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Background Combinations of exercise and nutritional interventions might improve the functional prognosis for cachectic cancer patients. However, high attrition and poor compliance with interventions limit their efficacy. We aimed to test the feasibility of the early induction of new multimodal interventions specific for elderly patients with advanced cancer Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) programme. Methods This was a multicentre prospective single‐arm study. We recruited 30 of 46 screened patients aged ≥70 years scheduled to receive first‐line chemotherapy for newly diagnosed, advanced pancreatic, or non‐small‐cell lung cancer. Physical activity was measured using pedometers/accelerometer (Lifecorder®, Suzuken Co., Ltd., Japan). An 8 week educational intervention comprised three exercise and three nutritional sessions. The exercise interventions combined home‐based low‐intensity resistance training and counselling to promote physical activity. Nutritional interventions included standard nutritional counselling and instruction on how to manage symptoms that interfere with patient's appetite and oral intake. Supplements rich in branched‐chain amino acids (Inner Power®, Otsuka Pharmaceutical Co., Ltd., Japan) were provided. The primary endpoint of the study was feasibility, which was defined as the proportion of patients attending ≥4 of six sessions. Secondary endpoints included compliance and safety. Results The median patient age was 75 years (range, 70–84). Twelve patients (40%) were cachectic at baseline. Twenty‐nine patients attended ≥4 of the six planned sessions (96.7%, 95% confidence interval, 83.3 to 99.4). One patient dropped out due to deteriorating health status. The median proportion of days of compliance with supplement consumption and exercise performance were 99% and 91%, respectively. Adverse events possibly related to the NEXTAC programme were observed in five patients and included muscle pain (Grade 1 in two patients), arthralgia (Grade 1 in one patient), dyspnoea on exertion (Grade 1 in one patient), and plantar aponeurositis (Grade 1 in one patient). Conclusions The early induction of multimodal interventions showed excellent compliance and safety in elderly patients with newly diagnosed pancreatic and non‐small‐cell lung cancer receiving concurrent chemotherapy. We are now conducting a randomized phase II study to measure the impact of these interventions on functional prognosis.

Purpose This systematic review and meta-analysis aimed to determine whether home-based preoperative physical activity (PA) influenced the incidence of postoperative complications (PCs) in patients who underwent oncologic surgery. Methods A comprehensive literature search was conducted using five electronic databases. Full articles with observational designs that compared by preoperative PA or PCs were included. The primary outcome was some type of PC, and a meta-analysis was performed to determine the impact of preoperative low PA on the incidence of PCs. Sub-analysis was performed to identify subgroups based on the severity of the PCs and the cancer site. Results Eight studies were included in the analysis. Low preoperative PA was associated with all PCs (odds ratio [OR] = 2.42, 95% confidence interval [CI] = 1.44 to 4.07) but not with severe PCs (OR = 1.93, 95% CI = 0.51 to 7.37). In a subgroup of patients with gastrointestinal cancers, low preoperative PA was associated with all PCs (OR = 3.44, 95% CI = 1.63 to 7.26) and severe PCs (OR = 2.93, 95% CI = 1.30 to 6.58). Conclusions This systematic review and meta-analysis revealed that patients with low preoperative PA undergoing oncologic surgery, particularly those with gastrointestinal cancers, are more likely to develop PCs. A definitive conclusion could not be reached, however, due to the limited number of studies exclusively examining this relationship in cancer patients.

