The benefits of exercise during cancer treatment, by Specialist Oncology and Palliative Care Physiotherapist, Hannah Leach
This blog post has been written as part of the special 30 Day Barre Challenge we are running in honour of a wonderful woman, Angie Rosemeyer, who was a huge part of our community. We are raising money throughout the month of October for Heart of Kent Hospice, a charity close to the heart of Angie’s family.
I wanted to let you know that this blog post will contain mentions of illnesses including cancer, death, grief and other topics that you may find difficult to read about. We are sharing these blog posts as useful resources for anyone going through, or anyone close to someone going through, anything relating to these topics. Having lost my Dad to pancreatic cancer last year, this is a topic that is very close to my heart.
Today’s blog post has been written by Hannah Leach, a Specialist Oncology and Palliative Care Physiotherapist. The post discusses how someone receiving cancer treatment might approach exercise during their treatment journey.
Hello, I’m Hannah! I am a specialist oncology and palliative care physiotherapist, with over 10 years experience in hospital, hospice, community, outpatient and online settings. Alongside my job at The Royal Marsden Hospital, I also run my own online cancer physiotherapy practice, StrongerThan. I am passionate about spreading evidence-based information to people living with and beyond cancer, to empower physical activity, promote self-management of symptoms, to support quality of life and to achieve the best possible treatment outcomes.
Assuming there is a large scale of how you would support people based on different types, stages and treatments of cancers, so generally speaking, at what point might a patient get in touch with you, what might they be looking for and how do you support them?
I work with people with all cancers at all stages of treatment, from diagnosis to survivorship or palliative care.
I am most commonly contacted by people immediately after diagnosis, or once they have finished treatment; these tend to be moments in time where people feel motivated to take action and support their health as much as possible. Medically, we call this prehabilitation (preparing your body for treatment) and rehabilitation (restoring your body after treatment).
At the time of diagnosis, people usually want to know how they can prepare their body and mind before starting treatment. There are many variables such as cancer type, cancer stage and the treatment plan; we will discuss the potential side effects of treatment and ways they can use exercise to manage their symptoms. This can help alleviate any worries and fears, to support my clients to feel ready for their treatment and achieve the best outcomes. I usually create a personalised prehabilitation programme and follow-up regularly throughout treatment to support adherence, make adjustments and provide reassurance.
Once treatment has finished, people often tell me they want to get back to feeling ‘normal’ as quickly as possible. For some this can be straight-forward, however for most people navigating a new normal can present many different challenges: physically, emotionally and socioeconomically. For example, exercising, going to work, attending social events and maintaining your role within the family may feel more difficult. I allow a safe space for my clients to share their challenges and will create a personalised rehabilitation plan, to empower them to make positive and proactive steps to rebuilding their life and achieving their goals.
What are the most common physical challenges cancer patients might be facing as a result of treatment? How can treatment typically impact a patient’s strength and mobility and how can movement help?
The most common physical challenge I hear from people going through cancer treatment is fatigue. Feeling tired is something everyone can relate to, but cancer-related fatigue is entirely different! It can be an all-consuming, unrelenting lack of energy that is unrelated to sleep. Cancer Research reports around 65% of people experience fatigue during cancer treatment, but this has been reported up to 90% by other sources.
Unfortunately, because fatigue is an ‘invisible’ symptom, it can feel frustrating and confusing. Cancer-related fatigue has many complex biological and physiological causes, such as chronic inflammation, overactive immune system, low blood counts, pain, hormone imbalance and many other reasons. It is a very real and complicated symptom that can limit basic daily activities, mood, relationships, work and family/social commitments.
Research has shown that the most effective way to manage fatigue is regular physical activity. This can feel like a ‘catch 22’, whereby finding the energy to exercise may be very challenging. Exercise is proven to help regulate hormone balance, reduce inflammation, support the immune system, improve cardiovascular fitness and maintain muscle strength. I work with my clients to create a personalised exercise plan, which is realistic and achievable. All rehabilitation plans must suit a client’s individual symptoms, treatment, lifestyle and routine, to effectively introduce safe and regular movement, to manage symptoms, maintain strength and optimise quality of life!
