Gymnastik- och idrottshögskolan, GIH

Despite the benefits of physical activity and exercise, including high-intensity interval training (HIIT), few cancer survivors meet the exercise oncology guidelines. Emerging evidence suggests peer support (i.e., assistance from individuals with lived experiences trained in behavior change techniques) may improve exercise adherence, yet its long-term safety and feasibility remain unclear. This study evaluates the safety and feasibility of 12 months of HIIT, with and without peer support, in cancer survivors. Breast, prostate, and colorectal cancer survivors completed 4 weeks (12 sessions) of supervised HIIT before being randomized to receive weekly peer support from people with lived experience of a cancer diagnosis (HIIT+PS) or no peer support (HIIT-Only) for 12 months. Both groups were provided 12 months of free access to local gymnasiums. Safety (adverse and severe adverse events) and feasibility (recruitment, attrition, attendance, adherence to intensity, duration, mode, peer supporter contact) were compared to a priori criteria. The a priori criterion was met for recruitment rate (38%) of study participants (n = 137). Peer supporters (n = 32) contacted participants 0.8 ± 0.5 times/week (n = 40 contacts/participant), preferring text messaging (50%) or face-to-face (41%) contacts, meeting the a priori criterion (0.77 contacts/week). Both groups met the a priori criteria for safety (n = 0 severe and n = 7 (0.5%) Grade 1/2 adverse events), duration, and mode, but not attendance or intensity across the full 12 months. A priori criterion for study attrition was met in the intervention group (23.7%) but not the HIIT-Only group (30.8%). Twelve months of HIIT with and without peer support was safe with participants meeting the prescribed duration, and mode, but not attendance or intensity. Peer support provided weekly for four of every 5 weeks appears insufficient to improve HIIT feasibility. Peer supporters preferred to provide contact via text messaging or face-to-face interactions. Future studies should explore strategies to improve long-term HIIT frequency and intensity adherence. Trial Registration: Australian New Zealand Clinical Trial Registry 12 618 001 855 213. Registered 14 November 2018. Trial registration includes all components of the WHO Trial Registration Data Set, as recommended by the ICMJE.

PurposeExercise following cancer treatment has been shown to improve health-related quality of life (HRQoL) and other important health outcomes, yet barriers to participation prevent many cancer survivors from exercising according to recommendations. Live-remote exercise methods could improve accessibility; however, evidence on their efficacy is limited. The EX-MED Cancer Sweden randomised controlled trial compared the effects of a 12-week live-remote online exercise intervention to usual care in adult cancer survivors.MethodsTwo hundred adults who had completed curative treatment for breast, prostate, or colorectal cancer were randomised to a 12-week live-remote online exercise intervention or a usual care control group. Intervention effects on the primary outcome overall HRQoL (EORTC-QLQ-C30) and secondary outcomes cardiorespiratory fitness (CRF), muscle strength, physical function, body composition, and other patient-reported outcomes were determined by comparing changes from baseline to 3 (primary timepoint) and 6 months between groups.ResultsNo significant effect was observed on overall HRQoL. However, live-remote exercise resulted in significant improvements at 3 months on the physical functioning domain of HRQoL (p <= 0.001), five-times sit-to-stand (p = 0.003), and moderate-vigorous physical activity levels (p <= 0.001) as well as estimated VO2 max (p = 0.045), and upper body strength (p = 0.010) at 3 and 6 months. No significant differences were observed between the groups on lower body strength, handgrip strength, fatigue, or the other functional domains or symptoms of the EORTC-QLQ-C30.ConclusionsA 12-week live-remote exercise intervention did not lead to improvements in overall HRQoL; however, it did result in significant benefits in physical function, CRF, and upper body strength in adults treated for breast, prostate, or colorectal cancer. These findings add to the limited evidence on the effects of virtually supervised exercise for cancer survivors.Implications for Cancer SurvivorsEX-MED Cancer Sweden addresses common exercise barriers for cancer survivors while providing the benefits of supervised exercise.Trial registrationNCT05064670, Trial registered on October 1, 2021, https://clinicaltrials.gov/ct2/show/NCT05064670

Purpose: Many people face multiple cancer- and treatment-related sequalae. Triage and referral to physical health services can manage such consequences, but a comprehensive understanding of available triage tools is lacking. This review (i) identifies tools used to triage to physical health services, (ii) maps tool characteristics and application outcomes and (iii) summarises existing gaps.

