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EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS
Kerri Winters-Stone, PhD, FACSMKnight Cancer Institute and School of Nursing
Oregon Health & Science University, Portland, OR
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By 2040, it is estimated that nearly half of cancer survivors will be age 75 or older
Right now
20 years from now
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Premature Physiologic Aging from Cancer
Ness et al JCO 31; 2018
Cancer treatment can speed the aging process over a short time and starts immediately
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FRAILTY
Muscle Loss
Fatigue
Slowness
Weakness
Inactivity
FALLS
DISABILITYDEPENDENCE
DEATH
Fractures
Cancer Treatment can Accelerate Frailty
Cancer Treatment
Aging
ROBUST (0) PRE-FRAIL (1-2) FRAIL (3-5)
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Breast cancer survivors perform worse than older women without cancer
Winters-Stone K et al, Oncol Nurs For,35(5):815-821, 2008
Endurance12-minute walk
met
ers
# st
ands
in 3
0 se
c
WeaknessChair stands
Slow Walk SpeedTandem walk
time
to w
alk
20’ (
sec)
53% of BCS fell in previous yr vs. 35% of controls34% of BCS had multiple falls vs. 11% of control
Mean age: 63.4 yrs
Mean age: 72.1 yrs
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Frailty Component Measure
Fra
il, P
re-F
rail
or R
obus
t Shrinking Appendicular lean body mass
Weakness Chair stand
Exhaustion SF-36 Vitality score
Slowness Usual walk speed
Inactivity Self-report PA
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4
0
20
40
60
80
Frailty Obese Frailty
Current ADT (n=120) Past ADT (n=62)Never ADT (n=109)
% o
f sam
ple p<0.001
p>0.1
p<0.001
p>0.1
Distribution of Frailty Components
SELF-REPORT
Current Past Never
Exhaustion 19.7% 24.2% 8.2%*
Weakness 15.4% 16.4% 3.1%*
Slowness 27.8% 25.4% 3.2%**
Illness 3.4% 4.8% 0.0%
Weight loss 11.0% 8.2% 5.1%
Obesity 41.2% 40.3% 16.2%**
*p<0.05, **p<0.01
Winters-Stone et al J Amer Geriatr Soc, 2017
Androgen Deprivation Therapy (ADT) for prostate cancer speeds aging, even after treatment stops
Frailty led to a 3-fold higher increase in fall risk
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Fig 2. Percentage of survivors in the St. Jude Lifetime Cohort Study (SJLIFE) who meet the criteria for frailty compared with participants in the Cardiovascular Health Study and normal controls. N = 1,922 (50.3% male); mean time since diagnosis, 25.5±7.7 years; mean age at diagnosis, 8.2±5.6 years; 43% leukemia; 33% with cranial radiation exposure.
Frailty in Adult Survivors of Childhood CancerSurvivors are ~34 years old
Comparator group is 65+
years old
From Ness et al JCO 31; 2018
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Functional Impairment•Weakness•Inactivity•Poor mobility•Muscle loss•Fatigue•Neuropathy•Vestibular loss
FRAILTY
FRACTURES
Aging
Falls
Dependence Hospitalization
Death
Cancer Treatment•Surgery•Radiation•Chemotherapy•HormoneManipulationTherapy
Comorbidities
EXERCISE Exercise could prevent or reverse frailty, but how do we train the frail?
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30 minutes of Aerobic and/or Resistance Training 3x/week improves many cancer-related health outcomes
STRONG MODERATE INSUFFICIENTAnxiety Bone Health CardiotoxicityDepressive Symptoms Sleep CIPNFatigue Cognitive Function
HR-QOL Frailty / Falls Lymphedema NauseaPhysical Function Pain
Sexual FunctionTreatment Tolerance
Campbell KL, Winters-Stone KM [Co First Authors], Wiskemann J, May AM, Schwartz AL, Courneya KS, Zucker DS, Matthews CE, Ligibel JA, Gerber LH, Morris GS, Patel AV, Hue TF, Perna FM, Schmitz KH. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019 Nov;51(11):2375-2390. doi:10.1249/MSS.0000000000002116. PubMed PMID: 31626055.
