**3. Benefits of exercise**

### **3.1 Risk factors**

Not all risk factors that predispose an individual to cancer can be controlled (i.e., age, gender, race, genetic factors). However, healthy behaviors and lifestyle choices, along with environmental exposure risk reduction, can help reduce cancer development. Fifty to 75% of cancer deaths in the US are related to risk factors such as smoking, poor dietary choices, and physical inactivity (National Cancer Institute, 2009). Specifically, obesity and physical inactivity are associated with approximately 25-30% of colon, breast, endometrial, kidney, and esophageal cancers in the US (National Cancer Institute, 2009). The World Health Organization lists physical activity among the nine modifiable risk factors for cancer (World Health Organization, 2009). In addition, recent research supports the assertion that physical activity helps to prevent certain forms of cancer (Kruk, 2007; Miles, 2007), including cancer of the colon (Courneya & Friedenreich, 2007), breast (Courneya & Friedenreich, 2007), endometrium (Courneya & Friedenreich, 2007), prostate (Courneya & Friedenreich, 2007; Friedenreich & Orenstein, 2002), lung (Courneya & Friedenreich, 2007; Friedenreich & Orenstein, 2002), kidney (Friedenreich & Orenstein, 2002), rectus (Friedenreich & Orenstein, 2002), and esophagus (Friedenreich & Orenstein, 2002) cancer. The average risk reduction for each of these cancers varies from approximately 10-40% (Wiggins & Simonavice, 2010). Moderate physical activity (>4.5 METs) appears to be associated with a greater protective effect than activities of lower intensity (Lee, 2003).

### **3.1.1 Cancer survivorship**

In addition to reducing the risk of developing certain forms of cancer, physical activity has also been suggested to increase cancer survivorship by decreasing the risk of cancer recurrence, slowing the progression of cancer, and reducing the risk of secondary lifethreatening diseases (Courneya & Friedenreich, 2007; Holmes et al., 2005; Haydon et al., 2005). One investigation (Holmes et al., 2005), revealed a reduction of 26-40% in the relative risk of breast cancer-related death and recurrence among the most active women compared with the least active. Similarly, higher levels of physical activity pre- and post-diagnosis of colon cancer and post-diagnosis of colorectal cancer were associated with a decrease in cancer-related mortality (Haydon et al., 2006; Meyerhardt et al., 2006a, 2006b). As such, the American Cancer Society recommends that exercise serve as an important part of an individual's cancer care plan, asserting that exercise will decrease feelings of fatigue both

Dehydration is often experienced during chemotherapy, either as a side effect of frequent vomiting and diarrhea, or as a direct effect on the kidneys. Large quantities of water are necessary to help the kidneys filter chemotherapy medication. Fatigue and dizziness are symptoms of dehydration, both of which will impact the exercise response. It is important to

Cancer survivors will face a multitude of emotions as they battle cancer, creating a strain on interpersonal relationships. These emotions may include anger, depression, anxiety, and elation. This emotional distress can significantly impact a cancer patient's desire to

Not all risk factors that predispose an individual to cancer can be controlled (i.e., age, gender, race, genetic factors). However, healthy behaviors and lifestyle choices, along with environmental exposure risk reduction, can help reduce cancer development. Fifty to 75% of cancer deaths in the US are related to risk factors such as smoking, poor dietary choices, and physical inactivity (National Cancer Institute, 2009). Specifically, obesity and physical inactivity are associated with approximately 25-30% of colon, breast, endometrial, kidney, and esophageal cancers in the US (National Cancer Institute, 2009). The World Health Organization lists physical activity among the nine modifiable risk factors for cancer (World Health Organization, 2009). In addition, recent research supports the assertion that physical activity helps to prevent certain forms of cancer (Kruk, 2007; Miles, 2007), including cancer of the colon (Courneya & Friedenreich, 2007), breast (Courneya & Friedenreich, 2007), endometrium (Courneya & Friedenreich, 2007), prostate (Courneya & Friedenreich, 2007; Friedenreich & Orenstein, 2002), lung (Courneya & Friedenreich, 2007; Friedenreich & Orenstein, 2002), kidney (Friedenreich & Orenstein, 2002), rectus (Friedenreich & Orenstein, 2002), and esophagus (Friedenreich & Orenstein, 2002) cancer. The average risk reduction for each of these cancers varies from approximately 10-40% (Wiggins & Simonavice, 2010). Moderate physical activity (>4.5 METs) appears to be associated with a greater protective

