Ehlers, Diane K.

The growing population of older cancer survivors faces an elevated risk of accelerated cognitive decline due to the combined effects of aging and cancer-related cognitive impairment. Loneliness and social isolation have also been linked to poorer cognitive outcomes and increased risk of Alzheimer’s Disease and Related Dementias (ADRD). At the same time, regular physical activity and social support interventions may improve cognitive function and reduce risk of cognitive decline. Despite these parallel lines of evidence, few interventions have addressed these modifiable risk factors simultaneously, particularly among older cancer survivors. In this perspective, we propose that group-based exercise may provide synergistic benefits for cognitive health by addressing both physical activity and social engagement. We present a conceptual model in which participation in group exercise promotes exercise-induced neurobiological adaptations that support cognitive function while simultaneously enhancing social connectedness. These processes may reduce loneliness and social isolation, promoting cognitive engagement. We also highlight key considerations for future research, including the potential for virtual or remotely delivered group exercise to increase accessibility, the importance of group dynamics in fostering social support, and the need to incorporate validated measures of loneliness, social isolation, and cognitive function in intervention studies.

Introduction Despite growing evidence to characterise cancer-associated cognitive decline (CACD) in women with breast cancer, interventions to mitigate CACD are limited. Emerging evidence suggests aerobic exercise may enhance cognition after breast cancer diagnosis and treatment; yet, CACD remains an understudied outcome of exercise, and few high-quality studies have been conducted. In addition to knowledge gaps in effectiveness, the translation of exercise interventions to community settings remains challenging. The Breast cancer Reasoning and Activity INtervention (BRAIN) investigates the effectiveness of aerobic exercise training, delivered in a community-based setting, for improving cognitive function in women with breast cancer and gathers information on the implementation success of the intervention. Methods and analysis This Hybrid Type I effectiveness–implementation study is conducted at an academic medical centre in the southwestern United States in partnership with a non-profit, community health and wellness organisation. The study enrols 160 women diagnosed with stage I–IIIa breast cancer and within 3–36 months of treatment completion into a 1:1 randomised controlled trial. Individuals randomised to the exercise group receive a 6-month, individually tailored aerobic exercise programme delivered by exercise trainers employed at local community fitness centres. The programme is progressive in nature and designed to help participants achieve aerobic exercise levels consistent with guidelines for cancer survivors. Individuals randomise to the control group receive a 6-month health education control intervention delivered virtually by hospital-based health educators. Cognitive performance (primary), self-reported cognition, patient-reported outcomes, physical activity and cardiorespiratory fitness are measured at baseline, 6 months (postintervention) and 12 months (follow-up). Brain structure and function are measured via magnetic resonance imaging (MRI) at baseline and 6 months. Implementation outcomes are defined by the RE-AIM framework, which includes reach, effectiveness, adoption, implementation and maintenance. RE-AIM outcomes are measured at baseline, 6 months, 12 months and ongoing during the study. Ethics and dissemination This study was approved by the Mayo Clinic Institutional Review Board (#23-000020). All participants provide informed consent prior to participation. Findings will be disseminated to scientific, clinical and community audiences through manuscripts, presentations and newsletters. Trial registration number NCT04816006.

Abstract Physical inactivity is a modifiable risk factor for Alzheimer’s Disease and Related Dementias (ADRD) that can be remediated using remotely delivered interventions. The 12-week telerehabilitation physical activity behavioral (TPAB) intervention includes receipt of a wearable sensor and weekly discussions about physical activity self-monitoring, goal setting, facilitators, and barriers. TPAB has been shown to be feasible and efficacious in increasing daily steps in older adults. However, evidence is lacking for TPAB’s use for people with MCI and using a dyadic approach (i.e., with their care partners). Results from the first phase of our study include descriptive information from two dyads about (1) dyad member interaction with the wearable sensor (i.e., how knowing the current daily step count impacted activity), (2) how dyad members helped each other overcome individual or shared barriers to daily stepping and (3) how dyad members planned activities together to achieve high daily average stepping. This project quantitatively identified (1) the highest stepping day each week was the same for both dyad members 46% of the time (2) the frequency of both dyad members meeting individual weekly stepping goals was 81% compared to just one dyad member or no dyad member reaching the weekly step goal. This project revealed barriers using wearable sensor technology (i.e., not looking at or wearing the wearable sensor). Our discussion will focus on how to enhance meaningful interaction with technology in dyads to track daily stepping that can be applied to improve behavioral change in people with MCI and care partners.

