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Effects of Supervised Exercise Training on Cardiopulmonary Function and Fatigue in Breast Cancer Survivors During and After Treatment
symptoms, were increased only during the treatment phase. Therefore, the extended observations of these trials have important implications for patients’ choices and for formulating large-scale public health policy. D. Tripathy, MD
References 1. Fisher B, Constantino JP, Wickerham DL, Redmond CK, Kavanah M, Cronin WM, et al. Tamoxifen for prevention of breast cancer: Report of the
Effects of Supervised Exercise Training on Cardiopulmonary Function and Fatigue in Breast Cancer Survivors During and After Treatment Schneider CM, Hsieh CC, Sprod LK, et al (Univ of Northern Colorado, Greeley; Natl Hsinchu Univ of Education, Taiwan, Republic of China; Regional Breast Ctr of Norhern Colorado, Greeley) Cancer 110:918-925, 2007
Background.—Cancer treatments have serious physiological and psychological side effects in cancer survivors. This investigation examined cardiopulmonary function and fatigue in breast cancer survivors during and after treatment by using similar exercise assessments, prescriptions, individualized interventions, and reassessments. Methods.—The study included 113 women diagnosed with breast cancer. Participants were grouped according to whether they participated in an individualized prescriptive exercise program during cancer treatment (DTm) or after cancer treatment (FTm). After a comprehensive screening and medical examination, cardiovascular endurance, pul-
National Surgical Adjuvant Breast and Bowel Project P-01 study. J Natl Cancer Inst. 1998;90:1371-1388. 2. Powles T, Eeles R, Ashley S, Easton D, Chang J, Dowsett M, et al. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet. 1998;352:98-101. 3. Veronesi U, Maisonneuve P, Rotmensz N, Costa A, Sacchini V, Travaglini R, et al. Italian randomized trial among women with hysterectomy: Tamoxifen and hormone-dependent breast cancer
monary function, and fatigue were assessed, which led to the development of an individualized 6-month exercise prescription and exercise intervention. Repeated-measures analysis of variance (ANOVA) and analyses of covariance (ANCOVA) were used to compare the effectiveness of the intervention and differences between groups. Results.—Cardiopulmonary function (systolic blood pressure, time on treadmill) improved in the DTm group (P < .05), whereas the FTm group showed reductions in systolic and diastolic blood pressure and resting heart rate (P < .05) with concurrent increases in percentage of predicted FVC, % of predicted FEV1, predicted VO2max, and time on treadmill (P < .05). Psychologically, the DTm group showed reductions in behavioral, sensory, and total fatigue (P < .05), whereas the FTm group showed reductions in behavioral, affective, sensory, cognitive/mood, and total fatigue (P < .05). Conclusions.—The current study suggested that moderate intensity, individualized, prescriptive exercise maintains or improves cardiovascular and pulmonary function with concomitant reductions in fatigue during and after cancer treatment. However, it is critical that
in high-risk women. J Natl Cancer Inst. 2003;95:160-165. 4. Cuzick J, Forbes J, Edwards R, Baum M, Cawthorn S, Coates A, et al. First results from the International Breast Cancer Intervention Study (IBIS-1): A randomised prevention trial. Lancet. 2002;360:817-824. 5. Early Breast Cancer Trialists’ Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomised trials. Lancet. 2005;365:1687-1717.
