Objective Measures Of Fitness Research Articles

Selected Frailty Testing Can Predict for Risk of Febrile Neutropenia in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplant

Introduction: Validated myeloma-specific frailty assessment tools, such as the IMWG geriatric assessment tool (IMW GAT) and the revised myeloma co-morbidity index (R-MCI), can be useful to tailor treatment intensity in MM patients (pts). To date, most MM studies of frailty have focused on older, transplant-ineligible populations, with less known about the utility of frailty assessments to guide therapeutic decision-making in younger, transplant pts. We previously reported that frailty scores largely validated in older MM cohorts correlate well with each other, but generally lack ability to discriminate between unfit and fit patients, when applied to a younger transplant population (Devasia et al ASH 2022). Here, we evaluate the use of pre-transplant frailty assessment, using a battery of subjective and objective tools, for predicting common post-transplant toxicities, such as febrile neutropenia (FN) and organ complications. Methods: 162 consecutive MM pts preparing for ASCT and consented for an ongoing prospective frailty study were included. Prior to ASCT, patients underwent comprehensive frailty assessments including: 1) objective measures of fitness [hand grip strength, 6-min walk test (6MWT), Timed Up and Go (TUG), 2) subjective measures of function (Fried Frailty Phenotype (FFP), Rockwood Frailty, KPS, ECOG, HSCT-CI, ESAS), 3) scoring systems integrating both objective and subjective measures (R-MCI, IMWG geriatric assessment tool (IMWG-GAT), and 4) routine screening for organ function (CrCl, serum albumin, hemoglobin, BNP, PFT, and cardiac imaging). Following ASCT, acute grade 3-4 organ-specific toxicities (including FN) occurring from stem cell infusion through engraftment to discharge were prospectively collected (NCI-CTCAE criteria V5.0). Patient/disease characteristics, stem cell dose, engraftment, and transfusion requirements were also collected from electronic patient records. Chi-square and/or Fisher's exact test, as appropriate, were used to assess the association of categorical covariates with frailty scores/measures. Logistic regression was used to assess the association of potential predictors to binary outcomes. All p-values were 2-sided and p<0.05 was considered statistically significant. Results: In total, 162 pts were included in this analysis, median age 62 yrs (range 35-73). Most pts received melphalan 200 mg/m2 conditioning, with 10 pts (6%) dose-reduced to 140mg/m2. All patients received antibiotic prophylaxis. Median stem cell dose was 2.82 x 10 6 CD34+ cells/kg Median neutrophil and platelet engraftment times were 13(10-17) and 14(8-45) days, respectively. 104(64%) pts developed FN post-transplant. Other grade 3-4 toxicities included: GI (41 pts; 25.3%), cardiac (12 pts; 7.4%), lung (4 pts; 2.4%). When correlating with pre-transplant frailty assessments, ECOG performance status and R-MCI appeared to predict for risk of FN, but not for specific organ toxicity (GI, cardiac) nor presence of >1 grade 3-4 toxicity (Table 1). In pts with ECOG 1-2 at baseline, the incidence of FN was 70.9% (83/117) compared to ECOG 0 pts 46.7% (21/45)(p=0.0039). There were no patients with ECOG 3-4 on study. Similarly, 58% (59/101) with baseline low risk frailty as per R-MCI developed FN, compared to 73.8% (45/61) in either R-MCI intermediate or high risk groups (p=0.050). We then evaluated the combined effect of ECOG and R-MCI on prediction of FN. Patients with ECOG 0 plus R-MCI low risk were grouped as “Low risk FN”, patients with ECOG 1-2 plus R-MCI intermediate/high risk were grouped as “High risk FN”. All other patients were grouped as “Intermediate risk FN” (Table 2). By using 2 scores, we could better predict for FN, with 72.5% in “High risk FN” compared with only 37% in “Low risk FN” (p=0.0008)]. Conclusions: This preliminary analysis of an ongoing frailty study in MM patients undergoing ASCT suggests potential utility of combining ECOG and R-MCI in predicting for development of FN. In pts with both ECOG 0 and R-MCI low risk (21% of total cohort), FN occurred in only 37%. Although further validation in a larger cohort is required, this finding may help to select at-risk patients for prophylactic peri-transplant antibiotics whilst avoiding routine use in all patients. This has clinical significance, given the emerging recognition of potentially detrimental effect on the gut microbiota and risk of antibiotic resistance in this setting.

