GSS cIRcle Open Scholar Award (UBCV Non-Thesis Graduate Work)

Effects of Exercise on Persons with Metastatic Cancer Beaton, Rebekah; Pagdin-Friesen, Wendy; Robertson, Christa; Vigar, Cathy; Watson, Heather 2008-08-21

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Effects of ExerciseEffects of Exerciseon Persons withon Persons withMetastatic CancerMetastatic CancerRebekah Beaton BSc, MPT candidateWendy Pagdin-Friesen BA, BEd, MPT candidateChrista Robertson BSc, MPT candidateCathy VigarBSc, MPT candidateHeather Watson BSc, BEd, MPT candidateSupervisor-Dr. Susan HarrisOutlineyyBackgroundyyMethodsyyResultsyyDiscussionyyConclusionyyAcknowledgements BackgroundBackgroundyyThe Canadian Cancer Institute estimates that in 2008, in Canada there will be:yy166,400 new cases of cancer yy73,800 cancer-related deaths1yyOf persons with a new cancer diagnosis 30% will already have metastatic disease2yyOnce metastasis has occurred, prognosis is generally poor3Cancer StatisticsMetastatic CanceryyCreates different challenges than that of non-metastatic cancer as it is a palliative disease4-8yyIt causes declines in quality of life (QOL), psychological barriers and fatigue4-8yyPersons with metastatic cancer are now living longer9yySuggest the need for research on interventions aimed at improving QOLPrevious ResearchyyFocused on exercise interventions for persons with local or regional cancer10-14yyMany reviews investigated the impacts of exercise on fatigue7,10-15yyFatigue is a prevalent symptomyy90% of persons with cancer experience cancer-related fatigue6yyCancer-related fatigue has also been linked with symptoms of anxiety and depression6Previous ResearchyyDemonstrated physical exercise is an effective intervention to improve QOL & fatigue in persons with non-metastatic cancer7,10-15yyTraditionally, persons with metastatic cancer were encouraged to rest7yyRest is no longer considered an appropriate interventionyyNew literature is emerging regarding the potential benefits of exercise for persons with metastatic cancer5,7,16,17PurposeTo synthesize the available literature on the effects of exercise on QOL and physical measures in persons with metastatic cancerReview Questions1.What exercise interventions are being used for persons with metastatic cancer?2.What is the effect of these interventions in respect to QOL and physical measures?3.What research needs to be completed in the future?4.Investigate the adverse effects and attrition rates documented in the studies.Definition of Metastatic CanceryyThe spread of cancer from one part of the body to another3?For the purpose of this review it includes:      ?advanced cancer?palliative cancer?stage IV cancer ?Frequent sites of metastases include: ?lung, liver, breast & bone9Quality of Life (QOL)EnvironmentSocial relationsLevel of independencePhysicalhealthSpiritualityQOL18Exercise??Any planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness?19Search StrategyUp to and including May 8, 2008Databases: yyMedline, Embase, CINAHL, PsychInfo, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Databases of Systematic Reviews (EBM Reviews-Ovid) and PEDroKeywords:yymetastatic OR palliative OR advanced ANDyycancer OR neoplasm AND yyexercise OR physical activity OR exercise therapy OR physical fitnessInclusion CriteriayyPopulation:persons with metastatic or advanced or palliative canceryyIntervention:exercise as the intervention or a component of the interventionyyPublication:in a peer-reviewed journalyyComparisons andoutcome measures:not screened at the initial stages to include all relevant studiesExclusion CriteriaPopulation: yyPersons with lymphoma, melanoma or myelomayyLess than 50% of the sample had metastatic or advanced canceryyWhen results of those with metastatic cancer could not be separated from those with non-metastatic cancer Type:yyStudies in a language other than English or FrenchyyNewspaper editorials, single article reviews and qualitative research studiesData ExtractionyyTool developed by reviewersyyPilot tested by two reviewersyyExtraction was performed on each study by one reviewer and then checked by a second revieweryyData extracted from 12 studies: methods, participants, inclusion/exclusion criteria, intervention, attrition, adherence, and outcomes.Quality AssessmentRandomized Controlled Trials (RCT?s) yyModified van Tulder