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1 EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS Kerri Winters-Stone, PhD, FACSM Knight Cancer Institute and School of Nursing Oregon Health & Science University, Portland, OR 1 By 2040, it is estimated that nearly half of cancer survivors will be age 75 or older Right now 20 years from now 2

EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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Page 1: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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

1

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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Page 2: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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Page 3: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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Page 4: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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Page 5: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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Page 6: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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Page 10: EXERCISE TRAINING FOR FRAIL CANCER SURVIVORS

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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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