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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 pressure, osteoporosis, diabetes and obesity Keeps joints, tendons and ligaments flexible Reduces some of the effects of aging

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Exercise plays a critical role in recovery and wellness during and after cancer

Exercise

Exercise plays a critical role in recovery and wellness during and after cancer.


Benefits of exercise

Benefits of Exercise

  • Reduces your risk of heart disease, high blood 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

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 plays a critical role in recovery and wellness during and after cancer

Exercise Reduces Risk of Recurrence Following Breast Cancer


Physical activity and risk of breast cancer recurrence holmes md 2004

Physical Activity and Risk of Breast Cancer Recurrence Holmes, MD, 2004

  • Subjects:

  • 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:

  • 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%


Exercise plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

Exercise Reduces Fatigue in Patients with Cancer


Cancer related fatigue

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

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

    Decreased Work Capacity

    Decreased Level of Activity Due to Fatigue

    More Fatigue


Exercise plays a critical role in recovery and wellness during and after cancer

Effects of Physical Activity on the Fatigue and Psychological Status of Cancer Patients during ChemotherapyDimeo FC et al, Amer Canc Soc, 1999

Subjects:

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)


Exercise plays a critical role in recovery and wellness during and after cancer

Effects of Physical Activity on the Fatigue and Psychologic Status of Cancer Patients during ChemotherapyDimeo FC et al, Amer Canc Soc, 1999

  • Critical Appraisal:

  • Pseudo – randomization, number of days admission unclear

  • Heterogenous group – increases generalizability

  • Conclusions:

  • Significant increase in fatigue and somatic complaints in control group, not seen in training group

  • Significant reduction in psychological distress in exercise group


Exercise plays a critical role in recovery and wellness during and after cancer

Daily fatigue patterns and effect of exercise in women with breast cancerSchwartz 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.


Exercise plays a critical role in recovery and wellness during and after cancer

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 Reduces Nausea During Breast Cancer Treatment


Exercise plays a critical role in recovery and wellness during and after cancer

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 Minimizes Bone Loss


Exercise plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

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


The effects of exercise on weight gain and body composition

The Effects of Exercise onWeight Gain andBody Composition


Exercise plays a critical role in recovery and wellness during and after cancer

Exercise and weight gain in breast cancer patients receiving chemotherapySchwartz 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%).


Exercise plays a critical role in recovery and wellness during and after cancer

  • 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


Exercise plays a critical role in recovery and wellness during and after cancer

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


Exercise plays a critical role in recovery and wellness during and after cancer

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

The Effects of Exercise on Lymphedema


Exercise plays a critical role in recovery and wellness during and after cancer

Weight Lifting in Women with Breast-Cancer-Related 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.


Exercise plays a critical role in recovery and wellness during and after cancer

Weight Lifting in Women with Breast-Cancer-Related 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.


Exercise plays a critical role in recovery and wellness during and after cancer

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


Exercise plays a critical role in recovery and wellness during and after cancer

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.


Exercise plays a critical role in recovery and wellness during and after cancer

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.


Exercise plays a critical role in recovery and wellness during and after cancer

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


Exercise plays a critical role in recovery and wellness during and after cancer

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


Exercise plays a critical role in recovery and wellness during and after cancer

  • 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 plays a critical role in recovery and wellness during and after cancer

Exercise Improves Quality of Life in Women following Breast Cancer


Exercise plays a critical role in recovery and wellness during and after cancer

Physical Exercise and Quality of Life Following Cancer Diagnosis: A Literature ReviewCourneya KS, Friedenreich CM, Annals Behav Med, 1999

Design:

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…


Exercise plays a critical role in recovery and wellness during and after cancer

Physical Exercise and Quality of Life Following Cancer Diagnosis: A Literature ReviewCourneya 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:

  • Functional capacity

  • Muscle strength

  • Flexibility

  • Hematological indices, natural killer cell activity

  • Self-esteem

  • Mood

  • Quality of Life

  • Satisfaction with Life

Decreased:

  • Fatigue

  • Nausea and diarrhea

  • Pain


Exercise plays a critical role in recovery and wellness during and after cancer

A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefitsKolden 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

    •  QOL + affect,

    • distress,

    • enhanced well-being, and

    • improved function.


Exercise and metastatic cancer

Exercise and Metastatic Cancer


Exercise plays a critical role in recovery and wellness during and after 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.


Exercise plays a critical role in recovery and wellness during and after cancer

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.


Exercise plays a critical role in recovery and wellness during and after cancer

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


Exercise plays a critical role in recovery and wellness during and after cancer

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

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


Exercise plays a critical role in recovery and wellness during and after cancer

The following benefits of exercise have been documented repeatedly in the literature:

(e.g. Courneya, 1999; Dimeo, 1999)

Decreased:

  • Risk of Recurrence

  • Nausea and diarrhea

  • Pain

  • Fatigue

Increased/improved:

  • Functional capacity

  • Muscle strength

  • Flexibility

  • Hematological indices, natural killer cell activity

  • Self-esteem

  • Mood

  • Quality of Life

  • Satisfaction with Life


Exercise plays a critical role in recovery and wellness during and after cancer

Reducing Risk of Breast Cancer with Exercise


Exercise plays a critical role in recovery and wellness during and after cancer

A Prospective Study of Recreational Physical Activity and Breast Cancer RiskRockhill 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

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

Five Stages of Change In Adding Exercise To Your Life.

Where is your patient now?


Exercise plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

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 plays a critical role in recovery and wellness during and after cancer

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

Make sure your patients think about exercise!


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