**The Role of Exercise in Cancer Survivorship**

Karen Y. Wonders

*Wright State University, Maple Tree Cancer Alliance, Dayton, United States of America* 

#### **1. Introduction**

124 Topics in Cancer Survivorship

Tehard, B., Friedenreich, C.M., Oppert, J.M., & Clavel-Chapelon, F. Effect of physical activity

Wolin, K.Y., Lee, I.M., Colditz, G.A., Glynn, R.J., Fuchs, C., & Giovannucci, E. Leisure-time

Wolin, K.Y., Yan, Y., Colditz, G.A., & Lee, I.M. Physical activity and colon cancer

*Cancer Epidemiol.Biomarkers Prev*. 15 (2006): 57-64.

prevention: a meta-analysis. *Br.J Cancer* 100 (2009): 611-616.

2776-2781.

on women at increased risk of breast cancer: results from the E3N cohort study.

physical activity patterns and risk of colon cancer in women. *Int.J Cancer* 121 (2007):

At the turn of the 20th century, the outlook was bleak for individuals diagnosed with cancer. The pathophysiology of cancer was not well understood, and the associated treatments were as dire as the disease itself. In 1971, President Nixon declared "war" on cancer (Haran & DeVita, 2005). Since then we have seen dramatic improvements in cancer prognoses. At present, more than 11.7 million men and women are living as cancer survivors in the US, primarily due to early detection and advances in treatment options (Centers for Disease Control, 2007). However, such treatments often result in long-term physical and psychological toxicities, which negatively impact the cancer survivor's quality of life (QOL). These sequelae include, but are not limited to, decreased muscle strength, reduced cardiorespiratory fitness, reduced lean body mass, bone loss, fatigue (Pihkala et al., 1995; Lucia et al., 2003), depression, emotional distress, and anxiety (Jones et al., 2010). Thus, cancer research has shifted from its initial focus on prevention, to one that is centered on controlling or eliminating treatmentrelated toxicities with pharmacologic, physical, or social interventions. Now more than ever, healthy behavior choices are being promoted in attempt to limit this disease. In 2006, 42% of NIH-funded research projects contained an intervention component designed to improve the psychosocial well-being, physical status, and/or health behaviors of cancer survivors (National Institutes of Health, 2011). One such intervention, exercise rehabilitation, has been widely reported in the literature to benefit cancer patients. With more than two decades of literature examining this topic, research continues to support a link between a physically active lifestyle and improvements in mental and physical QOL in cancer survivors (Douglas, 2005; Wiggins & Simonavice, 2009).Thus, the primary aim of this chapter will be to explore the role of physical activity and exercise in cancer recovery.

#### **2. Precautions during exercise**

Cancer survivors often have disease or treatment-specific limitations that affect the exercise response. The specific effects of cancer on the exercise response are determined by the tissues affected and their level of involvement. Treatment-specific limitations arise from the type and duration of anticancer therapy employed. Surgery, chemotherapy, and radiation are the most common forms of cancer treatment, and all are associated with both acute and chronic effects that may negatively impact the exercise response. Table 1 briefly lists some of the more common treatment-related effects. In addition, most people are treated with a combination of surgery, radiation, and chemotherapy, which may cause a host of treatmentrelated problems. Pain, lymphedema, risk of infection, shortness of breath, neural deficits,

The Role of Exercise in Cancer Survivorship 127

Patients with very low blood counts are advised to avoid exercise all together, as they are at an increased risk for anemia. Frequent hand washing is advised, particularly in fitness

Shortness of breath is common when cancer has affected the lungs. It also may result when the bone marrow is affected, causing low red blood cell counts. Red blood cells carry oxygen throughout the body. Their ability to carry oxygen is measured by the amount of hemoglobin present in the blood. A low level of hemoglobin is indicative of anemia. With anemia, the body must work harder to supply oxygen to the tissues, causing the patient to feel fatigued and short of breath. Thus, anemic patients often have a limited aerobic

Neural deficits are common when tumors involve the central nervous system and brain. Problems with neural repair and decreased neurotransmitter activity may also arise as a side effect of anticancer therapy, related to the ability of chemotherapy to cross the blood-brain barrier and cause DNA damage and shortened telomere length (Klein, 2009). Neurological deficits can impact memory and emotion in cancer patients and may influence their

