Effects of Physical Activity Interventions on Cancer Survivors: A Systematic Review of the Evidence

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Effects of Physical Activity Interventions on
Cancer Survivors A Systematic Review of the
Evidence

• Kathryn H. Schmitz, PhD, MPH
• Rebecca M. Speck, MPH
• University of Pennsylvania School of Medicine
• Philadelphia, Pennsylvania, USA

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Symposium Overview

• Overview (Schmitz)
• Background
• Methods
• Adverse Effects (Schmitz)
• Post-Treatment studies (Schmitz)
• Description
• Outcomes
• Ongoing studies PAL
• During-Treatment studies (Speck)
• Description
• Outcomes
• Ongoing studies - BALANCE
• Overall discussion (Audience)

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Definition of a Cancer Survivor

• Any individual that has been diagnosed with
  cancer, from the time of discovery and for the
  balance of life

National Coalition for Cancer Survivorship
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Background

• gt11 million cancer survivors alive in the U.S.
  today
• Improved cancer Tx ? ? survivors
• Effects of cancer Tx
• Physiologic
• Psychosocial
• Physical activity may be useful for
• Rehabilitation from negative Tx effects
• Reducing recurrence
• Improving survival

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Framework PEACECourneya and Friedenreich 2001
Diagnosis
Rehab ? Health Promotion
Prevention ? Detection ? Buffering ?
Coping
Survival
Palliation
Pre-screen Screening Pre-treatment
Treatment Post-treatment Resumption
Pre-diagnosis Post-diagnosis
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Key Question of This Review

• Examine the evidence that physical activity
  interventions are effective in helping cancer
  survivors improve their psychosocial or
  physiologic outcomes
• Also interested in negative outcomes (adverse
  events)
• This is an update of
• Schmitz et al. Cancer Epidemiology, Biomarkers,
  and Prevention, 2005

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Unique Features of This Review

• Focus on high quality studies
• All studies must have a concurrent comparison
  group
• Separation of results by during vs. post
  treatment time frames

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Methods

• Inclusion/Exclusion criteria
• Must be focused on individuals diagnosed with
  cancer
• Must include an intervention designed to increase
  physical activity
• Could not be delivered solely by physical
  therapists
• Must include a concurrent comparison group
• Must be published in English
• Studies conducted in children only were excluded

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Data abstraction and quality review

• Systematic abstraction of outcomes
• Double check for accuracy of at least 1 randomly
  selected outcome per study
• Study quality review
• 10 internal validity criteria
• High quality gt 5 criteria

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Literature Review

• 75 studies included in review
• 60 high quality studies
• 45 studies post treatment
• 37 high quality studies post treatment

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Description of Post Treatment Interventions
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Summary of Exercise Rx
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Adverse Events

• All 75 studies reviewed
• 32 commented on AEs
• 26 found no evidence of harm
• The remaining 6 reported
• Minor musculoskeletal injuries
• Myocardial Infarction
• Broken central venous catheter stitch
• Shoulder injuries
• Lymphedema

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Outcomes Abstracted

• Physical fitness
• Body size
• Quality of life
• Psychosocial
• Fatigue
• Anxiety
• Depression

• Self-esteem
• Physiological
• Pain
• Symptoms/side effects

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Qualitative Review

• Strong Evidence
• 3 studies, gt75 significant
• Some Evidence
• 3 studies, 26-75 significant
• Not effective
• 3 studies, but lt25 significant
• Insufficient Evidence
• lt3 high quality studies

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Strong Evidence

• Breast cancer subscale of quality of life survey
• 3 studies
• Courneya 2006 Aerobic only
• Daley 2007 Aerobic only
• Milne 2008 Aerobic and resistance training
• All significant large changes

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Breast Cancer Subscale

• I have been short of breath
• I am self-conscious about the way I dress
• One or both of my arms are swollen or tender
• I feel sexually attractive
• I am bothered by hair loss
• I worry that other members of my family might
  someday get the same illness I have
• I worry about the effect of stress on my illness
• I am bothered by a change in weight
• I am able to feel like a woman
• I have certain parts of my body where I
  experience significant pain

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Strong Evidence

• Arm volume
• 4 studies
• Ahmed - Resistance
• Courneya - Resistance
• Sandel - Dance
• Kilgour Stretching/flexibility
• No evidence of worse arm volume after
  interventions
• Kilgour was the only one NOT supervised

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Some Evidence (1 of 3)

• Physical Activity Level
• Physical Fitness
• Aerobic fitness
• Upper body strength
• Lower body strength
• Lower body flexibility
• Anthropometry
• Lean mass
• Body fat

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Some Evidence (2 of 3)

• Patient reported outcomes
• Quality of life
• Overall
• Physical
• Functional
• Social
• Psychosocial outcomes
• Vigor/Vitality
• Fatigue
• Depression
• Anxiety
• Pain
• Symptoms/Side effects

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Some Evidence (3 of 3)

• Physiological outcomes
• Immune parameters

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Not effective

• Shoulder flexibility
• Anthropometry
• BMI, Body weight
• Fat mass
• Waist circumference
• Quality of life
• Mental
• Social
• Satisfaction with life
• Physiologic outcomes
• Total cholesterol
• Glucose, insulin

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Insufficient evidence More research needed (1 of
2)

• Objectively measured physical function
• Quality of life
• Physical role
• General
• Psychosocial outcomes
• Sexual attractiveness
• Weight concerns
• Physical condition
• Positive mood
• Mood disturbance
• Anger
• Confusion
• Body image
• Self-esteem

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Insufficient evidence More Research Needed (2 of
2)

• Physiologic outcomes
• Bone
• Hemoglobin
• Hematocrit
• Lipids
• IGF-1, 2, BP-1, BP-3
• Testosterone
• PSA

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Interpretation

• Lack of evidence versus insufficient evidence
• Reasons for lack of evidence
• Take home messages
• Exercise is safe post-treatment
• Has a positive effect on many physiologic and
  psychosocial outcomes
• NO lymphedema risk noted
• To underscore this

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• Physical Activity
• and Lymphedema Trial

R01-CA106851
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Hypothesis

• Supervised slowly progressive controlled increase
  in physiological stress through strength training
  may be more beneficial to BrCa survivors vs.
  acute stress from activities of daily living
• Analogy
• Heart attack and shoveling snow
• Lymphedema and lifting a heavy object

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PAL Design
2
1
LYMPHEDEMA N 144
NO LYMPHEDEMA N 144
TREATMENT N 72
CONTROL N 72
TREATMENT N 72
CONTROL N 72

• 1 year randomized controlled intervention
• Target 288 Breast Cancer Survivors

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Baseline strength and body size in women WITH
lymphedema
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Baseline strength and body size in women WITHOUT
lymphedema
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Baseline Lymphedema Characteristics
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Intervention adherence

• With lymphedema
• 88 average attendance
• Without lymphedema
• 79 average attendance

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Strength changes in women WITH lymphedema
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Strength changes in women WITHOUT lymphedema
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Lymphedema outcomes in women WITH lymphedema
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Lymphedema outcomes in women WITHOUT lymphedema
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PAL Summary

• Twice weekly slowly progressive strength training
  is SAFE for breast cancer survivors who have had
  lymph node removal including
• Those WITH lymphedema
• Those AT RISK FOR lymphedema
• Risk of lymphedema flare-ups decreased by HALF
• May save insurance companies money
• Strength improvements with this program are
  substantive
• Body image improved too (results not shown)
• Translation to lower body lymphedema underway