Are there any types of movement or exercise that are most beneficial to patients during cancer treatment?
All movement is good movement! Aerobic/cardiovascular exercise is best for supporting the immune system, therefore aiming for 150 minutes of moderate physical activity a week is the goal. For many people, this can seem like a huge amount particularly alongside treatment, so starting small and building up gradually is the key.
It is also recommended to aim for 2 resistance training/strengthening sessions weekly, to maintain muscle mass which can easily be lost during chemotherapy or after surgery. Muscle is metabolically active and interacts with the other organs, therefore it is an essential for our body’s processing of chemotherapy or other medications. Generally speaking, the more muscle we can maintain, the better we may tolerate treatment!
Are there any particular exercises that help maintain or improve the immune system during cancer treatment?
Moderate aerobic/cardiovascular exercise is best for supporting our immune system. As mentioned, the best approach is to start small and build up gradually, in order to not increase the stress on your body too quickly. Exercising too vigorously, too quickly could have a detrimental effect on your immunity.
I often suggest the rule of 10% as a guide: find where you can start comfortably and aim to increase by approximately 10% each week. This could be any objective marker, such as step count, time or distance.
For example, if I was able to walk 20 minutes comfortably before needing a rest, the next week I may aim for 22 minutes, then 24 minutes, 26 minutes, etc.
An important consideration is where you exercise particularly during treatment. It is important to minimise the risk of infection, as this puts our immune system under additional strain. For this reason, swimming and use of public gyms should be either avoided or managed mindfully during chemotherapy, for example going during quiet times and cleaning equipment before each use.
Are there any types of movement that should be avoided?
Generally speaking, I would not discourage any type of movement or exercise that someone enjoys and is able to engage with consistently. Having said that, periods of intense exercise are not encouraged as they often promote a ‘boom and bust cycle’ where someone manages a small amount of intense activity, before experiencing increased fatigue burden and may feel unable to engage in further activities for the following days. Little and often is usually best when managing fatigue, for exercise and when managing any large tasks.
Depending on cancer diagnosis and treatment, there are circumstances where specific advice must be taken into account to prevent complications. For example, the removal of lymph nodes increases the risk of lymphoedema or the presence of bone metastases increases risk of pain and fracture. These clients will require support from a specialist physiotherapist or exercise specialist, to provide education and a personalised programme, to empower them to safely take control of their exercise routine.
How do you adapt exercise programmes for patients with different types or different stages of cancer or receiving different treatment (i.e. chemo, radiotherapy, surgery)?
Great question! While generally speaking, the physical activity guidance remains the same (150 minutes of moderate activity plus 2 strengthening sessions per week), this will undoubtedly vary through treatment depending on multiple factors.
After surgical treatment, you will have very clear guidance from your surgeon about when to return to physical activity (usually between 6-12 weeks). Building up gradually after surgery is important, instead of jumping straight back into your previous routine!
During chemotherapy treatment, it can be helpful to keep a diary of your symptoms, to find a routine that will suit you. For example, you may notice you feel fatigued or nauseous after treatment which eases after four days, therefore gentle stretching during the first four days after treatment followed by a walking regime with strengthening exercises on the following days, may be the best option for you.
During and after radiotherapy, you may experience fatigue and localised symptoms in the area. For example, if having radiotherapy to the chest area, it may be helpful to avoid upper limb strengthening exercise until inflammation settles and focus on gentle upper limb movement and lower limb strengthening, such as walking or static cycling.
How do your recommendations differ for someone receiving curative chemo vs palliative chemo?
My general advice is the same in terms of encouraging and empowering as much physical activity as possible. The main difference is shifting the focus towards quality of life and symptom control. Having worked with palliative care clients for over 8 years, I feel strongly that working together on physical goals is so important. It allows me to build a strong rapport with my clients in order to have more sensitive conversations about their holistic wellbeing and advance care planning. Having these difficult conversations with respect, trust and mutual understanding allows me to ensure their wishes and needs are met and advocate for clients where needed.
I have watched clients achieve incredible physical goals in their last weeks and months, for example, completing a 10k race, returning to play a full 18 holes of golf, conquering a tough summit to see their favourite view or walking down the aisle to marry the love of their life. These have been some of the true highlights of my career and I consider it an absolute privilege to support clients during such an important time.
