EXERCISEPROGRAMMINGFORCANCERSURVIVORSATELLICSR

DanielSantaMina,PhD(CSEP-CEP,RKin)Scien&st,ELLICSR,PrincessMargaret

AssistantProfessor,Kinesiology&PhysEd,U.Toronto

ExerciseResearchinCancer

Year

#ofpub

lica&

ons

•  QOL•  Physicalfunc&on•  Appe&te•  Immunesystemfunc&on•  Cardio-pulmonaryfunc&on•  Depression&anxiety

•  Sleep•  BoneHealth•  BodyComposi&on•  Hospitaliza&on•  TreatmentComple&on•  Fa&gue

•  Pain•  Postopera&veLOS•  Socialroles•  Self-efficacy•  Coping•  Tumourcellgrowth

•  Insulinsensi&vity•  Concentra&on•  Lymphedema•  Func&onalmobility•  Sexualfunc&on•  Survival

SEARCH: ("physical activity"[Title]) OR "exercise"[Title]) AND "cancer"[Title]

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Whenisagood&metostartexercising?

ExerciseisimportantatanyKmeofthecancerjourney:

Exerciseforcancerpreven&onandbeforediagnosis

Cancer Type # of Studies

Risk Reduction

Comment

Colon 60 20-25% Occupational PA = Recreational PA; Dose-response relationship; no relationship with rectal cancer

Breast 73 25% Dose-response relationship; PA after age 50 is more beneficial

Endometrial 20 20-30% Effects are independent of adiposity; dose-response; high-intensity may be more beneficial

Prostate 20+ 10-20% Increased protection from advanced/aggressive Ca; Obesity may increase risk of aggressive PCa; vigorous PA may be most beneficial

Lung 20+ 20-40% Studies did not always control for smoking status; PA benefit particularly seen in smokers; Rec PA > Occ PA

Ovarian 20+ 20% ? Vigorous PA Increase/decreases risk

Haematological ~20 -- Some benefit for NHL and Leukaemia, but not for MM or lymphoma; minimal evidence/inconclusive

(Friedenreich, 2010; 2002;’ (Giavannucci et al, 2005, AIM; (Hsing et al, 2006, Frontiers in Bioscience; Freedland, 2006, Ca Causes & Control

Preven&on

Detec&onExercisemayindirectlyaffectcancerdetec&onbyimprovinga^en&ontohealthbehaviours,includingscreening.

(Larson et al, BMC Gastroenterology, 2006; Courneya & Friedenreich, 2007, Sem Oncol Nursing)

Exercisebeforecancertreatment

Prehabilita&onincancer

Pre-op Rehabilita&on Post-RehabAcutePost-op

Func&onalThreshold

PhysicalAbility

Non-Prehab

Prehabilita&on:Ac&onsusedtoimproveyourphysical&mentalhealthandbuildupstrengthbeforeyoustarttreatment.

BenefitsofPrehabilita&oninCancer

•  Reduce hospital stay •  Reduce surgical

complications •  Improve activities of daily

living function •  Improve treatment

candidacy

•  Improve coping skills and reduce emotional distress

•  Reduce recovery time •  Reduce treatment & post-

treatment side effects

Exerciseduringtreatment

Benefits of exercise during treatment (Surgery, Radiation, Chemotherapy and Hormone Therapy)

•  Improvephysicalfitness–  Aerobic&musculoskeletal–  Muscleandfatpropor&ons

•  Lowerbloodpressure•  Reducetreatmentsideeffects

–  E.g.Pain,nausea,poorsleep•  Treatmenttolerance•  Improvedenergy•  Reducedfa&gue•  Improvequalityoflife

ExerciseDoesNOT:•  Worsentreatmentordisease-relatedsymptoms•  Underminetreatmentefficacy

Exerciseadertreatment

Benefitsofexerciseadertreatment•  Improved fitness •  Improved energy •  Improved cognitive function •  Reduced risk of lymphedema

(swelling) •  Reduced impact on ADLs •  Reduce fatigue (tiredness) •  Improved bone health •  Improve body composition

Exercise&Survival&Biomarkers•  27Observa&onalStudies:PA

associatedw/reducedall-cause,breast&coloncancermortality

•  13RCTs:beneficialeffectsonbiomarkers–  insulinandrelatedpathways–  inflamma&on–  immunity

(Ballard-Barbashetal,JNCI,2012)

HowphysicallyacKvearecancersurvivors?

