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Background In the earlier randomized controlled Physical Activity during Cancer Treatment (PACT) study, we found beneficial effects of an 18-week supervised exercise program on fatigue in patients with newly diagnosed breast or colon cancer undergoing adjuvant treatment. The present study assessed long-term effects of the exercise program on levels of fatigue and physical activity 4 years after participation in the PACT study. Methods The original study was a two-armed, multicenter randomized controlled trial comparing an 18-week supervised exercise program to usual care among 204 breast cancer patients and 33 colon cancer patients undergoing adjuvant treatment. Of the 237 PACT participants, 197 participants were eligible and approached to participate in the 4-year post-baseline measurements, and 128 patients responded. We assessed fatigue and physical activity levels at 4 years post-baseline and compared this to levels at baseline, post-intervention (18 weeks post-baseline), and at 36 weeks post-baseline. Results Intention-to-treat mixed linear effects model analyses showed that cancer patients in the intervention group reported significantly higher moderate-to-vigorous total physical activity levels (141.46 min/week (95% confidence interval (CI) 1.31, 281.61, effect size (ES) = 0.22) after 4 years compared to the usual care group. Furthermore, cancer patients in the intervention group tended to experience less physical fatigue at 4 years post-baseline compared to the usual care group (− 1.13, 95% CI –2.45, 0.20, ES = 0.22), although the result was not statistically significant. Conclusion Patients with breast or colon cancer who participated in the 18-week exercise intervention showed significant higher levels of moderate-to-vigorous total physical activity levels and a tendency towards lower physical fatigue levels 4 years post-baseline. Our result indicate that exercising during chemotherapy is a promising strategy for minimizing treatment-related side effects, both short and long term. Trial registration Current Controlled Trials ISRCTN43801571 , Dutch Trial Register NTR2138 . Trial registered on 9 December 2009.

Background The risk of breast cancer has been associated with various lifestyle factors, yet the evidence regarding how lifestyle modifications affect this risk remains limited. This study examines the relationship between changes in the Healthy Lifestyle Index (HLI) and postmenopausal breast cancer risk in women participating in the European Prospective Investigation into Cancer (EPIC). Methods HLI scores (ranging from 0 to 16) were computed based on smoking habits, alcohol consumption, body mass index (BMI), and physical activity levels, using data from baseline and follow-up questionnaires, which were separated by a median interval of 10  (IQR: 5.2–12.0) years. Among the 125,746 women included in the analyses, 2,175 developed breast cancer over a median follow-up period of nearly 4  (IQR: 2.9–8.4) years starting from the date of the second lifestyle questionnaire. Cox proportional hazards models were employed to estimate hazard ratios (HRs) and confidence intervals (CIs) for the relationship between changes in HLI and postmenopausal breast cancer risk, analysed both overall and by estrogen receptor (ER) status. Individual components of the HLI were also analysed, with sensitivity analyses addressing potential reverse causation by delaying the start of follow-up by 1 to 3 years. Results Each unit increase in the HLI—reflecting a healthier lifestyle—was not associated with the overall risk of postmenopausal breast cancer. Among individual components, only a one-unit increase in the BMI score, corresponding to a shift towards a healthier BMI, was inversely associated with overall (HR = 0.936; 95% CI 0.880–0.996) and ER-positive (HR = 0.930; 95% CI 0.865–1.000) postmenopausal breast cancer risks. Conclusions Lifestyle changes, as measured by the HLI, during mid-adulthood were not significantly associated with the risk of postmenopausal breast cancer. More specifically, the results of this study suggested that a shift towards a healthier BMI may contribute to breast cancer prevention. Further research involving diverse and larger study populations and lifestyle assessments at earlier life stages could provide deeper insights.

