신체활동과 체력이 암 치료와 미치는...
TRANSCRIPT
신체활동과 체력이 암 치료와 생존에 미치는 효과
김 연 수
서울대학교 체육교육과
PART Ⅰ
암 발생률 및 생존율
PART Ⅱ
암 경험자의 신체활동량
PART Ⅲ
암과 신체활동 효과
PART Ⅳ
암과 신체활동(체력) 연구사례
PART Ⅴ
암 경험자의 신체활동 지침
C O N T E N T S
모든 암 연도별 연령표준화발생률 추이
연령표준화발생률 : 우리나라 2000년 주민등록연앙인구를 표준인구로 사용
1999 – 2012 암 경험자 : 1,234,879명 / 41명당 1명 암 경험자 [국가암등록통계, 중앙암등록사업, 2012]
291.9 283.4
294.9 296.5 301.6 306.7 319.1 318 325 332.8 340 340.9 347
337.2
219.9 214.1 226.3 229.8
238.4 246.5 260.1 264.9
277.6 291.8
304.1 311.6 323.1 319.5
173.3 169 182
188.2 199.5 210.2
225.6 235.5
253.8 273.8
290.5 303.7
320.1 321.3
0
100
200
300
400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
10만
명당
발생
률
남자 남녀전체 여자
2012년 암생존율 / 5년 상대생존율
[모든 암의 5년 상대생존율 : 1993-2012]
[국가암등록통계, 중앙암등록사업, 2012]
41.2
31.7
53.4
44
35.3
55.3 53.8
45.3
54
65
56.3
74 68.1
59.6
76.6
0
20
40
60
80
100
전체 남자 여자
'93-'95 '96-'00 '01-'05 '06-'10 '08-'12 %
암 경험자의 사망원인
10년 이상 암 생존자 사망원인
[국가암등록통계, 중앙암등록사업, 2010]
1
2 3
4
5 자 살
당 뇨
암
뇌혈관질환 심혈관질환
60.7%
18.5%
7.8%
6.2%
6.8%
20년 이상 암 생존자 62.7%는 암 외 질환으로 사망
[Yi ming, AACR, 2012]
암 경험자의 신체활동률
Physical Activity among Patients with High Risk of Cancer and
Cancer Survivors Chae JS
Yonsei Univ. thesis, 2015
Total 503 patients who are at high risk of cancer(n=23) and cancer survivors(n=480)
Age : 59.01±11.77 years
Physical activity levels measured using the GPAQ questionnaire
암 경험자의 신체활동률 Type of Physical activity
(MET-hour/week) Gastric(n=175) Colorectal(n=191) Breast(n=47) Gynecologic(n=20) Other Cancer(n=47)
Work
Vigorous 1.01±9.73 1.17±16.21 0.00±0.00 0.00±0.00 0.00±0.00
Moderate 13.18±39.62 9.88±36.93 10.77±40.80 9.10±26.59 2.64±16.35
Total work 14.19±40.47 11.05±40.04 10.77±40.80 9.10±26.59 2.64±16.35
Transportation 10.23±15.33 11.07±14.69 7.32±9.55 4.63±7.31 9.27±12.71
Leisure time
Vigorous 6.23±16.45 8.09±21.09 5.36±15.29 5.60±25.04 8.96±22.65
Moderate 4.64±10.05 4.03±9.05 4.46±10.11 7.99±17.25 1.94±5.61
Total leisure time 10.87±19.10 12.12±23.30 9.83±22.06 13.59±28.82 10.91±22.55
Walking 5.70±10.07 6.35±11.37 5.44±9.53 10.68±8.88 5.34±7.68
Total physical activity 35.29±46.19 34.25±47.59 27.91±49.01 27.33±36.53 22.82±34.34
Sedentary time(min/da
y) 400.29±220.33 380.65±216.87 354.26±220.42 395.00±217.92 459.79±269.79
암 경험자 975명 운동 강도를 조사한 결과, 격렬한 신체활동 9.4%, 중등도 신체활동 43.5%, 저강도 신체활동 65.5
참여하는 것과 맥을 같이 함 [Blaney et al., psycho-oncology, 2013]
Health Behavior in Cancer Survivors(KNHANES Ⅳ,
2007-09)
Cancer survivors Non-cancer chronic disease controls Non-cancer non-chronic disease
controls p value
n %(SE) n %(SE) n %(SE)
Smoking status
Never 310 63.6(2.55) 3,645 54.7(0.74) 6,227 52.2(0.56) <.001
Former 145 26.8(2.46) 1,367 24.5(0.75) 1,823 17.7(0.43)
Current 48 9.6(1.58) 1,013 20.8(0.69) 2,769 30.1(0.53)
OR(95%CI)a 1.00 1.91(1.26 to 2.90) 2.57(1.70 to 3.90)
Heavy drinking
No 480 93.4(1.57) 5,386 87.7(0.55) 9,462 83.3(0.44) <.001
Yes 24 6.6(1.57) 558 12.3(0.55) 1,401 14.7(0.44)
OR(95%CI) a 1.00 1.42(0.84 to 2.42) 1.26(0.74 to 2.15)
Physical activity
No 378 74.0(2.35) 4,508 76.1(0.78) 8,029 74.5(0.57) .114
Yes 126 26.0(2.35) 1,418 23.9(0.78) 2,782 25.5(0.57)
OR(95%CI) a 1.00 0.83(0.65 to 1.08) 0.84(0.65 to 1.08)
•aAdjusted for age, sex, education, marital status
[Oh etl al., JJCO 2013]
암 경험자의 신체활동 장벽
Treatment and disease-related physical and psychological side effects are very common
PAIN Lack of time FATIGUE
[Park et al., 2015]
47.4% 34.8% 18.5%
Poor condition
19.2%
Lack of strength
42.9%
Perceived physical activity barriers_multiple response
암 경험자의 신체활동 관련 요인
Physical Activity
Correlate and determinant [“+”]
•Health status(subjective, objective)
•Self-efficacy
•History of physical activity
•Intention to exercise
Correlate but not-determinant [“-”]
•Age
•Overweight
•Perceived efforts
Socioeconomic factors
•Marital status
•Income, Education
•Occupation
“inconclusive”
“+”
“+ -”
Determinant and inconclusive correlation
•Physical and psychological outcome
•Action planning
•Stress
“+?”
