Cancer & Physical Activity

Overview

Cancer is a group of conditions where the body's cells begin to grow and reproduce in an uncontrollable way. These cells can then invade and destroy healthy tissue, including organs. Up to two-thirds of all cancers are caused by chance genetic mutations (Tomasetti and Vogelstein, 2017) although it's been estimated that up to 43% of all cancer cases in the UK are preventable (Parkin et al, 2011). Cancer sometimes begins in one part of the body before spreading to other parts. This process is known as metastasis.

Around 298,000 new cases of cancer are diagnosed each year in the UK. More than one in three people will develop some form of cancer during their lifetime.1 Data suggests that increased levels of physical activity are associated with lower rates of colon and breast cancer3 but this article is focussed on the use of physical activity and exercise with those individuals that have been diagnosed with cancer.

Management and Medication

Treatment options for cancer can include surgery, radiation, chemotherapy, and immunotherapy

Effects on Exercise Response

Individuals with, or recovering from, cancer can have physical limitations that result from the disease itself and/or the treatment for the disease. The effect that the disease has on the body is directly related to the tissues affected, for example, shortness of breath may be experienced with lung disease, or anaemia may be experienced if the bone marrow is affected.

The side effects of treatments can also be varied and whilst some may be an acute effect that resolves itself once treatment has ended, other side effects may occur later in the treatment process and could be permanent. Scar tissue can result in impaired cardiac, pulmonary or musculoskeletal function with pain or loss of flexibility being experienced long after the cancer has been treated.

Benefits of Exercise Training

Studies have shown that regular, moderate-intensity aerobic exercise during cancer therapy results in reduced levels of fatigue, greater body satisfaction, maintenance of body weight.

Exercise Recommendations2

• Aerobic - the goal is to improve & maintain work capacity, control body weight, improve mood, reduce fatigue and improve the Quality of Life. Individuals should aim to complete 20-60min sessions, 3-5 days/week at a symptom limited, moderate intensity of 40%-60% of HRR.

• Strength - the goal is to maintain or improve strength and increase maximal voluntary contraction. Stregnth exercise should be carried out 2-3 days/week for 20-30min, at 40-60% of 1RM 1-3 sets of 3-5 reps should be gradually increased to 8-15 reps although theintensity should be limited by symptoms.

• Flexibility - The goal is to increase/maintain ROM and to decrease stiffness resulting from lack of use. Flexibility exercises should be carried out 5-7 days/week with 2-4 reps/stretch holding each stretch for 20-30s.

• Functional - In order to improve gait and balance, return to work and maintain functional independence individuals should perform exercises that replicate functional activities (ie sitting, reaching, stepping). These should be performed daily.

Other considerations are that an instructor should assess a client's medical condition, functional ability and general health prior to each exercise sessions. There should also be an awareness of where the client is in the treatment schedule and the implications of this to allow for adjustment of the exercise programme where required.2 

Contraindications

Whilst all cancer patients and survivors are subject to the regular list of absolute and relative contraindications to exercise, there are a number of measures and signs that suggest an individuals exercise routine should be curtailed or adapted.

• Heamoglobin Level < 8.0 g/dL - This can imply that the exerciser has anemia and a reduced oxygen carrying capacity. Instructors should take note of raised heart rates, arrythmias, rapid or difficult breathing, extreme fatigue and high blood pressure. If this is suspected then high intensity exercises should be avoided.

• Absolute neutrophil count <0.5 x 109/microlitres - This implies that the client may have a low white blood cell count and may be more susceptible to infection. If the client has any blood values taken then they should be encouraged to pass them on to their instructor and if this is identified then the risk of bacterial infection should be minimised. This could be achieved by reducing group sizes, restricting those with contagious conditions and by maintaining high standards of hygiene at all times.

• Platelet count <50 x 109/microlitres - This could suggest that the client has thrombocytopenia and will bruise easily. If this is noted then the programme should be adapted to avoid activities with an increased risk of bleeding, eg heavy lifting, especially eccentric exercises and high impact sports.

• Fever>38C (100.4F) - This may indicate a systemic infection or pulmonary toxicity. It may be accompanied by increased breathing rate, and heart rate and feeling cold. Clients should avoid high intensity exercise if noted.

• Ataxia, dizziness, or peripheral sensry neuropathy - Those with gait problems may be at an increased risk of falls whilst exercising. This could be preceded oraccompanied by confusion, memory loss, seizures, loss of sensation, blurred vision, foot drop, muscle weakness an balance problems. Activities that require a keen sense of balance should ba avoided, although safely developing a sense of balance would be beneficial to the client. Exercise instructions should be kept clear and may need to be repeated at intervals.