•  Survey703KidneyCancerSurvivors–  ~70monthspost-dx

•  AssessedPAandQOLResults:•  ~56%werecompletelysedentary•  ~76%werebelowtheHealth

Canada/CSEPguidelines•  Kidneysymptomindexposi&vely

associatedwithPA(Trinhetal,2011,CaEpidemiol,Biomark,Prev)

ChangesinPAforAYAAderacancerdiagnosis,significantreduc&onsin:•  %mee&ngthePAguidelines

–  (150min/wkofmoderatetovigorousPA)•  TotalPAminutes•  SportPAminutes68%wouldlikeanAYAexerciseprogram

300250200150100500

(Murnaneetal,2015,SupportCareCancer)

CancerSurvivorsPreferencesforPAQuesKon Response(%)

WouldliketoreceivePAinfoaderdiagnosis? Yes=44 Maybe=31AbletodoaPAprogramforkidneycancersurvivors? Yes=48 Maybe=33

InterestedindoingaPAprogramforkidneycancersurvivors?

Yes=34 Maybe=37

WhentostartaPAprogram? Duringtx=5 3-6mon>tx=37

WheretodoaPAprogram CancerCentre=7 Home=52

Supervised/instructedorunsupervised/self-paced? Supervised=41 Unsupervised=59

Walking Summer=69 Winter=48Intensity Moderate=58 Light=35WouldliketoreceivePAinfofrom? Oncologist=22 Trainerw/Ca

knowledge=56(Trinhetal,2011,CaEpidemiol,Biomark,Prev)*Kidneycancersurvivors

Top10PrioriKesinExercise&Cancer1.   DoesPAreducetheriskforcancerrecurrenceand/orimprovesurvival?2.  DoesPAinfluencecancertxdecisions,comple&onrates,and/orresponse?3.  Whatistheop&malPAprescrip&onforcancersurvivors?4.  Whatistheroleofsedentarybehaviorincancersurvivorship?5.  Whatarethemosteffec&vePAbehaviorchangeinterven&onsforcancersurvivors?6.  WhichcancervariablesmodifythePAresponse?7.  WhatarethesafetyissuesconcerningPAincancersurvivors8.  WhichspecificcancersymptomscanbemanagedbyPA?9.  IstherearoleforPAinadvancedcancer?10.   HowdowetranslatePAresearchintoclinicalandcommunityoncologypracKce?

(Courneyaetal,2015,ResQuartExSport)

THE LATEST RESEARCH SHOWS THAT WE REALLY SHOULD DO SOMETHING

WITH ALL THIS RESEARCH

Exercise IS Recommended after a Cancer Diagnosis

CancerCareOntario•  Ontariogovernment’s(MOHLTC)advisoroncancer

–  Planscancerservicestomeetcurrentandfuturepa&entneeds,andworkswithhealthcareprovidersineveryLocalHealthIntegra&onNetwork(LHIN)tocon&nuallyimprovecancercareforthepeopletheyserve.

–  Conductsresearchandrapidlytransfersknowledgeofnewresearchintoimprovementsandinnova&onsinclinicalprac&ceandcancerservicedelivery.

•  CCOleadsmul&-yearsystemplanning,contractsforserviceswithhospitalsandproviders,developsanddeploysinforma&onsystems,establishesguidelinesandstandards,andtracksperformancetargetstoensuresystem-wideimprovementsincancermanagement

TheMandateàGuidelines

PrograminEvidence-BasedCare•  CCO’sPrograminEvidence-BasedCare(PEBC)isaninterna&onallyrecognizedguidelinedevelopmentprogramthatworkstoimprovethequalityofcancercarebyhelpingcliniciansandpolicymakerstoapplythebestscien&ficevidenceinprac&ceandpolicydecisions.

•  UsestheAGREEIImethodologytoassessthequalityandrepor&ngofprac&ceguidelines.–  UsedtoestablishtheCCOCancer-ExerciseGuidelines

ReviewofLiteratureandExpertInquiry

LiteratureSearchYields:-  3Guidelines-  18Systema&cReviews-  PrimaryLiterature

CCORecommenda&ons1.  Peoplelivingwithcancercansafelyengageinmoderateamountsofexercisewhileonac&ve

treatmentorpostcomple&onoftherapy.2.  ModerateamountsofexercisearerecommendedtoimproveQoLaswellasthemuscularand

aerobicfitnessofpeoplelivingwithcancer3.  Cliniciansshouldadvisetheirpa&entstoengageinexerciseconsistentwiththerecommenda&ons

outlinedbyCSEP&ACSM4.  Pre-exerciseassessmentforallpeoplelivingwithcancerbeforestar&nganexerciseinterven&on

isrecommendedtoevaluateforanyeffectsofdisease,treatmentsand/orco-morbidi&es5.  Itisrecommended,wherepossible,thatpeoplelivingwithcancerexerciseinagroupor

supervisedsesngasitmayprovideasuperiorbenefit/outcomeinQoLandmuscularandaerobicfitness.

