Exercise plays a critical role in recovery and wellness during and after cancer.

Exercise

Benefits of ExerciseReduces your risk of heart disease, high

blood pressure, osteoporosis, diabetes and obesity

Keeps joints, tendons and ligaments flexibleReduces some of the effects of aging Contributes to your mental well-being and

helps treat depression Helps relieve stress and anxiety Increases your energy and endurance Helps you sleep better Helps you maintain a normal weight by

increasing your metabolism

Benefits of Exercise Specific to Breast Cancer

Decreased Risk of RecurrenceDecreased Fatigue / Anemia Decreased Severity of NauseaMaintenance of Bone Mineral DensityImproved Body Composition Increased Quality of LifeReduction of LymphedemaPrevention of Lymphedema

Exercise Reduces Risk of

Recurrence Following

Breast Cancer

Physical Activity and Risk of Breast Cancer Recurrence

Holmes, MD, 2004Subjects:

2,167 women with stages I-III breast cancer (part of the nurses health study)

Design and Variables:

RETROSPECTIVE REVIEW

Activity level in hours per week; number of cases of BC recurrence

Conclusions:

• Moderate physical activity (1-3 hours/wk, at 3 miles/hour) decreased risk by 25%

• Increase in activity (3-8 hours/wk) decreased risk by 50%

How much exercise do women need to do to obtain the benefits of reducing the risk of breast cancer?

Walking and bicycling for 20-30 minutes 3-5 days per week has been shown to be effective!

Exercise Reduces Fatigue

in Patients with Cancer

Cancer Related Fatigue

One of most debilitating and common side effects associated with cancer and its treatment

Fatigue contributes to reduced quality of life

What causes fatigue during cancer treatment?

Etiology of Treatment-Related FatigueAnemia – chemo and radiation suppress RBC production;

cancer, itself, can change production of RBC by bone marrow

Fibrosis - (as a result of radiation therapy) can cause decreased lung function

Cycle - Cardio-respiratory and muscle deconditioning

Decreased Work Capacity

Decreased Level of Activity Due to Fatigue

More Fatigue

Effects of Physical Activity on the Fatigue and Psychological

Status of Cancer Patients during Chemotherapy Dimeo FC et al, Amer Canc Soc, 1999

Subjects:

63 Cancer patients; 25 Breast CA; 6 Metastatic Breast CA; others were lung sarcomas, Hodgkin disease, non-Hodgkin lymphoma

All were receiving high dose chemotherapy with autologous stem cell transplant as inpatients

Design and Variables:

RCT

Control and Training group

Training group rec’d daily bed ergometer exercise 30 min/day to at least 50% of cardiac reserve

Measured Profile of Mood Status (POMS) and Symptom Check List

(SCL-90-R)

Effects of Physical Activity on the Fatigue and Psychologic

Status of Cancer Patients during Chemotherapy Dimeo FC et al, Amer Canc Soc, 1999

Critical Appraisal:

Pseudo – randomization, number of days admission unclear

Heterogenous group – increases generalizability

Conclusions:

• Significant increase in fatigue and somatic complaints in control group, not seen in training group

• Significant reduction in psychological distress in exercise group

Daily fatigue patterns and effect of exercise in women with breast cancer

Schwartz AL. Cancer Pract, 2000

Several distinct patterns of fatigue:Most common pattern of fatigue - after

chemo had a sharp rise in fatigueSeveral women had a chaotic pattern with

erratic swings in their fatigue throughout study period

Women who adopted exercise hadfewer days of high fatigue levels and lower levels of fatigue for both average &

worst levels of fatigue.

RCT on the effects of aerobic exercise on erythrocyte levels during RT for BC.

Drouin JS, Young TJ, Beeler J. CANCER. 2006.Subjects: 20 sedentary breast cancer

patients undergoing radiation therapyIntervention: Brisk walking, 20-45 min., 3-5x

per week vs. placebo tx (stretching)Results: Increased oxygen capacity;

maintenance of RBC counts throughout radiation treatments.

