Surviving Cancer; Physical Realities

by Riggs Klika, PhD

Cardiorespiratory (CR) fitness is one of the most important indicators of health and longevity in humans. CR
fitness refers to the body’s ability to transport oxygen from the air to the body’s cells in order to produce energy
for a multitude of processes (e.g., muscle contraction, immune system function, among others). The integrity
of the cardiopulmonary system, as well as the circulatory system, dictates how well oxygen can be transported
and utilized in the body. Following cancer therapies, such as surgery, chemotherapy and/or radiation treatment,
CR fitness will be significantly reduced.

Notably, reduction of CR fitness primarily follows the decline in physical activity for most cancer patients.
Please read a more detailed review of this outcome by Courneya and Friedenreich (3). Furthermore, cancer
survivors typically reduce physical activity as a result of a myriad of competing distractions, including: doctor’s
visits, infusion therapy, radiation therapy, coping with family, work, and/or financial stressors. Frankly, remaining
active during cancer treatment is a very low priority for most cancer survivors.

In addition to reduced CR fitness, radiation and chemotherapy treatments may alter normal heart function (e.g.,
contractility, perfusion, stroke volume, among others) and affect systemic circulation such that blood flow is diminished
throughout the body. This may cause cancer survivors to lose the ability to efficiently and economically
process oxygen, especially in skeletal muscle. As a result, a cancer survivor’s fitness level is typically
lower than pre-diagnosis. Additionally, these adverse changes may alter substrate utilization and adjust energy
production such that the anaerobic system becomes more active during and immediately after treatments (this
remains to be determined (10)). Therefore, in our cancer rehabilitation center, one of the primary objectives is
to return CR fitness to pre-cancer levels post therapy and in many cases, increase it beyond pre-cancer diagnosis.
In other words, by promoting a high fitness level and even improving on it after debilitating therapies and
abrupt or adverse changes in lifestyle, a cancer survivor may decrease the chance of reoccurrence while rapidly
improving their activities of daily living. Why?

To underscore this last point, the American College of Sports Medicine (ACSM) convened a number of experts
from the field of exercise science and cancer rehabilitation who reviewed the current status of what is known
about physical activity and cancer survivorship. We recommend you review the researchers’ observations by
visiting the following web link: (http://journals.lww.com/acsm-msse/Fulltext/2010/07000/
American_College_of_Sports_Medicine_Roundtable_on.23.aspx.) (7). From the panel’s extensive review, it is
clear that cancer survivors who adopt an active lifestyle can have beneficial effects on the following areas:
• Improved physical function/physical fitness
• Improved aerobic fitness
• Increased muscular strength
• Improved flexibility
• Improved/maintain ideal body size (weight, BMI, body composition, muscle mass)
• Increased bone health
• Help with lymphedema-related outcomes
• Increased quality of life
• Increased energy level or vigor/vitality
• Decreased cancer related fatigue
• Improve sleep patterns
• Decreased depression
• Decreased anxiety
(Continued on page 3)
Feature Article: Surviving Cancer; Physsiiccall Realliittiiess
Riggs Klika, PhD, FACSM, Cancer Survivor Center, Aspen, CO
Scott Drum, PhD, FACSM, Western State College of Colorado, Gunnison, CO
CEPA Newsletter, Spring 2011 Page 3
• Improved Physiological outcomes (e.g., hemoglobin, blood lipids, IGF pathway hormones, oxidative
stress, inflammation, or immune parameters; includes PSA for prostate cancer)
• Decrease symptoms/adverse effects (including pain) (5).
Benefits of exercise for the cancer survivor also include decreasing the risk of developing cardiovascular disease
by lowering body fat, LDL-cholesterol, triglycerides, blood pressure, risk of developing diabetes mellitus
and being diagnosed with a secondary cancer, and increasing HDL-cholesterol. These benefits are essentially
the standards we see with any physical activity intervention. However, there is emerging epidemiological evidence
indicating that remaining physically active during and after treatment may decrease the risk of cancer
reoccurrence (6), as alluded to earlier. This is an important point and bears repeating: Being physically active
may prevent the risk of cancer reoccurrence for cancer survivors.

Exercise Guidelines for Cancer Survivors
The ACSM guidelines for cancer survivors include meeting the following criteria: > 150 minutes per week of
aerobic exercise at a moderate-to-vigorous level or > 75 minutes per week of aerobic exercise at a vigorous
intensity with specific exercise programming adaptations based on the disease and treatment-related adverse
effect (7). These general guidelines are meant to be a starting point for the cancer patient who has completed
treatment. While exercise is encouraged during treatment, the number of variables affecting each individual’s
health and capabilities is so vast that general guidelines have not been issued and remain a pertinent focus of
many studies.

