Because we observed different values for %HRR between the two time points without change in V˙O2max and Pmax values, our results also indicate that the relationship between HR and V˙O2 may have changed after intensive treatment. Although the results of the paired t-tests did not reach significant levels, this change should be considered when prescribing exercise intensities.
Despite having a large homogeneous sample, we observed a relatively large SD for %HRR, indicating that there is some heterogeneity in the data. Our regression models revealed influence of hemoglobin levels, gender, BMI, and age on the relationships; therefore, these parameters may also be important to consider when defining intensity prescriptions; when using values estimated from the equation 220 − age, the variation was even larger. However, recommendations on individual level, for example, using threshold concepts (e.g., VT and respiratory compensation point), might be more useful for identifying the appropriate exercise intensity for an individual patient. When this is not possible, our values provided in the tables can be used instead. In addition, we provide information about %Pmax and %VT because these parameters are also frequently used for prescribing exercise intensity in clinical practice. Our data show that %V˙O2max did not correspond to %Pmax, an important finding because both are frequently used interchangeably in practice. Notably, in our patients, VT occurred at 40% V˙O2max, which is lower than that in untrained healthy people (23). VT was already suggested as an indicator for functional capacity in diseased patients when maximal incremental tests are not possible (23). However, our maximal CPET protocol was not ideal for cancer patients (see below), and therefore, these results should be interpreted with caution. Further studies should focus on determining whether VT as a submaximal parameter can be used to give adequate endurance training prescriptions for these patients. In addition, prolonged exercise tests should be performed to further evaluate our recommended intensity values.
Our results are quite important from a clinical perspective because first studies in hematological cancer patients after HCT show a potential relationship between cardiorespiratory fitness and survival (40), underlying the high importance of adequate exercise programs that target an optimal effect on cardiopulmonary fitness. Furthermore, our results underscore the need of individualized exercise prescriptions in this patient group. This finding complements with other results from our group showing that the individual exercise training response depends on baseline fitness level in allo-HCT patients (38).
One strength of our analysis is the large patient population. All patients received allo-HCT, an aggressive and demanding treatment that is known to profoundly affect physical performance. Furthermore, we included two measurement points to see if the relationship between HR and V˙O2 changes over time. Moreover, we used single linear regressions to calculate intensity categories. However, a methodological limitation is that our maximal CPET protocol started at a relatively high intensity (50 W); therefore, the lowest intensity class might be imprecisely represented, especially in patients with low physical performance. The assessment of resting V˙O2 did not fulfill the criteria for resting measurement. However, Cunha et al. (9) did not find a significant effect of different resting measurement conditions on the regression equation between V˙O2R and HRR.
It becomes increasingly evident that maintaining cardiorespiratory fitness during cancer treatment and regaining fitness after treatment improves different outcomes, right up to survival. Despite a large body of evidence, accurate intensity recommendations regarding endurance training do not exist; instead, recommendations for healthy subjects are used. Our data show that this exercise intensity classification may not be valid in hematological cancer patients before and 180 d after allo-HCT because it may result in over- or underestimation of exercise intensity. We provide exercise intensity classifications that were derived from a large population of hematological cancer patients before and after allo-HCT. These classifications can be used to define more appropriate exercise prescriptions in hematological cancer patients and to compare intensities used in previous studies. Because of variability in the observed data, more research is needed to further evaluate optimal exercise intensities with respect to different treatment conditions in hematological cancer patients.
The authors thank the study participants who spend their time, Andrea Bondong, Linda Keilbach, and Kristin Zerfass from the case management in the allogeneic transplantation ambulance at the University Clinic Heidelberg for recruitment and coordination assistance, the MTAs of the department of Sports Medicine at the University Clinic Heidelberg for assistance in CPET, and Michael Paskow for critically reading the manuscript.
This study was funded by the German José Carreras Leukemia Foundation (project no. R10/42pf).
The authors declare no conflict of interest.
The results of the present study do not constitute endorsement by the American College of Sports Medicine.
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