Correlation Amongst Scoring of Various Frailty Tools in Myeloma Patients Undergoing Autologous Stem Cell Transplantation

Introduction: With the growing array of treatment options for multiple myeloma (MM) patients, it is important to individualize the approach at each point in the patient's treatment journey. Frailty scores such as the Revised Myeloma Comorbidity Index (R-MCI) can help match therapeutic intensity to patient fitness, particularly important in the elderly. The R-MCI has been prospectively validated in transplant patients and found to be predictive for PFS and OS outcomes. At our centre, we are enrolling patients deemed transplant-eligible by standard institutional criteria into a prospective study applying a variety of frailty tools, including objective measures of comorbidity/function and subjective measures based on patient self-assessment and physician opinion. These tools are applied at time of transplant clearance, not at diagnosis as previously studied, to take into consideration changes in frailty that occur during the initial treatment phase. The primary objective is to identify normative frailty scores at this timepoint and correlate with severity of transplant-related toxicity. In this analysis, we present data on the first 101 enrolled patients, reporting the various frailty scores and their inter-correlation. Patients and Methods: The first 101 consecutive MM patients preparing for autologous transplant (ASCT) and consented for the frailty study were included. Patients underwent comprehensive frailty assessments including: 1) objective measures of fitness [hand grip strength, 6-min walk test (6MWT), Timed Up and Go (TUG), 2) subjective measures of function (abbreviated Fried Frailty Phenotype Score (FFP), Rockwood Clinical Frailty Score, KPS, ECOG, HSCT-CI, ESAS), 3) scoring systems integrating both objective and subjective measures (R-MCI, International Myeloma Working Group geriatric assessment tool (IMWG-GAT), and 4) routine screening for organ function (creatinine clearance, serum albumin, hemoglobin, BNP, PFT, and cardiac imaging). Demographics including disease and treatment details were obtained from electronic medical records. Measures were evaluated with Chi-square/Fischer's exact test/Kruskal-Wallis test to assess the association between the various frailty scores. In addition, frailty scores were compared against R-MCI as baseline. All p values were 2-sided and p≥0.05 was considered statistically significant. Results: From Feb 2020 to July 2022, 101 patients consented for the frailty study and were included in this analysis. Patient characteristics and frailty scores are summarised in Table 1. ASCT was part of upfront treatment in 87 patients (86%), with 14 patients (14%) receiving salvage transplant at relapse. Median age was 63 years (35-75), with 9(9%) age 70 and above. In general, our transplant-eligible population tested well on most frailty scores, mostly falling within the fit or intermediate-fit categories, as expected. Notable exceptions were significantly poorer handgrip strength and 6MWT than observed in the literature. Only 2 of 101 patients in our analysis were able to walk >400 metres, a threshold for fitness cited in prior transplant studies. Most scoring systems in our analysis correlated in designating our cohort as "fit” or "intermediate fit". When using the transplant-validated R-MCI scores as our gold standard, we observed correlations with the IMWG-GAT and Rockwood scores (p=0.0014 and <0.0001 respectively). The simple-to-perform ECOG and HCT-CI indices also correlated highly with R-MCI.(Table 2) That said, the R-MCI lacked discrimination in our patient population, with almost all patients clustered into the fit or pre-fit categories (98/101; 98%). Conclusions: In this analysis of various frailty assessments applied at ASCT for MM, we report that most scoring systems correlated but generally lacked discrimination in this relatively fit cohort. Even the widely cited R-MCI which is validated in both myeloma and transplant, has limited utility in discriminating within this more homogeneously fit population. We will hence focus next on identifying scoring systems or individual tools that can further define the less fit or mildly frail within the "fit” category, allowing us to identify subgroups for medical optimization pre-ASCT. We also note that physical function testing such as handgrip and 6MWT may have limited utility in myeloma where disease-related disability may prevent full engagement. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Training for Marathons during a Marathon Pandemic: Effect of the COVID-19 Pandemic on Fitness among High-Level Nonelite Runners.