(1) Background. Cognitive dysfunction is prevalent among cancer survivors. Inflammation may contribute to impaired cognition, and diet represents a novel strategy to mitigate cognitive decline. The purpose was to (1) assess the impact of an educational cooking class on cancer survivor eating habits and their inflammatory potential and (2) determine the relationship between diet and cognitive function. (2) Methods. This was a non-randomized interventional study of a virtual educational cooking class in post-treatment, adult cancer survivors. Energy-adjusted Dietary Inflammatory Index (E-DII™) scores and subjective cognitive function were assessed at baseline and 1 month post-intervention. (3) Results. Of 22 subjects, all were female, White, and primarily had breast cancer (64%). There was a significant decrease in E-DII scores, which became more anti-inflammatory, one month after intervention (−2.3 vs. −2.7, p = 0.005). There were significant increases in cognition, including perceived cognitive impairment (COG-PCI, p < 0.001), comments from others (COG-OTH, p < 0.001), and quality of life (COG-QOL, p < 0.001). A change in calories was a significant predictor of a change in perceived cognitive ability (COG-PCA) after adjustment (β = 0.007, p = 0.04; 95% CI (0.000, 0.014)). (4) Conclusions. Educational cooking classes may be an effective way to impact diet-derived inflammation; additional research is needed to assess the long-term effects of dietary changes on cognition.

AbstractIntroductionThe American College of Sports Medicine provided guidelines for exercise prescriptions in cancer survivors for specific cancer‐ and treatment‐related health outcomes. However, there was insufficient evidence to generate exercise prescriptions for 10 health outcomes of cancer treatment. We sought to update the state of evidence.MethodsWe conducted a systematic review of these 10 understudied health outcomes (bone health, sleep, cardiovascular function, chemotherapy‐induced peripheral neuropathy (CIPN), cognitive function, falls and balance, nausea, pain, sexual function, and treatment tolerance) and provided an update of evidence.ResultsWhile the evidence base for each outcome has increased, there remains insufficient evidence to generate exercise prescriptions. Common limitations observed across outcomes included: variability in type and quality of outcome measurement tools, variability in definitions of the health outcomes, a lack of phase III trials, and a majority of trials investigating breast or prostate cancer survivors only.ConclusionWe identified progress in the field of exercise oncology for several understudied cancer‐ and treatment‐related health outcomes. However, we were not able to generate exercise prescriptions due to continued insufficient evidence base. More work is needed to prescribe exercise as medicine for these understudied health outcomes, and our review highlights several strategies to aid in research acceleration within these areas of exercise oncology.

Despite exercise benefits for cancer survivor health, most breast cancer survivors do not meet exercise recommendations. Few studies have examined associations between psychosocial symptoms and exercise barriers in this population. To improve physician exercise counseling by identifying survivors with high barriers in a clinical setting, associations between breast cancer symptoms (fatigue, mood, sleep quality) and exercise barriers were investigated. Physically inactive survivors (N = 320; average age 55 ± 8 years, 81% White, 77% cancer stage I or II) completed a baseline survey for a randomized physical activity trial and secondary analyses were performed. Potential covariates, exercise barriers interference score, Fatigue Symptom Inventory, Hospital Anxiety and Depression Scale (HADS), and Pittsburgh Sleep Quality Index were assessed. Based on multiple linear regression analyses, only HADS Global (B = 0.463, p < 0.001) and number of comorbidities (B = 0.992, p = 0.01) were independently associated with total exercise barriers interference score, explaining 8.8% of the variance (R2 = 0.088, F(2,317) = 15.286, p < 0.001). The most frequent barriers to exercise for survivors above the HADS clinically important cut point included procrastination, routine, and self-discipline. These results indicate greater anxiety levels, depression levels, and comorbidities may be independently associated with specific exercise barriers. Health professionals should consider mood and comorbidities when evaluating survivors for exercise barriers, and tailoring exercise counseling.

