Authors:
Professor Robert Thomas,
Nicola
Davies,
Lynn
Bateup|
Lifestyle and cancer - Published evidence |
| Contents and links: Lifestyle | Nutritional testing | Giving up smoking | Diet | Exercise | Survivorship | The Lifestyle After Cancer guide book. |
Authors:
Professor Robert Thomas,
Nicola
Davies,
Lynn
Bateup
Introduction
It has been firmly established in scientific literature that regular
exercise and a healthy lifestyle reduces the risks of developing cancer. In
fact, The World Cancer Research Fund estimate that over 80,000 patients
diagnosed with cancer each year could have avoided the disease by adopting a
healthier lifestyle. This amounts to 39% of cases of the twelve major cancers
which could be prevented through better diet, drinking, and exercise habits.
Part Two - The influence on risks,
side-effects and improved well-being;
Evidence that Lifestyle can Influence Cancer Outcomes
A number of epidemiological and cohort studies, have demonstrated that individuals with healthier lifestyles tend to present with less aggressive cancers, so their prognosis is better (Chan et al., 2005; Sonn, Aronson, and Litwin, 2005; Wilkinson and Chodak, 2003). For example, the health professionals study showed that men who consumed tomatoes, tomato sources, and olive oil developed prostate cancers which were less likely to have spread beyond the gland (Giovannucci et al., 2002). A large case-control study conducted in China demonstrated significantly lower grades of prostate cancer among individuals who regularly consumed foods containing tofu, soy and isoflavones (genistein and daidzein) compared to a matched cohort (Lee et al., 2003).
Although diets with good soya and tomato
intake appear to be beneficial, taking additional soya or lycopene supplements
appears not to be. A phase II study evaluated the effects of a low-fat diet or
a low-fat diet with the addition of a soy supplement in asymptomatic,
hormonally naive prostate cancer patients with rising prostate-specific
antigen (PSA) levels. Patients were commenced on a low-fat diet with a goal to
reduce fat intake to 15% of total daily calories. Serum was analysed for
changes in the sex hormone and insulin-like growth factor (IGF-I) axes. Among
18 evaluable patients (median follow-up of study 10.5-months), there was a
significant trend toward a longer PSA doubling time and a prolongation in
estimated median TTP of 3-months. After
the intervention, free testosterone levels significantly decreased by 5%.
On PSA progression, a soy protein supplement was added to the diet,
however, this did not reduce PSA levels or prolong the doubling time and IGF-I
levels actually increased by 22%, risking a potentially undesirable
biochemical effect (Spentzos et al.,
2003).
Schwarz
et al. (2008)
report a second randomised study, not involving men with cancer, which
demonstrated an effect on PSA in men with benign prostatic hyperplasia (BPH) who are
at an increased risk of progressing to cancer. This pilot study randomly
compared the effects of lycopene (15mg od) supplementation in elderly men (n = 20) diagnosed with BPH against those who were given placebo (n
= 20), both taken for 6-months. The lycopene supplementation significantly
decreased PSA levels, whereas there was no change in the placebo group. The
plasma lycopene concentration increased in the group taking lycopene, but
other plasma carotenoids were not affected. Whereas progression of prostate
enlargement occurred in the placebo group as assessed by trans-rectal
ultrasound and digital rectal examination, the prostate did not enlarge in the
lycopene group. Symptoms of the disease, as assessed via the International
Prostate Symptom Score questionnaire, were improved in both groups with a
significantly greater effect in men taking lycopene supplements
Pantuck
et al. (2006)
published a prospective phase two study evaluating men with PSA relapse
post-radiotherapy or prostatectomy (n
= 48), comparing PSA doubling time (PSAdt) before and after the consumption of
approximately 200ml pomegranate juice. There was a significant prolongation of
PSAdt from a mean of 15-months at baseline to 54-months post-treatment. As a
secondary end point, the patients’ baseline oxidative state was
significantly lower at baseline and after pomegranate consumption, measured
using three separate serum analyses (serum induced proliferation and apoptosis
of LNCaP cells, serum lipid peroxidation and serum nitric oxide levels).
Influence of Diet
The association between dietary
factors and survival from breast cancer has been derived from follow-up and
case-control studies (Holmes et al., 1999; Rohan, Hiller, and McMichael, 1993). The largest of these
is the Nurse’s Health Study in which women with breast cancer completed a
dietary questionnaire one-year following radical therapy. Women following
their description of a prudent diet (high fruit, vegetable and fiber;
low fat and salt) had a statistically significant lower overall mortality rate
compared to those with a typical western diet. The specific breast cancer
mortality overall was not, however, different except in the comparison of the
upper quartile of prudent with the upper quartile of western and then only in
a node positive subgroup (Kroenke et al., 2005).
Individual Components of Diet and their Mechanisms of Action:
Cruciferous Vegetables
Broccoli
and other cruciferous vegetable contain anti-carcinogenic isothiocyanates (ITCs),
particularly the potent sulforaphane, which may decrease risk of cancer
through induction of phase II enzymes, including glutathione S-transferases (GSTs).
A population-based, case-control study evaluated this hypothesis in men with
incident prostate cancer (n = 428)
and community controls (n = 537).
An in-person interview included an extensive food-frequency
questionnaire. Intakes of
cruciferous vegetables and broccoli, the greatest source of sulforaphane, were
associated with decreased prostate cancer risk at all levels above the lowest
consumers. These findings suggest
that two or more servings per month of cruciferous vegetables may reduce risk
of prostate cancer (Joseph et al., 2007).
Evidence from two large prospective studies (Augustsson et al., 2003;
Terry et al., 2001) and a smaller case-control study (Norrish et al., 1999)
suggests a protective effect of oily fish intake on cancer incidence and
mortality (Terry, Rohan, and Wolk, 2003). A unique nutritional component of
fish is the long-chain marine omega-3 fatty acids. Cell line xenografts and
small human studies have suggested that marine omega-3 fatty acids or the
ratio of marine omega-3: omega-6 fatty acid can modulate the cyclooxygenase-2
pathway, a potential route for prostate cancer development (Chaudry et al.,
1994). Laboratory experiments have
also demonstrated that oleic acid helps repair DNA damage caused by excessive
sunlight. This DNA repair affect is the reason olive oil is being used more
frequently in skin care products, particularly ‘after sun.’ Furthermore,
olive oil has been shown to suppress over-expressed Her-2 protein on breast
cancer cells (Flowers and Thompson, 2009).
Individuals with
diets rich in fruit and vegetables, particularly vegetarians, have nature
serum salicylate levels equivalent to a dose of 80mg of acetyl salicylate
(aspirin) a day. This is more than enough to reduce the conversion of
arachidonic acid to prostaglandins via the Cyclo-oxidase
(COX) pathway. Many
tumours over-express COX-2, particularly those with a more
aggressive phenotype or those which have become resistant to hormonal
therapies (Blacklock et al., 2001). In
vitro, inhibitors of COX-2 such as non-steroidal anti-inflammatory drugs (NSAID)
have been shown to induce apoptosis, inhibit proliferation, impair adhesion
and signal angiogenesis in cancer cell lines and
xenographs (Hsu et al., 2000). Prospective
studies, including a COCHRANE meta-analysis, have shown a reduced incidence of
malignancy associated with regular aspirin use (Egan et al., 1996; Fuchs et
al., 2005; Schreinemachers and Everson, 1994).
A prospective randomised clinical study showed a protective benefit
against recurrent bowel cancer in patients taking aspirin (Mahmud, Franco, and
Aprikian, 2003). Aspirin, however,
can cause gastrointestinal upset and the third generation non-steroidal
anti-inflammatory drugs have cardiac and renal safety issues (Dieppe, Ebrahim,
and Juni, 2004; Hippisley-Cox and Coupland, 2005).
High fruit and vegetable intake on the other hand is associated with
lower GI morbidity and does not have any adverse effect on the kidney –
clearly a much safer way to increase salicylate intake.
Carotenoids
and Vitamin A (Retinol and Beta-Carotene)
Lycopene is a naturally occurring pigment found in tomatoes, chillies and
other colourful fruits. As well as inducing antioxidant enzymes, there is
growing evidence related to cell differentiation and proliferation independent
of this mechanism of action (Stivala et al., 2000).
Lycopene has been shown to have a protective benefit on prostate cancer
risk among U.S. health professionals (Giovannucci et al., 2002).
For men with established cancer, a small non-randomised study looked at
lycopene intake prior to prostatectomy and demonstrated less aggressive
parameters compared to controls (Chen et al., 2001; Kucuk et al., 2002).
Vitamin A is a fat-soluble
essential vitamin found in fish, particularly cod liver and dairy food in the
preformed isoform retinol. Beta-carotene is a pro-vitamin A found in
carrots, green leafy vegetables and colourful fruits. Cancer cell line data have demonstrated an increased apoptosis and reduced
proliferation when exposed to synthetic retinoids such as fenretinide (Hsieh
and Wu, 1997). However,
trials of supplemented beta-carotene in patients at high risk of lung cancer
showed an elevated risk of lung and prostate cancer (Heinonen et al., 1998).
Another large chemo-prevention study combined beta-carotene with
retinol (Vitamin A) and showed a lower risk of prostate cancer in those with
pre-intervention low plasma levels of beta-carotene; those with high levels
had a higher risk (Omenn et al., 1996).
Antioxidants
Dietary antioxidants are thought to wield their anti-cancer properties by
directly or indirectly counterbalancing the superoxide free radicals produced
from our diet or other environmental factors (Chen et al., 2001; Giovannucci
et al., 2002; Giovannucci et al., 2006; Stivala et al., 2000). Although
patients with established cancer have already sustained DNA damage in order to
mutate from benign to malignant cells, avoiding further DNA insult may avoid
further mutation of indolent malignant or pre-malignant cells into more
aggressive phenotypes (Chan, Gann, and Giovannucci, 2005; Sonn, Aronson, and
Litwin, 2005; Wilkinson and Chodak, 2003). Otherwise known as free radical
scavengers, they are found in a wide variety of dietary sources (Chan, Gann,
and Giovannucci, 2005; Chlebowski et al., 2005).
The largest group of antioxidants are the non-oestrogenic phytochemicals or polyphenols, which include
the phenolic acids, namely benzoic acid (hydroxybenzoic acid, gallic acid) and
cinnamic acid (caffeic and quinic acid), together with the non-oestrogenic
flavanoids including anthocyanidins, the flavanols (catechins and
proanthocyanidins), lignans and stilbens (Chan, Gann, and Giovannucci, 2005;
Sonn, Aronson, and Litwin, 2005; Wilkinson and Chodak, 2003).
These phytochemicals do not act via a hormonal route, but have been
shown to have some direct anti-oxidative, anti-proliferative activities
(Wilkinson and Chodak, 2003). Kaempferol,
found in teas and kale, has particularly been shown to reduce the risks of
ovary and breast cancer within the ongoing Nurses’ Health Study.
These and other phytochemicals are also commonly found in flaxseed,
linseeds, nuts, dark greens, cruciferous vegetables, prunes, brightly coloured
vegetables, fruits and grains. Antioxidants
can be found in less obvious sources such as coffee and chocolate (Svilaas et
al., 2004), apples used for cider, and the tannin component of red wine (Schoonen
et al., 2005). The FDA have
published league tables relating to foods ability to induce these defence
enzymes, known as their Oxygen Radical Absorbance Capacity (ORAC) (FDA, 2006).
Phytoestrogens (Oestrogenic
Phytochemicals)
These include flavones, isoflavones and flavanones, which are derived in
the human diet mainly from soy beans and legumes including peas, lentils and
beans (Wilkinson and Chodak, 2003). Dietary
intake, for example, could potentially create a more favourable hormonal
milieu for men with prostate cancer by inhibiting 5 alpha-reductase, the
enzyme responsible for converting testosterone to the more active metabolite
dihydrotestosterone (Evans, Griffiths, and Morton, 1995).
The benefits or risks of
phytoestrogenic supplements on breast cancer remains controversial, although
this issue may be solved by an ongoing national NCRN DietCompLfy study,
which is correlating the risks of breast cancer relapse with levels of
phytoestrogenic intake (Leatham and Velentzis, 2006).
1996-2004
1001 with history of SCC or BCC
221 scc in 116 individuals
321 bcc in 149 individuals
Self administered dietary questionnaire
High Lutein zeaxanthin (leafy green vegetables)
50% reduction in new skin cancers
Higher risk beta carotene and Vit E
Caution should be taken with excessive antioxidant intake, especially in
supplement form, during chemotherapy or biological therapies. Antioxidant
polyphenols in green tea may potentially decrease the efficacy of the cancer
drug bortezomib (Velcade) and other boronic-acid proteasome inhibitors (Golden
et al., 2009). Among the most widely used herbal supplements is St
John’s Wort (Hypericum perforatum), believed to have anti-depressant
properties. This interacts with the liver enzyme (CYP3A4), decreasing the
concentration of the chemotherapy drugs irinotecan, docetaxol and the
biological agent imatinib ( and ). Although the evidence for a number of other supplements is less
robust, potential interactions have been reported with Echinacea, grape seed
and gingko. Ephedra can increase
blood pressure during cancer therapies and can compromise biological agents
such as sutent and nexavar, and kava-kava can increase the risk of liver
damage.
Vitamin C
Vitamin C has been shown to prevent the inhibition of gap-junction
intercellular communication (GJIC) induced by toxic products such as hydrogen
peroxide. Inhibition of GJIC is
related to carcinogenesis and tumour promotion (Lee, 2002).
Vitamin C is involved in the mechanism which enables DNA to ‘sense’
free radicals by integrating with the iron imbedded in DNA, thereby
facilitating DNA repair. It is
therefore an important factor in immune surveillance against cancer as,
according to estimates, each cell in the body can be expected to suffer
approximately 100,000 DNA-damaging events per day (Fraga, 1991).
A prospective double blind randomised trial involving men with
progressive prostate cancer (n = 110) showed no difference in PSA doubling time in those given
Vitamin C, magnesium, and copper gluconate or placebo (Thomas et al., 2005).
Vitamin
D (and Sun Exposure)
Vitamin D is converted to the active metabolite calciferol in
the kidney. Calciferol exposed to
cancer cell lines reduces proliferation, promotes differentiation, inhibits
invasion and loss of adhesion (Campell et al., 1997; Peehl et al., 1994;
Schwartz et al., 1994), and promotes apoptosis (Blutt et al., 2000).
It has also been shown to interact with the androgen signalling pathway
in vivo inhibiting angiogenesis (Hsieh and Wu, 1997; Zhao et al., 1999).
Eighty percent of humans’ Vitamin D intake is generated via sunlight on
skin, however, solar radiation is a well-established skin carcinogen,
responsible for more cancers worldwide than any other single agent.
The risk of skin cancer is particularly associated with sun burning and high
sun exposure at an early age (Nyugen and Ho, 2002).
More recently, there have also been concerns raised about the
increasing use of artificial sun beds following the publication of an overview
that analysed twenty studies which showed that the risk of skin cancer jumped
by 75% when people started using tanning beds before age 30 (Cheng, 2009).
Although the risk of skin cancers increases with sun exposure,
particularly burning, paradoxically the risk of cancers relapsing after
initial therapy may be helped by sensible regular sun exposure, as
demonstrated in the following studies.
A case controlled study from
Sweden and Denmark analysed sun exposure habits of patients with
lymphoma (n = 3,700) and controls (n
= 3,200). The risk of lymphoma was significantly lower among people reporting
prior regular sun exposure (Smedby et al., 2005).
The pathologist Berwick noted that subsequent mortality from
melanoma was approximately one-half as high among those with other
signs of sun exposure based on the histological specimen.
Based on this premise, the same author went on to evaluate patients who
had been surgically treated for localised cutaneous melanoma (n
= 528). They were followed for an average of 5-years and levels of sun
exposure were estimated by regular in-person interviews. A multivariable
analysis showed that regular sun exposure was significantly associated with an
inverse risk of death from melanoma (Berwick et al., 2005).
Vitamin D levels were measured in stored blood of women with
early breast cancer (n = 512),
diagnosed between 1989 to 1996. Vitamin
D levels were found to be deficient (< 50 nmol/L) in 37.5% of
patients, insufficient (50 to 72 nmol/L) in 38.5% of patients, and
sufficient (> 72 nmol/L) in 24% of patients. The mean follow-up was
11.6-years; 116 women had distant recurrences, and 106 women died.
Women with deficient vitamin D levels had a significantly increased
risk of distant recurrence compared with those who had
sufficient levels (Goodwin et al., 2009).
Pre-diagnosis levels of 25(OH)D were measured in a cohort of participants
in the Nurses' Health Study (n
= 304) and the Health Professionals Follow-Up Study (HPFS) who were
diagnosed with colorectal cancer from 1991 to 2002.
Higher plasma vitamin D levels were associated with a significant reduction
in overall mortality (Ng et al., 2008)
Vitamin E
Vitamin E in its eight naturally occurring isoform-tocopherols (Wilkinson
and Chodak, 2003) has been linked to a reduction in cancer risk (Chan, 1999).
The Alpha-Tocopherol Beta-Carotene cancer prevention study trial (ATBC),
involving 29,133 male smokers, reported a statistically significant reduction
of prostate cancer incidence and mortality although the primary end point of
lung cancer was higher (Heinonen et al., 1998).
