Optimal Management of Older Adults with Cancer

**Optimal Management of Exercise in Older Adults with Cancer**

Exercise and physical therapy has been proven to be effective in treating physical declines in older adults with cancer, improving overall quality of life. Identification of impairments can be done using the Geriatric Assessment.

**Objectives:**

1. Choose an appropriate outcome measure to identify impairments in older adults with cancer
2. Identify functional deficits that can be addressed through physical therapy interventions
3. Determine the benefits of exercise for older adults with cancer
4. Identify ways to improve quality of life in older adults with cancer

**Outcome Measure for Older Adults with Cancer**

According to the Journal of Clinical Oncology,1 the Geriatric Assessment has the ability to predict "oncology treatment-related complications." The Geriatric Assessment can detect impairments or risks such as functional or cognitive decline, as well as complications from surgery. There is an association between the findings on the Geriatric Assessment and the overall survival of the patient, including residual life expectancy and mortality from additional comorbidities or health impairments. The domains included in the Geriatric Assessment include: Demographic Data, Comorbidities, Functional Status, Cognition, Depression, Nutrition, Fatigue, Polypharmacy, and Geriatric Syndromes.

If the Geriatric Assessment is considered too much of a time consuming exam, an additional option is the Karnofsky Performance Status Scale identifies the patient's functional independence with different activities on a scale of 100 (no impairments) to 0 (dead).2

**Functional Deficits Addressed through Physical Therapy Interventions**

A study from the Journal of Geriatric Oncology noted that out of 529 patients with cancer, only 9% received PT/OT services within 12 months identifying a functional deficit, even though 64.5% had at least 1 functional deficit .3 This suggests that PT services are underutilized in patients receiving cancer. Of the individuals diagnosed with cancer, 70% are predicted to be 65 years of age or older by the year 2030.4 As the knowledge about cancer treatment grows, more patients are surviving the disease. According to the Journal of Clinical Oncology, most patients are reporting having poor health during and after cancer treatment.4 This poor health significantly affects activities of daily living and levels of participation. Physical therapy can play an important role in treating patients by addressing the physical impairments and functional limitations involved in their disease process. It is in the job description of a physical therapist to identify areas of loss of function and work to restore that physical function in order to improve the patient's quality of life.

Specific areas of impairment include:3

* Limitation with IADLs/ADLs
* History of falls
* Decreased gait speed
* Decreased participation in social activities
* Generalized weakness
* Difficulty ambulating

**Benefits of** **Exercise for Individuals with Cancer**

Patients with cancer can be a complex population, especially when prescribing exercise. Although more complex, there are still physical needs that need to be addressed through physical therapy in order to avoid poor health outcomes. Maintaining physical activity throughout the cancer disease process can significantly improve outcomes. Exercise can address the physical needs of the patient, as well as the psychological declines. Research shows that many times patients who are diagnosed with cancer will reduce their participation in physical activity and will never return to their original level of function, even after the disease.5

 Exercise specifically addresses "muscle weakness, fatigue, obesity, immune function, insomnia, anxiety, cognitive decline, and impaired quality of life."6-10

 Important aspects of interventions for physical activity includes salient exercises. Below is a summary of several RCT protocols used to improve levels of function in patients with cancer and their respective benefits:5

* Demark-Wahnefried et al (2006): 20-30 minutes bimonthly for 6 months, home-based exercise
	+ Increased function status, increased physical activity
* Morey et al. (2009): 30 minutes initially 3x/week, then bimonthly for 2 months, and then monthly for 1 year, home-based exercise
	+ Increased physical function, increased physical activity, increased QOL, and decreased BMI
* Winters-Stone et al (2012): 3-1 hour sessions/week for 12 months, progressive resistance and impact exercise
	+ Increased bench press and leg press strength
* Cormie et al (2015): 2 sessions/week, 60 minutes each, aerobic and resistance exercise for 3 months
	+ Increased preservation of lean mass, increased muscular strength, increased lower body function, decreased fatigue
	+ Increased social functioning, decreased psychological distress
* Winters-Stone et al (2015): 3-1 hour session/week, progressive resistance exercise and impact exercise for 12 months
	+ Increased bench press and leg strength, increased objective and self reported physical function, decreased disability
* Sprod et al (2015): 4 weeks, 2 session per week, 75 minute session of yoga
	+ Decreased cancer related fatigue, decreased global side effect burden

