Abstract
ground/Objectives:Endurance exercise increases oxygen demand and, when not balanced by antioxidant defenses, consequently, oxidative stress and inflam- matory cytokines increase too. In breast cancer survivors (BCS), post-treatment, physical capacity decreases, lowering life quality. Dragon boat (DB) paddling has shown benefits in reducing lymphedema and improving psychological well-being. This study aimed at non-invasively investigating in BCS, by means of saliva and urine samples, the sys- temic responses to oxy-inflammation, and appetite hormones after a DB endurance race. Methods: 15 BCS and 15
In breast cancer survivors (BCS), post-treatment, physical capacity decreases, lowering life quality. Dragon boat (DB) paddling has shown benefits in reducing lymphedema and improving psychological well-being. This study aimed at non-invasively investigating in BCS, by means of saliva and urine samples, the sys- temic responses to oxy-inflammation, and appetite hormones after a DB endurance race. Methods: 15 BCS and 15 healthy women (5 (CTR) who performed the DB race too) were studied. BCS and CTR were monitored pre- and post-race. Reactive oxygen species (ROS) production, total antioxidant capacity (TAC), lipid peroxidation (8-iso), DNA oxidation (8-OH-dG), nitric oxide metabolites (NOx), inflammation markers (IL-6-10 and TNFα), appetite hormones, electrolytes concentration, psychometric, and physical scales were assessed.Results: At rest, compared to healthy women, BCS showed a significant increase in oxy-inflammation biomarkers. BCS showed a general increase in oxy-inflammation parameters compared to CTR after the DB race. In BCS, there were the following results: ROS: +80%; lipid peroxidation: +103%; DNA oxidation: +44%; interleukins-6: +179%; IL-10: +55%; TNFα: +9%, NOx: +60% increases and unbalanced appetite hormones: leptin (−32%); and ghrelin (+53%). Moreover, the dragon boat offered a holistic approach to recovery, addressing emotional and social needs supporting belonging, love, and esteem needs, reported to be about 56% of the motivations in this activity, while post-race the following increased: a sense of fatigue (+55%); tiredness (48%); a cold sensation (+15%); and +32% pain.Conclusions: This study provided evidence that, in BCS, a DB endurance race produces an important imbalance in the oxy-inflammation state, at the same time being accompanied by a positive impact on subjective mood and general wellness. Future studies should focus on long-term effects. J. Clin. Med.2025,14, 2532 https://doi.org/10.3390/jcm14072532
J. Clin. Med.2025,14, 2532 2 of 22 Keywords:oxidative stress; inflammation; hormones; women; breast cancer; dragon boat; exercise; endurance; mood; quality of life 1. Introduction Endurance exercise, characterized by continuous and prolonged physical activity, enhances the demand for oxygen in muscles, thus increasing reactive oxygen species (ROS) levels [1]. While moderate exercise stimulates antioxidant defense mechanisms, excessive or intense exercise without adequate recovery can exacerbate oxidative stress (OxS) and cause damage to muscle tissue [2]. OxS arises when an imbalance between ROS production and the body’s ability to neutralize them using antioxidants takes place. This process can lead to cellular damage, affecting lipids, proteins, and DNA, and has been implicated in various diseases, including cancer, cardiovascular orders, and metabolic conditions [3]. Otherwise, in the context of physical activity, training increases the antioxidant defense system accompanied by a decrease in the exercise-induced oxidative stress [4–6]. As a consequence of physical exercise, some cytokines are produced by muscle contraction, for example, IL-6 and IL-10 increase [5]. Moreover, a linear increase of IL-10 has been seen in relation to a rise in exercise duration [7,8]. Also, appetite regulation that involves a sophisticated interplay of hormones is affected by exercise and energy balance [9,10]. Breast cancer is an important global health problem. In the latest report of the World Health Organization (WHO) [11], in 2022, the incidence in Southern Europe was 81.8% with 13.8% mortality. After