Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement.

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Responsiveness and interpretation of the PROMIS Cancer Function Brief 3D Profile.

BACKGROUND: Measuring function with valid and responsive tools in patients with cancer is essential for driving clinical decision-making and for the end points of clinical trials. Current patient-reported outcome measurements of function fall short for many reasons. This study evaluates the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Cancer Function Brief 3D Profile, a novel measure of function across multiple domains. METHODS: Two hundred nine participants across five geographically distinct tertiary care centers completed the assessment and pain rating at two outpatient cancer rehabilitation clinic visits. Patients and providers completed a global rating of change measure at the second visit to indicate whether the patient was improving or worsening in function. Multiple response indices and linear models measured whether the measure was responsive to self-reported and clinician-rated changes over time. Correlations between changes in function and changes in anchors (pain rating and performance status) were also calculated. RESULTS: Function as measured by the PROMIS Cancer Function Brief 3D Profile changed appropriately as both patients and clinicians rated change. Small to moderate effect sizes supported the tool's responsiveness. Function was moderately correlated with pain and more strongly correlated with performance status, and changes in function corresponded with changes in anchor variables. No floor/ceiling effect was found. CONCLUSIONS: The PROMIS Cancer Function Brief 3D Profile is sensitive to changes over time in patients with cancer. The measure may be useful in clinical practice and as an end point in clinical trials. LAY SUMMARY: We gave patients a questionnaire by which they told their physicians how well they were functioning, including how fatigued they were. This study tested that questionnaire to see whether the scores would change if patients got better or worse.

Factors Associated With Physical Activity Levels in Patients With Breast Cancer.

Physical activity (PA) is associated with improvement in breast cancer treatment-related symptoms and survival, yet most breast cancer survivors do not meet national PA guidelines. This study aimed to identify characteristics of participants that were associated with an increased likelihood of meeting PA guidelines. Adults with breast cancer seen at Mayo Clinic (Rochester, MN) were surveyed regarding their PA participation, and those who self-reported at least 150 minutes of moderate and/or strenuous aerobic PA weekly on average were considered to be "meeting guidelines". Three thousand participants returned PA data. Younger age, completion of the survey 7-12 years after diagnosis, absence of recurrence, no bilateral mastectomy, absence of metastatic disease, and lower BMI at the time of survey completion were associated with PA participation (P < .05 in univariate and multivariate analyses). Findings were similar when a threshold of 90 minutes was applied. These results may inform the development of targeted PA-facilitating interventions.

A View of the Development of Patient-Reported Outcomes Measures, Their Clinical Integration, Electronification, and Potential Impact on Rehabilitation Service Delivery.

Recognition of the importance of a patient's perception of their status and experience has become central to medical care and its evaluation. This recognition has led to a growing reliance on the use of patient-reported outcome measures (PROMs). Nevertheless, although awareness of PROMs and acceptance of their utility has increased markedly, few of us have a good insight into their development; their utility relative to clinician-rated and performance measures such as the FIM and 6-minute walk test or how their "electronification" and incorporation into electronic health records (EHRs) may improve the individualization, value, and quality of medical care. In all, the goal of this commentary is to provide some insight into historical factors and technology developments that we believe have shaped modern clinical PROMs as they relate to medicine in general and to rehabilitation in particular. In addition, we speculate that while the growth of PROM use may have been triggered by an increased emphasis on the centrality of the patient in their care, future uptake will be shaped by their embedding in EHRs and used to improve clinical decision support though their integration with other sources of clinical and sociodemographic data.

Correlation and Crosswalks Between Patient-Reported Functional Outcomes and PROMIS Physical Function Among Medically Ill Patients.

