Exercise & Cancer Rehabilitation

Lee W. Jones, Ph.D.

Behavioral Medicine Laboratory,
Faculty of Physical Education,
University of Alberta

HE ED 221 (E-121)
November 24, 1.00-2.00pm, 2003

Framework PEACE
DIAGNOSIS
DIAGNOSIS
3.3.
Rehabilitation
Rehabilitation

Prevention
Prevention

1.1.
Pre-Treatment
Pre-Treatment

2.2.
Treatment
Treatment

5.5.
Survival
Survival

4.4.
Palliation
Palliation

PRE-DIAGNOSIS

POST-DIAGNOSIS

Adapted from Courneya & Friedenreich, Ann Behav Med 2001

Why Exercise?

Cancer
Cancer Therapies
Therapies
Surgery
Tx for localized tumors
60% pts, 30% cure rate
Radiation
Local regional tx
50% patients
Systemic Therapy
Advanced solid tumors
Chemotherapy;hormonal therapy;
biological therapy

Cancer
Cancer &
& Quality
Quality of
of Life
Life
- Psychological/physical & functional side-effects
Surgery
- infection, loss of function, dyspnea, pain,
diarrhea, lymphedema
Radiation
- nausea, fatigue, vascular damage (cardiac &
lung tissue)
Chemotherapy
- myelosuppression, nausea, weight gain, cardiac
toxicity, fatigue
Shapiro NEJM 2001 344:1997-2008

Current
Current Quality
Quality of
of Life
Life Interventions
Interventions
- Cognitive-behavioral therapies, educational
strategies, grp psychotherapy
- Largely psychological in nature
- Unlikely to address physical/functional aspects
- Exercise not important or appropriate
Courneya, Mackey & Jones Phys SportsMed 2000

Cancer,
Cancer, Quality
Quality of
of Life,
Life, &
& Exercise
Exercise
Clinical Concerns:
-Immunosuppressive effects
-Pathological bone fractures
- Cardiotoxicity (RT & CT)
- Unwillingness of cancer pts
- Recent research dispelling myths

Courneya, Mackey & Jones Phys SportsMed 2000

Current Status Exercise & Cancer

Research

N u m b e r o f S tu d ie s
0
CT

Adjuvant Tx

RT
CT&RT

H e a d /n e c k

P ro s ta te

C h ild

C o lo re c ta l

S to m a c h

L e u k e m ia

M ix e d

B re a s t

A ll S ite s

50
45
40

35
30
25
20
15

N u m b e r o f S tu d ie s

10
5
0

8
8

7
7

N u m b e r o f S tu d ie s

N u m b e r o f S tu d ie s

Review of Literature

Cancer Site
Study Design

20

18

HDC/BMT

16

14

12

10
8

Obser
RCT's

Cycling Walking Self-Sel

Pre-Post

Exercise Modality

RT
AT+RT

Review of Literature
Outcomes/Results
All reported significant benefits
No Adverse events
Multiple Outcomes..
Physiologic Outcomes - VO2peak, body comp, NK
activity, flexibility
Tx-Related Symptoms fatigue, pain, nausea,
diarrhea, platelet transfusion, hospital stay
QOL Outcomes overall, PWB, FWB, SWB, SWL,
anx/dep
Courneya et al. Phys SportsMed 2000;28:49; Courneya ACSM;
ACSM; 2003

Review of Literature
Limitations
Small number of studies (n=47; only 14 RCTs)
Small sample sizes (heterogeneous)
Self-report measures of exercise
Methodology not well described
Courneya et al. Phys SportsMed 2000;28:49; Courneya ACSM;
ACSM; 2003

V. Clinical Exercise
Prescription Guidelines

General Guidelines
Cancer dx affects all aspects of physical
functioning
Unique manifestations
- Tumor
- Treatment
- Side effects
- Demographic profile
ACSM guidelines (3-5d/wk, 30-60mins, moderate
intensity)
Optimal guidelines not yet established

Prescription Guidelines
Mode

Walking / cycle ergometry natural

choice
Account for specific impairments
(e.g., colorectal, breast cancer)
Resistance/upper body
lymphedema concerns unfounded
Combined program optimal

Prescription Guidelines
Frequency & Intensity

At least 3-5d/wk
Daily for deconditioned patients
Moderate Intensity
50-70% VO2max
60-80% HRmax
RPE 11-14

Prescription Guidelines
Duration & Progression

20-30mins (continuous)
Intermittment bouts (5-10 mins)
Initially in frequency & duration then intensity
Progression slower for
deconditioned pts & those
suffering severe side effects

