Physical Activity in Cancer

Original Editor - Samara Paull

Top Contributors - Vidya Acharya, Wendy Walker, Adam Vallely Farrell, Kapil Narale, Tony Lowe, Kim Jackson, Khloud Shreif, George Prudden, Simisola Ajeyalemi, Rucha Gadgil, Nicole Hills, Lucinda hampton, Giulia Neculaes, Admin, Michelle Lee and Tarina van der Stockt  

Introduction

Cancer is characterized by the uncontrolled growth and reproduction of cells in a particular area of the body. These cancerous cells have the ability to invade and harm nearby healthy tissues, even affecting organs. With over 200 distinct types, each cancer has its own unique approaches to diagnosis and treatment.. For more detailed information on the pathophysiology and management of several of the different forms of cancer take a look at the Oncology Physiopedia page.

Decrease in physical fitness has been reported in both patients and survivors of childhood and adult cancers. This decline in physical activity is secondary to the side effects of both the disease and its treatment . Cancer survivors have an increased risk for negative health and psychosocial effects following treatment. Beyond people with cancer, insufficient physical activity is the leading risk factors of death worldwide.

By addressing physical activity and stress reduction techniques patients can control some of these modifiable risk factors . Furthermore, such adverse effects are aggravated by physical inactivity (such as reduced bone mineral density, loss of muscle mass, increased BMI and impaired motor performance) therefore more emphasis is being placed on integrating exercise and activity both during and after treatment .

With the increasing number of people diagnosed with cancer and surviving it, quality of life outcomes are increasing in importance with numerous studies supporting physical activity and its positive impact. In one systematic review, exercise and physical activity had a clinically relevant positive impact on health related quality of life both during and after medical intervention in people with cancer .

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Definitions

Physical Activity

Physical activity refers to any movement of the body that requires the use of skeletal muscles and leads to the expenditure of energy. This encompasses a wide range of activities, including everyday tasks like walking or cycling to reach a destination, engaging in active play, work-related movements, participating in recreational activities such as exercising at a gym, dancing, gardening, playing active games, and even organized and competitive sports. [1]. Exercise is a subset of physical activity that is planned, structured, repeated and has a final or an intermediate objective to the improvement or maintenance of physical fitness [2]

Besides having significant health benefits, PA is also preventative in many diseases including cardiovascular disease and diabetes. General recommendations for daily physical activity are based on age and can be found in the WHO publication Global Recommendations on Physical Activity for Health.

Cancer

Cancer is a related group of diseases in which cell’s in the body begin to grow and divide uncontrollably. It can spread to other areas of the body. The National Cancer Institute states there are over 100 types of cancer-based on its location in the body and can be found in both children and adults .

In 2018, an estimated 17 million new cases of cancer occurred worldwide. In 2018 the incidence of cancer is about 3 times higher in countries with a high Human Development Index (HDI) . The most prevalent cancers globally include lung, breast, colorectal, and prostate cancer. These four types collectively represent approximately 40% of all cancer cases detected worldwide.

Considering Ireland as an example, in this country, the cancer is a major cause of morbidity and mortality with 40,000 new cases being diagnosed each year and over 9000 dying annually, which is approximately 30% of all deaths.

Benefits of PA for Individuals with Cancer

Physical activity is not only beneficial for patients following activity cancer treatment but also during to help with the negative side effects secondary to the treatment itself. It has a positive impact on both physical and psychosocial factors such as fatigue, low mood and stress, overall de-conditioning and loss of independence. Specific programs also provide benefits following treatments including post-surgical tumour removal and lymphoedema management . Other benefits of exercise including helping to maintain healthy body weight, anti-thrombotic effect decreasing platelet adhesiveness, improved endothelial function, increased HDL cholesterol, decreased risk of NIDDM and reduced risk of other diseases e.g. heart disease, diabetes, osteoporosis, and hypertension.

PA as a Preventative Method for Cancer

Physical activity has also been linked to the reduced risk of many cancers including Breast, Colon, Endometrial and Prostate, as well as some cancers associated with increased weight gain . It also prevents the re-occurrence of the same cancers .

Cancer prevention by modifying environmental and lifestyle factors is the most viable long term strategy. Physical activity has been shown to reduce the risk of colon, breast and endometrial cancers by 25-50% in physically active individuals. There is emerging evidence for prostate, ovarian, lung and GI cancers. For cancer prevention 4-5 hours of moderate exercise per week is required. This reduced risk is likely due to insulin resistance, endogenous sex and metabolic hormone levels, inflammation, growth factors and enhanced immune function.

Physical activity decreases obesity and central adipose tissue which are established risk factors for colon, postmenopausal, endometrial, kidney and oesophageal cancers. Obesity mediates the carcinogenic effect via a shift in sex and metabolic hormone balance in the body, influencing insulin resistance, inflammatory pathways, energy-related signaling and growth factors.

