Jill Mayer PT, DPTIthaca College

ObjectivesBriefly discuss the benefits of physical

activity and its role in cancer preventionDetermine the effects of physical activity

during and after cancer treatmentDetermine the effects of physical activity on

cancer recurrence and survivalReview exercise guidelines and precautions

for cancer survivorsDetermine the role of PT in cancer treatment Discuss opportunities for community

outreach and student involvement

Benefits of Exercise/ Physical Activity 1

Control Your Weight

Reduce Your Risk of Cardiovascular Disease

Reduce Your Risk of Type 2 Diabetes and Metaboloic Syndrome

Strengthen your Bones and Muscles

Improve your mental health and mood

Improve function and balance

Increase your chances of living longer

Physical Activity and Cancer Prevention

Center for Disease Control: Physical activity is connected to a lower risk of breast and colon cancer 1

National Cancer Institute: Physical activity is connected to a lower risk of breast, colon, possibly lung and endometrial cancers 2

American Cancer Society: Physical activity may reduce the risk of breast, colon, endometrial, and prostate cancer 3

Physical Activity and Cancer Prevention4,5

Global data indicates a 25% reduction in breast cancer risk in physically active women compared to those who are least active 4

It is estimated that 20-30% of cancers may be related to being overweight and/or lack of physical activity 5

Prolonged sitting (>4 hours per day) has been associated with increased risk of cancer even with regular exercise 4

We don’t always have control! 3

Odds of being diagnosed with cancer in lifetime: Males 1 in 2 Females 1 in 3

Odds of dying from cancer: Males 1 in 4 Females 1 in 5

What if you already have a Diagnosis?

It is estimated that women decrease their activity level by 2 hours per week after a diagnosis of breast cancer6

What actions can we take?

Up until the late 1980s, standard recommendation was to rest and avoid exercise 7

It’s time to change our way of thinking and get involved!

Systematic Review: Physical exercise in cancer patients during and after medical treatment 8

Exercise improved the following during breast, mixed solid tumor and blood cancer treatment :Improved QOL- mood, psychological well beingIncreased aerobic capacity (endurance, breathing)Increased muscle strength Symptom relief- fatigue, nausea, pain, difficulty

sleeping, diarrheaIncreased bone mineral density in patients with

breast cancer and solid tumorsImproved body composition in patients with

breast and blood cancer

Systematic Review: Physical exercise in cancer patients during and after medical treatment

Mixed Solid Tumor:Boosts natural-killer cell activity

High-Dose Chemotherapy following Bone Marrow and Bone Stem Cell Transplant: Days in the hospital Creatinine exertion (Kidney Function)Neutropenia (low white blood cell count) Hemoglobin (carry oxygen) Lymphocytes and cell counts improved

Systematic Review: Physical exercise in cancer patients during and after medical treatment 8

Breast Cancer and Mixed Solid Tumors:Aerobic capacityFatigue, anxiety, depressionSelf Reported Quality of Life, including mood

and self- esteem Increase in physical strength and walking

distance

Systematic Review: Physical exercise in cancer patients during and after medical treatment 8

Following Breast cancer treatment:Positive cardiopulmonary changesPositive changes in Insulin-like growth factors (IGF1)

and Binding Proteins (IGFBP-3and -1)- High levels of IGF1 and Low levels of IGFBP-3 are associated with cancer recurrence and an adverse prognosis

Following Mixed Solid Tumor Treatment Decrease in body fat Increased flexibility Improved body avoidance Increased “fighting spirit”

New Research: The Journal of National Cancer Institute- March 20159Hypoxic tumors can be relatively impervious

to treatment Exercise improves post-ischemia to normal

tissue…what about tumors?Study focused on:

Improving oxygen to tumors through aerobic exercise in mice Estrogen Receptor (+) and (-) tumor cells 4 groups: sedentary, exercise, sedentary + chemo,

exercise + chemo

New Research: The Journal of National Cancer Institute- March 2015Aerobic exercise slowed the growth of breast

cancer tumors AND made the cancer more sensitive to chemotherapy

Decrease Tumor Growth 1.4 fold increase in apoptosis

Physical Activity and Survival 10 Nearly 3,000 female nurses with Stage I, II, or III

breast cancer followed from 1984 to 2004 through questionnaires

Studied reoccurrence and mortalityPhysical activity was re-assessed every 2 years

through a questionnaire Recorded number of hours per week walking at

an average pace (2-2.9mph)

Physical Activity and Survival: Results

5 Year Survival Rates:1-5 hours a week = 97%<1 hour per week = 93%Absolute Risk Reduction: 4%

10 Year Survival Rates: 3-5 hours per week = 92%1-3 hours per week = 89%<1 hour per week = 86%Absolute Risk Reduction: 6%

Physical Activity and Survival: Results Beneficial to all women regardless of:

Stage of diseaseMenopause statusActivity level prior to diagnosisWeight

Physical Activity and Survival: Results

The reduction in risk of adverse outcomes including mortality and breast cancer recurrence was 26-40%

Women who engaged in physical activity equivalent to walking 1 or more hours per week had better survival compared to those who exercised less or not all.

