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Abstract Introduction Integration of exercise into standard oncology care requires a highly skilled workforce of exercise professionals; however, competency requirements have not kept pace with advancements in the field. Therefore, the aim of this study was to obtain consensus on core competencies required for an exercise professional to be qualified to work with adults undergoing active cancer treatment. Materials and Methods A three‐round modified electronic Delphi process was used. In Round 1, an international group of 64 exercise oncology stakeholders (i.e., exercise oncology professionals (n = 29), clinical referrers (n = 21), and people with lived experience (n = 14)) responded to open‐ended prompts eliciting perspectives regarding competencies needed for an exercise oncology professional to work with adults receiving active cancer treatment. Subsequently, only exercise oncology professionals participated, ranking the importance of competencies. In Round 2, professionals received summary feedback, ranked new competencies generated from open‐ended responses, and reranked competencies not reaching consensus. In the final round, professionals finalized consensus ranking and rated frequency and mastery level for each. Results Consensus was reached on 103 core competencies required for exercise professionals to be qualified to deliver care to adults undergoing active cancer treatment. The core competencies represent 10 content areas and reflect the needs of clinical referrers and people with lived experience of receiving cancer treatment. Conclusions The core competencies identified reflect significant advancements in the field of exercise oncology. Results will underpin the development of education, certification, and employment requirements for exercise oncology professionals, providing a critical step toward achieving routine integration of exercise into standard oncology care.

Abstract The management of cancer-related symptoms with nonpharmacological treatment has been proven effective, but more studies are still required to strengthen the scientific evidence. Given the state of the evidence, one might wonder about the perceptions of pediatric oncology experts, healthcare providers and CAM providers regarding the use of supportive care in pediatric oncology. Related to this important question, Mora et al. recently published an exploratory qualitative study entitled “Supportive care for cancer-related symptoms in pediatric oncology: a qualitative study among healthcare providers” in the BMC Complementary Medicine and Therapies Journal. The data generated by the authors provided new insights and perspectives to the current literature. However, their findings must be put into perspective to increase the scope of the original article and to highlight that physical activity and psychosocial interventions are powerful nonpharmacological interventions to manage cancer-related symptoms.

Abstract Background Low skeletal muscle mass (myopenia) is common in cancer populations and is associated with functional decline and mortality, but prior oncology studies did not assess total body skeletal muscle mass. Instead, they measured surrogates such as cross‐sectional area (CSA) of skeletal muscle at L3 from computed tomography (CT) or appendicular lean mass (ALM) from dual‐energy X‐ray absorptiometry (DXA). D3‐creatine (D3Cr) dilution is a non‐invasive method to assess total body skeletal muscle mass, which has been examined in a variety of populations but not in cancer. To compare the associations of D3Cr muscle mass, CT CSA, and DXA ALM with myopenia and physical function, we conducted a cross‐sectional study among 119 patients with colon cancer (2018–2022). Methods For each technique (D3Cr, CT and DXA), myopenia was defined as the lowest sex‐specific quartile of its measurement. Physical function was measured by the short physical performance battery and grip strength. We calculated Pearson correlations (r) among three techniques, computed Cohen's kappa coefficients (κ) to assess the agreement of myopenia, and estimated Pearson correlations (r) of three techniques with physical function. All analyses were sex‐specific. Results Sixty‐one (51.3%) participants were male, the mean (standard deviation) age was 56.6 (12.9) years, and most (68.9%) had high physical function (short physical performance battery: ≥11 points). Correlations and myopenia agreement among three techniques were greater in men than women; for example, regarding D3Cr muscle mass versus CT CSA, r was 0.73 (P

Abstract Background Food gardening may positively influence cardiovascular disease (CVD) risk-related behaviors. However, the vast majority of existing gardening interventions have used an in-person delivery model which has limitations for scalability. It is not known whether a digitally delivered gardening intervention would be feasible or acceptable to participants. The purpose of this pilot study was to assess the feasibility of a digitally delivered gardening intervention in three domains: participant acceptability, demand, and practicality. Methods A single-arm, pre-post-study design was used. Participants (n = 30) were aged 20 + with no plans to garden in the coming season and had at least 1 CVD risk factor. The intervention included ten 1-h video-conferencing sessions, written materials, and access to a study website. Content focused on gardening skills, cooking skills, and the Dietary Approaches to Stop Hypertension (DASH) diet. Feasibility outcomes included acceptability (post-program ratings), demand (session attendance rate), and practicality (ability to start a garden and grow F&V). The study was considered feasible if the following criteria were met: ≥ 70% rated the intervention as good or excellent, overall session attendance rate was ≥ 70%, and > 70% were able to start a garden and grow F&V. We also assessed pre-post-program changes in behavioral mediators (gardening confidence, gardening enjoyment, cooking confidence, and nutrition knowledge). Descriptive statistics were calculated. Pre-post differences were evaluated with means and 95% confidence intervals (95% CI). Effect sizes were calculated (Cohen’s d). Results All feasibility criteria were met. A total of 93.3% of participants rated the intervention as good or excellent, 96% started a garden and grew F&V, and the overall session attendance rate was 81%. The largest mean pre-post changes were in gardening confidence (pre 7.1 [95% CI: 6.4, 7.9], post 9.0 [95% CI: 8.6, 9.5], Cohen’s d = 1.15), gardening enjoyment (pre: 6.3 [95% CI: 5.9, 6.7], post: 7.5 [95% CI: 7.1, 7.9], Cohen’s d = 1.69), and cooking self-efficacy (pre: 4.7 [95% CI: 4.3, 5.1], post: 7.7 [95% CI: 7.3, 8.0], Cohen’s d = 3.0). Conclusion A digitally delivered gardening intervention was feasible, acceptable to participants, and they had meaningful changes in behavioral mediators. The next step is to evaluate the impact of the intervention in a future randomized controlled trial.

