Exercise Before, During, and After Cancer

Therapy
Dec 04, 2019   |  Samer H. Ellahham, MD, FACC

Expert Analysis

Introduction

Early detection of cancer and its effective management have considerably

improved the 5-year disease-survival rates of common malignancies. However,
cancer and its treatment have physical, psycho-physical, and psychological adverse
effects. These can be acute or short-duration symptoms that develop before or
during cancer therapy, chronic symptoms that persist for months or years during
cancer treatment, and late symptoms that develop months or years after
treatment. These symptoms (Table 1) adversely affect the quality of lives of
patients with cancer.1-3

Table 1: Symptoms of Cancer and Cancer Therapy1-3

Symptom Type With Examples Acute Chronic Late

Physical: Bone loss and Nausea, Lymphedema, Osteoporosis, osteopenia,
metastases, changes in body vomiting, peripheral cardiovascular complications
composition (metabolic syndrome, skin rashes, neuropathy, (arrhythmias, arterial hypertension,
weight gain), loss of appetite, peripheral infertility, coronary artery disease (CAD),
cachexia, cardiovascular disease neuropathy, changes in diastolic dysfunction, heart failure,
(CVD), lymphedema, peripheral hair loss, body interstitial myocardial fibrosis,
neuropathy, nausea/vomiting, decline in composition, myocardial dysfunction, peripheral
diarrhea, dyspnea, constipation, physical pre-mature vascular disease, pulmonary
hair loss, sore mouth, and function menopause, hypertension, thromboembolism,
sweating cardio-vascular stroke, and valvular disease)
complications
Psycho-physical: Pain, fatigue, Pain, Fatigue Fatigue
decreased muscle strength, fatigue
inactivity, drowsiness, and
insomnia (sleep disturbance)
Psychological: Depression, Anxiety, Depression  
anxiety, quality of life (QOL), and depression,
self-esteem changes in
self-esteem
and body
image,
decline in
emotional
function

Several reviews, meta-analyses, and studies have shown that non-pharmacological

interventions such as healthy diet, yoga, and exercise are positively associated
with improved survival and QOL and reduction in some cancer-associated
symptoms (fatigue, pain, constipation, dyspnea, and weight and sleep problems)
and cardiovascular outcomes in patients with cancer.1,3-14 Therefore, oncologists
should incorporate these non-pharmacological interventions into the treatment
paradigm of their patients with cancer. Exercise can be prescribed right at the
time of diagnosis of cancer and through the treatment and post-treatment as well.
Oncologists should therefore be aware of the different exercise types, their
benefits, and their timing in the patient's journey. They should, however, know
that there is no evidence showing that exercise has beneficial effect on symptoms
like nausea/vomiting, diarrhea, or loss of appetite.2

Also, cancer and CVD have several common risk factors such as smoking,
diabetes, obesity, hypertension, and metabolic syndrome.15 Additionally, anti-
cancer anthracycline-based chemotherapies, monoclonal antibodies such as
trastuzumab, and radiation therapies that oncologists regularly prescribe are
known to have cardiac toxicities.16 Cardiologists form an integral part of the
cardio-oncology team to preempt, diagnose, and treat cardiovascular side effects
of oncologic treatments.17 Cardiologists are well-versed with cardiac rehabilitation
non-pharmacological intervention models such as prescribed exercise, education,
counseling, and lifestyle modifications. They can work with oncologists to
incorporate these models in the cancer setting as well.8 Oncologists should
collaborate with cardiologists, physiotherapists, dieticians, psychologists, and
others to form a multidisciplinary team that looks at the exercise and diet aspects
of patients with cancer. The physiotherapist in the cardio-oncology team should
also be able to recognize when the prescribed exercise starts exhausting their
patient and to change its type and intensity without majorly affecting its benefits,
where possible. This review is an attempt to educate the cardio-oncology team
about the types of exercises that can be prescribed to patients with cancer, when
the exercises can be prescribed, exercise intensity, and the benefits provided by
these exercises in alleviating the side effects of cancer and its treatment and in
improving the cardiovascular fitness of the patients with cancer and survivors of
cancer.

