Episode 10 Shownotes - Cancer Survivorship - The Significant Benefit In Survival From Exercise

Hi, and welcome back to episode 10. This week we are going to step back from the weight loss, and into another of the survivorship podcasts. What that means is that this week I predominately have my medical cap on, and there is going to be data, and it may be challenging to understand all of it. If you have questions, reach out through the Best Life After Cancer MD facebook page. This topic for this week is exercise. Many adults may consider exercise as a means to lose weight, or perhaps reduce their risk for cardiovascular disease, but they often do not realize that recreational physical activity (RPA) is an important tool in both the prevention of cancer and reduction in recurrence. This topic is near and dear to my heart for survivors. I feel really passionately that as a medical community, we may not be making this data clear to each and every one of our cancer survivors. One of the reasons I think some physicians don’t focus on it is because as a doctor, it is something we have no control over, and no way to measure. We also have limited time with each patient, and want to make sure we have covered all of the things related to our care first, and sometimes it just goes by the wayside. However, this is something I personally evaluate at almost every follow up with my patients with stage I-III disease. I track what they are doing, talk with them about the data, and try to encourage positive change. I hope that after this, you will have an understanding of just how important exercise is in terms of increasing survival for cancer patients. We are not talking marathon running or heavy duty weight lifting. What we are talking about is considered recreational physical activity – this includes brisk walking, enough to get your heart rate up, swimming, low impact aerobics, biking, brisk dancing and so on.
Brace yourself – we are headed into some of the technical stuff. A recent study in JAMA pooled data from 12 cohort studies of self-reported RPA and the risk for cancer among adults. The study included data from almost one and a half million adults, with a mean age of 59 years. High levels of activity were associated with significantly lower risks for development of 13 types of cancer. The inverse association between RPA and the risks for breast and gastrointestinal cancers are well-know, but in this study, recreational activity also reduced the risks for certain types of leukemia, head and neck, kidney, and bladder cancers. Moreover, it also had a preventive effect independent of body mass index and smoking status for most of these forms of cancer.

There is also evidence that recreational activity can also reduce the risk for mortality among patients with a known diagnosis of cancer. To date, this research has been focused on specific tumors. A study from the Lancet used a large database to investigate the effect of RPA on mortality outcomes across a broad range of adults with cancer. It found that exercise after a cancer diagnosis improves survival, even in patients who had not exercised previously. The findings in the Lancet study come from an analysis of detailed epidemiological data collected over the course of almost 15 years in almost 6000 patients who were diagnosed with a variety of cancers. A significant survival benefit of exercise was seen in patients with the following tumors: breast, colon, prostate, ovarian, bladder, endometrial, esophageal, and melanoma. Regular exercisers had the biggest survival advantage over their sedentary peers. Patients who exercised 3 to 4 times each week before and after their cancer diagnosis reduced their all-cause mortality risk by 40% and their cancer-specific mortality risk by 39% compared with patients with cancer who remained "habitually inactive." However, patients who exercised just 1 or 2 days each week before and after their cancer diagnosis also had significantly improved survival compared with sedentary counterparts. They enjoyed a 32% reduction in both all-cause mortality and cancer-specific mortality. Astonishingly, even veteran couch potatoes experienced dramatically improved survival when they exercised. The researchers found that patients who were sedentary in the decade before diagnosis experienced a 28% drop in all-cause and cancer specific-mortality when they exercised just 1 to 2 times a week in the year after cancer diagnosis. The survival benefits were observed regardless of the patient's sex, age, weight, smoking status, or cancer stage. In other words, from a Medscape interview with lead author Dr. Cannioto from Roswell Park Cancer Center, the association was seen in obese patients, persistent smokers, and in patients who were diagnosed with advanced-stage tumors. These findings show that "it is never too late to make healthy lifestyle changes that may affect the survival trajectory. This is good news for all cancer patients. These observations highlight the importance that any amount of regular weekly activity is better than inactivity. This is particularly encouraging given that cancer patients and survivors can be overwhelmed by the physical activity recommendations of 30 min per day of moderate-intensity physical activity. The study included more women than men (55% vs 45%). A total of 1390 patients (24.4%) said they did not exercise regularly before diagnosis, and 2400 (41.9%) said they did not exercise after cancer diagnosis. Self-reporting of physical activity is a primary limitation of this study, as it may be subject to recall error and misclassification, especially for the decade before diagnosis.