“+?” “-?”
[Bauman et al., 2012; Kaewthumanukul & Brown, 2006]
“의사권고가 암환자 운동습관 바꿔”
The effect of oncologists’ exercise recommendations on the level of
exercise and quality of life in survivors of breast and colorectal cance: A randomized controlled trial Park JH, Lee J, Oh, M, Park H, Chae J, Kim DI, Lee MK, Yoon YJ, Lee CW, Park S, Jeon JY et al.
Cancer, 2015
대 상 : 유방암, 대장암 환자 총 162명
한국의 암 전문의 중 40%만이 운동을 권고한 경험이 있음
운동을 권고하지 못하는 가장 큰 이유는?
진료시간이 부족해서(24%), 어떤 운동을 권고해야 할지 몰라서(21%) 등
그룹 1
대조군 : 운동권고 하지 않음
그룹 2
운동의 중요성 설명
→ 주당 40분 운동
그룹 3
운동의 중요성 설명+운동상담
15분
→ 주당 87분 운동
Physical Activity Across the Cancer Experience Framework
Pre Diagnosis
Post Diagnosis
Prevention Detection Treatment Preparation
Treatment Effectiveness
Recovery Rehabilitation
Disease Prevention Health Promotion
Palliation Survival
Prescreening Screening Pretreatment Treatment Survivorship End of Life
[Courneya & Friedenreich, Sem Oncol Nurs, 2007]
Hypothesized mechanisms linking physical activity to cancer
Physical Activity Benefits across the Cancer Continuum
Prevention [Screening]
Improves
•Immune surveillance
•Anti-inflammatory effect
•Insulin sensitivity
•Maintains normal growth factor production and activation
•DNA repair capacity
•Range of motion/flexibility
Reduces
•Obesity and central adiposity
•Chronic inflammation
•Oxidative stress
•Bowel transit time
Stage
Detection [Pre-treatment]
•Functional capacity
- musculoskeletal, cardiorespiratory function
•Post-operative outcomes
- health related quality of life
•Psychological benefits, opportunity to change health behavior
•Range of motion post-treatment
•Post-operative length of stay
•Stress, anxiety
•Post-operative complications
- muscle atrophy
- cardiopulmonary fitness
During Treatment
Improves
•Quality of life •Sleep
•Maintains functional capacity •Immune response
•Fatigue •Appetite
•Range of motion •Self-esteem
•Balance
•Body composition
Reduces
•Nausea
•Pain
•Swelling
•Muscle atrophy
•Shortness of breath
•Risk of depression
Stage
Survivorship •Quality of life
•Length of survival
•Self-esteem and happiness
•Functional capacity
-musculoskeletal strength, cardiopulmonary efficiency
•Energy levels
•Risk of recurrence
•Mortality
•Weight gain
•Cancer-related fatigue and pain
•Anxiety and depression
Palliative Care •Quality of life
•Circulatory function
•Strength
•Autonomy and indepencence
•Stress and Anxiety
•Fatigue
•Muscle atrophy
•Lymphedema
Physical Activity Benefits across the Cancer Continuum
암과 신체활동 연구 현황
PubMed
• “Breast” 298 studies
“cancer” 893 studies
• “Colon” 24 studies
• “Lung” 37 studies
• “Prostate” 60 studies
• “Gastric” 6 studies
• “Thyroid” 5 studies
Publication dates : 2005 to 2015
• “Ovarian” 34 studies
암 시기별 신체활동 효과
An update of controlled physical activity trials in cancer survivors : a systematic review and meta-analysSpeck RM, Courneya KS, Masse LC, Duval S, Schmitz KH
J Caner Surviv, 2010
Database : MedLine / 2005 to 2010
Keywords : exercise(or physical activity) and cancer
randomized controlled trial, intervention studies, clinical tria
Identify : 66 studies / 380 studies
Physical Activity Intervention_During treatment
6%
52%
33%
9%
64%
21%
9% 6%
88%
6% 6%
61%
18% 21%
[Intervention length] [Activity frequency]
[Activity mode] [Activity intensity]
Physical Activity Intervention_Post treatment
10%
45%
45%
55%
18%
8% 18%
76%
14%
10%
59%
6%
35%
[Intervention length] [Activity frequency]
[Activity mode] [Activity intensity]
Evidence of positive effects by during treatment
[Speck et al., J Cancer Surviv, 2010]
Outcome Trial pooled Effect size 95% CI Heterogeneity
Physical activity level 12 0.38 0.15 to 0.61 Low
Aerobic Fitness 17 0.33 0.08 to 0.57 Moderate
Upper body strength 8 0.39 0.12 to 0.65 Moderate
Lower body strength 7 0.24 0.07 to 0.41 Moderate
Body weight 8 -0.25 -0.49 to -0.01 Moderate
% Body fat 7 -0.25 -0.48 to -0.02 Low
Functoinal quality of life 4 0.28 0.02 to 0.54 Low
Anxiety 6 -0.21 -0.39 to -0.03 Low
Self-esteem 3 0.25 0.04 to 0.46 Low
Evidence of positive effects by post treatment
Outcome Trials pooled Effect size 95% CI Heterogeneity
Physical activity level 16 0.38 0.22 to 0.54 Moderate
Aerobic fitness 14 0.32 0.04 to 0.59 Moderate
Upper body strength 6 0.99 0.67 to 1.32 Low
Lower body strength 7 0.90 0.12 to 1.68 High
Body weight 14 -0.18 -0.31 to 0.06 Low
Body fat percentage 15 -0.18 -0.31 to 0.05 Low
Overall quality of life 16 0.29 0.03 to 0.54 High
Fatigue 14 -0.54 -0.90 to -0.19 High
Depression 10 0.30 -0.65 to 0.05 Moderate
Anxiety 7 -0.43 -0.88 to 0.03 Moderate
IGF-1 3 -0.31 -0.59 to -0.03 Low
Symptoms / side effects 4 -0.30 -0.57 to -0.04 Low
[Speck et al., J Cancer Surviv, 2010]
PA and incidence of specific cancers
European code against Cancer 4th Edition : Physical activity and cancer
Michael Leitzmann, Hilary Powers, Annie SA, Chiara Scoccianti, Franco Berrino et al.