exercise be individualized to specific needs of the cancer survivor to prevent exacerbation of cancer treatment toxicities. Research related to the benefits of exercise in cancer patients has expanded considerably in the last few years. The general conclusion from systematic reviews and meta-analyses of retrospective clinical trials is that exercise can facilitate rehabilitation after cancer treatment. Most previous studies have focused on the general quality-oflife benefits that exercise can provide, so it is nice to see new research studies that are more focused on assessing the potential physiologic benefits of exercise in cancer patients. The authors managed to recruit a reasonable-sized patient sample and invested a great deal of time providing patients with individualized exercise programs. However, although the findings look promising, the unequal group sizes (17 patients undergoing treatment vs 96 having completed treatment), the lack of blinded assessment and the pre- and post-study design/analyses mean that the findings must be interpreted with caution. I did agree with the inclusion of
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the case report because it is often difficult for readers to visualize what patients actually do in such studies. The authors concluded that “it is critical that exercise be individualized to specific needs of the cancer survivor.” However, I do not quite follow why it is important that the programs be individualized. Surely the goal should be to sim-
ply get cancer patients and survivors moving and to encourage them to do what they can, when they can? This might involve walking in their communities, swimming with their children, or biking in the park. I do not think it needs to be any more complex than this. Moreover, I doubt many health care organizations would have the resources to
provide all cancer patients and survivors with an individualized exercise regimen like the one used in this study. So my plea is that we educate patients that “rest is not best” and that we resist the temptation to get too technical about what we want them to achieve.
Social and Racial Differences in Selection of Breast Cancer Adjuvant Chemotherapy Regimens
age ≥70 years (P = .001), higher stage (P < .0001), insurance type (P = .048), employment status (P = .045), employment type (P = .025), and geographic location (P = .021) were associated with the use of nonstandard regimens in univariate analyses. In multivariate analysis, black race (P = .020), lower educational attainment (P = .024), age ≥70 years (P = .032), and higher stage (P < .0001) were associated with receipt of nonstandard regimens. Conclusion.—The more frequent use of non–guideline-concordant adjuvant chemotherapy regimens in black women and women with lower educational attainment may contribute to less favorable outcomes in these populations. Addressing such differences in care may improve cancer outcomes in vulnerable populations.
standard regimen, and patients with less than a high school education had a 3fold increased likelihood. However, because of the small number of patients in the study, the number of blacks who received nonstandard regimens represents only 2% of the sample (21 of 957 patients), and the number who had less than a high school education represents only 1.4% (14 of 957). As the authors point out, because many patients received active treatment regimens (primarily anthracyclines, taxanes, or both), it is unclear whether the use of nonstandard regimens plays a role in the disparity in outcomes that have been observed in these groups of women. Importantly, the authors do not report the number of patients treated in clinical trials in this cohort. Patients treated in clinical trials may have justifiable reasons for deviating from treatment guidelines. The findings in this study are provocative and warrant further exploration to better define the patient and physician factors that contribute to the use of nonstandard regimens and the effect of these regimens on breast cancer outcome.
Griggs JJ, Culakova E, Sorbero MES, et al (Univ of Rochester, NY; RAND Corp, Pittsburgh, Pa; Univ of Washington, Seattle; et al) J Clin Oncol 25:2522-2527, 2007