In the Health Professionals Follow-Up Study (HPFS), vitamin E intake
was also associated with decreased risk of prostate cancer in smokers, but not
overall (Chan, Gann, and Giovannucci, 1999).
The serum based Cancer Prevention II (CPII) Nutrition Cohort study
showed an inverse correlation between plasma vitamin E levels and prostate
cancer, again mainly among smokers and mostly the gamma-tocopherol isoform,
which is primarily found in the diet rather than over the counter supplements
(Rodriguez et al., 2004). In a
further trial involving 39,876 patients with diabetes or cardiovascular
disease, alpha-tocopherol demonstrated no reduction in cancer, and the
incidence of heart disease was slightly worse (Lee et al., 2005).
Likewise, in the ATBC study cerebral haemorrhage risk was also higher
in smokers with hypertension who took alpha-tocopherol.
Finally, the National Cancer Institute’s sponsored double-blind
randomised SELECT study showed no benefit of supplementary selenium and
vitamin E over placebo to prevent prostate cancer (Klein,
2009).
Vitamin
B12 and Folic Acid
Ebbing et al. (2009) evaluated the effects of
treatment with B vitamins on cancer outcomes and all-cause
mortality in two randomised placebo controlled trials in patients
with ischemic heart disease (n =
6,837). The Norwegian Vitamin Trial and Western Norway B Vitamin
Intervention Trial randomised men to oral treatment with folic acid (0.8 mg/d)
plus vitamin B12 (0.4 mg/d) and vitamin B6 (40
mg/d) (n = 1,708); folic
acid (0.8 mg/d) plus vitamin B12 (0.4 mg/d) (n = 1,703); vitamin B6 alone (40
mg/d) (n = 1,705); or
placebo (n = 1,721)
between 1998 – 2005. After a
median 39-months of treatment and an additional 38-months of
post-trial observational follow-up, 341 participants (10%) who
received folic acid plus vitamin B12 versus 288 participants (8.4%)
who did not receive such treatment were diagnosed with cancer.
Results were mainly driven by increased lung cancer
incidence in participants who received folic acid plus vitamin B12;
vitamin B6 treatment was not associated with any
significant effects (Ebbing et al., 2009).
A separate study found that those men who took folic acid
supplements were
more than twice as likely to develop prostate cancer, compared with men who
took a placebo. Researchers note that the estimated prostate cancer risk was
9.7% for participants in the folic acid group
and 3.3% for the placebo group. They
also found, however, that prostate cancer incidence
was slightly lower in men who had adequate
amounts of folate in their diet (Figueiredo
et al., 2009).
Essential
Minerals
Dietary trace elements, classified as antioxidants because manganese, zinc
and copper are essential for the production of superoxide dismutase (SOD) and
selenium is essential for glutathione peroxidase (Wilkinson and Chodak, 2003).
Together with catalase these form enzymic defence against carcinogenic
oxygen reduction metabolites (Marklund et al., 1982).
It has been postulated that intensive farming food techniques and food
processing may reduce these trace metals in our diet (Coombs, 2004; Jackson et
al., 2004). There is evidence of
an increased risk of carcinogenesis in the presence of copper, selenium
manganese or zinc deficiencies, particularly under conditions of high
carcinogenic attack where more SOD is needed (Chan, Gann, and Giovannucci,
2005; Sonn, Aronson, and Litwin, 2005; Wilkinson and Chodak, 2003; Levieux,
1991; Merli et al., 1995).
Human prostate cell lines have demonstrated greater growth inhibition with
normal selenium compared to
controls deficient in selenium (Mehta and Moon, 1991).
Two large studies in 1980 and 1990 showed that a low selenium status
was associated with an increased risk of developing cancer (Kok et al., 1987;
Knekt et al., 1990). They also showed that in-patients with selenium
deficiency, the cancer they developed were more likely to be more aggressive
and fatal. The Harvard Health Professional Survey, for example, linked low
selenium status (measured on toenail clippings) with higher rates of Gleason 8
and 9 prostate cancers. Both
Finnish and Taiwanese studies have linked lower blood levels of selenium with
higher rates of lung and hepatocellular carcinoma (HCC). In China, where the
incidence of HCC is high, the inhabitants of one village were supplemented
with sodium selenite whilst another five villages were given simple salt.
After six years, involving over 130,000 people, there was a 35% reduction in
the HCC rate in the selenium-supplemented village, but no change in the others
(Blot et al., 1993).
A double-blind trial evaluated the benefits of dietary selenium. The
primary end point, non-melanoma skin cancer, was not reduced but the incidence
of prostate cancer was significantly reduced (Clark et al., 1998).
The large SELECT study published in 2009 demonstrated that
supplementing selenium and vitamin E did not show any reduction in the risk of
prostate cancer (Klein,
2009).
Calcium
Four
prospective cohort studies relating calcium and prostate cancer have been
published (Sonn, Aronson, and Litwin, 2005).
Two studies with a mean calcium intake of between 1330-1840mg/day
showed no associated risk. Two others, one involving 86,404 men in the CP II
nutrition cohort, with mean intake of >2000mg/day from food and
supplements, showed a significantly higher risk of prostate cancer (Rodriguez
et al., 2004). Five of nine
further questionnaire surveys associated high intake of dairy food with
increased risk of prostate and breast cancer, but in these surveys high dairy
was associated with high fat intake (Sonn, Aronson, and Litwin, 2005).
Excessive dietary calcium reduces vitamin D, which has demonstrated anti-proliferative
benefits that in theory are therefore lost with excess calcium (Campell et
al., 1997).
Carcinogen Avoidance
Dietary or inhaled chemicals such as polycyclic
aromatic hydrocarbons and aromatic amines, found in super-heated processed or
fried foods, are converted to products which can directly or indirectly
oxidise water or oxygen into short lived but highly energetic free radicals.
These cause double or single DNA strand breaks, allowing cancer promoting
genes to escape from the influence of their suppressor gene guardians (Chan et
al., 2005). Numerous environmental
studies have linked carcinogens to cancers and the USA Food and Drug
Association (FDA) regularly publishes lists of foods containing high levels of
acrylamides and other potential carcinogens such as pesticides, toxic
additives, and chemical contaminants (FDA, 2006). Avoiding carcinogens may,
therefore, have a benefit in reducing the risk of developing further cancers
in patients who may be more susceptible from a pre-existing genetic signature
or damage from chemotherapy or radiotherapy.
This theory is supported by data from patients surviving the Hiroshima
and Nagasaki bombings. A
comprehensive medical follow-up of survivors of the atomic bombings by the
Radiation Effects Research Foundation (RERF) showed that those who undertook
regular exercise and had a higher intake of fruit and vegetables had a
significantly lower risk of cancers despite their acquired susceptibility
(Land, 1995).
Other environmental chemicals may have an adverse affect on cancer because
of their oestrogenic properties, either because they have a chemical structure
similar to oestrogen or affect the sex hormone activity in an indirect
pathway. The most common group of chemicals are the polychlorinated biphenyls
(PCB) and organochlorines found
in sources which include pesticides, herbicides, car pollution, fuels, drugs
and polycarbonate plastic baby bottles and food containers. It is difficult to
prove harm in humans but five separate laboratory studies that have
demonstrated that oestrogenic pollutant given in higher quantities to
laboratory mice, induce and promote mammary cancers the same (Kortenkamp,
2008). A further study in 1993 showed that rhesus monkeys developed a
thickened uterus (the first stages to develop cancer) and endometriosis after
being fed food that contained dioxin, a xenoestrogen, over a four-year period
(Rier et al., 1993). A class of
preservatives found in some deodorants and cosmetics are called parabens,
which in the laboratory have also been found to have harmful xenoestrogenic
properties. An initial concern in
humans was raised following a study in 2004 from Reading University, UK, which
demonstrated higher quantities of parabens in the outer part of the breast and
within breast cancer cells themselves. Although a direct link with cancer is
not proven it did encourage many manufacturers to remove parabens from their
products, but in some items they can still be seen on the label. Aluminium
salts are responsible for the anti sweating affect of anti-sweating affect of
anti-perspirants. A study in 2007 from Keel University, UK, created a lot of
media activity when it showed higher quantities of aluminium in the upper
outer area of the breast in those who used antiperspirants regularly.
Aluminium has also been shown to have harmful oestrogenic properties when
tested in the laboratory and consequently comes under the classification of
metaloestrogens. It would be difficult to design a human study to find out if
regular antiperspirant users have a higher risk of breast cancer, but their
presence in breast tissue is concerning particularly as exposure in some women
can be daily for many years.
There is strong evidence that
overweight individuals have a higher risk of cancer and a higher risk of
cancer-related deaths. For example, the Million Women’s study showed a
direct correlation between BMI and endometrial, post-menopausal breast cancer,
kidney, myeloma, pancreatic, ovarian and colorectal cancer (Reeves et al.,
2007).
After a diagnosis of cancer and
following its treatments, associations of obesity and outcome after cancer
treatments have been observed for colorectal cancer (Haydon et al., 2006;
Meyerhardt et al., 2005), but also for breast (Holmes et al., 1999; Holmes et
al., 2005) and prostate (Giovannucci et al., 2006) cancer, with the
improvement in survival being a result of decreased cancer and non-cancer
related weight loss (Amling et al., 2004; Chlebowski, Aiello, and McTiernan, 2002).
The National Surgical Adjuvant Breast
and Bowel Project (NSABP) trial analysed 4,288 patients between 1989-94
and showed that very underweight
(BMI < 19) and obese (BMI > 35) colon cancer patients had worse overall
survival than healthy weight patients. This
was due to greater risk of cancer recurrence as well as non-cancer deaths (Dignam
et al., 2006).
Similar findings were demonstrated in
a retrospective analysis of men with prostate cancer (n = 1,069), treated at
the Cedars-Sinai Medical Centre Los Angeles between 1994-2002; obese men had a
higher risk of early disease recurrence (Gross et al., 2006).
Li C et al. (2009) examined a cohort of 365 women with ER+ve breast cancer who had later
developed a contralateral breast cancer. He compared their lifestyles with 726
matched controls. Obesity (BMI > 30kg/m2), consumption of >7
alcoholic beverages a week, and smoking were all positivity associated with
the risk of a contralateral cancer, with an odds ratio of 1:4.
The
mechanism of risk
of being overweight for breast and endometrial cancer may lie in their higher
oestradiol levels, which have been reported to reduce following weight
reduction programmes (Wu et al., 1999). Diet
may also influence hormone production and metabolism by a direct action and
not via obesity; case-control studies have shown that diets low in fat and
high in fiber are associated with a high excretion of estrogen in the urine
independent of their adiposity (Adlercreutz, Fotsis, and Bannwart, 1986; Rose,
1992).
Leptin
- This is a multifunctional neuro-endocrine hormone generated primarily from
fat cells. There is a direct correlation with the amount of body fat levels
and circulating blood levels of leptin. There is also a correlation between
leptin and serum insulin, IGF-1 and progesterone levels. Leptin has been shown
in several laboratory experiments to promote proliferation, reduce apoptosis
and reduce the ‘stickiness’ of cancer cells encouraging them to spread and
metastasise. Higher leptin levels are associated with higher expression of
Cycloxidase 2 which also, as described below, encourages cancers to grow
faster and to spread.
Progesterone
- Another important hormone affecting overweight women is
progesterone. Compared to women with pre-menopausal ‘normal’ weight, obese
women in particular have reduced serum progesterone. There is a significant
body of evidence demonstrating that progesterone plays a protective role in
cancer progression, particularly in the ovaries. Progesterone increases in
pregnancy, which also adds some protection against breast and ovarian cancer.
In post- menopausal women who are not overweight (BMI < 35kg/m2),
the evidence is less clear. The risk of breast cancer, in one large study from
Physical
Activity
There is no doubt from the published literature that regular exercise,
independent of other risk factors such as obesity and diet, reduces the risk
of cancer. The most convincing
evidence for this comes from the European Prospective Investigation into
Cancer and Nutrition, where 218,169 pre-menopausal and post-menopausal women
from nine European countries were evaluated for a median of 6.4-years.
During this time, 3,423 incidents of invasive breast cancers were
identified. High non-occupational , household and recreational physical
activity were significantly associated with reduced breast cancer risk,
independent of other potential risk factors such as educational status, BMI,
smoking, alcohol use, age at menarche, age at first pregnancy, parity, current
oral contraceptive use, and hormone replacement therapy use (Lahmann, 2007).
Although no conclusive randomised data has been published, the benefit of
physical activity after a diagnosis has been established by a number of large
and convincing cohort studies. Irwin et al. (2008) investigated a cohort of
breast cancer survivors (n = 933) and found that those who consistently
exercised for more than 2.5 hours a week after diagnosis had approximately a
67% lower risk of all deaths compared to women who were not physically active.
Holmes
et al. (2005)
performed a separate evaluation of the women in the of the Nurses’ Health
Study (n = 2,987) and found that
women with breast cancer who were walking > 3 hours a week at an average
pace had lower recurrence rates and better overall survival than those engaged
in less exercise.
Holick
et al. (2008)
performed a prospective observational study of breast cancer survivors (n =
4482) and found that women who were physically active for more than 2.8 hours
a week had a significantly lower risk of dying from breast cancer (35-49%
reduction) compared to those who were less active.
Pierce
et al. (2007)
published similar results but looked at the combination of diet and exercise
among women who had been treated for breast cancer (n = 1,490). Women who ate
five or more servings of fruit and vegetables a day and were physically active
for at least 30-minutes 6-days a week had a higher 10-year survival.
Haydon et al. (2006) highlighted the benefits of
exercise after a diagnosis of colorectal cancer (n = 526).
There was a 31% reduction in cancer deaths for the physically active
compared with the physically inactive across all stages. The benefit was
greatest for stage II and III disease, with a hazard ratio (HR) for CRC-specific
survival of 0.49 (adjusting for age, sex, and stage) in this subgroup.
The CALBG 89803 study demonstrated a similar finding in which patients
with stage III colorectal cancer (n = 816) completed detailed lifestyle
questionnaires during and after adjuvant chemotherapy.
Increased physical activity was associated with improved disease free
survival (DFS) and overall survival (OS).
In practical terms, this equated to a 35% improvement in disease free
survival for individuals in the highest quintile of regular physical activity
compared with the lowest quintile (Meyerhardt et al., 2005).
Friedenreich CM et al 2009 from Alberta conducted a
randomized trial in 320 postmenopausal
women, ages 50 to 74 for one-year. 160 women were randomly assigned to 225
minutes a week of aerobic exercise, the remaining 160 maintained their usual
level of activity. At baseline, six months, and 12 months, the researchers
assessed circulating levels of estrone, estradiol, androstenedione, and
testosterone by radioimmunoassay and sex hormone-binding globulin (SHBG) by an
immunometric assay. At the beginning, most of the women were overweight, with
an average body mass index of about 29.
The intervention consisted of a monitored, structured
program of at least 45 minutes of aerobic exercise five days a week for 12
months at 70% to 80% heart rate reserve. At least three sessions per week were
done in a fitness facility with onsite exercise trainers and the remainder
were home-based. The exercise was recorded on weekly logs and the average
exercise achieved was 3.6 sessions a week, for an average exercise duration of
178.4 minutes a week which corresponded to an average estimated energy
expenditure of 5.7 metabolic equivalent-hours.
At the end of the trial, the researchers found moderate reductions in
weight in the exercsise group. They also found significant reductions in serum
estradiol and free estradiol (with treatment effect ratios of 0.93 and 0.91,
respectively) for the exercisers compared with the controls. After adjusting
for weight lost during the program, the changes in estradiol and free
estradiol remained significant (at P=0.014 and P=0.006,
respectively). There were no significant differences in estrone,
androstenedione, and testosterone levels.
Mechanisms of Benefit: Theories behind the mechanisms of benefit found with
physical activity include alterations in prostaglandin levels/ratios and
positive effects on the immune system (Meyerhardt et al., 2005; Quadrilatero
and Hoffman-Goetz, 2003; Westerlind, 2003).
For colon cancer, the traditional theory is that exercise may help by
increasing the bowel transit time, reducing the time that potentially
carcinogenic substances are in contact with the bowel wall (Knols, 2005),
although more recently this effect has been questioned. More likely, exercise
and diet help control the body's levels of serum lipids and cholesterol; high
levels of these fats have been particularly associated with greater risk of
advanced higher grade disease at presentation (Harvei et al., 1997; Kristal et
al., 2002).
Weight
reduction:
Several studies have demonstrated that lifestyle and exercise interventions
can help achieve a better weight. Adiposity influences the production and
availability of the body’s sex hormones including oestrogen, androgens and
progesterone. In post-menopausal women oestrogen is made in the peripheral
body fat whilst in pre-menopausal women it is produced primarily in the ovary.
This may explain a higher risk of breast and endometrial cancer for overweight
post-menopausal women but not pre-menopausal women. Fortunately, oestrogen
levels have been shown to reduce, following weight reduction programmes.
