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Exercise & Cancer Rehabilitation

Exercise & Cancer Rehabilitation. Lee W. Jones, Ph.D. Behavioral Medicine Laboratory, Faculty of Physical Education, University of Alberta. HE ED 221 (E-121) November 24, 1.00-2.00pm, 2003. Framework PEACE. DIAGNOSIS. 3. Rehabilitation. Prevention. 1. Pre-Treatment. 2. Treatment.

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Exercise & Cancer Rehabilitation

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  1. Exercise & Cancer Rehabilitation Lee W. Jones, Ph.D. Behavioral Medicine Laboratory, Faculty of Physical Education, University of Alberta HE ED 221 (E-121) November 24, 1.00-2.00pm, 2003

  2. Framework PEACE DIAGNOSIS 3. Rehabilitation Prevention 1. Pre-Treatment 2. Treatment 5. Survival 4. Palliation PRE-DIAGNOSIS POST-DIAGNOSIS Adapted from Courneya & Friedenreich, Ann Behav Med 2001

  3. Why Exercise?

  4. Cancer Therapies Surgery Tx for localized tumors 60% pts, 30% cure rate Radiation Local – regional tx 50% patients Systemic Therapy Advanced solid tumors Chemotherapy;hormonal therapy; biological therapy

  5. Cancer & Quality of Life - Psychological/physical & functional side-effects Surgery - infection, loss of function, dyspnea, pain, diarrhea, lymphedema Radiation - nausea, fatigue, vascular damage (cardiac & lung tissue) Chemotherapy - myelosuppression, nausea, weight gain, cardiac toxicity, fatigue Shapiro NEJM 2001 344:1997-2008

  6. Current Quality of Life Interventions - Cognitive-behavioral therapies, educational strategies, grp psychotherapy - Largely psychological in nature - Unlikely to address physical/functional aspects - Exercise – not important or appropriate Courneya, Mackey & Jones Phys SportsMed 2000

  7. Cancer, Quality of Life, & Exercise Clinical Concerns: -Immunosuppressive effects -Pathological bone fractures -  Cardiotoxicity (RT & CT) - Unwillingness of cancer pts - Recent research – dispelling myths Courneya, Mackey & Jones Phys SportsMed 2000

  8. Current Status – Exercise & Cancer Research

  9. Review of Literature Cancer Site Study Design Exercise Modality Adjuvant Tx

  10. Review of Literature Outcomes/Results All reported significant benefits No Adverse events Multiple Outcomes….. Physiologic Outcomes - VO2peak, body comp, NK activity, flexibility Tx-Related Symptoms – fatigue, pain, nausea, diarrhea, platelet transfusion, hospital stay QOL Outcomes – overall, PWB, FWB, SWB, SWL, anx/dep Courneya et al. Phys SportsMed 2000;28:49; Courneya ACSM; 2003

  11. Review of Literature Limitations Small number of studies (n=47; only 14 RCT’s) Small sample sizes (heterogeneous) Self-report measures of exercise Methodology not well described Courneya et al. Phys SportsMed 2000;28:49; Courneya ACSM; 2003

  12. V. Clinical Exercise Prescription Guidelines

  13. General Guidelines Cancer dx affects all aspects of physical functioning Unique manifestations - Tumor - Treatment - Side effects - Demographic profile ACSM guidelines (3-5d/wk, 30-60mins, moderate intensity) Optimal guidelines – not yet established

  14. Prescription Guidelines Mode Walking / cycle ergometry natural choice Account for specific impairments (e.g., colorectal, breast cancer) Resistance/upper body – lymphedema concerns - unfounded Combined program optimal

  15. Prescription Guidelines Frequency & Intensity At least 3-5d/wk Daily for deconditioned patients Moderate Intensity 50-70% VO2max 60-80% HRmax RPE 11-14

  16. Prescription Guidelines Duration & Progression 20-30mins (continuous) Intermittment bouts (5-10 mins) Initially in frequency & duration - then intensity Progression slower for deconditioned pts & those suffering severe side effects

