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AAESS Cancer Position Statement - Optimising cancer outcomes through exercise

AAESS Cancer Position Statement - Optimising cancer outcomes through exercise

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Published by SE Tan
Abstract
Cancer represents a major public health concern in Australia. Causes of cancer are multifactorial with lack of physical activity being
considered one of the known risk factors, particularly for breast and colorectal cancers. Participating in exercise has also been associated
with benefits during and following treatment for cancer, including improvements in psychosocial and physical outcomes, as well as better
compliance with treatment regimens, reduced impact of disease symptoms and treatment-related side-effects, and survival benefits for particular
cancers. The general exercise prescription for people undertaking or having completed cancer treatment is of low to moderate intensity, regular
frequency (3–5 times/week) for at least 20 min per session, involving aerobic, resistance or mixed exercise types. Future work needs to push
the boundaries of this exercise prescription, so that we can better understand what constitutes optimal, desirable and necessary frequency,
duration, intensity and type, and how specific characteristics of the individual (e.g., age, cancer type, treatment, presence of specific symptoms)
influence this prescription. What follows is a summary of the cancer and exercise literature, in particular the purpose of exercise following
diagnosis of cancer, the potential benefits derived by cancer patients and survivors from participating in exercise programs, and exercise
prescription guidelines and contraindications or considerations for exercise prescription with this special population. This report represents
the position stand of the Australian Association of Exercise and Sport Science on exercise and cancer recovery and has the purpose of guiding
exercise practitioners in their work with cancer patients.
Abstract
Cancer represents a major public health concern in Australia. Causes of cancer are multifactorial with lack of physical activity being
considered one of the known risk factors, particularly for breast and colorectal cancers. Participating in exercise has also been associated
with benefits during and following treatment for cancer, including improvements in psychosocial and physical outcomes, as well as better
compliance with treatment regimens, reduced impact of disease symptoms and treatment-related side-effects, and survival benefits for particular
cancers. The general exercise prescription for people undertaking or having completed cancer treatment is of low to moderate intensity, regular
frequency (3–5 times/week) for at least 20 min per session, involving aerobic, resistance or mixed exercise types. Future work needs to push
the boundaries of this exercise prescription, so that we can better understand what constitutes optimal, desirable and necessary frequency,
duration, intensity and type, and how specific characteristics of the individual (e.g., age, cancer type, treatment, presence of specific symptoms)
influence this prescription. What follows is a summary of the cancer and exercise literature, in particular the purpose of exercise following
diagnosis of cancer, the potential benefits derived by cancer patients and survivors from participating in exercise programs, and exercise
prescription guidelines and contraindications or considerations for exercise prescription with this special population. This report represents
the position stand of the Australian Association of Exercise and Sport Science on exercise and cancer recovery and has the purpose of guiding
exercise practitioners in their work with cancer patients.

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Journal of Science and Medicine in Sport 12 (2009) 428–434
Position stand
Australian Association for Exercise and Sport Science position stand:Optimising cancer outcomes through exercise
Sandra C. Hayes
a
,
, Rosalind R. Spence
b
, Daniel A. Galvão
c
, Robert U. Newton
c
a
 Institute of Health and Biomedical Innovation, School of Public Health, Queensland University of Technology, Australia
b
School of Human Movement Studies, University of Queensland, Australia
c
Vario Health Institute, Edith Cowan University, Western Australia, Australia
Received 19 November 2008; received in revised form 20 March 2009; accepted 20 March 2009
Abstract
Cancer represents a major public health concern in Australia. Causes of cancer are multifactorial with lack of physical activity beingconsidered one of the known risk factors, particularly for breast and colorectal cancers. Participating in exercise has also been associatedwith benefits during and following treatment for cancer, including improvements in psychosocial and physical outcomes, as well as bettercompliancewithtreatmentregimens,reducedimpactofdiseasesymptomsandtreatment-relatedside-effects,andsurvivalbenefitsforparticularcancers.Thegeneralexerciseprescriptionforpeopleundertakingorhavingcompletedcancertreatmentisoflowtomoderateintensity,regularfrequency (3–5times/week) for at least 20min per session, involving aerobic, resistance or mixed exercise types. Future work needs to pushthe boundaries of this exercise prescription, so that we can better understand what constitutes optimal, desirable and necessary frequency,duration,intensityandtype,andhowspecificcharacteristicsoftheindividual(e.g.,age,cancertype,treatment,presenceofspecificsymptoms)influence this prescription. What follows is a summary of the cancer and exercise literature, in particular the purpose of exercise followingdiagnosis of cancer, the potential benefits derived by cancer patients and survivors from participating in exercise programs, and exerciseprescription guidelines and contraindications or considerations for exercise prescription with this special population. This report representsthe position stand of the Australian Association of Exercise and Sport Science on exercise and cancer recovery and has the purpose of guidingexercise practitioners in their work with cancer patients.© 2009 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Keywords:
Exercise; Neoplasms; Rehabilitation; Survival; Quality of life; Cancer
1. Exercise and cancer prevention
One in three Australian men and one in four womenwill be directly affected by cancer before the age of 75,with melanoma, prostate, colorectal, breast and lung can-cers comprising the most common types.