Oestrodiol levels; Friedenreich CM et al 2009
found significant reductions in serum estradiol and free
estradiol for the exercisers compared with the controls even after adjusting
for weight lost during the program, the changes in estradiol and free
estradiol remained significant (at P=0.014 and P=0.006,
respectively). Dietary fats intake may also have an influence on oestrogen by
a direct effect, and not via exercise or obesity. Animal and case-controlled
studies have shown that diets low in fat and high in fibre are associated with
a high excretion of estrogen in the urine, which lowers blood levels
irrespective of the adiposity (Adlercreutz, Fotsis, and Bannwart, 1986; Rose, 1992).
Insulin-like
growth factors (IGF);
The most compelling evidence lies in the idea that physical activity exerts
its beneficial effect via insulin-like growth factors (IGF) (Giovannucci ,
2001; Kaaks et al., 2000; McTiernan et al., 1998). A number of cohort studies
have shown an increased risk of cancer, particularly colorectal, with higher
levels of insulin-like growth factor 1 (IGF-1) and C-peptide.
An inverse relationship with insulin-like growth factor binding protein
3 (IGFBP-3) levels (Giovannucci et al., 2000; Ma et al., 1999; Ma et al.,
2004; Nomura et al., 2003) has also been shown, although this effect has not
been confirmed in all studies (Palmqvist et al., 2002; Probst-Hensch et al.,
2001). The benefits of lowering IGF-1 may be linked to its central role in
growth regulation processes. The
main stimulus for IGF-1 production comes from growth hormone (Kaaks and
Lukanova, 2002). This stimulatory
effect of growth hormone is modulated by insulin, which increases growth
hormone receptor levels and in turn IGF-1 (Baxter and Turtle., 1978; Suikkari
et al., 1988). Early studies have
shown that after binding to its receptors, which are found on normal colonic
mucosal cells as well as colon cancer cells, IGF-1 can stimulate cell
proliferation, inhibit apoptosis (Yu and Rohan, 2000), and promote
angiogenesis (Freier et al., 1999; Warren et al., 1996).
In the circulation, as over 90% of IGF-1 is bound to IGFBP-3, binding
inhibits the action of IGF-1 by limiting the availability of free hormone.
The most convincing clinical evidence comes from a large cohort study
of 41,528 people aged between 27 and 75 years with colorectal cancer,
recruited between 1990 and 1994, in which they had previously demonstrated a
prognostic benefit of physical activity. This and another large prospective
cohort study from Melbourne Australia both reported statistically lower levels
of IGF-1 and higher IGFBP-3 in those physically active prior to diagnosis and
these collated with disease-specific survival and overall survival (Giles and
English, 2002).
Smoking
Continuing to smoke after a diagnosis of cancer has been shown to increase
risk of further neoplasm’s, increase complications in surgery, radiation and
chemotherapy, impair appetite and nutrition, and reduce survival (Yu et al.,
1997). Of course, a randomised
trial looking at disease-specific survival is not possible, but well conducted
cohort studies are still convincing.
Yu et al. (1997) reported the largest study looking at the influence of
continuing to smoke after cancer. This
study was conducted in Japan, where the incidence of smoking is increasing.
The authors evaluated 25,000 heterogeneous patients who had been treated for
lung, breast, or colorectal cancer. It was reported that the 1.5
year survival of the people who continued to smoke
was 44%, whereas in those who quit it was 55%.
Richardson et al. (1993)
reported a retrospective study of patients with histologically confirmed
small-cell lung cancer (n = 540), evaluating the outcomes of those who stopped
smoking at time of diagnosis compared to those who did not. The relative
risk of a second lung cancer was 11 (CI, 4.4 to 23) in the 70% who
managed to quit smoking, whereas, in the 30% who continued to
smoke, it was 32 (CI, 12 to 69).
Gritz, et al. (1993) and Ostroff et al.,(1995)
demonstrated the same finding in two further retrospective studies evaluating
outcomes following treatment for head and neck cancer. The chance of survival
from their primary disease was double if smoking ceased compared to the 40% if
they continued to smoke.
Li et al. (2009) examined a cohort of 365 women with ER+ve breast cancer who had later
developed a contralateral breast cancer. He compared their lifestyles with 726
matched controls. Smoking, consumption of >7 alcoholic beverages a week and
obesity were all positivity associated with the risk of a contralateral cancer
(odd ratio 1:4).
Mechanisms of Harm: Continuing to smoke exposes the body to high levels of
carcinogens, which can cause further DNA damage to existing cancers, encourage
the cancer to mutate into a more aggressive type, or develop mechanisms to
hide from the body’s immunological defences.
Patients who have already developed one cancer are likely to be more
susceptible to DNA damage from a pre-existing genetic vulnerability, or
acquired damage from chemotherapy or radiotherapy. Avoiding
carcinogens may, therefore, have a benefit in reducing the risk of developing
further cancers in patients who may be more susceptible from a pre-existing
genetic signature or damage from chemotherapy or radiotherapy. There is also
evidence that smoking reduces the effectiveness of some therapeutic agents.
Smoke interferes with hepatic cytochrome P450 CYP1A, which has been shown to
reduce bioavailability of erlotinib (tarceva) by 25% (Hamilton, Wolf, and
Rusk, 2006). It also induces
UDP-glucuronosyl transferase, important for conjugation of bile and conversion
of Irinotecan to its active component SN-38.
Smokers have demonstrated 40% more serum SN-38 than non-smokers, which
although lowering toxicity is also likely to lower effectiveness (van der Bol
et al., 2007).
Alcohol
The link between intakes of alcoholic beverages was most clearly
established by Allen et al. (2009) in the Million Women Study.
Since 1996 this study has been gathering detailed information from 1.28
million women ages 50 to 64 years. Amongst other lifestyle factors, they
examined how much alcohol women reported consuming when they volunteered for
the study and again three years later, examining whether there was any link
with the 68,775 cancers they developed over an average of the next seven
years. There were statistically significant increased risks of cancer in those
who regularly consumed alcohol. Another study by Thun et al. (1997) indicated that
more than one drink a day increased the risk of breast cancer, but up to one
drink was not associated with an increased risk (Thun et al., 1997). A further study from the University of California showed
that men who drank heavily (> 50g of alcohol or four drinks daily) doubled
their risk of high grade prostate cancers compared to other men. There was no difference in the incidence of low
grade cancers, implying that drinkers have a poorer prognosis (Gong et al.,
2009).
Schwartz et al. (2006) evaluated a cohort of survivors following head and
neck cancer, recording alcohol intake for a median follow-up of one year.
There was a significant difference in the rate of relapse, which in these
cases almost entirely led to death. Survival in those who continued to drink
excessively was 6% and in those who gave up or drank in moderation was 27%.
The evidence of alcohol and risk of relapse after breast and other cancers
is less convincing. In fact, one
study from the Catholic University and the National Research Council in Italy
showed that a glass of wine a day may cut the risk of treatment-linked skin
toxicity by two-thirds in women undergoing radiation therapy for breast
cancer. They evaluated the drinking habits of women with breast cancer (n =
348) and found that patients who drank wine on the days they had their
treatment had lower rates of Grade 2, or higher acute toxicity, than those who
did not (13.6% rate of skin toxicity compared to 38.4%). This observation did
beg the question that wine may also reduce the effectiveness of radiotherapy,
but relapse rate was not measured in this study (Mundell, 2009).
Li et al. (2009) examined a cohort of 365 women with ER+ve breast cancer who had later
developed a contralateral breast cancer. He compared their lifestyles with 726
matched controls. Consumption of >7 alcoholic beverages a week, obesity and
smoking were all positivity associated with the risk of a contralateral
cancer.
Mechanisms of Harm: The
underlying factors which increase the risk of cancer are not fully understood,
especially when it is known that some drinks contain antioxidants which in
theory could help fight oxidative stress. One factor is that acetaldehyde is
easily measured in the breath after drinking alcohol and this is a potent
carcinogen. Alcohol intake has also been shown to increase endogenous
oestrogen levels (Onland-Moret et al., 2005). Finally, alcohol is fattening
and increases the risk factors of adiposity described above.
Conclusion
and Recommendations (Improving Cancer Outcomes)
Understanding
the clinical studies which attempt to investigate the interaction between
specific aspects of lifestyle
and cancer is also complicated by the caveat that health-seeking enthusiasts
often follow a range of behaviours from exercise to dietary manipulation,
smoking cessation, reduction in body size, supplements and analgesic intake,
confounding the published data (Chan et al., 2005; Chlebowski et al., 2005;
Sonn, Aronson, and Litwin, 2005). Furthermore, the mechanisms of the benefits
of lifestyle are likely to be multi-factorial and additive (Thomas, Daly, and
Perryman, 2000). Nevertheless,
there is considerable evidence that lifestyle can improve clinical outcomes in
respect to a reduced risk of progression in some men with prostate cancer,
reducing the risk of relapse and improving the chance of survival. Evidence is
strongest following breast, bowel, lung, head and neck cancers but
self-management lifestyle strategies are likely to be person-specific rather
than disease or treatment specific.
Further
research is required, especially in the areas of levels of exercise and
correction of nutritional deficiencies with specific supplements, but in the
meantime, based on the available evidence, the following self-help lifestyle
strategies can be safely recommended:
Diet:
Dietary
supplements should not be
required if individuals are able to eat a varied, balanced diet. This review
found no evidence suggesting that they can improve cancer outcomes and, in
fact, studies involving vitamin A and E have shown increased cancer risks as
well as cardiac and cerebral vascular morbidity. There
is evidence from cohort and prevention studies that individuals with vitamin
or essential deficiencies benefit from specific nutritional supplements.
These, however, are not measured in routine clinical practice but ideally,
future trial designs should include bespoke patient analysis to identify those
individuals with sub-clinical deficiencies.
[2]
Evidence
for Lowering the Risks and Side-Effects during and after Cancer Treatments
Cancer-related
fatigue
The National Comprehensive Cancer
Network (NCCN, 2009) defines cancer-related fatigue (CRF) as a distressing,
persistent, subjective sense of physical, emotional and/or cognitive tiredness
or exhaustion related to cancer or cancer-related treatment that is not
proportional to recent activity and interferes with usual functioning.
Cancer-related fatigue can
have a profound effect on the whole person, physically, emotionally and
mentally and can persist for months or even years following completion of
treatment. It can have a phenomenal impact on a patient’s life, interfering
with daily activities and also may potentially have devastating social and
economic consequences. It can hinder a patient’s chance of remission or even
cure, owing to the effect it can have on the desire to continue with treatment
(Lucia,
Earnest, and Perez, 2003; Wagner and Cella, 2004; Thomas, 2005; Velthuis et al., 2009; NCCN, 2009).
The specific causes of
treatment-related fatigue are not fully understood, but there are several
associated conditions which can aggravate it.
These include anaemia; drugs such as opiates, antihistamines, and
anti-sickness medication; electrolyte imbalance; liver failure; steroid
withdrawal; and, of course, sedatives (Thomas, 2005). Some conditions can also
cause fatigue by disturbing a persons’ sleep pattern, such as anxiety,
depression, nocturia, night sweats and pruritis (itching). The first step to
treating CRF is to correct, if possible, any of these associated conditions.
Sleep hygiene advice is also recommended, but there is little evidence for its
effectiveness. The self-help strategy most extensively investigated for CRF is
exercise and the evidence for its benefit is described below.
This current review identified two records and initiatives in progress,
which were categorised into one type of support for CRF: Exercise (e.g. Home-Based Exercise Programmes – Walking; Resistance Exercises; Aerobics; Seated Exercises;
Supervised Exercise Programmes – Aerobics; Resistance Exercises;
Stretching).
Evidence from Randomised Controlled Trials
There have been two recent
meta-analyses addressing CRF and exercise interventions. The first, published
in 2008, reviewed 28 RCT’s (Cramp and Daniel, 2008) and the second, in 2009,
from the Netherlands, reviewed 18 RCT’s (Velthuis
et al., 2009).
Cramp and Daniel (2008) conducted and published a Cochrane
meta-analysis review, whereby twenty-eight studies were identified for inclusion (n = 2083
participants), with the majority comprising participants with breast cancer (n
= 16 studies; n = 1172 participants). A
pooled meta-analysis of all available data convincingly showed that exercise
was statistically more effective in reducing CRF than the control.
Velthuis et al.
(2009), from
the Netherlands, conducted and published a second
meta-analysis,where eighteen studies were reviewed (n = 1109 participants).
Pooled results of all studies in breast cancer patients (n = 674
patients included in the analysis) showed a significant reduction of CRF in favour of the exercise group.
During prostate cancer treatment, exercise also led to a significant
reduction of CRF compared to the non-exercise intervention groups.
The meta-analysis subdivided the data
into two main exercise strategies: 1) home-based programmes, involves giving
patient’s advice to exercise, unsupervised in their own home; 2) referring
patients to a supervised exercise programme within specific supervised
classes. Many of the interventions in this category include a combination of
aerobic and resistance exercises.
Home-Based Exercise Programmes
Patients included in home-based
exercise studies underwent hormonal therapy (Payne et al., 2008), radiotherapy
only (Drouin, Krause, and Orr, 2005), chemotherapy only (Headley et al., 2004;
Mock et al., 1994), and radiotherapy or chemotherapy (Mock et al., 2005; Payne
et al., 2008). The overall finding was that during breast cancer treatment,
home-based exercise led to a small, non-significant reduction in CRF.
In most studies, the home-based
exercise intervention consisted of walking (Mock et al., 1994; Mock et al.,
2001; Mock et al., 2005; Drouin, Krause, and Orr, 2005; Payne et al., 2008);
in one study, combined with resistance exercises (Crowley, 2003).
Patients walked between 3-6 times for 10-45 minutes per week. The
intensity of exercise varied between: “at
own desired pace” to 70% of maximum heart frequency (heart rate max)
adjusted for age. In the only study in patients with advanced breast cancer,
the home-based exercise programme consisted of seated exercises (Headley et
al., 2004). Home-based exercise
was mostly (in five out of seven studies) offered for the duration of
radiotherapy (6-7 weeks) or chemotherapy (3-6 months) (Mock et al., 1994; Mock
et al., 2001; Mock et al., 2005; Drouin, Krause, and Orr, 2005).
Seventy to 100% of the participants
were reported, in these studies, to have completed the home-based exercises,
indicating high compliance rates. Adverse
effects were rare, with one patient in one study needing to stop the exercise
programme due to over-exercising (shoulder tendonitis) (Drouin, Krause, and
Orr, 2005).
The pooled results of two high quality
studies out of seven studies describing a home-based exercise programme (n =
128 patients included in the analysis), showed a small, non-significant
reduction in CRF (Drouin, Krause, and Orr, 2005).
Data of three high quality studies (n = 84 patients in total) (Mock et
al., 1994; Mock et al., 2001; Crowley, 2003) and two low quality studies (n =
50 patients in total) (Headley et al., 2004; Payne et al., 2008) could
unfortunately not be included in the pooled analysis since data could not be
obtained from the researchers.
Windsor, Nichol, and Potter
(2004) published a study of 65 patients with
prostate cancer receiving radiotherapy. Participants were randomly allocated a
home-based exercise programme or standard supportive care.
The home-based exercise included walking 30-minutes three times a week,
with an intensity of 60%-70% heart rate max, for the duration of radiotherapy.
No adverse events were reported and a non-significant reduction of CRF
was found in the exercise group.
There has been one study in patients
with multiple myeloma (Coleman et al., 2003), which included a home-based
exercise programme during chemotherapy and peripheral blood stem cell
transplantation. The exercise programme consisted of a combination of aerobic
and resistance exercises, three times a week, 20-minutes, for the duration of
the chemotherapy (± 6 months). No
adverse events were reported and a small, non-significant reduction in CRF was
found in the exercise group.
Supervised Exercise Programmes
Five RCTs included a supervised
exercise programme in their design. In
one study, patients were treated with radiotherapy only (Hwang et al., 2008)
and in another with chemotherapy only (Courneya et al., 2007). In the
remaining three studies, patients were treated with a combination of either
radiotherapy only, chemotherapy only or both (Battaglini, 2004; Campbell et
al., 2005; Mutrie et al., 2007; Battaglini
et al., 2008).
Three supervised exercise
interventions consisted of aerobic exercises (Campbell et al., 2005; Courneya
et al., 2007; Mutrie et al., 2007). One
intervention group included aerobic and resistance exercises and a control
group (Courneya et al., 2007). Two
studies combined aerobic exercises with stretching and resistance (Battaglini,
2004; Hwang et al., 2008). The exercise programmes were offered two or three
times a week. Aerobic exercises were performed with an intensity of 40%-80% HR
max adjusted for age for 10-30 minutes. The
resistance exercises were performed with an intensity of 60-70% of one
repetition maximum (2 x 12 repetitions). In
two studies, duration (15-30 minutes) instead of intensity of the resistance
exercises was presented (Battaglini, 2004; Hwang et al., 2008).
The supervised exercise programme was
completed by 79-100% of the participants.
In only one of these four studies, two patients in total needed to stop
the exercise programme due to adverse events, namely light-headedness and
dizziness (Courneya et al., 2007). The
pooled results of studies involving a supervised exercise programme showed a
significant reduction in CRF in favour of the exercise groups.
The three studies in patients with
prostate cancer investigated effectiveness of supervised exercise during
radiotherapy and androgen deprivation therapy (Segal et al., 2003; Monga et
al., 2007; Segal et al., 2009).