In addition to reducing the risk of developing certain forms of cancer, physical activity has also been suggested to increase cancer survivorship by decreasing the risk of cancer recurrence, slowing the progression of cancer, and reducing the risk of secondary lifethreatening diseases (Courneya & Friedenreich, 2007; Holmes et al., 2005; Haydon et al., 2005). One investigation (Holmes et al., 2005), revealed a reduction of 26-40% in the relative risk of breast cancer-related death and recurrence among the most active women compared with the least active. Similarly, higher levels of physical activity pre- and post-diagnosis of colon cancer and post-diagnosis of colorectal cancer were associated with a decrease in cancer-related mortality (Haydon et al., 2006; Meyerhardt et al., 2006a, 2006b). As such, the American Cancer Society recommends that exercise serve as an important part of an individual's cancer care plan, asserting that exercise will decrease feelings of fatigue both

ensure adequate fluid intake before, during, and after each exercise session.

**2.9 Dehydration** 

**2.10 Emotional distress** 

**3. Benefits of exercise**

**3.1 Risk factors** 

participate in an exercise program.

effect than activities of lower intensity (Lee, 2003).

**3.1.1 Cancer survivorship** 

during and after treatment, and improve an individual's feeling of control and hope (American Cancer Society, 2011). In addition, the 2008 US Department of Health and Human Services (US DHHS) Physical Activity Guidelines for Americans indicate that individuals with chronic conditions, such as cancer, should be "as physically active as their abilities and conditions allow" (Physical Activities Guidelines Advisory Committee, 2008).

#### **3.2 General health benefits of exercise**

The general health benefits associated with participating in an exercise program are numerous, and include: improved cardiac output, increased ventilation; improved flexibility and range of motion; increased muscular strength and endurance; decreased resting heart rate; improved stroke volume, vasodilation, perfusion; improved metabolic efficiency; and improved blood counts (Wilmore et al., 2008). Likewise, there are several positive physiological and psychological changes for cancer survivors associated with moderate levels of physical activity and structured exercise.

#### **3.2.1 Aerobic capacity**

Research indicates that individuals being treated for cancer have the potential to significantly increase their aerobic capacity by engaging both home-based and structured exercise programs. Young-McCaughan et al (2003) reported an increase in VO2max in cancer survivors following a 12-week exercise program. Thorsen et al (2005) found a significant increase in VO2max for cancer survivors following a 14-week home training program. Wiggins and Simonavice (2008) reported an increase in VO2max in breast cancer survivors after 3 months of resistance and aerobic training. Improvements in VO2max will enhance heart and lung functioning, thereby promoting healthy a blood pressure, blood volume, and gas exchange (Swartz, 2009). In addition, beneficial effects on energy balance, body mass, intestinal transit time, hormone concentrations, and antioxidant enzyme levels have been observed following improvements in aerobic capacity. Research also indicates an inverse relationship between fatigue and aerobic capacity, in that the higher an individual's aerobic capacity, the lower their levels of fatigue, which translates into a positive influence on QOL (DeVita et al., 2008).

#### **3.2.2 Muscular strength and endurance**

Several studies report improvements in muscular strength and endurance as a result of participating in an exercise program. In one study, muscular strength increased by approximately 41% in patients who participated in a 6-week resistance training program (Quist et al., 2006). Likewise, a 12-month exercise program resulted in increases in upper body muscular strength and lower body endurance in breast cancer survivors (Wiggins & Simonavice, 2008). Finally, Cheema and Gual (2006) reported improvements in upper and lower body muscular endurance in previously trained breast cancer survivors following an 8-week exercise program. Increased levels of muscular strength and endurance have a positive effect on body composition, and is therefore associated with lower cancer mortality risk (American Heart Association, 2011).

#### **3.2.3 Psychosocial measures**

A favorable link between exercise and fatigue, psychosocial measures, and QOL has been reported in the literature. Historically, rest was the most common medical advice given for

The Role of Exercise in Cancer Survivorship 131

Muscular Degeneration:

fatigue.