Research in patients affected with Lung Cancer suggests that both licensed rehabilitation professional and clinical exercise physiologists offer complementary skill sets that optimize patient care for cancer rehabilitation.

Role of the Physiotherapist

There is a growing body of evidence that supports the role of the physiotherapist in the care of patients with cancer. This ranges from; Prevention – exercise to prevent cancer (especially colon and post-menopausal breast cancer). Obesity is strongly linked to the development of a number of cancers (adipose tissue is a tumour friendly environment). In the acute setting, the physiotherapist can be involved in the pre-op assessment and enhanced recovery after surgery. Advice and education on lymphedema prevention, wound, stretching and massage, return to work and physical activity.

Exercise prescription is a large part of rehabilitation post-op. Some studies suggest that there is a connection between the non-return to work and the labor tasks that require upper limb strength and range of motion in breast cancer survivors. The physiotherapist has a role in developing a tailored and individualised rehabilitation program and specific exercise instruction post breast surgery. The Breast Cancer Physiopedia page has detailed information of physiotherapy management in breast cancer patient. They can also encourage exercise during chemo/radiotherapy. Research suggests implementing multi-dimensional knowledge translation intervention has positive outcomes on exercise levels, quality of life, and overall health status among breast survivors.

Physiotherapists play an essential role in the interdisciplinary and holistic approach to palliative care by providing increased quality of life, function, and overall experience through physical and functional dimensions of care. Study shows the benefits of identified palliative care beds (IPCB) (treatment of pain, psychologist) in a medical oncology department of a private provincial hospital.

Research shows better outcomes with preoperative supervised home-based physiotherapy intervention (respiratory, strength, and aerobic). A longitudinal study suggests that pain, fatigue, and dyspnoea did not appear to impact occupational performance over time of people with advanced cancer . A scoping review aims to understand the benefits of physical activity on Bladder cancer outcomes. It aims to identify the interventions, their reported efficacy and feasibility, and a description of potential underlying biological mechanisms for their effects . A narrative review suggests neuromuscular electrical stimulation may enhance aerobic exercise capacity, muscle strength, and quality of life for individuals with cancer .

Researchers conducted a systemic review using the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool which suggests a vital role of health professionals in supporting cancer patients throughout the disease course. The review provided a physical activity recommendation for the patients (70%) with breast cancer or general cancer. The findings not only focused on rehabilitation exercises but also in symptom management or survivor care.

Study findings report patient's reflections on the values and meaningfulness of physiotherapy in palliative care to patients, families, and physiotherapists themselves.

Systematic Review of Randomized Controlled Trials highlights the importance of aerobic exercises in the breast cancer survivor and recommends aerobic exercises in rehabilitation programs .

Research shows positive results of physical exercises on cancer-related fatigue, physical function, symptom distress, sarcopenia and health-related quality of life (HRQoL) .

PA in Paediatric Cancer

There are few systematic reviews that exist summarising the positive effects of physical activity in paediatric oncology in comparison to adult studies. However, Baumann and Bloch (2013) determined that exercise interventions are not only feasible and safe, but also no adverse side effects were reported.  There was a positive effect on fatigue, strength and quality of life .

Beyond physical benefits, there was increased self-reporting of improvements in comfort and resilience to the disease following a relatively short term supervised exercise training programs. Li et al. (2013) reported an adventure-based health education program led to statistically significant improvements in their participants’ self-efficacy. Physical activity has also been shown to safe and effective despite the aggressiveness of neoadjuvant chemotherapy during treatment for solid tumours in paediatric cancer patients. More studies are needed regarding cognitive abilities, growth, and re-integration into peer groups, school, and sports.

A study by Rico-Mena et al. suggests that home-based physical rehabilitation programs involving parents of children in palliative care enhance the outcomes. A scoping review suggests the need for collaborative efforts to conduct multi-centre trials in paediatric oncology physiotherapy .

Guidelines for PA in Cancer

There are a large number of studies which show that physical activity is safe and appropriate for prior to, during and after active treatment.  With any exercise program, it is important for an individual to consult with their doctor and medical team prior to beginning any intervention.

The American Cancer Society (ACS), American Society of Clinical Oncology (ASCO), and American College of Sports Medicine (ACSM) have all made physical activity recommendations for cancer survivors post-diagnosis, which also factor for improvements in managing some of the common side effects such as fatigue and pain. The most agreed-upon recommendations are that all patients should avoid inactivity and return to normal daily activities as soon as possible after diagnosis. That they engage in at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week, and that they include resistance-training exercises at least two days per week.  To improve flexibility, adults should also stretch the major muscle groups and tendons on days they participate in other types of activity; older adults will also benefit from balance exercises.