Purpose.—Breast cancer outcomes are worse among black women and women of lower socioeconomic status. The purpose of this study was to investigate racial and social differences in selection of breast cancer adjuvant chemotherapy regimens. Methods.—Detailed information on patient, disease, and treatment factors was collected prospectively on 957 patients who were receiving breast cancer adjuvant chemotherapy in 101 oncology practices throughout the United States. Adjuvant chemotherapy regimens included in any of several published guidelines were considered standard. Receipt of nonstandard regimens was examined according to clinical and nonclinical factors. Differences between groups were assessed using χ2 tests. Multivariate logistic regression was used to identify factors associated with use of nonstandard regimens. Results.—Black race (P = .008), lower educational attainment (P = .003),
84 84
®
The authors report the rates and determinants of the use of nonstandard adjuvant chemotherapy regimens in community practices among women with nonmetastatic breast cancer. Approximately 12% of patients received a regimen that was not considered standard according to clinical practice guidelines; however, reassuringly, most of these patients received at least 1 chemotherapy drug that has activity against breast cancer. In addition, several “nonstandard” regimens were under investigation at the time of data collection. The authors report that black patients had a 2-fold increased likelihood of receiving a non-
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
A. J. Daley, PhD
D. L. Hershman, MD, MS
References 1. Fisher B, Constantino JP, Wickerham DL, Redmond CK, Kavanah M, Cronin WM, et al. Tamoxifen for prevention of breast cancer: Report of the
Effects of Supervised Exercise Training on Cardiopulmonary Function and Fatigue in Breast Cancer Survivors During and After Treatment Schneider CM, Hsieh CC, Sprod LK, et al (Univ of Northern Colorado, Greeley; Natl Hsinchu Univ of Education, Taiwan, Republic of China; Regional Breast Ctr of Norhern Colorado, Greeley) Cancer 110:918-925, 2007
Background.—Cancer treatments have serious physiological and psychological side effects in cancer survivors. This investigation examined cardiopulmonary function and fatigue in breast cancer survivors during and after treatment by using similar exercise assessments, prescriptions, individualized interventions, and reassessments. Methods.—The study included 113 women diagnosed with breast cancer. Participants were grouped according to whether they participated in an individualized prescriptive exercise program during cancer treatment (DTm) or after cancer treatment (FTm). After a comprehensive screening and medical examination, cardiovascular endurance, pul-
National Surgical Adjuvant Breast and Bowel Project P-01 study. J Natl Cancer Inst. 1998;90:1371-1388. 2. Powles T, Eeles R, Ashley S, Easton D, Chang J, Dowsett M, et al. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet. 1998;352:98-101. 3. Veronesi U, Maisonneuve P, Rotmensz N, Costa A, Sacchini V, Travaglini R, et al. Italian randomized trial among women with hysterectomy: Tamoxifen and hormone-dependent breast cancer
monary function, and fatigue were assessed, which led to the development of an individualized 6-month exercise prescription and exercise intervention. Repeated-measures analysis of variance (ANOVA) and analyses of covariance (ANCOVA) were used to compare the effectiveness of the intervention and differences between groups. Results.—Cardiopulmonary function (systolic blood pressure, time on treadmill) improved in the DTm group (P < .05), whereas the FTm group showed reductions in systolic and diastolic blood pressure and resting heart rate (P < .05) with concurrent increases in percentage of predicted FVC, % of predicted FEV1, predicted VO2max, and time on treadmill (P < .05). Psychologically, the DTm group showed reductions in behavioral, sensory, and total fatigue (P < .05), whereas the FTm group showed reductions in behavioral, affective, sensory, cognitive/mood, and total fatigue (P < .05). Conclusions.—The current study suggested that moderate intensity, individualized, prescriptive exercise maintains or improves cardiovascular and pulmonary function with concomitant reductions in fatigue during and after cancer treatment. However, it is critical that
in high-risk women. J Natl Cancer Inst. 2003;95:160-165. 4. Cuzick J, Forbes J, Edwards R, Baum M, Cawthorn S, Coates A, et al. First results from the International Breast Cancer Intervention Study (IBIS-1): A randomised prevention trial. Lancet. 2002;360:817-824. 5. Early Breast Cancer Trialists’ Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomised trials. Lancet. 2005;365:1687-1717.
