Transcript Slide 1

Exercise
Exercise plays a
critical role in
recovery and
wellness during
and after cancer.
Benefits of Exercise
 Reduces your risk of heart disease, high blood
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pressure, osteoporosis, diabetes and obesity
Keeps joints, tendons and ligaments flexible
Reduces 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 Recurrence
 Decreased Fatigue / Anemia
 Decreased Severity of Nausea
 Maintenance of Bone Mineral Density
 Improved Body Composition
 Increased Quality of Life
 Reduction of Lymphedema
 Prevention of Lymphedema
Exercise
Reduces Risk of
Recurrence
Following
Breast Cancer
Subjects:
Physical Activity and Risk of
Breast Cancer Recurrence
Holmes, MD, 2004
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:
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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 Fatigue
 Anemia – 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
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Decreased Work Capacity
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Decreased Level of Activity Due to Fatigue
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More Fatigue
Effects of Physical Activity on the Fatigue and Psychological
Status of Cancer Patients during Chemotherapy
Subjects:
Dimeo FC et al, Amer Canc Soc, 1999
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:
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Significant increase in fatigue and somatic complaints in control
group, not seen in training group
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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 fatigue
 Several women had a chaotic pattern with erratic
swings in their fatigue throughout study period
 Women who adopted exercise had
 fewer 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 therapy
 Intervention: 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 women
 Decline 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 participated
 3 groups: aerobic exercise, supervised resistance
exercise and usual care
 Duration of chemo (mean - 17 weeks)
 No new cases of lymphedema or other adverse events
 Both 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 Group
 Increased cardiovascular fitness
 Decreased % body fat
Resistance Exercise Group
 Increased mm. strength
 Increased lean body mass
 Increased chemotherapy completion rate
The Effects of
Exercise on
Lymphedema
Weight Lifting in Women with Breast-CancerRelated Lymphedema.
Kathryn H. Schmitz, Ph.D., M.P.H, et al. NEnglJMed 2009.
 141 BC survivors with stable LE
 One year exercise program – supervised for the first 13
weeks
 Ex Program included stretching, CV warm-up, abs and
back ex + weight-lifting.
 Slow progression with no upper limit
 Custom-fitted Jobst sleeves were worn during exercise
sessions.
Weight Lifting in Women with Breast-CancerRelated Lymphedema.
Kathryn H. Schmitz, Ph.D., M.P.H, et al. NEnglJMed 2009.
Results: weight lifting group showed decrease severity of LE symptoms
 increased upper and lower body strength
 lower 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 lymphedema
 20 weeks of aerobic and resistance ex
 Added dragon boat training at week 8
 All 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 participants
 Intervention: 10 minutes of standardized arm exercises
and deep breathing
 Measures: limb volume and perception
 Results: 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 >26
 Studies 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 Cancer
Locomba, 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 surgery
3. 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
Design:
Courneya KS, Friedenreich CM, Annals Behav Med, 1999
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
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:
Increased/improved:
Decreased:
 Functional capacity
 Fatigue
 Muscle strength
 Nausea and diarrhea
 Flexibility
 Pain
 Hematological indices, natural
killer cell activity
 Self-esteem
 Mood
 Quality of Life
 Satisfaction with Life
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
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 QOL + affect,
 distress,
enhanced wellbeing, 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 mets
 Intervention: 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 sleep
 Conclusion: 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 chemo
 Exercise group used the “Armchair Fitness” video;
control did not exercise
 30 min., 3x/week, low to mod intensity
 No equipment, no resistance
 FACIT-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-being
 Less 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
The following benefits of exercise have been
documented repeatedly in the literature:
(e.g. Courneya, 1999; Dimeo, 1999)
Increased/improved:
Decreased:
 Functional capacity
 Risk of Recurrence
 Muscle strength
 Nausea and diarrhea
 Flexibility
 Pain
 Hematological indices,
natural killer cell activity
 Fatigue
 Self-esteem
 Mood
 Quality of Life
 Satisfaction with Life
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 counseling
 85% preferred face to face ex. counseling
 77% 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 activities
 81% preferred walking
 57% preferred unsupervised exercise
 56% 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 discussed
 28% - the oncologist initiated a discussion of exercise
 14% - the patient initiated a discussion
 82% 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 tx
 exercised more total minutes during treatment
Make sure your patients think
about exercise!