Transcript Slide 1

The role of exercise during &
after treatment for colorectal
cancer
Outline of talk
• What is the rationale behind exercise
programmes after colorectal cancer diagnosis
• What is the evidence that exercise is beneficial
• What are the current guidelines with respect
to exercise prescription for this population
• What are the contra-indications?
• Are there any programmes currently out there?
Projections of Cancer Prevalence in the UK
2010
2020
2030
2040
Males
Colorectal
127 000 (415)
188 000 (572)
274 000 (783)
377 000 (1048)
Lung
39 000 (127)
40 000 (121)
41 000 (118)
42 000 (116)
Prostate
255 000 (835)
416 000 (1264)
620 000 (1771)
831 000 (2306)
Other
429 000 (1401)
579 000 (1759)
762 000 (2178)
966 000 (2684)
All
850 00 (2777)
1 223 000 (3717) 1 697 000 (4850) 2 216 000 (6153)
Colorectal
116 000 (368)
152 000 (451)
200 000 (561)
255 000 (697)
Lung
26 000 (81)
40 000 (120)
64 000 (179)
95 000 (261)
Breast
570 000 (1803)
840 000 (2500)
1 212 000 (3406) 1 683 000 (4598)
Other
517 000 (1635)
672 000 (1999)
866 000 (2434)
All
1 229 000 (3887) 1 705 000 (5071) 2 342 000 (6579) 3 125 000 (8538)
Females
Maddams et al BJC 2012
1 092 000 (2983)
The problem….
• 4 million people living cancer by 2030 (Macmillan)
• Chronic or late appearing side effects:
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Fatigue
Weight changes
Limited range of movement
Cardiotoxicity
Hernia
Anxiety
Depression
The problem…
• Commonest problems were:
– Crouching / kneeling
– Standing for 2 hours
– Walking ¼ mile
– Lifting / carrying a load (10lb)
– Standing up out of a chair
These are all basis
daily activities needed for
– housework
– shopping
– childcare etc.
Health behaviours in older cancer survivors
in the English Longitudinal Study of Ageing
Grimmet et al (2009) EJC
• Fewer cancer survivors reported being moderately
or vigorously active on more than one day per week
compared to those with no history of cancer (51%
versus 59%).
• The difference was significant after adjusting for
age and sex (p < .05) and remained after additional
adjustment for education and arthritis status (OR
0.82, CI 0.70–0.96, p < .05).
Cancer Rehabilitation: The key ‘drivers’
• Guidance on Cancer Services: Improving
Supportive and Palliative Care (NICE 2004)
• Cancer Reform Strategy (DH 2007)
• 2 million reasons (Macmillan 2008)
• National Cancer Survivorship Initiative
Vision Document (2010)
• Cancer Rehabilitation Pathways (NCAT 2010)
• Improving Outcomes: a strategy for
cancer (DH 2011)
NCSI Vision for future Survivorship Care
(Jan 2010)
• Assessment, information provision & care planning
• Support for self-management
• Tailored support for potential consequences of
treatment or further disease
• Measuring outcomes and experience
• This is a shift from a predominant focus on cancer as
an acute illness treated in the acute sector to a
greater focus on recovery, health, well- being and
return to work after cancer treatment. This shift will
enable people affected by cancer to be prepared for
the long term– for living with and beyond cancer
Rationale for exercise based
cancer rehabilitation:
• Reduces functional loss (CV and muscular)
• May reduce chronic and late appearing side effects
(e.g. fatigue, depression, weight gain, osteoporosis,
lymphoedema)
• Reduces long term reliance on NHS
• Reduces the risk of colorectal cancer recurrence and all
cause mortality
• No need to “reinvent the wheel” – use rehab
programmes with other chronic conditions – CHD,
diabetes, COPD as a template
Systematic review evidence:
PA during adjuvant treatment
Outcome
Evidence
Grade
Physical
Function
Significant increase in C/V fitness
similar modest increases in muscular
strength [ES 0.33) ; 17RCTs]
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Fatigue
No difference in fatigue between
exercise and control groups [ES 0.18;
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15RCTs ]
Well being
Small improvements in anxiety [ES 0.21;
6RCT] self esteem [ES 0.25; 3RCT] No effect
on QoL [10 RCT] or depression [6RCTs]
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Body
composition
Slight increase in lean body tissue,
significant reductions in body fat [ES 0.25;
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7RCTs]
Effect sizes: 0.2 = small; 0.5 = moderate; 0.8 = large
Outcome
Systematic review evidence:
PA after adjuvant treatment
Evidence
Grade
Physical
Function
Significant increase in C/V fitness [ES
0.32) ; 14RCTs] large increases in muscular
strength [ES 0.90) ; 7RCTs]
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Fatigue
Significant lowering of fatigue [ES 0.54;
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Well being
Significant improvements in QoL [ES 0.29;
16RCT] anxiety [ES 0.43; 7RCT] and
depression [ED 0.30; 10RCTs]
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Body
composition
Significant small reductions in body fat
[ES 0.18; 15RCTs] and increases in muscle
mass [ES 0.13; 5RCTs]
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Bone Health
Some encouraging findings on bone health density
were reported but overall results from 8 trial of
various designs were inconsistent
B
14RCTs ]
Other benefits of exercise...
