Carbohydrate mouth rinsing does not affect 6-min walk test performance and blood glucose responses in older adults.

PURPOSE: Carbohydrate (CHO) mouth rinsing (MR) prior to exercise has been shown to elicit enhanced performance and energy availability in some studies. Previous literature has concentrated on examining CHO MR strategies for improving aerobic endurance performance in younger athletic adults. Knowledge of the impact of CHO MR on functional performance in older adults is scarce. The purpose of this investigation was to determine if CHO MR would improve 6-min walk test (6MWT) performance, perceived exertion, and blood glucose responses in older adults. METHOD: Thirty-three individuals (16 males, 17 females), age ≥ 70 years performed two 6MWT trials, one of which utilized a 6.4% maltodextrin CHO MR and one of which utilized a placebo MR. Participants held the MR in their mouth for 20 s prior to the 6MWT, and trials occurred in a counterbalanced fashion. Total distance walked and rating of perceived exertion (RPE) were recorded upon completion of each 6MWT. Heart rate (HR), peripheral blood oxygen saturation (SpO2), systolic and diastolic blood pressures (BP), blood glucose, and blood lactate were measured before and after each 6MWT. RESULT: CHO MR did not alter the response of any study parameter compared to the placebo MR (p = 0.13-0.94). HR, systolic BP, and blood lactate increased and SpO2 decreased across time (p < 0.01). CONCLUSION: A 6.4% maltodextrin CHO MR did not alter total distance walked, perceived exertion, or other physiological responses elicited by the 6MWT in older adults.

Examination of clinical and laboratory measures of static and dynamic balance in breast cancer survivors.

Objectives: Balance in breast cancer survivors is understudied. Increased understanding of how postural control is affected when the body is stationary, moving, or engaged in a concurrent cognitive task, can aid clinicians who work with this population in identifying how altered postural control may indicate a potential functional decline. Therefore, the purpose of this study was to compare performance on several assessments of static and dynamic balance, with and without a concurrent cognitive task, in women with and without a history of breast cancer.Methods: Twenty-three women without a history of cancer (controls), and 20 women who were breast cancer survivors participated in the study. Static balance was assessed using the Single Leg Stance Test (SLS) and the NeuroCom Sensory Organization Test (SOT), the latter of which also included a serial sevens cognitive task. Dynamic balance was assessed using the Timed Up and Go Test (TUG) and the Fullerton Advanced Balance Scale (FABS).Results: Breast cancer survivors performed significantly worse on the TUG and the FABS compared to controls (p < .02). Performance on the SLS and SOT was largely similar between groups, including performance on the SOT with the serial sevens task (p > .05).Conclusion: Breast cancer survivors who were 0-5 years post-treatment appeared to exhibit similar static postural stability compared to controls, while some aspects of dynamic balance appeared altered. Assessing balance changes provides clinically useful information when constructing specific interventions aimed to improve function in these individuals post-treatment.

The effects of power and stretch yoga on affect and salivary cortisol in women.

Yoga practice is known to improve well-being and decrease stress. However, acute yoga is understudied. This study investigated the effects of two different types of yoga on affect and salivary cortisol levels in college women. Thirty-three women aged 18-30 years each completed 1-hour sessions of power yoga and stretch yoga. Measures of affect and salivary cortisol were assessed before, during, and after each session. Participants perceived power yoga to be more pleasurable and energizing. Salivary cortisol significantly decreased after both yoga sessions. Thus, even one session of yoga may be effective in improving affect and decreasing stress in college women.

Impact of Acute Intermittent Exercise on Natural Killer Cells in Breast Cancer Survivors.

BACKGROUND: Current research examining the effect of exercise on immune responses in cancer survivors is limited. OBJECTIVE: The aim of this pilot study was to examine the effect of 1 bout of intermittent exercise on natural killer (NK) cell numbers in breast cancer survivors. METHODS: A total of 9 women with stage I to III invasive breast cancer who were 3 to 6 months posttreatment and 9 sedentary women without a history of cancer completed 10 three-minute intervals of aerobic exercise on the cycle ergometer at 60% of VO2peak (peak oxygen uptake). Whole blood samples were taken pre-exercise, immediately postexercise, and at 2 hours and 24 hours postexercise. NK cell counts were assessed using flow cytometry. RESULTS: In both groups, NK cell counts significantly increased immediately postexercise compared with pre-exercise (P = .004-.008) and returned to near pre-exercise levels during recovery (P = .129-.547). Absolute NK cell counts were significantly lower in breast cancer survivors immediately postexercise when compared with controls (P = .046). CONCLUSIONS: The breast cancer survivor group exhibited NK cell responses to 30 minutes of moderate-intensity intermittent aerobic exercise that were comparable with that in the group of physically similar women without a history of cancer. Immune changes related to cancer treatments may be related to the lower absolute NK cell counts observed in the breast cancer survivor group. Although the results of this study are preliminary in nature, they suggest that this type of exercise does not disrupt this aspect of innate immunity in recent breast cancer survivors, thereby supporting current exercise recommendations for this population.

