Chemotherapy Completion Rates, Quality-of-Life Indicators Improve with Exercise

Oncologists can safely offer patients with early breast cancer two more ways to be involved in their treatment—physical exercise and yoga. Two recent reports, both published in the October 1 issue of the Journal of Clinical Oncology, showed that aerobic and resistance training and yoga can maintain or improve some quantifiable features in a breast cancer patient's quality of life. In the first study, of women undergoing chemotherapy for early-stage breast cancer, researchers from the University of Alberta reported that women taking resistance and aerobic exercise classes had improved physical fitness, self esteem, and lean body mass compared with controls receiving usual care. Exercise did not, however, improve cancer-specific quality of life, fatigue, depression, or anxiety, although there were trends that favored the exercise groups. JCO 2007;25:4387–4395 and 4396–4404 But women who performed aerobic or resistance exercises had higher chemotherapy completion rates than controls. In the second study, from Albert Einstein College of Medicine in the Bronx, NY, women taking yoga classes reported a stronger sense of social support, although the benefit was higher in patients who were not receiving chemotherapy during the study period. While not all patients in these two studies reported quality-of-life improvements, neither study reported adverse events related to the exercises and the authors could report that these “lifestyle interventions” are feasible and safe. Chemo Completion Rates In an editorial accompanying the two studies, Wendy Demark-Wahnefried, PhD, Professor of Behavioral Science at the University of Texas M. D. Anderson Cancer Center, said that cancer-specific quality of life may not be the optimal primary outcome measure in studies of women receiving chemotherapy because of the many emotional and physical challenges that women face. What did impress Dr. Demark-Wahnefried were the rates of women who completed 85% of their recommended chemotherapy dose: 78% in the resistance-training group, 74.4% in the aerobic exercise group, vs 65.9% in the controls receiving usual care. That completion of therapy data should be very practical information for oncologists, she said. “That is hugely exciting.” Lead author Kerry S. Courneya, PhD, Professor and Canada Research Chair in Physical Activity and Cancer at the University of Alberta, said that this was the first large study to examine how exercise might help cancer patients cope with treatment and recovery. He agreed that overall quality-of-life might not have been the study's ideal primary endpoint: “We didn't see differences in the primary endpoint, so in cancer research it would be viewed as a null trial. But in the behavioral or supportive care area we also look at improvements in fitness, strength, and self esteem as positive benefits.” Dr. Courneya said the study data did suggest that aerobic and resistant exercises are safe, with no meaningful adverse events seen in this trial, and that they are feasible. START Details Dr. Courneya's START (Supervised Trial of Aerobic versus Resistance Training) study included 242 women undergoing chemotherapy: 82 were randomly selected to attend three supervised resistance-exercise classes weekly, 78 to three supervised aerobic training sessions weekly, and 82 to a “usual care” group with no assigned exercise.Figure: The study led by Kerry S. Courneya, PhD, was the first large study to examine how exercise might help cancer patients cope with treatment and recovery.The median duration of chemotherapy and exercise was 17 weeks. The primary endpoint of cancer-specific quality of life was assessed by the FACT (Functional Assessment of Cancer Therapy) Anemia scale. On this scale, aerobic exercise was superior to usual care for improving self-esteem, aerobic fitness, and percent body fat. Resistance training was superior to the usual care for improving self-esteem, muscular strength, lean body mass, and chemotherapy completion rate. Exercise did not cause lymphedema or adverse events, the authors reported. Yoga Power The yoga study randomly assigned 84 of 128 study subjects to a 12-week yoga intervention program, and 44 to a 12-week wait list to enter the program. Lead author Alyson B. Moadel, PhD, Assistant Professor in the Department of Epidemiology & Population Health and Director of the Psychosocial Oncology Program at Albert Einstein, explained that the yoga study is unique in that it is possibly the first to include a multiethnic population: 42% of the 128 women were African American, 23% were Hispanic, 23% were non-Hispanic white, and 4% were classified as “other.” Also, 76% had educational levels of high school or less, while 24% had at least some college. Dr. Demark-Wahnefried, in her editorial, said that these were notable achievements because two-thirds of lifestyle interventions to date have relied on samples that were at least 90% white and 80% college educated. Approximately half the women in this trial were receiving medical