Outcome
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Bone Health
Bone health
Range of Movement
Range of movement
Lymphoedema
Lymphoedema
PositivePositive
mood Mood
Insulin regulation
Chemo-brain
Cardiotoxicity
Cardiotoxicity
ImmuneImmune
systemsystem
/ inflammation
Grade
B
B
B
B
B
C
C
C
B
B
B
B
C
C
Cancer diagnosis can signal an enhanced
motivation to change lifestyle behaviours –
become more receptive to health
behaviour change interventions.
“What can I do to stop the cancer coming
back?”
play
active
living
dance
recreation
activities
exercise
sport
Guidelines
Cancer survivors with curative intent
should aim to do the standard
recommended amount of physical
activity required to get the health
benefits
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How often each week?
How long each time?
What type of exercise?
What intensity must it be?
All healthy adults
All healthy adults aged 18–65 years should
aim to take part in at least 150 minutes per
week of moderate-intensity aerobic activity, or
at least 75 minutes of vigorous-intensity
aerobic activity, or equivalent combinations of
moderate- and vigorous-intensity aerobic
activities.
All healthy adults should also perform musclestrengthening activities on two or more days of
the week.
Beginners
Beginners should steadily work towards meeting the
physical activity levels recommended for ‘all healthy
adults.’
Even small increases in activity will bring some health
benefits in the early stages and it is important to set
achievable goals that provide success, build
confidence and increase motivation.
For example, a beginner might be asked to walk an
extra 10 minutes every other day for several weeks in
order to slowly reach the recommended levels of
activity for all healthy adults. It is also critical that
beginners find activities they enjoy and gain support
in becoming more active from family and friends.
Conditioned individuals
Conditioned individuals who have met the
physical activity levels recommended for ‘all
healthy adults’ for at least six months may
obtain additional health benefits by engaging in
300 minutes or more per week of moderateintensity aerobic activity, or 150 minutes or
more per week of vigorous-intensity aerobic
activity, or equivalent combinations of
moderate- and vigorous-intensity aerobic
activities.
Putting evidence into practice
Putting evidence into practice...
Twelve year process
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2000: Pilot study with 23 women
2003: CRUK Glasgow Study - randomised control trial
2007: BMJ paper on Glasgow Study
2008: Masters in exercise and cancer survivorship
2009 Active ABC started in Glasgow
2010 Macmillan funded 5 year follow up
2010 NVQ qualification for fitness instructors approved
2011 Move More campaign and CANmove programme
2012 J Cancer Survivorship paper on 5 year follow up
Results of the Glasgow Study
• 1054 women were informed of study – main reason for not taking
part was travel (425 women)
• 203 women were recruited into study in one year (age 38-75)
• 177 women completed the study
• After 12 weeks: those in exercise programme improved significantly
more than the usual care group in:
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Walking faster and more weekly activities
Shoulder mobility
Breast cancer specific quality of life
Positive mood
• 6 months later, those in exercise group still benefited more in terms
of improved
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Overall quality of life,
Physical functioning,
Positive mood,
Less fatigue and depressed.
Health costs/benefits
of exercise intervention
 NHS costs for intervention was £400 per women
 Safe and effective intervention
 Provided short term and long term physical,
functional and psychological gain
 Participants spent less nights in hospital and
visits to GP – an economic saving to NHS of
£1507 per person
 Intervention achieved conventional standards
of cost-effectiveness
5 year follow up
• Of the 203 women in the original study, 114
attended the 18 months follow up and 87 at 5 years.
• Women in the original exercise group still reported
significantly more leisure time physical activity and
a more positive mood than women in the original
control group.
• Those engaging in sufficient physical activity
recorded a larger decrease in depression levels at
all follow-up points.
• Train fitness instructors to a level that ensures all
participants are provided with individualised, safe
standard and effective programmes
• Ensure classes are delivered in areas easily
accessible to cancer survivors from more deprived
communities
• Link with MDT in all participating hospitals to
ensure all eligible patients are aware of the
programme
• Produce appropriate screening materials to ensure
a safe and appropriate referral process
• Encourage participants to move to being
independent exercisers – other main stream and
long term condition programmes
CanRehab Level 4
training programme
• Supported by CRUK, Macmillan and
Breast Cancer Care
• 4 days lectures and workshops
• Written exam
• Practical exam
• Case study
• Glasgow, London, Birmingham, Wales,
Dundee and Manchester.