  17. General Guidelines No evidence that one type of exercise is superior Safety is the primary concern Optimal program may combine resistance & aerobic training Key point is to be flexible - modify prescription based on response to treatment(s)

  18. Special Precautions • ComplicationPrecaution • Hemoglobin <8.0 g/dl Avoid high intensity exercise • Absolute neutrophil count Avoid exercises that may increase chance of infection (swimming) • Fever > 38oC Avoid exercise • Ataxia/dizziness Avoid exercises that require significant balance & coordination (treadmill) • Severe cachexia Loss of muscle mass limits exercise intensity - modify program accordingly • Bone pain Avoid high impact exercises • Extreme fatigue Exercise at lower power output, avoid maximal tests

  19. VI. Current Clinical Trials & Forthcoming Studies

  20. Breast Cancer

  21. REHAB Trial REHAB (Rehabilitation Exercise for Health After Breast Cancer) Trial Purpose Determine the effects of exercise training on cardiopulmonary, QOL, and biologic outcomes in postmenopausal b/c survivors Outcomes QOL, VO2peak, metabolic hormones (insulin, IGF-1), sex steroid hormones (estradiol, estrogen), biomarkers of CVD (CRP, lipids, etc.)

  22. REHAB Trial REHAB Trial Method 53 participants EG (n=25) or CG (n=28) Cycle ergometry 3x/wk, 15-35mins, 15wks, 70-75% VO2peak Results 52 participants completed trial 98.4% adherence (44.3/45 sessions)

  23. Results VO2peak QOL Courneya et al. JCO 2003

  24. Breast Cancer START (Supervised Trial of Aerobic vs Resistance Training) Purpose Determine the effects of aerobic vs. resistance training on QOL in early stage b/c patients on chemotherapy • Objectives • Compare AET Vs RET on fitness & QOL • Explore individual characteristics of these effects • Compare adherence rates • Investigate psychosocial determinants Courneya, et al. Funded by CBCRA

  25. START Trial Study Design 210 Early Stage B/C Patients Edmonton N=70 Ottawa N=70 Vancouver N=70 Tax/Non-Tax Tax/Non-Tax Tax/Non-Tax LM RT AE LM RT AE LM RT AE Procedure Eligible Pts Approached by Oncologist Baseline Assessment > 1st CT Intervention Concurrent with CT Post-Test 3wk > Last CT Courneya, et al. Funded by CBCRA

  26. START Trial Outcomes Primary: QOL Secondary: Fatigue; VO2peak; Muscular Strength; Body Composition; Lymphedema; Bio-markers (Cancer Recurrence & CV Risk Factors) Progress Edmonton (n=21; 83%) Ottawa (n=18) Vancouver (n=3) Courneya, et al. Funded by CBCRA

  27. Prostate Cancer

  28. Prostate Trial Prostate and Resistance Exercise Training Trial Purpose Determine the effects of resistance exercise on fatigue & HRQOL in prostate cancer patients receiving ADT. Outcomes HRQOL, fatigue, body composition, muscular fitness (strength, cardiopulmonary fitness) Segal et al. JCO 2003

  29. REHAB Trial Prostate Trial Method 155 RET (n=83) or CG (n=73) Resistance Training 3x/wk, 12wks, 9 exercises, 2 sets of 8-12 reps @ 60-70% 1 RM Results 135 participants completed 76.2% adherence (27/36 sessions)

  30. Prostate Results Leg Press Chest Press QOL Fatigue

  31. Colorectal Cancer

  32. CAN-HOPE RCT • Colorectal RCT (CAN-HOPE) • To determine if exercise can improve QOL in colorectal cancer survivors • Submaximal fitness test/QOL at baseline & 16 weeks • Moderate intensity, home-based exercise program (F=3-5/wk; D=20-30) • Randomized 102 patients (33 Control /69 EX) Courneya et al. EJCC, in press

  33. CAN-HOPE RCT Participant Characteristics Participant Characteristics Demographic Age: 60; 59% male 74% married; 40% university 60% >$40k Medical Mths Sx: 2 80% III/IV; 100% Sx; 20% RT; 65% CT