Exercise Reduces Nausea During Breast Cancer

Treatment

Exercise during adjuvant chemotherapy cancer treatment decreases nausea.

Lee J and Dodd M. Oncology Nursing Forum. 2007.

Subjects: 112 breast cancer patients, Stages I-III, receiving chemo (98 AC)

Intervention: Moderate to somewhat hard intensity aerobic ex, at least 20 min, at least 3x/week

Results: Decreased nausea severity following final cycle of chemo vs. control group

Exercise Minimizes Bone Loss

Exercise effects on bone mineral density in women with BC receiving chemotherapy.

Schwartz AL. Oncology Nursing Forum. 2007.

Subjects: Stages I-III, during chemo, over 12 week period

Intervention: Aerobic Ex, Resistance Ex and Usual Care Groups

Aerobic Ex: self-selected walking or jogging, 15-30 minutes, 4 days per week

Resistance Ex: 8 exercises with theraband, 2 sets of 10, 4 days per week

Exercise effects on bone mineral density in women with BC receiving chemotherapy.

Schwartz AL. Oncology Nursing Forum. 2007.Results: Premenopausal women had greater

bone loss than post menopausal womenDecline in BMD was least in aerobic ex group

(-0.8%), next in resistance (-4.9%) and greatest in usual care (-6.23%)

Note: aerobic exercise was weight bearing exercise

Exercise and weight gain in breast cancer patients receiving chemotherapy

Schwartz AL, Cancer Practice, 2000

78 women; Home-based exercise during 1st 4 cycles of adjuvant chemo

Women who adhered to exercise program maintained their body wt,

Nonexercisers steadily gained wt (P < .05).

no significant differences in incidence or intensity of nausea or anorexia exercisers vs. nonexercisers.

Women who exercised over 4 cycles chemo improved their fx. ability (mean 23%) vs. nonexercisers significant declines in fx. ability (mean -15%).

Suggests additional possible benefits of exposing breast cancer pts to increased exercise:

may affect QOL effect on QOL may be mediated by effects of

exercise on fatigue. Better retention of functional ability and Better weight control

Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy.

Courneya KS, Segal RJ. J Clin Onc. 2007

242 patients participated3 groups: aerobic exercise, supervised

resistance exercise and usual careDuration of chemo (mean - 17 weeks)No new cases of lymphedema or other

adverse eventsBoth exercise groups increased self-esteem

Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy.

Courneya KS, Segal RJ. J Clin Onc. 2007

Aerobic Exercise GroupIncreased cardiovascular fitnessDecreased % body fatResistance Exercise GroupIncreased mm. strengthIncreased lean body massIncreased chemotherapy completion rate

The Effects of Exercise on

Lymphedema

Weight Lifting in Women with Breast-Cancer-Related Lymphedema.

Kathryn H. Schmitz, Ph.D., M.P.H, et al. NEnglJMed 2009.141 BC survivors with stable LEOne year exercise program – supervised for

the first 13 weeksEx Program included stretching, CV warm-

up, abs and back ex + weight-lifting.Slow progression with no upper limitCustom-fitted Jobst sleeves were worn during

exercise sessions.

Weight Lifting in Women with Breast-Cancer-Related Lymphedema.

Kathryn H. Schmitz, Ph.D., M.P.H, et al. NEnglJMed 2009.

Results: weight lifting group showed-decrease severity of LE symptomsincreased upper and lower body strengthlower incidence of LE exacerbations

Conclusion: Slowly progressed wt lifting program had no effect on limb swelling and resulted in decreased LE symptoms and exacerbations.

The effect of a whole body ex program and dragon boat training on arm volume in women treated for breast

cancer.Lane K, Jesperson D. Eur J Cancer Care. 2005.

16 bc survivors without lymphedema20 weeks of aerobic and resistance exAdded dragon boat training at week 8All women increased in mm. strength, no new

cases of lymphedema

The effect of gentle arm exercise and deep breathing on secondary arm lymphedema.

Moseley AL, Piller NB. Lymphology. 2005.

