As America begins its next century, it has not yet seen an end to diagnoses of cancer. What this country has seen in terms of cancer research, however, is a tremendous growth in biotechnology, improvement in cancer diagnosis and better therapeutics. Behavioral research from Fawzy and Spiegal has shown improvements in survival time in metastatic cancers while attending support groups.
In the decade of the 1990s, athletes and celebrities such as figure skaters Peggy Fleming (breast cancer) and Scott Hamilton (testicular cancer), track athletes Steve Scott (testicular cancer) and Ludmila Enquist (breast cancer) have all been diagnosed and treated for their cancers and resumed their athletic careers.
Perhaps the most startling of these success stories is Tour de France champion Lance Armstrong, who was diagnosed with testicular cancer in 1997 and became metastatic. In an interview with USA Weekend (Dec. 12, 1999), he revealed that his doctors gave him a 40% survival chance. After two years off the racing circuit, he returned in 1998 and trained for the upcoming season. This cumulated with a win at the 1999 Tour de France, one of sport's toughest athletic events. He repeated his feat at the 2000 Tour with one of the most spectacular mountain climbing stages in the Tour’s history.
The increased reporting of athletes who have survived cancer has mirrored the sports medicine interest in this area. Back in the 1980s, there was virtually no information on the subject of exercise and cancer. The late Dr. Maryl Winningham pioneered the beginning level of this research with a series of reports on the effects of moderate interval aerobic training in fatigue, nausea and quality of life.
Why the Growing Interest in Exercise and Cancer?
Exercise programming for cancer may mirror the growth in the US in alternative medicine and self help. A report in Alternative Therapies Journal by Van deCreek et al suggests that exercise is second only to prayer as the top forms of complimentary therapies that breast cancer survivors have interest in (prayer=84%, exercise=76%) and actually participate in as part of their recovery (prayer=76%, exercise=38%). Secondly, the passage of the Balanced Budget Act in 1998 has curtailed many acute rehabilitation programs in the US. Therefore, many therapists are looking for programs to provide to their patients to expand their level of clinical services. In 1996, the publication of the US Surgeon General’s Report on Physical Activity put into perspective the importance of regular exercise in maintaining and improving one’s physical health. Lastly, health centers in the US and abroad are moving in the direction of new and innovative programming. Many health clubs want to forge stronger relationships with their community medical facilities. All of these elements make for an attractive fit to provide exercise for persons with cancer. Therefore, exercise may stand on its own as the premier form of complimentary medicine for cancer survivors.
Benefits of Exercise
Why would a cancer survivor who has recently undergone chemotherapy or radiation wish to participate in an exercise program? In essence, patients feel better when they are in good shape. Not only are they better able to tolerate their medications, but their quality of life improves. This section details some of the major sports medicine reports that lend support to participating in exercise as a preventive approach to cancer but (according to some oncology sources) also to improve the odds for survival after diagnosis.
The Epidemiology of Exercise and Cancer
In the mid 1980s, Dr. Rose Frisch detailed a report that stated that former collage athletes had a marked reduction in the incidence of certain types of cancer, some by up to 45% less than their sedentary counterparts. In the late 1980s, a report from Stanford stated that persons who engage in more than three hours of physical activity per week have a reduction in certain cancers (such as colon cancer) by about 15%. These were the first epidemiological reports that looked at physical activity in cancer prevention. It wasn’t until five years later that USC Professor Dr. Leslie Bernstein showed a 60% reduction in breast cancer incidence in premenopausal women who engaged in regular exercise each day. Three years later, Dr. Ingar Thune published a Swedish study on physical activity and breast cancer incidence in 25,000 women. Her results mirrored the work at USC and showed a reduction in incidence rates by over 25%. This is impressive based on the large sample size interviewed. In general, the consensus of epidemiology reports lend a tremendous amount of statistical power to inclusion of exercise into a cancer-prevention regime.
