The Benefits of Exercise in Cancer Survivorship and the Psychological Effect of a Healthier Well

Being in Cancer Patients.

Michelle Camburn

Msc Foundations of Clinical Psychology

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Abstract.

Literature review understanding the importance exercise has on cancer survivorship preventing

secondary disease and cancer reoccurrences. An idea into what being considered a cancer survivor

entails. Research went into how exercise improves physical abilities, quality of life, as well as acts

as therapy against depression and combats fatigue. Specific guidelines have been set for survivors

with the intent to tailor to specific needs and cancers. Main studies were based on breast and colon

cancer with future research to hopefully look into other cancers. Strengths included but were not

limited to studies focusing on an intent to primarily improve quality of life which has been

reported as lower in cancer survivors. A main limitation was promoting confidence and motivation

in patients to partake in an exercise intervention. Future research was discussed, including

broadening the spectrum of cancers looked at, and looking into whether group or team programs

are more motivational and beneficial than individual exercise. In conclusion it is proven that

exercise does improve quality of life after treatment and in high intensities. It also, acts as an

antidepressant against symptoms of depression and does help with fatigue. Physically, it does

improve body composition especially in those who have gained weight from hormonal therapy, as

in breast cancer, and improves mobility. While improving body composition, it also, fights against

secondary diseases such as obesity and cardiovascular which in turn helps prevent cancer

reoccurrence. While motivation among cancer survivors is seen as low with further instruction

from health care providers emphasizing the benefits exercise can bring more people should be

involved in some sort of exercise intervention.

Key Words: Exercise, Benefits, Cancer, Survivorship, Depression, Quality of Life, Dragon Boat

Racing, Breast Cancer, Colon Cancer, Exercise Guidelines

Databases Used: Pubmed, Journals, Internet, Psycho-Oncology, Up-to-date, Library Database

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Acknowledgements:

I wish to thank my parents for giving me the opportunity to come back to the country I was born

in and further my education. It has given me the opportunity to learn and grow more as a person.

I would like to thank Simon Thompson and Roger Baker for supervising and organizing the

course. I would also like to thank my course mates, for without their friendship and support this

experience would not be the same and I would not have gotten this far without them. Thank you!

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Contents: Page Number

Introduction-dissertation aim and significance 5

Introduction of Subheadings 6

Survivorship 8

Discussion 11

Physical Improvements

Quality of Life and Emotional Benefits

Prevention Against Cancer Reoccurrence and Secondary Diseases

Strengths 28

Limitations 31

Future Research 34

Conclusions 37

References 41

Appendices

Ethics Form

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Introduction:

The aim of the paper is to ascertain the beneficial aspects of implementing an exercise

intervention plan as a part of cancer treatment to improve survivorship outcomes. Research in

this area is necessary as it promotes a healthier lifestyle while improving emotional attitudes and

can lead to a longer life. Becoming a cancer survivor is not the end of their experience with

cancer; many suffer from long term side effects of treatment. Quality of life has often been

lowered and depression persists, as they have been physically and emotionally changed.

Survivors are at a greater risk of developing secondary diseases as a result of treatment such as

obesity and cardiovascular problems. Cancer reoccurrence becomes a clear threat as well.

Exercise has been proven to fight against these many obstacles survivors face. Those who do not

exercise post treatment live shorter lives than those who participate in some form of exercise

intervention. With initial diagnosis the aim of treatment is to cure and prolong life. With the

threat of secondary problems post treatment, it is important to keep this mind set. Research has

been developed setting exercise guidelines for patients and finding ways to motivate and

maintain interventions long term. There is still further research to be conducted in this area, and

with a growing amount of cancer survivors it is important to promote the development of

research to improve quality of life for those who have experienced the obstacle cancer brings to

their life. Educating survivors as well as health care providers is necessary to obtain this goal.

Without this research and further research in this area mortality rates for cancer survivors will

remain where they are. With evidence clearly stating that survivors’ who have engaged in an

exercise intervention, whether at the start of treatment or after, survive longer than those

survivors who live a more sedentary life. Surviving cancer is a remarkable miracle for many

people but the aim now needs to be on sustaining and improving that life to last as long as

possible. Exercise is a cheap and easy way to begin this new challenge. With evidence providing

positive results it is now time to share this evidence with the population of survivors and health

care providers alike. Through education and research many lives will be improved. People should

not have to suffer if simply starting an exercise regime can counteract the effects of treatment and

prevent further problems. With the focus being on health and life in cancer survivors the

beneficial aspects of implementing an exercise regime is clear and concise.

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Introduction of Subheadings:

Survivorship - Being a cancer survivor is difficult. In understanding how exercise can improve a

survivors’ life outcome it is important to understand exactly what being a survivor entails. There

can be side effects, there can be body disfigurements, body image problems, and of course the

internal battle survivors face within themselves.

Physical Impact - Throughout treatment, depending on the circumstances bodies change. A

cancer patient is not going to have the same body they had before diagnosis. While the human

body is resilient it has taken on a huge obstacle. Surgery can weaken muscles, radiation and

chemotherapy can cause fatigue. Numbness and tingling can occur. Depending on the type of

cancer the survivor had, they may have gained or lost a significant amount of weight. Exercise

can help improve mobility and overall function. It can help people lose weight, and through

resistance training gain more muscle. It is true that the less you use a muscle the faster it

diminishes. If a patient’s legs are so tired they cannot get up the stairs in their house, that’s a

problem. The inclination in this situation would be to get a lift, or move bedroom to downstairs.

Unfortunately the less those leg muscles are used, the more weak they become. In order to

improve strength you need to use that muscle group. Exercise amongst cancer survivors who may

be experiencing a loss in function can greatly benefit from some form of intervention.

Quality of Life and Emotional Well Being - A decline in quality of life is not beneficial to

anyone. Yet, those who have survived cancer, possibly their greatest battle, suffer a great amount

of decline in their quality of life. Social aspects and relationships have certainly been tested and

people may treat them differently. A lot of people do not know what to say. It was through an

experience with a patient and his partner that it was learned the relationship is tested in both

ways. The patient of course felt fatigued and different, but his partner admitted to carrying this

huge burden, she was just as exhausted as him. She may not have had the medical symptoms or

problems but she went through the entire experience with him. In this case both of them had

experienced a decline in quality of life. Many survivors say it is not the medical problems that

they struggle with the most, it is the emotional. These emotional demons go untreated and are left

to fester and further affect relationships and all aspects of life. Finding ways to help improve

quality of life and emotional demons is a necessity. Exercise has been proven to increase quality

of life in those who stuck to a higher intensity routine and fight depression.

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Secondary Diseases and Cancer Reoccurrence - The thought of the cancer returning can be

daunting for many survivors, and remain a constant fear in the back of their mind for years to

come. Plus, these survivors are more likely than others to develop secondary diseases, chronic

diseases. Obesity is a major issue with some cancer treatments, as well as developing diabetes.

Cardiovascular and pulmonary can be greatly affected. Exercise is the best thing to fight against

obesity and diabetes, as well as decreases blood pressure, and can increase lung capacity.

Exercise has through research been proved to combat against oxidative DNA damage procured

and fight against developing tumors. It is important to look at this research and encourage

survivors to engage in some intervention.

Strengths - When weeding through research, it is vitally important to pay attention to the

strengths that these studies produced. It is through these positive benefits that the research can be

used for educational purposes and as back bone for further research. All research in any area has

to start from somewhere, and it is necessary to pick up on those strengths, learn, and continue on

the path to making a difference. For that reason it is important to note and point out the strengths

in the research articles that have been observed. The idea that exercise is beneficial is in its self a

positive result for cancer survivors, especially those who may want to get active again but are

unsure if they can or should.

