Expert Review: Prehabilitation and rehabilitation session by Kim Hobbs, Clinical Specialist Social Worker, Department of Gynaecological Cancer, Westmead Hospital.
COSA Annual Scientific Meeting, Melbourne, Australia
Chairperson Mei Krishnasamy opened this session by attesting the fundamental need to address the concepts of prehabilitation and rehabilitation in cancer care.
Exercise prescription for bone metastatic cancer: Feasible and effective by Rob Newton
The first speaker Prof Rob Newton from the Edith Cowan University Health and Wellness Institute addressed the topic of whether exercise prescription is safe and feasible for patients with bone metastases. He began by defining exercise as a ‘planned therapeutic intervention, a medicine; not to be used interchangeably with the term physical activity’.
Exercise mediates endogenous medicines and facilitates other therapies so it is beneficial to patients with bone metastases – the notion that these patients need “rest” is a fallacy. Instead what these patients need is a structured, tailored exercise program to mitigate against muscle and bone loss, risk of falls and general frailty. However, he did caution that exercise prescriptions that included resistance training needed to be customised for each patient to avoid bone metastasis sites.
Exercise is NOT a single medicine. It requires targeted prescription, as does drug treatment in cancer care however the benefits can be great. Prof Newton reported on a pilot study (no controls) that demonstrated high involvement and compliance rates, with study participants attending 70% of their structured exercise sessions. No adverse events occurred and the participants reported decreased bone pain both within and between sessions. From these findings, Prof Newton concluded that structured exercise is safe if planned correctly, appropriately modified and adjusted for metastatic disease sites. The benefits of these exercise prescriptions included decreased pain, increased muscle strength, aerobic fitness, ambulation, lean mass and physical activity; and most improvements were sustained at six month follow up.
What I took from the presentation was our patients – at all stages of disease, even when on treatment – need to reject the “rest” strategy. As a guide, patients should aim to meet the generic position statements on exercise (75-150 minutes of medium to vigorous exercise per week, with at least two sessions of resistance training). And we can all help to increase patient compliance by supporting patients, encouraging family involvement and incorporating exercise in support group interventions.
Inactivity and functional decline in lung cancer by Catherine Granger
Catherine Granger, a research physiotherapist from the Royal Melbourne Hospital and University of Melbourne, spoke on the implementation of an exercise program with lung cancer patients. It’s well established that people with lung cancer suffer a high burden of disease with reduction in physical activity, activities of daily living and overall functional decline.
In the general adult population, adherence to the WHO guidelines for physical activity (150 minutes of moderate intensity, or 75 minutes of vigorous intensity exercise) reduces the risk of premature death.
In the cancer population early preliminary evidence in breast and colo-rectal cancer patients is pointing towards the possibility of improved survival with increased physical activity. Beyond the potential for survival benefits, there is good evidence for improvements in non- survival outcomes, such as, increased fitness and function, less fatigue and improvements in health related quality of life and mood.
Most of the evidence in support of exercise benefits comes from the breast, prostate and colo-rectal patient populations. There is little evidence for the benefits of exercise in lung cancer patients. In Catherine’s study, only 40% of patients met the minimum requirements for physical activity compared with 71% of controls. Thirty percent of study participants were sedentary at the time of diagnosis, compared with 6% of controls.
However, exercise training may play an important role in preventing functional decline in lung cancer patients. Three systematic reviews have been conducted, but with only a small number of non-RCT studies. Nevertheless, they have indicated potential for improvements in fitness, fatigue and post-operative complications. Results for quality of life are equivocal.
Catherine’s vision for the future is to see exercise training programs as a part of usual care for people with lung cancer. However questions about the optimal time for introducing exercise remain to be answered.
But there are three current RCT’s underway: the TIGER trial by Denehy and colleagues in Melbourne, Vardy and Dhillon in Sydney, and Jones and colleagues in the US. Stay tuned for definitive results!
Mindfulness as a strategy for living well during and after cancer by Jeremy Couper
Jeremy Couper reported on a mindfulness-based stress reduction program for head and neck cancer patients. This was an initiative of the Psycho-oncology Research Unit at Peter MacCallum Cancer Centre.
People with head and neck cancers have a high burden of illness from treatment and side-effects; as well as high rates of depression, anxiety and stigma associated with the lifestyle precursors of the disease. Head and neck cancers are the tenth most prevalent cancer type and are associated with high rates of emotional trauma and of suicide. They have low rate of referral to psycho-oncology services and yet they have a 60% five year survival rate.
A longitudinal observational study of head and neck patients found a high number with significant psychological distress. Males were more likely to be distressed and anxious than females. High levels of drug and alcohol use prior to treatment predicted higher rates of anxiety and depression post radiotherapy completion.
“Talking cures” and therapeutic interventions are not suitable for head and neck patients due to their reduced capacity for verbal communication. Mindfulness based stress reduction is known to be a good alternative therapeutic style for ill people, and has been shown to be effective with breast cancer patients.
The Peter Mac team adapted (with permission) an intervention developed by Linda Carlson and colleagues in Canada. The program involved seven sessions, each of 90 minutes duration, delivered one on one by a Clinical Psychologist. Nineteen patients commenced this first trial, of which 16 completed at least four of the seven sessions and 11 completed the whole program. Jeremy acknowledged that although numbers are small, higher levels of mindfulness were reported in those who participated, along with improved total quality of life, social and emotional well-being. In addition, there was a trend towards lower reported distress, especially anger and anxiety.
In summary, a tailored mindfulness intervention, designed specifically for this group of patients, demonstrated good adherence, compliance and acceptability; with a suggestion of improved psychosocial outcomes which is much needed for people with head and neck cancers.
Health literacy in relation to cancer: Addressing the silence about and absence of cancer discussion among Aboriginal people, communities and health services, by Carla Treloar
Carla Treloar from the UNSW Centre for Social Research in Health concluded the session with a paper on cancer-related health literacy for Aboriginal people. (Carla has provided OncologyNews with an in depth summary of her paper here which is well worth a read if you are interested in health literacy and Aboriginal health).
As limited health literacy is consistently demonstrated as being associated with poorer health outcomes in a variety of diseases, the aim of this qualitative study was to understand and integrate the perspectives of Aboriginal people, their carers and health workers.
Twenty-two Aboriginal people with cancer, 16 of their carers and 16 health workers (8 Aboriginal, 8 non-Aboriginal) participated in the study. The key recommendations from the study were:
- to recognise the susceptibility of Aboriginal people
- to recognise opportunities to learn from each other; and
- to integrate services and programs for health literacy into existing health systems.
Aboriginal people stated that they felt “silenced” due to the absence of Aboriginal people in mainstream media campaigns. Further, their low uptake of cancer screening programs and treatment are perpetuated by their misunderstandings and misconceptions about cancer; specifically, their beliefs of certain death once diagnosed with cancer.
The challenge for health workers with Aboriginal people is how to engage existing health services and primary care focussed organisations to design and deliver health care programs that address misunderstandings and improve health literacy.
But fundamentally, grass roots education is crucial to addressing these issues.
Kim has previously contributed expert commentary for OncologyNews: