Exercise Oncology

“That which is used develops. That which is not used wastes away.”
– Hippocrates

What can you change in 9 minutes?

What can you really change in only 9 minutes?

9815 different molecules.

A ground-breaking study recently revealed the magnitude of changes in people’s molecular profiles after exercise. The study revealed thousands of molecular changes and an orchestrated choreography of biological processes involving energy metabolism, oxidative stress, inflammation, tissue repair, and growth factor response, as well as regulatory pathways (1). Nine minutes to compose an integrated symphony in the body. Muscles work as a secretory organ that releases myokines/enzymes that can integrate, communicate and cross talk with other systems, tissues, cells and organs.

Like any symphony; a finely tuned metaphor of integration, harmony and cooperation.

The human body is a living interconnected network connected to the biodiversity of the external environment. Everything is interconnected: our health, our environment and our planet. Any harm to the beehive will affect the bees and subsequently the flowers. A coda to the synergy of nature.

Traditionally, exercise has been viewed as compartmentalised to one part of the body. Isolated from the interconnected network. When you curl your bicep; it simply doesn’t happen in isolation. Your movement brain never acts alone. Exercise has a crucial role in the restoration of health.

Exercise and Cancer

Exercise plays a predominant role in the restoration of health along the cancer continuum. Starting from the importance of exercise to the prevention of cancer, after diagnosis and during treatment, exercise produces immense short and long-term health benefits that reverse deconditioning.

What is the long-term health effect?

Making sure that cancer does not come back. Exercise has a positive effect on a broad range of quality-of-life parameters along your return to health. The benefits of exercise training have been well documented for cancer patients and are becoming increasingly evident and beneficial (2,3,4,5,6,7).

Historically, clinicians advised cancer patients to rest and to avoid activity; however, emerging research on exercise has challenged this recommendation. Exercise not only plays a role in managing side effects but can also improve functional harmony.

Benefits accrued through exercise during and beyond treatment for cancer have been extensively reviewed. A recent publication reported that 140 meta-analyses have been published to date, with the majority (75%) showing statistically significant and clinically relevant benefit through exercise on a range of treatment-related side effects, physical, functional, and psychosocial outcomes (8).

Health Benefits

Health Benefits Specific to a Return to Health

The symphony starts with how we hold ourselves structurally and move muscularly. If the oboe is out of tune the whole orchestra will be out of harmony. If you do not use it, you will lose it.

Musculoskeletal System – Muscle atrophy and muscle weakness commonly occur as a result of cancer and its treatment (9). Decreased muscle and the corresponding decrease in strength will lead to functional immobility.  Many activities of daily living, functional stability and mobility do not require large aerobic output but depend more on musculoskeletal functioning (10).

Haven’t you noticed that it takes more effort to stand up from a chair or walking upstairs?

This decreased mobility will impair glucose and energy homeostasis, and lead to dysfunctional neuromuscular function, impaired bone mineral density and mitochondrial dysfunction.

Muscle atrophy and muscle imbalances create deteriorated movement patterns and a mechanical disadvantage. Weak and overused muscles contribute to structural changes. A strong solid foundation will enable biomechanical homeostasis. Biomechanical homeostasis should be considered a critical part to prevent future structural and functional problems.

Importance of Biomechanical Homeostasis

Are 10 000 steps really the benchmark? Why aren’t we asking ourselves what does my first step look like? What does that first step feel like? Nothing happens in isolation.

Have you noticed how much your spine and neck are hunched over towards your work, computer screen or phone?

What about reoccurring back pain?

We are no longer structurally holding ourselves or moving according to Nature’s design. Instead of resisting gravity, we are assisting gravity. Humans did not evolve to sit all day and consequently we are out of tune. A strong biomechanical foundation is necessary to push back against the force of gravity.

A hunched over spine will squish, squeeze and compress your internal organs. The most deleterious effect will be on the lungs and respiration. Diminished oxygen in and less carbon dioxide out. Breathing is essential to life itself. Oxygen passes through our lungs into our blood for our tissues and organs to work properly. Build-up of carbon dioxide can also impair oxygenation of blood.

