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Exercise Oncology:
Improving Cancer Care Outcomes
Keeping FIt
Claudio Battaglini, Ph.D. FACSM
Get REAL & HEEL Breast Cancer Program Director
Exercise Oncology Research Laboratory Director
“Cancer Survivorship: A New Challenge
in Delivering Quality Cancer Care”
“Optimal care is care that allows you to
maximize the costs of survival (Physical,
emotional, social, economic), maximize your
health outcomes and enable you to be as
successful as possible in achieving your goals in
the context of this illness”.
Dr. Julia Rowland (Director of NCI Office of Survivorship), JCO, 2007
Cancer and Quality of life – what is it?
Fatigue
Social/Family
Well-Being
Emotional
Well-Being
Physical
Well-Being
Global
Quality of
Life
Functional
Well-Being
Cognitive
Function
Depression/
Stress
Tumor site
Symptoms
Components of quality of life
Biological Mechanisms
(Possible mechanisms involved in the relationship between exercise and cancer
prevention)
Cancer Site
Possible
Mechanisms
Rationale
Colon
↓ gastrointestinal transit
time; ↓ ratio of
protsaglandis, etc.
PA ↑ gut motility and
reduces mucosal exposure
to carcinogens
Breast
↓ lifetime exposure to
estrogen, etc.
PA delays menarche, ↓
ovarian estrogen
production; ↓ %BF (↓ fat
produced estrogens)
Prostate
↓ exposure to testosterone,
etc.
↑ production of sex
hormone-binding globulin
All Cancers
↑anti-tumor immune
defenses; decrease IGFs,
etc.
May ↑ # and activity of
macrophages, lymphokineactivated killer cells
(regulating cytokines)
Friedenreich & Orenstein J Nutr 2002
Exercise and survival after a cancer diagnosis:
biologic mechanisms
EXERCISE
Metabolism
Sex
Hormones
Other
RECURRENCE / SURVIVAL
Oxidative
Damage
Immune /
Inflammation
Purpose of the Exercise Oncology Projects
Treatment tolerability and enhanced chances for
treatment success may be improved if individuals
are able to develop their psychological and
physical strength, both of which have been shown
to combat the debilitating side effects of cancer
and cancer treatment.
(Battaglini, 2007)
 Examine the effects of exercise on treatmentrelated side-effects;
 Design of evidence-based exercise prescription
guidelines for cancer survivors.
Get REAL & Heel Breast Cancer Research Program
EXERCISE
Metabolism
Sex
Hormones
Other
RECURRENCE / SURVIVAL
Oxidative
Damage
Immune /
Inflammation
Cancer
Disease-Treatment
Exercise
Training
Pro-inflammatory Cytokines
IL-1() IL-6. IFN-,
TNF-, LIF, CNTF
Anorexia
Up - Regulation
Anti-inflammatory Cytokines
IL-1ra, IL-4, IL-10,
IL-15, sTNFR, sIL6R
Androgenic
Hormones
Sarcopenia
Muscle Tissue
Loss
 Functional
Capacity
Hackney & Battaglini, 2011
Up-Regulation
Muscle Protein Synthesis
 Functional
Capacity
Excitatory
Inhibitory
Get REAL & Heel Breast Cancer Research Program
EXERCISE
Metabolism
Sex
Hormones
Other
RECURRENCE / SURVIVAL
Oxidative
Damage
Immune /
Inflammation
Get REAL & Heel Breast Cancer Program
The Impact of Acute Intermittent Aerobic Exercise on Natural
Killer Cell, Catecholamine, and Cortisol Responses in Breast
Cancer Survivors
Evans, E.,, Hackney, A.C., McMurray, R., Randell, S., and Muss, H., Battaglini, C.L.
Heavy
Sedentary
Risk of Disease
(Peters 1994, Nieman 1995, Shore 1999, Na 2000,
Moderate
Fairey 2002, 2005, Lee 2010)
Training volume
EXERCISE
Metabolism
Sex
Hormones
Other
RECURRENCE / SURVIVAL
Oxidative
Damage
Immune /
Inflammation
EQUAL (Exercise and Quality of Life in
Leukemia/Lymphoma Patients)
EXERCISE
Metabolism
Sex
Hormones
Other
RECURRENCE / SURVIVAL
Oxidative
Damage
Immune /
Inflammation
Effects of Exercise on CRF
Effects of Exercise on PROs
Measure*
Piper, 0 - 10
Exercise
Control
FACT-F, 0-52
Exercise
Control
FACT-F, 0-52
Exercise
Control
, 6 - 30
Exercise
Control
EORTC, 0 - 100
Exercise
Control
LAS, 0 - 100
Exercise
Control
BFI, 0 – 10
Exercise
Control
MFI, 4 - 20
Exercise
Control
FSI (Severity), 0 - 10
Exercise
Control
Norwegian, 0 - 33
Exercise
Control
SympASF, 0 - 100
Exercise
Control
*Lower
Baseline
Mean
SD
Mean
Change
95% CI
N
10
4
483
114
4.6
3.8
1.0
1.3
3.5
4.0
1.4
0.5
1.1
+0.2
0.2 to 2.1
1.4 to 1.7
.019
.803
8
5
472
305
35.1
37.4
6.8
4.5
38.5
37.4
4.2
2.9
+3.4
0.0
0.9 to 7.8
2.6 to 2.6
.103
.984
4
2
146
61
21.9
11.4
11.0
0.8
16.1
10.5
10.3
2.3
5.8
0.9
0.2 to 11.9
14.9 to 13.1
.055
.563
2
2
73
56
13.2
13.7
3.5
4.0
11.1
15.4
1.2
2.8
2.1
+1.7
23.1 to 18.8
9.1 to 12.6
.417
.288
1
0
69
70
39.5
42.9


