DISCUSSION
esophageal cancer, lower extremity muscle strength, muscle mass
ESOPHAGEAL CANCER, RECRUITMENT, OESOPHAGEAL CANCER
This trial demonstrated that a specially designed 12‐week home‐based PA program improved lower extremity muscle strength among patients having undergone surgery for esophageal cancer 1‐year earlier, while no influence on hand grip strength or muscle mass was identified.Some methodological strengths and weaknesses of the trial should be considered. A major strength was the nationwide multicentered design that ensured that all eligible patients were identified yielding a high enrolment rate. Adherence to a rigorous protocol enabled homogeneity in the recruitment process also uniformity and completeness of the data collected. Moreover, a comprehensive variable list with patient and clinical data allowed for adjustment for predefined confounders and variables observed to vary between intervention and control groups at baseline. Another notable strength is the unique home‐visit design for data collection by the research nurse at baseline and research dietician at follow‐up, which aided increased completeness and reduced missing values at both time points. One potential limitation may have been the exclusion of patients not willing to start a PA intervention may present a potential for selection bias. In addition, a slightly higher attrition rate in the intervention group than the control group also may have contributed to some extent of selection bias. Another limitation is that although preoperative BMI was adjusted for in the analysis, unknown confounders such as pre‐operative muscle mass and distribution of body fat among patients may have still differed between the groups but unaccounted for in the analysis but the RCT design may help reduce these imbalances. In addition, the higher drop‐out rate (17% of those randomized) than assumed in the original sample size calculated is another limitation in the present study.To our knowledge, this is the first RCT to examine the effectiveness of a home‐based PA intervention in long‐term survivors of esophageal cancer. The results cannot be directly compared to other exercise trials among post‐operative esophageal cancer survivors since they were not conducted at the same time point after surgery. In other studies testing exercise interventions after esophageal cancer surgery, the intervention was either multidimensional including both PA and nutritional components or conducted immediately after surgery.A distinctive strength of our trial was the home‐based exercise intervention, that was designed to personalize the intervention according to patient specific considerations such as their average age, invasive treatment history and a nationwide recruitment. The intervention was designed to be simple, safe, easy to perform, monitored from distance, and inexpensive. Home‐based exercise programs show promising potential for effective improvement of symptoms, exercise capacity, and quality of life in patients with lung,The long and incomplete recovery with substantial limitations in long‐term recovery in postoperative survivors of esophageal cancer is a concern for patients, healthcare, and society. Most patients need many follow‐up appointments with healthcare during several years, and the limited availability of interventions that can help these patients is a great concern. Thus, the focus on the role of a physical training program after surgery for esophageal cancer in improving muscle strength, which is a major determinant of physical recovery, is imperative. The results of this trial, testing the intervention of a tailored 12‐week home‐based PA program contribute to the development in the post‐operative management of these patients. The results show promising potential for encouraging patients to be physically active after surgery and in turn enhance the rehabilitation and provide a novel and robust tool for better recovery. An improved recovery would decrease the burden on healthcare by increasing patient self‐care and reducing the need for further or extra appointments. A research partnership group consisting of patients operated on for esophageal cancer were presented with the results of the present study and inputs from their interpretation of the results are included in the discussion above.In conclusion, this nationwide multicenter RCT demonstrated that a tailored home‐based PA intervention induced improvement in lower extremity muscle strength among esophageal cancer patients who underwent surgery for esophageal cancer 1‐year earlier. Although further investigations are warranted to determine the optimum intensity of the intervention and potential measurement bias, the results should be enough for encouraging patients to be physically active after surgery in the longer term to improve the recovery.