Responsiveness and minimal clinically important difference of the 6-minute walk distance in patients undergoing colorectal cancer surgery.

PURPOSE: This study aimed to clarify the responsiveness and minimal clinically important difference (MCID) of the 6-minute walk distance (6MWD) from before and 1 week after surgery in patients with colorectal cancer (CRC). METHODS: This retrospective cohort study enrolled 97 patients with primary CRC scheduled for surgery. An anchor-based approach estimated the MCID of the 6MWD, with postoperative physical recovery and EuroQol 5-dimension 5L questionnaire assessments serving as anchors. Effect size (ES) and standardized response mean (SRM) of the 6MWD were calculated to evaluate responsiveness, and the receiver operating characteristic (ROC) curve was used to estimate the MCID of the 6MWD. RESULTS: Of the 97 patients, 72 were included in the analysis. The absolute value of ES and SRM of the 6MWD were 0.69 and 0.91, respectively. The ROC curve indicated that the optimal cut-off values for estimating the MCID of the 6MWD were -60 m (area under the curve [AUC] = 0.753 [95% CI: 0.640-0.866]) and -75 m (AUC = 0.870 [95% CI: 0.779-0.961]) at each anchor. CONCLUSION: From before to 1 week after surgery, the responsiveness of the 6MWD was favorable, and the MCID of the 6MWD was -75 to -60 m in patients with CRC.

The association between objectively measured preoperative light-intensity physical activity and postoperative ambulation in patients with gastrointestinal cancer.

[Purpose] To clarify the association between preoperative physical activity and postoperative ambulation based on physical activity intensity, and independent of functional capacity and depression, in patients with gastrointestinal cancer. [Participants and Methods] Seventy patients who underwent surgery for primary colorectal or gastric cancer were enrolled. Preoperative moderate-to-vigorous-intensity physical activity, light-intensity physical activity, and sedentary behavior were assessed using an accelerometer. The primary outcome was the days to postoperative first ambulation (capable of independently and continuously walking 150 m). Functional capacity and depression, as confounders, were evaluated by measuring the 6-minute walk distance and using the Hospital Anxiety and Depression Scale. [Results] Of the 70 patients, 28 had insufficient accelerometer data, and 42 were included in the analysis. Preoperative light-intensity physical activity, but not moderate-to-vigorous-intensity physical activity and sedentary behavior, was negatively associated with the days to postoperative first ambulation, after adjusting for age, preoperative functional capacity, and preoperative depression. [Conclusion] Preoperative light-intensity physical activity was associated with the days to postoperative ambulation independently of age, functional capacity, and depression. Hence, predicting delayed ambulation by preoperative light-intensity physical activity in patients with gastrointestinal cancer may be useful.

Prolonged preoperative sedentary time is a risk factor for postoperative ileus in patients with colorectal cancer: a propensity score-matched retrospective study.

PURPOSE: This study aimed to investigate the association between prolonged preoperative sedentary time (ST) and postoperative ileus (POI) after adjusting for confounders in patients with colorectal cancer (CRC). METHODS: This single-center retrospective study enrolled 155 consecutive patients who underwent surgery for primary CRC. A diagnosis of POI was made by the surgeons if the Clavien-Dindo classification (CD) grade is ≥ 2 within 30 days after surgery. Preoperative ST was assessed using the International Physical Activity Questionnaire usual week short version (Japanese version). Patients were classified into two groups (ST < 6 h/day and ST ≥ 6 h/day) based on results from the questionnaire, and data were analyzed using a propensity score-matching strategy to adjust for confounders. In addition, receiver operating characteristic (ROC) curve analysis was performed to identify the optimal cutoff value of preoperative ST for predicting POI. RESULTS: Of the 155 patients, 134 were included in the analysis. POI occurred in 16 (11.9%) patients of overall patients and 11 (12.5%) of the 88 matched patients. The logistic regression analysis after propensity score-matching showed that prolonged preoperative ST (ST ≥ 6 h/day) was associated with POI (odds ratio 5.40 (95% confidence interval: 1.09 - 26.60), p = 0.038). The ROC curve analysis indicated that the optimal cutoff value of preoperative ST for predicting POI was 6 h/day. CONCLUSION: Prolonged preoperative ST is a risk factor for POI in patients with CRC. Therefore, reducing preoperative ST may play an important role in preventing POI.