CANEP, 2015
Cancer type Number of studies Relative risk 95% CI
Substantial evidence
Colon 21 0.74 0.68 to 0.80
Endometrial 20 0.82 0.75 to 0.90
Breast 31 0.88 0.85 to 0.91
Weak or moderate evidence
Prostate 24 0.94 0.91 to 0.98
Stomach 18 0.90 0.76 to 1.06
Ovary 9 0.89 0.79 to 1.01
Kidney 19 0.89 0.80 to 0.99
Lung 14 0.77 0.73 to 0.81
Prevention Prevention
Leisure time physical activity and cancer risk
Leisure time physical activity and cancer risk : evaluation of the WHO’s recommendation based on 126 high-quality epidemiological stud
Li Lie, Yun Shi, Tingting Li, Qin Qin, Jiyun Yin, Shuo Pang, Shaofa Nie, Sheng Wei
BJSM, 2015 Prevention
Data base : Medline and Web of Science / until 2014
Methods : MOOSE(Meta-analysis of Observational Studies in Epidemiology) guidelines
Keywords : Exercise(OR physical activity OR walking) AND cancer(OR neoplasm OR tum
Dose-response analysis of RR for cancer in relation to LTPA
구 분 Number of comparison
s
Leisure time physical activity(MET-h/week)
0 10 20 40 60 80 P for non-
linearity
Overall 69 1.00 0.93(0.91 to
0.95)
0.91(0.88 to
0.93)
0.90(0.88 to
0.91)
0.89(0.87 to
0.92)
0.89(0.85 to
0.94) <.001
Sex
Male 10 1.00 0.97(0.92 to
1.02)
0.94(0.90 to
0.98)
0.92(0.88 to
0.97)
0.93(0.87 to
1.02) - .25
Female 41 1.00 0.95(0.93 to
0.98)
0.95(0.92 to
0.97)
0.93(0.90 to
0.95)
0.89(0.85 to
0.93)
0.86(0.79 to
0.93) .10
Cancer types
Breast
cancer 19 1.00
0.96(0.94 to
0.99)
0.95(0.93 to
0.98)
0.93(0.90 to
0.96)
0.90(0.86 to
0.95)
0.88(0.81 to
0.95) .41
Colorectal
cancer 10 1.00
0.92(0.85 to
1.00)
0.85(0.79 to
0.92)
0.86(0.80 to
0.94) - - .002
Endometrial
cancer 5 1.00
1.03(0.93 to
1.15)
0.97(0.87 to
1.08)
0.91(0.81 to
1.02) - - .46
Pancreatic
cancer 5 1.00
0.94(0.77 to
1.14)
0.90(0.73 to
1.09)
0.87(0.73 to
1.05)
0.88(0.69 to
1.12) - .72
Ovarian
cancer 4 1.00
0.89(0.75 to
1 05)
0.91(0.76 to
1 08)
0.99(0.81 to
1 22)
0.97(0.76 to
1 26)
0.91(0.68 to
1 23) .28
25
• 활동의 강도 및 에너지소비량의 지표
• 1MET (equals 3.5 mL/kg/min)는 휴식하는 동안의 산소소비량으로
이를 통하여 활동을 할 때 이에 비해 얼마나 더 산소를 소비하는가를 통하여
운동 강도를 알 수 있다.
