EXERCISEPROGRAMMINGFORCANCERSURVIVORSATELLICSR
DanielSantaMina,PhD(CSEP-CEP,RKin)Scien&st,ELLICSR,PrincessMargaret
AssistantProfessor,Kinesiology&PhysEd,U.Toronto
ExerciseResearchinCancer
Year
#ofpub
lica&
ons
• QOL• Physicalfunc&on• Appe&te• Immunesystemfunc&on• Cardio-pulmonaryfunc&on• Depression&anxiety
• Sleep• BoneHealth• BodyComposi&on• Hospitaliza&on• TreatmentComple&on• Fa&gue
• Pain• Postopera&veLOS• Socialroles• Self-efficacy• Coping• Tumourcellgrowth
• Insulinsensi&vity• Concentra&on• Lymphedema• Func&onalmobility• Sexualfunc&on• Survival
SEARCH: ("physical activity"[Title]) OR "exercise"[Title]) AND "cancer"[Title]
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Whenisagood&metostartexercising?
ExerciseisimportantatanyKmeofthecancerjourney:
Exerciseforcancerpreven&onandbeforediagnosis
Cancer Type # of Studies
Risk Reduction
Comment
Colon 60 20-25% Occupational PA = Recreational PA; Dose-response relationship; no relationship with rectal cancer
Breast 73 25% Dose-response relationship; PA after age 50 is more beneficial
Endometrial 20 20-30% Effects are independent of adiposity; dose-response; high-intensity may be more beneficial
Prostate 20+ 10-20% Increased protection from advanced/aggressive Ca; Obesity may increase risk of aggressive PCa; vigorous PA may be most beneficial
Lung 20+ 20-40% Studies did not always control for smoking status; PA benefit particularly seen in smokers; Rec PA > Occ PA
Ovarian 20+ 20% ? Vigorous PA Increase/decreases risk
Haematological ~20 -- Some benefit for NHL and Leukaemia, but not for MM or lymphoma; minimal evidence/inconclusive
(Friedenreich, 2010; 2002;’ (Giavannucci et al, 2005, AIM; (Hsing et al, 2006, Frontiers in Bioscience; Freedland, 2006, Ca Causes & Control
Preven&on
Detec&onExercisemayindirectlyaffectcancerdetec&onbyimprovinga^en&ontohealthbehaviours,includingscreening.
(Larson et al, BMC Gastroenterology, 2006; Courneya & Friedenreich, 2007, Sem Oncol Nursing)
Exercisebeforecancertreatment
Prehabilita&onincancer
Pre-op Rehabilita&on Post-RehabAcutePost-op
Func&onalThreshold
PhysicalAbility
Non-Prehab
Prehabilita&on:Ac&onsusedtoimproveyourphysical&mentalhealthandbuildupstrengthbeforeyoustarttreatment.
BenefitsofPrehabilita&oninCancer
• Reduce hospital stay • Reduce surgical
complications • Improve activities of daily
living function • Improve treatment
candidacy
• Improve coping skills and reduce emotional distress
• Reduce recovery time • Reduce treatment & post-
treatment side effects
Exerciseduringtreatment
Benefits of exercise during treatment (Surgery, Radiation, Chemotherapy and Hormone Therapy)
• Improvephysicalfitness– Aerobic&musculoskeletal– Muscleandfatpropor&ons
• Lowerbloodpressure• Reducetreatmentsideeffects
– E.g.Pain,nausea,poorsleep• Treatmenttolerance• Improvedenergy• Reducedfa&gue• Improvequalityoflife
ExerciseDoesNOT:• Worsentreatmentordisease-relatedsymptoms• Underminetreatmentefficacy
Exerciseadertreatment
Benefitsofexerciseadertreatment• Improved fitness • Improved energy • Improved cognitive function • Reduced risk of lymphedema
(swelling) • Reduced impact on ADLs • Reduce fatigue (tiredness) • Improved bone health • Improve body composition
Exercise&Survival&Biomarkers• 27Observa&onalStudies:PA
associatedw/reducedall-cause,breast&coloncancermortality
• 13RCTs:beneficialeffectsonbiomarkers– insulinandrelatedpathways– inflamma&on– immunity
(Ballard-Barbashetal,JNCI,2012)
HowphysicallyacKvearecancersurvivors?