Benefits of Exercise in Patients With Cancer

Exercise helps in alleviating cancer-related adverse effects, has a beneficial effect

on the whole body and cardiovascular health, and seems to slows cancer
progression through probably direct action on tumor-intrinsic factors and by
possibly improving the efficacy of the anti-cancer treatment.18 Additionally, a
review of 100 studies showed that patients who exercise post cancer diagnosis
had fewer cancer-related adverse effects and a lower risk of cancer recurrence
and mortality compared with patients who either did not exercise or exercised
minimally.19 Segal et al. reviewed 2 guidelines, 18 systematic reviews, and 29
randomized controlled trials studying the effect of exercise during active cancer
treatment and after it to conclude that exercise is safe in patients with cancer and
provides muscular and aerobic fitness and improves QOL.20

Clinicians should be aware that exercise has added benefit in reducing

cardiovascular risk in patients with cancer who exercise regularly versus those
who do not exercise if other cardiovascular health metrics (like body mass index,
blood pressure, total cholesterol, and fasting blood glucose) are under control
(Table 2).8,21

Table 2: Clinical and Cardiovascular Benefits of Exercise in Patients With

Cancer in Neo-Adjuvant and Adjuvant Setting8

Setting and Beneficial Outcomes of Exercise

Cancer Type
Adjuvant Setting
Breast Decreased CVD events and CAD mortality; cardio-respiratory fitness may remain the
same, improve, or decrease depending on patient's condition and breast cancer stage;
decreased left ventricular ejection fraction
Prostate and Improves cardio-respiratory fitness
Colorectal
Cancer
Post-Adjuvant Setting
Breast Decreased CVD events and all-cause mortality; cardio-respiratory fitness may improve
or remain the same; vascular function improves
Prostate Vascular function and cardio-respiratory fitness improves
Adult Decreased CVD events and all-cause mortality
Survivors of
Childhood
Cancers
Testicular Vascular function and cardio-respiratory fitness improves; improved Framingham risk
score
Colorectal Decrease in all-cause mortality; cardio-respiratory fitness may remain the same,
Cancer improve, or decrease
Leukemia and Improved cardio-respiratory fitness
Lymphoma

Exercise Prescription in Patients With Cancer By Type of Exercise

Clinicians should understand that exercise and physical activity are two distinct
entities. Physical activity is any movement by the musculoskeletal system resulting
in energy expenditure. Exercise is a planned, structured, and repetitive physical
activity that has a purpose and calculated and planned energy expenditure.
Exercise can be prescribed during the pre-habilitation phase (time period between
cancer diagnosis and initiation of its treatment), habilitation (during treatment),
and rehabilitation phase (after therapy in survivors).

How to Decide Which Exercise Will Benefit the Patient

There are various types of exercises (aerobic, resistance, strength, weight and
impact, balance, and flexibility and relaxation) that can be prescribed in various
combinations depending on the symptoms.

The cardio-oncology team can decide which exercise type will benefit the
concerned patient with cancer depending on the patient's physical, psycho-
physical, and psychological symptoms (Table 3).1,3 Restorative exercise along with
yoga helps significantly improve fatigue, pain, dyspnea, insomnia, constipation,
risk for lymphedema, feeling of overall wellbeing, and cognitive and social
functioning (p < 0.05).3,14

Table 3: Types of Exercises and Their Effect on Cancer Symptoms and Adverse
Effects of Cancer Therapy1