Limitations - While pin pointing the strengths is important, it is just as necessary to know what

limitations were presented in the study. In picking out areas that could be improved researchers

are able to grasp a better understanding of the topic and reinvent ways to get the answers they

need. Through these studies it is clear that sample sizes need to be bigger to produce a stronger

outcome. The limitations that have been developed in the area include health care provider

education on the topic.

Future Research - The point of the paper was to look into different studies and the literature on

the topic of exercise benefits in cancer survivors. While the studies looked at began in 2007, the

importance of the development through the past five years was crucial in understanding the

differences in each study. Studies are built upon studies, one question is answered and more are

developed. It is clear that exercise benefits in this population is continue to grow, for that reason

the future research that will be developed is vital. A major area that will, and needs to be looked

at is the specific guidelines for all kinds of individuals. Each survivor is different, each cancer is

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different, and of course different people have experienced and survived different stages. This

means that individual needs and boundaries are going to vary greatly amongst this ever growing

population.

Survivorship - To survive a cancer diagnosis is a significant step. Not only have patients

undergone treatments such as therapy, radiation and surgery but everything about them changes.

There could be many physical changes, social changes in their family dynamics, and emotional

changes. When diagnosed with cancer the primary goal is typically to treat it, and hopefully cure

it. Practitioners put the side effects aside, as, in the matter of life and death a few side effects do

not seem to be that big of an obstacle. The problem is what happens when they have survived,

when they have been in remission long enough that a patient is considered a survivor; for many,

they still experience long term side effects from treatment, and their physical self may be altered.

They face a greater likelihood of developing secondary diseases, or having a reoccurrence of the

cancer. In looking at how exercise can help prevent these health risks from arising, it is necessary

to look at what survivorship means and exactly what it encompasses.

Thanks to modern medicine and the new developments in technology, 60-80% of all child and

adult cancer patients survive beyond the legendary five year mark. These new therapies seem to

cross the boundary of miracles, and act as life saving therapies. With many patients’ lives in their

hands, and at stake, it does not seem strange that practitioners look by the wayside of what these

new therapies can do to the body. There is a new generation of survivors that are suffering from

lasting side effects of these toxic therapies. “There is today a greater recognition of symptoms

that persist after the completion of treatment and also those that arise years after primary therapy.

Both acute organ toxicities such as radiation pneumonitis and chronic toxicities such as

congestive cardiac failure, neurocognitive deficits, infertility and second malignancies are being

described as the price of cure or prolonged survival. The study of late effects, originally within

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the realm of pediatric cancer, is now germane to cancer survivors at all ages because concerns

may continue to surface throughout the life cycle.” (Aziz, N. 2007) Fitshugh Mullan, a physician

who overcame cancer defined cancer survivorship as similar to the seasons. There is the acute

stage-from diagnosis through to treatment, extended-initial remission followed by watchful

waiting, permanent survival-when likelihood of reoccurrence is rare.

The development of medicine is important, and the advances in the field should not be looked

down upon. However, practitioners need to spend some time and focus on this new population of

cancer survivors and create a plan that will help improve their quality of life. At the same time

develop ways in which they can work on preventing cancer reoccurrences and secondary

diseases. “Obesity is a well-established risk factor for cancers of the breast (post-menopausal),

colon, kidney (renal cell), esophagus (adenocarcinoma), and endometrium, thus a large

proportion of cancer patients tend to be overweight or obese at the time of diagnosis.”

(Bergstrom, Pisani, Tenet, 2001). The aim after treatment should be focused on health and life.

That is after all what they have been given, a new chance at life. Cancer survivorship is one of the

least studied aspects of a cancer diagnosis. To many, it does not seem as important, but to those

who have to live with the long term effects for the rest of their life it means something. Surviving

is defined by completing all medical treatment and being declared as cancer free. It seems to be,

that many patients have non-medical problems related to their cancer diagnosis that is never paid

attention to. “The practical and emotional consequences of dealing with cancer were often harder

than the medical issues.” (Feuerstein, M. 2007) Most of the support that comes to these patients

seems to mainly come from family and friends. “The emotional toll of cancer survivorship was

substantial with 72% of respondents stating they had to deal with depression as a result of their

cancer.” (Feuerstein, M. 2007). A majority of cancer survivors still believe they will die of cancer

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and spend a great deal of time thinking about cancer and cancer related issues. For this reason it

is even more important that exercise is looked at to help improve their lives once cancer free.

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Discussion

Physical Strengths

It is well known that exercise is good for the body. It improves health, can speed up metabolism,

and increase endorphins leaving a lasting effect of being happy. It helps control obesity and

diabetes and can lower blood pressure. For people who have undergone cancer treatment it can

make a substantial difference in their physical appearance. Motivating cancer survivors to

exercise can be a difficult task as they are unsure of what their body can now handle, and for

some it can be a daunting thought, but “A meta-analysis of physical activity intervention trials in

various cancer survivor populations concluded that physical activity was safe during and after

cancer treatment. Physical activity improved aerobic fitness, upper and lower body strength,

functional quality of life, mood, anxiety, self-esteem, body image, and fatigue in both the on-

treatment and post treatment phases.” (Denlinger, C., & Engstrom, P. 2011).

Cancer survivors need to be aware of the amount of physical activity that is needed to sustain

their health. “The current physical activity recommendation for adults aged between 18-65 years

to promote and maintain health is to accumulate at least 30 minutes of moderately intense

physical activity on at least five days of the week. Sedentary behaviour, such as time spent sitting

is positively associated with coronary heart disease risk factors, obesity, and development of the

metabolic syndrome. More recently, the link between sedentary behaviour and the development

of certain cancer types has been reported.” (Walsh, J. M., Hussey, J., Guinan, E., & Donnell, D.

O. 2010). Exercise after treatment can help with physical strength, fatigue, and weight issues but

it is noted that cancer survivors are not meeting the health recommendations. It is still unclear

what kind of exercise intervention should be developed for these patients. Survivors are at a

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greater risk than others at developing new tumours, and secondary disease due to either genetics

or treatment received. The toxicity of the chemotherapy drugs is harsh on the body and the

effects of chemotherapy can lead to a decline in physical fitness.

There are currently twelve million cancer survivors in the US; about half consisting of breast and

prostate cancer. “In the last two decades, it has become clear that exercise plays a vital role in

cancer prevention and control.” (Schmitz, K. H., Von Gruenigen, V. E., Matthews, C., Courneya,

K. S., Schwartz, A. L., Schneider, C. M., et al. 2010). Researchers are aware that exercise plays a

vital role in promoting a more positive recovery and long term outlook on life, it is important to

clarify to survivors the physical, and emotional benefits exercise can have for them. “Another

study found improvements in cardiopulmonary function, muscular strength, physical functioning,

fatigue, and health-related quality of life in survivors of various cancers enrolled in an 18-week

strength training program initiated within 6 weeks of completing chemotherapy; these effects

persisted after 1 year of follow-up.” (De Backer IC, Van

Breda E, Vreugdenhil A, Nijziel MR, Kester AD, Schep G 2007).

