Exercise and Cancer by Diana Adams

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By Dr Diana Adams for oncologynews.com.au 

Has the time come to ask why more oncologists are not prescribing it?

The benefits of exercise for cancer patients has again caught the media and social media in Australia. Quite often the ABC catalyst programme has sent back patients to their doctors to quiz whether they should be on that drug. This time you or your chemotherapy unit may have noticed patients have been asking to actually add something in and for you to prescribe it!

It’s something quite different – Exercise!

Prue Cormie, the Lead of the newly founded COSA Exercise Group championed Exercise and Cancer at a TED x , in Perth in November 2015 . When she asked the lay audience “what if there was a medicine that could tip the scales towards helping these treatments kill the cancer and diminish the severity of the side effects” the audience was probably imagining a new drug. Surprise and applause when she replied “This medicine is exercise”.

The Edith Cowan Group in Perth on the Catalyst programme showed integrating exercise in cancer care is multidisciplinary, possible and patients like it!

Teachable Moments

health concept - cloud of related words and topicsWendy Demark-Wahnefried commented that cancer brings a “Teachable Moment”. That moment of health education that can be translated to the patient is lost if not captured early in the diagnosis. That moment may be to stop smoking but also includes increasing exercise and addressing diet. It brings a message of self empowerment and self efficacy which many patients crave for at a time when cancer has removed so much control from their lives.

The American College of Sports medicine Roundtable on Exercise Guidelines for Cancer Survivors in 2010 showed there are benefits to exercise in physical functioning, quality of life and cancer related fatigue in several cancer survivor groups.

Integrating exercise into the Medical Oncology Advanced Trainee’s Curriculum

Gaps in knowledge in exercise and cancer remain. Barriers to exercise – patient, disease, clinician, infrastructure and financial – all exist in various forms.  We need to help the future oncologists to understand exercise’s benefits and forge closer links with exercise physiologists.

We need to increase knowledge of the role of exercise in the RACP Medical Oncology Advanced Trainee’s curriculum – domains of public health issues relevant to the medical oncologist include cancer epidemiology, and cancer prevention both primary and secondary.

Do your trainees know that:

  • endometrial cancer is a preventable disease in  4 out of 10 patients through exercise or diet?
  • obesity linked cancers include adenocarcinoma of the oesophagus, adenocarcinoma of the pancreas, high grade prostate cancers (and with a more aggressive phenotype), kidney cancers, gallbladder cancers as well as some breast cancers  and colorectal cancers?
  • the patient you cured of testis cancer will in 20 years time have doubled his risk of a heart attack and needs to take those teachable moments with him throughout his life when caring for his metabolic health?

training learning knowledge blackboard_oncology news australiaI am advocating that in the basic principle of cancer management multidisciplinary care, our trainees need to know allied health professionals including exercise physiologists. They also need to know that rehabilitation is not just post-surgery but pre and peri, and that rehabilitation is not just post surgery but post chemotherapy and radiation too. Health maintenance risk factors include exercise and reducing sedentary behaviour.

Reversing the Accelerated Aging Process of  Cancer and Its Treatment

Has your patient’s cancer or the treatment they needed accelerated their aging and what could you as their oncologist do to help them? An interesting article in the ASCO 2016 educational book expands on this and the role exercise may play using cardiovascular disease as a model.

Neoadjuvant Exercise?

Should the teachable moment of cancer be when you are unable to get up of the floor post surgery because you are so deconditioned or should we be making our patients stronger to deal with what lies ahead of them? With the advent of neoadjuvant chemotherapy in so many tumour streams should this not be the time to optimise their physical strength?

UK Professor of Anaesthesia Michael Grocott of the Preoperative Association presented provocative data at the ANZGOG ASM this year that neoadjuvant chemotherapy may impact physical fitness and even survival undergoing neoadjuvant chemotherapy.

Why We Should Not Just Sit Around Doing Nothing!

rWhat about sedentary behaviour? The Founding  Editor of the Journal of Global Oncology Prof David Kerr eloquently put it on You Tube –“ I would like to exhort all of you to get off your bottoms and exercise” when discussing the JCO paper from 2013 showing  sedentary behaviour and lack of exercise can increase the risk of colorectal cancer recurrence. Is going to the gym enough when you sit the rest of the day?

The Evidence and Trials in Australia

A Cancer Council Australia Cancer Forum 2015 edition called for exercise to be integrated into standard cancer care. It described current randomised control trials in Australia involving clinic as well as home based interventions for cancer patients.  Several are large Phase III studies. The Colon Health and Life-Long Exercise Change (CHALLENGE) Study of colorectal cancer patients’ post-adjuvant therapy is headed by Assoc Prof Janette Vardy from the University of Sydney and Kerry Courneya from the University of Alberta. The ECHO study by Prof Michael Friedlander and University of Queensland’s Exercise physiologist Sandi Hayes is a Phase III study using exercise during adjuvant chemotherapy for ovarian cancer.  Both are looking at the primary outcome whether exercise improves disease free survival.

So personally, I think the time has come for more oncologists  to prescribe exercise and we need to provide the tools and expert support required to achieve this.

How to prescribe Exercise to patients not within clinical trials

You may ask well if they are not in a trial how can I prescribe it?

Gym fitness training personal trainer exercise_oncology news australiaDifferent states may have different programmes some run by Cancer Councils, other by local groups and others may be claimable under a GP care programme. Those with private health insurance can often fund referrals to an exercise physiologist.  A recent article by Lee Jones in JCO May 2016  has advised of the benefits of exercise for breast cancer patients to reduce cardiovascular events. Cardiovascular disease is now the leading cause of death among women with non-metastatic breast cancer especially those older than 65 years old. No wonder the insurance community is advocating it!

In NSW your patient’s Primary Care Physician can write an Enhanced Primary Care ( EPC) referral that entitles them to five sessions with an ESSA accredited exercise physiologist. This may not be enough to change health behaviour but may get the ball rolling.

An Unbearable Advocate?

In July 2014,  I was asked in an article “where I see myself in 5 years, personally and professionally?” I replied, “ I see myself remaining as a clinician promoting wellness to my patients and an increasing role in a formal survivorship purpose built centre. I am currently doing Dry July for our centre to raise funds for this. Personally I hope to be more physically active like I used to be but could be more unbearable in my advocacy if I become a convert!”

Sadly I am that unbearable convert! I learnt from my own teachable moment what a (pre) cancer diagnosis can bring and exercise twice a week with my own exercise physiologists. I am doing Dry July to assist the ongoing running of an exercise programme within my hospital and run my own Exercise Oncology Clinic.

So personally, I think the time has come for more oncologists  to prescribe exercise and we need to provide the tools and expert support required to achieve this.

Dr Diana Adams is participating in Dry July to raise funds to help exercise become integrated into the care of cancer patients to help them recover. You can support her Dry July fundraising efforts here: www.dryjuly.com/users/diana-adams 


About Author

Diana Adams

Dr Diana Adams is a Consultant Medical Oncologist at Macarthur Cancer Therapy Centre, Sydney South West Area Health Service.

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