Runners and Cancer
This article is currently under review and may not be up to date. Please come back soon to see the finished work! (19/09/2024)
Introduction
Running is a widely recognized physical activity due to its numerous physical and physiological benefits, as well as its accessibility and versatility. Running is also frequently practised among individuals with cancer, offering notable health benefits for this population. [1][2]
Physical activity is known to be beneficial for the body and helps to prevent many cancers, including colon, breast, and endometrial cancer. [3] Many studies have shown that physical activity and exercise are safe and permitted to pursue while an individual is managing their cancer. Additional details are on the Physical Activity and Cancer page. The activity can help support ongoing therapies, thus decreasing the risk of recurrence and death. [1] In addition, many outdoor activities, including running, pose a risk factor for skin cancer due to exposure to strong ultraviolet rays, especially in the peak daylight hours. [3][4]
When comparing female cancer patients who wish to start or continue running with healthy controls, numerous motivators are noted alongside various barriers. Running while dealing with cancer poses challenges, particularly in managing symptoms and side effects, working with uninformed trainers, and navigating external factors like receiving incorrect information. [1]
In this article, we explore two sides to cancer and runners: how cancer affects patients who are already runners, how they manage to continue their running, and what may be risk factors for healthy runners that may lead to cancer. The topics of personalised training and disease-related factors for individuals who have cancer will be considered, exploring how a runner's exposure to the sun can lead to cancer. We will also explore the association between running and cancer in women.
Harnessing the Power of Running
Running provides cardiovascular, metabolic, musculoskeletal, and neuropsychiatric benefits; and is strongly correlated with a decreased body mass and smaller waist circumference. It has been shown to extend lifespan and is recommended as a therapeutic exercise to help prevent and reduce the impact of cancer and other chronic diseases. [1]
As mentioned, running with cancer is very difficult on the body, especially with managing any side effects of the treatment and having uninformed trainers. Running programs geared towards oncological patients needs to consider the patient's internal states and the effects while going through the particular cancer stages and their treatment. Exercise programs should be personalised, considering the patient's limitations, and designed by a qualified trainer. This approach helps motivate the patient and improves adherence, promoting a healthy and active lifestyle. [1]
Physical Activity and exercise, including running, can help with countering effects of the disease and treatment, such as fatigue, nausea, and vomiting, and improving the patient's quality of life. As for healthy individuals, it also helps these patients with cardiovascular fitness, strength, flexibility, and body composition. The American College of Sports Medicine outlines that cancer patients should not be inactive, and should participate in at least 90 minutes/week of moderate-intensity aerobic activity, and strength training twice a week. [1]
There are factors that help motivate individuals to run, even after cancer treatment. Some motivators for cancer survivors and healthy subjects included, prior exercise experiences, enjoyment, physical and mental benefits, exercise group support, family support, and the natural environment. Some motivators exclusively experienced by cancer survivors include a cancer-related challenge, hope for other patients, support from friends, physician support, and organised training. On the other hand, barriers between cancer survivors and healthy subjects are quite different. Barriers for cancer survivors include insufficient time in the long term, possibility of injury, side effects of the treatment or the disease itself, unqualified trainer, poor personal security, poor air quality, and the belief that exercise is only for athletes and body image. [1]
Additional factors that benefit cancer patients include gaining a deeper understanding of the advantages of exercise in cancer care and having the chance to train alongside other cancer survivors. [1] This would help lead to adherence and compliance to their specified running program [1], and help the runners to feel more informed, united, and conquer their mission together.
Sun Exposure and Skin Cancer Risks
While running provides numerous benefits, it is important to address the associated risks, particularly related to sun exposure.
