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Exercise Prescription in Oncology

Tuesday, 26th November 2024

Understanding the Impact and Importance for Cancer Survivors

As cancer rates continue to rise, with approximately 165,000 new cases of cancer diagnosed annually in Australia alone, the role of exercise in cancer treatment and survivorship has become more critical than ever. 1 in 4 men will die from cancer by the age of 85, and 1 in 6 women will face the same fate. In 2021, breast cancer surpassed prostate cancer to become the most diagnosed cancer in the country. Furthermore, nearly 49,000 deaths in Australia are attributed to cancer each year, underscoring the ongoing public health challenge.

While oncology may not always be the focus in every clinic, many cancer survivors pass through our doors, and understanding how exercise can aid in their recovery is essential. In this post, we’ll explore the latest research on exercise prescription for cancer patients, focusing on common cancers like breast, prostate, and colorectal, and how tailored exercise plans can improve outcomes and quality of life.

Why Exercise Matters for Cancer Patients

Cancer is a disease that affects not only the person diagnosed but also their loved ones, often leaving lasting physical and emotional impacts. Whether it’s firsthand experience or witnessing a loved one’s battle, the effects of cancer are undeniable. For example, breast cancer became the most commonly diagnosed cancer in Australia in 2021, with treatment protocols often involving surgery, chemotherapy, and radiation. Many patients experience debilitating side effects, from fatigue and bone loss to lymphedema and nerve damage. However, research consistently shows that exercise has the power to mitigate these side effects, improve physical and mental health, and ultimately contribute to better long-term survival outcomes.

Exercise has been shown to help cancer patients recover more quickly from surgery, maintain muscle mass during chemotherapy, combat fatigue, and reduce the risk of cancer recurrence. By incorporating a carefully structured exercise regimen into cancer care, healthcare providers can offer survivors a way to regain their strength, boost their immune system, and improve their overall quality of life.

Breast Cancer

Breast cancer is the most commonly diagnosed cancer in Australia and the leading cancer among women. Every day, approximately 57 Australians are diagnosed, totaling over 20,000 cases annually, including around 200 men.
Breast cancer is staged based on how far it has spread:

Stage I: Localized to the breast.
Stage II: Localized, but may have spread to the axillary lymph nodes.
Stage III: Spread to the chest wall, chest skin, and other lymph nodes.
Stage IV: Metastatic, meaning cancer has spread to other parts of the body.

Treatment

Treatment often involves surgery, chemotherapy, radiation, Immunotherapy and hormone therapy. Each treatment presents unique challenges for exercise prescription:

Surgery: Surgery to remove the tumor or affected tissue can lead to pain and limited movement due to muscle loss or cording (axillary web syndrome). Patients may experience reduced range of motion in the upper body, particularly in the arm and shoulder area, requiring tailored exercises to improve mobility and strength.
Chemotherapy: Chemotherapy can have several side effects, such as cardiotoxicity (damage to the heart), peripheral neuropathy (nerve damage), and fatigue, which can severely impact physical function. These side effects necessitate careful monitoring during exercise sessions and may require modifying exercise intensity and duration to prevent overexertion.
Radiation therapy: Radiation, particularly in the chest area, can cause skin reactions, fatigue, and increase the risk of cardiovascular issues. The impact on the skin and soft tissues also requires modifications in exercise programs to avoid irritation or injury.
Hormone Therapies: Hormone therapies, such as anti-estrogen treatments, aim to block hormones that fuel cancer growth. These treatments can cause side effects such as menopausal symptoms, weight gain, fatigue, and bone health issues. Exercise is essential to help manage these symptoms, especially for maintaining bone density and reducing fatigue.
Immune Therapies: Active immunotherapies stimulate the patient’s immune system to fight cancer, while passive immunotherapies involve man-made immune system components (e.g., monoclonal antibodies). These therapies can also affect overall energy levels and immune function, so exercise plans should consider the patient’s ability to tolerate exercise and avoid overtraining.

For breast cancer survivors, exercise guidelines generally emphasize safe, moderate-intensity aerobic and resistance exercises, while taking into account specific concerns like lymphedema, peripheral neuropathy, bone health, and the patient’s stage of recovery. Individualized exercise prescription is crucial to balance the therapeutic benefits of exercise with the potential challenges posed by cancer treatment.

Exercise:

Exercise offers numerous benefits for breast cancer survivors, including improved fatigue management, enhanced aerobic capacity and muscular strength, and significant psychological improvements that boost quality of life. Regular physical activity also lowers the risk of chronic diseases, such as cardiovascular conditions, and has been shown to decrease the recurrence rates of breast cancer. Additionally, exercise contributes to increased survivorship, helping patients maintain better overall health and well-being during and after treatment. General guidelines can be seen in the figure below.

Special Considerations:

When prescribing exercise for breast cancer survivors, several special considerations must be taken into account. Lymphedema can cause symptoms like heaviness, pain, tightness, and reduced range of motion in the limb, as long as this is monitored, exercise has been shown to be beneficial. Peripheral neuropathy may require balance training and a careful assessment of fall risk, with modifications to reduce injury risk during resistance and aerobic activities. For patients with bone metastases, aerobic and resistance exercises can be beneficial, but must avoid affected areas and minimize strain on the bones. Cardiotoxicity symptoms, such as shortness of breath, fatigue, weight gain, and edema, should be monitored closely during exercise to ensure safe participation. Lastly, Cording (Axillary Web Syndrome), common after lymph node surgery, can result in pain and limited shoulder movement, requiring exercises that gently improve range of motion without aggravating the condition.

