Feasibility of implementing an exercise intervention in older adults with hematologic malignancy

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Abstract

Older adults with Hematologic Malignancy (HM) are vulnerable to functional decline secondary to disease and treatment. Interventions for physical deconditioning, in concert with routine hematology care are limited. The feasibility of accrual, retention, and demand for an exercise intervention among a high-risk HM population was piloted.

Methods

Older adults with HM, on active treatment, with functional impairment were recruited prospectively to participate in a 6-month Otago Exercise Programme (OEP). Measures of motivation, self-efficacy, patient identified barriers to exercise, barriers to clinical trial enrollment, study satisfaction, and serious adverse events were captured.

Results

63 patients were approached, 18 declined trial enrollment, 45 consented, 30 patients enrolled in the exercise program. The main barrier for trial enrollment was transportation/travel concerns (n = 15). Of the 45 consented participants, 8 (12.7%) dropped out due to clinical deterioration, 5 (7.9%) withdrew, and 2 (3.2%) were ineligible prior to exercise-intervention intiation. The median age was 75.5 years (range 62–83) with plasma cell dyscrasia (63%), non-Hodgkin lymphoma (20%) and leukemia (17%). Retention of the physical therapist (PT) led-OEP was 76.6% of patients (n = 23/30), and end-of-study retention was 66.7% (n = 20/30). Of the evaluable patients, 23/29 completed the PE-led OEP yielding a completion rate of 79%. Participants were extremely motivated (72.4%) and strongly intended (89.7%) to engage in regular physical activity. Exercising when tired increased from a median score of 50 at Visit 1 to 70 at Visit 2, but dropped significantly to 45 at Visit 3 (p < 0.001). Participants reported significantly lower self-efficacy to exercise over the next 6 months from Visit 1 to Visit 3 (p = 0.001).

Conclusions

Older patients with HM had higher completion of in-person, PT-led exercise compared to at-home, independent exercise. Older adults were motivated and found the program acceptable, yet the ability to sustain a structured exercise program was challenging due to changes in health status.

ClinicalTrials.gov Identifier: NCT02791737

Introduction

Hematological malignances (HM) affect a disproportionate number of older adults (≥65 years) and account for an estimated 178,500 new cases and 56,840 estimated deaths in the United States in 2020 [1]. Survival probability of older adults with HM is dependent upon patient and disease characteristics with highly variable treatment modalities. Notably, maintaining quality of life (QoL) and functional status while receiving treatment is an important metric in recovery from both diagnosis and treatment toxicities.

Interventions for disease management and physical functioning in vulnerable older adults with HM are limited. Older adults with HM are vulnerable to functional decline and physical deconditioning due to both disease and treatment resulting in organ impairment and/or malignancy-induced cachexia [2]. In adults with HM, exercise increases cardiorespiratory fitness, muscle strength, and physical well-being, and reduces fatigue and depression [[3], [4], [5]]. Older adults who are long-term cancer survivors especially benefit from exercise to reduce functional decline and improve QoL [6]. However, exercise interventions have logistical challenges and identifying implementation barriers can facilitate dissemination of exercise programs across oncology centers

The Otago Exercise Program (OEP) is an evidence-based, individually tailored strength and balance training program designed to be carried out by physical therapists and includes prescribed in-person and home-based exercise [7]. The OEP has been found to be an effective exercise regimen to improve functional balance and muscle strength, and prevent fall-related injury and mortality [[8], [9], [10]]. OEP has been implemented among a diverse groups of older adults, including community-dwelling older adults with chronic diseases [[11], [12], [13], [14]] and residents in assisted living facilities [15]. Despite its record of effectiveness in a variety of older adults, the OEP has not been implemented among older cancer populations. We aimed to implement an exercise intervention for a higher risk population, identifying patients who are older, at risk for functional impairment, and actively receiving treatment for HM. Here we report the feasibility (recruitment and retention), acceptability (OEP implementation) and preliminary outcomes (e.g., self-efficacy and motivation) of implementing a structured exercise program for older adults with HM.

Section snippets

Recruitment

Potential participants were recruited from the hematology clinics at The Ohio State University Comprehensive Cancer Center. Patients who did not enroll in the OEP program were asked to complete a non-enrollment survey. The survey was abstracted [16] to identify protocol-related barriers, patient-related barriers, and physician/provider-related barriers (Supplement). Complete enrollment criteria are previously described [17]. The Institutional Review Board at The Ohio State University approved

Results

Sixty-three patients were approached from August 2016 to January 2018; 18 patients declined to participate and 45 consented to enrollment. A declined-enrollment survey was utilized to identify obstacles for abstained enrollment including protocol-related barriers, patient-related barriers and physician-related barriers. Obstacles to trial enrollment included transportation/travel concerns (n = 15), followed by uncertainty about exercise (n = 5), cost to insurance (n = 4), lack of support (n

Discussion

The study sought to examine the feasibility (recruitment and retention), acceptability (OEP implementation) and preliminary outcomes (e.g., self-efficacy and motivation) of implementing a structured exercise program among high-risk older adults with HMs. Our analysis identifies that in-person, PT-led OEP intervention (79% adherence), where patients met with a therapist regularly, had higher adhearance than the patient at-home, independent exercise portion of the program (66.7% adherence).

Conclusion

Implementing the OEP in older adults with HM has logistical challenges, yet our data suggest that participants found the OEP and exercise, in general, important and relevant during their treatment High satisfaction ratings with acceptable adherence rates indicate that the OEP is a well-accepted and enjoyable strategy to intervene on the physical function of older adults with HM undergoing therapy. Examination into long-term adherence is warranted to identify if adherence to physical activity

Funding

Dr. Rosko reports grants from NCI K23 Award, during the conduct of the study; other from accc, outside the submitted work; Dr. Presley reports other from consulting Onclive, other from Pontentia, consulting from Yale University, outside the submitted work.

Author contribution

A.R. Y.H. M.N. Designed research; A.R. D.J. R.O Enrollment of patients, A.R. Y.H. J.J. J.K-S. analyzed data; A.R. Y.H. D.J.C·P R.O. M.N. J.K-S. wrote, revised and edited the manuscript.

Support

Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under the Award Number UG1CA189823 (Alliance for Clinical Trials in Oncology NCORP Grant), K23 CA208010-01 (PI Rosko), and UG1CA233331. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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