Moving from the Guidelines to Practical Application
Both during and post-cancer treatment, exercise programs and limitations can be complex and it is suggested
that as a health professional working with cancer survivors that you have a minimal certification as a cancer
exercise fitness trainer. Currently ACSM/American Cancer Society offers this type of certification (ACSM/ACS
Certified Exercise Trainer). In our experience, it is critical that you or the individual working directly with the
cancer survivor have an understanding of the medical diagnosis(es), staging, pharmacology associated with
acute and chronic treatment of cancer, surgical treatments, and the associated side effects of the treatment options.
Additionally, you are strongly encouraged to confer with the client’s oncology team directly to gain a
minimal understanding of medical terminology, which is critical to your evolution as a certified cancer exercise
fitness trainer.

As ancillary health care providers in cancer management, you will need to assist the oncology team during the
rehabilitation phase. At our center, we monitor hematologic abnormalities (e.g., low platelets, hematocrit and
hemoglobin levels, neutrophil counts), musculoskeletal disorders (e.g., recent bone, back or neck pain; unusual
muscular weakness; extreme fatigue; severe cachexia [muscle mass loss]), gastrointestinal disorders (e.g., severe
nausea, vomiting and diarrhea, dehydration, poor nutrition), cardiovascular disorders (e.g., chest pain,
elevated resting heart rates, elevated blood pressure [both systolic and diastolic], irregular heartbeats, lymphedema),
pulmonary disorders (e.g., severe difficulty breathing, coughing/wheezing), and neurological disorders
(e.g., decline in cognitive status, dizziness/lightheadedness, disorientation, blurred vision, increased postural
instability). Each one of these conditions warrants further investigation or referral back to the primary
care physician and possible modification of the exercise plan. If you do not have prior clinical experience or
fail to fully understand the previous list, you should not be working with cancer survivors. Instead, consider referring
the cancer survivor to an experienced colleague and seek specialized training/certification, such as
mentioned prior.

At our center, we review blood work on a regular basis and conduct interviews (typically immediately before
an exercise session) about the potential health problems indicated above. As a rule, we use three consecutive
bloods test and monitor red and white blood cell counts (RBC and WBC, respectively). If RBC/WBC counts are
improving or stable (but all within normal limits), we continue with the exercise plan. If RBC/WBC numbers are
trending poorly albeit within normal limits (i.e., anemia and/or neutropenia) we consult with the client and typically
decrease INTENSITY or appropriate load (duration or frequency) of exercise for 3-5 days before resuming
with the original plan.

Safety: For most cancer patients and survivors, exercise is safe (4). If the cancer survivor is suffering from serious
adverse side effects of treatment or is a stage IV patient, we recommend consulting the client’s oncology
team before starting any exercise program. While it is difficult to broach, there are cancer patients/survivors
for whom the added stress of exercise may exacerbate physical decline and therefore be contraindicated. For
those individuals, we suggest a discussion with the client, family and/or significant others and the medical team
about why exercise should be limited.

If concerned about lymphedema, consider that Dr. Kathryn Schmitz, a lead author on the ACSM/ACS exercise
guidelines, led a recent study that found careful weight training can protect against lymphedema (8). Our
work has generally found that exercise does not exacerbate lymphedema when the cancer survivor is closely
monitored. There are excellent resources available to the cancer rehabilitation specialist at http://
www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/Patient/page1 regarding lymphedema and
lymphedema control.

How Much: Meeting the ACSM recommendations for cancer survivors is relatively simple; increase physical activity
to at least 150 minutes of exercise per week (i.e., 5 sessions/week x 30 minutes/session). This may be as
simple as prescribing walking 30 minutes per day, five days a week. This should be considered the minimum
level you need to set as a goal for your post-cancer treatment rehabilitation exercise program. We suggest
you start with a walking program and perhaps progress to a variety of other modalities (e.g., jogging, running,
cycling, swimming, alpine and/or Nordic skiing) as your client’s fitness and health level dictates. Additionally,
encourage a cancer survivor to choose what best fits their long term goals and interests.

How Hard: The current guidelines suggest ‘moderate-to-vigorous’ intensity for 150 minutes per week. While
moderate-to-vigorous intensity is defined specifically in the ACSM guidelines as 40-85% of maximal oxygen
uptake reserve or heart rate reserve, it is not uniform from individual to individual. This is where the certified
exercise physiologist is valuable. At our center, all cancer survivors complete a cardiopulmonary stress test (on
a cycle ergometer or treadmill) with lactate testing in order to provide precise measures of their initial fitness
level. This helps us establish individualized intensity guidelines for aerobic exercise programming. Although,
cardiopulmonary exercise testing may not be available to you, our philosophy is that an initial assessment of
the cancer survivor’s health status should be an integral part of all rehabilitation programs (9). If you are unable
to conduct an initial, advanced exercise assessment yourself or by a trained professional, there are alternative
methods available, such as a timed one mile walk test on a local track, to determine where your client
ranks with regards to fitness and appropriate general intensity guidelines.

