By David Mizrahi, University of New South Wales.
The concept of Exercise-Oncology is an emerging field, which introduces increased physical activity levels in the form of aerobic and strength based movement during and after cancer therapies.
In the last 10 years, there have been an increase in the amount of studies, particularly in breast and prostate cancer to show that not only is it safe to exercise throughout a chemotherapy regimen, but there is evidence to support the efficacy of reducing the severity of side-effects developed.
Fast forward to a clinical trial I was aiming to conduct in a group that experiences far worse symptoms and aggressive treatment than most, those with recurrent ovarian cancer. I would sit in numerous waiting rooms or chemotherapy clinics to discuss with various women about their experiences and physical challenges being able to remain functional in their lives, with daily tasks such as doing the shopping, washing or walking to catch a bus, a big challenge. There is very limited data for exercise-oncology for women with ovarian cancer, so it was important for clinicians and patients around the world to be able to have some further information that may help their journey to work off.
Firstly, we needed to know how much women with ovarian cancer were currently exercising and if there were specific challenges that they faced. We published a cross sectional study in the International Journal of Gynecological Cancer recruiting patients from two hospitals in Sydney and one in Canberra to document this question. It turns out 81% of patients during and after treatment were not meeting American College of Sports Medicine guidelines of 150 minutes a week of moderate intensity activity – this was worse than other cancer groups previously reported in the literature. The greatest barrier to exercise, reported in 38% of patients was fatigue – which is intriguing considering previous studies show that by increasing your activity, you can reduce your fatigue burden. A number of behavioural barriers followed, which can be addressed with education of evidence-based research and motivational strategies.
This prompted us to investigate further in an interventional study with the main question, can we safely implement a combined supervised and home-based aerobic and strength based exercise program during chemotherapy for women with recurrent ovarian cancer? We also wanted to know what the impact might be on these patients.
Recruitment was the first challenge. Women would ask how I expected them to exercise if they could hardly get out of bed. We discussed potential goals, starting very small and overtime we could amend them. We recruited 30 patients from 3 oncology clinics to participate in a 12 week, low-moderate intensity trial aiming for 90 minutes or more per week. Women were given resistance bands for home-based activity and prescribed an aerobic activity of their choice – generally walking, cycling or swimming. They were seen up to once weekly to go through their exercises and discuss any challenges they wanted to overcome. In general, if there were no symptomatic burdens, the program would be increased in duration or intensity the following week. Participants underwent a strength, cardiovascular, functional and balance test, as well as completed a questionnaire of patient-reported outcomes at baseline, 12 and 24 weeks.
Fast forward to the results that were also published this year in the International Journal of Gynecological Cancer. We were able to recruit around 63% of eligible participants, showing that patients have an interest in participating in supportive care interventions. 70% were retained until the end of the 12 week program, which was a great result considering the patient group often experiences a number of treatment complications. Participants averaged over double the initially prescribed 90 min/week target throughout the study and there were no adverse events from participation.
Participants who were able to complete the program, who generally underwent chemotherapy in the form of taxanes or doxorubicin, improved their quality of life (p=0.017), reduced their fatigue (p=0.004), improved symptoms of anxiety (p=0.007), improved muscular strength (p=0.001) and improved their balance (p=0.003) after the 12 week intervention. We found these improvements fascinating, considering it is usually a population highly burdened by treatment side-effects and a poor prognosis.
We also found that at the 24 week follow-up time-point (12 weeks after we stopped seeing participants), many women were still engaged in exercise and had maintained or even further improved some of these outcomes, which was a fantastic result for us. This displayed that a behaviour change is possible to implement in a challenged patient group.
The next step now is to implement a randomised controlled trial in this group to determine an appropriate exercise dose and even possibly investigating if there is a dose-response relationship between exercise intensity and overall survival, as has been displayed in breast and colon cancer patients.
In a nutshell, encourage your patients, friends or family members with cancer to move. Seek supportive care materials and talk to others about this area. Starting at a low level is the best place to begin and over time we can achieve great things.
David Mizrahi is an Exercise Physiologist and Oncology Researcher at the School of Medical Sciences, University of New South Wales.
Mizrahi D et al. An Exercise Intervention During Chemotherapy for Women With Recurrent Ovarian Cancer: A Feasibility Study. Int J Gynecol Cancer. 2015 Apr 24: http://www.ncbi.nlm.nih.gov/pubmed/25914961