Abstract Background Physical activity is associated with decreased breast cancer recurrence and mortality, as well as fewer treatment-related symptoms. Nevertheless, most breast cancer survivors do not meet physical activity guidelines. The purpose of this manuscript is to characterize physical activity trends over time in breast cancer survivors. Methods Mayo Clinic Breast Disease Registry participants received surveys at baseline and at 1 and 4 years after diagnosis; breast cancer recurrence and/or metastatic disease were exclusion criteria. Participants were considered to be meeting guidelines if they self-reported at least 150 minutes of moderate-intensity (eg, fast walking) and/or strenuous (eg, jogging) physical activity per week. Statistical analyses include analysis of covariance methods, paired t tests, conditional logistic regression models, and McNemar tests of homogeneity. Results A total of 171 participants were included in the analysis. The amount of total physical activity decreased over time (P = .07). Mild-intensity physical activity (eg, easy walking) decreased most over time (P = .05). Among participants aged 18-49 years, mild-intensity (P = .05) and moderate-intensity (P = .02) physical activity decreased over time. Strenuous-intensity physical activity levels decreased over time among participants with a normal body mass index (P = .002) and with obesity (P = .01). Conclusions We found a trend-level decrease in total physical activity over time, driven mostly by a decrease in mild-intensity physical activity. Young breast cancer survivors are especially likely to reduce their physical activity over time. Further research on implementing physical activity guidelines in clinical practice is warranted.

Breast cancer survivors with obesity have an increased risk of cancer recurrence, second malignancy, and comorbidities. Though physical activity (PA) interventions are needed, investigation of the relationships between obesity and factors influencing PA program aspects among cancer survivors remain understudied. Thus, we conducted a cross-sectional study examining associations amongst baseline body mass index (BMI), PA program preferences, PA, cardiorespiratory fitness, and related social cognitive theory variables (self-efficacy, exercise barriers interference, social support, positive and negative outcome expectations) from a randomized controlled PA trial with 320 post-treatment breast cancer survivors. BMI was significantly correlated with exercise barriers interference (r = 0.131, p = 0.019). Higher BMI was significantly associated with preference to exercise at a facility (p = 0.038), lower cardiorespiratory fitness (p < 0.001), lower walking self-efficacy (p < 0.001), and higher negative outcome expectations (p = 0.024), independent of covariates (comorbidity score, Western Ontario and McMaster Universities osteoarthritis index score, income, race, education). Those with class I/II obesity reported a higher negative outcome expectations score compared with class III. Location, walking self-efficacy, barriers, negative outcome expectations, and fitness should be considered when designing future PA programs among breast cancer survivors with obesity.

Abstract Purpose Exercise program preferences are important for designing physical activity (PA) interventions; yet may change following an intervention. Further, the relationship between preferences and PA behavior change is unclear. This study evaluated exercise program preferences among breast cancer survivors (BCS) before and after a behavioral intervention and associations between program preferences and PA change. Methods BCS were randomized to the BEAT Cancer intervention (n = 110) or written materials (n = 112). Questionnaires assessed exercise program preferences. Minutes per week of moderate-to-vigorous PA (MVPA) were accelerometer-measured and self-reported at baseline (M0), post-intervention (M3), and 3-month follow-up (M6). Results At M0, the majority of intervention group participants preferred exercising with others (62%) yet shifted to preferring exercising alone (59%) at M3 (p < 0.001). Furthermore, preferring exercising with others at M0 was associated with greater increases in self-reported MVPA between M0 and M6 (124.2 ± 152 vs. 53.1 ± 113.8, p = 0.014). BCS preferring facility-based exercise decreased after the BEAT Cancer intervention (14% vs. 7%, p = 0.039) and preferring exercising at home/had no preference at M0 had greater improvements in accelerometer-measured MVPA from M0 to M3 (74.3 ± 118.8 vs. -2.3 ± 78.4, p = 0.033) and M0 to M6 (44.9 ± 112.8 vs. 9.3 ± 30.4, p = 0.021). Exercise program preferences regarding mode of counseling, training supervision, and type of exercise changed from M0 to M3 but were not associated with changes in MVPA. Conclusion Findings suggest BCS exercise program preferences may change after an intervention and be associated with changes in MVPA. Understanding the role of PA preferences will better inform the design and success of PA behavior change interventions. ClinicTrials.gov, ClinicalTrials.gov number: NCT00929617.