6.  Itisrecommended,wherepossible,thatpeoplelivingwithcancerperformexerciseatamoderateintensity(threetosix&mesbaselineres&ngstate)onanongoingbasis,asapartoftheirlifestylesothatimprovementsinQoLandmuscularandaerobicfitnesscanbemaintainedforthelongterm.

Guidelines

150minutesofmoderate-tovigorous-intensityaerobicPA/week Same!

Muscleandbonestrengtheningac&vi&esusingmajormusclegroups,at

least2daysperweek.Same!

MoredailyPAprovidesgreaterhealthbenefits.

Avoid inactivity Return to daily activities as quickly as possible after surgery Continue normal daily activities as much as possible during and after nonsurgical treatments

Year OrganizaKon Frequency Intensity Time

2003 ACS >5days/week Moderatetovigorous >30min

2009 ESSA (A)3-5days/week(R)1-3days/week

(A)  RPE11-14,60-80%HRmax(R)50-80%1RM

(A)20-30min(R)1-4setsx6-10exercises

2010 ACSM (A)150min/weekofmoderateor75min/weekofvigorousphysicalacKvity;Strengthtraining2days/week

2011 CCCN >5days/week Atleastmoderateintensity >30min

2012 ACS 150minutesofphysicalac&vity/week;strengthtraining2days/week

2012 BASES 150minutes/weekofmoderatetovigorousphysicalac&vity;strengthtraining2days/week

Buffart et al. (2014) Cancer Treatment Reviews 40 (2014) 327–340

Exerciseprescriptionguidelinesincancer

Screening

Follow-upQues&ons

Screening&RiskStra&fica&on

(Burr,Jones&Shephard,2012,CanFamPhys)

eCancer

Health&FitnessAssessment

•  Cancerhistory•  Treatmenthistory•  Social&func&onalhistory•  Fa&gue•  Pain&paraesthesias•  Lymphedema

HealthAssessment FitnessAssessment•  Bodycomposi&on•  Musculoskeletalfitness•  AerobicFitness•  Physicalac&vityvolume•  Balance•  Flexibility•  Adapta&ons&accommoda&ons•  Exerciseintolerance?

Exercise-RelatedCancerToxicityCentral/Systemic•  Chemo-related…

–  Bradycardia,myocardialischemia,myocardialinfarc&on,CHF

•  MAB/TKIrelated…–  CHF,cardiomyopathy,thrombosis

•  Hormonetreatmentrelated…–  Centraladiposity,increasedBF%,

hyperinsulinemia,procoagulantchanges,hypertension

•  Surgery/Radia&onlocalizeddysfunc&on

Peripheral/Musculoskeletal•  Chemo-related…

–  Peripheralneuropathy/parasthesias,

•  Hormonetreatmentrelated…–  Bonedegrada&on,decreased

musclemass/strength•  Surgery/Radia&onlocalized

dysfunc&on

Exercisetoleranceinpersonswithcancer

(Jones et al. Lancet Oncology, 2009)

~25-40%reduc&oninVO2forcancersurvivorscomparedtoage/sex-matchedcontrols

CRfitnessinCancerSurvival

Sources:Farrelletal.,Obesity(2011)19,2261–2267

Cardiorespiratoryfitnesstestinginclinicaloncology:exercisetestmodality

•  Safety•  In843par&cipants,therateofadverseeventduringmaximalfitnesstes&ngincancersurvivorswas1%

• Reportedadverseeventsincluded:• Asymptoma&cECGabnormality• Lowbloodoxygensatura&on• Pre-syncope/syncope

• CPETtes&ngappearstobesafeandfeasibleincancersurvivorswhenappropriatelyconductedaccordingtoguidelines