diagnosis and during treatments there is a reduction in indi- vidual physical capacity with a consequent reduction in the quality of life (QoL). Most of these cancers (70–80%) express an estrogenic receptor, so a five-year hormone therapy to reduce the estrogenic level is indicated. This treatment results in further impairment of musculoskeletal activity [12]. One of the post-operative complications of breast cancer is lymphedema, due to the removal of the axillary lymph nodes on the operated side, which leads to the retention of lymphatic fluid in the interstitial tissues. Regular physical exercise helps to prevent lymphedema. In particular, it has been seen that the activity carried out on the dragon boat (DB) is specific for women operated on for
of breast cancer is lymphedema, due to the removal of the axillary lymph nodes on the operated side, which leads to the retention of lymphatic fluid in the interstitial tissues. Regular physical exercise helps to prevent lymphedema. In particular, it has been seen that the activity carried out on the dragon boat (DB) is specific for women operated on for breast cancer [13]. It has now been demonstrated how important physical activity is for improving one’s quality of life thanks to the positive effects not only on the body, but also on cognitive functions [14,15]. In these contexts, the discipline of DB is inserted. Dragon boat discipline was born in China more than 2000 years ago, but it was only in 1998 that McKenzie [16] published the first study on breast cancer survivors (BCS) who participated in the Vancouver Dragon Boat Festival. Two years before, he created the first DB team constituted by BCS to prove the positive effect of this kind of sport on lymphedema and, in general, on the well-being of women with breast cancer. A dragon boat is a long canoe with 20 seats (10 on each side) with a drummer at the bow and a helmsman at the stern. In addition to the positive effects on the upper limbs, for those with lymphedema, paddling on a DB plays also beneficial effects on a psychological level and in terms of social relationships among women sharing the same problems and helping each other [13]. A study on elite rowers, a sport comparable to dragon boating, demonstrated increased markers of OxS following high-intensity exercise [6]. Many studies report the importance of physical activity in both physiological and pathological conditions (i.e., cancer patients) [17], but few studies have been carried out regarding the changes in oxidative stress and inflammatory status in patients with breast cancer who practice the dragon boat sport [18].
J. Clin. Med.2025,14, 2532 3 of 22 Considering the importance of exercise, social relationships, the psychological health benefit, and the lack of data in the scientific literature, women who are breast cancer survivors’ (BCS) pre- and post-extreme physical activity, that is an endurance race, was studied. The aim of this observational study was to monitor a breast cancer survivors (BCS) group through non-invasive methods (saliva and urine samples), oxidative stress, inflammation, and hormones of appetite changes before and after a dragon boat non- competitive endurance race (Vogalonga 2023—Venice). Subjective mood and general wellness were also evaluated to determine the effects of the dragon boat on the well-being of breast cancer athletes. 2. Materials and Methods 2.1. Study Design The study conducted on “Breast Cancer Survivors’ Dragon Boat Team” was performed in 2023 during the “47th Vogalonga”, a non-competitive paddling/rowing race of approxi- mately 32 km through the city of Venice and the lagoon, up to Burano, and returning to Venice passing through Murano. In Figure, the route of the race and the sketch of the experimental protocol are reported.J. Clin. Med. 2025, 14, 2532 3 of 21 survivors’ (BCS) pre- and post-extreme physical activity, that is an endurance race, was studied. The aim of this observational study was to monitor a breast cancer survivors (BCS) group through non-invasive methods (saliva and urine samples), oxidative stress, inflammation, and hormones of appetite changes before and after a dragon boat non- competitive endurance race (Vogalonga 2023—Venice). Subjective mood and general wellness were also evaluated to determine the effects of the dragon boat on the well-being of breast cancer athletes. 