OBJECTIVES: To develop scoring crosswalks between a new multidomain patient-reported outcome measure, the Functional Assessment in Acute Care (FAMCAT), with a Patient-Reported Outcomes Measurement (PROMIS) measure of physical function, and examine correlations with existing legacy instruments. DESIGN: Cross-sectional, single-group design study. SETTING: Large, Midwestern academic teaching hospital. PARTICIPANTS: A sample of patients (N=1885; 53% men; average age, 62±16y) hospitalized on the general medical services between May 2016 and June 2017. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Scores from the FAMCAT administered via computerized adaptive testing were compared with scores on the 8-item PROMIS Physical Function (PROMIS PF) short form. RESULTS: Correlations with the FAMCAT and the PROMIS PF were strong for initial scores (MCAT_Mobilty: r=0.78, P<.0001; MCAT_DailyAct: r=0.81, P<.0001). The Applied Cognition scale did not demonstrate adequate correlations and thus was not a candidate for crosswalk scores. Although the MCAT_Mobility scale could be initially linked, subsequent analysis did not support a valid crosswalk. Linking criteria were applied with the Daily Activity scale to developing a final concordance table. CONCLUSIONS: The FAMCAT Daily Activity scale yielded robust correlations to develop crosswalk scores with the PROMIS PF. The resulting crosswalk conversion metric may be useful to compare outcomes across these constructs for assessing functional abilities among patients on general medical services. The Applied Cognition and Basic Mobility scales did not meet the criteria; therefore, alternate legacy instruments are needed to develop additional crosswalks.

Adaptive Measurement of Change: A Novel Method to Reduce Respondent Burden and Detect Significant Individual-Level Change in Patient-Reported Outcome Measures.

OBJECTIVE: To describe the adaptive measurement of change (AMC) as a means to identify psychometrically significant change in reported function of hospitalized patients and to reduce respondent burden on follow-up assessments. DESIGN: The AMC method uses multivariate computerized adaptive testing (CAT) and psychometric hypothesis tests based in item response theory to more efficiently measure intra-individual change using the responses of a single patient over 2 or more testing occasions. Illustrations of the utility of AMC in clinical care and estimates of AMC-based item reduction are provided using the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), a newly developed functional multidimensional CAT-based measurement of basic mobility, daily activities, and applied cognition. SETTING: Two quaternary hospitals in the Upper Midwest. PARTICIPANTS: Four hundred ninety-five hospitalized patients who completed the FAMCAT on 2 to 4 occasions during their hospital stay. INTERVENTION: N/A. RESULTS: Of the 495 patients who completed more than 1 FAMCAT, 72% completed 2 sessions, 13% completed 3, and 15% completed 4, with 22.1%, 23.4%, and 23.0%, respectively, exhibiting significant multivariate change. Use of the AMC in conjunction with the FAMCAT reduced respondent burden from that of the FAMCAT alone for follow-up assessments. On average, when used without the AMC, 22.7 items (range, 20.4-24.4) were administered during FAMCAT sessions. Post hoc analyses determined that when the AMC was used with the FAMCAT a mean±standard deviation reduction in FAMCAT number of items of 13.6 (11.1), 13.1 (9.8), and 18.1 (10.8) would occur during the second, third, and fourth sessions, respectively, which corresponded to a reduction in test duration of 3.0 (2.4), 3.0 (2.8), and 4.7 (2.6) minutes. Analysis showed that the AMC requires no assumptions about the nature of change and provides data that are potentially actionable for patient care. Various patterns of significant univariate and multivariate change are illustrated. CONCLUSIONS: The AMC method is an effective and parsimonious approach to identifying significant change in patients' measured CAT scores. The AMC approach reduced FAMCAT sessions by an average of 12.6 items (55%) and 2.9 minutes (53%) among patients with psychometrically significant score changes.

Identifying Clinically Relevant Functional Strata to Direct Mobility Preservation Among Patients Hospitalized With Medical Conditions.

