What is Exercise Oncology?

Cancer-related fatigue (CRF) is one of the most common and most persistent side effects of cancer and is experienced by up to 80-90% of survivors.⁵

• Physical activity is consistently demonstrated to improve overall quality of life in patients with CRF.^1,19,23-29
• There is an 80% improvement of CRF when surrounding a person with support groups versus 14% with education only. Exercise is also the #1 combatting force according to a video (see below) by Dr Mike Evans.⁹⁰
• Exercise and psychotherapy are significantly more effective than pharmaceutical intervention such as stimulants, anti-depressants, and steroids.^23,96
• Yoga may not be as effective during chemotherapy treatments, but is extremely beneficial in patients who have already gone through treatment.¹⁹
• Qigong and meditation have demonstrated decreased fatigue and improved outlook of cancer survivors.^20-22
• Other modifiable risk factors such as nutrition, alcohol use and managing emotional stress may also impact CRF.^1,3,24

The nervous system is extremely sensitive to drugs, disease, and inactivity. Cancer-induced peripheral neuropathy (CIPN) presents as starting in the hands and feet on both sides and progressing upward.⁹⁷ Problems can occur when the altered sensation causes difficulty walking or holding objects, especially things like a hot saucepan.^5,34

• As of today, there is no medication or supplement available to prevent or treat CIPN. Aerobic exercise, reducing alcohol intake, and treating pre-existing conditions have been proven to alleviate the pain and altered sensation associated with CIPN.^{23,26,34,35,97}
• A program consisting of both yoga and meditation has demonstrated excellent results regarding decreasing pain, improving function and transferring skills to daily activities.³⁶

Cancer-related cognitive impairment (CRCI) is noted in up to 80% of cancer patients.³⁰ There is promising research that exercise may be a treatment for CRCI if executed appropriately.^5,31,32 

• Moderate-to-vigorous physical activity is superior to light-intensity physical activity in breast cancer patients regarding cognitive function and sleep.³³ 
• Eastern based complementary therapies also have demonstrated benefits at improving mental clarity in cancer patients.^20-23,26

Although secondary lymphedema is most commonly seen and researched in breast cancer patients, it can present with anyone who has had a lymphadenectomy. The lower extremities may be affected in patients with cervical cancer, colorectal cancer, and even a patient with prostate cancer. Lymphedema may also present in various head and neck cancers. 

• Research as shown that resistance exercise is safe and effective for patients with secondary lymphedema, both during and after treatment.³⁷
• Excellent results are also noted with what is referred to as complete decongestive therapy, which is administered by a trained healthcare practitioner and consists of 4 different parts: manual lymphatic drainage, deep breathing, specific exercises to stimulate the lymph nodes, and compression.^23,27

Axillary web syndrome (AWS) can affect up to ~85% of breast cancer patients status post a lymphadenectomy. It is characterized by soft-tissue cords in the affected side that lies in the subcutaneous tissue. It occurs most often a few months after surgery, but can be present even a few years after surgery. Physical therapy is extremely effective as treatment.^5,38

As the risk of cancer related mortality is decreasing, the risk of cancer related heart failure is rising. It is now the leading cause of mortality in this population. Emerging evidence suggests that exercise is a safe and provides significant improvements in VO_2max.³⁹

Emotional distress is one of the most common side effects of cancer, if not one of the leading with cancer-related fatigue.¹ Managing depression, anxiety and fear of recurrence early can significantly improve quality of life.^{1,27,28,42,56} In reality, the risk of suicide increases with a diagnosis of cancer.⁵⁶ Integrating lifestyle choices consistent with dimensions of wellness can play a key role in cancer survivors quality of life and risk of cancer recurrence.

Cancer related pain^{1,21,23,27,28,40,41} is very common which can be alleviated with physical activity. It’s been shown that higher levels of activity are directly correlated with decreased pain levels.⁴⁰

Excessive body weight is attributed to a combination of physical inactivity and poor dietary habits. Increased stress negatively affects our immune system. Our cells require a nutritional balance with appropriate levels of energy to function properly. Sometimes cellular mutations may be beneficial, others neutral. However, when added stress such as chronic inflammation, excessive body weight, diabetes and heart disease occur, then genetic mutations may occur and turn into cancer cells.

