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SPORT | Exercise after diagnosis

In this book excerpt from The Cancer Revolution, Professor Robert Thomas talks about the benefits of physical

activity after a cancer diagnosis

become 84 per cent.1,2 To achieve this and similar successes in other types of cancer, however, patients usually have to endure complex and arduous therapies, often involving acute or long-term side effects, that can considerably diminish their quality of life.

Fortunately, well-conducted clinical studies have demonstrated a significant benefit for exercise and that it can play a major role in reducing the severity of many of these adverse effects. A meta-analysis of 34 randomised trials, published in the British Medical Journal in 2012, showed that patients who took exercise after cancer experienced improvements in terms of fatigue, mood, anxiety, depression, muscle power, hand grip, exercise capacity and quality of life.3 Other trials have shown that regular exercise during and after cancer treatments reduces the serious risk of blood clots, which affects up to 15% of cases, and in some can be life-threatening.4,5 The evidence for the benefits of exercise spans the common cancer types and has been demonstrated following a range of treatments including surgery, radiotherapy, chemotherapy, hormone treatment and even the newer biological therapies. I now go on to describe some specific programmes and clinical studies addressing some of the common symptoms that often plague those who have survived cancer.

CANCER-RELATED FATIGUE (CRF)Fatigue has overtaken nausea and pain as the most distressing symptom experienced by cancer patients both during and after cancer treatments. It is reported by 60-96% of patients during chemotherapy, following radiotherapy or after surgery.6

CRF can have a profound effect on the whole person, physically, emotionally and mentally, and can persist for months or even years following completion of treatment.7 It is also reported in up to 40% of patients taking long-term treatments such as hormone or biological therapies.8

The first step to treating CRF is to correct, if possible, medical conditions that can aggravate it – anaemia, medication, electrolyte imbalance, liver failure, steroid withdrawal, depression, nocturia (the need to get up in the night to urinate), night sweats and pruritis (the desire to scratch).9 Drugs such as opiates, antihistamines, anti-sickness medication and sedatives can also worsen the condition.

The self-help strategy most extensively investigated for CRF is exercise. There have been two meta-analyses addressing the use of exercise to combat CRF. The first showed a modest benefit. The second subdivided the data into two main exercise strategies:♦ Home-based programmes, involving

Most of us realise – whether we do anything about it or not – that regular

exercise and a healthy lifestyle reduce our risk of developing many serious diseases, including cancer. What is less well known is that, after a diagnosis of cancer, exercise can bring enormous benefits, not only to reduce the side effects of treatment and improve physical and psychological well-being, but also to increase the chances of long-lasting remission and cure. In many cases, the magnitude of these benefits is on a par with that provided by chemotherapy, yet mainstream oncology units have been slow to offer exercise guidance and support for their patients.

This chapter taken from The Cancer Revolution, reviews the evidence from

published clinical studies and describes the underlying mechanism of how exercise fights cancer. It also makes tried and tested suggestions on how, when and how often to exercise.

EVIDENCE THAT PHYSICAL ACTIVITY IMPROVES WELL-BEING AFTER CANCERThrough a combination of earlier detection and enhanced treatments, the chance of surviving cancer has significantly improved during the last two or three decades. For example, the average chance of living five years from diagnosis for a woman with breast cancer when I first became a consultant in 1990 was just 54 per cent; by 2012 it had

Fit for life

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Exercise after diagnosis | SPORT

patients being advised to exercise, unsupervised, in their own homes.♦ Referring patients to a supervised exercise programme, including a combination of aerobic exercises (e.g. running or rowing) and resistance exercises (e.g. weight lifting).

The studies involving supervised aerobic exercise programmes showed a statistically significant improvement; the degree of improvement was also better than that of the home-based programmes.7,10

WEIGHT GAIN AND BODY COMPOSITIONWeight gain during and after adjuvant chemotherapy is becoming an ever-increasing concern. Nearly half of women with breast cancer, for example, report significant weight gain, often at a time in their lives when losing it is difficult. In men, a study of 440 prostate cancer survivors reported that more than half were overweight or obese.11 For individuals with bowel cancer, a trial showed that a third of these patients were overweight after chemotherapy and that a third were obese or very obese.12 There are several reasons for this. Some patients are concerned about undue weight loss, perhaps as a result of outdated and misleading information, and they tend to overeat; others with fatigue and nausea stop exercising. Certain drugs, including steroids and hormone therapies such as tamoxifen (for breast cancer) or Zoladex (for prostate cancer), can also promote weight gain. Numerous reviews and meta-analyses of published medical literature have demonstrated that individuals who gain weight after cancer treatments have poorer survival rates and increased chances of complications.13 Fortunately, supervised exercise programmes have been shown to reduce weight problems and to be significantly beneficial for body constitution and fitness, including lean mass indices, bone mineral density, heart and lung function, muscle strength and walking distance.13