MET(metabolic equivalent, 대사당량)
MET
• 저강도 : 3 METs 미만, 노래를 부를 수 있다
• 중강도 : 3-5.9 METs, 말은 하지만 노래를 부르지는 못한다
• 고강도 : 6 METs 이상, 문장을 이어서 말하기가 어렵다
신체활동 강도목록
• 신체활동평가를 위한 한국어판 신체활동 목록과 컴퓨터 프로그램 개발
• 박재현 등 한국체육학회지44권 2호. 2005 pp.385-404
Colon Transit Time and Physical Activity
Colon Transit Time According to Physical Activity Level in AdultSong BK, Cho KO, Oh JW, Kim YS
J Neurogastroenterol Motil 2015 Prevention
Participants : male(n=24), female(n=25)
Age : 37.4±8.3years
Physical activity levels measured using accelerometer
Male(n=24) Female(n=25)
LPAG MPAG HPAG Total LPAG MPAG HPAG Total
RCTT(hr) 4.0±6.5 4.2±6.7 1.4±1.4 3.4±5.7* 10.4±10.6 14.5±15.2
* 2.4±4.4 10.1±12.7
LCTT(hr) 0.8±0.9 1.0±2.7 1.0±0.9 0.9±2.0 3.2±5.8 0.7±1.4 0.6±1.8 1.3±3.1
RSCTT(hr) 4.4±9.0 5.2±7.8 2.8±3.2 4.4±7.1* 21.8±14.4 15.3±13.8 3.8±7.0* 14.0±13.8
TCTT(hr) 9.2±11.2 7.6±10.8 5.2±4.0 7.4±9.3* 35.4±27.9
*
30.5±22.1
* 2.8±3.4* 25.8±24.1
•RCTT : right colon transit time, LCTT : left colon transit time, RSCTT : Recto-sigmoid colon transit tim TCTT : total colon transit time, * : <.05
Gastrointestinal Motility and Aerobic Exercise
Aerobic Exercise improves gastrointestinal motility in
psychiatric inpatients
Song BK, Cho KO, Oh JW, Kim YS
World J Gastroenterol, 2011 Prevention
Participants : exercise group(n=23), control group(n=19)
Intervention : aerobic exercise program vs. ordinary daily activities
Aerobic exercise program
Frequency 60min, 3times/week, 12weeks
Exercise program
Warming-up Stretching(10min)
Main exercise
1-4week
50%HRR
5-8week
60%HRR
9-12week
70%HRR
Walking & Running(40min)
Cooling-down Stretching(10min)
Effects of a 12-week aerobic exercise program on segmental and total colon transit time in psychiatric inpatients
•A : right colon, B : left colon, C : recto-sigmoid colon, D : total colon, •b : p<.01, baseline to study-end change in total colon transit time for Exercise vs. Control group
CardiorespiratoryFitness(CRF) and Risk of Incident Cancer
Midlife Cardiorespiratory Fitness, Incident Cancer, and Surviva
After Cancer in Men Lakoski SG, Willis BL, Barlow CE, Leonard D, Gao A, DeFina LF, Jones LW et al.
JAMA Oncol, 2015
Cance
r
Events,
No.
Hazard Ratio(95% CI)
Low
CRF
Moderate
CRF High CRF
1-MET
Increase
Lung 200 1 0.57(0.41
-0.81)
0.45(0.29-
0.68)
0.83(0.77-
0.90)
Colon 181 1 0.67(0.46
-0.98)
0.56(0.36-
0.87)
0.91(0.84-
0.99)
Prosta
te 1,310 1
1.04(0.88
-1.23)
1.22(1.02-
1.46)
1.03(1.00-
1.06)
•Adjusted for age, visit date, BMI, smoking
Prevention
Association between CRF and Late-life Incident cancer and Cause-Specific Mortality
•”Healthy” was defined as having no observed incident cancer or CVD at baseline •Adjusted for age, visit date, BMI, smoking
Health Status Events, No. Hazard Ratio(95% CI)
Low CRF Moderate CRF High CRF 1-MET Increase
Healthy to
Cancer diagnosis 1,691 1 0.94(0.83-1.08) 1.07(0.93-1.24) 1.01(0.99-1.04)
Cancer to
cancer-related death 219 1 0.76(0.53-1.08) 0.68(0.47-0.98) 0.90(0.84-0.97)
Cancer to CVD-related
death 64 1 0.59(0.33-10.5) 0.32(0.14-0.64) 0.75(0.66-0.87)
Healthy to
Cancer-related death 281 1 0.73(0.54-0.98) 0.66(0.48-0.91) 0.96(0.91-1.02)
Healthy to CVD-related
death 495 1 0.48(0.39-0.59) 0.38(0.29-0.48) 0.84(0.80-0.89)
Survival
가정기반 복합운동프로그램이 ADT를 받는 전립선암 환자의 신체활동량, 체력, 그리고 삶의 질에 미치는 영향
김연수, 임정준, 문홍상, 최홍용
Treatment
Participants : 호르몬차단요법(ADT)를 받는 전립선암 환자
- randomly assigned 가정기반 복합운동프로그램 그룹(n=20), usual
care(n=9),
Intervention : total 12weeks, 주 1회 supervised by exercise specialists, 운동처방과 상담
가정기반운동: 만보계, 탄력밴드, 운동일지, 문자메세지 주 2회
-근력운동: 탄력밴드프로그램 교육후 3 times / week, 2set,
8-12reps of 10 different exercise
-유산소운동 : 1일 30분 이상 5 times/week 걷기, 만보계 활용
Primary outcome : 신체계측, 체력, 신체활동량, 삶의 질, 피로도, 우울증, 낙상두려움, 혈액변인
Exercise in Men Receiving ADT for Prostate Cancer
그룹 종류 강도 시간, 빈도 사용도구 비고
실험군
유산소운동 운동자각도 11~13 1회 30분
주 5회 이상 만보계
걷기 위주
점진적 증가
근력운동 운동자각도 12~15 1회 30분
주 3회 이상 저항성밴드
대근육 위주
점진적 증가