Subjects: 38 women participantsIntervention: 10 minutes of standardized arm

exercises and deep breathingMeasures: limb volume and perceptionResults: decreased volume after ex.,

reductions persisted at 1 hour, 24 hours and 1 week follow-ups

10 mins. am and pm led to volume decreases persisting for 1 month.

RCT comparing low-fat diet with a weight reduction diet in breast cancer-related lymphedema.

Shaw C, Mortimer P, Judd P. Cancer. 2007.

64 women with BCRL and with BMI >26Studies on diet alone (no exercise)Result: findings demonstrated that weight

loss reduced lymphedema volumes regardless of the method used to achieve wt loss.

Effectiveness of early physiotherapy to prevent lymphoedema after surgery

for breast cancer: randomized, single blinded, clinical trial.

Locomba, MT et al. , British Medical Journal, February, 2010

Background:

Purpose was to determine the effectiveness of early physical therapy intervention in reducing the risk of post-op lymphedema in women with unilateral mastectomy or lumpectomy and axillary node dissection.

The findings are important because this is the first prospective study to examine an intervention to decrease women’s risk of, or prevent, lymphedema.

Locomba, MT et al. , British Medical Journal, February, 2010

Early Physical Therapy Decreases Risk of Lymphedema in Women with Breast CancerLocomba, MT et al. , British Medical Journal, February, 2010

Results: 1. At 12 month follow -up the incidence of lymphedema was significantly lower in the physical therapy group at 7% (4 women) compared to 25% in the control group (14 women)2. Women in the control group developed lymphedema more quickly after surgery3. The study is the first demonstrate the relationship between axillary cording and subsequent development of lymphedema.

Exercise Improves

Quality of Life in Women

following Breast Cancer

Physical Exercise and Quality of Life Following Cancer

Diagnosis: A Literature Review Courneya KS, Friedenreich CM, Annals Behav Med, 1999Design:

SYSTEMATIC REVIEW

Literature Search and Critical Review of studies that met criteria of involving designs with exercise to increase cardiovascular and/or

muscular fitness in patients with cancer

24 studies found that met criteria

14/24 studies involved Stage I and II Breast Cancer patients; 7 studies carried out during adjuvant treatment; 11 studies post-treatment

Exercise:

Bicycle (n=8), Walking (n=6), mainly supervised, some home

3-5 days/wk, 20-60 minutes at 60-90% max HR

Measures:

Functional Capacity, walk tests, strength, flexibility, QOL, FACT-B…

Physical Exercise and Quality of Life Following Cancer

Diagnosis: A Literature Review Courneya KS, Friedenreich CM, Annals Behav Med, 1999

Increased/improved:

Functional capacity

Muscle strength

Flexibility

Hematological indices, natural killer cell activity

Self-esteem

Mood

Quality of Life

Satisfaction with Life

Decreased:

Fatigue

Nausea and diarrhea

Pain

RESULTS:

89% of intervention studies had statistically significant positive results of exercise in patients with cancer. The following benefits of exercise have been documented repeatedly in the literature:

A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and

health benefits Kolden GG et al., Psychooncology, 2002

Demonstrated GET-- feasible, safe, and well-tolerated.

Participants experienced significant health benefits over course of intervention in multiple dimensions Fitness/vigor

aerobic capacity, strength, and flexibility.

• QOL QOL + affect, distress, enhanced well-

being, and improved

function.

Exercise and

Metastatic Cancer

Aerobic exercise for a patient suffering from metastatic bone disease.

Crevenna R, Shmidinger M. Support Cancer Care. 2003.

Case report (n=1), 48 y.o.Metastatic breast cancer with lung, liver and

extensive skeletal metsIntervention: stationary bike at 60% max HR,

3x/week, 30-50 min/session, 1 year. Patient exercised as part of an outpatient exercise group for cancer patients.

Aerobic exercise for a patient suffering from metastatic bone disease.

Crevenna R, Shmidinger M. Support Cancer Care. 2003.

Results: vo2 max, work capacity, quality

of life, fatigue, improved sleepConclusion: stationary bicycling at low to

moderate intensity was safe and practical for patient with advanced breast cancer. Similar benefits to patients in Stages I-III.

