Impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer

The evolvement of breast cancer therapies: What we have done and where all these head off

Although, from a therapeutic standpoint, breast cancer (BC) is considerably well-characterized, it still leaves puzzling spots. The Her-2+/PR+/ER+ BC can benefit from the mainstays of anticancer therapy and immunotherapy and overall have a better prognosis. Triple-negative BC, due to the concomitant absence of Her-2/PR/ER receptors, is more challenging and necessitates different strategies. It has been learned that the mainstay anti-BC therapies were initially designed to demolish as many cancer cells as they possibly could. However, the number of reports on the adverse effects of these mainstay therapies has recently been increasing. It underpins efforts to reshape such therapies into much better and safer forms over time. Moreover, some current findings on the molecular markers, which are target-potential, have also shifted the paradigm from radical-to-local-yet-precise-approach to meet the need for a therapy platform that is less cytotoxic to normal cells yet efficiently kills cancer cells.

Assessing the Impact of Organ Failure and Metastases on Quality of Life in Breast Cancer Patients: A Prospective Study Based on Utilizing EORTC QLQ-C30 and EORTC QLQ-BR45 Questionnaires in Romania

Breast cancer (BC) significantly impacts the quality of life (QoL) of affected individuals. This study, conducted at Colțea Clinical Hospital, Bucharest, aimed to assess the impact of organ failures and metastases on QoL in breast cancer patients using EORTC QLQ-C30 and EORTC QLQ-BR45 questionnaires and the survival rate to understand the clinical journey and the quality of life status in breast cancer patients. From January 2019 to October 2022, a prospective, observational study surveyed 874 patients, revealing 201 fatalities, 66 refusals, and 607 eligible participants. Results indicated statistically significant differences in various QoL aspects for patients experiencing heart failure, including physical functioning, pain, insomnia, global health status, and overall summary score. Kidney failure exhibited significance in physical functioning for QLQ-C30 and body image, sexual functioning, and endocrine sexual symptoms for QLQ-BR45. Respiratory failure demonstrated significant differences across multiple QoL domains. Patients with bone metastases reported lower physical functioning (p = 0.006) and increased pain (p = 0.002). This study has revealed an overall 5-year life expectancy of 68.8%, with survival rates of 93.8% for Stage I, 86.3% for Stage II, and 77.2% for Stage III breast cancer. Metastatic cancer patients have shown a 35.6% survival rate over 45 months, with a median survival duration of 36 months. A significant limitation of our study was the administration of the questionnaire only once, preventing us from quantifying the impact of specific treatment types on quality of life. This study emphasizes the necessity of using standardized QoL assessments in clinical practice from the initial presentation to ongoing follow-up.

Understanding changes in pulmonary function and functional status in breast cancer patients after systemic chemotherapy and radiotherapy: a prospective study

BACKGROUND

Respiratory complications in breast cancer (BC) patients after chemotherapy (CT) and radiotherapy (RT) have been well acquainted and these complications should be investigated to prevent secondary problems and/or improve BC patients' clinical outcomes. Therefore, this study aimed to assess the potential acute effect of systemic chemotherapy and radiotherapy on respiratory function and functional status of patients with breast cancer.

METHODS

A total of 25 BC patients who were candidates for systemic chemotherapy and radiotherapy were recruited after oncological examination and included in this study. Respiratory function and functional status were assessed with the Pulmonary Function Test (PFT) and the Six-Minute Walk Test (6MWT), respectively. Patients were assessed before CT (c0), after CT (c1), and after RT (r1).

RESULTS

25 BC patients were assessed in c0 and c1 while only 15 out of 25 patients (60%) were assessed in r1. The actual values of Forced vital capacity (FVC) (t = 2.338, p =.028), Forced expiratory volume in 1s (FEV1 (t = 2.708, p =.012), and the forced expiratory flow of between 25% and 75% of vital capacity (FEF25-75%) (t = 2.200, p =.038) were found significantly different after systemic CT. Inspiratory (MIP) and expiratory (MEP) muscle strength also did not show a significant change from c0 to c1. A significant effect of the type of surgery was found (Wilks' lambda, F [1, 19] = 6.561, p =.019, ηp2 = 0.25) between c0 and c1 in actual FVC value. The main effect of time was found significant in FVC (F [2, 28] = 4.840, p =.016, ηp2 = 0.25) from c0 to r1. Pairwise comparisons with Bonferroni correction showed that there was a significant difference between c0 and r1 (p =.037).

