Protocol of a randomised controlled multicentre trial investigating the effectiveness and safety of a wilderness programme on the mental and physical well-being of adolescents and young adults affected by cancer: the WAYA-2 study.

INTRODUCTION: Adolescents and young adults (AYAs) affected by cancer are an understudied group. Effective interventions are needed to support coping with the late effects of cancer, its treatment and to promote quality of life. Nature-based interventions may be promising in support of the self-management and health of AYAs affected by cancer. However, randomised controlled studies (RCTs) on the effectiveness of such interventions are lacking. We performed a first pilot RCT (n=42) that showed that it is feasible and safe to conduct such a study. Here, we propose a full-scale RCT to investigate the effectiveness and safety of a wilderness programme on the mental and physical health of AYAs affected by cancer. METHODS AND ANALYSIS: Participants are 150 AYAs affected by cancer, aged 16-39 years, who will be randomised to a wilderness (n=75) or a hotel stay (n=75). The wilderness programme is an 8-day intervention including a 6-day wilderness expedition. This is followed 3 months later by a 4-day intervention including a 2-day basecamp. Activities include hiking, backpacking, kayaking, rock climbing, mindfulness and bush-crafting. The comparison group is an 8-day hotel stay followed by a 4-day hotel stay (interventions include two travel days) at the same hotel after 3 months. Primary outcomes are psychological well-being and nature connectedness up to 1 year after the study start. Secondary outcomes are quality of life, physical activity and safety parameters. ETHICS AND DISSEMINATION: The Swedish Ethical Review Authority approved the study protocol on 27 September 2023 (reference: 2023-05247-01). The recruitment started on 19 February 2024 and the first part is planned to end on 31 December 2027. Study results will be disseminated by means of scientific publications, presentations at conferences, popular articles, interviews, chronicles and books. News items will be spread via social media, websites and newsletters. TRIAL REGISTRATION NUMBER: ISRCTN93856392.

The Role of Long-Term Physical Activity in Relation to Cancer-Related Health Outcomes: A 12-Month Follow-up of the Phys-Can RCT.

PURPOSE: While moderate-to-vigorous intensity physical activity (MVPA) is associated with various health improvements shortly after completion of exercise interventions, it remains unclear which health benefits can be expected when MVPA levels are maintained in the long term in cancer survivors. We aimed to assess the associations of (1) MVPA level at 12-month follow-up and (2) long-term MVPA patterns (from immediately post-intervention to 12-month follow-up) with different cancer-related health outcomes. METHODS: In the Physical training and Cancer (Phys-Can) RCT, 577 participants diagnosed with breast (78%), prostate (19%), or colorectal (3%) cancer were randomized to 6 months of exercise during curative cancer treatment. Accelerometer-assessed physical activity and outcome data (ie, cancer-related fatigue, health-related quality of life [HRQoL], anxiety and depression, functioning in daily life, cardiorespiratory fitness, sedentary time and sleep) were collected immediately post-intervention and at 12-month follow-up. Based on the sample's median of MVPA immediately post-intervention (65 minutes/day) and the changes between the 2 measurement points, 4 categories with different long-term MVPA patterns were created: High & Increasing, High & Decreasing, Low & Increasing, and Low & Decreasing. Multiple linear regression analyses were performed for the analyses. RESULTS: A total of 353 participants were included in the analyses. At 12-month follow-up, a higher MVPA level was significantly associated with lower fatigue in 3 domains (general fatigue [ß = -.33], physical fatigue [ß = -.53] and reduced activity [ß = -.37]), higher cardiorespiratory fitness (ß = .34) and less sedentary time (ß = -.35). For long-term MVPA patterns, compared to the participants in the "Low & Decreasing" category, those in the "High & Increasing" category reported significantly lower fatigue in 3 domains (general fatigue [ß = -1.77], physical fatigue [ß = -3.36] and reduced activity [ß = -1.58]), higher HRQoL (ß = 6.84) and had less sedentary time (ß = -1.23). CONCLUSION: Our results suggest that long-term physical activity is essential for improving health outcomes post-intervention in cancer survivors. Cancer survivors, including those who reach recommended MVPA levels, should be encouraged to maintain or increase MVPA post-intervention for additional health benefits. TRIAL REGISTRATION: NCT02473003 (10/10/2014).

How many days of continuous physical activity monitoring reliably represent time in different intensities in cancer survivors.

