Cancer and exercise

Cancer and ExerciseCancer and Exercise

B. Elizabeth Delasobera, MDB. Elizabeth Delasobera, MDSports Medicine FellowSports Medicine Fellow

OutlineOutlineThe mechanism for how exercise can The mechanism for how exercise can

prevent cancerprevent cancerThe evidence for exercise and increased The evidence for exercise and increased

cancer survivalcancer survivalThe exercise prescription for cancer The exercise prescription for cancer

patients and survivorspatients and survivors

Cancer ReviewCancer ReviewExcessive, uncontrolled cellular Excessive, uncontrolled cellular

proliferation with potential for metastasisproliferation with potential for metastasisSymptoms can be local or systemicSymptoms can be local or systemicVariety of treatmentsVariety of treatments

Surgery, Radiation, Chemotherapy, Surgery, Radiation, Chemotherapy, ImmunotherapyImmunotherapy

Designed to attempt remission or cure, or for Designed to attempt remission or cure, or for disease control or symptom reliefdisease control or symptom relief

Mechanism for Cancer Mechanism for Cancer Reduction with ExerciseReduction with Exercise

Physical activity lowers levels of biologically Physical activity lowers levels of biologically available sex hormonesavailable sex hormonesDecreased lifetime exposure to endogenous Decreased lifetime exposure to endogenous

sex hormones -> decreased risk of hormone-sex hormones -> decreased risk of hormone-related cancersrelated cancersBreast, endometrial, ovaries, prostate, testesBreast, endometrial, ovaries, prostate, testes

Exercise decreases endogenous insulin Exercise decreases endogenous insulin productionproductionHigher levels of circulating insulin linked with Higher levels of circulating insulin linked with

several cancersseveral cancersExercise associated with decreased levels Exercise associated with decreased levels

of IGFof IGFHigh levels of IGF-1 a/w several cancers High levels of IGF-1 a/w several cancers

(colon, prostate, breast, lung)(colon, prostate, breast, lung)



Adiposity and Cancer RiskAdiposity and Cancer Risk Increased fat associated with increased risk of Increased fat associated with increased risk of

cancers of colon, kidney, esophagus, endometrium, cancers of colon, kidney, esophagus, endometrium, thyroid, post-menopausal breastthyroid, post-menopausal breast

Physical activity decreases colon transit timePhysical activity decreases colon transit time Decreases colonic exposure to carcinogens in stoolDecreases colonic exposure to carcinogens in stool

Level of physical activity inversely related to levels of Level of physical activity inversely related to levels of C-reative proteinC-reative protein

NSAID use in physically activeNSAID use in physically active NSAID use appears to decrease colon cancer riskNSAID use appears to decrease colon cancer risk

The Evidence:The Evidence:Exercise and Cancer RiskExercise and Cancer Risk

Breast CancerBreast Cancer Invasive Breast Cancer risk decreased by 15%-50% Invasive Breast Cancer risk decreased by 15%-50%

among physically active womenamong physically active women Women < 40yo exercising 4 hrs/week or more during Women < 40yo exercising 4 hrs/week or more during

reproductive years had 50% risk reductionreproductive years had 50% risk reduction Postmenopausal women with higher rates of recreational Postmenopausal women with higher rates of recreational

activity have lower incidence of breast canceractivity have lower incidence of breast cancer Confirmed in over 30 studies in multiple demographic and Confirmed in over 30 studies in multiple demographic and

population groupspopulation groups Studies focused solely on Studies focused solely on in situin situ Breast Cancer have shown Breast Cancer have shown

similar reductions in risksimilar reductions in risk Estrogren receptor negative cancer seem to be most reduced Estrogren receptor negative cancer seem to be most reduced

with exercisewith exercise

Bernstein L, AACR Education Book 2008:225-231 (2008)


Breast CancerBreast Cancer Greatest reduction is risk found with exercise during Greatest reduction is risk found with exercise during

reproductive years, strenuous activity, at least 5 hours reproductive years, strenuous activity, at least 5 hours per weekper week

