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Piper KS, Suetta C, Schou JV, Ryg J, Andersen HE, Langevad LV, Evering D, Mikkelsen MK, Lund C, Christensen J. The SaVe project - Sarcopenia and Vertigo in aging patients with colorectal cancer: A study protocol for three randomized controlled trials. J Geriatr Oncol 2024; 15:101770. [PMID: 38631243 DOI: 10.1016/j.jgo.2024.101770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Older patients with cancer range from fit to frail with various comorbidities and resilience to chemotherapy. Besides nausea and fatigue, a significant number of patients experience dizziness and impaired walking balance after chemotherapy, which can have great impact on their functional ability and health related quality of life. Symptoms are easily overlooked and therefore often underreported and managed, which is why symptoms could end up as long-lasting side effects. The aim of this study is to investigate the development of dizziness, decline in walking balance, and sarcopenia and the effect of a comprehensive geriatric assessment and 12 weeks of group-based exercise on these symptoms. The exercise intervention includes vestibular and balance exercises, and progressive resistance training, to counteract the symptoms in older patients with colorectal cancer treated with chemotherapy. MATERIALS AND METHODS This is a randomized controlled trial including patients ≥65 years initiating (neo)adjuvant or first-line palliative chemotherapy for colorectal cancer. Patients will undergo a comprehensive assessment program including measures of vestibular function, balance, muscle strength, mass, and endurance, peripheral and autonomic nerve function, and subjective measures of dizziness, concern of falling, and health related quality of life. Tests will be performed at baseline, 12, and 24 weeks. Patients will be placed in three different randomized controlled trials depending on chemotherapy regimen and randomized 1:1 to comprehensive geriatric assessment and exercise three times/week or control. Participants in both groups will continue with usual care, including standardized oncological treatment. In total, 150 patients are needed to assess the two primary outcomes of (1) maintenance of walking balance assessed with Dynamic Gait Index and (2) lower limb strength and endurance assessed with 30 Second Sit-to-Stand Test at 12 weeks. The primary outcomes will be analyzed using a mixed linear regression model investigating the between-group differences. DISCUSSION Trial enrollment began in April 2023 and is the first trial to evaluate reasons for dizziness, decline in walking balance, and sarcopenia in older patients receiving chemotherapy. The trial will provide new and valuable knowledge in how to assess, manage, and prevent dizziness, decline in walking balance, and sarcopenia in older patients with colorectal cancer. TRIAL REGISTRATION The Regional Ethics Committee (j.nr. H-22064206). Danish Data Protection Agency (P-2023-86) and ClinicalTrials.gov (NCT05710809).
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Affiliation(s)
- Katrine Storm Piper
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Charlotte Suetta
- CopenAge, Copenhagen Center for Clinical Age Research, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark; Department of Geriatric Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospitals, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Jakob Vasehus Schou
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Jesper Ryg
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark; Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Hanne Elkjær Andersen
- Department of Geriatric Medicine, Copenhagen University Hospital, Amager and Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
| | - Line Vind Langevad
- Department of Geriatric Medicine, Copenhagen University Hospital, Amager and Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
| | - Delaney Evering
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Marta Kramer Mikkelsen
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Cecilia Lund
- CopenAge, Copenhagen Center for Clinical Age Research, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark; Department of Geriatric Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospitals, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark; Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Jan Christensen
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Mikkelsen MK, Jensen HE, Spiegelhauer G, Amdi K, Madsen K, Nybom KS, Holm-Petersen RB, Nielsen D. Satisfaction with and perceived benefits of needs-assessment related to rehabilitation after chemotherapy among patients with breast cancer. Disabil Rehabil 2023:1-10. [PMID: 37345500 DOI: 10.1080/09638288.2023.2225880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