SteinsBisschopetal.,SportsMed2012;42(5):367-379

CancerSurvivorFunc&onCon&nuum

SevereImpairment HighlyFunc&oning

ImpairmentDrivenExercise

•  PrimaryClinician:MD/PT/OT

ExerciseforPerformanceOp&miza&on

•  PrimaryClinician:RKin/ExPhys

InterprofessionalApproach

ImpairmentExamplesIm

pairm

entS

everity

Breast Prostate Lung Sarcoma H&N

LymphedemaFrozenShoulderBodyImage

Erec&ledysfunc&onUrinaryIncon&nence

SOB Limbdysfunc&onAmputa&on

DysphagiaSpeechimpairment

Fa&gue,Pain,Neuropathy,Psycho-socialdysfunc&on,muscleatrophy,secondaryosteoporosis

ExercisePrescrip&on…Mustbeindividualized!!!•  Eachpersonscon&nuumisdifferent•  Everyonehasmul&plecon&nuumsthatrelatetodifferent

organsystems,muscles/joints,mo&va&ons,etc.

VigorousLight

150minsperweekofmoderatetovigorousPAperweek;boutsof10+mins

Adapted from Warburton et al; Canada’s Physical Activity Guide to Healthy Living; ACSM's Guidelines for Exercise Testing and Prescription; and Howley et al. HR= Heart Rate; HRR = Heart rate reserve.

AerobicTrainingRecommenda&ons

ResistanceTrainingRecommenda&on

%1RM, percentage of one repetition maximum. Adapted from Warburton, adapted from information provided by Warburton et al. and ACSM

IntensityClassifica&on

%1-Repe&&onMaximum ExampleAc&vi&es

VeryLightEffort <30 Wateringthelawnorgarden

LightEffort 30-49 Generalhousecleaning,Ironing

ModerateEffort 50-69 Rakingleaves,Vacuuming

HardEffort 70-84 Woodsplisng,Shovelingsnow

VeryHardEffort >84 Carryinggroceriesupstairs

MaximalEffort 100 Lidingaheavyloadthatyoucanonlylidonce

2daysperweek,targe&ngmajormusclegroups

TypesofExercises

Aerobic(Cardiovascular)

Resistance/Weight(Concentric/Eccentric)

Mixed(Aerobic&Resistance)

ImpactLoading(plyometrics)

Yoga/T’aiChi Sport

Adap&ngPAPrescrip&ons•  Metasta&cdisease(bonemets)•  Secondaryosteoporosis•  Infec&on•  Dehydra&on•  Bleeding•  Fa&gue•  Lymphedema•  Drains&Lines•  Paresthesias•  Brainfog

Hospital-based

University-Based

Community-Based

Home-Based

Severaltypesofexerciseprogramsareavailableforcancersurvivors

NotyouraveragepersonaltrainerTraining:•  ACSM–“CancerExerciseTrainer”(Webinar+Exam,musthavebasedACSMcer&fica&on)•  U.ofNorthernColoradoCancerRehabInst.–“CancerExerciseSpecialist”•  Wellspring–“CancerSmartExercise”(exerciseandrehabilita&onfocus)•  UniversityofCalgary/Thrive–Cancer&Exercise

Experience:•  Volunteer•  StudentInternshipsOngoingLearning:•  Rounds,workshops,webinars,mentors

Wellness&ExerciseforCancerSurvivors(WE-Can)

IniKatedin2014OurMandate:•  Supportthewell-beingofcancer

survivorswithevidence-basedexerciseprogrammingandrelated-services

•  Conductnovelresearchintotheeffects,accessibility,andsupportofexerciseprogramsforcancersurvivors.

InternalMDReferral

InterdisciplinaryIntakeAssessment

RKinFitnessAssessment

Home-BasedProgram

WklyGroup-BasedBoosterSessions

Aerobic+Resistance

On-LineResources

Follow-upWk6,12,24,48

InternalMDReferral

InterdisciplinaryIntakeAssessment

RKinFitnessAssessment

8-WkGroup-Exercise&EducaKon

Follow-up(12-wkspost)

Cancer Rehab & Survivorship

EducaKonalTopics•  GoalSesng•  ExerciseTips&Safety•  Diet•  BrainHealth•  Fa&gue•  Mood•  Relaxa&on/StressMgmt

Othercancerexerciseprograms•  Wellspring (Several Sites in GTA)

–  www.wellspring.ca

•  Gilda’s Club –  http://www.gildasclubtoronto.org/

•  UW WELL-FIT (Waterloo) –  www.uwaterloo.ca/uw-fitness/uw-well-fit

•  CANWELL (Hamilton) –  www.canwellprogram.ca

e.daniel.santamina@utoronto.caw.ellicsr.ca/en/clinics_programs/we_can

t.@DR_SantaMina

Thankyou.Ques&ons?