Exercise Is Medicine: Restoring Function in Older Adults with Hematologic Malignancy

Background: Exercise programs are proven to positively impact physical fitness, quality of life, and late toxicities in cancer patients, and many recent reports document the benefit of exercise in patients with diverse cancers.^1-3 However, such programs are underutilized in patients with hematologic malignancy.^2,3 As anemia and thrombocytopenia associated with hematologic diseases are risk factors for falls and bleeding complications, exercise has not been routinely recommended. Thus, exercise programs have yet to gain traction in patients with hematologic malignancy and are rarely seen as a preventative measure for functional decline. Of critical importance, functional decline is not an inevitable part of illness or aging and is potentially modifiable.^4,5 Here, we identified older adults with functional decline and incorporated a preventative exercise program to attenuate complications associated with disease- and therapy-related de-conditioning.

Methods: This is a single center, pilot prospective study of older adults (≥60 years) with hematologic malignancy actively receiving chemotherapy. Patients enrolled had mild or moderate impairments in physical function, as defined by a score ≤9 on the Short Physical Performance Battery (SPPB). The SPPB is an objective, validated tool used to capture at risk patients and has been shown to be prognostic in predicting decline in function, re-hospitalization, and mortality.⁶ The primary objective was to assess the feasibility of implementing a structured exercise program; including recruitment and retention, adherence, sustainability, adverse events and implementation challenges. Reasons why patients decline exercise participation were also tracked. The Otago Exercise Program (OEP) has been found to be an effective exercise regimen to improve functional balance, muscle strength, and prevent fall-related injury and mortality.⁸ The OEP is a structured combination of physical therapist prescribed individualized exercise plans with home-based exercise, demonstrated to improve balance and functional decline.⁹ The OEP focuses on strengthening, balance retraining, and walking.

Results: Older adults actively receiving chemotherapy with a median age of 75.5 (62-83) with hematologic malignancy (myeloma=18, NHL=6, leukemia=5) were enrolled. Chemotherapy regimens were variable (e.g. R-EPOCH, venetoclax, IMiDS, proteasome inhibitors, bone marrow transplant). Patients were approached (n=63) for participation of a structured exercise program and a target accrual of n=30 was achieved over 17 months. Reasons for declining participation included travel (n=13), inconvenience (n=12), not appropriate (n=5) or concern for side effects/cost/uninformed (n=3). There was no relationship with distanced traveled and exercise completion, R=-0.01 (p=0.94). Adherence was excellent with all 8 sessions complete (n=18) or 7 sessions complete (n=4), at time of analysis. Geriatric assessment factors were analyzed at baseline (Visit 1) and following 4 months of exercise (Visit 2). Physical health scores as measured by the MOS-PFS increased significantly [MOS-PFS: V1=55 (0-100), V2=67.5 (30-100), p=0.005], where patient reported KPS were similar [KPS V1=80 (40-100), V2=85 (60-100), p=0.065]. Importantly, objective measures of physical function improved to normal scores by visit 2 [SPPB V1=7(0-11), V2=11(2-12), p<0.001]. Moreover, quality of life scores by PROMIS demonstrated improvement in physical health symptoms. No adverse events were attributable to exercise.

Conclusions: In this pilot study evaluating a structured exercise program for older adults undergoing chemotherapy, physical deficits normalized for patients, resulting in improved subjective and objective measurements of functional capacity. The program was feasible, sustainable and adherence was optimal. Here we demonstrate that exercise programs can attenuate complications associated with disease- and therapy-related de-conditioning and are feasible in older adults.