Fitness after chemotherapy

Abstract

Editor—We read with interest the study of West and colleagues1West MA Loughney L Lythgoe D et al.Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study.Br J Anaesth. 2014; 114: 244-251Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar and the accompanying editorial addressing the issue of exercise training before surgical resection in colorectal patients. We would like to add our experiences of post-chemotherapy decline in fitness to the growing body of evidence suggesting that there is a demonstrable decline in cardiorespiratory reserve after neoadjuvant chemotherapy. The current UK management of operable oesophagogastric cancer includes three cycles of preoperative chemotherapy [epirubicin, cisplatin, and capecitabine (ECX)] followed by resection and then a further three cycles of postoperative chemotherapy. We have observed that only 86% of our patients complete preoperative chemotherapy and that only 43% complete the postoperative component of this regimen. As part of a service evaluation, we retrospectively reviewed 30 patients who received preoperative ECX chemotherapy for operable oesophagogastric adenocarcinoma and who had paired preoperative and postoperative chemotherapy cardiopulmonary exercise testing (CPET). The ventilatory anaerobic threshold (AT) was determined by the V-slope method as an objective, reproducible measure of cardiorespiratory reserve. Peak oxygen uptake (VO2 peak) and ventilatory equivalents for carbon dioxide were also measured. The median AT and VO2 peak before and after chemotherapy were compared using a paired Student’s t-test. We found that the median oxygen uptake at the AT before and after chemotherapy was 13.9 (sd 3.1) and 11.5 (sd 2.0) ml kg−1 min−1, respectively. The mean decrease was 2.4 ml kg−1 min−1 (95% CI 1.3–3.85, P<0.001). The median VO2 peak also decreased by 2.17 ml kg−1 min−1 (95% CI 1.02–3.84, P+0.001) after neoadjuvant chemotherapy. Ventilatory equivalents were unchanged. This clinically important reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after chemotherapy. These results are consistent with previously published data within this field, including that of West and colleagues1West MA Loughney L Lythgoe D et al.Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study.Br J Anaesth. 2014; 114: 244-251Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar in January’s BJA and Jack and colleagues.2Jack S West MA Rawa D et al.The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery.Eur J Surg Oncol. 2014; 40: 1313-1320Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar This reduction in AT might be considered most important when it changes the perceived risk to our operative candidates. When a borderline or ‘high-risk’ (low AT) patient is considered for major surgery, it is important to know that preoperative chemotherapy might have had a significant impact on cardiorespiratory reserve. Indeed, not infrequently this loss of reserve results in patients becoming substantially higher risk based on our current best evidence that low cardiorespiratory reserve is associated with a higher chance of postoperative complications.3Snowden C Prentis J Anderson H et al.Submaximal cardiopulmonary exercise testing predicts mortality and hospital length of stay in patients undergoing major surgery.Ann Surg. 2010; 251: 535-541Crossref PubMed Scopus (210) Google Scholar, 4Wilson RJT Davies S Yates D Redman J Stone M Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery.Br J Anaesth. 2010; 105: 297-303Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar, 5West MA Lythgoe D Barben CP et al.Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study.Br J Anaesth. 2014; 112: 665-671Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar We agree with the authors that preventing this decline in cardiorespiratory reserve might have benefits both during preoperative chemotherapy and postoperatively. We look forward to seeing further developments within this research area. None declared.