So what does this mean for you in particular? What I, and many other oncologists, recommend is optimally 150 minutes of mild to moderate activity per week for all patients with Stage I-III cancer without clinical reasons to NOT recommend exercise. There has been some concern expressed about how the exercise needs of seriously ill patients with cancer can be balanced without creating additional health risks, though. Here is where you get the sentence you always get – I am a doctor, but not yours, so discuss with your team your fitness and capacity for exercise. I do not ususally recommend exercise for my patients with metastatic disease, especially with bone metastases, because I do have concerns about the risk of causing fractures, and because it has not shown to improve survival in patients with stage IV disease to the same degree it does in Stage I-III cancer.
In stage I-III cancer, though, there is evidence that exercise improves survival almost as much as chemotherapy in some cancers, so you really can’t underestimate the importance of this. This data is very robust and well proven in breast cancer especially. Exercise is something only you can commit to doing and actually get done. If you have never done it before or are very deconditioned after treatment, many cancer centers have a cancer fitness program, which can help patients get in the swing of things. In many places, the YMCA also offers free or low cost cancer fitness programs. Remember that exercising for 3 to 4 days per week was associated with the greatest survival advantage. The pace of walking was the only variable that produced a linear effect in reducing the risk for death. So, ambling or strolling doesn’t cut it. You have to walk briskly to get the benefit. Even though 3-4 days a week had the best outcomes, we need to keep in mind that comparing patients who reported pre and postdiagnosis RPA of only one to two days a week compared with habitually inactive adults, had 32% less deaths. Formerly inactive patients who initiated RPA 1-2 times a week only after the diagnosis of cancer experienced a 28% reduction in all-cause and cancer-specific mortality. That is HUGE. It is something you have under your control to directly improve your odds. It is something that you can start small, and work up. It doesn’t have to be perfect right off the bat. Any steps you take towards this will impact positively on your survival.

If that is not enough reason to start, then this might convince you. I have a very frank discussion with all patients who say they are still tired 3-6 months after their treatment completes. I am going to have the same frank discussion with you now. Most people become more sedentary during their treatment. They don’t feel good, they are more tired, so understandably, they are less active. It only makes sense that if you do not get back to your precancer fitness level, you are never going to feel as strong, vigorous, and well as you did before cancer. This means you HAVE to get off the couch and get moving again. You can take this knowledge one of two ways. You can decide it makes so much sense and give you a goal to help you get back to feeling awesome. Or you may think it is impossible that it is ever going to happen that you can get back to that place. It you think it will happen, you increase your odds hugely. If you don’t believe it is possible, well, I have to tell you, likely it never will happen, and likely you will never again feel as good as you did before cancer. It is not easy. Your body has been through a lot. The first two weeks of being more active, you likely will feel MORE tired. You may have sore muscles, joint aches and so on, that were never there before. You have to push through this and persist. I am not going to tell you it is going to be fun. I will also not tell you it is going to be quick. For many people, it takes 6 months after treatment completes to get back where they were before. But, I will tell you, in my experience over 20 plus years, having treated literally thousands of patients, it is the best guarantee you will get to help you get back to your baseline in terms of how you feel.

I want to point out something here. Exercise is NOT part of the weight loss talk. I believe that exercise is actually pretty limited in its ability to help with weight. You have to be exercising almost constantly to override bad eating habits. The goal of this exercise recommendation is not to be thinner, it is to improve the odds of your survival and help you feel better. What is definitely true for many people, though, is that exercise DOES help in how you LOOK. It might not help you lose weight, but it does tighten and tone, so I think it is really great in helping to feel better about how you look after cancer. Remaining a couch potato after treatment likely will leave you squishy and tired, which I think most of us can agree is not the best look for most people. I also want to put out there that I am not a huge fan of super aggressive exercise in my cancer patients. By this, I mean excessive running, marathons, triathalons, very heavy weight lifting, or other exercise to extremes. There are multiple reasons for this.

