VITRUVIAN EXERCISE PHYSIOLOGY
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EXERCISE & CANCER
The role of exercise in cancer care
Exercise functions as an effective adjunct therapy in cancer care. The evidence is clear and continues to show effectiveness for its use before, during and after treatment. Organisations including Cancer Research UK, Macmillan Cancer Support, the American Society of Clinical Oncology, the American College of Sports Medicine and the Clinical Oncology Society of Australia advocate integrating exercise into cancer care.
Exercise prescription is person centred and tailored to the individual. The old ‘rest and recovery’ approach has been replaced by current clinical evidence pointing towards ‘exercise as medicine’. For example, the recent CHALLENGE trial, released in the New England Journal of Medicine found that, compared to participants who simply received advice about general health, those receiving structured exercise programs had a 28% reduced risk of recurrence after colon cancer diagnosis.
For individuals with cancer, exercise has the potential to:
Improve survival rates
Improve quality of life
Reduce recurrence
Increase physical function
Combat treatment related side effects
Reduces the risk of
all-cause mortality
Exercise in this setting is modified according to each individual’s diagnosis, treatment type and treatment cycles, changing symptoms and personal history. Ultimately, it prioritises personalised adaptations to maintain safety while maximising the physiological benefits of exercise during and after treatment.
How does exercise help?
Exercise supports medical treatment by altering internal physiological processes and activating the body’s natural defences, creating a more hostile environment for cancer to thrive. The proposed mechanisms include:
Improved immune system function
Exercise bouts trigger the mobilisation of immune cells into the bloodstream including Natural Killer cells, T lymphocytes and macrophages, therefore improving immune surveillance against cancer cells.
Reduced systemic inflammation and oxidative damage
During exercise, the act of contracting our muscles releases myokines into circulation. Myokines are signalling proteins that allow muscles to communicate with other organs in the body. They play a role in reducing inflammation, reducing DNA damage and inhibiting tumour cell proliferation.
Improved treatment tolerance
Patients who exercise can often tolerate higher doses of treatment and are less likely to require dose reductions or delays, which is critical for the success of the therapy.
Reshaping the tumour microenvironment
Emerging evidence suggests exercise may improve tumour vascularity (more and better formed blood vessels), increasing blood flow and therefore improving delivery of cancer treatment agents such as chemotherapy.
Energy metabolism and hormonal regulation
Exercise, (particularly higher intensity exercise) alters the systemic environment, assisting in blood glucose control and reducing hormones such as insulin-like growth factor (IGF-1), making the body less hospitable to tumour progression.
Exercise also has the potential to mitigate common side effects of cancer treatment, including:
Cancer-related
fatigue
Cancer-related fatigue (CRF) is the most common side effect of treatment. This fatigue is not simply ‘being tired’. CRF appears to be a multi-system condition, involving mechanisms such as chronic systemic inflammation and mitochondrial dysfunction, combined with stress and anxiety, pain and co-morbid conditions. Exercise is the most effective non-pharmacological intervention for CRF.
Psychological
distress
All individuals with cancer will experience some level of distress.
It can present along a continuum from normal feelings of vulnerability and fear to disabling problems such as depression and anxiety. Medications and psychological therapies can be helpful. So can exercise, as evidence supports its use for mental health across all adults and is recognised as a first-line treatment option by the British, Australian and American Psychological Societies.
Reduced physical function and loss of muscle mass
Treatment and inactivity often leads to decreased fitness, strength, function and balance, making everyday activities more difficult. Progressive muscle wasting may occur, especially in older individuals where sarcopenia (age related muscle loss) may already be present. Structured exercise and adequate nutrition are important considerations in combating these side effects.
Bone loss
Treatments can result in a loss of bone density through the reduction of estrogen and testosterone as well as through steroid use. Additionally, a lack of physical activity means the skeletal system isn’t being appropriately loaded to stimulate bone health. Appropriate exercise along with a healthy diet (including calcium and Vitamin D), medications as required, smoking cessation and reduced alcohol consumption are key factors in management.
Cardiotoxicity
Cancer treatments may lead to a variety of cardiovascular issues including ischemic heart disease, stroke and heart failure. These conditions can occur during or after treatment and in some instances
may take years before symptoms present. Inactivity can exacerbate problems. Evidence from cancer patients demonstrates decreased
levels of cardiotoxicity in those with higher levels of physical activity.
Lymphoedema
Refers to swelling in a body segment (commonly arm, hand, armpit, neck, groin, legs) caused by a reduced ability to clear lymph fluid from the surrounding tissues. It can occur following surgery and radiation therapy as a result of the removal of, or damage to, lymph vessels and nodes. Resistance training in particular has been shown to decrease incidence and severity and improve function. Compression garments can be used during exercise to help control symptoms.
Exercise and cancer - what type, frequency and intensity?
It may seem a daunting prospect to undertake exercise during treatment and it is normal to have questions
relating to safety and the type of exercise that is recommended.
Firstly, and very importantly, one size does not fit all when it comes to exercise during and after cancer treatment. Exercise is safe. It is key to prioritise personalised adaptations, modifications and self-regulation to maintain safety while maximising the physiological benefits of exercise during and after cancer care. Use a ‘start low, go slow’ approach.
In most cases, individuals with cancer will have come to see a clinical exercise physiologist (CEP) following referral by an Oncologist or General Practitioner. Clinical collaboration and communication between exercise specialists and the medical team is vital, especially during active treatment.