Palliative care has been changing rapidly over recent years due to constant progress in modern medicine meaning treatment options and life expectancy are improving compared to previous decades. Palliative care no longer represents only end of life care and many of my clients having palliative treatment live for many years with good physical health.
Should cancer patients be getting the go ahead from their GP/Oncologist before making exercise a part of their routine?
Generally speaking, I would encourage my clients to have discussed exercise with their oncologist and getting written permission to progress. Occasionally, I have clients who find their oncologist or GP is unable to give specific advice for their circumstance and will be told to avoid exercise to prevent any complications. Unless there is a clear reason to avoid exercise, this unfounded advice can have a big impact on quality of life and health outcomes. In these cases, I may speak directly to the oncologist or use the patient’s medical information and scan results to guide clinical reasoning and personalised advice. Anyone going through cancer treatment can benefit from regular physical activity, so we should not be discouraging anyone from exercise unless we can give a clear reason why.
Historically, cancer patients were encouraged to rest in bed throughout treatment. Although we now know this has a detrimental impact on outcomes and health professionals generally encourage physical activity within cancer care, there are still many health professionals who feel unconfident to give the right advice.
What positive impact have you seen movement have on patients receiving cancer treatment? Maybe that could be both physically and mentally.
I strongly believe that our physical and psychological health cannot be entirely separated. There is a correlation between strength of body and mind. Cancer treatment is one the biggest tests of both and will have a significant impact on your physical and psychological health. Using exercise and movement to feel in control and to look after yourself is an accessible and important part of treatment.
Can you share 3 simple exercises that someone receiving cancer treatment could do at home to stay active during treatment?
This is a tricky question, as there are so many beneficial exercises and exercise types!
Taking it back to basics, we should aim to include a push, a pull and leg exercise. For example, high level could be body weight squats, full push ups and tricep dips or lower level could be sit-to-stands, wall push ups and resistance band rowing.
Do you have any advice on how a friend or family member could support and encourage someone receiving treatment to stay active?
Having the support of friends and family can be so helpful when aiming to stay active; it can provide comradery, accountability, encouragement, reassurance and motivation. Whether it’s joining your loved one on regular walks or attending a group session together. Aim to support them with compassion and with joint goals, rather than being prescriptive or dictatorial!
How does movement and exercise support long term recovery and survivorship in cancer patients?
Exercise is an essential part of long-term recovery and survivorship. The aim of cancer treatment is to eradicate cancer and to restore body function. Research tells us that exercise helps to significantly reduce the risk of 13 cancers, including breast cancer (Moore et al, 2016). Therefore, exercise is an essential aspect of survivorship to support full recovery and prevent cancer recurrence. Due to the growing evidence base, exercise is considered by some as another form of cancer treatment and should be prescribed in the same way as medications.
What have you learnt from working with cancer patients that has surprised you the most?
People’s resilience in the face of adversity never fails to amaze and inspire me. The body’s true ability to surpass expectations is also amazing, when the body and mind are aligned. I will never say never!
What misconceptions do people often have about exercise during cancer treatment?
The number one thing I get asked is “is it safe to exercise?”. This also comes off the back of the historical narrative that exercise causes damage and the best option is to rest in bed to avoid any complications. We know now that this advice is actually damaging in itself, because it allows the body to decondition and not achieve the best treatment outcomes. Research tells us time and time again that exercise is an important part of cancer care. As mentioned, some even call it “the 6th cancer treatment”.
Dr Prue Cormie said: “If the effects of exercise could be encapsulated in a pill, it would be prescribed to every cancer patient worldwide and viewed as a major breakthrough in cancer treatment. If we had a pill called exercise it would be demanded by cancer patients, prescribed by ever cancer specialist, and subsidised by the government.”
What advice would you give to someone newly diagnosed with cancer regarding movement?
Don’t be afraid of movement, it will do you more good than harm.
Find a balance between movement and rest that works for you.
Never suffer in silence and ask for help when you need it.
Stay strong!
Hannah
References:
Moore SC et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016 Jun 1;176(6):816-25.