통제군 교육 - 2회 - 스트레칭, 신체활동
교육
가정기반 신체활동프로그램
Physical activity program
• 스트레칭을 통한 Warm-up
• 난이도 별 24가지 체중부하운동과 22가지의 밴드운동 (0-6주: Green, 7-12주: Blue)
• 유산소운동은 걷기, 조깅, 싸이클 등으로 환자 선호에 따라 일상생활에서의 실천 권고
주1 회 그룹 신체활동 프로그램(실험군)
Physical activity program
신체활동 프로그램(실험군)
Physical activity program
• 월 2회 신체활동 프로그램 교육
• 한 주 동안의 신체활동 기록지 분석 및
운동처방
• 주 2회 신체활동 증진을 위한 문자발송
신체활동 프로그램(실험군)
Physical activity program
신체활동 프로그램(통제군)
• 스트레칭 및 신체활동 교육 2회 제공
• 월 2회 안부 문자발송
Physical activity program
구 분
신체계측
측정 항목
신장, 체중, 혈압, 허벅지/허리둘레, 신체조성 신장계, 혈압계, 줄자, Inbody
측정도구
혈액변인
체력 악력, 하지근력, Senior Fitness Test 악력계, MMT ,줄자, 초시계
삶의 질
FACT-Prostate. FACIT-Fatigue
우울증
Beck Depression Index
낙상두려움
Korean Fall Efficacy Scale -International
PSA, TC, HDL-C, LDL-C, TG, Glucose -
설문지
Measurements
측정항목
Variable Con G Mean ± SD(n=8)
Ex G mean ± SD(n=11) P value
Age (yrs) 78.38±3.11 73.00±8.23 .068
Height (cm) 161.82±2.95 163.02±4.70 .505
Weight (kg) 64.41±7.76 65.38±8.91 .967
Lean body mass (kg) 24.58±2.74 24.55±2.82 .980
Body fat mass (kg) 23.43±1.70 25.31±3.78 .166
Waist circumference (cm) 89.72±9.50 89.66±7.79 .988
Thigh circumference (cm) 48.15±3.32 50.35±4.04 .680
PSA (ng/ml) 1.35±2.55 3.98±5.92 .296
ADT duration (month) 43.66±29.26 53.11±45.27 .416
Gleason score 7.63±1.02 7.87±0.99 .618
Prostate Specific Antigen: PSA Androgen Deprivation Therapy: ADT Values are Mean±SD, *p<.05, **p<.01
<표. 1> 인구통계학적 자료
Anthropometric characteristics
<표. 2> 12주간의 신체활동 프로그램이 신체계측에 미치는 영향
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
Weight (kg)
Con(n=8) 64.41±7.76 64.97±7.25 .056 .815
Ex(n=11) 65.38±8.91 66.08±7.85
Lean body mass (kg)
Con(n=8) 23.43±1.70 22.73±3.08 1.703 .209
Ex(n=11) 25.31±3.78 25.65±3.61
Body fat mass (kg)
Con(n=8) 21.03±6.39 22.91±7.18 1.827 .194
Ex(n=11) 19.06±5.38 19.32±5.42
BMI (kg/m²)
Con(n=8) 24.58±2.74 24.85±2.62 .427 .522
Ex(n=11) 24.55±2.82 25.11±2.46 Waist
circumference (cm)
Con(n=8) 89.72±9.50 89.55±5.45 2.113 .164
Ex(n=11) 89.64±7.79 89.55±5.45
Thigh circumference
(cm)
Con(n=8) 48.15±3.32 47.66±3.11 14.194 .002**
Ex(n=11) 50.35±4.04 51.6±3.47
SBP (mmHg)
Con(n=8) 124.88±13.65 125.38±15.58 .002 .968
Ex(n=11) 120.36±14.85 121.09±19.68
DBP (mmHg)
Con(n=8) 73.75±11.94 78.25±8.84 1.051 .320
Ex(n=11) 70.73±9.90 70.45±10.69
Values are Mean±SD, *p<.05, **p<.01
Body Mass Index: BMI, Systolic Blood Pressure: SBP Diastolic Blood Pressure: DBP
Results
<표. 3> 12주간의 신체활동 프로그램이 체력에 미치는 영향
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
Grip Strength (kg) Con(n=8) 26.45±5.12 26.17±4.49
5.292 .034* Ex(n=11) 30.08±7.08 32.21±6.28
Chair stand (count/30 sec)
Con(n=8) 21.13±6.53 19.13±6.55 34.374 <.001**
Ex(n=11) 23.00±5.96 31.55±7.6
Arm curl (count/30 sec)
Con(n=8) 25.87±7.68 25.25±5.92 28.873 <.001**
Ex(n=11) 28.1±11.21 39.27±10.63
Chair sit and reach (cm)
Con(n=8) 0.88±15.08 3.25±11.91 2.573 .127
Ex(n=11) 7.50±11.62 15.63±10.64
Back scratch (cm)
Con(n=8) -24.57±13.69 -21.31±10.74 .145 .708
Ex(n=11) -21.55±11.39 -19.54±9.74
Up and go (sec)
Con(n=8) 5.93±1.18 6.24±1.05 14.845 .001**
Ex(n=11) 6.71±2.05 5.23±0.94 Single leg
stance (sec)
Con(n=8) 6.41±4.34 12.03±8.57 .073 .791
Ex(n=11) 19.43±23.39 23.74±21.17
2-min step (count/2 min)
Con(n=8) 205.63±83.24 191.37±45.71 16.883 .001**
Ex(n=11) 211.55±37.42 279.18±22.04
Values are Mean±SD, *p<.05, **p<.01
Results
<표. 4> 12주간의 신체활동 프로그램이 각근력에 미치는 영향
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
Left knee extensor (Nm/kg)
Con(n=8) 112.65±28.92 118.25±28.57 10.351 .005**
Ex(n=11) 121.25±24.82 163.00±30.01
Left knee flexor (Nm/kg)
Con(n=8) 99.40±13.07 82.16±13.67 26.295 <.001**
Ex(n=11) 107.97±28.54 124.73±28.08
Right knee extensor (Nm/kg)
Con(n=8) 118.88±25.69 125.53±23.06 5.152 .037*
Ex(n=11) 129.59±24.63 176.22±46.07
Right knee flexor (Nm/kg)
Con(n=8) 106.30±23.17 80.88±11 24.539 <.001**
Ex(n=11) 104.85±21.85 125.76±25.59
Values are Mean±SD, *p<.05, **p<.01
Results
<표. 5> 12주간 신체활동 프로그램이 신체활동정도에 미치는 영향