Methods: A systematic search was conducted (three databases, April 2024). Articles were included if they used a tool to triage to physical health services. Tools were classified by triaged disciplines (i.e., diet, exercise, physical rehabilitation, multidisciplinary) and screened physical impairments (e.g., malnutrition). Tool characteristics (e.g., triage method) and application outcomes (i.e., reach, triage rates) were extracted.

Results: Of 23,369 records retrieved, 67 studies were included. Studies comprised 78 instances of tool use (64 unique tools), where n = 33 triaged to dietetics (42%), n = 6 exercise (8%), n = 11 physical rehabilitation (14%), and n = 28 a combination of health disciplines (36%). Mean age was 65 years. Most tools were used during-treatment (45%), in hospital settings (62%), measured malnutrition/physical function (60%) and used single cut-off scores (68%). Reach and triage rates varied, with exercise (reach = 89%) and diet (triage = 63%) rates highest.

Conclusion: Many physical health triage tools exist, most solely for dietetics, with heterogeneous characteristics and application outcomes. Updated tools are needed for triage to exercise/physical rehabilitation, multiple age cohorts across the cancer continuum, and that potentially use multiple cut-off scores. Cancer care professionals can use this compendium to identify which tool characteristics best suit their healthcare setting, for optimal outcomes.

OBJECTIVES: To examine the associations between changes in cardiorespiratory fitness (CRF) in adulthood and prostate cancer incidence and mortality.

METHODS: In this prospective study, men who completed an occupational health profile assessment including at least two valid submaximal CRF tests, performed on a cycle ergometer, were included in the study. Data on prostate cancer incidence and mortality were derived from national registers. HRs and CIs were calculated using Cox proportional hazard regression with inverse probability treatment weights of time-varying covariates.

RESULTS: During a mean follow-up time of 6.7 years (SD 4.9), 592 (1%) of the 57 652 men were diagnosed with prostate cancer, and 46 (0.08%) died with prostate cancer as the primary cause of death. An increase in absolute CRF (as % of L/min) was associated with a reduced risk of prostate cancer incidence (HR 0.98, 95% CI 0.96 to 0.99) but not mortality, in the fully adjusted model. When participants were grouped as having increased (+3%), stable (±3%) or decreased (-3%) CRF, those with increased fitness also had a reduced risk of prostate cancer incidence compared with those with decreased fitness (HR 0.65, 95% CI 0.49 to 0.86), in the fully adjusted model.

CONCLUSION: In this study of employed Swedish men, change in CRF was inversely associated with risk of prostate cancer incidence, but not mortality. Change in CRF appears to be important for reducing the risk of prostate cancer.

INTRODUCTION: The aim of this prospective cohort study was to investigate the associations between changes in cardiorespiratory fitness (CRF) and the risk of colorectal and prostate cancer in men.

METHODS: Data from men who completed a health assessment both in military conscription in youth and an occupational health profile assessment (HPA) later in life were used. CRF was assessed as estimated V̇O_2max, using a cycle ergometer fitness test at both time points. We linked the assessment data to national register data on colorectal and prostate cancer incidence, and hazard ratios and confidence intervals were estimated using Cox proportional hazard regression.

RESULTS: 139,764 men with a mean age of 18 (SD 0.6) at conscription and 43 (SD 8.9) at HPA were included. The average time between the two assessments was 25.9 (SD 9.0) years and mean follow-up time following HPA test was 10.0 (SD 5.6) years for prostate and colorectal cancer. Annual percentage change in relative and absolute V̇O_2max from conscription to HPA was inversely associated with the risk of colorectal cancer incidence, hazard ratio of 0.83 (95% CI [0.72-0.94]) and 0.88 (95% CI [0.79-0.99]), respectively. These associations were driven by data from individuals in the lowest and moderate level fitness tertials at conscription. Change in CRF was not associated with prostate cancer incidence risk.

CONCLUSIONS: Changes in, not only level of, CRF from youth to adulthood are related to colorectal cancer incidence risk and therefore, improving CRF should be considered as an important colorectal cancer risk reduction strategy.

INTRODUCTION: Reliable peripheral quantitative computed tomography (pQCT) assessment is essential to the accurate longitudinal reporting of bone and muscle quality. However, the between-day reliability of pQCT and the influence of age on outcome reliability is currently unknown.