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Exercise Studies in Older Cancer Survivors
• Handful of RCTs specific to older survivors• Vulnerable samples often excluded
• Upper age limit• Lack of physician clearance / contraindications• Disinterest, inaccessible, protected by family
• Lack of secondary analyses of oldersurvivors within exercise trials• Small sample sizes• Limited statistical approaches• Complicated by comorbidities
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Frail survivors may have low exercise tolerance• Prostate, breast, colorectal cancer• 65+ yrs.• Home-based diet + PA (aerobic +
resistance training)
Intent to Treat• Showed favorable & sustainable
outcomes
Sensitivity analysis• Participants with SF-36 scores < 50
did not respond to the intervention• Low functioning patients more likely
to have higher BMI
Demark-Wahnefried W, Morey MC, Sloane R, et al. J Clin Oncol, 2012
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Poor compliance among limited survivors
• 3-arm RCT in older (>65 year old) breastcancer survivors (n=114)
• Resistance (RET) vs Stretching (control)
• 35 women had Physical PerformanceBattery (PPB) scores < 9• Eliminating these women from analyses
changed outcomes
• Strength
• Fatigue
• Function (self-report and objective)
• Compliance NOT attendance
Winters-Stone et al in review
75
80
85
90
95
100
Baseline 12 months
RET - Whole Sample CON Whole SampleRET - High PPB CON - High PPB
Self-
rep
ort
phy
sica
l fun
ctio
n
* p<0.05
ITT analysis
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What Might Limit Exercise in Frail Survivors?Patient Behavior
• Fear over safety• Effort• Self-efficacy• Meaningfulness• Pain
Patient Limitations• Orthopedic limitations• Cardiovascular limitations• Comorbidities (obesity, diabetes, etc)• Low capacity / endurance / mobility• Pain• Poor kinesthetic awareness
NONE OF THESE SHOULD BE REASONS AGAINST EXERCISE
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Triage & Tailor Functionally-Based
Support Movement Preparation (Posture & Mobility)
PATIENTSUCCESS
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One ExRx may not fit all: Triage & Tailor
• Safety• Limitations• Tolerance• Goals
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Triage to Appropriate Training*
SF-36 PF <50; Frail on FRAIL scale; PPB < 9; GS <0.9m/s; 5xSTS > 12 sec
Self-Report or Objective Patient Assessment
Frail &/or Functionally Limited?
YES
Physical Therapy 1-on-1 Small
group txn
NO
Train as usual
Suggested Triage Pathway
* Training must take into account other health hx, comorbidities, etc andfocus on restoring function and independence
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Tailoring Exercise for Frail Adults• Modifications are highly likely
• Know several modifications and/or substitutesfor exercises
• Progress to harder versions based on tolerance
• Consider ability to get onto/off of floor• Wall / seated modifications
• Consider small groups and/or individualcoaching sessions• Initial individual coaching with check-ins• Options for varying levels of ability• Check-ins for group exercise w/ individual
coaching as needed• Start low and progress s l o w
Winters-Stone et al J Supp Care Cancer 26; 2018
Exercise video instructed @ 3 levels of intensity
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Functional Movements vs. MachinesMachine-
basedFunctionally-
based
Accessible
Meaningful
Relevant toADLs
Builds strength
Safe
e.g., chair raise,step up, heelraise, push up,row, plank,bridge
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Movement PreparationStart training with a program focused on: 1) smaller stabilizing muscles; 2) postural alignment, and 3) mobility
Movement Prep Exercises (sample list)Wall sitHip ab/adduction (standing/sitting)Side step w/ bandWall angelsWall (chest) openersArm (band) pullsShoulder (band) internal/external rotationBridges (chair)Plank (chair, counter)
Functional ExercisesChair rise / sit or SquatStep UpsFront / side squat / lungeChest pressPush upRows
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Support• Create a less intimidating space
• May take one on one or small group• Progress to larger groups as self-efficacy builds
• Focus on form, but build confidence• Form needs to be “good enough” to maintain
safety and have some benefit
• Progress based on individual needs• Incremental improvement is OK!• Celebrating the small success to
encourage progress.• Include care partner / spouse if possible
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Summary & Recommendations• Cancer treatment often accelerates aging leading to frailty à using
chronological age may not accurately reveal safety and programmingconsiderations EVEN in younger survivors
• Growing percentage of older, frail, and functionally limited patients notaddressed in current exercise recommendations and programs• Frail patients may need exercise MORE than non-frail patients, but
delivery approach needs special consideration• Triage & tailor• Focus on function• Prepare patient for exercise training• Provide extra and continual support
• Special attention to exercise considerations can maximize success!
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Kerri Winters-Stone, PhD, FACSMKnight Cancer Institute & School of NursingOregon Health & Science UniversityEmail: [email protected]: @winters_stoneWeb page: www.ohsu.edu/survivorship
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