Prognostic Impact of Postoperative Loss of Skeletal Muscle Mass in Patients Aged 70 Years or Older with Esophageal Cancer.

BACKGROUND: The number of patients with esophageal cancer aged ≥ 70 years with a poor prognosis is increasing. In general patients with esophageal cancer, postoperative loss of skeletal muscle mass (SMM) is a prognostic factor. This study was designed to investigate the prognostic impact of postoperative loss of SMM in patients aged ≥ 70 years with esophageal cancer. METHODS: This study was a single-center, retrospective cohort study. Patients with esophageal cancer who underwent R0 esophagectomy between 2016 and 2020 were included. The percentage postoperative loss of skeletal muscle mass index (SMI%) was calculated using computed tomography images before and at 4 ± 2 months after surgery. RESULTS: The number of subjects in the ≥ 70-year and < 70-year age groups was 166 and 218, respectively. The median SMI% was 5% in all patients; thus, 5% was defined as the cutoff point to define major loss of SMI. Major loss of SMI impacted 3-year overall survival (OS) in the ≥ 70-year age group, independent of age, sex, clinical stage, pathological T and N factors, Charlson comorbidity index, and length of hospital stay (adjusted hazard ratio [HR]: 4.400; 95% confidence interval: 1.202-16.105; P = 0.025). The adjusted HR of major loss of SMI in the ≥ 70-year age group was higher than in the < 70-year age group (adjusted HR: 4.400 vs. 2.388, respectively). CONCLUSIONS: Postoperative loss of SMI in patients with esophageal cancer aged ≥ 70 years more strongly impacted 3-year OS than in patients aged < 70 years.

Oncology care providers' awareness and practice related to physical activity promotion for breast cancer survivors and barriers and facilitators to such promotion: a nationwide cross-sectional web-based survey.

PURPOSE: A known barrier to getting breast cancer survivors (BCSs) to engage in habitual exercise is a lack of information on recommended physical activity levels provided to them by oncology care providers (OCPs). However, the actual situation in Japan remains unclear. This study sought to clarify OCPs' awareness and practice related to Japan's physical activity recommendation for BCSs and to ascertain barriers to routine information provision. METHODS: We conducted a web-based survey involving members of the Japanese Breast Cancer Society (JBCS) and the Japanese Association of Cancer Rehabilitation between Dec. 2018 and Feb. 2019. RESULTS: Of 10,830 members, 1,029 (9.5%) responded. Only 19.1% were aware of the details of the JBCS physical activity recommendation, and only 21.2% routinely provided physical activity information to BCSs. Factors related to being aware of the recommendation details were 1) availability of the guidelines, 2) experience reading relevant parts of the guidelines, and 3) involvement in multidisciplinary team case meetings. Barriers to routine information provision were 1) absence of perceived work responsibility, 2) underestimation of survivors' needs, 3) lack of resources, 4) lack of self-efficacy about the recommendation, and 5) poor knowledge of the recommendation. CONCLUSIONS: Only one fifth of the OCPs routinely provided physical activity information. Barriers to provision were poor awareness, self-efficacy, and attitudes and unavailable resources. The physical activity recommendation needs to be disseminated to all OCPs and an information delivery system needs to be established for BCSs to receive appropriate information and support to promote their engagement in habitual physical activity.

[Exercise Therapy for Cancer Cachexia].

The treatment of cancer cachexia requires not only anti-cancer therapy but also multidisciplinary treatment including nutrition therapy, exercise therapy, and psychosocial intervention. In recent years, exercise therapy is expected to be one of the non-pharmacological treatments for cancer cachexia. However, there is a lack of evidence for exercise therapy for cancer cachexia, and no standard exercise therapy has been established. We have developed a multimodal intervention program (The Nutrition and Exercise Treatment for Advanced Cancer program: NEXTAC program)for older patients with advanced cancer who are at high risk of cachexia, combining nutrition and exercise therapy from the time of initial chemotherapy. In this article, we present an overview of the exercise therapy program in the NEXTAC program and discuss the current best practices for cancer cachexia.

