Underserved Topics in Oncology: The Role of Physical Activity in Improving Quality of Life and Decreasing Recurrence Risk in Patients With Cancer

Author: Robert J. Morgan Jr MD
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Overheard conversation in a Medical Oncology Waiting Area:

Amy: “I’m glad that I’m here getting my chemotherapy. My doctor told me that the chemo will decrease the chances of my breast cancer recurring by about 2%, but I want to do everything that I can.”

Christina: “Me too. My doctor told me to keep active also. I wonder if being more active will help. I really just want to sit and sleep all the time.”

Amy: “Oh, all of that stuff is just complementary medicine. I don’t believe in those things. Just like acupuncture. But I like to take vitamins. I read in Woman’s Day that some actresses recommend them.”

The tools available to an oncologist for the purpose of treating cancer include surgery, radiation, and systemic treatments, including chemotherapy and, in the past decade, targeted therapy. There has been an explosion of new knowledge regarding the biology and molecular bases of cancer etiology and metastasis. One only needs to attend any of the national oncology meetings and saunter through poster sessions to understand that pharmaceutical companies and academic investigators are working feverishly to develop new agents that we hope will help our patients live better or longer.

Complementary and alternative medicine (CAM) treatments are also used by a large percentage of our patients.1 Studies show that up to 80% of patients are using some form of CAM, even if the treating oncologist is unaware of the use.2 Methods of CAM are legion, and classes of these interventions include whole medical systems, mind-body medicine (various forms of meditation), biologically based practices (often vitamins or unproven pharmaceuticals), manipulative and body-based practices (touch therapy or physical activity interventions), and energy medicine procedures. However, little convincing scientific evidence is available for most CAM practices.

Modern oncologists primarily use surgery, radiation, and systemic therapies to treat and prevent recurrences, and early-stage cancer often requires a combination of these modalities. Systemic adjuvant chemotherapy in many cancers is administered after surgery based on efficacy shown in randomized clinical trials. Interestingly, studies have shown that, after informed discussion, substantial proportions of patients will accept toxic adjuvant chemotherapy offering a benefit as little as 1% in overall 5-year survival.3

However, “Western” allopathic and CAM medical practices can merge in some areas. One such area—which is an “underserved” area of treatment for patients with cancer and certainly underused and underencouraged in cancer centers—involves the implementation of physical activity therapy for patients with cancer. Much evidence has been published in the past decade documenting the benefits of physical activity for patients with cancer. Physical activity has been shown to improve quality of life during and after treatment, and remarkably increases survival and decreases recurrence rates at least in patients with breast or colon cancers who maintain a minimum activity level.4-6 Recommendations regarding the amount of activity suggest that only modest levels of physical exertion (as little as 30 minutes per day of brisk walking) are necessary to obtain large improvements in quality of life measurements and substantial decreases in hazard ratios for cancer recurrence.

Physical activity is measured in units of “metabolic equivalents of task” (MET). These measurements are an effort to quantify the amount of energy that is expended during a certain amount of exertion; a physiologic measure expressing the cost of physical activities during a defined physical activity. One MET is roughly defined as the amount of energy expended by an individual during rest. Increasing activity levels result in increasing energy being used and, therefore, an increased number of METs. For example, slow walking expends approximately 2 METs per hour; dancing about 4 METs per hour; moderate bicycling between 6 and 10 METs per hour; and running 8 miles per hour expends about 13.5 METs per hour.

Published studies suggest that physical activity of moderate activity (9 METs/h/wk) for 30 minutes 3 to 5 times per week is adequate to achieve benefits. This level of activity has been shown to decrease cancer-specific mortality in patients with breast cancer by more than 30% to 45%.5,7 This is many times more effective than some chemotherapy regimens.8 The underlying scientific explanation remains unknown; however, some hypothesize that physical activity affects inflammation in ways that may be important in cancer recurrence.

Based on these and other data, perhaps oncologists, cancer centers, and payers should recognize the importance of lifestyle changes in the overall treatment plans for patients with cancer. Physical activity interventions will result in a decreased overall cost of care based on decreased cancer recurrences. Although definitive results of randomized trials are lacking, data shows that physical activity affects overall health-related quality of life, morbidity, and mortality during and after treatment.9,10 The benefits of physical activity are present irrespective of the patient’s prediagnosis activity level. These data suggest that oncologists should be directly referring patients to facilities that can impact their activity levels as a component of multidisciplinary care. Some national research and intervention programs such as the Gynecologic Group Protocol Lifestyle Intervention for Ovarian Cancer Enhanced Survival (GOG 0225) and the Survivorship Training and Rehabilitation (STAR) Program are ongoing, but these are not available to all patients with cancer.

These multiple observations suggest that direct relationships between cancer care providers and providers of structured exercise therapy sessions (such as gymnasiums) should be organized.11 Payers should recognize that these interventions are as important as very expensive pharmaceutical agents and should reimburse for their use, and provision of personal trainers or structured classes should be covered by insurance plans. If exercise were a drug with results as promising as those reported, patients would be lined up for miles to participate. Therefore, oncologists and cancer centers should realize the benefits for patients with cancer, their families, and society, and ensure that this information is communicated to patients and that appropriate structures are in place to provide referrals for these therapeutic interventions. Furthermore, exercise physiologists, physical therapists, and even athletic trainers should participate in designing classes for patients with cancer that are appropriate for specific groups based on age, performance status, and ability level. No one should be left out.

References

  • 1.

    Chase DM, Gibson SJ, Sumner DA. Appropriate use of complementary and alternative medicine approaches in gynecologic cancers. Curr Treat Options Oncol 2014;15:1426.