Background Most advanced elderly cancer patients experience fatigue, anorexia, and declining physical function due to cancer cachexia, for which effective interventions have not been established. We performed a phase I study of a new nonpharmacological multimodal intervention called the nutritional and exercise treatment for advanced cancer (NEXTAC) program and reported the excellent feasibility of and compliance with this program in elderly patients with advanced cancer who were at risk for cancer cachexia. We report here the background, hypothesis, and design of the next-step multicenter, randomized phase II study to evaluate the efficacy of the program, the NEXTAC-TWO study. Methods Patients with chemo-naïve advanced non-small cell lung cancer or pancreatic cancer, age ≥ 70 years, performance status ≤2, with adequate organ function and without disability according to the modified Katz index will be eligible. In total, 130 participants will be recruited from 15 Japanese institutions and will be randomized into either the intervention group or a control group. Computer-generated random numbers are allocated to each participant. Stratification factors include performance status (0 to 1 vs. 2), site of primary cancer (lung vs. pancreas), stage (III vs. IV), and type of chemotherapy (cytotoxic vs. others). Interventions and assessment will be performed 4 times every 4 ± 2 weeks from the date of randomization. Interventions will consist of nutritional counseling, nutritional supplements (rich in branched-chain amino acids), and a home-based exercise program. The exercise program will include low-intensity daily muscle training and lifestyle education to promote physical activity. The primary endpoint is disability-free survival. It is defined as the period from the date of randomization to the date of developing disability or death due to any cause. This trial also plans to evaluate the improvements in nutritional status, physical condition, quality of life, activities of daily living, overall survival, and safety as secondary endpoints. Enrollment began in August 2017. The study results will demonstrate the efficacy of multimodal interventions for elderly cancer patients and their application for the maintenance of physical and nutritional conditions in patients with cancer cachexia. This work is supported by a grant-in-aid from the Japan Agency for Medical Research and Development. Discussion This is the first randomized trial to evaluate the efficacy and safety of a multimodal intervention specific for elderly patients with advanced cancer. Trial registration Registered at August 23, 2017. Registry number: UMIN000028801 .

Purpose A known barrier to getting breast cancer survivors (BCSs) to engage in habitual exercise is a lack of information on recommended physical activity levels provided to them by oncology care providers (OCPs). However, the actual situation in Japan remains unclear. This study sought to clarify OCPs’ awareness and practice related to Japan’s physical activity recommendation for BCSs and to ascertain barriers to routine information provision. Methods We conducted a web-based survey involving members of the Japanese Breast Cancer Society (JBCS) and the Japanese Association of Cancer Rehabilitation between Dec. 2018 and Feb. 2019. Results Of 10,830 members, 1,029 (9.5%) responded. Only 19.1% were aware of the details of the JBCS physical activity recommendation, and only 21.2% routinely provided physical activity information to BCSs. Factors related to being aware of the recommendation details were 1) availability of the guidelines, 2) experience reading relevant parts of the guidelines, and 3) involvement in multidisciplinary team case meetings. Barriers to routine information provision were 1) absence of perceived work responsibility, 2) underestimation of survivors’ needs, 3) lack of resources, 4) lack of self-efficacy about the recommendation, and 5) poor knowledge of the recommendation. Conclusions Only one fifth of the OCPs routinely provided physical activity information. Barriers to provision were poor awareness, self-efficacy, and attitudes and unavailable resources. The physical activity recommendation needs to be disseminated to all OCPs and an information delivery system needs to be established for BCSs to receive appropriate information and support to promote their engagement in habitual physical activity.

Purpose. Skeletal muscle mass (SMM) is an important biomarker for health in older cancer patients. However, there is limited information on the recovery course of SMM after esophagectomy in older patients. This study aimed to investigate the recovery course of SMM after esophagectomy and the predictors in older cancer patients. Methods. We conducted a single-center, retrospective cohort study. Esophageal cancer patients who underwent esophagectomy were included. The skeletal muscle mass index (SMI) was calculated using computed tomography images. The loss of SMI at 4 and 12 months after surgery was calculated as [(preoperative − postoperative SMI) ÷ preoperative SMI] × 100%. Nonrecovery was defined as an SMI loss of ≥2% at 12 months after surgery, considering physiological loss with aging. One-way analysis of variance and multivariate logistic regression analysis was used for statistical analysis. Results. A total of 105 older (≥70 years) and 156 nonolder (<70 years) patients were analyzed. Older patients had a significantly larger loss of SMI 4 months (mean: 5.7% vs. 3.1%; p=0.021) and 12 months (mean: 1.0% vs. −1.4%; p=0.040) after surgery than nonolder patients. In older patients, the number of patients with nonrecovery of SMI at 12 months after surgery was 55 (52%). In older patients, significant predictors for the nonrecovery of SMI were preoperative sarcopenia (adjusted OR: 0.297; p=0.012), neoadjuvant chemotherapy (adjusted OR: 0.248; p=0.015), and loss of SMI 4 months after surgery (per 1%; adjusted OR: 1.076; p=0.018). Conclusions. It is suggested that older esophageal cancer patients have a larger unmet need for long-term postoperative loss of SMM than nonolder patients. Continuous outpatient rehabilitation, including exercise and nutritional therapy after discharge, which targets improvement in SMM at 4 months, may improve SMI at 12 months after surgery in older esophageal cancer patients.

