Talking about cancer and exercise

There is a growing and convincing body of evidence to describe the links between cancer and physical exercise. Much of this examines the multitude of reasons in which exercise can help improve the lives, and indeed lifespan, of cancer patients and survivors.

The evidence draws a clear picture of why we might decide, as people who have had a cancer diagnosis, to become or remain active, for the rest of our days.

Please note: When thinking about the links between exercise and cancer the statistics are important, but they don’t bring with them any guarantees for anybody individually, therefore I will opt for the term ‘risk reduction’ rather than ‘prevention’.

At first, exercise was only really considered, studied and suggested for people after treatment had ended. It was believed ‘rest is best’ and there were concerns that exercising during treatment would be too much. Increasingly though, it is helping people at every point, right from their day of diagnosis.

Cancer ‘Prehab’, between diagnosis and the start of treatment, has been shown to have broad benefits and is being adopted across the NHS. Exercising mid-treatment – once unheard of – has been proven to be safe and to be advantageous. One clinical trial describes a chemo suite with an exercise bike in it for patients to use during their infusions.

Then, for many, comes the end of treatment – which can be a much more complex experience than many outside the world of cancer will realise. This was one of Macmillan’s observations in their ‘Two million reasons’ campaign some years ago – people experienced a tangible sense of abandonment once their clinic visits stopped. Many people live with worry and ‘Scanxiety’ during follow up or active surveillance – just ask the men undergoing regular PSA testing.

Living and exercising with secondary, or advanced cancer, is now recognised as feasible and advantageous in helping people regain a sense of control and routine during their ongoing treatment. If you follow social media, you’ll find some impressive role models who are #busylivingwithcancer.

I think many people wouldn’t realise that some hospices now have fitness suites and perhaps a swimming pool. Exercise for those in supportive care has developed significantly in recent years and is recognised for its immensely helpful contribution to pain management and in instilling a sense of wellbeing – emotional as well as physical.

Exercising after cancer can save lives. 

Now, this is a bold statement, and I believe that we need to be cautious here because big studies of populations can give one picture but the individual stories of the people within them are myriad (i.e., it is very well established that smoking tobacco causes cancer, however most people know somebody who has smoked for all of their adult lives and not developed it.).

That said, evidence shows exercise can help reduce the risk, for people who’ve already had a primary cancer diagnosis, of us dying from it. Multiple studies have shown this to be the case and studies of the most common cancers have suggested that exercise can reduce breast, bowel and prostate cancer mortality by 30-40%[1].

Exercise can also reduce the risk of cancer coming back and can help to slow down disease progression for people living with secondary or advanced cancer. An extensive academic review of all of the scientific knowledge in 2017 concluded that ‘cancer patients involved in greater levels of exercise have a lower relative risk of cancer mortality and a lower relative risk of cancer recurrence, and they experience fewer and/or less severe treatment-related adverse effects.’[2]

Lots of us who’ve had cancer, or are living with it, don’t know this 

Beyond the bigger picture statistics are people’s everyday experiences. For many of us there are long term health issues, often from the effects of treatment rather than the cancer itself. 60% of people who’ve had cancer treatment say they have unmet physical and psychological needs.

If you’ve been through it, you’ll know:

• fatigue
• depression, anxiety,
• weight loss or gain, altered body image
• pain, nerve damage, neuropathy
• reduced bone density, bone and joint pain
• swelling and lymphoedema
• hot flushes and night sweats
• Menopause, including treatment-induced crash menopause.

Evidence shows that exercise can help manage all of these.

In cardiac care, getting fit is a routine part of recovery and rehabilitation. Patients are automatically referred to specialist-led fitness classes. 

Cancer care services are rapidly catching up with their cardiac counterparts and there is a view that exercise may well become a fourth mode of treatment, alongside surgery, radiotherapy and chemo/biological therapies.

‘If exercise was a pill it would be prescribed to every patient’[3]

Over recent years the term ‘exercise oncology’ has emerged, to describe the idea that exercise could be considered a form of cancer treatment. The clarity and persuasiveness of evidence around such an idea was reinforced in 2018 when the Clinical Oncology Society of Australia produced a position statement[4] that hit the headlines globally. They advised, based on scientific evidence, that exercise should be prescribed to all cancer patients, just like a drug. They went further than this though: they stated that exercise should be embedded as part of standard practice in cancer care, and they said that to not do so would be harmful.

Here in the UK there was some superb work in Greater Manchester to spearhead the provision of cancer ‘prehab’ to all people at the time of their diagnosis. Prehab is now rolling out to more and more areas and there are services beginning within some of the London hospital trusts. There are also trials underway looking examining exercise as a treatment option alongside chemotherapy and instead of some prostate active surveillance.

Fatigue in cancer survivors is really significant – up to 95% report it. The tiredness can absolutely floor you.

Although it perhaps sounds counterintuitive, there is substantial evidence to show that exercise can help people to cope with cancer-related fatigue, and in some cases to reduce the risk of developing it or lessen the severity. 

There are consistencies within the data – particularly in encouraging people to exercise regularly rather than occasionally and at a manageable intensity and duration. There is also evidence about the (positive) effects of higher intensity exercise.

If you’ve been out of action for a while, the chances are you’ll have lost some of your muscular strength and this can be why simply climbing the stairs or getting out of a chair feels harder than it did.  Resistance training can help to rebuild our functional strength.

Alongside muscle loss, cancer treatments can leave us with stiff or painful joints and with reduced range of motion, and exercise can be used to help diminish pain and to build strength in the connective tissue – the tendons and ligaments that support the joints and help them to remain mobile.

Some of the hormones used in cancer treatment are linked to lowered bone density, and there’s very good evidence to show that weight-bearing exercise can help to slow down bone mineral loss and in some cases to actually increase density.

Similarly there is specific evidence that exercise, when performed with good technique, can help prevent and manage lymphoedema.

My recommendation is threefold:

1. Definitely do strength training as part of your general activities. Make sure you learn really good technique

2. Use light resistance at first, but do work up to lifting weights

3. Do weight bearing exercise to protect your bones

I think we need to consider exercising through the entire cancer ‘pathway’, starting at diagnosis and then onwards, for the rest of our lives. Living with cancer involves much transition from one point to the next and exercise could, in this instance, become a constant and something that is part of what we are and what we do.

It’s hard to get back to work after a cancer diagnosis.  Of those diagnosed in the UK, half are of working age, but cancer survivors are 1.4 times more likely to be out of work than average. Exercise increases return to work rates (although of course you may not want to go back!)

Exercise can also help you to get back to normal, to feel more like yourself or to build your own ‘new normal’. It can help you get your oomph back.

[1] Physical Activity and Cancer Fact Sheet – National Cancer Institute

[2] The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects

Prue Cormie, Eva M Zopf, Xiaochen Zhang, Kathryn H Schmitz, Epidemiologic Reviews, Volume 39, Issue 1, January 2017, Pages 71–92, https://doi.org/10.1093/epirev/mxx007

[3] Cancer: ‘If exercise was a pill it would be prescribed to every patient’ | Cancer | The Guardian

[4] Clinical Oncology Society of Australia position statement on exercise in cancer care

Med J Aust 2018 Aug 20;209(4):184-187 Prue Cormie  et al