PSYCHOLOGICAL WELL-BEINGBeing diagnosed with cancer is of course a stressful experience and requires a high level of emotional and social readjustment. While many people accept a cancer diagnosis reasonably well, psychological distress is consistently reported in over a quarter of patients.14 Still, psychological well-being, including mood status, depression and anxiety, is under-diagnosed in up to half of cases.13 As well as being distressing for the patients and their carers, depression may have a physical impact. Cohort studies (those examining a selected group of similar patients) have suggested that people with lung and breast cancer who are also depressed, for example, have reduced

Lifestyle factors that increase the risk factors for developing osteoporosis include a low intake of calcium, a low-protein diet, lack of physical activity, smoking and excessive alcohol intake.24,25 A number of well-conducted retrospective and randomised studies have identified exercise as an intervention to reduce the risk of bone mineral loss, which is a common factor in all the conditions listed above.26,27

SUMMARY♦ Regular light exercise reduces cancer-related fatigue.♦ Too much intense exercise can make fatigue worse.♦ Supervised exercise regimens have the best results for reducing fatigue.♦ Exercise programmes improve psychological well-being.♦ Group and socially interactive programmes have the best results for improving mood and anxiety levels.♦ Regular exercise reduces the risk of blood clots during chemotherapy.♦ Regular exercise during cancer treatments helps prevent weight gain.♦ Regular exercise helps individuals lose weight after cancer treatments.♦ The best weight-control programmes combine exercise with a healthy calorie-reducing diet.♦ Weight-bearing exercise is best to prevent bone loss.♦ Non-weight-bearing exercise nevertheless also helps to prevent bone loss.♦ Exercise has to be sustained for several months before any benefits are noticeable.

survival compared with those who are psychologically healthy.15,16 A number of observational studies (those with no control group of patients for comparison) among people undergoing chemotherapy, radiotherapy, hormone and other therapies, have demonstrated reduced levels of depression and anxiety as well as improved quality of life, mood, happiness and self-esteem for those on an exercise programme, especially when group activities are involved.17

OVERALL QUALITY OF LIFERegular exercise has been shown to improve quality of life at all stages of illness and for several different types of cancer. For example, in a study involving 1,966 patients with colorectal cancer, those achieving at least 150 minutes of physical activity per week had an 18% higher quality of life (QoL) score than those who reported no physical activity.18 Another study showed similar benefits in relation to exercise in a randomised trial of breast-cancer survivors who had completed surgery, radiotherapy or chemotherapy; it also demonstrated that change in peak oxygen consumption (a measure of physical fitness) correlated with change in overall QoL.19 Another randomised trial compared supervised resistance exercise versus a similar group of 135 men with prostate cancer and not involved in exercise who were scheduled to receive hormone therapy for at least three months. There was a significant improvement in QoL in the exercise group and a significant decline in the comparison group.20

BONE HEALTH (OSTEOPOROSIS)Pre-menopausal women who have had breast cancer treatment are at increased risk of osteoporosis and fracture due to reduced levels of oestrogen brought on by a premature menopause; this can be caused by chemotherapy, surgery or hormones. Men who receive hormone-deprivation therapy for prostate cancer also have an increased risk of developing osteoporosis.21 Post-menopausal women are at a higher risk if they receive aromatase inhibitors such as Arimidex.22 Osteoporosis, its precursor osteopenia and increased rates of fracture have also been noted in those who have survived many other types of cancer, including testicular, thyroid, gastriointestinal and that of the central nervous system as well as non-Hodgkin’s lymphoma and various haematological (blood) malignant diseases.23 Medical conditions associated with a higher risk of osteopenia include thyroid disorders and prolonged warfarin or corticosteroid intake.

