**1.4.1 As regards risk factors for breast cancer it should be noted that**

these have been identified in the:


All the listed factors above are involved in the proliferative in vitro and in vivo cancer processes (Stephenson, 2003; Del Giudice 1998; Bruning 1995; Sachdev 2001; IARC 2002).

In literature there are few data about the effects of physical activity on women related to the parameters listed above (Schmitz 2005)


end of the first year after diagnosis, 68% showed a weight gain between 1.7 and 4.7 kg and 74% increased their fat mass between 2.1 and 3.9%. Three years after diagnosis, the patients with greater weight gain were those with the higher stage, post-menopausal, younger, with greater reductions in physical activity after diagnosis (Irwin 2005).


#### **1.5 Weight and physical exercise**

180 Topics in Cancer Survivorship

All the listed factors above are involved in the proliferative in vitro and in vivo cancer processes (Stephenson, 2003; Del Giudice 1998; Bruning 1995; Sachdev 2001; IARC 2002). In literature there are few data about the effects of physical activity on women related to the

There is evidence that obesity is a risk factor for breast cancer (Stephenson 2003, World

 The high caloric intake in relation to the energy needs has been indicated as a possible cause of increased risk of breast cancer, but studies have given conflicting results. A positive relationship was described by 7 out of 15 case control studies (Franceschi 1996; Iscovitch 2004; Katsouyanni 1994, Levi 1993; Toniolo 1989; vant'Veer 1990, Yu 1990), 2 out of 10 prospective studies (Gaard 1995; Barrett -Connor 1993), with a relative risk between 1.3 and 3.5. Instead, no relationship was found by other authors (Malin 2005; Graham 1991.1992; Holmberg 1994, Ingram 1991; Katsoiyanni 1988, Miller 1978, Rohan 1995, Yuan 1995, Holmes 1999, Howe 1991, Jones 1999; Kushi Velie 1992 2000; van der

 In a latest prospective study, 38.660 women aged from 55 to 74 years were monitored in the U.S.A. between 1993-2003. In that period of time, 764 new cases of breast cancer were diagnosed. The use of questionnaires allowed us to quantify the contribution of energy, the amount of physical activity, the weight, the height and the BMI of the population. The relative risk (RR) of breast cancer for patients with the highest quartile of caloric intake compared with women with the lowest quartile was equal to 1.25 BMI > 30Kg/m2 compared with BMI < 22.5 kg/m2 and led to a risk equal to 1.35. Women with intense physical activity > 4 hours weekly reduced their RR to 0.78% compared to less active ones. Patients with the highest energy intake, with a higher BMI, doing less

 Obesity, at the moment of diagnosis, is an unfavorable prognostic factor both for recurrence and for survival (Chlebowsky 2002, Boyd 1981, Goodwin 2002, Kumar 2000,

 The weight gain after the diagnosis is a common phenomenon (Rock 1999; Demark-Wahnefried 1997, 2001; McInnes 2001; Goodwin 1999; Asiani 1999; Harvie 2004; Freedman 2004; xxDonegan 1978; Donegan 1978; Dixon 1978; Hernandez 1983; Bonomi 1984; Foltz 1985; Heasman 1985; Hunington 1989; Chlebowski 1986, 1993, Goodwin 1988, 1998, Gordon 1990; Levine 1991; Demark-Wahnefried 1983,1997; Faber-

 In the Health Eating and Lifestyle Study (HEAL), 514 women with breast cancer, stage 0-IIIA, were monitored for body composition by DEXA for a period of 2 years. At the

Brandt 1993) and an author found an inverse relationship (Knekt 1990).

physical activity than the others, have a RR of 2.10 (Chang, 2006).

**1.4 Breast cancer and the management of physical exercise**  Breast cancer is the most common female cancer in many countries.

Increased plasma levels, Insulin Like Growth Factor

these have been identified in the:

High insulin on an empty stomach

parameters listed above (Schmitz 2005)

Cancer Research Fund 2007)

 Excess weight Excess body fat

Insulin resistance

Newman 1986)

Langendoen 1996, Cheney 1997).