Neurotoxicity:

Cardiotoxicity:

Pulmonary Toxicity:

**4.1.1 Prescreening** 

integrity of the airways

tissues

Cancer treatments damage muscle tissue. Muscle damage may be severe enough to cause weakness and

Cancer treatments cause a decrease in motor function.

Cancer treatments cause: decreased left ventricular dysfunction, reduced ejection fraction, diminished contractility, reduced cardiac output and stroke volume, decreased nutrient and oxygen delivery to

Cancer treatments cause a disruption in the structural

**4.1 Phase 1: Exercise during treatment** 

Table 2. Persistent Effects of Cancer Treatments Relative to Exercise Training.

program for patients who are currently undergoing cancer treatment.

with a medical examination and physician referral (Schneider et al., 2003).

The following procedures will assist the fitness trainer to design a safe and effective exercise

Given that cancer survivors often have limitations that pose challenges to exercise, it is necessary that the exercise intervention be individualized according to the needs of each patient. Current health status, cancer treatments, and anticipated disease trajectory must all be taken into consideration by the fitness trainer before designing an exercise program (Schmitz et al., 2010). Therefore, it is important that fitness professionals work closely with physicians and understand the specifics of the cancer survivor's diagnosis and treatments received, including existing health conditions and fitness level prior to cancer diagnosis. This is best obtained through comprehensive prescreening paperwork, which should include information regarding health history, cancer history, and psychological status, along

**Cancer Treatment Toxicity Effect of Exercise** 

Exercise increases the integrity of

Exercise can enhance motor unit recruitment and improve neurochemical availability at the cellular and tissue levels (Fischer et al., 2003; Snyder, 1986).

Exercise can improve ventilation and transport of oxygen from the environment to the cellular level (Chabner & Longo 2010; Wilson,

muscle tissue and protein synthesis, stimulates the release of numerous hormones that increase muscle cell growth and development, and improves metabolism (DeVita et al., 2001;

Fischer et al., 2003).

Exercise can improve cardiovascular efficiency by strengthening the myocardium, increasing cardiac output and stroke volume, and decreasing resting heart rate and lowering exercise heart rate (DeVita et al., 2001; Fischer et al., 2003).

1978).

the treatment of fatigue (Courneya et al., 2000; Coon & Coleman, 2004; Meyerowitz et al., 1983). Unfortunately, this can lead to even more fatigue (Schneider et al., 2003), as well as to aerobic de-conditioning and a lower functional capacity (Courneya et al., 2005). Conversely, several investigations have found that exercise is beneficial in reducing the fatigue experienced by individuals undergoing cancer treatment (Dimeo et al., 1996; Mock et al., 2007; Schwartz et al., 2001; Segal et al., 2001). In general, fatigue tends to subside within the first 5-10 minutes of activity. In terms of long-term improvement, research indicates that regular aerobic exercise over a period of 6 months improved endurance in breast cancer survivors (Damush et al., 2005) and decreased fatigue in patients with prostate and Hodgkin Disease (Watson & Mock, 2004). 

Improvements in QOL (Wiggins & Simonavice, 2008, 2009; Courneya et al., 2009), anxiety (Courneya et al., 2003, 2000), depression (Courneya et al., 2003, 2000; Pirl & Roth, 1999), body image (Pinto et al., 2003), immune function (Galvo & Newton, 2005), and emotional well-being (Courneya et al., 2003) have also been reported following structured exercise programs. This holds true, even when cancer treatment has failed. It is believed that feelings of self-confidence and hope are directly related to the restored energy levels obtained through improved cardiorespiratory functioning. In addition, chronic exercise leads to a reduction in obesity and improved gastrointestinal functioning, both of which improve selfimage and overall outlook on life (Harriss et al., 2007).

#### **3.2.4 Cancer-specific benefits**

A concern with cancer survivors is that they often have comorbid conditions that will influence exercise prescription and management. More often than not, these comorbidities result from the very medications that are used to fight cancer. The good news, however, is that in most cases, exercise has been found to exert a positive effect on these toxicities. An outline of some of these conditions and the associated benefits of exercise is presented in Table 2. It should be noted that, for these adverse effects of cancer treatment, there may be predisposing factors which will influence the severity of the treatment effects.