In two studies, patients allocated to
the intervention group participated three times a week in a supervised
exercise programme consisting of aerobic exercises with an intensity of,
respectively, 65% of the maximum heart frequency (HR max) adjusted for age and
50%-75% of the VO2peak (15-45 minutes) (Monga et al., 2007; Segal et al.,
2009). In the other supervised
exercise programme, the intervention consisted of resistance exercises for two
or three times a week with an intensity of two sets of 8-12 repetitions
60%-70% of the one repetition maximum (Segal et al., 2003).
Over 80% of the participants were
reported to have completed the supervised exercise programme, however, the
programme did result in one knee injury, chest pain, fainting, and an acute
myocardial infarction.
Pooled results from the two supervised
aerobic studies showed a large, non-significant reduction in CRF in favour of the exercise group (Monga et al., 2007; Segal et al., 2009).
The resistance exercise study showed a small, non-significant reduction
in CRF in favour of the resistance exercise
group (Segal et al., 2003).
Chang et al. (2008) published a study involving patients with acute myelogeous leukemia (n =
22), which included allocation to the intervention group, a three-week
supervised walking programme during chemotherapy.
Participants walked five times a week for 12-minutes, in the hospital
hallway. The supervised exercise
programme was completed by 69% of the participants and no adverse events were
reported. A medium-sized,
non-significant reduction in CRF was found in the exercise group.
Conclusion and Recommendations (CRF)
Cancer-related fatigue is a
significant problem for patients during and after their treatment. It is
common to all cancer types and a wide range of therapies including
post-surgery, radiotherapy, hormone therapies, but above all chemotherapy. It
has a major impact on quality of life and psychological well-being. Several
measures of CRF exist but the two emerging as the most reliable in the
published literature are the EORTC QLQ-C30 or the FACT-F (Minton and Stone,
2009). Fortunately, evidence from 28 RCT and 2 meta-analyses has demonstrated
that intervention with exercise and lifestyle programmes can reduce the
severity of CRF and its effect on QoL. The studies reviewed here also showed
that supervised aerobic exercise programmes were more effective in reducing
CRF during breast cancer treatment than home-based exercise advice.
Adverse events during exercise were extremely low. Adherence was
excellent for a supervised program (70-100%) and fair for a home exercise
advice model (<40%), except for a walking programme (100%) although this
did not demonstrate a significant benefit. Although more research on the
optimal timing and duration of exercise would be useful, these studies are
sufficiently robust to recommend:
Weight Gain and Body
Composition
Weight
gain during and after adjuvant chemotherapy is becoming an ever-increasing
significant concern. Women with breast cancer, for example, report a 45%
incidence of significant weight gain often at a time in their lives that makes
losing it difficult (ref Thomas). For
individuals with bowel cancer the CALBG 8980 trial showed that 35% of patients
post chemotherapy were overweight (BMI 25.0–29.9); and
34% were obese BMI 30.0–34.9) or very obese (BMI >35); (Meyerhardt
et al., 2008). The reasons for this are multifactorial, some patients
concerned about weight loss, perhaps from dated and misleading information
sources, tend to overeat; others, with fatigue and nausea, stop exercising;
and, drugs, including steroids and hormone therapies such as tamoxifen.
Exercise and
Nutritional Counselling Strategies:
Whatever the reasons for weight gain, numerous
reviews and meta analysis of the published literature have demonstrated
significant reductions in obesity {Knols R, 2005 #93; Winningham M, 1989 #210,
Iop et al., 2004, (Kim, Kang, and Park, 2009). These strategies, do not just
improve weight but have significant other benefits on body constitution and
fitness such a lean mass indices, bone mineral density, cardiopulmonary
function, muscle strength and walking distance {MacVicar M, 1989 #211}.
Examples of studies which evaluated the benefits of lifestyle and exercise on
well being are described below:
Kim,
Kang, and Park (2009)
published a meta-analysis of 10 studies involving 588 women who had been
treated for breast cancer, examining the effectiveness of aerobic
exercise interventions on cardiopulmonary function and body
composition, conducted during or after cancer treatments. They concluded that
regular aerobic exercise significantly improved cardiopulmonary
function as assessed by absolute VO2 peak, relative VO2
peak, and 12-minute walk test, as well as improved body composition
as assessed by percentage body fat (although body weight and lean body mass
did not change significantly).
Chlebowski
RT et al, (2005)
published
the results of a RCT where 2,437 postmenopausal women with early breast cancer
were randomised to nutritional and lifestyle counselling, or not, as part of
routine follow-ups. The dietary intervention included eight bi-weekly
individual counselling sessions. Dietary fat intake reduction was
significantly greater in the dietary group. This major study also demonstrated
a survival advantage in women who lost weight and is described again in Part 2
of this review.
Courneya
et al. (2007)
published a multicentre RCT in which women with breast cancer on adjuvant
chemotherapy were randomly assigned to usual care (n = 82),
supervised resistance exercise (n = 82), or supervised aerobic
exercise (n = 78) for the duration of their chemotherapy (median,
17 weeks; 9 to 24 weeks). There was 70% adherence to supervised
exercise. Aerobic exercise was superior to usual care for improving
aerobic fitness and percent body fat, whilst resistance exercise was superior
to usual care for improving muscular strength, lean body mass, and
chemotherapy completion rate.
Schmitz
et al. (2005)
evaluated the safety and effects of twice-weekly weight training among 85
breast cancer survivors in an RCT. Women
were randomised into immediate or delayed treatment groups. The immediate
group trained from months 0 to 12; the delayed treatment group served as a no
exercise parallel comparison group from months 0 to 6 and trained from months
7 to 12. The intervention resulted in significant increases in lean mass, as
well as significant decreases in percentage body fat. Only one participant
experienced a study related injury that prevented continued participation.
Mefferd
et al. (2006)
specifically evaluated overweight or obese breast cancer survivors. Eight five
women were randomly assigned to a once weekly, general exercise and dietary
counselling for 16-week intervention or standard care. The intervention
addressing a reduction in energy intake, as well exercise, with a goal of an
average of one hour a day of moderate to vigorous activity. Seventy six women
(89.4%) completed the intervention. At 16-weeks, significant group differences
were evident in weight, body mass index, percent fat, trunk fat, leg fat, as
well as waist and hip circumference. Levels
of triglycerides and total cholesterol/high density lipoprotein cholesterol
levels were also significantly reduced following the intervention.
Segal
et al. (2009)
conducted a RCT with 121 men with prostate cancer initiating
radiotherapy with or without androgen deprivation therapy. They
were randomly assigned to usual care, resistance exercise and aerobic exercise
for 24 weeks. Median adherence to
prescribed exercise was 85.5%. Compared with usual care, training
improved aerobic fitness, upper- and lower-body strength, and
triglycerides, while preventing an increase in body fat.
Resistance exercise generated longer-term improvements and
additional benefits for strength, triglycerides, and body fat.
There were no reported adverse events in the exercise group.
Conclusion
and Recommendations (Lifestyle, Exercise and Body Constitution)
Supervised exercise programmes with or without
dietary counselling are highly effective in improving body constitution.
What’s more, they are safe and have other major benefits on health,
including improving fitness, walking distance, muscle power, reducing
cholesterol and high density lipoproteins. Compliance to supervised exercise
programmes is high (72-86%). The following strategies are recommended:
Table
2. Summarising Evidence for Exercise and Body Composition
|
Authors |
Design |
Cohort |
Intervention |
Outcome |
|
Kim, Kang, and Park (2009) |
Meta-analysis |
Breast cancer |
Aerobic exercise during or after treatment |
SS better PBF and CPF |
|
Chlebowski et al. (2005) |
RCT |
Breast cancer |
Bi-weekly lifestyle and exercise counselling |
SS better weight reduction and overall suvival |
|
Courneya et al. (2007) |
RCT |
Breast Cancer |
Supervised aerobic and resistance training |
SS better PBF, LBM and strength |
|
Schmitz et al. (2005) |
RCT |
Breast Cancer |
Twice weekly Weight training classes |
SS better PBF |
|
Mefferd et al. (2006) |
RCT |
Overweight breast cancer |
Weekly exercise counselling 16 weeks |
SS better weight, BMI, PBF, triglycerides and total cholesterol |
|
Segal et al. (2009) |
RCT |
Prostate cancer on radiotherapy |
Resistance and aerobic exercise |
Improved strength, body fat, triglycerides |
SS
– Statistically significant; BMI – Body Mass Index, LBM- Lean Body Mass;
PBF- Percentage Body Fat; CPF – Cardiopulmonary function
Psychological
Well-Being
Understandably, being diagnosed with cancer is a stressful
experience and requires a high level of emotional and social readjustment
(Holmes and Rahe, 1967). Whilst
many people adjust well to a cancer diagnosis, prevalence rates of 25-30% for
psychological distress are consistently reported (Deragotis et al., 1983;
Farber, Weinerman, and Kuypers, 1984; Stefanek, Derogatis, and Shaw, 1987;
Zabora, 1998; Zabora, 2001). Indeed,
the first three months of a cancer diagnosis are thought to be the most
distressing, evoking an ‘existential plight’ whereby an individual
desperately seeks to make sense of their current circumstances (Mathieson and
Stam, 1991; O’Connor et al., 1990). Still,
psychological
well-being, such as mood status, depression and anxiety are
under-diagnosed in up to 50% of cases (Knols, 2005). As well as being
distressing for the patient and carers, cohort studies have also suggested
that depressed patients, for example, with lung and breast cancer have reduced
survival compared to those who are psychologically healthy (Kadan-Lottick,
2005). A
number of observational studies among patients receiving therapies ranging
from chemotherapy, radiotherapy and hormone therapies have demonstrated
reduced levels of depression, anxiety and improved quality of life (Mock,
1997; Mock, 2001). Continuing exercise into the follow-up period has also been
show in women with breast cancer, who have demonstrated improved mood, happiness,
self-esteem, and energy (Courneya, 2003; McKenzie, 2003; Pinto, 2003).
Examples of studies
evaluating the benefits of lifestyle on psychological well being are
summarised below:
Hospital-Based Exercise Interventions after High Dose
Chemotherapy
Dimeo
et al. (1999)
published a small RCT involving 59 cancer patients (breast, lung,
non-Hodgkin’s lymphoma) receiving high dose chemotherapy. They were
randomised to an aerobic training group (n = 27) or control group (n = 32).
The aerobic training group took part in an exercise programme during
hospitalisation, comprising ‘cycling’ on an ergometer (allowing the
simulation of the cycling motion without leaving the bed) following an
interval training pattern: they cycled for one-minute with intensity
sufficient to reach a heart rate equivalent of at least 50% of the cardiac
reserve. This was repeated fifteen
times with pauses of one-minute between; therefore, training was performed for
a total of 30-minutes per day. During
training sessions, patients were supervised by study personnel. By the time of
hospital discharge, the training group reported significant improvements in
psychological distress, particularly in regard to obsessive compulsive traits,
fear, interpersonal sensitivity, and phobic anxiety.
Supervised
Aerobic and Resistance Exercise during Chemotherapy
Courneya et al. (2007) evaluated 242 women in a
prospective, three-armed, randomised controlled trial who
had stage I to IIIA breast cancer and were beginning first-line adjuvant
chemotherapy. Participants were
stratified by chemotherapy protocol (taxane based v non–taxane
based) and randomly assigned to supervised aerobic exercise (AET;
n = 82), supervised resistance exercise (RET; n = 82), or usual care (UC; n =
78) in a 1:1:1 ratio. Participants exercised for the duration of their
chemotherapy (median = 17-weeks; 9-24 weeks), beginning
1-2 weeks after starting chemotherapy and ending 3-weeks after
chemotherapy. Warm-up and cool-down periods were 5-minutes of
light aerobic activity and stretching. The AET group was asked
to exercise three times per week on a cycle ergometer,
treadmill, or elliptical beginning at 60% of their maximal
oxygen consumption, for weeks 1-6 and progressing to 70% during weeks 7-12 and
80% beyond week 12. Exercise
duration began at 15-minutes for weeks 1-3 and increased by 5-minutes every
3-weeks until the duration reached 45-minutes at week 18. The
RET group were asked to exercise three times per week,
performing two sets of 8-12 repetitions of nine different
exercises at 60% to 70% of their estimated one-repetition
maximum. The exercises were leg extension, leg curl,
leg press, calf raises, chest press, seated row, triceps extension,
bicep curls, and modified curl-ups. Resistance was increased
by 10% when participants completed more than twelve repetitions. The
UC group was asked not to initiate an exercise program and was
offered a 1-month exercise program after post-intervention assessments.
They reported
that both aerobic and resistance exercise were superior to usual
care for improving self-esteem and psychological functioning as measured by
the Rosenberg Self-Esteem Scale; the Center for
Epidemiological Studies Depression Scale; and, the Spielberger State
Anxiety Inventory. They did not find that the exercise had an impact on QoL as
measured by cancer-specific QoL (FACT-Anemia).
Self-Reported
Exercise
Pinto and Trunzo (2004) report on a non-randomised cross-sectional study among 79 women treated
for early-stage breast cancer in the past 5-years.
The regular exercisers, who self-reported exercising vigorously three
or more times a week for a duration of 20-minutes each time or moderately five
or more times per week for a duration of 30-minutes each time, had
significantly more positive attitudes toward their physical condition and
expressed greater sexual attractiveness. They
were also significantly less depressed and reported less total mood
disturbance measured by the Body Esteem Scale and the Psychological outcomes
Mood States (POMS).
Yoga
Rao et al.
(2008)
report a single-centre RCT involving 68 women with stage II and III breast
cancer patients, to evaluate the
effects of a yoga intervention versus supportive therapy and exercise
rehabilitation on psychological well-being.
The intervention group received an ‘integrated yoga program’ and the
control group received ‘supportive counselling and exercise
rehabilitation.’ These sessions were administered by an instructor at the
subjects' bedside prior to surgery and during their post-operative
recuperation in the hospital. Following their discharge, subjects were asked
to practise at home for the next four-weeks. Subjects were also provided
audiotapes of an instructor's voice to help them practise at home so that a
familiar voice could be heard on the cassette. Their practice was monitored
daily by their instructor through telephone calls once a week. Subjects were
encouraged to maintain a daily log listing the yoga practices done, use of
audio-visual aids for practice, duration of practice, and experience of
distressing symptoms.
They reported a significant decrease in anxiety states, measured by the proxy of anxiety index (STAI), and improvements in QoL, assessed
using the Functional Living Index of Cancer (FLIC)
following surgery in the yoga group as compared to controls, but not in terms
of depression. There was also a significant decrease in symptom severity in
the yoga group as compared to the controls following surgery.
Lengacher
et al. (2009)
published a two-armed RCT with a total of 84
women previously diagnosed with Stage 0, I, II, or III breast cancer who
underwent surgery and received adjuvant radiation and/or chemotherapy within
the prior 18-months. They were randomised to a 6-week mindfulness-based stress
reduction (MBSR), psychologist led intervention program of meditation and yoga
or control group. The results of this
study demonstrated that participants in the 6-week mindfulness-based stress
reduction program reported significantly lower levels of depression, anxiety,
and fear over recurrence than did usual care as measured by the Concerns about
Recurrence Scale; State-Trait Anxiety Inventory; CES-D; Life Orientation Test;
Perceived Stress Scale
Vadiraja et al.
(2009) provide further support for the
psychological benefits of yoga in an RCT involving 72 women recently diagnosed
with stage II and III breast cancer who had undergone surgery as their primary
treatment and were receiving adjuvant radiotherapy. The intervention yoga
program comprised a combination of a set of asanas (postures done
with awareness), breathing exercises, meditation and yogic relaxation
based on principles of stimulation and relaxation. Participants
were asked to attend a minimum of at least three in-person sessions per week
for 6-weeks during their adjuvant radiotherapy treatment in the hospital, with
self-practice as homework on the remaining days. Both intervention and control
groups were offered supportive education and counselling by a trained social
worker during radiotherapy and for 6 weeks after. The yoga group
showed significant improvement in positive affect, decrease in negative
affect, and improvement in emotional function as measured by the QoL scale
EORTC QLQ-C30). There was
also a significant positive correlation between positive affect and physical
function (QoL domain).
Lifestyle
and Nutritional Counselling (RCTs)
Scheier et al. (2007) evaluated the effects of
lifestyle and teaching coping strategies in 252 women with early-stage (0-II) breast cancer
within 2-months of having completed active non-hormonal adjuvant
therapy. They were randomly assigned to standard medical care or education and
nutritional counselling. The
education and nutrition participants received a series of four two-hour
group sessions that met once a month for four consecutive
months. They received information about their disease and
treatment and were provided with a set of relevant coping
skills, together with information on how to adopt and adhere to a low-fat,
high-fruit and vegetable diet. They
reported a significant impact, by the intervention, on the level of depressive
symptoms, mental and physical health functioning (SF-36) and
personality measures of dispositional optimism Life Orientation (Fritz
and Helgeson Scale). The level of benefit was influenced by co-morbidities and
social support measured by the Unsupportive
Social Interactions Inventory.
Those with negative social factors or co-morbidities had the greatest
benefit.