**1.4.1 As regards risk factors for breast cancer it should be noted that** 

Increased plasma levels of hormones at estrogen and androgen activity


Rehabilitation in Cancer Survivors: Interaction Between Lifestyle and Physical Activity 183

 The American College of Sports Medicine, through a consensus, hopes for neoplastic patients a moderate-intensity physical activity of at least 150 minutes per week or 75 minutes per week of intense activity, combined with two/three weekly stretching

Studies on the role of physical activity in reducing the colon cancer risk are those which oncologists recognize as the most convincing (Vainio 2002). Literature provides numerous prospective studies (Lee 1995; Gerhardsson 1988, Martinez 1997, Wu 1987; Thun 1992; Dancing 1990-Barbash, Albanian 1989, Severson 1989; Lynge 1988, Paffembarger 1987, Giovannucci 1995), and retrospective (Fraser 1983 , Longnecker 1995, Wittemore 1990, Kuna 199 °, Markowitz 1992, Peters 1989, Brownson 1989, Kato 1990, Fredriksson 1989). A meta-analysis of 19 cohort studies showed a reduction in the incidence of cancer in 22% of

Another meta-analysis of 52 observational studies showed that physical activity reduces the

 the use of hormone replacement therapy alone tends to reduce the risk of cancer and this gives serious problems of interpretation when the examined women were older ; the combination of moderate physical activity all life long with high-intensity recreational physical activity has for women little impact on cancer risk (Mai 2007); women, who did physical activity in the fertile age at least 4 hours a week, have a 25% lower risk than those whose activities did not exceed 30 minutes per week (Mai 2007) post-menopausal women, who didn't do any hormone treatment, have a 46% risk

women with hormone therapy do not have further risk reductions with the regular

In a study of 680 patients with colon cancer, who belong to a population of 51.500 subjects, recruited by the Health Professional Follow-up Study, the survivors in the period 1986-2004 were monitored every 2 years with a specific questionnaire for assessing physical activity in MET, the results showed that subjects with an energy expenditure higher than 18 MET per

27 MET per week, compared with patients with MET <3, showed a reduction in mortality risk equal to 0.47. Free from cancer patients were 82.2% with activity <3 MET, 87.4%, those between 3 and 27 MET, 92.1% those with > 27 MET in 5 years. Free of cancer patients were, for 3 MET levels, were respectively 79.4%, 81.2%, 88.3% in 10 years. Mortality in patients with activities <27 MET had a death rate of 50% lower than the sedentary ones; this result was not related to age, disease stage, BMI, tumor location and physical activity before the

 From an observational prospective cohort study, the Nurses' Health Study, conducted among 121.700 subjects in the period 1986-2002, 573 women with a diagnosis of colon cancer, stage I-III, were enrolled. All participants were monitored with a questionnaire and a scale which was able to measure the activity in MET hours/week. If no response was given, they did a research aimed at establishing the evolution of the illness or the death. The level of physical activity before the diagnosis had no effect on the mortality rate.The physical activity after diagnosis reduced, in subjects with <18 MET hours /

sessions for the most important muscle groups (Schmitz 2010).

males and in 29% of women with physical activity (Samad 2005).

data are more convincing in men than in women (Cheblowski 2004);

reduction, if they did physical activity for at least 4 hours a week ;

physical activity doesn't give any risk reduction of the rectum cancer.

week had a 50% risk reduction of recurrence. An activity over

development of colon cancer (Wolin 2009).

practice of physical activity ;

diagnosis. (Meyerhardt 2009).

However:

amount of physical activity (Monninkhof 2007). The evidence is weaker for premenopausal women in which a risk reduction of 6% per weekly additional hour of physical activity, but only in half of the studies considered of the "highest quality".

 In particular, women with breast cancer, who exercise more than 9 MET per week, show a reduction in recurrence between 40 and 67% (McTiernan, 2008; Ibrahim 2010, Irwin 2007) compared with sedentary individuals.

#### **1.6 The management of physical exercise in case of prostate cancer**


#### **1.7 Cancer of the colon-rectum and the management of physical exercise during cancer disease**

Colon cancer is one of the forms of neoplasia with increasing incidence, with a prevalence in some countries, reaching 10% of the population suffering from cancer (Jemal 2010, Bhatia 2008).

The improvement of diagnostics and treatments has led to a substantial improvement in survival at 5 years that has passed through the most severe not localized forms (Altekruse 2010), from 51% in 1975 to 69.5% in 2006.

Survivors are at risk of developing a second cancer of the colon or of other organs, mainly breast, prostate, skin and lungs (Green 2002, Andre 2009, Birgisson 2005).

Most of the survivors of colon cancer are at risk of developing other diseases, mainly cardiovascular, pulmonary and psychiatric (Phipps, 2008, Jansen 2010; Yabroff 2004, Trentham-Dietz, 2003; Brown 1993; Denlinger 2011).

