The Clinical Oncology Society of Australia Annual Scientific Meeting showcased new insights in the field of exercise and cancer. The conference also marked the launch of the COSA Position Statement on Exercise in Cancer Care.
The highlights in brief:
- COSA calls for exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.
- Oncology health professionals believe that exercise is beneficial, safe and important for their patients during cancer treatment but less than a third refer to exercise services.
- Patients with poorer health status and higher symptomology have the greatest improvement in fatigue, distress, physical function and quality of life following exercise.
- Participation in exercise decreases as childhood cancer survivors increase age suggesting early monitoring and interventions are required to minimise the risk of late-effects.
- There is early evidence suggesting exercise provides meaningful health benefits and is well tolerated by patients with poor prognosis cancers.
- Exercise may help alleviate the severity of peripheral neuropathy and cognitive decline associated with chemotherapy.
COSA Position Statement on Exercise in Cancer Care
The level of evidence now available on the role of exercise in cancer care has led COSA to develop a position statement. I announced the content of the position statement during a highly attended soapbox session. As the peak national body representing multidisciplinary health professionals whose work encompasses cancer control and care, COSA calls for:
- Exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.
- All members of the multi-disciplinary cancer team to promote physical activity and recommend people with cancer adhere to exercise guidelines.
- Best practice cancer care to include referral to an accredited exercise physiologist and/or physiotherapist with experience in cancer care.
COSA’s position is:
- All people with cancer should avoid inactivity and return to normal daily activities as soon as possible following diagnosis (i.e. be as physically active as current abilities and conditions allow).
- All people with cancer should progress towards and, once achieved, maintain participation in:
- at least 150 minutes of moderate‐intensity or 75 minutes of vigorous‐intensity aerobic exercise (e.g. walking, jogging, cycling, swimming) each week; and
- two to three resistance exercise (i.e. lifting weights) sessions each week involving moderate‐ to vigorous‐intensity exercises targeting the major muscle groups.
- Exercise recommendations should be tailored to the individual’s abilities noting that specific exercise programming adaptations may be required for people with cancer based on disease and treatment‐related adverse effects, anticipated disease trajectory and their health status.
- Accredited exercise physiologists and physiotherapists are the most appropriate health professionals to prescribe and deliver exercise programs to people with cancer.
- All health professionals involved in the care of people with cancer have an important role in promoting these recommendations.
The statement includes a summary of the available evidence and a glossary of relevant exercise terminology. The full position statement will be available on the COSA website in the coming weeks. The position statement is formally endorsed by the Medical Oncology Society of Australia, Cancer Council Australia, Exercise and Sports Science Australia and the Australian Physiotherapy Association. A series of other organisations have formally supported COSA’s position and a listing of these organisations will also be available online.
Oncology Health Care Professionals Views on Exercise
The views of Australian oncology health professionals about exercise for cancer patients receiving treatment were reported by Jane Turner from the University of Sydney. The survey of 392 participants comprised of health professionals spanning 17 discipline areas predominately allied health (25%), nursing (23%) and medical oncology (15%). The majority of respondents viewed exercise as beneficial (73%), important (71%) and safe (62%) for their patients currently receiving treatment. A lesser proportion of respondents believed their patients are capable of exercising during treatment (39%) and that the recommendation to exercise during treatment would be well received (44%). Exercise discussions of 1-5 minutes during consultations were reported by 42% of respondents and referrals to exercise services were provided by 30% of respondents. The most common barriers to discussing exercise during consultations included patient factors limiting exercise capacity (30%); patient financial constraints (30%); and too many things to discuss (19%). A significant proportion of oncology health professionals report not knowing the level of evidence for impact of exercise on physical function (35%), fatigue (28%), distress (32%), quality of life (22%) and risk of cancer mortality (~35%). A limitation of this data is that the sample may not be representative of the broad population of oncology health professionals as most of the respondents reported to engaging in exercise themselves (87%).