It is clear that the importance of exercise for cancer patients is a worldwide phenomenon. It is a

topic that is of high interest and studies span the continents; in the, American College Of Sports

Medicine Roundtable On Exercise Guidelines For Cancer Survivors, “some of the psychological

and physiological challenges faced by cancer survivors can be prevented, attenuated, treated, or

rehabilitated through exercise.” (Schmitz, K. H., Von Gruenigen, V. E., Matthews, C., Courneya,

K. S., Schwartz, A. L., Schneider, C. M., et al. 2010). There was little to be found on research in

the field of exercise intervention specifically for cancer patients; so in 2009 experts in both

research and exercise gathered to implement new ideas. “The recent US Departments of Health

and Human Services guidelines indicate that, when individuals with chronic conditions such as

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cancer are unable to meet the stated recommendation on the basis of their health status, they

‘‘should be as physically active as their abilities and conditions allow.’’ (Schmitz, K. H., Von

Gruenigen, V. E., Matthews, C., Courneya, K. S., Schwartz, A. L., Schneider, C. M., et al. 2010)

The program consensus states the recommended weekly exercise should consist of one hundred

and fifty minutes of moderate exercise and seventy five minutes of vigorous exercise a week as

well as two classes a week in strength training focusing on specific muscle groups. One aspect

that needs more attention is that this recommendation will not work for all survivors, as each may

require different needs. Almost all cancer patients undergo some sort of surgery ranging from

small to big, and about half of patients receive radiation. “To best evaluate a cancer survivor’s

exercise tolerance and prescribe a safe and effective exercise program, it is necessary to

understand the specifics of a cancer survivor’s diagnosis and treatments received. Further, these

effects will need to be understood in the context of existing health (premorbid conditions) and

fitness level before cancer diagnosis.” (Schmitz, K. H., Von Gruenigen, V. E., Matthews, C.,

Courneya, K. S., Schwartz, A. L., Schneider, C. M., et al. 2010) One factor that needs to be taken

into account is the level of fitness the patient had before diagnosis. It is stated that adverse effects

from treatment can be immediate or long term. “Specific risks of exercise training by cancer site

should be understood by fitness professionals, such as elevated fracture risk among breast or

prostate cancer survivors who have undergone certain types of hormonal therapy, and

lymphedema risk more commonly seen among breast and urogynecologic cancer survivors.”

(Schmitz, K. H., Von Gruenigen, V. E., Matthews, C., Courneya, K. S., Schwartz, A. L.,

Schneider, C. M., et al. 2010)

It is not just aerobic exercise that is needed, it is a combination of aerobic and resistance. While

some may partake in aerobic exercise even less do any resistance training “Less than half of

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cancer survivors participate in recommended levels of aerobic exercise and even fewer

participate in recommended amounts of resistance training.” (Irwin, 2012)

Breast cancer is the leading cancer diagnosis for women and the affects of therapy, and surgery

can be debilitating as well as have a large impact on a patients weight, health, and psychological

well being. Exercise is an efficient way at keeping all these things in check in a healthy

individual but there is growing evidence that there can be a large benefit for cancer patients and

survivors. The journal article, Benefits Of Supervised Group Exercise Programme For Women

Being Treated For Early Stage Breast Cancer: Pragmatic Randomised Controlled Trial, begins

to look into how exercise can help women. “Current programmes in cancer rehabilitation are

mainly based on psychotherapy or social support. Such therapies do not usually deal with the

physical problems encountered by patients, such as fatigue, loss of functional capacity, and

weight gain. Exercise is an intervention that may improve a broad range of quality of life

problems after diagnosis of cancer.” (Mutrie, Campbell, White, McConnachie, Emslie, Lee, et all

2007) The aim was to take a group of women and place them in a structured exercise routine for

twelve weeks at the early stage of breast cancer diagnosis in conjunction with their therapy. A

follow up was then done at six months. While quality of life was the primary measure, one of the

secondary measures included an increase in mobility. “The classes consisted of a warm-up of 5-

10 minutes, 20 minutes of exercise (for example walking, cycling, low level aerobics, muscle

strengthening exercises, or circuits of specifically tailored exercises), and a cool-down and

relaxation period. The exercise class lasted 45 minutes in total. Women were monitored

throughout the class to ensure that they were exercising at a moderate level.” (Mutrie, Campbell,

White, McConnachie, Emslie, Lee , et all 2007). Each week, for whole 6 weeks, a health theme

was brought up in a discussion, and at the end of the twelve weeks women were encouraged to

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plan their own exercise intervention outside of the study. At the end of the study, women showed

an increase in physical and psychological function, and continued with exercise through to the 6

month follow up.

In a journal article from Italian Oncology, the positive effects exercise can have on patients has

been emphasized. The basis of the importance is “The rationale posed for physical activity

interventions following cancer diagnosis relates to minimizing biological processes associated

with cancer promotion enhancing behavioural changes linked with minimising lifestyle risk

factors for recurrence of cancer, and improving psychosocial factors during and after cancer

treatments.” (Valenti, M., Porzio, G., Aielli, F., Verna, L., Cannita, K., Manno, R., et al, 2008).

More importantly there is little evidence on specific instructions for different cases, especially

women who may be less inclined to participate in resistance training. “There is still a lack of

knowledge about the optimal types, duration, frequency, and timing of exercise. The aerobic

component has been emphasised in physical exercise programmes and health promotion in

general, to the detriment of other types of exercise, such as strength training.” (Valenti, M.,

Porzio, G., Aielli, F., Verna, L., Cannita, K., Manno, R., et al, 2008) The participants in this

study were female breast cancer survivors with a diagnosis of stage I-II. Overall Quality of Life

(QOL) was assessed by the Italian version of the World Health Organisation, Quality of Life

BREF assessment instrument. It was tested at 3 months from diagnosis and 3 months post

treatment. “Exercise behaviour was assessed by the Leisure Score Index (LSI) of the Godin

Leisure-Time Exercise Questionnaire. The LSI assesses the average frequency of mild (minimal

effort), moderate (not exhausting) and strenuous intensity exercise during free time in a week.

Patients were asked to report their average weekly exercise for three cancer-related time periods,

i.e. pre-diagnosis, during active treatment and off-treatment.” (Valenti, M., Porzio, G., Aielli, F.,

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Verna, L., Cannita, K., Manno, R., et al, 2008) Statistics show a correlation between increased

physical activity and increased quality of life. Although, this study did denote that mild physical

activity showed an indication of severity in disease.

Breast cancer patients are at an increased risk for weight gain and bone density problems as a

result of treatment. With breast cancer being a prominent disease among women, it is important

to allocate some attention to their exercise needs as in, Exercise Improves Body Fat, Lean Mass,

And Bone Mass In Breast Cancer Survivors. For the study, seventy five women were chosen who

had been classified as inactive and postmenopausal. “Body composition was assessed at baseline

and 6-months via dual energy x-ray absorptiometry by one radiologist blinded to the intervention

group of the participants. On average, exercisers increased moderate-intensity aerobic exercise by

129 min/wk over and above baseline levels compared with 45 min/wk among usual care

participants.” (Irwin, M. L., Knobf, M. T., Jones, B., Chung, G. G., Yu, H., Mayne, S. T., et al.

