exercise guidance after a cancer diagnosis: evidence and ... · exercise guidance after a cancer...
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Exercise Guidance after a Cancer Diagnosis: Evidence and Logistics
Kathryn Schmitz, PhD, MPH, FACSMPresident Elect, American College of Sports Medicine
Professor, Penn State College of MedicineAssociate Director of Population Sciences
Penn State Cancer Institute
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Overview
• Evidence
– Why exercise?
– Pre-exercise evaluation?
• Logistics
– Getting it done
• Time for your questions
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Schmitz et al. MSSE, 2010
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American Cancer Society
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National Comprehensive Cancer Network
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• AVOID INACTIVITY
MOST IMPORTANT MESSAGE FOR US ALL:
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Overview of common exercise recommendations for cancer survivors
• 150 minutes aerobic activity per week
• 2-3 times weekly strength training
• Flexibility on days when other activities are performed (daily)
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Why Exercise? Address Adverse effects of cancer treatment
Function, quality of life and survival
Fatigue
Lymph-edema
Physical Function
CIPNArthralgias
Poor Bone outcomes
CV late effects
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Why Exercise? Reduce health care costs
• $9988 USD per cancer survivors per year
• Upper-body symptoms, fatigue, or poor upper-body function OOP costs
• 4+ common adverse treatment effects
– OOP costs X 2
• Interventions costing <$4000 USD per patient per year worth exploring
Schmitz et al. Supportive Care in Cancer, 2015
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• For Example
– Morey et al. JAMA 2009 (RENEW Trial)
– Brown et al. JCO 2015 (PAL Trial)
• Increased strength is associated with improved functional capacity in older adults
• Aerobic exercise is definitely associated with improved physical abilities (aerobic fitness)
Exercise will Improve Physical Function After Cancer
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Pre tx During tx Post treatment
3-6m 12m
Fatigued 30% 93% 50% 25%
Cancer Related Fatigue
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Data from Hayes et al.
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• Brown et al. 2011 meta-analysis
– Exercise reduced CRF especially in programs that involved moderate-intensity, resistance exercise among older cancer survivors and that were guided by theory
• National Comprehensive Cancer Network
– Aerobic exercise is the #1 recommended non-pharmacologic treatment for cancer related fatigue
Exercise Improves Fatigue
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• Medications, switching or discontinuing Aromatase Inhibitors, Acupuncture
• And … Exercise!
– Project HOPE, Irwin et al. JCO 2015
• 150 min/week walking
• 2x weekly strength training
What helps with Aches & Pains in Cancer Survivors?
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• Treatment-related causes of bone health problems in cancer survivors:– Chemotherapy-induced premature ovarian failure
– Medical or surgical ovarian ablation therapy
– Hormonal treatments
• Other causes:– Inactivity
– Use of corticosteroids
– Inadequate intake of calcium and Vitamin D
Bone Health
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• Quitting smoking• Adequate Calcium/Vit D• Bisphosphonates• Stress Reduction• Bone Density Testing• Exercise!
– Particularly weight training!– Nelson et al. JAMA 1994– Excellent evidence in prostate cancer survivors as well
(Segal et al. JCO 2003)– Winters-Stone et al. 2014
What helps with promoting Bone Health?
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• Personal and behavioral risk factors for Heart Disease:– Age
– Body mass index
– Diet
– Physical activity levels
– Smoking
– Cholesterol
– Blood lipids
• Treatment-related factors too…
Heart Health & Breast/Prostate Cancer
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Cardiovascular Disease Competes with Breast Cancer as Cause of Death in Survivors
Patnaik 2011 17
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• Quit smoking• Good nutrition, weight control• Omega-3 fatty acids• Treatment for hypertension and dyslipidemia• Screening for cancer related heart health
problems is available. • Exercise!
– Aerobic exercise has long been recognized to be protective against cardiovascular disease outcomes
– Aerobic exercise is specifically good for those with and at risk for congestive heart failure
American Heart Association Guidelines for Heart Health
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• Does Exercise help with Lymphedema symptoms?
– YES!
• In the PAL trial,
– Control group women with lymphedema had 2X the number of ‘flare-ups’ compared with those who did weight-lifting
– Weight-lifting women without lymphedema who had 5+ nodes removed were 70% less likely to develop increased arm swelling compared to the control group
What about Lymphedema?
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Could Exercise be helpful during Chemotherapy?
• Increasing evidence that exercise may improve the ability to complete chemotherapy –particularly WEIGHT TRAINING
– Courneya et al. JCO 2007, Breast Cancer Exercise Trial
– Van Waart et al. 2011, Breast Cancer Exercise Trial
– Cespedes et al., JAMA Oncology 2018, observational evidence that muscle mass is associated with dose limiting toxicities
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Physical activity and obesity
• Question:
– Can you lose weight through exercise alone?
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• You cannot exercise your way out of a poor diet
– http://www.youtube.com/watch?v=UQbuzsY_34Q
• Exercise is best for weight maintenance
• Exercise is useful for weight LOSS when combined with caloric restriction
Exercise alone works well to MAINTAIN, but not to LOSE Weight
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Low Risk: Exercise Guidelines
Early Stage
No Comorbidities
High Baseline Activity Level
Follow General Recommendations
for Survivors
Okay for Unsupervised
Exercise in home/community
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Moderate Risk: Exercise Guidelines
Peripheral Neuropathy
Musculoskeletal Issues
Bony Metastases or Poor Bone Health
Modify recommendations
Recommend Pre-exercise Medical
Evaluation
Consider a Supervised Program (Personal
Trainer, Physiotherapist, Occupational Therapist)
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High Risk: Exercise Guidelines
Lung or Abdominal Surgery
Ostomy
Cardiopulmonary Disease
Lymphedema
Extreme Fatigue
Physician clearance prior to exercise
Medical Evaluation Prior to Exercise
Supervised Setting Recommended
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Logistics
Getting It Done!
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Find an a qualified professional• ACSM Cancer Exercise Trainers
– http://members.acsm.org/source/custom/online_locator/onlinelocator.cfm
– Choose the ‘ACSM/ACS Certified Cancer Exercise Trainer’
• Physical Therapists trained to work with oncology patients– http://www.apta.org/apta/findapt/index.aspx?na
vID=10737422525
– Choose the ‘Cancer’ practice area
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Goal Setting
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Start where you are
• Start LOW
• Progress SLOW
• Let SYMPTOMS be your guide
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Use What You Have
• Laps around the house if that’s where you are
– Increase laps till its time to walk outside
– Keep progressing
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Do what you can• PROGRESSION is important, but in small
increments
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• Awareness of the variability of exercise tolerance
• Awareness of and adaptation for symptom changes
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Thank you!Questions?