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ACSM'S Health & Fitness Journal:
doi: 10.1249/01.FIT.0000312438.07851.4b

Living With Cancer: Part 2: Exercise and Other Treatment Options

Scott, Shelby M.D., FACSM, FAAFP

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Shelby Scott, M.D., FACSM, FAAFP, is part-time faculty at Natividad Medical Center in Salinas, CA, and associate clinical faculty at University of California-San Francisco School of Medicine. She practices Family Practice and Sports Medicine in the Santa Cruz area of California.

The first part of this column examined how exercise and other lifestyle modifications help prevent cancer. Cancer is a complex multifactorial disease; people develop cancer because of hereditary, environmental, and infectious factors. Because of the different processes involved, some people will acquire cancer despite the healthiest of lives. Lifestyle modification decreases the incidence of cancer but cannot prevent it completely. There are many different types of cancer, but all cancers are defined as uncontrolled growth and spread of abnormal cells. If the growth of these abnormal cells remains uncontrolled, the result is death.

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Once a person develops cancer, the treatment options available depend on the type of cancer and stage of the disease. Some cancers are benign, that is, not dangerous. Their treatment is usually limited to surgical resection or removal. Two examples of benign cancers treated surgically are basal cell skin cancer and teratoma. Most other cancers have the potential to become malignant. Malignancy is defined by rapid growth of the tumor, invasion of local tissues, and spread to other are as of the body. The latter process is known as metastasis of the tumor cells. Metastases can occur either as direct growth or through the blood or lymph systems. Hematogenous spread, distribution of cancer cells through the blood, leads to more global disruption of body function. The staging of the cancer is based on the histological typing of the cell compared with its parent cell type and the extent of invasion of the local and distant tissues.

Treatment of malignant cancer aims at slowing growth and reducing tumor bulk (1-3). Surgical resection of the tumor directly reduces tumor size. It also reduces the mass effect on the surrounding tissues. Chemotherapy and radiation therapy damage the rapidly growing cells, generally at the deoxyribonucleic acid level. Cancer cells lack the repair mechanisms of more mature and differentiated cells; therefore, they are affected more than noncancerous cells. As a result, the cancer cells will die more quickly. These cancer treatments may affect any rapidly reproducing cells in the body, like the cells lining the gastrointestinal tract and hair follicles. That is why some chemotherapy leads to hair loss and gastrointestinal problems.

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The symptoms and findings related to a cancer illness depend on both the type of cancer and degree of involvement in the body, or the stage of the cancer. A full discussion of the different types of cancers is beyond the scope of this column. Generally, people with cancer have weight loss, anemia of chronic illness, muscle wasting, and fatigue. Pain is a later effect of cancer. It develops from the direct effect of the tumor; invasion of the surrounding tissues, pressure on the nerves, or pressure on surrounding structures as the tumor grows. Chemotherapy-induced neuropathy and radiation-induced fibrosis are common sources of pain associated with cancer treatment.

Cancer-related pain, whether from the disease or the treatment, is complex. It varies from person to person and with different treatments and advancement of the disease. Pain stimulus is then processed by the cognitive, affective, behavioral, and cultural influences of the individual. Modification of the psychological response to pain is very important in the course of treatment for cancer (4). Add to this the overriding fear of death, the fear of becoming dependent on others, and individual family issues. Pain is subjective, being interpreted by the person experiencing it. Some people deal with their pain better than others. The ability to handle pain depends on the number and aptitude of a person's coping skills. A strong self-esteem helps deal with pain, as does an extensive social support system (5). An individual's spiritual beliefs also can influence how they manage their pain.

Fatigue often is the first sign of cancer for some people. As with pain, fatigue may be directly related to disease process or from the treatment. It increases with the number of cancer treatments used and the progression of the disease. More than 74% of cancer patients have cancer-related fatigue in the course of their illness, with 32% having daily fatigue (6). Unfortunately, most people think that fatigue is a normal part of cancer. Even when questioned by a physician, they may not report feeling tired. Patients are afraid that, if they report fatigue, they may have treatment delayed or be excluded from treatment protocols. People may feel that fatigue represents advancing disease or a worsening prognosis and therefore feel anxious about discussing it.

Fatigue due to cancer is related to different physiological and psychological issues. Anemia can develop as a side effect of cancer or from chemotherapy. As people have loss of appetite, their impaired nutritional status leads to anemia. People with cancer have a wasting syndrome that results in loss of muscle mass, decreased metabolism, and fatigue. In response to the chronic stresses of disease, increased cortisol production can produce fatigue. Disruption in the normal sleep-wake cycle leads to fatigue for many reasons. And the direct central nervous system effects of chemotherapy or metastatic disease lead to fatigue. Radiation treatment produces moderate to severe fatigue; fatigue is a normal response in the postoperative setting. Poor nutrition due to the gastrointestinal effects of cancer treatment or cancer-associated anorexia increases fatigue. Poor nutrition can lead to abnormalities in electrolytes, which results in fatigue. Any comorbid illness can magnify fatigue, in particular uncontrolled diabetes, thyroid disease, renal insufficiency, and liver disorders.

Another important side effect of cancer and cancer treatment is depression and other affective or mood disorders. More than half of the people with cancer have an underlying psychiatric diagnosis (7). Patients with a comorbid psychiatric diagnosis are twice as likely to develop cancer-related pain. Living with pain can increase depressive symptoms (5). As the symptoms of affective disorders increase, they lead to increased pain perception and delayed healing time. This can develop into a snowball effect of worsened depression, increased pain, and impaired treatment response. Additionally, depression can be exacerbated by the medications used to treat pain-opioid narcotics. Depression, pain, and chemotherapy can hinder proper sleep cycle; sleep is necessary for the production of growth hormone and the normal diurnal cycle of the stress hormone, cortisol. Without proper sleep, it is nearly impossible to cope with the symptoms and stresses of cancer. The interrelatedness of depression and cancer makes treatment of depression very difficult. It is almost impossible to treat with medications alone. Health care providers have to use a multifactorial approach.

