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Exercise in Cancer: Progressing Towards Integration

by Daniel Santa Mina, PhD; Andrew G. Matthew, PhD

Read the original paper in Current Oncology here.

Any comprehensive (and arguably introductive) discussion of strategies to optimize cancer survivorship considers the role of exercise.  Following a diagnosis, exercise has been shown to improve pre-, peri, and post-treatment physical and psychosocial outcomes in many cancers and their related treatments.  The breadth of the existent evidence that describes these benefits continues to grow at an unmatched rate in the field of complimentary therapies in oncology.  As such, reviews of the literature have been published multiple times per year over the past few years.  Certainly, one would assume that with this rapidly expanding volume of evidence, a movement towards clinical integration of exercise in oncology would follow in haste.  Unfortunately, this has not been the case as community-based or clinically-integrated cancer exercise programs remain the exception rather than the norm, even amongst larger tertiary care institutions.  However, there are signs that we are on the cusp of a new era in survivorship where exercise is considered an essential adjunct therapy and is recommended to a majority of patients with some facilitation of a safe and effective exercise prescription.

This evolution in cancer care is evident in the variety of emerging publications. First, indications of the maturity of the field are represented by the number of studies reporting on long-term outcomes of exercise interventions.  Earlier work in the field was limited to post-intervention follow-ups of 6 months, whereas now, we are beginning to see benefits that are sustained for up to 2 years(1, 2).  Second, there is a growing body of research that assesses the exercise preferences for specific cancer survivors.  This literature expands on the established efficacy of exercise and pursues the programmatic and individual nuances that facilitate initial participation and long-term adherence. Third, investigations into the role of exercise now include a more liberal definition of ‘exercise’, with a significant amount of research conducted on specific modalities (e.g. aerobic versus resistance training) and intensities (vigorous versus mild).  Furthermore, alternative exercise approaches, such as t’ai chi and yoga have also gained a strong reputation for their cancer-specific benefit.  Dr. Culos-Reed and colleagues reviewed 25 studies examining the role of yoga for cancer survivors and found numerous clinically relevant benefits(3).  Fourth, the development of clinical practice guidelines for exercise in oncology (most notably those of the American College of Sports Medicine to “avoid inactivity” and to try to acquire a minimum of 150 minutes of moderate to vigorous physical activity plus 2-3 sessions per week of strength training(4)) is becoming more refined with specific recommendations for different cancer types and treatments(5).  These exercise recommendations incorporate adaptations and additions to the general exercise prescription to address the disease-specific sequelae.  Fifth, individualized exercise prescriptions for cancer survivors are supported by evidence-based risk assessment tools to ensure that exercise testing and training can be conducted safely.  Burr, Jones, and Shephard (2012) have developed a clinical decision tree to assess the risk of a serious adverse event related to exercise among cancer patients as a guide for clinicians to use when recommending exercise with consideration for the type of supervision needed (6). Sixth, cancer-exercise program evaluation reports are more apparent in the literature suggesting that the availability of these services is expanding. These cancer-exercise programs appear in a variety of settings, including cancer care centres (7, 8), community-based organizations (9, 10), and universities(11).  This literature is likely the most direct reflection of knowledge translation in this field and representative of the more widespread clinical integration.  Seventh, studies are now starting to incorporate the economic feasibility of their interventions with formal cost-benefit analyses (12). These are likely the missing piece of the literature that will ultimately lead to systemic resource allocation to exercise-based cancer rehabilitation programs, especially in a publicly funded healthcare setting.  This is generally considered the catalyst for eventual incorporation of exercise into standard post-cardiac intervention care (13).  Finally, clinicians and researchers are more frequently disseminating  call to action papers, calling upon their colleagues within oncology and sub-disciplines to respond to the overwhelming and compelling empirical literature with integrated exercise programming for their patients (e.g. (8, 14-16)).  These professional pleas for cancer-exercise programs reflect the urgency for which these services are needed and appreciated by patients and their clinicians.

In practice, cancer-exercise services likely fall under the mandate of ‘survivorship’ or ‘rehabilitative’ programming.  In this respect, exercise is among a variety of complimentary therapies aimed at reducing the cancer burden post-diagnosis.  Such services include lymphedema management, sexual function rehabilitation, and general psychosocial support and counselling.  Interestingly, exercise may be considered a core component to each of these distinct programs which is another indicator of expanding clinical integration.

