JOURNAL PRESENTATION

PRESENTED BY:

NANDINI VERMA

M.SC(N)2ND YEAR
Volume 11 number 3
July-September 2019
 TITLE

Physical activity among postoperative esophageal cancer patients

NAME AND PLACE OF WORK

 Chijo, Yuka. Takeda, Yuko. Oguma, Yuko. Kitagawa, Yuko. Takeuchi,

Hiroya, Doorenbos, Ardith Z, FAAN
INTRODUCTION

 Esophageal cancer is the eighth most common cancer and sixth most

common cause of death from cancer in the world.' Incidence and

mortality rates of esophageal cancer are high, especially for men in East
Asia (incidence is 17.0 per 100000 people, and mortality is 14.1 per
100000 people)."
 The mainstay of curable treatment is esophagectomy, an invasive surgery

that causes disease and treatment-related symptoms such as pain, cough,

shortness of breath, and also esophageal specific symptoms, such as
feeling full quickly, feeling bloated, nausea, and diarrhea postoperatively.
A finding in a recent meta-analysis was that esophagectomy influences
esophageal cancer patients' long-term health-related quality of life
(HRQOL).
 Previous research has reported that postoperative esophageal cancer

patients recovered most aspects of their preoperative HRQOL after 3 years,

but their physical function, including the ability to carry heavy objects and
walk long distances, remained substantially reduced. In addition, findings
from longitudinal studies indicate that postoperative esophageal cancer
patients tend to have lower levels of physical activity (PA) compared with
their preoperative levels.
 Previous research has confirmed that regular Physical Activity has

multiple health benefits, including disease prevention and promotion of

mental health. A population-based study documented a strong
relationship between PA and quality of life (QOL) generally.
 Regarding the effects of surgery, esophagectomy can greatly influence

eating. In particular, the lymph node dissection in the neck requires

operating near the recurrent laryngeal nerve, which increases the risk of
recurrent nerve paralysis and dysphagia. Reconstructive surgery is also
needed in an esophagectomy, and this brings risk of anastomotic stricture,
which can contribute to choking.
 METHODS

 The Physical ExeRcise Following Esophageal Cancer Treatment

(PERFECT) study is a multicenter randomized controlled trial including 61
esophageal cancer patients after surgery with curative intent. Patients are
randomly allocated to an exercise group or usual care group. The exercise
group participates in a 12-week combined aerobic and resistance exercise
program, supervised by a physiotherapist near the patient’s home-address.
SAMPLE AND SAMPLING TECHNIQUE

A total no of 61 patients with esophageal cancer after surgery with curative

intent are planned to be included in the “PERFECT” study is designed as a
multicenter, randomized controlled trial with two study arms: (1) a group
offered a supervised exercise program in addition to usual care and (2) a
control group receiving usual care without exercise intervention.
 DESIGN
 This study used a descriptive cross-sectional design. Data were collected at a university
hospital in Tokyo, Japan, which has more than 1000 beds.
Inclusion criteria were male esophageal cancer Exclusion criteria were male esophageal cancer
patients patients who:
More than 6 months post-thoracic esophagectomy Had been diagnosed with another cancer

Between 20 and 80 years old Were receiving adjuvant therapy

Able to read, understand, and answer the Had feeding tubes

questionnaire in Japanese

Judged by each patient's physician to be able to Had recurrence postoperatively

participate in the research.
 PROCEDURE
 After ethical approval was obtained from the ethical review boards of
keio university graduate school of health management and the
participating hospital, the primary physician at the hospital clinic referred
all potential participants to the study during the 6 month data collection
period.
 Physician briefly informed potential participants about the study, if a
potential participant showed interest, the physician introduced the
researcher.
 The researcher then explained the study to the participants and obtain
written consent.
CONCEPTUAL MODEL

 In this study they have used an ecological model of 4 domains of active

living as a conceptual frame work. This model presents 4 domains of

active living i.e. recreation, transport, occupation and household.
 INSTRUMENTS

 Demographic and disease variables collected including age, cancer stage,

operation method, adjuvant therapy, comorbidities and post operative
complications such as recurrent nerve paralysis.
 Measures of physical activity
 In this study they have used Japanese long version of the international
physical activity questionnaire(IPAQ) was used to assess the daily
moderate intensity and vigorous intensity activity.
 The Japanese version of the IPAQ has established validity and reliability
and has been successfully used as a self report measure.
MEASURES OF PHYSICAL ACTIVITY

 IPAQ measures the time and amount of moderate intensity and vigorous
intensity activity that are performed more than 10 minutes continuously 4
domains related to work, active transportation, domestic and garden, and
leisure time.
 For work related physical activity, they measure occupational status(i.e.
participant had a job) was asked, and only participants who had a job
answered the questions for work related physical activity.
 The physical activity data can be reported as continuous measure by
calculating the metabolic equivalents.
 The Physical Activity Index (PAI), or the amount of PA per week, is

calculated by multiplying the intensity, time, and frequency of PA during an

average week. The question, "Did you participate in moderate or vigorous
leisure-time PA at least once a week before diagnosis?" was added to the
questionnaire in this study. Participants who answered "yes" to this
question also asked the time, frequency, and intensity of the PA before
diagnosis.
 The amount of time participants performed PA before diagnosis was compared

with the Physical Activity Guidelines for Americans (PAG), and participants who
performed more than 150 minutes per week of moderate or vigorous leisure-time
PA before diagnosis were considered to have had a past leisure-time PA behavior
before diagnosis. Case studies for participants who scored 0 (performing <10
minutes continuously or no activity) in IPAQ were performed to understand the
reasons for scoring low in PA, by examining the medical records.
NUTRITIONAL STATUS AND DYSPHAGIA