Background In our previous study (NEXTAC‐ONE), the Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) program (including home‐based exercise and branched‐chain amino acid‐containing supplements combined with nutritional counselling) was shown to potentially prevent low muscle mass‐related disability in elderly cancer patients. This randomized controlled trial (NEXTAC‐TWO) was conducted to elucidate whether the NEXTAC program prolongs disability‐free survival in elderly patients with advanced pancreatic or non‐small cell lung cancer. Methods This open‐label, multicentre, randomized phase II study was conducted at 15 Japanese hospitals. Patients aged ≥ 70 years, with pathologically proven advanced pancreatic or non‐small cell lung cancer, who were scheduled to undergo systemic chemotherapy for treatment‐naïve tumours were randomly assigned (1:1) to undergo observation or receive the NEXTAC program for 12 weeks. Randomization was performed by the minimization method, using performance status and types with cancer diagnosis and anticancer treatment as adjustment factors. The primary endpoint was disability‐free survival (period from randomization to the date patients were evaluated as needing care or death due to any cause). Key secondary endpoints were change in weight, muscle mass, physical activity, nutritional assessment, safety and survival. This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000028801). Results From 2017 to 2019, 131 patients were enrolled and randomly assigned to NEXTAC (n = 66) or control arms (n = 65, median age 76.0 years). After randomization, two patients in the NEXTAC arm declined further participation. As a result, 64 patients (median age 75.5 years) received at least one session of the NEXTAC program. The completion rate of the planned exercise and nutrition consultation sessions was 98.4% in the NEXTAC arm. Of the 129 patients, 91 (71%) had a disability (44 in the NEXTAC arm; 47 in the control arm). In the primary analysis, median disability‐free survival periods were 478 days (95% confidence interval [CI], 358–576) in the NEXTAC arm and 499 days in the control arm (95% CI, 363–604), with no significant differences between them (p = 0.884). The hazard ratio for disability‐free survival in the NEXTAC arm compared with the control arm was 0.970 (95% CI 0.642–1.465). There were no differences in the secondary endpoints between the two arms. Conclusions The patients had good compliance with the 12‐week NEXTAC program but failed to show significant improvements in disability‐free survival as compared to observation alone. Further study on the progression of low muscle mass in the NEXTAC arm is needed.

PurposeTo develop consensus-based components used in the first evidence-based cancer survivorship guidelines in Japan.MethodsPurposive sampling was used to recruit a panel of experts in oncology clinical practice, nursing, health science, epidemiology, and patient advocacy. The panel engaged in a modified Delphi process to (1) generate consensus related to the definition of survivorship, (2) determine the aim and target users of the guideline, and (3) identify clinical issues for inclusion. A Web-based survey and panel meeting were conducted to obtain the panelists’ feedback on the initial draft proposed by the secretariat. Multiple online votes were then completed until all elements of the proposed guidelines reached an approval rate of 80% or higher. Following each round, iterative refinements were made based on all panelists’ feedback.ResultsTwenty-two experts were enrolled in the panel and participated in four rounds of online voting and two face-to-face meetings. Ultimately, the panel reached consensus on the definition of survivorship, the aim of the guidelines, and target users. Moreover, 11 of the original 17 clinical issues were retained. Finally, the panel selected two priority areas to implement immediately.ConclusionThe panel’s consensus on the definition of survivorship, aim and target users of the guideline, and 11 clinical issues will serve as a compass for the development of comprehensive cancer survivorship guidelines in Japan.Implications for Cancer SurvivorsA culturally sensitive consensus approach was developed to improve the long term health and well- being of cancer survivors in Japan.

