Based on experience, bloggers can provide a playbook of sorts for those navigating the cancer continuum, including end of life care. Having been a friend of Guy’s (one of many around the world) and a visitor/observer during his last New Year’s weekend, IMHO, his family wrote an indelible chapter for that playbook. May we all be so lovingly attended to.
Guy, center-right in vintage Nike gear, 1980 prior to World Cross Country Championships, Longchamp racecourse, Paris, France.
Great runner, cancer foundation, exercise-oncology researcher, and cancer institute. Please support!
Thank you!
Source: GRETE’S PLACE
Exercise is good for the immune system but what about high volume, high intensity, chronic (long-term) exercise? For cancer patients, a couple of things may be worth considering, but first a few things about immune cells. In a general sense, cancer is a failure of the immune system to detect and eliminate defective cells, or maybe more accurately, the ability of cancer cells to evade detection from immune cells.
Two categories of immune cells are: innate immune cells; and, adaptive immune cells. Natural Killer cells (NK cells) are a part of the innate immune system and they respond quickly to tumor formation and virally infected cells. T-cells are a part of the adaptive immune system. T-cells remember previous invaders, and cancer, and respond faster the second time to the same invader. Moderate intensity exercise and life long aerobic fitness improves aspects of both of these immune cell types. However, high volume, high intensity, long-term extreme exercise can have negative effects (1,2).
A study (3) followed Ironman competitors training for 6 months prior to the event and for a few weeks afterwards. The researchers found that by the end of study period the ratio of some T-cell subtypes changed to a composition that an older person is more likely to have. Naive T-cells, which are highly responsive mature T-cells, decreased, while terminally differentiated T-cells (senescence) increased. Terminally differentiated T-cells are not as ‘nimble’ as naive T-cells in responding to invaders, and the ratio between the two can change as one ages – more terminally differentiated T-cells accumulate and less naive T-cells are found. This change is thought to make the elderly more susceptible to infections. However, increasing aerobic fitness can lower the proportion of age-related senescent T-cells and increase naive T-cells, regardless of age (4), but maybe only to a point, as elite endurance athletes are known to get more upper respiratory infections and changes in immune cells are thought to play a role in this (5).
Another piece in this exercise puzzle is a virus, Cytomegalovirus (CMV). CMV is a common herpes virus infecting approximately 50% of American adults, and that percentage increases with age. CMV affects the exercise response of NK cells, increasing their numbers and cytotoxicity (killing ability). However, that changes at exercise intensities eliciting a blood lactate concentration of 4 millimoles, which is about +15% of the blood lactate threshold (as defined by Weltman, A., 1995). This is an intensity that many endurance athletes periodically train at in order to improve performance – tempo runs for marathon runners are an example. After exercise that induces 4 millimoles blood lactate, NK cell numbers and cytotoxicity are decreased, but not in healthy individuals, only in CMV infected individuals, and regardless of sex (6).
So what does this mean for cancer patients wanting to do a triathlon, marathon, or ultra? Right now there isn’t enough evidence to change the general American College of Sports Medicine (ACSM) guidelines of 150 minutes per week of moderate intensity exercise or 75 minutes per week of vigorous exercise. Although a recent breast cancer study (7) found that 300 minutes per week of moderate intensity exercise was best for post-menopausal breast cancer patients who were not on hormones. Surprisingly, another study found that higher levels of cardiorespiratory fitness was associated with higher risk of prostate cancer (8), the CMV status of those subjects was not reported and may not be known. Outside Magazine recently did an article (9) on the deleterious effects ultra-marathons has had on some participants. Perhaps CMV status or changes in T-cell proportions may be emerging as important markers to follow. Exercise can help protect us against infection and fight tumors but that does not also mean greater amounts of exercise is better. Until more evidence is presented, the ACSM exercise recommendations, as generic as they are, appear to be about right for cancer patients, and maybe particularly for those who are CMV positive.
For more in-depth information about exercise and immunity, a couple of recent articles are worth reading (10,11,12), if you can get full access (12).
The impact of 6-month training preparation for an Ironman triathlon on the proportions of naïve, memory and senescent T cells in resting blood. Coagrove, C., et al. Eur J Appl Physiol (2012) 112:2989–2998.
Aerobic fitness is associated with lower proportions of senescent blood T-cells in man. Spielmann, G., et al. Brain, Behavior, and Immunity 25 (2011) 1521–1529.
Acute exercise preferentially redeploys NK-cells with a highly-differentiated phenotype and augments cytotoxicity against lymphoma and multiple myeloma target cells. Part II: Impact of latent cytomegalovirus infection and catecholamine sensitivity. Bigley, A.B., et al. (Article in Press) Brain, Behavior, and Immunity xxx (2015) xxx–xxx.
Effects of a High vs Moderate Volume of Aerobic Exercise on Adiposity Outcomes in PostmenopausalWomen. A Randomized Clinical Trial. Friedenreich C.M., et al., JAMA Oncol. doi:10.1001/jamaoncol.2015.2239.
Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men. The Cooper Center Longitudinal Study. Lakoski, S.G., et al., JAMA Oncol. 2015;1(2):231-237. doi:10.1001/jamaoncol.2015.0226.
A recent study (1) found that a high level of cardiorespiratory fitness (CRF) was associated with an increased risk for localized prostate cancer. The reasons for this are unknown. The researchers speculate that perhaps this group was more likely to undergo preventative screening or detection. However, higher CRF still showed a 32% decreased risk of cancer specific death for lung, colorectal, or prostate cancers; or 68% decreased risk of death from cardiovascular disease (CVD). Note: some cancer treatments can be toxic to the heart.
From: Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men: The Cooper Center Longitudinal Study.
Lakoski, S.G., et al. JAMA Oncol. 2015;1(2):231-237
Figure Legend: Cardiorespiratory Fitness (CRF) and Risk of Incident Lung, Colorectal, and Prostate Cancer. The low CRF group is the referent group relative to moderate and high fitness. The error bars for moderate and high fitness represent the 95% confidence limits. Adjusted for age, examination year, body mass index, smoking, total cholesterol level, systolic blood pressure, diabetes mellitus, and fasting glucose level.
The authors distinguish CRF from physical activity (I believe research data for both could be provided by valid and reliable activity trackers):
“Cardiorespiratory fitness is also highly reproducible and objectively assessed via incremental exercise tolerance testing compared with physical activity, which is largely determined by self-report questionnaires [and/or activity trackers?]. A prior study demonstrated that CRF is be a more potent marker of mortality than physical activity. As such, given the current study findings and prior evidence, we contend that measurement of CRF should be used more frequently in the cancer prevention setting.”