Background The COVID-19 pandemic has had a profound effect on all aspects of life, including physical fitness and well-being of the general population. In the present study, we assessed the effect of the pandemic on the subjective and objective fitness of high-level nonelite runners. Methods The MASTERS Athletic Study is an ongoing survey of training and health habits of high-level nonelite runners, the majority of whom compete in marathons and other extreme endurance events. We invited participants to a web-based questionnaire regarding training and fitness during the COVID-19 pandemic. Comparisons were made between subjective and objective fitness as well as well as the relationship of prepandemic training volume and history of COVID-19 on change in fitness during the pandemic, using Mann–Whitney rank-sum tests and chi-square tests for nonparametric and categorical variables, respectively. Results A total of 189 runners completed the survey, of whom 26 (13.8%) reported prior diagnosis with COVID-19. In terms of the subjective sense of fitness compared to before the pandemic, 49 (25.9%) reported they were less fit, 55 (29.1%) reported they were more fit, and 85 (45.0%) reported their fitness was unchanged. These assessments correlated well with objective measurement of training volume in MET-min/week. Runners with improved fitness at present had a lower calculated training volume before the pandemic versus those who reported unchanged or worsened fitness. There was no relationship between the report of prior COVID-19 and either subjective or objective measures of fitness. Conclusion The COVID-19 pandemic has had a variable effect on the fitness of high-level nonelite runners. We found an inverse relationship between baseline training volume and the likelihood of runners reporting improved fitness and no relationship between a history of COVID-19 and change in fitness through the pandemic. Understanding the effect of the COVID-19 pandemic on athletic fitness will help guide strategies to maintain physical health and wellness through future public health crises.

Supported exercise programme for adults with Congenital Heart Disease (SEACHange)

BackgroundCongenital heart disease (CHD) is a lifelong condition. Many patients will require repeated interventions. Long term morbidity due to heart failure, arrhythmias and recurrent hospital admissions is common. The benefits of regular exercise are well known. The aim of this study is to determine the feasibility of introducing a supported exercise programme to develop physical and psychological wellbeing in adults with CHD, living in Scotland. MethodsPatients were mainly recruited via the Adult Congenital Heart Disease (ACHD) review clinic at the Golden Jubilee National Hospital (GJNH). Participants were initially assessed using a 6-min walk test (6MWT) and stratified in to either Group 1 (n = 10) or Group 2 (n = 18). Further baseline measurements (Grip strength, Bicep strength, Quadriceps strength, and psychological measurements) were completed for both groups. Sniff Nasal Inspiratory Pressure (SNIP) was also assessed for Group 1. All measurements were repeated after 12 weeks. ResultsFor both groups 1 and 2 the majority of individuals improved upon their baseline measurements across all physical metrics (6MWT, quadriceps, bicep and grip strength). Although not achieving statistical significance individually, when combined groups 1 and 2 demonstrated a statistically significant increase in the objective measures of fitness from those measured at baseline to week 12. ConclusionsExercise in the adult congenital cardiac population is safe when patients are given guidance and structure.

Psychosis risk individuals show poor fitness and discrepancies with objective and subjective measures

Exercise is a promising intervention for individuals at clinical high-risk for psychosis (CHR). However, these youth may not be reliable reporters on fitness. There have been no investigations that utilized objective fitness assessment in this population. The present study objectively characterizes the level of fitness in CHR youth, compares the accuracy of self-report measures to objective fitness indices, and explores clinical factors that may influence the accuracy of self-reported measures of fitness. Forty CHR individuals completed an exercise survey and objective indices of fitness (i.e., VO2max and BMI). Forty healthy volunteers completed objective indices of fitness and a structured clinical interview ruling out the presence of psychiatric illness. CHR youth showed greater BMI and lowered VO2max compared to healthy volunteers. In the CHR group, self-report items (perceived fitness) did not reflect objective indices of fitness, whereas specific exercise behaviors (intensity of exercise) showed stronger correlations with objective fitness measurements. Exploratory analyses suggested that symptoms (grandiosity and avolition) related to errors in self-perception. Results indicate that CHR individuals are less fit than controls as indexed by objective measures of fitness and that it is important to consider unique population clinical characteristics when employing self-report data.