1
There are anestimated 108,000 new cancer cases and 41,000 registeredcancer deaths each year in Australia, and consequently can-cer represents a major public health concern.
2
While thecauses for many cancers remain unknown, lifestyle factorsincludingphysicalactivitylevelsareconsideredcontributoryand modifiable for some.
Since the first report linkingphysical activity and cancer risk was published in 1922,morethan190reportsfromepidemiologicalstudiesandover
Corresponding author.
 E-mail address:
sc.hayes@qut.edu.au(S.C. Hayes).
10 reviews have examined this relationship.
5
The scientificevidence supporting physical activity as a means of can-cer prevention is now considered ‘strong’ and ‘convincing’for particular cancers including colon/colorectal and breast,‘probable’ for prostate and ‘possible’ for lung and endome-trial cancers, with risk ratios or odds ratios reported for thephysicallyactivegroupsrangingfrom0.3to0.8(representingrisk reductions of 25% to more than three-fold).
5
Evidenceto date is considered preliminary and insufficient to makeany causal inferences for melanoma, testicular, ovarian, kid-ney, pancreatic and thyroid cancers.
5
A review and analysisof the potential biological mechanisms underlying the possi-ble anti-carcinogenic effects of physical activity has recentlybeen published and gives the relationship more credibility.
6
Thepreciseexerciseprescription,inrelationtotype,intensity,durationandfrequency,neededforcancerprotectionremainsunknown.
7
However, since exercise prescription in this set-
1440-2440/$ – see front matter © 2009 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.jsams.2009.03.002
 
S.C. Hayes et al. / Journal of Science and Medicine in Sport 12 (2009) 428–434
429
ting is not only about the prevention of cancer, but morebroadly encompasses prevention of chronic disease and opti-mising health, quality of life and function, it seems relevantfor the application of national physical activity guidelines aswell. Of note, published evidence supports a dose–responserelationship between physical activity levels and some can-cers including colorectal, breast and prostate, showing thatcancer risk decreases as activity levels increase. Therefore,the notion that some activity is better than none, and moreactivity is generally better than less (at least up to levelsmeeting national guidelines), should be considered whenprescribing exercise to healthy populations.
2. Exercise and cancer recovery
Survivalprospectsfollowingcancerdiagnosisareincreas-ing, with females experiencing higher survival probabilitiesthan males (five-yr relative survival rates are 64% and 58%,respectively).
1
For some of the more common forms of can-cer, five-yr survival prospects are even higher: melanoma,92%; breast, 88%; prostate, 85%.
1
Whether treatmentintention is curative or palliative, the disease and treatment-related side-effects may create numerous problems for thepatient.Aloneorincombination,cancertreatmentsincludingsurgery, radiation and systemic chemo- or hormone therapycanleadtoarangeofcomplicationsincludinglossoffunction(musculoskeletal, cardiovascular, cardiopulmonary), infec-tions, diarrhoea, pain, numbness, lymphoedema, nausea,fatigue, reduction in bone mass, and body compositionchanges, to name a few.
8
While the presence of side-effectstends to peak during treatment, symptoms may persist formany mths or even years following treatment
9
and somecomplications, such as lymphoedema, may not present untilseveralyearsfollowingtreatment.