I agree. Furthermore, I would like to see physical activity, CRF, or aerobic capacity assessed when the cancer diagnosis process begins. How beneficial would it be to tie fitness to an actual biopsy tissue specimen? It’s interesting that CRF in the Cooper Clinic Longitudinal Study was assessed by the duration of performance achieved on a maximal treadmill test (2). Then, based on subjects’ performance time, maximal oxygen uptake (VO2max) and maximal METs achieved were estimated, not measured. If estimates can be used to assess CRF then it’s possible that some activity trackers could also be used. Granted, screening patients before a CRF test is recommended, but some activity tracking data may already provide an adequate assessment of CRF. A few devices already assess VO2max using heart rate, and with acceptable errors (for field measurements) in the 6-7% range (11, 12). Stratifying data from activity trackers may be an important part of sorting its value: data for showing a training effect requires good accuracy; less accurate data is probably acceptable to assess CRF; and, data for tracking physical activity volume (MET-hours per week, etc.) can perhaps be the least precise of these – particularly since current population research using questionnaires tends to overestimate actual physical activity (13).
In discussing limitations of their study the authors mention something I believe may be significant for exercise-oncology research, and which I think validated activity trackers may be able to provide data for:
“CRF was assessed years prior to a diagnosis of lung, colorectal, or prostate cancer or death in men diagnosed as having cancer. Thus, it is not known how changes in CRF and related behaviors, such as physical activity from the initial preventive health care to cancer diagnosis as well as changes in CRF and physical activity after diagnosis, may have had an impact on these current findings.”
I believe that exercise during the time from cancer diagnosis until first treatment will be found to have a positive impact on cancer treatments, treatment side effects, and on survival. Sophisticated activity trackers that also estimate VO2max, or measure heart rate variability (HRV), which is related to CVD, have the potential to provide data in and around the diagnosis/treatment time period. Furthermore, they can provide data across more cancer types by doing it in a more cost-effective manner than mailing out questionnaires or doing a CRF test on every cancer patient. One overlooked benefit of activity trackers is that consumers subsidize the data.
Some useable physical activity data already exists in activity tracking databases but sits there underutilized. Most physical activity data needs standard medical codes to improve its interoperability. Other data could be retooled by correcting METs, which could provide more accurate estimates of energy expenditure (4, 5, 6, 7, 8), population specific intensity levels (9, 10), and might influence adherence to exercise training programs. Regarding METs, an issue for some researchers is that the ‘standard’ MET (3.5 ml oxygen/kg/min) was based on the measurements derived from one 70 kilogram, 40-year-old man (5), and then applied to survey research. Conversely, some activity trackers use ‘standard’ MET values from the Compendium of Physical Activities, which are intended for survey research, to estimate the energy expenditure and exercise intensity for an individual, which the Compendium advises is not its intended purpose.
Besides valid data, another issue activity trackers face is how should data be displayed or reported within an Electronic Health Record (EHR)? Doctors are already over-worked and many complain about the burden of EHRs, adding physical activity data to their workload and expecting them to do something proactive with it (without reimbursement too) is not going to happen. Make physical activity data easy for doctors to accommodate: summarize activity tracker data into an indicator of ‘compliance‘ or ‘non-compliance‘ with recommended physical activity guidelines, and provide that to an EHR. For research, and for the more inquisitive and less time constrained physician, the underlying data supporting a compliance indicator could be accessible via EHR patient portals (e.g. EPIC’s MyChart).
Finally, a new study (3) found the ActiGraph GT3X+ accelerometer not to be very accurate at low and moderate intensity levels. Of the few validation studies done on accelerometer based activity trackers, some were validated against the Actigraph as the criterion measure. However, this study itself also missed an opportunity for better measurement when they estimated Resting Metabolic Rate (RMR) using the Schofield equations rather than measuring it with the Oxycon Mobile system they had – RMR is essentially what 1 MET is. The study’s authors do disclose that they have receive funding support from Bodymedia, which Jawbone recently bought.
There is more to be sorted out in the consumer fitness/activity tracking eco-space. I think devices and apps that produce valid and reliable data can make an impact in exercise-oncology research, particularly in the time periods surrounding diagnosis and treatment.
1. Lakoski, S.G., et al. Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men The Cooper Center Longitudinal Study. JAMA Oncol. 2015;1(2):231-237. doi:10.1001/jamaoncol.2015.0226
2. Pollock ML, Bohannon RL, Cooper KH, et al. A comparative analysis of four protocols for maximal treadmill stress testing. Am Heart J. 1976; 92(1):39-46.
3. Kim, Y., Welk G.J. Criterion Validity of Competing Accelerometry-based Activity Monitoring Devices. Med. Sci. Sports Exerc. 2015 Apr 23. [Epub ahead of print]
4. McMurray, R.G., et al. Examining Variations of Resting Metabolic Rate of Adults: A Public Health Perspective. Med. Sci. Sports Exerc., Vol. 46, No. 7, pp. 1352–1358, 2014.
5. Byrne, N., et al. Metabolic equivalent: one size does not fit all. J Appl Physiol 99: 1112–1119, 2005.
6. Kozey, S., et al. Errors in MET Estimates of Physical Activities Using 3.5 ml·kg–1·min–1 as the Baseline Oxygen Consumption. Journal of Physical Activity and Health, 2010, 7, 508-516.
7. Wilms, B., et al. Correction factors for the calculation of metabolic equivalents (MET) in overweight to extremely obese subjects. International Journal of Obesity (2014) 38, 1383–1387.
8. Hall, K., et al. Activity-Related Energy Expenditure in Older Adults: A Call for More Research. Med Sci Sports Exerc 2014 Dec;46(12):2335-40.
9. Blair, C.K., et al. Light-Intensity Activity Attenuates Functional Decline in Older Cancer Survivors. Med Sci Sports Exerc 2014 Jul;46(7):1375-83.
10. Herzig, K-H, et al. Light physical activity determined by a motion sensor decreases insulin resistance, improves lipid homeostasis and reduces visceral fat in high-risk subjects: PreDiabEx study RCT..International Journal of Obesity (2014), 1–8
11. Montgomery, P.G., et al. VALIDATION OF HEART RATE MONITOR–BASED PREDICTIONS OF OXYGEN UPTAKE AND ENERGY EXPENDITURE. Journal of Strength and Conditioning Research 23(5)/1489–1495.
12. Lebouf, SF., et al. Earbud-based sensor for the assessment of energy expenditure, HR, and VO2max. Med Sci Sports Exerc 2014;46(5):1046-52.