Exercise in patients with breast cancer and healthy controls: energy substrate oxidation and blood lactate responses.

The aim of this study was to compare select aspects of exercise energy metabolism in patients with breast cancer with that of healthy controls across a variety of exercise intensities. Posttreated patients with breast cancer were matched with healthy women based on age, physical fitness level, and menopausal status. Subjects participated in low-, moderate-, and high-intensity submaximal exercise sessions that corresponded with 40% of maximal oxygen consumption (Vo(2max)), 60% Vo(2max), and 70% Vo(2max). Oxygen consumption and respiratory exchange ratio were taken during submaximal exercise sessions to determine substrate oxidation rates for carbohydrate (CHO) and fat. Blood lactate and blood glucose were also measured before and after each of the submaximal exercise sessions as indices of CHO metabolism. Results indicate that the patients with breast cancer had a significantly (P≤.05) lower CHO oxidation rate and higher fat oxidation rate at all exercise intensities compared with healthy women. The patients with breast cancer had a significantly (P≤.05) lower blood lactate response to exercise across all intensities compared with the healthy women. Glucose responses tended (P<.08) to be more elevated in patients with cancer both before and after the exercise sessions. The findings indicate that posttreated patients with breast cancer have augmented fat metabolism and a reduced CHO-based energy metabolism during submaximal exercise. It is unclear whether these changes are the result of the patient's cancer or their treatment regimen for the cancer.

Radiation-induced reductions in regional lung perfusion: 0.1-12 year data from a prospective clinical study.

PURPOSE: To assess the time and regional dependence of radiation therapy (RT)-induced reductions in regional lung perfusion 0.1-12 years post-RT, as measured by single photon emission computed tomography (SPECT) lung perfusion. MATERIALS/METHODS: Between 1991 and 2005, 123 evaluable patients receiving RT for tumors in/around the thorax underwent SPECT lung perfusion scans before and serially post-RT (0.1-12 years). Registration of pre- and post-RT SPECT images with the treatment planning computed tomography, and hence the three-dimensional RT dose distribution, allowed changes in regional SPECT-defined perfusion to be related to regional RT dose. Post-RT follow-up scans were evaluated at multiple time points to determine the time course of RT-induced regional perfusion changes. Population dose response curves (DRC) for all patients at different time points, different regions, and subvolumes (e.g., whole lungs, cranial/caudal, ipsilateral/contralateral) were generated by combining data from multiple patients at similar follow-up times. Each DRC was fit to a linear model, and differences statistically analyzed. RESULTS: In the overall groups, dose-dependent reductions in perfusion were seen at each time post-RT. The slope of the DRC increased over time up to 18 months post-RT, and plateaued thereafter. Regional differences in DRCs were only observed between the ipsilateral and contralateral lungs, and appeared due to tumor-associated changes in regional perfusion. CONCLUSIONS: Thoracic RT causes dose-dependent reductions in regional lung perfusion that progress up to approximately 18 months post-RT and persists thereafter. Tumor shrinkage appears to confound the observed dose-response relations. There appears to be similar dose response for healthy parts of the lungs at different locations.

Aerobic exercise intensity in breast cancer patients: a preliminary investigation.

