Download Copenhagen University Hospital, Rigshospitalet, Denmark

Centre of integrated rehabilitation of cancer patients - CIRE
Exercise in Advanced
Stage Cancer
Morten Quist, MHS, PT, PhD. stud.
Copenhagen University Hospital,
Rigshospitalet, Denmark
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Background
Cancers figure among the leading causes of morbidity and mortality
worldwide, with approximately 14 million new cases and 8.2 million
cancer related deaths in 2012.
Among men, the 5 most common sites of cancer diagnosed in 2012
were lung, prostate, colorectum, stomach, and liver cancer.
Among women the 5 most common sites diagnosed were breast,
colorectum, lung, cervix, and stomach cancer.
World Cancer Report 2014
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Background
Around one third of cancer deaths are due to the 5 leading
behavioural and dietary risks: high body mass index, low fruit and
vegetable intake, lack of physical activity, tobacco use, alcohol
use.
Tobacco use is the most important risk factor for cancer causing
around 20% of global cancer deaths and around 70% of global lung
cancer deaths.
It is expected that annual cancer cases will rise from 14 million in
2012 to 22 within the next 2 decades.
World Cancer Report 2014
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Background
Patients with advanced stage cancer report more
symptoms and side effects than other cancer diagnoses:
• Increased anxiety and depression levels
• Impaired quality of life
Grønvold et al 2006
Emotional distress in cancer patients (anxiety or
depression) is associated with
•Reduced Quality of life
•Reduced compliance with medical treatment
•Increased Mortality (Pinquart and Duberstein 2010; Satin et al. 2009;
Greer et al. 2008)
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Background
Functional capacity (6 minute walk distance < 400
m) before chemotherapy:
• Higher disease progression
• Higher mortality
Kasymjanova et al 2009
Functional capacity was an independent
predictor of survival (P = 0.003)
Jones et al 2011
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Overview Today
Few studies have examined physical activity in palliative cancer
patients, and the current evidence is limited largely to case
reports and uncontrolled trials.
Palliative cancer patients are willing and able to tolerate physical
activity interventions, with some patients demonstrating
improvement in some supportive care outcomes post
intervention.
The potential role for physical activity as a supportive care
intervention is promising and further feasibility studies are
needed to substantiate preliminary findings and further advance
this emerging area of research
Lowe et al 2009
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Background
Main concerns for patients with advanced stage
cancer are:
• fear of losing independence.
• being a burden on their caregivers
• not being able to perform daily activities
• fear of losing function
(Breitbart et al. 2004, Gralla et al 2014)
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Model of negative interactions
Reduced
cardiovascular
fitness, muscle
strength and
functional
capacity
Reduced
HRQOL
Patient with
advanced
stage cancer
Isolation Reduced
activities
of daily life
Increased
anxiety
and
depression
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Impact of exercise
Improved
cardiovascular
fitness,
muscle
strength and
functional
capacity
Normal or
improved
activities
of daily life
Improved
quality of
life
Reduced
anxiety
and
depression
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
The role of exercise
• Physiological
• Cardiovascular fitness
• Muscle strength
• Functional capacity
• Psychological
• Anxiety
• Depression
• Quality of life
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
The Approach
Physiological
Psychological
• Goals
• Pre and post test
• Program
• Continuity
• Expectations
• Demands
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
The Approach
physiological
•
•
Goals
•
Pre and post test
•
Program
•
Continuity
•
Expectations
•
Demands
•
•
Functional capacity
• 6 Minute walk test
• Sit and stand
• Stair climbing
Aerobe capacity
• Watt-max
• Steady state test
Strength
• 1RM
• Repetitions
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
The Approach
Psychological
Survivor
Victim
•
Goals
•
Pre and post test
•
Program
•
Continuity
•
Expectations
•
Demands
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
The ‘EXHALE’ study
The aim of this study is to investigate the effect of a
six-week physical and psychosocial program
Monday
Tuesday
Wednesday
Thursday
Supervised
(1½ hour)
Supervised
(1½ hour)
Relaxation
(½ hour)
Relaxation
(½ hour)
Copenhagen University Hospital, Rigshospitalet, Denmark
Friday
Centre of integrated rehabilitation of cancer patients - CIRE
Intervention
Warm up
Strength
Aerobic 10 min
10 min
70%-100% of 1RM
70%-100% of HRmax
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Leg press
Lat. machine
Chest press
Leg extension
Low back
Abdominal
5-8 repetitions of 70%-90% of 1RM
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Aerobic
5-8 Intervals
20-30 sec high rpm.