General Guidelines
No evidence that one type of exercise is superior
Safety is the primary concern
Optimal program may combine resistance &
aerobic training
Key point is to be flexible - modify prescription
based on response to treatment(s)

Special Precautions
Complication

Precaution

Hemoglobin <8.0 g/dl

Avoid high intensity exercise
Absolute neutrophil count Avoid exercises that may increase
chance of infection (swimming)
Fever > 38oC
Avoid exercise
Ataxia/dizziness
Avoid exercises that require
significant balance & coordination
(treadmill)
Severe cachexia
Loss of muscle mass limits
exercise
intensity - modify program
accordingly
Bone pain
Avoid high impact exercises
Extreme fatigue
Exercise at lower power output,
avoid maximal tests

VI. Current Clinical Trials & Forthcoming

Studies

Breast Cancer

REHAB Trial
REHAB (Rehabilitation Exercise for Health After Breast
Cancer) Trial
Purpose
Determine the effects of exercise
training on cardiopulmonary, QOL,
and biologic outcomes in
postmenopausal b/c survivors

Outcomes
QOL, VO2peak, metabolic
hormones (insulin, IGF-1), sex
steroid hormones (estradiol,
estrogen), biomarkers of CVD
(CRP, lipids, etc.)

REHAB Trial
Method
53 participants EG (n=25) or CG
(n=28)
Cycle ergometry 3x/wk, 1535mins, 15wks, 70-75% VO2peak
Results
52 participants completed trial
98.4% adherence (44.3/45
sessions)

VO2peak

22

QOL
122

21

120
118

20

FACT-B

Peak Oxygen Consumption

Results

19

116
114
112

18

110

17

108

Baseline

Courneya et al. JCO 2003

Posttest

Baseline

Posttest

Breast Cancer
START (Supervised Trial of Aerobic vs Resistance
Training)

Purpose

Determine the effects of aerobic vs. resistance training on

QOL in early stage b/c patients on chemotherapy
Objectives
1. Compare AET Vs RET on fitness & QOL
2. Explore individual characteristics of these effects
3. Compare adherence rates
4. Investigate psychosocial determinants
Courneya, et al. Funded by CBCRA

START Trial
Study Design

210 Early Stage

B/C Patients

Edmonton
N=70

Ottawa
N=70

Tax/Non-Tax

LM

RT

Vancouver
N=70

Tax/Non-Tax

AE

LM

RT

Tax/Non-Tax

AE

LM

RT

AE

Procedure
Eligible Pts
Approached by
Oncologist

Baseline
Assessment > 1st CT

Courneya, et al. Funded by CBCRA

Intervention
Concurrent with CT

Post-Test 3wk
> Last CT

START Trial
Outcomes
Primary: QOL
Secondary: Fatigue; VO2peak; Muscular Strength;
Body Composition; Lymphedema; Bio-markers
(Cancer Recurrence & CV Risk Factors)
Progress
Edmonton (n=21; 83%)
Ottawa (n=18)
Vancouver (n=3)
Courneya, et al. Funded by CBCRA

Prostate Cancer

Prostate Trial
Prostate and Resistance Exercise Training Trial
Purpose
Determine the effects of resistance
exercise on fatigue & HRQOL in
prostate cancer patients receiving
ADT.

Outcomes
HRQOL, fatigue, body composition,
muscular fitness (strength,
cardiopulmonary fitness)

Segal et al. JCO 2003

Prostate
REHAB Trial
Trial
Method
155 RET (n=83) or CG (n=73)
Resistance Training 3x/wk,
12wks, 9 exercises, 2 sets of 812 reps @ 60-70% 1 RM
Results
135 participants completed
76.2% adherence (27/36
sessions)

Prostate Results
Chest Press

45

40

35

30

Leg Press

50

Leg Press Repetitions

Chest Press Repetitions

50

25

45

40

35

30

Baseline

Posttest

Baseline

122

Posttest

12.5

QOL

Fatigue

12

121

11.5

Fatigue

FACT-P

120
119
118

11
10.5
10
9.5

117

116

8.5

Baseline

Posttest

Baseline

Posttest

Colorectal Cancer

CAN-HOPE RCT
Colorectal RCT (CAN-HOPE)

To determine if exercise can

improve QOL in colorectal
cancer survivors

Submaximal fitness test/QOL

at baseline & 16 weeks

Moderate intensity, homebased exercise program

(F=3-5/wk; D=20-30)

Randomized 102 patients (33

Control /69 EX)
Courneya et al. EJCC,
EJCC, in press

CAN-HOPE RCT
Participant Characteristics
Demographic
Age: 60; 59% male
74% married; 40% university
60% >$40k
Medical
Mths Sx: 2
80% III/IV; 100% Sx; 20% RT; 65%
CT