PURPOSE: This study compared the heart rate (HR), rate of perceived exertion (RPE), and blood lactate (BL) responses to aerobic exercise between posttreated breast cancer patients and apparently healthy, age-matched controls. METHODS: Seven patients and 7 control subjects underwent a submaximal treadmill test for the estimation of Vo(2max). Exercise intensities of 40%, 60%, and 70% of Vo(2max) were calculated from the treadmill test and randomly examined between groups during three 9-minute exercise bouts on 3 different days. Independent samples t tests were used to examine the HR, RPE, and BL responses at each intensity between groups. RESULTS: No significant differences were observed between the control and patient groups for HR, RPE, and BL at 40% (101 +/- 9 vs 101 +/- 11 bpm, P = .979; 8 +/- 1 vs 9 +/- 3, P = .237; and 1.11 +/- 0.73 vs 1.26 +/- 0.64 mmol/L, P = .188, respectively) and 60% (127 +/- 17 vs 117 +/- 13 bpm, P = .523; 12 +/- 2 vs 11 +/- 3, P = .267, and 3.83 +/- 2.48 vs 2.23 +/- 1.65 mmol/L, P = .237, respectively) of Vo(2max) . At 70% of Vo(2max), no significant differences were found for HR (151 +/- 27 vs 135 +/- 13 bpm, P = .704) and RPE (14 +/- 1 vs 13 +/- 3, P = .181), but lower BL responses were observed in the patient group (7.70 +/- 1.62 vs 3.29 +/- 1.08 mmol/L, P < .0005). CONCLUSIONS: The results suggest similar HR, RPE, and BL responses between patients and control subjects at 40%, 60%, and 70% of Vo(2max) , except for BL at 70% of Vo(2max). The lower BL response in the patient group at 70% of Vo(2max) was somewhat unexpected. Further research is needed to confirm or refute the results of this study to allow for a clearer understanding of the physiological responses of breast cancer patients to aerobic exercise at moderate or higher intensities so that safer aerobic exercise prescriptions can be developed for this population.

Prospective assessment of radiotherapy-associated cardiac toxicity in breast cancer patients: analysis of data 3 to 6 years after treatment.

BACKGROUND: Radiation therapy (RT) to the left breast/chest wall has been linked with cardiac dysfunction. Previously, the authors identified cardiac perfusion defects in approximately 50% to 60% of patients 0.5 to 2 years post-RT. In the current study, they assessed the persistence of these defects 3 to 6 years post-RT. METHODS: From 1998 to 2006, 160 patients with left-sided breast cancer were enrolled onto an Institutional Review Board-approved, prospective study. All patients received tangential photons to the left breast/chest wall. Patients had pre-RT and serial post-RT single-photon emission computed tomography (SPECT) scans to assess changes in regional cardiac perfusion, wall motion, and ejection fraction (EF). Forty-four patients had SPECT scans 3 to 6 years post-RT and were evaluable for the current analysis. RESULTS: The overall incidence of perfusion defects at 3 years, 4 years, 5 years, and 6 years was 52% (11 of 21 patients), 71% (17 of 24 patients), 67% (12 of 18 patients), and 57% (4 of 7 patients), respectively. The rate of abnormal SPECT scans 3 to 6 years post-RT in patients who had scans at 0.5 to 2 years that were either all abnormal, intermittently abnormal, or all normal was 80%, 67%, and 63%, respectively. The incidence of wall motion abnormalities in patients with or without perfusion defects 3 to 6 years post-RT was low and did not differ statistically (17% vs 7.1%, respectively; P = .65), as was the incidence of reductions in EF of >/=5% (27% vs 36%, respectively; P = .72). CONCLUSIONS: The results from this study indicated that RT-induced perfusion defects may persist or initially may appear 3 to 6 years post-RT in a high percentage of patients. However, these defects were not associated with changes in regional wall motion or EF. Additional study will be needed to determine the clinical relevance of these defects. In the meantime, the authors believe that every effort should be made to minimize incidental irradiation of the heart while maintaining adequate coverage of target volumes.

The role of functional imaging in the diagnosis and management of late normal tissue injury.

Normal tissue injury after radiation therapy (RT) can be defined based on either clinical symptoms or laboratory/radiologic tests. In the research setting, functional imaging (eg, single-photon emission computed tomography [SPECT], positron-emission tomography [PET], and magnetic resonance imaging [MRI]) is useful because it provides objective quantitative data such as metabolic activity, perfusion, and soft-tissue contrast within tissues and organs. For RT-induced lung, heart, and parotid gland injury, pre- and post-RT SPECT images can be compared with the dose- and volume-dependent nature of regional injury. In the brain, SPECT can detect changes in perfusion and blood flow post-RT, and PET can detect metabolic changes, particularly to regions of the brain that have received doses above 40 to 50 Gy. On MRI, changes in contrast-enhanced images, T(1) and T(2) relaxation times, and pulmonary vascular resistance at different intervals pre- and post-RT show its ability to detect and distinguish different phases of radiation pneumonitis. Similarly, conventional and diffusion-weighted MRI can be used to differentiate between normal tissue edema, necrosis, and tumor in the irradiated brain, and magnetic resonance spectroscopy can measure changes in compounds, indicative of membrane and neuron disruption. The use of functional imaging is a powerful tool for early detection of RT-induced normal tissue injury, which may be related to long-term clinically significant injury.

The impact of induction chemotherapy and the associated tumor response on subsequent radiation-related changes in lung function and tumor response.