33.7
25.9


5.8





2
2
55
49
35.9
35.3
9.3
8.9
20.8
37.3
8.9
7.1
15.1
+2.0
18.8 to 11.3
13.9 to 17.8
.012
.363
2
1
83
22
4.7
2.1
0.4

4.5
4.8
0.2

0.2
+2.7
5.3 to 4.9

.705

1
0
49
22
13.1



9.2



3.9





1
0
17

3.9

1.7

3.3

2.0

6.0





1
0
12

21.5



12.1



9.4

6.0


1
1
23
23
14.0
25.0


26.0
45.0


+12.0
+20.0




scores reflect lower fatigue except where indicated
scores reflect lower fatigue; decreased scores reflect lower fatigue
Increased
Postintervention
Mean
SD
No. of
studies
P
Exercise and Cancer: becoming aware of the
implications of working with a cancer patient
Prescribing Exercise for Cancer Patients
• Cancer dx affects all aspects of physical
functioning
• Unique manifestations
-Tumor
-Treatment
-Side-effects
• ACSM / ACS guidelines
• Optimal guidelines yet to be established
Clinical Concerns
• Unwillingness of cancer patients
• Immunosuppressive effects
• Pathological bone fractures
• Cardiotoxicity (RT & CT)
Kang, J. Environmental Health Perspectives Suppl. (109) S1, 2001;
Courneya,Mackey, & Jones. Phys SportsMed, 2000.
Health Screening
Comprehensive health screening procedure should include:
1.
Oncology physician consent for participation in physical activity
- Family physician consent
2. Intake Meeting
- Informed consent form
- PAR-Q
- Medical History Questionnaire ???
- Lifestyle Evaluation (Physical Activity
- Resting Vitals (BP, RHR, SPO2, ECG)
Levels)
Exercise Testing Recommendations
Chapter 5. Cardiorespiratory Fitness Testing in Clients Diagnosed With Cancer
Jones, L & Battaglini, C. 2012
Exercise Testing
Considerations
1. Max tests (w/ direct or estimated measurement of
VO2peak) vs. Submaximal Tests
2. Purpose
3. Setting (clinical vs. non-clinical facility)
4. Type of cancer patient
Cardiorespiratory Endurance
- CPET, Stress Tests, Sub-maximal Protocols
(Modified Bruce Protocol, YMCA Bike Protocol, Rockport
Walking Test, etc.)
(Dependent on Functional Status of Patient)
Muscular Strength/ Endurance
- 1RM, Sub-maximal Protocols [Rocky Mountain
Cancer Rehabilitation Protocol (“Exercise and Cancer Recovery”, Schneider,
C., Dennehy, C., and Carter, S., 2003)],
Partial curl-ups, Push-ups, etc.
(Dependent on Functional Status of Patient)
Flexibility/ Balance
-Goniometry, Sit-and Reach, more sophisticated tests for
specific deficiencies (i.e.: shoulder function, ROM)
- Balance (Static and Dynamic Tests; Single limb stance,
Timed 360o turn, Four square step test)
(Dependent on Functional Status of Patient)
Exercise Prescription Recommendations
Mode
• Walking/ cycle ergometry
(natural choice)
• Account for specific
impairments (e.g., colorectal,
breast cancer)
• Resistance training (upper
body concerns i.e lymphedema
(unfounded)
• Combined aerobic and
resistance training optimum
Frequency and Intensity
• 2-5d/wk
• Extreme caution w/
patients suffering
extreme fatigue
• Moderate intensity
• 50-75% of VO2max
• 40-80% HRR
Duration and Progression
• 20-45 min (continuous)
• Multiple short exercise bouts during the day
• Initially work on frequency and duration – then
intensity
• Progression slower for patients suffering severe
side-effects
All dependent of the disease stage and
overall health of patient
Special Precautions
Complication
Precaution
Hemoglobin <8.0 g/dl
exercise
Avoid high intensity
Absolute neutrophil count
Ataxia/dizziness
Avoid exercises that may
increase chance of infection
(swimming)
Avoid exercises that require
significant balance &
coordination (treadmill)
Special Precautions Continued
Complication
Precaution
Severe cachexia
Loss of muscle mass limits
exercise intensity modify program accordingly
Bone pain
Avoid high impact exercises
Extreme fatigue
Exercise at lower power output,
avoid high intensity exercise
Dehydration
Inability to efficiently
thermoregulate
Exercise Session Example
1. Check resting vitals
2. Cardio Workout
Whole Body
Stretches/
Specific
Stretches
3. Stretching (Whole
Body)
4. Weight Training
5. Finals Stretches/
Relaxation
Cardio
Workout
20%
25%
15%
Cool Down
Stretches/
Relaxation
40%
Weight Training
Workout
• No evidence that one type of exercise is
superior
• Safety is the primary concern
• Optimal program may combine resistance
and aerobic exercises
• Key point: be flexible with prescriptions;
modify prescription based on response to
treatment(s)
Acknowledgements
• All of the wonderful UNC physicians, cancer
researchers, exercise physiology colleagues, and
my students
Special thanks to:
• Department of Exercise and Sport Science
• Lineberger Comprehensive Cancer Center
• UNC Cancer Hospital
THANK YOU!
Contact Information:
Dr. Claudio Battaglini
Department of Exercise and Sport Science
(919) 843-6045
[email protected]