Exercise Guidance after a Cancer Diagnosis: Evidence and Logistics

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1 Exercise Guidance after a Cancer Diagnosis: Evidence and Logistics Kathryn Schmitz, PhD, MPH, FACSM President Elect, American College of Sports Medicine Professor, Penn State College of Medicine Associate Director of Population Sciences Penn State Cancer Institute

2 Evidence Overview Why exercise? Pre-exercise evaluation? Logistics Getting it done Time for your questions

3 Schmitz et al. MSSE, 2010

4 American Cancer Society

5 National Comprehensive Cancer Network

6 MOST IMPORTANT MESSAGE AVOID INACTIVITY FOR US ALL:

7 Overview of common exercise recommendations for cancer survivors 150 minutes aerobic activity per week 2-3 times weekly strength training Flexibility on days when other activities are performed (daily)

8 Why Exercise? Address Adverse effects of cancer treatment Fatigue CV late effects Lymphedema Poor Bone outcomes Function, quality of life and survival Physical Function Arthralgias CIPN

9 Why Exercise? Reduce health care costs $9988 USD per cancer survivors per year Upper-body symptoms, fatigue, or poor upper-body function OOP costs 4+ common adverse treatment effects OOP costs X 2 Interventions costing <$4000 USD per patient per year worth exploring Schmitz et al. Supportive Care in Cancer, 2015

10 For Example Exercise will Improve Physical Function After Cancer Morey et al. JAMA 2009 (RENEW Trial) Brown et al. JCO 2015 (PAL Trial) Increased strength is associated with improved functional capacity in older adults Aerobic exercise is definitely associated with improved physical abilities (aerobic fitness) 10

11 Cancer Related Fatigue Pre tx During tx Post treatment 3-6m 12m Fatigued 30% 93% 50% 25% Data from Hayes et al. 11

12 Exercise Improves Fatigue Brown et al meta-analysis Exercise reduced CRF especially in programs that involved moderate-intensity, resistance exercise among older cancer survivors and that were guided by theory National Comprehensive Cancer Network Aerobic exercise is the #1 recommended nonpharmacologic treatment for cancer related fatigue 12

13 What helps with Aches & Pains in Medications, switching or discontinuing Aromatase Inhibitors, Acupuncture And Exercise! Cancer Survivors? Project HOPE, Irwin et al. JCO min/week walking 2x weekly strength training 13

14 Bone Health Treatment-related causes of bone health problems in cancer survivors: Chemotherapy-induced premature ovarian failure Medical or surgical ovarian ablation therapy Hormonal treatments Other causes: Inactivity Use of corticosteroids Inadequate intake of calcium and Vitamin D 14

15 What helps with promoting Bone Health? Quitting smoking Adequate Calcium/Vit D Bisphosphonates Stress Reduction Bone Density Testing Exercise! Particularly weight training! Nelson et al. JAMA 1994 Excellent evidence in prostate cancer survivors as well (Segal et al. JCO 2003) Winters-Stone et al

16 Heart Health & Breast/Prostate Cancer Personal and behavioral risk factors for Heart Disease: Age Body mass index Diet Physical activity levels Smoking Cholesterol Blood lipids Treatment-related factors too 16

17 Cardiovascular Disease Competes with Breast Cancer as Cause of Death in Survivors Patnaik

18 American Heart Association Guidelines for Heart Health Quit smoking Good nutrition, weight control Omega-3 fatty acids Treatment for hypertension and dyslipidemia Screening for cancer related heart health problems is available. Exercise! Aerobic exercise has long been recognized to be protective against cardiovascular disease outcomes Aerobic exercise is specifically good for those with and at risk for congestive heart failure 18

19 What about Lymphedema? Does Exercise help with Lymphedema symptoms? YES! In the PAL trial, Control group women with lymphedema had 2X the number of flare-ups compared with those who did weight-lifting Weight-lifting women without lymphedema who had 5+ nodes removed were 70% less likely to develop increased arm swelling compared to the control group 19

20 Could Exercise be helpful during Chemotherapy? Increasing evidence that exercise may improve the ability to complete chemotherapy particularly WEIGHT TRAINING Courneya et al. JCO 2007, Breast Cancer Exercise Trial Van Waart et al. 2011, Breast Cancer Exercise Trial Cespedes et al., JAMA Oncology 2018, observational evidence that muscle mass is associated with dose limiting toxicities

21 Physical activity and obesity Question: Can you lose weight through exercise alone?

22 Exercise alone works well to MAINTAIN, but not to LOSE Weight You cannot exercise your way out of a poor diet Exercise is best for weight maintenance Exercise is useful for weight LOSS when combined with caloric restriction 22

23 Low Risk: Exercise Guidelines Early Stage No Comorbidities High Baseline Activity Level Follow General Recommendations for Survivors Okay for Unsupervised Exercise in home/community

24 Moderate Risk: Exercise Guidelines Peripheral Neuropathy Musculoskeletal Issues Bony Metastases or Poor Bone Health Modify recommendations Recommend Preexercise Medical Evaluation Consider a Supervised Program (Personal Trainer, Physiotherapist, Occupational Therapist)

25 High Risk: Exercise Guidelines Lung or Abdominal Surgery Ostomy Cardiopulmonary Disease Lymphedema Extreme Fatigue Physician clearance prior to exercise Medical Evaluation Prior to Exercise Supervised Setting Recommended

26 Logistics Getting It Done!

27 Find an a qualified professional ACSM Cancer Exercise Trainers locator/onlinelocator.cfm Choose the ACSM/ACS Certified Cancer Exercise Trainer Physical Therapists trained to work with oncology patients vid= Choose the Cancer practice area

28 Goal Setting

29 Start where you are Start LOW Progress SLOW Let SYMPTOMS be your guide

30 Use What You Have Laps around the house if that s where you are Increase laps till its time to walk outside Keep progressing

31 Do what you can PROGRESSION is important, but in small increments

32 Awareness of the variability of exercise tolerance Awareness of and adaptation for symptom changes

33 Thank you! Questions?

Influence of Weight Management and Exercise on Other Outcomes

Influence of Weight Management and Exercise on Other Outcomes Melinda L. Irwin, PhD, MPH Professor of Epidemiology, Yale School of Public Health Associate Director for Population Sciences, Yale Cancer