Effect of physical exercise on muscle mass and strength in cancer patients during treatment—A systematic review

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Abstract

Cancer treatment and its side effects may cause muscle wasting. Physical exercise has the potential to increase muscle mass and strength and to improve physical function in cancer patients undergoing treatment. A systematic review was conducted to study the effect of physical exercise (aerobic, resistance or a combination of both) on muscle mass and strength in cancer patients with different type and stage of cancer disease. Electronic searches were performed up to January 11th 2012, identifying 16 randomised controlled trials for final data synthesis. The studies demonstrated that aerobic and resistance exercise improves upper and lower body muscle strength more than usual care. Few studies have assessed the effect of exercise on muscle mass. Most studies were performed in patients with early stage breast or prostate cancer. Evidence on the effect of physical exercise on muscle strength and mass in cancer patients with advanced disease is lacking. More exercise studies in patients with advanced cancer and at risk of cancer cachexia are warranted.

Introduction

Cancer patients are faced with a range of disease- and treatment-related effects that might alter metabolism, food intake and body composition and cause significant physical and psychosocial impairment. Physical exercise has in general a positive impact on many biological processes such as energy expenditure, insulin resistance, inflammation and most body organs and tissues. In cancer patients, there is evidence that physical exercise contributes to reduce fatigue [1], improves quality of life [2], [3] and relieves many of the adverse side-effects experienced both during and after treatment [4], [5].

Physical exercise is defined as an activity that is planned, structured, repetitive and purposeful, with the aim to improve or maintain one or more components of physical fitness, i.e. endurance, muscular strength and body composition [6]. According to national and international physical activity recommendations, 150 min of weekly moderate intensity aerobic exercise, or alternatively 75 min of high-intensity exercise, are required to promote and maintain health in adults. Additionally, muscle-strengthening exercise is recommended to be performed twice weekly [7].

In principle, the same activity recommendations apply to patients with cancer [8]. However, a range of factors beyond those usually encountered when providing exercise advice in healthy populations must be considered, especially in patients who are undergoing cancer treatment or experience adverse side-effects of treatment [9], [10]. Physical exercise is considered to be well-tolerated, feasible and safe during and following cancer treatment [5], [11] and even cancer patients with advanced stages of disease are willing to engage in physical exercise [12]. Thus, based on current knowledge, it is considered clinically sound to advise most cancer patient to perform physical exercise.

Cancer cachexia is “a multifactorial condition characterised by an on-going loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment” [13]. As much as 60–80% of patients with advanced cancer, depending on diagnosis, develop this condition and at present there are few efficient therapeutic options [14]. Loss of muscle mass and strength is one of several factors that is associated with involuntary weight loss in cancer cachexia [15]. Physical exercise may be of particular importance for cancer patients with advanced disease in a pre-cachectic or cachectic stage because of its potential effects on muscle mass and strength [16]. Experimental trials have demonstrated possible anti-inflammatory effects of exercise in cachectic mice [17] as well as partial rescue of muscle mass and strength in tumour-bearing mice when exercise was combined with eicosapentiaenoic acid [18]. Furthermore, a small number of clinical studies have demonstrated the contribution of exercise to reduce or delay cachexia in patients with chronic diseases other than cancer [19], [20]. Previous reviews on effects of physical exercise in patients with cachexia have been narrative and not specific to cancer patients [21], [22], or have mainly discussed biological and pathophysiological effects of exercise on cachexia-related muscle wasting [23], [24].

Primarily, our idea for a systematic review was to examine the scientific evidence of effects of physical exercise on muscle mass and strength in cancer patients in a pre-cachectic or cachectic stage. Our first systematic search, per January 2012, did not identity controlled studies to answer this question, and therefore we re-defined our aims to include a wider group of cancer patients. We consider it appropriate to guide further clinical studies in patients with advanced cancer by extrapolating data from general cancer.

The overall aim of this systematic review was to evaluate the scientific evidence of effect of physical exercise on muscle mass and strength in patients with cancer. The following research questions were formulated:

  • 1.

    What type of physical exercise intervention, i.e. aerobic, resistance or combined aerobic and resistance exercise, is most effective at improving muscle mass and strength?

  • 2.

    Is the effect on muscle mass and strength consistent between different cancer patient cohorts with different diagnoses and stage of disease?

Section snippets

Search strategy and selection criteria

Electronic searches were performed on January 11th 2012 in PubMed (National Library of Medicine), Pedro (Centre for Evidence-Based Physiotherapy), Embase (Elsevier through OvidSP, edition 1980–2012, week 1) and Cochrane Central Registry of Controlled Trials (CENTRAL) through the Cochrane Library (John Wiley and Sons Ltd.), edition 2011 October, issue 4 of 4. Additionally, the bibliographies of included studies and relevant systematic reviews were reviewed.

The searches consisted of combinations

Search results and selection of studies

The database searches retrieved 1321 records which were reduced to 405 after removal of duplicates and exclusion of irrelevant records by title. After screening of abstracts, 76 records were found to meet the inclusion criteria. Furthermore, nine records were identified by manual searches, giving 85 full text publications to be screened for eligibility. Out of these, 67 papers did not meet the selection criteria and were excluded. Thus, data extraction was performed on 18 papers. Two of the

Summary of results

In this systematic review of 16 trials with cancer patients during active treatment, both aerobic and resistance exercise, and a combination of these, improves upper and lower body muscle strength more than usual care. Muscle mass was reported in only six trials and shows a tendency towards an effect of physical exercise on maintaining muscle mass during treatment. There are some indications that resistance exercise (RE) is more effective than aerobic exercise (AE) both on muscle mass and

Funding

The manuscript is conducted as part of a PhD Thesis funded by the joint research fund of the Regional Health Authorities of Middle Norway and the Norwegian University of Science and Technology in Trondheim.

Conflict of interest

The author(s) has no conflicts of interest associated with this manuscript.

Reviewer

Matthew Maddocks, Cicely Saunders Institute, London, United Kingdom.

Acknowledgements

Thanks to Tora Solheim, MD Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital/PhD student, European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, for valuable feedback on the manuscript and support throughout the writing process.

Guro Birgitte Stene (MSc Physiotherapy) is an experienced physiotherapist who has had a research position at the Faculty of Medicine, Norwegian University of Science and Technology (NTNU) since 2007. She is involved in clinical trials at the Cancer Clinic at St. Olav Hospital, Trondheim University Hospital, and in international research projects initiated by the European Association for Palliative Care Research Network (EAPC–RN) and the European Palliative Care Research Centre (PRC). She

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    Guro Birgitte Stene (MSc Physiotherapy) is an experienced physiotherapist who has had a research position at the Faculty of Medicine, Norwegian University of Science and Technology (NTNU) since 2007. She is involved in clinical trials at the Cancer Clinic at St. Olav Hospital, Trondheim University Hospital, and in international research projects initiated by the European Association for Palliative Care Research Network (EAPC–RN) and the European Palliative Care Research Centre (PRC). She currently holds a position as a senior physiotherapist and researcher at the Cancer Clinic, Department of Education and Research, St.Olavs Hospital, Trondheim University Hospital, and is finalising an international PhD in Palliative Care Research at NTNU.

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