2. Materials and Methods 2.1. Study Design The study conducted on “Breast Cancer Survivors’ Dragon Boat Team” was performed in 2023 during the “47th Vogalonga”, a non-competitive paddling/rowing race of approximately 32 km through the city of Venice and the lagoon, up to Burano, and returning to Venice passing through Murano. In Figure 1, the route of the race and the sketch of the experimental protocol are reported. The only rule of the race is the use of rowing boats, without any restrictions regarding
Vogalonga”, a non-competitive paddling/rowing race of approximately 32 km through the city of Venice and the lagoon, up to Burano, and returning to Venice passing through Murano. In Figure 1, the route of the race and the sketch of the experimental protocol are reported. The only rule of the race is the use of rowing boats, without any restrictions regarding weight, size, or the number of rowers. “Vogalonga” is the most important non- competitive regatta in Venice—open to all types of rowing boats—and is a tribute to the navigation techniques of the past (from 1974), an event created to promote the use of sustainable boats and to protect the city of Venice from wave motion. The crew object of this study performed the race in 5 h, with a cruising speed of about 6 km per hour and an average of 50 paddles per minute. The weather was partly cloudy with an average temperature of 22 °C (min 19 °C–max 25 °C), humidity: 58%, average wind speed: 10 km/h, and sea level pressure: 1014 mb. Figure 1. Sketch of the experimental protocol and map showing the navigation route. Data were collected before departure (Pre-Race), and Post Race “Vogalonga 2023”. Map was obtained by Google, Inst. Geogr. National. Race route Vogalonga 2023: bacino di San Marco, canale delle Navi, canale della Bissa, canale Passaora, canale Crevan, Burano, Mazzorbo, canale S. Giacomo, canale Scomenzera, canale Bisatto, Murano, canale di Tessera, rio di Cannaregio, Canal Grande, Rialto, Punta della Salute. Figure 1.Sketch of the experimental protocol and map showing the navigation route. Data were collected before departure (Pre-Race), and Post Race “Vogalonga 2023”. Map was obtained by Google, Inst. Geogr. National. Race route Vogalonga 2023: bacino di San Marco, canale delle Navi, canale della Bissa, canale Passaora, canale Crevan, Burano, Mazzorbo, canale S. Giacomo, canale Scomenzera, canale Bisatto, Murano, canale di Tessera, rio di Cannaregio, Canal Grande, Rialto, Punta della Salute. The only rule of the race is the use of rowing boats, without any restrictions regarding weight, size, or the number of rowers. “Vogalonga” is the most important non-competitive regatta in Venice—open
della Bissa, canale Passaora, canale Crevan, Burano, Mazzorbo, canale S. Giacomo, canale Scomenzera, canale Bisatto, Murano, canale di Tessera, rio di Cannaregio, Canal Grande, Rialto, Punta della Salute. The only rule of the race is the use of rowing boats, without any restrictions regarding weight, size, or the number of rowers. “Vogalonga” is the most important non-competitive regatta in Venice—open to all types of rowing boats—and is a tribute to the navigation techniques of the past (from 1974), an event created to promote the use of sustainable boats and to protect the city of Venice from wave motion. The crew object of this study performed
J. Clin. Med.2025,14, 2532 4 of 22 the race in 5 h, with a cruising speed of about 6 km per hour and an average of 50 paddles per minute. The weather was partly cloudy with an average temperature of 22 ◦ C (min 19 ◦ C–max 25 ◦ C ), humidity: 58%, average wind speed: 10 km/h, and sea level pressure: 1014 mb. 2.2. Participants This study was conducted following the Declaration of Helsinki and was approved by the Bio-Ethical Committee of the University of Milan (Aut. n 37/17). Informed consent was obtained from all subjects involved in the study. The crew was made up of a helmsman and 20 women, 15 of them with a breast cancer history (BCS), whose characteristics are reported in Table. The remaining part of the crew was made up of 5 healthy women (CTR). Table 1.BCS group characteristics. IDC = Invasive Ductal Carcinoma of the breast; DCIS = Ductal Carcinoma in Situ. Subjects n = 15 Mean ±SD Age (years) 55.73±4.96 Body weight (kg) 65.27±12.60 Height (cm) 163.3±4.2 BMI (kg.m −2 ) 24.43±4.30 Diagnosis age (years) 46.9±5.6 Histopathological Characterization: IDC 86% (n = 13) DCIS 13% (n = 2) Years after surgery 8.8±4.9 Axillary lymph node dissection 46.7% (n = 7) Chemotherapy 53.3% (n = 8) Targeted drugs 26.7% (n = 4) Hormone therapy 73.3% (n = 11) Radiotherapy 66.7% (n = 10) Ongoing therapy 33.3% (n = 5) hormone therapy (Aromatase inhibitors, 2.5 mg/die) 6.7% (n = 1) other therapies (Levothyroxine for Hypothyroidism) Metastases 0% Recurrences 6.7% (n = 1) Experience on dragon boat (years) Range 2–5 To compare the basal values of the selected biomarkers, a control group of heathy athletic women (HFS n = 15), age 50.67±4.25 years; body weight 59.67±7.65 kg; height 165.10±1.98 cm ; and BMI 21.87±2.56 kg.m −2 , was enrolled too. Five women from this group were the components of the crew examined and they were tested pre- and post-race, too. All participants have obtained a certificate of medical sports suitability for competitive activity issued by the Italian Medical Sport Federation, FIMS/CONI. In the healthy group,
59.67±7.65 kg; height 165.10±1.98 cm ; and BMI 21.87±2.56 kg.m −2 , was enrolled too. Five women from this group were the components of the crew examined and they were tested pre- and post-race, too. All participants have obtained a certificate of medical sports suitability for competitive activity issued by the Italian Medical Sport Federation, FIMS/CONI. In the healthy group, the exclusion criteria comprised alcohol, obesity, smoking, current use of medicines, special diet, minerals, vitamins or other kind of supplementation, as well as antioxidant supply.
J. Clin. Med.2025,14, 2532 5 of 22 2.3. Sample Collection Saliva and urine samples were collected from all participants just before (at 8 a.m.: pre- race) and, from all crew components, immediately after the race (about 3 p.m.; post-race). Saliva samples were obtained using Salivette collection devices (Sarstedt Nümbrecht); the samples were centrifuged for 5 min at 1000×gand stored at –80 ◦ C for further analyses. Urine samples were contemporarily collected in sterile containers by voluntary voiding and were stored at 4 ◦ C in a portable cooler and during the transport back to the laboratory. The specimens were then stored in multiple aliquots at−80 ◦ C until assayed and thawed only once before analysis. 2.4. Biomarkers 2.4.1. ROS Detection by Electron Paramagnetic Resonance An electron paramagnetic resonance spectrometer, operating in X-band (E-Scan, Bruker Co., Manning Park Billerica, MA, USA) at 9.3 GHz was used to measure and quantitate ROS production. Samples (saliva) were stabilized at 37 ◦ C using a Tempera- ture and Gas Controller “Bio III” unit (Noxigen Science Transfer & Diagnostics GmbH, Elzach, Germany), interfaced with the E-Scan. ROS detection methods were previously described [19,20]. Spin probe 1-hydroxy-3-methoxycarbonyl-2,2,5,5tetramethyl-pyrrolidine- hydrochloride (CMH, Noxygen Science Transfer & Diagnostics, Germany) (1 mM) was used. The EPR signal, intrinsically proportional to the number of unpaired electrons of the investigated specimen, can be converted into absolute concentration (µmol·min −1 ) by using the stable CP•(3-Carboxy-2,2,5,5-tetramethyl-1-pyrrolidinyloxy) compound as a reference. By using this approach, the absolute quantification of radical species is obtained. The high reproducibility of the method has been previously demonstrated [4]. 2.4.2. Total Antioxidant Capacity (TAC) The Trolox-equivalent antioxidant capacity (TAC) assay is a commonly used commer- cial method (Cayman Chemical, Ann Arbor, Michigan, USA, Item No. 709001) and was employed to measure TAC levels. The procedure followed the manufacturer’s instructions and established protocols [21]. 2.4.3. Oxidative Damage in Urine Lipid peroxidation was assessed in urine by measuring 8-isoprostane concentra- tion (8-iso-PGF2α ) (Cayman Chemical, Ann Arbor, Michigan, USA, Item No. 516351). The method was previously described [19,22]. DNA damage (urinary concentrations of 8-OH-dG) was measured using a commercial ELISA kit (Cayman