• Severe cachexia (loss of >35% premorbid weight - Those that have undergone a significant loss of weight should avoid high intensity exercise.

• Dyspnea - Shortness of breathe may indicate pulmonary toxicity and exercise should only be completed to the individuals level of tolerance.

• Bone Pain -  Exercisers with bone pain should avoid activities that increase the risk of fracture eg high impact sports, spinal flexion, and end-ROM movements.

• Severe Nausea - This may result from a change in intestinal mucosa, and a subsequent change in intestinal absorption. This may in turn result in malnutrition and a limited capacity to exercise. The client should only be encouraged to exercise within their levelof tolerance and encouraged to seek medical help.

• Extreme Fatigue and/or muscle weakness - individuals should be encouraged to only exercise within the boundaries of their own tolerance.

Click here for more on special considerations for cancer survivors.

References

1. NHS Choices - Cancer [click here]

2. American College of Sports Medicine (2009) ACSM's exercise management for persons with chronic diseases and disabilities (3rd Ed) Champaign, IL: Human Kinetics [google books]

3. Bouchard, C., Blair, S.N., Haskell, W.L. (eds) (2006) Physical Activity and Health. Champaign, IL: Human Kinetics [google books]

4. Fitzmaurice, C., Allen, C., Barber, R. M., Barregard, L., Bhutta, Z. A., Brenner, H., ... & Fleming, T. (2017). Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA oncology, 3(4), 524-548. doi:10.1001/jamaoncol.2016.5688

5. Tomasetti, C., Li, L., & Vogelstein, B. (2017). Stem cell divisions, somatic mutations, cancer etiology, and cancer prevention. Science, 355(6331), 1330-1334. https://doi.org/10.1126/science.aaf9011 

6. Parkin, D. M., Boyd, L., & Walker, L. C. (2011). The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British journal of cancer, 105(S2), S77. https://doi.org/10.1038/bjc.2011.489 

Key Guidelines

Buffart, L. M., Galvao, D. A., Brug, J., Chinapaw, M. J. M., & Newton, R. U. (2014). Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions. Cancer Treatment Reviews, 40(2), 327-340. https://doi.org/10.1016/j.ctrv.2013.06.007 

Cormie, P., Atkinson, M., Bucci, L., Cust, A., Eakin, E., Hayes, S., ... & Adams, D. (2018). Clinical Oncology Society of Australia position statement on exercise in cancer care. Medical Journal of Australia, 209(4), 184-187. https://doi.org/10.5694/mja18.0019 [www]

Rock, C. L., Doyle, C., Demark-Wahnefried, W., Meyerhardt, J., Courneya, K. S., Schwartz, A. L., Bandera, Elisa, V., et al. (2012). Nutrition and Physical Activity Guidelines for Cancer Survivors. CA: Cancer Journal for Clinicians, 00. doi:10.3322/caac.21142 [full text]

Santa Mina, D., Langelier, D., Adams, S. C., Alibhai, S. M., Chasen, M., Campbell, K. L., ... & Chang, E. (2018). Exercise as part of routine cancer care. The Lancet Oncology, 19(9), e433-e436. DOI:https://doi.org/10.1016/S1470-2045(18)30599-0 

Suderman, K., McIntyre, C., Sellar, C., & McNeely, M. L. (2019). Implementing Cancer Exercise Rehabilitation: An Update on Recommendations for Clinical Practice. Current Cancer Therapy Reviews, 15(2), 100-109. https://doi.org/10.2174/1573394714666180730100432 

Key Texts

Irwin, M.L. (2012) ACSM's guide to exercise and cancer survivorship. Champaign, IL: Human Kinetics [google books]

Courneya, K. S., & Friedenreich, C. M. (Eds) (2011). Physical activity and cancer. London: Springer [full text]

Further Reading 

ACSM (2010) American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise 42 (7):1409-1426 [full text]

Ballard-Barbash, R., Friedenreich, C. M., Courneya, K. S., Siddiqi, S. M., McTiernan, A., & Alfano, C. M. (2012). Physical activity, biomarkers, and disease outcomes in cancer survivors: a systematic review. Journal of the National Cancer Institute, 104(11), 815-840. https://doi.org/10.1093/jnci/djs207 

Bower, J. E. (2014). Cancer-related fatigue—mechanisms, risk factors, and treatments. Nature reviews Clinical oncology, 11(10), 597. 