Having a physically active lifestyle after cancer diagnosis is beneficial for health, and this needs to be continued into survivorship to optimize long-term benefits. We found that patients, who participated in an 18-week exercise intervention, reported significant higher physical activity (PA) levels 4 years after participation in a randomized controlled trial of supervised exercise delivered during chemotherapy (PACT study). This study aimed to identify social-ecological correlates of PA levels in breast and colon cancer survivors 4 years after participation in the PACT study. Self-reported PA levels and potential correlates (e.g. physical fitness, fatigue, exercise history, and built environment) were assessed in 127 breast and colon cancer survivors shortly after diagnosis (baseline), post-intervention and 4 years later. Multivariable linear regression analyses were performed to identify social-ecological correlates of PA 4 years post-baseline. The final model revealed that lower baseline physical fatigue (β = -0.25, 95% CI -0.26; -0.24) and higher baseline total PA (0.06, 95% CI, 0.03; 0.10) were correlated with higher total PA levels 4 years post-baseline. Higher baseline leisure and sport PA (0.02, 95% CI 0.01; 0.03), more recreational facilities within a buffer of 1 km (4.05, 95% CI = 1.28; 6.83), lower physical fatigue at 4-year follow-up (-8.07, 95% CI -14.00; -2.13), and having a positive change in physical fatigue during the intervention period (0.04, 95% CI 0.001; 0.07) were correlates of sport and leisure PA levels 4 years post-baseline. This study suggests that baseline and 4-year post-baseline physical fatigue, and past exercise behaviour, were significant correlates of PA 4 years after participation in an exercise trial. Additionally, this study suggests that the built environment should be taken into account when promoting PA. Understanding of socio-ecological correlates of PA can provide insights into how future exercise interventions should be designed to promote long-term exercise behaviour. Current Controlled Trials ISRCTN43801571, Dutch Trial Register NTR2138. Trial registered on 9 December 2009, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2138.

Background Exercise is an effective strategy to reduce cancer- and treatment-related side effects and improve quality of life (QoL). Larger exercise effects are observed in cancer survivors with a higher symptom burden and when exercise interventions are supervised. Most studies conducted to date have not screened for symptoms at baseline and tailored the exercise intervention accordingly. Additionally, time and travel distance are common barriers to participation in supervised in-person exercise programs. Live-remote exercise, where exercise sessions are supervised by an exercise professional via a videoconferencing platform, might help overcome these barriers. Here, we describe the design of the LION randomized controlled trial (RCT). This RCT aims to assess the (cost-)effectiveness of side effect-targeted, live-remote exercise on QoL and the participants’ most burdensome side effect—fatigue, emotional distress, low physical functioning, or chemotherapy-induced peripheral neuropathy (CIPN)—in individuals who have completed primary curative cancer treatment. Methods The LION study is a multinational RCT that will enroll 352 individuals who have completed primary curative cancer treatment including chemotherapy, within the previous 12–52 weeks and screen positive for ≥ 1 of the targeted side effects. Participants are randomly allocated (1:1) to the intervention or wait list control group. Participants in the intervention group receive a 12-week supervised exercise program consisting of three live-remote exercise sessions per week. Each participant receives the same base module (2×/week) and one specific module (1×/week) targeting their most burdensome side effect. Wait list control participants receive the same exercise program 12 weeks post-baseline. The primary outcomes are HRQoL (EORTC QLQ-C30 summary score) and a standardized symptom score based on each participant’s most burdensome side effect (physical fatigue: EORTC QLQ-FA12, emotional distress: PHQ-ADS, physical functioning: EORTC QLQ-C30 modified physical functioning scale, CIPN: EORTC QLQ-CIPN20), assessed at baseline, 6, 12 (primary time point), 18 (wait list control group only), 24 and 36 weeks post-baseline. Discussion This RCT will provide evidence regarding the (cost-)effectiveness of side effect-targeted, live-remote exercise in individuals experiencing side effects following primary curative cancer treatment. If proven (cost-)effective, live-remote exercise could be offered to individuals as part of standard follow-up cancer care to extend the reach of exercise support. Trial registration NCT06270628. Registered on February 13, 2024.

Purpose As survival of patients with metastatic breast cancer (MBC) improves, their work situation is gaining importance. The aim of the current study was to identify factors associated with work status and quality of working life (QWL) in patients with MBC. Additionally, we investigated the effects of an exercise intervention on work status. Methods Within the multinational PREFERABLE‐EFFECT exercise trial, 287 patients with MBC of working age (18–65 years) reported on their working situation over 9 months as a secondary endpoint. Among a subgroup of participants, QWL was assessed by the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ‐CS) (N = 59). Results At baseline, 157 (54.7%) participants were employed, of whom one‐third reported having recently reduced their amount of work because of fatigue (41.7%), cognitive problems (33.3%), or inability to meet work demands (33.3%). Participants wished for more flexible working hours (29.2%) and less productivity pressure (37.5%). Participants were less likely to work if they experienced higher levels of pain (p = 0.014). Among working participants, an academic education and higher levels of psychological distress were associated with a higher number of working hours (all p < 0.05). Fatigue, an academic education, and performing mentally strenuous tasks at work were negatively associated with QWL (all p < 0.05). The exercise intervention did not affect the number of hours worked during the study. Conclusions Symptom management might be important for patients' ability to work. To help patients stay employed and improve QWL, employers should consider offering more flexible work arrangements and adapting to their employees' changing needs and abilities. Trial Registration: The PREFERABLE‐EFFECT trial was registered with ClinicalTrials.gov on October 9, 2019 (NCT04120298).