13. A systematic review of reliability and objective criterion-related validity of physical activity questionnaires. International Journal of Behavioral Nutrition and Physical Activity 2012, 9:103 pgs 1-55.
Yep, there are issues with activity trackers. Just because a tracker may have a well-known name doesn’t mean it is accurate, or accurate for all activity measures. And just because a tracker says it measures variable “X” doesn’t mean it is measured accurately. Very few activity trackers and fitness apps have been validated, and if they have, results may not match the assertions marketed by the product developers.
Most activity tracker data is not yet ready for entry into Electronic Health Records (EHRs). First, products need to be validated, then their measures need to have standard codes (LOINC, SNOMED, UCUM) attached to them before the data should be accepted into EHRs or research databases. For some unknown reason, exercise stakeholders lag far behind other key adopters of health IT codes (‘big” labs, all health-related federal agencies, care organizations, insurance companies, EHR vendors, and Health Information Exchanges; source: LOINC) in utilizing the codes for the variables they measure.
Regarding validation studies, I applaud FirstBeat for their extensive listing of studies on, or using, their products/technology (I receive no compensation nor am I an investor or currently an owner of a FirstBeat product). It’s often difficult just to find out how a fitness app or activity tracker measures (estimates) calories – which equation is used, and equations are misused e.g. Resting Metabolic Rate (RMR) for Basal Metabolic Rate (BMR). Simple errors like this can contribute 10-20% overestimation of calories and energy expenditure (1).
Furthermore, RMR can vary significantly with gender, age, or obesity (2,3,4,5). However, most physical activity observational studies, which is what activity trackers are suited for, still use the ‘standard’ MET (Metabolic Equivalent) oxygen value of 3.5 ml/kg/min as RMR. This RMR few adults have, most are significantly lower (2,3,4,5). Since the ‘standard’ MET is widely used in observational studies, and most of those studies use questionnaires that have their own validity issues (6), accuracy can vary significantly from an MET that was actually measured in a lab.
Activity trackers have the potential to gather more accurate physical activity measures compared to the same measures gathered from patient reported questionnaires. This can be a good thing for observational research. However, if activity trackers also defer to the ‘standard’ MET, use metabolic equations incorrectly, are not validated, do not attach their measures to standard health IT codes, and importantly, if EHRs, researchers, and users do not demand that they do, then tapping into their research potential will be delayed.
References:
1. Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, Amino Acids. IOM 2005; page 112.
2. Metabolic equivalent: one size does not fit all. J Appl Physiol 99: 1112–1119, 2005.
3. Examining Variations of Resting Metabolic Rate of Adults: A Public Health Perspective. Med. Sci. Sports Exerc., Vol. 46, No. 7, pp. 1352–1358, 2014.
4. Errors in MET Estimates of Physical Activities Using 3.5 ml·kg–1·min–1 as the Baseline Oxygen Consumption. Journal of Physical Activity and Health, 2010, 7, 508-516.
5. Correction factors for the calculation of metabolic equivalents (MET) in overweight to extremely obese subjects. International Journal of Obesity (2014) 38, 1383–1387.
6. A systematic review of reliability and objective criterion-related validity of physical activity questionnaires. International Journal of Behavioral Nutrition and Physical Activity 2012, 9:103 pgs 1-55.
This video is how I see exercise data in oncology. Of all the training I’ve done, which I recorded but which no one else did, and of all my data sitting in Garmin, Moves, RunKeeper, Moov, and MiFitLife databases, not one byte of it is in my EHR (Electronic Health Record). However, during my stay in a hospital isolation ward for my allogeneic stem cell transplantation (donor HSCT) my bowel movements were recorded and entered into my EHR. Exercise affects gut microbiota (bacteria) and immune function (1), and diversity of gut microbiota correlates to improved survival from a donor HSCT (2). Did the exercise I did prior to and throughout my stem cell transplantation preserve my gut microbes, affecting my immune system, which helped me breeze through stem cell transplantation? Who knows? But since the data for all this exists, it sure would be nice if it were gathered together in the same place (EHR) in order for me and other patients to find out.
At home, my treadmill is Bluetooth compatible, but none of the workout miles I’ve done on it are in my EHR either.
Outside, sigh … you get the picture. Fitbit, Nike, Jawbone, Garmin, or ‘fitness this’ and ‘fitness that’ app/device, please do not spend one more dime on another advertisement touting your latest model or bells and whistles. Instead, hire more (or better) IT people proficient in medical coding/HIT, exercise science, and data interoperability, and free our data from your proprietary databases so that it can be used, if we agree, within EHRs for research. Looking at a graph of the last few months of my training does not benefit others, no matter how inspiring some may think my training to be. We are losing too many people like Laurie Becklund, and activity tracker data on us may be significant toward improving survival from cancer. Exercise decreases cancer metastasis, in mice studies anyway (3, 4, 5). Is the data right at our wrists for metastatic significance in humans?
ResearchKit, can data flow back into subjects’ EHRs? Exercise researchers, how much of the study data generated from subjects goes back to them so that it can enter their EHR? EHR vendors, do your patient portals even accommodate exercise data should it become useable? National Coalition for Cancer Survivorship, can we improve the Journey Forward, Survivorship Care Plan tool’s small section on exercise and populate it with valid activity tracker data similarly to how it is populated with cancer registry data?
This is not rocket science, neither is it a billion dollars in new drug development that marginally improves survival for a few months, this is already here, we just have to capture it in ways that can actually be used to save lives.
There’s a lot of interest in tracking physical activity, ranging from simple weight loss tools to more high-tech gadgets for mountain climbing or ultra-endurance events. Altitude, distance, speed, calories, heart rate, steps, type of activity, intensity, and even time spent sitting, are just some of the variables being recorded. Smartphone ‘apps’, watches/bands, heart rate straps, pocket/clip-on devices, ear buds, and web-based diaries are able to collect these variables. However, few of these devices, including ‘apps’, have been validated – scientifically tested for accuracy against a criterion (standard). This is important if we want to use consumer fitness data (Patient-Generated Health Data – PGHD) for more than just personal curiosity, which typically wanes after a few months. If you haven’t validated your device, do it. If you fear the results, then improve your product so that it accurately records valid fitness measures.
For exercise-oncology research, and exercise research in general, in many ways PGHD from validated activity trackers can be more accurate than Patient Reported Outcomes from validated questionnaires. Either way, data comes from patients, but some fitness trackers are as accurate as the criterion (6). This I like because it will require other fitness trackers to improve accuracy. Developers unwilling to validate and improve their device will be relegated to the Big Data sidelines, if they survive at all. Regardless of how sophisticated and proprietary a devices sensors are, most end measures will be the same as from other devices – energy expenditure – kcal, estimated VO2, METs. No longer should an app be able to use a metabolic equation inaccurately and have their data be relevant.