In the initial consultation, your CEP will gather further information with the following considerations in mind:
Cancer type
Cancer stage and location of cancer spread
When diagnosed
Previous, current and future treatments
Treatment schedule / phases
Presence and severity of side effects
Presence of comorbidities
Previous and current exercise levels
Individual goals and expectations
Discussion around the benefits of exercise
Depending on the information gathered and your physical capabilities, some objective assessments may be performed to attain further information on fitness, strength, balance, functional capacity and provoking activities when pain is present.
This information is then used to guide the exercise prescription. The evidence on exercise during cancer treatment acknowledges one simple fact, something is always better than nothing. Avoiding inactivity is key. A fundamental goal for all cancer survivors is to avoid being sedentary.
Practical strategies like ‘exercise snacks’ can be helpful for those unable to exercise for longer bouts. This involves accumulating minutes of physical activity throughout the day, a few minutes at a time, in order to increase tolerance slowly and accrue benefits.
During times of treatment, the "dose" of exercise—including its frequency, intensity, and duration—must be modified based on acute treatment side effects such as fatigue and nausea. During treatment phases it is recommended to prioritise frequency and consistency rather than intensity and duration.
Once capacity and tolerance allow, guidelines recommend aiming for exercise bouts of a minimum of 10-15 mins at a time. This is considered a minimum effective dose for encouraging physiological stimulus, mitigating treatment side effects and boosting the body’s natural defences. Over the course of a week, this might look like:
90 mins of moderate-intensity aerobic exercise alone
OR
2 x resistance training sessions alone
OR
+
A combined aerobic and resistance training session performed 3 times a week for 30 mins per session
Ultimately, clinical guidelines recommend that the optimal dose of exercise matches the World Health Organisation and the American College of Sports Medicine’s recommendations for all adults. This amounts to a weekly goal of:
Aerobic Exercise
Resistance Training
OR
+
150 minutes
(at least) of moderate intensity aerobic exercise.
75 minutes of vigorous intensity aerobic exercise.
2-3x resistance training sessions, typically involving 1 -3 sets of 8 -12 repetitions for major muscle groups.
Flexibility and balance exercises may be required for certain individuals, for example, post-surgery and/or older individuals at risk of falls.
Cancer treatments and medications may influence heart rate response to exercise and therefore it is recommended to use the rating of perceived exertion (RPE) scale to monitor intensity.
RPE
Description
0
Nothing at all
1
Very light
Light
2
3
Moderate
4
Hard
6
Hard
7
Extremely hard
Somewhat hard
5
Very hard
8
Very hard
9
10
Maximal
The American College of Sports Medicine guidelines typically recommend:
Moderate exercise = 4-6
&
Vigorous exercise = 7-8
The American College of Sports Medicine also suggests the following to gauge exercise intensity:
Light intensity – a slight increase in breathing
Moderate intensity – a noticeable increase in breathing
Vigorous intensity – a substantial increase in breathing
This allows for monitoring of exercise response and suitable modifications.
A combination of aerobic and resistance exercise offers the most benefit. Within the above guidelines, exercise professionals will modify according to each individual’s unique set of circumstances, requirements and fluctuations in status.
Cautions and considerations
The evidence is clear, exercise is safe. There are, however, necessary cautions and considerations to observe and monitor. The type of cancer and the treatments used can all affect the body in different ways.
It is important to remain vigilant for the presence of new signs and symptoms or unusual changes in existing signs and symptoms, including new and worsening pain. This will require referral to the treating physician for investigation.
Special caution must be applied with certain presentations, including:
Bone metastases
Avoid high impact, high loads and high torque exercises, specifically at the site of the lesion. Emphasis is on controlled, non-impact movements, with a focus on unaffected areas of the body.
Acute infection/fever
Withhold exercise during acute fever or signs of systemic infection. Resume gradually after resolution as tolerated.
Cardiotoxicity
Exercise is safe when prescribed appropriately but clearance from a medical professional may be warranted. Ultimately, exercise is protective of the heart and cardiovascular system.
Severe anaemia
Cancer treatments may result in decreased red blood cell or haemoglobin counts and therefore reduced exercise tolerance due to a decreased availability of oxygen. Focusing on light intensity regular activities of daily living is recommended until adequate oxygenation is reached. Gradually and carefully return to higher exercise volume and intensity once resolved.
Sudden or Worsening Chest Pain
Any new or escalating chest pain requires immediate cardiac evaluation. Exercise is contraindicated and referral to the treating physician required.
Below are some common side effects of cancer treatment that will require consideration and modifications to the exercise prescription.
-
Fatigue
-
Pain
-
Nausea
-
Shortness of breath (dyspnoea)
-
Limited range of motion
-
Lymphedema
-
Peripheral neuropathy
-
Muscle weakness
-
Reduced bone mass
-
Cognitive Function ‘Chemo Brain’
-
Depression and Anxiety
-
Presence of medical devices: (PICC lines, Port-A-Caths, Ostomy [stoma bags])
Conclusion
Being physically active and engaging in tailored exercise is recommended before, during and after cancer treatment. It has the potential to improve treatment outcomes, combat treatment side effects and improve the health, function and quality of life of individuals going through cancer treatment. To maximise safety and therapeutic effect, exercise is ideally prescribed and delivered under the supervision of a clinical exercise physiologist or physiotherapist, with a focus on self-managed exercise over time as appropriate.
The Vitruvian Team.
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