OBJECTIVE: To develop a system to guide interpretation of scores generated from the newly developed item response theory (IRT)-based Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), which assesses 3 important domains of function: Mobility, Daily Activities, and Applied Cognition. DESIGN: Cross-sectional data was used to inform a modified Delphi approach to establish FAMCAT cutpoints delineating various functional ability levels. SETTING: Large midwestern academic teaching hospital. PARTICIPANTS: Patients hospitalized to an inpatient medical service (N=2049). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FAMCAT Basic Mobility, Daily Activity, and Applied Cognition scores. RESULTS: IRT-based score estimation data was successfully integrated with expert clinical feedback using a modified Delphi process to arrive at consensus yielding 4 functional level strata (ranging from bed-based mobility to independent mobility) for both the FAMCAT Mobility and Daily Activity scales; 1 cutpoint was supported to delineate 2 functional strata for Applied Cognition. CONCLUSIONS: Meaningful cutpoints were established for each FAMCAT domain using a data-informed, modified Delphi process for achieving consensus. The resulting FAMCAT interpretation guide may be used to develop an ability-matched mobility preservation program and identify patients who may require a higher level of supervision based on the resulting FAMCAT scores.

Multidimensional Computerized Adaptive Testing: A Potential Path Toward the Efficient and Precise Assessment of Applied Cognition, Daily Activity, and Mobility for Hospitalized Patients.

OBJECTIVE: To develop and evaluate an efficient and precise variable-length functional assessment of applied cognition, daily activity, and mobility to inform mobility preservation and rehabilitation service delivery among hospitalized patients. DESIGN: A multidimensional item bank tapping into these dimensions was developed, with all items calibrated using a multidimensional graded response model. The items were adaptively selected from the item banks to maximize the test information, and the test ended when a joint stopping rule was satisfied. A simulation study was conducted based on the completed instrument, the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), to compare its measurement precision and efficiency capabilities relative to conventional unidimensional computerized adaptive testing. Precision was measured by the bias and root mean squared error between the estimated and true (ie, simulated) θ estimates, whereas efficiency was measured by average test length. Data were collected by an interviewer reading questions from a tablet computer and entering patients' responses. SETTING: A large Midwestern hospital. PARTICIPANTS: A total of 4143 patients hospitalized with medical diagnosis and/or surgical complications, with 2060 in the calibration sample and 2083 in the validation cohort. INTERVENTION: Not applicable. RESULTS: Among the 2083 patients in the validation sample, FAMCAT administration required an average of 6 (SD=3.11) minutes. Ninety-six percent had their tests terminated by the standard error rule after responding to an average of 22.05 (SD=7.98) items, whereas 15 were terminated by the change in θ rule, with an average test length of 45.27 (SD=11.49). The remaining 76 responded until reaching the maximum test length of 60 items. CONCLUSIONS: The FAMCAT has the potential to satisfy the need for structured, frequent, and precise assessment of functional domains among hospitalized patients with medical diagnosis and/or surgical complications. The results are promising and may be informative for others who wish to develop similar instruments when concurrent assessment of correlated domains is required.

Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers.

Practice changing standardization of lower extremity lymphedema quantitative measurements with integrated patient reported outcomes will likely refine and redefine the optimal risk-reduction strategies to diminish the devastating limb-related dysfunction and morbidity associated with treatment of gynecologic cancers. The National Cancer Institute (NCI), Division of Cancer Prevention brought together a diverse group of cancer treatment, therapy and patient reported outcomes experts to discuss the current state-of-the-science in lymphedema evaluation with the potential goal of incorporating new strategies for optimal evaluation of lymphedema in future developing gynecologic clinical trials.

Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery Patients.