Referral Pathway
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Diagnosis
During treatment
After treatment
Follow up clinic
GOALS OF EXERCISE PROGRAMME
Improve functional status
prior to
treatment or
prevent/attenuate
functional decline during
treatment
•Maintain muscle mass (lean
body mass) and strength
Maintain / optimise
cardiorespiratory function
Maintain joint range of
motion/ muscle/connective
tissue length
Address treatment-specific
impairments during and
following treatment:
Optimize general health in
the Recovery period
following cancer treatment:
•Pain
•Fatigue/ anaemia
•Muscular weakness
(specific)
•Deficits in joint range of
motion
•Poor balance or coordination
•Lymphoedema/ oedema/
swelling
•Peripheral neuropathy
•Bone: oesteopenia,
osteoporosis
•Steroid-induced myopathy
•Improve body composition:
reduce fat mass, increase
lean body mass
•Improve muscular
endurance
•Improve muscular strength
•Improve cardiorespiratory
fitness
•Improve flexibility
Improve physical functioning
• During Cancer Treatment
• exercise to tolerance.
• depends on fitness and treatment toxicities.
• 3-5/wk, 20-30 minutes, RPE 11-14
• walking will most likely meet this prescription.
• progression is not always linear.
© CanRehab
Mode:
 Most exercises will involve large muscle groups e.g.
walking and cycling because they are safe and
tolerable for patients. Exercises will be modified
based on acute or chronic treatment effects from
surgery, chemotherapy, and/or radiotherapy.
Frequency:
 At least 3-5 times/wk, but daily exercise may be
preferable for deconditioned patients who do lighter
intensity and shorter duration exercises.
Intensity:
 Moderate, depending on current fitness level and
medical treatments. Guidelines recommend 50% to
75% HRreserve, 60% to 80% HRmax, or an RPE of 11 to
14
© CanRehab
Duration:
 At least 20-30 min of continuous exercise; however,
deconditioned patients or those experiencing severe
side effects of treatment may need to combine
short exercise bouts (eg, 3-5 min) with rest
intervals.
Progression:
 Patients should meet frequency and duration goals
before they increase exercise intensity. Progression
should be excluded those who are experiencing
severe side effects of treatment or slower and more
gradual for deconditioned patients.
Designing an exercise programme for the client
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Individualise the programme based on information gathered
from referral
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Consider needs, goals and exercise preferences of the survivor
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Identify any potential barriers to exercise including long-term
treatment and disease-related side effects that may
compromise ability to exercise
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Consider the principles of exercise prescription: overload,
adaptation, specificity and reversibility
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Set prescription variables for components of exercise
programme (e.g. frequency, intensity, type & time)
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Re-evaluate and modify programme to address changes in
medical status and physical fitness and functioning
Cancer-specific contraindications
for colorectal cancer patient
• Advisable to avoid intra-abdominal pressures for patients
with ostomy.
• Contact sports (risk of blow) and weight training (risk of
hernia) not recommended for patients with an ostomy
• Individuals with known metastatic disease to the bone will
require modifications to their exercise programme
concerning intensity, duration, and mode and increased
supervision to avoid fractures.
• Individuals with cardiac conditions (secondary to cancer or
not) will require modifications and may require increased
supervision for safe exercise
• Refer back if unusual fatigue, muscle weakness, head, neck
or back pain.
3 Levels of care and support
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Proposed referral
pathway for all
cancer patients to
access
rehabilitation
Pros
•Opt - out
•Not hospital based.
•Large volumes
patients can access
service.
•HCP input needed
if required.
•Reduces NHS
burden
•Normalises living
with cancer/LTC.
•Protects patient
data.
•Cost effective
•Offers an
evidenced based
service not
currently available
elsewhere
•Free
•Patients can access
PA services
•Promotes selfmanagement
HCP refers patient
using CANmove
guidelines.
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Patient
*contacted by
ISE
Aim to develop an opt-out
electronic system.
Aim to develop an
information sharing
agreement allowing fitness
instructors to be part of MDT
(NHS)
Aim to develop a risk
stratification process
Patient
*contacted by
CRT/SPCS
Patient CANmove
consultation *
Patient attends
CANmove
Programme*
Patient completes
CANmove programme
& referred on to local
community facilities
Contraindications
to exercise:
-re-refer *
Exe
consultation:
-Home P
-Walk P
-sign post to
other PA venue.
Cons ?
Future Plans...
Expand access to classes for all cancers, where possible in 2013,
focusing promotion on Prostate, Breast and Colorectal which have the
strongest evidence base relating to the positive effects of exercise
Expand the programme across Scotland
Develop a clearer referral pathway for NHS and relevant charities
Deliver more classes to ensure areas of deprivation have equal access.
Establish the exit strategy for participants to maintain an active
lifestyle.
Ultimate goal
Opt out - not opt in...
Let’s make an exercise based rehabilitation
programme a sustainable part of every cancer
survivors’ care pathway