Self‐rated physical fitness and measured cardiorespiratory fitness, muscular strength, and body composition

The purpose was to examine the correlation and association between a single-item question of self-rated physical fitness and objective measures of fitness and cardiometabolic risk factors in a large population-based study. Participants were 3441 men and women aged 18-85years who filled in a questionnaire and participated in a clinical health examination in the Danish Health Examination Survey 2007-2008. Cardiorespiratory fitness was estimated by an indirect maximal exercise test. Muscle strength was measured by (a) sit-to-stand test, (b) handgrip strength, and (c) bent arm strength. Body mass index and fat percentage were used as measures for body composition. Associations were derived from regression analyses, correlations were calculated using Spearman's correlation test, and agreement was tested by kappa statistics. Within categories of self-rated physical fitness moving from lowest to highest, objectively measured cardiorespiratory fitness increased. Self-rated physical fitness was strongly correlated to cardiorespiratory fitness (rmen =0.69 and rwomen =0.65) and moderately correlated to the sit-to-stand test (rmen =0.49 and rwomen =0.48), bent arm strength (r = 0.45) and fat percentage (r = 0.46) among men, and handgrip strength among women (r =0.41). Mutually adjusted analysis showed a significant association between self-reported physical fitness and cardiorespiratory fitness for men and women and bent arm strength for women. The single-item question of physical fitness was correlated to cardiorespiratory fitness, muscle strength, and body composition. However, this study suggests that it mainly captures cardiorespiratory fitness. At the population level, the single-item question could be a useful tool to identify and monitor variation in fitness levels.

Body Image in Patients with Marfan Syndrome.

This study aimed to assess body image impairments of individuals with Marfan syndrome and to determine to what extent psychological, physical, and sociodemographic factors influence body image. We assessed the physical fitness and psychosocial health of 42 patients with Marfan syndrome at the beginning of an inpatient rehabilitation program. All participants filled out a body image questionnaire consisting of two scales: (1) Negative Body Evaluation and (2) Vital Body Dynamics. We compared body image data of the study sample with the German representative norming sample and carried out two separate regression analyses in order to determine which variables were associated with the two dimensions of patients’ body image. Body image of individuals with Marfan syndrome appeared to be significantly impaired, with high percentile ranks for Negative Body Evaluation (women = 88, men = 91) and low percentile ranks for Vital Body Dynamics (women = 11, men = 4). Vital Body Dynamics was predicted by age (p = 0.016) and by depression (p < 0.001), and Negative Body Evaluation was predicted by anxiety (p = 0.001). Body image in individuals with Marfan syndrome is not primarily determined by objective measures of fitness or by objective cardiac impairment but by psychological variables like depression and anxiety and by age. This finding can inform treatment and rehabilitation concepts. Accepting Marfan syndrome, including the acceptance of being visually different, may not only demand medical treatment and physical rehabilitation but also psychological treatment for depression and anxiety.

Fried Frailty Phenotype Predicts Mortality for Newly Diagnosed Older Patients with Acute Myeloid Leukemia or High Risk Myelodysplastic Syndrome

Fried Frailty Phenotype Predicts Mortality for Newly Diagnosed Older Patients with Acute Myeloid Leukemia or High Risk Myelodysplastic Syndrome