BACKGROUND: Physical activity (PA) monitoring is applied in a growing number of studies within cancer research. However, no consensus exists on how many days PA should be monitored to obtain reliable estimates in the cancer population. The objective of the present study was to determine the minimum number of monitoring days required for reliable estimates of different PA intensities in cancer survivors when using a six-days protocol. Furthermore, reliability of monitoring days was assessed stratified on sex, age, cancer type, weight status, and educational level. METHODS: Data was obtained from two studies where PA was monitored for seven days using the SenseWear Armband Mini in a total of 984 cancer survivors diagnosed with breast, colorectal or prostate cancer. Participants with ≥22 hours monitor wear-time for six days were included in the reliability analysis (n = 736). The intra-class correlation coefficient (ICC) and the Spearman Brown prophecy formula were used to assess the reliability of different number of monitoring days. RESULTS: For time in light PA, two monitoring days resulted in reliable estimates (ICC >0.80). Participants with BMI ≥25, low-medium education, colorectal cancer, or age ≥60 years required one additional monitoring day. For moderate and moderate-to-vigorous PA, three monitoring days yielded reliable estimates. Participants with BMI ≥25 or breast cancer required one additional monitoring day. Vigorous PA showed the largest within subject variations and reliable estimates were not obtained for the sample as a whole. However, reliable estimates were obtained for breast cancer survivors (4 days), females, BMI ≥30, and age <60 years (6 days). CONCLUSION: Shorter monitoring periods may provide reliable estimates of PA levels in cancer survivors when monitored continuously with a wearable device. This could potentially lower the participant burden and allow for less exclusion of participants not adhering to longer protocols.

Mediation of lifestyle-associated variables on the association between occupation and incident cardiovascular disease.

The main aim was to examine the association between occupational groups and incident cardiovascular disease (CVD), and to which extent associations are mediated by lifestyle-associated variables (cardiorespiratory fitness, smoking, BMI, exercise, and diet). A total of 304,702 participants (mean age 42.5 yrs., 47% women), who performed a health profile assessment in Sweden between 1982 and 2019, were included in the analyses. CVD incidence was obtained from national registers. All participants were free from CVD prior to the health profile assessment. Occupational group was defined using the Swedish Standard Classification of Occupations and analyzed separately (13 different occupational groups) as well as after aggregation into four occupational groups (white-collar high-skilled, white-collar low-skilled, blue-collar high-skilled and blue-collar low-skilled). Cardiorespiratory fitness, BMI, exercise, smoking, and diet were included as mediators and analyzed separately in single models and simultaneously in one multiple mediation model. All mediation analyses were adjusted for sex, age, length of education and calendar time. White-collar high-skilled was set as reference in all analyses. Blue-collar and low-skilled occupation had a higher risk of incident CVD compared to the reference. Cardiorespiratory fitness, BMI, exercise, smoking, and diet mediated 48% to 54% of the associations between reference and the other aggregated occupational groups. In the single model, the strongest mediators were cardiorespiratory fitness, smoking and BMI. In conclusion, blue-collar and low-skilled occupations had a significantly higher risk for incident CVD compared to white-collar high-skilled workers, with the association mediated to a large extent by variation in lifestyle-associated variables.

Does inflammation markers or treatment type moderate exercise intensity effects on changes in muscle strength in cancer survivors participating in a 6-month combined resistance- and endurance exercise program? Results from the Phys-Can trial.

BACKGROUND: Resistance exercise has a beneficial impact on physical function for patients receiving oncological treatment. However, there is an inter-individual variation in the response to exercise and the tolerability to high-intensity exercise. Identifying potential moderating factors, such as inflammation and treatment type, for changes in muscle strength is important to improve the effectiveness of exercise programs. Therefore, we aimed to investigate if inflammation and type of oncological treatment moderate the effects of exercise intensity (high vs. low-moderate) on muscular strength changes in patients with breast (BRCA) or prostate cancer (PRCA). METHODS: Participants with BRCA (n = 286) and PRCA (n = 65) from the Physical training and Cancer study (Phys-Can) were included in the present study. Participants performed a combined resistance- and endurance exercise program during six months, at either high or low-moderate intensity. Separate regression models were estimated for each cancer type, with and without interaction terms. Moderators included in the models were treatment type (i.e., neo/adjuvant chemotherapy-yes/no for BRCA, adjuvant androgen deprivation therapy (ADT)-yes/no for PRCA)), and inflammation (interleukin 6 (IL6) and tumor necrosis factor-alpha (TNFα)) at follow-up. RESULTS: For BRCA, neither IL6 (b = 2.469, 95% CI [- 7.614, 12.552]) nor TNFα (b = 0.036, 95% CI [- 6.345, 6.418]) levels moderated the effect of exercise intensity on muscle strength change. The same was observed for chemotherapy treatment (b = 4.893, 95% CI [- 2.938, 12.724]). Similarly, for PRCA, the effect of exercise intensity on muscle strength change was not moderated by IL6 (b = - 1.423, 95% CI [- 17.894, 15.048]) and TNFα (b = - 1.905, 95% CI [- 8.542, 4.732]) levels, nor by ADT (b = - 0.180, 95% CI [- 11.201, 10.841]). CONCLUSIONS: The effect of exercise intensity on muscle strength is not moderated by TNFα, IL6, neo/adjuvant chemotherapy, or ADT, and therefore cannot explain any intra-variation of training response regarding exercise intensity (e.g., strength gain) for BRCA or PRCA in this setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02473003.