DISCUSSION

The present study showed decreased FVC and FEV1 actual values and percent predicted rates from baseline to the completion of treatment. Since the interactional effect of the type of surgery was significant, we suggest that clinical and demographic factors such as age should be considered when interpreting the early changes in PFT. In addition, the significant linear trend of decreasing in some specific outcomes in respiratory function also highlighted the need for continuous monitoring of potential respiratory problems in patients with BC from baseline to the completion of chemotherapy and radiotherapy.

Effects of an urban forest healing program on cancer-related fatigue in cancer survivors

PURPOSE

This study aimed to examine the effects of an eight-session structured urban forest healing program for cancer survivors with fatigue.

BACKGROUND

Cancer-related fatigue (CRF) is a complex and multifactorial common symptom among cancer survivors that limits quality of life (QoL). Although health benefits of forest healing on physiological, physical, and psychological aspect as well as on the immune system have been reported in many studies, there is limited evidence on the efficacy of specialized forest program for cancer survivors.

METHOD

A single-blinded, pre-test and post-test control group clinical trial was conducted with -75 cancer survivors assigned to either the forest healing group or the control group. The intervention was an eight-session structured urban forest program provided at two urban forests with easy accessibility. Each session consists of three or four major activities based on six forest healing elements such as landscape, phytoncides, anions, sounds, sunlight, and oxygen. Complete data of the treatment-adherent sample (≥ 6 sessions) was used to examine whether sociodemographic, clinical, physiological (respiratory function, muscle strength, balance, 6-min walking test) and psychological (distress, mood state, sleep quality, QoL) characteristics at baseline moderated the intervention effect on fatigue severity at 9 weeks.

RESULTS

Significant time-group interactions were observed muscle strength, balance, 6-min walking test, distress, fatigue, moods, and QoL. The mean difference in fatigue between pre- and post-forest healing program was 9.1 (95% CI 6.2 to 11.9), 11.9 (95% CI 7.6 to 16.1) in moods, and -93.9 (95% CI -123.9 to -64.0) in QoL, showing significant improvements in forest healing group, but no significant improvements in the control group.

CONCLUSION

This study suggests that a forest healing program positively impacts the lives of cancer survivors, by addressing both physical and psychological challenges associated with CRF.

TRIAL REGISTRATION NUMBER

KCT0008447 (Date of registration: May 19, 2023).

Investigation of the relationship between spinal posture and mobility to respiratory muscle strength and pulmonary functions in unilateral breast cancer surgery survivors: a cross-sectional study

PURPOSE

Despite the research on structural and functional changes that may occur in breast cancer survivors, no study has investigated the relationship between spinal characteristics and the respiratory system. Therefore, we aimed to investigate the relationship between spinal posture and mobility to respiratory muscle strength and pulmonary functions in breast cancer patients who have completed their treatment METHODS: This cross-sectional study included 38 female breast cancer surgery survivors. Participants underwent the following evaluations: Chest wall mobility with a tapeline; postural assessments (spinal curvature, spinal mobility, and spinal inclination) with a non-invasive, computer-assisted electromechanical device; and pulmonary function test and respiratory muscle strength with a portable digital spirometer device. The relationship between spinal posture and mobility to respiratory muscle strength and pulmonary functions was analyzed by the bivariate correlation analysis.

RESULTS

Increased thoracic curvature angle was associated with decreased FEV1 (r=-0.360, p=0.026) and decreased subcostal mobility (r=-0.385, p=0.017), and the increase in thoracic frontal mobility was associated with decrease in PEF (r=-0.342, p=0.036). Increased lumbar mobility was associated with increased FVC (r=0.324, p=0.047), and increased total spinal inclination mobility was associated with decreased MIP (r=-0.396, p=0.017). Chest wall mobility was associated with postural assessments at varying rates (the r value ranged from -0.357 to 0.661, p<0.05).