#### **4. Components of an exercise program**

As demonstrated above, exercise is safe and effective both during and after most types of cancer treatment, and should therefore be included as an integral part of an individual's cancer care plan. The American Cancer Society recommends that exercise be part of a continuum of cancer survival care, spanning from treatment to recovery, as well as after-recovery maintenance and living-with-advanced-cancer (Doyle et al., 2006). At present, exercise and cancer recovery programs specifically designed for survivors are being implemented all over the country. The following protocols for exercise training with cancer patients are those employed by the Maple Tree Cancer Alliance® (MTCA®), a cancer rehabilitation center in southwest Ohio dedicated to improving the quality of life of individuals afflicted with cancer by focusing on their physical and spiritual needs. All procedures used by MTCA® follow the guidelines set forth by the American College of Sports Medicine (ACSM). Typically, the training sessions resemble that of a general exercise program, in that they often involve an aerobic component, resistance training, and flexibility exercises. However, given the unique challenges imposed by working with cancer survivors, ACSM recommends that fitness professionals working with cancer patients obtain a specialized training certification prior to training this group of individuals (Schneider & Carter, 2003).

the treatment of fatigue (Courneya et al., 2000; Coon & Coleman, 2004; Meyerowitz et al., 1983). Unfortunately, this can lead to even more fatigue (Schneider et al., 2003), as well as to aerobic de-conditioning and a lower functional capacity (Courneya et al., 2005). Conversely, several investigations have found that exercise is beneficial in reducing the fatigue experienced by individuals undergoing cancer treatment (Dimeo et al., 1996; Mock et al., 2007; Schwartz et al., 2001; Segal et al., 2001). In general, fatigue tends to subside within the first 5-10 minutes of activity. In terms of long-term improvement, research indicates that regular aerobic exercise over a period of 6 months improved endurance in breast cancer survivors (Damush et al., 2005) and decreased fatigue in patients with prostate and Hodgkin

Improvements in QOL (Wiggins & Simonavice, 2008, 2009; Courneya et al., 2009), anxiety (Courneya et al., 2003, 2000), depression (Courneya et al., 2003, 2000; Pirl & Roth, 1999), body image (Pinto et al., 2003), immune function (Galvo & Newton, 2005), and emotional well-being (Courneya et al., 2003) have also been reported following structured exercise programs. This holds true, even when cancer treatment has failed. It is believed that feelings of self-confidence and hope are directly related to the restored energy levels obtained through improved cardiorespiratory functioning. In addition, chronic exercise leads to a reduction in obesity and improved gastrointestinal functioning, both of which improve self-

A concern with cancer survivors is that they often have comorbid conditions that will influence exercise prescription and management. More often than not, these comorbidities result from the very medications that are used to fight cancer. The good news, however, is that in most cases, exercise has been found to exert a positive effect on these toxicities. An outline of some of these conditions and the associated benefits of exercise is presented in Table 2. It should be noted that, for these adverse effects of cancer treatment, there may be

As demonstrated above, exercise is safe and effective both during and after most types of cancer treatment, and should therefore be included as an integral part of an individual's cancer care plan. The American Cancer Society recommends that exercise be part of a continuum of cancer survival care, spanning from treatment to recovery, as well as after-recovery maintenance and living-with-advanced-cancer (Doyle et al., 2006). At present, exercise and cancer recovery programs specifically designed for survivors are being implemented all over the country. The following protocols for exercise training with cancer patients are those employed by the Maple Tree Cancer Alliance® (MTCA®), a cancer rehabilitation center in southwest Ohio dedicated to improving the quality of life of individuals afflicted with cancer by focusing on their physical and spiritual needs. All procedures used by MTCA® follow the guidelines set forth by the American College of Sports Medicine (ACSM). Typically, the training sessions resemble that of a general exercise program, in that they often involve an aerobic component, resistance training, and flexibility exercises. However, given the unique challenges imposed by working with cancer survivors, ACSM recommends that fitness professionals working with cancer patients obtain a specialized training certification prior to

predisposing factors which will influence the severity of the treatment effects.