Often the survivors suffer from the consequences of therapies such as ostomy, neuropathies, chemotherapy, asthenia and depression. These may represent important limitations to the use of physical exercise as a therapeutic tool (Phipps 2008, Rauch 2004, Schneider 2007).

Physical activity has been proposed as a therapeutic but non- pharmacological tool to improve the quality of life and prognosis of patients suffering from colorectal cancer as well as a primary prevention means.


 The American College of Sports Medicine, through a consensus, hopes for neoplastic patients a moderate-intensity physical activity of at least 150 minutes per week or 75 minutes per week of intense activity, combined with two/three weekly stretching sessions for the most important muscle groups (Schmitz 2010).

Studies on the role of physical activity in reducing the colon cancer risk are those which oncologists recognize as the most convincing (Vainio 2002). Literature provides numerous prospective studies (Lee 1995; Gerhardsson 1988, Martinez 1997, Wu 1987; Thun 1992; Dancing 1990-Barbash, Albanian 1989, Severson 1989; Lynge 1988, Paffembarger 1987, Giovannucci 1995), and retrospective (Fraser 1983 , Longnecker 1995, Wittemore 1990, Kuna 199 °, Markowitz 1992, Peters 1989, Brownson 1989, Kato 1990, Fredriksson 1989). A meta-analysis of 19 cohort studies showed a reduction in the incidence of cancer in 22% of males and in 29% of women with physical activity (Samad 2005).

Another meta-analysis of 52 observational studies showed that physical activity reduces the development of colon cancer (Wolin 2009).

However:

182 Topics in Cancer Survivorship

 There are a lot of studies in literature which suggest a low risk reduction. (Vanio 2002). Instead, physical activity reduces the risk of the prostatic adenoma (Platz 1998) There is, however, some evidence that, in the groups, the most active men show a reduced risk of 10-30%, compared with the less active ones, and that the benefit is much more evident when high-intensity physical activity has started early in life

 In a case control study of patients with grade 2 or more of prostate cancer, physical activity, which they had started in adolescence and which they had continued at high intensity for the rest of life, showed no substantial risk reduction (Friedenreich 2004) Cohort studies didn't demonstrate significant risk reduction, but they reduced the incidence of more severe forms or the ones with a fatal outcome (Friedereich 2004,

The prostate cancer survivors have a reduced mortality of 61% if they do high-intensity

Colon cancer is one of the forms of neoplasia with increasing incidence, with a prevalence in some countries, reaching 10% of the population suffering from cancer (Jemal 2010, Bhatia

The improvement of diagnostics and treatments has led to a substantial improvement in survival at 5 years that has passed through the most severe not localized forms (Altekruse

Survivors are at risk of developing a second cancer of the colon or of other organs, mainly

Most of the survivors of colon cancer are at risk of developing other diseases, mainly cardiovascular, pulmonary and psychiatric (Phipps, 2008, Jansen 2010; Yabroff 2004,

Often the survivors suffer from the consequences of therapies such as ostomy, neuropathies, chemotherapy, asthenia and depression. These may represent important limitations to the use of physical exercise as a therapeutic tool (Phipps 2008, Rauch 2004, Schneider 2007). Physical activity has been proposed as a therapeutic but non- pharmacological tool to improve the quality of life and prognosis of patients suffering from colorectal cancer as well

 The National Comprehensive Cancer Network recommends, during and at the end of anticancer treatment, a program of lasting and resistance physical activity to reduce

 The American Cancer Society wishes a physical activity program to improve the quality of life, preventing recurrences or the incidence of concomitant diseases (Brown 2003)

**1.7 Cancer of the colon-rectum and the management of physical exercise during** 

Irwin 2007) compared with sedentary individuals.

(Friedenreich 2002)

**cancer disease** 

2008).

Giovannucci 2005, Patel 2005)

2010), from 51% in 1975 to 69.5% in 2006.

as a primary prevention means.

asthenia.

Trentham-Dietz, 2003; Brown 1993; Denlinger 2011).