PURPOSE To investigate satisfaction with and perceived benefits of a model of needs-assessment related to rehabilitation (NARR) in women with early breast cancer after (neo)adjuvant chemotherapy. MATERIALS AND METHODS Mixed methods were applied using survey (N = 200) along with interviews (N = 20). The survey included measurement of distress and self-assessed need of and satisfaction with the NARR. Type of experienced side/late effects were registered along with numbers of and reasons for referrals to rehabilitation. Individual semi-structured interviews were conducted. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed with thematic analysis. RESULTS Overall, 217 patients participated in a NARR and 200 (92%) accepted participation in the survey. Furthermore, 20/37 (54%) invited patients were interviewed. After the NARR, 39 patients (20%) were referred to rehabilitation. While satisfaction was high, findings regarding distress and need of the NARR were equivocal and indicated a need for talking about experiences throughout the cancer trajectory. CONCLUSIONS While only 20% had rehabilitation needs, satisfaction with the NARR was high and patients benefitted from being confirmed in normality of their experiences. It is recommended to address patients' side/late effects after chemotherapy for early breast cancer to identify rehabilitation needs, reduce distress, and improve quality of life.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Helle Elisabeth Jensen
- Department of Oncology, Clinical Research Unit, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Guri Spiegelhauer
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Kirsten Amdi
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Kasper Madsen
- Department of Oncology, Clinical Research Unit, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Kirstine Steen Nybom
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Dorte Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
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Andersen HH, Mikkelsen MK, Obarzanek CE, Paludan C, Nielsen D. Reasons for declining participation in an exercise-based trial among older women with breast cancer receiving systemic anti-cancer treatment - a qualitative interview study. Physiother Theory Pract 2023:1-11. [PMID: 36892484 DOI: 10.1080/09593985.2023.2187675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Breast cancer is the most frequently diagnosed cancer in the world. Exercise is widely recommended for patients with breast cancer during and after treatment. However, there is a lack of studies investigating barriers related to participation in real-world exercise-based trials for older patients with breast cancer. OBJECTIVE To explore reasons for declining participation in an exercise-based trial among older patients with breast cancer during (neo)adjuvant or palliative systemic treatment. METHODS A qualitative study using semi-structured interviews. Patients who declined participation in an exercise-based trial (N = 50) were invited to participate. Semi-structured interviews were conducted with 15 participants. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analysis. RESULTS Identified main themes: 1) Lack of energy and resources, including two subthemes: 1a) Overwhelmed both mentally and physically, and 1b) The program is too comprehensive; 2) Uncertainty about reactions to chemotherapy; 3) The hospital is not the optimal exercise setting, including two subthemes: 3a) Transportation and time consumption, and 3b) No desire to spend additional time at the hospital; and 4) Staying active in my own way, including two subthemes: 4a) Motivation to exercise, and 4b) Preferences for exercise activities. CONCLUSION Many barriers were identified, including time of recruitment, information overload, symptoms and side effects, and the hospital as the exercise setting due to practical challenges and negative feelings. Participants were motivated to exercise from knowledge about the benefits of exercising. Furthermore, they preferred activities that they were already involved in or had experience with.
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Affiliation(s)
- Høgni Hammershaimb Andersen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
| | - Marta Kramer Mikkelsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
| | | | - Camilla Paludan
- Institute for Sports and Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Dorte Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
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Dolin TG, Mikkelsen MK, Jakobsen HL, Vinther A, Zerahn B, Nielsen DL, Johansen JS, Lund CM, Suetta C. The prevalence of sarcopenia and cachexia in older patients with localized colorectal cancer. J Geriatr Oncol 2023; 14:101402. [PMID: 36424269 DOI: 10.1016/j.jgo.