Epidemiology Degree

“What’s the one thing I should Start doing NOW as it relates to Exercise forCancer?” How to Exercise for Cancer Exercise programming for cancer may mirrorthe growth in the US in alternative medicine and self help. A report inAlternative Therapies Journal by Van deCreek et al suggests that exercise issecond only to prayer as the top forms of complimentary therapies that breastcancer survivors have interest in (prayer=84%, exercise=76%) and actuallyparticipate in as part of their recovery (prayer=76%, exercise=38%). Secondly,the passage of the Balanced Budget Act in 1998 has curtailed many acuterehabilitation programs in the US. Therefore, many therapists are looking forprograms to provide to their patients to expand their level of clinicalservices. In 1996, the publication of the US Surgeon General’s Report onPhysical Activity put into perspective the importance of regular exercise inmaintaining and improving one’s physical health. Lastly, health centers in theUS and abroad are moving in the direction of new and innovative programming.Many health clubs want to forge stronger relationships with their communitymedical facilities. All of these elements make for an attractive fit to provideexercise for persons with cancer. Therefore, exercise may stand on its own asthe premier form of complimentary medicine for cancer survivors. Benefits ofExercise Why would a cancer survivor who has recently undergone chemotherapy orradiation wish to participate in an exercise program? In essence, patients feelbetter when they are in good shape. Not only are they better able to toleratetheir medications, but their quality of life improves. This section detailssome of the major sports medicine reports that lend support to participating inexercise as a preventive approach to cancer but (according to some oncologysources) also to improve the odds for survival after diagnosis. TheEpidemiology of Exercise and Cancer In the mid 1980s, Dr. Rose Frisch detaileda report that stated that former collage athletes had a marked reduction in theincidence of certain types of cancer, some by up to 45% less than theirsedentary counterparts. In the late 1980s, a report from Stanford stated thatpersons who engage in more than three hours of physical activity per week havea reduction in certain cancers (such as colon cancer) by about 15%. These werethe first epidemiological reports that looked at physical activity in cancerprevention. It wasn’t until five years later that USC Professor Dr. LeslieBernstein showed a 60% reduction in breast cancer incidence in premenopausalwomen who engaged in regular exercise each day. Three years later, Dr. IngarThune published a Swedish study on physical activity and breast cancerincidence in 25,000 women. Her results mirrored the work at USC and showed areduction in incidence rates by over 25%. This is impressive based on the largesample size interviewed. In general, the consensus of epidemiology reports lenda tremendous amount of statistical power to inclusion of exercise into acancer-prevention regime. Improved Immune System Reports from the early 1990sby Dr. David Nieman confirmed that exercise enhanced natural killer (NK) cellactivity. This immune system component has effects on chemoprotection. However,the criticism in the immunology community is that changes in the immune systemare transient, and it is hard to pinpoint whether or not regular exercisestimulates these cells enough to produce a long-term effect. In a conversationwith Dr. Nieman early in 1999, his response to this was for physiologists andphysicians to understand the concept of immunoenhancement – the sum of changein the immune system over time. This changing pattern over time may improve theprotective status of the immune system without being detected on a random blooddraw. Nonetheless, this may explain why some persons who exercise regularly mayhave a reduced incidence rate of certain types of cancers. Hormonal ChangesSome theories recently published by Dr. Ann McTiernan state that improving thehormone state will have a tremendous impact on cancer development. It seems asthough components such as insulin and insulin-like growth factor (IG-F) have aneffect on tumor development. Modulating these hormones (along with cortisol andsex hormones) may reduce the ability of tumor cells to grow and proliferate.Other Physiological Mechanisms There are other hypotheses that may indeed havean impact on tumor cell development and proliferation. Like the newangiogenesis inhibitors that are being tested in the cancer field, exerciseredistributes blood flow. This redistribution may have an impact on bloodsupply to the developing tumor cell. Exercise also increases body coretemperature, changes body pH and increases the amount of lactate producedmetabolically. These changes, although not currently tested in cancer, may alsohave an impact on tumor cell growth. We can only speculate as to the