CONCLUSION

The changes in spinal posture and mobility of women who have undergone unilateral breast cancer surgery were associated with respiratory parameters and thoracic cage mobility. These patients' spinal posture and mobility should be taken into account in conjunction with respiratory functions for a comprehensive assessment.

[Influence of physical activity on radiotherapy-treated breast cancer patients: A systematic review]

INTRODUCTION

The number of survivors with cancer is growing worldwide, but the adverse effects of the radiotherapy are still frequent, affecting effort capacity, respiratory function and quality of life. The objective is to know how the physical exercise influences the respiratory function and tolerance to effort, in pacients with breast cancer after the radiotherapy treatment.

MATERIALS AND METHODS

The searches were carried out in the databases of Pubmed, PEDro, Web Of Science, Cochrane, EMBASE, UptoDate and Tripdatabase. Were included studies with patients with breast cancer treated with radiotherapy and included in an exercise program. The main results were: maximum oxygen consumption, 6 minutes walking test, forced vital capacity, vital capacity, forced expiratory volume in 1 second, total lounge capacity, inspiratory capacity, and the diffusion capacity of the lungs for carbon monoxide.

RESULTS

The results show an increase of the effort capacity with 15% improvements in the maximum oxygen consumption and 6.675% in the 6 minutes walking test, while they are limited for the respiratory function.

CONCLUSIONS

The physical exercise is effective for improve the effort capacity in pacients with breast cancer treated with radiotherapy, without changes in the respiratory function. Nevertheless, new studies are necessary to investigate deeply how the physical exercise influences in those pacients, and the ideal design of the programs.

Radiation pneumonitis in relation to pulmonary function, dosimetric factors, TGFβ1 expression, and quality of life in breast cancer patients receiving post-operative radiotherapy: a prospective 6-month follow-up study

PURPOSE

To investigate development of radiation pneumonitis (RP) in relation to pulmonary function, dosimetric factors, and transforming growth factor beta-1 (TGFβ1) expression in irradiated breast cancer patients.

METHODS

A total of 49 breast cancer patients who received post-operative radiotherapy (RT) were evaluated in terms of pulmonary function tests (PFTs), quality of life (QoL), development of RP, dosimetric factors, cytokine levels, and lung high-resolution computed tomography (HRCT) before and after RT. ROC analysis was performed for performance of dosimetric factors in predicting RP, while frequencies of single nucleotide polymorphisms (SNPs) genotyped for TGFβ1 (rs11466345 and rs1800470) were also evaluated.

RESULTS

All cases with RP (10.2%) recovered clinically at the end of third post-RT month. PFT and HRCT parameters were similar before and after RT overall, as well as by RP and the radiation field subgroups. ROC analysis revealed the significant role of the ipsilateral V5 (cutoff value of 45.9%, p = 0.039), V10 (29.4%, p = 0.015), V20 (23%, p = 0.017), and MLD (1200 cGy, p = 0.030) in predicting RP. Higher post-RT TGFβ1 levels (p = 0.037) were noted overall and in patients with RP. Patient and control groups were similar in terms of frequencies of SNPs genotyped for TGFβ1 (rs11466345 and rs1800470). EORTC QLQ-C30 and QLQ-BR-23 scores were similar in patients with vs. without RP.

CONCLUSION

Our findings revealed significant role of dosimetric factors including MLD, V20 as well as the low dose-volume metrics in predicting the risk of RP among breast cancer patients who received post-operative RT. Implementation of RT, extent of radiation field or the presence of RP had no significant impact on PFTs.

Adjunctive inspiratory muscle training during a rehabilitation program in patients with breast cancer: an exploratory double-blind, randomized, controlled pilot study

Objective

To investigate whether inspiratory muscle training (IMT) offered adjunctively to an exercise training program reduces symptoms of dyspnea in survivors of breast cancer.

Design

Double-blind, parallel-group, randomized controlled trial.

Setting

Outpatient rehabilitation program in a university hospital.