Conclusion
and Recommendations (Psychological Well-Being)
The benefits of physical activity, yoga,
meditation and a healthy diet on psychological outcomes have been demonstrated
in cancer survivors. The benefits apply to patients both undergoing active
acute treatments including surgery, chemotherapy and radiotherapy as well as
those in the “survivorship” period. The
psychological benefits ranged from improved mood, affect, self-esteem to lower
fear of recurrence, depression, and pessimism. Both aerobic and resistance
exercises have demonstrated benefits in psychological outcomes
with the evidence suggesting that survivors who exercise regularly for the
long-term had the most benefit. Evidence from these studies indicates that vigorous exercise three or more
times a week for a duration of 20-minutes each time or moderately five or more
times per week for a duration of 30-minutes each time is sufficient for
improvements in psychological well-being (Dimeo et al., 1999; Pinto and Trunzo,
2004).
More gentle exercises, such as yoga, have also been found to be effective in
terms of stress reduction (Rao et al., 2008) and improving mood (Vadiraja et
al., 2009), with both studies introducing supervised yoga sessions during
treatment as well as providing preparation for home-based yoga post-treatment.
This again highlights the importance of exercise maintenance, with
initial supervised exercise being a potentially useful first step towards
self-initiated exercise.
Table 3: Summary of
Evidence for Lifestyle and Psychological Well-Being
|
Authors |
Design |
Cohort |
Intervention |
Outcome |
|
Dimeo et al. (1999) |
RCT (n=59) |
Breast Cancer; Lung Cancer; Non-Hodgkin’s
Lymphoma |
30mins aerobic exercise during hospitalisation for
high-dose chemotherapy |
SS improvements in psychological distress. |
|
Pinto and Trunzo (2004) |
Cohort (n=79) |
Breast Cancer |
Self-reported regular exercisers |
SS more positive attitudes and sexual
attractiveness. |
|
Courneya et al. (2007) |
RCT |
Breast Cancer |
Supervised aerobic and resistance training |
SS improvements in self-esteem and psychological
functioning. |
|
Scheier et al. (2007) |
RCT (n=252) |
Breast Cancer |
Education and nutritional counselling |
SS impact on levels of depressive symptoms, mental
and physical health, and optimism. |
|
Rao et al. (2008) |
RCT |
Breast Cancer |
Yoga pre-surgery and during post-operative
recuperation |
SS decrease in anxiety and symptom severity. SS
improvements in QoL. |
|
Lengacher et al. (2009) |
RCT |
Breast Cancer |
6-week mindfulness-based stress reduction (MBSR) |
SS lower levels of depression, anxiety, and fear
over recurrence. |
|
Vadiraja et al. (2009) |
RCT (n=72) |
Breast Cancer |
6-week yoga and relaxation during adjuvant
radiotherapy |
SS improvement in emotional function and positive
affect. SS decrease in negative affect. |
Quality
of Life
The advancements in diagnosis and
treatment that have contributed to the rise in survivorship are a magnificent
feat for medical science. However,
it is important to recognise that this has also resulted in an increase in the
number of people living with the physical and psychological consequences of
cancer and its treatment. Quality
of life outcomes are thus becoming just as important as ‘hard’ outcomes
such as mortality (Rosenbaum, Fobair and Spiegel, 2006), An increase in
evidence showing QoL to be more predictive of cancer survival than measures of
performance status (Eton et al., 2003; Wenzel et al., 2005). Several factors
effect Qol, including the physical and psychological disabilities caused by
the cancer and its treatments as well as social depravation, family, cultural
and financial support but a good QoL questionnaire should be able to encompass
most of them to give a measurable score which can be statistically compared in
clinical trials (Cella et al., 2009). This review addresses interventions
which have been evaluated for their influence on QoL.
In the main the published literature emphasises exercise including, aerobic, resistance, dance
and Chinese movement either on their own or combined with nutrition counselling or Cognitive Behaviour Training.
Self-Reported Physical Activity
Lynch et al. (2008) examined physical activity and QoL data collected as
part of the Colorectal Cancer and Quality of Life Study. Telephone
interviews were conducted at approximately 6, 12, and 24 months
after diagnosis 1,966
patients with colorectal cancer.
They reported that participants achieving at least
150-minutes of physical activity per week had an 18% higher QoL
score than those who reported no physical activity measured by the QoL
(FACT-C).
Supervised Aerobic and
Resistance Training
Courneya et al. (2003) evaluated QoL outcomes in
relation to exercise
in a RCT of breast cancer survivors who
had completed surgery, radiotherapy or
chemotherapy. Participants trained three times per week for 15-weeks on
recumbent or upright cycle ergometers. Exercise duration began at 15-minutes
for weeks 1-3, and then systematically increased by
five-minutes every 3-weeks to 35-minutes for weeks 13-15. The exercise group completed 98.4% (44.3 of 45) of the prescribed exercise
sessions, demonstrating high adherence rates.
Overall
QoL increased by 9.1 points in the exercise group compared with 0.3
points in the control group. Change
in peak oxygen consumption correlated with change in overall QoL,
demonstrating a relationship between exercise and increases in QoL.
Daley et al. (2007)
conducted an RCT which provided further support for aerobics exercise and QoL in
women who were not regularly active and who had been treated
for localised breast cancer 12-36 months previously.
The women were randomised to one of three groups: exercise therapy –
aerobics (n = 34); exercise-placebo – body conditioning (n = 36); or, usual
care (n = 38). The primary outcome
was differences in QoL at the 8-week follow-up (FACT-G). In
the exercise therapy group, 50-minute one-to-one sessions took place
with an exercise specialist three times per week for 8-weeks.
Adherence to the interventions was good; 77% of the exercise therapy
and 88.9% of the exercise-placebo groups, respectively, attended
70% (at least 17 of 24 sessions) or more of the sessions.
The results demonstrated a significant mean difference of
9.8 units in QoL scores, favouring aerobic exercise therapy at 8-weeks
compared to usual care.
Segal
et al. (2003) reported an RCT comparing supervised resistance
exercise versus control in 135 men with prostate
cancer who were scheduled to receive androgen deprivation
therapy for at least 3-months. The primary outcome was QoL
measured by a prostate cancer–specific health-related QoL questionnaire
(FACT-P). Secondary outcomes were muscular fitness and body
composition measured by anthropometric data and scored
questionnaire responses. Men in the intervention group met with a certified
fitness consultant within 7-days of the pre-assessment. The
fitness consultant provided patients with the results of their
exercise assessment and introduced the personalised resistance
exercise program. Each participant was led through a
standardised series of warm-up and cool-down exercises to be
performed at each exercise session. Resistance exercise
consisted of nine strength-training exercises carried out
under supervision three times per week, at 60% to 70% of
one-repetition maximum (1-RM; the maximum amount of weight
that can be lifted once), estimated from the standard load
test. Two sets of 8-12 repetitions
of the following nine exercises were performed: leg extension,
calf raises, leg curl, chest press, latissimus pull down,
overhead press, triceps extension, biceps curls, and modified
curl-ups. Sixty percent of the participant’s 1-RM was used
as the starting resistance. Patients were instructed to increase
the resistance by 5lb when they were able to complete more
than twelve repetitions. Attendance at the prescribed resistance
exercise sessions averaged 79% (28 of 36 sessions). During the
intervention period, eight men (9.8%) dropped out in the
intervention group compared with twelve men (16.4%) in the control
group.
There
was a significant improvement in QoL outcomes in the intervention group and a
significant decline in the control group.
Resistance exercise improved QoL regardless of whether men
were treated with curative or palliative intent, or
whether androgen deprivation therapy had been received for less
than one-year or
1 year. The
authors commented that another possible explanation for the difference in QoL
outcomes might be that the men in the intervention group were also receiving
structured attention three times per week, whilst the control group were not.
Milne et al. (2007) reported a RCT with women who had
stage I–II breast cancer, evaluating the effects of a 12-week supervised aerobic
and resistance exercise program. They were within
24-months of their cancer diagnosis. Participants were asked to attend the
rehabilitation clinic three times a week for 12-weeks any time during clinic
hours. The sessions, three times a week, were supervised by two exercise
physiologists who ensured every participant received one-on-one contact during
each session. The program included an aerobic component that utilised the
cycle and rowing ergometers, the mini-trampoline, and the step-up blocks. The
cardiovascular component of the program was conducted for 20-minutes and ended
with a five-minute cool down. The resistance training component consisted of
twelve different exercises (chest press, chest extension, biceps curls,
triceps extension, leg extension, leg curls, hip abduction and adduction, back
extension, abdominal crunches, standing fly’s and leg press). For each
exercise, participants performed two sets of 10–15 repetitions of
lightweights and progressed to a heavier weight once the current weight and
repetitions could be achieved easily and with good form. Finally, five-minutes
of stretching were performed at the beginning and end of each session in order
to increase flexibility. The average attendance was 60.4%. The intervention
demonstrated a significant increase in overall QoL from baseline to week six,
12, 18 and 24 weeks. Benefits were demonstrated across several subscales of
the FACT-B questionnaire including physical well-being, emotional well-being,
functional well-being and breast cancer concerns all demonstrated the same
pattern of results.
Cadmus et al. (2009) report on two RCTs: The Increasing or Maintaining
Physical Activity during Cancer Treatment (IMPACT) study and the Yale Exercise
and Survivorship (YES) study. Both
studies examine the impact of a 6-month moderate to vigorous sports and
recreational physical activity versus usual care on QoL among breast cancer
survivors (n = 45 and n = 67, respectively).
The IMPACT study tested a home-based approach among newly diagnosed
survivors, while the YES study examined a combined supervised – and
hone-based intervention for post-treatment survivors.
Both studies are reported together in order to compare the effects of
exercise at two different points in survivorship.
Data collection for both studies involved a screening phone call,
baseline interview and clinic visit, and 6-month follow-up.
QoL was assessed using the FACT-B and SF-36.
Both exercise interventions were based on the
national recommendation of 30-minutes of moderate to vigorous physical
activity five days per week. Participants
chose from a variety of sports and recreational activities, with most women
performing walking as their main activity.
The IMPACT home-based exercise programme was based on the theory of
planned behaviour and transtheoretical model, and was thus designed to promote
self-efficacy and help participants overcome common barriers to exercise.
At the beginning of the programme, each participant received an
educational book, a binder containing specialised weekly informational
handouts, and a Polar heart rate monitor (used to maintain activity at 60-80%
of predicted maximal heart rate). Participants
recorded each session in a 7-Day Physical Activity Log and returned these logs
once every month. Each participant
was taught exercise techniques and principles during weekly phone-based
meetings with a staff member, calls lasting approximately 20-minutes and
including discussion of the previous week and goal-setting for the next week.
The YES intervention comprised a supervised training
programme at a local health club, where participants exercised during
designated session three days a week. They
also exercised an additional two days per week at the health club or on their
own.
Exercise was not associated with QoL
benefits in the full sample of either study; however, exercise was associated
with significantly improved social functioning among post-treatment survivors
who reported low social functioning at baseline (Cadmus et al., 2009).
Dance
and Movement
Sandel
et al. (2005) report on a
cross-over RCT testing the outcomes of a 12-week dance and movement
exercise programme in 38 women within 5-years of treatment for breast
cancer. The study included a
waiting list control (n = 19) and crossover at 13-weeks. Women attended two
supervised dance sessions for six weeks and one session per week for an
additional 6-weeks, for a total of eighteen sessions. All outcome measures
were obtained at baseline, 13-weeks, and 26-weeks, and included the FACT-B as
the primary outcome as well as the SF-36 as a secondary measure of general QoL
and the Body Image Scale. At week 14, the waiting list group crossed over and
performed the movement program during weeks 14-25, whereas the intervention
group continued their usual activities.
The classes
followed a standardised regime: Warm-up (10-15 minutes) - Every session began
with breathing and stretching designed to improve lymphatic drainage. This
included deep breathing, head and neck stretches, shoulder rotations, torso
contractions, side-to-side arm extensions, body torso lengthening, and large
arm circles. This was usually done sitting in a circle, to percussion music
orchestrated for these movements. Bilateral stretching exercises in a standing
position followed, using a chair for support. During the first few weeks,
lower body movements alternated with upper body movements; Core Exercises -
Upper extremity movements of the shoulder, elbow, and wrist were performed
bilaterally to music, with four or fewer repetitions per side. Imagery was
used to encourage a progressive increase in the ROM in shoulder abduction,
forward and backward flexion, and adduction (e.g., “reaching for the
stars,” “lifting a tray of fruit”). Lower body movements, such as
side-to-side hip swings, walking around with various attitudes, and balance
exercises with chairs, were inserted to provide rest from upper body exertion
and to increase energy flow. Exercises using resistance bands were introduced
in the fifth week; Dance Movements (25-30 minutes) - The dance components were
designed to address, in a subtle way, the existential challenges that most
women report following the diagnosis and treatment of breast cancer: body
image, sexuality, sense of control, meaning in life, grief, and loss.
Movements were simple and designed for women with no dance experience, and who
may have poor balance or no confidence. Initially, four simple movements were
taught to music and repeated several times as a “routine.” As the women
learned a repertoire of familiar dance moves (by the fifth week), they were
able to follow the instructor’s lead in a more spontaneous flowing dance.
The dances used a variety of musical traditions including Celtic, American,
Jazz, Afro-Cuban, Reggae, Middle-Eastern, and Cajun. Rhythmic patterns based
on multiples of four beats were most adaptable to the tempo of the movements;
a waltz rhythm in multiples of three beats was also successful. No fast
movements were performed although fast music was used. A large, tubular
stretch band made of blue jersey was introduced into the group dance to
provide an external focus and decrease anxiety (i.e., something to hang onto).
As each cohort progressed, they became less reliant on such props and more
comfortable with moving their bodies. There was also a 10-minute ‘wrap-up’
at the end of each session with a seated ritual using gentle stretching,
meditative movements, and quiet music. Finger rolls and extensions were
performed. The final activity was focused breathing with soothing music,
mirroring the beginning of the session. As the music ended, the leader asked
the group how they were feeling and whether there were any questions, allowing
for a 10-30 minutes exchange of information.
A total of 35
(92%) women completed the regimen. Reasons for dropping out included fatigue,
other commitments, and one participant reported shoulder discomfort. No falls
or acute injuries occurred during the dance sessions.
Breast cancer–specific QoL (FACT-B) improved significantly in the
intervention group compared to the waiting list group at 13-weeks, which
remained unchanged.
Chinese Exercises
Mustian, Palesh, and Flecksteiner
(2008) reported a pilot RCT comparing QoL and functional capacity in 21
breast cancer survivors provided with Tai Chi Chuan (TCC; a moderate intensity
Chinese exercise) versus psychosocial support. The exercise intervention
lasted for 12-weeks (60-minutes three times a week).
The TCC group demonstrated significant improvements in functional
capacity, including aerobic capacity, muscular strength, and flexibility, as
well as QoL; the psychosocial support therapy group showed significant
improvements only in flexibility, with declines in aerobic capacity, muscular
strength, and QoL.
Oh et al. (2009) reported a RCT examining the QoL outcomes of
Medical Qigong (MQ), a mind–body practice that uses physical activity and
meditation to harmonise the body, mind and spirit. 162 patients with
a confirmed diagnosis of malignancy of any stage and an expected survival
length of >12-months were randomised to control or to 10-weeks with two
supervised 90-minute sessions per week. Each session consisted of 15-minutes
discussion of health issues, 30-minutes gentle stretching and body movement in
standing postures, 15-minutes movement in seated posture, 30-minutes
meditation including breathing exercises and visualisation. Drop-out
was relatively high (although equivalent between the groups) - 32% in the
intervention arm and 35% in the control.
At 10-week follow-up, participants in the
MQ group reported larger improvements in QoL (FACT-G),
than those in the usual care group.
QoL sub-domain analyses also showed that changes in scores were
significantly larger for all sub-domains of QoL (physical, functional,
emotional, and social well-being) in the intervention compared with the
control group.
Exercise
combined with Nutritional Counselling
Mosher
et al. (2009) reported at a prospective cohort study
examining the diet and exercise patterns of
753 breast,
prostate, and colorectal cancer survivors who were at least
5-years post-diagnosis, seeking to identify any relationships with QoL
outcomes. Survivors underwent two
45-60 minute telephone surveys administered by the Diet Assessment Center. The
length of time between interviews ranged from 2-days to 3-weeks. Other
measures completed before the intervention include: physical
activity (The Community Healthy Activities Models Program);
dietary intake (assessed from two unannounced, 24-hour recalls
performed by trained interviewers before diet quality was assessed via the
Healthy Eating Index 05 (HEI05); BMI and,
QoL (SF-36).
The data
demonstrated that greater weekly minutes of exercise were associated with
better physical QoL, including less pain and better health perceptions,
physical functioning, and vitality. More exercise was also correlated with
better social functioning. Diet quality had a positive association with a
range of physical QoL outcomes in analyses that were adjusted for age, level
of education, and co-morbidities. Greater BMI was associated with worse
physical QoL, including greater pain and role limitations because of physical
problems and worse health perceptions, physical functioning, and vitality.
These associations remained significant when adjusting for age, ethnicity,
level of education, cancer-type, and co-morbidities.
However, a limitation to this study is the questionable reliability of
self-report data.