A randomized phase II study of nutritional and exercise treatment for elderly patients with advanced non-small cell lung or pancreatic cancer: the NEXTAC-TWO study protocol.

BACKGROUND: Most advanced elderly cancer patients experience fatigue, anorexia, and declining physical function due to cancer cachexia, for which effective interventions have not been established. We performed a phase I study of a new nonpharmacological multimodal intervention called the nutritional and exercise treatment for advanced cancer (NEXTAC) program and reported the excellent feasibility of and compliance with this program in elderly patients with advanced cancer who were at risk for cancer cachexia. We report here the background, hypothesis, and design of the next-step multicenter, randomized phase II study to evaluate the efficacy of the program, the NEXTAC-TWO study. METHODS: Patients with chemo-naïve advanced non-small cell lung cancer or pancreatic cancer, age ≥ 70 years, performance status ≤2, with adequate organ function and without disability according to the modified Katz index will be eligible. In total, 130 participants will be recruited from 15 Japanese institutions and will be randomized into either the intervention group or a control group. Computer-generated random numbers are allocated to each participant. Stratification factors include performance status (0 to 1 vs. 2), site of primary cancer (lung vs. pancreas), stage (III vs. IV), and type of chemotherapy (cytotoxic vs. others). Interventions and assessment will be performed 4 times every 4 ± 2 weeks from the date of randomization. Interventions will consist of nutritional counseling, nutritional supplements (rich in branched-chain amino acids), and a home-based exercise program. The exercise program will include low-intensity daily muscle training and lifestyle education to promote physical activity. The primary endpoint is disability-free survival. It is defined as the period from the date of randomization to the date of developing disability or death due to any cause. This trial also plans to evaluate the improvements in nutritional status, physical condition, quality of life, activities of daily living, overall survival, and safety as secondary endpoints. Enrollment began in August 2017. The study results will demonstrate the efficacy of multimodal interventions for elderly cancer patients and their application for the maintenance of physical and nutritional conditions in patients with cancer cachexia. This work is supported by a grant-in-aid from the Japan Agency for Medical Research and Development. DISCUSSION: This is the first randomized trial to evaluate the efficacy and safety of a multimodal intervention specific for elderly patients with advanced cancer. TRIAL REGISTRATION: Registered at August 23, 2017. Registry number: UMIN000028801 .

Impact of early postoperative factors on changes in skeletal muscle mass after esophagectomy in older patients with esophageal cancer.

BACKGROUND: Loss of skeletal muscle mass, measured by the skeletal muscle mass index (SMI), after esophagectomy negatively impacts prognosis. However, the information to develop novel supportive care options for preventing loss of skeletal muscle mass is limited. The purpose of this retrospective cohort study was to investigate the impact of early postoperative factors on change in SMI 4 months after curative esophagectomy in older patients with esophageal cancer. METHODS: This study included 113 subjects who underwent esophagectomy between 2015 and 2020. Preoperative and postoperative SMI (cm2/m2) were calculated from computed tomography images. The percentage change in SMI 4 months after surgery (SMI%) was calculated as follows: ([postoperative SMI - preoperative SMI] ÷ preoperative SMI) × 100. Potential factors affecting percentage change of SMI after surgery were analyzed by multiple regression. RESULTS: The mean SMI% was - 5.6%. The percentage change (per 1%) in quadriceps muscle strength in the first month after surgery (standardized ß = 0.190, p = 0.048) impacted the SMI%, which was independent of age, sex, preoperative SMI, comorbidity, pathological stage, and neoadjuvant chemotherapy. CONCLUSION: Quadriceps muscle weakness in the first month after esophagectomy impacted the SMI% in a dose-dependent relationship.

Preoperative Low Physical Activity is a Predictor of Postoperative Delirium in Patients with Gastrointestinal Cancer: A Retrospective Study.

