**1. Introduction**

176 Topics in Cancer Survivorship

Kabat-Zinn, J.; Massion, A.O.; Hebert, J.R.; Rosenbaum, E. (1998). Meditation. In: Holland JF

#### **1.1 Physical activity, body composition and cancer**

Cancer is not a new disease, there are findings of neoplasia in the mummies of ancient Egypt, there are descriptions of the Romans and the Greeks and even remains in the fossil of dinosaurs. The study of the epidemiology of cancer, however, demonstrates an increasing incidence with an alarming progression, which is also involving countries which were considered "protected" or otherwise at low risk until last century.

 The progressive industrialization has led to an increase of environmental pollution with newly synthesized toxic substances, unknown by biological systems during the evolutionary process. Technological innovation has also increased the yield in agriculture, which has resulted in an increased food availability and a profound change in eating habits both for the type and for the amount of introduced nutrients. Technological development has also radically changed lifestyle with a progressive increase in sedentariness, a reduction to the sun exposure, causing a vitamin D deficiency also in children, by altering the circadianicity of circadian rhythms which regulate, depending on sunlight, the correct functioning of our body, including cell proliferation.

In general, the standard of living has increased in many countries, it has lengthened the life expectancy and, with it has increased cancer.

The improvement of recovery rates and survival with the progressive increase in the average age, in association with a greater focus on the quality of life, has led to basic definitions for cancer rehabilitation. This aims to help both to minimize the effects induced by the disease and the treatment (surgery, chemotherapy, radiotherapy, hormone therapy) and to regain control of many aspects of life in order to become an effective means of prevention for recurrences and comorbidity (Carver, JR.; Shapiro, CL 2007 ).

The rehabilitative intervention, therefore, shouldn't aim only to control physical pain but also to relieve the mental, social and spiritual pain, with all the other symptoms ( Mikkelsen T .2009) (Fialka-Moser, V Crevenna, R.. 2003 ).

Since the 80's, scientific literature has stressed the link between sedentariness and certain types of cancer (Garabrant 1984).

Rehabilitation in Cancer Survivors: Interaction Between Lifestyle and Physical Activity 179

the relationship between the mass of our body and the height has always been a guide for trainers to do their job. Older clinicians spoke about constitutional types, such as brachytype to mean short people in stature or those who appeared long-limbed, basically thin and tall. Today the relationship between weight in kilograms and height in squared meters, called BMI (Body Mass Index), has become a useful indicator of easy calculation to define the population in terms of normal-weight (BMI between 19 and 25), underweight (BMI <19), overweight (BMI between 25 and 30) or obese (between 30 to 35) or super-obese (> 35). The BMI correlates with the amount of fat, with the production of inflammatory proteins, with blood pressure, with the risk of many disabling diseases or life-threatening conditions such as diabetes, dementia, arthritis, depression, cardiovascular diseases and, with increasing evidence, cancer. The World Health Organization estimates that worldwide there are at least 1.6 billion overweight people (WHO 2006). Obese people exceed 400 millions whose incidence in Western countries has now reached and in some cases exceed 20% of the entire

 The link between the weight gain and the incidence of cancer has been linked to biochemical factors that characterize the increase of fat mass like the increase of insulin, of IGF (Insulin Like Growth Factor), of Adipokine, Steroids, but also hypoxia linked to obesity and the entering into circulation of stromal fat cells (IARC 2002, World Cancer

 Today there are a lot evidences of a strong correlation between obesity and cancer, with specificity for each sex, with the involvement of a growing type of cancer in different

 The obesity is linked to 20% of all cancer deaths in women and 14% in men (Calle 2003) It is evident that in case of obesity, exercise becomes an important moment to fight

 Tumors associated with increased BMI are cancer of breast in post-menopausal women, of prostate, of kidney, of esophagus, of endometrium, and it was determined that there

There is a direct correlation between BMI and plasma insulin levels (McKeown-Eyssen

 High levels of insulin are associated with insulin resistance and low plasma levels of Insulin like Growth Factor Binding Protein 1 and 2 (IGFBP1/2), proteins which bind IGF-1 (Insulin-like Growth Factor 1) which in turn has an activity to promote cell proliferation. The reduction of IGFBP1 and IGFBP2 increases the levels of free IGF-1. Many epidemiological studies have shown that high plasma levels of insulin before eating, C peptide (an insulin secretion indicator of the pancreas), are related to risk of endometrial, pancreatic, colorectal, postmenopausal breast cancer (Goodwin 2002,