2009) The end result showed a decrease in body fat and increase in lean mass for those in the

intervention; whereas those in the usual care group experienced an increase in body fat and

decrease in lean mass. Participants were instructed to work out 5 times a week, 3 times at a local

health club and twice a week on their own. The chosen exercise was brisk walking. It was shown

that participants also increased their amount of exercise day from the usual group, with an

increase in 0.9 miles a day versus 0.5 miles a day. “Furthermore, women who were taking

aromatose inhibitors, which significantly decrease estrogen concentrations to undetectable levels,

and randomized to exercise, experienced decreases in body fat, increases in lean mass and

maintenance of BMD and BMC, compared to no change in body fat and losses in LBM, BMD,

and BMC among women randomized to usual care.” (Irwin, M. L., Knobf, M. T., Jones, B.,

Chung, G. G., Yu, H., Mayne, S. T., et al. 2009)

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With a more scientific focus, exercise can have an impact on physical biomechanics. “For

example, the beneficial effects of physical activity on cancer survival may be mediated through a

reduction in body fat and beneficial changes in metabolic hormones (insulin), growth factors

(insulin-like growth factor IGF-1 and its binding protein IGFBP-3), and adipokines (leptin,

adiponectin). In this review, Irwin and colleagues (2008) demonstrated that a six-month aerobic

exercise intervention produced statistically significant increases in lean mass and decreases in

body fat, insulin levels, IGF-1, and IGFBP-3, whereas women randomized to usual care

experienced increases in these biomarkers.” (Pekmezi, D., & Demark-Wahnfried, W. 2011)

Insulin levels were also found to be affected after a 16 week intervention that involved aerobic

and strength conditioning. This is the first finding of there being a relation between exercise and

the modulation of oxidative DNA damage which is implicated through carcinogenesis and cancer

relapse. Further research on oxidative DNA damage has been show in studies with colon cancer,

“Oxidative DNA damage and inflammatory cytokines may also be affected. Short-term

moderate-intensity exercise is associated with lower levels of urinary markers of oxidative

damage in colorectal cancer survivors after primary therapy. High-intensity exercise increased

these markers, suggesting that oxidative damage can be influenced by physical activity and a

threshold of intensity may exist between protective and damaging effects.”

(Allgayer H, Owen RW, Nair J, Spiegelhalder B, Streit J, Reichel C, et al. 2008). 

Fatigue is a major aspect with cancer treatment. The human body is very resilient and can

overcome many obstacles, but major surgery can have an impact on the body for months. The

affects of radiation do not seem to be as harsh, but can cause fatigue. The most brutal offender is

chemotherapy, the toxic drugs, can cause debilitating fatigue that can last past treatment into

remission and further into survivorship. In a battle to get their lives back to any kind of normalcy

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from before being diagnosed, survivors need to find ways to help tackle their fatigue. “The

National Comprehensive Cancer Network recommends activity enhancement, including initiating

a program encompassing endurance and resistance exercise during active treatment and post

treatment, to combat cancer-related fatigue.” While motivation is a factor with fatigue, there is

the problem if survivors can participate and maintain an exercise regime.

Quality of Life Improvement and Psychological Impact

A better quality of life leads to a longer life. Understandably patients that have been through

cancer and are now survivors tend to estimate that their quality of life is lower than others or to

what it was pre diagnosis. “Physical and functional well-being are essential dimensions for

overall quality of life, and poor physical functioning may explain some of the psychological

distress experienced by cancer survivors” (Walsh, J. M., Hussey, J., Guinan, E., & Donnell, D. O.

2010). Quality of life is based on social, mental, physical and emotional well being and is

distinguished through a self-report questionnaire. The two most general are the SF-36 and the

Fact survey.

Depression occurs quite regularly in cancer patients, and can continue through to survival

“causing reduced quality of life, impaired social and occupational functioning, and intermittent

bouts of suffering. Depression is also associated with obesity, diabetes, and the development of

cardiovascular disease.” (Craft, L., Vanlterson, E., Helenowski, I., Rademaker, A., & Coumeya,

K. 2011) Depression can be caused from disfigurement, severity of symptoms, and side effects

from therapy. There has been evidence that steroids may increase the probability of developing

depression as well as estrogen depleting therapies that affect serotonin levels which could cause

depression. Practitioners in general, universally use the BECK depression inventory to score the

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severity of depression amongst patients. Initially treatment for depression was based on

pharmaceutical and psychotherapy but it has been proved that this is not sufficient for all cancer

patients and survivors. Some may not be able to effectively communicate due to the treatment or

cancer they had. Exercise has now been deemed a successful treatment for depression as well as

maintains physical benefits. In the general population, exercise is an effective antidepressant.

“Meta-analytic studies indicate that the effect size (ES) of exercise on depression is large, ranging

from 0.72 to 1.4 (19–21). Individuals with moderate and more severe depression benefit similarly

and exercise is equally effective for men and women across a wide range of ages. Exercise effects

are comparable with psychotherapy and medication, particularly for those with mild to moderate

depression.” (Craft, L., Vanlterson, E., Helenowski, I., Rademaker, A., & Coumeya, K. 2011).

Some patients may opt out of taking any antidepressants and want other options. It is necessary to

educate survivors who experience depression as an aftermath of their cancer, that exercise can

help “The aim of this meta-analysis was to evaluate the current literature on the antidepressant

effects of exercise in cancer survivor. In this study, exercise produced modest effects on

depression in cancer survivors across cancer types (primarily breast), stages (predominantly early

stage), treatment status at baseline, and baseline severity of depressive symptoms (most were not

depressed) Most participants in our meta-analysis scored within a "normal" range on depression

inventories. Thus, a floor effect may have been observed.” (Craft, L., Vanlterson, E., Helenowski,

I., Rademaker, A., & Coumeya, K. 2011) Results showed that participants primarily expressed

more depressive symptoms when performing the exercise intervention at home versus at another

location.

Exercise intervention should start at the beginning of treatment and last throughout life.

Unfortunately, as proved in the journal article, Benefits Of Supervised Group Exercise

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Programme For Women Being Treated For Early Stage Breast Cancer: Pragmatic Randomised

Controlled Trial, where the primary outcome was quality of life, it was not until the 6 month

follow up that an impact in quality of life was noted. This is most likely due to the follow up

being post treatment. While quality of life may not improve during treatment it is still essentially

important to participate in some form of exercise intervention to help combat the side effects that

treatment can cause.

In an Italian study, again the primary outcome was quality of life and the benefit of this study

was that it targeted long time cancer survivors who were older and perhaps somewhat

overweight. Most studies done on exercise with cancer patients is aimed at younger patients who

have just finished treatment and have a stronger affinitive for engaging in an exercise program.

“Previous cross-sectional studies have found that quality of life is significantly higher among

cancer survivors who meet public health physical activity guidelines, and results from this study

provide cause-and-effect evidence that supports this association.” (Morey, M. C., Snyder, D. C.,

Sloane, R., Cohen, H. J., Peterson, B., Hartman, T. J., et al. 2009).

Whilst main studies focus on how exercise can improve quality of life, it is important to note that

a low amount of aerobic exercise shows almost no improvement in quality of life, but high

intensity exercise does have an impact specifically on women. Again this brings up the problem

of needing specific regimes for specific cases.

In a review cited in the Cochrane database, the results of which were based off a large sample

size of cancer patients including breast, colorectal, head, neck, lymphoma, and more positive

effects of exercise on quality of life were confirmed. “The review included 40 trials with a total

of 3694 people. The results suggest that exercise may improve overall quality of life right after

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the exercise program is completed. Exercise may also reduce the person's worry about his or her

cancer, and affect the way the person views his or her body.  Exercise may also help the way the

person deals with emotions, sexuality, sleep problems, or functions in society.  Exercise also

reduced anxiety, tiredness, and pain at different times during and after the exercise program.  No

effect of exercise was found on the person’s ability to think clearly or his or her role function in

society.  Also, no effect of exercise was found on the way the person views his or her spiritual or

physical health, or physical ability.” (Mishra SI, Scherer RW, Geigle PM, Berlanstein DR,

Topaloglu O, Gotay CC, Snyder C, 2012) This was a very large study that included multiple

trials, unfortunately this promoted one main limitation. Each trial was given a different exercise

regime and a different way of measuring quality of life, which could impact the results.