**Improving the Quality of Life in Patients with Cancer**

Exercise programs that are salient to each individual patient as well as exercise classes that include a social support aspect increase levels of participation in older adults with low physical activity.11 If a patient is unable to acquire the CDC recommended guidelines for exercise due to their health status, it has been recognized that "avoiding inactivity" can still be beneficial. For patients with cancer that are sedentary, educating them on lifestyle changes in older to promote physical activity can also be beneficial. The goal with individuals who are sedentary is to decrease the time they are sedentary. This means increasing activity during all "leisure, occupational, and household activities."

Increased participation in physical activity and increased socialization can improve the quality of life in patients with cancer. While social and environmental factors play a role into an individual's participation in activity, programs that allow patients to choose exercises based on their preference, "provide social support, and remove obstacles" are the best programs to encourage involvement. Even light intensity exercise can be beneficial to sedentary patient. Lifestyle interventions that improve physical function in every aspect of life can improve overall quality of life in cancer survivors.11

**References**

1. Wildiers H, Heeren P, Puts M, et al. Consensus on geriatric assessment in older patients with cancer. *Journal of Clinical Oncology*. 2014;32(24):2595-2603.
doi:10.1200/JCO.2013.54.8347.

2. Jolly T, Deal A, Nyrop K, Williams G, Pergolotti M, Wood W, Alston S, Gordon B, Dixon S, Moore S, Taylor W, Messino M, Muss H. Geriatric assessment-identified deficits in older cancer patients with normal performance status. *The Oncologist*. 2015;20:379-385. doi: 10.1634/theoncologist.2014-0247.

3. Pergolotti M, Deal A, Lavery J, Reeve B, Muss H. The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. *J Geriatr Oncol.* 2015;6(3):194-201. doi:10.1016/j.jgo.2015.01.004.

4. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. Journal of Clinical Oncology. 2009; 27(17):2758–65. [PubMed: 19403886].

5. Kilari D, Soto-Perez-de-Celis E, Mohile s, Alibhai S, Presley C, Wildes T, Klepin H, Demark-Wahnefried W, Jatoi A, Harrison R, Won E, Mustian K. Designing exercise clinical trials for older adults with cancer: recommendations from 2015 cancer and aging research group NCI U13 Meeting. *J Geriatr Oncol.* 2016; 7(4): 293-304. doi:10.1016/j.jgo.2016.04.007.

6. Brown JC, Huedo-Medina TB, Pescatello LS, Pescatello SM, Ferrer RA, Johnson BT. Efficacy of exercise interventions in modulating cancer-related fatigue among adult cancer survivors: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2011; 20(1):123–133. [PubMed: 21051654]

7. Irwin ML, Alvarez-Reeves M, Cadmus L, Mierzejewski E, Mayne ST, Yu H, et al. Exercise improves body fat, lean mass, and bone mass in breast cancer survivors. Obesity. 2009; 17(8):1534–1541. [PubMed: 19629060]

8. Gleeson M, Bishop NC, Stensel DJ, Lindley MR, Mastana SS, Nimmo MA. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol. 2011; 11(9):607–615. [PubMed: 21818123]

9. Tang MF, Liou TH, Lin CC. Improving sleep quality for cancer patients: benefits of a home-based exercise intervention. Support Care Cancer. 2010; 18(10):1329–1339. [PubMed: 19834744]

10. Salmon P. Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory. Clin Psychol Rev. 2001; 21(1):33–61. [PubMed: 11148895]

11. Koll T, Semin J, Grieb B, Dale W. Motivating older adults with cancer to keep moving: the implications of lifestyle interventions on physical activity. *Geriatric Oncology.* 2017; 19:68. doi:10.1007/s11912-017-0623-4.