BACKGROUND: There is a continued perception that intravenous line (IV) placement is contraindicated in the arm ipsilateral to prior breast cancer surgery to avoid breast cancer-related lymphedema (BCRL). The aim of this retrospective study was to determine the risk for development of BCRL in ipsilateral arm IV placement compared to contralateral arm IV placement to prior breast cancer surgery. METHODS: We performed a retrospective review, via our Integrated Clinical Systems and Epic Electronic Heath Record of IV placement for anesthesia and surgery in patients with a prior history of breast cancer surgery with or without axillary lymph node dissection. Complication rates were compared for IVs placed in the ipsilateral and contralateral arms. We identified 3724 patients undergoing 7896 IV placements between January 1, 2015, and May 5, 2018, with a prior history of breast cancer surgery via their index anesthesia and surgical procedures. RESULTS: The median time from breast cancer surgery to IV placement was 1.5 years (range, 1 day to 17.8 years). Of 2743 IVs placed in the arm contralateral to prior breast cancer surgery, 2 had a complication, corresponding to an incidence of 7.3 per 10,000 (95% confidence interval [CI], 0.9-26.3 per 10,000). Of 5153 IVs placed in the arm ipsilateral to prior breast cancer surgery, 2 IVs had a complication, for an incidence of 3.9 per 10,000 (95% CI, 0.5-14.0 per 10,000). The frequency of complications was not found to differ significantly between the groups (P = .91), and the 95% CI for the risk difference (ipsilateral minus contralateral) was -23 to +8 complications per 10,000. The complication rate is similar when only the first IV placed following breast cancer surgery is considered (overall 5.4 per 10,000 [95% CI, 0.7-19.4] per 10,000; contralateral 7.0 [95% CI, 0.2-39.0] per 10,000, ipsilateral 4.4 [95% CI, 0.1-24.2] per 10,000; P = 1.00; 95% CI for risk difference [ipsilateral minus contralateral], -41 to +22 per 10,000). CONCLUSIONS: We found very few complications in patients who had an IV placed for surgery following a previous breast cancer surgery and no complications in those patients with IV placement ipsilateral with axillary node dissection. Avoidance of IV placement in the arm ipsilateral to breast cancer surgery is not necessary.

The Physical Consequences of Chemotherapy-Induced Peripheral Neuropathy.

PURPOSE OF REVIEW: Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of numerous chemotherapy drugs. CIPN negatively impacts function and quality of life during and after treatment. We will provide a review of the data describing the physical consequences of CIPN and discuss the possible long term impact on emotional well-being and quality of life. RECENT FINDINGS: CIPN negatively affects physical function and many aspects of quality of life. Exercise interventions are likely to reduce the risk of falls associated with CIPN. There remains a need for evidence-based interventions focused on improving symptoms, function, and quality of life in persons with CIPN.

Core Outcome Measures for Chronic Musculoskeletal Pain Research: Recommendations from a Veterans Health Administration Work Group.

OBJECTIVE: Chronic musculoskeletal pain (CMSP) disorders are among the most prevalent and disabling conditions worldwide. It would be advantageous to have common outcome measures when comparing results across different CMSP research studies. METHODS: The Veterans Health Administration appointed a work group to recommend core outcome measures for assessing pain intensity and interference as well as important secondary domains in clinical research. The work group used three streams of data to inform their recommendations: 1) literature synthesis augmented by three recently completed trials; 2) review and comparison of measures recommended by other expert groups; 3) two Delphi surveys of work group members. RESULTS: The single-item numerical rating scale and seven-item Brief Pain Inventory interference scale emerged as the recommended measures for assessing pain intensity and interference, respectively. The secondary domains ranked most important included physical functioning and depression, followed by sleep, anxiety, and patient-reported global impression of change (PGIC). For these domains, the work group recommended the Patient-Reported Outcome Information System four-item physical function and sleep scales, the Patient Health Questionnaire two-item depression scale, the Generalized Anxiety Disorder two-item anxiety scale, and the single-item PGIC. Finally, a single-item National Health Interview Survey item was favored for defining chronic pain. CONCLUSIONS: Two scales comprising eight items are recommended as core outcome measures for pain intensity and interference in all studies of chronic musculoskeletal pain, and brief scales comprising 13 additional items can be added when possible to assess important secondary domains.

Prenatal diethylstilbestrol exposure and mammographic density.

