Multiple organizations around the world have issued evidence‐based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its ...exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health‐related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home‐based or community‐based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.
We evaluated the effectiveness of a low-intensity, home-based physical activity program (Onco-Move) and a moderate- to high-intensity, combined supervised resistance and aerobic exercise program ...(OnTrack) versus usual care (UC) in maintaining or enhancing physical fitness, minimizing fatigue, enhancing health-related quality of life, and optimizing chemotherapy completion rates in patients undergoing adjuvant chemotherapy for breast cancer.
We randomly assigned patients who were scheduled to undergo adjuvant chemotherapy (N = 230) to Onco-Move, OnTrack, or UC. Performance-based and self-reported outcomes were assessed before random assignment, at the end of chemotherapy, and at the 6-month follow-up. We used generalized estimating equations to compare the groups over time.
Onco-Move and OnTrack resulted in less decline in cardiorespiratory fitness (P < .001), better physical functioning (P ≤ .001), less nausea and vomiting (P = .029 and .031, respectively) and less pain (P = .003 and .011, respectively) compared with UC. OnTrack also resulted in better outcomes for muscle strength (P = .002) and physical fatigue (P < .001). At the 6-month follow-up, most outcomes returned to baseline levels for all three groups. A smaller percentage of participants in OnTrack required chemotherapy dose adjustments than those in the UC or Onco-Move groups (P = .002). Both intervention groups returned earlier (P = .012), as well as for more hours per week (P = .014), to work than the control group.
A supervised, moderate- to high-intensity, combined resistance and aerobic exercise program is most effective for patients with breast cancer undergoing adjuvant chemotherapy. A home-based, low-intensity physical activity program represents a viable alternative for women who are unable or unwilling to follow the higher intensity program.
PURPOSETo explore current practice variation and degree of consensus among international clinical experts regarding the diagnosis, classification, measurement, and treatment of head and neck ...lymphedema (HNL) after head and neck cancer treatment.MATERIALS AND METHODSWe conducted an online Delphi study. Eligible participants were clinical researchers who had (co)authored at least one publication on HNL and healthcare professionals who had treated at least five patients with HNL the last two years. The first round was to collect views about current best practices. The second and third rounds delved deeper into these topics using statements with 7-point adjective rating scales.RESULTSAn expert panel of seventeen participants (7 clinicians, 8 researchers, and 2 others) from 8 countries completed all rounds. Regarding diagnosis, there was limited consensus on most subjects, with palpation being most endorsed. No consensus was reached on the need to use standardized classification systems. As a treatment method, complex decongestive therapy (CDT) was the most commonly used in practice and investigated in the literature. However, no consensus was reached on the importance of aspects of CDT.CONCLUSIONSThere is substantial intra- and international practice variation in the management of HNL. This calls for more robust evidence and guidelines.
•Lung resection impacts objectively measured physical behavior in NSCLC patients.•Better physical activity one month postoperative relates to better health outcomes.•Patterns and change of physical ...behavior shows high variability between patients.•Physical behavior profiling through accelerometry facilitates tailored goal setting.
Our objectives were to 1) characterize daily physical behavior of operable non-small cell lung cancer (NSCLC) patients, from preoperative to six months postoperative using accelerometry, and explore if physical behavior preoperative or one month postoperative is associated with better health outcomes at six months postoperative.
A prospective study with 23 patients (13 female) diagnosed with primary NSCLC and scheduled for curative lung resection was performed. Outcome measures were assessed two weeks preoperative, and one, three and six months postoperative, and included accelerometer-derived physical behavior measures and the following health outcomes: six minute walking distance (6MWD), questionnaires concerning health-related quality of life (HRQOL), fatigue and distress.
On group average, physical behavior showed significant changes over time. Physical behavior worsened following surgery, but improved between one and six months postoperative, almost reaching preoperative levels. However, physical behavior showed high variability between patients in both amount as well as change over time. More time in moderate-to-vigorous physical activity in bouts of 10 min or longer in the first month postoperative was significantly associated with better 6MWD, HRQOL, distress, and fatigue at six months postoperative.
As expected, curative lung resection impacts physical behavior. Patients who were more active in the first month following surgery reported better health outcome six months postoperative. The large variability in activity patterns over time observed between patients, suggests that physical behavior ‘profiling’ through detailed monitoring of physical behavior could facilitate tailored goal setting in interventions that target change in physical behavior.