Disease (Watson & Mock, 2004).

**3.2.4 Cancer-specific benefits** 

image and overall outlook on life (Harriss et al., 2007).

**4. Components of an exercise program** 

training this group of individuals (Schneider & Carter, 2003).


Table 2. Persistent Effects of Cancer Treatments Relative to Exercise Training.

#### **4.1 Phase 1: Exercise during treatment**

The following procedures will assist the fitness trainer to design a safe and effective exercise program for patients who are currently undergoing cancer treatment.

### **4.1.1 Prescreening**

Given that cancer survivors often have limitations that pose challenges to exercise, it is necessary that the exercise intervention be individualized according to the needs of each patient. Current health status, cancer treatments, and anticipated disease trajectory must all be taken into consideration by the fitness trainer before designing an exercise program (Schmitz et al., 2010). Therefore, it is important that fitness professionals work closely with physicians and understand the specifics of the cancer survivor's diagnosis and treatments received, including existing health conditions and fitness level prior to cancer diagnosis. This is best obtained through comprehensive prescreening paperwork, which should include information regarding health history, cancer history, and psychological status, along with a medical examination and physician referral (Schneider et al., 2003).

The Role of Exercise in Cancer Survivorship 133

Fig. 2. Muscular Endurance Assessment.

Fig. 3. Flexibility Assessment.

### **4.1.2 Fitness assessment**

Once the prescreening paperwork is completed and reviewed, the patient's current level of fitness should be evaluated through a comprehensive fitness assessment. A comprehensive fitness assessment is one that measures body composition, cardiorespiratory fitness, muscular strength and endurance, flexibility, balance, and range of motion. Specifically, ACSM recommends a graded treadmill or bicycle ergometer test to assess cardiovascular function, a spirometer test for pulmonary function, dumbbells or resistance machines for muscular strength and endurance tests, and the modified sit and reach for flexibility assessment (Schneider & Carter, 2003). In most cases, cancer patients can tolerate the standardized assessment protocols (Swartz, 2009); however, adaptations for certain exercise tests may be necessary if the patient has limited mobility or impaired functioning. Pictures of standard assessments are shown below (Figures 1-5).

Fig. 1. Muscular Strength Assessment.

Once the prescreening paperwork is completed and reviewed, the patient's current level of fitness should be evaluated through a comprehensive fitness assessment. A comprehensive fitness assessment is one that measures body composition, cardiorespiratory fitness, muscular strength and endurance, flexibility, balance, and range of motion. Specifically, ACSM recommends a graded treadmill or bicycle ergometer test to assess cardiovascular function, a spirometer test for pulmonary function, dumbbells or resistance machines for muscular strength and endurance tests, and the modified sit and reach for flexibility assessment (Schneider & Carter, 2003). In most cases, cancer patients can tolerate the standardized assessment protocols (Swartz, 2009); however, adaptations for certain exercise tests may be necessary if the patient has limited mobility or impaired functioning. Pictures

**4.1.2 Fitness assessment** 

of standard assessments are shown below (Figures 1-5).

Fig. 1. Muscular Strength Assessment.

Fig. 2. Muscular Endurance Assessment.

Fig. 3. Flexibility Assessment.

The Role of Exercise in Cancer Survivorship 135

Fitness assessments are useful to quantitatively monitor progress during exercise training. Of note, however, is the fact that cancer-specific norms have not yet been developed. Therefore, the scores received by the cancer patient during his/her fitness assessment are compared to norm charts from a healthy population. This must be taken into consideration during goal setting, particularly for those individuals who are currently undergoing treatment. Typically, for these individuals, as well as patients with recurrent disease, the goal of the exercise program should be simply to preserve function. It is important to have realistic expectations for the exercise intervention so that the patient does not become discouraged, as research indicates that adherence to an exercise intervention is a challenging