There are areas that remain to be addressed which will ultimately support cancer-exercise programming.  At present, we do not know how to effectively maintain the magnitude of benefit over time, largely because exercise behaviour tends to decline following the formal intervention phase.  To this end, more research is needed that examines methods of boosting exercise adherence during and, more importantly, after the intervention.  Strategies to optimize long-term exercise maintenance may include electronic health coaches or some type of immediate, professional feedback to assist with barriers to exercise as they arise.  Similarly, more research is needed to establish what program delivery models (e.g. home-, hospital-, or community-based) are most beneficial, economically efficient, and provide enduring health behaviour changes.

The advancement of exercise as a clinical modality in oncology is apparent and trends in the literature suggest that implementation is becoming more universal.  Although much more research is needed to clarify and exploit the positive determinants of exercise in cancer survivors, many have suggested that the literature is sufficient to justify the inclusion of exercise in management of most cancers.  The path towards clinical integration has been forged by our colleagues in cardiology that utilize exercise as the foundation for rehabilitative success. Clinicians and researchers in oncology are several years behind but have made great strides towards the ultimate goal exercise as a standard of care for all cancer survivors.

Exercise and Physical Activity as Treatment for Cancer Related Fatigue

Exercise During and After Cancer Treatments

 

 


 

References

 1.            Ottenbacher AJ, Day RS, Taylor WC, Sharma SV, Sloane R, Snyder DC, et al. Long-term physical activity outcomes of home-based lifestyle interventions among breast and prostate cancer survivors. Support Care Cancer. 2012.

2.            Haas BK, Kimmel G, Hermanns M, Deal B. Community-Based FitSTEPS for Life Exercise Program for Persons With Cancer: 5-Year Evaluation. Journal of Oncology Practice. 2012.

3.            Culos-Reed SN, Mackenzie MJ, Sohl SJ, Jesse MT, Zahavich ANR, Danhauer SC. Yoga & Cancer Interventions: A Review of the Clinical Significance of Patient Reported Outcomes for Cancer Survivors. Evidence-Based Complementary and Alternative Medicine. 2012;2012:17.

4.            Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-26. Epub 2010/06/19.

5.            Irwin M, editor. ACSM’s Guide to Exercise and Cancer Survivorship. Champaign, IL: Human Kinetics; 2012.

6.            Burr JF, Jones L, Shephard RJ. Physical activity for cancer patients. Can Fam Physician. 2012;58(9):970-3.

7.            Segal R, Evans W, Johnson D, Smith J, Colletta SP, Corsini L, et al. Oncology Rehabilitation Program at the Ottawa Regional Cancer Centre: program description. CMAJ. 1999;161(3):282-5.

8.            Santa Mina D, Matthew AG, Alibhai SMH, Steele J, Trachtenberg J, Guglietti CL, et al. Exercise in the Clinical Care for Cancer: A Call to Action and Program Development Description. Current Oncology. 2012;19(3):e136-44.

9.            Rajotte E, Yi J, Baker K, Gregerson L, Leiserowitz A, Syrjala K. Community-based exercise program effectiveness and safety for cancer survivors. Journal of Cancer Survivorship. 2012;6(2):219-28.

10.          Haas BK, Kimmel G. Model for a Community-Based Exercise Program for Cancer Survivors: Taking Patient Care to the Next Level. Journal of Oncology Practice. 2011;7(4):252-6.

11.          Noble M, Russell C, Kraemer L, Sharratt M. UW WELL-FIT: the impact of supervised exercise programs on physical capacity and quality of life in individuals receiving treatment for cancer. Support Care Cancer. 2012;20(4):865-73. Epub 2011/05/13.

12.          Courneya KS, Booth CM, Gill S, O’Brien P, Vardy J, Friedenreich CM, et al. The Colon Health and Life-Long Exercise Change trial: a randomized trial of the National Cancer Institute of Canada Clinical Trials Group. Curr Oncol. 2008;15(6):271-8. Epub 2008/12/17.

13.          Certo CM. History of Cardiac Rehabilitation. Physical Therapy. 1985;65(12):1793-5.

14.          Schmitz KH, Stout NL, Andrews K, Binkley JM, Smith RA. Prospective evaluation of physical rehabilitation needs in breast cancer survivors. Cancer. 2012;118(S8):2187-90.

15.          Valdivieso M, Kujawa AM, Jones T, Baker LH. Cancer survivors in the United States: a review of the literature and a call to action. International journal of medical sciences. 2012;9(2):163-73.

16.          Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the Crest of the Teachable Moment: Promoting Long-Term Health After the Diagnosis of Cancer. J Clin Oncol. 2005;23(24):5814-30.

 

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2 Responses to Exercise in Cancer: Progressing Towards Integration

  1. Thank you for highlighting the importance of exercise in not only preventing, but in treating and moving beyond a cancer diagnosis. Exercise should be a standard part of all treatment protocols!

  2. Pingback: Exercise During and After Cancer Treatments | Cancer Knowledge Network

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