Abstract Background A higher chemotherapy completion rate is associated with better outcomes including treatment efficacy and overall survival. Exercise may have the potential to improve relative dose intensity (RDI) by reducing the frequency and severity of chemotherapy‐related toxicities. We examined the association between exercise adherence and RDI and possible clinical‐ and health‐related fitness predictors of RDI. Methods Chemotherapy records were extracted from the electronic medical record for patients enrolled in the ENACT trial (n = 105). Chemotherapy completion was assessed using average RDI. A threshold of 85% was established for “high” versus “low” RDI. Logistic regression analyses were used to estimate the associations between the clinical‐ and health‐related fitness predictors of RDI. Results Patients with breast cancer (BC) had a significantly higher average RDI (89.8% ± 17.6%) compared with gastrointestinal cancer (GI) (76.8% ± 20.9%, p = 0.004) and pancreatic cancer (PC) (65.2% ± 20.1%, p

Background: Long term survivors of childhood cancer have a high prevalence of chronic pain. Novel, multidisciplinary approaches to manage pain, are needed to allow for a reduction in the use of opioids for pain management. Physical activity is highly effective in managing chronic pain in children and adolescents, however, evidence about the combination of physical activity intervention and pain medications in chronic pain management in childhood cancer survivors is lacking. The aim of this study is to investigate the feasibility, acceptability and preliminary effects of a behavioral physical activity intervention integrated into standard post cancer directed treatment care to mitigate chronic pain in this unique population. Methods: This is a single site pilot randomized controlled trial of a 16-week physical activity intervention coupled with standard care. The primary aim is to assess the feasibility and acceptability of the physical activity intervention in childhood cancer survivors with chronic pain. Secondary aims include evaluating the differences in functional and psychosocial outcomes along with self-reported pain scores and cumulative dose of pain medications between the exercise group and standard cancer care group. The physical activity intervention is a home-based program structured to increase patients' physical activity behavior and to favor low intensity bodily movement using aerobic exercise and resistance training. Conclusions: This study will demonstrate that behavioral supportive measures like physical activity may be a novel means to improve cancer related chronic pain in young survivors of childhood cancer and decrease medication usage for pain along with improvement in functional and psychosocial outcomes.

Abstract Background Patients with pancreatic cancer often lose weight during chemotherapy with associated changes in body composition. The goal of the present analysis was to describe changes in body composition in pancreatic cancer patients on an exercise regimen. The long‐term goal is to determine whether an exercise intervention may attenuate changes in body composition and function. Methods Twenty‐two pancreatic cancer patients of all stages who were to receive chemotherapy were recruited into a pre‐post exercise intervention study. A standard exercise prescription was individualized to include aerobic, resistance, stretch, and balance exercises. Pre‐ and post‐intervention computed tomography‐derived measures of body composition [skeletal muscle index (SMI), skeletal muscle density, visceral fat area, and subcutaneous fat area] and physical function measures (grip strength, timed up and go, 30‐s chair stand, and tandem balance stand) were evaluated using paired t‐tests, χ2 tests, and Pearson correlation coefficients. Results The subjects were, on average, 62 years of age, 55% were female, 95% non‐Hispanic White, and 45% were Stage IV. Body composition changes included a median 4.6% decrease in SMI (P = 0.04), 7.91% increase in skeletal muscle density (P = 0.05), 25.07% decrease in visceral fat area (P = 0.0001), and 22.08% decrease in subcutaneous fat area (P = 0.001). Adherence to aerobic and strength exercise was 65% and 57%, respectively. Some physical function measures improved, though not significantly: chair stands increased from a mean of 11.5 to 13.0 (P = 0.59) and timed up and go improved from a mean of 11.7 to 10.3 (P = 0.26). Change in right hand grip strength was marginally positively associated with changes in SMI (r = 0.53, P = 0.06). Improvements in skeletal muscle density were seen in 63% of patients, including Stage IV patients but did not correlate with change in function. Conclusions Exercise is feasible during neoadjuvant chemotherapy for pancreatic cancer patients of all stages and may assist with maintaining physical function and improving body composition. Further research is needed.

