The effect of two exercise programs on the rehabilitation of individuals with colorectal cancer in an inpatient setting in Germany

Dissertation / Doktorarbeit von Liat Levy

Abstract:

Research in the field of exercise therapy for cancer patients primarily focused on individuals with breast cancer who receive exercise interventions under outpatient conditions. This research study investigated individuals with colorectal cancer under inpatient conditions and aimed to broaden the application of exercise intervention treatments beyond that of breast cancer. The research included two study groups; standard exercise group (SEG, n=44) receiving indoor gymnastic exercise (IGE) and modified exercise group (MEG, n=39) receiving IGE plus additional outdoor walking activity. Participation in the specific exercise therapy program was independent of other therapies received in the inpatient rehabilitation program (IRP). The patients completed QOL questionnaires (QLQ-C30 & QLQ-CR38), psychological distress scale (HADS) and underwent treadmill stress-testing (TST) at the beginning (T1) and upon completion (T2) of the IRP. The QOL and the HADS questionnaires were administrated after a six month follow up (T3) proceeding the IRP completion.

Results indicate significant QOL and HADS improvements in pre to post-testing for both study groups. The TST results indicate superior improvements in the MEG in comparison to the SEG. Some of the T1 to T2 QOL and HADS improvement maintained at T3.

We conclude that 3 weeks IRP was adequate to reveal improvements in QOL, psychological measures and functional capacity. Future research should emphasize patient motivation for participation in physical activity after completing IRP.

This background chapter encompasses the different fields of knowledge which are relevant to the present study, starting with colorectal cancer (epidemiology, etiology, pathology and the International Classification of Functioning, Disability and Health), continuing with the subjects Quality of life, Movement and Sports in the Rehabilitation. The chapter ends with a review of previous physical activity and cancer studies.

Descriptive epidemiological knowledge of colorectal cancer is essential for understanding the etiology of the disease and is used in the process of developing screening methods. Large bowel carcinoma is one of the most common cancers in the western world (15% of all cancer cases) and despite advanced diagnostic and therapeutic methods, the prognosis is relatively poor (Faivre et al. 2002). The WHO classification supplies the mortality data of colon cancer separately from rectum cancer. However, the information on death certificates is often imprecise and does not enable correct classification. That is the reason for the presentation of malignant neoplasm of the colon and rectum in the literature as a single entity (Becker & Wahrendorf 1998, 162). Considering colon and rectum to be a single unit does not allow recording the epidemiological characteristic differences between colon and rectal cancer. One of those differences is the magnitude of geographical variation of the incidence rate between high and low risk areas. For rectal cancer there are four to fivefold variations in incidence rates between high and low risk areas, whereas these variations for colon cancer is 10 to 15-fold (excluding Africa). Furthermore, there are often variations of high risk areas for colon and rectal cancer. In North America and Australia, colon cancer is more frequent than rectal cancer, while in Europe the colon cancer incidence rate is rather similar to rectal cancer rates. The International Classification of Diseases (ICD) allows the colon cancer descriptive epidemiology to study the subsites of the colon. Incidence rates of right colon cancer are similar for both genders, whereas left colon cancer is more frequent in males and shows a higher incidence rate than that of right colon cancer in males, this is true especially for populations with a high risk of colon cancer. By women in North America right colon cancer is more frequent than left colon cancer, while in Europe women show a slight predominance of left colon cancer (Faivre et al. 2002).

Statistics of cancer mortality in Germany relies on the death certificate, and therefore is reliable. In the German Federal Republic there is no official documentation for the number of new cases. The federal state Saarland is the only state which has long term documentation for all cancer diseases. Therefore, the number of new cases of all cancer diseases can only be estimated. The estimated number of new cases is published annually by the Robert Koch institute, this publication is based on the national German cancer register. Nowadays all the federal states in Germany are in the process of preparing for future official documentation of new cases for all cancer diseases (Schriftenreihe des Bundesministeriums für Gesundheit 2001, 122).

Statistical Data – Germany: The German statistical federal department report indicates for the year 2000 that 25% of all the death cases were caused by cancer. The total number of death cases for that year were 838,796 (388,981 males and 499,815 females) and the total number of death cases caused by cancer were 211,000 (109,700 males and 101,300 females) (Statistisches Bundesamt 2001). The colorectal cancer statistics in Germany show in the west higher mortality for colon cancer and in the east higher mortality for rectal cancer. Here, too, the data might be biased because of false classification. These two types of cancer together represent the second leading cause of cancer death in Germany. The colorectal cancer mortality rate is almost identical in both parts of Germany: approximately 12% in males and 14% in females. The incidence rate for colorectal cancer is significantly higher than the mortality rate. In 1995 the number of colorectal cancer death cases was 13,465 males and 17,094 females (Becker & Wahrendorf 1998, 188), while the estimated annual incidence is 22,800 new cases of colorectal cancer in male, and 27,700 new cases of colorectal cancer in female (Becker & Wahrendorf 1998, 162). The great difference between the incidence and death rates is explained through the high survival rate of colorectal cancer. Fifty to sixty percent of newly diagnosed colon cancer and 70% to 80% of rectum carcinoma patients are cured (Markman 2003, 215). The relative 5 years survival in male and females in Germany is shown in Table 1.

Time trends in Germany: The decades following the Second World War were characterized by a significant increase in the mortality rate from colorectal cancer. This tendency lasted through the mid 1970’s; thereafter no increase was shown in Western Germany. The recorded tendency since reaching the stable level in the end of the 1980’s was a slight reduction of male mortality and even greater decline of female mortality. On the other hand, Eastern Germany showed until 1990 a consistently lower mortality rate than in Western Germany (for both genders). In 1990 following German reunification the colorectal mortality rates in Eastern Germany have shown a steady rise, this increase was greater for males than for females and reached the levels of West German mortality rates.

The incidence rate of colorectal carcinoma varies greatly throughout the world. The latest world data (1988-1992) provided by cancer registers show very high incidence rates in North America, Australia and New Zealand. The incidence rate in Europe and Japan are slightly lower. A great variation in incidence rates is found within continents and countries, for example in Europe: the incidence rate for males in Triest, Italy is 49.4 per 100,000 compared to 16.4 in Kielce, Poland. Female incidence rates vary in Europe from 31.4 per 100,000 Saarland, Germany to 10.3 per 10,000 in Kielce, Poland. One of the highest incidence rate is found in the Czech Republic and that is despite general low incidence rate which is recorded in Eastern Europe. This tendency of contrasted incidence rates is also observed in Northern Europe. In Southern Europe, a high incidence rate is reported in Northern Italy and low rates in Greece (Faivre et al. 2002).

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