Different modalities for the treatment of pain, fatigue, and depression related to cancer and chemotherapy are cognitive therapy, relaxation techniques, imagery, and exercise.

Cognitive, or behavioral therapy, can improve self-esteem and outlook on life. As previously mentioned, a low self-esteem increases pain perception. Mental exercises aimed at improved self-love and appreciation can improve a person's ability to cope with all the problems the disease throws at them. This may be an especially difficult task when one already has cancer, but it is important for quality of life and within the treatment process. Cognitive therapy was honed for use in the 1960s by psychiatrist Aaron Beck. Depressed people, according to Beck, have views such as "I never do a good job," and their negative thought processes lead to worse depression and negative sense of self. Beck also described the hopelessness theory of depression, stating that hopelessness depression is caused by a state of hopelessness. Hopelessness develops when a person believes that only negative outcomes are possible and that they have no ability to affect a positive result. Cancer can definitely worsen the sense of hopelessness. Specific thought exercises, like self-affirmations, and journaling can help break the negative cycle. Journaling helps individuals recognize factors that are under their control and how they can cope with and approach different problems.

Another form of movement and thought process treatment is Qigong (Chi Kung). Qigong focuses on diaphragm breathing, which is an important component of relaxation. Proper diaphragm breathing facilitates the relaxation response. Qigong can be practiced while lying in bed, making it useful as adjunctive therapy through all stages of cancer treatment. In the movement phases of Qigong, the exercises help maintain flexibility, strength, and joint movement. It is not a standard part of western medical care but is covered in the Chinese health care system. Other processes for relaxation and positive imagery have been shown in clinical trial to reduce pain in cancer patients (8). Relaxation and imagery work better for predictable pain, but the skills can be cultivated to work for unexpected pain as well.

Imagery uses techniques similar to Beck's cognitive models. People draw pictures of themselves, their bodies fighting the cancer, and other positive events. The "pictures" may be physical or mental. Imagery is the ultimate of positive thinking and prayer: that believing so positively in an event can help it happen. Mostly, imagery disrupts negative thought processes and lends to a more relaxed state of mind. Imagery distracts the brain from the automatic negative thoughts associated with cancer, cancer pain, and cancer treatment; it helps to lessen pain and facilitate the treatment processes. Norman Cousins was a famous editor and journalist who made imagery as treatment popular. He performed an experiment on himself to document the positive effects of laughter and positive thinking (9). He outlived the fatal diagnoses given him by his physicians and had a very positive quality of life.

The last topic for discussion in "alternative" treatment for cancer is exercise. Exercise cannot cure cancer, nor can any of the modalities above. But when used in combination with accepted medical treatments, exercise can lessen pain, increase longevity, and improve quality of life (2-4,8). Physical therapy often is forgotten in treatment of chronic disease, particularly cancer. Exercise helps patients cope with pain by releasing endorphins, or opiate like chemicals, in the brain. People who exercise sleep better and have more energy for their daily activities. Physical activity prevents muscle wasting and joint stiffness, which are common side effects of both cancer and cancer treatment. There are no studies demonstrating that one form of exercises is more beneficial than another (10-12). Nor are there studies quantifying the amount of exercise required for benefit. The few studies show that any form of physical activity increases both quality and quantity of life (11,12). The American Cancer Society recommends 30 minutes of moderate-intensity physical activity at least 5 times a week (10). While promoting an active lifestyle in clients with cancer, one must also convey that not exercising regularly will not make their cancer worse.

There are physical activity limitations with cancer and cancer treatment (Table). The biggest factor to consider is the daily energy level. Exercise should help a person feel better, not more fatigued. It also is important to promote an activity that is safe and reasonable (13). Exercise should be fun and enjoyable. The goal is to promote healing and reduce stress. Forced exercise, or exercise while fatigued, can increase stress and counter any positive benefits of exercise.

TABLE Safe Exercise ...
TABLE Safe Exercise ...
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In summary, activity and lifestyle modifications can prevent cancer but are not adequate in the treatment of cancer. Lifestyle modification is still intrinsically important in the management of stress, depression, sleep disturbance, fatigue, and pain associated with cancer and treatment. A brief discussion of different treatments is presented in this column. There are many other nonpharmacological treatments not discussed.

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1. American Cancer Society (2006). Cancer Facts and Figures-2006. Atlanta: American Cancer Society, 2006.

2. Available at Accessed February 28, 2008.

3. Available at Accessed February 28, 2008.

4. Bajwa, Z., and C. Warfield. Nonpharmacologic therapy of cancer pain. Updated April 24, 2007. Available at Accessed May 17, 2008.

5. Passik, S.D., and K.L. Kirsh. Management of psychiatric and psychological disorders in patients with cancer. Updated October 17, 2007. Available at Accessed May 17, 2008.

6. Escalante, C. Cancer-related fatigue: assessment and treatment. Updated May 28, 2008. Available at Accessed June 10, 2008.

7. Derogatis, L.R., G.R. Morrow, J. Fetting, et al. The prevalence of psychiatric disorders among cancer patients. Journal of the American Medical Association 249:751-757, 1983.

9. Cousins, N. Anatomy of an Illness as Perceived by the Patient. New York: WW Norton & Co, 1979. Supplemented with personal comments made to the author, 1988.

© 2008 American College of Sports Medicine


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