Exercise and Cancer
What is cancer?
Cancer is the growth of abnormal cells. Cancer can arise from any of our organs or body structure that are composed of tiny cells that has lost its abilities to stop growing. In other words, cancer is the inability of immune cells of the body to identify and destroy the transformation of a normal cell into a cancerous cell as they grow in numbers (1). The risk of cancer increases when the immune system is suppressed by old age, chronic stress, chronic diseases, previous use of chemotherapy or abuse of drugs such as antibiotics, corticosteroids or analgesics.
Cancer cell continue to grow unless it is removed through surgery, chemotherapy, radiotherapy or if the cancer cells shrink and disappear on its own (this is extremely rare but it is possible). Cancer treatments causes profound debilitation that leads to fatigue, decrease in physical function and impaired quality of life(2). Currently, only a third of breast cancer survivors have the aerobic capacity that is above what is required for functional independence (3) and other cancer survivors were observed to have decreased in aerobic capacity by 10-33% after over a 12-week period of chemotherapy (4-6).
How can exercise help?
Compelling evidence has shown that these declines can be minimised or prevented by exercise. Progressive program of restorative exercise during and following treatment has demonstrated with reductions in recurrence and mortality by 30-60% in colorectal and breast cancers (7-9). It has also been found to reduce or prevent negative effects after cancer treatments such as muscle weakness, fatigue, decrease in functional ability, cardiovascular capacity, body composition,neuropathy, and quality of life (2,4,10-20). For example, breast cancer survivors that engaged in weight lifting, not only strengthen their affected arm but had a lower tendency of lymphedema (16) while men with prostate cancer that were going through androgen deprivation therapy gained muscle strength, improved physical function, body composition, quality of life and reduced fatigue through exercise despite battling profound changes in skeletal muscle mass and strength from treatment (17-20).
There is a growing body of evidence that shows regular bouts of exercise (3-5hours of moderate-intensity walking/week) lead to a 30-50% reduction in the risk of cancer-specific mortality and all cause mortality as compared to patients who weren't physically active (21). Simple exercises such as walking 30 minutes 3 - 4 days/week conveys beneficial effects that can improve functional abilities (7). In addition, recent studies have reported that exercise is an effective strategy to improve psychological status such as depression, anxiety and sleep quality in lung, breast, head and neck, colorectal, ovarian and lymphoma cancer survivors during and after treatment (41-47). It has also shown beneficial effects on quality of life (48,49,50), emotional (51), social and role functioning (50) with cancer patients.
It is not surprising that patients with cancer faces the prevalence of depression given the deterioration in emotional, role and social functioning and the chances ranges from 8-24% (22). In most cases, this is where exercise can be beneficial. Regular exercise can positively impact serotonin levels in the brain (23), boosting mood, improves patients' appetite (24) and overall sense of well-being (25). Exercise emits psychological and physiological mechanisms such as thermogenic hypothesis (26), endorphin hypothesis (27,28), monoamine hypothesis (30,31), distraction hypothesis (29), and self-efficacy improvement (32,33). Exercise elevates core body temperature (26), increases release of β-endorphins (27,28), increases in the availability of brain neurotransmitters (eg. dopamine, serotonin, norepinephrine) (30,31) and these mechanisms are responsible for the reduction of depression symptoms. Exercise also serves as a distraction from depressing thoughts while enhancing of self-efficacy through exercise may be a way in which exercise serves its role in antidepressant effects (32,33).
Combining both resistance training with aerobic exercise appears to be most favourable to reduce cancer related fatigue in men with prostate cancer (34,35,36) and improve quality of life in cancer patients. (35-40). In two studies, improvements in cancer related fatigue were observed after 12 weeks of structured supervised exercise (2-3times/week) and fortnightly diet advice (17,18). On top of that, healthy eating and exercise have shown sustained improvements in cancer related fatigue at six months follow up as well (17,18). The inclusion of balance and flexibility training such as Yoga and Taichi have shown to improve quality of life and other cancer-related outcomes (53). A well balanced, structured and progressive exercise prescription with the objective to improve strength, mobility and aerobic capacity is shown to improve functionality for cancer patients in daily activities with reduced risk of falls, discomfort, pain or concerns (52).