In a prospective cohort study of the health effects associated with prenatal Diethylstilbestrol (DES) exposure, DES was associated with an increased breast cancer risk after 40 years of age. It is unknown whether it is associated with greater mammographic density, which strongly predicts breast cancer risk. A cohort of DES-exposed and unexposed women was assembled at the Mayo Clinic in 1975, and followed through 2012 as part of the National Cancer Institute's DES follow-up study. Mammographic density from 3,637 mammograms for 332 (222 DES-exposed, 110 unexposed) women in this cohort screened at the Mayo Clinic, Rochester between 1996 and 2015 was determined clinically using the Breast Imaging Reporting and Data System (BI-RADS). Any effect of prenatal DES exposure on mammographic density was estimated using repeated measures logistic regression. There was no association between prenatal DES exposure and high mammographic density for either premenopausal [Odds ratios (OR) = 0.92 (95% Confidence Interval (CI): 0.50, 1.7] or postmenopausal women (OR = 0.90; 95% CI: 0.54, 1.5). Among premenopausal women, associations differed by body mass index (BMI), with ORs of 1.47 (0.70, 3.1) for women with BMI above the median and 0.53 (0.23, 1.3) for those with BMI below the median (pinteraction = 0.05). Overall, however, prenatal DES exposure was not associated with high mammographic density in this sample of DES Study participants. Consequently, this study does not provide evidence that high mammographic density is involved with the influence of DES on breast cancer risk.

Changes in arm tissue composition with slowly progressive weight-lifting among women with breast cancer-related lymphedema.

BACKGROUND: Studies in breast cancer-related lymphedema (BRCL) have exclusively examined total arm volume, but not the specific tissue composition that contributes to total volume. We evaluated baseline differences in arm tissue composition [fat mass, lean mass, bone mineral content (BMC), and bone mineral density (BMD)] between the affected and unaffected arms in women with BRCL. We compared changes in arm tissue composition and self-reported lymphedema symptoms after 1 year of weight-lifting versus control. METHODS: We utilized data from physical activity and lymphedema trial that included 141 women with BRCL. Arm tissue composition was quantified using dual-energy X-ray absorptiometry. The severity of lymphedema was quantified using self-report survey. Weight-lifting was performed at community fitness facilities. RESULTS: At baseline, the affected arm had more fat (∆ = 89.7 g; P < 0.001) and lean mass (∆ = 149.1 g; P < 0.001), but less BMC (∆ = -3.2 g; P < 0.001) and less BMD (∆ = -5.5 mg/cm2; P = 0.04) than the unaffected arm. After 12 months of weight-lifting, composition of the affected arm was improved: lean mass (71.2 g; P = 0.01) and BMD (14.0 mg/cm2; P = 0.02) increased, arm fat percentage decreased (-1.5%; P = 0.003). Composition of the unaffected arm was only improved in lean mass (65.2 g; P = 0·04). Increases in lean mass were associated with less severe BCRL symptoms. CONCLUSIONS: Among women with BRCL, slowly progressive weight-lifting could improve arm tissue composition. Changes in arm tissue composition predict changes in symptom burden. Investigating the combined effects of exercise and weight loss on arm tissue composition and BCRL symptoms may provide additional insight into the benefits of lifestyle modification on lymphedema biology.

Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort. METHODS: We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990-2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis. RESULTS: A total of 1794 patients with stage 0-3 breast cancer with a median of 10 years follow-up were included. The cumulative incidence of BCRL diagnosis within 5 years was 9.1% [95% confidence interval (CI) 7.8-10.5%]. No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n = 1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p < 0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5 and 4.1% at 5 years, p = 0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5 vs. 9.5% at 5 years, p = 0.01). The groups with highest risk (>25% at 5 years) all involved ALND with nodal RT and/or anthracycline/cytoxan + taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation, and obesity. CONCLUSIONS: BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher body mass index.

Relationship between pre-transplant physical function and outcomes after kidney transplant.

