Combined aerobic and resistance training improves bone health of female cancer survivors Hawley C. Almstedt a, ⁎, Silvie Grote a,b , Joshua R. Korte a , Stephanie Perez Beaudion a , Todd C. Shoepe a , Sarah Strand a , Heather P. Tarleton a a Department of Health and Human Sciences, Loyola Marymount University, Los Angeles, CA, USA b Center for Nutrition, Healthy Lifestyle, and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, CA, USA abstract article info Article history: Received 22 July 2016 Received in revised form 7 September 2016 Accepted 20 September 2016 Available online 21 September 2016 Introduction: Cancer pathogenesis and resulting treatment may lead to bone loss and poor skeletal health in survi- vorship. The purpose of this investigation was to evaluate the influence of 26 weeks of combined aerobic and resis- tance-training (CART) exercise on bone mineral density (BMD) in a multi-racial sample of female cancer survivors. Methods: Twenty-six female cancer survivors volunteered to undergo CART for 1 h/day, 3 days/week, for 26 weeks. The Improving Physical Activity After Cancer Treatment (IMPAACT) Program involves supervised group exercise sessions including 20 min of cardiorespiratory training, 25 min of circuit-style resistance-training, and 15 min of ab- dominal exercises and stretching. BMD at the spine, hip, and whole body was assessed using dual-energy X-ray ab- sorptiometry (DXA) before and after the intervention. Serum markers of bone metabolism (procollagen-type I N- terminal propeptide, P1NP, and C-terminal telopeptides, CTX) were measured at baseline, 13 weeks, and at study completion. Results: Eighteen participants, with the average age of 63.0 ± 10.3 years, completed the program. Mean duration since completion of cancer treatment was 6.2 ± 10.6 years. Paired t-tests revealed significant improvements in BMD of the spine (0.971 ± 0.218 g/cm 2 vs. 0.995 ± 0.218 g/cm 2 , p = 0.012), hip (0.860 ± 0.184 g/cm 2 vs. 0.875 ± 0.191 g/cm 2 , p = 0.048), and whole body (1.002 ± 0.153 g/cm 2 vs. 1.022 ± 0.159 g/cm 2 , p = 0.002). P1NP declined 22% at 13 weeks and 28% at 26 weeks in comparison to baseline (p b 0.01) while CTX showed a non-significant decrease of 8% and 18% respectively. Conclusions: We report significant improvements in BMD at the spine, hip, and whole body for female cancer sur- vivors who completed 26 weeks of CART. This investigation demonstrates the possible effectiveness of CART at im- proving bone health and reducing risk of osteoporosis for women who have completed cancer treatment. The IMPAACT Program appears to be a safe and feasible way for women to improve health after cancer treatment. © 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Bone mineral density Osteoporosis Oncology Cancer-induced bone loss Bone turnover markers 1. Introduction Improvements in cancer treatment and detection, as well as growth of the population, have led to increased survival rates among those diag- nosed with cancer. As of 2014, there was an estimated 14.5 million can- cer survivors in the United States, 64% who are 5-year survivors, while 15% are 20-year survivors [1]. Cancer survivors are living longer but experience greater comorbidity than age-matched peers who never had cancer. Survivors demonstrate comorbidities such as higher rates of obesity, type 2 diabetes, cardiovascular disease, and osteoporosis [2–4]. Osteoporosis is a chronic disease of low bone mass, characterized by skeletal fragility and increased risk for fracture. Women experience a greater burden of this disease accounting for 80% of people with osteoporosis. Previous research reports that 12 months of treatment for a gyneco- logical cancer can cause 6–10% reduction in bone mineral density (BMD) due to elevated resorption during treatment [5]. Elevated re- sorption and its associated loss in BMD increases risk for fracture. In fact, women with a history of breast cancer experience significantly more skeletal fractures than women who never had breast cancer [6]. Bone loss during cancer treatment appears to be in addition to losses ex- perienced with cessation of ovarian function. Survivors of gynecological cancers, who were diagnosed before menopause and underwent Bone Reports 5 (2016) 274–279 Abbreviations: BMD, bone mineral density; BTM, bone turnover marker; CART, combined aerobic and resistance training; CTX, C-terminal telopeptides; DXA, dual- energy X-ray absorptiometry; FFQ, food frequency questionnaire; IMPAACT, improving physical activity after cancer treatment; P1NP, procollagen-type I N-terminal propeptides; NTX, N-telopeptide cross-linked collagen type I. ⁎ Corresponding author at: Department of Health and Human Sciences, 1 LMU Drive, MS 8888, Loyola Marymount University, Los Angeles, CA 90045, USA. E-mail address: Hawley.almstedt@lmu.edu (H.C. Almstedt). http://dx.doi.org/10.1016/j.bonr.2016.09.003 2352-1872/© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 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