• Survey703KidneyCancerSurvivors– ~70monthspost-dx
• AssessedPAandQOLResults:• ~56%werecompletelysedentary• ~76%werebelowtheHealth
Canada/CSEPguidelines• Kidneysymptomindexposi&vely
associatedwithPA(Trinhetal,2011,CaEpidemiol,Biomark,Prev)
ChangesinPAforAYAAderacancerdiagnosis,significantreduc&onsin:• %mee&ngthePAguidelines
– (150min/wkofmoderatetovigorousPA)• TotalPAminutes• SportPAminutes68%wouldlikeanAYAexerciseprogram
300250200150100500
(Murnaneetal,2015,SupportCareCancer)
CancerSurvivorsPreferencesforPAQuesKon Response(%)
WouldliketoreceivePAinfoaderdiagnosis? Yes=44 Maybe=31AbletodoaPAprogramforkidneycancersurvivors? Yes=48 Maybe=33
InterestedindoingaPAprogramforkidneycancersurvivors?
Yes=34 Maybe=37
WhentostartaPAprogram? Duringtx=5 3-6mon>tx=37
WheretodoaPAprogram CancerCentre=7 Home=52
Supervised/instructedorunsupervised/self-paced? Supervised=41 Unsupervised=59
Walking Summer=69 Winter=48Intensity Moderate=58 Light=35WouldliketoreceivePAinfofrom? Oncologist=22 Trainerw/Ca
knowledge=56(Trinhetal,2011,CaEpidemiol,Biomark,Prev)*Kidneycancersurvivors
Top10PrioriKesinExercise&Cancer1. DoesPAreducetheriskforcancerrecurrenceand/orimprovesurvival?2. DoesPAinfluencecancertxdecisions,comple&onrates,and/orresponse?3. Whatistheop&malPAprescrip&onforcancersurvivors?4. Whatistheroleofsedentarybehaviorincancersurvivorship?5. Whatarethemosteffec&vePAbehaviorchangeinterven&onsforcancersurvivors?6. WhichcancervariablesmodifythePAresponse?7. WhatarethesafetyissuesconcerningPAincancersurvivors8. WhichspecificcancersymptomscanbemanagedbyPA?9. IstherearoleforPAinadvancedcancer?10. HowdowetranslatePAresearchintoclinicalandcommunityoncologypracKce?
(Courneyaetal,2015,ResQuartExSport)
THE LATEST RESEARCH SHOWS THAT WE REALLY SHOULD DO SOMETHING
WITH ALL THIS RESEARCH
Exercise IS Recommended after a Cancer Diagnosis
CancerCareOntario• Ontariogovernment’s(MOHLTC)advisoroncancer
– Planscancerservicestomeetcurrentandfuturepa&entneeds,andworkswithhealthcareprovidersineveryLocalHealthIntegra&onNetwork(LHIN)tocon&nuallyimprovecancercareforthepeopletheyserve.
– Conductsresearchandrapidlytransfersknowledgeofnewresearchintoimprovementsandinnova&onsinclinicalprac&ceandcancerservicedelivery.
• CCOleadsmul&-yearsystemplanning,contractsforserviceswithhospitalsandproviders,developsanddeploysinforma&onsystems,establishesguidelinesandstandards,andtracksperformancetargetstoensuresystem-wideimprovementsincancermanagement
TheMandateàGuidelines
PrograminEvidence-BasedCare• CCO’sPrograminEvidence-BasedCare(PEBC)isaninterna&onallyrecognizedguidelinedevelopmentprogramthatworkstoimprovethequalityofcancercarebyhelpingcliniciansandpolicymakerstoapplythebestscien&ficevidenceinprac&ceandpolicydecisions.
• UsestheAGREEIImethodologytoassessthequalityandrepor&ngofprac&ceguidelines.– UsedtoestablishtheCCOCancer-ExerciseGuidelines
ReviewofLiteratureandExpertInquiry
LiteratureSearchYields:- 3Guidelines- 18Systema&cReviews- PrimaryLiterature
CCORecommenda&ons1. Peoplelivingwithcancercansafelyengageinmoderateamountsofexercisewhileonac&ve
treatmentorpostcomple&onoftherapy.2. ModerateamountsofexercisearerecommendedtoimproveQoLaswellasthemuscularand
aerobicfitnessofpeoplelivingwithcancer3. Cliniciansshouldadvisetheirpa&entstoengageinexerciseconsistentwiththerecommenda&ons
outlinedbyCSEP&ACSM4. Pre-exerciseassessmentforallpeoplelivingwithcancerbeforestar&nganexerciseinterven&on
isrecommendedtoevaluateforanyeffectsofdisease,treatmentsand/orco-morbidi&es5. Itisrecommended,wherepossible,thatpeoplelivingwithcancerexerciseinagroupor
supervisedsesngasitmayprovideasuperiorbenefit/outcomeinQoLandmuscularandaerobicfitness.
