By Tammy Petersen
Cancer survivors are often highly motivated to learn more about exercise and cancer survivorship
Not surprisingly, cancer survivors are often highly motivated to learn more about exercise and cancer survivorship. This is in addition to nutrition, supplements and herbal remedies that might improve treatment outcomes and ultimately their survival and quality of life.
For many of the most important cancer exercise questions, the scientific evidence comes only from observational and laboratory animal data or unreliable reports from poorly designed clinical studies.
Moreover, the findings from these studies are often contradictory. And even fewer controlled clinical trials have been done to test the impact of diet, nutritional supplements, or nutritional complementary methods on cancer outcomes among cancer survivors.
Once a virtual death sentence, cancer today is a curable disease for many and a chronic illness for most. With continued advances in strategies to detect cancer early and treat it effectively, along with the aging of the population, the number of individuals living years beyond a cancer diagnosis can be expected to continue to increase.
The statistics for American cancer survivors
As of January 2016, there were approximately 15.5 million Americans who were cancer survivors. This represents 4.8% of the population. The number of cancer survivors is expected to increase by 31%, to 20.3 million, by 2026. This represents an increase of more than 4 million survivors in 10 years.
Anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of his or her life is considered a cancer survivor. And, while not all cancer survivors are older adults, many are simply because of the cumulative effect of years of lifestyle issues that are risk factors for their disease.
Survivors less than or equal to 19 years old comprise 1% of the cancer survivor population; 6% of survivors are aged 20–39 years; 33% are aged 40–64 years; and 60% (more than half) are older adults aged greater than or equal to 65 years.
Breast cancer survivors are the largest constituent group within the overall population of cancer survivors (22%).
Breast ccancer is followed by prostate cancer survivors (19%) and colorectal cancer survivors (11%). Gynecological and other genitourinary cancers each account for 9% of cancer survivors, followed by hematological cancers and lymphoma (7%) and lung cancer (4%).
Other cancer sites account for much smaller percentages and together are responsible for 19% of the total number of survivors.
In terms of stratification by gender, more than two thirds (69%) of all female cancer survivors have a history of breast (41%), gynecological (17%) or colorectal (11%) cancer.
For male survivors, two thirds (66%) have a history of prostate (39%), other genitourinary (such as testicular or renal) (14%) or colorectal (13%) cancer.
Between 2011 and 2015, overall cancer death rates decreased by an average of 1.8 percent per year for men and an average of 1.4 percent per year for women
Eleven of the 18 most common cancers in men showed decreases in mortality: leukemia, melanoma, myeloma, non-Hodgkin lymphoma, cancers of the colon/rectum, esophagus, kidney, larynx, lung and bronchus, prostate, and stomach.
Lung and bronchus cancer had the greatest decrease in mortality. Non-melanoma skin cancer and cancers of the brain and other nervous system, liver, oral cavity and pharynx, pancreas, and soft tissue including heart showed increases in mortality for men between 2011 and 2015.
Non-melanoma skin cancer had the greatest increase.
Fourteen of the 20 most common cancers in women showed decreases in mortality: leukemia, melanoma, non-Hodgkin lymphoma, cancers of the bladder, breast, cervix, colon/rectum, esophagus, gallbladder, kidney, lung and bronchus, oral cavity and pharynx, ovary, and stomach.
Non-Hodgkin lymphoma had the greatest decrease in mortality.
Cancers of the brain and other nervous system, uterus, liver and pancreas showed increases in mortality for women between 2011 and 2015, with liver cancer having the greatest increase.
Researchers believe that rising obesity has contributed to the increasing death rates for endometrial, pancreatic and liver cancers.
Researchers also believe that hepatitis C infection among Baby Boomers has contributed to increasing rates for liver cancer and that human papillomavirus (HPV) infection has contributed to the increasing rates for oral cavity and pharynx cancers.
Researchers say the decreases in mortality for lung cancer and several other cancer sites are largely due to reduced tobacco use.
