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Prepared by:Daniel Santa Mina, PhD (Cand); CEP/CES
Exercise for Cancer Patients: Evidence and Benefits
When do the benefits start?
Now!•
Extensive research has shown that exercise at any
point during the cancer journey is beneficial
Prevention/
Pre‐D
iagnosis
During Treatment
Pre‐Treatment
Post‐Treatment
Research at All Levels of Life
QOL
Physical
Emotional
Cellular
Cancer and Associated Treatments Can Cause:
•
Weight gain•
Fatigue•
Bone loss•
Muscle Loss•
Appetite Loss•
Depression•
Anxiety•
Poor sleep•
Pain•
Stiffness•
Confusion•
Reduced Quality of Life
Exercise Can Help!
Exercise for Prevention / Pre‐Diagnosis
Prevention/
Pre‐D
iagnosis
Physical Activity Can Help Prevent Some Cancers
•
Colon Cancer
(20‐25% risk reduction)•
Breast Cancer
(25% risk reduction)
•
Endometrial Cancer (20‐30% risk reduction)
•
Prostate Cancer
(10‐20% risk reduction)•
Lung Cancer
(20‐40% risk reduction)
•
Ovarian Cancer
(20% risk reduction)
((FriedenreichFriedenreich, 2010; 2002), 2010; 2002)
How exercise can protect us from cancer
Exercise can improve:•
Immune system function•
Body fat %•
Hormone regulations (e.g. insulin, testosterone,
estrogen)•
Overall healthier lifestyle (quit smoking, better diet,
cancer screening)
Exercise Before Cancer Treatment
Prevention /
Pre‐D
iagnosis
Pre‐Treatment
Preparing for Treatment
Exercise can help you prepare for your treatment by improving your fitness levels, so you can:
•
Tolerate your treatment better•
Proceed with difficult treatments•
Reduce treatment complications•
Reduce hospitalization duration•
Maintain minimum levels of strength, even after
long periods of bed rest•
Keep you calm•
Recover more quickly
Exercise During Treatment
Prevention /
Pre‐D
iagnosis
During Treatment
Pre‐Treatment
Exercise During Treatment IS possible!
Exercise can be safely done during:•
Radiation•
Chemotherapy•
Hormone therapy•
Before surgery (and after recovery)•
Bone marrow/Stem cell transplant•
Immunotherapy
…For stage I‐IV cancers
(Young-McCaughan & Arzola, 2007)
What Exercise Does NOT Do…
Exercise Does NOT:
•
Worsen treatment or disease‐related symptoms
•
Compromise treatment effectiveness
Exercise During Treatment: The Benefits
•
Improves fatigue•
Improves physical
function•
Decreases weight and
body fat•
Improves immune
system function•
Improves cardio‐
pulmonary function•
Improves upper
extremity lymphedema
•
Improves quality of life•
Reduces depression &
anxiety•
Regulates bowel movements•
Improves appetite•
Improves sleep•
Preserves bone health•
Reduces hospitalization
duration
(Systematic Reviews: Galvao & Newton, 2005; Schmitz et al, 2005; Knols et al, 2008)
Fatigue
•
Fatigue is the most common side effect of cancer and its treatment, affecting 70‐100% of patients
•
Fatigue is the most
distressing treatment‐related symptom
•
94% of oncologists treat pain; only 5% treat fatigue
•
May cause patients to discontinue/reduce treatment
(Mock et al, 2001, Cancer Practice)
(National Cancer Institute, 2007)
Cancer‐Related Fatigue (CRF):
Decreased
Functional &
Fitness
Anxiety/
Depression
Other
illnesses
Sleep
Disturbance
Treatment
Tumour
CRF
Sedentary
Behaviour
Physical
Deconditioning
Fatigue Cycle
ExerciseFatigue
Better Sleep
& Functional Capacity
RECONDITIONING
Reduced functional capacity/
Increased work for routine tasks
Many research studies have shown that exercise improves cancer‐related fatigue
Fat and Cancer
May be lifestyle or treatment induced
