The purpose of this article is to discuss exercise recommendations for cancer survivors at different stages of survivorship. The survivorship period for patients with cancer is defined by the National Cancer Institute as beginning on the day of cancer diagnosis and continuing through the end of life. This definition is broad and includes people with no tumor burden as well as those in the final stages of multiple organ failure at the end of life. Clearly, exercise regimens need to be tailored to address individual needs and abilities at various points along the survivorship trajectory. This article includes a succinct review of current research into exercise in the cancer setting and a discussion of the American College of Sports Medicine (ACSM) exercise recommendations for cancer survivors. Common acute, long-term, and late effects of cancer and its treatment are also described in the context of ways in which these side effects impact the ability to exercise. We conclude with a brief discussion of ongoing exercise programs in the community, at cancer centers, and in culturally adapted programs that have been developed for specific underserved communities.
Overview of Research Into Exercise for Cancer Patients and Survivors
Cancer treatment causes profound debilitation that leads to reduced physical function and impairs quality of life. Negative sequelae have been observed across a range of treatment types—from surgery, to radiation, to hormonal treatment and targeted therapies. For example, aerobic capacity, an important indicator of physical fitness and function, has been shown to decrease by 10% to 33% over a 12-week period of chemotherapy for breast and other cancers.[2-4] Almost one-third of breast cancer survivors have aerobic capacity below the minimum physiologic threshold required for functional independence. Peak oxygen consumption, which has been found to be reduced in patients with breast cancer across the survivorship continuum, may also be an independent predictor of survival in those patients with metastatic disease.
The declines in physical abilities and physiologic function that are commonly observed in cancer patients can be minimized or prevented with a well-thought-out progressive program of restorative exercise. A substantial body of evidence demonstrates that exercise improves a variety of objectively measured and self-reported outcomes. Exercise during and following treatment has been associated with reductions in cancer recurrence and disease-specific mortality rates of 30% to 60% in breast and colorectal cancers.[6-8] Exercise also has been found to prevent or ameliorate many treatment-related negative effects—such as fatigue, muscle weakness, declines in cardiovascular function and overall functional ability, neuropathy, altered body composition, and reduced quality of life.[1,2,9-19]
The aforementioned treatment-related effects are observed across different tumor types (eg, in breast, prostate, colorectal, and lung cancer patients; in the setting of bone marrow transplant; and in other clinical scenarios), during and after treatment, and at different stages. Among breast cancer survivors, for example, the incidence rate of lymphedema has been reported to range from 6% to 70%. Risk factors include extent of axillary surgery and treatment with radiation therapy and/or chemotherapy. However, a study of breast cancer survivors showed that those who engaged in a slow, progressive program of resistance exercise (weight lifting) not only strengthened their affected arms but also had a lower incidence and severity of lymphedema. Similar benefits have been observed in multiple studies of prostate cancer survivors receiving androgen deprivation therapy—which has a profound impact on skeletal muscle mass and strength, as well as body composition. Men who exercised gained muscle strength; improved their body composition, physical function, and quality of life; and experienced reductions in fatigue.[16-19]
Only a moderate amount of physical activity is required to achieve many of the protective benefits of exercise. Walking for 30 minutes 5 days a week at a speed of about 2.5 miles per hour conveys health benefits and is an attainable goal for most cancer survivors. During a period when we expect patients to become debilitated, simple exercises such as walking 3 or 4 days per week can prevent the typical declines and, in many cases, improve functional ability.
Despite a rapidly growing body of evidence for the benefits of exercise for cancer survivors, 80% of oncology care providers (nurses and physicians) have reported being unaware of the availability of exercise guidelines in this setting and lack knowledge about when to implement them and where to refer survivors for exercise programs. As a result, few cancer survivors receive formal information about exercise, a referral to rehabilitation or physical therapy, or even direction to an appropriate community-based exercise program. Notably, oncology care providers who are physically active themselves and meet the national exercise guidelines are significantly more likely to discuss exercise with their patients and provide a referral.
To provide optimal care during and following treatment, healthcare providers should refer cancer survivors to programs of restorative exercise to reduce their fatigue, weakness, pain, and (in some patients) risk for lymphedema, and to improve their overall functional ability. The facility to which a survivor is referred for physical rehabilitation may be based on the individual’s level of physical function, previous experience with exercise, degree of debilitation, and number and types of comorbidities. Initially, a survivor with severe debilitation and other comorbidities that greatly limit his or her physical abilities may achieve the greatest benefit from working with a physical therapist. Survivors who are able to perform activities of daily living and are not experiencing any specific deficit(s) (eg, lymphedema, peripheral neuropathy, pain, muscle weakness) that significantly compromise their physical abilities will benefit from a community-based program directed by a cancer exercise specialist, such as the exercise programs offered by LIVESTRONG at the YMCA.
ACSM Exercise Guidelines for Cancer Survivors
In 2009, the ACSM convened a multidisciplinary group of experts to review cancer exercise research and develop guidelines for survivors.[1,9] In many ways the ACSM Exercise Guidelines for Cancer Survivors (summarized in Table 1) mirror the US Department of Health and Human Services Physical Activity Guidelines for Americans, but specific recommendations are given for different sites of cancer; stages of disease; types of treatment; and acute, long-term, and late treatment effects. The overwhelming message to convey to all cancer survivors is that inactivity should be avoided and any level of physical activity may provide some degree of health benefit.
The ACSM guidelines recommend that all cancer survivors engage in at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity per week and 2 days per week of resistance exercise at a moderate to high intensity for all major muscle groups. In addition, the guidelines recommend flexibility exercises for the eight major muscle groups. Exercises to improve balance are recommended for older adults, and there is little downside to including them in a survivor regimen for individuals of any age, especially for survivors at increased risk of falling. The guidelines make explicit exercise recommendations for cancer-specific conditions such as lymphedema, peripheral neuropathy, breast reconstruction, and central lines, as well as for colorectal cancer survivors who should avoid excess abdominal pressure, because of ostomies. While there are limitations on the generalizability of the research to date, which does not include all cancer populations, the overall findings are strong enough to recommend that exercise is safe and should be encouraged, whereas inactivity should be avoided. Table 2 highlights the goals of exercise programs for cancer survivors.
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