However, cigarette smoking still accounts for more than 25% of cancer deaths in the US. Improved treatments have also helped lower the death rate for several cancers, especially breast, prostate, colorectal, leukemia, and Non-Hodgkin lymphoma.
Between 2010 and 2014, seven of the 17 most common cancers in men showed decreases in incidence
Between 2010 and 2014, seven of the 17 most common cancers in men showed decreases in incidence: prostate, lung and bronchus, colon/rectum, bladder, esophagus, brain and other nervous system, and larynx.
Prostate cancer had the greatest decrease in incidence. Leukemia, melanoma, myeloma, and cancers of the kidney, liver, oral cavity, pancreas, and thyroid in men showed increases in incidence between 2010 and 2014, with liver cancer having the greatest increase.
On average, the overall cancer incidence rate in men decreased 2.2 percent per year.
Between 2010 and 2014, seven of the 18 most common cancers in women showed decreases in incidence
Between 2010 and 2014, seven of the 18 most common cancers in women showed decreases in incidence: non-Hodgkin lymphoma, bladder, brain and other nervous system, cervix, colon/rectum, lung and bronchus, and ovary.
Colorectal cancer had the greatest decrease in incidence.
Leukemia, melanoma, myeloma, and cancers of the breast, uterus, kidney, liver, oral cavity and pharynx, pancreas, and thyroid showed increases in incidence among women between 2010 and 2014. Liver cancer had the greatest increase.
The overall cancer incidence rate in women on average did not change year by year between 2010 and 2014.
An Expert Committee to identify and evaluate the scientific evidence related to optimal nutrition and physical activity for cancer survivors
To identify and evaluate the scientific evidence related to optimal nutrition and physical activity after the diagnosis of cancer, the American Cancer Society (ACS) convened a group of experts in nutrition, physical activity and cancer.
The findings of this group guide healthcare providers, cancer survivors and their families through the mass of information and help them make informed choices related to diet and exercise.
The Expert Committee reviewed all of the scientific evidence and best clinical practices for different types of cancer and “graded” both the quality and certainty of the scientific evidence for factors affecting the most common cancers.
As was already mentioned, there are few clear answers to many questions, a wide range of sources and often conflicting information.
But these experts agree that even when the scientific evidence is incomplete, reasonable conclusions can be made that can help to guide choices in the areas of nutrition and physical activity.
Exercise, diet and weight interventions and the benefit potential for cancer survivors
Physical activity may help cancer patients build up their physical condition; decrease the number of comorbid conditions (like heart disease and diabetes); reduce drug interactions; help cancer patients cope with treatment; restore good health; improve quality of life during and after treatment; and help cancer patients and survivors maintain independence as long as possible.
Physical rehabilitation programs similar to those for cardiac rehabilitation may be effective in managing, controlling or preventing adverse medical and psychosocial outcomes manifested during cancer survivorship. For example, cancer exercise programs are being developed as interventions to improve the physical functioning of persons who have problems with mobility because of therapy.
These programs are also being shown to be efficacious for weight control after breast cancer treatment, lessen the effects of chronic fatigue, improve quality of life, prevent or control osteoporosis, as a result of premature menopause and prevent or control future or concurrent comorbidities.
Diet, weight and physical activity interventions carry tremendous potential to affect length and quality of survival in a positive manner and prevent or control morbidity associated with cancer or its treatment.
Why corrective exercise for cancer survivors is so important
Cancer surgery often causes muscle imbalances and range of motion limitations. Therefore, corrective exercise for cancer survivors is important.
Following any cancer surgery there is bound to be pain, scar tissue, and the possibility of adhesions. All of these can contribute to muscle imbalances and range of motion limitations and the need for corrective exercise.
Most muscle pain is the result of a muscle spasm and the resulting ischemia (inadequate circulation to a local area due to blockage of the blood vessels in the area) from the prolonged muscle contraction.
When someone comes to you with chronic musculoskeletal pain it may suggest that the problem lies within the muscle, or group of muscles. It will usually not stem from the bones, joints, and ligaments.