Improved Immune System
Reports from the early 1990s by Dr. David Nieman confirmed that exercise enhanced natural killer (NK) cell activity. This immune system component has effects on chemoprotection. However, the criticism in the immunology community is that changes in the immune system are transient, and it is hard to pinpoint whether or not regular exercise stimulates these cells enough to produce a long-term effect.
In a conversation with Dr. Nieman early in 1999, his response to this was for physiologists and physicians to understand the concept of immunoenhancement - the sum of change in the immune system over time. This changing pattern over time may improve the protective status of the immune system without being detected on a random blood draw. Nonetheless, this may explain why some persons who exercise regularly may have a reduced incidence rate of certain types of cancers.
Some theories recently published by Dr. Ann McTiernan state that improving the hormone state will have a tremendous impact on cancer development. It seems as though components such as insulin and insulin-like growth factor (IG-F) have an effect on tumor development. Modulating these hormones (along with cortisol and sex hormones) may reduce the ability of tumor cells to grow and proliferate.
Other Physiological Mechanisms
There are other hypotheses that may indeed have an impact on tumor cell development and proliferation. Like the new angiogenesis inhibitors that are being tested in the cancer field, exercise redistributes blood flow. This redistribution may have an impact on blood supply to the developing tumor cell. Exercise also increases body core temperature, changes body pH and increases the amount of lactate produced metabolically. These changes, although not currently tested in cancer, may also have an impact on tumor cell growth. We can only speculate as to the true mechanisms of why those who exercise may be at a reduced risk for development.
Quality of Life Changes
The past 10 years of behavioral research has given quite a bit of information as to the power of support groups and positive thinking on cancer survivorship. Recent behavioral reports have shown that persons with metastatic cancer who are involved in group support live longer than their non-support group counterparts. In the behavioral aspects of exercise, what we do know for certain is that physical activity enhances the quality of life for all of its participants. There are more reports coming out each year on the effects of exercise on quality of life issues. A 1997 report by Dr. Bernadine Pinto stated that 16 breast cancer survivors who participated in regular aerobic exercise had improved profile of mood scores than their sedentary controls. A 1998 report by Michelle Segar from the University of Michigan stated that 24 breast cancer survivors who performed regular aerobic conditioning had improved self efficacy scores and less anxiety than their controls. A 1999 review of over 20 behavioral reports by Dr. Kerry Courneya from Canada states that 75% of these reports show positive effects of exercise on cancer survivorship. A paper presented at 1999 by the HealthEmotions Research Institute states that 41 women with breast cancer who underwent a 16-week group exercise program improved blood pressure, body weight and well-being scores. This is some of the most profound research available on the benefits of exercise for cancer survivors. The ability to enjoy life and participate more fully in daily activities is shown through regular exercise at even a low level of training.
Current Clinical Studies
One of the first publications on therapeutic exercise for cancer patients was published by Rosenbaum in 1979. This guidebook may have been years ahead of its time in terms of its practical application to acute exercise programming for cancer survivors. However, in the 1990s, there are more reviews on the subject of exercise in terms of its application to the rehabilitation profession. A recent report from Dimeo states that patients who are on high dose chemotherapy and stem cell transplantation can improve physical measures such as hemoglobin and physical performance. This report details how even patients receiving large amounts of medication can derive exercise benefits. Winningham introduced the concept of the WAIT protocol, which uses interval aerobic conditioning to improve the fitness level of participants. Durak has used moderate to heavy progressive resistance strength training to improve overall function and quality of life scores in stage I and II cancer survivors. This program has also looked at health status over five years for participants who are continually exercising. Most of them (90% of 18 interviewed) still exercise and take nutritional supplements daily as part of their recovery process. A summary of the epidemiological and clinical benefits of exercise and cancer is listed in Table 1 below.