PURPOSE: To assess the impact of induction chemotherapy, and associated tumor shrinkage, on the subsequent radiation-related changes in pulmonary function and tumor response. METHODS AND MATERIALS: As part of a prospective institutional review board-approved study, 91 evaluable patients treated definitively with thoracic radiation therapy (RT) for unresectable lung cancer were analyzed. The rates of RT-associated pulmonary toxicity and tumor response were compared in the patients with and without pre-RT chemotherapy. In the patients receiving induction chemotherapy, the rates of RT-associated pulmonary toxicity and tumor response were compared in the patients with and without a response (modified Response Evaluation Criteria in Solid Tumor criteria) to the pre-RT chemotherapy. Comparisons of the rates of improvements in pulmonary function tests (PFTs) post-RT, dyspnea requiring steroids, and percent declines in PFTs post-RT were compared in patient subgroups using Fisher's exact test, analysis of variance, and linear or logistic regression. RESULTS: The use of pre-RT chemotherapy appears to increase the rate of radiation-induced pneumonitis (p = 0.009-0.07), but has no consistent impact on changes in PFTs. The degree of induction chemotherapy-associated tumor shrinkage is not associated with the rate of subsequent RT-associated pulmonary toxicity. The degree of tumor response to chemotherapy is not related to the degree of tumor response to RT. CONCLUSIONS: Additional study is needed to better clarify the impact of chemotherapy on radiation-associated disfunction.

Prospective assessment of dosimetric/physiologic-based models for predicting radiation pneumonitis.

PURPOSE: Clinical and 3D dosimetric parameters are associated with symptomatic radiation pneumonitis rates in retrospective studies. Such parameters include: mean lung dose (MLD), radiation (RT) dose to perfused lung (via SPECT), and pre-RT lung function. Based on prior publications, we defined pre-RT criteria hypothesized to be predictive for later development of pneumonitis. We herein prospectively test the predictive abilities of these dosimetric/functional parameters on 2 cohorts of patients from Duke and The Netherlands Cancer Institute (NKI). METHODS AND MATERIALS: For the Duke cohort, 55 eligible patients treated between 1999 and 2005 on a prospective IRB-approved study to monitor RT-induced lung injury were analyzed. A similar group of patients treated at the NKI between 1996 and 2002 were identified. Patients believed to be at high and low risk for pneumonitis were defined based on: (1) MLD; (2) OpRP (sum of predicted perfusion reduction based on regional dose-response curve); and (3) pre-RT DLCO. All doses reflected tissue density heterogeneity. The rates of grade > or =2 pneumonitis in the "presumed" high and low risk groups were compared using Fisher's exact test. RESULTS: In the Duke group, pneumonitis rates in patients prospectively deemed to be at "high" vs. "low" risk are 7 of 20 and 9 of 35, respectively; p = 0.33 one-tailed Fisher's. Similarly, comparable rates for the NKI group are 4 of 21 and 6 of 44, respectively, p = 0.41 one-tailed Fisher's. CONCLUSION: The prospective model appears unable to accurately segregate patients into high vs. low risk groups. However, considered retrospectively, these data are consistent with prior studies suggesting that dosimetric (e.g., MLD) and functional (e.g., PFTs or SPECT) parameters are predictive for RT-induced pneumonitis. Additional work is needed to better identify, and prospectively assess, predictors of RT-induced lung injury.

Impact of patient-specific factors, irradiated left ventricular volume, and treatment set-up errors on the development of myocardial perfusion defects after radiation therapy for left-sided breast cancer.

PURPOSE: The aim of this study was to assess the impact of patient-specific factors, left ventricle (LV) volume, and treatment set-up errors on the rate of perfusion defects 6 to 60 months post-radiation therapy (RT) in patients receiving tangential RT for left-sided breast cancer. METHODS AND MATERIALS: Between 1998 and 2005, a total of 153 patients were enrolled onto an institutional review board-approved prospective study and had pre- and serial post-RT (6-60 months) cardiac perfusion scans to assess for perfusion defects. Of the patients, 108 had normal pre-RT perfusion scans and available follow-up data. The impact of patient-specific factors on the rate of perfusion defects was assessed at various time points using univariate and multivariate analysis. The impact of set-up errors on the rate of perfusion defects was also analyzed using a one-tailed Fisher's Exact test. RESULTS: Consistent with our prior results, the volume of LV in the RT field was the most significant predictor of perfusion defects on both univariate (p = 0.0005 to 0.0058) and multivariate analysis (p = 0.0026 to 0.0029). Body mass index (BMI) was the only significant patient-specific factor on both univariate (p = 0.0005 to 0.022) and multivariate analysis (p = 0.0091 to 0.05). In patients with very small volumes of LV in the planned RT fields, the rate of perfusion defects was significantly higher when the fields set-up "too deep" (83% vs. 30%, p = 0.059). The frequency of deep set-up errors was significantly higher among patients with BMI > or =25 kg/m2 compared with patients of normal weight (47% vs. 28%, p = 0.068). CONCLUSIONS: BMI > or =25 kg/m2 may be a significant risk factor for cardiac toxicity after RT for left-sided breast cancer, possibly because of more frequent deep set-up errors resulting in the inclusion of additional heart in the RT fields. Further study is necessary to better understand the impact of patient-specific factors and set-up errors on the development of RT-induced perfusion defects.