Exercise combined with Cognitive Behavioural Training
Korstjens et al. (2008)
reported a RCT comparing physical training (PT) with combined physical and
cognitive behavioural training (PT+CBT) and also with controls on a waiting
list. A mixed sample of 209 cancer
survivors had completed curative cancer treatment at least 3-months
previously. But were judged by a medical specialist to have at least three of
the following criteria: physical complaints, reduced physical capacity,
psychological problems, increased fatigue, sleep disturbances, and problems in
coping with reduced physical and psychosocial functioning due to cancer.
Each exercise session consisted of
individual aerobic bicycle training (0.5 hour), based on baseline graded
exercise testing, muscle strength training (0.5 hour), and group sports and
games (1-hour). Sports and games, such as badminton, soccer, swimming, and
balancing games, were aimed at promoting enjoyment in sports and improving
self-efficacy to incorporate sporting activities into daily life and to adopt
a physically active lifestyle. Additionally, patients received information on
exercise physiology, illness perceptions, and self-management to support them
in regulating their PT. Participants learned to use by themselves heart rate
sport testers, the Borg Scale for dyspnoea and fatigue, and training logs to
monitor and evaluate their performance; they received feedback, information,
and support from their therapists in regulating their performance. During the
first 4-weeks, participants followed a tailor-made basic training program
based on individual baseline testing. Then, in cooperation with the
therapists, participants determined their personal goals for training from
week five onward. They could choose one of four modules: improvement of
physical condition; improvement of muscular strength; coping with fatigue; or,
handling limitations.
CBT included interactive psycho-education
and structured self-management skills training. This training was formatted in
line with a cognitive behavioural problem-solving therapy protocol for
individual cancer patients and a group problem-solving protocol successfully
applied in patients with non-specific low back pain.
CBT aimed to enable participants to effectively solve their personal
problems associated with cancer. They learned to apply self-management skills
in striving for personal goals (e.g., in work, household, hobbies, physical
activity, family relationships, and social contacts). Generalisation to daily
life during and after rehabilitation was promoted by practicing activities
during sessions and by homework assignments (maximum of 0.5 hour weekly).
Every session was structured: 1) summarising the previous week’s session and
exchanging daily life experiences; 2) discussing home assignments; 3)
introducing new topics or self-management skills; 4) practicing
self-management skills; 5) introducing the next homework assignments; and 6)
relaxation exercises. Participants used a workbook containing a summary of the
training, self-management worksheets and assignments as well as information on
additional topics relevant to cancer patients. The first 3-weeks focused
primarily on exchanging participants’ experiences with cancer,
psycho-education about stress, relaxation, fatigue, exercise physiology,
illness perceptions, and promoting optimism and self-efficacy for
self-management. From week four onward, participants were primarily trained in
applying self-management skills to realize personal goals by practicing the
following steps in the circular problem-solving process: 1) problem
orientation; 2) problem definition and formulation, and goal setting; 3)
generation of alternative solutions; 4) decision-making; and 5) solution
implementation and verification.
Compared
with no intervention, participants in both rehabilitation groups
showed significant and clinically relevant improvements in role
limitations due to physical problems, and in physical
functioning, vitality, health change and QoL (SF-36), measured at
baseline 3 and 6 months. Adding
cognitive-behavioural training to group-based self-management
physical training did not have additional beneficial effects on
cancer survivors’
Conclusion and
Recommendations (Lifestyle, Exercise and QoL)
There is convincing evidence that exercise and lifestyle interventions
can improve the QoL of cancer survivors. This benefit has been proven through
well conducted randomised trials addressing interventions during active
treatments and in the long-term survivorship stage.
Lifestyle interventions appear to help people with a wide range of
cancer types who have received treatments ranging from surgery, chemotherapy,
radiotherapy or hormonal therapies, although no trials have yet been published
specifically addressing the newer biological therapies. Even when not directly associated with overall QoL,
exercise has been found to significantly improve social functioning among
post-treatment survivors (Cadmus et al., 2009).
The benefits of physical activity on holistic
QoL appear to be present under a number of conditions, be the physical
activity supervised or home-based (Cadmus et al., 2009), individualised or
group-based (Korstjens et al., 2008). A
vast array of different types of exercise techniques have been tested in the
studies evaluated in this review, highlighting the potential for survivors to
choose activities according to preference. Considering the evidence for
lifestyle and QoL, the following recommendations would likely benefit
patients:
Table
4: Summary of Evidence for Exercise and QoL
|
Authors |
Design |
Cohort |
Intervention |
Outcome |
|
Courneya
et al. (2003) |
RCT |
Colorectal
Cancer |
15-weeks
supervised aerobic and resistance training |
Increased
QoL. |
|
Segal
et al. (2003) |
RCT
(n=135) |
Prostate
Cancer |
Supervised
resistance exercise |
SS
improvement in QoL. |
|
Sandel
et al. (2005) |
RCT
(n=38) |
Breast
Cancer |
12-weeks
dance and movement programme |
SS
improvement in QoL. |
|
Daley
et al. (2007) |
RCT
(n=117) |
Breast
Cancer |
8-weeks,
50mins supervised aerobic and resistance training |
SS
improvement in QoL. |
|
Milne
et al. (2007) |
RCT
(n=60) |
Breast
Cancer |
12-weeks
supervised aerobic and resistance training |
SS
increase in QoL. |
|
Korstjens
et al. (2008) |
RCT
(n=209) |
All
Cancers |
Exercise
combined with CBT |
SS
better physical functioning, vitality, and QoL.
|
|
Lynch
et al. (2008) |
Cohort
Study (n=1,966) |
Colorectal
Cancer |
Self-reported
physical activity of at least 150-minutes per week |
Higher
QoL. |
|
Mustian,
Palesh, and Flecksteiner (2008) |
RCT
(n=21) |
Breast
Cancer |
12-weeks,
60mins three times per weeks Tai Chi Chaun |
SS
improvements in functional capacity, muscular strength, flexibility, and
QoL. |
|
Cadmus
et al. (2009) |
Two
RCTs: IMPACT (n=45); YES (n=67) |
Breast
Cancer |
6-months,
30mins per day sports and
recreational physical activity |
Not
associated with QoL benefits. SS improvement in social functioning. |
|
Mosher
et al. (2009) |
Prospective
Cohort Study (n=753) |
Breast
Cancer; Prostate Cancer; Colorectal Cancer |
Self-reported
diet and physical activity |
Exercise
SS associated with better QoL. > BMI with worse QoL. |
|
Oh
et al. (2009) |
RCT
(n=162) |
Range
of cancers; mainly Breast and Colorectal. |
10-weeks
Medical Qigong |
SS
larger improvements in QoL. |
|
Vadiraja
et al. (2009) |
RCT
(n=72) |
Breast
Cancer |
6-week
yoga and relaxation during adjuvant Rxt |
SS
improvement in emotional function and positive affect. |
Lymphoedema
The
presence of cancer in the lymph nodes of the axilla is the most important
prognostic factor in breast cancer, and thus the removal and evaluation of
these lymph nodes are integral components of breast cancer management (Morrell
et al., 2005). However, removal of
the lymph nodes can result in a number of side-effects, including lymphoedema
(Swenson et al., 2001). The more
lymph nodes that are removed, the higher the risk of developing the condition,
which is estimated to affect about 30% of women after breast cancer treatment
(Deo et al., 2004; Williams et al., 2005).
It manifests usually as a swelling to the affected arm, but can also
occur in the hand, trunk and breast. It
can develop immediately or many years after treatment (Mortimer et al., 1996).
Whenever it develops, lymphoedema is a chronic, debilitating condition
that can cause severe physical and psychological morbidity as well as a
reduction in quality of life (Deo et al., 2004).
This review summarises
studies which evaluated intervention lifestyle strategies including aerobic
exercise, weight lifting and diet in addition to the standard management of
physiotherapy and compression bandaging (Moseley and Piller 2008,
de Rezende et al., 2006, Deo et al., 2004).
Physiotherapy
De Rezende et al., (2006)
reported a prospective RCT
testing the efficacy of two types of physiotherapy on shoulder
function and lymphatic disturbance in post-operative rehabilitation, as performed with 60 breast cancer patients who had
undergone modified radical mastectomy or quadrantectomy with axillary
dissection. Participants were
randomised to either the directed physiotherapy group or the free-moving
physiotherapy group. The physiotherapy technique used in was kinesiotherapy,
based on spontaneous exercises including movements for flexion, extension,
abduction, adduction and internal and external rotation of the shoulder,
either isolated or combined. The directed group performed physiotherapy with a
regimen of nineteen exercises, all of the movements being performed ten times
with a 60-second interval between exercises. The free group performed the
exercises without a previously defined sequence or number of repetitions, the
exercises being done to the rhythm of music. Three exercises were started the
first day after surgery in both groups. All patients were advised to maintain
free activity with the compromised limb in their daily activities. Starting
48-hours after surgery, the exercises were performed in 40-minute sessions
with a frequency of three times a week for a period of 42-days. The exercises
were practiced in groups of 5-20 women and administered by a team of five
physical therapists and ten physical therapy trainees. Results indicated that the
averages of the flexion, abduction and external rotational movements of the
shoulder showed significantly better recovery in the directed group compared
to the free group, with there being no significant difference between the
groups in terms of lymphatic disturbance.
Weight
Reduction Dietary Interventions
Shaw,
Mortimer, and Judd, (2007) examined the impact of diet and weight loss on lymphoedema in a UK RCT comprising
two dietary intervention groups (a low-fat diet and a weight reduction diet)
and a control group continuing their usual diet. Women with arm lymphoedema (n
= 21) after treatment for breast cancer were recruited from the lymphoedema
clinic at the Royal Marsden Hospital. The inclusion criteria was that the
subjects had a swollen arm of 20% or greater excess volume when compared with
the unaffected arm, and were in remission from cancer having had no
chemotherapy or radiotherapy in the previous 12-months. After
the 24-week period of dietary intervention there were significant differences
in the mean body weight, BMI, skinfold thickness, and percentage body fat
between the control group and both the weight-reduction and low-fat groups.
There was a reduction in excess arm volume over the 24-week period but there
was no significant difference between the three groups.
However, there was a significant correlation between weight loss and a
reduction in excess arm volume irrespective of the dietary group.
There were small changes in arm volume of the unaffected arm over the
24-week period compared with changes in the arm affected by lymphoedema. There
was a significant difference in mean weight loss between the three groups at
both 12-weeks and 24-weeks. Weight
loss occurred in all groups, with nine participants (60%) losing weight in the
control group, eighteen (95%) in the weight-reduction group, and thirteen
(76%) in the low-fat diet group. Overall, the study showed a slightly
greater reduction in excess arm volume in both dietary intervention groups
compared with the control, although this was not statistically significant.
Post-hoc analysis demonstrated a statistically significant correlation between
weight loss and loss of swollen arm volume irrespective of the reason for
weight loss.
Moseley
and Piller (2008)
reviewed eleven studies for evidence supporting the benefits of a variety of
exercise interventions for those with limb lymphoedema, using the findings to
propose how exercise might be incorporated into self-management programmes.
Their key findings were that exercise improved lymph
clearance; reduce limb volume and improved subjective symptoms and is a viable
option for people with lymphoedema.
Aerobic
Exercise (ergonometry, rowing, movement)
Havas
et al. (2000) found that two
hours of steady exercise increased lymph clearance rate five-fold in the first
15-minutes, while the rest of the time it was increased 2–3 fold. These
findings are confirmed by a study by Lane et al. (2005), which demonstrated
increased lymphatic clearance in the hands of healthy women who performed arm
crank ergonometry for five-minutes.
Moseley
and Piller (2008) reviewed
the safety of weight lifting among ladies with lymphoedema and concluded that
a wide variety of strenuous exercise can be undertaken by those at risk of
developing lymphoedema and those who already have the condition without
adverse effects. Two studies have shown that women who have undergone breast
cancer treatment can participate in vigorous exercise, such as rowing and
upper body exercise, without exacerbating the lymphoedema, and without
increasing risk of lymphoedema in those women without the condition (Harris
and Niesen-Vertommen, 2000; Lane et al., 2005). The ability to undertake more
active exercise has also been demonstrated in other studies, including women
with secondary arm lymphoedema undertaking resistive arm exercise with hand
weights (McKenzie and Kalda, 2003; Johansson et al, 2004), a dance programme (Sandel
et al., 2005) and a moderately intensive exercise programme which included
aerobic and resistive exercise (Turner et al, 2004).
Exercise combined with Compression Garments
McKenzie
and Kalda (2003) and Johansson et al. (2004), in two studies, examined the outcomes of
exercising while wearing a compression garment (both of which involved
resistive weight exercises. Both
studies demonstrated a reduction in arm volume of 15ml (at 24-hours) and 2%,
respectively. Interestingly, Johansson et al. (2004) also investigated the
same resistive weight exercises without using a compression garment, which
also produced the same reduction.
Supervised Aerobics and Resistance Exercise
Moseley et al. (2005) evaluated
a programme of arm exercise combined with deep breathing.
McKenzie and Kalda, (2003), Johansson et al., (2004), and Buckley et
al. (2004) investigated resistive arm exercise with weights and a 30-minute
limb aerobic exercise programme. Three
of the studies that included control groups (McKenzie and Kalda, 2003; Box et
al., 2004; Moseley et al., 2005) demonstrated either a minimal decrease in
limb volume or an actual increase when compared with the exercise group.
Of particular note is that two studies (Buckley et al., 2004; Johansson
et al., 2004) demonstrated an average initial increase in arm volume (12ml in
both studies), which was shown to be only a temporary increase in volume, with
an overall volume decrease 20-minutes (24ml) (Buckley et al, 2004) and
24-hours (15ml) (Johansson et al., 2004) after exercise.
Hildegard, and Turner
(2009) reported a RCT which assessed the implications
of exercise in 32 women who completed breast cancer treatment at least
6-months prior and had subsequently developed unilateral, upper-limb
lymphoedema. The intervention
group participated in twenty supervised, group, aerobic and resistance
exercise sessions over 12-weeks, whereas the control group was instructed to
continue habitual activities. Average
attendance was more than 70% of supervised sessions and there were no
withdrawals. Mean ratio and volume
measures at baseline were similar between the two groups although exercise did
not exacerbate secondary lymphoedema.
Supervised Weight Training with
Stretching
Ahmed et al. (2006) conducted a 6-month
randomised controlled weight training trial to examine the incidence
and symptoms of lymphoedema in 45 breast cancer survivors. Participants were
4-36 months post-treatment, and had axillary dissection as part of their
treatment. Thirteen women had prevalent lymphoedema at baseline.
The weight training intervention comprised a
one-hour process: for the first 3-months of weight training,
participants met twice-a-week with a certified fitness
professional; performed warm-up, weight training, cool down,
and stretching exercises. Nine
common weight training exercises were performed using variable resistance machines
and free weights, targeting muscles of the arms, back, chest,
buttocks, and legs. For the upper body, participants started
with no weight or half-pound wrist weights for each exercise.
Women were also taught stretching exercises to increase range
of motion. Participants were encouraged to continue
lymphoedema self-care therapy during the study, and adherence to
this was monitored at measurement visits. All but one intervention-group
participant attended at least 80% of exercise sessions, and
adherence did not vary by baseline lymphoedema prevalence,
suggesting intervention acceptability. From baseline to 6-months, neither the
incidence of lymphoedema nor the onset of lymphoedema symptoms
varied in the intervention-group versus control-group
participants.
Schmitz
et al. (2009) published, in the New England Journal of Medicine, the largest and
best designed RCT evaluating the influence of weight lifting on the incidence
of lymphoedema and its consequences. One hundred and forty one women with
breast cancer were randomised to a supervised weight lifting programme or
control. They all had received an axillary node clearance and had completed
adjuvant chemotherapy or radiotherapy. Both groups received standard
lymphoedema advice. The intervention group received twice weekly supervised
exercise sessions for 6 months. Weight lifting started with a warm up and warm
down which included significant stretching exercises. The initial weight and
escalation determined at each session by a certified exercise professional. At
six months there was no statistical significance in arm thickness but muscle
strength was improved and there was a significant difference in the number
lymphoedema flares which required acute intervention (either infection or
sudden deterioration in upper limb circumference.
Exercise for Leg
Lymphoedema
Moseley et al. (2003) and
Buckley et al. (2004) investigated the effect of exercise on secondary leg lymphoedema. These
two studies demonstrated that both mechanical limb elevation plus passive
exercise (Moseley et al., 2003) and 30-minutes of limb exercise (Buckley et
al., 2004) can produce a reduction in limb volume and subjective improvements
in symptoms. In the study by Moseley et al. (2003), the limb volume reduction
was significant (330ml), while in Buckley et al.’s (2004) study it was much
smaller (55ml). Both studies also demonstrated a volume reduction at
follow-up, including at 20-minutes post-exercise (31ml) (Buckley et al., 2004)
and one-month after trial completion (220ml) (Moseley et al., 2003).
Conclusion and
Recommendations (Lifestyle, Exercise and Lymphoedema)
These results indicate a need to
re-evaluate the common clinical guidelines that breast cancer survivors avoid
upper body resistance activity for fear of increasing risk of lymphoedema.
They all show that a wide range of exercises including vigorous
aerobics and strenuous weight lifting are safe and supervised programmes are
enthusiastically attended patients. No trial showed that exercise increased
the severity of lymphoedema if already established or increased the incidence
after axillary no clearance. A number of prospective studies reviewed by Moseley
and Piller (2008) demonstrate that exercise can
improve lymph clearance, reduce limb volume, and improve subjective symptoms
and QoL. Furthermore, weight reduction, if initially overweight, improved limb
circumference in those already suffering form lymphoedema.