PERCEIVED PHYSICAL FATIGABILITY PREDICTS ALL-CAUSE MORTALITY: THE LONG LIFE FAMILY STUDY

Fatigability, the likelihood of fatigue with lower versus higher levels of exertion, is associated with declines in physical function and disability and related to fitness. Thus, fatigability may be a good predictor of mortality. We examined this relationship in the Long Life Family Study (LLFS), an international family cohort enriched for longevity and their spousal controls. We measured perceived physical fatigability at Visit 2 (2014-2017) using the Pittsburgh Fatigability Scale (PFS, 0-50 with higher score=greater fatigability). We identified deaths by family members notifying field centers, reporting during annual phone follow-up, or finding an obituary when unable to reach. Otherwise, we censored participants at most recent contact date when confirmed alive. Covariates included age, sex, and self-reported physical activity using the Framingham Physical Activity Index. We adjusted all analyses for field center and family structure. Participants alive ≥60 years (range 60-108, mean 73.6±10.5) and completed the PFS (N=2,326) at Visit 2 were predominantly white (99.5%) and female (55.1%). Post-Visit 2, 195 (8.4%) died during mean 2.5±1.0 years of follow-up. Age-adjusted PFS score was 7.7 points greater (p<.0001) for those who died (19.8) compared to alive (12.1). Using Cox Proportional-Hazard modeling, each 5-point greater PFS score was associated with 31% (HR: 1.31, 95% CI 1.18,1.43) higher all-cause mortality rate adjusted for covariates listed above. Further adjustment for comorbidities did not attenuate association. PFS’s perceived physical fatigability score may be a useful self-report clinical tool to predict higher risk of mortality among older adults when objective measures of fitness and function are unavailable.

Qualitative Study of Factors That Influence Treatment Decision-Making Among Community Oncologists and Older Patients with Acute Myeloid Leukemia

Introduction:Despite data supporting the safety and efficacy of treatment for many older adults with AML, <40% of adults aged ≥65 receive any leukemia-directed therapy. The reasons for why the majority of older patients with AML do not receive therapy are unclear. The use of objective fitness measures (e.g. physical function and cognition) has been shown to predict outcomes and may assist with treatment decision-making, but is underutilized. As most patients are initially evaluated in community practices, exploring clinical decision-making and the barriers to performing objective fitness assessments in the community oncology setting is critical to understanding current patterns of care. We conducted a qualitative study: 1) to identify factors that influence treatment decision making from the perspectives of the community oncologists and older patients with AML, and 2) to understand the barriers to performing objective fitness assessments among oncologists. The findings will help to inform the design of a larger study to assess real-life treatment decision-making among community oncologists and patients.Methods:We conducted semi-structured interviews with 13 community oncologists (9 states) and 9 patients aged ≥60 with AML at any stage of treatment to elicit potential factors that influence treatment decisions. Patients were recruited from the outpatient clinics in a single institution and oncologists were recruited via email using purposive samples (patients: based on treatment received and stage of treatment; oncologists: based on practice location). Interviews were audio-recorded and transcribed. We utilized directed content analysis and adapted the decision-making model introduced by Zafar et al. to serve as a framework for categorizing the factors at various levels. A codebook was provisionally developed. Using Atlas.ti, two investigators independently coded the initial transcripts and resolved any discrepancies through an iterative process. The coding scheme was subsequently applied to the rest of the transcripts by one coder.Results:Median age of the oncologists was 37 years (range 34-64); 62% were females, 92% were white, 38% had practiced more than 15 years, and 92% reported seeing <10 older patients with AML annually. Median age of the patients was 70 years (64-80), 33% were females and all were Caucasian. In terms of treatment, 66% received intensive induction therapy, 22% received low-intensity treatment, and 11% received both. Three patients also received allogeneic hematopoietic stem cell transplant. Eighty-nine percent were initially evaluated and 56% were initially treated by a community oncologist. Factors that influenced treatment decision-making are shown in Figure 1. When making treatment decisions, both patients and oncologists considered factors such as patient's overall health, chronological age, comorbidities, insurance coverage, treatment efficacy and tolerability, and distance to treatment center. Nonetheless, there were distinct factors considered by patients (e.g. quality of care and facility, trust in their oncologist/team) and by oncologists (e.g. local practice patterns, availability of transplant/clinical trials, their own clinical expertise and beliefs) when making treatment decisions. The majority of oncologists do not perform an objective assessment of fitness. Most common reasons provided included: 1) Do not add much to routine assessments (N=8), 2) Lack of time, resources, and expertise (N=7), 3) Lack of awareness of the tools or the evidence to support its use (N=4), 4) Specifics are not important (e.g. impairments are clinically apparent and further nuance is not necessarily helpful; N=5), 5) Impairments are usually performed by other team members (N=2), and 6) Do not want to rely on scores (N=2).Conclusions:Treatment decision-making for older patients with AML is complex and influenced by many factors at the patient, disease/treatment, physician, and organizational levels. Despite studies supporting the utility of objective fitness assessments, these were not commonly performed in the community due to several barriers. Our framework will be useful to guide a larger study to assess real-life treatment decision-making in the community settings. We also identified several barriers raised by community oncologists that could be targeted to allow incorporation of objective fitness assessments. [Display omitted] DisclosuresLiesveld:Onconova: Other: DSMB; Abbvie: Honoraria. Stock:Jazz Pharmaceuticals: Consultancy. Majhail:Anthem, Inc.: Consultancy; Atara: Honoraria; Incyte: Honoraria. Wildes:Janssen: Research Funding. Klepin:Genentech Inc: Consultancy.