Once the fitness assessment has been completed and reviewed, the fitness trainer may design an individualized exercise prescription for the patient. An exercise prescription is a plan of fitness-related activities designed for a specific purpose. In other words, an exercise prescription is a prescription for exercise. Recommendations pertaining to the frequency, intensity, duration, mode, and progression of exercise must be addressed. Ideally, for an individual undergoing cancer treatment, the prescription will include a whole-body workout that targets all the major muscle groups. The overall goal of the exercise program should be to minimize the general de-conditioning that often results from cancer treatment so that the cancer treatments are better tolerated. In general, the exercise prescription should include a slow progression and demonstrate adaptability to changes in the patient's health status, which frequently will change from day-to-day during treatment. According to ACSM (Schmitz et al., 2010), the general objectives for exercise training among cancer survivors are

1. To regain and improve physical function, aerobic capacity, strength, and flexibility.

5. Potentially, to reduce or delay recurrence or a second primary tumor.

regarding recurrence or a second primary cancer.

4. To improve cardiorespiratory, endocrine, neurological, muscular, cognitive, and

6. To improve the ability to physically and psychologically withstand the ongoing anxiety

8. To improve the physiologic and psychological ability to withstand any current or future

At present, the optimal frequency, duration, and time course of adaptation to aerobic and resistance exercise training in cancer patients are not known, although research indicates that individuals undergoing cancer therapy benefit from low-to-moderate intensity aerobic and resistance exercise (Swartz, 2009). Based on available data, Table 3 presents some general guidelines a fitness professional may follow when designing an exercise program (Schmitz et al., 2010; Physical Activities Guidelines Advisory Committee, 2008; Haskell et

Initially, intensity will depend on the patient's functional status and exercise history prior to cancer diagnosis. Typically, previously active cancer patients may continue their exercise regimen, although intensity may need to be decreased during treatment. Progression should consist of increases in frequency and duration rather than in intensity (Physical Activities

7. To reduce, attenuate, and prevent long-term and late effects of cancer treatment.

task (Markes et al., 2006).

as follows:

**4.1.3 Exercise prescription** 

2. To improve body image and QOL. 3. To improve body composition.

psychosocial outcomes.

cancer treatments.

al., 2007; Schneider & Carter, 2003).

Fig. 4. Body Composition Assessment.

Fig. 5. Cardiovascular Endurance Assessment.

Fig. 4. Body Composition Assessment.

Fig. 5. Cardiovascular Endurance Assessment.

Fitness assessments are useful to quantitatively monitor progress during exercise training. Of note, however, is the fact that cancer-specific norms have not yet been developed. Therefore, the scores received by the cancer patient during his/her fitness assessment are compared to norm charts from a healthy population. This must be taken into consideration during goal setting, particularly for those individuals who are currently undergoing treatment. Typically, for these individuals, as well as patients with recurrent disease, the goal of the exercise program should be simply to preserve function. It is important to have realistic expectations for the exercise intervention so that the patient does not become discouraged, as research indicates that adherence to an exercise intervention is a challenging task (Markes et al., 2006).

#### **4.1.3 Exercise prescription**

Once the fitness assessment has been completed and reviewed, the fitness trainer may design an individualized exercise prescription for the patient. An exercise prescription is a plan of fitness-related activities designed for a specific purpose. In other words, an exercise prescription is a prescription for exercise. Recommendations pertaining to the frequency, intensity, duration, mode, and progression of exercise must be addressed. Ideally, for an individual undergoing cancer treatment, the prescription will include a whole-body workout that targets all the major muscle groups. The overall goal of the exercise program should be to minimize the general de-conditioning that often results from cancer treatment so that the cancer treatments are better tolerated. In general, the exercise prescription should include a slow progression and demonstrate adaptability to changes in the patient's health status, which frequently will change from day-to-day during treatment. According to ACSM (Schmitz et al., 2010), the general objectives for exercise training among cancer survivors are as follows:


At present, the optimal frequency, duration, and time course of adaptation to aerobic and resistance exercise training in cancer patients are not known, although research indicates that individuals undergoing cancer therapy benefit from low-to-moderate intensity aerobic and resistance exercise (Swartz, 2009). Based on available data, Table 3 presents some general guidelines a fitness professional may follow when designing an exercise program (Schmitz et al., 2010; Physical Activities Guidelines Advisory Committee, 2008; Haskell et al., 2007; Schneider & Carter, 2003).

