November 18, 2021
Following diagnosis and treatment of their cancer, survivors often face challenges related to declining physical functioning, which can affect their quality of life and independence.
This makes an active lifestyle and physical fitness an important topic for physicians to address with cancer survivors.
Literature review data from an article published in Medicine & Science in Sports & Exercise showed strong evidence that moderate-intensity aerobic training alleviated anxiety, depressive symptoms and fatigue and improved health-related quality of life and overall physical function.
“Most individuals who have survived a bout of cancer and treatment have lingering adverse effects, be it from the disease, the treatment or both, that limit to some extent their physical function,” G. Stephen Morris, PT, PhD, FACSM, a distinguished professor in the department of physical therapy at Wingate University in North Carolina, told Healio in an interview. “It is increasingly important in the rehabilitation world that return to maximal functionality be recognized as an essential part of the management of cancer survivors.”
Morris added that physical therapists are important members of the cancer care team because survivors can often experience problems with gait, deconditioning, and residual functional deficits arising from surgical interventions, exposure to radiation and treatment with chemotherapeutic agents.
“The conclusion of treatment does not mean an end to the physical challenges faced by the survivors,” he said. “There [are] ample data to show that timely recognition and appropriate management of these lingering dysfunctions can improve the survivor’s quality of life, increase their productivity and hasten their return to a more normal way of living. Most of my colleagues and the oncologists I work with would agree that rehabilitation in the oncology arena is an area that is poorly understood and inadequately utilized.”
Healio spoke with experts in cancer recovery and rehabilitation about specific patient and treatment factors that should be considered when designing an exercise program for a cancer survivor and exercise techniques that can be most rehabilitative.
For the greatest benefit, cancer survivors should be assessed individually to determine their specific needs when it comes to physical activity and exercise. Age, sex and type of cancer treatment received can affect the survivor’s level of physical decline or determine the kind of exercise program that is appropriate.
Although the American College of Sports Medicine’s Frequency, Intensity, Time and Type, or FITT, model, is frequently used to prescribe exercise and develop fitness plans for patients, such frameworks can be too generic or homogenous for patients who have had cancer, Morris wrote in a perspective published in Rehabilitation Oncology. He suggested alternative approaches to generate personalized prescription, including high-intensity training, periodization, and programs designed in the context of comorbidities or treatment-related adverse effects present in the survivor.
For some survivors, Morris recommends high-intensity training to ensure that the the respiratory, cardiac and muscular systems are sufficiently stressed to bring about adaptive responses to exercise and use of fast-twitch skeletal muscle fibers.
Periodization, which integrates cycles of varying exercise components (frequency, intensity and duration) with planned periods of rest and recovery. This type of exercise program provides balanced muscular and aerobic fitness while also avoiding “overtraining” and tedious exercise programs, he added.
Finally, identifying specific cancer- or treatment-related adverse effects can help define the optimal exercise program for a patient.
As an example, Morris noted that some chemotherapeutic agents, such as doxorubicin, have been associated with increased risk for cardiac disease.
“Because the mean age of a cancer diagnosis in this country is 56 [years], these patients face an increase in cardiovascular risk factors both from their age at which they’re diagnosed and the deconditioning that often accompanies patients going through cancer treatment,” Morris said. “One of the biggest problems is that these patients are typically badly deconditioned, and if that deconditioning is accompanied by gait or functional deficits, physical therapists can work with that patient to both improve their gait while at the same time improving their conditioning status.”
Guidelines from the American College of Sports Medicine recommend cancer survivors engage in at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week with resistance training sessions twice a week to improve overall health.
Although cancer survivors should adhere to this guidelines, Morris said that some may not be able to.
“In such cases the Department of Health and Human Services recommends that these individuals should engage in regular physical activity according to their abilities,” he said. “Above all, these survivors should avoid inactivity.”
However, data from the National Health Interview Survey show many survivors do not meet these goals. Because physical fitness is so important for post-cancer recovery, some institutions have developed specific programs or teams to support patients in increasing their physical activity.
Healio spoke with Karen Basen-Engquist, PhD, MPH, a professor of behavioral science and director of the Center for Energy Balance in Cancer Prevention and Survivorship at The University of Texas MD Anderson Cancer Center, who led team that developed the 12-week Active Living After Cancer program.
The development of the program followed data from Cooper Institute’s Project ACTIVE that showed a lifestyle physical activity intervention — or a focus on activities that can be incorporated into daily life without having to go to a gym or requiring specific time goals be met — improved physical activity and cardiorespiratory health in the general population.
“The Project Active intervention took place over 6 months and primarily focused on giving people the cognitive and behavioral skills they need to make that change and make it a lasting change,” Basen-Engquist said.
She and colleagues adapted the program to be shorter (12 sessions), simplified the text and translated the program into Spanish, and developed a training program for community health educators.
The team published results from 127 survivors of breast cancer who participated in the program between 2014 and 2017. Their findings showed physical activity and mental and physical quality of life significantly improved among the survivors from baseline to follow-up (P < .01). Also, the participants demonstrated improvements in physical functioning as measured by sit-to-stand repetitions (mean, 12.5 vs. 14.9) and 6-minute walk distances (mean, 428 m vs. 470 m; P < .01 for both).
“That intervention was effective in improving breast cancer survivors’ functioning, so once the Cancer Prevention and Research Institute of Texas came forth with a request for programs in survivorship, we adapted it for more of a community implementation model,” Basen-Engquist said. “However, because Active Living After Cancer is now virtual, we can provide it to anybody throughout the state.”
Additionally, the researchers had focused their sights on underserved and minority populations during the initial development.
“We wanted to make sure that survivors who had less access to other exercise resources would have access to this program,” she said. “We know that all survivors could use access to high-quality exercise and physical activity programs that meet their needs, but we feel that often the minority and medically underserved populations have less access to these kinds of services. The funder wanted to make sure that we ensured access to those populations, but we also felt like it was really important to make it widely available and not just to people who can afford other exercise and physical activity resources as well.”
Awareness and accessibility
Unfortunately, not all cancer survivors will have regular access to certain specialists like physical therapists, exercise physiologists, specialized training programs, or potentially expensive exercise options like home equipment or gym memberships.
Therefore, it is vital that all health care providers are aware of the importance of physical fitness for these patients so they can educate them about the simple lifestyle changes they can make at home.
“Bring fitness up with your patients and support the idea that they should stay active through cancer treatment and after,” Basen-Engquist said. “While a physician recommendation might not be enough alone, it’s still critical for the patient to hear from their doctor that exercise is an important part of their overall health.”
Morris added that getting this message to patients as soon as possible will lead to the greatest results.
“The earlier a cancer survivor is recognized as being physically deconditioned, the sooner they can initiate efforts to recover their physical fitness status. By doing so, they will improve their quality of life and their ability to participate in activities around them,” he said. “It can help to limit the risk for a recurrence of their cancer and it will help to reduce risk for adverse cardiovascular events. There is a whole litany of benefits that the cancer survivor can derive from participation in physical activity.”