Abstract Background With an aging population, rising incidence of breast cancer, improved survival rates, and obesity epidemic, there will be a growing population of older adult breast cancer survivors with obesity. This complex population, often with multimorbidity, is at risk for several poor health outcomes, including recurrence, cardiovascular disease, dementia, and diabetes, and a number of deleterious symptoms, including a worsened inflammatory profile, breast cancer‐ related lymphedema, mobility disability, cognitive impairment, anxiety, and depressive symptoms. A wealth of meta‐analytic and randomized controlled trial evidence show that adherence to World Health Organization and 2018 United States Physical Activity guidelines‐based levels of moderate‐to‐vigorous physical activity (MVPA) reduces risk of all‐cause mortality, and improves symptoms. However, few survivors engage in recommended levels of MVPA, and symptoms related to their multimorbidity may preclude engaging in sufficient levels of MVPA. Additional research of MVPA in this population is warranted; however, understudied light‐intensity physical activity (LIPA) may be a more pragmatic target than MVPA among this complex population facing extensive challenges meeting MVPA recommendations. Large benefits are likely to occur from increasing these survivors' total activity, and LIPA prescriptions may be a more pragmatic approach than MVPA to aid this transition. Methods We present a broad, narrative review of the evidence for MVPA and LIPA in this population on an array of health outcomes across the translational science spectrum (clinical, implementation, and public health), and identify a number of directions for future research focused on understanding the potential diverse health effects of LIPA. Conclusion Additional LIPA research is warranted, as LIPA prescriptions may be a pragmatic strategy to effectively promote physical activity to this complex population.

Background: Screening for poor physical performance has the potential to identify older adults at risk for loss of future independence, yet clinically feasible measures have yet to be identified. Methods: Using data from the National Health and Aging Trends Study, we evaluated the diagnostic utility of self-reported physical capacities of older adults (walking three blocks or six blocks, climbing 10 stairs or 20 stairs) compared to the objectively measured Short Physical Performance Battery (SPPB). Sensitivity, specificity, and likelihood ratio (LR) were calculated across three SPPB cut-points (≤8, ≤9, ≤10). Results: Sensitivity of single item-measures for detecting a low SBBP averaged 0.39 (range: 0.26–0.52), specific averaged 0.97 (range: 0.94–0.99) and likelihood ratio averaged 20.0 (range: 9.0–35.5). Among age and gender subgroups, all measures maintained clinically applicable LRs (minimum = 4.59). Conclusion: Single-item self-reported physical capacities are accurate for screening older adults with physical limitations, making them potentially useful in healthcare settings.

Background: Metastatic Breast Cancer (MBC) patients often feel their symptom-related needs are unmet, despite visiting their doctors up to once a week. Novel approaches are needed to address symptoms without requiring additional appointments. Technology based symptom management approaches to address symptoms have not been well tested. Methods: Nurse AMIE (Addressing Metastatic Individuals Everyday) is a technology based supportive care platform that provides guideline-concordant symptom management interventions in response to patient reported symptoms. We have previously successfully implemented a tablet version of Nurse AMIE. However, some eligible patients chose not to participate because they were overwhelmed by the technology. To address this barrier, we translated the Nurse AMIE platform to the Amazon Echo Show, which allowed for voice-based interactions. Forty-two MBC patients were randomized 1:1 to receive the Nurse AMIE for Echo Show immediately for six months, or to receive the same intervention for three months, after a three month delay. The primary outcome was change in physical distress over three months, and secondary outcomes included feasibility, acceptability, patient reported outcomes and usability. Conclusions: Results from the Nurse AMIE for Echo Show trial will identify the feasibility, acceptability, and preliminary effects of the Nurse AMIE for Echo Show on patient reported outcomes. Untested novel technologies, particularly voice-based artificial intelligence devices may an effective and scalable vehicle through which we can deliver supportive care interventions. Clinicaltrials.gov identifier: NCT04673019.

Abstract Purpose To evaluate the feasibility of a home-based moderate-to-vigorous intensity, phased (introduction, intermediate, maintenance), exercise prescription in breast cancer patients receiving cardiotoxic neoadjuvant chemotherapy. Methods Nineteen breast cancer patients were randomized to intervention or control for the duration of chemotherapy (16–24 weeks). The intervention was one aerobic exercise session at 80–90% VO2max for 25 min/week and 65%-75% VO2max for ≥ 50 min/week. Adherence to the tailored home-based program was assessed by heart rate monitors. Acceptability, tolerability, feasibility, efficacy, change in VO2max, and patient reported outcomes, safety, and clinical events were assessed. Results 25.7% of eligible women consented (acceptability). Adherence was 87.6%. Women were not able to maintain exercise intensity as chemotherapy progressed (23.7% of exercise minutes were completed at prescribed heart rate during maintenance). Efficacy of the intervention was demonstrated by maintenance of VO2max (−1.0 ± 13.2%) compared to (−27.5 ± 7.4%) the control group. Further, during and after therapy, patients in the intervention arm reported less fatigue (control-baseline: 14.4 ± 15.9; midpoint: 19.0 ± 11.4; follow-up: 29.4 ± 20.0; intervention-baseline: 29.2 ± 24.6; midpoint: 24.6 ± 14.4; follow-up: 23.6 ± 11.9), impairment in activities (control-baseline: 13.7 ± 16.0; midpoint: 32.8 ± 17.0; follow-up: 58.6 ± 27.9; intervention-baseline: 38.7 ± 31.8; midpoint: 47.1 ± 27.5; follow-up: 47.5 ± 31.0), and pain (control-baseline: 80.8 ± 17.1; midpoint: 73.9 ± 20.7; follow-up: 50.7 ± 25.7; intervention-baseline: 68.7 ± 28.4; midpoint: 61.4 ± 22.5; follow-up: 65.3 ± 22.4). There were no differences in adverse events, treatment delays, or pathological complete response. Conclusions Neoadjuvant breast cancer patients maintained approximately one hour/week of moderate-intensity exercise over the course of their treatment. Further, this volume of exercise was sufficient to maintain fitness capacity and quality of life compared to the control group. Trial registry: ClinicalTrials.gov Identifier: NCT03280836, prospectively registered 9/13/2017, https://clinicaltrials.gov/ct2/show/NCT03280836 .