BACKGROUND: Postoperative delirium (POD) is one of the most common postoperative complications in gastrointestinal surgery patients. POD has been reported to affect long-term activities of daily living, cognitive function decline, and mortality. Previous studies have indicated that preoperative physical activity (PA) predicted POD in patients with other diseases, but we have not found any reports in patients with gastrointestinal cancer. In this retrospective study, we investigated the relationship between preoperative PA and POD in gastrointestinal cancer patients. METHODS: POD was diagnosed based on the short confusion assessment method. We divided patients into active and inactive groups based on their preoperative PA assessed by the International Physical Activity Questionnaire (Japanese version). Multivariate logistic analysis was conducted to investigate the association between preoperative PA and POD. RESULTS: POD occurred in 25 of the 151 patients (16.6%). Preoperative low PA was associated with POD after adjusting for confounders, namely, diabetes mellitus, sedentary time, and usual gait speed (odds ratio, 2.83; 95% confidence interval: 1.06-7.58; p=0.03). CONCLUSION: Preoperative low PA was a predictor of POD independent of the confounding factors in patients with gastrointestinal cancer.

Preoperative physical activity predicts postoperative functional recovery in gastrointestinal cancer patients.

PURPOSE: The present study aimed to investigate the association between preoperative physical activity (PA) and postoperative functional recovery in gastrointestinal cancer patients. MATERIALS AND METHODS: In this prospective study, we included 101 patients who underwent colorectal or gastric cancer surgery. Primary outcome was 6-minute walk distance (6MWD) decline ratio ((postoperative 6MWD value - preoperative 6MWD value)/preoperative 6MWD value × 100 (%)), which was determined as postoperative functional recovery. Patients were divided into two groups according to the median of 6MWD decline ratio: above the median (non-decline group) and below the median (decline group). The International Physical Activity Questionnaire (IPAQ-SV) (the usual seven-day short version) was used to assess preoperative PA and sedentary time. Multivariate logistic regression analysis was performed to identify predictive factors of postoperative functional recovery. RESULTS: Preoperative PA (odds ratio (OR): 3.812; 95% confidence interval (CI): 1.326-10.956; p = 0.01), 6MWD (OR: 1.006; 95% CI: 1.002-1.011; p < 0.01), C-reactive protein (OR: 4.138; 95% CI: 1.383-12.377; p = 0.01), and combined resection (OR: 3.425; 95% CI: 1.101-10.649; p = 0.03) were associated with postoperative functional recovery. CONCLUSIONS: Preoperative PA is a predictor of postoperative functional recovery in patients who undergoing gastrointestinal cancer surgery.Implications for rehabilitationThe association between preoperative physical activity (PA) and postoperative functional recovery has been unclear in gastrointestinal cancer patients.We indicated that preoperative PA predicts postoperative functional recovery.Patients who low preoperative PA need to be monitored carefully in the postoperative course.Patients with low preoperative PA may need enhanced postoperative rehabilitation to reduce postoperative functional decline.

The effects of exercise therapy on delirium in cancer patients: a retrospective study.

PURPOSE: The present study aimed to investigate the effects of exercise therapy on delirium in cancer patients. METHODS: We conducted a retrospective study of cancer patients who were admitted to Kyoto University Hospital and referred to the Palliative Care Team. Subjects were divided into two groups [an exercise therapy group (EG) and a non-exercise therapy group (NG)] according to whether exercise therapy was being used for early ambulation at the time delirium occurred. To examine whether any characteristics differed significantly between the two groups, we also compared age, performance status, alcohol use, existence of metastatic brain tumors or preexisting CNS illnesses, levels of opioid exposure, and survival time from the onset of delirium. Moreover, we investigated whether there were differences in antipsychotic drug doses administered between these two groups in order to better analyze the specific effects of exercise therapy on the course of delirium. RESULTS: EG and NG groups did not differ significantly in terms of any characteristics. The administered dose of antipsychotic drugs was significantly lower in the EG group versus the NG group (2.198 mg versus 5.533 mg, p = 0.036). In comparison, the dose of opioids used did not differ significantly between the two study groups. CONCLUSIONS: Given the relatively low antipsychotic doses used, it is conceivable that delirium symptoms were attenuated in patients who received exercise therapy. This study suggests that exercise therapy may be useful as one environmental/supportive intervention for delirium.

The reliability and preliminary validity of game-based fall risk assessment in community-dwelling older adults.