Programming for Exercise and Cancer
Most programs for cancer survivors use aerobic training (walking or stationary bike protocols) to improve function and quality of life scores for patients. The Cancer Well-Fit Program in Santa Barbara, California uses a four component approach for exercise. This model concentrates on progressive resistance strength training as the primary training regime. Patients select stations that fit their initial fitness level and medical concerns and progress to higher weight levels and additional stations as pain free fitness levels and strength improves. Aerobic training concentrates on machines (so patients can check improvement in Watts and MET values from computer readouts), step classes and group walking. The important aspect about training in a community health club environment is that patients can select from a variety of classes (designed for them) and aerobic machines to improve their aerobic capacity during their initial 10 weeks of supervised exercise. The third component is range of motion and flexibility. This concentrates on working out scar tissue deficits and balancing general musculature. The last component is mind/body fitness, which consists of breathing, relaxation, one to two yoga classes within the 10 weeks and some meditation programs. All of these are part of the health club programming. They are offered to cancer participants along with water exercise, NIA training and other club programs. This model is one that many health clubs and clinics are looking to emulate because, over the past five years, programs in Southern California, Colorado and Illinois have trained hundreds of cancer survivors using this model, and outcomes have been published on many of these participants with regards to increases in strength (over 45%), aerobic capacity (30%) and a multitude of quality of life improvements (in general over 29%). Over five years of recovery, over 90% of participants continue to exercise either self paced or in a club, and the same percentage take supplements on a daily basis. Their level of vigor is over 80% (on a 100 scale), and almost all use some type of complimentary therapy to enhance their recovery process.
Future Directions in the Field
Exercise and cancer is slowly making its presence felt in the sports medicine community. For now, personal trainers, therapists and oncology nurses have the resources to provide exercise programs for cancer survivors in a safe and supervised environment.
Personal trainers will play a critical role in the development of long-term health outcomes for cancer survivors. As we have seen in our recent national survey of personal trainers, fitness instructors can help cancer survivors with their orthopedic concerns (after referrals from PT), psycho-social needs through group exercise and improvement in self efficacy and can inform them on topics of health education, nutrition and mind-body fitness.
Health clubs will also play a role in cancer wellness through the developing of programs in their facilities and working with local medical agencies (physical therapy, nursing and oncology) to facilitate the growth of such programs for all types of cancer survivors.
If cancer and exercise is to reach the status of cardiac rehabilitation in this decade, then it is essential we increase our awareness and knowledge of dealing with cancer survivors (some of whom already exercise in the health club setting) and improve our communication with oncologists and therapists to ensure a smoother referral network into these exercise programs. Exercise professionals are going to lead the change in this area of health care, and they will do it in a big way.
This article is dedicated to the memory of Dr. Maryl Winningham, who pioneered the use of exercise for cancer patients. She lost her battle with breast cancer in February of 2001, but her spirit remains.
||Type of Program
||Change that occurred
|Daily physical activity
|Higher amounts of PA reduced rate of breast cancer incidence
||PA / exercise
||75% of reviewed papers showed imp. in behavioral indexes Leisure Score Index, FACT-B, Satisfaction with Life Scale
||Improved treadmill 1997 performance, hemo- globin, and fatigue scores in high dose chemotherapy patients
|Strength, aerobic, flexibility, relaxation
||Improved fitness and quality of life scores using modified Rotterdam survey
|Follow up survey (n=30/2 groups)
||Current health and exercise habits
||90% maintained their exercise and vitamin regimes over 5 years of recovery
|National survey (n=100 in 2 groups)
||Exercise habits and quality of life aspects in cancer survivors who work out nationally vs. local injuries, and MD
||17% improvement in quality of life, and information on yoga, mind body fitness, awareness of patient Program participation
||Performed strenuous exercise in varsity athletics
||Lower lifetime occurrence of breast and reproductive cancers by up to 40%
|Case control (n=41)
||Improved strength, VO2, ROM, self- reported well being
|Case control (n=72)
||Improved BSI, COPE, and Duke functional support surveys
||Aerobic exercise training
||Improved scores on Beck depression, Spelberger Anxiety Inventory, and Rosenberg self-esteem scale.
|Primary prevention (n=25,624)
||Reduction in incidence of breast cancer by 25% in women with higher levels of PA.
|Self reported surveys (n=112)
||Exercise and prayer
||Higher percentage of breast cancer survivors participate in exercise than general population
||66% maintained exercise throughout medical treatment and reported less cases of nausea and fatigue vs. controls
- Bernstein, L., Henderson, BE, Hanisch, R., Halley, JS, Ross, E. Physical exercise and reduced risk of breast cancer in young women. J. Nat. Cancer Inst. 86;18:1403-08, 1994.