Participants

Ninety-eight female patients with breast cancer who completed adjuvant treatment and subsequently entered cancer rehabilitation were screened for participation. Inclusion criteria were reduced inspiratory muscle strength and/or symptoms of dyspnea. Twenty patients (N=20) were randomly assigned to an intervention group (n=10) or a control group (n=10).

Intervention

Both groups received a 3-month exercise training program in combination with either IMT (intervention) or sham-IMT (control).

Main Outcome Measures

Changes in dyspnea intensity perception (10-point Borg Scale) at comparable time points (isotime) during constant work rate cycling was the primary outcome. Secondary outcomes included changes in respiratory muscle function, exercise capacity, and changes in symptoms of dyspnea during daily life (Transitional Dyspnea Index [TDI]).

Results

The intervention group achieved a larger reduction in exertional dyspnea at isotime compared with the control group (−1.8 points; 95% CI, −3.7 to 0.13; P=.066). The intervention group also exhibited larger improvements in dyspnea during daily life (TDI score, +2.9 points; 95% CI, 0.5-5.3; P=.022) and improved both respiratory muscle endurance (+472 seconds; 95% CI, 217-728; P=.001) and cycling endurance (+428 seconds; 95% CI, 223-633; P=.001) more than the control group.

Conclusions

Because of the limited sample size all obtained findings need to be interpreted with caution. The study offers initial insights into the potential of adjunctive IMT in selected survivors of breast cancer. Larger multicenter studies should be performed to further explore the potential role and general acceptance of this intervention as a rehabilitation tool in selected patients after breast cancer treatment.

Respiratory Physiotherapy Intervention Strategies in the Sequelae of Breast Cancer Treatment: A Systematic Review

Breast cancer treatments can trigger respiratory sequelae. Respiratory physiotherapy helps to eliminate or mitigate the sequelae by optimizing respiratory function. This systematic review aims to synthesize the scientific evidence and assess its quality regarding the use of respiratory physiotherapy in the sequelae of breast cancer. The Cochrane Library, Physiotherapy Evidence Database, PubMed, Web of Science, Scientific Electronic Library Online, Cumulative Index of Nursing and Allied Literature Complete, and Scopus were searched. Study quality was determined using the PEDro scale, STROBE Statement, and Single-Case Experimental Design Scale. Ten studies, six clinical trials, one case study, and three observational studies were selected. The mean methodological quality of the clinical trials was 5.6, that of the case study was 7, and that of the observational studies was 56%. Respiratory physiotherapy has been observed to improve respiratory capacity, lung function, respiratory muscle strength, effort tolerance, dyspnea, fatigue, thoracic mobility, upper limb volume, sleep quality and quality of life, as well as sensitivity to adverse physiological reactions, nausea, vomiting, and anxiety. However, it is not effective for vasomotor symptoms. More clinical trials are needed. These studies should homogenize the techniques used, as well as improve their methodological quality.

Effectiveness of Therapeutic Exercise and Patient Education on Cancer-Related Fatigue in Breast Cancer Survivors: A Randomised, Single-Blind, Controlled Trial with a 6-Month Follow-Up

This study aimed to determine the effectiveness of therapeutic exercise plus patient therapeutic education on perceived fatigue, functional capacity and pain in breast cancer survivors with cancer-related fatigue. A randomised, single-blind, clinical trial was conducted with a total of 80 breast cancer survivors who presented cancer-related fatigue. Women were randomised into a supervised therapeutic exercise group (STE-G) (n = 40) or an unsupervised exercise group (UE-G) (n = 40). Both interventions included patient therapeutic education and were delivered in three sessions per week over eight weeks. The main outcome was perceived fatigue as assessed by the Spanish version of the Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-F). Other evaluated outcomes were pain measured on a visual analogue scale, and distance measured using the 6-Minute Walk Test. Data were collected at baseline, immediately post-intervention, and at three and six months after baseline. Significantly greater improvements across all variables were observed in the STE-G throughout the entire follow-up period with the exception of pain. Conclusions: A supervised therapeutic exercise program plus patient therapeutic education significantly reduce perceived fatigue and increase functional capacity in breast cancer survivors suffering from cancer-related fatigue compared to an unsupervised physical exercise program based on individual preferences with patient therapeutic education.