Brown, J.K. et al (2003) Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices CA Cancer J Clin Vol. 53, 268-291 [full text]

Brown, J. C., Winters‐Stone, K., Lee, A., & Schmitz, K. H. (2012). Cancer, physical activity, and exercise. Comprehensive Physiology, 2(4), 2775-2809. https://doi.org/10.1002/cphy.c120005

Buffart, L. M., Galvão, D. A., Brug, J., Chinapaw, M. J. M., & Newton, R. U. (2014). Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions. Cancer treatment reviews, 40(2), 327-340. 

Campbell, A., Stevinson, C. and Crank, H. (2011). The BASES expert statement on exercise and cancer survivorship. The Sport and Exercise Scientist (28), 16-17 [full text]

Capozzi, L. C., Nishimura, K. C., McNeely, M. L., Lau, H., & Culos-Reed, S. N. (2016). The impact of physical activity on health-related fitness and quality of life for patients with head and neck cancer: a systematic review. Br J Sports Med, 50(6), 325-338. http://dx.doi.org/10.1136/bjsports-2015-094684 

Christensen, J. F., Simonsen, C., & Hojman, P. (2018). Exercise Training in Cancer Control and Treatment. Comprehensive Physiology, 9, 165-205. https://doi.org/10.1002/cphy.c180016 

Cormie, P., Zopf, E. M., Zhang, X., & Schmitz, K. H. (2017). The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiologic Reviews, 39(1), 71-92. https://doi.org/10.1093/epirev/mxx007

Courneya, K. S., Rogers, L. Q., Campbell, K. L., Vallance, J. K., & Friedenreich, C. M. (2015). Top 10 research questions related to physical activity and cancer survivorship. Research quarterly for exercise and sport, 86(2), 107-116. https://doi.org/10.1080/02701367.2015.991265

Courneya, Kz. S., Jones, L. W., Fairey, A. S., Campbell, K. L., Ladha, A. B., Friedenreich, C. M., & Mackey, J. R. (2004). Physical activity in cancer survivors : implications for recurrence and mortality Review Article. Cancer Therapy, 2, 1–12 [full text]

Courneya, K. S. (2003) Exercise in Cancer Survivors: An Overview of Research. Med. Sci. Sports Exerc., Vol. 35, No. 11,1846-1852 [abstract]

Cramp F, Byron-Daniel J. (2012) Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, Issue 11. Art. No.: CD006145. DOI: 10.1002/14651858.CD006145.pub3. [full text]

Czosnek, L., Richards, J., Zopf, E. et al. Exercise interventions for people diagnosed with cancer: a systematic review of implementation outcomes. BMC Cancer 21, 643 (2021). https://doi.org/10.1186/s12885-021-08196-7 

Dimeo, F., Rumberger, B.G. and Keul, J. (1998) Aerobic exercise as therapy for cancer fatigue Med. Sci. Sports Exerc. Vol. 30, No. 4, 475-478 [full text]

Dimeo, F., Schwartz, S., Wesel, N., Voigt, A.& Thiel, E. (2008) Effects of an endurance and resistance exercise program on persistent cancer-related fatigue after treatment Annals of Oncology 19: 1495–1499 [full text

Doyle, C. et al. (2006) Nutrition and physical activity during and after cancer treatment: An American Cancer Society Guide for Informed Choices. CA: A Cancer Journal for Clinicians Vol.56, No.6, 323-53[full text]

Durstine, J.L., Moore, G.E., Painter, P.L. & Roberts, S. (eds) (2009) ACSM's exercise management for persons with chronic diseases and disabilities (3rd Ed) Champaign, IL: Human Kinetics

Ehrman, J., Gordon, P., Visich, P.S., Keteyianby, S. (2009) Clinical Exercise Physiology (2nd Ed). Champaign IL: Human Kinetics [google books]

Fairey, A.S., Courneya, K.S., Field, C.J. and Mackey, J.R. (2002) Physical exercise and immune system function in cancer survivors: A comprehensive review and future directions Cancer Vol. 94, No. 2, 539–551[full text]

Galvao, D.A. and Newton, R.U. (2005) Review of Exercise Intervention Studies in Cancer Patients J Clin Oncol Vol.23, 899-909. [full text amongst others]

Hojman, P., Gehl, J., Christensen, J. F., & Pedersen, B. K. (2018). Molecular mechanisms linking exercise to cancer prevention and treatment. Cell metabolism, 27(1), 10-21. https://doi.org/10.1016/j.cmet.2017.09.015 

Humpel, N., Iverson, D.C. (2005) Review and critique of the quality of exercise recommendations for cancer patients and survivors Supportive Care in Cancer Vol. 13, No.7, 493-502 Doi: 10.1007/s00520-005-0811-x [abstract] 

Irwin, M.L. (2009) Physical activity interventions for cancer survivors. Br J Sports Med Vol.43, 32-8 [full text]