CAN-HOPE Results
70

QOL

68

108

66

TOI

TOI

110

106

64

104

62

102

60

Baseline

Baseline

Posttest

Anxiety

Posttest

40

38

Fitness
Fitness

Anxiety

FACT-C

112

36

34

32

30

Baseline

Posttest

Courneya et al. EJCC, in press

Lung Cancer

Exercise Capacity & NSCLC

Purpose
Determine the Prognostic Value of Symptom-Limited
Exercise Testing on Survival in Inoperable NSCLC
Patients
Method
New Patient Rounds via Medical
Record Review
Blood draw/PFT/GXT

Jones et al. In Process

Exercise Capacity & NSCLC

Outcomes
Primary: Survival
Secondary:
-Association with traditional
predictors
VO2peak & Tx response/tolerability
-VO

Jones et al. In Process

Exercise Capacity & NSCLC

Progress

Total Number of
Patients Screened
N=49

Total Number of
Patients Eligible
Reasons for Non-recruitment
(n=8)
Does Not Believe in Exercise
(n=1)
Exercise Test Too Risky (n=1)
Too Sick (n=3)
Too Much On (n=3)

N=20 (20/49 = 41%)

Reasons for Non-Eligibility

(n=29)
Recent CHD (n=4)
Physically Disabled (n=7)
TB (n=1)
Age (n=2)
O2 Dependent (n=5)
Extensive Met Disease (n=4)
Psychological Distress (n=2)
Co-morbidities (n=4)
Non Lung Cancer (n=1)
No Treatment (n=1)

Total Number of
Patients Interested
N=12 (12/20 = 65%)

Total Number of
Patients Tested
N=10 (10/12 = 83%)
Jones et al. In

Exercise Capacity & NSCLC

Results
Age: 71

Range: 64 - 83

VO2peak: 16.2

Range: 9.4 24.3

BMI: 27

Range: 21 35

Aims:
Accurate prognostic information
Optimal therapeutic approach
Feasibility & safety - RCT

RER: 1.2

Pre Surgery Exercise RCT

Method
Surgeon Referral
Two-armed RCT Exercise Training (n=25) vs.
Usual Care (n=25)
AET 4/5x/wk, 10-45mins, 50-75% VO2peak for 6 wks
Outcomes
Primary: Perioperative Complications (infection, O2
utilization, etc.)
Secondary: VO2peak, QOL, length of hospital stay
Timing of Assessments: baseline, pre-sx, 5-7d post sx
Jones et al. In Progress

Other Cancers

Exercise & Anemia Trial

EXTRA (EXercise TRaining & Anemia) Trial
Purpose
Determine if a 12-wk exercise program can improve QOL
in anemic patients receiving Aranesp
Method
Two-armed RCT Aranesp Alone (n=50) vs. Aranesp +
Exercise (n=50)
Periodized Cycle Ergometry 3x/wk, 30-45mins, 60-75%
VO2peak for 12 wks
Outcomes
Primary: QOL (FACT-An)
Secondary: VO2peak, Hb Response, Blood Markers

Mackey, Courneya, Jones et al. Funded by Amgen Inc

EXTRA Trial
Results
Age: 51

Range: 25 - 71

VO2peak: 16.5

Range: 11 25.3

Hb: 100

Range: 91 - 107

RER: 1.23

Multiple Myeloma
Purpose
Examine the Potential Role of Exercise in Multiple
Myeloma Cancer Patients
Objectives
1. Exercise preferences/level of interest
2. Exercise Rates
3. Determinants of exercise (attitudes, perceived
capability)
4. Association with QOL & fatigue

Jones et al. In

Exercise
Exercise &
& Multiple
Multiple Myeloma
Myeloma
Method
Cross-sectional provincial survey ACB registry
Oncologist-approval
162 sent questionnaire
Results
11 returned (6 deceased, 5 moved)
87 (87/151 = 58%) completed questionnaire

Jones et al. In

Exercise & Glioma RCT

Purpose
To determine the effect of exercise training on QOL in
newly diagnosed primary glioma cancer patients
during RT
Method
Two-armed RCT: usual care (n=12) vs. exercise training
(n=12)
Intervention
3x/wk; 60-90 minutes, 8wks
AET: 50-70% VO2peak
RET: 8-12 repetitions @ 70-80% 1-RM of 8 upper/lower
Jones et al. Submitted for Funding CIHR/ACB
body exercises

Summary

ACSM Guidelines Early Stage Patients

Advanced Cancer Pts More Care

Safety primary concern
Integral component of comprehensive care
for cancer patients