What Type of Exercise? Aerobic exercise is heavily emphasized in our programs. Why? Circulating oxygenated
blood is the best method we have to help the body heal itself (2). The benefits of emphasizing an aerobic
based cancer rehabilitation program are: increased cardiorespiratory fitness, augmented immune system
function, increased red and white blood cell production, and possibly augmented circulation throughout the
body to aid in removing cytotoxic agents (7).

Because cancer treatments also affect bone mineral density and overall muscle mass integrity, we prescribe a
strength training component for most of our clients during exercise sessions (11). Our strength training programs
are based on three pillars of body function: posture, mobility, and stability (5). For instance, a woman
who has undergone chemotherapy, radiation treatment, and surgery for breast cancer, requires comprehensive
strength training to improve posture (i.e., neutral spine position), upper body range of motion (or mobility) on
both sides, stability in the shoulder girdle, and muscular strength and endurance (possibly to help hold a child
for a prolonged period of time). Because most of our clients are 50+ years, promoting improved posture,
greater mobility of the hips and upper body musculature, and spinal stability with neuromuscular ‘re-education’,
we see stellar results in overall enhanced movement patterns. These improved movement patterns allow the
older adult to exercise and move/walk safely while avoiding falls and potential future orthopedic complications.
It also allows our clients to engage safely in other aerobic activities.

Last, we highly suggest exercising with a partner. Why? Researchers believe that exercising together may increase
exercise adherence while improving physical function and mental wellbeing (1). Moreover, a majority of
cancer survivors will not have the financial resources to hire a one-on-one personal trainer for motivation. At our
center, nutrition advice and mental health counseling are also an integral part of the rehabilitation phase of
cancer which will be addressed in the next issue for CEPA.

In summary, the evidence that exercise should be a critical component of all cancer rehabilitation programs is
compelling and continues to mount. The guidelines for cancer rehabilitation programs are outlined in the ACSM
roundtable guidelines for Cancer Survivors (7). These guidelines should be seen as the minimum level of physical
activity needed for the cancer survivor with alterations made for each individual based on their unique cancer
history, current health status, and/or undulating energy levels if currently undergoing cancer treatment.
Ideally, we encourage cancer survivors to engage in five days of aerobic activity per week for 30 minutes per
session at moderate-to-vigorous intensity. These levels should be established by a trained exercise professional
who critically understands the distinctive health needs/fluctuations of a cancer survivor. Additionally, most cancer
survivors will benefit from a twice-a-week strength training program designed to increase posture, mobility
and stability. Even if this prescription appears rather aggressive, we have found the diagnosis of cancer, while
startling, is often a life altering opportunity for individuals to start and continue working towards health and
longevity.

References:
1. Bennett JA, Winters-Stone K. Motivating older adults to exercise: What works? Age Ageing.2011;40
(2):148-9.
2. Bitterman, H. Bench-to-bedside review: Oxygen as a drug. Critical Care 2009;13:205-213.
3. Courneya KS, Friedenreich CM. Physical activity and cancer: An introduction. Recent Results Cancer
Res. 2011;186:1-10.
4. Jones LW, et al. Safety and feasibility of aerobic training on cardiopulmonary function and quality of
life in postsurgical nonsmall cell lung cancer patients: a pilot study. Cancer. 2008;113(12):3430-9.
5. McGill, S. Core Training: Evidence translating to better performance and injury prevention. Strength
Cond J: 2010; 32(3): 33-46
6. Pekmezi DW, Demark-Wahnefried W. Updated evidence in support of diet and exercise interventions
in cancer survivors. Acta Oncol. 2011; 50(2):167-78.
(Surviving Cancer….Continued from page 4)
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CEPA Newsletter, Spring 2011 Page 5
7. Schmitz, KH et al. American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer
Survivors. Med Sci Sports Exerc. 2010;42:1409-1426.
8. Schmitz, KH et al. Weight lifting for women at risk for breast cancer-related lymphedema: A randomized
trial JAMA. 2010;304(24):2699-70.
9. Schneider CM, CA Dennehy, SD Carter. Exercise and Cancer Recovery. Human Kinetics, Champaign, IL,
2003.
10. Tosti KP, Hackney AC, Battaglini CL, Evans ES, Groff D. Exercise in patients with breast cancer and
healthy controls: energy substrate oxidation and blood lactate responses. Integr Cancer Ther. 2011;10
(1):6-15.
11. Winters-Stone KM, Schwartz A, Nail LM. A review of exercise interventions to improve bone health in
adult cancer survivors. J Cancer Surviv. 2010;4(3):187-201.
About the authors:

Dr. Klika is a Fellow of the American College of Sports Medicine (ACSM) and Director of the Cancer Survivor
Center. He is a clinical exercise physiologist and cancer rehabilitation specialist.
Dr. Scott Drum is also a Fellow of the ACSM and Associate Professor at Western State College of Colorado in
Gunnison, CO in the Department of Recreation and Exercise & Sport Science.