Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

Abstract

Exercise-based, multimodal rehabilitation programming similar to that used in the existing models of cardiac or pulmonary rehabilitation or prehabilitation is a holistic potential solution to address the range of physical, psychological, and existential (e.g., as their diagnosis relates to potential death) stressors associated with a cancer diagnosis and subsequent treatment. The purpose of this study was to systematically evaluate the structure and format of any type of exercise-based, multimodal rehabilitation programs used in individuals with cancer and the evidence base for their real-world effectiveness on metrics of physical (e.g., cardiorespiratory fitness, blood pressure) and psychological (e.g., health-related quality of life) health. Very few of the 33 included exercise-based, multimodal rehabilitation programs employed intervention components, education topics, and program support staff that were multi-disciplinary or cancer-specific. In particular, a greater emphasis on nutrition care, and the evaluation and management of psychosocial distress and CVD risk factors, with cancer-specific adaptations, would broaden and maximize the holistic health benefits of exercise-based rehabilitation. Despite these opportunities for improvement, exercise-based, multimodal rehabilitation programs utilized under real-world settings in individuals with cancer produced clinically meaningful and large effect sizes for cardiorespiratory fitness (VO2peak, ±2.9 mL/kg/min, 95% CI = 2.6 to 3.3) and 6-minute walk distance (+47 meters, 95% CI = 23 to 71), and medium effect sizes for various measures of cancer-specific, health-related quality of life. However, there were no changes to blood pressure, body mass index, or lung function. Overall, these findings suggest that exercise-based, multimodal rehabilitation is a real-world therapy that improves physical and psychological health among individuals with cancer, but the holistic health benefits of this intervention would likely be enhanced by addressing nutrition, psychosocial concerns, and risk factor management through education and counselling with consideration of the needs of an individual with cancer.

Research Quality and Impact of Cardiac Rehabilitation in Cancer Survivors

“… 12 Similarly, a recent meta-analysis of 33 studies assessing the impact of both cardiac and pulmonary rehabilitation programs in cancer survivors reported the interventions caused significant and clinically meaningful improvements in CRF, 6-minute walk distance, and quality of life. 13 The magnitude of improvement in V o 2peak -defined CRF (2.58 mL O 2 /kg/min) shown here was similar to that reported by the aforementioned meta-analysis (2.9 mL O 2 /kg/min). 13 This is encouraging; however, the findings of these reviews should be interpreted with caution.…”

“… 13 The magnitude of improvement in V o 2peak -defined CRF (2.58 mL O 2 /kg/min) shown here was similar to that reported by the aforementioned meta-analysis (2.9 mL O 2 /kg/min). 13 This is encouraging; however, the findings of these reviews should be interpreted with caution. For instance, 1 study included in our review reported no intervention effect on CRF but could not be included in our meta-analysis because of missingness of data.…”

“… 39 More broadly, the moderate-to-high attrition rates (25%-80%) reported by 80% of our included studies bias the findings toward demonstrating an intervention effect—a factor that was unaddressed and likely biased the findings of the previously mentioned meta-analysis. 13 In theory, this source of bias would have been less of an issue if the included studies were RCTs that followed an intention-to-treat analytic approach. However, there has only been a single unpowered pilot RCT published to date assessing the impact of CR-based interventions in cancer survivors.…”

“…Two prior reviews have described the practical elements (eg, intervention components) of CR-based research in oncology. 12 , 13 However, the reported associations 12 and causal impact 13 of the tested interventions on the evaluated outcomes were either minimally 12 or not 13 discussed in the context of the quality of the evidence (eg, high attrition rates and the majority were single-arm and nonrandomized studies), which has potentially led to biased interpretations of the safety, tolerability, and benefits of CR-based interventions for cancer survivors. 14 …”

Adherence, safety and satisfaction of a cardio-oncology rehabilitation program framework versus community exercise training for cancer survivors: findings from the CORE trial

“…Exercise-based programs for cancer survivors are a topic of contemporary interest [19,[31][32][33]. However, several studies have focused on speci c cancer subtypes (mostly breast cancer), with small samples, different endpoints and usually comprising CR versus usual care (no rehabilitation/ no exercise intervention) [19,[31][32][33]. In the CORE trial, high CV risk survivors of various types of cancer, previously undergoing several treatments options (regarding cardiotoxicity), and/or with different CV comorbidities were eligible, reproducing the clinical practice heterogeneity, without depriving any cancer patient from a guided exercise intervention, as to attempt to reproduce real-word settings.…”