This pain within a muscle or a group of mucles will ultimately lead to fatigue and result in a decreased ability to meet normal postural and movement demands. In the acute phase of pain, the muscles may respond by altering movement patterns to compensate for the injured area. As time passes, the CNS will adapt this altered movement pattern.
Muscle imbalance may be the source of the pain or it may be the result of the pain
Our bodies have a protective adaptation to pain in which the flexor response is activated to protect the injured area. Not only will this affect movement patterns, it will also result in decreased range of motion. These altered movement patterns will ultimately lead to altered joint position which will cause more stress on the joints.
This can also be caused by altered reciprocal inhibition. This is the process by which a tight muscle causes decreased neural drive and, therefore, optimal recruitment of its functional antagonist is not achieved. Altered reciprocal inhibition may lead to synergistic dominance.
This is the process in which a synergist compensates for a prime mover to maintain force production (the force generated by a muscle action).
To address these altered movement patterns is why corrective exercise for cancer survivors is needed.
General exercise guidelines for cancer survivors
In general, physical activity is likely to be beneficial for most cancer survivors. Recommendations on the type, frequency, duration and intensity of exercise should be individualized to the survivor’s age, previous fitness activities, type of cancer, stage of treatment, type of therapy and comorbid conditions.
Particular issues for cancer survivors may affect or contraindicate their ability to exercise. Effects of their cancer treatment may also promote the risk for exercise-related injuries and other adverse effects.
The following specific precautions are from the American Cancer Society (ACS):
- Survivors with severe anemia should delay exercise, other than activities of daily living, until the anemia is improved.
- Survivors with compromised immune function should avoid public gyms and other public places until their white blood cell counts return to safe levels.
- Survivors who have completed a bone marrow transplant are usually advised to avoid exposure to public places with risk for microbial contamination, such as gyms, for 1 year after transplantation.
- Survivors suffering from severe fatigue from their therapy may not feel up to an exercise program, so they may be encouraged to do 10 minutes of stretching exercises daily.
- Survivors undergoing radiation should avoid chlorine exposure to irradiated skin (e.g., swimming pools and whirlpools).
- Survivors with indwelling catheters should avoid water or other microbial exposures that may result in infections as well as resistance training of muscles in the area of the catheter to avoid dislodgment.
- Survivors with significant peripheral neuropathies may have a reduced ability to perform exercises that use the affected limbs because of weakness or loss of balance. They may do better with a stationary reclining bicycle, for example, than walking outdoors.
Summary of physical activity recommendations for cancer survivors
For the general population, the ACS and other health organizations recommend at least 30 minutes of moderate physical activity at least 5 days per week to reduce the risk for cancer, cardiovascular disease and diabetes.
These levels of activity have not been studied or tested specifically in cancer survivors, however. For the general population and for cancer survivors, any movement is likely beneficial.
Therefore, although daily and regular activity may be preferred and may be a goal, any steps that are taken to move from a sedentary to an active lifestyle should be encouraged.
For survivors wanting maximum benefit, the message should be that the health benefits of exercise are generally linear, with benefit related to higher intensity and duration, although extremely high levels of exercise might increase the risk for infections.
Being overweight is likely to be the most important modifiable risk factor related to diet and exercise for a breast cancer survivor. Unlike most other cancer survivors, weight gain and obesity among women who have undergone adjuvant chemotherapy for breast cancer is a consistently reported finding.
Evidence exists that post diagnosis weight gain may adversely affect disease-free or overall survival among breast cancer survivors.
In addition, obesity at the time of breast cancer diagnosis is an established negative prognostic factor that may be associated with a higher risk of cardiovascular disease, diabetes and other comorbid conditions.
This may hold true for survivors of other cancer sites as well, especially those that are hormone dependent. Chemotherapy induced weight gain is distinct in that patients lose muscle as they gain adipose tissue, thus calling for interventions that promote resistance training.
Breast cancer survivors, even when weight stable, demonstrate trends toward decreasing lean body mass making exercise even more important for this group.
A weight loss of 5% to 10% over 6-12 months is sufficient to reduce the levels of risk factors associated with disease risk such as elevated plasma lipids.