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The incidence of colorectal cancer (CRC) increases with age. In combination with an ageing population, the number of older patients undergoing surgical treatment for CRC is therefore expected to increase. Sarcopenia and cachexia are potentially modifiable risk factors of a negative surgical outcome. Sarcopenia can be categorized into primary (age-related) and secondary where diseases, such as malignancy, are influential factors. We aimed to investigate the prevalence of preoperative sarcopenia and cachexia in older (≥65 years) vulnerable patients with localized CRC. MATERIALS AND METHODS Patients included in the randomized study "Geriatric assessment and intervention in older vulnerable patients undergoing resection for colorectal cancer," were screened for sarcopenia and cachexia prior to surgery. All patients in the present cohort were considered vulnerable with Geriatric 8 ≤ 14 points. Sarcopenia was defined according to European Guidelines (EWGSOP2), based on low muscle strength-low handgrip-strength and/or slow 5xChair-Stand-Test-and low appendicular lean mass assessed by dual-energy X-ray absorptiometry. Cachexia was defined as self-reported unintended weight loss >5% within three months or 2-5% with body mass index <20 kg/m2. RESULTS Sixty-four patients (mean age 79.6 years ±6.4 years, 36 women) were assessed. Of these, 28% (n = 18, 11 women) had low muscle strength and 13% (n = 8, 4 women) fulfilled the criteria for sarcopenia, however, 33% (n = 21, 13 women) had low muscle mass. There was no correlation between low muscle strength and low muscle mass (r = 0.16, P = 0.22). The prevalence of cachexia was 36% (n = 23, 16 women). Low muscle mass was associated with cachexia (φ = 0.38, P = 0.005), but there was no association between sarcopenia and cachexia (φ = 0.01, P = 1.0). DISCUSSION Despite the included patients who fulfilled the criteria for vulnerability according to G8, relatively few (28%) had low muscle strength. Moreover, there was poor overlap between the prevalence of sarcopenia according to the EWGSOP2 guidelines (13%) and prevalence of low muscle mass (33%) in older patients with CRC. Of note also, there was no association between sarcopenia and cachexia, but an association between cachexia and low muscle mass, which highlights the importance of assessing muscle mass in patients with cancer. TRIAL REGISTRATION The GEPOC trial has been prospectively registered at http://clinicaltrials.gov (NCT03719573).
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Affiliation(s)
- Troels Gammeltoft Dolin
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; CopenAge - Copenhagen Center for Clinical Age Research - University of Copenhagen, Denmark.
| | - Marta Kramer Mikkelsen
- Department of Oncology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Henrik Loft Jakobsen
- Department of Gastrointestinal Surgery, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy - Copenhagen University Hospital, Herlev and Gentofte, Herlev, Denmark; Hospital Secretariat and Communications; Research, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Julia Sidenius Johansen
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; Department of Oncology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Cecilia Margareta Lund
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; CopenAge - Copenhagen Center for Clinical Age Research - University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Charlotte Suetta
- Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Herlev and Gentofte, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Geriatric Research Unit, Department of Geriatric and Palliative Medicine, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark
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Mikkelsen MK, Lindblom NAF, Dyhl-Polk A, Juhl CB, Johansen JS, Nielsen D. Systematic review and meta-analysis of C-reactive protein as a biomarker in breast cancer. Crit Rev Clin Lab Sci 2022; 59:480-500. [PMID: 35403550 DOI: 10.1080/10408363.2022.2050886] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Inflammation is an enabling characteristic of the hallmarks of cancer. There has therefore been increasing interest in the clinical value of circulating inflammatory biomarkers in cancer. In this review, we summarize results on C-reactive protein (CRP), alone or as part of the Glasgow Prognostic Score (GPS, composed of CRP and serum albumin), as a biomarker of prognosis or prediction and monitoring of therapeutic response in patients with breast cancer. A systematic literature search was performed in Medline and Embase from 1990 to August 2021. The association of serum CRP and overall survival and disease/progression-free survival was summarized in meta-analyses using a random effects model. The results from a total of 35 included studies (20,936 patients) were divided according to three identified patient settings (metastatic, non-metastatic, and general setting). Most of the studies examined prognostic utility. Several larger studies observed associations between high serum CRP and poor survival, but the meta-analyses suggested a limited value in a non-metastatic and general breast cancer setting (populations with unknown or varied disease stage). In metastatic patients, however, more consistent findings supported an association between serum CRP and prognosis (hazard ratio for overall survival: 1.87 (95% CI 1.31-2.67). Only five studies examined a role in prediction or monitoring of therapeutic response. One study reported a significant association between serum CRP levels and response to chemotherapy. Findings regarding serum CRP as a biomarker in breast cancer appear inconsistent, particularly in non-metastatic and general breast cancer, where the prognostic value could not be confirmed. In patients with metastatic breast cancer we suggest that high serum CRP is an indicator of poor prognosis. Too few studies assessed the role of serum CRP in prediction or monitoring of treatment response to allow conclusions.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | | | - Anne Dyhl-Polk