  34. CAN-HOPE Results QOL TOI Anxiety  Fitness  Fitness Courneya et al. EJCC, in press

  35. Lung Cancer

  36. Exercise Capacity & NSCLC Purpose Determine the Prognostic Value of Symptom-Limited Exercise Testing on Survival in Inoperable NSCLC Patients Method New Patient Rounds via Medical Record Review Blood draw/PFT/GXT Jones et al. In Process

  37. Exercise Capacity & NSCLC • Outcomes • Primary: Survival • Secondary: • Association with traditional predictors • VO2peak & Tx response/tolerability Jones et al. In Process

  38. Exercise Capacity & NSCLC Progress Total Number of Patients Screened N=49 Reasons for Non-Eligibility (n=29) Recent CHD (n=4) Physically Disabled (n=7) TB (n=1) Age (n=2) O2 Dependent (n=5) Extensive Met Disease (n=4) Psychological Distress (n=2) Co-morbidities (n=4) Non Lung Cancer (n=1) No Treatment (n=1) Total Number of Patients Eligible N=20 (20/49 = 41%) Reasons for Non-recruitment (n=8) Does Not Believe in Exercise (n=1) Exercise Test Too Risky (n=1) Too Sick (n=3) Too Much On (n=3) Total Number of Patients Interested N=12 (12/20 = 65%) Total Number of Patients Tested N=10 (10/12 = 83%) Jones et al. In Process

  39. Exercise Capacity & NSCLC Results Age: 71 Range: 64 - 83 VO2peak: 16.2 Range: 9.4 – 24.3 RER: 1.2 BMI: 27 Range: 21 – 35 Aims: Accurate prognostic information ‘Optimal’ therapeutic approach Feasibility & safety - RCT

  40. Pre Surgery Exercise RCT Method Surgeon Referral Two-armed RCT – Exercise Training (n=25) vs. Usual Care (n=25) AET 4/5x/wk, 10-45mins, 50-75% VO2peak for 6 wks Outcomes Primary: Perioperative Complications (infection, O2 utilization, etc.) Secondary: VO2peak, QOL, length of hospital stay Timing of Assessments: baseline, pre-sx, 5-7d post sx Jones et al. In Progress

  41. Other Cancers

  42. Exercise & Anemia Trial EXTRA (EXercise TRaining & Anemia) Trial Purpose Determine if a 12-wk exercise program can improve QOL in anemic patients receiving Aranesp Method Two-armed RCT – Aranesp Alone (n=50) vs. Aranesp + Exercise (n=50) Periodized Cycle Ergometry 3x/wk, 30-45mins, 60-75% VO2peak for 12 wks Outcomes Primary: QOL (FACT-An) Secondary: VO2peak, Hb Response, Blood Markers Mackey, Courneya, Jones et al. Funded by Amgen Inc

  43. EXTRA Trial Results Age: 51 Range: 25 - 71 VO2peak: 16.5 Range: 11 – 25.3 RER: 1.23 Hb: 100 Range: 91 - 107

  44. Multiple Myeloma Purpose Examine the Potential Role of Exercise in Multiple Myeloma Cancer Patients • Objectives • Exercise preferences/level of interest • Exercise Rates • Determinants of exercise (attitudes, perceived capability) • Association with QOL & fatigue Jones et al. In Process

  45. Exercise & Multiple Myeloma Method Cross-sectional provincial survey – ACB registry Oncologist-approval 162 sent questionnaire Results 11 returned (6 deceased, 5 moved) 87 (87/151 = 58%) completed questionnaire Jones et al. In Process

  46. Exercise & Glioma RCT Purpose To determine the effect of exercise training on QOL in newly diagnosed primary glioma cancer patients during RT Method Two-armed RCT: usual care (n=12) vs. exercise training (n=12) Intervention 3x/wk; 60-90 minutes, 8wks AET: 50-70% VO2peak RET: 8-12 repetitions @ 70-80% 1-RM of 8 upper/lower body exercises Jones et al. Submitted for Funding CIHR/ACB

  47. Summary ACSM Guidelines – Early Stage Patients Advanced Cancer Pts – More Care Safety primary concern Integral component of comprehensive care for cancer patients

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