OBJECTIVE: To quantify the same- and between-day reliability of morphological pQCT at proximal and distal segments of the forearm, shank, and thigh, and explore the influence of participant body size, age, and sex on outcome reliability.

METHODS: Men and women (49 % female, 18-85 years, n=72-86) completed two consecutive-day pQCT testing sessions, where repeat measurements were conducted on day-one for technical error, and between-day for biological error quantification. Testing was undertaken following best practice body composition testing guidance, including standardized presentation and consistent time-of-day.

RESULTS: All measurements of bone were classified as having 'good' to 'excellent' reliability [intraclass correlation coefficient (r=0.786- 0.999], as were measurements of muscle area (ICC r=0.991-0.999) and total fat (r=0.996-0.999). However, between- and same-day muscle density measurements at the thigh and forearm were classified as 'poor' (r=0.476) and 'moderate' (r=0.622), respectively. Likewise, intramuscular fat area at the thigh was classified as 'moderate' (r=0.737) for between-day measurement. Biological error was inflated compared to technical error by an average of 0.4 % for most measurements. Error values tended to increase proportionally with the amount of tissue quantified and males had significantly greater biological error for measurement of distal tibial bone (p<0.002) and trabecular area (p<0.002). Biological error was inflated among older adults for measurement of forearm muscle density (p<0.002).

CONCLUSIONS: Most pQCT outcomes can be implemented with confidence, especially outcomes that assess bone area and density at any of the radial, tibial, and femoral sites investigated herein. However, it is important to account for the influence of biological measurement error in further studies, especially for muscle and intramuscular fat outcomes derived by pQCT.

IMPORTANCE: Cardiorespiratory fitness (CRF) levels appear to be an important risk factor for cancer incidence and death.

OBJECTIVES: To examine CRF and prostate, colon, and lung cancer incidence and mortality in Swedish men, and to assess whether age moderated any associations between CRF and cancer.

DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted in a population of men who completed an occupational health profile assessment between October 1982 and December 2019 in Sweden. Data analysis was performed from June 22, 2022, to May 11, 2023.

EXPOSURE: Cardiorespiratory fitness was assessed as maximal oxygen consumption, estimated using a submaximal cycle ergometer test.

MAIN OUTCOMES AND MEASURES: Data on prostate, colon, and lung cancer incidence and mortality were derived from national registers. Hazard ratios (HRs) and 95% CIs were calculated using Cox proportional hazards regression.

RESULTS: Data on 177 709 men (age range, 18-75 years; mean [SD] age, 42 [11] years; mean [SD] body mass index, 26 [3.8]) were analyzed. During a mean (SD) follow-up time of 9.6 (5.5) years, a total of 499 incident cases of colon, 283 of lung, and 1918 of prostate cancer occurred, as well as 152 deaths due to colon cancer, 207 due to lung cancer, and 141 deaths due to prostate cancer. Higher levels of CRF (maximal oxygen consumption as milliliters per minute per kilogram) were associated with a significantly lower risk of colon (HR, 0.98, 95% CI, 0.96-0.98) and lung cancer (HR, 0.98; 95% CI, 0.96-0.99) incidence, and a higher risk of prostate cancer incidence (HR, 1.01; 95% CI, 1.00-1.01). Higher CRF was associated with a lower risk of death due to colon (HR, 0.98; 95% CI, 0.96-1.00), lung (HR, 0.97; 95% CI, 0.95-0.99), and prostate (HR, 0.95; 95% CI, 0.93-0.97) cancer. After stratification into 4 groups and in fully adjusted models, the associations remained for moderate (>35-45 mL/min/kg), 0.72 (0.53-0.96) and high (>45 mL/min/kg), 0.63 (0.41-0.98) levels of CRF, compared with very low (<25 mL/min/kg) CRF for colon cancer incidence. For prostate cancer mortality, associations remained for low (HR, 0.67; 95% CI, 0.45-1.00), moderate (HR, 0.57; 95% CI, 0.34-0.97), and high (HR, 0.29; 95% CI, 0.10-0.86) CRF. For lung cancer mortality, only high CRF (HR, 0.41; 95% CI, 0.17-0.99) was significant. Age modified the associations for lung (HR, 0.99; 95% CI, 0.99-0.99) and prostate (HR, 1.00; 95% CI, 1.00-1.00; P < .001) cancer incidence, and for death due to lung cancer (HR, 0.99; 95% CI, 0.99-0.99; P = .04).

