A B S T R A C T PurposeTo evaluate cardiopulmonary function (as measured by peak oxygen consumption [VO 2peak ]) across the breast cancer continuum and its prognostic significance in women with metastatic disease. Patients and MethodsPatients with breast cancer representing four cross-sectional cohorts-that is, (1) before, (2) during, and (3) after adjuvant therapy for nonmetastatic disease, and (4) during therapy in metastatic disease-were studied. A cardiopulmonary exercise test (CPET) with expired gas analysis was used to assess VO 2peak . A Cox proportional hazards model was used to estimate the risk of death according to VO 2peak category (Ͻ 15.4 v Ն 15.4 mL ⅐ kg Ϫ1 ⅐ min Ϫ1 ) with adjustment for clinical factors. ResultsA total of 248 women (age, 55 Ϯ 8 years) completed a CPET. Mean VO 2peak was 17.8 Ϯ a standard deviation of 4.3 mL ⅐ kg Ϫ1 ⅐ min Ϫ1 , the equivalent of 27% Ϯ 17% below age-matched healthy sedentary women. For the entire cohort, 32% had a VO 2peak less than 15.4 mL ⅐ kg Ϫ1 ⅐ min Ϫ1 -the VO 2peak required for functional independence. VO 2peak was significantly different across breast cancer cohorts for relative (mL ⅐ kg Ϫ1 ⅐ min Ϫ1 ) and absolute (L ⅐ min Ϫ1 ) VO 2peak (P ϭ .017 and P Ͻ .001, respectively); VO 2peak was lowest in women with metastatic disease. In patients with metastatic disease (n ϭ 52), compared with patients achieving a VO 2peak Յ 1.09 L ⅐ min Ϫ1 , the adjusted hazard ratio for death was 0.32 (95% CI, 0.16 to 0.67, P ϭ .002) for a VO 2peak more than 1.09 L ⅐ min Ϫ1 . ConclusionPatients with breast cancer have marked impairment in VO 2peak across the entire survivorship continuum. VO 2peak may be an independent predictor of survival in metastatic disease.

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

The purpose of this study was to evaluate the effectiveness of interactive video games (combined with stationary cycling) on health-related physical fitness and exercise adherence in comparison with traditional aerobic training (stationary cycling alone). College-aged males were stratified (aerobic fitness and body mass) and then assigned randomly to experimental (n = 7) or control (n = 7) conditions. Program attendance, health-related physical fitness (including maximal aerobic power (VO2 max), body composition, muscular strength, muscular power, and flexibility), and resting blood pressure were measured before and after training (60%-75% heart rate reserve, 3 d/week for 30 min/d for 6 weeks). There was a significant difference in the attendance of the interactive video game and traditional training groups (78% +/- 18% vs. 48% +/- 29%, respectively). VO2 max was significantly increased after interactive video game (11% +/- 5%) but not traditional (3% +/- 6%) training. There was a significantly greater reduction in resting systolic blood pressure after interactive video game (132 +/- 6 vs. 123 +/- 6 mmHg) than traditional (131 +/- 7 vs. 128 +/- 8 mmHg) training. There were no significant changes in body composition after either training program. Attendance mediated the relationships between condition and changes in health outcomes (including VO2 max, vertical jump, and systolic blood pressure). The present investigation indicates that a training program that links interactive video games to cycle exercise results in greater improvements in health-related physical fitness than that seen after traditional cycle exercise training. It appears that greater attendance, and thus a higher volume of physical activity, is the mechanism for the differences in health-related physical fitness.

Cardio-oncology is an emerging discipline focused predominantly on the detection and management of cancer treatment-induced cardiac dysfunction (cardiotoxicity), which predisposes to development of overt heart failure or coronary artery disease. The direct adverse consequences, as well as those secondary to anticancer therapeutics, extend beyond the heart, however, to affect the entire cardiovascular-skeletal muscle axis (ie, whole-organism cardiovascular toxicity). The global nature of impairment creates a strong rationale for treatment strategies that augment or preserve global cardiovascular reserve capacity. In noncancer clinical populations, exercise training is an established therapy to improve cardiovascular reserve capacity, leading to concomitant reductions in cardiovascular morbidity and its attendant symptoms. Here, we overview the tolerability and efficacy of exercise on cardiovascular toxicity in adult patients with cancer. We also propose a conceptual research framework to facilitate personalized risk assessment and the development of targeted exercise prescriptions to optimally prevent or manage cardiovascular toxicity after a cancer diagnosis.

Background. We conducted a meta-analysis to determine the effects of supervised exercise training on peak oxygen consumption (VO 2peak ) in adults with cancer. Studies were selected using predetermined criteria, and two independent reviewers extracted data. Weighted mean differences (WMDs) were calculated using random effect models.Results. Six studies evaluated VO 2peak involving a total of 571 adult cancer patients (exercise, n ‫؍‬ 344; usual care control, n ‫؍‬ 227). Pooled data indicated that exer-

No abstract

This mini-review summarizes the literature regarding the mechanisms of exercise intolerance in patients with heart failure and reduced or preserved ejection fraction (HFREF and HFPEF, respectively). Evidence to date suggests that the reduced peak pulmonary oxygen uptake (pulm V̇o₂) in patients with HFREF compared with healthy controls is due to both central (reduced convective O₂ transport) and peripheral factors (impaired skeletal muscle blood flow, decreased diffusive O₂ transport coupled with abnormal skeletal morphology, and metabolism). Although central and peripheral impairments also limit peak pulm V̇o₂ in HFPEF patients compared with healthy controls, emerging data suggest that the latter may play a relatively greater role in limiting exercise performance in these patients. Unlike HFREF, currently there is limited evidence-based therapies that improve exercise capacity in HFPEF patients, therefore future studies are required to determine whether interventions targeted to improve peripheral vascular and skeletal muscle function result in favorable improvements in peak pulm and leg V̇o2 and their determinants in HFPEF patients.

The field of exercise-oncology has increased dramatically over the past two decades, with close to 100 published studies investigating the efficacy of structured exercise training interventions in patients with cancer. Of interest, despite considerable differences in study population and primary study end point, the vast majority of studies have tested the efficacy of an exercise prescription that adhered to traditional guidelines consisting of either supervised or home-based endurance (aerobic) training or endurance training combined with resistance training, prescribed at a moderate intensity (50–75% of a predetermined physiological parameter, typically age-predicted heart rate maximum or reserve), for two to three sessions per week, for 10 to 60 min per exercise session, for 12 to 15 weeks. The use of generic exercise prescriptions may, however, be masking the full therapeutic potential of exercise treatment in the oncology setting. Against this background, this opinion paper provides an overview of the fundamental tenets of human exercise physiology known as the principles of training, with specific application of these principles in the design and conduct of clinical trials in exercise-oncology research. We contend that the application of these guidelines will ensure continued progress in the field while optimizing the safety and efficacy of exercise treatment following a cancer diagnosis.