One vital piece of cancer survivorship care is keeping active
Cancer and its various treatments can strain the body to the point that participation in fitness activities and exercise is often drastically decreased, reducing the survivor’s level of physical fitness and adding to their medical problems.
Because of this decline in fitness levels, also known as deconditioning, remaining physically active is a key component of all phases of cancer survivorship.
Studies have shown that the symptom of fatigue persists among approximately 25% of cancer survivors many years after they have completed treatment, which contributes to difficulty in returning to work or independent living. Additionally, many chemotherapeutic agents can increase the risks for heart disease or directly damage the survivor’s heart, and surgical interventions can lead to nerve or muscle dysfunction. Collectively, these effects can reduce fitness levels and discourage participation in an exercise program.
“Cancer and its treatments can cause many impairments,” Julie K. Silver, MD, associate professor and associate chair in the department of physical medicine and rehabilitation at Harvard Medical School, told Healio in an interview. “For example, many breast cancer survivors have rotator cuff impingement or postmastectomy pain syndrome, and these factors are not necessarily related to their fitness level, but secondarily to the interventions.”
Silver continued that those are separate issues from general deconditioning or fitness level and that it’s important to differentiate a patient’s physical impairments from their fitness status. These impairments should be treated by trained professionals such as physiatrists, occupational therapists and physical therapists.
“The related issue of deconditioning is also important, and many patients may benefit from a supervised exercise program overseen by a physical therapist or an exercise physiologist,” she said.
Healio spoke with cancer survivorship and rehabilitation experts about how participation in an exercise program can diminish cancer-related fatigue while improving other symptoms and the survivor’s quality of life. In a related story, Healio also spoke with experts about specific exercise programs that can benefit cancer survivors.
Benefits of activity
Evidence from the literature has shown numerous benefits that cancer survivors can accrue from participation in even a light- to moderate-intensity exercise program.
A meta-analysis conducted by Khosravi and colleagues showed that exercise training reduces pro-inflammatory markers — which are thought to support a pro-cancer environment — in cancer survivors, especially among prostate and breast cancer survivors.
The researchers found exercise training led to a small but significant decrease in pro-inflammatory markers (P = .001) with moderate heterogeneity across 26 articles (P < .001). Exercise programs that included a combination of aerobic and resistance training had the greatest effect (P < .001), especially among breast (P = .001) and prostate (P = .004) cancer survivors. C-reactive protein (P = .025) and tumor necrosis factor (P = .004) demonstrated the greatest change in response to exercise training.
Another study from McCrary and colleagues showed evidence of rehabilitation potential from participation in multimodal exercise among patients with persistent chemotherapy-induced peripheral neuropathy.
After an 8-week exercise intervention, 29 cancer survivors with chemotherapy-induced peripheral neuropathy (CIPN) showed improvements in both objective measures and patient-reported symptoms of CIPN; in function adversely affected by CIPN including dynamic balance, standing balance and mobility; and quality of life (P < .05 for all).
Specialized care
Results from these studies and others like them provide support for the need to involve rehabilitation specialists such as physical therapists in the cancer survivor care team.
“There are approximately 20 million survivors in this country today and most of these survivors carry with them functional deficits arising from their treatment,” G. Stephen Morris, PT, PhD, FACSM, distinguished professor in the department of physical therapy at Wingate University in North Carolina, told Healio. “Oftentimes those functional deficits are not recognized or treated and therefore allowed to worsen before help is sought. There is an emerging patient care model designed to help reduce this inadequacy in care. This model, referred to as the prospective surveillance model, calls for cancer survivors to be periodically screened by physical therapists and other rehabilitation professionals for the presence of functional deficits after they’ve completed treatment, in an effort to identify dysfunction earlier rather than waiting until it becomes grossly manifested and much more difficult to deal with.”
Morris said that physical therapists are part of the cancer care team and can aid with problems related to gait, deconditioning and residual functional deficits associated with surgical interventions, chemotherapy and radiation treatment.
Additionally, the Academy of Oncologic Physical Therapy, a component of the American Physical Therapy Association, recognizes physical therapists who have advanced training in oncology rehabilitation as being specialists in oncologic care. Receipt of this recognition requires additional clinic hours in an oncology rehabilitation setting and successfully passing a test that focuses on oncology rehabilitation principles, patient assessments and treatment interventions.
“Cancer survivors can seek out specially trained physical therapists and feel confident that they’re being treated by the most competent physical therapists available,” Morris said.
One aspect that Morris felt is not frequently recognized outside of the physical therapy community when it comes to cancer survivors is their increased fall risk.
“The increased fall risk present in many cancer survivors is associated with factors such as diminished vision secondary to chemotherapy, their age and unsafe living conditions,” he said. “The significance of this issue is that, once these patients fall, they are afraid of falling again, and that this fear can bring about changes in how they walk and where they’re willing to walk, leading these survivors to stay close to home and decreasing their level of physical activity.”
Getting ahead
Engaging in physical activity is important in the aftermath of receiving a cancer diagnosis, while receiving treatment and throughout survivorship, but there is also an opportunity to mitigate any deconditioning or intervention-related physical decline.
“One of the most underappreciated opportunities to improve fitness is prior to surgery,” Silver said. “Many cancer survivors are getting second opinions and there are built-in delays such as getting biopsies and staging, in which someone has the time to improve their fitness prior to surgery, and that is called prehabilitation.”
Silver said that although prehabilitation has been around for many years — frequently used in orthopedics — there is emerging evidence that it may have significant positive effects for patients with cancer after surgery, including decreasing length of stay and hospital readmissions. It also allows a patient to better tolerate future oncology-directed therapies such as radiation or chemotherapy.
“Cancer prehabiliation has been evolving and now, instead of just being exercise only, the prehabiliation prescription usually involves multiple interventions,” she said. “For example, increasing protein intake, which may improve outcomes, is a sports medicine concept. When you increase someone’s activity in sports medicine you also typically increase their protein intake.”
Silver added that because of the number of cancer care delays due to the COVID-19 pandemic, it is an important time to focus on keeping patients as strong as possible throughout their cancer-directed treatment, as well as after that treatment has concluded.
“Cancer survivors should aim to be as active at home and in their community environments as possible,” she said.
References:
- Campbell KL, et al. Med Sci Sports Exerc. 2019;doi:10.1249/MSS.0000000000002116.
- Khosravi N, et al. Brain Behav Immun. 2019;doi:10.1016/j.bbi.2019.08.187.
- McCrary JM, et al. Support Cancer Care. 2019;doi:10.1007/s00520-019-04680-w.
For more information:
G. Stephen Morris, PT, PhD, FACSM, can be reached at s.morris@wingate.edu.
Julie K. Silver, MD, can be reached at julie_silver@hms.harvard.edu.
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