Hypopharynx cancer has the worst prognosis of all head and neck squamous cell cancers. Since the 1990s, a treatment shift has appeared from a total laryngectomy towards organ preservation therapies. ...Large randomized trials evaluating treatment strategies for hypopharynx cancer, however, remain scarce, and frequently this malignancy is evaluated together with larynx cancer. Therefore, our aim was to determine trends in incidence, treatment and survival of hypopharynx cancer. We performed a population-based cohort study including all patients diagnosed with T1–T4 hypopharynx cancer between 1991 and 2010 in the Netherlands. Patients were recorded by the national cancer registry database and verified by a national pathology database. 2999 patients were identified. The incidence increased significantly with 4.1% per year until 1997 and decreased non-significantly afterwards. For women, the incidence increased with 1.7% per year during the entire study period. Total laryngectomy as primary treatment significantly decreased, whereas radiotherapy and chemoradiation increased. The 5-year overall survival significantly increased from 28% in 1991–2000 to 34% in 2001–2010. Overall survival for T3 was equal for total laryngectomy and (chemo)radiotherapy, but for T4-patients the survival was significantly better after primary total laryngectomy (± adjuvant radiotherapy). This large population-based study demonstrates a shift in treatment preference towards organ preservation therapies. The 5-year overall survival increased significantly in the second decade. The assumed equivalence of organ preservation and laryngectomy may require reconsideration for T4 disease.
Highlights • This meta-analysis of individual patient data from 34 randomised controlled trials ( n = 4519 patients) found significant benefits of exercise effects on quality of life and physical ...function. • Exercise effects on quality of life and physical function were comparable across patients with different demographic and clinical characteristics. • Exercise effects on quality of life and physical function were significantly larger for supervised than unsupervised interventions.
The purpose of our study was to evaluate the effect of cognitive behavioral therapy (CBT), physical exercise (PE), and of these two interventions combined (CBT/PE) on menopausal symptoms (primary ...outcome), body image, sexual functioning, psychological well-being, and health-related quality of life (secondary outcomes) in patients with breast cancer experiencing treatment-induced menopause.
Patients with breast cancer reporting treatment-induced menopausal symptoms (N=422) were randomly assigned to CBT (n=109), PE (n=104), CBT/PE (n=106), or to a waiting list control group (n=103). Self-report questionnaires were completed at baseline, 12 weeks, and 6 months. Multilevel procedures were used to compare the intervention groups with the control group over time.
Compared with the control group, the intervention groups had a significant decrease in levels of endocrine symptoms (Functional Assessment of Cancer Therapy-Endocrine Symptoms; P<.001; effect size, 0.31-0.52) and urinary symptoms (Bristol Female Lower Urinary Tract Symptoms Questionnaire; P=.002; effect size, 0.29-0.33), and they showed an improvement in physical functioning (36-Item Short Form Health Survey physical functioning subscale; P=.002; effect size, 0.37-0.46). The groups that included CBT also showed a significant decrease in the perceived burden of hot flashes and night sweats (problem rating scale of the Hot Flush Rating Scale; P<.001; effect size, 0.39-0.56) and an increase in sexual activity (Sexual Activity Questionnaire habit subscale; P=.027; effect size, 0.65). Most of these effects were observed at both the 12-week and 6-month follow-ups.
CBT and PE can have salutary effects on endocrine symptoms and, to a lesser degree, on sexuality and physical functioning of patients with breast cancer experiencing treatment-induced menopause. Future work is needed to improve the design and the planning of these interventions to improve program adherence.
