ReviewA systematic review of pre-surgical exercise intervention studies with cancer patients
Introduction
Advances in treatments have had a significant impact on cancer survivorship. However, these improvements still result in various negative psychosocial and physical side effects [1]. Exercise rehabilitation programmes for cancer patients have been discussed and recommended by major professional organisations such as the American Cancer Society and American College of Sports Medicine (ACSM) to help address the acute effects of cancer [2], [3]. Considerable evidence suggest that exercise reduces symptoms of chronic diseases [4] and can alleviate most of the negative effects of cancer treatments [5]. These outcomes were demonstrated in a review of breast cancer survivors that undertook progressive resistance training as a form of exercise to derive functional, physiological, psychological and clinical benefits [6]. Exercise as a form of rehabilitation for cancer survivors has been shown to increase cardiorespiratory fitness levels, muscle strength, QOL, and also reduce fat mass [7].
To integrate exercise into clinical practice, it is important to determine the optimal timing of exercise interventions. The Physical Exercise Across the Cancer Experience (PEACE) framework suggests six different time periods [8], [9]. Most research studies conducted specifically with patients undergoing surgery as the primary treatment modality have focused on the impact of post-surgical exercise interventions on different physiological and psychological outcomes [3]. Research into the correlation between pre-surgical exercise and the adverse effects of surgery could offer cancer survivors a better quality of recovery. Currently, detrimental after-effects of invasive surgery include long periods of physical inactivity, which in turn induces loss of muscle function, decreases QOL, increases the chances of medical complication and, in severe cases, may hasten mortality [10].
The introduction of exercise prior to surgery has the potential to enhance post-surgery recovery [11], [12], [13]. A large RCT of 279 patients undergoing coronary artery by-pass graft surgery [11] found that pre-operative intensive inspiratory muscle training reduced post-operative pulmonary complications and hospitalisation time. Similarly, for cardiac surgery patients, surgical complications were inversely proportional to pre-operative exercise participation [12]. Pre-surgical exercise intervention for patients undergoing mastectomies significantly improved shoulder mobility after surgery [13]. Early studies on pre-operative assessments indicated that poor fitness prior to an operation increased: the likelihood of a longer hospital stay post-surgery; the possibility of higher incidence of various surgical complications and decreased the 30-day survival rate [14], [15]. While there is significant support for a pre-surgical exercise intervention, there is a limited number of pre-surgical exercise studies specifically assessing the outcomes for cancer patients.
This review aims to systematically assess the current level of evidence for pre-surgical exercise for cancer patients. The main objective(s) of our review are: 1) to systematically review the available literature regarding exercise training interventions in cancer patients prior to surgery, and 2) to examine its effect on physiological outcomes. Specific focus will be directed towards the physiological outcomes derived from exercise with the effects on QOL and length of hospital stay also examined.
Section snippets
Study design
The key criterion for the inclusion of studies in this review was that all RCTs and non-RCTs had to have some form of physical exercise training intervention undertaken prior to surgery. An exercise training intervention has been defined as more than two training sessions; while non-RCT studies have been defined as single group or controlled trials. Controlled trials have been defined as two non-randomised distinct groups.
Exclusions
All abstracts, case reports, prospective and retrospective observational
Database search
The database search strategy for each step shown in Fig. 1 yielded an initial total of 411 journal articles. After screening all search results, 239 articles were excluded as they were considered irrelevant. Of the remaining 172 articles, full texts were retrieved for a detailed evaluation. Of these articles, only 16 fulfilled the inclusion criteria for this review.
A further database search was done from references in 21 review articles [4], [5], [6], [10], [19], [20], [21], [22], [23], [24],
Discussion
Recent narrative reviews have suggested that enhancing cardiorespiratory and functional capacity before surgery holds the possibility of not only accelerating post-surgical recovery, but also reducing complication rates [32]. However, the effect of pre-surgical exercise intervention in cancer patients has not been fully examined. To our knowledge, this is the first review to evaluate pre-surgical exercise specifically for cancer.
Overall, the available evidence suggests that pre-surgical
Conflict of interest statement
The authors declare that they have no conflict of interest.
Authorship statement
Guarantor of the integrity of the study: [Singh, Baker, Newton, Galvão, Spry]
Study concepts: [Singh, Baker, Newton, Galvão, Spry]
Study design: [Singh, Baker, Newton, Galvão, Spry]
Literature research: [Singh, Baker]
Data acquisition: [Singh, Baker]
Data analysis: [Singh, Baker]
Statistical analysis: [Singh, Baker]
Manuscript preparation: [Singh]
Manuscript editing: [Singh, Baker, Newton, Galvão, Spry]
Manuscript review: [Singh, Baker, Newton, Galvão, Spry]
Acknowledgements
DAG is funded by a Movember New Directions Development Award obtained through Prostate Cancer Foundation of Australia's Research Program. The authors sincerely appreciate the contributions of Mr. Gregory Levin in the preparation of this manuscript.
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