The term “cancer survivor” refers to anyone who has been diagnosed with cancer, no matter where they may be in their journey. With earlier detection and improvements in screening and treatment, cancer survivors are living longer. ACSM recommends for patients to aim for 150 minutes per week of moderate aerobic exercise with an additional two to three sessions of strength training (such as weight lifting) unless contraindicated. A 2017 systematic review suggests that there is sufficient research to support the promotion of exercise for adults with cancer, and some to support the promotion of exercise in group or supervised settings and for a long period of time to improve quality of life and muscular and aerobic fitness (1). Exercising at moderate intensities can be sustainable for longer periods of time and could encourage the formation of an exercise habit. It is important that an assessment be conducted to evaluate the effects of disease, treatments, and comorbidities and that a survivor receives clearance from their oncologist (1).

How cancer patients should approach exercise?

A patient’s approach to exercise should be rehabilitative and should consider their fitness level prior to diagnosis and treatment. The survivor will need to consider the recency of surgery, chemotherapy, radiation, hormonal therapy, and any side effects that may have occurred with each. The patient’s oncologist/physical therapist/trainer can be helpful in identifying side effects that could influence one’s performance and help them determine what modality of exercise could be the most appropriate to prevent injury. These health/fitness professionals should also work with the patient to come up with realistic activity goals. Having goals will increase motivation and facilitate a lasting behavior change!

Some of the best exercise for cancer patients – does this vary between those who are currently undergoing cancer treatment versus those in remission?

The best exercise is the one that fits the individual. Again, it’s important to consider any treatment-related side effects that may be present. This can serve as a foundation for tailoring the patient’s regimen. Common treatment-induced side effects that could have implications on exercise include neuropathy, lymphedema, and cardiotoxicity.

If the survivor is experiencing neuropathy (often referred to as chemotherapy-induced peripheral neuropathy (CIPN)), it would be best to steer away from high-impact free weights and aerobic exercises that require a lot of balance. Safer modalities would be low-impact exercises such as swimming and biking. For lower extremity neuropathy, patients should try to incorporate calf stretches, ankle circles, walking, leg lifts, and balancing exercises (2).

While most common in breast cancer survivors, lymphedema can be present in any part of the body that has been subject to surgery or radiation. It is essential to seek out care from a lymphedema specialist and resolve the issue. Contrary to popular belief, once the lymphedema is under control, it is safe to exercise at a slow and progressive rate (3). The survivor will need to pay close attention to any changes in the affected area. This can include swelling of part or all of your arm or leg including fingers or toes, a feeling of heaviness or tightness, restricted range of motion, aching or discomfort, recurring infections, or hardening and thickening of the skin (4).

For those experiencing cardiotoxicity after chemotherapy (in particular, anthracycline-based treatment) or radiation to the chest area, it will be important to get physician clearance before engaging in exercise. However, engaging in a low-to-moderate intensity exercise regime prior to or during treatments could potentially mitigate the severity of treatment-induced cardiotoxicity (5).


Why exercise is so important for cancer patients.

The benefits from exercise for this population are extensive. Cancer survivors are almost three times more likely to report fair or poor health after treatment and twice as likely to have psychosocial disabilities and physical and functional limitations as persons without cancer (6). In addition to the possibility of neuropathy, lymphedema, and cardiotoxicity as mentioned above, some other lingering effects of treatment include but are not limited to cancer-related fatigue, weight gain, weight loss, depression, anxiety, insomnia, altered body composition, and changes in bone mineral density. Of these, strong evidence suggests that exercise can directly improve fatigue, weight changes, depression, anxiety, and bone health (7).

  • Fatigue: Fatigue occurs in approximately 50-90% of patients undergoing treatment. While it may seem contradictory, exercise happens to be the number one non-pharmaceutical approach to combatting cancer-related fatigue. It can be hard to get started, but great benefits will be reaped if one can get going…even if it’s something as small as walking around the block for 10 minutes or doing house cleaning. A meta-analysis of 70 studies reported that exercise reduces fatigue by 32% during treatment and by 38% after cancer treatment [8]. Resistance, aerobic, flexibility and mixed training programs have all demonstrated improvements in fatigue levels.
  • Weight loss/weight gain: There are many mechanisms that can cause a patient to lose weight. One is associated with the side effects of chemotherapy such as nausea, vomiting, diarrhea, and anorexia. Another mechanism is the presence of an altered metabolism and increased inflammatory cytokines that speed up muscle degradation and can lead to a more serious condition called cancer cachexia (7). On the other hand, weight gain and/or increased fat-to-lean mass ratio can be caused by certain cancer therapies, especially hormonal therapies (7). Exercise can mediate inflammation and help maintain lean mass to help keep weight in check.
  • Depression/Anxiety/Insomnia: Some of us are familiar with the endorphins and serotonin increase that exercise brings on, but exercise is also associated with increased levels of endocannabinoids which have an anti-anxiety effect and promote a sense of well-being [9]. Physical activity also helps patients develop an increased sense of control in his/her own life. Exercise also reduces many negative emotions such as anger, contempt, disgust, guilt, fear and nervousness. The anti-anxiety and antidepressant effects of exercise has been demonstrated in patients undergoing treatment [10, 11] as well as cancer survivors [12]. Insomnia is often induced by increased depression and anxiety, so by treating the root of the problem (depression and anxiety), insomnia can be reduced.
  • Bone health: Bone density can be by hormonal therapies or by metastases to the bone. In those without mets, impact and weight exercise training are preferred to maximize bone health (7). Impact exercises include activities such as running and jumping. Weight and resistance training refer to activities that require the shortening (contraction) and elongation of muscles. By loading the bones through impact and weight bearing activity, you help to prevent further bone loss. If mets are present in the bones, you will want to be extra careful when choosing appropriate activities. As with other exercises, if a patient is experiencing bone metastases or a loss of bone mineral density, it will be essential to seek out advice from an experienced fitness professional.