truemechanisms of why those who exercise may be at a reduced risk for development.Quality of Life Changes The past 10 years of behavioral research has givenquite a bit of information as to the power of support groups and positivethinking on cancer survivorship. Recent behavioral reports have shown thatpersons with metastatic cancer who are involved in group support live longerthan their non-support group counterparts. In the behavioral aspects ofexercise, what we do know for certain is that physical activity enhances thequality of life for all of its participants. There are more reports coming outeach year on the effects of exercise on quality of life issues. A 1997 reportby Dr. Bernadine Pinto stated that 16 breast cancer survivors who participatedin regular aerobic exercise had improved profile of mood scores than theirsedentary controls. A 1998 report by Michelle Segar from the University ofMichigan stated that 24 breast cancer survivors who performed regular aerobicconditioning had improved self efficacy scores and less anxiety than theircontrols. A 1999 review of over 20 behavioral reports by Dr. Kerry Courneyafrom Canada states that 75% of these reports show positive effects of exerciseon cancer survivorship. A paper presented at 1999 by the HealthEmotionsResearch Institute states that 41 women with breast cancer who underwent a16-week group exercise program improved blood pressure, body weight andwell-being scores. This is some of the most profound research available on thebenefits of exercise for cancer survivors. The ability to enjoy life andparticipate more fully in daily activities is shown through regular exercise ateven a low level of training. Current Clinical Studies One of the firstpublications on therapeutic exercise for cancer patients was published byRosenbaum in 1979. This guidebook may have been years ahead of its time interms of its practical application to acute exercise programming for cancersurvivors. However, in the 1990s, there are more reviews on the subject ofexercise in terms of its application to the rehabilitation profession. A recentreport from Dimeo states that patients who are on high dose chemotherapy andstem cell transplantation can improve physical measures such as hemoglobin andphysical performance. This report details how even patients receiving largeamounts of medication can derive exercise benefits. Winningham introduced theconcept of the WAIT protocol, which uses interval aerobic conditioning toimprove the fitness level of participants. Durak has used moderate to heavyprogressive resistance strength training to improve overall function andquality of life scores in stage I and II cancer survivors. This program hasalso looked at health status over five years for participants who arecontinually exercising. Most of them (90% of 18 interviewed) still exercise andtake nutritional supplements daily as part of their recovery process. A summaryof the epidemiological and clinical benefits of exercise and cancer is listedin Table 1 below. Programming for Exercise and Cancer Most programs for cancersurvivors use aerobic training (walking or stationary bike protocols) toimprove function and quality of life scores for patients. The Cancer Well-FitProgram in Santa Barbara, California uses a four component approach forexercise. This model concentrates on progressive resistance strength trainingas the primary training regime. Patients select stations that fit their initialfitness level and medical concerns and progress to higher weight levels andadditional stations as pain free fitness levels and strength improves. Aerobictraining concentrates on machines (so patients can check improvement in Wattsand MET values from computer readouts), step classes and group walking. Theimportant aspect about training in a community health club environment is thatpatients can select from a variety of classes (designed for them) and aerobicmachines to improve their aerobic capacity during their initial 10 weeks ofsupervised exercise. The third component is range of motion and flexibility.This concentrates on working out scar tissue deficits and balancing generalmusculature. The last component is mind/body fitness, which consists ofbreathing, relaxation, one to two yoga classes within the 10 weeks and somemeditation programs. All of these are part of the health club programming. Theyare offered to cancer participants along with water exercise, NIA training andother club programs. This model is one that many health clubs and clinics arelooking to emulate because, over the past five years, programs in SouthernCalifornia, Colorado and Illinois have trained hundreds of cancer survivorsusing this model, and outcomes have been published on many of theseparticipants with regards to increases in strength (over 45%), aerobic capacity(30%) and a multitude of quality of life improvements (in general over 29%).Over five years of recovery, over 90% of participants continue