Validated activity trackers have the potential to expand physical activity related observational research to every Electronic Health Record (EHR) – this is a big number, over a billion, which is much larger than the fitness geek marketplace. For small population cancer types, which get little, or no, exercise research due to their inability to recruit enough patients from single or multiple healthcare facilities, this could do wonders for statistical power. Might we find similar benefits for exercise among other cancer types as have been found in brain, breast, colorectal, and prostate cancers? Will we discover more information about intensity, duration, frequency, and type of exercise regarding proximity to diagnosis and treatment?
For cancer patients, having our physical activity automatically tracked, medically coded, encrypted, summarized, and made available for upload into our EHRs, this may be the least invasive thing involving our body, and with the lowest cost per survival outcome.
1. The microbiota: an exercise immunology perspective. Bermon, S., et al. Exercise Immunology Review 2015;21:70-9.
2. The effects of intestinal tract bacterial diversity on mortality following allogeneic hematopoietic stem cell transplantation. Taur, Y., el al. Blood, 14 August 2014 x Volume 124, Number 7.
3. Effects and potential mechanisms of exercise training on cancer progression: A translational perspective. Allison S. Betoff, Mark W. Dewhirst, Lee W. Jones. Brain, Behavior, and Immunity 2013 Mar;30 Suppl:S75-87.
4. Exercise modulation of the hosttumor interaction in an orthotopic model of murine prostate cancer. Jones, LW., et al. J Appl Physiol (1985). Jul 15, 2012; 113(2): 263–272.
5. Exercise modulation of the host-tumor interaction in an orthotopic model of murine prostate cancer. Jones, LW., et al. J Appl Physiol 113: 263–272, 2012.
6. Earbud-based sensor for the assessment of energy expenditure, HR, and VO2max. Lebouf, SF., et al. Med Sci Sports Exerc 2014;46(5):1046-52.
Don’t sweat the little things!
I don’t like waiting … waiting for results, waiting in lines, waiting in traffic, or waiting for elevators. Regarding the latter, if I’m only going 1-3 flights, stairs are often quicker anyway, plus, I feel like I’m doing something pro’active’ for my health. A typical flight of stairs might be 16-20 steps, that’s 8-10 repetitions lifting my entire body weight with each leg. Do this a few times a day, all year-long, as a habit, and it can help maintain leg strength and muscle mass. Consistently taking the elevator can contribute to loss of leg strength and muscle mass. Use it or lose it – just like muscles that atrophy from lack of use while in a cast.
A hidden downside to losing muscle mass is that it can contribute to weight gain, fat weight. Muscles are good calorie burners, when used, if not used, they atrophy. If one continues eating what they normally do, they will gradually put on weight, because less of the calories consumed will being burned by muscle, so the unused calories get stored as fat. Initially, this small amount of weight may hardly be noticeable, but after a number of years it can be substantial, affecting health and quality of life. This makes climbing stairs more tiring, which can perpetuate elevator use and de-conditioning.
Major lifestyle changes, including exercising or the lack thereof, can start this way. Don’t overlook the little things in a day – like taking the stairs or shopping – embracing these small physical tasks can lead to change. Shopping provides another simple opportunity to make a small change. Park farther away from the doors rather than waiting for a spot up close, or, return your cart. This may seem trivial, and in terms of calories burned, it may be, but it helps change the habits of our mind, habits which often prevent us from getting out the door for walks or other forms of exercise.
During chemotherapy, stairs served as my unofficial barometer of drug efficacy. Prior to my cancer diagnosis I found myself getting tired after going up a single flight of stairs, my quads would burn as if I had just run up a hill. This was a big warning sign that something was wrong with me. Each day after starting chemo I would walk up stairs to see how my legs reacted, after a few days I notice a significant difference – my quads did not burn after getting to the top. I knew then that the drugs were working, they were killing the cancer and I started to regain the weight I had lost from cancer related muscle wasting (cachexia). For cancer patients with balance issues and wanting to use stairs, having someone assist you would be a good idea, certainly, use the handrail.
For those cancer patients accustom to exercising, yet finding themselves preparing for cancer treatment, in the midst treatment, or recovering from it, they might have to lower their exercise expectations. I’ve talked with a number of cancer survivors frustrated about feeling lousy during workouts, or unable to complete a workout like they could before cancer. First, I commend them for continuing to exercise throughout their cancer experience. However, cancer treatments can have a significant effect of on the body – anemia, muscle weakness from anti-inflammatory steroids, lymphedema, surgical pain and tightness, neuropathy in the hands and feet, and the yet unknown sources of treatment related fatigue. In spite of these treatment related obstacles, many cancer patients do exercise, and some quite a lot. However, returning to normal gradually, or with different strategies, may be in order rather than jumping right back into their old workout routine.
One strategy I and others have found helpful, and has long been touted by former US Olympic marathoner, Jeff Galloway, is walk/run. For me, building up to walking 4.2 miles per hour at 11% grade on my treadmill, a good workout in itself, became physically awkward, running seemed like it would be more comfortable. However, starting out running a little bit at a time was easier than trying to cover 3 miles all at once right out of the gate. I used walk/run, beginning with walking 100 meters, then running 100 meters. That soon progressed to 200 meters, 400 meters, then eventually 3 miles straight, and soon I was back to my normal running routine. Rest/exercise, coast/pedal-paddle-row, float/swim, etc., could be applied to other activities.
A number of cancer survivors have returned to the highest levels of competition as professional athletes: tennis players Ross Hutchins and Alisa Kleybanova; hockey players Mario Lemieux and Saku Koivu; major league pitchers Jon Lester and Dave Dravecky; and runner Gabe Grunewald; among many others. The fitness demands of those sports are significant, yet their bodies recovered, and so can yours, probably not to the level of those professionals, but to a level where you are not confined to the couch. Little things can add up!
I often read stories about cancer patient’s (survivor, warrior, thriver, whatever we want to be called) physical accomplishments before, during, or after treatments – marathons, triathlons, ultras, century rides – all impressive stuff, even outside the realm of cancer. The accomplishments seem understandable too, since exercise has been found to:
Interestingly, more exercise did not reduce risk any further in the breast (1) or brain cancer studies. However, for their results, the brain cancer subjects had to exceed the recommended physical activity levels (6) of 150 minutes of moderate intensity exercise per week. Walking was also as good as running in the brain cancer study, subjects just had to walk farther.