measure TAC levels. The procedure followed the manufacturer’s instructions and established protocols [21]. 2.4.3. Oxidative Damage in Urine Lipid peroxidation was assessed in urine by measuring 8-isoprostane concentra- tion (8-iso-PGF2α ) (Cayman Chemical, Ann Arbor, Michigan, USA, Item No. 516351). The method was previously described [19,22]. DNA damage (urinary concentrations of 8-OH-dG) was measured using a commercial ELISA kit (Cayman Chemical, Ann Arbor, Michigan, USA, Item No. 89320). The samples were read in duplicate at a wavelength 412 nm and concentration deter- mined using standard curves as previously described. The coefficient of variation (CV) was indicated by the manufacturer: inter-assay CV 11.2% and 10.7% and intra-assay CV 14.6% and 11.6%, respectively, for 8-iso-PGF2αand 8-OH-dG. 2.4.4. Quantification of Inflammatory Markers in Saliva IL-6, IL-10, and TNF-a saliva levels were determined by ultrasensitive ELISA im- munoassays (Fine Test, Wuhan, China, Cat No.: EH0201; EH0173; EH0302), according to the manufacturer’s instructions [20,22]. The assays are based on a double-antibody sandwich technique. Saliva levels of inflammatory markers in pg/mL were calculated. The samples’ concentrations were determined at 450 nm. The coefficient of variation (CV) was indicated by the manufacturer for IL-6, IL-10, and TNFα: inter-assay CV 4.62%, 5.26%, and 5.56% and intra-assay CV 5.35%, 5.05%, and 5.53%, respectively.
J. Clin. Med.2025,14, 2532 6 of 22 2.4.5. No Metabolites (Nitrite and Nitrate) in Urine NO2+ NO3= NO metabolites levels were assessed in urine by using a method based on the Griess reaction, using a commercial kit (Cayman Chemical, Ann Arbor, Michigan, USA, Item No. 780001) [19]. The coefficient of variation (CV) was indicated by the manufacturer: inter-assay CV 3.4% and intra-assay CV 2.7%. 2.4.6. Appetite Hormones Salivary leptin, ghrelin, and Insulin-like Growth Factor-1 (IGF-1) levels were measured using enzyme-linked immunosorbent assay (ELISA kit cat. No.: EH0216, EH0355 and EH0165 FineTest, Wuhan, China) kits, following the manufacturer’s instructions [20,23,24]. The inter-assay coefficient of variation was in the range indicated by the manufacturer: leptin 5.73%, ghrelin 4.23%, and IGF-1 5.03%. Every assessment was carried out in duplicate and read at 450 nm by a microplate reader spectrophotometer (Infinite M200, Tecan Group Ltd., Männedorf, Switzerland). 2.4.7. Creatinine, and Neopterin in Urine Urinary creatinine and neopterin concentrations were measured in duplicate us- ing isocratic high-pressure liquid chromatography. The calibration curves were linear for neopterin (0.125–1µmol/L) and creatinine (1.25–10 mmol/L). The inter-assay and intra-assay variation coefficients were below 5%. The methods have been previously described [19,25]. 2.4.8. Uric Acid and Electrolytes Urea, sodium (Na + ), potassium (K + ), chlorine (Cl − ), magnesium (Mg 2+ ), phosphorus (P), calcium (Ca 2+ ), and uric acid were investigated in urine samples before and after the race. The method was previously described [26]. After thawing and vortexing the samples, 500µL of each was placed in a plastic test tube. The test tubes were allocated in the autosampler of a Roche Cobas ® 6000 analyzer (Roche Diagnostics, Basel, Switzerland). The reported total imprecision was <2.8%, while the intra-assay CV% was <1.8%. 2.4.9. Psychometric and Physical Scale The quality of recovery was assessed before and after the race by using the Total Quality of Recovery scale (TQR) proposed by Kenttä and Hassmén [26,27]. Perceived exertion was evaluated immediately after the race based on physical sen- sations, with muscle fatigue assessed using the Borg Rate of Perceived Exertion scale. (RPE) [26]. To assess subjective mood, overall wellness
Description
This study investigates systemic responses to oxy-inflammation and appetite hormones in breast cancer survivors after a dragon boat endurance race.