One Size Doesn’t Fit All – Responders and Non-Responders to Exercise
Calls within the COSA position statement to tailor exercise recommendations to the individual cancer patient have been supported by new research led by Associate Professor Prue Cormie from Australian Catholic University. An analysis of 600 people with over 40 different types of cancer explored which cancer patients do and don’t respond to exercise and what factors influence the magnitude of response. Participants were diagnosed ~2 years prior and just over a third were current receiving treatment during a 3-month exercise program involving supervised moderate-intensity aerobic and resistance exercise. Significant differences existed in the magnitude of change in physical function, fatigue, distress and quality of life non-responders, low-responders, moderate-responders and high responders. The magnitude of change did not vary between patients currently on- versus off-treatment, <1-year versus >1-year since diagnosis or between common versus rare cancer types. Higher attendance at the exercise session (>70% versus <70% attendance) was associated with greater change in physical function but not fatigue, distress or quality of life. These data demonstrate that the patients who benefit the most from the structured exercise program are actually those who are the most tired, distressed and physically impaired. It is possible that many health care professionals don’t recommend exercise to their patients experiencing significant side-effects. This research suggests that these are the patients who have the greatest need to be referred to an exercise program because they are the ones who benefit the most.
Do Childhood Cancer Survivor Get Enough Exercise?
Survivors of childhood cancers are at increased risk of chronic and late side-effects of cancer treatments. Epidemiological and clinical trial evidence suggests exercise could be an effective therapy to minimise the risk of late-effects and help rehabilitate/manage ongoing impairments following treatment. The proportion of survivors of childhood cancers who participate in exercise and factors influencing the amount of exercise completed was reported by David Mizrahi from the University of New South Wales. The analysis of 914 participants from the ANZCHOG Survivorship Study invluded 193 child survivors (~13 years old), 378 adult survivors (~26 years old), 111 age-matched child controls and 233 age-matched adult controls. Child survivors were reported to be more physically active than age-matched controls (31% of cancer survivors versus 23% of controls met guideline levels of exercise), but adult survivors of childhood cancers were less physical active than age-matched controls (30% of cancer survivors versus 39% of controls guideline levels of exercise). The level of exercise decreases by just over 1 hours/week with each decade survivors of childhood cancers age. The investigators propose that early monitoring and interventions targeting at-risk survivors who are not exercising are required to minimise the risk of late-appearing treatment related adverse effects.
Exercise for Patients with Poor Prognoses
The COSA ASM featured exciting new work investigating the impact of exercise in cancer patients who have poor prognoses – high grade brain cancer, mesothelioma and metastatic breast cancer. Patients with poor prognoses commonly experience significant levels of symptomology and report high levels of unmet needs. Despite the potential for exercise to help manage some symptoms and treatment-related side effects, very little research has investigated the impact of exercise on patients with poor prognoses. Data presented by various teams at the COSA ASM suggest exercise provides meaningful health benefits and is well tolerated by these patients. A structured exercise program was safe, well tolerated and improved physical function in patients undergoing chemoradiotherapy for high grade glioma. Qualitative analyses revealed that these patients enjoyed the exercise program, helped them feel stronger and enabled them to feel a sense of control and active involvement in managing their cancer. Mesothelioma patients involved in a structured resistance exercise program (i.e. lifting weights) experienced significant improvements in fitness (6 min walk test), strength (leg press 1-repetition maximum), function (timed up and go) and mental health (SF-36). These patients rated the intervention burden as low and were able to maintain high attendance to the exercise sessions (3 sessions/week over 6 weeks). Similarly, a small trial involving an 8 week structured exercise intervention for patients with metastatic breast cancer reported no adverse events, high adherence and trends towards improved fitness and fatigue.
Impact of Exercise on Peripheral Neuropathy and Cognitive Decline
Peripheral neuropathy and cognitive decline negatively impact the wellbeing of a proportion of patients undergoing chemotherapy. Few effective management strategies exist to counteract these side-effects. Emerging evidence from small trials presented at the COSA ASM suggest exercise may play a role in alleviating the severity of peripheral neuropathy and cognitive decline. Matt McCrary and colleagues from the University of New South Wales explored the effects of exercise on a sample of 12 cancer patients displaying grade ≥2 chemotherapy-induced peripheral neuropathy. Following an 8-week exercise intervention, significant improvements were observed in neuropathy symptoms, balance and quality of life. The impact of physical activity on chemotherapy-induced cognitive impairment was investigated by a team from the University of Queensland led by Melissa Arnell. The study involved a small sample of younger breast cancer patients who participated in a lifestyle intervention targeting increased exercise participation. A trend towards improved cognitive function and cognition-related quality of life was reported following the 12-week program.
In collating the findings of research presented at the COSA ASM it is clear that exercise has the potential to provide meaningful improvements in the health and wellbeing of people with cancer.