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Carsten Bogh Juhl
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Holmen Olofsson G, Mikkelsen MK, Ragle AM, Christiansen AB, Olsen AP, Heide-Ottosen L, Horsted CB, Pedersen CMS, Engell-Noerregaard L, Lorentzen T, Persson GF, Vinther A, Nielsen DL, thor Straten P. High Intensity Aerobic exercise training and Immune cell Mobilization in patients with lung cancer (HI AIM)—a randomized controlled trial. BMC Cancer 2022; 22:246. [PMID: 35247994 PMCID: PMC8897734 DOI: 10.1186/s12885-022-09349-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/28/2022] [Indexed: 12/30/2022] Open
Abstract
Background The increasing role of exercise training in cancer care is built on evidence that exercise can reduce side effects of treatment, improve physical functioning and quality of life. We and others have shown in mouse tumor models, that exercise leads to an adrenalin-mediated increased influx of T and NK cells into the tumor, altering the tumor microenvironment (TME) and leading to reduced tumor growth. These data suggest that exercise could improve immune responses against cancer cells by increase immune cell infiltration to the tumor and potentially having an impact on disease progression. Additionally, there are data to suggest that infiltration of T and NK cells into the TME is correlates with response to immune checkpoint inhibitors in patients. We have therefore initiated the clinical trial HI AIM, to investigate if high intensity exercise can mobilize and increase infiltration of immune cells in the TME in patients with lung cancer. Methods HI AIM (NCT04263467) is a randomized controlled trial (70 patients, 1:1) for patients with non-small cell lung cancer. Patients in the treatment arm, receive an exercise-intervention consisting of supervised and group-based exercise training, comprising primarily intermediate to high intensity interval training three times per week over 6 weeks. All patients will also receive standard oncological treatments; checkpoint inhibitors, checkpoint inhibitors combined with chemotherapy or oncological surveillance. Blood samples and biopsies (ultrasound guided), harvested before, during and after the 6-week training program, will form basis for immunological measurements of an array of immune cells and markers. Primary outcome is circulating NK cells. Secondary outcome is other circulating immune cells, infiltration of immune cells in tumor, inflammatory markers, aerobic capacity measured by VO2 max test, physical activity levels and quality of life measured by questionnaires, and clinical outcomes. Discussion To our knowledge, HI AIM is the first project to combine supervised and monitored exercise in patients with lung cancer, with rigorous analyses of immune and cancer cell markers over the course of the trial. Data from the trial can potentially support exercise as a tool to mobilize cells of the immune system, which in turn could potentiate the effect of immunotherapy. Trial registration The study was prospectively registered at ClinicalTrials.gov on February 10th 2020, ID: NCT04263467. https://clinicaltrials.gov/ct2/show/NCT04263467
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Lund CM, Mikkelsen MK, Theile S, Michelsen HM, Schultz M, Sengeløv L, Nielsen DL. Age-related Differences in Recall of Information and Handling of Chemotherapy-related Side Effects in Cancer Patients: The ReCap Study. Oncologist 2022; 27:e185-e193. [PMID: 35641212 PMCID: PMC8895734 DOI: 10.1093/oncolo/oyab034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/23/2021] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
To prevent severe toxicity and hospital admissions, adequate management and recall of information about side effects are crucial and health literacy plays an important role. If age-related factors impact recall of given information and handling of side effects, revised ways to give information are required.
Patients and Methods
We undertook a questionnaire-based survey among 188 newly diagnosed patients with pancreatic cancer or colorectal cancer and chemo-naive patients with prostate cancer treated with adjuvant or first-line palliative chemotherapy comprising satisfaction with given information, recall of potential side effects, and handling of hypothetical side effect scenarios. We evaluated the association between baseline characteristics, ie, age, frailty (G8 score), comorbidity (Charlson Comorbidity Index), cognitive function (Mini-Cog), satisfaction, recall of information, and handling of side effects.
Results
Reduced ability to recall information about several side effects (eg, chest pain) was associated with older age (odds ratio adjusted for cancer [aOR] 0.94 [95% CI, 0.88-0.98]) and poor cognitive screening (aOR 0.56 [95% CI, 0.33-0.91]). Insufficient or dangerous handling of side effects was associated with older age (aOR 0.96 (95% CI, 0.92-0.99)) and cognitive impairment (aOR 0.70 [95% CI, 0.50-0.95]).
