The Link Between Ambulatory Dysfunction and Mortality in Cancer Survivors

Assessing and Improving Mobility in Cancer Survivors

Dr Salerno’s findings suggest that asking survivors about their perceived walking pace in terms of estimated miles per hour, for example, may represent a simple way to identify those who may warrant additional screening and testing to detect and assess the degree of ambulatory dysfunction. Comparing self-reported ambulatory function to objective measures “would allow us to determine if and how we need to target ambulatory function after cancer to have a lasting impact on survival.”

Dr Winters-Stone recommended that clinicians monitor patients for slowing or changing gait and weakness: “Watching a patient walk down the hall or getting out of a chair can reveal signs of functional decline. Providers can also ask patients how well they are functioning independently and how much time they are spending in a chair or in bed,” she explained. Caregivers may be included in such conversations to provide further insights into a patient’s ambulatory capacity.

As is the case within the general population, exercise in various forms — including strengthening, stretching, and endurance exercises — may be helpful in preserving function in cancer survivors. Dr Winters-Stone and colleagues have conducted multiple studies to explore the effectiveness of resistance training in preserving function in older cancer survivors. “For example, one of our studies found that resistance training reverses self-reported disability in [patients with] prostate cancer on androgen deprivation therapy — a type of treatment we have also shown increases the risk of frailty and falls,” she said.^4,5

Additionally, Dr Salerno mentioned a roundtable report⁶ from the American College of Sports Medicine (co-authored by Dr Winters-Stone) that “highlights strong evidence for the benefits of physical activity for reducing anxiety, depressive symptoms, fatigue, and lymphedema, as well as improving health-related quality of life and physical function, in cancer survivors.”

For patients who are unable or unwilling to engage in more formal types of exercise, efforts to reduce sedentary time and incorporate short bouts of movement into their day can be helpful, Dr Winters-Stone advised.

In a study published in 2023, Aronson et al examined the effects of an in-hospital intervention in which patients on an oncology unit (without bedrest orders) were mobilized at least 2 times per day with the assistance of a mobility aide. Each session was tailored to the abilities the patient and lasted 15 to 30 minutes.²

Compared with patients who did not receive the intervention, those who were mobilized showed significantly lower odds of hospital readmission within 30 days of discharge (OR, 0.53; 95% CI, 0.37-0.78; P =.001) and greater mobility as indicated by a final score at or above the median (OR, 1.60; 95% CI, 1.04-2.45; P <.05) on the nurse-administered Activity Measure for Post-Acute Care (AMPAC) questionnaire.²

Aiming to increase “patients’ mobility during their hospital stay represents a key opportunity to prevent functional decline in both the short term and long term,” the authors wrote.²

Dr Winters-Stone noted that referral to physical therapy can be an excellent resource to improve physical activity in cancer survivors, and “given the role of muscle mass and weight in mobility, referral to a nutritionist might also help to ensure that patients have adequate dietary intake to preserve muscle and health.”

Remaining Clinical and Research Needs

Dr Winters-Stone cited a range of remaining needs to better understand and address ambulatory dysfunction in cancer survivors, including education for patients and providers regarding the effect of cancer and cancer treatment on mobility to facilitate integration of this aspect into standard care.

“This could be simply integrated into patient charts, and clinicians could ask simple questions or administer short clinical tests to document mobility at baseline and watch for declines that indicate a need for intervention,” she suggested. “There also needs to be a much more ubiquitous and seamless relationship between oncology and rehabilitation to initiate surveillance of patient function and trigger referrals when appropriate.”

In terms of research, there is a need for further study to “identify the precise etiology and predictors of functional decline, to identify characteristics of patients at high risk of functional decline with treatment, and to determine the optimal timing and type of intervention to preserve function,” Dr Winters-Stone added. In an ongoing NIH-funded study (PATTERN; ClinicalTrials.gov Identifier: NCT05790538), she and colleagues are investigating the development of peripheral neuropathy and its effect on patient functioning during and after chemotherapy.⁷ “We hope PATTERN can begin to address the research gaps I mentioned.”

Dr Salerno pointed to the need for additional research regarding screening and intervention for ambulatory dysfunction in cancer survivors. Given the numerous competing demands placed on both patients and providers after a diagnosis, future “research into the design and implementation of screening processes and referral mechanisms that are low-burden and low-cost will be imperative for maximizing health during survivorship,” she stated.

References

1. Huang MH, Blackwood J, Godoshian M, Pfalzer L. Factors associated with self-reported falls, balance or walking difficulty in older survivors of breast, colorectal, lung, or prostate cancer: Results from Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey linkage. PLoS One. 2018;13:e0208573. doi:10.1371/journal.pone.0208573
2. Aronson JH, Allen OS, Berkalieva A, et al. Benefits of an early mobility program for hospitalized patients with cancer. JCO Oncol Pract. Published online April 21, 2023. doi:10.1200/OP.22.00761
3. Salerno EA, Saint-Maurice PF, Willis EA, Moore SC, DiPietro L, Matthews CE. Ambulatory function and mortality among cancer survivors in the NIH-AARP Diet and Health Study. Cancer Epidemiol Biomarkers Prev. 2021;30:690-698. doi:10.1158/1055-9965.EPI-20-1473
4. Winters-Stone KM, Dobek JC, Bennett JA, et al. Resistance training reduces disability in prostate cancer survivors on androgen deprivation therapy: evidence from a randomized controlled trial. Arch Phys Med Rehabil. 2015;96:7-14. doi:10.1016/j.apmr.2014.08.010
5. Winters-Stone KM, Moe E, Graff JN, et al. Falls and frailty in prostate cancer survivors: Current, past, and never users of androgen deprivation therapy. J Am Geriatr Soc. 2017;65:1414-1419. doi:10.1111/jgs.14795
6. Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: Consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51:2375-2390. doi:10.1249/MSS.0000000000002116
7. ClinicalTrials.gov. Predicting the impact of treatment toxicities on health during cancer.  ClinicalTrials.gov Identifier: NCT05790538. Updated March 30, 2023. Accessed July 4, 2023.