 Data about height and weight (body mass index), total protein, and serum
albumin were collected to examine nutritional status. The participants'
level of dysphagia was evaluated using the Japanese version of the 10-
item Eating Assessment Tool (EAT-10) The Japanese version of EAT-10
has established validity and 30 reliability. This instrument is used in
clinical practice as an assessment tool for aspiration. The EAT-10
questions are scored from 0 to 4 (0 points for no problem, 4 points for
severe problem), and if the total score is 3 or higher, the participant is
classified as having dysphagia.
HEALTH RELATED QUALITY OF LIFE

 The European Organization for Research and Treatment of Cancer

(EORTC) has given Quality of Life Questionnaire (QLQ-C30)to assess
participants’ health related quality of life
 This study used the Japanese version of the cancer-specific score
questionnaire (QLQ-C30) and a module specific to esophageal cancer
 The QLQ-C30 includes global quality-of- life scale, 5 functional scales
(physical, role, emotional, cognitive, and social), and 9 symptom scales
(fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss,
constipation, diarrhea, and financial difficulties).
 Each item uses a Likert-type scale. The global quality-of-life scale ranges
from 1 to 7, and the functional scales range from 1 to 4, both meaning
higher scores show better HRQOL.
 The symptom scales also ranged from 1 to 4, but higher scores show worse
level of symptoms. The QLQ-OES18 was developed, and its validity is
proven." It assesses symptoms specific to 33, 34 esophageal cancer and has
1 functional scale (dysphagia), where higher scores mean better
functioning, and 9 symptom scales (eating, reflux, esophageal pain,
swallowing saliva, choking when swallowing, dry mouth, taste problem,
coughing, and speech problems), where higher scores mean worse
level of symptoms.
STATISTICAL ANALYSIS

 All statistical analyses were performed with Easy R (EZR, Saitama,

Japan), a graphical user interface for the statistical software R. It is a
modified version of R commander to add statistical functions frequently
used in biostatistics.“
 Descriptive statistics were applied to demographic and disease-related
characteristics, PA, nutritional status, level of dysphagia, and HRQOL.
Spearman rank correlation coefficients were calculated to explore
continuous variables related to PAI (i.e., nutrition, dysphagia, and
HRQOL)
RESULT

 Sixty-one potential participants were recruited, and 58 participants

returned the study questionnaire (response rate, 95%). This high response
rate is typical for research conducted in Japan." The 3 people who declined
participation either did not show interest in the study, or the reason for
declining is unknown because they did not return the questionnaire by
mail. The average age of participants was 65.7 (SD, 7.3) years, and the
average time since surgery was 28 (SD, 15.3) months.
Variable Mean SD Range

Age, Y 65.7(7.3) 48-79

Postoperative time 28(15.3) 6-57

Body mass index kg/m 19.6(2.1) 15.2-24.5

Serum albumin g/dL 4.2(0.3) 3.3-4.7

Total protein g/dL 6.8(0.4) 5.9-8.0

 Mann-Whitney U tests and Fisher exact tests were used to explore
categorical variables (i.e., demo- graphics) related to PAI. Variables
described above were also compared between subgroups of participants
meeting or not meeting the PAG, which is more than 150 minutes of
moderate or vigorous activity per week, using Mann-Whitney U tests or
Fisher exact tests. For participants who scored 0 (performing <10 minutes
continuously or no activity) in IPAQ, their questionnaires and medical
records were examined for comorbidities, postoperative complications,
medications, and length of hospital stays to explore the reasons for
physical inactivity.
 DISCUSSION
 Despite past research about cancer patients and PA, only a few studies have

described postoperative esophageal cancer patients. Most (79%) of this

study's participants met the PAG. Comparing the median scores among PA
domains, leisure-time PAI was the highest, and transportation PAI was the
second highest. Many participants walked during leisure time and
transportation for at least 1 day per week. which is typical in Japanese culture
where common transportation methods are walking and using public
transportation.
 These results are similar to data in a study about middle-aged people in

Fujisawa City, Japan. The study showed similar results in the percentage of
participants who walked for transportation, walked during leisure time, and
did moderate to vigorous leisure- time PA at least once a week. Despite the
postoperative symptoms that esophageal cancer patients generally experience.
The majority of participants in this study performed adequate PA.
 Positive reinforcement is needed for patients who perform adequate levels

of Physical activity, and a review of the benefits of regular PA is necessary

for all. Focusing on facilitators of Physical activity in this group may reveal
findings that help other postoperative esophageal cancer patients who are
having trouble performing adequate Physical activity.
 There are a few limitations to this study. Because only 1 sampling hospital was

used, sample size and variation were limited. Future suggestions to choose
participants in various settings, to achieve larger sample size and more
variation. This is especially true for Physical activity , because Physical activity
was defined as moderate or vigorous activity for at least 10 minutes
continuously per day, and activities that lasted less than 10 minutes were not
considered Physical activity.
 CONCLUSION

 Almost 80% of the participants met the Physical activity guidelines. The
participants performed especially well in leisure-time Physical activity and
transportation Physical activity. Occupational status was related to leisure-
time Physical activity. Past leisure-time Physical activity behavior before
the cancer diagnosis was related to current leisure-time PA and meeting the
PAG. This information can be used to promote PA among postoperative
esophageal cancer patients. Participants who did no PA during an average
week tended to score low on health related quality of life (HRQOL), which
indicates that this population needs additional support to improve both PA
levels and health related quality of life (HRQOL).