Cardiotoxicity is mitigated after a supervised exercise program in HER2-positive breast cancer undergoing adjuvant trastuzumab

A Call to Action: implementing Cardio-Oncology Rehabilitation Programs for Comprehensive Patient Care

Cancer patients face a significantly higher risk of cardiovascular diseases (CVD), with heart disease mortality rates exceeding those in the general population. Cardio-Oncology Rehabilitation (CORe) programs have emerged as a therapeutic tool, incorporating cardiovascular risk assessment, exercise training, and nutritional guidance. Despite evidence supporting the effectiveness of CORe programs in improving functional capacity, muscle mass, strength, and quality of life, their clinical implementation remains limited. CORe programs are designed similarly to traditional cardiac rehabilitation but tailored to meet the specific needs of cancer patients. They generally include three phases: inpatient (risk stratification and health education), outpatient (including supervised and/or telemonitored exercise), and maintenance (long-term support through collaboration with primary care providers and patient associations). Effective collaboration among medical doctors (e.g., cardiologists, oncologists) and physiotherapists is crucial. CORe programs offer effective strategies for managing and preventing CVD in cancer patients through a comprehensive approach to patient care. Ongoing research is essential to confirm their long-term benefits and support wider clinical implementation. CONTRIBUTION OF THE PAPER.

Effectiveness of exercise-based interventions in preventing cancer therapy-related cardiac dysfunction in patients with breast cancer: A systematic review and network meta-analysis

BACKGROUND

Despite advances in cancer treatment that have improved survival rates among patients with breast cancer, they are at high risk of developing cancer therapy-related cardiac dysfunction, which typically manifests as heart failure. Although exercise improves cardiorespiratory fitness in these patients, its effectiveness in preventing cancer therapy-related cardiac dysfunction remains unclear.

OBJECTIVE

To assess the effectiveness of exercise-based interventions using cardiac function parameters and to identify the optimal exercise modality for preventing cancer therapy-related cardiac dysfunction.

DESIGN

A systematic review and network meta-analysis.

METHODS

A comprehensive search was conducted across PubMed, Embase, Scopus, Web of Science, and the Cochrane Library databases, covering all records from their inception through August 6, 2024. Studies that used exercise-based interventions, either exercise alone or with other interventions, were included. Those with insufficient data for the primary and secondary outcomes were excluded. Quality appraisal was evaluated using the risk of bias tool (RoB-2). All statistical analyses were conducted using the meta (version 7.0-0) and gemtc (version 1.0-2) packages in R software (version 4.3.3). For continuous outcomes, pairwise and network meta-analysis were employed to estimate mean differences (MDs) and 95 % confidence intervals (CI). The Surface Under the Cumulative Ranking Curve (SUCRA) was employed to rank treatments. The study protocol has been registered on PROSPERO (ID: CRD42024501160).

RESULTS

In total, 13 randomized controlled trials involving 1122 participants were included in the review. There was low-to-high risk of bias across thirteen studies. Compared to usual care, exercise-based interventions significantly improved left ventricular ejection fraction (MD, 1.68; 95 % CI, 0.59-2.77) and global longitudinal strain (MD, 1.40; 95 % CI, 0.59-2.21). Based on the ranking probabilities, combined aerobic and resistance exercise was the most efficacious method for improving left ventricular ejection fraction (four studies; SUCRA, 0.96), followed by exercise-based cardio-oncology rehabilitation (two studies; SUCRA, 0.45) and aerobic exercise (four studies; SUCRA, 0.42). In terms of improving global longitudinal strain, combined aerobic and resistance exercise also ranked highest (three studies; SUCRA, 0.88). However, exercise-based cardio-oncology rehabilitation (two studies; SUCRA, 0.47) and aerobic exercise (one study; SUCRA, 0.45) were less effective.

CONCLUSIONS

This network meta-analysis showed very low certainty for the prospective efficacy of exercise-based interventions, especially the combined aerobic and resistance exercise, in preventing cancer therapy-related cardiac dysfunction. Further rigorous studies are required to confirm the effectiveness of exercise-based interventions in preventing cancer therapy-related cardiac dysfunction among patients with breast cancer.

New insights into cardioprotection in breast cancer patients undergoing physical exercise during chemotherapy: A systematic review and meta-analysis

BACKGROUND

Chemotherapy associated with breast cancer often induces cardiotoxicity, which compromises patients' health and quality of life.

OBJECTIVE

To verify the effect of physical exercise on chemotherapy-induced cardiotoxicity, through the assessment of cardiac function in patients with breast cancer.