If a breast cancer survivor is overweight and motivated to lose weight, a loss of 1-2 pounds per week is safe as long as the oncologist approves it, and it is monitored closely and does not interfere with treatments.
At the very least women should be encouraged to hold their weight steady during treatment and then concentrate on safe weight loss through increased exercise and a healthy diet. Moderate physical activity during and after treatment may help survivors maintain lean muscle mass while avoiding excess body fat.
Lymphedema is a common problem for cancer survivors
Cancer treatment surgeries for breast, gynecological, head and neck, prostate or testicular, bladder or colon cancer, all of which currently require removal of lymph nodes, put patients at risk of developing secondary lymphedema. If lymph nodes are removed, there is always a risk of developing lymphedema, but it is most common in breast cancer survivors.
In breast cancer survivors, the condition causes swelling in the soft tissues of the arm, hand, trunk and chest on the side or sides affected by surgery. Women who have undergone an axillary (underarm) dissection and/or radiation treatment are at particular risk. Between 15% and 20% of breast cancer patients who undergo axillary lymph node removal develop lymphedema. According to the American Cancer Society, of the two million breast
cancer survivors in the U.S., approximately 400,000 must cope with lymphedema on a daily basis.
Lymph nodes act as filters, producing the lymphocytes that help destroy bacteria, cancerous cells, and other wastes. When nodes are removed, the remaining lymph nodes must compensate for the ones that have been removed. If they cannot, lymphedema can result.
Radiation can produce further damage to the lymphatic system and the natural tendency to favor an affected limb after surgery causes a loss of mobility that can interfere with normal lymph drainage.
This often causes infection and, subsequently, lymphedema. Lymphedema can also develop when chemotherapy is administered to the already affected area (the side on which the surgery was performed) or after repeated removal of fluid which commonly occurs post-operatively in the axilla (underarm), around the breast incision, or groin area. This often causes infection and, subsequently, lymphedema.
Secondary lymphedema can develop immediately post-operatively, or weeks, months, even years later and can be triggered by infection, injury, repetitive motion, insect bites, vigorous massage or obesity. Symptoms of lymphedema include heaviness, aching, fatigue and sometimes pain.
It causes limited movement in the limbs affected and decreased muscle strength, leading to restrictions in daily activities. The limb may feel harder to the touch as the lymphedema worsens.
Air travel has also been linked to the onset of lymphedema in patients post-cancer surgery (likely due to the decreased cabin pressure). Post surgery survivors should always wear a compression garment (sleeve, stocking) when they fly, even if they do not have lymphedema. Another cause of lower extremity lymphedema is that resulting from the use of Tamoxifen. This medication can cause blood clots and subsequent DVT (deep venous thrombosis).
Radiation therapy, used in the treatment of various cancers can damage otherwise healthy lymph nodes and vessels, causing scar tissue to form which interrupts the normal flow of the lymphatic fluid. Radiation can also cause skin dermatitis or a burn similar to sunburn.
It is important to closely monitor the radiated area for any skin changes, such as increased temperature, discoloration (erythema) or blistering which can lead into the development of lymphedema. Keeping the area soft with lotion will usually be recommended by the radiation oncologist.
Currently, there is no general consensus among doctors regarding a uniform standard of care for the treatment of lymphedema. Treatment options are individualized to the patient’s specific situation and take into account a variety of factors including the severity of the lymphedema.
In recent years, Complete Decongestive Physiotherapy has gained popularity for the treatment of lymphedema. This type of treatment consists of manual lymphatic drainage, compression bandaging, exercise therapy, and patient education regarding skin care.
Exercise and lymphedema recommendations for cancer survivors
The goal of exercise is to enhance muscle pump activity and thus promote improved venous and lymphatic return in the involved extremity. The risk of exacerbating lymphedema is low when decongestive exercise is performed appropriately with shortstretch compression bandages worn on the involved limb.
Deep abdominal breathing enhances pumping in the thoracic duct and muscle contractions performed proximal to distal can enhance lymphatic return.
