Cancer is a wake-up call to start a healthy lifestyle / Part 1: Fitness for Cancer Survivors

This year, nearly 1.5 million Americans will hear those frightening words “You have a cancer” (Snowden 2009). Many more -1 in 2 men and 1 in 3 women - will receive a cancer diagnosis in their lifetime (Runowicz 2006).

The good news: cancer is not a death sentence. For many of the most common forms of cancer—including breast, prostate and skin cancer—the 5-year survival rates following an early-stage diagnosis are close to 90% or higher (Ries et al. 2008).

As cancer survivors face the challenge of reclaiming their health, there is strong growing evidence that exercise can help. Unfortunately, most cancer survivors are not physically active. In a survey of more than 11 4,000 Canadian adults, fewer than 22% of cancer survivors exercise adequately (Courneya, Katzmarzyk & Bacon 2008). The statistics for Americans are equally dismal, with the majority of survivors not accumulating the recommended 150 minutes of activity per week (Blanchard, Courneya & Stein 2008).

Nicole Culos-Reed, PhD, associate professor of kinesiology at the University of Calgary and founder of the Yoga Thrive program for cancer survivors, believes that having cancer can be an opportunity to start a healthy lifestyle changes: “Cancer is a teachable moment and a wake-up call. It’s a real opportunity to change the behaviors we know are critical to survival.”

Living Longer, Living Better

Following the shock of diagnosis, one of the first things survivors want to know is: What can I do to make sure this disease won’t come back, and doesn’t kill me? According to Culos-Reed, who also conducts research on the benefits of exercise for cancer survivors, “Physical activity is the single largest modifiable risk factor we know of to prevent recurrence.”

A recent review in the British Journal of Sports Medicine identified nine studies showing that physical activity reduced the risk of death in cancer survivors (Irwin 2009). Most striking was the finding, across a number of studies, that 3-hours a week of moderate-intensity exercise was associated with a 50% – 53% lower risk of death in breast cancer survivors and a 39% – 59% lower risk of death in colon cancer survivors. Although other forms of cancer have not been studied sufficiently to draw strong conclusions, there is no reason to suspect that exercise would not benefit people with other types of cancer.

Living longer is a powerful motivator, but quality of life can be equally important. A recent national survey of more than 9,000 cancer survivors found that for all types of cancer, meeting the recommended guidelines for physical activity was associated with a higher health-related quality of life, including less pain, fewer difficulties completing daily tasks, better physical functioning and better general health (Blanchard, Courneya & Stein 2008).

Is Exercise Safe During Treatment?

Many exercise programs for cancer survivors recommend that participants wait until after surgery, chemotherapy or radiation to begin. However, a review of 22 studies found that exercise during cancer treatment could enhance immune-system and physical functioning and improve the following symptoms and side effects: anxiety, mood swings, depression, fatigue, difficulty sleeping, pain, nausea, muscle weakness, reduced bone mineral density and poor body composition (Knols et al. 2005).

Culos-Reed states that almost all oncologists now support starting physical activity as soon as patients are ready, including before or during treatment—something she says is a big change in medical opinion from even a decade ago. She recommends that patients get as much activity as they can during treatment, as long as they have clearance from their physician. This sometimes runs counter to patients’ instincts. “If they have physical side effects and fatigue, they think they have to protect the body. They don’t want to stress it, so they pull back and don’t engage.”

But the evidence suggests that appropriate exercise during treatment can restore energy, not deplete it. A recent meta-analysis of 28 studies—15 of which examined physical activity during treatment—found that exercise significantly improved fatigue in cancer survivors (Cramp & Daniel 2008). A wide variety of exercise types, including cardiovascular exercise (e.g., walking, stationary cycling), strength training, flexibility training and yoga, helped boost energy.

Testimonial

Margaret Zuccotti, a 40-year-old mother of three with stage 4 breast cancer, is a perfect example of staying active during treatment. “Right from the beginning, running made chemo tolerable,” she says. “I ran or walked most days throughout my 7 months of weekly treatments, and felt like I was actively going after my cancer in more ways than one.” Zuccotti has won the survivors’ division of the Philadelphia Susan G. Komen Race for the Cure 2 years in a row. “I am on Herceptin every 3 weeks from now until forever, but I run and compete to my heart’s content. Running helps me remember all that I am in addition to being a survivor.”

Finding Strength and Support

Zuccotti’s story points to another important benefit: exercise can give cancer survivors a sense of control and positive action. Doreen Puglisi, MS, founder and program director of the Pilates-based Pink Ribbon Program for breast cancer survivors, says, “This is one thing they can choose to do that feels good to them. All the other choices—chemo, surgery—they [also] have to make, but they don’t feel good. You do them because you want to survive. Exercise is the one thing that feels good both physically and mentally.”

Another key benefit of exercise programs for cancer survivors is social support. Cerrito agrees that the social component keeps people coming back to the Starting-Over program. “It’s not a support group per se, but a supportive environment. The people in the program bond with each other because they have so much in common.”

Understanding Symptoms and Side Effects

The symptoms and side effects of survivors’ treatment are far-ranging. They influence what they are able to do safely and what they need from an exercise program. To workout efficiently and safely, survivors must learn about the treatment symptoms and side effects, and how to address them.

Take, for example, lymphedema[1]: Exercise can help lymphedema but also make it worse. According to the National Lymphedema Network (2008), aerobic exercise, gentle stretching, and slow, repetitive movements without extra resistance may be helpful for reducing or preventing lymphedema. To avoid harm, a compression garment should be worn during exercise to prevent additional swelling. Strength training should begin with a low load, and progress gradually, allowing adequate rest between sets. Aggressive stretching should be avoided.

In practice, these recommendations can look quite conservative. Cerrito says, “Instead of going on a machine with a minimum weight of 20 pounds, we start with 1-pound hand weights. If you do well, maybe next week or so you’ll try 2-pound weights. If there are any adverse symptoms, such as pain, tingling or more swelling, then you back off.”

Another common side effect of chemotherapy is cognitive impairment—what we call “chemo brain.” “Chemo brain really affects memory and coordination skills,” says Hall. “Survivors are aware of it and will often joke about it or get really frustrated. I am very patient with them and try my best to make the workouts a positive experience.” Cerrito agrees that patience is key.

Fatigue, the most common side effect of cancer treatment, can be quite unlike the kind of tiredness most of us are familiar with. Laura Thatcher, MS, exercise physiologist for the Cancer Wellness Program at McConnell Heart Health Center in Columbus, Ohio, says, “During treatment, individuals have a different level of fatigue. It is not the fatigue of ‘I had a hard day at work,’ but more like, ‘I am completely exhausted.’ On certain days after treatment, survivors may not be able to even come close to what they would normally do.” Her program helps survivors find their “new normal” and overcome any frustrations that arise if they cannot do as much as they could before the diagnosis.

Promoting Lasting, Positive Change

According to Culos-Reed, an 8-week exercise program can be a big success; but “maintenance is a huge challenge.” There are many things you can do to support survivor’s commitment.

Survivor should do the kind of exercise that they enjoy doing it. The doctor might say walking is good for you, but unless you enjoy it, it doesn’t matter, because you won’t do it.

Culos-Reed also encourages having a workout buddy and recruit the social support they need to make exercise a priority. For example, the Yoga Thrive program invites cancer survivors to bring a support person to class. Like survivors, caregivers are often exhausted and stressed out by the experience of cancer treatment. They can benefit from exercise while supporting the survivors in staying active.

What’s the Best Exercise for Cancer Survivors?

There is little evidence that any one form of exercise is superior to others for cancer survivors. Existing research supports the benefits of a wide variety of exercise types, from cardiovascular training to yoga. That said, a 2006 review by Conn et al. found that almost all supervised exercise interventions for cancer survivors included some form of aerobic exercise (e.g., walking, treadmill, stationary cycling).

Most interventions were designed to provide moderate-intensity exercise. About half of the programs included resistance and flexibility training. Interventions tended to be 10 weeks or longer, with three sessions per week. Findings on mind-body approaches are not as far along as the research on more traditional fitness approaches. However, a 2009 review by Smith and Pukall found direct positive evidence that yoga could improve health-related quality of life, stress, and mood in cancer survivors.

American Cancer Society’s Physical Activity and Nutrition Guidelines for Cancer Survivors

• Engage in at least 30 minutes, and preferably 45–60 minutes, of moderate-to-vigorous activity 5 or more days a week.

• Balance caloric intake with physical activity.

• Achieve and/or maintain a healthy weight.

• Eat five or more servings of vegetables and fruits each day.

• Choose whole grains over processed grains.

• Limit consumption of processed and red meats.

• Limit alcohol to one drink per day for women or two per day for men.

Meeting these guidelines (Doyle et al. 2006) may be quite challenging. A survey by the American Cancer Society found that the majority of cancer survivors do not meet the physical activity guidelines, and only 5% meet the guidelines for both physical activity and nutrition (Blanchard, Courneya & Stein 2008). Nicole Culos-Reed, PhD, associate professor of kinesiology at the University of Calgary and founder of the Yoga Thrive program for cancer survivors, recommends making these guidelines the ultimate goal, but not an all-or-nothing demand. “It has to be a gradual progression. If survivor try 30 minutes and are sore the next day, he/she might decide, ‘That’s it, I’m done, I quit.’ 30 minutes a day is the goal. Five minutes a day is okay. Ten minutes a day is okay.”

As more and more physicians recommend exercise, many cancer survivors will be looking for support from the fitness community. And many will have trouble finding knowledgeable trainers who can work with them. “The worst thing that can happen is someone walks into a gym, says he has cancer, and the staff says, ‘Oh, we’re sorry,’” says Culos-Reed. “[Survivors] don’t want you to be sorry—they want you to know what to do, how to keep it safe and how to work with them.”

Survivor Fitness Program in Bangkok for Free (available end of June 2017)

I’m a personal trainer and health coach in Bangkok. In 2014 I was diagnosed with colon cancer. When I looked for an exercise program to help me overcome the pain, stiffness, and other side effects of treatment; I could not find anything specifically for colon cancer survivors and the general guidelines were all missing serious studies and results. All the recommendations were so vague and incomprehensible.

During my cancer treatment I completed the American College of Sport Medicine (ACSM) course: ACMS’s Guide to Exercise and Cancer Survivorship.

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[1] Lymphedema is a buildup of lymphatic fluid in the arms or legs that is a common side effect of radiation, chemotherapy, or surgery

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