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Dec 16, 2012 - T he adolescent and young adult (AYA) cancer patient population is a medically and developmentally unique

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Journal of Adolescent and Young Adult Oncology About This Journal...

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Exploring the Role of Physical Activity During Palliative Care for Adolescent and Young Adult Cancer Patients

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To cite this article: Hillary M. Woodside and Melanie R. Keats. Journal of Adolescent and Young Adult Oncology. March 2013, 2(1): 35-37. https://doi.org/10.1089/jayao.2012.0016

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Published in Volume: 2 Issue 1: March 7, 2013 Online Ahead of Print: December 16, 2012

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Hillary M. Woodside1 and Melanie R. Keats, PhD1,2,3

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1School of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia, Canada. 2School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada.

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3Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.

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Address correspondence to: Melanie R. Keats, PhD School of Health and Human Performance (Kinesiology) Dalhousie University P.O. Box 15000 6230 South Street Halifax, Nova Scotia B3H 1T8 Canada Email: [email protected]

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Related content in Liebert Online T HE ADOLESCENT AND YOUNG ADULT (AYA) cancer patient population is a medically and developmentally unique group that is distinctly different from the pediatric and older adult cancer populations.1 Notwithstanding the unique biological and medical issues surrounding cancers in adolescence and young adulthood, the developmental tasks of the AYA with cancer are no different than those of their “healthy” peers.2 Specifically, a developmental cornerstone of the AYA is transitioning from extreme independence to becoming an autonomous, healthy adult. In the face of a palliative cancer diagnosis (i.e., progressive, incurable disease with a life expectancy of less

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than 12 months),3 the challenge becomes to foster their development (e.g., peer social inclusion and parental independence) while acknowledging that they are dying.2 With a cancer diagnosis, AYA-aged patients often feel isolated, disconnected, and alone.1 This sense of isolation can greatly decrease the AYA palliative cancer patient's (PCP) quality of life (QOL), thus negatively impacting the overall remaining life they have to live. The implications for providing a sound supportive care plan to maintain the AYA cancer patient's

Hillary M. Woodside Melanie R. Keats

QOL (i.e., the degree to which individuals are able to carry out the activities or social interaction that are most valuable to them) 4 are undoubtedly complex, as these individuals are trying to plan for a life that is quickly coming to an all-too-early end. With cancer being the leading cause of disease-related death in AYAs, it would seem appropriate to identify additional ways to improve QOL during palliative

palliative care

care. One modality that has shown promise in both cancer patients and survivors is physical activity (PA).3,5–8

physical activity quality of life

Implications of a Palliative Cancer Diagnosis

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supportive care symptom management autonomy

Palliative disease results in a progressive loss of QOL due to treatment- and disease-related side effects (e.g., pain, fatigue) and the inability to carry out activities of daily living (ADLs).9–11 Losing the ability to perform ADLs independently is reported as one of the most distressing concerns during palliative care.12,13 As a group striving for autonomy, the loss of independence is of great concern. Cancerrelated symptoms reported to hinder the ADLs of AYA-aged cancer patients, in order of highest to lowest frequency, are: cancer-related fatigue (CRF), reduced mobility, pain, and poor appetite.13 Wein et al. found that 89% of AYA-aged cancer patients reported experiencing

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three or more of these symptoms,13 which can contribute to the increase in total suffering experienced by the PCP. It is also important to emphasize the frequency and burden of CRF. CRF has been reported among 60%–90% of adult PCPs, and is associated with anxiety, depression, pain, dyspnea, insomnia, anorexia, nausea, and drowsiness.9 CRF is a key contributor to diminishing ADLs and, by consequence, affects the PCP's overall QOL.9 To help manage cancer and its treatment-related symptoms while maintaining the patient's QOL, those not responding to curative treatment are often placed under palliative care.14 The main goal of palliative care is to maximize the QOL of the PCP by managing their cancer-related symptoms and minimizing physical and emotional distress.3,4,13,15 Due to medical and technological advancements, the survival times of PCPs have been increasing.11 While the successes are to be celebrated, this means that those bearing a palliative diagnosis will live longer with the burden of their cancer and its progressive functional deterioration.4,16 Current palliative care models for AYAs with cancer involve managing symptoms and offering the appropriate transitional support between health and death.13,16 This commentary highlights the potential benefits of PA and outlines the rationale for PA's inclusion in the supportive care plan to reduce further the physical and psychosocial burdens associated with a palliative cancer diagnosis in the AYAaged patient.