treatment. Dr. Demark-Wahnefried noted that the data uncovered a most important point regarding the timing of lifestyle intervention, in that the subset of women not receiving chemotherapy did experience significantly improved quality of life, emotional well being, social and spiritual well being, and less distress compared with those receiving therapy during the yoga classes. “When we talk about endpoints like quality of life, we first have to know when to intervene,” she said. “In the yoga study, the real value to patients came after treatment, as opposed to during treatment, and that's a valuable lesson.” As with the Canadian study, no significant differences were found in quality of life, fatigue, or distress between women assigned to yoga and women in the usual-care group. But the authors did find a significant difference in social well being. Dr. Moadel said the yoga classes appeared to preserve and protect the yoga patients' sense of social support, whereas those not in the classes reported a deterioration. Deterioration in social life and a sense of isolation is not uncommon among people dealing with cancer, Dr. Moadel said. Patients may not feel strong enough or well enough to socialize, and friends and family might avoid the patient because they are uncomfortable around them.Figure: Alyson G. Moadel, PhD, lead author of the trial of yoga among a multiethnic sample of breast cancer patients, said that yoga classes usually aren't considered something that minority women can afford, or would even be interested in. But on the contrary, she said, the yoga classes at her institution continue to add three or four new women a month, more than double the number joining traditional breast cancer support groups there.“Even patients who have a supportive family will say that ‘no one understands what we're going through unless they have it themselves,'” she said. “The family might care, but they don't know how to [emotionally] support the patient.” Dr. Moadel said that yoga classes usually aren't considered something minority women can afford, or even be interested in. But to the contrary, she said the yoga classes at her institution continue to add three or four new women per month, more than double the number joining traditional breast cancer support groups there. Dr. Moadel said she hoped oncologists would be reassured by these data, that they would be supportive and give breast cancer patients “permission” to investigate yoga as a complement to their medical treatment. Study Evaluating Fatigue, Depression, & Immune Factors A study at Ohio State University Medical Center is assessing whether yoga can relieve fatigue and depression and positively affect immune function in breast cancer survivors. The study, based in the Institute for Behavioral Medicine Research, will examine the effects of consistent yoga practice on women who have completed treatment for Stage I, II, or IIIa breast cancer. Women must have completed treatment within the past two years, but must not have had surgery, radiation or chemotherapy within the past two months. The study, which aims to enroll 250 women, is led by Janice Kiecolt-Glaser, PhD, Director of the Division of Health Psychology and co-leader of a separate ongoing study at Ohio State of yoga's effects on stress in women. “Everyone thinks yoga has health benefits, but a look at the literature shows we just don't have good evidence proving those benefits exist,” she said in a news release. “An important population of women stands to benefit from this new study, which will improve understanding of how yoga may alter moods and produce immunological and hormonal changes that are relevant to health.” Patients will be randomly assigned to one of two groups: One will perform usual activities for six months as a control before beginning the intervention and then will participate in a 90-minute yoga session twice a week for 12 weeks. They will practice yoga at home using DVDs or videos. Patients will also keep a daily yoga diary. The other group will immediately begin participating in a 90-minute yoga session twice a week for 12 weeks, practice yoga at home using DVDs or videos, and keep a daily yoga diary. Patients in both groups will undergo a physical assessment and interview and fill out questionnaires, and undergo blood and saliva sample collection periodically for laboratory studies. The outcomes assessed will include the presence of pro-inflammatory cytokines, fatigue and depressive symptoms, and quality-of-life measures related to perceived stress and stress responsiveness, health behaviors, physical pain and flexibility, and physiological stress responses. “We're hopeful that we can find biological evidence that demonstrates that gentle physical activity accessible to virtually everyone might help women in their ongoing recovery from breast cancer,” said Charles Shapiro, MD, Director of Breast Medical Oncology at the James Cancer Hospital and Solove Research Institute at Ohio State and a co-principal investigator for the study.

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