Compression of the spine can also contribute to the disharmony of the gastrointestinal tract. Gut microbiota is paramount to homeostasis and to the innate immune system. The gut ecosystem development and its stability can be influenced by an existing dynamic balance between intrinsic and extrinsic factors such as host physiology, lifestyle, and exercise (11,12).

Cardiorespiratory
Fitness

Cancer patients and survivors of cancer have a greater burden of cardiovascular disease compared to the general population. Much of the elevated cardiovascular risk in these individuals is likely attributable to hypertension, as individuals with cancer have a particularly high incidence of hypertension following cancer diagnosis (13).

Exercise is an important lifestyle modification that can mitigate hypertension and hyperlipidemia. Regular exercise will increase high-density lipoprotein while lowering low-density lipoproteins.

A meta-analysis of 48 randomized clinical trials concluded that exercise therapy should be recommended for patients with adult-onset cancer as an effective adjunctive modality to improve their cardiorespiratory fitness (14).

Chronic Inflammation

Reduction in Visceral Adipose Tissue Mass

Long term chronic inflammation creates an environment that is associated with the development and progression of dis-ease.

Recent large-scale epidemiological studies show that abdominal adiposity is associated with low fitness and low-grade inflammation independent of body mass index. Evidence suggests that an accumulation of visceral fat (biologically active) leads to a network of inflammatory pathways that promote insulin resistance, impairs immunity, hyperlipidemia and is harmful to metabolic health (15).

Exercise disrupts the vicious cycle of chronic inflammation, both directly through induction of anti-inflammatory cytokines during each bout of exercise (yes, every little step adds up) and indirectly, by decreasing visceral fat (16).

Current Exercise Prescription Recommendations:

The American College of Sports Medicine

To ease the most common cancer treatment side effects and improve health:

  • moderate-intensity aerobic exercise at least 3 times per week, for at least 30 minutes
  • resistance exercise at least 2 times per week, doing at least 2 sets of 8 to 15 repetitions, using a weight or resistance that is at least 60% of a person’s one-repetition maximum (19)

Do you remember those 9 minutes?

A starting exercise prescription may need to involve multiple short bouts (5–10 min duration) daily, to accumulate at least 20 min on any given day. As exercise capacity improves, progression towards longer sessions of at least 20 min duration on most days of the week is recommended (20).

Shifting Paradigm from Rest and Inactivity

The wide ranging and pervasive benefits of exercise should be a part of a health restoration strategy. The Clinical Oncology Society of Australia (COSA) is very clear on its directive on recommendations:

 

  • Exercise should be embedded as part of standard practice in cancer care and viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.
  • All members of the multi-disciplinary cancer team should promote physical activity and help their patients adhere to exercise guidelines.
  • Best practice cancer care should include referral to an accredited exercise physiologist and/or physical therapist with experience in cancer care (21).

One Size Does Not Fit All

At Oasis we approach Exercise Oncology as part of an integrated network. Looking at the whole picture, instead of an oversimplified narrative of just more exercise. Simply telling a person “more exercise” is misleading, dogmatic and does not work!

How you stand is a powerful emotional statement. Exercise is an interrelationship between your inner and outer posture; so that movement can initiate in any direction.

Isn’t one of the hallmarks of being human – adaptability?

The human body is continually adapting to inner and outer posture. At Oasis we have the knowledge, expertise and experience to modify your exercise prescription parameters (mode, frequency, duration and intensity) to accommodate and facilitate individualized short- and long-term health benefits.

Your personalized Exercise Oncology prescription will be tailored to your individual specific needs and circumstances. Individualization that includes safety, specificity and feasibility through the application of evidence, clinical experience and sport science principals. A key component is the adaptability to accommodate “higher energy days/ weeks” and “lower energy days/ weeks “. Cancer related fatigue may lower exercise tolerance and this might fluctuate from day to day.