Estrogen receptor-negative Breast Cancer responds Estrogen receptor-negative Breast Cancer responds better to exercise than receptor-positive cancerbetter to exercise than receptor-positive cancer

Meta-analysis revealed a dose-response relationship Meta-analysis revealed a dose-response relationship of 6% decrease in relative risk for each additional of 6% decrease in relative risk for each additional hour of physical activity per weekhour of physical activity per week

Monninkhof EM, et al. Epidemiol 2007;18:137–57. Monninkhof EM, et al. Epidemiol 2007;18:137–57.

Bernstein L, AACR Education Book 2008:225-231 (2008)

The Evidence: The Evidence: Exercise and Cancer SurvivalExercise and Cancer Survival

Breast Cancer Survival Meta-AnalysisBreast Cancer Survival Meta-Analysis24% - 67% reduction in total deaths and 50% 24% - 67% reduction in total deaths and 50%

reduction in breast cancer recurrence in reduction in breast cancer recurrence in women who are physically activewomen who are physically active

Best effect in women who underwent Best effect in women who underwent equivalent of brisk walking 3h per weekequivalent of brisk walking 3h per week

Effect observed in pre and post-menopausal, Effect observed in pre and post-menopausal, overweight and normal weight women, and overweight and normal weight women, and those with stage I-III diseasethose with stage I-III disease


Colon CancerColon Cancer 43 out of 51 studies demonstrated decreased risk of 43 out of 51 studies demonstrated decreased risk of

colon cancer in the most physically active participantscolon cancer in the most physically active participants Risk reduction averaged 40%-50%, up to 70%Risk reduction averaged 40%-50%, up to 70% Consistent risk reduction despite differing study Consistent risk reduction despite differing study

designs and populations and types of exercisedesigns and populations and types of exercise Greater effect in men vs. womenGreater effect in men vs. women

Hormone supplementation in postmenopausal women also Hormone supplementation in postmenopausal women also has protective effecthas protective effect

Unclear exercise effect on rectal cancerUnclear exercise effect on rectal cancer

Bernstein L, AACR Education Book 2008:225-231 (2008)Friedenreich CM, et al. J Nutr 132:3456-3464, 2002.

The Evidence: The Evidence: Exercise and Cancer SurvivalExercise and Cancer Survival

Colon cancer survivalColon cancer survival3h per week of moderate physical activity 3h per week of moderate physical activity

after colon cancer diagnosis:after colon cancer diagnosis:39%-59% decreased risk of colon cancer death39%-59% decreased risk of colon cancer death50%-63% decreased risk of total death50%-63% decreased risk of total deathEffect essentially unchanged across age, sex, BMI, Effect essentially unchanged across age, sex, BMI,

disease stage, age at diagnosisdisease stage, age at diagnosis Meyerhardt JA, et al. Meyerhardt JA, et al. J Clin OncolJ Clin Oncol 2006; 2006;2424:3535–41 :3535–41

The Evidence:The Evidence:Exercise and Cancer PreventionExercise and Cancer PreventionProstate CancerProstate Cancer

Less consistent data, risk reduction averaged Less consistent data, risk reduction averaged 10% - 30%10% - 30%

Poor understanding of natural history of Poor understanding of natural history of Prostate CancerProstate Cancer

Exercise can also reduce risk of BPHExercise can also reduce risk of BPHExercise lowers severity of disease and Exercise lowers severity of disease and

fatalities from prostate cancerfatalities from prostate cancerLikely that very high level of exertion early in Likely that very high level of exertion early in

life needed to influence implicated hormoneslife needed to influence implicated hormonesBernstein L, AACR Education Book 2008:225-231 (2008)Friedenreich CM, et al. J Nutr 132:3456-3464, 2002.