Conclusion
Older age and poor cognitive screening may impact patients’ ability to understand and adequately handle chemotherapy-related side effects. Cognitive screening and focus on individual ways to give information including assessment of recall and handling are needed.
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Affiliation(s)
- Cecilia Margareta Lund
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte, Copenhagen, Denmark
- CopenAge, Copenhagen Center for Clinical Age Research, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - M K Mikkelsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - S Theile
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - H M Michelsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - M Schultz
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte, Copenhagen, Denmark
- CopenAge, Copenhagen Center for Clinical Age Research, University of Copenhagen, Copenhagen, Denmark
| | - L Sengeløv
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - D L Nielsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
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Dyhl-Polk A, Mikkelsen MK, Ladekarl M, Nielsen DL. Clinical Trials of Immune Checkpoint Inhibitors in Hepatocellular Carcinoma. J Clin Med 2021; 10:2662. [PMID: 34208788 PMCID: PMC8234948 DOI: 10.3390/jcm10122662] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction: Several immune checkpoint inhibitors (CPIs) are under clinical development in hepatocellular carcinoma (HCC) and the field is advancing rapidly. In this comprehensive review, we discuss published results and report on ongoing clinical trials. Methods: A literature search was carried out using PubMed and EMBASE; data reported at international meetings and clinicaltrials.gov were included as well. The search was updated 5 March 2021. We evaluated studies with monotherapy CPI's, combinations of CPI's and combinations of CPI's with other treatment modalities separately. Only studies with at least 10 included patients were considered. Results: We identified 2649 records published in the English language literature. After review, 29 studies remained, including 12 studies with preliminary data only. The obtained overall response rate of PD-1/PDL-1 monotherapy in phase II studies in the second-line setting was 15-20% with disease control in approximately 60% of patients. The responses were of long duration in a subset of patients. Furthermore, the safety profiles were manageable. However, a phase III study comparing nivolumab with sorafenib in the first-line setting and a phase III study evaluating pembrolizumab versus best supportive care in the second-line setting did not meet their prespecified endpoints. More recently, a phase I/II study of nivolumab and ipilimumab has resulted in a response rate of approximately 30% with a median OS of 22 months in the second-line setting. Multiple trials have been initiated to evaluate CPIs in combination with molecularly targeted drugs, especially anti-angiogenic drugs or local therapy. A phase III study investigating atezolizumab plus bevacizumab versus sorafenib in the first-line setting showed significantly increased survival in the combination arm. Conclusions: The combination of atezolizumab and bevacizumab represents a new standard of care in the first-line setting for fit patients with preserved liver function. CPIs can produce durable tumor remission and induce long-standing anti-tumor immunity in a subgroup of patients with advanced HCC. Although phase III trials of CPI monotherapy have been negative, the combination of PD-1/PD-L1 inhibitors with other anti-angiogenic drugs, CTLA-4 inhibitors or other modalities may result in new treatment options for patients with HCC. Research on predictive biomarkers is crucial for further development of CPIs in HCC.
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Affiliation(s)
- Anne Dyhl-Polk
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; (M.K.M.); (D.L.N.)
| | - Marta Kramer Mikkelsen
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; (M.K.M.); (D.L.N.)
| | - Morten Ladekarl
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Hobrovej 19-22, 9000 Aalborg, Denmark;
| | - Dorte Lisbet Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; (M.K.M.); (D.L.N.)