Overall, there is growing evidence over the decade evaluating the role of exercise in an oncology setting supporting exercise implementation during and after treatment reduced morbidity, improved function and quality of life with very low risk of harm. However, it is important to note that the mode of exercise, intensity, frequency, duration and progression is dependent on cancer type and the goal of the patient. It is advisable and highly recommended to seek a health professional for the appropriate exercise prescription and dosage for cancer patient's needs to be individualised and targeted according to patient-cancer specific considerations.
Do feel free to contact us if you'll like to seek any exercise consultations specific to your condition.
Always happy to help :)
Hanahan D, Weinberg RA. Hallmarks of cancer: The next generation. Cell 2011;144:646-74.
Schmitz KH, Courneya KS, Matthews C et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine & Science in Sports & Exercise. 2010. July 1;42(7):1409–26.
Jones LW, Courneya KS, Mackey JR et al. Cardiopulmonary function and age-related decline across the breast cancer survivorship continuum. Journal of Clinical Oncology. 2012. May 21;30(20):2530–7.
Schwartz AL, Winters-Stone K, Gallucci B. Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy. Oncology Nursing Forum. 2007. May 1;34(3):627–633.
Schwartz AL, Thompson JT, Masood N. Interferon Induced fatigue In Melanoma: A pilot study of exercise and methylphenidate. Oncology Nursing Forum. 2002. August 1;29(7), web feature.
Winters-Stone KM, Dobek J, Bennett JA et al. The effect of resistance training on muscle strength and physical function in older, postmenopausal breast cancer survivors: a randomized controlled trial. Journal of Cancer Survivorship. 2012. June 1;6(2):189–99.
Irwin ML, McTiernan A, Manson JE et al. Physical Activity and Survival in Postmenopausal Women with Breast Cancer: Results from the Women’s Health Initiative. Cancer Prevention Research. 2011. April 1;4(4):522–9.
Meyerhardt JA, Heseltine D, Niedzwiecki D et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. Journal of Clinical Oncology. 2006. August 1;24(22):3535–41.
Irwin ML, Smith AW, McTiernan A et al. Influence of pre-and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. Journal of Clinical Oncology. 2008. August 20;26(24):3958–64.
Wolin KY, Schwartz AL, Matthews CE et al. Implementing the exercise guidelines for cancer survivors.The Journal of Supportive Oncology. 2012. September;10(5):171.
Moore SC, Lee IM, Weiderpass E et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA internal medicine. 2016. June 1;176(6):816–25.
Bea JW, De Heer HD, Schwartz AL. Symptom Management: Weight Gain In: Supportive Cancer Care2016. (pp. 241–269). Springer International Publishing.
Winters-Stone KM, Dobek J, Nail L et al. Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Breast cancer research and treatment. 2011. June 1;127(2):447–56.
Winters‐Stone KM, Schwartz AL et al. A prospective model of care for breast cancer rehabilitation: bone health and arthralgias. Cancer. 2012. April 15;118(S8):2288–99.
Schmitz KH, Ahmed RL, Troxel A et al. Weight lifting in women with breast-cancer–related lymphedema. New England Journal of Medicine. 2009. August 13;361(7):664–73.
Schmitz KH, Troxel AB, Cheville A et al. Physical Activity and Lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemporary clinical trials. 2009. May 31;30(3):233–45.
Bourke L, Doll H, Crank H et al. Lifestyle intervention in men with advanced prostate cancer receiving androgen suppression therapy: a feasibility study. Cancer Epidemiology and Prevention Biomarkers. 2011. February 18;20(4):647–57.
Bourke L, Gilbert S, Hooper R et al. Lifestyle changes for improving disease-specific quality of life in sedentary men on long-term androgen-deprivation therapy for advanced prostate cancer: a randomised controlled trial. European Urology. 2014. May 31;65(5):865–72.
Cormie P, Galvão DA, Spry N et al. Can supervised exercise prevent treatment toxicity in patients with prostate cancer initiating androgen‐deprivation therapy: a randomised controlled trial. BJU International. 2015. February 1;115(2):256–66.
Galvão DA, Spry N, Denham J et al. A multicentre year-long randomised controlled trial of exercise training targeting physical functioning in men with prostate cancer previously treated with androgen suppression and radiation from TROG 03.04 RADAR. European urology. 2014. May 31;65(5):856–64.