Fatigue is the most frequently reported symptom of cancer treatment (Schneider et al., 2003), affecting up to 96% of patients (Douglas, 2005). It is a whole-body tiredness that interferes with normal functioning and leaves the patient feeling irritable and unmotivated. Chronic fatigue has a negative impact on activities of daily life, social reintegration, and overall quality of life (Hartvig et al., 2006). In some patients, this fatigue is so debilitating to the

Nausea, vomiting, and diarrhea are common effects of radiation and chemotherapy, leaving the patient feeling weak and at risk for electrolyte imbalances and dehydration. Cancer patients should avoid exercise for 24-hours after bouts of vomiting and diarrhea (Young-McCaughan, 2006). As a result, it is important that exercise schedules be flexible to accommodate these bouts of irritation. Research indicates that in some instances, exercise will reduce feelings of nausea. However, if nausea persists upon initiation of exercise,

Cachexia is a physical wasting syndrome accompanied by loss of muscle mass, fat mass, overall weight, and appetite. It affects up to 75% of cancer patients, especially those who are in the advanced stages of pancreas, esophagus, and stomach cancer. It is a metabolic disturbance that can result in electrolyte imbalances, weakness, fatigue, and reduced strength. Often, treatment with nutrient supplementation is ineffective (Martingnoni et al., 2003). Patients suffering from cachexia often lack the energy to exercise, so little is known

individual that treatment must be discontinued or limited (Schneider et al., 2003).

performance because of the reduced oxygen-carrying capacity (Swartz, 2009).

centers, where germ count tends to be very high.

motivation to adhere to an exercise program.

activity should be stopped (Young-McCaughan, 2006).

about the impact of exercise on this condition.

**2.4 Shortness of breath** 

**2.5 Neural deficits** 

**2.6 Fatigue** 

**2.8 Cachexia** 

**2.7 Nausea and vomiting** 


fatigue, nausea and vomiting, cachexia, dehydration, and emotional distress are all common effects of cancer and its associated treatments on the patient's exercise tolerance.

Table 1. Potential Side Effects of Anticancer Therapy (Swartz, 2009).

#### **2.1 Pain**

Depending on the specific location of the cancer, patients may experience high levels of pain. A tumor often causes pain, particularly when it involves the musculoskeletal system, causing it to press on bones, nerves, or body organs. In addition, chronic pain is frequently reported following surgery, often when large amounts of healthy tissue are removed along with cancer tissue. Chemotherapy and radiation treatments may also cause pain resulting from such side effects as peripheral neuropathy, mucositis, and radiation injuries (American Cancer Society, 2011). In most situations, physicians can prescribe medications to alleviate pain; however the intensity, type, duration, and frequency of exercise may need to be adjusted until the pain is brought under control.

#### **2.2 Lymphedema**

Lymphedema is a swelling that results from a blockage of the lymph vessels that drain fluid from tissues. It is commonly caused by a mastectomy or the removal of underarm lymph nodes during breast cancer surgery, and is experienced by approximately 10-15% of breast cancer patients (Muss, 2007). It is characterized by a persistent swelling, typically of the arm or leg. Often, patients may be treated with compression bandages to limit swelling. It is advised that exercises be carefully designed, so as not to increase the swelling or cause infection (Kercher et al., 2008).

#### **2.3 Risk of infection**

Chemotherapy, radiation, and immunotherapy often have a substantial impact on white blood cell count. Consequently, immune function often weakens during cancer treatment. Patients with very low blood counts are advised to avoid exercise all together, as they are at an increased risk for anemia. Frequent hand washing is advised, particularly in fitness centers, where germ count tends to be very high.

#### **2.4 Shortness of breath**

126 Topics in Cancer Survivorship

fatigue, nausea and vomiting, cachexia, dehydration, and emotional distress are all common

**Cancer Treatment Potential Side Effects** 

Loss of flexibility

Cardiac and/or lung scaring

Changes in body composition that influence

Skin changes Loss of flexibility

Fatigue Nausea Myopathies Neuropathies Muscle weakness

Wasting

Depending on the specific location of the cancer, patients may experience high levels of pain. A tumor often causes pain, particularly when it involves the musculoskeletal system, causing it to press on bones, nerves, or body organs. In addition, chronic pain is frequently reported following surgery, often when large amounts of healthy tissue are removed along with cancer tissue. Chemotherapy and radiation treatments may also cause pain resulting from such side effects as peripheral neuropathy, mucositis, and radiation injuries (American Cancer Society, 2011). In most situations, physicians can prescribe medications to alleviate pain; however the intensity, type, duration, and frequency of exercise may need to be