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Mikkelsen MK, Juhl CB, Lund CM, Jarden M, Vinther A, Nielsen DL. The effect of exercise-based interventions on health-related quality of life and physical function in older patients with cancer receiving medical antineoplastic treatments: a systematic review. Eur Rev Aging Phys Act 2020; 17:18. [PMID: 33088348 PMCID: PMC7574419 DOI: 10.1186/s11556-020-00250-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 10/08/2020] [Indexed: 12/25/2022] Open
Abstract
Older patients with cancer are underrepresented in trials investigating the effect of exercise therapy. The aim of this systematic review was to investigate the effect of exercise therapy during medical antineoplastic treatment in older patients (≥ 65 years) with cancer. A systematic review following the Cochrane guidelines was performed. Randomized controlled trials were identified through a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL up to December 2019. Study selection was performed independently by two reviewers. Four randomized controlled trials published between 2014 and 2019 were included comprising a total of 412 participants. Most participants were diagnosed with breast, prostate or colorectal cancer. The studies were characterized by large differences in design, interventions and outcomes, which prevented meta-analyses. The interventions ranged from 4 weeks to 12 months and involved both supervised and unsupervised exercise programs. Some evidence of beneficial effects from the interventions were documented on physical function, muscle strength, physical activity and cognitive function. No evidence of effects was found for health-related quality of life, aerobic capacity, body composition, cancer-related symptoms and side effects, or for any clinical outcomes. No adverse events were reported. Exercise therapy seems to be safe and feasible in older patients with cancer. However, due to a limited number of studies, small sample sizes and heterogeneity across study design, the effects of exercise in older patients with cancer receiving medical antineoplastic treatment are inconclusive.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology and Hematology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.,Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Carsten Bogh Juhl
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
| | - Cecilia Margareta Lund
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Mary Jarden
- Department of Oncology and Hematology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.,QD-Research Unit, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
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Andersen HH, Mikkelsen MK, Lundager I, Lund CM, Johansen JS, Vinther A, Bogh Juhl C, Zerahn B, Ragle AM, Nielsen DL. Exercise in older women with breast cancer during systemic therapy: study protocol of a randomised controlled trial (BREACE). BMJ Open 2020; 10:e038674. [PMID: 33033025 PMCID: PMC7542931 DOI: 10.1136/bmjopen-2020-038674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/05/2020] [Accepted: 08/12/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Exercise interventions have been widely investigated in patients with cancer and demonstrate beneficial effects. However, intervention studies that include older women with breast cancer exercising during medical treatment are scarce. Hence, the aim of this study is to investigate the effect of a 12-week exercise-based intervention in older women (≥65 years) with breast cancer receiving (neo)adjuvant or first-line or second-line systemic therapy. METHODS AND ANALYSIS This is a single-centre, two-armed randomised controlled trial. We anticipate including 100 patients, who will be randomised 1:1 to exercise-based intervention or control stratified by treatment setting ((neo)adjuvant or metastatic) and treatment (chemotherapy or endocrine therapy + cyclin-dependent kinase (CDK) 4/6 inhibitors). The intervention group will receive standard oncological treatment and a 12-week supervised exercise-based intervention comprising a progressive resistance exercise programme two times per week, a protein supplement after exercise and a home-based walking programme based on daily step counts. The control group will receive standard oncological treatment. Assessments will be performed at baseline and 6, 12 and 24 weeks after start of the intervention. Primary outcome is physical function, measured by the 30-second Chair Stand Test. Secondary outcomes are feasibility (compliance and adherence to intervention), objective and patient-reported functional measures (6-meter and 10-meter gait speed; 6-min Walk Test; Handgrip Strength; Stair Climb Test; Physical Activity Questionnaire), symptom burden and well-being (MD Anderson Symptom Inventory; Hospital Anxiety and Depression Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and B23), body composition (dual-energy X-ray absorptiometry scan), side effects, inflammatory biomarkers, hospitalisation and survival. ETHICS AND DISSEMINATION The protocol was reviewed and accepted by the Scientific Ethics Review Committee of the Capital Region of Denmark, 17 June 2018 (VEK ref.: H-18021013). Trial results will be submitted for publication in a peer-reviewed journal and presented on conferences, in oncology wards, exercise centres in municipalities and patient organisations, ensuring dissemination to relevant stakeholders. TRIAL REGISTRATION NUMBER https://clinicaltrials.gov/ on 3 September 2018. Identifier: NCT03656731.