One of the most distinguishing features of Exercise Oncology at Oasis is structured education programs and curriculum to facilitate behavior change for your restoration to health. The mind needs the body. The body needs the mind.

Some of the behavior change techniques include processed based goal setting, positive reinforcement, self-monitoring, identifying barriers to exercise and helping patients problem solve and identifying past stigmatizing experiences that affect adherence to exercise.

For those who are sedentary or deconditioned we will help you to alleviate fears and barriers associated with ‘doing too much’. Through education and collaborative care, you will learn the differences between treatment-related side effects and normal, short term physiological responses to exercise.

An overall harmonious active healthy lifestyle is superior to routine exercise. It simply is not enough to exercise or be active at one specific time of the day. Here at Oasis, you will learn  how to add more mindful movement into your day so that you can respond appropriately in any situation.

What Can
You Do?

If you are currently undergoing treatment for cancer or have been diagnosed with cancer the exercise recommendations can feel overwhelming and immense. More exercise can be the last thing on your mind.

However, it is important to move more, and it is never too late to start.

 

Start with more movement in your day

According to a 2017 study, breaking sitting with standing and light-intensity walking effectively improved 24h glucose levels and improved insulin sensitivity in individuals with type 2 diabetes to a greater extent than structured exercise (22).

 

Stand up right now.

Simply by standing up you have taken the compression force off your spine from sitting.

Try it a second time. This time try to be a little more mindful of how your body moves and feels: kinesthetic awareness. The muscles are “turned on” and are cross talking with other cells, tissues and organs.

Interrupt long sitting time with light activities; so, go and make some green tea or get a glass of water. Just think of the extra movement with that extra trip to the bathroom.

 

Walking

One of the most effective forms of exercise is walking. You will not burn a lot of calories; calorie counting is an ineffective processed based goal. Moving muscles secrete myokines and enzymes that cross talk with other cells and organs. Walking is also an effective modality to increase fascial fitness and improve your structural posture. Timing is also crucial. Fifteen minutes of walking after your evening meal may an effective means to blunt postprandial glycemic excursions (23).