Key summary points Aim The aim of this retrospective cohort study was to investigate the impact of early postoperative factors on change in skeletal muscle mass 4 months after curative esophagectomy in older patients with esophageal cancer. Findings The change (per 1%) in quadriceps muscle strength in the first month after surgery (standardized β = 0.190, p = 0.048) impacted the change (per 1%) in skeletal muscle mass 4 months after surgery, which was independent of age, sex, preoperative skeletal muscle mass, comorbidity, pathological stage, and neoadjuvant chemotherapy. Message We believe that our findings will progress the development of novel comprehensive rehabilitation, including exercise and nutrition therapy after the perioperative phase in older patients with esophageal cancer. Background Loss of skeletal muscle mass, measured by the skeletal muscle mass index (SMI), after esophagectomy negatively impacts prognosis. However, the information to develop novel supportive care options for preventing loss of skeletal muscle mass is limited. The purpose of this retrospective cohort study was to investigate the impact of early postoperative factors on change in SMI 4 months after curative esophagectomy in older patients with esophageal cancer. Methods This study included 113 subjects who underwent esophagectomy between 2015 and 2020. Preoperative and postoperative SMI (cm 2 /m 2 ) were calculated from computed tomography images. The percentage change in SMI 4 months after surgery (SMI%) was calculated as follows: ([postoperative SMI – preoperative SMI] ÷ preoperative SMI) × 100. Potential factors affecting percentage change of SMI after surgery were analyzed by multiple regression. Results The mean SMI% was – 5.6%. The percentage change (per 1%) in quadriceps muscle strength in the first month after surgery (standardized β  = 0.190, p  = 0.048) impacted the SMI%, which was independent of age, sex, preoperative SMI, comorbidity, pathological stage, and neoadjuvant chemotherapy. Conclusion Quadriceps muscle weakness in the first month after esophagectomy impacted the SMI% in a dose-dependent relationship.

Purpose The present study aimed to investigate the effects of exercise therapy on delirium in cancer patients. Methods We conducted a retrospective study of cancer patients who were admitted to Kyoto University Hospital and referred to the Palliative Care Team. Subjects were divided into two groups [an exercise therapy group (EG) and a non-exercise therapy group (NG)] according to whether exercise therapy was being used for early ambulation at the time delirium occurred. To examine whether any characteristics differed significantly between the two groups, we also compared age, performance status, alcohol use, existence of metastatic brain tumors or preexisting CNS illnesses, levels of opioid exposure, and survival time from the onset of delirium. Moreover, we investigated whether there were differences in antipsychotic drug doses administered between these two groups in order to better analyze the specific effects of exercise therapy on the course of delirium. Results EG and NG groups did not differ significantly in terms of any characteristics. The administered dose of antipsychotic drugs was significantly lower in the EG group versus the NG group (2.198 mg versus 5.533 mg, p  = 0.036). In comparison, the dose of opioids used did not differ significantly between the two study groups. Conclusions Given the relatively low antipsychotic doses used, it is conceivable that delirium symptoms were attenuated in patients who received exercise therapy. This study suggests that exercise therapy may be useful as one environmental/supportive intervention for delirium.

ObjectivePhysical functioning (PF), emotional functioning (EF), overall quality of life (QOL) and activities of daily living (ADL) such as walking and toilet transfer are the primary outcomes of dignity in patients with terminal cancer. However, few studies have investigated the association of PF, EF and overall QOL with ADL based on end-of-life stages in patients with cancer who are receiving at-home palliative care.MethodsThis prospective cohort study included 88 patients with terminal cancer receiving home-based rehabilitation as part of their home-based palliative care at the Mariana Home Nursing Station (Nagoya-city, Aichi, Japan). The variables were measured at 4 and 2 weeks before death of patients. PF, EF and overall QOL scores were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care and ADL were assessed using the Functional Independence Measure-motor items. Multiple regression analysis was used to examine the association, considering the effect of physical symptoms.ResultsPF and overall QOL scores at 4 and 2 weeks before death were significantly associated with toilet transfer and walking scores, even after considering the influence of physical symptoms. EF scores were significantly associated with toilet transfer and walking scores 4 weeks before death, but not 2 weeks before death.ConclusionsIn addition to managing physical symptoms, supporting ADL such as walking and toilet transfer is necessary to maintain PF, EF and overall QOL in patients with terminal cancer receiving home-based palliative care. This may help preserve their dignity, even in deteriorating general condition.