Lymphedema is a swelling that results from a blockage of the lymph vessels that drain fluid from tissues. It is commonly caused by a mastectomy or the removal of underarm lymph nodes during breast cancer surgery, and is experienced by approximately 10-15% of breast cancer patients (Muss, 2007). It is characterized by a persistent swelling, typically of the arm or leg. Often, patients may be treated with compression bandages to limit swelling. It is advised that exercises be carefully designed, so as not to increase the swelling or cause

Chemotherapy, radiation, and immunotherapy often have a substantial impact on white blood cell count. Consequently, immune function often weakens during cancer treatment.

gait and balance.

effects of cancer and its associated treatments on the patient's exercise tolerance.

Surgery Pain

Radiation Fatigue

Chemotherapy Anemia

adjusted until the pain is brought under control.

**2.1 Pain** 

**2.2 Lymphedema** 

infection (Kercher et al., 2008).

**2.3 Risk of infection** 

Table 1. Potential Side Effects of Anticancer Therapy (Swartz, 2009).

Shortness of breath is common when cancer has affected the lungs. It also may result when the bone marrow is affected, causing low red blood cell counts. Red blood cells carry oxygen throughout the body. Their ability to carry oxygen is measured by the amount of hemoglobin present in the blood. A low level of hemoglobin is indicative of anemia. With anemia, the body must work harder to supply oxygen to the tissues, causing the patient to feel fatigued and short of breath. Thus, anemic patients often have a limited aerobic performance because of the reduced oxygen-carrying capacity (Swartz, 2009).

#### **2.5 Neural deficits**

Neural deficits are common when tumors involve the central nervous system and brain. Problems with neural repair and decreased neurotransmitter activity may also arise as a side effect of anticancer therapy, related to the ability of chemotherapy to cross the blood-brain barrier and cause DNA damage and shortened telomere length (Klein, 2009). Neurological deficits can impact memory and emotion in cancer patients and may influence their motivation to adhere to an exercise program.

#### **2.6 Fatigue**

Fatigue is the most frequently reported symptom of cancer treatment (Schneider et al., 2003), affecting up to 96% of patients (Douglas, 2005). It is a whole-body tiredness that interferes with normal functioning and leaves the patient feeling irritable and unmotivated. Chronic fatigue has a negative impact on activities of daily life, social reintegration, and overall quality of life (Hartvig et al., 2006). In some patients, this fatigue is so debilitating to the individual that treatment must be discontinued or limited (Schneider et al., 2003).

#### **2.7 Nausea and vomiting**

Nausea, vomiting, and diarrhea are common effects of radiation and chemotherapy, leaving the patient feeling weak and at risk for electrolyte imbalances and dehydration. Cancer patients should avoid exercise for 24-hours after bouts of vomiting and diarrhea (Young-McCaughan, 2006). As a result, it is important that exercise schedules be flexible to accommodate these bouts of irritation. Research indicates that in some instances, exercise will reduce feelings of nausea. However, if nausea persists upon initiation of exercise, activity should be stopped (Young-McCaughan, 2006).

#### **2.8 Cachexia**

Cachexia is a physical wasting syndrome accompanied by loss of muscle mass, fat mass, overall weight, and appetite. It affects up to 75% of cancer patients, especially those who are in the advanced stages of pancreas, esophagus, and stomach cancer. It is a metabolic disturbance that can result in electrolyte imbalances, weakness, fatigue, and reduced strength. Often, treatment with nutrient supplementation is ineffective (Martingnoni et al., 2003). Patients suffering from cachexia often lack the energy to exercise, so little is known about the impact of exercise on this condition.

The Role of Exercise in Cancer Survivorship 129

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).

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

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

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

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

**3.2 General health benefits of exercise** 

**3.2.1 Aerobic capacity** 

(DeVita et al., 2008).

**3.2.2 Muscular strength and endurance** 

risk (American Heart Association, 2011).

**3.2.3 Psychosocial measures** 

levels of physical activity and structured exercise.

#### **2.9 Dehydration**

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