Jones, L.W., Demark-Wahnefried, W. (2006) Diet, exercise, and complementary therapies after primary treatment for cancer. Lancet Oncology, Vol. 7, 1017-26 [full text]

Kerr, J., Anderson, C., & Lippman, S. M. (2017). Physical activity, sedentary behaviour, diet, and cancer: an update and emerging new evidence. The Lancet Oncology, 18(8), e457-e471. DOI: https://doi.org/10.1016/S1470-2045(17)30411-4 

Lee, C. E., Leslie, W. D., & Lau, Y. J. (2012). A pilot study of exercise in men with prostate cancer receiving androgen deprivation therapy. BMC cancer, 12, 103.

Lynch, B. M., & Leitzmann, M. F. (2017). An Evaluation of the Evidence Relating to Physical Inactivity, Sedentary Behavior, and Cancer Incidence and Mortality. Current Epidemiology Reports, 1-11. https://link.springer.com/article/10.1007/s40471-017-0119-7 

Litterini, A. J., & Jette, D. U. (2011). Exercise for managing cancer-related fatigue. Physical Therapy, 91(3), 301-4 [full text]

Luctkar-Flude, M., Groll, D., Woodend, K., & Tranmer, J. (2009). Fatigue and physical activity in older patients with cancer: a six-month follow-up study. Oncology Nursing Forum, 36(2), 194-202. [abstract]

Mcgonigal, B. (2009). Fitness For Cancer Survivors. Idea Fitness Journal, (November-December), 53-59.McIntyre, P (2008) Why "plenty of bed rest" could be bad advice. Cancer World Sept/Oct. 52-56 [full text]

McTiernan, A. (Ed.) (2010) Physical Activity, Dietary Calorie Restriction and Cancer. London: Springer [google books][full text]

Meyerhardt, J.A. (2006) Impact of Physical Activity on Cancer Recurrence and Survival in Patients With Stage III Colon Cancer: Findings From CALGB 89803 Journal of Clinical Oncology, Vol 24, No 22, 3535-3541[full text]

Midtgaard, J., Christensen, J. F., Tolver, A., Jones, L. W., Uth, J., Rasmussen, B., ... & Rørth, M. (2013). Efficacy of multimodal exercise-based rehabilitation on physical activity, cardiorespiratory fitness, and patient-reported outcomes in cancer survivors: a randomized, controlled trial. Annals of oncology, mdt185. [full text]

Mishra, S. I., Scherer, R. W., Snyder, C., Geigle, P. M., Berlanstein, D. R., & Topaloglu, O. (2012). Exercise interventions on health‐related quality of life for people with cancer during active treatment. Cochrane Database of Systematic Reviews, (8). DOI: 10.1002/14651858.CD008465.pub2 

Mishra, S. I., Scherer, R. W., Geigle, P. M., Berlanstein, D. R., Topaloglu, O., Gotay, C. C., & Snyder, C. (2012). Exercise interventions on health‐related quality of life for cancer survivors. Cochrane Database of Systematic Reviews, (8). DOI: 10.1002/14651858.CD007566.pub2 

Mitchell, S. A., Hoffman, A. J., Clark, J. C., DeGennaro, R. M., Poirier, P., Robinson, C. B., & Weisbrod, B. L. (2014). Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment. Clinical journal of oncology nursing, 18, 38-58. 

Moore, S. C., Lee, I. M., Weiderpass, E., Campbell, P. T., Sampson, J. N., Kitahara, C. M., ... & Adami, H. O. (2016). Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Internal Medicine, 176(6), 816-825. doi:10.1001/jamainternmed.2016.1548. 

Mustian, K. M., Alfano, C. M., Heckler, C., Kleckner, A. S., Kleckner, I. R., Leach, C. R., ... & Scarpato, J. (2017). Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: A meta-analysis. JAMA Oncology. http://jamanetwork.com/journals/jamaoncology/fullarticle/2606439

Newton, R.U. and Galvao, D.A. (2008) Exercise in Prevention and Management of Cancer Current Treatment Options in Oncology DOI 10.1007/s11864-008-0065-1 [full text amongst others]

Patel, A. V., Friedenreich, C. M., Moore, S. C., Hayes, S. C., Silver, J. K., Campbell, K. L., ... & Matthews, C. E. (2019). American College of Sports Medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Medicine and science in sports and exercise, 51(11), 2391.  https://dx.doi.org/10.1249%2FMSS.0000000000002117  

Reeves, G. K., Pirie, K., Beral, V., Green, J., Spencer, E., & Bull, D. (2007). Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ, 335(7630), 1134. doi:10.1136/bmj.39367.495995.AE [full text]