CONCLUSIONS AND RELEVANCE: In this cohort of Swedish men, moderate and high CRF were associated with a lower risk of colon cancer. Low, moderate, and high CRF were associated with lower risk of death due to prostate cancer, while only high CRF was associated with lower risk of death due to lung cancer. If evidence for causality is established, interventions to improve CRF in individuals with low CRF should be prioritized.

BACKGROUND: Regular exercise has been shown to have beneficial health effects in cancer survivors, including improving quality of life and other important health outcomes. However, providing people with cancer with easily accessible, high-quality exercise support and programs is a challenge. Therefore, there is a need to develop easily accessible exercise programs that draw upon the current evidence. Supervised, distance-based exercise programs have the benefit of reaching out to many people whilst providing the support of an exercise professional. The aim of the EX-MED Cancer Sweden trial is to examine the effectiveness of a supervised, distance-based exercise program, in people previously treated for breast, prostate, or colorectal cancer, on health-related quality of life (HRQoL), as well as other physiological and patient-reported health outcomes.

METHODS: The EX-MED Cancer Sweden trial is a prospective randomised controlled trial including 200 people that have completed curative treatment for breast, prostate, or colorectal cancer. Participants are randomly allocated to an exercise group or a routine care control group. The exercise group will participate in a supervised, distanced-based exercise program delivered by a personal trainer who has undertaken specialised exercise oncology education modules. The intervention consists of a combination of resistance and aerobic exercises with participants completing two 60-min sessions per week for 12 weeks. The primary outcome is HRQoL (EORTC QLQ-C30) assessed at baseline, 3- (end of intervention and primary endpoint) and 6-months post-baseline. Secondary outcomes are physiological (cardiorespiratory fitness, muscle strength, physical function, body composition) and patient-reported outcomes (cancer-related symptoms, fatigue, self-reported physical activity), and self-efficacy of exercise. Furthermore, the trial will explore and describe the experiences of participation in the exercise intervention.

DISCUSSION: The EX-MED Cancer Sweden trial will provide evidence regarding the effectiveness of a supervised, distance-based exercise program for survivors of breast, prostate, and colorectal cancer. If successful, it will contribute to the implementation of flexible and effective exercise programs as part of the standard of care for people following cancer treatment, which is likely to contribute to a reduction in the burden of cancer on the individual, health care system and society.

CLINICALTRIALS: gov NCT05064670. Registered on October 1, 2021.

Background

Exercise is recommended for people with cancer. The aim of this study was to evaluate the harms of exercise in patients with cancer undergoing systemic treatment.

Methods

This systematic review and meta-analysis included published and unpublished controlled trials comparing exercise interventions versus controls in adults with cancer scheduled to undergo systemic treatment. The primary outcomes were adverse events, health-care utilization, and treatment tolerability and response. Eleven electronic databases and trial registries were systematically searched with no date or language restrictions. The latest searches were performed on April 26, 2022. The risk of bias was judged using RoB2 and ROBINS-I, and the certainty of evidence for primary outcomes was assessed using GRADE. Data were statistically synthesised using pre-specified random-effect meta-analyses. The protocol for this study was registered in the PROESPERO database (ID: CRD42021266882).

Findings

129 controlled trials including 12,044 participants were eligible. Primary meta-analyses revealed evidence of a higher risk of some harms, including serious adverse events (risk ratio [95% CI]: 1.87 [1.47–2.39], I2 = 0%, n = 1722, k = 10), thromboses (risk ratio [95% CI]: 1.67 [1.11–2.51], I2 = 0%, n = 934, k = 6), and fractures (risk ratio [95% CI]: 3.07 [3.03–3.11], I2 = 0%, n = 203, k = 2) in intervention versus control. In contrast, we found evidence of a lower risk of fever (risk ratio [95% CI]: 0.69 [0.55–0.87], I2 = 0% n = 1109, k = 7) and a higher relative dose intensity of systemic treatment (difference in means [95% CI]: 1.50% [0.14–2.85], I2 = 0% n = 1110, k = 13) in intervention versus control. For all outcomes, we downgraded the certainty of evidence due to imprecision, risk of bias, and indirectness, resulting in very low certainty of evidence.

Interpretation

The harms of exercise in patients with cancer undergoing systemic treatment are uncertain, and there is currently insufficient data on harms to make evidence-based risk-benefits assessments of the application of structured exercise in this population.

Funding

There was no funding for this study.