Exercises to stretch the pectoralis major and trapezius muscles and strengthen the rotator cuff are useful to gain better mobility in the arm and enhance drainage for breast cancer survivors with lymphedema. Exercises that focus on deep breathing and flexibility like yoga and Pilates are especially recommended.
Flexibility/Stretching Exercise for cancer survivors with lymphedema
The goal of flexibility exercises is to stretch soft tissues thereby minimizing tightness and the effects of scarring which can block lymph flow. In addition, flexibility for normal movement is maintained and improved.
The risk of exacerbating lymphedema when performing stretching exercises occurs when stretching is performed too vigorously. Tissue tears and inflammation can occur. Flexibility exercises for cancer survivors should be done slowly and progressed
gradually to avoid pain and injury.
Resistive exercise for cancer survivors with lymphedema
Progressive resistive exercise has been found to be beneficial in the treatment of lymphedema. The introduction of weights should be gradual with the individual’s response monitored in order to avoid injury, overuse and exacerbation of lymphedema.
The primary goal of strength training and resistive exercise is to improve muscle power, stamina and tone. But this type of exercise poses the greatest risk to cancer survivors with lymphedema. This is because in addition to the risk of tears and injury, strength training increases local blood flow and the production of waste products which increases the load on the lymphatic system.
This could result in an increase of lymphedema, or trigger lymphedema in an individual at risk for developing lymphedema. Adequate rest intervals are important between sets of exercise. The involved limb should have appropriate and sufficient compression from garments or bandages. The amount of compression may need to be adjusted to prevent an increase in swelling.
Endurance exercise for cancer survivors with lymphedema
Aerobic exercise is beneficial for cancer survivors with lymphedema. By improving cardiovascular fitness, overall health is improved. Increased deep respiration (deep breathing) enhances venous and lymphatic return.
The risks of exacerbating lymphedema associated with aerobic exercise relate to increased blood flow and increased metabolic waste which can then trigger an increase in lymphatic flow and lymphatic load. Injuries associated with overuse such as tendonitis, bursitis, sprains, strains, blisters and skin abrasions are also concerns.
Key points to remember regarding exercise and lymphedema for cancer survivors
- Before starting any exercise program individuals should be medically cleared.
- Before initiating a strength training program, consultation with a lymphedema specialist is recommended. (You can find one at The National Lymphedema Network.)
- If heaviness, aching, redness, fever, pain or itching or blotches occur in the affected area contact the physician immediately.
- In individuals with lymphedema, adequate compression should be utilized.
- The swelling from lymphedema should be adequately managed prior to engaging in strength training.
- When swimming or exercising in water, compression garments are not needed on the limb if it is submerged. The properties of water will provide some compression.
- Good hydration should be maintained while exercising.
- If possible, exercise should be done in an air-conditioned environment.
- When exercising outdoors a cooler time of day should be selected, and overexposure to heat and sun minimized or avoided.
- Use sunscreen and bug repellent when exercising outdoors.
- Avoid massage in the area at risk.
- Regain range of motion first and then work on strength.
- Avoid saunas, steam rooms, whirlpools, and hot baths.
- Avoid tight fitting jewelry on the affected hand or arm.
- Exercise should be started gradually and progressed slowly.
- The exercise routine should be stopped if pain or an uncomfortable sensation results, especially if this occurs in the affected limb or the limb at risk.
- Strain or overuse should be avoided.
- Exercises that focus on deep breathing and flexibility like yoga and Pilates are especially recommended.
- Focus on the muscles of the shoulder and back (deltoids, trapezius, rhomboids and rotator cuff) for cancer survivors whose arm is affected to optimize shoulder strength and promote an alternative drainage pathway.
- Work the abdominal muscles to encourage lymphatic flow back to the thoracic duct.
- Many daily activities (at home and at work) may cause the same effects on the lymphatics as exercise and may require modification.
- Avoid carrying heavy bags on the shoulder of the affected arm for upper extremity lymphedema.
- Do not wear socks or hosiery with tight elastic bands that can restrict blood flow if lower extremity lymphedema is present.