Prostate Cancer

Prostate cancer (PCa) is the most commonly diagnosed cancer in men and the second most commonly diagnosed cancer overall, after breast cancer, accounting for around 13% of all cancer diagnoses. In Australia, more than 90,000 men have been diagnosed with prostate cancer in the past five years, and there are currently over 200,000 prostate cancer survivors in the country. The five-year survival rate for prostate cancer is high, at approximately 95%. Prostate cancer is staged using the TNM system, where T describes the depth of tumor invasion, N indicates whether the lymph nodes are affected, and M indicates whether the cancer has spread to other parts of the body. Stages range from T1, where the cancer is not detectable during a physical examination, to T4, where cancer has spread to nearby organs. Understanding these stages is crucial for determining treatment and prognosis for individuals living with prostate cancer.

Treatment

Prostate cancer, often diagnosed in older men, presents its own set of challenges. Early-stage prostate cancer may involve monitoring rather than immediate treatment. However, for those undergoing treatments like surgery (e.g., radical prostatectomy), radiation (including external beam radiation therapy (EBRT) and internal radiation therapy (brachytherapy)), and hormone therapy (such as androgen deprivation therapy (ADT) or orchidectomy), exercise prescription becomes crucial for managing side effects. These treatments can cause a range of issues:

Hormone therapy can result in reduced bone mineral density, increased body fat, and muscle loss, which exercise, particularly resistance training and aerobic exercise, can help mitigate.
Surgery can lead to sexual dysfunction, fatigue, and incontinence, making physical activity key for improving recovery and quality of life.

Exercise recommendations for prostate cancer survivors have evolved significantly. Research shows that moderate to high-intensity exercise, including both aerobic and resistance training, can be highly beneficial. It helps improve bone health, mitigate the effects of testosterone suppression, and support overall physical function. This approach is especially effective when combined with the management of treatment side effects, contributing to improved survivorship and quality of life.

When prescribing exercise for prostate cancer survivors, several factors must be considered to ensure safety and optimize outcomes. Densitometry and antiresorptive therapy are important for monitoring and managing bone health, particularly in patients undergoing hormone therapy (ADT), which can lead to bone density loss. Adequate intake of vitamin D and calcium is essential to support bone health, while sufficient protein intake is crucial for maintaining muscle mass and strength, especially during and after treatment.

For patients with bone metastases, exercise should be chosen carefully to avoid further injury. Exercises that involve high torque and rotational movements should be avoided, especially if metastases are in the pelvis, femur, spine, or upper body. In addition, it’s also important to encourage smoking cessation, as smoking can weaken bones and slow recovery. See the image below for guidelines to exercise prescription.

Colorectal Cancer:

Each year, around 15,500 Australians are diagnosed with bowel cancer, which is most common in individuals over 50, though it can occur at any age. By the age of 85, 1 in 20 people will be diagnosed. Approximately 90% of bowel cancers are adenocarcinomas, with small bowel cancer being rare. The 5-year survival rate is about 70%. Bowel cancer is staged as follows: Stage 1 (tumour in the lining of the bowel), Stage 2 (tumour spread to the bowel walls), Stage 3 (spread to nearby lymph nodes), and Stage 4 (spread to other body parts). Radiation therapy is not used for colon cancer, although it may be used for rectal cancer.

Treatment:

Treatment options for colorectal cancer include a combination of surgery, radiation, chemotherapy, exercise, and immune therapy:

Surgery: This may involve a colectomy (keyhole or open surgery) or resections to remove the cancerous tissue.
Radiation: Used as adjuvant or neoadjuvant therapy, including brachytherapy and external beam radiation therapy (EBRT).
Chemotherapy: Administered as adjuvant or neoadjuvant treatment, typically through oral or intravenous medications.
Exercise: Aerobic and resistance training help improve physical function and recovery.
Immune Therapy: Administered through IV infusion to help boost the body’s immune response against cancer cells.

Special Considerations for Exercise

Special considerations for exercise prescription in colorectal cancer include:

Blood issues: Anemia, neutropenia, and thrombocytopenia can affect exercise tolerance.
Chemotherapy-induced peripheral neuropathy (CIPN): Commonly leads to nerve damage, causing weakness, numbness, or pain, and requiring adjustments in exercise.
Cramping: A frequent side effect, which may need to be managed during exercise.
Proximity to a toilet: Patients may need to be near a restroom due to bowel changes or discomfort.
Stoma awareness: Individuals with a stoma may be concerned about herniation and need modifications to avoid strain.
Central port: A catheter may be in place for extended periods, requiring careful consideration during exercise.
Fatigue fluctuations: Patients often experience varying levels of fatigue, which may impact their exercise capacity.
Lymphedema: Swelling, often in the legs, may require monitoring and adjustments in exercise intensity.
Core muscle recovery: Post-surgery, strengthening core muscles is important for recovery.
Bone metastases: Exercise must be adjusted for patients with bone metastases to avoid injury and manage pain.

Exercise plays a vital role in cancer treatment and survivorship. By tailoring exercise plans to the individual needs of cancer patients, healthcare providers can help improve physical function, reduce treatment side effects, and enhance overall well-being. Whether it’s managing fatigue, improving bone health, or enhancing immune function, the benefits of exercise for cancer survivors cannot be overstated. For cancer patients and survivors, a structured and evidence-based exercise plan can be an essential part of the recovery journey.

If you or someone you know is undergoing cancer treatment, be sure to consult with a healthcare provider to develop a safe and effective exercise plan tailored to their needs.

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