What does this all mean for those of us affected by cancer? Well, for the cancers mentioned above, if you’re not moving at the levels showing significance, perhaps it is time to get clearance from your physician, and start. Practically, make exercise or physical activity a part of your weekly schedule. It is easy to fill up your calendar with other things and people but forget to plan you into your week. Take a good look at your week, find days and times that work best to accomplish what you want, then write you into those time slots, and keep the appointment. Book others to meet with you if needed, guilt can be the right motivator sometimes.
Hypothetically, what if completing an Ironman Triathlon improved survival by 80%, would cancer patients, the majority of whom are sedentary, start training? I wouldn’t be surprised if many did, determination can be great when faced with a cancer diagnosis. However, even if willing to simply change their lifestyle, or intensely train for an Ironman, are we already hindering patients’ ability to do so by not pre-habilitating (8) them for the insult some treatments inflict on the body? If most cancer patients do not already like to exercise, how are we ever going to convince them to start if we let their physical function decline further prior to or during the treatment process?
For those of us already in the exercise choir, and for cancer types other than those listed above, how much exercise is enough, and what may warrant caution (9) or be too much? Unfortunately, most fitness stories remain just that, stories, unless we happen to be in a study, because, until physical activity is routinely recorded in oncology we will never know to what extent many physical accomplishments affect cancer survivorship (the ‘survivorship beginning at diagnosis’ definition). Most of us in the cancer exercise choir, myself included, are just figuring it out as we go along, sometimes overdoing it (7), or maybe we’re not doing enough, and we share what we’ve learned with others. Ironically, in spite of all the data we generate when training with our consumer fitness tools, there still isn’t the right statistical data to guide many of us.
Missing data …
A physical activity profile (using a short, scientifically validated, questionnaire) is not routinely recorded when extracting biopsy tissue from patients. Is there evidence in tissue samples that could correlate physical activity to cancer treatment response rates and survival? How are tissue samples different, if at all, between those who exercise versus those who don’t? If different, can the differences be exploited to improve cancer treatment outcomes or to develop new drugs? Exercise and physical activity are positively affecting survival for those cancers listed above, but how is this happening? What are the physiological mechanisms, and are we overlooking routine biopsies as sources of evidence? Exercise physiologists sometimes pay study volunteers and take muscle biopsy samples to find out what exercise did. In oncology, other than pathology, how much thought is given to our biopsy samples, which patients pay for, and exorbitantly too?
I wouldn’t limit recording patients’ physical activity to biopsies only, we should be updating fitness profiles at diagnosis, first treatment, scans, and subsequent healthcare visits too. The studies mentioned above were observational ones done over a number of years, some only assessing physical activity every two years (1,3), which doesn’t allow for teasing out information in the weeks specifically surrounding a cancer diagnosis or treatment. Some physical activity questionnaires have gone electronic, but collecting data using paper forms, interviews, and calls to subjects is still done. In today’s electronic world this sounds archaic, but this is how the best observational evidence has been obtained so far.
Or … data to nowhere
With all the new consumer fitness products available we are still unable to get much of the data they generate into our electronic health records (EHRs). My Garmin data, Moves data, and the information I type into my training and treatment log, all just sit there in electronic form somewhere in cyberspace. My information cannot be pooled with the fitness data from others to search for statistical significance. You can be sure the consumer fitness developers know a lot of things about me, but the products they have developed are generating data that goes nowhere – lots of data rather than ‘Big Data’ – my cancer and fitness story has no statistical power even though plenty of Information Technology (IT) is attached to it.
Recent announcements regarding consumer fitness and IT may change this and move us closer to continuously updated physical activity profiles by using data automatically uploaded through privacy ensured patient portals (EPIC’s ‘MyChart’ would be a good example). Physical activity information could then be accessible when needed by clinicians from EHRs, and more importantly, tied to pathology, treatment, and other information within EHRs. Apple’s collaboration with The Mayo Clinic, Nike, and the prominent EHR system, EPIC, appears to be headed in this direction. However, without the broad use of internationally standardized exercise and physical activity codes for the common measures most exercise stakeholders are recording – steps, calories, heart rate, etc. – integrating the fitness data into EHRs will remain problematic. Medicine wants valid standardized data and evidence before they will change clinical practice. Our fitness stories, with isolated data on only one person, will not change clinical practice.
There is interest among cancer patients in allowing their data to be shared for research purposes, 87% reporting a willingness to do so (10) as long as privacy was adequately addressed. How many of them have stories on the extreme ends of the physical activity spectrum and how is cancer survivorship going for them out there? Fitness stories may motivate or guide others, but we also need statistical significance in order to impact clinical practice.
References:
1. Holmes MD, et al., Physical activity and survival after breast cancer diagnosis. JAMA. 2005;393:2479-86.
2. Meyerhardt JA, et al., Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J. Clin Oncol. 2006: 24:3535-41.
3. Giovannucci EL, et al., A prospective study of physical activity and incident and fatal prostate cancer. Arch. Intern. Med. 2005:165:1005-10.
4. Williams PT, Reduced risk of brain cancer mortality from walking and running. Med. Sci. Sports Exerc. 2014 May;46(5):927-32.
5. Irwin ML, et al., Influence of pre and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J. Clin. Oncol. 2008:26:3958-64.
6. Schmitz K.H, et al., American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Med Sci Sports Exerc. 2010 Jul;42(7):1409-26.
7. Kano S, et al., [A case with myositis as a manifestation of chronic graft-vs-host-disease (GVHD) with severe muscle swelling developed after aggressive muscular exercise.] Rinsho Shinkeigaku. 2003 Mar;43(3):93-7.
8. Julie K. Silver, MD and Jennifer Baima, M.D. Cancer Prehabilitation: An opportunity to Decrease Treatment-Related Morbidity, Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes. Am J Phys Med Rehabil. 2013 Aug;92(8):715-27.
9. Stan, D, et al., Pilates for Breast Cancer Survivors: Impact of Physical Parameters and Quality of Life After Mastectomy. Clinical Journal of Oncology Nursing. Volume 16, Number 2; pp:131-141.
10. Rechis, R, et al., The Promise of Electronic Health Information Exchange: A LIVESTONG Report.
Update:
The Future of Medicine Is in your Smartphone. Eric J. Topol, MD. The Wall Street Journal, 1/9/2015.
http://www.wsj.com/articles/the-future-of-medicine-is-in-your-smartphone-1420828632
Boxing was a big deal when I was growing up, and the brilliance of Muhammad Ali’s boxing strategies stand out: ‘crazy man’ against Sonny Liston; and, ‘rope-a-dope’ against George Foreman are my favorites. Getting into the heads of his formidable opponents gained Ali an edge, and the wins, but it also highlighted something important, effort is not everything, knowing when to give it all is. If you want to win a marathon you don’t run the first mile as fast as you can, measured patience is valuable, thinking things through is important.