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men had less risk of dying from prostate cancer if they walked for four or more hours per week. In addition, compared with men who walked for less than an hour and a half at an easy walking pace, those who walked for that amount of time (or longer) at a normal to very brisk pace halved the risk of death from all causes. More vigorous activity, and longer duration of activity, was associated with significant further reductions in risk.28 In a separate study of 1,455 men with prostate cancer, researchers found that walking at a pace of at least

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Robert Thomas is Consultant Oncologist at Bedford and Addenbrooke’s Hospitals, a Professor at Cranfield University and clinical teacher at Cambridge University. He is a strong advocate of self-help and lifestyle strategies to improve well-being and outcome. He is author of Lifestyle and Cancer: The Facts (2008) and has published over 100 scientific papers, including the world’s largest prospective trial evaluating lifestyle and prostate-cancer progression. He was chief investigator of the first double-blind randomised controlled trial of a polyphenol supplement (Pomi-T) in men with prostate

cancer. Having designed the UK’s first level 4 cancer rehabilitation course for exercise professionals, he is also Media Spokesman and Chair of the Macmillan Cancer Support Exercise Advisory Group. www.cancernet.co.uk

References1 Coleman MP, Babb P, Damiecki P,

et al (1999). Cancer survival trends in England and Wales 1971–1995: deprivation and NHS region, Studies on Medical and Population Subjects (No. 61). The Stationery Office: London.

2 Office for National Statistics (2012). Cancer survival in England: patients diagnosed 2006-2010 and followed up to 2011, ONS Statistical Bulletin.

3 Fong DY, Ho JW, Hui BP, et al (2012). Physical activity for cancer survivors: meta-analysis of randomised controlled trials, British Medical Journal 344: e70.

4 Blackwell Publishing Ltd (2007). Regular exercise reduces risk of blood clots, study suggests, Science Daily (Retrieved October 5, 2015 from www.sciencedaily.com/releases/2007/11/071120124245.htm)

5 Lyman, GH (2011). Venous thromboembolism in the patient with cancer, Cancer 117(7): 1334–1349.

6 Cella D (1998). Quality of life in cancer patients experiencing fatigue and anemia, Anemia Oncology: 2–4.

7 Velthuis MJ, Agasi-Idenburg SC, Aufdemkampe G, et al (2010). The effect of physical exercise on cancer-related fatigue during cancer treatment: a meta-analysis of randomised controlled trials, Clinical Oncology 22(3): 208-221.

8 Wagner LI and Cella D (2004). Fatigue and cancer: causes, prevalence and treatment approaches, British Journal of Cancer 91(5): 822-828.

9 Thomas R (2005). Anaemia fatigue and epoeitin in oncology, British Journal of Cancer Management 2(4): 12-15.

10 Cramp F and Daniel J (2008). Exercise for the management of cancer-related fatigue in adults, Cochrane Database of Systematic Reviews 16(2): CD006145.

11 Thomas RJ, Holm M, Williams M, et al (2013). Lifestyle factors correlate with the risk of late pelvic symptoms after prostatic radiotherapy, Clinical Oncology 25(4):246-251.

12 Meyerhardt JA, Niedzwiecki D, Hollis D, et al (2008). Impact of Body Mass Index and weight change after treatment on cancer recurrence and survival in patients with stage III colon cancer: findings from cancer and Leukemia group B 89803, Journal of Clinical Oncology 26(25): 4109–4115.

13 Knols R, Aaronson NK, Uebelhart D, et al (2005). Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials, Journal of Clinical Oncology 23(16): 3830-3842.

14 Drouin JS, Armstrong H, Krause S, et al (2005). Effects of aerobic exercise training on peak aerobic capacity, fatigue, and psychological factors during radiation for breast cancer, Rehabilitation Oncology 23: 11-17.

15 Watson M, Haviland JS, Greer S, et al (1999). Influence of psychological response on survival in breast cancer: a population-based cohort study, Lancet 354(9187): 1331–1336.

16 Nakahara Y, Mochizuki Y, Miyamoto Y, et al (2002). Mental state as a possible independent prognostic variable for survival in patients with advanced lung carcinoma, Cancer 94(11): 3006–3015.

17 Mock V, Pickett M, Ropka ME, et al (2001). Fatigue and quality of life outcomes of exercise during cancer treatment, Cancer Practice 9(3): 119-127.