Comparing self-reported physical activity and sedentary time to objective fitness measures in a military cohort

ObjectivesRegular vigorous physical activity (PA) and high levels of physical fitness (PF) confer health benefits. Conversely, sedentary time is a risk factor for chronic illness, independent of PA. We evaluated associations between self-reported PA, sedentary time, and objective PF measures in military Service members. DesignCross-sectional study including 10,105 Air Force Millennium Cohort participants with a valid physical fitness assessment (PFA). MethodsLinear regression assessed associations between self-report PA, screen time, and usual activity and abdominal circumference (AC) and VO2 max; logistic regression was used for PFA failure. We stratified by age and sex. ResultsMen who self-reported high versus low levels of PA had greater AC (19–29 years: β=0.23in., 95% CI 0.07, 0.39; 30–39 years: β=0.45in., 95% CI 0.17, 0.72). High versus low self-reported PA was also associated with greater VO2Max (β=:0.81–1.41mL/kg/min). Self-reported strength training for ≥2days/week was associated with greater VO2Max in 19–29year old men (β=0.84mL/kg/min, 95% CI 0.09, 0.60) and 30–39year old women (β=0.74mL/kg/min, 95% CI 0.02, 1.46). For younger men and women,<2h of screen time/day was associated with greater VO2Max (Males 19–29years: β=0.23mL/kg/min, 95% CI 0.44, 1.26; Females 19–29years: β=0.83mL/kg/min, 95% CI 0.25, 1.42). PA was not associated with PFA failure, while screen time was (Males OR: 0.32–0.65, 95% CI 0.17–0.92, p<0.001–0.016). ConclusionsSelf-reported PA and screen time were associated with some objective PF measures, including VO2Max and AC. However, screen time alone was associated with PFA failure.

Effectiveness of a standardised exercise programme for recurrent neck and low back pain: a multicentre, randomised, two-arm, parallel group trial across 34 fitness clubs in Finland

BackgroundNeck and low back pain (LBP) are common in office workers. Exercise trials to reduce neck and LBP conducted in sport sector are lacking. We investigated the effectiveness of the...

Beat the Street in Reading A city-wide physical activity intervention to get a whole population active using RFID/NFC technology

Beat the Street in Reading A city-wide physical activity intervention to get a whole population active using RFID/NFC technology

Assessing sustainability of InSHAPE participants' fitness activities in a community mental health setting.

