The American Cancer Society estimated that in 2017, 135,430 people in the United States were diagnosed with colorectal cancer, and about 50,260 would die of the disease.1 Despite these numbers, mortality as a result of colorectal cancer has been declining over the past 20 years, thanks to improvements in screening and treatment.2 The 5-year survival rate is now about 65%.3 Because of the growing number of survivors in the United States, clinicians in all areas of medicine can expect to counsel and treat patients who have survived colorectal cancer.3
Patients may report ongoing physical and psychologic impairments, including cancer recurrence, secondary cancers, toxicity-related comorbidities, persistent fatigue, deconditioning, poor sleep quality, anxiety, and depression.4 As the number of survivors continues to increase, implementing physical activity and exercise in this population is of increasing importance, as it has been demonstrated to improve quality of life, slow functional decline, and decrease all-cause mortality.4 Although some patients may have difficulty participating in exercise, the American College of Sports Medicine has evidence-based data that exercise is safe during and after treatment for cancer.5 Clinicians should always try to incorporate exercise into a management plan for patients who have survived colorectal cancer.
EFFECT ON QUALITY OF LIFE
Increased levels of physical activity and exercise can have great effects on short- and long-term quality of life and overall health for patients who have survived colorectal cancer. However, studies have shown that the amount of physical activity in which these patients engage declines during treatment and does not return to baseline in survivorship. Moreover, physical activity and exercise in this population is low compared with other groups of cancer survivors.6 Although most patients with colorectal cancer survive more than 10 years after diagnosis, many face continuing physical and psychosocial problems due to cancer and its treatment.7 Some of these problems are weight gain; muscle weakness; peripheral neuropathy; depression; deconditioning; sleep disturbances; and decreases in physical ability, mobility, and range of motion.4 Physically active patients have a higher overall health-related quality of life, as well as less fatigue, pain, insomnia, and mental distress.7,8 Based on this evidence, the American Cancer Society and American College of Sports Medicine recommend a minimum of 150 minutes per week of moderate-intensity aerobic activity for patients being treated for cancer and those who have survived it.9
Quality of life, although difficult to quantify, often is impaired by diagnosis and treatment for colorectal cancer, and is important to measure given the longevity of patients who survive the disease. Fortunately, a substantial positive association exists between physical activity and exercise and health-related quality of life, which is consistent over time for patients who survive 2 or more years after a colorectal cancer diagnosis.7 Survivors meeting public health exercise guidelines of 150 minutes of physical activity and exercise per week had clinically meaningful increases of 13.7 points on the global quality of life score compared with survivors who did not meet these guidelines.7 The results of this study underline the importance of exercise training in survivorship care.
EFFECT ON FATIGUE AND SLEEP QUALITY
Persistent fatigue and psychologic distress are common in patients who have survived cancer. Fatigue often is tied to physiologic and psychologic adverse reactions to treatment, including depression, deconditioning, physical inactivity, and poor sleep quality.4 Furthermore, psychologic distress is nearly twice as common in patients who have survived cancer as in the general population and appears to be related to physical inactivity.4 However, statistically significant improvements in reported fatigue have been noted after 8 weeks of home-exercise programs in patients who survived stage IV colorectal cancer.10 Another study evaluating the effects of a 1-year cancer survivorship exercise program based on a cardiac rehabilitation model also demonstrated statistically significant declines in fatigue along with mental health improvements.9 This study reported improvements in depression by 25.1% and anxiety by 18.5% as measured by the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, respectively.9 This research demonstrates that regular physical activity has valuable effects on perceived fatigue and mood in patients who have survived colorectal cancer.
Along with fatigue, patients also are affected by poor sleep quality. Evidence suggests that cancer survivors struggle with this as a result of their diagnosis and treatment.4 However, studies have demonstrated improvements in sleep quality and decreased sleep disturbances in groups of cancer survivors who engage in exercise programs.10 One study demonstrated that patients who survived stage IV colorectal cancer and who participated in a home-based exercise program had statistically significant improvements in reported sleep quality compared with themselves at the beginning of the study and compared with the control group.10 Although limited in size, this study represents the potential improvements in sleep quality that patients obtain from exercise.