First. Very aggressive exercise puts strain on joints and ligaments that might have been affected by treatment, increasing the risk of pain and injury. I would much rather see my patients doing body-loving exercise that they can do for 20+ years over something that will burn them out in a shorter time.

Second, there is evidence that very aggressive exercise increases cortisol. Cortisol is produced when the body faces periods of stress and there is growing evidence that abnormally prolonged cortisol production inhibits the body’s immune response. This could potentially make the body more susceptible to recurrence of cancer, according to researchers at the University of Rochester. Cortisol also impairs weight loss, and we know that being overweight can increase cancer risk.

Third, I think that aggressive exercise runs the risk of further damaging parts of your body that were operated on in the treatment of your cancer. Scar tissue does not stretch like normal tissues do. Scar tissue is more likely to be torn than unscarred tissue. These aggressive types of exercise often require people to ignore pain, and I think it is really important after cancer to listen to what your body is saying about what feels like good exercise and what feels like misery. Misery can lead to months of not being able to exercise at all, which we KNOW is not useful.

In all honesty, what I would love to have all of my patients do is walk or swim. Both are low impact, but walking is the most versatile. It also is weight bearing, so helps maintain bone density in women and men on any type of androgen deprivation therapy (most often used in prostate cancer treatment). It can be done in almost any weather with the right jacket. If it is summer, it can be done early in the morning or later at night for better temps. It is free. It does not require any equipment. It does not damage your joints, does not raise your cortisol, and actually, likely decreases stress and cortisol. It can be solitary or social. It can be something you use as a meditation time, getting even more benefit out of it. It can easily be tracked and documented. It is a no brainer from my standpoint.

Ok. So now you are convinced. How to get yourself to do it. Here the coach hat goes back on. Plan ahead. On Sunday, look at the weather for the week. Plan what days you will walk. Plan the time. Set an alarm or reminder for those days. The day before, if you are getting up and going early, set out your clothes and shoes. Maybe even fill your water bottle with ice for the morning. When the time comes, and the timer or alarm goes off, you don’t have to decide to walk. Decide to get out of bed and use the toilet. Next, decide to put the clothes on. Then, decide to put the shoes on. By then, you will likely have enough momentum to actually do it. Decisions ahead of time, and doing what ever you can to make it as easy as possible will definitely help to increase the odds that you will do it. But you have to plan a day and time, and what you will do instead if the weather doesn’t cooperate. A yoga video? 5 minutes of the steps in your house? Plan it and write it down.

Ok – so the review for this week. Exercise reduces the risk of getting many cancers up front. It also significantly reduces the risk of your cancer coming back. Furthermore, it helps you get back to how you felt before cancer. More is better, but any is better than none. It doesn’t have to be, and from my standpoint, shouldn’t be marathon running or competitive weight training. It shouldn’t be with a goal of being thin. Make a plan ahead of time, and stick to it.

As a scientist, I feel the need to reference the studies I discussed – they are listed on the facebook page if you want to look up any of them for more details. Alright, my best lifers – that is it for this week! I’ll talk with you soon!

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2521826.
Cannioto RA, Dighe S, Mahoney MC, et al. Habitual recreational physical activity is associated with significantly improved survival in cancer patients: evidence from the Roswell Park Data Bank and BioRepository. Cancer Causes Control. Published online November 28, 2018. https://link.springer.com/article/10.1007%2Fs10552-018-1101-5. Accessed December 20, 2018.
The Lancet Oncology. Exercise and cancer treatment: balancing patient needs. Lancet Oncol. 2018;19(6):715. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(18)30376-0/fulltext.
COSA position statement on exercise in cancer care. https://www.cosa.org.au/media/332488/cosa-position-statement-v4-web-final.pdf. April 2018.
Mulcahy N. Prescribe Exercise to All Cancer Patients, Says New Guideline. https://www.medscape.com/viewarticle/896686. May 16, 2018.
Mina DS, Langelier D, Adams SC, et al. Exercise as part of routine cancer care. Lancet Oncol. 2018;19(9):e433-e436. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(18)30599-0/fulltext..