18 Lynch BM, Cerin E, Owen N, et al (2008). Prospective relationships of physical activity with quality of life among colorectal cancer survivors, Journal of Clinical Oncology 26(27): 4480-4487.

19 Courneya KS, Mackey JR, Bell GJ, et al (2003). Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes, Journal of Clinical Oncology 21(9): 1660-1168.

20 Segal RJ, Reid RD, Courneya KS, et al (2003). Resistance exercise in men receiving androgen deprivation therapy for prostate cancer, Journal of Clinical Oncology 21(9): 1653-1659.

21 Smith MR (2007). Androgen deprivation therapy for prostate cancer: new concepts and concerns, Current Opinion in Endocrinology, Diabetes, and Obesity 14(3): 247-254.

22 Mackey JR and Joy AA (2005). Skeletal health in postmenopausal survivors of early breast cancer, International Journal of Cancer 114(6): 1010-1015.

23 Brown TT, Ruppe MD, Kassner R, et al (2004). Reduced bone mineral density in human immunodeficiency virus-infected patients and its association with increased central adiposity and postload hyperglycemia, Journal of Clinical Endocrinology and Metabolism 89(3):

1200-1206.24 NIH Osteoporosis and Related

Bone Diseases National Resource Center (2014). Handout on Health: Osteoporosis (Retrieved from http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/osteoporosis_hoh.asp )

25 Weikert C, Hoffmann K, Dierkes J, et al (2005). Homocysteine metabolism related dietary pattern and the risk of coronary heart disease in two independent German study populations, Journal of Nutrition 135(8): 1981–1988.

26 Waltman NL, Twiss JJ, Ott CD, et al (2010). The effect of weight training on bone mineral density and bone turnover in postmenopausal breast cancer survivors with bone loss: a 24-month randomized controlled trial, Osteoporosis International 21(8): 1361-1369.

27 Schwartz AL, Winters-Stone K, Gallucci B (2007). Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy, Oncology Nursing Forum 34(3): 627-633.

28 Kenfield SA, Stampfer MJ, Giovannucci E, et al (2011). Physical activity and survival after prostate cancer diagnosis in the health professionals follow-up study, Journal of Clinical Oncology 29(6): 726-732.

29 Richman EL, Kenfield SA, Stampfer MJ, et al (2011). Physical activity after diagnosis and risk of prostate cancer progression: data from the cancer of the prostate strategic urologic research endeavour, Cancer Research 71(11): 3889-3895.

SPORT | Exercise after diagnosis

WHAT TYPE AND HOW MUCH EXERCISE DO WE NEED?In terms of improved well-being and reducing side effects of cancer treatment, the best results appear to involve programmes that combine aerobic and anaerobic exercise, particularly within a social group. Studies have demonstrated benefits in those who practise gym, medical qigong and tai chi chuan or those who dance in such styles as Celtic, American, jazz, Afro-Cuban, reggae, Middle Eastern and Cajun. The precise amount of exercise has to be determined on an individual basis: the choice of limit depends on such factors as pre-treatment ability, current disability caused by the cancer itself, surgery, radiotherapy or chemotherapy and how much time there is before the next major treatment. Exercise programmes supervised by trained professionals can offer significant advantages. They can design a bespoke regimen that starts slowly and gradually builds up to an acceptable and enjoyable pace. They can help motivate the individual to continue exercising, whether on a short- or long-term basis. They can judge the optimal exercise levels to reduce fatigue, not to aggravate it.

In terms of exercise to reduce the chances of a cancer relapse, most of the cohort studies (studies of a selected group of similar patients) suggest moderate exercise for around two and a half to three hours a week for those with breast cancer, while

three miles per hour for three hours or more per week halved the risk of relapse compared with men who walked the same amount, but slower.29

CONCLUSIONThere is little doubt now that maintaining regular exercise not only reduces the risk of illness, but can also have a significant effect on your recovery. Even during

treatment, efforts made to exercise regularly affect energy

levels and can accelerate recovery. Many GPs are now able to ‘prescribe’ sessions at exercise classes, gyms and with personal trainers. After

treatment, exercise will get you well and keep you well.

It is all absolutely worth the investment of time and effort.

WITH

THANKS TO...Professor Robert Thomas,

Patricia Peat, Yes to Life and Win-win Health Intelligence Limited for

granting the FHT permission to publish this book excerpt

from The Cancer Revolution www.thecancer revolution.co.uk