Dragon boat racing was first started in China, where dragons are a symbol of guardian angels.

“The sport of dragon boat racing involves the “strenuous, repetitive upper body activity of 18 to

20 paddlers propelling a 40-60 foot craft along a race course of 500 to 650 meters.” (Harris &

Niesen-Vertommen, 2000, p. 95) In a research effort to understand more about lympgedema

breast cancer survivors banded together to try out the sport of dragon boat racing. “The pursuit

originated with a small research project designed to study the impact of paddling on

lymphedema.”(McKenzie, 1998). The conclusion showed that boat racing, mainly the rowing

motion with the arms, did not increase lymphedema. People believed that since it was the end of

research there would be no more racing but the sport of dragon boat racing for survivors of breast

cancer has spread worldwide to include ninety three teams. Any survivor of breast cancer can

participate, no matter the age as long as they are six months post treatment and are willing to

make the commitment to the year round team. “The women were remarkably enthusiastic about

their involvement in dragon boat racing. They described the pursuit as “physically challenging,”

21

but nonetheless “fun,” “rewarding,” and “enjoyable.” (Parry, D. C. 2008). Not only is the sport

promoting healthy exercise but it also creates a vision of a team, a band of women, who can all

relate and talk about their experiences and come together to do something that will make a

difference in their lives. As one participant stated: “I think you go through more emotional strain

after the treatments, than you do during them. During the treatments you’re too busy trying to get

better. And afterwards you’re just left with this life that you have to rebuild from scratch, that

you’re so weak and so tired from everything that you’ve just been through. During that time it’s

hard to feel normal because everything has changed, but with dragon boat racing I just felt so, so

normal. And from my everyday life, that was so uncomfortable for so long, for this 2 hours that

I’m with them [teammates], twice a week, it was a reprieve. It was 4 hours a week that made me

feel normal, 4 hours a week that I felt so good and felt a little bit like I could cope. It’s so

important to feel normal [throughout breast cancer survivorship]. I think it helps you recover a lot

faster and better. I think if I wasn’t doing the dragon boat racing I think I would be in really bad

shape emotionally. And no matter how bad I’m feeling physically, emotionally I feel really

happy.” (Parry, 2008)

It became a form of therapy for these women, and a way of coping with the challenges they have

been faced with. Many of the women say that the racing and rowing has helped in their physical

strength and improved some of the ailments they picked up as side effects of the treatment they

received. One aspect of this form of exercise for cancer survivors that has not yet been explored,

is the stress release it provides for the woman. It promotes a release of endorphins that some say

are better than any drugs could combat.

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Cancer Recurrence and secondary diseases

Introduction- While improving quality of life for survivors is necessary, it is just as important to

make sure that the cancer does not come back. On top of that survivors need to be aware of, is

secondary disease that can arise as a result of being post treatment. Exercise could be the solution

“The most exciting evidence suggests that cancer survivors who exercise regularly after their

treatment are less likely to have a cancer recurrence, less likely to die from their cancer, and more

likely to live longer than survivors who do not exercise.” (Vallance, Spark, Eakin, 2012)

Research shows that cancer survivors are at least 50% more likely to die from non-cancer related

diseases than the rest of the population. Most cancer survivors are unaware of the benefits that

can come with participating in a regular exercise routine. Some, also, lack motivation that is

required to get up and do physical activity due to being drained from what they have already been

through, or never having the motivation in the first place.

Most cancer patients face comorbities with their disease. Being diagnosed with cancer is not just

about the stage or where the tumour may be, there is a lot behind the scenes that goes one with a

persons’ emotional and physical wellbeing, “Sequelae of the cancer and treatment, such as

fatigue, physical discomfort, negative body image, depression, and physical limitations, may

persist for years after diagnosis.” (Denlinger, C., & Engstrom, P. 2011). The most important

thing to be aware of with survivorship is that there are long term effects. During treatment

practitioners focus on the immediate symptoms and side effects that come along with

chemotherapy, radiation, or surgery. For this reason there needs to be a clear definition between

what an acute effect of treatment may be, versus a late and long term effect. Here is one such

definition that fully encompasses all side effects and symptoms that can arise. “Late and long-

term effects can be classified further as: (a) system specific (such as damage, failure or premature

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aging of organs, immunosuppression or compromised immune systems, and endocrine damage);

(b) second malignant neoplasms (such as an increased risk of a certain cancer associated with the

primary cancer and a second cancer associated with cytotoxic or radiological cancer therapies);

(c) functional changes (such as lymphedema, incontinence, pain syndromes, neuropathies and

fatigue); (d) cosmetic changes (such as amputations, ostomies and skin and hair alterations); and

(e) associated comorbidities (such as osteoporosis, arthritis, scleroderma and hypertension). The

risk of a recurrence of the primary malignancy also must be kept in mind.” (Aziz, N. 2007)

Cancer patients are generally at more of a risk for developing secondary diseases or a recurrence

of the cancer. Exercise has been found to help cancer patients, just like normal healthy people,

increase in physical function, decreases fatigue and lowers body fat, and weight. It has been

found that in breast cancer patients; there is an increased risk of cardiopulmonary diseases as a

result of the cancer or treatment which can further reduce the quality of life. Exercise will have

benefits on health whether or not it prevents a direct cessation in cancer recurrence, it will have

an impact on cardiovascular health that may have been impacted; as well as reduce fatigue and

body weight.

In some cancers, post chemotherapy can cause weight gain. Breast cancer treatment includes

hormone therapy that induces menopause in most women. In a majority of women the onset of

menopause also results in a change in the physique of the body, and weight gain is common.

In the article, Effects of Home-Based Diet and Exercise on Functional Outcomes Among Older,

Overweight Long-term Cancer Survivors, “Five-year survival rates for early stage colorectal,

breast, and prostate cancer currently exceed 90% and are increasing. Cancer survivors are at

greater risk for second malignancies, other comorbidities, and accelerated functional decline.

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Lifestyle interventions may provide benefit, but it is unknown whether long-term cancer

survivors can modify their lifestyle behaviors sufficiently to improve functional status.” (Morey,

M. C., Snyder, D. C., Sloane, R., Cohen, H. J., Peterson, B., Hartman, T. J., et al. 2009). The

study was organized around a twelve month home based exercise program that had been tailored

for patients by counseling over the phone, and having materials sent to the house. So far the

studies that have been looked at have been focused on exercise during treatment and immediately

after treatment. These interventions need to be life changes that survivors make. In this study it

can be seen that in long time survivors of colorectal, breast, and prostate cancer the twelve month

intervention program reduced the rate of functional decline.

Over time, research has evolved, and more focus has been on how much exercise is needed for

cancer survivors. “Various organizations, such as the American Cancer Society (ACS), the World

Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) and most

recently, the American College of Sports Medicine (ACSM) have issued guidelines for diet

and/or physical activity that target cancer survivors.” (Pekmezi, D., & Demark-Wahnfried, W.

2011). One of the toughest aspects of exercising for survivors is motivation. They have just been

through treatment, and they are tired. One main goal of this next study is behavioural motivation.