Initially, intensity will depend on the patient's functional status and exercise history prior to cancer diagnosis. Typically, previously active cancer patients may continue their exercise regimen, although intensity may need to be decreased during treatment. Progression should consist of increases in frequency and duration rather than in intensity (Physical Activities

The Role of Exercise in Cancer Survivorship 137

this scale, a light-to-moderate intensity (RPE of 11 to 14) should be encouraged. If dizziness, nausea, or chest pain occurs, all exercise should be stopped. Frequent short breaks are sometimes encouraged to accommodate therapy-related fatigue. Aerobic exercise should be followed up by static stretching and range of motion exercises for all major muscle groups.

The type of resistance exercise performed will depend on the patient's range of motion, tissue removal, and wound healing. ACSM recommends at least 48 hours of rest between each resistance training session (Schneider & Carter, 2003). Therefore, it may be advisable to plan a whole body approach to resistance training, where all major muscle groups are targeted in one day. If the patient is unwilling or unable to participate in traditional modes of strength training, Yoga or Pilates may serve as an alternative form of strength exercise.

At the conclusion of the exercise session, the patient should perform a 5-10 minute cool down along with some mild stretching. Sample stretches are shown in the pictures below (Figures 11 and 12). A proper cool down will reduce the potential for muscle soreness,

For patients who have completed cancer therapy, exercise is important to maintain or improve function and prevent the development of diseases associated with inactivity (i.e. diabetes, cardiovascular disease, obesity) (Swartz, 2009). The objective of exercise training during cancer recovery should be to return the patient to their former level of physical function and make exercise an integral part of everyday life. Some side effects of anticancer medications do not appear for months or years after the discontinuation of treatment, therefore it is advised to maintain contact with the patient's physician, in order to monitor

decrease post-exercise dizziness, and allow the heart rate to return to its resting state.

Fig. 6. The Borg Scale Rating Perception of Effort (RPE).

Sample exercises are shown in pictures below (Figures 7-10).

**4.2 Phase 2: Exercise after cancer recovery** 


Guidelines Committee, 2008; Schneider & Carter, 2003). To assist in progression, patients should be reassessed approximately every 6 months (Schneider & Carter, 2003).

\* HRR = Heart Rate Reserve

HRR = [(Maximum Heart Rate – Resting Heart Rate) x % Intensity] + Resting Heart Rate

Table 3. Guidelines for Designing an Exercise Prescription for Individuals Undergoing Cancer Treatment.

#### **4.1.4 Supervised exercise sessions**

Once the individualized exercise prescription has been created, the patient may begin supervised training sessions with the fitness professional. Prior to each exercise session, it is advisable to assess the patient's readiness to exercise. Resting heart rate and blood pressure should be measured, and general information regarding the patient's overall health status should be obtained. Contraindications to exercise are listed in Table 4. Depending on the information attained, the exercise intervention may need to be adjusted for that day.


Table 4. Contraindications to exercise in cancer patients.

Each session should begin with a 5- to 10-minute warm-up that stimulates blood flow to the working muscles. The warm-up should involve some mild stretching and light aerobic activity. During the aerobic component of exercise, it is important to frequently monitor blood pressure and heart rate. If the patient is on a medication that affects heart rate, the Borg Scale of Exertion (Borg, 1973) (Figure 6) may be used to monitor intensity. Based on

Guidelines Committee, 2008; Schneider & Carter, 2003). To assist in progression, patients

Frequency 3-5 days/wk 2-3 days/wk 2-7 days/wk

Intensity 40-60% HRR\* 40-60% HRR\* Stretch to the point

Aerobic Training Strength Training Flexibility Training

per exercise

balls

Free weights, machines, resistance bands, resistance

of mild discomfort

10-30 seconds per

Static stretching

stretch

should be reassessed approximately every 6 months (Schneider & Carter, 2003).

Duration 20-60 min/session 1-3 sets, 8-12 reps

HRR = [(Maximum Heart Rate – Resting Heart Rate) x % Intensity] + Resting Heart Rate

Table 3. Guidelines for Designing an Exercise Prescription for Individuals Undergoing

information attained, the exercise intervention may need to be adjusted for that day.