exercise be individualized to specific needs of the cancer survivor to prevent exacerbation of cancer treatment toxicities. Research related to the benefits of exercise in cancer patients has expanded considerably in the last few years. The general conclusion from systematic reviews and meta-analyses of retrospective clinical trials is that exercise can facilitate rehabilitation after cancer treatment. Most previous studies have focused on the general quality-oflife benefits that exercise can provide, so it is nice to see new research studies that are more focused on assessing the potential physiologic benefits of exercise in cancer patients. The authors managed to recruit a reasonable-sized patient sample and invested a great deal of time providing patients with individualized exercise programs. However, although the findings look promising, the unequal group sizes (17 patients undergoing treatment vs 96 having completed treatment), the lack of blinded assessment and the pre- and post-study design/analyses mean that the findings must be interpreted with caution. I did agree with the inclusion of
®
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
83 83
the case report because it is often difficult for readers to visualize what patients actually do in such studies. The authors concluded that “it is critical that exercise be individualized to specific needs of the cancer survivor.” However, I do not quite follow why it is important that the programs be individualized. Surely the goal should be to sim-
ply get cancer patients and survivors moving and to encourage them to do what they can, when they can? This might involve walking in their communities, swimming with their children, or biking in the park. I do not think it needs to be any more complex than this. Moreover, I doubt many health care organizations would have the resources to
provide all cancer patients and survivors with an individualized exercise regimen like the one used in this study. So my plea is that we educate patients that “rest is not best” and that we resist the temptation to get too technical about what we want them to achieve.
Social and Racial Differences in Selection of Breast Cancer Adjuvant Chemotherapy Regimens
age ≥70 years (P = .001), higher stage (P < .0001), insurance type (P = .048), employment status (P = .045), employment type (P = .025), and geographic location (P = .021) were associated with the use of nonstandard regimens in univariate analyses. In multivariate analysis, black race (P = .020), lower educational attainment (P = .024), age ≥70 years (P = .032), and higher stage (P < .0001) were associated with receipt of nonstandard regimens. Conclusion.—The more frequent use of non–guideline-concordant adjuvant chemotherapy regimens in black women and women with lower educational attainment may contribute to less favorable outcomes in these populations. Addressing such differences in care may improve cancer outcomes in vulnerable populations.
standard regimen, and patients with less than a high school education had a 3fold increased likelihood. However, because of the small number of patients in the study, the number of blacks who received nonstandard regimens represents only 2% of the sample (21 of 957 patients), and the number who had less than a high school education represents only 1.4% (14 of 957). As the authors point out, because many patients received active treatment regimens (primarily anthracyclines, taxanes, or both), it is unclear whether the use of nonstandard regimens plays a role in the disparity in outcomes that have been observed in these groups of women. Importantly, the authors do not report the number of patients treated in clinical trials in this cohort. Patients treated in clinical trials may have justifiable reasons for deviating from treatment guidelines. The findings in this study are provocative and warrant further exploration to better define the patient and physician factors that contribute to the use of nonstandard regimens and the effect of these regimens on breast cancer outcome.
Griggs JJ, Culakova E, Sorbero MES, et al (Univ of Rochester, NY; RAND Corp, Pittsburgh, Pa; Univ of Washington, Seattle; et al) J Clin Oncol 25:2522-2527, 2007
Purpose.—Breast cancer outcomes are worse among black women and women of lower socioeconomic status. The purpose of this study was to investigate racial and social differences in selection of breast cancer adjuvant chemotherapy regimens. Methods.—Detailed information on patient, disease, and treatment factors was collected prospectively on 957 patients who were receiving breast cancer adjuvant chemotherapy in 101 oncology practices throughout the United States. Adjuvant chemotherapy regimens included in any of several published guidelines were considered standard. Receipt of nonstandard regimens was examined according to clinical and nonclinical factors. Differences between groups were assessed using χ2 tests. Multivariate logistic regression was used to identify factors associated with use of nonstandard regimens. Results.—Black race (P = .008), lower educational attainment (P = .003),
84 84
®
The authors report the rates and determinants of the use of nonstandard adjuvant chemotherapy regimens in community practices among women with nonmetastatic breast cancer. Approximately 12% of patients received a regimen that was not considered standard according to clinical practice guidelines; however, reassuringly, most of these patients received at least 1 chemotherapy drug that has activity against breast cancer. In addition, several “nonstandard” regimens were under investigation at the time of data collection. The authors report that black patients had a 2-fold increased likelihood of receiving a non-
Breast Diseases: A Year Book Quarterly Vol 19 No 1 2008
A. J. Daley, PhD
D. L. Hershman, MD, MS