In the hopes to help with weight loss in obese breast cancer survivors, the implementation of

group classes was used. The article builds on a previous article by one of the same authors. “The

diet-based pilot study by Djuric and colleagues, utilized group classes to promote weight loss in

obese African-American breast cancer survivors, using either a Weight Watcher ® based-

approach or an approach that incorporated spirituality. In contrast, the other weight management

studies employed multi-component interventions that incorporated both diet and exercise

elements. These interventions targeted cancer survivors across the cancer continuum, from those

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who were newly diagnosed and undergoing treatment, to those within five years of diagnosis, as

well as those who were long-term survivors, i.e., five or more years beyond diagnosis.” (Pekmezi,

D., & Demark-Wahnfried, W. 2011). Again the exercise recommendation put forth was in

general similar to that of the general population, 30 min of cardio a day but with specifics tailored

to the individual. “The finding from these studies suggest that exercise is a safe and effective way

to provide rehabilitation for cancer survivors and that even brief exercise interventions can be

beneficial. Outcomes included improved aerobic capacity, strength, body composition quality of

life as well as reduced fatigue, emotional distress, lymphedema symptoms, and oxidative DNA

damage.” (Pekmezi, D., & Demark-Wahnfried, W. 2011). The article includes improved

variations of the study including trials with less supervision, and smaller but more group sizes.

Breast cancer treatments can cause chronic side effects such as estrogen deprivation symptoms,

arthralgia, fatigue, lymphedema, peripheral neuropathy, reduced bone health, upper extremity

functional impairments and overall functional decline.” (Mutrie, N., Campbell, A., Barry, S.,

Hefferon, K., McConnachie, A., Ritchie, D., et al. 2012) As stated in five-year follow-up of

participants in a randomised controlled trial showing benefits from exercise for breast cancer

survivors during adjuvant treatment. Are there lasting effects? It is believed that exercise can help

prevent fatigue and lymphedema as well as increase upper body movement. Three hours a week

of aerobic exercise is all that is needed to help prevent cancer recurrence. In the original study,

participants were seen at the beginning, end, and after 6 months. In this study they looked at the

18 month, and 60 month follow up of some of these patients. It was noted that some interventions

noted at 6 months were still recorded at 60 months; for example an increase in self-reported

leisure time activity, and a more positive mood. There were significant increases in reported

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quality of life and mood. It was apparent that statistically significant differences were noted

more at the 18 month follow up than the 60 month follow up.

“However, there are still limitations to the conclusion that benefits result from post diagnosis

physical activity, including the possibility that women, who are not able to be active after a

cancer diagnosis may differ in other ways that explain their poorer outcomes. For example,

women who are inactive post diagnosis may have had a higher stage disease and thus may be

more likely to experience recurrence or mortality.” (Schmitz, K. 2011) It is easy for practitioners

to recommend exercise and back up their prescription with evidence that it can help with cancer

recurrence, but there is little evidence to clarify and distinguish the amount and intensity of

exercise needed for different groups of cancer patients. For those who may only have had an

early stage cancer therapy, treatment may not have been as aggressive compared to a patient

diagnosed with a more advanced stage cancer. Clearly there will be differences in the

survivorship and side effects felt as well as ability to perform exercise regimes. For example

physical capacity could vary greatly between someone who has survived stage one cancer to that

of someone who has survived stage four cancer.

Obesity is a common problem among many different types of cancer survivors, and not only

increases chances of a secondary cancer developing, but creates problems associated with being

overweight; such as hypertension and Type II diabetes. Through a healthy routine exercise,

regime patients can lower their total body mass index decreasing their likelihood of acquiring

these problems.

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Strengths

Throughout the research on exercise benefits in cancer survivors, it is clear that more focus has

been placed on survivor treatment. There had been a lack of studies and attention to patients’ post

treatment and how to combat side effects that may linger for life. It is important that research has

focused on the physical impacts exercise has for this population. For example, with the

possibility of treatment leading to weight gain and a decrease in physical ability, survivors need

to be aware that they can fight these changes.

Fatigue is a common problem amongst many survivors and evidence backing up exercise as a

way to combat fatigue, can help many people. Benefits of Supervised Group Exercise

Programme for Women Being Treated for Early Stage Breast Cancer: Pragmatic Randomized

Controlled Trial was one of the initial studies looking into the benefits exercise has on cancer

patients. The problem with feeling tired is that it makes you want to do nothing but rest. People

who have been through cancer may feel that rest is needed. Most patients feel so fatigued they do

not engage themselves in activities, which in turn makes them feel worse and leads to loss of

quality of life. Positively it was the first full scale randomized study into exercise of breast cancer

patients, and included an excellent number of participants to make the study more valid. Not

surprising there was no recorded improvement in quality of life until after treatment had resolved.

The benefit of the study that looked more deeply into the affects exercise has on older long time

cancer survivors, was that it targeted long time cancer survivors who were older and perhaps

somewhat overweight. Most studies done on exercise with cancer patients is aimed at younger

patients who have just finished treatment, and have a stronger affinitive for engaging in an

exercise program. Cancer can affect younger adults, and it is important to focus on lifelong

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strategies to help them in their recovery. The reality is that the highest incidence of cancer is

amongst the elderly patients, and research that focuses on ways to improve their lives is just as

important as research focused on younger healthier people.

There is significant importance to these findings, the chemotherapy and endocrine therapy breast

cancer patients receive, has a huge effect on body composition and bone mass, leading to possible

obesity and more fractures. The effect that exercise can have on women who have undergone

treatment for breast cancer, shows positive results for those who are postmenopausal and are

instructed to take aromatase inhibitors to help with their prognosis. Aromatase inhibitors can

cause an accelerated degree of bone loss due to the estrogen deprivation. There are drugs to help

alleviate this bones loss, such as bisphosphonate, but that comes with its own side effects such as

gastrointestinal toxicity. This study has such proved that the bone loss as a result of aromatase

inhibitors can be prevented, and endocrine therapy can be continued without the increase worry

in osteoporosis.

Most are aware of the benefits exercise can have on ones’ health. It has been proved that there are

positive benefits in physical capability, mental health, overall quality of life, and fatigue, but in

an article by Giovannucci we can see the effects exercise has on combating cancer itself.

“Physical activity could have direct effects on the tumor that are mediated through alterations of

various hormones, including insulin, insulin like growth factor 1, estrogen, and adiponectin.

Many of these hormones, and others, have been associated with cancer risk and prognosis, which

indirectly supports a causal role of physical activity on cancer-specific death. These factors may

promote or inhibit tumor cell growth, and thus directly affect tumor progression. Exercise also

has immune-modulating effects, which theoretically could affect cancer development or

progression.” Giovannucci E, Harlan DM, Archer MC, et al (2010) He also discussed how

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diabetics who develop cancer are at a greater risk for early mortality. Exercise, done correctly and

in sufficient amounts is a direct fighter against diabetes.

Since 2007, there has been a significant increase in the amount of evidence suggesting the

positive benefits exercise has on cancer patients, in particular those participants with breast

cancer. With the onset of further research there is a deeper look into long term affects. In the

beginning, initial research looked at benefits of an exercise regime during treatment and up to 6

months after. Research is now showing benefits up to 60 months follow up from intervention.