The most convincing RCT also showed a significant reduction in acute
chronic lymphoedema flare events which are very distressing for those already
suffering the inconvenience and indignity of lymphoedema. In addition to
standard advice for treating and preventing lymphoedema, including the
benefits of weight reduction and compression garments the following
recommendations are appropriate based on the published evidence:
Table
5: Summary of Evidence for the Benefits of Exercise and Lifestyle on
Lymphoedema
|
Authors |
Design |
Cohort |
Intervention |
Outcome |
|
Havas
et al. (2000) |
RCT (n=8) |
Endurance-trained men |
2-hours of steady exercise. |
Increased lymph clearance rate five-fold in first
15mins and 2-3 fold rest of time. |
|
McKenzie
and Kalda (2003) |
RCT (n=14) |
Breast Cancer |
Resistive weights exercise combined with
compression garments |
Reduction in arm volume of 15ml. |
|
Johansson
et al. (2005) |
RCT (n=31) |
Breast Cancer |
Exercise combined with compression garments |
Reduction in arm volume of 2% |
|
Moseley
et al. (2005) |
RCT (n=38) |
Breast Cancer |
Arm exercises combined with deep breathing |
Reduced limb volume. |
|
Ahmed
et al. (2006) |
RCT (n=45) |
Breast Cancer |
6-months, twice weekly supervised weight training |
At minimum, exercise does not exacerbate
lymphoedema. |
|
de
Rezende et al. (2006) |
RCT (n=60) |
Breast Cancer |
Supervised kinesiotherapy (physiotherapy) |
SS better recovery. |
|
Shaw,
Mortimer, and Judd (2007) |
RCT (n=21) |
Breast Cancer |
24-week dietary intervention |
Reduction in arm volume. Correlation between weight
loss and arm volume. |
|
Moseley
and Piller (2008) |
Systematic Review (n=11) |
Breast Cancer |
A variety of exercise interventions. |
Improved lymph clearance and symptoms. Reduced limb
volume. |
|
Hayes,
Hildegard, and Turner (2009) |
RCT (n=32) |
Breast Cancer |
12-weeks supervised aerobic and resistance training |
Exercise did not exacerbate lymphoedema. |
SS – Statistically significant.
Bone
Health (Osteoporosis)
Osteoporosis is a condition in
which the bones become less dense and more likely to fracture, which in turn
can result in significant pain and disability.
If undetected, bone loss can progress for many years without symptoms
until a fracture occurs. Pre-menopausal women who have had breast cancer treatment may be at
increased risk for osteoporosis and fracture due to reduced levels of
oestrogen brought on by a premature menopause caused by chemotherapy, surgery,
or hormones whilst men who receive hormone deprivation therapy for
prostate cancer also have an increased risk of developing osteoporosis (National
Institutes of Health Osteoporosis
and Related Bone Diseases, 2009). Among post menopausal women, it has been reported
that 80% of breast-cancer patients have osteopenia (below normal bone-mineral
density [BMD]) or osteoporosis at initial diagnosis (Twiss et al., 2001).
Osteopenia, osteoporosis, and increased rates of fracture have been
noted in survivors of many cancers, including breast, prostate, testicular,
thyroid, gastric, and CNS cancers, as well as non-Hodgkin’s lymphoma and
various haematological malignant diseases (Brown et al., 2003);
Other
medical conditions which are associated with a higher risk of osteopenia
include thyroid disorders, prolonged warfarin and corticosteroid intake.
Lifestyle factors which increase the risk factors for developing osteoporosis
include a low calcium intake, low protein diet, lack of physical activity,
smoking, and excessive alcohol intake (Mackey and Joy, 2005).
This
section reviewed the evidence that lifestyle factors may influence the
prevention, development, progression or severity of impairments of bone
mineral density among cancer survivors. It categorised self-management
lifestyle strategies into exercise including home-based aerobics, walking and resistance programmes, diet
including plant proteins, Soya product and fibres,
and other lifestyle factors including excessive alcohol intake and smoking.
Home-Based Aerobics and Resistance Programmes
Schwartz, Winters-Stone, and Gallucci, (2007) evaluated the impact of aerobics and resistance training on BMD in an
RCT involving 66 women with histologically confirmed invasive stage I-III
breast cancer. Strenuous regular exercisers, defined as women who
exercised more than 250-minutes per week were excluded. At baseline (before
chemotherapy) and at six-months, bone mineral density, aerobic capacity
(12-minute walk), and upper and lower body muscle strength (single-repetition
maximum test) were measured. Women were randomised to one of three groups:
home-based aerobic exercise; home-based resistance exercise; or usual care,
and stratified according to menopausal status (pre-menopausal or
post-menopausal). Post-menopausal women were defined as those who had
cessation of menses for at least six consecutive months prior to beginning
chemotherapy.
Women randomised to the home-based aerobic exercise intervention were
instructed to choose an aerobic activity they enjoyed (e.g. walking, jogging)
and exercise for 15-30 minutes four days per week for the duration of the
study, at a symptom-limited, moderate intensity such that they were breathing
hard but able to talk.. Caloric expenditure during each exercise session was
measured using Caltrac Accelerometers™. Resistance exercise subjects were
instructed to exercise at home four days per week using resistance bands and
tubing. The average decline in BMD was -6.23% for usual
care, -4.92% for resistance exercise, and -0.76% for aerobic exercise.
Pre-menopausal women demonstrated significantly greater declines in BMD than
post-menopausal women. Aerobic capacity increased by almost 25% for women in
the aerobic exercise group and 4% for resistance exercise. Participants in the
usual care group showed a 10% decline in aerobic capacity. The data suggest
that weight-bearing aerobic exercise attenuates declines in BMD and that
aerobic and resistance exercise improve aerobic capacity and muscle strength
at a time when women generally show marked declines in functional ability.
Waltman
et al. (2009) evaluated the
efficacy of a strength and weight training programme in 223 post-menopausal
women who had completed breast cancer treatment (except tamoxifen and
aromatase inhibitors) at least 6-months earlier.
The women were randomised to the two treatment groups: exercise with
medication (n = 110) and medication only (n = 113). The medication taken by both groups included:
risedronate (osteoporosis medication), calcium (1500mg per day) 400 IU vitamin D per day,
and vitamin D
(400 IU per day). Participants who were 50% or greater adherent to exercises were
significantly less likely than participants on medications alone, to lose BMD
at the total hip and femoral neck.
Diet, Plant Proteins and Fibres
Weikert
et al., (2005)
performed a sub-analysis of the European Prospective Investigation into Cancer
and Nutrition (EPIC) Potsdam cohort study which included 8,178 females and
examined the association between protein intake, dietary calcium, and bone
structure. It was concluded that
high consumptions of animal protein may be unfavourable, whereas higher
vegetable protein may be beneficial to bone health.
These results support the hypothesis that high calcium intakes combined
with adequate protein intake based on a high ratio of vegetables to animal
protein may be protective against osteoporosis. Indeed, evidence has
demonstrated the relationship between lower incidence of osteoporosis in Asian
women and vegetarian populations due to a diet rich in vegetables and fruit (Fujii
et al., 2009; Merill and Aldana, 2009; Thorpe et al., 2008).
Furthermore, a large-scale dietary modification intervention of
post-menopausal women (n = 48,83) showed that an increased consumption of
plant proteins and fibres from fruits, vegetables and grains reduced the risk
of multiple falls and slightly lowered hip BMD, although it did not change the
risk of osteoporotic fractures (McTiernan et al., 2009).
New
et al. (2003; 2004)
further highlighted the benefits of plant proteins and fibres on bone health
in two reviews by where a positive link between a high consumption of fruit
and vegetables and bone health has been demonstrated.
In the first report, it was found that fruit and vegetables have
beneficial effects on bone mass and bone metabolism in men and women across
the age ranges, whilst in the second review it was concluded that although the
impact of a vegetarian diet on bone health is much more complex than merely
being related to diet, vegetarians do tend to have ‘normal’ bone mass.
Soya Products
Marini
et al., (2008)
reported a randomised, double-blind, placebo-controlled trial of the soya
derivative genistein aglycone and its effects on bone health after 3-years of
389 women with breast and endometrial.
Bone mineral density increases were greater with genistein for both
femoral neck and lumbar spine compared to placebo. There were no differences
in discomfort or adverse events between groups, the conclusion being that
after 3-years of treatment, genistein exhibited a promising
safety profile with positive effects on bone formation in this
cohort of osteopenic, post-menopausal women
Ryan et al. (2007)
present some findings on osteoporosis risk, as elicited from the US05 study, a
randomised, placebo-controlled study of zoledronic acid versus placebo in
patients with prostate cancer (n = 120) without bone metastases and within the
first 12-months of ADT. Participants
completed a baseline questionnaire regarding osteoporosis risk factors,
eliciting the following medical and lifestyle information. The accumulated data demonstrated that osteopenia or
osteoporosis was detected in two thirds of the men.
A positive association between BMI and bone
density of the hip was observed, suggesting that a higher BMI is protective of
bone density loss in men with prostate cancer and that weight loss could
increase risk of osteoporosis. Calcium and vitamin D supplement use by study
subjects was associated with greater bone density measurements at the total
hip, supporting the use of dietary supplementation in patients with prostate
cancer. Greater bone density was found in men consuming seven or more
alcoholic beverages weekly than in non-drinkers, highlighting the potential
benefits of moderate alcohol consumption, as also demonstrated by the National
Osteoporosis Risk Assessment longitudinal observational study (Siris et al.,
2001).
Ryan et al. (2007)
evaluated the importance of weight in relation to BMD amoung breast cancer
survivors. They found that smoking and being underweight (BMI less than 18.5)
were associated with lower BMD.
Conclusion and Recommendations (Bone
Health)
The
evidence summarised within this review suggests that lifestyle factors,
although not increasing bone density, have a significant impact on maintaining
BMD and avoiding fractures. The evidence for benefits of lifestyle have been
reported mainly for survivors of breast and prostate cancer but as impairments
of bone health effects patients with a wide variety of cancer types it is
likely to be treatment and person specific rather cancer specific. The
benefits applied to those embarking on lifestyle programmes alone or in
conjunction with vitamin D and calcium supplement or bisphosphonates.
Based on this evidence the benefits of exercise and lifestyle factors
to prevent osteoporosis and maintain bone health should be emphasised to
patients verbally and within in multimodal information materials.
Patient information:
§
Stop
smoking
§
Avoid
excess alcohol intake
§
Incorporate
more physical exercise within the activities of daily living
§
Perform
regular aerobic and resistance exercise in formal programmes
§
Eat a
diet rich in vegetables, pulses, fruit and grains
§
Increase
intake of Soya based foods (beans, miso, tempeh, soy milk, tofu)
§
Ensure
adequate calcium intake (nuts, dairy products, shell fish)
§
Ensure
regular gentle sun exposure to increase Vitamin D levels
§
Avoid
being underweight (BMI < 19)
Medical interventions:
§
Ensure
information pathways include the benefits of lifestyle on bone health
§
Provide
detailed information on local exercise classes including walking groups, gyms,
dance and aerobics classes
§
Provide
local exercise rehabilitation
classes or supervised facilities
§
Measure
bone density after cancer treatment
§
Advise
supplements or bisphosphonates according to national guidelines.
Table 6: Summary of Evidence for Lifestyle and Bone Health
|
Authors |
Design |
Cohort |
Intervention |
Outcome |
|
Weikert
et al. (2005) |
Cohort
(n=8,178) |
Breast
Cancer |
Self-reported
dietary patterns |
Vegetables
(plant proteins and fibres) are beneficial for bone health. |
|
Ryan
et al. (2007) |
RCT
(n=120) |
Prostate
Cancer |
Self-reported
lifestyle patterns |
A
positive association between BMI, Ca and vitamin D supplement and BMD of
the hip. |
|
Schwartz, Winters-Stone, and Gallucci (2007). |
RCT |
Breast
Cancer |
Aerobic
and resistance exercise |
Improved
aerobic capacity and muscle strength. |
|
Marini et al. (2008) |
RCT
sub-cohort (n=138) |
Breast
Cancer; Endometrial Cancer |
Genistein
aglycone daily, plus calcium and vitamin D |
Positive
effects BMD. |
|
Swenson
et al. (2009) |
RCT |
Breast
Cancer |
Prescribed
physical activity during chemotherapy, plus oral calcium and vitamin D |
Less
effective in preventing bone loss. |
|
Waltman
et al. (2009). |
RCT
(n=223) |
Breast
Cancer |
Strength
and weight training, plus risedronate, calcium and vitamin D |
At
a minimum, BMD was maintained. |
SS –
Statistically significant; BMD – Bone mineral density.
Overall Conclusions, Discussion and
Recommendations
A number of methodological limitations confound the interpretation of
the benefits of exercise and diet after a diagnosis of cancer from other risks
such as smoking, body size, supplements and analgesic intake.
Furthermore, many of the studies are of a small sample size, lack
long-term follow-up. Nevertheless,
despite these caveats there is now persuasive evidence that a healthy
lifestyle during and after cancer is associated with improved physical and
psychological well-being, reduced risks of treatment, enhanced self-esteem,
reduced risk of recurrence, and improved survival.
Prising the individual anti-cancer components of a healthy lifestyle
will require extensive further evaluation and even then they are likely to be
multi-factorial.
In terms of slowing progression of an existing cancer
the only prospective data comes from men with prostate can where, in some on active
surveillance, the slow progression allows time for alternative interventions
(Thomas et al., 2006). Although these trials are relatively small, they
suggest a useful role for dietary and exercise advice for men with prostate
cancer as a complement to active surveillance. This includes more fruit,
vegetables, particularly those containing high levels of antioxidants
including pomegranates and tomatoes. The data on taking extra dietary
supplements is conflicting and requires further research particularly lycopene
and Soya products.
In terms of reducing the risks of relapse, evidence is strongest
following breast, bowel, lung, head and neck cancers but self help lifestyle
strategies are likely to be person specific rather than disease or treatment
specific so are likely to apply to all patients recovering from cancer.
The main areas of evidence are categorised as:
Exercise:
Other lifestyle factors:
Diet:
Aim
for a healthy, varied diet avoiding fads and ensuring adequate intake of
vitamins, essentially minerals, fibre, essentially fatty acids and
antioxidants (Appendix 3):
Vitamin and mineral
supplements should not be required if individuals are able
to eat a varied balanced diet. This review found no evidence suggesting that
they can improve cancer outcomes and in fact, a studies involving vitamin A
and E increased subsequent lung cancer risks as well as cardiac and cerebral
vascular morbidity. Patients who
took regular zinc supplement for long periods of time were found to have a
higher risk of prostate cancer. Furthermore Folic acid and Vitamin B increased
the cancer risk if given to patients after myocardial infarction. There is,
however, evidence from cohort and prevention studies showed that individuals
with vitamin or essential deficiencies had a higher incidence of cancer and
the risk diminishes following specific nutritional correction with
supplements. The evidence suggests therefore that if individuals are deficient
in a vitamin or mineral they have an increased risk of cancer but if they take
supplements with normal baseline levels the subsequent excess also increases
the risk of cancer. It appears therefore that a normal level rather than high
or low is ideal. These nutrients, however, are not measured in routine
clinical practice but ideally, future trial designs should include bespoke
patient analysis to identify those individuals with sub-clinical deficiencies.
Fish oil supplement are a good way to increase omega 3 intake but there are no
trials to suggest they help relapse rates although one study suggest they
could help arthralgia. There may be a role for nutritional supplements which
contains antioxidants such as lycopene, pomegranate or higher intake of green
but trials have so far had relatively small numbers. They should not be taken
during chemotherapy as they can interact with its mechanism of action. In
summary, there may be a role for nutritional supplements but they need to be
individualised to the needs of each patients and subject to further
investigation before they can be recommended routinely.
How
to Integrate Self-Management Lifestyle Strategies into Routine Management
Adopting a paternalistic approach and simply telling people is not enough.
If the medical community want to help their patients embark on a road of
recovery which includes regular exercise, there has to be a comprehensive and
well funded package of education, guidance and support. Although some
individuals may have exercised enthusiastically before their diagnosis they
may not have the same motivation or abilities afterwards. The cancer itself,
surgery, or the anticancer therapies, have resulted in physical disability,
notwithstanding the commonly associated fatigue, lethargy, weight gain and
reduced esteem in body image. Patient survivors may have to relearn their
lifestyle and exercise patterns and consider a broad range of activities,
particularly those which previously they may not have considered. The two
fundamental approaches to encouraging patients to change their lifestyles to
the better are: 1) Information provision, and 2) Supervised rehabilitation
programmes.
1)
Patient
Information Provision
Evidence based information, emphasising the importance of lifestyle,
ideally should be formally introduced into routine clinical practice early in
the treatment pathway and re-enforced at regular intervals thereafter. This
ensures patients and their relatives do not miss the teachable moment where
they are most susceptible to positive advice (Demark-Wahnefried et al., 2005).