    • Search Google Scholar
    • Export Citation
  • 2.

    Paul M, Davey B, Senf B. Patients with advanced cancer and their usage of complementary and alternative medicine. J Cancer Res Clin Oncol 2013;139:15151522.

    • Search Google Scholar
    • Export Citation
  • 3.

    Thiel FC, Schrauder MG, Fasching PA. Shared decision-making in breast cancer: discrepancy between the treatment efficacy required by patients and by physicians. Breast Cancer Res Treat 2012;135:811820.

    • Search Google Scholar
    • Export Citation
  • 4.

    Meyerhardt JA, Heseltine D, Niedzwiecki D. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol 2006;24:35353541.

    • Search Google Scholar
    • Export Citation
  • 5.

    Irwin ML, McTiernan A, Manson JE. Physical activity and survival in postmenopausal women with breast cancer: results from the women’s health initiative. Cancer Prev Res (Phila) 2011;4:522529.

    • Search Google Scholar
    • Export Citation
  • 6.

    Holmes MD, Chen WY, Feskanich D. Physical activity and survival after breast cancer diagnosis. JAMA 2005;293:24792486.

  • 7.

    Chlebowski RT. Nutrition and physical activity influence on breast cancer incidence and outcome. Breast 2013;22(Suppl 2):S3037.

  • 8.

    Irwin ML, Smith AW, McTiernan A. Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J Clin Oncol 2008;26:39583964.

    • Search Google Scholar
    • Export Citation
  • 9.

    Mishra SI, Scherer RW, Geigle PM. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev 2012;8:CD007566.

    • Search Google Scholar
    • Export Citation
  • 10.

    Mishra SI, Scherer RW, Snyder C. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev 2012;8:CD008465.

    • Search Google Scholar
    • Export Citation
  • 11.

    Scott JM, Koelwyn GJ, Hornsby WE. Exercise therapy as treatment for cardiovascular and oncologic disease after a diagnosis of early-stage cancer. Semin Oncol 2013;40:218228.

    • Search Google Scholar
    • Export Citation

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Robert J. Morgan Jr, MD, is Professor of Medical Oncology, Department of Medical Oncology and Therapeutics Research, at City of Hope Comprehensive Cancer Center in Duarte, California, where he also is Co-director Gynecological Cancers Program; Co-director, Gynecological Oncology/Peritoneal Malignancy Program; Director, Continuing Medical Education; Associate Director for Medical Education, Medical Oncology & Therapeutics Research. He is also Assistant Clinical Professor of Medicine at UCLA Medical School in Los Angeles, California.

Dr. Morgan earned his medical degree at the University of Illinois College of Medicine. He completed a fellowship in medical oncology and therapeutics research at City of Hope National Medical Center, as well as a research fellowship in hematology, fellowship in hematology, and residency in internal medicine at Mayo Graduate School of Medicine. Dr. Morgan is board certified in internal medicine, hematology, medical oncology, and palliative medicine.

Dr. Morgan has been a member of numerous NCCN committees, advisory boards/teams and panels, including the Cervical/Uterine Cancer Panel, Ovarian Cancer Panel, and Guidelines Steering Committee. He is also involved in many other professional associations.

The ideas and viewpoints expressed in this commentary are those of the author and do not necessarily represent any policy, position, or program of NCCN.

  • 1.

    Chase DM, Gibson SJ, Sumner DA. Appropriate use of complementary and alternative medicine approaches in gynecologic cancers. Curr Treat Options Oncol 2014;15:1426.

    • Search Google Scholar
    • Export Citation
  • 2.

    Paul M, Davey B, Senf B. Patients with advanced cancer and their usage of complementary and alternative medicine. J Cancer Res Clin Oncol 2013;139:15151522.

    • Search Google Scholar
    • Export Citation
  • 3.

    Thiel FC, Schrauder MG, Fasching PA. Shared decision-making in breast cancer: discrepancy between the treatment efficacy required by patients and by physicians. Breast Cancer Res Treat 2012;135:811820.

    • Search Google Scholar
    • Export Citation
  • 4.

    Meyerhardt JA, Heseltine D, Niedzwiecki D. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol 2006;24:35353541.

    • Search Google Scholar
    • Export Citation
  • 5.

    Irwin ML, McTiernan A, Manson JE. Physical activity and survival in postmenopausal women with breast cancer: results from the women’s health initiative. Cancer Prev Res (Phila) 2011;4:522529.

    • Search Google Scholar
    • Export Citation
  • 6.

    Holmes MD, Chen WY, Feskanich D. Physical activity and survival after breast cancer diagnosis. JAMA 2005;293:24792486.

  • 7.

    Chlebowski RT. Nutrition and physical activity influence on breast cancer incidence and outcome. Breast 2013;22(Suppl 2):S3037.

  • 8.

    Irwin ML, Smith AW, McTiernan A. Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J Clin Oncol 2008;26:39583964.

    • Search Google Scholar
    • Export Citation
  • 9.

    Mishra SI, Scherer RW, Geigle PM. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev 2012;8:CD007566.

    • Search Google Scholar
    • Export Citation
  • 10.

    Mishra SI, Scherer RW, Snyder C. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev 2012;8:CD008465.

    • Search Google Scholar
    • Export Citation
  • 11.

    Scott JM, Koelwyn GJ, Hornsby WE. Exercise therapy as treatment for cardiovascular and oncologic disease after a diagnosis of early-stage cancer. Semin Oncol 2013;40:218228.

    • Search Google Scholar
    • Export Citation
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