- Courneya, KS, Friedenreich, SM. Physical exercise and quality of life following cancer diagnosis: A literature review. Ann. Behav. Med. 21;2:1-10, 1999.
- Dimeo, R.C., Tilmann, M.H.M., Bertz, H., Kanz, L., Mertelsmann, R., Keul, JR. Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. Cancer. 79:1717-22, 1997.
- Durak, E.P, Lilly, P.C. The Application of a Total Conditioning Program with Cancer Patients: Effects on Strength and Endurance. J. Str. Condit. Res.. 12;1:3-6, 1998.
- Durak, EP, Lilly, PC. A five year follow up survey on health and exercise habits in women breast cancer survivors. Br. Cancer Res. Treat. 57;1:92 (abstract), 1999.
- Durak, EP, MSc, Harris, JM, Ceriale, SM. The Effects of Exercise on Quality of Life Changes in Cancer Survivors: The Results of a National Survey. Submitted to Cancer, September, 2000
- Frisch, R.E., Wyshak, G., Albright, N.L., Albright, T.E., Schiff, I., Witschi, J.,Marguglio, M. Lower lifetime occurrence of breast cancer and cancers of the reproductive system among former college athletes. Am. J. Clin. Nutr. 45:328-35, 1987.
- Kolden, G, Staruman, T., Woods, T., Schneider, K, et al. Exercise is associated with improved physical and mental health in women with breast cancer. Br. Cancer Res. Treat. 57:1:131 (abstract), 1999.
- McTiernan, A, Ulrich, CM, Yancey, D, Stalte, S., et al. The Physical Activity for Total Health (PATH) Study: Rationale and design. Med. Sci. Sports Ex. 31;9:1307-12, 1999.
- Nieman, DC, Nehlsen-Cannarella, SL. Exercise and infection. In: Exercise and Disease. R.R. Watson, ed. CRC Press, Boca Raton, FL pp. 121-148, 1992.
- Pinto, B., Maruyama, N., Thebarge, R. Exercise participation in breast cancer patients. (abstract). Psycho-Oncol. 1996; 5;3:S-3:3, 1996.
- Rosenbaum, E.R., Rosenbaum, I. Rehabilitation Exercises for the Cancer Patient. Bull Publishing, Palo Alto, CA, 1980.
- Segar, M., Katch, V.L., Garcia, A., Haslanger, S., Wilkens, E. Aerobic exercise reduces depression, and anxiety, and increases self-esteem among breast cancer survivors. Oncol. Nur. Forum. 20:317-21, 1998.
- Shephard, R.J. Physical activity and cancer. Int. J. Sports Med. 11:413-20, 1990.
- Spiegal, D., Bloom, J., Kraemer, H, et al. Effect of psychological treatment on survival of patients with metastatic breast cancer. Lancet 14 (October): 888-91, 1989.
- Thune, I., Brenn, T., Lund, E., Gaard, M. Physical activity and the risk of breast cancer. The New Engl. J. Med. 336;18:1269-75, 1997.
- Van deCreek, Rogers, E, Lester, J. Use of alternative therapies among breast cancer outpatients compared with the general population. Alt. Ther. Health Med. 5;1:71-77, 1999
- Winningham, M.L., MacVicar, M.G. The effect of aerobic exercise on patient reports of nausea. Oncol. Nurs. Forum. 15;4:447-50, 1988.