METHODS

A systematic review and meta-analysis of clinical studies was conducted to evaluate the effectiveness of physical training in chemotherapy-induced cardiomyopathy in the PubMed, Web of Sciences and Scopus databases. Thirteen studies were included in the systematic review and eleven studies in the data meta-analysis.

RESULTS

Global longitudinal strain presents a cardioprotective effect when compared to the control group (Heterogeneity: Chi² = 12.81, df = 10 (p = 0.23); I² = 22 %.) Test for global effect: Z = 2, 13 (p = 0.03). Physical training is more effective (test for subgroup differences, p = 0.031) in attenuating the impairment of %GLS induced by chemotherapy if performed concomitantly with exposure to chemotherapy (95 % CI; Heterogeneity: Chi² = 7.49, gl = 5 (p = 0.19); I² = 33 %; Test for global effect: Z = 2.33 (p = 0.02) when compared after chemotherapy treatment, or in the long term (for 12 months or more). However, without benefits in LVEF (Heterogeneity: Chi² = 42.14, df = 10 (p < 0.00001); I² = 76 %) Test for global effect: Z = 2.51 (p = 0.01) Conclusion: Exercise training is a cardioprotective approach in breast cancer patients who experience chemotherapy-induced cardiotoxicity. Exercise during exposure to chemotherapy has greater effects on preserving cardiac function.

Exercise-based cardio-oncology rehabilitation for cardiotoxicity prevention during breast cancer chemotherapy: The ONCORE randomized controlled trial

BACKGROUND

Breast cancer (BC) treatment with anthracyclines and/or anti-human epidermal growth factor receptor-2 (HER2) antibodies is associated with an increased risk of cardiovascular disease complications, including cancer therapy-related cardiac dysfunction (CTRCD). While Cardio-Oncology Rehabilitation (CORe) programs including exercise have emerged to minimize these risks, its role in preventing CTRCD is unclear.

OBJECTIVES

We investigated the effectiveness of an exercise-based CORe program in preventing CTRCD [left ventricular ejection fraction (LVEF) drop ≥10% to a value <53% or a decrease >15% in global longitudinal strain (GLS)]. Secondary outcomes examined changes in cardiac biomarkers, physical performance including peak oxygen consumption, psychometric and lifestyle outcomes. Safety, adherence, and patient satisfaction were also assessed.

METHODS

This is a randomized controlled trial including 122 early-stage BC women receiving anthracyclines and/or anti-HER2 antibodies, randomized to CORe (n = 60) or usual care with exercise recommendation (n = 62). Comprehensive assessments were performed at baseline and after cardiotoxic treatment completion. The average duration of the intervention was 5.8 months.

RESULTS

No cases of CTRCD were identified during the study. LVEF decreased in both groups, but was significantly attenuated in the CORe group [-1.5% (-2.9, -0.1); p = 0.006], with no changes detected in GLS or cardiac biomarkers. The CORe intervention led to significant body mass index (BMI) reduction (p = 0.037), especially in obese patients [3.1 kg/m2 (1.3, 4.8)]. Physical performance and quality-of-life remained stable, while physical activity level increased in both groups. No adverse events were detected.

CONCLUSIONS

This study suggests that CORe programs are safe and may help attenuate LVEF decline in BC women receiving cardiotoxic therapy and reduce BMI in obese patients.

The efficacy and safety of exercise regimens to mitigate chemotherapy cardiotoxicity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cardiotoxicity is one of the most common adverse events of the chemotherapy. Physical exercise was shown to be cardioprotective. We aim to estimate the efficacy and safety of exercise in cancer patients receiving cardiotoxic chemotherapy.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, Cochrane, Clinical Trials.gov, and MedRxiv through July 17th, 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI).

PROSPERO ID

CRD42023460902.

RESULTS

We included thirteen RCTs with a total of 952 patients. Exercise significantly increased VO2 peak (MD: 1.95 with 95% CI [0.59, 3.32], P = 0.005). However, there was no significant effect regarding left ventricular ejection fraction, global longitudinal strain, cardiac output, stroke volume, left ventricular end-diastolic volume, left ventricular end-systolic volume, E/A ratio, resting heart rate, peak heart rate, resting systolic blood pressure, and resting diastolic blood pressure. Also, there was no significant difference regarding any adverse events (AEs) (RR: 4.44 with 95% CI [0.47, 41.56], P = 0.19), AEs leading to withdrawal (RR: 2.87 with 95% CI [0.79, 10.43], P = 0.11), serious AEs (RR: 3.00 with 95% CI [0.14, 65.90], P = 0.49), or all-cause mortality (RR: 0.25 with 95% CI [0.03, 2.22], P = 0.21).