Obesity increases risk for several cancers:•
Colon, breast (post‐menopausal),
endometrial, kidney, esophageal
Obesity negatively affects:•
Cancer progression (by hormone changes)
•
Other illnesses (cardiovascular disease, diabetes, etc.)•
Joint pain / dysfunction•
Treatments (e.g. surgical risk)•
Mortality
Cancer‐Related Osteopenia
& Osteoporosis
Bone loss during cancer and treatment can be due to:•
The tumour
itself (osteosarcoma, metastatic
lesions)
•
Chemotherapy•
Radiation•
Steroids •
Surgery•
Hormone therapy•
Reduced calcium and Vitamin D absorbance•
Resultant sedentary lifestyle from fatigue & malaise
Exercise and Bone Density in Cancer
•
Only a few (8) studies have assessed the effect of exercise on bone health for cancer patients
•
Research shows that exercise can help maintain bone health
•
Exercise may add to the benefits of bone maintaining medications (bisphosphonates)
•
Resistance training and possibly high‐impact exercise may be best for stimulating bone development
Waltman , 2010
Newton et al , 2010, ACPCRA Conference
Lymphedema
Lymphedema is an accumulation of lymphatic fluid, often in the extremities.
It can cause:•
Swelling•
Pain•
Loss of Function•
Increased Risk of Infection•
Hardening/Thickening of the skin•
Ulcers
Exercise and Lymphedema
•
Research shows that exercise does not worsen upper extremity lymphedema; but may actually help it
•
Persons with lymphedema should exercise with caution (consult with your doctor, a physiotherapist,
or trained Wellspring Cancer Exercise leader)
•
The relationship between lower limb lymphedema and exercise is not well understood
(Schmitz, 2010, NEJM, Harris, 2000, J Surg Onc; McKenzie & Kalda, 2003, JCO, Ahmed et al, 2006, JCO; Lacomba, 2010, BMJ; Katz, 2010)
Exercise Can Improve Emotional and Cognitive Well‐being
In many cancers, exercise has shown to improve: •
Quality of Life•
Confusion / Mental Function•
Mood disturbance•
Anger/ Hostility•
Body Image•
Weight Concerns•
Sexual Attractiveness•
Self‐Esteem
Exercise Post‐Treatment
Post‐Treatment
Prevention /
Pre‐D
iagnosis
Pre‐Treatment
During Treatment
Physical Activity Post‐Treatment... Continued Benefits
From systematic reviews…
•
Cardiovascular & musculoskeletal fitness
•
Vigor•
Mental Clarity•
Lymphedema•
Physical functioning•
Fatigue•
Bone mineral density•
Body composition
•
Joint mobility•
Immune factors•
Quality of Life•
Reduced Risk of comorbidities•
Reduced chronic treatment‐
related side‐effects•
Improved body image and
self‐esteem•
Survival
(Schmitz et al, 2005, Ca Epi, Bio, Prev; Galvao et al, 2006, JCO)
Exercise and Post‐Treatment Pain
•
Concern that exercise will cause pain
•
Highly sensitive to changes in pain
•
Exercise has been associated with reduced pain in cancer patients
(Alfano et al, 2007; J of Cancer Survivorship; McNeely, 2004, Head & Neck)
Exercise and Survival After Cancer
New research is demonstrating that survival can be improved with exercise for
•
Breast Cancer•
Colorectal Cancer•
Prostate Cancer
Benefits include cancer and non‐cancer survival improvement
Holmes, 2005, JAMA; Meyerhardt, 2006, JCO; Kenfield, 2011, JCO)
Physical Activity Post‐Treatment / Palliation
In late stage cancer, Exercise is associated with:•
Improved tolerance of symptoms•
Improved mobility•
Improved coping•
Maintenance of physical function•
Maintenance of quality of life
… and is generally well tolerated
(Courneya & Friedenreich, 2007, Seminars in Nursing Oncology;
Oldervoll et al, 2004/2005)
Again…When do the benefits start?