Furthermore,cancerandits associated treatment may increase risk of other commonchronic conditions, such as cardiovascular disease, diabetesand osteoporosis.
Of all the potential side-effects duringand following cancer treatment, fatigue is regarded as one of the most common and disabling.
The potential and expected benefits derived from partic-ipation in exercise will vary according to timing of cancertreatment, as well as whether treatment was considered suc-cessful (that is, patient no longer has evidence of disease).
Courneya and Friedenreich
developed the Physical activ-ity and cancer control framework (PACC), which suggestsresearchersandcliniciansconsiderthefollowingperiodsandclinical outcomes from the point of diagnosis, with respectto exercise prescription: treatment preparation/coping beforetreatment, treatment effectiveness/coping during treatment,recovery/rehabilitation, disease prevention/health promotionand survival during ‘survivorship’ (the period between diag-nosis and recurrence or death) and palliation for thoseapproaching the end of life. In the Australian context, thetreatment preparation period before treatment is limited toselect cases (e.g. ‘watchful waiting’ following a diagnosis of lymphoma) as the time between cancer diagnosis and sur-gical or adjuvant treatment is typically minimal for mostcancers (usually 1–2 weeks). Therefore, clinicians are morelikely to play a significant role during and following cancertreatment, in the prevention of treatment-related concerns,reducing the impact of these when they exist, overcomingside-effects and generally assisting this population to ‘bridgethe gap’ between treatment cessation and effectively return-ing to ‘normal’ daily lives. Further, the potential role of exercise prescription extends to improvement of long-termhealth through optimising function, as well as prevention of cancer recurrence and other chronic disease.Over 70 exercise intervention trials have been conducted,mostlyinvolvingwomenwithbreastcancerinNorthAmerica(i.e. USA and Canada). This literature is examined in severalqualitative, narrative reviews,
which together indi-cate that exercise during and/or following treatment preventsdecline and/or improves cardiorespiratory and cardiovas-cular function, improves body composition (preservationor increase in muscle mass, loss of fat mass), improvesimmunefunction,improvesstrengthandflexibility,improvesbody image, self-esteem and mood, reduces the numberand severity of side-effects including nausea, fatigue andpain, reduces hospitalisation duration, improves chemother-apy completion rates, allows for better adjustment to illness,and reduces stress, depression and anxiety, all of whichcontribute to improvements in quality of life (Table 1). While impressive findings, conclusions from such narrativereviews emphasise consistency and direction of findings butdo not consider the magnitude of the observed effects.
Hence the potential clinical relevance of the ‘exercise effect’cannot be derived from these reviews and the potentialpublic health impact remains unknown. More recently, theresultsfromseveralmeta-analyses,conductedontheexerciseand cancer recovery literature, have been published.
The results demonstrate persuasive findings for a small(weighted mean effect size [WMES]=0.2–0.5) to moderate(WMES=05–0.8) effect of physical activity interventionson specific outcomes, in particular cardiovascular and car-diorespiratory fitness (WMES=0.5,
p
<0.01), activity levels(WMES=0.3,
 p
=0.01),physiologicoutcomessuchasblood
Table 1Summary of potential benefits of exercise during and/or following cancertreatment
a
.Preservation or improvements ReductionsMuscle mass, strength, power Number of symptoms andside-effects reported, such asnausea, fatigue and painCardiorespiratory fitness Intensity of symptoms reportedPhysical function Duration of hospitalisationPhysical activity levels Psychological and emotional stressRange of motion Depression and anxietyImmune functionChemotherapy completion ratesBody image, self esteem and mood
a
Benefits reported in qualitative, narrative reviews of the literature.
 
430
S.C. Hayes et al. / Journal of Science and Medicine in Sport 12 (2009) 428–434
transfusions, blood counts, days in hospital (WMES=0.3,
 p
<0.01) and symptoms/side-effects (WMES=0.4,
p
<0.01)during treatment, as well as fitness (WMES=0.7,
p
<0.01)andvitality(WMES=0.8,
 p
<0.04)followingtreatment.
