swanson - jelowicki - exercise fatigue and cancer

8/7/2019 Swanson - Jelowicki - Exercise Fatigue and Cancer

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Exercise, Fatigue and Cancer

Presented by:

Tara Swanson PT, MSc (RS)

Marta Jelowicki, PT

McGill Cancer Nutrition and Rehabilitation Program


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PRESENTATION OVERVIEW

Section One:

Overview of Cancer-Related Fatigue

Section Two:Findings From Recent Study: PhysiologicalCorrelates in Cancer-Related Fatigue

Section Three:Practical Considerations Related to Exercisein Cancer Patients


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Section One:

Overview of Cancer-Related Fatigue


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WHY FATIGUE

Fatigue is often one of the first symptoms,

starting at the presentation of a cancer

diagnosis

This may be due to several factors including:

Tumour being metabolically active May have decrease in appetite/food intake

May have a decrease in activity levels, leading to

de-conditioning


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CANCER-RELATED FATIGUE(CRF)

a persistent, subjective sense of tiredness

related to cancer or cancer treatment thatinterferes with usual functioning.

(National Comprehensive Cancer Network 2003)


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DIMENSIONS of CRF

Affective Dimension

(irritability, anxiety, depression) Cognitive Dimension

(poor concentration & memory)

Physical Dimension

(muscle fatigue & weakness, breathlessness)


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MEASUREMENT of CRF

May take a multi-dimensional or

uni-dimensional approach

May use a specific tool or subscale on QOL

tools


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STATUS OF KNOWLEDGE

Fatigue during treatment seems to berelated to type of cancer, chemotherapy

regimen, psychological status, sleepdifficulties, pain, activity, anemia

Fatigue after treatment seems to be related

to age, gender, psychological status, sleepdifficulties, pain, activity and shortness of

breath


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STATUS OF KNOWLEDGE

Effective interventions include:

Education (energy conservation, stressreduction, distraction)

Sleep hygiene

Nutrition

Specific Medications

Exercise


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GAPS IN KNOWLEDGE

There are many, including a limited

understanding how physical factors beyond

pain and shortness of breath influence thefatigue experience and its impact on function

This information is essential to refining our

measurements and interventions to addressCRF


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Section Two:

Findings From Recent Study


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PHYSIOLOGICAL CORRELATES OFCANCER-RELATED FATIGUE

Swanson T, Dalzell MA, Small D, Kreisman H,MacDonald N, St-Pierre DMM

McGill University, School of Physical and Occupational Therapy

Jewish General Hospital, Department of Pulmonary Medicine

Montreal, Quebec Canada


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OBJECTIVES

OBJECTIVE 1: Identify the physical factorscontributing to CRF

OBJECTIVE 2: Determine to what extent these

factors contribute to CRF


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MEASUREMENT

Brief Fatigue Inventory (BFI)Cancer-Related Fatigue

TOOLVARIABLE


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Mendoza et al. Cancer (1999)


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MEASUREMENT

Hand Grip DynamometerMuscular Endurance

Routine Blood TestingHemoglobin & C-Reactive

Protein (CRP) Levels

30 second Chair Rise (CR)

Hand Grip Dynamometer

Muscular Strength

Pulse OxymeterO2 Saturation with Activity

2-Minute Walk Test (2MWT)Exercise Capacity

TOOLVARIABLE


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MEASUREMENT

Visual Analogue Scale (0-10)Sleep

Visual Analogue Scale (0-10)Weakness

Visual Analogue Scale (0-10)Overall Breathlessness

Visual Analogue Scale (0-10)Pain

TOOLVARIABLE


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STATISTICAL ANALYSIS

UNIVARIATE REGRESSION between variables and

cancer-related fatigue (as assessed by the BFI)

MULTIVARIATE REGRESSION to determine a

predictive model of cancer-related fatigue


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STUDY POPULATION

INCLUDED

Stage III or IV non small cell lung cancer

Referred to McGill Cancer Nutrition and Rehabilitation

Program

EXCLUDED

Unable to complete questionnaires Unable to complete the assessment tasks due to pain

or safety reasons


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RESULTS: PREVALENCE OF CRF

90% reported some degree of fatigue in the past

24hrs


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0 1-4 5-7 8-10

Worst Fatigue Score

10

20

30

40

50

%Respondents


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RESULTS: PREVALENCE OF CRF

84% reported fatigue to have interfered with at leastone function in the past 24 hrs


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RESULTS: IMPACT OF CANCER-RELATED FATIGUE

100

80

60

40

20

Generalactivity

WalkingAbility

NormalWork

MoodRelations

with OthersEnjoyment

Of Life

DIMENSION OF FUNCTIONING

%Respond

ents


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10

20

30

40

%Respondents

0 1-3 4-6 7-10

General Activity Score

50


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FACTORS RELATED TO CRF:UNIVARIATE ANALYSIS

0.21**Lower Limb Strength (CR)

0.30**Overall Breathlessness (VAS)

0.18**Exercise Capacity (2MWT)

0.29**Pain (VAS)

0.45**Weakness (VAS)

R2FACTOR

** p


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FACTORS UNRELATED TO CRF:UNIVARIATE ANALYSIS

0.02C-Reactive Protein (CRP)

0.03Sleep (VAS)

0.07Hemoglobin

0.04Upper Limb Endurance

0.03O2 Saturation - Exercise

0.07Upper Limb Strength

R2FACTOR


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MODEL BYMULTIPLE REGRESSION

Weakness (VAS)

Overall breathlessness (VAS)

Measurement of lower limb strength

(CR performance):

Combined R2 value 0.62(p


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CONCLUSIONS

Cancer-related fatigue is prevalent and interferes

with function of NSCLC patients

Lower limb strength (CR), weakness (VAS) and

overall breathlessness (VAS) explain 62% of the

variance in cancer-related fatigue scores


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CLINICAL SIGNIFICANCE

Management of breathlessness may improve CRF inthis population

Weakness, especially in the lower limbs, contributedto CRF in this population

Strength training programs, in combination withcardiovascular training, may lead to improvement inCRF and ultimately enhance patient QOL


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Section Three:

Practical Considerations Related to Exercise inCancer Patients


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Outline

Why exercise?