 Obese individuals usually have high plasma levels of IGF-1 (Frystyk 2004), and high plasma levels of IGF-1 have been linked to high risk for cancer of the colon and the rectum, the prostate and the premenopausal breast (Renehan 2004) and, with less evidence, in the postmenopausal phase (Renehan, 2006). The IGF-1 elevation in adipose tissue results in an increase of aromatase, an enzyme involved in the conversion of androgen hormones into estradiol hormone at high mitogenic activity on the epithelium

is an increased risk for each increment of 5 Kg/m2 at the BMI (Roberts 2010)

**1.3 As regards the creation of a proper physical exercise for the individual it should** 

**be noted that** 

population (CDC 2006).

populations.

what described above.

1994, Giovannucci 1995)

Pisani 2008; Wolpin 2009)

of the mammary gland (Travis 2003).

Research 2007, Renehan 2006, 2008, 2009).

Physical activity is one of the modulators of the cancer risk and survival factors that awakens our attention to the possibility of implementing a strategy within our operational capabilities.

In the history of scientific analysis of data related to physical activity, the capability to monitor it has come up against many methodological difficulties which have prevented to gather uncontaminated data, due to poor sensitivity and specificity of the used methods. In particular, seven are the highlighted weak points:


#### **1.2 As regards the management of physical activity after the patient's diagnosis, it should be noted that**


Physical activity is one of the modulators of the cancer risk and survival factors that awakens our attention to the possibility of implementing a strategy within our operational

In the history of scientific analysis of data related to physical activity, the capability to monitor it has come up against many methodological difficulties which have prevented to gather uncontaminated data, due to poor sensitivity and specificity of the used methods.

1. most of the studies used questionnaires, often in retrospective and self-administration situations , giving many problems related both to their poor reliability of self assessment, typical of overweight people (as they often are physically inactive people) and to the inconsistencies sometimes found between the body mass and the energy

2. The quantification considered the so-called occupational (work-related activities) and / or recreational activities. Monitoring involved long periods of time in which the introduced technologies in the workplace have often increased sedentary lifestyle. 3. Most of our literature hasn't revealed the composition of each person's diet both under a calorie and under a composition point of view, right now when we are focusing our attention to glycemic index of food for their capability to induce abnormal insulin

4. We can't very often have reported data on the qualitative composition of lipids or their quantitative distribution during the day: the intake of dietary fat with a "cafeteria" diet (often connected with the type of job) shows the capability to induce inflammation and

5. We can't always find reliably identified the duration and intensity of each physical activity and not always the used algorithms are normalized for the mass of each

6. The daily activities are not located in the light and dark temporal space. Furthermore we don't have any idea, even indirect, of the situation of the vitamin D connected with the sun exposure and whose lack, especially in over 60 year people, can be a risk factor

7. We do not always have signs of body composition, being the BMI (Body Mass Index) the parameter for measuring the individual's structure, but it does not give an idea of body fat (especially in Asian people). This is an important piece of information as body fat is a good parameter to consider the relationship between energy intake and energy expenditure in physical activity. Fat is also an active organ under an inflammatory and hormonal point of view for **carcinogenesis** processes and tumor progression, but it is

**1.2 As regards the management of physical activity after the patient's diagnosis, it** 

1. the American College of Sports Medicine has recommended to everybody, healthy and tumor-bearing, to do physical activity, even if of moderate intensity, for at least 30

2. the American Institute for Cancer Research and the Word Cancer Fund recommends to practise physical activity at least 60 minutes a day, even if of moderate intensity, or 30

minutes of intense activity (World 2007) in order to reduce cancer risk.

elevations, an anabolic hormone but with powerful proliferative activities.

In particular, seven are the highlighted weak points:

to trigger a chain of pro-cancerous events.

also a sensitive tissue in its plasticity in physical activity.

minutes for 5 days a week (Haskell 2007, Schmitz 2010);

for different types of neoplasia.

expenditure calculation;

individual.