Adipocyte dysregulation is one mechanism linking overweight and breast cancer recurrence. Exercise and weight loss are associated with a decreased risk of breast cancer recurrence in breast cancer survivors with overweight or obesity, which may be mediated through reduced leptin levels, increased adiponectin levels, and an elevated adiponectin to leptin (A:L) ratio. The four-arm randomized controlled WISER Survivor trial examined the 12-month intervention effects of exercise, weight loss, and the combination of exercise and weight loss on adipokine levels among breast cancer survivors (n = 339) with overweight or obesity. Compared with Control, the Combination of Exercise and Weight Loss decreased leptin levels (−35.9%; 95% CI: −46.8%, −25.0%) and increased A:L ratio (11.6%; 95% CI: 5.6%, 17.6%) but did not change adiponectin levels (4.1%; 95% CI: −3.1%, 11.2%). Compared with Control, Weight Loss Alone decreased leptin levels (−35.6%; 95% CI: −46.6%, −24.5%) and increased A:L ratio (10.6%; 95% CI: 4.7%, 16.5%) but did not change adiponectin levels (0.9%; 95% CI: −6.0%, 7.9%). Compared with Control, Exercise Alone did not change leptin levels, adiponectin levels, or A:L ratio. In analyses that consolidated intervention groups, compared with Control, weight loss of ≥5% decreased leptin levels (p trend < 0.01) and increased A:L ratio (p trend < 0.01) but did not alter adiponectin levels (p trend = 0.53). Weight loss, with or without exercise, was associated with decreased leptin levels in breast cancer survivors with overweight or obesity. Improvements in the adipokine secretion profile (A:L ratio) were primarily driven by a weight loss-induced change in leptin levels.

Abstract To manage acute, long‐term, and late effects of cancer, current guidelines recommend moderate‐to‐vigorous intensity aerobic and resistance exercise. Unfortunately, not all cancer survivors are able or willing to perform higher intensity exercise during difficult cancer treatments or because of other existing health conditions. Tai Chi is an equipment‐free, multicomponent mind–body exercise performed at light‐to‐moderate intensity that may provide a more feasible alternative to traditional exercise programs for some cancer survivors. This systematic review evaluated the therapeutic efficacy of Tai Chi across the cancer care continuum. We searched MEDLINE/PubMed, Embase, SCOPUS, and CINAHL databases for interventional studies from inception to 18 September 2020. Controlled trials of the effects of Tai Chi training on patient‐reported and objectively measured outcomes in cancer survivors were included. Study quality was determined by the RoB 2 tool, and effect estimates were evaluated using the Best Evidence Synthesis approach. Twenty‐six reports from 14 trials (one non‐randomized controlled trial) conducted during (n = 5) and after treatment (after surgery: n = 2; after other treatments: n = 7) were included. Low‐level evidence emerged to support the benefits of 40–60 min of thrice‐weekly supervised Tai Chi for 8–12 weeks to improve fatigue and sleep quality in cancer survivors. These findings need to be confirmed in larger trials and tested for scaling‐up potential. Insufficient evidence was available to evaluate the effects of Tai Chi on other cancer‐related outcomes. Future research should examine whether Tai Chi training can improve a broader range of cancer outcomes including during the pre‐treatment and end of life phases.