Case Studies in Physiology: Cardiopulmonary exercise testing and inspiratory muscle training in a 59-year-old, four years after an extra-pleural pneumonectomy

This case report characterizes the physiological responses to incremental cycling and determines the effects of 12 weeks of inspiratory muscle training (IMT) on respiratory muscle strength, exercise capacity and dyspnea in a physically active 59-year-old female, four years after a left-sided extra-pleural pneumonectomy (EPP). On separate days, a symptom limited incremental exercise test and a constant work rate (CWR) test at 75% of peak work rate (WR) were completed, followed by 12 weeks of IMT and another CWR test. IMT consisted of two sessions of 30 repetitions twice daily for 5 days per week. Physiological and perceptual variables were measured throughout each exercise test. The participant had a total lung capacity that was 43% predicted post-EPP. A rapid and shallow breathing pattern was adopted throughout exercise, and the ratio of minute ventilation to carbon dioxide output was elevated for a given work rate. Oxygen uptake was 74%predicted and WR was 88%predicted. Following IMT, maximal inspiratory pressure improved by 36% (-27.1 cmH₂O) and endurance time by 31s, with no observable changes in any submaximal or peak cardiorespiratory variables during exercise. The intensity and unpleasantness of dyspnea increased by 2 and 3 Borg 0-10 units, respectively, at the highest equivalent submaximal exercise time achieved on both tests. Despite having undergone a significant reduction in lung volume post-EPP, the participant achieved a relatively normal peak incremental WR, which may reflect a high level of physical conditioning. This case report also demonstrates that IMT can effectively increase respiratory muscle strength several years following EPP.

Correlation and Predicted Equations of MIP/MEP from the Pulmonary Function, Demographics and Anthropometrics in Healthy Thai Participants aged 19 to 50 Years

Objective:

To identify the correlations and possible predicted equations of maximal inspiratory (MIP) and expiratory mouth pressure (MEP) values from pulmonary function test (PFT), demographics, and anthropometrics.

Methods:

This study involved 217 healthy participants (91 males and 126 females) aged 19 to 50 years. The PFT (forced vital capacity; FVC, forced expiratory volume in 1 second; FEV1, maximal mid-expiratory flow; MMEF, and peak expiratory flow; PEF) was performed by spirometry, whereas MIP and MEP were evaluated by a respiratory pressure meter. Pearson correlation and multiple linear regression, with the stepwise method, were used for statistical analysis.

Results:

The MIP and MEP had a significant positive correlation with weight, height, body mass index (BMI), and waist circumference. MIP had a significant positive correlation with FVC (%) and PEF (L/s and %), as well as a negative correlation with FEV1/FVC (ratio and %) and MMEF (%). Whereas, MEP showed a significant positive correlation with PEF (L/s and %) and negative correlation with FEV1/FVC (ratio and %) and MMEF (L/s). Finally, the predicted MIP and MEP equations were 103.988−97.70 × FEV1/FVC + 31.292 × Sex (male = 1 and female = 0) + 0.662 × PEF (%) and 47.384 + 3.603 × PEF (L/s)−9.514 × MMEF(L/s) + 30.458 × Sex (male = 1 and female = 0) + 0.534 × PEF (%), respectively.

Conclusion:

The respiratory muscle strengths can be predicted from the pulmonary function test, and gender data.

Physical Activity as an Imperative Support in Breast Cancer Management

Breast cancer (BC) is the most common malignancy and the second cause of cancer-related death among women. It is estimated that 9 in 10 cases of BC are due to non-genetic factors, and approximately 25% to 30% of total breast cancer cases should be preventable only by lifestyle interventions. In this context, physical activity represents an excellent and accessible approach not only for the prevention, but also for being a potential support in the management of breast cancer. The present review will collect the current knowledge of physical activity in the background of breast cancer, exploring its systemic and molecular effects, considering important variables in the training of these women and the evidence regarding the benefits of exercise on breast cancer survival and prognosis. We will also summarize the various effects of physical activity as a co-adjuvant therapy in women receiving different treatments to deal with its adverse effects. Finally, we will reveal the impact of physical activity in the enhancement of quality of life of these patients, to conclude the central role that exercise must occupy in breast cancer management, in an adequate context of a healthy lifestyle.