Rock, C. L., Doyle, C., Demark-Wahnefried, W., Meyerhardt, J., Courneya, K. S., Schwartz, A. L., Bandera, Elisa, V., et al. (2012). Nutrition and Physical Activity Guidelines for Cancer Survivors. CA: Cancer Journal for Clinicians, 00. doi:10.3322/caac.21142 [full text]

Russell, C., Noble, M., Kraemer, L. & Sharratt, M. (2009). Active Living for Older Adults in Treatment for Cancer. University of Waterloo, Waterloo, ON. Canada [full text]

Sasso, J. P., Eves, N. D., Christensen, J. F., Koelwyn, G. J., Scott, J., & Jones, L. W. (2015). A framework for prescription in exercise‐oncology research. Journal of cachexia, sarcopenia and muscle, 6(2), 115-124. https://doi.org/10.1002/jcsm.12042 

Saxton, J., Daley, A. (eds) (2010) Exercise and Cancer Survivorship: Impact on Health Outcomes and Quality of Life. London: Springer [google books][full text]

Schmitz, K.H., Holtzman, J., Courneya, K.S. et al (2005) Controlled physical activity trials in cancer survivors: a systematic review and meta‐analysis. Cancer Epidemiol Biomarkers Prev. Vol.14, No.7, 1588–1595 [full text]

Schneider, C.M. and Dennehy, C.A. (2003) Exercise and Cancer Recovery. Champaign, IL: Human Kinetics [amazon]

Schneider, C.M., Hsieh, C.C., Sprod, L.K., Carter, S.D. and Hayward, R. (2007) Cancer treatment-induced alterations in muscular fitness and quality of life: the role of exercise training Ann Oncol Vol.18, No. 12, 1957-1962. [full text]

Schwartz, A.J. (2005) Cancer Fitness: Exercise Programmes for patients and survivors. New York, NY: Fireside [amazon][amazon preview]

Speck, R.M., Courneya, K.S., Mâsse, L.C., Duval, S. & Schmitz, K.H. (2010)  An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis J Cancer Surviv DOI 10.1007/s11764-009-0110-5 [full text]

Shen, D., Mao, W., Liu, T., Lin, Q., Lu, X., Wang, Q., ... & Wijndaele, K. (2014). Sedentary behavior and incident cancer: a meta-analysis of prospective studies. PLoS One, 9(8), e105709. https://doi.org/10.1371/journal.pone.0105709

Spence, R.R., Heesch, K. and Brown, W.J. (2010) Exercise and Cancer Rehabilitation: A Systematic Review. Cancer Treatment Reviews, Vol.36, No.2. 185‐194 [full text]

Sprod, L.K. (2009) Considerations for Training Cancer Survivors Strength Cond J. Vol. 31, No.1, 39–47[full text]

Sprod L.K., Hsieh C.C., Hayward R., Schneider C.M. (2010) Three vs. Six Months of Exercise Training in Cancer Survivors.  Breast Cancer Research and Treatment  121:412-419 [abstract]

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Further Links

• Macmillan Cancer Support. (2016). What motivates people with cancer to get active: Understanding the motivations and barriers to physical activity in people living with cancer.[full text]

• Macmillan Cancer Support (2011)The importance of physical activity for people living with and beyond cancer: A concise evidence review [full text]

• Macmillan Cancer Support (2012) Interventions to promote physical activity for people living with and beyond cancer: Evidence-based guidance [full text]

• Exercise after Cancer - Macmillan Cancer Care

• NACER (National Association of Cancer Exercise Rehabilitation) - www.nacer.org.uk

• Cancer Rehabilitation - http://www.canrehab.co.uk/

• Cancer Council of Western Australia (2009) Nutrition for people living with cancer [full text]

• Cancer Council of Western Australia (2009) Exercise for people living with cancer [full text]

• Cancer Council of Western Australia (2009) Guidelines for implementing exercise programs for cancer patients [full text]

• Rocky Mountain Cancer Rehabilitation Institute - [Click here]

• http://www.healthtalkonline.org/Cancer/

• BACSUP (Bournemouth After Cancer Survivorship Progamme)

• MacMillan Cancer Care - Click here for more information on cancer

• NHS Improvement - Click here for more

• CancerWorld - Click here

• "the subject is complex, the story is clear" article by Simon Crompton (2006) [full text]

• Exercise and cancer survivorship. Exercise Guidelines and Certifications: What’s new? Anna Schwartz presentation slides [Click here]

• Make Time Cancer prevention graphic [click here]

• NW London NHS Network Cancer & PA Resources [click here]

• A tale of cancer - A poo story