Another strength that has been noted is the team aspect. Being part of team definitely gives some

people more aim and motivation. Supporting teams, and especially teams that are created from

cancer survivors, such as the breast cancer dragon boat teams is a crucial part to promoting

exercise. More importantly in an article from Support Care Cancer, a study proved the theory

behind a team dynamic promoting more people. The outcome not only showed more survivors

participated when it was part of a team, but that survivors are willing to join a team. “A total of

600 CRC survivors completed the survey (34 % response rate). Almost a quarter (23.0 %) of

CRC survivors reported participating in a sport in the past month, with the most common sport

being golf (58.7 %). In multivariate regression analysis, 33.0 % (p = 0.001) of the variance in

sport participation was explained by being male (β = 0.12; p = 0.006), in better general health (β 

= 0.12; p = 0.006), and ≥ 5 years post-diagnosis (β = 0.09; p = 0.031). The most common barriers

to sport participation were time, age/agility, and no interest/dislike of sports. The most common

anticipated benefits of sport participation were improved physical fitness, meeting people, and

improved health. Over half (57.2 %) of CRC survivors were possibly interested in learning about

sport participation opportunities.” McGowan, E., Speed-Andrews, A., Rhodes, R., Blanchard, C.,

Culos-Reed, S., Friedenreich, C., et al. (2013)

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Limitations

The aim of this paper was to look at cancer survivorship, and how exercise can be beneficial in a

longer healthier life. In order to examine the positives that come out of routine exercise,

researchers need to spend more time focusing on what cancer survivorship entails. There are

many definitions that can be pulled together, but to look deeper into how to better maintain

survivorship, research needs to first identify what it means to be a survivor. “The goal of cancer

survivorship research is to examine questions and develop interventions or strategies that will

lead to a decrease in physiologic and psychologic morbidity and mortality associated with post-

treatment survival from cancer.” (Aziz, 2007)

Depression occurs at a high rate in cancer survivors, and exercise could be a healthy alternative to

pharmaceutical or psychotherapy for some patients. The Meta analysis looked at, only found a

slight significant results in depressive symptoms after implementation of exercise. The limitation

though, is that not all participants in the study entered as being considered depressed. Further

studies need to look at depression as the sole variable.

One major limitation in almost all of the studies is the use of self reported questionnaires. Self

reported questionnaires have been a recurring form of measurement in the studies looking at

exercise benefits. With this comes the problem of participants answering questions based on what

they think the researcher wants to hear. These studies also seem to target participants who are

more highly motivated in exercise. There needs to be further research on people who are

sedentary before diagnosis as well as after. There could be a major difference if you have a group

of people were exercise fanatics before diagnosis, and were therefore highly motivated to get

back into shape after treatment, versus someone who has never been motivated to exercise.

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The limitations were clear, there needs to be more specific recommendations for exercise

depending on cancer site and treatment. For example some cancers such as head, neck, or

stomach may cause a patient to lose weight with treatment, whereas breast and prostate may

cause a person to gain weight with the hormonal changes. Ideally one would need professionals

focused solely on each cancer, constantly aware of any changes in treatment and new advances in

therapy.

Maintenance of exercise intervention is defined as continuing the regime 6 months post

intervention. Most studies do not show results of maintenance post intervention. Maintenance

management is especially important in cancer survivors because of their increased risk of

recurrence and secondary diseases.

Most of these studies deal with small sample sizes. Besides the one large trial that included 40

trials, most have a limited supply of participants. In order to get a more accurate account that can

be based on a wider range of people studies need to be able to gather more participants. The

problem is that “Many cancer rehabilitation programs and/or trials which include a physical

rehabilitation are lengthy in duration, extremely intensive and have tight eligibility criteria. They

would be expensive to translate into general clinical practice or to apply to the general cancer

survivor population.” Walsh, J. M., Hussey, J., Guinan, E., & Donnell, D. O. (2010).

From the time of diagnosis through to the end of their medical treatment, patients heavily rely on

their provider to explain anything that is medically important to them or their health. “Health

care providers may also provide inadvertent barriers, as many cancer survivors report conflicting

messages from their providers regarding their ability to exercise, many providers admit to a lack

of knowledge of the benefits of physical activity, do not feel comfortable making physical

32

activity recommendations, and are not convinced that cancer survivors are capable of exercising

during treatment or would follow an exercise recommendation.”

Anderson A, Caswell S, Wells M, Steele R, MacAskill S, (2010) As being their main point of

contact and someone they rely heavily on, providers need to be aware of exercise guidelines.

There needs to be more direction than just suggesting that a patient partake in exercise, patients

want to know the specifics, they are scared and in unknown territory and no longer feel like they

know the body they once did. It is essential health care providers are educated and stay up to date

with research, including exercise.

Clinics run through as many patients as possible in a short amount of time. That means each

patient or survivor is limited to the amount of time they can spend with the practitioner. Most

often topics of concern are present symptoms that are bothering the patient and overcoming them.

Providers do not have the time to advise on proper exercise regimes to their patients. “On the

basis of the Theory of Planned Behavior and Self-Determination Theory, survivors will engage in

a behavior if they perceive that the benefit outweighs the risk or their lack of interest in

performing the behavior, that authority figures value and encourage the behavior, and that the

behavior is under their control.” Peddle CJ, Plotnikoff RC, Wild TC, Au HJ, Courneya KS,

(2008)

In terms of getting survivors to exercise the biggest limitation is confidence, “one potential

barrier to physical activity participation among cancer survivors, most commonly, a lack of

confidence resulting from the cancer and the effects of treatment. The lack of confidence was

related to survivors no longer knowing what they were able to, what was safe for them to do in

terms of exercising, and what to do with body image issues, such as hair loss or the effects of

surgery.” Robertson, L., Richards, R., Egan, R., & Szymlek-Gay, E. (2012).

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Further research

A lot of patients are afraid to exercise after cancer treatment. They are unaware of how much

they can do, if their body can take it, and if it is in fact good for them. Some feel so fatigued they

lack motivation. Others had no motivation to begin with. Future research needs to look at ways to

increase motivation and increasing a long lasting maintenance.

Follow up on long term effects of treatment needs to be implemented amongst adults’ cancer

survivors. Follow up slowly decreases as time goes on, but some patients are left with significant

symptoms for life, and they seem to be addressing these problems with their oncologist. This

means that oncologists need to be prepared and researched in the area of long term problems in

survivorship. One limitation is that long term follow up is much more frequent among pediatric

patients versus adults. In children, practitioners are constantly monitoring progress, symptoms

and looking for any signs of reoccurrence throughout the rest of their lives. Adults are slowly

looked after less and less. For the patient, the decrease in doctor visits at first comes as a relief,

but as time goes on and worries creep in they want to be able to talk to their oncologist and not

always their general practitioner.

There should also be more research done on cancer survivorship. While this does not directly

entail exercise, the exercise intervention that is implemented for survivors will greatly be affected

by what researchers know about survivorship. “The goal of cancer survivorship research is to

examine questions and develop interventions or strategies that will lead to a decrease in

physiologic and psychologic morbidity and mortality associated with post-treatment survival

from cancer.” (Aziz, 2007)

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Studies can be done on whether or not having counseling on exercise throughout treatment

increases motivation. “Research evidence suggests that many cancer survivors would like

exercise counseling or information about participating in exercise at some stage during their

cancer experience.” Rogers LQ, Markwell SJ, Verhulst S, McAuley E, Courneya KS

Research is limited in the direct correlation between depression and exercise intervention, and an

improvement in body image. Body image after surgery or hair loss can be very low and finding

ways to increase body image would make a significant impact. For example for women who have

undergone mastectomies, swimming may be a challenge, but if it is all they are willing to do for

exercise, is there the possibility of promoting swim groups specifically for that, would that help

or hinder body image for women. “The ‘labeling’ of cancer survivors that may be associated with

cancer-specific programmes could represent a barrier, preventing some people from participating

in these groups.” Robertson, L., Richards, R., Egan, R., & Szymlek-Gay, E. (2012).