InSHAPE (Self Help Action Plan for Empowerment), an exercise and nutrition wellness program, is gaining national recognition for its success in helping individuals with serious mental illness (SMI) improve physical fitness and dietary habits. Although gains have been reported in objective measures of fitness as participants progressed through the year-long program, there is little information about what happens with participants after program completion. To address this gap in knowledge, the authors conducted a longitudinal qualitative study in which 11 InSHAPE participants were interviewed both near the end of their year in the program and 9 months later. Participants identified the trainer's ability to contain their initial feelings of distress and form a working alliance as factors that contributed to their exercise persistence. Current findings suggest that individuals with SMI may need a longer period of time working closely with fitness trainers to sustain physical activity levels achieved during the program.

Twenty-five years of research on the effects of exercise training in breast cancer survivors: A systematic review of the literature.

To investigate the role of exercise training the past 25 years on major physiological-psychological outcomes studied thus far in this patient population. PubMed, MedlinePlus, the Cochrane Library, Web of Science, SportDiscus, Embase, Scorpus, and Google Scholar were searched from September to November 2013 to identify exercise training studies that used objective measurements of fitness and/or patient reported outcomes assessed pre and post-exercise training with statistical analyses performed in at least one of the following outcome measurements: Cardiorespiratory function, body composition, muscular strength, fatigue, depression, and overall quality of life. Five reviewers independently identified the studies that met the criteria for the review and discrepancies were resolved by consensus among all authors. Fifty-one studies were included in this review with 5 from the period between 1989-1999, 11 from 2000-2006, and 35 from 2007-2013. The evolution of study designs changed from aerobic only exercise training interventions (1989-1999), to a combination of aerobic and resistance training (2000-2006), to studies including an arm of resistance training or examining the effects of resistance training as the main mode of exercise (2007-2013). Overall, the benefits of exercise showed improvements in cardiorespiratory function, body composition, strength, and patient reported outcomes including fatigue, depression, and quality of life. Exercise training appears to be safe for most breast cancer patients and improvements in physiological, psychological, and functional parameters can be attained with regular participation in moderate intensity exercise.

Reply to A. Surbone et al

We read with interest the letter by Surbone and Kagawa-Singer entitled, “Culture Matters As Well.” We share their enthusiasm for the promotion of “nondiscriminatory referring clinician practices,” as well as greater exploration of the impact of anthropology and ethnography on patients’ decisions regarding cancer care and clinical trial involvement. However, we have no evidence in the early-phase setting that these factors are more important than, for example, objective measures of fitness and comorbidities. Improving cancer clinical trial access for all patients requires greater understanding of the social, cultural, physical, and emotional barriers that patients face. We are reminded by Unger et al not to overlook the importance of aspects of trial design and possible toxicity in patients’ decisions to participate. They demonstrated that choosing not to participate in a clinical trial was more likely to be motivated by such clinical considerations than by cost or convenience. Now that we have demonstrated a disparity in referrals for earlyphase trials between the least and most affluent patients in our catchment area, we are motivated to explore causality. At present, we can only speculate on the relative importance of factors such as culture, comorbidity, and referrer bias. James Spicer King’s College London; and Guy’s & St Thomas’ National Health Service Foundation Trust, London, United Kingdom

ACTIVEDEP: a randomised, controlled trial of a home-based exercise intervention to alleviate depression in middle-aged and older adults

ObjectiveTo evaluate the efficacy of a home-based exercise programme added to usual medical care for the treatment of depression.DesignProspective, two group parallel, randomised controlled study.SettingCommunity-based.Patients200 adults aged 50 years or...

Adjuvant chemotherapy in elderly women with breast cancer (AChEW): an observational study identifying MDT perceptions and barriers to decision making

BackgroundAs few older women with breast cancer receive adjuvant chemotherapy, we examined the barriers and perceptions of 24 UK NHS multidisciplinary breast cancer teams to offering this treatment to women ≥70 years. Patients and methodsQuestionnaires regarding 803 patients with newly diagnosed breast cancer were completed by specialist teams following discussion or outpatient consultation. ResultsOf 803 patients, 116 (14%), all <85 years, were offered chemotherapy and 66 (8%) received it. Only 94 of 309 (30%) of women with high-risk disease were offered chemotherapy, and 53 (17%) received it. The most common reasons for not offering chemotherapy were ‘other treatments more appropriate’ (usually patients with ER-positive tumours) or ‘benefits too small’ (63% and 54% of patients, respectively). Co-morbidities and frailty were less common reasons but became more frequent with increasing age. Recommendations regarding chemotherapy were made in the absence of documented HER2 and performance status in 29% and 33%, respectively. Treatment offered varied considerably between cancer centres. ConclusionsNational guidelines need development describing the minimally acceptable data for decision making, incorporating objective fitness measures and specific treatment recommendations. Such guidelines will require educational support for implementation but should standardise care and improve chemotherapy uptake in this increasing population of older patients.