Exploring Moderators of the Effect of High vs. Low-to-Moderate Intensity Exercise on Cardiorespiratory Fitness During Breast Cancer Treatment - Analyses of a Subsample From the Phys-Can RCT.

Introduction: The results from the physical training and cancer randomized controlled trial (Phys-Can RCT) indicate that high intensity (HI) strength and endurance training during (neo-)adjuvant cancer treatment is more beneficial for cardiorespiratory fitness (CRF, measured as peak oxygen uptake [VO2peak]) than low-to-moderate intensity (LMI) exercise. Adherence to the exercise intervention and demographic or clinical characteristics of patients with breast cancer undergoing adjuvant treatment may moderate the exercise intervention effect on VO2peak. In this study, the objective was to investigate whether baseline values of VO2peak, body mass index (BMI), time spent in moderate- to vigorous-intensity physical activity (MVPA), physical fatigue, age, chemotherapy treatment, and the adherence to the endurance training moderated the effect of HI vs. LMI exercise on VO2peak. Materials and Methods: We used data collected from a subsample from the Phys-Can RCT; women who were diagnosed with breast cancer and had a valid baseline and post-intervention VO2peak test were included (n = 255). The exercise interventions from the RCT included strength and endurance training at either LMI, which was continuous endurance training at 40-50% of heart rate reserve (HRR), or at HI, which was interval training at 80-90% of HRR, with similar exercise volume in the two groups. Linear regression analyses were used to investigate moderating effects using a significance level of p < 0.10. Statistically significant interactions were examined further using the Johnson-Neyman (J-N) technique and regions of significance (for continuous variables) or box plots with adjusted means of post-intervention VO2peak (for binary variables). Results: Age, as a continuous variable, and adherence, dichotomized into < or > 58% based on median, moderated the effect of HI vs. LMI on CRF (B = -0.08, 95% CI [-0.16, 0.01], p interaction = 0.06, and B = 1.63, 95% CI [-0.12, 3.38], p interaction = 0.07, respectively). The J-N technique and regions of significance indicated that the intervention effect (HI vs. LMI) was positive and statistically significant in participants aged 61 years or older. Baseline measurement of CRF, MVPA, BMI, physical fatigue, and chemotherapy treatment did not significantly moderate the intervention effect on CRF. Conclusion: Women with breast cancer who are older and who have higher adherence to the exercise regimen may have larger effects of HI exercise during (neo-)adjuvant cancer treatment on CRF.

Cardiorespiratory fitness and lifestyle on severe COVID-19 risk in 279,455 adults: a case control study.