6. Itisrecommended,wherepossible,thatpeoplelivingwithcancerperformexerciseatamoderateintensity(threetosix&mesbaselineres&ngstate)onanongoingbasis,asapartoftheirlifestylesothatimprovementsinQoLandmuscularandaerobicfitnesscanbemaintainedforthelongterm.
Guidelines
150minutesofmoderate-tovigorous-intensityaerobicPA/week Same!
Muscleandbonestrengtheningac&vi&esusingmajormusclegroups,at
least2daysperweek.Same!
MoredailyPAprovidesgreaterhealthbenefits.
Avoid inactivity Return to daily activities as quickly as possible after surgery Continue normal daily activities as much as possible during and after nonsurgical treatments
Year OrganizaKon Frequency Intensity Time
2003 ACS >5days/week Moderatetovigorous >30min
2009 ESSA (A)3-5days/week(R)1-3days/week
(A) RPE11-14,60-80%HRmax(R)50-80%1RM
(A)20-30min(R)1-4setsx6-10exercises
2010 ACSM (A)150min/weekofmoderateor75min/weekofvigorousphysicalacKvity;Strengthtraining2days/week
2011 CCCN >5days/week Atleastmoderateintensity >30min
2012 ACS 150minutesofphysicalac&vity/week;strengthtraining2days/week
2012 BASES 150minutes/weekofmoderatetovigorousphysicalac&vity;strengthtraining2days/week
Buffart et al. (2014) Cancer Treatment Reviews 40 (2014) 327–340
Exerciseprescriptionguidelinesincancer
Screening
Follow-upQues&ons
Screening&RiskStra&fica&on
(Burr,Jones&Shephard,2012,CanFamPhys)
eCancer
Health&FitnessAssessment
• Cancerhistory• Treatmenthistory• Social&func&onalhistory• Fa&gue• Pain¶esthesias• Lymphedema
HealthAssessment FitnessAssessment• Bodycomposi&on• Musculoskeletalfitness• AerobicFitness• Physicalac&vityvolume• Balance• Flexibility• Adapta&ons&accommoda&ons• Exerciseintolerance?
Exercise-RelatedCancerToxicityCentral/Systemic• Chemo-related…
– Bradycardia,myocardialischemia,myocardialinfarc&on,CHF
• MAB/TKIrelated…– CHF,cardiomyopathy,thrombosis
• Hormonetreatmentrelated…– Centraladiposity,increasedBF%,
hyperinsulinemia,procoagulantchanges,hypertension
• Surgery/Radia&onlocalizeddysfunc&on
Peripheral/Musculoskeletal• Chemo-related…
– Peripheralneuropathy/parasthesias,
• Hormonetreatmentrelated…– Bonedegrada&on,decreased
musclemass/strength• Surgery/Radia&onlocalized
dysfunc&on
Exercisetoleranceinpersonswithcancer
(Jones et al. Lancet Oncology, 2009)
~25-40%reduc&oninVO2forcancersurvivorscomparedtoage/sex-matchedcontrols
CRfitnessinCancerSurvival
Sources:Farrelletal.,Obesity(2011)19,2261–2267
Cardiorespiratoryfitnesstestinginclinicaloncology:exercisetestmodality
• Safety• In843par&cipants,therateofadverseeventduringmaximalfitnesstes&ngincancersurvivorswas1%
• Reportedadverseeventsincluded:• Asymptoma&cECGabnormality• Lowbloodoxygensatura&on• Pre-syncope/syncope
• CPETtes&ngappearstobesafeandfeasibleincancersurvivorswhenappropriatelyconductedaccordingtoguidelines
SteinsBisschopetal.,SportsMed2012;42(5):367-379
CancerSurvivorFunc&onCon&nuum
SevereImpairment HighlyFunc&oning
ImpairmentDrivenExercise
• PrimaryClinician:MD/PT/OT
ExerciseforPerformanceOp&miza&on
• PrimaryClinician:RKin/ExPhys
InterprofessionalApproach
ImpairmentExamplesIm
pairm
entS
everity
Breast Prostate Lung Sarcoma H&N
LymphedemaFrozenShoulderBodyImage
Erec&ledysfunc&onUrinaryIncon&nence
SOB Limbdysfunc&onAmputa&on
DysphagiaSpeechimpairment
Fa&gue,Pain,Neuropathy,Psycho-socialdysfunc&on,muscleatrophy,secondaryosteoporosis
ExercisePrescrip&on…Mustbeindividualized!!!• Eachpersonscon&nuumisdifferent• Everyonehasmul&plecon&nuumsthatrelatetodifferent
organsystems,muscles/joints,mo&va&ons,etc.