Practical considerations related to exercise incancer patients

Motivation and resources


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Why Exercise

Exercise training is safe and feasible for

cancer survivors following the completion of

primary therapy

[Exercise]may be associated with

potentially clinically meaningful

improvements in exercise capacity and

overall QOL

Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am 22 (2008)


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Why Exercise

Physical activity interventions may reduce

the risk of developing some cancers, help

cancer survivors cope with and recover from

treatments, improve the health of long-term

cancer survivors, and possibly even reduce

the risk of recurrence and extend survival

after a cancer diagnosis

Courneya, K.S. and Friedenreich, C.M., Seminars in Oncology Nursing, 2007


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Why Exercise

Physical Activity and Survival After BreastCancer Diagnosis

Prospective observational study

2987 women diagnosed with stage I-III breast cancerfrom the Nurses Health Study cohort

Patients were divided into groups depending on howengaged they were in physical activity

Physical activity was measured in MET-hrs per week

Holmes et al. JAMA, 2005


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Why Exercise

Physical Activity and Survival After BreastCancer Diagnosis

Results:Any category of activity higher than the reference

category of less than 3 MET-hrs per week wasassociated with a decreased risk of an adversebreast cancer outcome

Absolute unadjusted mortality risk reduction was6% at 10 yrs for women who engaged in 9 ormore MET-hrs per week

Holmes et al. JAMA, 2005


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Practical Considerations

Treatment Side-effects Chemo-induced

Radiation-induced

Surgical

Other treatments: eg: Stem-Cell Transplant, steroids

Disease-Related Site of tumor

Metastases Nutritional status

Psychosocial impact


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Chemo-Induced

Fatigue

Thrombocytopenia

Anemia Neutropenia

Loss of hair


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Chemo-Induced

Decreased appetite

Nausea and vomiting

Changes in bowel function Neuropathy

Altered mentation, Chemo-brain

Cardiotoxicity


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Radiation-Induced

Burns

Fibrosis

Fatigue


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Surgical

Pain

Anatomical changes

Scar mobility

Added management difficulties if followedclosely by radiation

Foot drop

Post-op restrictions due to type of surgery

Post-op restrictions suggested by surgeon


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Other Treatments

Stem Cell Transplant (SCT)

Decreased Immunity

Avoid public pools, lakes, and crowded areas

Graft vs Host Disease (allogeneic-SCT)

Sun exposure precautions

Sclerodermatic tissue changes with skin GvHD

Corticosteroids:

Used in many treatment regimens


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Site of Tumor

Gastroesophageal

Breast

Prostate Hepatobiliary

Lung

Hematologic

Other


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Metastases

Liver

Lung

Brain Bone


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Nutritional Status


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Psychosocial Impact

CognitiveCognitive

OccupationalOccupational

FinancialFinancial

PhysicalPhysical

RelationshipsRelationships

Spiritual

Religious

Spiritual

Religious

EmotionalEmotional

CopingCoping

PersonPerson


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Some Guidelines from Cancer ExerciseSpecialist Training Course

Individualize

Moderate intensity activity level

Full body exercise at each session 3x/wk Monitor blood counts

Progress slowly and vary workout with treatment

effects


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Some Guidelines from Cancer ExerciseSpecialist Training Course

50-60% HRR (starting);

RPE = 4-5

Active, moderate health,

average fitness

30-40% HRR (starting);

RPE = 1-3

Sedentary, poor health,

low fitness

Recommended Intensity LevelStatus

Exercise and Cancer Recovery, Schneider, C. M. et al., 2003


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Motivation

Some ideas. Patients have control: CHOICE

Prevention of complications or secondary

problems Potential benefits

Sense of achievement

Goal setting New habit: can take 30-60 times to develop

Exercise can be FUN, really


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Take-Home Message

Do not avoid, but be cautious when prescribing

Physical Exercise

MODERATE INTENSITY, slow progression

Keep in mind the whole person, the individual

Exercise is an important and integral part of life

prior to, with, and after cancer, have fun with it!


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Resources

Canadian and American Cancer Societies Comprehensive Health Improvement Program

(CHIP) at Atwater Club

Cummings Center

Jewish Rehabilitation Hospital

McGills Cancer Nutrition-Rehabilitation Programs

Wellness Center (CDN)

Yoga classes (Happy Tree) Many community activities, gyms, and.. the great

outdoors


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References

Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am22 (2008) 319-342

Holmes et al., JAMA May 25, 2005, Vol 293, No. 20

Courneya, K.S. and Friedenreich, C.M., Physical Activty and

Cancer Control, Seminars in Oncology Nursing, Vol. 23, no. 4(Nov.) 2007 (pp 242-252)

Franklin, D. J. MD, PhD, Phys Med and Rehab Clin of N Am18899-924 (2007)

Exercise and Cancer Recovery, Schneider, C. M. et al., 2003

[email protected]

swanson - jelowicki - exercise fatigue and cancer

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