Criteria20yyOne criterion added: ?Was the study?s purpose clearly stated??yyLow = 0-4, Medium = 5-8, High = 9-12Case Series yyModified Case Series Criteria21yyRemoval of criterion 6: comparison of sub-seriesyyLow = 1-2, Medium = 2.5-3.5, High = 4-5Case Reports yyCase Study Methodological Quality Assessment Tool22yyLow = 1-3, Medium = 4-5, High = 6-7Data SynthesisyyStudy characteristics were compiled in a tableyyMeta-analysis was not possible due to study heterogeneity in:?Study populations?Exercise interventions?Outcome measures ?Study designsArticles found through hand searchingN = 1Studies included after evaluation of full textN = 12(96% Agreement)Full text reviewedN = 27(84.7% Agreement)Abstracts reviewedN = 225Studies included after title screeningN = 224(100% Agreement)Titles reviewedafter inital search of databasesTotal = 67412 Included Studies: 5 RCT?syyRummans24: 103 persons with advanced cancer of various primary sites participated in a multi-dimensional exercise program for 3 weeksyyBrown4: 115 persons from the Rummans et al.24study, followed for 4 weeks to investigate if improvements in quality of life (QOL) impact fatigue in patientsyyLapid23: Geriatric subgroup of 33 persons from the Rummans et al24study followed for 4 weeksyyHeadley16: 38 women with advanced breast cancer completed seated exercises for 12 weeksyySegal25: 60 men with palliative prostate cancer completed resistance exercises for 12 weeks12 Included Studies: 5 Case SeriesyyOldervoll26: 52 persons w/ metastatic cancer of various 1?sites completed circuit training, standing balance & aerobic endurance ex?s for 6 wksyyAdamsen, 200327: 27 persons w/ advanced cancer of various 1?sites participated in a multi-dimensional intervention: resistance ex & stationary cycling for 6 wksyyAdamsen, 200628: As per Adamsen200327w/ 115 participantsyyCarson29: 21 women with metastatic breast cancer performed yoga exercises for 8 wksyyPorock7: 9 persons w/ metastatic cancer of various 1?sites performed individual home exercises for 2-4 wks12 Included Studies:2 Case ReportsyyCrevenna30: 1 female with metastatic breast cancer performed ergometriccycling for 1 yearyyKelm31: 1 male with metastatic adenocarcinomaof the rectum completed endurance training and strength exercises for 13 weeksAnd then there were TENyyRummans et al.24, Brown et al.4& Lapid et al.23were based on the same study sampleyyTo demonstrate the breadth of literature all 3 studies were included in the characteristics tableyyTo prevent skewing of the results, only Rummans et al.24was included in the text of the results & discussion sections, resulting a total of 10 studiesStudy CharacteristicsPopulation yyCancer status:five studies25,26,29-31metastatic, four studies16,24,27,28advancedand one study25palliativeyyPrimary cancer sites:varied yyConcurrent treatment:eight studies included persons undergoing concurrent chemotherapy & four studies included persons undergoing radiation therapyCharacteristics of the StudiesIntervention yyType:included yoga, balance, coordination, aerobic & strength trainingyyFrequency:generally 2-3 x/wk for 3-13 wkyyIntensity:strength @ 40-95% of 1RM 25,27,28,31& aerobic @ low-moderate intensity7,30,31Most Frequent Outcome Tools yyPhysical measures:1RM27,28,31& VO2 max27,28,30yyQOL measures:EORTC QLQ-3026-28& the SF 3627,28,30Inclusion & Exclusion CriteriaDiffered across studies in regards to: yyLife expectancy e.g. Porock8 versus Oldervoll26yyCo-morbidities e.g. bone metastases/lesionsyyMental health status e.g. Adamsen28Attrition, Adherence & Adverse EffectsAttrition: yyRCT?s?ranged from 7-16%yyCase Series ?ranged from 14-35%yyCase Reports ?0%Adherence:ranged from 75-100% Adverse Effects:no adverse effects were notedQuality Assessment -RCT?syyThree RCT?s assessed with the modified van Tulder Criteria20yyAll were rated as high quality (9/12)yyAll failed to conceal the treatment allocation and blind the patient to the intervention (criterion C & D)yyTwo studies24,25did not blind the therapist to the intervention (criterion F )yyHeadley et al.16was able to blind the therapist to the intervention (criterion F)Quality Assessment -Case SeriesyyFive case series were assessed with the modified Case Series Criteria21yyAll five studies were rated as medium qualityyyNone of the case series were able to fulfill blinding (criterion 5.2) or representative