Abstract Objective The purpose of this study was to determine the impact of prehabilitation exercise intervention with respect to (1) acceptability, feasibility, and safety; and (2) physical function, measured by 6‐minute‐walk test (6MWT). Data sources PRISMA guidelines were used to systematically search PubMed, Embase, and CINAHL databases evaluating prehabilitation exercise interventions. Study selection The inclusion criteria were studies investigating patients who underwent surgery for their cancer and underwent prehabilitation exercise. Data extraction and synthesis Guidelines were applied by independent extraction by multiple observers. Data were pooled using a random‐effects model. Main outcome(s) and measure(s) Acceptability, feasibility, and safety rates were calculated. 6MWT (maximum distance a person can walk at their own pace on a hard, flat surface, measured in meters, with longer distance indicative of better performance status) was compared using two arms using the DerSimonian and Laird method. Results Objective 1. Across 21 studies included in this review, 1564 patients were enrolled, 1371 (87.7%) accepted the trial; of 1371, 1230 (89.7% feasibility) completed the intervention. There was no grade 3+ toxicities. Objective 2. Meta‐analysis of five studies demonstrated a statistically significant decrease in 6MWT distance postoperatively in the control group (mean difference = +27.9 m; 95% confidence interval (CI): 9.3; 46.6) and a significant improvement postoperatively in the prehabilitation group (mean difference = −24.1 m; 95% CI: −45.7; −2.6). Meta‐analysis demonstrated improvements in 6MWT distance 4–8 weeks postoperatively in the prehabilitation group compared to the control group (mean difference = −58.0 m, 95% CI: −92.8; −23.3). Conclusions and relevance Prehabilitation exercise for cancer patients undergoing surgery was found to be safe, acceptable, and feasible with a statistically significant improvement in the 6MWT, indicating that prehabilitation can improve postoperative functional capacity.

Abstract Background Excess adiposity and dysregulated metabolism are associated with increased cancer risk. Triglycerides, cholesterol, glucose, insulin, HOMA‐IR, and VO2max are robust clinical‐metabolic biomarkers of overall health. Aims Aerobic exercise may improve clinical‐metabolic biomarkers and decrease cancer risk. This secondary analysis of the WISER Sister randomized controlled trial investigated dose‐dependent effects of aerobic exercise on clinical biomarker levels in women at high genetic risk for breast cancer. Methods and Results One hundred thirty‐nine participants were randomized to: control (80% of their exercise dose. A significant dose‐dependent increase in VO2max was observed for the low‐dose and high‐dose groups compared to control. No intervention effects were observed for plasma biomarkers. Overweight women (BMI > 25) showed a significant decrease in insulin levels and a trend for decreased triglycerides following exercise intervention. Significant increases in VO2max were independent of BMI stratification. Conclusion Women at high genetic risk for breast cancer should maintain healthy weights and aerobic capacities through aerobic exercise to achieve measurable benefits on overall health. For overweight women, exercise appears to improve subclinical metabolic dysregulation. However, normal weight women were unaffected by aerobic exercise as their biomarker levels may be below the threshold for improvement. VO2max increases solely quantified the benefits of exercise in already healthy women at high‐risk for breast cancer.

Purpose: Our objectives are to assess (1) the acceptability and feasibility of dietary interventions for patients undergoing radiation therapy (RT), and (2) the impact of dietary interventions on patient reported outcomes, toxicities, and survival. Methods: A PICOS/PRISMA/MOOSE selection protocol was used to include articles that evaluate adding dietary interventions to patients receiving RT. Acceptability was defined as (# accepting/# approached); feasibility was (# completing/# approached). Patient-reported outcomes were reported based on questionnaires used in each study and survival was measured from the date of diagnosis until death in each study. Level of evidence was assessed with Center for Evidence-Based Medicine (CEBM) criteria. Results: Sixteen articles were included; among these, 2027 patients were approached regarding the intervention, and 1661 accepted (81.9%); of these, 1543 (92.9%) completed the prescribed diet + RT course. The most common cancers included were gynecological, head and neck, and gastrointestinal. For patients with pelvic cancers, a high fiber diet may improve diarrhea (CEBM level 1b). Enteral nutrition formula, including formulas with proteins such as L-arginine, lipids such as eicosapentaenoic acids, glucids, and ribonucleotides, may help prevent of malnutrition in head and neck cancer patients undergoing RT (level 2b). Vitamin C and β-carotene may reduce of xerostomia in head and neck cancer patients; however, the studies evaluating these vitamins included vitamin E, which increases all-cause mortality (level 2b). No dietary intervention for cancer patients receiving RT has been shown to improve survival. Conclusion: There are limited data to support safe and efficacious use of dietary interventions during RT.

Abstract Background There is strong evidence supporting the efficacy of exercise oncology programs to improve physical and psychosocial outcomes during active treatment. However, there is a paucity of evidence on the effect of exercise on healthcare utilization and cost analyzes of exercise oncology programs. Aims Our objective was to assess the effects of a pragmatic exercise oncology program (ENACT) during active chemotherapy treatment on healthcare utilization and associated costs. Methods We conducted post‐hoc analyzes on 160 ENACT participants and 75 comparison participants matched on cancer site, stage, age range, and gender. We obtained complete healthcare utilization histories for each patient (specific to emergency department [ED] visits and hospital admissions) coinciding with their participation in ENACT. A sub‐analysis was conducted for advanced stage breast, gastrointestinal, and pancreatic cancer patients. Results Healthcare costs for patients who participated in the ENACT exercise oncology intervention were numerically lower than healthcare costs for the comparison group, even after accounting for the cost of the intervention. However, the differences were not statistically significant. Conclusion Our findings suggest that an exercise oncology program during active chemotherapy treatment are at least cost neutral for all cancer patients, including advanced stage cancers. Additional research is warranted to evaluate the potential for exercise oncology programs to reduce healthcare utilization, particularly in advanced cancer patients.

