Avoid inactivity—That's the main message a roundtable convened by the American College of Sports Medicine (ACSM) wants oncologists to get across to their patients.
While clinicians have historically advised cancer patients to rest and avoid activity, emerging research challenges that recommendation, said Kathryn H. Schmitz, PhD, MPH, lead author of the new guidelines and Associate Professor of Epidemiology and Biostatistics at the Abramson Cancer Center of the University of Pennsylvania School of Medicine.
Cancer patients should be as physically active as possible both during and after treatment, said Dr. Schmitz. The guidelines appear in the July issue of ACSM's journal, Medicine & Science in Sports & Exercise (2010;42:1409-1426).
“We have to get past the idea that exercise is harmful for cancer patients,” said Dr. Schmitz, who also presented the guidelines at this year's ASCO Annual Meeting.
Exercise is not only safe for most patients, but also can improve physical fitness and strength, decrease fatigue, improve quality of life, and improve body image, she said.
With roughly 12 million cancer survivors alive in the US today, the recommendations have far-reaching implications, said the moderator of the ASCO discussion on the guidelines, Jennifer A. Ligibel, MD, Instructor in Medicine at Harvard Medical School and a medical oncologist at Dana-Farber Cancer Institute.
Many cancer patients who stop being physically active during treatment and early recovery never start up again, she said. “If we can prevent people from becoming inactive in the first place, we can stop them from going down that slippery slope.”
On the plus side, there are more and more articles in the literature regarding cancer and exercise, she noted. “If you had done a search between 1950 and 1979 using the words ‘exercise’ and ‘cancer,’ you would have found a dozen references. By 2009, there were almost 500.”
Moderate Activity Recommended
The 13-person ACSM panel came up with the exercise recommendations after reviewing published studies looking at the safety and effectiveness of physical activity during and after cancer therapy. The panel focused on breast, prostate, hematologic, colon, and gynecologic cancers, although most of the studies have been in breast cancer, Dr. Ligibel noted.
In general, the same 30 minutes a day, five days a week, of moderate-paced activity such as walking recommended for the general population is beneficial for cancer patients, even during treatment, according to the guidelines.
But it's not a one-size-fits-all prescription, and regimens should be tailored to individuals, taking into account their overall fitness, diagnoses, and other factors that could affect safety, the panel said.
Although stress testing is generally not needed prior to starting a moderate-intensity exercise program, some medical assessments are recommended, Dr. Schmitz said.
For example, evaluation for musculoskeletal morbidities and peripheral neuropathies secondary to treatment is recommended, regardless of how long it's been since the patient underwent treatment. Patients who have undergone hormonal therapy should be evaluated for fracture risk, and patients whose disease has metastasized to the bone should have medical clearance before starting an exercise program.
Patients with cardiac conditions, whether related to their cancer or not, as well as those who are morbidly obese, may require additional supervision and exercise modifications, the guidelines state.
It may be advisable to tell patients with gastrointestinal cancers as well those whose cancers have metastasized to the bone to avoid heavy weight-training, Dr. Schmitz said.
Yoga generally appears safe, and as for Pilates, she noted, there was no published evidence for the panel to review, so a recommendation could not be made one way or the other.
Women with breast cancer can do upper body training—“but it should be done very slowly, which is not how many people approach it,” Dr. Ligibel said.
People with compromised immune systems should be advised to avoid exercising in public gyms, she added, and if a patient has peripheral neuropathy, a stationary bike may be preferable to weight-bearing exercise.
While large gains have been made regarding the benefits of exercise in certain cancers, particularly breast, there are still large research gaps, Dr. Schmitz said. For example, colon cancer is the third most common cancer and has a fairly good prognosis, yet few trials have examined the potential contributions of exercise toward recovery.
Also, most cancer survivors are over age 65, yet most exercise studies have been conducted in younger patients. There is also a need for assessing the benefits of alternative forms of exercise such as Pilates, Dr. Schmitz said.
Finally, because cancer treatments are increasingly customized according to specific tumor characteristics, fitness trainers who work with cancer survivors need to learn as much as possible about the specifics of patients' cancer diagnoses and treatments in order to make informed safe choices, she said.
The Bottom Line
Asked to comment on the panel's recommendations, prostate cancer specialist Brant Thrasher, MD, Chairman of Urology at the University of Kansas, said they were long overdue.
“No one is recommending people go out and take a run the day they are having chemo,” he added. “Patients know their bodies best, so work with them to come up with an exercise program with which they feel comfortable.”
Echoing the panel's bottom line, Dr. Thrasher concluded: “The important thing is to avoid inactivity.”
ACSM's Exercise Guidelines for Cancer Survivors
The new guidelines stress that patients should avoid inactivity and engage in normal daily activities and exercise as much as possible during and after treatment, but clinicians need to be aware of certain risks and the potential need for exercise modifications in different populations of cancer patients.
Breast cancer: Be aware of fracture risk.
As far as resistance training, start the patient on a supervised program at very low resistance, with additional resistance added in small increments. Watch for arm/shoulder symptoms, including lymphedema, and reduce resistance or stop specific exercises according to symptom response. There is no upper limit on the amount of weight to which survivors can progress.
Yoga appears safe as long as arm and shoulder morbidities are taken into consideration. Dragon boat racing was not empirically tested, but the volume of participants provides face validity of its safety. There are no data on organized sport or Pilates.
Prostate cancer: Same situation, to be vigilant for the increased potential for fracture. As far as resistance training, pelvic floor exercises should be added for men who undergo radical prostatectomy.
Colon cancer: As far as aerobic activities, patients with an ostomy should be cleared by a physician prior to participation in contact sports.
With resistance training, start the patient at low resistance and progress resistance slowly to avoid herniation at the stoma.
Recommendations for flexibility training are generally the same as for the general population, but care should be taken to avoid excessive intra-abdominal pressure for patients with ostomies.
If an ostomy is present, modifications will be needed for swimming or contact sports.
Gynecologic cancers: There are no data on the safety of resistance training in women with lower limb lymphedema secondary to gynecologic cancer. This condition is very complex to manage.
Proceed with caution if the patient has had lymph node removal and/or radiation to lymph nodes in the groin.
General statement: For patients with metastatic bone disease, exercise programs need to be modified to avoid fractures. Patients with cardiac conditions, secondary to cancer or not, may require exercise modifications as well as greater supervision for safety.