BACKGROUND: The impact of cardiorespiratory fitness (CRF) and other lifestyle-related factors on severe COVID-19 risk is understudied. The present study aims to investigate lifestyle-related and socioeconomic factors as possible predictors of COVID-19, with special focus on CRF, and to further study whether these factors may attenuate obesity- and hypertension-related risks, as well as mediate associations between socioeconomic factors and severe COVID-19 risk. METHODS: Out of initially 407,131 participants who participated in nationwide occupational health service screening between 1992 and 2020, n = 857 cases (70% men, mean age 49.9 years) of severe COVID-19 were identified. CRF was estimated using a sub-maximum cycle test, and other lifestyle variables were self-reported. Analyses were performed including both unmatched, n = 278,598, and sex-and age-matched, n = 3426, controls. Severe COVID-19 included hospitalization, intensive care or death due to COVID-19. RESULTS: Patients with more severe COVID-19 had significantly lower CRF, higher BMI, a greater presence of comorbidities and were more often daily smokers. In matched analyses, there was a graded decrease in odds for severe COVID-19 with each ml in CRF (OR = 0.98, 95% CI 0.970 to 0.998), and a two-fold increase in odds between the lowest and highest (< 32 vs. ≥ 46 ml·min-1·kg-1) CRF group. Higher BMI (per unit increase, OR = 1.09, 1.06 to 1.12), larger waist circumference (per cm, OR = 1.04, 1.02 to 1.06), daily smoking (OR = 0.60, 0.41 to 0.89) and high overall stress (OR = 1.36, 1.001 to 1.84) also remained significantly associated with severe COVID-19 risk. Obesity- and blood pressure-related risks were attenuated by adjustment for CRF and lifestyle variables. Mediation through CRF, BMI and smoking accounted for 9% to 54% of the associations between low education, low income and blue collar/low skilled occupations and severe COVID-19 risk. The results were consistent using either matched or unmatched controls. CONCLUSIONS: Both lifestyle-related and socioeconomic factors were associated with risk of severe COVID-19. However, higher CRF attenuated the risk associated with obesity and high blood pressure, and mediated the risk associated with various socioeconomic factors. This emphasises the importance of interventions to maintain or increase CRF in the general population to strengthen the resilience to severe COVID-19, especially in high-risk individuals.

Lifestyle Habits and Mental Health in Light of the Two COVID-19 Pandemic Waves in Sweden, 2020.

The COVID-19 pandemic has become a public health emergency of international concern, which may have affected lifestyle habits and mental health. Based on national health profile assessments, this study investigated perceived changes of lifestyle habits in response to the COVID-19 pandemic and associations between perceived lifestyle changes and mental health in Swedish working adults. Among 5599 individuals (50% women, 46.3 years), the majority reported no change (sitting 77%, daily physical activity 71%, exercise 69%, diet 87%, alcohol 90%, and smoking 97%) due to the pandemic. Changes were more pronounced during the first wave (April-June) compared to the second (October-December). Women, individuals <60 years, those with a university degree, white-collar workers, and those with unhealthy lifestyle habits at baseline had higher odds of changing lifestyle habits compared to their counterparts. Negative changes in lifestyle habits and more time in a mentally passive state sitting at home were associated with higher odds of mental ill-health (including health anxiety regarding one's own and relatives' health, generalized anxiety and depression symptoms, and concerns regarding employment and economy). The results emphasize the need to support healthy lifestyle habits to strengthen the resilience in vulnerable groups of individuals to future viral pandemics and prevent health inequalities in society.

Can Talented Youth Soccer Players Who Have Undergone Anterior Cruciate Ligament Reconstruction Reach the Elite Level?

BACKGROUND: Anterior cruciate ligament (ACL) ruptures are common in soccer players, and reconstructive surgery is often performed to restore knee stability and enable a return to play. PURPOSE: To investigate whether an ACL reconstruction for talented youth soccer players affects their potential to become elite players at the senior level. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All soccer players who participated in the Swedish National Elite Camp for 15-year-old players between 2005 and 2011 (N = 5285 players; 2631 boys and 2654 girls) were matched with the Swedish National Knee Ligament Registry to identify the players who had undergone ACL reconstruction. Information on player participation in Swedish league games and level of play was collected from the Swedish Football Association's administrative data system. The players with an ACL reconstruction who were injured at the ages of 15 to 19 years were compared with the rest of the players who participated in the National Elite Camp to see whether an early ACL reconstruction affected whether they remained active as soccer players and their chance to play at the elite level as seniors. RESULTS: A total of 524 (9.9%) players had undergone an ACL reconstruction, and 292 (5.5%; 75 male and 217 female) had sustained their injury at age 15 to 19 years. During the follow-up period, 122 (23.3%) players underwent ACL reconstruction: revision (11.5%; n = 60) or contralateral (11.8%; n = 62). Male and female soccer players undergoing an ACL reconstruction at age 15 to 19 years experienced no significant effect on being active or playing at the elite level in the season that they turned 21 years old. Of the youth players who underwent ACL reconstruction, 12% of the male players and 11.5% of the female players progressed to the elite level at the age of 21 years compared with 10.3% of the men and 11.1% of the women among the uninjured players. CONCLUSION: ACL reconstructive surgery in talented youth soccer players offers them the opportunity to become elite players as seniors and permits an activity level on a par with that of their uninjured peers. However, almost 1 in 4 requires further ACL surgery, so the players' future knee health should be considered when deciding on a return to play.