EFFECT ON ALL-CAUSE MORTALITY
Patients who survive cancer are at greater risk for cancer recurrence, secondary cancers, and comorbidities such as cardiovascular disease, diabetes, and osteoporosis compared with the general population.11 These comorbidities are linked with increased risk of death. However, several studies have demonstrated the benefits of exercise pre- and postdiagnosis in decreasing colorectal cancer recurrence and all-cause mortality.11-13 The exact physiologic mechanism is unknown but studies have suggested physical activity and exercise may influence insulin metabolism and affect the insulin-like growth factor (IGF) axis, which have been linked to colorectal adenoma formation, a known precursor to colorectal cancer.14-16 One study indicated that patients who had engaged in tasks of 8.75 or greater metabolic equivalents before being diagnosed with colorectal cancer had a 28% decreased all-cause mortality compared with the least physically active patients (defined as less than 3.5 metabolic equivalents).13 Postdiagnosis recreational activity levels demonstrated a 48% multivariable relative risk reduction for all-cause mortality when comparing the most active group with the least active.13 Research indicates that recreational activity levels about equivalent to 150 minutes of walking per week, before or after colorectal cancer diagnosis, are associated with decreased all-cause mortality in survivors compared with lower levels or no physical activity.11-13 This information further supports the benefits of elevated levels of physical activity and exercise in patients who have survived colorectal cancer and may help increase longevity in this population.
BARRIERS TO PARTICIPATION
Although physical activity and exercise have evident benefits in patients who have survived colorectal cancer, barriers often prevent patients from meeting their fitness goals. The absence of an exercise plan makes it less likely for patients to begin exercise. Research reveals that action planning may enable patients to initiate exercise rather than only consider it.13 Clinicians can motivate patients by working with them to identify the “why, when, and how” of their exercise routine. This can include referring patients to medically supervised exercise programs or physical therapy for improved functional status. Clinicians must encourage patients to acknowledge personal obstacles to exercise as well as to develop strategies to achieve exercise objectives.17 Concrete and attainable exercise plans let patients incorporate fitness programs into daily living.
According to research, patients who have survived colorectal cancer are inconsistent with continuing physical activity and exercise long term. Most physical activity and exercise interventions concentrate on short-term results; however, patients tend to revert to previous less-active lifestyles.7 In a study of patients who were within 5 years of completing treatment for colorectal cancer, the home-based exercise intervention group reported a significant increase in total minutes of exercise at 3 months compared with the control group, yet the increase was not maintained—minutes of daily physical activity progressively decreased at 6 and 12 months.3 This demonstrates a need for intervention programs directed at increasing physical activity and exercise throughout survivorship.
Studies show that patients may have reduced physical activity due to various medical conditions, including treatment-induced neuropathy. Lower physical activity levels are common in people with diabetic neuropathy, and research indicates that the same tendency is seen in patients who have survived colorectal cancer. Even survivors who stated that neuropathy did not interfere with their physical activity demonstrated lower physical activity and exercise minutes than those without neuropathy.17 Medical conditions limit physical activity in patients with colorectal cancer, and more incentives to increase physical activity may be needed in these patients.
Another barrier is the lack of oncology rehabilitation programs nationwide.14 Although programs could help overcome many of these boundaries and address cancer-specific problems, few programs are available to cancer patients and survivors.
STRATEGIES TO IMPROVE PARTICIPATION
Studies have examined implementing sporting events, group exercise, health coaching, and incentive programs as ways to improve physical activity and exercise in patients who have survived colorectal cancer. Patients who participated in sporting events reported having improved physical fitness, better weight control, more energy, improved strength, more subjective enjoyment, improved social interaction, and decreased stress levels.6 Although these benefits were notable, the patient groups more likely to engage in sporting events included those that were male, married, alcohol drinkers, in very good or excellent health, at 5 or more years postdiagnosis, and with fewer than four comorbidities.6 Clinicians should take this information into account when making physical activity and exercise recommendations for patients and identify potential barriers to compliance.
