newton meter) at baseline and 6 months. MIPT of the elbow and hip flexors increased from 51.8 to 66.0 Nm and 213.8 to 239.7 Nm, respectively, after 6 months. Physical fatigue decreased by 65% and distress by about 50% after 9 months. The firefighter passed a test for occupational fitness after 6 months and was permitted to work with an exterior crew on a pump truck.

CONCLUSION

It is possible for colorectal cancer survivors with ostomy to regain occupational fitness for physically demanding tasks like firefighting through an individually tailored and supervised training program.

Factors Influencing Amount of Weekly Exercise Time in Colorectal Cancer Survivors

BACKGROUND

Performing regular exercise of at least 150 minutes weekly has benefits for colorectal cancer survivors. However, barriers inhibit these survivors from performing regular exercise.

OBJECTIVES

The aim of this study was to explore exercise behaviors and significant factors influencing weekly exercise time of more than 150 minutes in colorectal cancer survivors.

METHODS

A cross-sectional study design was used to recruit participants in Taiwan. Guided by the ecological model of health behavior, exercise barriers were assessed including intrapersonal, interpersonal, and environment-related barriers. A multiple logistic regression was used to explore the factors associated with the amount of weekly exercise.

RESULTS

Among 321 survivors, 57.0% of them had weekly exercise times of more than 150 minutes. The results identified multiple levels of significant factors related to weekly exercise times including intrapersonal factors (occupational status, functional status, pain, interest in exercise, and beliefs about the importance of exercise) and exercise barriers related to environmental factors (lack of time and bad weather). No interpersonal factors were found to be significant.

CONCLUSIONS

Colorectal cancer survivors experienced low levels of physical and psychological distress. Multiple levels of significant factors related to exercise time including intrapersonal factors as well as exercise barriers related to environmental factors should be considered.

IMPLICATIONS FOR PRACTICE

Healthcare providers should discuss with their patients how to perform exercise programs; the discussion should address multiple levels of the ecological model such as any pain problems, functional status, employment status, and time limitations, as well as community environment.

Outdoor adventure therapy to increase physical activity in young adult cancer survivors

PURPOSE

Despite the health benefits of physical activity (PA), limited research has examined PA interventions in young adult cancer survivors (YACS). This study used a two-group parallel design to examine the effects of a 7-day outdoor adventure camp vs. waitlist control on PA levels among YACS. Secondary aims examined effects on sedentary behavior and PA correlates.

METHODS

50 camp and 66 control participants were assessed at baseline, end of camp, and 3 months.

RESULTS

Intent-to-treat analyses indicated that, relative to baseline, camp participants had significantly (p = 0.0001) greater increases in PA than controls during camp (+577 vs. +9 minutes/week) and 3 months post-camp (+133 vs. -75 minutes/week, p = 0.001). Camp participants also reported significantly greater improvements in TV viewing (p = 0.001), hours sitting (p = 0.001), PA variety (p = 0.0001), barriers to PA (p = 0.007), and enjoyment of structured activities (p = 0.04) during camp but not 3 months post-camp.

CONCLUSION

A week-long outdoor adventure therapy camp increased PA levels during camp and 3 months after camp termination, although effects were attenuated over time.

IMPLICATIONS FOR CANCER SURVIVORS

Outdoor adventure therapy camps may increase PA and its correlates in YACS, but future research should explore methods to promote sustained PA after camp termination.

Is referral of postsurgical colorectal cancer survivors to cardiac rehabilitation feasible and acceptable? A pragmatic pilot randomised controlled trial with embedded qualitative study

OBJECTIVES

(1) Assess whether cardiac rehabilitation (CR) is a feasible and acceptable model of rehabilitation for postsurgical colorectal cancer (CRC) survivors, (2) evaluate trial procedures. This article reports the results of the first objective.

DESIGN AND SETTING

A pragmatic pilot randomised controlled trial with embedded qualitative study was conducted in 3 UK hospitals with CR facilities. Descriptive statistics were used to summarise trial parameters indicative of intervention feasibility and acceptability. Interviews and focus groups were conducted and data analysed thematically.

PARTICIPANTS

People with CRC were considered for inclusion in the trial if they were ≥ 18 years old, diagnosed with primary CRC and in the recovery period postsurgery (they could still be receiving adjuvant therapy). 31% (n=41) of all eligible CRC survivors consented to participate in the trial. 22 of these CRC survivors, and 8 people with cardiovascular disease (CVD), 5 CRC nurses and 6 CR clinicians participated in the qualitative study.

INTERVENTION

Referral of postsurgical CRC survivors to weekly CR exercise classes and information sessions. Classes included CRC survivors and people with CVD. CR nurses and physiotherapists were given training about cancer and exercise.

RESULTS

Barriers to CR were protracted recoveries from surgery, ongoing treatments and poor mobility. No adverse events were reported during the trial, suggesting that CR is safe. 62% of participants completed the intervention as per protocol and had high levels of attendance. 20 health professionals attended the cancer and exercise training course, rating it as excellent. Participants perceived that CR increased CRC survivors' confidence and motivation to exercise, and offered peer support. CR professionals were concerned about CR capacity to accommodate cancer survivors and their ability to provide psychosocial support to this group of patients.

CONCLUSIONS

CR is feasible and acceptable for postsurgical CRC survivors. A large-scale effectiveness trial of the intervention should be conducted.

TRIAL REGISTRATION NUMBER

ISRCTN63510637.

The influence of high-intensity compared with moderate-intensity exercise training on cardiorespiratory fitness and body composition in colorectal cancer survivors: a randomised controlled trial

PURPOSE

Following colorectal cancer diagnosis and anti-cancer therapy, declines in cardiorespiratory fitness and body composition lead to significant increases in morbidity and mortality. There is increasing interest within the field of exercise oncology surrounding potential strategies to remediate these adverse outcomes. This study compared 4 weeks of moderate-intensity exercise (MIE) and high-intensity exercise (HIE) training on peak oxygen consumption (V̇O2peak) and body composition in colorectal cancer survivors.

METHODS

Forty seven post-treatment colorectal cancer survivors (HIE = 27 months post-treatment; MIE = 38 months post-treatment) were randomised to either HIE [85-95 % peak heart rate (HRpeak)] or MIE (70 % HRpeak) in equivalence with current physical activity guidelines and completed 12 training sessions over 4 weeks.

RESULTS

HIE was superior to MIE in improving absolute (p = 0.016) and relative (p = 0.021) V̇O2peak. Absolute (+0.28 L.min(-1), p < 0.001) and relative (+3.5 ml.kg(-1).min(-1), p < 0.001) V̇O2 peak were increased in the HIE group but not the MIE group following training. HIE led to significant increases in lean mass (+0.72 kg, p = 0.002) and decreases in fat mass (-0.74 kg, p < 0.001) and fat percentage (-1.0 %, p < 0.001), whereas no changes were observed for the MIE group. There were no severe adverse events.

CONCLUSIONS

In response to short-term training, HIE is a safe, feasible and efficacious intervention that offers clinically meaningful improvements in cardiorespiratory fitness and body composition for colorectal cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

HIE appears to offer superior improvements in cardiorespiratory fitness and body composition in comparison to current physical activity recommendations for colorectal cancer survivors and therefore may be an effective clinical utility following treatment.