Palliative Care and Physical Activity

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As physical wellness is strongly associated with perceptions of QOL, it is plausible to assume that including PA into the overall supportive palliative care plan could enhance or maintain the PCP's QOL.4,9,10,15,17 In the not-too-distant past, patients with incurable malignancies were often discouraged from participating in PA. It was thought that these individuals needed to conserve their physical power; thus inactivity and rest were suggested as the most appropriate treatments.11 While a growing body of literature has emerged in support of the benefits of PA for both childhood and adult cancer patients and survivors (e.g., reduced fatigue and cancer worry and increased muscular strength, functional fitness, emotional and social well-being, self-esteem, and QOL),6–8 relatively little is known about the role of PA for the PCP. However, emerging studies in adults suggest that PA may help PCPs manage their cancer-related symptoms, preserve functional mobility, decrease sleep problems, gain an overall sense of well-being, and have a positive impact on QOL,3,5,9,11,18–20 and as such may be an essential addition to the comprehensive supportive palliative care plan.11 Even with a life expectancy as short as 3–12 months, adult PCPs who participated in a PA program reported positive results related to fatigue and emotional well-being.17 In some cases, PA has acted as a valuable means to distract the PCP from their diagnosis, giving the patient an opportunity to feel some aspect of control over their body.21 While the role of PA as a supportive care intervention in PCPs is relatively unexplored, preliminary evidence suggests that PA interventions are tolerated, wellreceived, and lead to improved patient outcomes.5,10,11

Implications for the Health Professional

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Regrettably, the literature surrounding the optimal PA prescription for PCPs is limited and inconclusive.9 Moreover, PA needs and preferences are as varied and unique as each individual.10 However, preliminary data with adult PCPs suggest that patients prefer to engage in PA immediately after completing treatment, rather than during the treatment period.10 With regards to the most preferred type of PA, adult PCPs rate walking as most desirable.10 Walking seems to be the most common form of PA because it is inexpensive, can be performed anywhere, requires minimal equipment, and the patient can set the duration and intensity unique to their daily physical status.15 The use of a bicycle ergometer has also demonstrated beneficial effects on PCPs' physical capacity.21 Yoga, an increasingly popular activity, has shown to increase disease acceptance, boost daily energy, reduce fatigue, and improve trends in pain and relaxation.22 Furthermore, group yoga has been shown to provide psychosocial benefits to PCPs, as they are able to attend classes with individuals with a similar condition.23 This may be of particular importance for AYA-aged PCPs, as forming friendships, maintaining peer support, and sharing similar experiences has been found to help AYA-aged cancer survivors cope with psychosocial problems, and may help them overcome their profound sense of isolation.24,25 With respect to location, the majority of adult PCPs appear to prefer a home-based PA program.10 Allowing the PCP to perform their PA program at home has been recognized as an approach to maintain the patient's dignity and autonomy.15 Home-based walking programs have demonstrated high adherence because they have been receptive to and respectful of the patient's needs (e.g., progressive fatigue and physical disability) and preferences (e.g., can be completed alone).10 Importantly, it appears that PA is a structured event that PCPs can look forward to and reminds the patient they still have a life to live, despite facing a palliative diagnosis.26 As no similar studies exist for AYA-aged PCPs, we look instead to the work conducted with AYA-aged cancer survivors.8,27 In the younger cohort, PA programs performed in a supervised environment, such as a hospital or university facility, have fostered the strongest PA outcomes (e.g., physical and emotional well-being).8 Improvements in functional fitness found in a professionally supervised environment may be partially attributed to the ability to immediately address any concerns or problems that may arise, consequently reducing survivor fears associated with participating (e.g., injury, increased pain or fatigue, inability to perform activities). Moreover, the one-to-one feedback and peer support provided in a group-based setting may foster greater engagement and a sense of belonging.8 While much is left to be explored, any PA intervention should be tailored to the individual and maintain a balance between the patient's needs (e.g., treatment and fatigue symptoms), preferences, and ability.10

Summary

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Recognizing both the importance of QOL and that pain and symptom management are ranked as important palliative care priorities for AYA-aged cancer patients, it would seem appropriate to incorporate a therapeutic intervention that could improve or maintain QOL and control pain.3,4,13,15 To date, the literature concerning PCPs and PA shows promise, with beneficial improvements in QOL for adult PCPs.3,5,9–11,17,19,21,22 Although still in its infancy, researchers have found that adult PCPs who participate in a PA program gain feelings of increased energy, autonomy, and independence, and that PA can provide PCPs with situations where they can set goals and experience an environment of normalcy during a very challenging time.9,15,19 PA has also been shown to help PCPs accept their diagnosis 23 and gain a greater sense of autonomy.19 Palliative care models for both adults and children are similar to those of the AYA-aged cancer patient; however, various physical and psychosocial factors underlie why these groups are distinctly different. To date, there is no direct evidence in the literature to suggest that a PA program for AYA-aged PCPs would be beneficial in improving QOL or pain and symptom management. However, studies of adult PCPs and AYA-aged pediatric cancer survivor populations suggest that there are benefits to including PA in the overall supportive care plan.3,5,9–11,17,19,21–24,26 These findings give reason to believe a PA program for AYA-aged PCPs would be a meaningful addition to current models of palliative care, and further study is encouraged.

Author Disclosure Statement

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No competing financial interests.