I think many cancer patients can learn from Ali’s strategies. It’s often heard, and it may be the only frame of reference that newly diagnosed cancer patients have going into their first treatments, ‘I’m fighting hard against cancer’, and Jim Valvano’s ‘Don’t give up, don’t ever give up’. Worthy mantras for sure, attitude is important. However, Ali exploited a similar mindset in 1974 when fighting George Foreman for the heavyweight champion of the world in the famous Rumble in the Jungle in Kinshasa, Zaire.
Ali let Foreman punch him round after round, absorbing the blows while leaning back against the ropes, guarding his body and face with his arms and gloves. The undefeated Foreman eventually grew tired, punched out, and Ali then came off the ropes and knocked Foreman out in the eight round. Ali strategized NOT to stand toe to toe and match brute punch with brute punch. Instead, Ali exploited Foreman’s aggressiveness to his own advantage, until George was tired and vulnerable, then Ali was able to quickly finish him off for the heavyweight title. As the fight was developing Ali was being criticized and questions for how he was, or was not, fighting, but he knew exactly what he was doing, and it worked perfectly. Ali went against conventional thought and won.
Can cancer patients learn from this? Perhaps. Cancer patients can beat cancer but lose the battle to an infection due to their weakened physical condition. Can exercise help, probably. Can considering how to fight help as well? I say yes. I have an example from one of my own treatment experiences.
I had heard about bone pain associated with Neulasta (Pegfilgrastim), a common drug given to chemotherapy patients to boost their white blood cell counts and to help prevent infection. After receiving my first injection of Neulasta I waited for the bone pain to start. After a few days I didn’t have any pain, I felt lucky. However, on the third day, while driving to complete some errands, I started having pulsing pain in my pelvis. I thought, pelvis, a large flat bone that produces blood cells, this makes sense. The pain would pulse stronger with each heart beat, for about 8 beats, then it would subside for about another 8 beats, giving me welcome relief from the pain before repeating this cycle. It must have frightened other drivers to see me gripping my steering wheel with white knuckles, grimacing hard, and shouting out. I wasn’t working on Ali’s ‘crazy man’ strategy either. Good thing they couldn’t hear me in the car!
When I got home I called the oncology clinic to tell them about the pain and to find out what I should do. I was told to use some Tylenol, which blunted the pain, although I could still feel the pulsing going on. Ok, this is part of dealing with cancer and cancer treatments. Tough it out, I’m fighting cancer I thought. That night the pain moved from my pelvis to my sternum, another flat bone, makes sense. I thought my femur (the head of long bones produce blood cells too) might be next. However, the experience of the sternum pain was different. Although the pain was blunted, I started feeling my blood pressure drop and I got some mild chills and shakes. This concerned me since I was already laying down, and the direction my blood pressure was headed, lower, wasn’t a good direction. I didn’t tell my wife, something common between cancer survivors and their caregivers, since she had just fallen asleep, but I was concerned about whether I would wake up if I fell asleep.
The next morning, a day ahead of schedule, I went to see my oncologist. He listened to me give all the details about how I was doing, then he started backing to the door signaling that our session was over. He had just put his hand on the door handle when I mentioned the chills and shakes from the night before. “That was the most important thing you’ve said, I think you have a bone infection.” He started me on an antibiotic infusion, and half an hour into the three-hour infusion I felt completely better. I had been walking around with a bone infection and I had thought it was just part of the pain from the Neulasta shot. What might have happened had he left the appointment not hearing about the chills and shakes? The Tylenol was masking the pain and I accepted the pulsing in my bones as part of fighting cancer. I was rope-a-doping myself – fighting with maximal effort, being tough, accepting the pain, when I may have been on the verge of being knocked out, maybe even for good.
So, for all you tough, stubborn, cancer fighters out there, keep it up, but also be willing to sometimes consider backing off and redirecting your efforts. And for those of you who have been putting off getting that lump or mole checked out, or if you have not had a physical exam in years, get in there! Don’t rope-a-dope yourself before any fighting even begins, and set aside time each week to improve your fitness, if you have to fight, it’s better to be physically ready for it. It is no fun getting a prostate exam or colonoscopy, but dropping your drawers, bending over, and taking it up the backside can be a winning strategy.
A cancer study published earlier this year found some very interesting results regarding the blood flow of tumors at rest versus during exercise. For some of you, it may be a surprise to learn that this had not yet been studied in animals or in humans. For me, I have been waiting for something like this for the past 2 1/2 years, since I began looking into exercise and cancer survivor research. In spite of all the cancer fundraising events where people exercise to raise money for cancer research, little is know about what all that exercise may be doing to tumors.
The study (only in rats) examined prostate tumor tissue at rest and during low to moderate intensity exercise. At rest, the blood flow to prostate tumor tissue was less than that of the surrounding prostate tissue and less than that of the control animals’ prostate tissue. However, during exercise, the prostate tumor tissue blood flow increased 200%, significantly above that of the surrounding prostate tissue or that of the control animals’ prostate tissue, both of which remained the same as at rest.
If you’ve ever had chemotherapy or accompanied someone who has, you may remember those nice, comfortable, recliners for resting in while the drugs pump into the veins. Well, if we could extrapolate the results of this study, resting in recliners would seem to limit blood flow into tumors at the very time that we want it to be at its maximum – while the drugs are flowing in. Now, before you get too concerned about infusion nurses yelling at chemotherapy patients to ‘push it’ for 30 more seconds on the treadmill, remember, the study used low to moderate intensity, and as I wrote previously, intensity is relative to each cancer patient’s fitness level. For many patients, I would not be surprised if strolling around the infusion ward was low to moderate intensity exercise, and for some, maybe even near maximal intensity. Currently, one of the best parts of chemo infusions could actually be the walking out of the infusion ward when it’s over, plus, any ‘exercise’ (shopping, walking, work/household duties) done afterwards until the chemotherapy drugs are metabolized or eliminated.
They let us walk into and out of the chemotherapy infusion wards, why not walk during infusion? Some concerns may be over balance due to any sedatives administered as a part of the infusion process. True, but some sedative doses can be decreased. When I had to drive myself home after a series of infusions, they cut my Benadryl in half so that I wouldn’t be woozy for the drive home. There must be other sedatives as well that could be similarly adjusted.