Van Blarigan EL, Meyerhardt JA (2015) Role of physical activity and diet after colorectal cancer diagnosis. J Clin Oncol 33(16): 1825–1834. 10.1200/JCO.2014.59.7799
Krebber A.M., Buffart L.M., Kleijn G. Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psychooncology. 2014;23:121–130. doi: 10.1002/pon.3409.
Yuan T.-F., Paes F., Arias-Carrión O., Rocha N.B.F., Filho A.S.D.S., Machado S. Neural Mechanisms of Exercise: Anti-Depression, Neurogenesis, and Serotonin Signaling. CNS Neurol. Disord. Drug Targets. 2015;14:1307–1311. doi: 10.2174/1871527315666151111124402.
Yeh S.-H., Lin L.-W., Chuang Y.K., Liu C.-L., Tsai L.-J., Tsuei F.-S., Lee M.-T., Hsiao C.-Y., Yang K.D. Effects of Music Aerobic Exercise on Depression and Brain-Derived Neurotrophic Factor Levels in Community Dwelling Women. BioMed Res. Int. 2015;2015:135893. doi: 10.1155/2015/135893.
Bedillion M.F., Ansell E.B., Thomas G.A. Cancer treatment effects on cognition and depression: The moderating role of physical activity. Breast. 2019;44:73–80. doi: 10.1016/j.breast.2019.01.004.
deVries H.A. Tranquilizer effects of exercise: A critical review. Phys. Sportsmed. 1981;9:46–55. doi: 10.1080/00913847.1981.11711206.
Johnsgard K.W. The Exercise Prescription for Anxiety and Depression. Plenum Publishing; New York, NY, USA: 2020.
Morgan W.P. Affective beneficience of vigorous physical activity. Med. Sci. Sports Exerc. 1985;17:94–100. doi: 10.1249/00005768-198502000-00015.
Leith L.M. Foundations of Exercise and Mental Health. Fitness Information Technology; Morgantown, WV, USA: 1994
Dishman R.K. Physical Activity and Mental Health. Taylor & Francis; Washington, DC, USA: 1997. The norepinephrine hypothesis.
Ebert M.H., Post R.M., Goodwin F.K. Effect of physical activity on urinary MHPG excretion in depressed patients. Lancet. 1972;2:766. doi: 10.1016/S0140-6736(72)92064-8.
Bandura A. Self-Efficacy: The Exercise of Control. WH Freeman & Company; New York, NY, USA: 1997.
Martinsen E.W. Benefits of exercise for the treatment of depression. Sports Med. 1990;9:380–389. doi: 10.2165/00007256-199009060-00006.
Cormie P., Galvao D.A., Spry N., Joseph D., Chee R., Taaffe D.R., Chambers S.K., Newton R.U. Can supervised exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: A randomised controlled trial. BJU Int. 2015;115:256–266. doi: 10.1111/bju.12646.
Galvao D.A., Taaffe D.R., Spry N., Joseph D., Newton R.U. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: A randomized controlled trial. J. Clin. Oncol. 2010;28:340–347. doi: 10.1200/JCO.2009.23.2488.
Hojan K., Kwiatkowska-Borowczyk E., Leporowska E., Górecki M., Ozga-Majchrzak O., Milecki T., Milecki P. Physical exercise for functional capacity, blood immune function, fatigue, and quality of life in high-risk prostate cancer patients during radiotherapy: A prospective, randomized clinical study. Eur. J. Phys. Rehabil. Med. 2016;52:489–501.
Santa Mina D., Alibhai S.M., Matthew A.G., Guglietti C.L., Pirbaglou M., Trachtenberg J., Ritvo P. A randomized trial of aerobic versus resistance exercise in prostate cancer survivors. J. Aging Phys. Act. 2013;21:455–478. doi: 10.1123/japa.21.4.455.
Segal R.J., Reid R.D., Courneya K.S., Malone S.C., Parliament M.B., Scott C.G., Venner P.M., Quinney H.A., Jones L.W., et al. Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. J. Clin. Oncol. 2003;21:1653–1659. doi: 10.1200/JCO.2003.09.534.
Segal R.J., Reid R.D., Courneya K.S., Sigal R.J., Kenny G.P., Prud’Homme D.G., Malone S.C., Wells G.A., Scott C.G., Slovinec D’Angelo M.E. Randomized controlled trial of resistance or aerobic exercise in men receiving radiation therapy for prostate cancer. J. Clin. Oncol. 2009;27:344–351. doi: 10.1200/JCO.2007.15.4963.