The purpose of this study was to examine whether the Nintendo Wii Fit program could be used for fall risk assessment in healthy, community-dwelling older adults. Forty-five community-dwelling older women participated in this study. The "Basic Step" and "Ski Slalom" modules were selected from the Wii Fit game program. The following 5 physical performance tests were performed: the 10-m walk test under single- and dual-task conditions, the Timed Up and Go test under single- and dual-task conditions, and the Functional Reach test. Compared with the faller group, the nonfaller group showed a significant difference in the Basic Step (P < .001) and a nonsignificant difference in the Ski Slalom (P = .453). The discriminating criterion between the 2 groups was a score of 111 points on the Basic Step (P < .001). The Basic Step showed statistically significant, moderate correlations between the dual-task lag of walking (r = -.547) and the dual-task lag of the Timed Up and Go test (r = -.688). These results suggest that game-based fall risk assessment using the Basic Step has a high generality and is useful in community-dwelling older adults.

Preoperative Sedentary Time Predicts Postoperative Complications in Gastrointestinal Cancer.

BACKGROUND: Gastrointestinal cancer has a high global prevalence. Postoperative complications (PCs) affect the length of hospital stay and long-term outcomes. However, it is unclear whether preoperative sedentary time is associated with PCs, independently of physical activity (PA). We aimed to investigate the association between preoperative sedentary time and PCs independently of PA in patients who underwent surgery for gastrointestinal cancer. METHODS: In this prospective study, we included 112 patients who underwent colorectal cancer or gastric cancer surgery. Patient characteristics and surgery-related variables were collected. The Japanese version of the International Physical Activity Questionnaire (the usual 7-day short version) was used to assess preoperative PA and sedentary time. Patients were classified into two groups according to the grade of PCs: Clavien-Dindo (CD) grade.

Developing the structure of Japan's cancer survivorship guidelines using an expert panel and modified Delphi method.

PURPOSE: To develop consensus-based components used in the first evidence-based cancer survivorship guidelines in Japan. METHODS: Purposive sampling was used to recruit a panel of experts in oncology clinical practice, nursing, health science, epidemiology, and patient advocacy. The panel engaged in a modified Delphi process to (1) generate consensus related to the definition of survivorship, (2) determine the aim and target users of the guideline, and (3) identify clinical issues for inclusion. A Web-based survey and panel meeting were conducted to obtain the panelists' feedback on the initial draft proposed by the secretariat. Multiple online votes were then completed until all elements of the proposed guidelines reached an approval rate of 80% or higher. Following each round, iterative refinements were made based on all panelists' feedback. RESULTS: Twenty-two experts were enrolled in the panel and participated in four rounds of online voting and two face-to-face meetings. Ultimately, the panel reached consensus on the definition of survivorship, the aim of the guidelines, and target users. Moreover, 11 of the original 17 clinical issues were retained. Finally, the panel selected two priority areas to implement immediately. CONCLUSION: The panel's consensus on the definition of survivorship, aim and target users of the guideline, and 11 clinical issues will serve as a compass for the development of comprehensive cancer survivorship guidelines in Japan. IMPLICATIONS FOR CANCER SURVIVORS: A culturally sensitive consensus approach was developed to improve the long term health and well- being of cancer survivors in Japan.

Feasibility of early multimodal interventions for elderly patients with advanced pancreatic and non-small-cell lung cancer.

