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Scott JM, Lee J, Michalski MG, Batch K, Simpson AL, Peoples J, Lee CP, Harrison JN, Yu AF, Sasso JP, Dang C, Moskowitz CS, Jones LW, Eves ND. Mechanisms of Exercise Intolerance Across the Breast Cancer Continuum: A Pooled Analysis of Individual Patient Data. Med Sci Sports Exerc 2024; 56:590-599. [PMID: 38485730 PMCID: PMC10948020 DOI: 10.1249/mss.0000000000003348] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
PURPOSE The purpose of this study is to evaluate the prevalence of abnormal cardiopulmonary responses to exercise and pathophysiological mechanism(s) underpinning exercise intolerance across the continuum of breast cancer (BC) care from diagnosis to metastatic disease. METHODS Individual participant data from four randomized trials spanning the BC continuum ([1] prechemotherapy [n = 146], [2] immediately postchemotherapy [n = 48], [3] survivorship [n = 138], and [4] metastatic [n = 47]) were pooled and compared with women at high-risk of BC (BC risk; n = 64). Identical treadmill-based peak cardiopulmonary exercise testing protocols evaluated exercise intolerance (peak oxygen consumption; V̇O2peak) and other resting, submaximal, and peak cardiopulmonary responses. The prevalence of 12 abnormal exercise responses was evaluated. Graphical plots of exercise responses were used to identify oxygen delivery and/or uptake mechanisms contributing to exercise intolerance. Unsupervised, hierarchical cluster analysis was conducted to explore exercise response phenogroups. RESULTS Mean V̇O2peak was 2.78 ml O2.kg-1·min-1 (95% confidence interval [CI], -3.94, -1.62 mL O2.kg-1·min-1; P < 0.001) lower in the pooled BC cohort (52 ± 11 yr) than BC risk (55 ± 10 yr). Compared with BC risk, the pooled BC cohort had a 2.5-fold increased risk of any abnormal cardiopulmonary response (odds ratio, 2.5; 95% confidence interval, 1.2, 5.3; P = 0.014). Distinct exercise responses in BC reflected impaired oxygen delivery and uptake relative to control, although considerable inter-individual heterogeneity within cohorts was observed. In unsupervised, hierarchical cluster analysis, six phenogroups were identified with marked differences in cardiopulmonary response patterns and unique clinical characteristics. CONCLUSIONS Abnormal cardiopulmonary response to exercise is common in BC and is related to impairments in oxygen delivery and uptake. The identification of exercise response phenogroups could help improve cardiovascular risk stratification and guide investigation of targeted exercise interventions.
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Affiliation(s)
- Jessica M. Scott
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Jasme Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Anthony F. Yu
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | - Chau Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Chaya S. Moskowitz
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Lee W. Jones
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Neil D. Eves
- University of British Columbia, Kelowna, BC, CANADA
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Scott JM, Lee J, Herndon JE, Michalski MG, Lee CP, O’Brien KA, Sasso JP, Yu AF, Rowed KA, Bromberg JF, Traina TA, Gucalp A, Sanford RA, Gajria D, Modi S, Comen EA, D'Andrea G, Blinder VS, Eves ND, Peppercorn JM, Moskowitz CS, Dang CT, Jones LW. Timing of exercise therapy when initiating adjuvant chemotherapy for breast cancer: a randomized trial. Eur Heart J 2023; 44:4878-4889. [PMID: 36806405 PMCID: PMC10702461 DOI: 10.1093/eurheartj/ehad085] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS The most appropriate timing of exercise therapy to improve cardiorespiratory fitness (CRF) among patients initiating chemotherapy is not known. The effects of exercise therapy administered during, following, or during and following chemotherapy were examined in patients with breast cancer. METHODS AND RESULTS Using a parallel-group randomized trial design, 158 inactive women with breast cancer initiating (neo)adjuvant chemotherapy were allocated to receive (1:1 ratio): usual care or one of three exercise regimens-concurrent (during chemotherapy only), sequential (after chemotherapy only), or concurrent and sequential (continuous) (n = 39/40 per group). Exercise consisted of treadmill walking three sessions/week, 20-50 min at 55%-100% of peak oxygen consumption (VO2peak) for ≈16 (concurrent, sequential) or ≈32 (continuous) consecutive weeks. VO2peak was evaluated at baseline (pre-treatment), immediately post-chemotherapy, and ≈16 weeks after chemotherapy. In intention-to-treat analysis, there was no difference in the primary endpoint of VO2peak change between concurrent exercise and usual care during chemotherapy vs. VO2peak change between sequential exercise and usual care after chemotherapy [overall difference, -0.88 mL O2·kg-1·min-1; 95% confidence interval (CI): -3.36, 1.59, P = 0.48]. In secondary analysis, continuous exercise, approximately equal to twice the length of the other regimens, was well-tolerated and the only strategy associated with significant improvements in VO2peak from baseline to post-intervention (1.74 mL O2·kg-1·min-1, P < 0.001). CONCLUSION There was no statistical difference in CRF improvement between concurrent vs. sequential exercise therapy relative to usual care in women with primary breast cancer. The promising tolerability and CRF benefit of ≈32 weeks of continuous exercise therapy warrant further evaluation in larger trials.