BACKGROUND: Performance-based measures of physical function predict morbidity following non-transplant surgery. Study objectives were to determine whether physical function predicts outcomes after kidney transplant and assess how physical function changes post-transplant. METHODS: We conducted a prospective study involving living donor kidney transplants recipients at our center from May 2012 to February 2014. Physical function was measured using the Short Physical Performance Battery (SPPB [balance, chair stands, gait speed]) and grip strength testing. Initial length of stay (LOS), 30- day rehospitalizations, allograft function, and quality of life (QOL) were assessed. RESULTS: The majority of the 140 patients in our cohort had excellent pre-transplant physical function. In general, balance scores were more predictive of post-transplant outcomes than the SPPB. Decreased pre-transplant balance was independently associated with longer LOS and increased rehospitalizations but not with post-transplant QOL; 35% of patients experienced a clinically meaningful (≥ 1.0 m/s) improvement in gait speed 4 months post-transplant. CONCLUSIONS: Decreased physical function may be associated with longer LOS and rehospitalizations following kidney transplant. Further studies are needed to confirm this association. The lack of relationship between pre-transplant gait speed and outcomes in our cohort may represent a ceiling effect. More comprehensive measures, including balance testing, may be required for risk stratification.

Nested Cohort Study to Identify Characteristics That Predict Near-Term Disablement From Lung Cancer Brain Metastases.

OBJECTIVE: To test whether the presence of patient- and imaging-level characteristics (1) are associated with clinically meaningful changes in mobility among patients with late-stage cancer with metastatic brain involvement, and (2) can predict their risk of near-term functional decline. DESIGN: Prospective nested cohort study. SETTING: Quaternary academic medical center. PARTICIPANTS: The study population consisted of a nested cohort of the patients with imaging-confirmed brain metastases (n=66) among a larger cohort of patients with late-stage lung cancer (N=311). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional evaluations with the Activity Measure for Post-Acute Care Computer Adaptive Test (AM-PAC-CAT) and symptom intensity ratings were collected at monthly intervals for up to 2 years. RESULTS: In exploratory univariate models, whole brain radiation therapy (WBRT) and imaging findings of cerebellar or brainstem involvement were associated with large AM-PAC-CAT score declines reflecting worsening mobility (-4.55, SE 1.12; -2.87, SE, 1.0; and -3.14, SE 1.47, respectively). Also in univariate models, participants with new neurologic signs or symptoms at imaging (-2.48; SE .99), new brain metastases (-2.14, SE .99), or new and expanding metastases (-2.64, SE 1.14) declined significantly. Multivariate exploratory mixed logistic models, including WBRT, cerebellar/brainstem location, presence of new and expanding metastases, and worst pain intensity, had excellent predictive capabilities for AM-PAC-CAT score declines of 7.5 and 10 points (C statistics ≥0.8). CONCLUSIONS: Among patients with lung cancer and brain metastases, cerebellar/brainstem location, new and expanding metastases, and treatment with WBRT may predict severe, near-term mobility losses and indicate a need to consider rehabilitation services.

How Receptive Are Patients With Late Stage Cancer to Rehabilitation Services and What Are the Sources of Their Resistance?

OBJECTIVE: To describe the proportion and characteristics of patients with late stage cancer that are and are not receptive to receiving rehabilitation services, and the rationale for their level of interest. DESIGN: Prospective mixed-methods study. SETTING: Comprehensive cancer center in a quaternary medical center. PARTICIPANTS: Adults with stage IIIC or IV non-small cell or extensive stage small cell lung cancer (N=311). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Telephone-acquired responses to the administration of (1) the Activity Measure for Post Acute Care Computer Adaptive Test (AM-PAC-CAT); (2) numerical rating scales for pain, dyspnea, fatigue, general emotional distress, and distress associated with functional limitations; (3) a query regarding receptivity to receipt of rehabilitation services, and (4) a query about rationale for nonreceptivity. RESULTS: Overall, 99 (31.8%) of the study's 311 participants expressed interest in receiving rehabilitation services: 38 at the time of enrollment and an additional 61 during at least 1 subsequent contact. Participants expressing interest were more likely to have a child as primary caregiver (18.18% vs 9.91%, P=.04) and a musculoskeletal comorbidity (42.4% vs 31.6%, P=.05). Function-related distress was highly associated with receptivity, as were lower AM-PAC-CAT scores. Reasons provided for lack of interest in receiving services included a perception of their limited benefit, being too busy, and prioritization below more pressing tasks/concerns. CONCLUSIONS: One-third of patients with late stage lung cancer are likely to be interested in receiving rehabilitation services despite high levels of disability and related distress. These findings suggest that patient misperception of the role of rehabilitation services may be a barrier to improved function and quality of life. Efforts to educate patients on the benefits of rehabilitation and to more formally integrate rehabilitation as part of comprehensive care may curb these missed opportunities.