CONCLUSION

Exercise is associated with increased VO2 peak in cancer patients receiving cardiotoxic chemotherapy. However, there was no significant difference between exercise and usual care regarding the echocardiographic and safety outcomes.

A Review on the Role of Exercise Training to Prevent a Decline in Cardiorespiratory Fitness and Cardiac Function in Breast Cancer Survivors

PURPOSE

Improvements in diagnosis and treatment mean that the long-term health of breast cancer survivors (BCS) is increasingly dictated by cardiovascular comorbidities. This is partly a consequence of exposure to cardiotoxic therapies, which result in cardiac dysfunction and decreased cardiorespiratory fitness (CRF). Exercise training (ExT) is a key therapeutic strategy for secondary prevention and increasing CRF in adults with established cardiovascular disease. Exercise-based cardio-oncology rehabilitation (CORE) has been proposed as an emerging strategy to address CRF and cardiac impairment in BCS. This review aims to (1) provide an overview of the impact of breast cancer therapy on CRF; (2) provide an up-to-date summary of the effects of ExT on CRF and cardiac function in BCS undergoing cardiotoxic therapy; and (3) discuss how traditional ExT approaches can be adapted for BCS undergoing therapy.

REVIEW METHODS

A literature review was performed based on an intensive literature search for systematic reviews and meta-analyses, randomized and non-randomized controlled trials and single-arm trials investigating the impact of exercise training or cardiac rehabilitation on CRF and/or cardiac function in BCS who are undergoing or have completed cardiotoxic cancer therapy.

SUMMARY

Overall, current evidence suggests that ExT induces clinically meaningful benefits for CRF in BCS during and after therapy. There is also emerging evidence that ExT can improve peak exercise measures of cardiac function; however, there is a need for further research to understand how to adapt these effective ExT approaches into clinical CORE-based settings.

Differential Impact of Exercises on Quality-of-Life Improvement in Breast Cancer Survivors: A Network Meta-Analysis of Randomized Controlled Trials

This study aimed to assess the effectiveness of various exercise interventions in enhancing the quality of life for breast cancer survivors. To achieve this, randomized controlled trials were identified from major electronic databases, focusing on the relationship between exercise and quality of life in breast cancer survivors. The primary outcome was the impact of exercise on quality of life 12 weeks after the intervention, with a secondary outcome comparing dropout rates between intervention groups and a regular care control group. The study protocol was registered with INPLASY (INPLASY202340007). A network meta-analysis of nine randomized controlled trials involving 725 participants was conducted, examining aerobic and strength training, aerobic activity, yoga, and strength exercise. Results showed that aerobic and strength training was the most effective intervention, significantly improving the quality of life of breast cancer survivors (1.31; 95% confidence interval: 0.49 to 2.12). Aerobic activity had a borderline effect (0.83; 0.03 to 1.63), while no exercise interventions were associated with an increased dropout risk compared to the control group (regular care). The study concluded that concurrent aerobic and strength training can improve breast cancer survivors' quality of life after 12 weeks of intervention without increasing dropout risk compared to regular care.

A randomized trial to evaluate the effects of a supervised exercise program on insomnia in patients with non-metastatic breast cancer undergoing chemotherapy: design of the FATSOMCAN study

BACKGROUND

Up to 70% of breast cancer patients report symptoms of insomnia during and after treatment. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed and poorly managed in breast cancer patients. Sleep medications treat symptoms but are ineffective to cure insomnia. Other approaches such as cognitive behavioral therapy for insomnia, relaxation through yoga and mindfulness are often not available for patients and are complex to implement. An aerobic exercise program could be a promising treatment and a feasible option for insomnia management in breast cancer patients, but few studies have investigated the effects of such a program on insomnia.

METHODS

This multicenter, randomized clinical trial evaluate the effectiveness of a moderate to high intensity physical activity program (45 min, 3 times per week), lasting 12 weeks, in minimizing insomnia, sleep disturbances, anxiety/depression, fatigue, and pain, and in enhancing cardiorespiratory fitness. Patients with breast cancer be recruited from six hospitals in France and randomly allocated to either the "training" or the "control" group. Baseline assessments include questionnaires [Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index questionnaire (PSQI), Hospital Anxiety Depression Scale (HADS), Epworth Sleepiness Scale (ESS)], home polysomnography (PSG), and 7-day actigraphy coupled with completion of a sleep diary. Assessments are repeated at the end of training program and at six-month follow-up.

DISCUSSION

This clinical trial will provide additional evidence regarding the effectiveness of physical exercise in minimizing insomnia during and after chemotherapy. If shown to be effective, exercise intervention programs will be welcome addition to the standard program of care offered to patients with breast cancer receiving chemotherapy.