BACKGROUND: Combinations of exercise and nutritional interventions might improve the functional prognosis for cachectic cancer patients. However, high attrition and poor compliance with interventions limit their efficacy. We aimed to test the feasibility of the early induction of new multimodal interventions specific for elderly patients with advanced cancer Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) programme. METHODS: This was a multicentre prospective single-arm study. We recruited 30 of 46 screened patients aged ≥70 years scheduled to receive first-line chemotherapy for newly diagnosed, advanced pancreatic, or non-small-cell lung cancer. Physical activity was measured using pedometers/accelerometer (Lifecorder® , Suzuken Co., Ltd., Japan). An 8 week educational intervention comprised three exercise and three nutritional sessions. The exercise interventions combined home-based low-intensity resistance training and counselling to promote physical activity. Nutritional interventions included standard nutritional counselling and instruction on how to manage symptoms that interfere with patient's appetite and oral intake. Supplements rich in branched-chain amino acids (Inner Power® , Otsuka Pharmaceutical Co., Ltd., Japan) were provided. The primary endpoint of the study was feasibility, which was defined as the proportion of patients attending ≥4 of six sessions. Secondary endpoints included compliance and safety. RESULTS: The median patient age was 75 years (range, 70-84). Twelve patients (40%) were cachectic at baseline. Twenty-nine patients attended ≥4 of the six planned sessions (96.7%, 95% confidence interval, 83.3 to 99.4). One patient dropped out due to deteriorating health status. The median proportion of days of compliance with supplement consumption and exercise performance were 99% and 91%, respectively. Adverse events possibly related to the NEXTAC programme were observed in five patients and included muscle pain (Grade 1 in two patients), arthralgia (Grade 1 in one patient), dyspnoea on exertion (Grade 1 in one patient), and plantar aponeurositis (Grade 1 in one patient). CONCLUSIONS: The early induction of multimodal interventions showed excellent compliance and safety in elderly patients with newly diagnosed pancreatic and non-small-cell lung cancer receiving concurrent chemotherapy. We are now conducting a randomized phase II study to measure the impact of these interventions on functional prognosis.

Promotion of Behavioral Change and the Impact on Quality of Life in Elderly Patients with Advanced Cancer: A Physical Activity Intervention of the Multimodal Nutrition and Exercise Treatment for Advanced Cancer Program.

OBJECTIVE: Physical activity (PA) may improve the quality of life (QOL) of cancer survivors. However, the impact on patients with advanced cancer with high cachectic potential is unknown. We analyzed the feasibility of PA intervention using the multimodal program Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) and the impact on QOL in elderly patients with advanced cancer. METHODS: We recruited 30 patients aged ≥70 years who were scheduled to receive the first-line chemotherapy for newly diagnosed advanced pancreatic or non-small-cell lung cancer. The QOL was assessed using the European Organization for Research and Treatment of Cancer QOL Questionnaire version 3.0, while the PA was measured using a pedometer/accelerometer. Instructors counseled patients to increase daily activity in an 8-week educational intervention. We assessed patient attendance, compliance, and intervention efficacy. RESULTS: The median patients' age was 75 years (range, 70-84 years). Twelve patients (40%) were cachectic at baseline. Twenty-eight (93%) patients attended all sessions. Six (21%) and 15 (52%) patients increased their indoor and outdoor activity, respectively. There were significant differences in measured PA, global QOL, and role and emotional functioning between the patients who increased outdoor activity and those who did not. CONCLUSIONS: The PA intervention of the NEXTAC program was feasible as the elderly patients with advanced cancer in this study were highly compliant. The majority of patients demonstrated behavioral changes that were associated with the improvement in global QOL. We conduct a randomized phase II study to measure the impact of the NEXTAC program on QOL and functional prognosis.

The effect of walking speed on gait kinematics and kinetics after endoprosthetic knee replacement following bone tumor resection.

Gait function is one of the most important components of functional outcome evaluation in patients with a tumor around the knee. In addition to walking at a preferred speed, the patients might be sometimes required to walk fast in daily life (e.g., schooling and working) because the major types of bone tumors often occur in adolescence and young adults. Therefore, recovering the ability to walk fast would increase the quality of life of these patients. To clarify which parts of the lower limb are exerted while walking fast, we investigated the kinematic and kinetic changes during fast walking in patients who underwent endoprosthetic knee replacement after bone tumor resection. Laboratory-based gait analysis was performed on eight patients who had undergone endoprosthetic knee replacement following resection of a tumor around the knee. Patients walked at a preferred and faster speed, and the gait parameters were compared between the two walking speeds for each leg. To increase walking speed, patients tended to rely on the bilateral hip, ankle, and contralateral knee to generate additional power. Kinetic analysis showed that involved-side vertical body support was not significantly increased during late stance to increase walking speed, which was associated with a small increase in ankle plantarflexion moment and concentric power. These results suggest to patients after knee reconstruction how to effectively increase their walking speed or redistribute the mechanical load on the muscles and joints to prevent excessive stress on the lower limbs.