Research has focused on supervised groups or talks through the telephone. Could internet support

groups with an emphasis on exercise intervention be beneficial for some survivors? It is true that

online support groups help people lose weight when they have someone they can report to, and

not have to see or hear; maybe the same could be true for cancer survivors.

Research so far has focused on short term effects, some under supervision, some a combined

home based and supervised routine, and others just home based. In an article on Cancer Nursing

it depicts this deficit after completing a study on lung cancer patients who underwent a 10 week

exercise intervention program that was supervised. “Short-term supervised resistance exercise

training may improve some motivational outcomes for lung cancer survivors. Intentions appeared

to be weakened after the intervention. More research is needed to examine the long-term effects

35

of supervised resistance exercise on motivational outcomes in lung cancer survivors.” (Peddle-

McIntyre, C., Bell, G., Fenton, D., McCargar, L., & Courneya, K. 2013). Only one study looked

at how the exercise intervention made an impact at 60 months following treatment. If it is

important to maintain an exercise regime for good health in the long run, there needs to be studies

that show the significance of exercise in the long term not just short term.

While the two most prominent cancers today are breast cancer affecting women, and colon or

prostate cancer affecting men, most research has been focused on those two. There needs to be

further studies looking into how exercise can help people with more diverse or latter stage

cancers.

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Conclusion

Exercise is a healthy lifestyle for anyone; it promotes a better wellbeing, and has many benefits.

It seems to be even more beneficial for those who are survivors of cancer. While evidence is in

their favor, statistics show that survivors are not getting nearly enough exercise and even less are

participating in resistance training. Unfortunately, survivors are more susceptible to secondary

diseases as well as having cancer reoccurrences. Research shows that exercise interventions can

help prevent these challenges from occurring.

It is clear health care providers initially did not put much thought into what being considered a

survivor of cancer really entailed. While some research has been conducted it is clear more

research needs to be done in the area of how to help patients who are now cancer free but still

experiencing significant symptoms. Long term effects of chemotherapy, radiation, and surgery

can last for life. Along with physical symptoms, comes the constant fear of the cancer returning,

and depression. Patients found that the medical course of their cancer treatment was not nearly as

bad as the emotional battle they faced. Depression and fatigue are prominent features of

survivors. In an effort to learn about survivorship and encourage patients the benefits of exercise

specifically in cancer survivors has been studied.

It is important to note that exercise for survivors helps in many features and aspects of their life.

It can improve physical fitness, decrease body fat, improve quality of life and depression, fight

against fatigue, and may prevent secondary diseases from occurring. Physically it can improve

mobility that has been lost, and build muscle tone. The endorphins that are released through

higher intensity exercise are an excellent form of antidepressant to those who face depression. By

preventing secondary diseases, it promotes a longer, healthier life. Breast cancer survivors seem

at a greater risk of developing some of the secondary diseases after cancer treatment. Obesity, or

weight gain, is a common effect for these patients as they undergo hormonal therapy. With

obesity, sometimes people can develop diabetes. Implementing an exercise intervention has been

shown to help combat these diseases from occurring. “Though direct effects of physical activity

on cancer are not definitively proven, given that physical activity is generally safe, improves

37

quality of life for cancer patients, and has numerous other health benefits, adequate physical

activity should be a standard part of cancer care.” Giovannucci, E. (2012)

When first going through research and looking for journal articles that could be used, the initial

goal was to find out how exercise benefited against these secondary diseases. An aspect that was

unthought-of, that seems to be the most important aspect in exercise in cancer survivors is an

improvement in quality of life. Quality of life for cancer survivors has been proven to be lower

than those who have not had cancer. Improving quality of life for this population is essential in

that it encompasses physical, emotional, mental, and social aspects of life. By increasing quality

of life there is also an increase in health and wellbeing. While exercise is recommended during

treatment as well as after, research has shown that quality of life does not seem to improve until

post treatment.

While there has been much research in the past five years in how exercise benefits survivors, the

population of those that participate in an exercise intervention is low. Many cancer survivors face

body image issues, as well as lack confidence they once had. Finding ways to motivate these

people is essential, as well as making sure the interventions are maintained for long term. One

such form of motivation is a team sport. The example of dragon boat racing, for women who

have survived breast cancer, is an excellent example of how joining together with people who

have been through the same experiences as you helps recovery. The yearlong season requires a

commitment, and provides a positive atmosphere for women to band together and exercise.

The benefit of exercise for survivors is evident; it helps in all areas of life. There are clear areas

that need some work though. Practitioners need to be more educated in what kind of exercise

intervention is needed, and counsel patients on the benefits exercise provides. There has been

some confusion amongst practitioners on if exercise is good, with some advising it to patients and

others advising rest. When patients rely so heavily on their practitioners’ recommendations it is

necessary for them to stay up to date and informed in the area of exercise intervention. Most

importantly, it is clear that there needs to be more motivation for this ever growing population of

people. For some it is easier than others, for example if they participated in exercise regularly

before diagnosis, they are likely to be able to pick it up again after, with more ease than those

who have been noted as sedentary before diagnosis.

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“The beneficial effects of physical activity as primary, secondary, and tertiary prevention have

prompted multiple national organizations to recommend or endorse exercise in the general

population and, more recently, in the cancer survivor population.” (Denlinger, C., & Engstrom, P.

2011) Exercise intervention is growing and should be a part of treatment. Gyms are beginning to

promote groups specifically for cancer patients and helping them understand what they can and

are capable of doing. Most research done on exercise benefits has been on breast cancer and

colon cancer survivors. It is important for further research to include a broader area of education

in all cancers. Also, while exercise guidelines have been put in place by specialists in cancer and

exercise, it is important to note that each individual has different needs. There needs to be

specialists, specifically in this area to help each individual understand what they are capable of.

Most importantly, exercise is not only beneficial for survivors, and improves quality of life it is

safe, both during and after treatment, whether the patient has undergone a lifesaving treatment or

not, it is safe.

Throughout this literature review much has been gained. A new understanding for this population

of people has been brought to attention and through further research much more can be done.

Surviving cancer does not mean the end of the journey; it instead represents the start of a new

life. This new life comes with a body that has experienced a great battle, and with this new body

comes the understanding that while it may need further work, the importance of maintaining a

healthy life through exercise does not just help the body recover, but the mind as well.

Throughout this experience a lot of knowledge has been gained in the area. Many, who have not

experienced it, believe remission means the end, but that is clearly not the case. The long term

side effects can be debilitating and an unwelcome part of survival. Most people are unaware

survivors continue to suffer, the psychological impact is forever ingrained in the mind, and the

physical ones marked on the body. Being an avid advocate of exercise and healthy lifestyle the

effect of a “runners high” is well known. Of course that high that is experienced is a rush of, feel

good endorphins. Some people become addicted to exercise, like it is a drug, because of that

release of endorphins. The idea that through exercise, without the use of any drugs, people can

lift themselves up is remarkable. That is why exercise itself acts as an antidepressant. It is not just

something that can improve a life, and enable people, especially survivors, to live longer; it can

help them feel better. It can bring back purpose that was lost and re-invent a new sense of

39

confidence that is stronger that what the survivor started with. Everyone in the world is only

given one body, and if you want it to work to its best ability and last for many years to come, you

must respect it. Exercise is a way to promote not only a healthier body but a healthier mind, and

the more research that goes into proving this, and the more educated people become, hopefully a

change will be seen, and that low number of less than half survivors reaching the recommended

amount of daily exercise will start to grow.

40

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