Abstract Background Observational studies suggest that regular physical activity may reduce cardiovascular morbidity and cancer recurrence in survivors of breast cancer. The association between physical activity and cardiac function with breast cancer therapy is unknown. Methods Self‐reported physical activity was assessed using the Godin Leisure‐Time Exercise Questionnaire at repeated intervals in a longitudinal cohort study of 603 breast cancer participants treated with doxorubicin and/or trastuzumab. Multivariable regression models estimated associations between clinical variables and physical activity. Generalized estimating equations adjusted for prespecified variables estimated associations between baseline physical activity and longitudinal echocardiographic measures of systolic and diastolic function. Results Physical activity was low at baseline, prior to cancer therapy initiation. More than half of participants reported no moderate‐strenuous physical activity, and only 12.1% met guideline recommended levels of physical activity. Physical activity increased after chemotherapy completion; however, only 26.0% of individuals were sufficiently active 3 years after cancer diagnosis. Body mass index, hyperlipidemia and higher cancer stage were significantly associated with lower total physical activity at baseline. Higher baseline physical activity was very modestly associated with an attenuation in the absolute decline in left ventricular ejection fraction over time (β 0.4%, 95% CI 0.1, 0.7, P = .02 for each 10‐unit increase in total activity). There tended to be a cardioprotective association with cardiotoxicity risk, although this was not statistically significant (HR 0.83, 95% CI 0.66, 1.04, P = .097). Conclusions A small proportion of breast cancer patients and survivors are engaged in regular moderate‐strenuous physical activity. While only modest associations between self‐reported physical activity and left ventricular systolic function were observed, our findings do not exclude a cardioprotective benefit of exercise.

Abstract Background While 3.5 million breast cancer survivors in the USA are indicative of promising disease-free survival, many experience adverse effects in recovering from treatment. Evidence-based exercise programs may be a low-cost, easily disseminable solution to the challenge of recovering from adverse treatment affects. Therefore, after establishing efficacy in a large randomized controlled trial, we developed the Strength after Breast Cancer (SABC) program and the accompanying online course for clinicians interested in physical therapy to learn to deliver this rehabilitative exercise program to individuals with breast cancer. We surveyed clinicians who took the course to assess implementation of the program in outpatient rehabilitation clinics. Methods Ninety-six clinicians completed the survey between June and December, 2017 (24% response). Guided by Proctor’s implementation outcomes framework, the respondents were asked if they had implemented (adoption) and are still implementing the program (sustainability), and which programmatic components they implemented (fidelity). Respondents were asked how many patients completed the program (reach), how patients got into the program (reach), the program’s delivery format (appropriateness), and whether clinics were reimbursed by third-party payers (cost). Finally, respondents were asked what barriers they faced in delivery of SABC (feasibility) and whether others in the clinic completed the course (penetration). Results Seventy-six percent of respondents implemented SABC and among those, 93% (68/73) were still delivering it. All programmatic components were implemented by over two thirds of respondents (67–95%). On average, the program was delivered to 13 patients per clinic by the time respondents took the survey. Most patient referrals were from oncology clinics (50%). The majority of clinicians delivered SABC one-on-one (96%) and 72% of clinics were compensated via third-party payers. Major barriers were lack of referrals from oncologists (40%) and clinic’s competing demands (33%). We found no differences (Fisher’s exact test p > .05) in reported barriers between those who implemented the program and those who did not. Conclusion Our findings suggest that the online training was sufficient to successfully implement the SABC program in outpatient rehabilitation clinics with high levels of adoption, fidelity, reach, and capacity for sustainability. Information on patient acceptability, cost-effectiveness, and how to overcome implementation barriers are still needed.

Background: A large body of evidence supports the positive effects of leisure time physical activity (LTPA) and exercise on cancer survivors. However, only a fraction of survivors manages to attain international PA recommendations. This can be attributed to several external and internal barriers toward PA those patients seem to encounter, with cancer related fatigue (CRF) being the most reported internal barrier. Nevertheless, self-efficacy and knowledge about the utilization of LTPA can serve as facilitators of PA, which also correspond to certain constituents of physical activity related health competence (PAHCO). Since PAHCO is not investigated in cancer survivors we investigated if PAHCO can mediate the negative relationship between CRF and LTPA.Methods: We surveyed 398 cancer survivors with different cancer types and therapy status. The patients completed the EORTC QLQ-FA12 (EORTC FA12) to assess CRF, the PAHCO questionnaire to assess PAHCO and the SQUASH to assess LTPA. We followed a two-step structural equation modeling approach. The first step established the measurement model, in the second step we fitted the mediation model. Since 163 patients chose not to answer the SQUASH, the mediation model was only fitted to the data of the remaining 235 participants.Results: The proposed measurement model of the PAHCO offered an excellent fit. We found small to moderate positive associations between the PAHCO dimensions and the LTPA, and negative moderate relationships between the PAHCO and the EORTC FA12 dimensions. We did not observe a relationship between the EORTC FA12 dimensions and the LTPA (p > 0.05). The hypothesized mediation models did not display an appropriate fit.Conclusion: The PAHCO confirmed its factorial validity; furthermore, it appears to have a positive relationship to LTPA. Therefore, integrating psycho-educational aspects can be beneficial in order to increase the PAHCO in exercise interventions. Because of the cross-sectional character of this study, causal conclusions are not suitable, therefore the longitudinal relationships of LTPA, CRF, and PAHCO require further investigation.