**should be noted that** 

capabilities.

#### **1.3 As regards the creation of a proper physical exercise for the individual it should be noted that**

the relationship between the mass of our body and the height has always been a guide for trainers to do their job. Older clinicians spoke about constitutional types, such as brachytype to mean short people in stature or those who appeared long-limbed, basically thin and tall. Today the relationship between weight in kilograms and height in squared meters, called BMI (Body Mass Index), has become a useful indicator of easy calculation to define the population in terms of normal-weight (BMI between 19 and 25), underweight (BMI <19), overweight (BMI between 25 and 30) or obese (between 30 to 35) or super-obese (> 35). The BMI correlates with the amount of fat, with the production of inflammatory proteins, with blood pressure, with the risk of many disabling diseases or life-threatening conditions such as diabetes, dementia, arthritis, depression, cardiovascular diseases and, with increasing evidence, cancer. The World Health Organization estimates that worldwide there are at least 1.6 billion overweight people (WHO 2006). Obese people exceed 400 millions whose incidence in Western countries has now reached and in some cases exceed 20% of the entire population (CDC 2006).


Rehabilitation in Cancer Survivors: Interaction Between Lifestyle and Physical Activity 181

 Weight gain after diagnosis is a negative prognostic factor for survival (Chlebowsky 1987; Camora 1990; Bonomi, 1985), however, it was denied by other authors (Levine

Women with breast cancer have an increased risk for hypertension and diabetes (Aziz

Excess weight and reduced physical activity are included in a proportion between one-

 Physical activity is considered a reliable factor for breast cancer risk reduction in postmenopausal women (IARK 2002, World Cancer Research Fund in 2007, Monninkhof 2007; Friedenreich 2008), regular physical activity in itself can reduce the

 Case-control studies (Vanio 2002, Bernstein 1994, Carpenter 1999, Carpenter 2003; Yang Bernstein 2005) and cohort studies (McTiernan, 2003; Patel 2003; Dallal 2007; Lahmann 2007) demonstrated that the risk of invasive cancer of the breast is reduced by a percentage varying from 15 to 50% in women who do physical activity. Furthermore, a reduction of 50% has been reported in women of childbearing age with 4 hours of physical activity per week or post-menopausal women with the habit of regular and intense physical activity (Carpenter 1999, 2003). The results were confirmed in geographically different populations. They involved Asian and African-American women (Yang) Bernstein 2005). The risk of carcinoma in situ is reduced in women with

 The California Teachers Study (CTS), a prospective study on 133.000 women, showed that both the invasive breast cancer and the carcinoma in situ show a level of risk inversely correlated with the amount of physical activity as long as women were

 However, it should be noted that moderate or intense protracted physical activity for a long period of life has demonstrated protection only for the risk of invasive cancer, compared with positive neoplasia for estrogen receptors, but not for invasive cancers

 The EPIC (European Prospective Investigation into Cancer and Nutrition) showed that women with higher recreational or occupational physical activity have a lower risk than those with the lowest quartile of physical activities, both in pre and post menopause. In an absolute sense neither recreational nor occupational activity show a relation with

 With regard to breast cancer in postmenopausal women in a meta-analysis of 19 cohort studies and 29 case-control studies showed an inverse relationship between risk and

Lanhendoen 1996; Camora 1990 )

2002; Ganz 1998)

**1.5 Weight and physical exercise** 

risk up to 20% (Warburton 2007)

regular physical activity as well (Patel 2003)

involved at least 5 hours per week during all their fertile life.

which are negative for these receptors (Dallal 2007)

the risk. (Lahmann 2007).

1991; Heasman 1985, Goodwin 1988, Costa 2002)

quarter to one-third of breast cancer carriers (IARC 2002)

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). The chemotherapy has an important role in weight gain. The role of Tamoxifen would seem poor, instead, more important is the effect of other drugs such as Cyclophosphamide, Metrotexate, Epirubicin, Fluorouracil (Demark-Wahnefried 1993, Goodwin 1999, Cheney 1998 Fisher 1997; Ascani 1999, Shepherd 2001, Faber-

### **1.4 Breast cancer and the management of physical exercise**

Breast cancer is the most common female cancer in many countries.
