Feasibility and Safety of Cardiopulmonary Exercise Testing in Acute Leukemia Patients during Induction Chemotherapy

Special Article - Leukemia

Ann Hematol Oncol. 2018; 5(1): 1188.

Feasibility and Safety of Cardiopulmonary Exercise Testing in Acute Leukemia Patients during Induction Chemotherapy

Coffman EM¹, Bryant AL², Deal AM³, Wang Y4, Hanson ED5, Phillips B6, Foster M7, Wood WA7, Bailey C8, Muss H9 and Battaglini CL10*

¹Clinical Research Coordinator, The University of North Carolina at Chapel Hill, USA

²School of Nursing,The University of North Carolina at Chapel Hill, USA

³Biostatistics Core Facility, The University of North Carolina at Chapel Hill, Lineberger Comprehensive, USA

4Department of Biostatistics, The University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, USA

5Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, USA

6Clinical Research Coordinator, Hemophilia and Thrombosis Center, The University of North Carolina at Chapel Hill, USA

7Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, USA

8Clinical Research Specialist I, Survivorship, Lifestyle, and Supportive Health, AHSP-Samuel Oschin, Comprehensive Cancer Institute, USA

9Geriatric Oncology Program, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill

10Department of Exercise Sports and Science, Lineberger Comprehensive Cancer Center, UNC Exercise Oncology Research Laboratory, The University of North Carolina at Chapel Hill, USA

*Corresponding author: Battaglini C, Department of Exercise Sports and Science, Lineberger Comprehensive Cancer Center, UNC Exercise Oncology Research Laboratory, University of North Carolina at Chapel Hill, USA

Received: November 20, 2017; Accepted: January 18, 2018; Published: February 05, 2018

Abstract

The interest and use of exercise as an adjuvant therapy for the alleviation of treatment-related side effects in cancer patients has grown significantly the past decade. The need for the use of objective measures to not only inform the prescription of exercise, to assess the beneficial effects of exercise, but also as a screening tool for exercise participation is paramount for the development of evidence-based exercise programs for cancer patients.

Purpose: The purpose of this study was to evaluate the feasibility and safety of administering a cardiopulmonary exercise test (CPET) in newly diagnosed acute leukemia patients enrolled in a randomized clinical trial examining the effects of an exercise program during induction chemotherapy.

Methods: Seventeen patients recently diagnosed with acute leukemia were randomized into the exercise intervention (n=8) or usual care (n=9). Patients attempted a multistage CPET at the hematology oncology unit to assess peak oxygen uptake (VO2peak) at baseline (within 4 days of admission for induction chemotherapy) and at the end of the exercise program (at discharge from hospital).

Results: Only 47% of all planned baseline and post-intervention CPETs (total of 16 tests out of 34) were completed. Exploratory analyses revealed a significant correlation between VO2peak and the Timed Up and Go test (TUG, r=-0.6, p=.003) and 6-minute walk distance test (6MWT, r=0.61, p=.001, respectively).

Conclusion: The administration of a CPET in newly diagnosed acute leukemia participating in an exercise study during induction therapy appears to be safe, however, based on the feasibility criteria adopted in this study, the use a CPET for the assessment of cardiopulmonary function (CRF) at baseline and discharge does not appear to be feasible, since the large majority of the patients enrolled in the control group were not able to complete the CPET at discharge.

Keywords: Acute leukemia; Acute myelogenous leukemia; Hematological cancers

Introduction

Acute leukemia is a hematological cancer that often requires immediate hospitalization for initiation of induction chemotherapy due to its rapid onset and development. In 2017, it is estimated there will be 62,130 new cases of leukemia. Even though relative survival rate has increased since the 1960s, in patients diagnosed with acute myelogenous leukemia (AML) for example, the fiveyear overall relative survival rates remain low at 26%, compared to other types of hematological cancers [1]. Initial treatment (induction chemotherapy), consists of daily high-dose of chemotherapy administration for a week, followed by 3-6 weeks of inpatient recovery. The aggressive nature of treatment puts these patients at greater risk for serious treatment-associated complications including nausea, vomiting, and diarrhea. The burden of these symptoms can result in poor nutrition and reduced physical activity. The physical and psychological effects of the high-dose chemotherapy and recovery are the perfect recipe for reduced physical functioning, significant reductions in Cardiorespiratory Fitness (CRF) and potentially less favorable treatment prognosis and poor quality of life [2].

Cardiorespiratory fitness (CRF) has been shown to be predictive of mortality in healthy adults, those with chronic disease (i.e. cardiovascular disease [3-5], and most recently, individuals with certain types of cancers [6,7]. Cardiopulmonary exercise testing (CPET), is considered the gold standard method for the evaluation of CRF. Guidelines and recommendations for the assessment of CRF in cancer patients have been previously published [8]. However, issues associated with the administration of symptom-limited CPET in inpatient cancer populations include but are not limited to: accessibility to a metabolic cart, personnel qualified to conduct such tests, time constraints with treatments, and most importantly, the ability and willingness of patients to undergo such testing during different phases of treatment.

Few studies have attempted to use exercise interventions aimed to alleviate the severe physical function decline observed during acute leukemia treatment. However, the existing exercise trials that have attempted to alleviate treatment-related side effects of chemotherapy have yielded promising results [9-13]. Even though most of these progressive and innovative trials used objective measurements for the assessment of different fitness and functionality parameters, none have directly measured CRF via gold standard CPET with indirect calorimetry.

The purpose of this study was to evaluate the feasibility and safety of administering a CPET in recently diagnosed acute leukemia patients enrolled in a randomized clinical trial examining the effects of an exercise program during induction chemotherapy. Exploratory analyses were used to examine the associations between changes in CRF and physical function measures.

Methods

General procedures

This randomized clinical trial (NCT 02246907) recruited patients between October 2014 and November 2015. Adults with acute leukemia were recruited at the NC Cancer Hospital (Lineberger Comprehensive Cancer Center) within 4 days of admission for induction treatment. If a patient demonstrated interest in participating, their oncologists were consulted and asked to evaluate the patient’s eligibility to enroll in the study based on the inclusion/ exclusion criteria. Inclusion criteria consisted of: 1) adults > 18 years old, newly diagnosed with AML or ALL, 2) admitted to begin induction chemotherapy with an expected hospital stay of 4-6 weeks, and 3) able to speak and understand English. Exclusion criteria included: cardiovascular disease; acute or chronic respiratory disease; acute or chronic bone, muscle or joint abnormalities; altered mental state, dementia, or any other psychological condition that would prevent understanding of informed consent, being actively treated for other co-morbidities that compromise safe participation in a maximal/peak cardiopulmonary exercise testing (CPET). If a patient met the inclusion/exclusion criteria, and after the oncologist cleared the patient to enroll in the study, patients were introduced to the study. Those interested in participating in the study were asked to sign informed consent approved by the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center Protocol Review Board and the UNC Biomedical Institutional Review Board prior to participating in any study activities.

Eighty-two patients were screened for participation in the study (Figure 1). Sixty-four failed to meet the inclusion criteria: cardiac, respiratory, joint/musculoskeletal comorbidities (n=24), diagnosed with another type of hematological cancer besides leukemia (n=12), missed recruitment window (n=10), a hospital stay less than 3 weeks (n=5), less than 18 years old (n=3), exercise physiologist not available for testing (n=3), unable to speak or understand English (n=2), VO2peak testing equipment unavailable (n=2), bleeding, thrombosis, hemodynamically unstable, uncontrolled pain (n=2), prior malignancy (n=2), unable to provide informed consent (n=1), or patient discharged to hospice (n=1).