Does transforming growth factor-beta1 predict for radiation-induced pneumonitis in patients treated for lung cancer?

The purpose of the study was to reassess the utility of transforming growth factor-beta-1 (TGF-beta1) together with dosimetric and tumor parameters as a predictor for radiation pneumonitis (RP). Of the 121 patients studied, 32 (26.4%) developed grade > or =1 RP, and 27 (22.3%) developed grade > or =2 RP. For the endpoint of grade > or =1 RP, those with V30>30% and an end-RT/baseline TGF-beta1 ratio> or =1 had a significantly higher incidence of RP than did those with V30>30% and an end-RT/baseline TGF-beta1 ratio<1. For most other patient groups, there were no clear associations between TGF-beta1 values and rates of RP. These findings suggest that TGF-beta1 is generally not predictive for RP except for the group of patients with a high V30.

Is there an increased risk of local recurrence under the heart block in patients with left-sided breast cancer?

UNLABELLED: Tangential radiotherapy for left-sided breast cancer may be cardiotoxic. Shaping the field with a heart block reduces cardiac exposure but may under-dose the breast and/or chest wall. We compared the incidence and location of local recurrences in patients irradiated with and without a heart block. METHODS AND MATERIALS: Between 1994 and 1998, 180 patients irradiated to the left breast and/or chest wall were retrospectively reviewed. The local recurrence rates in patients treated with and without a heart block were compared using a 2-tailed Fisher exact test. An in-depth dosimetric analysis was performed in 23 patients to assess the percentage of breast tissue under-dosed by inclusion of the heart block. RESULTS: Overall, the local recurrence rates in patients with or without a heart block were similar. In postlumpectomy patients with inferiorly located tumors, the rates of local recurrence with and without a heart block were 2 of 6 patients versus 0 of 19 patients, respectively. In the dosimetric analysis, the average percentage of breast tissue under-dosed by the inclusion of a heart block was 2.8% (range, 0%-11%). DISCUSSION: A heart block is a reasonable method to limit cardiac dose but should be used cautiously following a lumpectomy in patients with inferiorly located tumors. Additional study with larger numbers of patients is warranted.

Challenges in defining radiation pneumonitis in patients with lung cancer.

PURPOSE: To assess the difficulty of assigning a definitive clinical diagnosis of radiation (RT)-induced lung injury in patients irradiated for lung cancer. METHODS: Between 1991 and 2003, 318 patients were enrolled in a prospective study to evaluate RT-induced lung injury. Only patients with lung cancer who had a longer than 6-month follow-up (251 patients) were considered in the current analysis. Of these, 47 of 251 patients had Grade >/=2 (treated with steroids) increasing shortness of breath after RT, thought possibly consistent with pneumonitis/fibrosis. The treating physician, and one to three additional reviewing physicians, evaluated the patients or their medical records, or both. The presence or absence of confounding clinical factors that made the diagnosis of RT-induced uncertain lung injury were recorded. RESULTS: Thirty-one of 47 patients (66%) with shortness of breath had "classic" pneumonitis, i.e., they responded to steroids and had a definitive diagnosis of pneumonitis. In 13 of 47 patients (28%), the diagnosis of RT-induced toxicity was confounded by possible infection; exacerbation of preexisting lung disease (chronic obstructive pulmonary disease); tumor regrowth/progression; and cardiac disease in 6, 8, 5, and 1 patients, respectively (some of the patients had multiple confounding factors and were counted more than once). An additional 3 patients (6%) had progressive shortness of breath and an overall clinical course more consistent with fibrosis. All 3 had evidence of bronchial stenosis by bronchoscopy. CONCLUSIONS: Scoring of radiation pneumonitis was challenging in 28% of patients treated for lung cancer owing to confounding medical conditions. Recognition of this uncertainty is needed and may limit our ability to understand RT-induced lung injury.