• In 2017, it was estimated that 35% of Americans are overweight, and another 31% are obese. Of this, Louisiana is ranked 3rd within the US.⁸⁹ 16% of cancer related case are attributed to body weight alone,^59,89 which is disturbing considering the rise of childhood obesity rates.
• The American Institute for Cancer Research and World Cancer Research Fund have collaborated and created what they call the Continuous Update Project.⁶⁰ The experts have found that between 30-50% of all new cancer cases are preventable through healthy lifestyle choices and avoiding environmental pollutions (including excessive sun exposure), certain long-term infections and exposure to occupational carcinogens.
• There is strong evidence to support that increased body weight can contribute to 12 cancers: esophagus, pancreas, liver, colorectal, breast, endometrial, kidney, mouth/pharynx/larynx, stomach, gallbladder, ovary and prostate cancers.⁶⁰
• There is also strong evidence that maintaining a healthy weight will decrease the risk of breast cancer, both post-menopausal and pre-menopausal.⁶⁰

Besides improving fitness and quality of life, the American Institute for Cancer Research reports that side effects such as nausea, fatigue, depression, anxiety and length of hospitalization stay can be decreased. Exercise can also reverse the negative impact cancer medications can have vital signs, such as heart rate and blood pressure.⁵⁸

• Chemotherapy tends to induce fast twitch muscle fiber loss affecting the overall ability to generate power.^45,46 By emphasizing higher loads during exercise training throughout the course of chemotherapy treatment can counteract this shift from fast twitch to slow twitch fibers. When thinking about age related changes and the aging population as a whole, this can significantly improve balance and decrease fall risks.
• Exercise also affects the tumor microenvironment and prevents harmful cellular adaptation. By increasing tissue perfusion, medication can be more effectively transported into the tumor cells, thereby improving the efficacy of the medication.^8,9,45-47
• It is becoming evident that moderate-to-vigorous physical activity levels^25,33,43,44 are superior to lower intensity activity levels and should be encouraged in cancer survivors. It is demonstrated to be safe and effective for patients at all stages of disease and during treatment.
• 16 weeks of a high-intensity interval training program during chemotherapy is beginning to show both short term and long term (up to 2 years) beneficial outcomes in breast cancer patients regarding quality of life, CRF, muscle strength, body mass and less time away from work. Developing a high-intensity interval training session can shorten exercise duration and improve compliance as cancer patients tend to have more appointments, obligations and side effects of treatment.^25,43,44 
• The problem lies in that cancer patients are the least likely to stay compliant with a high-intensity training program over other forms of exercise.⁴⁸ This is dependent on where they are at in their treatment regimen.¹⁵ That being said, some patients are unable to tolerate high-intensity interval training, so any level of physical activity is superior to no exercise at all.
• Emerging evidence is demonstrating that riding a bike for 20 minutes during chemotherapy infusion treatments is safe, and possibly enhances drug perfusion and reduces boredom.⁴⁹
• A pre-operative exercise regimen is effective at reducing risks, hospital length of stay and recovery rate if a patient is undergoing a lung resection due to cancer. It is controversial whether the risk of pneumonia is reduced, however functional capacity is improved which may lessen the severity of the symptoms.^50,51 Pre-operative exercises have also been shown to decrease the tumor size during adjuvant chemoradiation to localized areas in patients with rectal cancer.⁷
• In patients receiving any sort of treatment to the thoracic wall, such as radiation, a decrease in chest wall mobility is noted. This is directly related to a decrease in functional oxygen capacity which can be counterbalanced by exercise.⁵²

Mind-body therapies (MBT) include activities such as yoga, tai chi, qigong, hypnosis, acupuncture and meditation.

• Qigong has demonstrated to be highly effective at improving quality of life, CRF, CRCI, immune function and cortisol levels. Heart rate variability has also been reduced in subjects practicing qigong.^20-22,27
• There is quality evidence to support the use of yoga in breast cancer survivors after treatment regarding decreased fatigue levels.¹⁹ Performing yoga during or after treatment can reduce the effects of CIPN, decrease fall risk, and improve quality of life.^26,36,40
• Yoga, meditation, music therapy and relaxation have been shown to be effective at reducing anxiety management and mood disorders.^22,23,40
• Acupuncture has been demonstrated to be effective at reducing chemotherapy-induced nausea and      vomiting.^8,22,23

Poor diet has been directly linked with certain cancers.^55,59,60 Only 33% of adults get the recommended 2+ servings of fruit a day and 16% of adults eat the recommended vegetable servings of 3+ helpings per day.^89,93 Clinicians and patients need to be aware of associated risks, especially regarding certain cancer types.⁶⁰ A recent study has even demonstrated that diet alone is the cause of approximately 5% of new cancer related cases in the year 2015.⁵⁹

• The Continuous Update Project from the American Institute for Cancer Research and World Cancer Research Fund has broken down dietary habits and specific relationships with specific cancers (see page 14). In fact, of their 10 cancer recommendations, a majority are related to diet. These include eating diets rich in wholegrain, vegetables, fruits and beans; limiting processed foods and fast foods; limit consumption of red and processed meats; limit alcohol consumption and limit consumption of sugary drinks.⁶⁰
• The American Cancer Society validates this research and recommends a diet rich in plant-based foods, limiting processed meats and limiting alcohol intake.⁵⁵ 
• The Continuous Update Project specifically recommends obtaining nutrients from your diet and to not use supplements to prevent cancer.⁶⁰ 
• The American Institute for Cancer Research lists common side effects with dietary suggestions to help soothe symptoms from fatigue to weight management to nausea.⁶¹
• There are a myriad of tools and recommendations specific to cancer survivors listed at the end of this document in the Resources section. Although there are many more, I tried to list a few important ones that were comprehensible, yet simple.

