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. Evidence continues to show effectiveness for its use before, during and after treatment. Exercise supports medical treatment by boosting the body’s natural defences and helping to combat side effects of treatment. Organisations including Cancer Research UK, the American College of Sports Medicine and the Clinical Oncology Society of Australia now recommend moving away from the old ‘rest and recovery’ mindset and instead advocate for ‘exercise as medicine’.
One recent study, the CHALLENGE trial, showed that a structured exercise plan could reduce the risk of recurrence of colon cancer by 28%. For those 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 prescription is tailored to each individual and prioritises personalised modifications to maintain safety while maximising the benefits.
How does exercise help?
Exercise supports medical treatment by activating the body’s natural defences and creating a more hostile environment for cancer to thrive. The proposed mechanisms include:
Improved immune system function
Exercise bouts stimulate the mobilisation of immune cells (including Natural Killer cells, T lymphocytes and macrophages) into the bloodstream. This enhances immune surveillance, improving the body’s ability to detect and destroy abnormal or cancerous cells.
Reduced systemic inflammation
During exercise, muscle contractions stimulate the release of proteins called myokines into the bloodstream. Myokines enable communication between muscles and organs. They play an important role in promoting health by reducing inflammation, limiting DNA damage and inhibiting the growth and proliferation of tumour cells.
Improved treatment tolerance
Patients who exercise regularly 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. Exercise can improve treatment tolerance by preserving muscle mass, metabolic stability and cardiovascular capacity.
Energy metabolism and hormonal regulation
Improves blood glucose regulation and reduces levels of hormones such as insulin-like growth factor (IGF-1). These changes create a metabolic environment that is less favourable for tumour growth and progression.
Reshaping the tumour microenvironment
Exercise improves the health of our vascular system. Emerging evidence suggests exercise may help improve the number and quality of blood vessels within the tumour. This results in increased blood flow and therefore enhanced delivery of cancer treatment agents such as chemotherapy.
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’. While short recovery periods are appropriate, prolonged inactivity can exacerbate the mechanisms contributing to CRF. These mechanisms appear to include chronic inflammation, endocrine disruption, mitochondrial dysfunction and muscle loss. 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
Some treatments can result in a loss of bone density through the reduction of hormones that usually support strong bones (e.g., oestrogen 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, 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. These 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, radiation or chemotherapy as a result of the removal or damage to lymph vessels and nodes. Resistance training in particular has been shown to decrease incidence and severity. 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. From a risk perspective, avoiding exercise carries greater long-term consequences than engaging in appropriately prescribed exercise.
Current best evidence recommends that, when appropriate, a combination of aerobic and resistance exercise is performed. Resistance and aerobic training influence different physiological systems and therefore offer different therapeutic effects.
- Creates mechanical tension - Stimulates muscle protein synthesis - Improves neuromuscular recruitment - Restores strength - Improves bone health
Resistance Training
- Improves cardiovascular function - Improves oxidative capacity - Improves mitochondrial health - Enhances metabolic regulation
Aerobic Training
One size does not fit all. An individual with reduced bone and muscle strength due to particular treatments will require a different program focus to someone with reduced respiratory capacity associated with lung cancer.
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. Exercise dose matters and will determine its therapeutic benefit.
-
Frequency
-
Intensity
-
Time
-
Type
-
Volume
-
Progression
Exercise
In most cases, individuals with cancer will have come to see a clinical exercise physiologist (CEP) following referral by an Oncologist or General Practitioner. Collaboration and communication between exercise specialists and the medical team is vital, especially during active treatment.
In the initial consultation, your CEP will gather 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
Musculoskeletal limitations
Previous and current exercise levels
Individual goals and expectations
Discussion around the benefits of exercise
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. Use a ‘start low, go slow’ approach.
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 = 6-8
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. 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.
Exercise itself is not a risk and complications are rare. Complications are more likely to arise if exercise is unsupervised, poorly prescribed, or based on generic fitness advice rather than an appropriate assessment.
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. Aerobic and resistance training is still recommended, with an emphasis on controlled, non-impact movements, focusing on unaffected areas of the body. Exercise is contraindicated for unstable bone lesions with imminent fracture risk.
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.
Treatment-related 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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