20-30 sec active rest
5-8 Intervals
20-30 sec high load
20-30 sec active rest
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Design and Methods
Design
Prospective, explorative, single arm (n=114)
Inclusion from November 2008 to March 2012
Quantitative methods
Physiological assessment of
VO2peak
• 1RM
• Fev1
• 6 MWT
Questionnaires
HADs, FACT-L
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Inoperable Lung cancer patients NSCLC
III-IV and SCLC ED during November
2008 – June 2012
N = 713
Eligible Lung cancer patients
NSCLC III-IV and SCLC ED
N = 369
Informed consent and baseline test
N = 114
Completed the intervention and 6
weeks test
N = 71
Flow chart
Exclusion N = 344
Bone metastases
Performance
Brain metastases
Miscellaneous
141
99
76
28
Not interested
255
Dropout rate N = 43
Disease progression
No energy to train
Did not wish to
undertake training
Copenhagen University Hospital, Rigshospitalet, Denmark
10
12
21
Centre of integrated rehabilitation of cancer patients - CIRE
Results
Variable (n=71)
BMI
Base Mean (SD)
Post Mean (SD)
95 % CI of diff
P value
24.7 (3.8)
24.8 (3.8)
0.08 (-0.06 to 0.22)
0.2578
1.9 (0.7)
1.9 (0.7)
-0.08 (-0.08 to 0.16)
0.5080
1.3 (0.4)
1.4 (0.5)
0.08 (0.04 to 0.12)
0.0003
527.4 (121.5)
561 (124.7)
33.6 (20.3 to 47.0)
<0.0001
Legpress (Kg)
71.5 (30.2)
86.1 (32.8)
14.5 (11.6 to 17.4)
<0.0001
Chestpress (Kg)
29.3 (13.4)
34.5 (15.8)
5.2 (3.7 to 6.7)
<0.0001
Lat machine (Kg)
34.6 (13.3)
36.5 (15.0)
1.9 (0.6 to 3.3)
0.0063
Abdominal crunch (Kg)
35.5 (13.5)
42.2 (15.7)
6.7 (5.3 to 8.2)
<0.0001
Lower back (Kg)
37.5 (14.7)
43.3 (16.7)
5.9 (4.4 to 7.3)
<0.0001
Leg Extension (Kg)
24.9 (9.9)
28.3 (11.5)
3.4 (2.5 to 4.3)
<0.0001
Lung function
FEV1
Functional capacity
VO2peak (l/min)
6MWD (m)
Strength
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Results (FACT-L)
Variable (N=70)
Base Mean (SD)
Post Mean (SD)
95 % CI of diff
94.4 (18.9)
96.0 (18.4)
1.60 (-1.34 to 1.62)
0.2815
Personal Well-being
20.4 (5.0)
20.8 (4.9)
0.36 (-0.78 to 1.5)
0.5314
Social Well-being
23.9 (4.5)
22.7 (5.4)
-1.22 (-2.03 to -0.41)
<0.0001
Functional well-being
16.5 (5.9)
17.0 (5.5)
0.50 (-0.46 to 1.46)
0.3031
Emotional well-being
15.2 (5.0)
16.6 (4.4)
1.44 (0.75 to 2.13)
0.0036
Lung cancer subscale
18.4 (4.8)
18.9 (4.6)
0.52 (-0.41 to 1.46)
0.2683
Trial outcome index
55.3 (13)
56.7 (12.8)
1.38 (-0.96 to 3.72)
0.2422
FACT-L Total score
Copenhagen University Hospital, Rigshospitalet, Denmark
P value
Centre of integrated rehabilitation of cancer patients - CIRE
Results HADs
Variable (N=72)
Base Mean (SD)
Post Mean (SD)
95 % CI of diff.
P value
Anxiety
7.2 (4.4)
6.3 (4.2)
-0.9 (-1.55 to -0.25)
0.0070
Depression
5.3 (3.8)
4.7 (3.5)
-0.59 (-1.23 to 0.06)
0.0755
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Discussion
The clinical significance of an improved V02peak is not known
for inoperable lung cancer patients, but V02peak has been
demonstrated to be an independent predictor of mortality in a
wide range of adult non-cancer populations
Kavanagh et al 2002, Myers et al 2002
The clinical significance of anxiety for inoperable lung cancer
patients is not clear, but studies that have examined the
importance of psychological stress including anxiety, have
shown that increased psychological distress increase mortality
in cancer patients with advanced-stage cancers
Hamer et al 2009, Jimenez et al 2011
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Conclusion and Perspective
The results of this study show that lung cancer patients with
advanced disease through a 6-week hospital based
supervised, structured and group-based outpatient exercise
programme can improve their exercise capacity and
functional capacity.
This reduces the patient's anxiety level. The patients'
condition is not stationary - disease status, side effects and
other factors can also change within the 6 weeks. The
possible impact of this intervention should therefore be
tested in a randomised design.
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Limitations
• Non-randomized
• Single arm
• Selection bias
More motivated
Not included
Brain metastasis
Bone metastasis
Poor performance status
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Take home message
“Just because the future looks grim it
doesn’t mean that all hope is gone”
Copenhagen University Hospital, Rigshospitalet, Denmark
Centre of integrated rehabilitation of cancer patients - CIRE
Acknowledgements
All current and former patients participating in this study
Seppo W. Langer MD, PhD
Mikael Rørth, Professor, MD
Lis Adamsen, Professor, RN, MSc. Soc
Jørgen H Laursen, RN
The study is supported by grants from The Center for Integrated Rehabilitation of
Cancer patients (CIRE), a center established and supported by The Danish Cancer
Society and The Novo Nordisk Foundation. The study was also supported by a grant
from Roche a/s.
Copenhagen University Hospital, Rigshospitalet, Denmark