An editorial that accompanied the cancer study I cited above, mentioned how emerging evidence is ‘beginning to challenge the current perception of exercise as a “soft” intervention that “cannot hurt.” ‘ This is similar to what cardiology went through decades ago. Then, patients were sent home to bed rest for weeks after a heart attack. Once more research started coming in, showing that patients did better if they started exercising soon after their heart attack, cardiology started getting patients moving. This may be where we are with cancer treatments and exercise – leaving the ‘soft’ intervention realm and moving into the “A Team’ of evidence that shows improvements in existing cancer treatments. But we need human studies first.
I hope you’ll help us to move evidence like this along into human studies. This is not rocket science but basic physiology, much of which has been overlooked in favor of billion dollar drug development. Fair enough, there are many effective cancer drugs, I’m not opposed to them, but can we improve the delivery of those drugs with something as simple as switching from recliners to strolling the infusion ward halls? Furthermore, what else might we discover about these physiological mechanisms that might improve cancer treatments? We will never know unless we do more research like this. Please support exercise-oncology research.
Thank you!
References:
Modulation of Blood Flow, Hypoxia, and Vascular Function in Orthotopic Prostate Tumors During Exercise. McCullough, D.J., et al. J Natl Cancer Inst 2014 Mar 13. [Epub ahead of print]
Therapeutic Properties of Aerobic Training After a Cancer Diagnosis: More Than a One-Trick Pony? Lee W. Jones, Mark W. Dewhirst. JNCI J Natl Cancer Inst (2014)dju042doi: 10.1093/jnci/dju042First published online: March 13, 2014
The male brain is odd enough (I heard those amens ladies!), apply some chemotherapy to it and the results can be, well, let’s just be kind and say … interesting. A typical generalization is that men are driven to solve problems while women are motivated by emotion. Us guys try to fix things, that’s what we’re wired to do. Note the word ‘try’, because we’ve been known to make things worse (I know ladies, I know).
One of my favorite stories is from the book And In Health by Dan Shapiro, PhD. On pages 143-144 Dan tells the story of a couple talking, then laughing, about how lucky they were when the chemo brain affected husband nearly burned down their house after forgetting he was cooking something on the stove. The lucky part was that the overflow from the bath he forgot he was running upstairs crashed though the ceiling and put out the fire. I laughed until I cried at that story. Check that off the bucket list.
My story is not nearly as dramatic but is probably not uncommon for the types of distorted plans men can come up with under the influences of chemo brain. As patients, we are given time between chemo cycles so our bodies can repair before the next toxic assault. Well, tumors are a part of the body and they can regrow and repair between chemo cycles too, some drugs may even contribute to that process. I wasn’t about to let that happen without the potentially ‘normalizing’ affects of exercise, which I hypothesized would influence, in my favor, any regrowth or repair that my lymphoma tumors might be trying to do.
After my chemo cycles I often had low blood pressure, which caused me to become dizzy from standing up. A cancer specialist physical therapist told me a technique of pumping my legs before standing up to raise my blood pressure. This helped. However, that first day home, I was concerned that my plans for walking on the treadmill might be dismantled by my low blood pressure, so I fired up the chemo man brain for a solution.
I decided I would text my wife ‘ok’ every 5 minutes while walking on the treadmill. If she didn’t get a text then she should call the EMTs. Great plan I thought, some of you guys are agreeing while others are already improving on the man plan – you should have done ‘face time’ or done such and such. The other brains, women’s, are rolling their eyes, just like my wife did at work while she and her colleagues agreed that my plan was the dumbest they had ever heard of.
The walk went well. I actually felt better since my blood pressure increased due to the physical exertion. Afterwards I continued to feel better than before the ‘workout’ (1.36 miles on treadmill at a max of 2.7 mph & 0% grade for 30 minutes – slowest of my life). When my wife came home that evening she reiterated the stupidity of my plan. “I had the front door unlocked for the paramedics” I told her. “Well you forgot to tell me that” she replied, as if it even mattered. “Why didn’t you just wait until I came home from work?” she asked. “I didn’t think of that” I replied. D’oh! Chemo man brain.
If you have a chemo man brain story I’d love to read it. Post a reply! Thanks!
References:
Therapy-Induced Acute Recruitment of Circulating Endothelial Progenitor Cells to Tumors. Shaked, Y., et al. Science 313, 1785 (2006): DOI10.1126/science.1127592 http://www.sciencemag.org/content/313/5794/1785.full.pdf
NORMALIZATION OF THE VASCULATURE FOR TREATMENT OF CANCER AND OTHER DISEASES. Goel S., et al. Physiol Rev 91: 1071–1121, 2011 doi:10.1152/physrev.00038.2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258432/pdf/nihms348021.pdf
Physical activity and tumor vessel morphology among men with prostate cancer. Van Blarigan, E., et al. http://mb.cision.com/Public/3069/9520261/82b38a3d9391d0bb.pdf
Exercise modulation of the host-tumor interaction in an orthotopic model of murine prostate cancer. Jones, L.W., et al. J Appl Physiol 113: 263–272, 2012.
And in health A Guide for Couples Facing Cancer Together. Dan Shapiro, PhD., First Edition, Trumpeter Boston & London 2013, ISBN 978-1-61180-017-3 (pbk.)
You can find out more about Ken’s treatments and training here.
The text from the transplant coordinator read ‘Congratulations, your brother is a match!’ Oddly, this puzzled me, which probably reflects the altered mental state a cancer diagnosis can put you in, and I ever so briefly entertained the thought that she might be joking. Then it dawned on me, this was real, and this was great news! Next I thought of how relieved my stressed-out wife would be and of how the coordinator must welcome sending a message like that.
My older brother was the first potential donor that we tested for my stem cell transplant. I felt lucky, the chances of curing my complex lymphomas just went up. Even though we are different in many ways, other than a twin, he was an excellent match.
Two weeks before the scheduled transplant he flew out to stay with us. The flight was another source of altered mental state concern. If he catches something from another passenger will the transplant be delayed? Should he wear a mask? Tell him to take hand sanitizer with him. What if the plane crashes? Should we drive him out? Which is safer, driving or flying? That close to a cure, stressing the little things became a hobby if not a necessity. However, upon his arrival I had a different plan of action, physical action.
I had just read some research finding that donors that exercised improved the stress resistance of their stem cells, and that increased the survival of the recipient by three fold. Even though the study was in mice, my brother was going to start exercising, I’d put him on a treadmill and feed him cheese if necessary.
Luckily for him I had a Garmin GPS watch with a heart rate monitor that he could wear. As if giving his stem cells wasn’t enough, each day he uploaded his ‘training’ into my Garmin online account, which I could access via my iPad from my hospital room on the transplant isolation ward where I was for eight days while they wiped out my bone marrow.