Now!Exercise is beneficial during every phase of cancer:
Prevention/
Pre‐D
iagnosis
During Treatment
Pre‐Treatment
Post‐Treatment
Exercise Guidelines
Goals of Exercise Programs for Cancer Survivors
1.
Regain and improve physical function2.
Improve body image and quality of life
3.
Improve body composition4.
Improve cardiorespiratory, hormone, neurological,
muscular, cognitive and psychosocial outcomes5.
Reduce or delay recurrence or second primary cancer
6.
Improve coping with recurrence / a second primary 7.
Reduce/prevent long‐term & late effects of treatment
8.
Improve tolerance to current & future treatments
(Schmitz et al, 2010 MSSE, ACSM Roundtable)
Careful Consideration Before Starting An Exercise Program
Consult with your family doctor or oncologist or trained Wellspring Cancer Exercise leader before starting an exercise
program.
Be cautious when exercising if you have:
•
Recently completed surgery (up to 8 weeks after surgery)•
Extreme fatigue or anemia•
Low blood counts of immune cells or platelets•
Any local restrictions (e.g. lymphedema, scarring, skin
sensitivity)•
Drains (e.g. JP drains, ostomy, catheters)•
High fracture risk
(Schmitz et al, 2010 MSSE, ACSM Roundtable)
Exercise Guidelines for Cancer Survivors
General Statement:•
Avoid inactivity•
Return to daily activities as quickly as possible after
surgery•
Continue normal daily activities as much as possible
during and after non‐surgical treatments•
Individuals with cardiac conditions may require
modifications & greater supervision
30‐60 mins
of moderate‐to‐vigorous PA, >5d/wk
(Schmitz et al, 2010 MSSE, ACSM Roundtable)
Cancer and Exercise Guidelines: FITT Principle
•
Frequency▫
The number of days per week that you participate in a
certain activity•
Intensity▫
The amount of effort you put into the exercise
▫
The level of difficulty of the exercise•
Time▫
The duration of the activity
•
Type▫
The specific activity that you take part in
General Exercise Prescription for Cancer Patients
Modality Frequency Intensity Volume (Time)
Aerobic/Cardio 3‐5 50‐90% Max Heart Rate 4‐7/10 Rating of
Perceived Exertion
20‐60 mins (continuous or
intermittent)
Anaerobic/Resistance
1‐3 50‐80% 1 Repetition Maximum;
4‐7/10 RPE
1‐4 sets per muscle group
Flexibility 2‐3 ? 2‐4 sets per muscle group,
hold for 10‐30s
Galvao & Newton, 2005, JCO
Exercise Adherence: “The extent to which individuals’
exercise behaviours correspond with the exercise prescription“
Schmitz et al, Can Epi
Bio 2005
Exercise needs to be a long‐term commitment…
•
Only 30% of cancer survivors are meeting physical activity recommendations
•
Studies have shown that after an exercise program is discontinued, negative side effects of cancer and
treatment return
Duration of Exercise = Duration of Benefits
(Culos-Reed et al,2007; Courneya & Friedenreich, 1997)
(Bellizzi et al, 2007)
Barriers to Physical Activity in Cancer Survivors
•
Unaware of exercise benefits•
Emotional factors (depression)•
Psychosocial factors (body image, feeling sick)•
Fatigue•
Nausea and vomiting•
Time (vacation, medical appointments)•
Lack of confidence/comfort/familiarity with exercise•
Lack of social support•
Lack of time•
Distance from the exercise centre•
Low motivation•
Worry about injuries, disease progression•
Travel (“Snow Bird Effect”)
Strategies to Facilitate Adherence
•
Home‐based equipment
•
Physician Referral &
Follow‐up
•
Group Exercise &
Exercise Support Groups
•
Goal Setting
•
Exercise Manuals /
Educational Documents
•
Educational seminars
•
Qualified trainers
•
Self‐rewards
•
Problem solving
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