Impact of self-reported physical activity and health promotion behaviors on lung cancer survivorship.

BACKGROUND: There is some initial evidence that an enhanced physical activity level can improve fquality of life, and possibly survival among patients with lung cancer. The primary aim of this project was to evaluate the impact of physical activity on the quality and quantity of life of lung cancer survivors. METHODS: Between January 1, 1997, and December 31, 2009, a total of 1466 lung cancer survivors completed a questionnaire with patient-reported outcomes for quality of life (QOL), demographics, disease and clinical characteristics, and a measure of physical activity (Baecke Questionnaire). Chi-square tests compared lung cancer survivors who reported being physically active versus not on a variety of the other covariates. Kaplan-Meier estimates and Cox models evaluated the prognostic importance of physical activity level on Overall Survival (OS). RESULTS: Roughly half of the lung cancer survivors had advanced stage disease at the time of survey. Treatment prevalence rates were 61, 54, and 33 % for surgery, chemotherapy and radiotherapy, respectively. The majority (77 %) of survivors reported themselves as physically active. Physically active survivors reported greater activity across all individual Baecke items. Lung cancer survivor-reported QOL indicated the benefits of physical activity in all domains. Survivors receiving chemotherapy or radiation at the time of questionnaire completion were less likely to be physically active (74 and 73 % respectively). In contrast, 84 % of surgical patients were physically active. Disease recurrence rates were the same for physically active and inactive patients (81 % vs 82 %, p = 0.62). Physically active patients survived an average of 4 more years than those who were not physically active (8.4 years versus 4.4 years respectively, log rank p < 0.0001). CONCLUSIONS: Being physically active was related to profound advantages in QOL and survival in a large sample of lung cancer survivors.

Randomized pilot trial of yoga versus strengthening exercises in breast cancer survivors with cancer-related fatigue.

PURPOSE: Fatigue is one of the most common and bothersome refractory symptoms experienced by cancer survivors. Mindful exercise interventions such as yoga improve cancer-related fatigue; however, studies of yoga have included heterogeneous survivorship populations, and the effect of yoga on fatigued survivors remains unclear. METHODS: We randomly assigned 34 early-stage breast cancer survivors with cancer-related fatigue (≥4 on a Likert scale from 1-10) within 1 year from diagnosis to a 12-week intervention of home-based yoga versus strengthening exercises, both presented on a DVD. The primary endpoints were feasibility and changes in fatigue, as measured by the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). Secondary endpoint was quality of life, assessed by the Functional Assessment of Cancer Therapies-Breast (FACT-B). RESULTS: We invited 401 women to participate in the study; 78 responded, and we enrolled 34. Both groups had significant within-group improvement in multiple domains of the fatigue and quality of life scores from baseline to post-intervention, and these benefits were maintained at 3 months post-intervention. However, there was no significant difference between groups in fatigue or quality of life at any assessment time. Similarly, there was no difference between groups in adherence to the exercise intervention. CONCLUSIONS: Both DVD-based yoga and strengthening exercises designed for cancer survivors may be good options to address fatigue in breast cancer survivors. Both have reasonable uptake, are convenient and reproducible, and may be helpful in decreasing fatigue and improving quality of life in the first year post-diagnosis in breast cancer patients with cancer-related fatigue.