Cancer treatments, including surgery, chemotherapy and radiotherapy, have several short and long-term side effects on patients and their ability to function. Can we, as physiotherapists, do anything to help these patients maintain their quality of life and manage the acute effects of treatment as well as prevent or mitigate the risk of long-term and late appearing effects?
The big idea
Cancer is a devastating illness. Side effects of cancer treatments include fatigue, pain, muscular weakness and poor quality of life. Since we know that exercise can improve muscular and cardiovascular endurance, increase energy levels and ameliorate quality of life, theoretically, it should be easy to treat this population, right?
Unfortunately, it’s not that straightforward…
Our take on this…
It’s true that the research shows many positive benefits from physical activity in cancer patients undergoing treatment. In our experience, physiotherapists with proper knowledge of how cancer and its treatments can affect the different body systems can greatly assist cancer patients undergoing treatment.
Ongoing assessment of medical status
Regular assessment of the patient’s medical and treatment status, symptom profile, and physical function is essential.
When cancer patients experience fatigue and nausea or vomiting following chemotherapy, they may not be interested or able to exercise. While actual exercise may need to be avoided, we should still encourage patients to move and stay as active as possible during these ‘down days’. A week later, the patient may once again feel ready and able to exercise. Cycles of ‘ups and downs’ are not unusual while a patient is undergoing chemotherapy treatment.
Along with symptoms such as nausea and vomiting, there are several other cancer- andtreatment-related effects that require caution and special consideration when prescribing exercise. These include:
- Post-surgical tissue healing, adhesive scar tissue, and other musculoskeletal issues
- Abnormal blood counts: anemia (low red blood cell count), risk of infection due to neutropenia (low neutrophil count) and risk of bleeding due to thrombocytopenia (low platelet count)
- Peripheral neuropathies (tingling/numbness and/or weakness) and other neurological issues
- Skeletal fragility from bone metastases or chemotherapy-induced osteoporosis
- Symptoms such as pain and fatigue
- Transient edema, lymphedema and chronic swelling
- Chemotherapy-related cardiotoxicity and cardiovascular autonomic insufficiency
- Acute radiation effects (tissue inflammation and breakdown), long-term radiation fibrosis
While patients presenting with treatment-related effects can benefit from exercise interventions, we need to be prepared to vary the exercise prescription based on the presentation of the patient.
Safe exercise prescription during cancer treatment
Unfortunately, we do not yet know the optimal exercise prescription for patients undergoing cancer treatment. However, according to the American Cancer Society’s Nutrition and Physical Activity Guidelines (2012), exercise should be personalized to the patient’s condition and preferences, taking into consideration the impact of treatment on bone health, muscular strength as well as other physical and psychosocial metrics. The published guidelines also include some general recommendations for prescribing exercise during treatment based on whether the patient is already exercising (e.g., the need for lower intensity and/or duration of exercise) or sedentary prior to treatment (e.g., introducing low intensity exercise such as brief, slow walks, and stretching exercises).
But really, how much is enough?
A recent meta-analysis (2015) found that supervised aerobic exercise training at a moderate intensity provided a beneficial effect on aerobic capacity among survivors who were both on and off treatment. The review findings suggest a moderate-to-large benefit from workloads of 90 minutes or more per week. Interestingly, a systematic review by Carayol and colleagues (2013) also found that a workload in the range of 90-120 minutes per week of moderate intensity exercise during adjuvant cancer therapy was more beneficial than higher volumes of exercise in improving symptoms of fatigue and quality of life.
While current physical activity guidelines recommend a minimum of 150 minutes of moderate intensity exercise per week, a lower overall exercise volume during cancer treatment (which may be more tolerable and acceptable to patients) appears to optimize symptoms, physical functioning and quality of life.
Data is also emerging that supports targeted exercise prescriptions based on both the type of cancer and chosen treatment regimen. Early evidence suggests benefit from high-intensity exercise training post-surgically for lung cancer patients, and resistance training programs to mitigate muscle mass loss in men with prostate cancer undergoing androgen deprivation therapy. Thus, we are just beginning to understand how best to prescribe exercise to target cancer- and treatment-related effects for patients during and following cancer treatment.
What we can do
In 2010, the American College of Sports Medicine convened a Roundtable on Exercise Guidelines for Cancer Survivors. This roundtable included both a review of the literature on the safety and efficacy of exercise for patients undergoing (or having undergone) adjuvant cancer therapy, as well as the development of specific guidelines on how we can adapt exercise programs to meet these patients’ needs.
Some practical guidelines based on our experience include:
- Identifying the factors contributing to symptoms and their patterns to help us time our interventions appropriately
- Making adjustments to the exercise parameters/program based on treatment cycles and associated symptoms
- Monitoring vitals, perceived exertion, and signs and symptoms during and after exercise
- Ensuring the patient understands the exercise plan and goals, and that modifications based on symptoms are normal and anticipated.
We appreciate that it can be challenging (and somewhat intimidating) to work with the cancer population. As physiotherapists, we can play an important role in guiding patients with cancer on safe function and physical activity that can help mitigate symptoms and deconditioning during treatment.
Read more about exercise during cancer treatment in this American College of Sports Medicine article by Dr. Courneya and Dr. McNeely
If you’re interested in reading more about the positive benefits of physical activity for patients undergoing cancer treatment, check out the following:
- Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies. Med Oncol. 2011;28(3):753-65. doi:10.1007/s12032-010-9536-x. (Not open access)
- Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL et al.Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):243-74. doi:10.3322/caac.21142. (Open access)
Do you feel you could benefit from learning more about physical therapy for cancer patients and survivors? Visit the Oncology Division Website for upcoming oncology courses.
Have you ever had the experience of working with a client who had a complex and changing presentation? How did you modify your approach?
Have you ever had the experience of working with a client who had a complex and changing presentation? How did you modify your approach? Share your story.
About Shirin Shallwani and Margaret McNeely
Shirin Shallwani is a physiotherapist and certified lymphedema therapist currently working with the Hope and Cope Rehabilitation and Exercise Oncology Program at the Segal Cancer Centre and the Lymphedema Program at the McGill University Health Centre, both in Montreal, Quebec. She teaches as a guest lecturer at the McGill University School of Physical and Occupational Therapy and assists in continuing education courses on rehabilitation and exercise in oncology for health professionals. Shirin volunteers with the CPA Oncology Division as newsletter editor as well as with the Lymphedema Association of Quebec.
Margaret (Margie) McNeely is an Assistant Professor in the Department of Physical Therapy at the University of Alberta in Edmonton, Canada. She currently holds a joint appointment in the Department of Oncology and performs clinical research in the Rehabilitation Medicine Department at the Cross Cancer Institute. Dr. McNeely’s research interests are in the area of cancer rehabilitation and exercise. Her research to date has focused on upper limb dysfunction and cancer-related symptoms of pain, fatigue and lymphedema.