sampling (criterion 1)yyCarson et al.29did not have explicit inclusion criteria (criterion 2)Quality Assessment -Case ReportsyyTwo case reports were assessed using the Case Study Methodological Quality Assessment Tool22yyCrevenna et al.30was rated high quality (6/7)yyKelm et al.31was rated medium quality (4/7)yyBoth failed to clearly state their hypothesis (criterion B)yyThe effect size in the Kelm et al.31study was not clinically important (criterion F) and limitations were not identified (criterion G)Levels of EvidenceThree RCT?s= 2B Five case series = 4Two case reports = 5Assigned using the Oxford Centre for Evidence-Based Medicine (CEBM) Levels of Evidence32Oxford CEBM Level 2BImprovements in physical measures including: ?Increased upper and lower extremity muscle endurance25Improvements in QOL measures including: ?Improved quality of life16,24,25?Increased overall spiritual well being in the intervention group, and increased emotional distress in the control group24?The intervention group experienced a slower decline in total QOL16Oxford CEBM Level 4Improvements in physical measures including:?Increased strength and aerobic fitness27,28?Increased physical activity28?Increased walking distanceand faster sit-to-stand26Oxford CEBM Level 4Improvements in QOL measures including: ?Increased levels of invigoration and acceptance30?Decreased physical fatigue26?Increased role emotional, social and dyspneasubscales26?Improved role-physical score28?General increase in QOL29?Decreased anxiety8Oxford CEBM Level 5Improvements in physical measures including: ?Increased aerobic fitness30,31?Improved respiratory function31?Increased or maintained 1 RM31LimitationsHeterogeneity of: yystudy samples yydecreased external validityyyexercise interventions yyunable to determine optimal frequency, intensity, exercise type and session durationyyoutcome measuresyyNo single measure for QOL33LimitationsOutcome Measures yyReliable and valid outcome measures found to be most widely used25,34-37:yyEuropean Organization for Research and Treatment of Cancer QOL Questionnaire Core 30 (EORTC-QLQ-C30)yyFunctional Assessment of Chronic Illness Therapy (FACIT)yySymptom Distress Scale (SDS)yy36-Item Short Form (SF-36)yyMultidimensional Fatigue Inventory (MFI)yyHospital Anxiety and Depression Scales (HADS)AttritionyyShort life expectancy and debilitating symptoms make retention of participants challengingyyIt could be expected that attrition rates would be higher than normal for this population33yyHowever, all 10 studies have attrition rates well below normal rangeAdherence & Adverse EffectsyyDocumented adherence rates ranged from 75%   to 100% yyNo comment on potential reasonsyySpeculation: individualized programming, group participation or even noticeable improvements as motivators?yyNo adverse effects documentedImplications for Future PracticeyyProvides evidence to support exercise as a safe and effective intervention for persons with metastatic canceryyUnable to direct a specific exercise prescriptionyyExercise has a positive effect on QOL and physical statusyyImportant to communicate benefits and goals of exercise to patients and their familiesRecommendations for Future ResearchyyConduct larger and more rigorous RCT?syyInvestigate metastatic cancer sub-groupsyyUse consistent terminology to define cancer statusyyDetermine acceptable attrition ratesyyClarify optimal (or minimal) exercise prescription yyUse consistent outcome measures1.There is a positive associationbetween exercise and changes in both QOL and physical status.2.Clinicians working with persons withmetastaticcancer should use cautionwith exercise prescription, as there is currently no agreement upon optimal exercise parameters. 3.Further research in the area should focus on large-scale RCT?sto identify optimal and safe exercise parameters for this population.Concluding StatementsAcknowledgments yySusan Harris -Clinical Faculty, Department of Physical Therapy, UBC yyCharlotte Beck -Health Sciences Reference Librarian, UBC yyAngela Busch -Associate Professor, School of Physical Therapy, University of SaskatchewanyyElizabeth Dean -Professor, Department of Physical Therapy, UBCyyPhysiotherapy Canada for considering our review for publication (submitted July 1, 2008)References1.Canadian Cancer Society. 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