Physical exercise both during and after curative cancer treatment has been shown to reduce side effects. Evidence in the metastatic cancer setting is scarce, and interventions that improve health-related quality of life (HRQOL) are much needed for patients with metastatic breast cancer (MBC). The multinational randomized controlled PREFERABLE-EFFECT trial assessed the effects of exercise on fatigue and HRQOL in patients with MBC. In total, 357 patients with MBC and a life expectancy of ≥6 months but without unstable bone metastases were recruited at eight study centers across five European countries and Australia. Participants were randomly assigned (1:1) to usual care (control group, n  = 179) or a 9-month supervised exercise program (exercise group, n  = 178). Intervention effects on physical fatigue (European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-FA12 scale) and HRQOL (EORTC QLQ-C30 summary score) were determined by comparing the change from baseline to 3, 6 (primary timepoint) and 9 months between groups using mixed models for repeated measures, adjusted for baseline values of the outcome, line of treatment (first or second versus third or higher) and study center. Exercise resulted in significant positive effects on both primary outcomes. Physical fatigue was significantly lower (−5.3 (95% confidence interval (CI), −10.0 to −0.6), Bonferroni–Holm-adjusted P  = 0.027; Cohen's effect size, 0.22) and HRQOL significantly higher (4.8 (95% CI, 2.2–7.4), Bonferroni–Holm-adjusted P  = 0.0003; effect size, 0.33) in the exercise group than in the control group at 6 months. Two serious adverse events occurred (that is, fractures), but both were not related to bone metastases. These results demonstrate that supervised exercise has positive effects on physical fatigue and HRQOL in patients with MBC and should be recommended as part of supportive care. ClinicalTrials.gov Identifier: NCT04120298 . In this large interventional, randomized controlled trial, structured and individualized exercise in patients with metastatic breast cancer led to lower levels of fatigue and improved health-related quality of life.

Purpose This study examined the Sense of Coherence (SOC) of patients participating in the randomized controlled ‘Optimal Training for Women with Breast Cancer’ (OptiTrain) study and assessed how patient characteristics were associated with SOC. Secondary aims were to assess the association between SOC and patients’ participation in this study and to determine whether SOC moderates the effect of the 16-week exercise intervention on fatigue, quality of life (QoL), and symptom burden in women with breast cancer undergoing chemotherapy. Methods Modified Poisson regression analyses were conducted to determine the relative risk of weak-normal SOC versus strong SOC in terms of exercise session attendance, study and intervention dropout, and long absence rates. Analyses of covariance were performed to assess whether SOC moderated the effect of the exercise intervention ( p interaction  ≤ 0.10). Results Two hundred and forty women with early breast cancer (mean age 53 ± 10) participated in the OptiTrain study. Women with strong SOC reported less fatigue, lower symptom burden, and higher QoL. Women with weak-normal SOC were significantly more likely to drop out from the OptiTrain study and tended to have slightly poorer exercise session attendance. Women with breast cancer and weaker SOC benefitted as much from the exercise intervention, in terms of fatigue and QoL, as those with stronger SOC ( p interaction  > 0.10). Conclusions Strong SOC appears to be associated with a more positive subjective state of health. Women with weak-normal SOC may need additional support to encourage participation and adherence in exercise trials. Assessing SOC may assist clinicians to identify and provide extra support for participants with weak SOC, who may be less inclined to participate in exercise programs.