Barriers to PA in Cancer

Exercise is safe both during and after most types of cancer treatment, including intensive life-threatening treatments such as bone-marrow transplants. Despite the proven benefits of exercise, even while receiving treatments, research shows that the many cancer patients report significant decreases in their physical activity levels after their cancer diagnosis. Patients have identified both psychological and physical barriers as factors in their decrease in activity.

The Memorial sloan Kettering Cancer study recruited 622 cancer patients and identified psychological barriers including difficulty getting motivated (67% of subjects) and trouble remaining disciplined (65%). Physical barriers, including fatigue (78%) and pain (71%) associated with cancer treatments, as factors contributing to this decrease in activity. 

Other physical activity related issues to be considered include;

• Being immuno-compromised (secondary to low white cell count) leads to a high risk of infection. Patients need to be aware of the cleanliness of their environment. For example, very busy public gyms increase infection risk and so hand washing must always be a priority.
• Having low platelet and haemoglobin levels (Anaemia) leaves patients fatigued and at higher risk for internal bleeding. Contact and high impact sports are not recommended when blood counts are low. Make sure to check with a physician before engaging in activity.
• Over 90% of patients undergoing cancer treatment experience fatigue and pain-related symptoms. It is important to encourage daily low-intensity physical activity to prevent de-conditioning and further increase fatigue.
• Fear and feeling overwhelmed sometimes makes it harder to prioritise physical activity amongst their other chemotherapy, radiation and medication schedules.

Contraindications to PA in Cancer

Bertorello et al. (2011) studied the physical activity and late effects on long term Acute Lymphoblastic Leukaemia survivors and determined not only is exercise NOT contraindicated, but should be promoted as much as possible and 'No' exercise-related risks were encountered in either adults or children with hematological cancer . However, if a child or adult has an implanted device for chemotherapy, such as a Broviac, or a feeding tube or catheter, swimming may be contra-indicated due to the high risk of infection.

Precautions

Also, with certain cancers, extra precautions need to be considered.

• Bone cancer or osteosarcoma: patients need to understand their weight-bearing status which can change based on the integrity of the bone. They are at higher risk for fracture and should consider lower impact activities such as swimming or yoga. This is also true of patients with osteoporosis.
• Chemotherapy-induced peripheral neuropathy: Sensation changes or loss in the hands and/or feet may make certain activities more difficult or increase the likelihood of injuries and falls. Stationary biking is a good alternative to running because of its low impact and allows the longer duration of activity prior to fatigue.
• Following breast cancer resections, patients should begin with a gentle range of motion activities and should avoid aggressive upper extremity strengthening programs. A physical therapist can progress their exercise program to help prevent lymphedema and further injury to the area.
• Patients with compromised/reduced immune function (this includes those with low white blood cell count as well as those on immuno-suppressing medication) should avoid exercising in public gyms or swimming pools, due to the risk of infection.

Promotion of PA

Yoga THRIVE is a therapeutic yoga program for cancer survivors. It is a research-based, modified program to help with physical manifestations of cancer treatment like joint stiffness and pain and also emotional symptoms like stress and fatigue .

One study found that gross motor function improved in children participating in therapeutic yoga. It is important to acknowledge that yoga has not been proven to cure or prevent cancer; however, it can have positive benefits during and after treatment. More studies are needed for yoga as a complementary therapy for cancer patients .

The Pediatric Oncology Exercise Manual (or POEM) is an evidence-based tool for both parents and health professionals aimed at increasing physical activity for children with cancer.

Stride to Survive is another exercise guide aimed towards young adults who have completed treatment and want to begin a safe exercise program and increase their physical activity.

Feel free to read the page on Runners and Cancer to explore the perspective of runners with cancer continuing their activity, and how runner's without cancer can be at a risk of cancer

Resources

• The Motivate2Move website, created by Wales Deanery, has a very useful section on Physical Activity effects on Cancer.
• The University of Calgary has a series of relevant infographics and a comprehensive document on PA in Pediatric Cancer, POEM
• Cancer Research UK has Exercise Guidelines for Cancer Patients
• The American Cancer Society has comprehensive information on their website about Physical Activity and the Cancer Patient
• Cancer Care Ontario has a document with detailed information about Exercise for People with Cancer
• Cormie P, Zopf EM, Zhang X, Schmitz KH. The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiologic reviews. 2017 Jan 1;39(1):71-92.
• Guidelines for implementing exercise programes for cancer patients, Cancer Council, Australia.
• Moving Through Cancer, from American college of sports medicine
• Cancer Exercise Toolkit.
• This free module " The health benefits of physical activity: cancer" from Public Health England.
• Thune I, Cancer. In: Physical activity in the prevention and treatment of disease. Swedish National Institute of Public Health.