TRIAL REGISTRATION

National Clinical Trials Number (NCT04867096).

Feasibility of Aerobic Exercise Training to Mitigate Cardiotoxicity of Breast Cancer Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

Current anticancer treatments for breast cancer (BC) may cause cardiotoxicity. This study aimed to investigate the effectiveness of aerobic exercise in mitigating cardiotoxicity caused by BC therapy.

MATERIALS AND METHODS

PubMed, Embase, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database were searched until February 7, 2023. Clinical trials investigating the effectiveness of exercise training, including aerobic exercise, in BC patients receiving treatments that could cause cardiotoxicity were eligible. Outcome measures included cardiorespiratory fitness (CRF) (peak oxygen consumption, VO₂peak), left ventricular ejection fraction, and peak oxygen pulse. Intergroup differences were determined by standard mean differences (SMD) and 95% confidence intervals (CIs). Trial sequential analysis (TSA) was utilized to ensure whether the current evidence was conclusive.

RESULTS

Sixteen trials involving 876 participants were included. Aerobic exercise significantly improved CRF measured by VO₂peak in mL/kg/min (SMD 1.79, 95% CI 0.99-2.59) when compared to usual care. This result was confirmed through TSA. Subgroup analyses revealed that aerobic exercise given during BC therapy significantly improved VO₂peak (SMD 1.84, 95% CI 0.74-2.94). Exercise prescriptions at a frequency of up to 3 times per week, an intensity of moderate to vigorous, and a >30-minute session length also improved VO₂peak.

CONCLUSION

Aerobic exercise is effective in improving CRF when compared to usual care. Exercise performed up to 3 times per week, at a moderate-to-vigorous intensity, and having a session length >30 minutes is considered effective. Future high-quality research is needed to determine the effectiveness of exercise intervention in preventing cardiotoxicity caused by BC therapy.

Exercise for the Prevention of Anthracycline-Induced Functional Disability and Cardiac Dysfunction: The BREXIT Study

BACKGROUND

Breast cancer survivors treated with anthracycline-based chemotherapy (AC) have increased risk of functional limitation and cardiac dysfunction. We conducted a 12-month randomized controlled trial in 104 patients with early-stage breast cancer scheduled for AC to determine whether 12 months of exercise training (ExT) could attenuate functional disability (primary end point), improve cardiorespiratory fitness (VO₂peak), and prevent cardiac dysfunction.

METHODS

Women 40 to 75 years of age with stage I to III breast cancer scheduled for AC were randomized to 3 to 4 days per week aerobic and resistance ExT for 12 months (n=52) or usual care (UC; n=52). Functional measures were performed at baseline, at 4 weeks after AC (4 months), and at 12 months, comprising: (1) cardiopulmonary exercise testing to quantify VO₂peak and functional disability (VO₂peak ≤18.0 mL·kg^-1·min^-1); (2) cardiac reserve (response from rest to peak exercise), quantified with exercise cardiac magnetic resonance measures to determine changes in left and right ventricular ejection fraction, cardiac output, and stroke volume; (3) standard-of-care echocardiography-derived resting left ventricular ejection fraction and global longitudinal strain; and (4) biochemistry (troponin and BNP [B-type natriuretic peptide]).

RESULTS

Among 104 participants randomized, greater study attrition was observed among UC participants (P=0.031), with 93 women assessed at 4 months (ExT, n=49; UC, n=44) and 87 women assessed at 12 months (ExT, n=49; UC, n=38). ExT attenuated functional disability at 4 months (odds ratio, 0.32 [95% CI, 0.11-0.94]; P=0.03) but not at 12 months (odds ratio, 0.27 [95% CI, 0.06-1.12]; P=0.07). In a per-protocol analysis, functional disability was prevented entirely at 12 months among participants adherent to ExT (ExT, 0% versus UC, 20%; P=0.005). Compared with UC at 12 months, ExT was associated with a net 3.5-mL·kg^-1·min^-1 improvement in VO₂peak that coincided with greater cardiac output, stroke volume, and left and right ventricular ejection fraction reserve (P<0.001 for all). There was no effect of ExT on resting measures of left ventricular function. Postchemotherapy troponin increased less in ExT than in UC (8-fold versus 16-fold increase; P=0.002). There were no changes in BNP in either group.

CONCLUSIONS

In women with early-stage breast cancer undergoing AC, 12 months of ExT did not attenuate functional disability, but provided large, clinically meaningful benefits on VO₂peak and cardiac reserve.

REGISTRATION

URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12617001408370.