Resource books for training cancer survivors
Exercise Therapy and the Cancer Patient
This guide will help patients, regardless of their type of cancer, regain lost physical and psychological functions. Conditions such as fatigue, loss of strength, and depression are all too common with many cancers. Indeed, it is often not the cancer itself but the treatment and the inactivity that follow that affect the afflicted individual.
Doctor Stidwill’s latest book is written to be understood and applied by both medical professionals and cancer survivors alike. After 12 years of working with cancer patients, Stidwill offers sound advice and sample exercises in an easy to implement format, including an exercise prescription for specific cancers.
Available through Amazon: www.Amazon.com.
Most cancer patients and survivors think that “rest” will decrease their fatigue and speed their recovery. But in fact, rest can make patients weak and debilitated during treatment and may prolong hospitalization.
Based on Dr. Anna Schwartz’s research and her life’s work as a nurse and a coach, Cancer Fitness offers cancer patients and survivors comprehensive advice and an easy step-by-step program to begin improving their physical and emotional health and reclaiming their lives beyond cancer.
Through exercise patients will regain some control over their body, manage side effects more successfully, and increase their body’s ability to heal. Cancer Fitness provides clear directions to safely start an exercise program and the tools to make exercise a long-lasting lifestyle change to heal body and soul.
Available through Medical Health Fitness: www.medhealthfit.com and Amazon: www.Amazon.com.
Exercises for Chemotherapy Patients
The diagnosis of cancer and the beginning of chemotherapy treatment trigger questions, fears, and feelings of helplessness. But there is one step patients can take immediately to take charge of their health–and it is exercise. In their new book, Exercises for Chemotherapy Patients, Harry Raftopoulos, MD, and Erin O’Driscoll, RN, MA, help people with cancer take control of their bodies and gain strength, courage, and confidence.
Available through Medical Health Fitness: www.medhealthfit.com and Amazon: www.Amazon.com.
Fitness specialty programs for working with cancer survivors
This program is designed to give you a complete understanding of the entire cancer process from diagnosis and treatment to reconstruction and survivorship. With its unique and individualized programming, it will help to improve your patient’s ability to cope with the mental and physical stress following cancer diagnosis and treatment.
The course offers the most current evidence-based information compiled by the American College of Sports Medicine (ACSM) for working with survivors of many types of cancers and is designed to assist health and fitness professionals in using exercise to help cancer survivors with recovery, rehabilitation and reducing the risk of recurrence.
This course provides advanced continuing education for health and fitness professionals who wish to work safely and effectively with mature adults who have experienced cancer or would like to specialize in training cancer survivors in general. It identifies cancer risk factors and provides cancer prevention strategies related to lifestyle.
The SrFit™ Mature Fitness course provides advanced training for experienced, certified health and fitness professionals who wish to safely and effectively work with active agers. With this course, you will gain an understanding of how the aging process affects all the systems of the body, identify dietary changes that may be needed; and develop effective training strategies to improve flexibility, endurance, strength and optimal function in your mature clients.
You will learn how to individualize a training regimen that fits the physiological capabilities of mature adults, including those who are very frail and cancer survivors.
American Cancer Society, Surveillance Research, 2018. Estimated Number of Deaths for the Four Major Cancers by Sex and Age Group, 2018 (PDF)
American Cancer Society, Surveillance Research, 2018. Estimated Number of New Cases for the Four Major Cancers by Sex and Age Group, 2018 (PDF)
Bluethmann SM, Mariotto AB, Rowland, JH. Anticipating the ”Silver Tsunami”: Prevalence Trajectories and Comorbidity Burden among Older Cancer Survivors in the United States. Cancer Epidemiol Biomarkers Prev. 2016; 25:1029-1036.
Miller, K. D., Siegel, R. L., Lin, C. C., Mariotto, A. B., Kramer, J. L., Rowland, J. H., Stein, K. D., Alteri, R. and Jemal, A. (2016), Cancer treatment and survivorship statistics, 2016. CA: A Cancer Journal for Clinicians.