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
TEE (kcal/day)
Con(n=7) 297.45±132.59 239.69±103.38 2.377 .143
Ex(n=11) 329.62±166.69 357.47±144.94
Step (count/day)
Con(n=7) 7511.50±3869.16 6307.17±4451.85 5.819 .028*
Ex(n=11) 5863.21±3234.26 8110.30±3095.42
Light activity (min/day)
Con(n=7) 273.24±103.70 250.05±79.02 .081 .779
Ex(n=11) 283.81±86.25 268.30±67.44
MTV (min/day)
Con(n=7) 36.13±27.49 24.10±25.54 5.179 .037*
Ex(n=11) 30.49±27.47 116.10±107.78
Sedentary ratio (%/day)
Con(n=7) 65.96±11.60 68.14±10.32 2.445 .137
Ex(n=11) 68.56±8.72 66.82±5.36
Sedentary break (count/day)
Con(n=7) 17.62±5.59 17.41±6.71 .196 .664
Ex(n=11) 18.69±2.89 19.32±3.90
Values are Mean±SD, *p<.05, **p<.01
Results
Total Energy Expenditure: TEE Moderate To Vigorous: MTV
<표. 6> 12주간 신체활동 프로그램이 혈액변인에 미치는 영향
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
PSA Con(n=8) 6.71±9.45 3.06±6.09
2.131 .164 Ex(n=10) 1.49±2.65 0.92±2.57
TC Con(n=8) 170.75±48.79 162.37±38.61
.628 .439 Ex(n=11) 178.00±27.57 180.90±38.36
HDL-C Con(n=6) 46.83±13.52 51.66±13.47
.081 .781 Ex(n=7) 49.14±13.68 52.71±11.26
LDL-C Con(n=6) 92.33±19.78 88.33±24.52
.114 .742 Ex(n=7) 109.71±30.19 103.85±33.11
TG Con(n=5) 130.20±33.25 132.00±32.58
4.778 .054 Ex(n=7) 124.57±47.12 103.85±39.12
Glucose Con(n=8) 115.84±20.67 139.00±61.25
5.476 .032* Ex(n=11) 140.18±55.83 117.18±23.15
Values are Mean±SD, *p<.05, **p<.01
Results
Prostate Specific Antigen: PSA, Total Cholesterol: TC, Triglycerides: TG High Density Lipoprotein: HDL-C, Low Density Lipoprotein: LDL-C
Results
<Table. 7> 12주간 신체활동 프로그램이 삶의 질에 미치는 영향
Values are Mean±SD, *p<.05, **p<.01
Variable Group Pre Mean±SD Post Mean±SD F Time*Group
FACT-P Con(n=8) 102.62±16.66 80.50±12.23
20.744 <.001** Ex(n=11) 95.36±20.61 116.54±15.58
FACIT-F Con(n=8) 41.12±9.18 36.87±8.60
4.610 .047* Ex(n=11) 28.27±10.01 44.90±7.95
BDI Con(n=8) 10.50±7.50 14.25±8.27
4.818 .042* Ex(n=11) 13.63±11.41 4.54±7.97
KFES-I Con(n=8) 24.75±11.42 24.12±11.26
7.749 .013* Ex(n=11) 24.09±7.25 16.54±1.29
Functional Assessment of Cancer Therapy-Prostate: FACT-P Functional Assessment of chronic Illness Therapy-Fatigue: FACT-F Beck Depression Inventory: BDI, Korean Fall Efficacy Scale-International: KFES-I
summary
minimize ADT syndrome
PA program
신체활동 연구 사례_대장암
Impact of physical activity on cancer recurrence and
survival in patients with stage Ⅲ colon cancer : finding from CALGB 89803
Meyerhardt JA, Heseltine D, Niedzwiecki D, Hollis D, Satiz LB, Mayer RJ, Fuchs CS et al.
J Clin Oncol, 2006 Recurrence
Sample size for physical activity(n=832) in the Cancer and Leukemia Group B(CALGB)
Physical activity assessment : “During the past 2 months, what was your average time per spent at each of the following recreational activities?” - walking, bicycling, swimming, racket sports, other aerobic exer
Follow-up period : 2.7 years
Impact of PA on Colon Cancer Recurrence and Mortality
Outcome
Total MET-hours per week
<3 3-8.9 9-17.9 18-26.9 ≥27 p for trend HR(95%CI) HR(95%CI) HR(95%CI) HR(95%CI) HR(95%CI)
Cancer recurrence or death from any cause
No. of events 67 42 30 11 22
Unadjusted 1 0.94(0.64-1.38) 0.89(0.58-1.37) 0.51(0.27-0.97) 0.58(0.36-0.94) .01
Adjusted 1 0.87(0.58-1.29) 0.90(0.57-1.40) 0.51(0.26-0.97) 0.55(0.33-0.91) .01
Cancer recurrence
No. of events 62 38 27 10 22
Unadjusted 1 0.92(0.61-1.37) 0.87(0.55-1.37) 0.50(0.26) 0.63(0.39-1.02) .03
Adjusted 1 0.86(0.57-1.30) 0.89(0.55-1.42) 0.51(0.26-1.01) 0.60(0.36-1.01) .03
Overall mortality
No. of events 33 21 13 8 9
Unadjusted 1 0.93(0.53-1.60) 0.75(0.39-1.43) 0.79(0.37-1.72) 0.50(0.24-1.04) .05
Adjusted 1 0.85(0.49-1.49) 0.71(0.36-1.41) 0.71(0.32-1.59) 0.37(0.16-0.82) .01
•Adjusted for sex, age, baseline performance status, weight change, BMI Participation of PA over 18 MET-h/week would prevent recurrence of cancer by about 50%,
however, more than 27 MET-h/week exercise does not warrant better outcome.