Another way to improve physical activity is to encourage patients to join group exercise programs. According to the social cognitive theory, people are more likely to learn from and engage in certain behaviors when these behaviors have been modeled for them. This ideology has been studied in promoting behavior changes in relation to health interventions.11 The theory was implemented in a 12-month randomized controlled trial that found that participants assigned to an experimental program consisting of individual and group counseling, as well as once-weekly group exercise sessions, were more likely to meet their physical activity goals than participants assigned to individual counseling sessions (70.4% meeting goal versus 43.4%).8 Therefore, social support in group exercise programs may greatly contribute to increased physical activity among patients who have survived colorectal cancer.
Telephone coaching is another option and can lead to exercise and improved dietary behavior that improve patient health-related outcomes, including better physical function, basic and advanced lower extremity function, mental health, and decreased body mass index.11 In another study, a 12-month program of telephone-delivered health coaching produced a significant decrease in sedentary behavior for older (age over 60 years), male, and nonobese patients who had survived colorectal cancer compared with those receiving only educational brochures.18 These studies demonstrate that even when exercise programs are not available, telephone interventions may help increase patient participation in physical activity and exercise.
Incentive programs also have been shown to promote physical activity and exercise among cancer survivors. Simple interventions such as pedometers and exercise logs may be enough to significantly increase physical activity in motivated patients participating in home-based exercise programs.19 In a recent randomized controlled study, cancer survivors receiving an exercise motivation package (exercise DVDs, pedometer, exercise diary, and one 15-minute education session) increased their exercise time by almost 48 minutes per week compared with those receiving no exercise materials or education.20 Although this study did not examine long-term benefits, it demonstrates how beneficial incentives might be in encouraging patients to engage in physical activity and exercise or to increase the amount of activity they participate in per week.
The current literature supports the value of physical activity and exercise in the overall health of patients who have survived colorectal cancer. Research suggests that physical activity and exercise mediates the regulation of insulin and the IGF axis, which have been linked to the formation and prognosis of colorectal cancer. However, understanding of the biologic mechanisms that contribute to colorectal cancer development, recurrence, and mortality is incomplete. Further studies are required to fully evaluate the relationship of physical activity, exercise, and biophysical markers throughout the course of colorectal cancer.
In this patient population, numerous studies demonstrate the benefits of physical activity and exercise in both subjective and objective measures. These include improvements in quality of life, fatigue, mood, sleep quality, as well as decreased cancer recurrence and all-cause mortality. Previous studies have used various parameters for defining high- and low-activity groups when determining associations with outcomes. Current studies also vary in program length, and many do not evaluate the effects of long-term physical activity maintenance in patients. Further investigation with randomized controlled trials is needed to establish clear guidelines for optimal intensity and duration of activity, as well as the effect of maintained physical activity and exercise in this population. Additionally, future studies are required to determine the most useful physical activity and exercise plans for patients based on their medical needs and available resources.
Clinicians in all practice settings should recognize the importance of physical activity and exercise in the treatment and survivorship of patients with colorectal cancer. Patients will benefit from a personalized physical activity and exercise prescription to engage in regular physical activity and avoid sedentary behavior. This should be quantified and spell out recommendations for the type of exercise, such as brisk walking and strength training, and the duration of exercise prescribed. Clinicians and patients should establish SMART (specific, measurable, achievable, relevant, and time bound) goals and schedule follow-ups to promote adherence to the recommendations. Despite strong evidence for the benefit of physical activity and exercise, initiating lifestyle changes often is challenging for patients. Clinicians must be cognizant of these barriers and tailor physical activity and exercise plans to the patient.
To enhance and maintain participation, clinicians may encourage recreational activities, group fitness, or medically supervised training. Patients may need referral to physical therapy or oncology rehabilitation for appropriate evaluation. The current literature suggests that physical activity and exercise is a useful tool in preventing colorectal cancer recurrence. Future research will aid in defining best practice guidelines for providers to motivate patients to implement and participate in sustained physical activity programs.
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Keywords:Copyright © 2018 American Academy of Physician Assistants
colorectal cancer; physical activity; exercise; survivor; mortality; quality of life