to exerciseeither self paced or in a club, and the same percentage take supplements on adaily basis. Their level of vigor is over 80% (on a 100 scale), and almost alluse some type of complimentary therapy to enhance their recovery process.Future Directions in the Field Exercise and cancer is slowly making itspresence felt in the sports medicine community. For now, personal trainers,therapists and oncology nurses have the resources to provide exercise programsfor cancer survivors in a safe and supervised environment. Personal trainerswill play a critical role in the development of long-term health outcomes forcancer survivors. As we have seen in our recent national survey of personaltrainers, fitness instructors can help cancer survivors with their orthopedicconcerns (after referrals from PT), psycho-social needs through group exerciseand improvement in self efficacy and can inform them on topics of healtheducation, nutrition and mind-body fitness. Health clubs will also play a rolein cancer wellness through the developing of programs in their facilities andworking with local medical agencies (physical therapy, nursing and oncology) tofacilitate the growth of such programs for all types of cancer survivors. Ifcancer and exercise is to reach the status of cardiac rehabilitation in thisdecade, then it is essential we increase our awareness and knowledge of dealingwith cancer survivors (some of whom already exercise in the health clubsetting) and improve our communication with oncologists and therapists toensure a smoother referral network into these exercise programs. Exerciseprofessionals are going to lead the change in this area of health care, andthey will do it in a big way. This article is dedicated to the memory of Dr.Maryl Winningham, who pioneered the use of exercise for cancer patients. Shelost her battle with breast cancer in February of 2001, but her spirit remains.References: 1. Bernstein, L., Henderson, BE, Hanisch, R., Halley, JS, Ross, E.Physical exercise and reduced risk of breast cancer in young women. J. Nat.Cancer Inst. 86;18:1403-08, 1994. 2. Courneya, KS, Friedenreich, SM. Physicalexercise and quality of life following cancer diagnosis: A literature review.Ann. Behav. Med. 21;2:1-10, 1999. 3. Dimeo, R.C., Tilmann, M.H.M., Bertz, H.,Kanz, L., Mertelsmann, R., Keul, JR. Aerobic exercise in the rehabilitation ofcancer patients after high dose chemotherapy and autologous peripheral stemcell transplantation. Cancer. 79:1717-22, 1997. 4. Durak, E.P, Lilly, P.C. TheApplication of a Total Conditioning Program with Cancer Patients: Effects onStrength and Endurance. J. Str. Condit. Res.. 12;1:3-6, 1998. 5. Durak, EP,Lilly, PC. A five year follow up survey on health and exercise habits in womenbreast cancer survivors. Br. Cancer Res. Treat. 57;1:92 (abstract), 1999. 6.Durak, EP, MSc, Harris, JM, Ceriale, SM. The Effects of Exercise on Quality ofLife Changes in Cancer Survivors: The Results of a National Survey. Submittedto Cancer, September, 2000 7. Frisch, R.E., Wyshak, G., Albright, N.L.,Albright, T.E., Schiff, I., Witschi, J.,Marguglio, M. Lower lifetime occurrenceof breast cancer and cancers of the reproductive system among former collegeathletes. Am. J. Clin. Nutr. 45:328-35, 1987. 8. Kolden, G, Staruman, T.,Woods, T., Schneider, K, et al. Exercise is associated with improved physicaland mental health in women with breast cancer. Br. Cancer Res. Treat. 57:1:131(abstract), 1999. 9. McTiernan, A, Ulrich, CM, Yancey, D, Stalte, S., et al.The Physical Activity for Total Health (PATH) Study: Rationale and design. Med.Sci. Sports Ex. 31;9:1307-12, 1999. 10. Nieman, DC, Nehlsen-Cannarella, SL.Exercise and infection. In: Exercise and Disease. R.R. Watson, ed. CRC Press,Boca Raton, FL pp. 121-148, 1992. 11. Pinto, B., Maruyama, N., Thebarge, R.Exercise participation in breast cancer patients. (abstract). Psycho-Oncol.1996; 5;3:S-3:3, 1996. 12. Rosenbaum, E.R., Rosenbaum, I. RehabilitationExercises for the Cancer Patient. Bull Publishing, Palo Alto, CA, 1980. 13.Segar, M., Katch, V.L., Garcia, A., Haslanger, S., Wilkens, E. Aerobic exercisereduces depression, and anxiety, and increases self-esteem among breast cancersurvivors. Oncol. Nur. Forum. 20:317-21, 1998. 14. Shephard, R.J. Physicalactivity and cancer. Int. J. Sports Med. 11:413-20, 1990. 15. Spiegal, D.,Bloom, J., Kraemer, H, et al. Effect of psychological treatment on survival ofpatients with metastatic breast cancer. Lancet 14 (October): 888-91, 1989. 16.Thune, I., Brenn, T., Lund, E., Gaard, M. Physical activity and the risk ofbreast cancer. The New Engl. J. Med. 336;18:1269-75, 1997. 17. Van deCreek,Rogers, E, Lester, J. Use of alternative therapies among breast canceroutpatients compared with the general population. Alt. Ther. Health Med.5;1:71-77, 1999 18. Winningham, M.L., MacVicar, M.G. The effect of aerobicexercise on patient reports of nausea. Oncol. Nurs. Forum. 15;4:447-50, 1988.19. Erik Durak