**1.6 The management of physical exercise in case of prostate cancer** 

physical activity for at least 3 hours per week (Kenfield 2011)

breast, prostate, skin and lungs (Green 2002, Andre 2009, Birgisson 2005).

amount of physical activity (Monninkhof 2007). The evidence is weaker for premenopausal women in which a risk reduction of 6% per weekly additional hour of physical activity, but only in half of the studies considered of the "highest quality". In particular, women with breast cancer, who exercise more than 9 MET per week, show a reduction in recurrence between 40 and 67% (McTiernan, 2008; Ibrahim 2010,


In a study of 680 patients with colon cancer, who belong to a population of 51.500 subjects, recruited by the Health Professional Follow-up Study, the survivors in the period 1986-2004 were monitored every 2 years with a specific questionnaire for assessing physical activity in MET, the results showed that subjects with an energy expenditure higher than 18 MET per week had a 50% risk reduction of recurrence. An activity over

27 MET per week, compared with patients with MET <3, showed a reduction in mortality risk equal to 0.47. Free from cancer patients were 82.2% with activity <3 MET, 87.4%, those between 3 and 27 MET, 92.1% those with > 27 MET in 5 years. Free of cancer patients were, for 3 MET levels, were respectively 79.4%, 81.2%, 88.3% in 10 years. Mortality in patients with activities <27 MET had a death rate of 50% lower than the sedentary ones; this result was not related to age, disease stage, BMI, tumor location and physical activity before the diagnosis. (Meyerhardt 2009).

 From an observational prospective cohort study, the Nurses' Health Study, conducted among 121.700 subjects in the period 1986-2002, 573 women with a diagnosis of colon cancer, stage I-III, were enrolled. All participants were monitored with a questionnaire and a scale which was able to measure the activity in MET hours/week. If no response was given, they did a research aimed at establishing the evolution of the illness or the death. The level of physical activity before the diagnosis had no effect on the mortality rate.The physical activity after diagnosis reduced, in subjects with <18 MET hours /

Rehabilitation in Cancer Survivors: Interaction Between Lifestyle and Physical Activity 185

The IGF-1 levels during the disease are not related to the prognosis of the survivors

 The IGFBP-3 (Insulin like Growth Factor Binding Protein-3) levels, a protein whose deficiency increases the percentage of circulating free IGF-1, correlate inversely with mortality. In subjects with higher IGFBP-3 levels, the mortality risk was reduced by

**2. Our point of view with regard to an ideal physical activity in oncological** 

promotion of a better quality of life, especially in terms of individual perception.

disease, as it happens for other important but not lethal diseases.

Therefore, we divided our therapeutic intervention in 3 phases:

Phase 2 Recovery sensory-motor and functional capacity.

Phase 1 Recovery of Residual Capacity.

Phase 3 Recovery of the quality of Life.

damage and to the diseases; 2. increasing the uninjured muscle tone;

and dynamic scheme.

The aim of the therapy is to:

**2.1 Phase 1: Recovery of residual capacity**  The rehabilitation strategy is aimed at:

his/her residual performance with progressive metabolic load by METs .

The development of exercise in cancer rehabilitation context has as its primary goal the

The rehabilitation outcome has to be measured in terms of an individual perception of wellbeing, and it is also expressed in a collective form, involving all the interested subjects to

The outcome, in general, has to do with the return to society of people who experienced the

After having expressed, in the international review, what is believed to induce positive effects in the body system which survived cancer, through the use of physical exercise, we find useful to propose a rehabilitative treatment which is not limited to recommend regular metabolic activity but aims to recover the remaining capacity of the subject, through a specific approach to the patient and the pathology but, at the same time, it aims to increase

1. recovering joint mobility and elasticity of muscle tissue, according to the existing

3. rebalancing the muscle synergies of the body system, by reprogramming the body static

 induce the gradual recovery of joint mobility through passive and active exercises; induce a sensory stimulus for body perception in the space. This is realized by us by using tools such as PANCAFIT or similar and the postural bench system (TecnoBody, Bergamo, Italy), equipped with six independent sensors, each one positioned at the dorsal, lumbar and sacroiliac level. It allows real-time to assess the load that the patient places on each of the sensors. This feedback visual system allows the operator to assess and to work on deficient areas of the body from the proprioceptive and muscle point of view. It also allows the patient to modify, to learn and to increase his/her perception of the body in the

space, inducing the acquisition of a suitable elastic posture for the two hemisomas;

Our rehabilitation method uses instrumental and not instrumental techniques.

(Haydon 2006).

**patients to survive** 

this topic in its definition.

50%.

week energy expenditure, the index of mortality risk to 0.39 compared with women with <3 MET activity. Mortality in 5 years gave the following percentages: 14.1% for patients with <3 MET activity, 14.4% for those whose activity was between 3 and 17.9 MET hours per week, 62% for the > 18 MET group. Those women who increased their physical activity compared with the pre diagnosis period reduced by 50% their risk of mortality.