Physical Activity and Breast Cancer
Physical Activity and Survival After Breast Cancer Diagnosis
Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA
JAMA, 2005 Recurrence Recurrence
Physical activity after diagnosis, MET-h/week
Total (n=2,987)
<3 (n=959)
3-8.9 (n=862)
9-14.9 (n=335)
15-23.9 (n=428)
≥24 (n=403)
p for trend
Total deaths 463 188 126 38 51 60
Age-adjusted RR(95%CI) 1 0.69(0.55-0.87) 0.53(0.37-0.75) 0.56(0.41-0.77) 0.67(0.50-0.90) .004
Multivariable-adjusted
RR(95%CI) 1 0.71(0.56-0.89) 0.59(0.41-0.84) 0.56(0.41-0.77) 0.65(0.48-0.88) .003
Breast cancer deaths 280 110 84 20 32 34
Age-adjusted RR(95%CI) 1 0.79(0.60-1.06) 0.47(0.29-0.76) 0.60(0.41-0.89) 0.64(0.44-0.94) .01
Multivariable-adjusted
RR(95%CI) 1 0.80(0.60-1.06) 0.50(0.31-0.82) 0.56(0.38-0.84) 0.60(0.40-0.89) .004
Recurrence 370 137 108 29 45 51
Age-adjusted RR(95%CI) 1 0.82(0.64-1.06) 0.53(0.35-0.79) 0.66(0.47-0.93) 0.76(0.55-1.04) .05
Multivariable-adjusted
RR(95%CI) 1 0.83(0.64-1.08) 0.57(0.38-0.85) 0.66(0.47-0.93) 0.74(0.53-1.04) .05
•Adjusted for age, smoking status, BMI, menopausal status, hormone therapy use, age at first birth and parity, disease stage Breast cancer survival benefit from more than 9 MET-h per week physical activity.
심폐체력 연구 사례_유방암
A prospective study of cardiorespiratory fitness and breast cancer mortality Peel JB, Sui X, Adams SA, Hebert JR, Hardin JW, Blair SN
MSSE, 2009 Survival
Participants : Age – 43.0±10.5 years, Mean maximal METs – 9.5 ± 2.2, Total n=14,811
심폐체력 연구 사례_폐암
Peak oxygen consumption and long-term all-cause mortality in nonsmall cell lung cancer Jones LW, Watson D, Herndon JE, Eves ND, Haithcock BE, Loewen G, Kohman L
CANCER, 2010 Survival
Participants : stage Ⅰto ⅢA lung cancer(n=398)
Age : 64 ± 9 years
Determine VO2peak : began cycling at 20W, workloads were increased 5 to 20W/min until volitional exhaustion or until a symptom limitation was achieved
VO2peak, ml/kg/min : 15.8 ± 0.43
Association between VO2peak(ml/kg/min) and all-cause mortality
•Adjusted for age, sex, age, performance status
Analysis VO2paek(ml/kg/min)
<13.9 14.0-17.3 >17.3 P trend
All patients
No. of events 111 101 82
Median, mo 30.5(18.7-43.4) 42.7(35.2-54.6) 39.1(29.3-57.9)
Unadjusted HR Reference 0.80(0.61-1.05) 0.74(0.56-0.99) .0403
Adjusted HR Reference 0.79(0.59-1.04) 0.76(0.56-1.04) .0837
Resected patents
No. of events 82 85 70
Median, mo 44.0(31.7-57.5) 43.9(35.8-56.3) 46.2(31.0-66.0)
Unadjusted HR Reference 0.91(0.67-1.24) 0.84(0.61-1.16) .2888
Adjusted HR Reference 0.88(0.64-1.21) 0.86(0.61-1.21) .3937
Nonresected patients
No. of events 29 16 12
Median, mo 11.4(6.7-15.5) 23.1(15.9-47.5) 19.5(11.1-43.3)
Unadjusted HR Reference 0.45(0.24-0.86) 0.57(0.29-1.13) .0385
Adjusted HR Reference 0.34(0.17-0.67) 0.32(0.14-0.71) .0015
ACS, WCRF/AICR, ACSM 신체활동 대한 기본 원칙
ACS WCRF/AICR ACSM
[활동적인 생활습관을 가져라]
•성인 : 일상적인 활동에 추가로 하
루
최소 30분 이상 중등도 강도 신체
활동을
주당 5일 이상 유지(45-60분 활동
권고)
•어린이와 청년 : 일주일에 5일 이
상
하루 최소 60분 이
상
중등도 강도 신체활동 유
지,
모니터 앞의 시간
은
[매일 일상에서 활동적이 되어라]
•매일 하루 최소 30분 이상 중등도
강도 신체활동 유지
•신체적 적합성이 향상된다면 중등
도
활동 60분 이상 또는 고강도 활
동
30분 이상으로 목표 상향
•TV 시청과 같은 정적인 습관 제
한
[비활동성을 피하라]
•수술 이후 최대한 빨리 정상적인
활동으로 돌아가도록 노력
•비수술적 치료의 도중/이후 정상
적인
일상 활동 운동을 최대한 지속
•유산소운동, 저항성운동, 유연성운
동
권장사항은 일반인을 위한 가이드라인
과 동일
- 중강도 (150분/주) 또는 고강도(75분/주) 신
•ACS : American Cancer Society
•WCRF : World Cancer Research Fund
•AICR : American Institute for Cancer Research
•ACSM : American College of Sports Medicine
ACSM 암 생존자를 위한 운동 가이드라인 근거수준 분류
구 분 유방암
(치료 도중) 유방암
(치료 이후) 전립선암
혈액암 (HSCT도중/이후)