The results for fatigue were less compelling (WMES=0.1,
 p
=0.12). While exercise does not exacerbate fatigue, thereductions reported in the literature may not be of suffi-cientmagnitudetobemeaningfulforthepatient.
However,anecdotally, patients do report reductions in fatigue and itis therefore plausible that the lower mean effect size isattributable to the sensitivity of the tools used to capturefatigue. Nonetheless, it is important to remember that theimplementation of appropriate exercise prescription (that is,individualisedwithrespecttostartingpointandspeedofpro-gression)minimisesriskofinjuryandoptimisesthepotentialfor individual gain. Exercise under these circumstances, atworst, does no harm, but more likely leads to a range of benefits during and following treatment (Table 1)that in turn positively influence quality of life. Furthermore, lack of physical activity during and/or following cancer treatmenthas the potential to exacerbate symptoms (e.g. fatigue) andcontribute to loss of function (musculoskeletal and cardio-vascular health), hence contributing to reductions in qualityof life.
While the literature examining the role of physical activ-ity on quality of life following cancer diagnosis is vast (withover 70 exercise trials being conducted), only more recentlyhave results from observational studies of colon/colorectalandbreastcancerpatientsexaminedtherelationshipbetweenexercise and survival.
Since 2005, several papers havereported positive associations between participation in phys-ical activity following breast
or colorectal
cancerdiagnosis with improved survival and reduced risk of recur-rence
.
The findings indicate that participation in physicalactivity reduces the risk of recurrence and death by up tohalf, when compared with those who are sedentary (engag-ing in less than 3 metabolic equivalent-task hours per week of activity). A change in activity level from pre- to post-diagnosis was also important, with those who increased theiractivity levels following cancer diagnosis reducing their risk of death,
while those who decreased their activity lev-els increasing their risk four-fold.
There is also evidencesuggesting a dose–response relationship exists, with someexercise being better than none and more better than less.
Unfortunately,thelowerthresholdforattainingsurvivalben-efits, as well as the upper threshold beyond which no furthersurvival benefit is accrued, remain unknown. While there ismuch to be learned with respect to physical activity and sur-vival following cancer, particularly for cancers other thanbreast and colorectal, these findings are promising and excit-ing. Further investigations through randomised, controlledtrials are currently underway.
Table 2Aerobic-based exercise prescription recommendations during and following cancer treatment.Parameter Recommendation and commentType Most exercises involving large muscle groups are appropriate. Cancer survivors do notneed to be restricted to walking and stationary cycling. Below are
examples
of when toavoid specific types of activity:Type When to avoid:Swimming During periods of increased risk of infection (e.g., low absolute neutrophil counts, whencatheters are being used, during wound recovery from surgery)High-impact activities or contact sports Primary or metastatic bone cancer patients, when platelet counts are low, presence of bonepainActivities requiring balance and coordination(e.g., treadmill exercise, cycling)Ataxia, dizziness or peripheral sensory neuropathyUse of public facilities (e.g. local gymnasium) During periods of increased risk of infectionFrequency At least 35times/week, but daily exercise may be preferable for deconditioned patientswho do lower intensity and shorter duration exercise sessionsIntensity Moderate, depending on current tness level and medical treatments. Guidelinesrecommend 50–75% VO
2
max or HR
reserve
, 60–80% HR
max
, or an RPE of 11–14(original Borg scale). HR
reserve
is the best guideline if HR
max
is estimated rather thanmeasured.
Examples
of when to avoid high intensities include low haemoglobin levels,immunosuppressed states or the presence of fever. When nausea, dyspnea, fatigue and/ormuscle weakness exist, exercise intensity and duration should be prescribed to tolerance.Duration At least 2030min continuous exercise; however, deconditioned patients or thoseexperiencing severe side-effects of treatment may need to combine short bouts (e.g.,3–5min) with rest intervals.Progression Progression should be slower and more gradual for deconditioned patients or those whoare experiencing severe side-effects of treatment. Patients should meet frequency andduration goals before they increase intensity. Of note, progression for some could actuallymean maintenance of weekly activity levels or slower declines in total physical activitylevels. That is, declines in activity may be inevitable during certain treatment periods, butan exercise program can assist in minimising these declines.Table has been reproduced and modified, with permission, from[37].

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