Six-minute stepper test in hospitalized elderly patients: Convergent validity, test-retest reliability and safety

OBJECTIVE

To evaluate the convergent validity of the six-minute stepper test (6MST) with the variables used in the diagnosis of sarcopenia (appendicular muscle mass, handgrip strength and six-meter gait speed test), as well as to evaluate test-retest reliability and safety when applied to hospitalized elderly patients. Finally, we aimed to compare the performance in the 6MST between hospitalized elderly patients and healthy elderly from the community.

MATERIALS AND METHODS

Observational and cross-sectional study. Elderly patients admitted to a private hospital and healthy elderly from the community were recruited. On the first day, the patients included underwent the following assessments: anthropometric, handgrip strength (HGS), six-meter gait speed test (6GST) and 6MST. On the second day, before breakfast, patients underwent body composition assessment. The healthy elderly were evaluated on a single day and performed only anthropometric assessment and 6MST.

RESULTS

30 hospitalized patients (age 71.0±7.9 years) and 15 healthy elderly (age 68.1±5.8 years) were included. There was a high correlation of 6MST with 6GST (r = 0.78; p<0.001), moderate correlation with HGS (r = 0.59; p<0.001) and low correlation with appendicular muscle mass (r = 0.45; p = 0.01). There was no statistical difference between the first and second 6MST performed by hospitalized elderly (196.2±91.0 cycles vs. 191.3±103.7 cycles; p = 0.66), in addition to an excellent agreement between these measures (ICC = 0.90; 95% IC 0.78-0.95). Only one adverse event (3.3%) occurred in the sample.

CONCLUSION

6MST showed convergent validity with the functional variables used in the diagnosis of sarcopenia. In addition, excellent test-retest reliability was observed, which indicates the need for a single assessment in hospitalized elderly patients. The prevalence of adverse events during the application of the test is low, without resulting in clinical symptoms; therefore, the test is considered safe for this population. In addition, hospitalized elderly patients perform worse in the 6MST compared to healthy elderly from the community.

Increased C-reactive protein is associated with the severity of thoracic radiotherapy-induced cardiomyopathy

BACKGROUND

Irradiation of the heart during cancer radiotherapy is associated with a dose-dependent risk of heart failure. Animal studies have demonstrated that irradiation leads to an inflammatory response within the heart as well as a reduction in cardiac reserve. In the current study we aimed to evaluate whether inflammatory biomarkers correlated with changes in cardiac function and reserve after radiotherapy for breast or lung cancer.

METHODS AND RESULTS

We studied 25 subjects with a history of breast or lung cancer without a prior diagnosis of cardiovascular disease or heart failure, 1.8 years [0.4-3.6] post-radiotherapy involving at least 5 Gray (Gy) to at least 10% of the heart. High-sensitivity C-reactive protein (CRP) was abnormal (≥2 mg/L) in 16 (64%) subjects. Cardiac function and reserve was measured with Doppler echocardiography before and after exercise and defined as left-ventricular ejection fraction (LVEF), early diastolic mitral annulus velocity (e'), and increase in LV outflow tract velocity time integral cardiac output (cardiac reserve) with exercise. Subjects with abnormal CRP had significantly lower LVEF (51 [44-59] % vs 61 [52-64] %, P = 0.039), lower e' (7.4 [6.6-7.9] cm/sec vs 9.9 [8.3-12.0] cm/sec, P = 0.010), and smaller cardiac reserve (+ 1.5 [1.2-1.7] L/min vs + 1.9 [1.7-2.2] L/min, P = 0.024).

CONCLUSION

Elevated systemic inflammation is associated with impaired left-ventricular systolic and diastolic function both at rest and during exercise in subjects who have received radiotherapy with significant incidental heart dose for the treatment of cancer.