This requires close work with clinicians, specialist nurses, patients and
advocacy groups to enable information about new strategies to be integrated
into existing local information pathways and materials. Indeed, the new
information prescriptions currently being pilot tested provide ample
opportunity for integrating lifestyle advice into survivorship care plans
(Office for Public Management, University of York, and GfK NOP for DH, 2008).
As the level and complexity of information provided to patients and their
relatives, who originate from a wide range of educational, cultural and
religious backgrounds, increases a wide range of multimodal materials may need
to be considered including DVD, websites, blogs and mobile phones (Thomas et
al – video paper).
Before investing time and money on patient information materials, a vital
first step is to convince the consultants, other direct clinical staff and
organisers of clinical services that lifestyle advise is a priority and to
re-allocate resources to enable sufficient time to discuss these issues within
routine consultations. One study,
for example, found that patients who were encouraged by their oncologist,
exercised significantly more than patients who did not (Segar et al., 1998).
As well as further scientific research, this may require a degree of
lobbying from organisations such as Macmillan as well as formal teaching
programmes, conferences, local lectures and courses. The next step is to back
up the medical consultation with further practical verbal and written advice
from specialist nurses or information officers. One UK oncology unit, for
example, does this as part of a formal lifestyle interview together with a
bespoke lifestyle information toolbox (Thomas, Taylor, and Williams, 2009).
During this interview patients, can be referred to smoking cessation clinics,
nutritionalist, and physiotherapist where necessary. The specialist nurse
conducting this interview provides written information and advice to patients,
and just as importantly their friends and family, about local support groups,
dietary measures, where to buy healthy foods and specific local exercise
facilities which may entice them ranging from ballroom, line and salsa dance
lessons, aerobics, yoga and fitness classes, local walking, swimming and
cycling groups through to gyms, sport centre, tennis and badminton courts, and
pilates classes, giving times, contact numbers and locations to make it as
easy as possible to follow the advice. The rationale for these interviews is
that individualised lifestyle counselling is more likely to elicit a response,
than generic general advice. The
specialist nurse then follows up the advice by telephone and further
consultations as prompting has been shown to improve update. A study from
North Bedfordshire, for example, showed that although 52% of patients accepted
referral for exercise in a local Gym a further 23% decided to attend classes
only after additional prompting from the nurse either by telephone.
Many UK Oncology Units already have instigated an exit interview system to
discuss follow up arrangements and this process could be expanded to include
lifestyle counselling provided the specialist nurses involved have received
extra training. This training should include a knowledge of the evidence and
importance of diet, lifestyle and exercise after cancer as well as ways to
appropriately advise home-based exercise regimens and how to direct patients
towards the myriad of council or independent exercise activities available
locally to them. The courses may require additional communication and
motivational skills training to enable nurses to adapt advice depending on
their client’s cultural, psychological and physical preferences.
2)
Supervised
Exercise Rehabilitation
Experience from the more mature cardiac rehabilitation
programs tells us that encouragement to exercise and improve other lifestyle
factors based on written information alone is not enough (Oldridge et al.,
1998, Ades, Huang, and Weaver, 1992). Various schemes have been investigated
to improve motivation to exercise ranging from diaries to reminder wrist bands
(refs). But the most powerful factors to improving physical activity is direct
personal, supervision and support especially if lifestyle changes are to be
sustained for long term benefit (Jolliffe et al., 2000; Quadrilatero and
Hoffman-Goetz, 2003; Haydon et al., 2006). This especially applies to patients
surviving cancer who have endured fundamental changes in their aspirations and
abilities following their treatment or where the cancer itself may have caused
physical disability, fatigue, weight gain and reduced esteem in body image.
The evidence from the review of cancer related fatigue also showed that
supervised programmes were significantly more likely to result in a higher
level of overall exercise and improvements in fatigue (Velthuis et al., 2009).
In practical terms this means a national network of supervised exercise
and lifestyle courses which patients can be referred to during or following
their adjuvant treatment as part of a formal cancer rehabilitation programme.
In the USA such programmes for patients and their relatives are firmly
established with the most well known established in the Rocky Mountains (Sprod,
2009). Although, more evidence is necessary to establish the relevance and
timing of a formal rehabilitation programmes, initial data is encouraging.
Rogers et al. (2009) evaluated the effectiveness of a 12-week physical
activity course for breast cancer survivors. Forty-one women with stage I, II,
or IIIA breast cancer who had completed primary chemotherapy and radiotherapy
currently receiving hormonal therapy were randomly assigned to receive the
12-week supervised exercise or usual care. The intervention resulted in
statistically significant sustained improvements in physical activity,
strength, central adiposity, and social well-being measured at baseline and at
3 months. These benefits were also sustained at least up to 3 months after 3
months after intervention completion particularly in the measurement of lower
extremity function (Rogers et al., 2009). There is further evidence that
patients find exercise in their local gym acceptable. A study in north
Bedfordshire referred 60 patients post chemotherapy and radiotherapy to
designated municipal gyms for 24 supervised exercise sessions with a personal
trainer. Eight percent declined the
referral initially, 52% contacted
gyms after initial referral and a further 23%
contacted gyms only after prompting. Of the 75%
proceeded to exercise sessions all completed the course (Thomas, Taylor, and
Williams, 2009). A questionnaire at 12 weeks revealed that over 50% had never
been to a gym before, the rate of good or excellent satisfaction was 94% and
over 75% stated they would continue in the Gym after the scheme finished.
Provided further training is forthcoming, suitably qualified personal trainers
are also in an ideal position to continue the lifestyle advice started in the
hospital setting.
Further research is needed to find out why these
other 25% did not take up the offer of exercise supervision although there are
already some indicators. For
example, higher family support has been shown to be associated with a slower
decline in physical activity in after taking part in an exercise intervention
(Emery et al., 2009). Emotional
health-related QoL following diagnosis with breast cancer also appears to be
important for sustaining physical activity (Courneya et al., 2008), indicating
that physical activity interventions among breast cancer survivors might be
more successful if any depressive symptoms are addressed early in the course
of treatment. Evidence is
available of the effectiveness of telephone counselling in helping people to
change exercise and dietary behaviours (Pierce et al., 2004).
The benefits of self-management are also highlighted in evidence
suggesting that survivors who self-refer themselves to a lifestyle
intervention as opposed to being registry-ascertained show significantly
greater increases in exercise at 1-year follow-up and significantly greater
increases in fruit and vegetable consumption at both 1- and 2-year follow-up
(Irwin et al., 2008; Snyder et al., 2008).
Where
should exercise rehabilitation programmes be located?
The cardiac model is that patients recovering from myocardiac infarction
have a 6 weeks, or more, formal exercise rehabilitation programme in hospital
(Oldridge et al., 1998, Ades, Huang, and Weaver, 1992). They are then
transferred via the national activity for health referral scheme to local
municipal Gyms. In the gyms
patients, or at this stage more appropriately referred to as clients, are
provided with exercise programmes supervised by exercise professional who have
been specifically trained to a level 4 grade, determined by the organisation
Skills Active (Sector for Skills Council for UK based leisure and learning).
Following the same hospital-initiated model for cancer rehabilitation
would require considerable investment within hospitals in terms of money,
space, time and extra physiotherapist. No doubt an in house rehabilitation
scheme would be an advance for more complex or disabled patients and to get
the ball rolling but may not be necessary for the majority who or undergoing
or have completed adjuvant therapies or who have stable low volume metastatic
disease. A significantly more cost effective scheme for the majority of
patients would involve tapping into the existing national network of 5,700
municipal Gyms and their resident exercise professionals. For this reason, a
joint application from Professor Thomas and a charitable organisation called
the Wright foundation was submitted to Skills Active in October 2009.
Following a national consultation process the template for designing courses
for exercise professionals has now been accepted. This has paved they way for
training organisations, such as The Wright Foundation, to start training
exercise professional to a level 4 grade in cancer rehabilitation.
This level 4 training unit for exercise professional ensures they have a
range of appropriate knowledge and skills to protect the patients/clients and
themselves. These include communication skills; a good understanding of the
principles of training and guidelines for teaching relevant to the cancer
survivor; an understanding of the disease process and how it is
managed; how physical activity influences the disease process; how the
disease process influences the ability to safely exercise; the positive and
negative aspects of physical activity on cancer; an understanding of
cancer medications and their influence on the individual's ability to
exercise; a knowledge of what to look out for during exercise,
when to ask for help, when and how to feed back to the medical team.
The next step is to lobby the
Department of Health to provide the finances to be able to integrate lifestyle
counseling and supervised programmes within hospital and to expand the
exercise referral scheme to include cancer as a primary indication. Further
research would help persuade key decision makers, but in the mean time
organisations such as Macmillan Cancer Support are in an ideal position to
apply pressure for change based on the convincing evidence reviewed in this
and other similar reports.
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Appendix
1
Summary
of self help dietary strategies to improve the odds of better cancer outcomes
|
Food |
Advice |
|
Reduce Saturated Fats |
Unless underweight, avoid processed fatty foods, cakes,
biscuits, crisps and other fatty snacks, pastries, cream, and fried foods.
Cut the fat off the meat and check serum cholesterol regularly. |
|
Meat and intake |
Use meat for its taste, preferably not more than once a day.
Remove excess fat gently grill rather than fried to further reduce the fat
content and avoid burning. If extra oil is needed use vegetable oils
rather than animal fat. Increase fibre intake when eating meat such as
salad and vegetables |
|
Increase all fish intake |
All fresh fish, but particularly the oily varieties such as
mackerel and sardines. Fresh water fish such as trout have the advantage
of avoiding the potential heavy metal contamination of tuna & sword
fish which some suggest should not be eaten more than twice a week. |
|
Reduce Exposure to Potential Carcinogens |
Try to avoid heavily processed foods, which often contain
high concentrations of fat, salt, sugar and food additives. Wash salads
and vegetables thoroughly to avoid airborne chemicals, which may have
settled on them. Avoid excessive amounts of foods containing high levels
of aromatic hydrocarbons and acrylamides such as smoked food or those
associated with high temperature cooking processes such as deep fried
foods, crisps, chips, barbecued, and heavily fried meats. |
|
Essential minerals |
Vary the diet to ensure intake of adequate quantities of
essential minerals consider; Mixed nuts, including Brazils; Seafood
including sardines, prawns and shell fish; Pulses and grains. Vary
carbohydrate sources such as pasta, rice, different brands of potatoes,
pulses such as lentils and quinoa. |
|
Dietary Vitamins |
Fresh fruit, raw and calciferous vegetables, grains, oily
fish, nuts and salads. Unless you have diarrhoea try to increase the
amount of ripe fruit you eat each day, ideally by eating the whole fruit.
Freshly squeezed fruit juices are recommended. |
|
Polyphenols |
Onions, leeks, broccoli, blueberries, red wine, tea,
apricots, pomegranates, chocolate, coffee, blueberries, kiwis, plums,
cherries, ripe fruits, parsley, celery, tomatoes, mint, citrus fruit. |
|
Phytoestrogens |
Soybeans and other legumes including peas, lentils, pinto
(baked beans), and other beans and nuts (supplements not recommended). |
|
Non-oestrogenic Polyphenols |
Skin of colourful foods such as cherries, strawberries,
blackcurrant, blackberries, dates, cranberries, red grapes, white button
mushrooms. |
|
Lignans & Stilbens |
Flaxseed, linseeds, hemp nuts, grains. |
|
Increase Carotenoids (Lycopene) |
Tomatoes, tomato sauce, chilli, carrots, green vegetables
and dark green salads. |
Appendix
2
Table to summarise tips to increase daily
exercise activities
|
Category |
Lifestyle
Advice |
|
Generally |
Exercise
should not just be a passing fad but be incorporated into our daily lives
for the rest of our lives. During the day we have several choices,
which require more or less levels of exertion. Try to take the more active
option, such as walking instead of using the car for short journeys or
getting off the bus or tube one stop earlier. |
|
Home |
If
you like exercising at home it is worth having a semi-formal programme to
follow. There are many useful gadgets available to make it more fun
(exercise bikes, treadmills, rowing machines, etc). Alternatively, follow
an exercise video - there are many good ones available. When watching TV
try to get up and walk around for a few minutes at every break. |
|
Office |
Use
the stairs instead of the lift. If possible take a walk at lunchtime. Try
desk exercises - You may look odd but they can keep you alert especially
when you get tired or sleepy. Do not worry about the comments - people
will secretly admire your enthusiasm. |
|
Social
Life |
There
is an alternative to the pub or the TV. Exercise can and should be
sociable and enjoyable - find something which is fun otherwise you will
give it up very quickly. |
|
Walking |
In
addition to integrating walking into our daily routine, social walking
groups are available in many areas and are a good way to meet new people,
view interesting scenery and exercise to a variety of ability levels.
Golf is a good encouragement to walk and clubs are available
throughout Britain for all levels. |
|
Cycling |
Cycling
socially with family or part of a daily commute, even if only once or
twice a week, can be fun and even save money. Consider buying a bike with
a basket for the shopping. |
|
Gym |
Joining
a gym is always a good start. Paying money every month is a good incentive
to use it. Even if you are overweight or unfit don't worry as so are most
other people and nobody of worth will criticise your efforts. In some area
there are exercise referral schemes to special instructors - ask your GP |
|
Exercise
Classes |
There
are numerous enjoyable ways to exercise in groups at a variety of levels.
Your local sports centre will also have many activities from 5-aside
football, squash, badminton, volleyball, netball, and numerous exercise
aerobics classes. |
|
Swimming
|
Many
pools offer classes to learn to swim; they often offer single sex or
disabled and disabled classes. |
|
Dance |
There
are numerous dance classes available in most towns, from traditional
ballroom and line dancing to rock & roll or salsa. |
Cancernet.co.uk/exercise is
able to search for a range of activities by postcode, providing times, contact
numbers and locations.
Appendix
3
Table to summarise tips
to encourage healthy eating
|
Food |
Advice |
|
Reduce Saturated Fats |
Avoid processed fatty foods, cream, and fried foods. Check
serum cholesterol. |
|
Reduce Meat Intake |
Use meat for its taste, preferably not over once a day.
Excess fat should be removed and the meat gently grilled rather than fried
to further reduce the fat content and avoid burning. If extra oil needs to
be used in cooking, use olive oil rather than animal fat. |
|
Increase all fish intake |
All fresh fish, but particularly the oily varieties such as
mackerel and sardines. Fresh water fish such as trout have the advantage
of avoiding the potential heavy metal contamination of tuna & sword
fish which some suggest should not be eaten more than twice a week. |
|
Reduce Exposure to Potential Carcinogens |
Try to avoid heavily processed foods, which often contain
high concentrations of fat, salt, sugar and food additives. Reducing the
amount of time that vegetables are cooked should maintain the flavour.
Wash salads and vegetables thoroughly to avoid pesticides and airborne
chemicals, which may have settled on them. Organic foods reduce the
pesticide exposure further. Avoid excessive amounts of foods containing
high levels of aromatic hydrocarbons and acrylamides such as smoked food
or those associated with high temperature cooking processes such as deep
fried foods, crisps, chips, barbecued, and heavily fried meats. |
|
Increase Dietary Selenium |
Brazil nuts, sardines, prawns; 60-75mcg/day; no more than
200mcg/day. |
|
Avoid Excessive Calcium and Zinc |
Unless prescribed for other reasons avoid supplements which
give more than 1500mg of calcium and 11mg zinc per day. |
|
Increase Dietary Vitamins |
Fresh fruit, raw and calciferous vegetables, grains, oily
fish, nuts and salads. Unless you have diarrhoea try to increase the
amount of ripe fruit you eat each day, ideally by eating the whole fruit.
Freshly squeezed fruit juices. |
|
Polyphenols |
Onions, leeks, broccoli, blueberries, red wine, tea,
apricots, pomegranates, chocolate, coffee, blueberries, kiwis, plums,
cherries, ripe fruits, parsley, celery, tomatoes, mint, citrus fruit. |
|
Phytoestrogens |
Soybeans and other legumes including peas, lentils, pinto
(baked beans), and other beans and nuts (supplements not recommended). |
|
Non-oestrogenic Polyphenols |
Skin of colourful foods such as cherries, strawberries,
tannins (red wine), blackcurrant, blackberries, dates, cranberries, red
grapes, white button mushrooms. |
|
Lignans & Stilbens |
Flaxseed, linseeds, hemp nuts, grains. |
|
Increase Carotenoids (Lycopene) |
Tomatoes, tomato sauce, chilli, carrots, green vegetables
and dark green salads. |
Further
information The book Lifestyle
After Cancer summarises the lifestyle evidence from around the world
and provides practical advice for all stages in the cancer journey. A detailed
film available in English, Italian, Urdu,
Bengali, Gujarati & Hindi explains Radiotherapy & Chemotherapy. Cancernet.co.uk
is a comprehensive cancer information resource written by an experienced team of
doctors, health professionals and patients. It contains links and information
on: Specific cancers:
Breast |
Prostate |
Bowel. Cancer
treatments: Chemotherapy |
Radiotherapy |
Hormones | Biological
agents | Complementary
therapies . Lifestyle and cancer:
Exercise | Diet |
Smoking | Sunbathing
| Alcohol. Tips to help
with symptoms and side effects. Financial issues: Traveling
| Travel insurance| Links
to support groups | Books | Tests
for cancer | Clinical trials | What
is cancer | How to avoid cancer | Glossary
| About us | Disclaimer.
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