The effect of seated exercise on fatigue and QoL in women with advanced breast cancer.

Headley JA, Ownby KK, John LD. Onc Nurs Forum. 2004.

RCT (n=32); Stage IV pts during chemoExercise group used the “Armchair Fitness”

video; control did not exercise30 min., 3x/week, low to mod intensityNo equipment, no resistanceFACIT-F: functional assessment of chronic

illness therapy – fatigue version

The effect of seated exercise on fatigue and QoL in women with advanced breast cancer.

Headley JA, Ownby KK, John LD. Onc Nurs Forum. 2004.

Women in the exercise group showed:Slower decline in total well-being Slower decline in physical well-beingLess increase in fatigue

Many participants reported that the exercises were not challenging enough or were not motivating.

Precautions and Contraindications for Patients During Chemotherapy

Monitoring physiologic responses (e.g., vital signs) to exercise important in immunosuppressed population.

Watch closely for early signs cardiopulmonary complications of cancer Rx. during exercise (such as dyspnea, pallor, sweating, and fatigue).

Current guidelines recommend pts. should be advised not to exercise within 2 hrs of chemo or radiation

Increased/improved:

Functional capacity

Muscle strength

Flexibility

Hematological indices, natural killer cell activity

Self-esteem

Mood

Quality of Life

Satisfaction with Life

Decreased:

Risk of Recurrence

Nausea and diarrhea

Pain

Fatigue

The following benefits of exercise have been documented repeatedly in the literature:

(e.g. Courneya, 1999; Dimeo, 1999)

Reducing Risk of Breast Cancer with

Exercise

A Prospective Study of Recreational Physical Activity and Breast Cancer Risk Rockhill B et al, Arch Int Med, 1999

Subjects:

121,701 female RN’s 30-55 years of age; 1976 – 1996 (again part of the Nurses’ Health Study)

Design and Variables:

PROSPECTIVE COHORT

Activity level in hours per week; number of cases of BC

Controlled for age, menstrual regularity and age at menarche.

Conclusions:

• Moderate physical activity reduces risk of developing breast cancer.

• Physical activity may affect risks differently in pre and post menopausal women – less or nil in younger women.

Summary of the Evidence to Support Exercise in Breast Cancer:

There is support in the literature for exercise intervention related to reducing breast cancer risk as

well as supporting wellness during and following breast cancer treatment.

Five Stages of Change In Adding Exercise To Your Life.

Where is your patient now?

Exercise counseling and programming preferences of cancer survivors.Jones LW, Courneya KS. Cancer Practice. 2002.

Survey of 307 survivors of breast, prostate, colorectal or lung cancer

RESULTS:For exercise counseling85% preferred face to face ex. counseling77% preferred ex. counseling from a

professional specializing in cancer care

Exercise counseling and programming preferences of cancer survivors.Jones LW, Courneya KS. Cancer Practice. 2002.

For exercise programming:98% preferred recreational activities81% preferred walking57% preferred unsupervised exercise56% preferred moderate intensity

Exercise counseling and programming preferences of cancer survivors.Jones LW, Courneya KS. Cancer Practice. 2002.

CLINICAL IMPLICATIONS: A key to success for inactive cancer survivors

may be reassurance that exercise is a safe, beneficial modality.

A key to success for active cancer survivors is reassurance that moderate intensity walking yields results!

Exercise discussions during cancer treatment consultations.

Jones LW, Courneya KS. Cancer Practice. 2002.

Survey of 311 cancer survivors.RESULTS:58% - exercise was not discussed28% - the oncologist initiated a discussion of

exercise14% - the patient initiated a discussion82% preferred that the oncologist initiate the

discussion of exercise

Exercise discussions during cancer treatment consultations.

Jones LW, Courneya KS. Cancer Practice. 2002.

Survivors whose oncologist initiated discussion @ exercise:

held stronger beliefs about the benefits of exercise

exercised more frequently during txexercised more total minutes during

treatment

Make sure your patients think about exercise!