The Evidence:The Evidence:Exercise and Cancer PreventionExercise and Cancer PreventionEndometrial CancerEndometrial Cancer

Strong association with Breast CancerStrong association with Breast CancerFewer/lower quality studiesFewer/lower quality studies

Majority still show decreased risk of endometrial Majority still show decreased risk of endometrial cancer with increased physical activitycancer with increased physical activity

Risk Reduction varied: 0 – 90%, average 30% - 40%Risk Reduction varied: 0 – 90%, average 30% - 40%Majority of studies show dose response effectMajority of studies show dose response effect

Bernstein L, AACR Education Book 2008:225-231 (2008)Friedenreich CM, et al. J Nutr 132:3456-3464, 2002.

The Evidence:The Evidence:Exercise and Cancer PreventionExercise and Cancer PreventionLung CancerLung Cancer

Physical activity Physical activity probablyprobably decreases risk of decreases risk of lung cancer, but effect not well-establishedlung cancer, but effect not well-established

Meta-analysis shows 13% risk reduction with Meta-analysis shows 13% risk reduction with moderate recreational physical activity and moderate recreational physical activity and 30% decreased risk with strenuous activity30% decreased risk with strenuous activityStudies may not reflect differences in smoking Studies may not reflect differences in smoking

habitshabits

Tardon A, et al. Cancer Causes Control 2005;16:389–97.Tardon A, et al. Cancer Causes Control 2005;16:389–97.

The Evidence:The Evidence:Exercise and Cancer PreventionExercise and Cancer PreventionLimited and/or insufficient evidence:Limited and/or insufficient evidence:

Ovarian CancerOvarian CancerTesticular CancerTesticular CancerRenal Cell CancerRenal Cell CancerPancreatic CancerPancreatic CancerThyroid CancerThyroid CancerMelanomaMelanoma

Survivors and ObesitySurvivors and Obesity Improvements in treatment means more survivorsImprovements in treatment means more survivors 11 million cancer survivors in US alone11 million cancer survivors in US alone Obesity and a sedentary lifestyle prevalent among Obesity and a sedentary lifestyle prevalent among

cancer survivors (Irwin ML, cancer survivors (Irwin ML, BJSMBJSM 2009; 2009;4343:32-38):32-38) Higher than general populationHigher than general population Increases risk of cancer recurrence and deathIncreases risk of cancer recurrence and death

In breast cancer survivors, obesity assoc w/ 50% In breast cancer survivors, obesity assoc w/ 50% increase in cancer recurrence and death (Kroenke increase in cancer recurrence and death (Kroenke CH, et al. CH, et al. J Clin OncolJ Clin Oncol 2005; 2005;2323:1370–8):1370–8)

Cancer survivors die from non-cancer related CVD Cancer survivors die from non-cancer related CVD and DM2 at a higher rate than the general and DM2 at a higher rate than the general populationpopulation

So Are Cancer Pts Exercising?So Are Cancer Pts Exercising?Despite these well documented dramatic Despite these well documented dramatic

effects, the great majority of cancer effects, the great majority of cancer survivors do not participate in regular survivors do not participate in regular physical activityphysical activity

Many cancer survivors decrease their Many cancer survivors decrease their physical activity after diagnosisphysical activity after diagnosis

Women with breast cancer exercise, on Women with breast cancer exercise, on average, 2 hours less per week 1 year average, 2 hours less per week 1 year after diagnosis than pre-diagnosis. after diagnosis than pre-diagnosis.

Recs for Exercising with CancerRecs for Exercising with CancerGoal is to preserve and possibly improve Goal is to preserve and possibly improve

functionfunctionMust be individualizedMust be individualized

Tailor to level of functionTailor to level of functionAccommodate for periods of increased fatigue Accommodate for periods of increased fatigue

and cycles of treatmentand cycles of treatmentMake exercise an integral part of everyday Make exercise an integral part of everyday

lifelife

Recs for Exercising with CancerRecs for Exercising with Cancer

30-50% of breast cancer deaths among 30-50% of breast cancer deaths among post-menopausal women can be attributed post-menopausal women can be attributed to being overweightto being overweight