IntroductionExercise is vital to health and well-being after a cancer diagnosis yet is poorly integrated in cancer care. Knowledge mobilization (KM) is essential to enhance exercise opportunities. We aimed to (1) develop and refine a list of highly important exercise oncology research and KM themes and (2) establish the relative importance of the themes for supporting the implementation of exercise as a standard of care for people living with and beyond cancer.MethodsInformed by the Co-Produced Pathway to Impact KM framework, a modified Delphi study approach was used to develop, rate, and rank exercise oncology research and KM themes through an international stakeholder workshop and a three-round iterative online survey. Open-ended stakeholder feedback from cancer survivors, healthcare practitioners (HCPs), qualified exercise professionals (QEPs), policy makers, and researchers was used to update themes between survey rounds. Themes were ranked from highest to lowest importance and agreement was examined across all stakeholders and within stakeholder groups.ResultsA total of 269 exercise oncology stakeholders from 13 countries participated in the study. Twelve final exercise oncology research and KM themes were produced. The final top ranked research themes were related to: (1) QEP integration into primary cancer care teams, (2) Exercise oncology education for HCPs, and (3) Accessibility of cancer exercise programs & support services. There was statistically significant agreement between stakeholders (p

Healthy lifestyle behaviors can improve health-related quality of life (HRQOL) in cancer survivors; but the combination of behaviors most important for HRQOL is not known. This study investigated the patterns of lifestyle behaviors among cancer survivors and differences in HRQOL between behavioral classes. Cancer survivors (n = 2,463) were invited to participate in a cross-sectional survey. Participants (N= 591) were predominately female (63%) and non-Hispanic White (90%). Survey items included self-reported physical activity, diet, smoking, sleep, HRQOL, and demographics. Behavioral classes were estimated by latent class analysis. Differences between classes were assessed by latent class regression. Compared with the "healthy lifestyles" class (higher probabilities of meeting aerobic/strength-based activity guidelines, high fruit/vegetable intake, and no sleep problems; 11% of sample), the "sleep and diet problems with inconsistent physical activity" class (higher probabilities of not meeting strength-based guidelines, low fruit/vegetable intake, some sleep problems; marginally higher probability of meeting aerobic guidelines; 41%) had poorer general and physical HRQOL. The "poor physical activity and diet" class (higher probabilities of not meeting aerobic/strength-based guidelines, low fruit/vegetable intake, and some sleep problems; 48%) had poorer general, physical, and mental HRQOL. Few participants exhibited healthy lifestyle patterns associated with HRQOL. The findings provide opportunities to develop differentiated multiple behavior-change interventions, targeted to two common patterns of behavior. A large subgroup of cancer survivors was susceptible to suboptimal physical activity and diet, warranting interventions exclusively targeting these behaviors. Another subgroup was susceptible to suboptimal physical activity, diet, and sleep, indicating interventions for this group should include strategies targeting these three behaviors.

Abstract Background Obesity is associated with an increased risk of breast cancer recurrence and cancer death. Recurrent cancers arise from the pool of residual tumor cells, or minimal residual disease (MRD), that survives primary treatment and persists in the host. Whether the association of obesity with recurrence risk is causal is unknown, and the impact of obesity on MRD and breast cancer recurrence has not been reported in humans or in animal models. Methods Doxycycline-inducible primary mammary tumors were generated in intact MMTV-rtTA;TetO-HER2/neu (MTB/TAN) mice or orthotopic recipients fed a high-fat diet (HFD; 60% kcal from fat) or a control low-fat diet (LFD; 10% kcal from fat). Following oncogene downregulation and tumor regression, mice were followed for clinical recurrence. Body weight was measured twice weekly and used to segregate HFD mice into obese (i.e., responders) and lean (i.e., nonresponders) study arms, and obesity was correlated with body fat percentage, glucose tolerance (measured using intraperitoneal glucose tolerance tests), serum biomarkers (measured by enzyme-linked immunosorbent assay), and tissue transcriptomics (assessed by RNA sequencing). MRD was quantified by droplet digital PCR. Results HFD-Obese mice weighed significantly more than HFD-Lean and LFD control mice (p < 0.001) and had increased body fat percentage (p < 0.001). Obese mice exhibited fasting hyperglycemia, hyperinsulinemia, and impaired glucose tolerance, as well as decreased serum levels of adiponectin and increased levels of leptin, resistin, and insulin-like growth factor 1. Tumor recurrence was accelerated in HFD-Obese mice compared with HFD-Lean and LFD control mice (median relapse-free survival 53.0 days vs. 87.0 days vs. 80.0 days, log-rank p < 0.001; HFD-Obese compared with HFD-Lean HR 2.52, 95% CI 1.52–4.16; HFD-Obese compared with LFD HR 2.27, 95% CI 1.42–3.63). HFD-Obese mice harbored a significantly greater number of residual tumor cells than HFD-Lean and LFD mice (12,550 ± 991 vs. 7339 ± 2182 vs. 4793 ± 1618 cells, p < 0.001). Conclusion These studies provide a genetically engineered mouse model for study of the association of diet-induced obesity with breast cancer recurrence. They demonstrate that this model recapitulates physiological changes characteristic of obese patients, establish that the association between obesity and recurrence risk is causal in nature, and suggest that obesity is associated with the increased survival and persistence of residual tumor cells.