How family and friends can help show their support (fitness and nutrition wise).

Encouragement! Exercise can be daunting for some. It is important to recognize the benefits of exercise and help your loved one find a good regimen that fits their needs. You may also consider exercising with them. That way you hold each other accountable and both get the amazing benefits of exercise.

Where our readers can go for more information.

Look for an ACSM Cancer Exercise Trainer in your area.

ACSM.org, WCRF/AICR


References:

  1. Segal, R., Zwaal, C., Green, E., Tomasone, J. R., Loblaw, A., Petrella, T., & Exercise for People with Cancer Guideline Development Group (2017). Exercise for people with cancer: a systematic review. Current oncology (Toronto, Ont.)24(4), e290–e315. doi:10.3747/co.24.3619
  2. Tips for Managing Neuropathy. (n.d.). Retrieved from https://www.dana-farber.org/health-library/articles/tips-for-managing-neuropathy/
  3. Lymphedema (PDQ): Health professional version. National Cancer Institute. https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-hp-pdq#section/all. Accessed Sept. 24, 2017.
  4. Lymphedema. (2017, December 21). Retrieved from https://www.mayoclinic.org/diseases-conditions/lymphedema/symptoms-causes/syc-20374682
  5. Chen, J. J., Wu, P., Middlekauff, H. R., & Nguyen, K. (2017). Aerobic exercise in anthracycline-induced cardiotoxicity: A systematic review of current evidence and future directions. American Journal of Physiology-Heart and Circulatory Physiology, 312(2). doi:10.1152/ajpheart.00646.2016
  6. Hewitt Maria, Rowland Julia H, Yancik Rosemary. Cancer survivors in the United States: age, health, and disability. The journals of gerontology. Series A, Biological sciences and medical sciences. 2003;58:82–91.
  7. Ferioli, M., Zauli, G., Martelli, A. M., Vitale, M., McCubrey, J. A., Ultimo, S., … Neri, L. M. (2018). Impact of physical exercise in cancer survivors during and after antineoplastic treatments. Oncotarget9(17), 14005–14034. doi:10.18632/oncotarget.24456
  8. Puetz TW, Herring MP. Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis. Am J Prev Med. 2012;43:e1–24. https://doi.org/10.1016/j.amepre.2012.04.027.
  9. De Moor MH, Beem AL, Stubbe JH, Boomsma DI, De Geus EJ. Regular exercise, anxiety, depression and personality: a population-based study. Prev Med. 2006;42:273–9.
  10. Mehnert A, Veers S, Howaldt D, Braumann KM, Koch U, Schulz KH. Effects of a physical exercise rehabilitation group program on anxiety, depression, body image, and health-related quality of life among breast cancer patients. Onkologie. 2011;34:248–53. https://doi.org/10.1159/000327813. [PubMed] [Google Scholar]
  11. Quist M, Adamsen L, Rorth M, Laursen JH, Christensen KB, Langer SW. The impact of a multidimensional exercise intervention on physical and functional capacity, anxiety, and depression in patients with advanced-stage lung cancer undergoing chemotherapy. Integr Cancer Ther. 2015;14:341–9. https://doi.org/10.1177/1534735415572887. [PubMed] [Google Scholar]
  12. Courneya KS, Friedenreich CM, Quinney HA, Fields AL, Jones LW, Fairey AS. A randomized trial of exercise and quality of life in colorectal cancer survivors. Eur J Cancer Care (Engl) 2003;12:347–57. [PubMed] [Google Scholar]
  13. Rizzo A. (2016). The Role of Exercise and Rehabilitation in the Cancer Care Plan. Journal of the advanced practitioner in oncology, 7(3), 339–342.


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