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Affiliation(s)
- Jessica M Scott
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Jasme Lee
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, 8020 Hock Plaza, Durham, NC 27705, USA
| | - Meghan G Michalski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Catherine P Lee
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Kelly A O’Brien
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - John P Sasso
- School of Health and Exercise Sciences, University of British Columbia, 1147 Research Road, Kelowna, BC V1V 1V7, Canada
| | - Anthony F Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Kylie A Rowed
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jacqueline F Bromberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Tiffany A Traina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Ayca Gucalp
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Rachel A Sanford
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Devika Gajria
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Shanu Modi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Elisabeth A Comen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Gabriella D'Andrea
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Victoria S Blinder
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Neil D Eves
- School of Health and Exercise Sciences, University of British Columbia, 1147 Research Road, Kelowna, BC V1V 1V7, Canada
| | - Jeffrey M Peppercorn
- Division of Hematology/Oncology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Chaya S Moskowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
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Scott JM, Thomas SM, Herndon JE, Douglas PS, Yu AF, Rusch V, Huang J, Capaci C, Harrison JN, Stoeckel KJ, Nilsen T, Edvardsen E, Michalski MG, Eves ND, Jones LW. Effects and tolerability of exercise therapy modality on cardiorespiratory fitness in lung cancer: a randomized controlled trial. J Cachexia Sarcopenia Muscle 2021; 12:1456-1465. [PMID: 34658160 PMCID: PMC8718021 DOI: 10.1002/jcsm.12828] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 09/01/2021] [Accepted: 09/11/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Poor cardiorespiratory fitness (CRF) is a cardinal feature of post-treatment primary lung cancer. The most effective exercise therapy regimen to improve CRF has not been determined. METHODS In this parallel-group factorial randomized controlled trial, lung cancer survivors with poor CRF (below age-sex sedentary values) were randomly allocated to receive 48 consecutive supervised sessions thrice weekly of (i) aerobic training (AT)-cycle ergometry at 55% to >95% of peak oxygen consumption (VO2 peak); (ii) resistance training (RT)-lower and upper extremity exercises at 50-85% of maximal strength; (iii) combination training (CT)-AT plus RT; or (iv) stretching attention control (AC) for 16 weeks. The primary endpoint was change in CRF (VO2 peak, mL O2 ·kg-1 ·min-1 ). Secondary endpoints were body composition, muscle strength, patient-reported outcomes, tolerability (relative dose intensity of exercise), and safety. Analysis of covariance determined change in primary and secondary endpoints from baseline to post-intervention (Week 17) with adjustment for baseline values of the endpoint and other relevant clinical covariates. RESULTS Ninety patients (65 ± 9 years; 66% female) were randomized (AT, n = 24; RT, n = 23; CT, n = 20; and AC, n = 23) of the planned n = 160. No serious adverse events were observed. For the overall cohort, the lost-to-follow-up rate was 10%. Mean attendance was ≥75% in all groups. In intention-to-treat analysis, VO2 peak increased 1.1 mL O2 ·kg-1 ·min-1 [95% confidence interval (CI): 0.0, 2.2, P = 0.04] and 1.4 mL O2 ·kg-1 ·min-1 (95% CI: 0.2, 2.5, P = 0.02) in AT and CT, respectively, compared with AC. There was no difference in VO2 peak change between RT and AC (-0.1 mL O2 ·kg-1 ·min-1 , 95% CI: -1.2, 1.0, P = 0.88). Favourable improvements in maximal strength and body composition were observed in RT and CT groups compared with AT and AC groups (Ps < 0.05). No between-group changes were observed for any patient-reported outcomes. Relative dose intensity of exercise was lower in RT and CT compared with AT (Ps < 0.05). CONCLUSIONS In the context of a smaller than planned sample size, AT and CT significantly improved VO2 peak in lung cancer survivors; however, the tolerability-to-benefit ratio was superior for AT and hence may be the preferred modality to target impaired CRF in post-treatment lung cancer survivors.