Maximum Benefit walking 3-5 hours per week at an average pace (2-2.9mph)

Variations in physical activity dosage4,11,12,13,14

Physical activity and prognosis 12

75% of studies conducted in patients with breast, prostate, GI, ovarian, glioma, and non-small cell lung cancer found a significant inverse relationship between exercise and prognosis

Range of risk reduction for cancer specific or all cause mortality: 15- 67% and 18%- 67% respectively

What Should We Recommend?The extent of risk reduction is dependent on many variables 8, 12:

Type of cancerStage of disease Exercise prescription and type Study design Patient lifestyleGenetics?

American College of Sports Medicine (ACSM) Guidelines- Adopted by the American Cancer Society (ACS)

ACSM:Exercise Guidelines15,16

ACSM: Cancer Specific Considerations

ACSM: Precautions for Exercise

TABLE 3. Exercise prescription for cancer survivors.15

ACSM Guidelines: other considerations15

Cardiac conditions will require modifications and may require increased supervision

Allow adequate time to heal after surgeryAvoid exercise during periods of extreme

fatigue, anemia, dizziness, low platelet count, nausea, or ataxia

Physical Therapy Role

Supervised vs Home Based vs Usual care 7, 18 Exercise Prescriptions should be

individualized 15, 17

Most patients were interested in receiving physical activity information preferably by an exercise specialist. 15

Adherence: only about ½ of patients who were offered an exercise program actually undertook and completed it. 19

Physical therapy RoleAPTA Cancer EDGE Task Force

Outcome Measures: 6MWT, QOL, Balance, Strength

PT concerns:Lymphedema management Cardiovascular care Neuropathy/ neurological involvement Chemotherapy Toxicity General DebilityExercise progressionPelvic Floor

Community Involvement

Questions???

References1. Center For Disease Control and Prevention. Cancer Prevention and Control. http://www.cdc.gov. Accessed

January 22, 2015.2. National Cancer Institute at the National Institutes of Health. Cancer Statistics. http://www.cancer.gov.

Accessed January 20, 2015.3. American Cancer Society. Explore Research. http://www.cancer.org. Accessed January 20, 2015.4. Lemanne D, Cassileth B, Gubili J. The role of physical activity in cancer prevention, treatment, recovery,

and survivorship. Oncology. 2013;27(6):580-585.5. American Institute of Cancer Research. Reduce Your Cancer Risk. http://www.aicr.org. Assessed February

2, 2015.6. Irwin ML, Crumley D, McTiernan A, et al. Physical activity levels before and after a diagnosis of breast

carcinoma: the Health, Eating, Activity, and Lifestyle (HEAL) study. Cancer. 2003;97(7):1746-1757.7. Jones LW, Alfano CM. Exercise-Oncology research: past, present, future. Acta Oncol. 2013;52(2):195-215. 8. Knols R, Aaronson NK, Uebelhart D, et al. Physical exercise in cancer patients during and after medical

treatment: a systematic review of randomized and controlled clinical trials. J Clin Oncol. 2005;23(16):3830-3842.

9. Betof AS, Lascola CD, Weitzel D, et al. Modulation of Murine Breast Tumor Vascularity, Hypoxia and Chemotherapeutic Response by Exercise. J Natl Cancer Inst. 2015; 107 (5). doi: 10.1093/jnci/djv040

10. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA. 2005;293(20):2479-2486.

11. Irwin ML, Smith AW, McTiernan A, et al. Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J Clin Oncol. 2008;26(24):3958-3964.

12. Betof As, Dewhirst MW, Jones LW. Effects and potential mechanisms of exercise training on cancer progression: a translational perspective. Brain Behav Immun. 2013;30 Suppl:S75-87.

References 13. Meyerhardt JA, Giovannucci EL, Holmes MD, et al. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol. 2006;24(22):3527-3534.14. Meyerhardt JA, Heseltine D, Niedzwiecki D, et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol. 2006;24(22):3535-3541. 15. Buffart LM, Galvao DA, Brug J, Chinapaw MJ, Newton RU. Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions. Cancer Treat Rev. 2014;40(2):327-340.16. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-1426.17. Bourke L, Homer KE, Thaha MA, et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2013 Sep 24;9:CD010192. doi: 10.1002/14651858.CD010192.pub2.18. Broderick JM, Guinan E, Kennedy MJ. Feasibility and efficacy of a supervised exercise intervention in de-conditioned cancer survivors during the early survivorship phase: the PEACH trial. J Cancer Surviv. 2013;7(4):551-562. 19. Maddocks M1, Mockett S, Wilcock A. Is exercise an acceptable and practical therapy for people with or cured of cancer? A systematic review. Cancer Treat Rev. 2009;35(4):383-90.