Despite the inverse relationship between physical activity (PA) and physical function, few older adults achieve PA recommendations. In response to observations that “lack of time” underlies reduced PA among older adults, recent work suggests even short bouts of PA can improve health and fitness. In addition, because they are frequently visited by older adults, an important conduit for PA promotion could be the primary care physician (PCP). However, most PCPs receive little training related to PA, rendering it difficult for them to offer meaningful counseling. Therefore, we explored the feasibility and impact of a PCP-prescribed one-minute daily functional exercise program, consisting of 30 s each of bodyweight push-ups and squats, among 24 patients 60 years of age or older. 42% of patients who were contacted started the exercise prescription and, over 24-weeks, completed approximately 114 sessions, while 75% completed at least half of the possible daily exercise sessions. As a group, the patients demonstrated increases in both maximal push-up and squat performance, though these increases plateaued following week-12. These preliminary results suggest that a PCP prescription of one-minute of daily functional exercise among older adult patients was feasible, acceptable, and effective for improving functional physical fitness. Given these findings, formal controlled research with recruitment from multiple clinics, random assignment to treatment conditions, and blinded assessments of objective functional physical performance should be pursued.

Obesity-associated breast cancer recurrence is mechanistically linked with elevated insulin levels and insulin resistance. Exercise and weight loss are associated with decreased breast cancer recurrence, which may be mediated through reduced insulin levels and improved insulin sensitivity. This is a secondary analysis of the WISER Survivor clinical trial examining the relative effect of exercise, weight loss and combined exercise and weight loss interventions on insulin and insulin resistance. The weight loss and combined intervention groups showed significant reductions in levels of: insulin, C-peptide, homeostatic model assessment 2 (HOMA2) insulin resistance (IR), and HOMA2 beta-cell function (β) compared to the control group. Independent of intervention group, weight loss of ≥10% was associated with decreased levels of insulin, C-peptide, and HOMA2-IR compared to 0–5% weight loss. Further, the combination of exercise and weight loss was particularly important for breast cancer survivors with clinically abnormal levels of C-peptide.

Introduction. High BMI is a risk factor for upper body breast cancer-related lymphedema (BCRL) onset. Black cancer survivors are more likely to have high BMI than White cancer survivors. While observational analyses suggest up to 2.2 times increased risk of BCRL onset for Black breast cancer survivors, no studies have explored race or other social factors that may affect BCRL severity, operationalized by interlimb volume difference (ILD). Materials and Methods. ILD was measured by perometry for 296 overweight (25 > BMI < 50) Black (n=102) or White (n=194) breast cancer survivors (>6 months from treatment) in the WISER Survivor trial. Multivariable linear regression examined associations between social and physical factors and ILD. Results. Neither Black race (−0.26, p=0.89) nor BMI (0.22, p=0.10) was associated with ILD. Attending college (−4.89, p=0.03) was the strongest factor associated with ILD, followed by having more lymph nodes removed (4.75, p=0.01), >25% BCRL care adherence (4.10, p=0.01), and years since treatment (0.55, p

Cancers of the digestive system remain highly lethal; therefore, the care of patients with malignant diseases of the digestive tract requires the expertise of providers from multiple health disciplines. Progress has been made to advance the understanding of epidemiology and genetics, diagnostic and screening evaluation, treatment modalities, and supportive care for patients with gastrointestinal cancers. At the Multi-Disciplinary Patient Care in Gastrointestinal Oncology conference at the Hershey Country Club in Hershey, Pennsylvania on 29 September 2017, the faculty members of the Penn State Health Milton S. Hershey Medical Center presented a variety of topics that focused on this oncological specialty. In this continuing medical education-certified conference, updates on the population sciences including health disparities and resistance training were presented. Progress made in various diagnostic evaluation and screening procedures was outlined. New developments in therapeutic modalities in surgical, radiation, and medical oncology were discussed. Cancer genetic testing and counseling and the supportive roles of music and arts in health and cancer were demonstrated. In summary, this disease-focused medical conference highlighted the new frontiers in gastrointestinal oncology, and showcase the multi-disciplinary care provided at the Penn State Cancer Institute.