Behavioral strategies have been proven to enhance adherence to healthy lifestyle modifications. The problem is that healthcare providers don’t always feel comfortable educating patients regarding health and wellness strategies.^17,53 Health professional education rates for remediable physical impairments in cancer patients range between 1-2%,²³ which demonstrates failure on our parts as clinicians. It is possible to use evidence-based techniques such as motivational interviewing to facilitate a positive change within our patients lifestyle habits.

• Although the National Cancer Institute notes that there is a weak link of stress actually causing cancer, there is research that recognizes stress reduces the rate at which cancer may reoccur. It is also recognized that stress can be the cause of unhealthy lifestyle choices such as smoking, poor diet and lack of exercise, all of which do have a direct link to causing cancer.^60,70,89
• The National Cancer Institute even specifically reports that “various types of cellular and tissue stress, as well as smoking, obesity, low levels of physical activity and a poor diet are all under study as potential modifiers of telomere length.”⁷⁰ A telomere is an area of chain of our DNA that protects it from deteriorating and cancer is a result of cellular maladaptation.⁶²
• Models of behavioral change have been developed to assist clinicians in facilitating a healthy lifestyle. These include, but are not limited to the transtheoretical model, social cognitive model, theory of planned behavior and motivational interviewing.^10,12 It is shown that patients value their relationships with their clinicians, and establishing plans together does improve adherence to healthy lifestyle habits.^13,15,16,53
• Motivational interviewing is a form of dialogue between the healthcare professional and patient that is patient centered. Although initially started to assist people with addiction problems, research has shown it assists with the decision making process to facilitate change towards healthy behaviors such as healthy diets and exercise programs.^87,88,92
• Since we are all at different perceptual stages in regards to our health habits, a bulk of this project is designed to guide patients towards positive changes based on what stage the person is at. Different plans of action are necessary to address the uniqueness of our environments.
• Demographic factors such as being male, lower socioeconomic status and being single/widowed/divorced all play a role in lower adherence rates. Adherence to activity programs is also affected by when the patient initiates the program. Patient undergoing treatments tend to be non-compliant than those before or after.^13,48,54
• Adherence rates tend to be around 60-80% throughout the studies I’ve read, however threats to external validity do need to be accounted for due to the shear nature of being supervised. The end of that statement recognizes the importance of maintaining a relationship with the survivor as patients tend to respond to being held accounted for.
• The use of technology such as web-based or mobile applications appears to improve adherence with proper nutrition and physical activity levels, but it is still inconsistent as time goes on, especially when progressing through the phases of cancer treatment.^11,17,18

Although physical therapists are not directly in the place to develop true smoking cessation and alcohol management programs, there are still certain treatment related implications related to these lifestyle habits. As clinicians, we always have the opportunity to educate patients and refer out if needed.

• Thanks to the 1964 US Surgeon General’s warning of the harmful effects of smoking, tobacco cancer-related deaths have decreased significantly. The prevalence of adult smokers has decreased from 42% in 1965 to 14% in 2017. In 2017, Louisiana was ranked 3rd, with Tennessee, with a prevalence of 23% use of tobacco in adults over 17 years old. Texas was ranked 28th with a prevalence of 16%.⁸⁹
• As tobacco is claimed to be the number one most preventable cause of death in the United States, it still accounts from anywhere between 20-30% of all cancer related deaths. It is also known that quitting smoking has immediate impacts on reducing the risk of cancer. This is due to the carcinogens in tobacco that can cause mutations in our DNA.^60,89
• Smoking tobacco sets patients up for risks such as tendinopathies and tears and slows the rate of healing. Educating patients to at least cut back on smoking during physical therapy treatments can significantly improve treatment outcomes.
• It was estimated in 2017 that 6% of cancer related cases are attributed to alcohol consumption.⁸⁹
• Although there is evidence that alcohol decreases the risk of kidney cancer, there is strong evidence that it is linked with an increased risk of gastrointestinal (including the mouth, pharynx and larynx), liver and both premenopausal and postmenopausal breast cancer cases.⁶⁰
• Alcohol is also associated with increased caloric intake which can feed into unhealthy dietary habits and increased BMI. As already shown, there are direct links between poor dietary health and an increased risk of cancer.

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