Exposure to the UV rays from the sun is a potent risk factor towards skin cancer. The knowledge, behaviour, and attitudes of such athletes towards protection from the sun seems to be quite limited or not present. [4] It is commonly known that individuals who participate in outdoor sports such as running do not sufficiently protect themselves from the sun, which can be a factor leading to skin cancer. [3]
It is said that UV exposure may be facilitated by a change in the sunlight's absorption spectrum to shorter wavelengths due to the hydration of the stratum corneum, thus decreasing reflection and diffusion. This results in a greater UVB transmission, and a greater sensitivity of moistened skin to ultraviolet rays. [3] UV exposure can result in a dose- and time- dependent facilitation of damage to one's DNA. This effect can be accelerated with sweating, as discussed below. [4]
A greater risk of developing skin cancer is correlated with sweating, which increases the photosensitivity of the sun-exposed skin. This induces skin photosensitivity and activity-induced immunosuppression. [3][4] There is no material in sweat that is said to increase the sensitivity of the skin to sunlight. The sweating caused by an increased exposure to the sun, heat, and physical effort while running outdoors can cause an erythema reaction, which can lead to an increased chance of a sunburn. [3]
UV radiation is a primary risk factor of malignant melanoma (MM), and non-melanoma skin cancers (NM-SCs). Melanoma and non-melanoma skin cancers seem to be common in marathon runners. [3] Melanocytic nevi and actinic lentigines are common within marathon runners, which are related to the development of malignant melanoma. [3][4] The incidence of these skin cancers is gradually increasing worldwide, and is the most common in Australia and New Zealand. However, these are the most preventable types of cancers. Two-thirds of melanomas and 90% of other skin cancers are correlated with the overexposure of UV rays. Melanoma is associated with intense and frequent exposure to the sun, which can lead to sunburn. A study showed that lifelong exposure to the sun with outdoor running can be a risk factor for melanoma, which also relates to the duration of exposure. [3]
Squamous Cell Carcinoma (SCC) can also occur in marathon runners. This can be associated with prolonged exposure to the sun and a high cumulative exposure. [3]
Individuals with a lighter skin tone can be at an increased risk as well. [3]
Protecting oneself from the sun's rays can help prevent skin damage and skin cancers. Exposure to the sun's rays causes both chronic skin damage and sunburn. Sunburn occurs with extreme exposure to the intense sun, which leads to an acute inflammatory response. The radiation from the sun causes suppression of the immune system, which can lead to the development of cancer. Runners who may be overtraining can result with tissue injury, which may lead to immunosuppression. [3]
Prevention and Protection
It is important that runners are aware of methods to protect themselves from the frequent overexposure t0 UV radiation, and with increased sweating. The level of sweating and environmental factors should be taken into account. This can help reduce skin damage in terms of sunburn, erythema, pigmentary disorders, photoaging, precancerous lesions, and skin cancers. There are many ways to protect from the intense sun rays. [3]
Photoprotective agents can include: [3]
- Natural agents, such as ozone, clouds, fog, pollutants, and the skin
- Physical agents, such as clothes (including sun protective clothing with UV protection factors (UPFs)), hats, or sunglasses
- Sunscreens, and
- Antioxidants, which are present in the diet, and reduce the oxidative effects from the exposure to ultraviolet radiation - this would include vitamin E (tocopherol), vitamin C, beta-carotene, and flavonoids.