혈액암 (HSCT 하지않음)
안전성 A A A A
신체적 적합성 A A A C B
근 력 A A A C
신체조성 B B B
QOL B B B C
피 로 B B A C B
긴 장 B B
신체적 기능 A B
림프부종 A
• A : RCT 기반 수준 높은 데이터; B : RCT 연구 적거나, 규모가 작고 일관되지 않은 결과; C : uncontrolled, unrandomized, 그리고/또는 관찰연구;
D : 근거 불충분; 빈칸 : 데이터 자체 불충분
• HSCT(Hematopoietic stem cell transplantation)
암 경험자의 권장 운동
• 스트레칭, 요가
•관절 가동범위를 유지하거나 늘리는 동작 → 관절 유연성, 통증감소
•걷기, 달리기, 자전거 타기
•전신 근육을 규칙적으로 움직여 심폐기능 회복
•체중 부하 운동, 저항 밴드 운동
•암 치료과정 중 소실된 근육과 근력 회복
•하지 근력 단련
•낙상위험 감소
유연성 운동
유산소 운동
근력 운동
균형 운동
[Garber et al., MSSE, 2011; WHO, 2010]
Fig.1 Steps/day scale schematic linked to time spent in MVPA
10,000steps
Physical Activity and Cancer Recommendations
Prevention
Type
•Aerobic
-Brisk walking
-Cycling
-Swimming
•Resistance
-Free weights
-Elastic resistance bands
Frequency
•Bouts of 10min more
Stage
Pre-treatment
Intensity
•Moderate-Vigorous
Time
•150min per week
•Aerobic
•Resistance
•Flexibility
•2 times per week •Maintain •For a duration that
suits the unique need of
the individual
•Resistance
-Free weights
-Elastic resistance bands
•1 set of 10-15 reps
•Gradually work to
2 sets of 10-15 reps
•2 times pre week
•Rest muscles at least
one day between sessions
•Ensure 1-2 min rest
between each set
Physical Activity and Cancer Recommendations
During Treatment
Type Frequency Stage
Survivorship
Intensity Time
•Aerobic
•Resistance
•Flexibility
-Gentle stretching
•As often as able •Maintain •For a duration that
suits the unique need of
the individual
•Aerobic
-Brisk walking / Jogging
-Cycling
-Swimming
•Resistance
-Free weights
-Elastic resistance bands
•3-5 days per week •Moderate
•Vigorous
•150min per week
•75min per week
•Resistance
-Resistance machines
-Weight Bearing
•1 set of 10-15 reps
•Gradually work to
2 sets of 10-15 reps
•2-3 days per week
•Ensure 1-2 min rest
between each set
•Flexibility
-Stretching
•Target all muscle group
•Daily
•Hold each stretch for 30s
repeat on opposite site
Physical Activity and Cancer Recommendations
Type Frequency Stage
Palliative Care
Intensity Time
•Aerobic
-Brisk walking / Jogging
-Cycling
-Swimming
-Yoga
-Tai Chi
•1-2 times per week •Light to moderate •For a duration that
suits the unique need of
the individual
•Resistance
-Body weight
-Elastic bands
-Free weight
•1-2 times per week
•For a duration that
suits the unique need of
the individual
•Flexibility
-Stretching
-Range of motion activities
•Target all muscle group
•Daily
•Hold each stretch for 30s
repeat on opposite site
[ACSM’s guidelines for exercise testing and prescription 9th, 2014] [National comprehensive cancer network’s physical activity survivorship guidelines, 2[Bouillet T, Oncol Hematol, 2015] [Silver JK & Baima J, Am J Phys Med Rehabil, 2013]
ACSM Cancer Survivors Exercise Guidelines
구 분 유산소운동 저항성운동 유연성운동
Physical activity
guideline for american;PAG
A
•중등도운동 150분/주 또는 고강도운동 75분/
주
•주요 근육군에 대해 최소 중등도 이상으로
최소
주당 이틀 이상의 근력강화 운동
•다른 신체활동을 시행하는 날 주요 근육군과
건을
함께 스트레칭 실시
유방암 •PAGA와 동일
•골절 발생 위험성에 유의
•최소 16반복 이상의 낮은 저항 운동으로 시
작하여
점진적 증가
•림프부종 및 저항성
•PAGA와 동일
•상지/견관절 병증에 유의하여 시행 시 요가도
안전
대장암
•PAGA와 동일
•장루를 가진 경우 접촉 운동 전 의사의 승인
권장
•PAGA와 동일
•장루가 있는 경우 낮은 저항에서부터 점차 늘
려서
탈장을 방지할 수 있도록 함
•PAGA와 동일
•장루가 있는 경우 수영 등 접촉 운동 조정
필요
성인 혈액암
(no HSCT) •PAGA와 동일 •PAGA와 동일 •PAGA와 동일
성인 HSCT •운동의 면역효과를 고려하여 과도한 운동은
제한
•골수이식 환자의 경우 유산소운동보다 저
항성
운동이 더 중요할 수 있음
•PAGA와 동일
전립선암 •PAGA와 동일
•골절 발생 위험성에 유의
•PAGA와 동일
•근치적 전립선 절제술을 받은 경우 골반저 운동
포함
•골절 발생 위험성에 유의
•PAGA와 동일
부인과암 •말초신경병증이 있는 경우 자전거운동이 체중
부하 운동보다 선호될 수 있음
•부인과암으로 인한 2차적 하지 림프부종의
경우
저항운동의 안전성에 대한 연구 부족
•림프절 절제술 또는 림프절에 방사선치료•PAGA와 동일