Objectively-measured and self-reported physical activity and fitness in relation to inflammatory markers in European adolescents: The HELENA Study

ObjectiveAtherogenesis involves an inflammatory process that occurs early in life even though clinical symptoms are not observed until adulthood. Two important protective factors for low-grade inflammation may be physical activity (PA) and fitness. We examined the independent associations of objective and subjective measurements of PA and fitness with low-grade inflammation in European adolescents. MethodsA total of 1045 adolescents, aged from 12.5 to 17.5 years old from 10 European cities, were selected from the HELENA-Cross-Sectional Study. Objectively-measured and self-reported PA variables were obtained by accelerometry and the International PA Questionnaire for Adolescents, respectively. Overall, cardiorespiratory, muscular and motor fitness variables were assessed by standardized field-based fitness tests and the International Fitness Scale. C-reactive protein (CRP), complement factors 3 (C3) and 4 (C4), interleukin-6 and TNF-α inflammatory markers were measured. ResultsObjectively-measured vigorous PA was inversely associated with C3 (β=−0.094, P=0.021) but it did not remain significant after any objective fitness indicator was included in the model. Other objectively measured or self-reported assessments of PA were not significantly associated with inflammatory markers. All objective measures of fitness were inversely associated with CRP, C3 and C4, whereas only self-reported motor fitness remained significantly associated with C3, C4 and TNF-α. All these observations were independent of age, sex, city and body mass index or waist circumference. ConclusionHigh PA in adolescence may play an indirect role on lessening low-grade inflammation through improvements in fitness.

Comprehensive evaluation of a single-stage submaximal treadmill walking protocol in healthy, middle-aged women

Cardiorespiratory fitness is an independent predictor of cardiovascular events in women; however, maximal oxygen consumption (VO(2max)) protocols are not always feasible. The Evaluation of Physical Activity Measures in Middle-Aged Women Study was a 6-week study designed to evaluate six physical activity (PA) measures in women, aged 45-65years. We investigated the Ebbeling submaximal treadmill (EbbTM) protocol's ability to reflect an active lifestyle in 66 women [median (IQR) age, 51.0 (48.0, 56.5) years]. Participants were screened using ACSM and AHA guidelines and classified as moderate or low cardiovascular risk. VO(2max) was estimated using the EbbTM in all participants (TEST1). Moderate risk women repeated the EbbTM (TEST2) while low risk completed a maximal treadmill test. Intraclass correlation coefficients (ICC) and minimal detectable change (MDC(90)) score were calculated to examine reliability. Spearman rank order or Pearson product-moment correlation coefficients were used to determine the association between estimated VO(2max) and physical fitness and activity measures. Estimated VO(2max) from the EbbTM protocol had excellent reproducibility [ICC=0.95 (95% CI: 0.89, 0.98) and MDC(90) was 1.62mLkg(-1)min(-1). The EbbTM protocol was associated with measured VO(2max) (ρ=0.48; p=0.01) and was positively correlated with moderate- (ρ=0.32; p=0.02), vigorous- (ρ=0.47; p=0.0005) and moderate-to-vigorous-intensity PA (ρ=0.36; p=0.009), pedometer steps (ρ=0.41; p=0.002) and inversely correlated with waist circumference (ρ=-0.58; p<0.0001), body fat (ρ=-0.55; p<0.0001), and right leg endurance (ρ=-0.41; p=0.003). The EbbTM protocol was shown to be reliable and associated with objective measures of fitness and PA in healthy, middle-aged women.