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Affiliation(s)
- Høgni Hammershaimb Andersen
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Oncology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Marta Kramer Mikkelsen
- Department of Oncology, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Oncology and Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Ida Lundager
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte University Hospital, Herlev, Denmark
| | | | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Medicine, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte University Hospital, Herlev, Denmark
- QD-Research Unit, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Carsten Bogh Juhl
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte University Hospital, Hellerup, Denmark
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Anne-Mette Ragle
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Herlev and Gentofte University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
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Mikkelsen MK, Nielsen DL, Vinther A, Lund CM, Jarden M. Attitudes towards physical activity and exercise in older patients with advanced cancer during oncological treatment - A qualitative interview study. Eur J Oncol Nurs 2019; 41:16-23. [PMID: 31358249 DOI: 10.1016/j.ejon.2019.04.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE Older patients with cancer are underrepresented in exercise-based trials. To engage older patients in physical activity (PA), it is necessary to consider age-related decline in health, comorbidities and practicalities. The study aim was to explore attitudes towards PA and exercise among older patients with cancer to inform future exercise-based interventions. METHOD Individual interviews (N = 23) were conducted in patients ≥ 65 years with advanced lung, biliary tract and pancreatic cancer receiving palliative oncological treatment. Patients were recruited with a purposive sampling strategy. A semi-structured interview guide focusing on attitudes towards PA and exercise, including barriers, facilitators and motivators, was used. Data on the informants' medical history, demographics and PA level was collected. RESULTS Identified themes were: 1) a general positive perception of physical activity is expressed 2) comorbidities and external circumstances prevent physical activity, 3) fatigue overshadows life, 4) social support is key to short and long-term motivation, 5) fixed conditions keep one focused, 6) familiarity raises confidence and motivation. CONCLUSIONS Even though perceptions of PA were positive among older patients with cancer, most struggled to stay physically active during oncological treatment. Several factors related to cancer and aging were identified as barriers; most profoundly was the overwhelming feeling of fatigue. Improving physical and mental well-being, fixed conditions (e.g. group-based exercise and supervision) and social support were identified as motivators and facilitators. Preferences for PA varied, but activities that were familiar increased motivation. Exercise programs for older patients with cancer must be adjustable to each patient's limitations, needs and personal resources.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology and Hematology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark; Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Dorte Lisbet Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark; QD-Research Unit, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Cecilia Margareta Lund
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Mary Jarden
- Department of Oncology and Hematology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
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Mikkelsen MK, Lund CM, Vinther A, Tolver A, Ragle AM, Johansen JS, Chen I, Engell-Noerregaard L, Larsen FO, Zerahn B, Nielsen DL, Jarden M. Engaging the older cancer patient; Patient Activation through Counseling, Exercise and Mobilization - Pancreatic, Biliary tract and Lung cancer (PACE-Mobil-PBL) - study protocol of a randomized controlled trial. BMC Cancer 2018; 18:934. [PMID: 30261853 PMCID: PMC6161425 DOI: 10.1186/s12885-018-4835-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/18/2018] [Indexed: 01/06/2023] Open
Abstract
Background Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy. Methods PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks. Discussion The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field. Trial registration The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200). Electronic supplementary material The online version of this article (10.1186/s12885-018-4835-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology and Hematology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark. .,Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Cecilia Margareta Lund
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, Herlev, 2730, Denmark
| | - Anders Vinther
- Department of Rehabilitation, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,QD-Research Unit, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Anders Tolver
- Data Science Laboratory, Department of Mathematical Sciences, University of Copenhagen, 2100 Copenhagen Ø, Denmark
| | - Anne-Mette Ragle
- Department of Rehabilitation, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, Herlev, 2730, Denmark
| | - Inna Chen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Lotte Engell-Noerregaard
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Finn Ole Larsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Mary Jarden
- Department of Oncology and Hematology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, 1014 Copenhagen K, Denmark
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Mikkelsen MK, Thomsen FB, Berg KD, Jarden M, Larsen SB, Hansen RB, Brasso K. Associations between statin use and progression in men with prostate cancer treated with primary androgen deprivation therapy. Scand J Urol 2017; 51:464-469. [DOI: 10.1080/21681805.2017.1362032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Frederik Birkebæk Thomsen
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen N, Denmark
| | - Kasper Drimer Berg
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen N, Denmark
| | - Mary Jarden
- University Hospitals Center for Health Research, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Signe Benzon Larsen
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen N, Denmark
- Danish Cancer Society Research Center, Copenhagen Ø, Denmark
| | - Rikke Bølling Hansen
- Department of Urology, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Klaus Brasso
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen N, Denmark
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