Cancer survivors die of non-cancer Cancer survivors die of non-cancer causes at a higher rate than persons in the causes at a higher rate than persons in the general population (CV dz, DM, etc)general population (CV dz, DM, etc)

Recs for Exercising with CancerRecs for Exercising with Cancer Special Considerations for Cancer and Special Considerations for Cancer and

Exercise:Exercise:Cancer treatment can cause osteoporosis; bony Cancer treatment can cause osteoporosis; bony

metastases may weaken bone = higher risk of metastases may weaken bone = higher risk of pathologic fracturepathologic fracture

Be aware of Hickman cathethers, Port-a-caths, Be aware of Hickman cathethers, Port-a-caths, other access linesother access lines

If platlet count is below 50k, consider risk of If platlet count is below 50k, consider risk of bleedingbleeding

Consider concomitant effects of CVD and anemiaConsider concomitant effects of CVD and anemia

Recs for Exercising with CancerRecs for Exercising with Cancer Medications That Can Effect Exercise Tolerance:Medications That Can Effect Exercise Tolerance:

Glucocorticoids: may cause muscle weakness and Glucocorticoids: may cause muscle weakness and wastingwasting

Growth factors: may cause bone painGrowth factors: may cause bone pain Chemotherapy: may cause anemia, fatigue, and nausea; Chemotherapy: may cause anemia, fatigue, and nausea;

possibly myopathies and neuropathiespossibly myopathies and neuropathies Anthracyclines can cause cardiomyopathy, heart failure and Anthracyclines can cause cardiomyopathy, heart failure and

coronary vasospasmcoronary vasospasm Radiation: may cause skin breakdown, muscle and joint Radiation: may cause skin breakdown, muscle and joint

constriction, and cardiopulmonary fibrosisconstriction, and cardiopulmonary fibrosis


American Cancer Society Recs:American Cancer Society Recs:While getting adjuvant treatment recs 3-5 While getting adjuvant treatment recs 3-5

days/week for 20-30 mins tailored to fitness days/week for 20-30 mins tailored to fitness level and tx side effects (ex, walking, resistance level and tx side effects (ex, walking, resistance training, yoga)training, yoga)

Survivors use ACSM sports prescription Survivors use ACSM sports prescription guidelines (keep in mind any limitations based guidelines (keep in mind any limitations based on prior slides) on prior slides)


Things to Keep in Mind with Return to Things to Keep in Mind with Return to Sport:Sport: Immunocompromised? (neutropenia, on chemo, Immunocompromised? (neutropenia, on chemo,

etc)etc)At risk of bleeding? (platlet count, coags, meds)At risk of bleeding? (platlet count, coags, meds)At risk of CV issues? (meds)At risk of CV issues? (meds) ““Neck check”Neck check”

SummarySummaryMultiple biologic explanations for benefits Multiple biologic explanations for benefits

of exercise with respect to cancer risk of exercise with respect to cancer risk reduction and survivalreduction and survival

Exercise and Cancer PreventionExercise and Cancer PreventionConvincing evidence for increased activity Convincing evidence for increased activity

and prevention of colon, breast, and prostate and prevention of colon, breast, and prostate cancercancer

Probable evidence for endometrial and lung Probable evidence for endometrial and lung cancercancer

Insufficient evidence for all othersInsufficient evidence for all others

SummarySummary Exercise and Cancer SurvivalExercise and Cancer Survival

Increasing numbers of survivors in populationIncreasing numbers of survivors in population Decreasing physical activity among survivorsDecreasing physical activity among survivors Increased physical activity significantly lowers cancer Increased physical activity significantly lowers cancer

recurrence and total death in survivorsrecurrence and total death in survivors Exercise PrescriptionExercise Prescription

Must be individualizedMust be individualized Many confounding factors (be aware of meds and Many confounding factors (be aware of meds and

side effects)side effects) Keep it simple, make it regular, progress graduallyKeep it simple, make it regular, progress gradually

Cancer and exercise

Health & Medicine

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