Exercise as it relates to Disease/Effect of high intensity training exercise as an intervention in cancer patients undergoing chemotherapy

This wiki books will be a critique of the research paper "Effect of a multimodal high intensity exercise intervention in cancer patients undergoing chemotherapy: randomised controlled trial" that was published in the BMJ medical journal in 2009.

What is the background to this research?

Improvements in cancer treatments have resulted in the extended survival of the individual and better control of any treatment related complications that occur. However, a large number of patients will still face side effects from the chemotherapy ranging from nausea, vomiting, body/muscle pain, insomnia (sleeping difficulties), loss of appetite and fatigue. Diagnosis of these symptoms are linked closely with those found in individuals who have an inactive daily lifestyle. One of the problems faced by individuals who lead a sedentary lifestyle include fatigue, due to loss of muscle mass and muscle strength. Hence exercise training is beginning to be introduced to patients to help improve their quality of life and their physical and emotional capabilities, in the hopes to improve their quality of life per and post treatment..Current studies have shown that a wide range of low intensity resistance programs that also incorporate psychological aspects such as relaxation and massage are recommended in conjunction with pharmaceutical therapies to relieve side effects such as nausea and pain to help the patient feel a greater sense of self control.

Where is the research from?

This research paper came out of Denmark, with multiple contributors extending to many research areas such as: Research Physiotherapists, Research Nurses, and extends to multiple Professors of Oncology. Jørn Herrstedt who is a professor of clinical oncology is one of the notable contributors/editors of this research paper. One notable author is Jørn Herrstedt, who currently has 132 published papers, and out of those 132 papers, 52 of them have him as the number 1 researcher/contributor to the paper. He is also the reviewer for more than 15 international cancer journals worldwide.

Along with the other contributors to this paper, he brings a vast array of knowledge and experience to help further this area of health and disease.

What kind of research was this?

This study was a short term randomised clinical trial (RCT) that was conducted on 269 patients with cancer. Of the 269 patients, 73 were men and 196 were women, with the mean age being 47 years old. The study therefore was a focus on female cancer patients as they made up 73% of the population in question. The patients were selected based on eligibility. This being if they had a diagnosis of cancer, received one cycle of chemotherapy and were aged between 18-65 years old. Patients were approached by research nurses and enrolled into the intervention if they met the criteria, or they could self enrol into the program. Comparisons of evidence across all the other research modes can be made, that being exercise in patients undergoing chemotherapy will be beneficial as it shows improvements of general health and other aspects such as wellbeing, physical ability and reducing fatigue . However, using a RCT as a method of implementing and measuring an intervention program is widely accepted as the "gold standard" of deducting conclusions from the enforced program. But other methods such as meta analysis and systematic reviews have their own benefits of data analysis.

What did the research involve?

The basic objective of the study was to investigate the effects of a six week intervention, comprising of high intensity physical training and low intensity modes of therapy, then comparing the results to a control group of patients. A secondary aim was to test the hypothesis that this type of intervention, as an adjuvant form of care, could improve the primary goal of reducing fatigue and improve a number of other key factors impacting the lives of these patients.

The methodology used ensured that the patients were safe, and allowed them to gather data that showed a range of results for the effects of a multimodal high intensity intervention. To measure the primary outcome (fatigue), they used the "European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire" (EORTCQLQ-C30). And to measure all secondary outcomes, the same questionnaire was used, using the sections that preceded the main outcome. Measurements were taken on a scale of 0-100 with a high score on the scale representing a higher quality of life, which allowed the participants to convey how they felt when it came time to get measurements.

Throughout the duration of the research, the people involved worked to minimise anything that could potentially degrade the evidence or measurements taken. However, limitations existed. For example, the paper mentions that participants were able to self recruit into the intervention program, and hence might have meant these individuals had elevated levels of motivation compared to other patients who did not self recruit into the program. Another limitation of the research is the time frame of the study. A short term clinical trial might not be able to improve the quality of life for patients undertaking the trial due to the nature of their treatment and disease.

What were the basic results?

Table 1.0 - EORTC-QLQ-C30 Main Outcome Variables Comparison

Outcome Variable	Control		Difference (+/-)	Intervention		Difference (+/-)
	Baseline	6 weeks		Baseline	6 Weeks
Global health status/Quality of life	60.2	63.3	+3.1	63.8	67.2	+3.4
Fatigue	43.0	41.0	-2.0	39.7	34.6	-5.1
Emotional Functioning	75.7	76.6	-1.1	77.6	81.3	+3.7
Physical Functioning	84.0	84.4	+0.4	84.7	89.0	+4.3

The important findings can be seen in the table 1.0 above. The intervention program failed to highlight improvements in the quality of life for the patients undertaking the intervention program compared with the control group, as there is a +0.3 difference between the two groups. However, as seen in the results, physical and emotional functioning variables improved in the intervention group which meant that even though there wasn't a huge improvement in fatigue indicators, they seemed to be happier and therefore ranked higher on the quality of life scale. Other variables such as nausea and vomiting did not improve across the intervention program. This might be evident that some side effects of chemotherapy can only be treated using pharmaceutical means and exercise whilst it has its benefits, will not improve some quality of life aspects for this type of patient.

What conclusions can we take from this research?

The study showed that although there is enough evidence to promote an exercise intervention that will improve physical and emotional functioning, the study also showed that there are also aspects that cannot be altered through an exercise intervention , and must be treated using pharmaceutical means, such as nausea and vomiting.

These results can be compared to other studies which looked at a bigger population and showed that "Many of the positive outcomes were observed in some, but not all trials." when observing improvements due to other exercise based interventions in cancer populations . They showed similar results in that overall quality of life was improved; however, there were aspects that did not benefit from the intervention in question

Practical advice

• This study shows the importance of pre screening and health checks before allowing a participant with cancer to undertake a training program.
• It also shows that there is still benefits of exercise that can improve the quality of life for cancer patients; however, consideration of any medications the patient is taking must be taken into consideration when designing a program.
• Any program must be formally monitor for, and report the incidence of any potentially adverse events that may occur during exercise.

Further readings:

• Physical Exercise in Cancer Patients During and AfterMedical Treatment: A Systematic Review of Randomised and Controlled Clinical Trials (article in question)
• https://www.cancervic.org.au/living-with-cancer/exercise
• This research paper primarily focusses on female patients, therefore readers should have a look studies that have a greater focus on interventions that includes an equal percentage of both sexes.