Purpose We aimed to identify metastatic breast cancer (MBC) patients’ preferences for exercise programs and identify patients’ characteristics associated with these preferences, to facilitate implementation of exercise programs for MBC patients. Methods We used data from a multinational cross-sectional survey conducted among MBC patients. Patients reported their preferred exercise frequency, intensity, type, session duration, and supervision mode. We used latent class analysis to identify subgroups with similar preferences and descriptive statistics to compare demographic and clinical characteristics of patients within subgroups. Results Four distinct classes were identified based on data from 409 participants. Class 1 (47% of participants) is characterized by a preference for moderate exercise with supervision within the health care setting. Most participants in this class had bone metastases. Class 2 (30%) is characterized by a preference for vigorous exercise with supervision. This class included participants who were, on average, younger, and had a higher education level. Class 3 (13%) is characterized by a preference for active walking. These participants were less likely to have bone metastases or comorbidities. Class 4 (10%) is characterized by a preference for recreational walking and included participants who were, on average, older, and less likely to be employed. Conclusion We identified four classes of patients with different preferences for exercise programs. Many patients with MBC express exercise preferences that meet the current guideline recommendations. Some patients with MBC may benefit from targeted education to align their preferences and behavior with the amount of exercise that is necessary to gain health benefits.

Purpose Participation in a post-treatment exercise program improves cardiorespiratory fitness and aspects of quality of life for esophageal cancer survivors. For optimal effects, high adherence to the exercise intervention is important. We assessed which facilitators and barriers to exercise adherence are perceived by esophageal cancer survivors, who participate in a post-treatment exercise program. Methods The current qualitative study was performed within the randomized controlled PERFECT trial, in which we investigated effects of a 12-week supervised exercise program with moderate-to-high intensity and daily physical activity advice. Semi-structured interviews were conducted with patients randomized to the exercise group. A thematic content approach was used to derive perceived facilitators and barriers. Results Thematic saturation was reached after inclusion of sixteen patients. Median session attendance was 97.9% (IQR 91.7–100%), and relative dose intensity (compliance) to all exercises was ≥90.0%. Adherence to the activity advice was 50.0% (16.7–60.4%). Facilitators and barriers were captured in seven themes. The most important facilitators were patients’ own intention to engage in exercise and supervision by a physiotherapist. Barriers were mainly experienced in completion of the activity advice, and included logistic factors and physical complaints. Conclusions Esophageal cancer survivors are well capable to attend a moderate-to-high intensity post-treatment exercise program, and to fulfill the exercises according to protocol. This is facilitated by patients’ own intention to engage in exercise and supervision of the physiotherapist, and only minimally affected by barriers as logistic factors and physical complaints. Implications for cancer survivors When implementing postoperative exercise programs in clinical care, it can be useful to be aware of perceived facilitators and barriers of cancer survivors in order to achieve optimal exercise adherence and maximize beneficial exercise effects. Trial registration Dutch Trial Register NTR 5045

Background Many patients with metastatic breast cancer experience cancer- and treatment-related side effects that impair activities of daily living and negatively affect the quality of life. There is a need for interventions that improve quality of life by alleviating fatigue and other side effects during palliative cancer treatment. Beneficial effects of exercise have been observed in the curative setting, but, to date, comparable evidence in patients with metastatic breast cancer is lacking. The aim of this study is to assess the effects of a structured and individualized 9-month exercise intervention in patients with metastatic breast cancer on quality of life, fatigue, and other cancer- and treatment-related side effects. Methods The EFFECT study is a multinational, randomized controlled trial including 350 patients with metastatic breast cancer. Participants are randomly allocated (1:1) to an exercise or control group. The exercise group participates in a 9-month multimodal exercise program, starting with a 6-month period where participants exercise twice a week under the supervision of an exercise professional. After completing this 6-month period, one supervised session is replaced by one unsupervised session for 3 months. In addition, participants are instructed to be physically active for ≥30 min/day on all remaining days of the week, while being supported by an activity tracker and exercise app. Participants allocated to the control group receive standard medical care, general written physical activity advice, and an activity tracker, but no structured exercise program. The primary outcomes are quality of life (EORTC QLQ-C30, summary score) and fatigue (EORTC QLQ-FA12), assessed at baseline, 3, 6 (primary endpoint), and 9 months post-baseline. Secondary outcomes include physical fitness, physical performance, physical activity, anxiety, depression, pain, sleep problems, anthropometric data, body composition, and blood markers. Exploratory outcomes include quality of working life, muscle thickness, urinary incontinence, disease progression, and survival. Additionally, the cost-effectiveness of the exercise program is assessed. Adherence and safety are monitored throughout the intervention period. Discussion This large randomized controlled trial will provide evidence regarding the (cost-) effectiveness of exercise during treatment of metastatic breast cancer. If proven (cost-)effective, exercise should be offered to patients with metastatic breast cancer as part of standard care. Trial registration ClinicalTrials.gov NCT04120298 . Registered on October 9, 2019.