Galvao D.A., Spry N., Denham J., Taaffe D.R., Cormie P., Joseph D., Lamb D.S., Chambers S.K., Newton R.U. A multicentre year-long randomised controlled trial of exercise training targeting physical functioning in men with prostate cancer previously treated with androgen suppression and radiation from TROG 03.04 RADAR. Eur. Urol. 2014;65:856–864. doi: 10.1016/j.eururo.2013.09.041.
Taso C.-J., Lin H.-S., Lin W.-L., Chen S.-M., Huang W.-T., Chen S.-W. The Effect of Yoga Exercise on Improving Depression, Anxiety, and Fatigue in Women with Breast Cancer: A randomized controlled trial. J. Nurs. Res. 2014;22:155–164. doi: 10.1097/jnr.0000000000000044.
Chen H.M., Tsai C.M., Wu Y.C., Lin K.C., Lin C.C. Randomised controlled trial on the effectiveness of home-based walking exercise on anxiety, depression and cancer-related symptoms in patients with lung cancer. Br. J. Cancer. 2015;112:438–445. doi: 10.1038/bjc.2014.612.
Avancini A., Sartori G., Gkountakos A., Casali M., Trestini I., Tregnago D., Bria E., Jones L.W., Milella M., Lanza M., et al. Physical Activity and Exercise in Lung Cancer Care: Will Promises Be Fulfilled? Oncologist. 2019;25:e555–e569. doi: 10.1634/theoncologist.2019-0463.
Samuel S.R., Maiya A.G., Fernandes D.J., Guddattu V., Saxena P.U.P., Kurian J.R., Lin P.-J., Mustian K.M. Effectiveness of exercise-based rehabilitation on functional capacity and quality of life in head and neck cancer patients receiving chemo-radiotherapy. Support. Care Cancer. 2019;27:3913–3920. doi: 10.1007/s00520-019-04750-z.
Zhang Q., Li F., Zhang H., Yu X., Cong Y. Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial. Int. J. Nurs. Stud. 2018;78:52–60. doi: 10.1016/j.ijnurstu.2017.08.010.
Kim J.Y., Lee M.K., Lee D.H., Kang D.W., Min J.H., Lee J.W., Chu S.H., Cho M.S., Kim N.K., Jeon J.Y. Effects of a 12-week home-based exercise program on quality of life, psychological health, and the level of physical activity in colorectal cancer survivors: A randomized controlled trial. Support. Care Cancer. 2019;27:2933–2940. doi: 10.1007/s00520-018-4588-0.
Liu L., He X., Feng L. Exercise on quality of life and cancer-related fatigue for lymphoma survivors: A systematic review and meta-analysis. Support. Care Cancer. 2019;27:4069–4082. doi: 10.1007/s00520-019-04983-y.
Cho I., Son Y., Song S., Bae Y.J., Kim Y.N., Kim H.-I., Lee D.T., Hyung W.J. Feasibility and Effects of a Postoperative Recovery Exercise Program Developed Specifically for Gastric Cancer Patients (PREP-GC) Undergoing Minimally Invasive Gastrectomy. J. Gastric Cancer. 2018;18:118–133. doi: 10.5230/jgc.2018.18.e12.
Choi J.Y., Kang H.S. Effects of a Home-based Exercise Program for Patients with Stomach Cancer Receiving Oral Chemotherapy after Surgery. J. Korean Acad. Nurs. 2012;42:95–104. doi: 10.4040/jkan.2012.42.1.95.
Argudo N., Rodó-Pin A., Martínez-Llorens J., Marco E., Visa L., Messaggi-Sartor M., Balañá-Corberó A., Ramón J.M., A Rodríguez-Chiaradía D., Grande L., et al. Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: An interventional pilot study. Dis. Esophagus. 2020;34:doaa086. doi: 10.1093/dote/doaa086.
Rawla P., Barsouk A. Epidemiology of gastric cancer: Global trends, risk factors and prevention. Gastroenterol. Rev. 2019;14:26–38. doi: 10.5114/pg.2018.80001.
Chang J.T. Morton S.C. Rubenstein L.Z. et al Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004; 328: 680
Danhauer S.C. Addington E.L. Sohl S.J. et al.Review of yoga therapy during cancer treatment. Support Care Cancer. 2017; 25: 1357-1372