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Affiliation(s)
- Jessica M Scott
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | | | | | | | - Anthony F Yu
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Valerie Rusch
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - James Huang
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | | | | | | | - Tormod Nilsen
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Elisabeth Edvardsen
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | | | - Neil D Eves
- University of British Columbia, Kelowna, BC, Canada
| | - Lee W Jones
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Scott JM, Thomas SM, Peppercorn JM, Herndon JE, Douglas PS, Khouri MG, Dang CT, Yu AF, Catalina D, Ciolino C, Capaci C, Michalski MG, Eves ND, Jones LW. Effects of Exercise Therapy Dosing Schedule on Impaired Cardiorespiratory Fitness in Patients With Primary Breast Cancer: A Randomized Controlled Trial. Circulation 2020; 141:560-570. [PMID: 32065769 DOI: 10.1161/circulationaha.119.043483] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Current exercise guidelines for clinical populations recommend an exercise therapy (ET) prescription of fixed intensity (moderate), duration (40-50 minutes per session), and volume (120-160 min/wk). A critical overarching element of exercise programming that has received minimal attention is dose scheduling. We investigated the tolerability and efficacy of 2 exercise training dose regimens on cardiorespiratory fitness and patient-reported outcomes in patients with posttreatment primary breast cancer. METHODS Using a parallel-group randomized trial, we randomly allocated 174 postmenopausal patients (2.8 years after adjuvant therapy) with impaired peak oxygen consumption (VO2peak) to 1 of 2 supervised exercise training interventions delivered with a standard linear (LET) (fixed dose intensity per session for 160 min/wk) or nonlinear (NLET) (variable dose intensity per session for ≈120 min/wk) schedule compared with a stretching attention control group for 16 consecutive weeks. Stretching was matched to exercise dosing arms on the basis of location, frequency, duration, and treatment length. The primary end point was change in VO2peak (mL O2·kg-1·min-1) from baseline to after intervention. Secondary end points were patient-reported outcomes, tolerability, and safety. RESULTS No serious adverse events were observed. Mean attendance was 64%, 75%, and 80% for attention control, LET, and NLET, respectively. In intention-to-treat analysis, VO2peak increased 0.6±1.7 mL O2·kg-1·min-1 (P=0.05) and 0.8±1.8 mL O2·kg-1·min-1 (P=0.07) in LET and NLET, respectively, compared with attention control. Change in VO2peak ranged from -2.7 to 4.1 mL O2·kg-1·min-1 and from -3.6 to 5.1 mL O2·kg-1·min-1 in LET and NLET, respectively. Approximately 40% of patients in both exercise dosing regimens were classified as VO2peak responders (ie, Δ ≥1.32 mL O2·kg-1·min-1). NLET improved all patient-reported outcomes compared with attention control. CONCLUSIONS Short-term exercise training, independently of dosing schedule, is associated with modest improvements in cardiorespiratory fitness in patients previously treated for early-stage breast cancer. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01186367.
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Affiliation(s)
- Jessica M Scott
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Samantha M Thomas
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Jeffrey M Peppercorn
- Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.).,Massachusetts General Hospital Cancer Center, Boston (J.M.P.)
| | - James E Herndon
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Pamela S Douglas
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Michel G Khouri
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.).,Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.)
| | - Anthony F Yu
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Diane Catalina
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Cristi Ciolino
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Catherine Capaci
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Meghan G Michalski
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Neil D Eves
- University of British Columbia, Kelowna, British Columbia, Canada (N.D.E.)
| | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.).,Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.)
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Jones LW, Devlin SM, Maloy MA, Wood WA, Tuohy S, Espiritu N, Aquino J, Kendig T, Michalski MG, Gyurkocza B, Schaffer WL, Ali B, Giralt S, Jakubowski AA. Prognostic Importance of Pretransplant Functional Capacity After Allogeneic Hematopoietic Cell Transplantation. Oncologist 2015; 20:1290-7. [PMID: 26446235 DOI: 10.1634/theoncologist.2015-0200] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/18/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the prognostic importance of functional capacity in patients undergoing allogeneic hematopoietic cell transplantation (HCT) for hematological malignancies. PATIENTS AND METHODS Using a retrospective design, 407 patients completed a 6-minute walk distance (6 MWD) test to assess functional capacity before HCT; 193 (47%) completed a 6 MWD test after hospital discharge. Cox proportional hazards regression was used to estimate the risk of nonrelapse mortality (NRM) and overall survival (OS) according to the 6 MWD category (<400 m vs. ≥ 400 m) and the change in 6 MWD (before HCT to discharge) with or without adjustment for Karnofsky performance status (KPS), age, and other prognostic markers. RESULTS Compared with <400 m, the unadjusted hazard ratio for NRM was 0.65 (95% confidence interval, 0.44-0.96) for a 6 MWD ≥ 400 m. A 6 MWD of ≥ 400 m provided incremental information on the prediction of NRM with adjustment for age (p = .032) but not KPS alone (p = .062) or adjustment for other prognostic markers (p = .099). A significant association was found between the 6 MWD and OS (p = .027). A 6 MWD of ≥ 400 m provided incremental information on the prediction of OS with adjustment for age (p = .032) but not for other prognostic markers (p > .05 for all). Patients presenting with a pre-HCT 6 MWD of <400 m and experiencing a decline in 6 MWD had the highest risk of NRM. CONCLUSION The 6 MWD is a significant univariate predictor of clinical outcomes but did not provide prognostic information beyond that of traditional prognostic markers in HCT. IMPLICATIONS FOR PRACTICE The pretransplant 6-minute walk test is a significant univariate predictor of clinical outcomes in hematological patients beyond age but not beyond that of performance status. On this basis, 6-minute walk distance testing should not be considered part of the standard battery of assessments for risk stratification before hematopoietic cell transplantation.
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Affiliation(s)
- Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Sean M Devlin
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Molly A Maloy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sharlynn Tuohy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Noel Espiritu
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Jennifer Aquino
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Tiffany Kendig
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Meghan G Michalski
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Boglarka Gyurkocza
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Wendy L Schaffer
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Benzar Ali
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York, USA Weill Cornell Medical College, Cornell University, New York, New York, USA
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