Methods of photoprotection, and preventing skin cancer, can include: finding shade, minimising sun exposure in the peak sunlight hours, using sun-protective clothes, using sunscreen with an SPF of <30, covering your arms and legs with sleeves, and using hats and/or sunglasses. Sunscreens that are water resistant should be reapplied after 3 hours of perspiration. [3]
In a study, it was seen that the most common protection from the sun used by runners was by wearing sunglasses. [3] In terms of sunscreen application, 49% claimed they forgot to use it, and 17.3% found it uncomfortable. [3] It is interesting to note that sun protection was more commonly used in runners who are women, elderly, completed fewer miles per week, with a lower BMI, and previously experienced skin cancer. [3][4] In addition, it is seen that runners less than 45 years of age are more likely to experience sunburn. In a study, it was found that younger age, low Fitzpatrick skin type (I and II), or running for more than 3 hours a day, were risk factors for sunburn. In this study, the most common protective measures from UV radiation (from most to least common) were: sunglasses, sunscreen, wearing a hat, and protective clothing. A study by Christoph et al. mentions that older (between the ages of 35 and 54), fair-skinned (type I and II), and female runners have a greater awareness of skin cancer, and are more conscious of utilising protective measures. As well, individuals with a personal history of skin cancer had a higher photoprotection score, However, this was not the case in individuals with a family history of skin cancer. [3]
In a cross-sectional online survey, seven sun protective behaviours were compared to note the differences. These seven behaviours, included the use of sunscreen on the face and/or body, a hat, sunglasses, long sleeves, running in the shade, and avoiding running in the midafternoon sunshine. About 54%-84% of runners claim that they occasionally use some of these methods, but only 7-45% claim that they frequently use these methods of protection. From individuals who did not use sunscreen, 49% claimed they forgot, 17.3% found it uncomfortable, and 6.1% wanted to maintain a tan, while 5.1% wanted to take advantage of the vitamin D intake. Other reasons people did not use sunscreen were they didn't believe they were at a higher risk of skin cancer, being ignorant of sunburn or wrinkles, and the expense of the sunscreen. When noting sun exposure behaviour, 39.2% had a fear of skin cancer, 28.7% were uncomfortable, and 15.8% wanted to avoid ageing of the skin. These behaviour statistics were similarly found in the United States, and Europe. Within the study, it was found that the runners were most likely to wear sunglasses for protective clothing, and least likely to use full sleeve clothes. It was also found that facial protection, such as sunscreen on the face, hat, or sunglasses, were more likely to be used than full body protection, such as sunscreen on the entire body, or wearing full sleeves. [4]
Breast Cancer in Women
It is known that physical activity can help reduce the risk of breast cancer. The association between running and risk of breast cancer may vary among women. It is seen that in younger, healthy and toned women, there may be greater risk of breast cancer in those with larger breasts. It is seen in previous studies that there may be a relationship of breast cancer with breast volume. [5]
Women who run (or walk for exercise) are seen to be healthier and toned in comparison to other women. This may affect whether their breast size is a risk factor for mortality. When assessed at different exercise intensity levels, women who ran at a vigorous intensity (≥ 7.5 MET hours/week) were 41% less likely than those who ran at a moderate or light pace (< 7.5 MET hours/week) to be at risk of breast cancer. [5]
In addition, higher circulating levels of oestrogen are related to an increased risk of breast cancer. Physical activity helps to lower circulating oestrogen, thus lowering the risk of breast cancer. Women with larger breasts and a narrow waist, seen in physically active women, have a much higher oestrogen concentration, as opposed to women with a larger waist. [5]
Screening using The Flag System
Clinical and psychosocial flags are crucial in evaluating patients, especially in cases like cancer recovery, as they help identify potential barriers to treatment and rehabilitation. Clinical flags, such as red flags, signal serious medical conditions requiring immediate attention, while yellow, blue, and black flags focus on psychological, social, and work-related obstacles that may slow recovery or impact a patient’s mental health.
Considering these flags allows healthcare providers to take a more holistic approach, ensuring both the physical and emotional aspects of recovery are addressed. For example, fear of re-injury (yellow flag) or lack of family support (black flag) can be just as significant as physical symptoms in slowing down recovery. By addressing both clinical and psychosocial factors, a comprehensive and supportive care plan can be tailored for optimal recovery outcomes.
The Impact of Rehabilitation on Runners with Cancer
Rehabilitation plays a crucial role in supporting runners with cancer, offering substantial benefits in terms of physical and psychological well-being. Integrating exercise, including running, into cancer care and rehabilitation strategies has been shown to enhance outcomes and improve the quality of life for cancer patients.
Physical and Psychological Benefits
Researchers continue to review the significant benefits of physical activity for cancer patients. Exercise, including running, helps improve physical fitness, reduces fatigue, and enhances the overall quality of life for cancer survivors. Personalised exercise programs, which are tailored to individual needs and treatment stages, are particularly effective. A customised exercise program can also lead to better adherence and improved outcomes for cancer patients.
