Preoperative Exercise for Patients with Pancreatic Cancer: Feasibility, Influences, and Outcomes

Risk for adverse disease- and treatment-related outcomes increases with older age and prevalent frailty, cachexia, and sarcopenia among patients with pancreatic cancer, the 3rd leading cause of US cancer-related death. Complex surgeries can allow for longer-term survival among patients with resectable tumors, but postoperative recovery is arduous. Preoperative treatment for pancreatic cancer frequently entails chemotherapy and chemoradiation that contribute to reduced fitness. Therefore, maintaining preoperative health and well-being provides an important intervention target. The purpose of this project was to determine the feasibility of multimodal exercise among patients undergoing preoperative treatment for pancreatic cancer and to examine adherence-related influences and outcomes. Fifty eight patients [48.3% female, mean age 65.8 (SD=7.7)] with localized pancreatic adenocarcinoma enrolled and completed study requirements from 2015-2017. Patients were encouraged to perform ≥120 minutes of moderate-intensity, multimodal exercise per week (≥60 min aerobic and ≥60 min strengthening exercise). Patients received instruction and equipment (resistance tube sets, pedometers), materials (video and printed/photo instructions) and regular phone communication to encourage adherence. Physical activity (PA) and exercise adherence were measured using questionnaires, daily logs, and accelerometers. Socioecological physical activity supports, such as social support from family and friends and perceived neighborhood walkability, were measured using questionnaires. Outcome measures included self-reported health-related quality of life (QOL) and skeletal muscle cross-sectional area in computerized tomography (CT) scans. A subsample participated in structured, qualitative interviews to examine overall satisfaction, suggestions for improvement, and perceived barriers, facilitators, and outcomes related to participation. Patients reported significantly higher physical activity at preoperative restaging compared to baseline [mean(SD) weekly metabolic equivalent minutes 2321.4(2282.8) vs. 1370.4(1833.7), Z(51)=-2.2, p=.03]. Including all preoperative phases (chemotherapy, chemoradiation, and rest), patients reported, on average, 168.3 minutes of multimodal exercise per week (SD=88.2). Patients exceeded the weekly recommendation for aerobic exercise minutes [mean(SD)=124.8(81.2)] but did not meet the weekly strengthening recommendation [mean(SD)=43.3(31.8)]. Average accelerometer-measured moderate-to-vigorous physical activity was 145.8 min/week (SD=135.7). There were no statistically significant differences in physical activity or exercise adherence by phase. Social support and exercise adherence had weak but statistically significant associations after adjusting for age, sex, and surgical determination. Family participation and weekly strengthening minutes (ß=.36, p=.03) and overall strengthening volume (ß=.40, p=.02), between family rewards and punishment and strengthening volume (ß=.56, p<.01), and between family and friend participation and weekly strengthening minutes (ß=.35, p=.03) and strengthening volume (ß=.38, p=.03) were all positively associated. Weekly accelerometer-measured light and total physical activity and QOL at preoperative restaging were positively associated (ß=.35, p=.04 and ß=.35, p=.03, respectively) after adjusting for age, sex, exercise program duration, and final surgical determination. There were also positive associations between aerobic and multimodal exercise volumes and change in skeletal muscle cross-sectional area (ß=.31, p=.03 and ß=.32, p=.02, respectively) from baseline to preoperative restaging. In qualitative interviews, patients expressed general program satisfaction and recommended fitness facility use to increase strengthening exercise adherence. Patients identified disease- and treatment-related fatigue and side effects as exercise barriers. However, patients widely agreed that social support from family and friends and accountability through daily exercise logs and communication with program staff helped them overcome these barriers. Finally, patients perceived reduced fatigue and improved fitness leading to surgery, which they attributed to consistent preoperative exercise. These findings indicate that exercise is generally feasible for patients undergoing preoperative treatment for pancreatic cancer, but extra support may improve strengthening exercise adherence. Clinicians and researchers should formally incorporate exercise in treatment plans for patients with potentially resectable pancreatic cancer. Future studies should further explore the potential for exercise to improve perioperative health and well-being and identify additional factors influencing exercise motivation in this context.