Decreased heart rate and blood pressure with increased workload

Once the individualized exercise prescription has been created, the patient may begin supervised training sessions with the fitness professional. Prior to each exercise session, it is advisable to assess the patient's readiness to exercise. Resting heart rate and blood pressure should be measured, and general information regarding the patient's overall health status should be obtained. Contraindications to exercise are listed in Table 4. Depending on the

Each session should begin with a 5- to 10-minute warm-up that stimulates blood flow to the working muscles. The warm-up should involve some mild stretching and light aerobic activity. During the aerobic component of exercise, it is important to frequently monitor blood pressure and heart rate. If the patient is on a medication that affects heart rate, the Borg Scale of Exertion (Borg, 1973) (Figure 6) may be used to monitor intensity. Based on

trainers, swimming

Mode Walking, cycling, cross

\*

HRR = Heart Rate Reserve

**4.1.4 Supervised exercise sessions** 

Onset of nausea following exercise initiation

Chemotherapy treatment within the last 24-hours

Table 4. Contraindications to exercise in cancer patients.

Vomiting within the last 24 hours

Difficult or shallow breathing Unusual muscle weakness Numbness in the extremities

Irregular pulse during exertion Disorientation and confusion

Cancer Treatment.

Leg pain

Chest pain

Dizziness

this scale, a light-to-moderate intensity (RPE of 11 to 14) should be encouraged. If dizziness, nausea, or chest pain occurs, all exercise should be stopped. Frequent short breaks are sometimes encouraged to accommodate therapy-related fatigue. Aerobic exercise should be followed up by static stretching and range of motion exercises for all major muscle groups.

Fig. 6. The Borg Scale Rating Perception of Effort (RPE).

The type of resistance exercise performed will depend on the patient's range of motion, tissue removal, and wound healing. ACSM recommends at least 48 hours of rest between each resistance training session (Schneider & Carter, 2003). Therefore, it may be advisable to plan a whole body approach to resistance training, where all major muscle groups are targeted in one day. If the patient is unwilling or unable to participate in traditional modes of strength training, Yoga or Pilates may serve as an alternative form of strength exercise. Sample exercises are shown in pictures below (Figures 7-10).

At the conclusion of the exercise session, the patient should perform a 5-10 minute cool down along with some mild stretching. Sample stretches are shown in the pictures below (Figures 11 and 12). A proper cool down will reduce the potential for muscle soreness, decrease post-exercise dizziness, and allow the heart rate to return to its resting state.

#### **4.2 Phase 2: Exercise after cancer recovery**

For patients who have completed cancer therapy, exercise is important to maintain or improve function and prevent the development of diseases associated with inactivity (i.e. diabetes, cardiovascular disease, obesity) (Swartz, 2009). The objective of exercise training during cancer recovery should be to return the patient to their former level of physical function and make exercise an integral part of everyday life. Some side effects of anticancer medications do not appear for months or years after the discontinuation of treatment, therefore it is advised to maintain contact with the patient's physician, in order to monitor

The Role of Exercise in Cancer Survivorship 139

Fig. 8. Lateral Chest Press.

any changes in health status. The fitness professional should follow the same general guidelines and procedures listed above when working with a cancer survivor.

Fig. 7. Lat Pull Down.

any changes in health status. The fitness professional should follow the same general

guidelines and procedures listed above when working with a cancer survivor.

Fig. 7. Lat Pull Down.

Fig. 8. Lateral Chest Press.

The Role of Exercise in Cancer Survivorship 141

Fig. 10. Leg Press.

Fig. 11. Lower body stretch.

Fig. 9. Shoulder Press.

Fig. 10. Leg Press.

Fig. 9. Shoulder Press.

Fig. 11. Lower body stretch.

The Role of Exercise in Cancer Survivorship 143

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Cella, D., Lai, J.S., Chang, C.H., Peterman, A., & Slavin, M. (2002). Fatigue in cancer patients

Centers for Disease Control and Prevention. (2007). Cancer survivors—United States, 2007.

Cheema, B.S.B, & Gual, C.A. (2006). Full-body exercise training improves fitness and quality

Coon, S.K. & Coleman, E.A. (2004). Keep moving: Patients with myeloma talk about exercise

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