References

  1. Contrepois K, Wu S, Moneghetti KJ, et al. Molecular Choreography of Acute Exercise. Cell. 2020;181(5):1112-1130.e16. doi:10.1016/j.cell.2020.04.043
  2. Hojman P, Gehl J, Christensen JF, Pedersen BK. Molecular Mechanisms Linking Exercise to Cancer Prevention and Treatment. Cell Metab. 2018;27(1):10-21. doi:10.1016/j.cmet.2017.09.015
  3. Heywood R, McCarthy AL, Skinner TL. Efficacy of Exercise Interventions in Patients With Advanced Cancer: A Systematic Review. Arch Phys Med Rehabil. 2018;99(12):2595-2620. doi:10.1016/j.apmr.2018.04.008
  4. Singh B, Hayes SC, Spence RR, Steele ML, Millet GY, Gergele L. Exercise and colorectal cancer: a systematic review and meta-analysis of exercise safety, feasibility and effectiveness. Int J Behav Nutr Phys Act. 2020;17(1):122. Published 2020 Sep 24. doi:10.1186/s12966-020-01021-7
  5. Thune I, Furberg AS. Physical activity and cancer risk: dose-response and cancer, all sites and site-specific. Med Sci Sports Exerc. 2001;33(6 Suppl):S530-S610. doi:10.1097/00005768-200106001-00025
  6. Brown JC, Winters -Stone K,Lee A, Schmitz KH. Cancer,physical activity and exercise. Compr Physiol 2012;2(4):2775-2809,doi:10.1002/cphy.ct20005
  7. Lee W Jones, Neil D Eves, Jeffrey Peppercorn, Pre-exercise screening and prescription guidelines for cancer patients, The Lancet Oncology, Volume 11, Issue 10, 2010, Pages 914-916.
  8. Fuller JT, Hartland MC, Maloney LT, Davison K. Therapeutic effects of aerobic and resistance exercises for cancer survivors: a systematic review of meta-analyses of clinical trials. Br J Sports Med. 2018;52(20):1311. doi:10.1136/bjsports-2017-098285
  9. Mustian, Karen M.; Sprod, Lisa K.; Palesh, Oxana G.; Peppone, Luke J.; Janelsins, Michelle C.; Mohile, Supriya G.; Carroll, Jennifer Exercise for the Management of Side Effects and Quality of Life Among Cancer Survivors, Current Sports Medicine Reports: November-December 2009 – Volume 8 – Issue 6 – p 325-330 doi: 10.1249/JSR.0b013e3181c22324
  10. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. 2006;174(6):801-809. doi:10.1503/cmaj.051351
  11. Monda V, Villano I, Messina A, et al. Exercise Modifies the Gut Microbiota with Positive Health Effects. Oxid Med Cell Longev. 2017; 2017:3831972. doi:10.1155/2017/3831972
  12. Petriz, B. A. et al. Gut microbiota modification: another piece in the puzzle of the benefits of physical exercise in health? Front. Physiol 7, 511 (2016).
  13. Cohen JB, Geara AS, Hogan JJ, Townsend RR. Hypertension in Cancer Patients and Survivors: Epidemiology, Diagnosis, and Management. JACC CardioOncol. 2019;1(2):238-251. doi:10.1016/j.jaccao.2019.11.009
  14. Scott JM, Zabor EC, Schwitzer E, et al. Efficacy of exercise therapy on cardiorespiratory fitness in patients with cancer: a systematic review and meta-analysis. J Clin Oncol. 2018;36:2297-2305
  15. Wedell-Neergaard AS, Lang Lehrskov L, Christensen RH, et al. Exercise-Induced Changes in Visceral Adipose Tissue Mass Are Regulated by IL-6 Signaling: A Randomized Controlled Trial. Cell Metab. 2019;29(4):844-855.e3. doi:10.1016/j.cmet.2018.12.007
  16. Benatti, F. B., & Pedersen, B. K. (2015). Exercise as an anti-inflammatory therapy for rheumatic diseases-myokine regulation. Nature reviews. Rheumatology, 11(2), 86–97. https://doi.org/10.1038/nrrheum.2014.193
  17. Lin TW, Kuo YM. Exercise benefits brain function: the monoamine connection. Brain Sci. 2013;3(1):39-53. Published 2013 Jan 11. doi:10.3390/brainsci3010039
  18. Speck RM, Courneya KS, Mâsse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2010 Jun;4(2):87-100. doi: 10.1007/s11764-009-0110-5. Epub 2010 Jan 6. Erratum in: J Cancer Surviv. 2011.
  19. Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, Zucker DS, Matthews CE, Ligibel JA, Gerber LH, Morris GS, Patel AV, Hue TF, Perna FM, Schmitz KH. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019 Nov;51(11):2375-2390. doi: 10.1249/MSS.0000000000002116. PMID: 31626055.
  20. Lee W Jones, Neil D Eves, Jeffrey Peppercorn, Pre-exercise screening and prescription guidelines for cancer patients, The Lancet Oncology, Volume 11, Issue 10, 2010, Pages 914-916.
  21. COSA Position Statement on Exercise in Cancer Care (2018) https://www.cosa.org.au/media/332488/cosa-position-statement-v4-web-final.pdf, accessed on 03/18/2021.
  22. Duvivier BM, Schaper NC, Hesselink MK, et al. Breaking sitting with light activities vs structured exercise: a randomised crossover study demonstrating benefits for glycaemic control and insulin sensitivity in type 2 diabetes. Diabetologia. 2017;60(3):490-498. doi:10.1007/s00125-016-4161-7
  23. Colberg SR, Zarrabi L, Bennington L, et al. Postprandial walking is better for lowering the glycemic effect of dinner than pre-dinner exercise in type 2 diabetic individuals. J Am Med Dir Assoc. 2009;10(6):394-397. doi:10.1016/j.jamda.2009.03.015