  Aerobic Resistance Strength Weight and Balance Flexibility and

Exercise Exercise Exercise Impact Exercise Exercise Relaxation Exercise
Physical Aspects
Bone Loss and
  X   X    
Disease
Muscle and Fat
X   X      
Mass Imbalance
Cachexia X X        
Peripheral
    X   X  
Neuropathy
Lymphedema   X        
Psycho-Physical Aspects
Pain X          
Fatigue X X X     X
Sleep Disorders X         X
Psychological Aspects
Depression,
X          
Anxiety
QOL X X X     X
Self-Esteem   X        
Adapted from Ferioli et al.1

How to Write an Exercise Prescription and Assess Intensity of Exercise

Each exercise prescription should follow the FITT principle and clearly state
frequency (the number of times the exercise will be performed per week),
intensity, time or duration, and type of exercise.22,23 Intensity of exercise can be
measured subjectively by the patient and objectively by the physician or trainer
(Figure 1).22,24-26 At each stage, patients should be monitored carefully and the
exercise regimen modified based on the patient's physical condition, endurance,
and fatigue level along with cardiovascular fitness and presence of cardiovascular
risk factors.8,21,23

Figure 1: Measuring Exercise Intensity22,24-26

Exercise Prescription in Patients With Cancer By Exercise Intensity

Usually, patients with cancer can safely perform moderate intensity exercise
during and after treatment, and this helps improve their aerobic and muscular
fitness and QOL.22 Simple exercises like walking 3-4 days a week can improve
functional ability of patients with cancer.3 Compared with high-intensity exercises,
moderate-intensity exercise can be sustained over a longer period of time and
provide the required protective benefits, including cardiovascular
protection.3,8,21,22

Several American and Canadian societies recommend 150 minutes of moderate

intensity exercise over 3-5 days and at least 2 days devoted to resistance exercise
every week. Each exercise session should include a warm-up and a cool-down. The
resistance exercise session should involve 2 sets of 8-10 major muscle groups
repeated 8-10 times.3,22 Flexibility exercises should also include all major muscle
groups, and balance exercise should be included for all elderly patients and for
those who have balance issues.3

Exercising in a Supervised Setting

Patients with cancer who are severely debilitated and have other comorbidities or
cardiovascular risk factors or have experienced or are at risk of experiencing
cardiovascular side effects due to cancer therapy should initially be exercised in a
supervised setting by a trained physical therapist. Community-based programs will
benefit cancer survivors with least debility.21,27 Exercise programs in a supervised
or group setting have multiple benefits and are found to be superior in improving
QOL, fatigue, and muscular strength than an individual exercising alone. These
programs provide the right motivation, exercise technique, and a safe
environment to exercise.20,28

Pre-Exercise Assessment for Patients With Cancer

The next important thing for the cardio-oncology team is to assess the patient's
condition to chalk out an exercise regimen that would be beneficial for the
patient. The pre-exercise assessment should include the patient's general
condition and special considerations (e.g., lymphedema, peripheral neuropathy,
cardiovascular risk, musculoskeletal morbidities, cardiac issues, and special
situations such as central lines, ostomies, or breast reconstruction) (Table 4).3,8,22

Table 4: Pre-Exercise Assessment of Patients With Cancer8

Normal Testing
Cardiopulmonary Exercise Testing (CPET)
 Resting blood pressure (BP) ≤160/90 mmHg (If elevated, recheck after 5 minutes. If still elevated,
then reschedule CPET after patient is seen by provider to adjust BP medications.)
Normal BP response to exercise
No inducible ischemia
No atrial or ventricular arrhythmias
Maintain normal O2 saturations
No symptoms (Symptoms such as dyspnea, chest pain, or dizziness or other cardiac symptoms
during exercise deemed abnormal by supervising physician.)
6-Minute Walk Test
Resting BP ≤160/90 mmHg (If elevated, recheck after 5 minutes. If still elevated, then reschedule
CPET after patient is seen by provider to adjust BP medications.)
Maintain normal O2 saturations
Laboratory Studies
Absence of severe anemia (<8.0 g/dL)
Absolute neutrophil count >500 mm3
Platelet count >50 000/mcL
No Baseline Symptoms
Acute nausea during exercise
Vomiting within 24 hours
Disorientation
Blurred vision
Ongoing Cancer Complications
Acute infection
Acute metabolic disease (Examples include abnormal thyroid function, uncontrolled diabetes
mellitus, and electrolyte abnormalities.)
New-onset lymphedema
Mental or physical impairment to exercise
Initial wound healing after surgery
Bone or brain metastasis (For patients with bone or brain metastases, a plan needs to include a
consultation with oncology rehabilitation to establish a patient-specific safe exercise plan.)
Displays Exercise Knowledge
Understands functions of aerobic and resistance equipment
Demonstrates correct form on equipment
Understands perceived exertion and heart rate goals; performs exercise accordingly
Adapted from Gilchrist et al.8