VigorousLight
150minsperweekofmoderatetovigorousPAperweek;boutsof10+mins
Adapted from Warburton et al; Canada’s Physical Activity Guide to Healthy Living; ACSM's Guidelines for Exercise Testing and Prescription; and Howley et al. HR= Heart Rate; HRR = Heart rate reserve.
AerobicTrainingRecommenda&ons
ResistanceTrainingRecommenda&on
%1RM, percentage of one repetition maximum. Adapted from Warburton, adapted from information provided by Warburton et al. and ACSM
IntensityClassifica&on
%1-Repe&&onMaximum ExampleAc&vi&es
VeryLightEffort <30 Wateringthelawnorgarden
LightEffort 30-49 Generalhousecleaning,Ironing
ModerateEffort 50-69 Rakingleaves,Vacuuming
HardEffort 70-84 Woodsplisng,Shovelingsnow
VeryHardEffort >84 Carryinggroceriesupstairs
MaximalEffort 100 Lidingaheavyloadthatyoucanonlylidonce
2daysperweek,targe&ngmajormusclegroups
TypesofExercises
Aerobic(Cardiovascular)
Resistance/Weight(Concentric/Eccentric)
Mixed(Aerobic&Resistance)
ImpactLoading(plyometrics)
Yoga/T’aiChi Sport
Adap&ngPAPrescrip&ons• Metasta&cdisease(bonemets)• Secondaryosteoporosis• Infec&on• Dehydra&on• Bleeding• Fa&gue• Lymphedema• Drains&Lines• Paresthesias• Brainfog
Hospital-based
University-Based
Community-Based
Home-Based
Severaltypesofexerciseprogramsareavailableforcancersurvivors
NotyouraveragepersonaltrainerTraining:• ACSM–“CancerExerciseTrainer”(Webinar+Exam,musthavebasedACSMcer&fica&on)• U.ofNorthernColoradoCancerRehabInst.–“CancerExerciseSpecialist”• Wellspring–“CancerSmartExercise”(exerciseandrehabilita&onfocus)• UniversityofCalgary/Thrive–Cancer&Exercise
Experience:• Volunteer• StudentInternshipsOngoingLearning:• Rounds,workshops,webinars,mentors
Wellness&ExerciseforCancerSurvivors(WE-Can)
IniKatedin2014OurMandate:• Supportthewell-beingofcancer
survivorswithevidence-basedexerciseprogrammingandrelated-services
• Conductnovelresearchintotheeffects,accessibility,andsupportofexerciseprogramsforcancersurvivors.
InternalMDReferral
InterdisciplinaryIntakeAssessment
RKinFitnessAssessment
Home-BasedProgram
WklyGroup-BasedBoosterSessions
Aerobic+Resistance
On-LineResources
Follow-upWk6,12,24,48
InternalMDReferral
InterdisciplinaryIntakeAssessment
RKinFitnessAssessment
8-WkGroup-Exercise&EducaKon
Follow-up(12-wkspost)
Cancer Rehab & Survivorship
EducaKonalTopics• GoalSesng• ExerciseTips&Safety• Diet• BrainHealth• Fa&gue• Mood• Relaxa&on/StressMgmt
Othercancerexerciseprograms• Wellspring (Several Sites in GTA)
– www.wellspring.ca
• Gilda’s Club – http://www.gildasclubtoronto.org/
• UW WELL-FIT (Waterloo) – www.uwaterloo.ca/uw-fitness/uw-well-fit
• CANWELL (Hamilton) – www.canwellprogram.ca
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