Physical activity can improve immune system function by mobilising leukocytes with increased functional capacities into circulation. [6]
A study found that an 8-week exercise program, with 60-minute sessions twice a week, including resistance, flexibility, and cardio exercises for cancer patients, enhanced emotional expression, improved functional capacity, and positively impacted mental health. [7]
Impact on Cancer Recurrence and Survival
Several studies have shown that increased physical activity is linked to reduced mortality in cancer patients. In colorectal, breast, and prostate cancer patients, physical activity can reduce mortality risk by 40-50%. Palesh et al. found moderate exercise extended survival and lowered cancer-related mortality in advanced breast cancer patients.[8] Di Maso's research emphasised the benefits of vigorous activity, particularly in reducing cardiovascular and cancer mortality risks.[9] Meeting physical activity guidelines notably decreased mortality hazards in breast cancer patients. At the same time, while Wang et al. found that recreational physical activity reduced prostate cancer-specific mortality by 31%.[10]
Engaging in physical activity is associated with a lower risk of cancer recurrence and improved survival rates. This suggests that incorporating running into rehabilitation programs can be an effective strategy for managing long-term cancer outcomes.
Summary
Incorporating running and other forms of exercise into rehabilitation programs for cancer patients offers numerous benefits, from improved physical fitness and survival outcomes to enhanced quality of life. However, it is essential to address potential risks, such as increased skin cancer risk due to sun exposure, and implement appropriate protective measures. Rehabilitation specialists should consider these factors to design effective, personalised exercise programs that support cancer patients' overall health and well-being.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Avancini A, Skroce K, Tregnago D, Frada P, Trestini I, Cercato M.C, Bonaiuto C, Tarperi C, Schena F, Milella M, Pilotto S, Lanza M. “Running with cancer”: A qualitative study to evaluate barriers and motivations in running for female oncological patients. PLoS ONE. 2020:15(4):1-13.
- ↑ Allan J, Buss LA, Draper N, Currie MJ. Exercise in people with cancer: a spotlight on energy regulation and cachexia. Frontiers in Physiology. 2022 Feb 25;13:836804.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 Kliniec K, Tota M, Zalesinska A, Łyko M, Jankowska-Konsur A. Skin Cancer Risk, Sun-Protection Knowledge and Behaviour in Athletes—A Narrative Review. Cancers. 2023:15:1-19.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Tenforde A.S, Fredericson M, Toth K.E.S, Sainani K.L. Sun Protective Behaviours and Attitudes of Runners. Sports. 2022:10 (1):1-8.
- ↑ 5.0 5.1 5.2 Williams P.T. Breast Cancer Mortality vs. Exercise and Breast Size in Runners and Walkers. PLoS ONE. 2013:8(12):1-6.
- ↑ Misiąg W, Piszczyk A, Szymańska-Chabowska A, Chabowski M. Physical Activity and Cancer Care-A Review. Cancers (Basel). 2022 Aug 27;14(17):4154.
- ↑ Cataldi S, Amato A, Messina G, Iovane A, Greco G, Attilio Guarini, et al. Effects of combined exercise on psychological and physiological variables in cancer patients: a pilot study. Acta Medica Mediterranea [Internet]. 2020;36:1105.
- ↑ Palesh O, Kamen C, Sharp S, Golden A, Neri E, Spiegel D, et al. Physical Activity and Survival in Women With Advanced Breast Cancer. Cancer Nursing. 2018;41(4):E31–8.
- ↑ Di Maso M, Augustin LSA, Toffolutti F, Stocco C, Dal Maso L, Jenkins DJA, et al. Adherence to Mediterranean Diet, Physical Activity and Survival after Prostate Cancer Diagnosis. Nutrients. 2021 Jan 16;13(1):243.
- ↑ Wang Y, Jacobs EJ, Gapstur SM, Maliniak ML, Gansler T, McCullough ML, et al. Recreational Physical Activity in Relation to Prostate Cancer–Specific Mortality Among Men with Nonmetastatic Prostate Cancer. European Urology. 2017 Dec;72(6):931–9.