Barriers to Exercise During Cancer Therapy and Predictors of Adherence

Clinicians should be aware of the challenges and barriers that prevent patients
with cancer from adhering to their exercise programs. Exercising can be a
challenge in patients with cancer because physical activity decreases during
course of disease, resulting in de-conditioning or reduced exercise capacity.
Additionally, cancer cells release substances such as circulating cytokines,
proteolysis-inducing factor, and lipid-mobilizing factor that impair energy
metabolism. Cancer and its treatment can cause anorexia, nausea, vomiting,
dehydration, systemic inflammation, oxidative stress, mitochondrial death, and
skeletal muscle atrophy, all of which reduce the exercise capacity. Cardiovascular
complications of cancer treatment also make exercising difficult.21,29

Apart from this, several oncology care settings lack proper exercise screening,
implementation, and referral programs. Oncologists and patients both lack proper
guidance and knowledge about exercising, and the multidisciplinary team often
does not have a trained physical therapist to guide the exercise sessions.30
Similarly, the multitude of surgical procedures, treatment options and their side
effects, types of cancer, and variance in metastatic spread makes it impossible to
develop a single exercise protocol/regimen that can be universally followed.23

Positive exercise history, high motivation level, fewer exercise limitations, and
availability of an exercise center close to home are independent predictors of
adherence to exercise during cancer treatment. In cancer survivors, adherence to
exercise during cancer treatment, high motivation levels, decreased alcohol
consumption, availability of physical trainers and training centers, less extensive
surgery, family support, and the right patient education predict higher adherence
to exercise.31

Strategies to Make Exercise a More Accessible Therapy

A single-center program offering exercise counseling consultation along with

cardio-oncology care is beneficial in improving self-reported QOL and physical and
psychosocial symptoms in patients with cancer.28 The benefits multiply with each
exercise counseling session, stressing the need to integrate exercise counseling
into the treatment paradigm of patients with cancer.28

Strategies to improve exercise adherence would need to be constantly researched

and various care models developed and tested to see what model works best.
Easy access to diverse community-, center-, or home-based exercise programs is
required. These programs should be either low cost or fully reimbursed by
insurance (Figure 2). To make this possible, there is a need to spread awareness
about these programs and their benefits and necessity among patients,
oncologists, and policy makers.32

Figure 2: Action Steps to Increase the Availability and Uptake of Multimodal

Interventions Including Exercise for Patients With Cancer and Survivors32

Reproduced with permission from Basen-Engquist et al.32

 Conclusion

This review
highlights the
importance
of exercise as
a safe and
effective
strategy to
improve
physical,
muscular,
and

cardiovascular fitness in adult patients with cancer and improve their QOL.
Multimodal regimens incorporating exercise with nutrition and psychological
support need to be tested to find a model that can be universally applied with
scope for suitable alterations. Exercise does seem to have some cognitive benefit,
and this should continue to be studied in detail. There is still not much clarity on
the timing, type, intensity, and frequency of exercise that gives maximum
cognitive benefit.33,34 Further research in this area will empower the cardio-
oncology team to better adjust exercise in their oncology prescriptions, improve
their cardio-respiratory fitness, and reduce associated cardiovascular risk.

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