(1) Background: Chemoradiotherapy (CRT) for head and neck cancer (HNC) is associated with severe toxicity resulting in fatigue and weight loss, including loss of skeletal muscle mass. Exercise ...interventions might positively affect physical fitness and quality of life. Sufficient adherence and compliance rates are necessary for optimal effects. This study aimed to gain insight into expectations and experiences and factors influencing adherence, retention and compliance of HNC patients participating in exercise intervention during CRT. (2) Methods: Consecutive participants were invited for semi-structured interviews, conducted pre- and post-intervention. A deductive approach was used to identify themes and factors influencing adherence, retention and compliance. (3) Results: Thematic saturation was reached after interviewing 14 patients pre-intervention. Five themes were identified: planning and time management, treatment toxicity, motivation to exercise, exercise intervention and supervision by a physiotherapist. The intensity of the treatment schedule and treatment toxicity were important barriers. Facilitators mentioned were physical and emotional benefits, social support as well as the simplicity and home-based setting of the intervention. (4) Conclusions: A personalised approach, considering the individual facilitators and barriers of HNC patients, is important to increase adherence, retention and compliance to exercise intervention and to reap the optimal effects of the program.
Abstract Background Complication rates after inguinal lymph node dissection (ILND) are high. Risk factors for early wound complications after ILND in patients with penile carcinoma have not yet been ...studied. Objectives To assess the frequency of early wound complications in a contemporary series and to identify clinical risk factors for early wound complications after ILND for penile carcinoma. Design, setting, and participants We evaluated 237 ILNDs in 163 patients with penile cancer treated between 2003 and 2012 at the Netherlands Cancer Institute. Outcome measurements and statistical analysis We assessed the occurrence of wound infection, skin-flap problems, and seroma formation and graded complications using the modified Clavien system. Univariable and multivariable penalised mixed effects logistic regression was used to identify clinical risk factors for occurrence of any complication (grade ≥1) and of moderate to severe complications (grade ≥2). Results and limitations One complication or more occurred in 58% of the procedures, and 10% of those complications were severe. Wound infection occurred in 43%, seroma formation occurred in 24%, and skin-flap problems occurred in 16%. Palpable disease was the only factor associated with grade ≥1 complications in the univariable analysis (odds ratio OR: 0.43; p = 0.02). In the multivariable model, after penalisation, no statistically significant risk factors remained. Univariable associations for grade ≥2 complications were present for body mass index (BMI; OR of 1.66 for a 5.8-point change in BMI; p = 0.05) and sartorius muscle transposition (OR: 2.64; p = 0.04). In the reduced multivariable model, the OR for sartorius muscle transposition was 2.12 ( p = 0.06) and for BMI was 1.76 ( p = 0.03). In addition, bilateral dissection approached significance in the multivariable model (OR: 2.17; p = 0.06). This study is limited by its observational nature. Conclusions Wound complication rates after ILND are high in this cohort. BMI, sartorius muscle transposition, and bilateral dissection were the factors most strongly associated with the occurrence of grade ≥2 wound complications.
Immunomodulatory therapies that improve the outcome of sepsis are not available. We sought to determine whether treatment of critically ill patients with sepsis with low-dose erythromycin-a macrolide ...antibiotic with broad immunomodulatory effects-decreased mortality and ameliorated underlying disease pathophysiology.
We conducted a target trial emulation, comparing patients with sepsis admitted to two intensive care units (ICU) in the Netherlands for at least 72 h, who were either exposed or not exposed during this period to treatment with low-dose erythromycin (up to 600 mg per day, administered as a prokinetic agent) but no other macrolides. We used two common propensity score methods (matching and inverse probability of treatment weighting) to deal with confounding by indication and subsequently used Cox regression models to estimate the treatment effect on the primary outcome of mortality rate up to day 90. Secondary clinical outcomes included change in SOFA, duration of mechanical ventilation and the incidence of ICU-acquired infections. We used linear mixed models to assess differences in 15 host response biomarkers reflective of key pathophysiological processes from admission to day 4.
In total, 235 patients started low-dose erythromycin treatment, 470 patients served as controls. Treatment started at a median of 38 IQR 25-52 hours after ICU admission for a median of 5 IQR 3-8 total doses in the first course. Matching and weighting resulted in populations well balanced for proposed confounders. We found no differences between patients treated with low-dose erythromycin and control subjects in mortality rate up to day 90: matching HR 0.89 (95% CI 0.64-1.24), weighting HR 0.95 (95% CI 0.66-1.36). There were no differences in secondary clinical outcomes. The change in host response biomarker levels from admission to day 4 was similar between erythromycin-treated and control subjects.
In this target trial emulation in critically ill patients with sepsis, we could not demonstrate an effect of treatment with low-dose erythromycin on mortality, secondary clinical outcomes or host response biomarkers.
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