References

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1. Zebrack B, Mathews-Bradshaw, Siegel S. Quality cancer care for adolescents and young adults: a position statement. J Clin Oncol. 2010;28(32):4862–7. 2. George R, Hutton S. Palliative care in adolescents. Eur J Cancer. 2003;39(18):2662–8. 3. Lowe S, Watanabe SM, Courneya KS. Physical activity as a supportive care intervention in palliative care patients: a systematic review. J Support Oncol. 2009;7(1):27–34. 4. Chui Y, Kuan H, Fu I, et al. Factors associated with lower quality of life among patients receiving palliative care. J Adv Nurs. 2009;65(9):1860–71. 5. Albrecht T, Taylor A. Physical activity in patients with advanced-stage cancer: a systematic review of the literature. Clin J Oncol Nurs. 2012;16(3):293–300. 6. Mishra S, Scherer R, Snyder C, et al. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012;15(8):CD008465. 7. Mishra S, Scherer R, Geigle P, et al. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012;15(8):CD007566. 8. San Juan A, Wolin K, Lucia A. Physical activity and pediatric cancer survivorship. Recent Results Cancer Res. 2011;186:319–47. 9. Eyigor S. Physical activity and rehabilitation programs should be recommended on palliative care for cancer patients with cancer. J Palliat Med. 2010;13(10):1183–4. 10. Lowe S, Watanabe S, Baracos V, Courneya K. Physical activity interests and preferences in palliative cancer patients. Support Care Cancer. 2010;18(11):1469–75. 11. Oechsle K, Jensen W, Schmidt T, et al. Physical activity, quality of life, and the interest in the physical exercise programs in patients undergoing palliative chemotherapy. Support Care Cancer. 2012;19(5):613–9. 12. Eva D, Wee B. Rehabilitation in end-of-life management. Curr Opin Support Palliat Care. 2010;4(3):158–62. 13. Wein S, Pery S, Zer A. Role of palliative care in adolescent and young adult oncology. J Clin Oncol. 2010;28(32):4819–24. 14. World Health Organization. Palliative care. Accessed August 28, 2012 from: www.who.int/cancer/palliative/en/ 15. National Cancer Institute. Coping with cancer: supportive and palliative care. Accessed August 28, 2012 from: www.cancer.gov/cancertopics/coping 16. Kamal A, Bull J, Kavalieratos D, et al. Palliative care needs of patients with cancer living in the community. J Oncol Pract. 2011;7(6):382–8. 17. Oldervoll L, Loge J, Paltiel H, et al. The effect of a physical exercise program in palliative care: a phase II study. J Pain Symptom Manage. 2006;31(5):421–30. 18. Courneya K, Friedenreich C. Physical activity and cancer control. Semin Oncol Nurs. 2007;23(4):242–52. 19. Lowe S. Physical activity and palliative cancer care. Recent Results Cancer Res. 2011;186:349–65. 20. Clark M, Vickers K, Hathaway J, et al. Physical activity in advanced-stage cancer actively receiving chemotherapy. J Support Oncol. 2007;5(10):487–93. 21. Crevenna R, Schmidinger M, Nuhr H, et al. Aerobic exercises as additive palliative treatment for a patient with advanced heptocellular cancer. Wein Med Wochenschr. 2003;152(9):237–40. 22. Carson J, Carson K, Porter K, et al. Yoga for women with metastatic breast cancer: results from a pilot study. J Pain Symptom Manage. 2007;33(3):331–41. 23. Selman L, Williams J, Simms V. A mixed-methods evaluation of complementary therapy services in palliative care: yoga and dance therapy. Eur J Cancer Care (Engl). 2012;21(1):87–97. 24. Zebrack B, Mills J, Weitzman T. Health and supportive care needs of young adult cancer patients and survivors. J Cancer Surviv. 2007;1(2):137–45. 25. Albritton K, Bleyer W. The management of cancer in the older adolescent. Eur J Cancer. 2003;39:2584–99. 26. Gulde I, Oldervoll L, Martin C. Palliative care patients' experience of physical activity. J Palliat Care. 2011;27(4):296–302. 27. Huang TT, Ness KK. Exercise interventions in children with cancer: a review. Int J Pediatr. 2011;2011:461–512.

This paper was cited by: Understanding the experiences of adolescents and young adults with cancer: A meta-synthesis Bora Kim, Kate White, Pandora Patterson European Journal of Oncology Nursing. Oct 2016, Vol. 24: 39-53 Crossref A Feasibility Study to Measure Physical Activity, Fatigue, Sleep–Wake Disturbances, and Depression in Young Adults During Chemotherapy Jeanne M. Erickson, PhD, RN, Katharine E. Adelstein, MSN, RN, and Lisa C. Letzkus, RN, MSN, CPNP-AC Journal of Adolescent and Young Adult Oncology. Mar 2014, Vol. 3, No. 1: 37-41 Abstract | Full Text PDF or HTML | Reprints | Permissions | Download Metadata About This Journal...

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