My altered mental state kicked into high gear a few days before transplant when my wife called saying that she was headed out to search for my brother. He had called asking her to come get him from his walk and he seemed disoriented. Oh no, had all the walking given him a heart attack? What was wrong? Was he ok? Was he going to make it? His stem cells, was the transplant in jeopardy? My marrow was already being wiped out, was there a contingency plan?
Fortunately, his disorientation was only geographically related and not a medical issue. He had started his walk late in the day and it had gotten dark which hid the landmarks that he’d recently become accustom to. Scare over but lesson learned. From the Garmin online data I saw that just strolling around our town’s neighborhoods for an hour a day was in his heart rate training zone. So I asked him to just keep his walks leisurely, to enjoy himself, and to walk in the mornings! He ended up walking 12 of the 14 days prior to donating his stem cells, more than 6 miles on one of those days.
For a brief time I’d thought that my zeal to improve the chances of a successful transplant may have killed my brother, but he was doing it all to save me.
References:
Exercise and Hematopoietic Stem and Progenitor Cells: Protection, Quantity, and Function. Michael De Lisio and Gianni Parise. Exerc. Sport Sci. Rev., Vol. 41, No. 2, pp. 116-122, 2013. http://journals.lww.com/acsm-essr/Fulltext/2013/04000/Exercise_and_Hematopoietic_Stem_and_Progenitor.8.aspx
a unique record of my donor’s exercise prior to harvesting his stem cells http://workoutcancer.org/uploads/Donor.pdf
February 2013, after being diagnosed with my third cancer in as many years, and on our middle child’s 13th birthday, I was admitted to the hospital to start chemotherapy. This new transformed cancer, Diffuse Large B Cell Lymphoma (DLBCL), was aggressive and required an intensive treatment regimen (R+ESHAP) that consisted of being hooked up to a chemotherapy infusion pump 24 hours a day for nearly 7 days straight. I was 54, had no other health conditions, and, having just abandoned my training to break my age group mile world record (4:25), was very fit. Therefore, my oncologist thought I could handle the treatment.
An unsuccessful attempt was made to insert an iv PICC line into the crook of my arm to thread up through the vein to a larger vein at the top of my chest. Besides being painful, this concerned me since I wanted to maintain the exercise routine that I had established in anticipation of needing chemotherapy, and thought full use of my arms worth keeping. Instead, a Hickman line was inserted into my chest, which was not much of a problem. However, finding a stationary bike was.
I asked my nurse if there was a stationary bike that I could use. I was surprised to hear that they had none on the oncology ward, and I was equally surprised to hear that in her 5 years of working there that no one had ever asked for an exercise bike. This was an MD Anderson affiliated hospital, and, at that time, MD Anderson was the #1 ranked cancer hospital in the US. I was disappointed to realize how little exercise was being used as a part of cancer treatments.
There were some bikes in the cardiology unit (exercise is a part of rehab after a heart attack) but I wasn’t able to use them because cardiology was in another building and that would require me to go outside to get there – not allowed. A patient coordinator then set about trying to locate a bike for me and her initial search found one in our building, in the basement of the psychiatric ward. In order to get to the bike I had to navigate some stairwells, so they reluctantly disconnected me from the infusion pump and gave me one hour to complete my exercise and to shower afterwards. I also had to be escorted and accompanied by a nurse (not the shower though), so off we went.
Arriving at the psychiatric ward was a bit surreal. In the small lobby there were two locked doors, one of them had an unsettling notice on it “Extreme escape risk”. I wondered about the patients behind those doors, each going through something different from me but also sharing something similar – the need to get healthy again. This was a sobering reminder that there were other debilitating things besides cancer, and that my health issues, although somewhat complicated and rare, in the grand scheme of things, were nothing special. I felt fortunate, I was beginning my recovery with a clear action plan, literally too, and with an understanding of what I needed to do and why. I wasn’t sure the psychiatric patients had as clear of a way forward, and I felt for them.
After buzzing for assistance we were given the okay to go to the basement where the bike was. Down more stairs we came to an old, small, gym. It was odd, with ceramic tile walls and bars on the windows, and most of the equipment had been abused and was in need of repair. The only decently functioning piece of equipment was an air-dyne bike, this is the type with big fan blades on the front wheel, which makes cycling at higher RPMs difficult, if not impossible.
Another problem was that the bike’s handlebars were connected to the pedals, this made the handlebars move backwards and forwards with each pedal revolution. I was not going to be able to use the handlebars that way because I was still sore from the PICC line attempt in my right arm. Plus, my left arm was also sore from the recent biopsy surgery that removed an entire lymph node in order to confirm my cancer diagnosis. A final problem was that there were no toe clips on the bike. For support, I held on with my left hand to a broken display console that was mounted between the handlebars. With no toe clips and a fan for a front wheel, this was going to be one interesting, if not difficult, ride.
For a moment I thought about the situation, me: chock full of tumors, in a psychiatric ward basement, chemotherapy drugs still coursing through my veins, and wanting to ride a dysfunctional exercise bike. I chuckled nervously to myself “Maybe I belong here”. Then I started pedaling.
As a runner, I broken 4 minutes for the mile, ran under 2 hours and 10 minutes for the marathon, and won numerous races around the world, but I never accomplished anything more uplifting than turning the pedals on that derelict bike. I rode that thing for 30 minutes while trying to control my emotions so that I could finish the workout and still have time to shower before being hooked up again to the infusion pump. The nurse was nearby texting on his cell phone, unaware of my riding predicament or of my emotions.
Prior to being admitted for chemotherapy I had been researching exercise and cancer treatments, and I had come across only one study, done on a small group of breast cancer patients, where someone had exercised during chemotherapy infusion. I had advocated that there be more studies on whether this could improve a patient’s response to chemotherapy – could exercise during infusion enhance chemotherapy and increase survival rates? I already knew that exercise was good for my quality of life, but now it was my turn as guinea pig. This added a different perspective to a study of this type, and it increased my respect and appreciation for patients who volunteer for research studies or clinical trials, they are heroes to me.
In the basement of that psychiatric ward, while riding a rickety old exercise bike, and with chemo drugs doing their thing inside me, I was alone with the enormity of that moment … and I was elated. Somehow this all seemed to fit for me – a bike, science, and faith, versus cancer – and I liked my chances.
NOTE: The hospital’s patient coordinator was able to locate a better bike in a storage room and they kindly brought it to my room for the remainder of my first chemo cycle. I was then able to exercise without being disconnected from the chemotherapy infusion pump. They also had the bike waiting for me when I started my 2nd chemo cycle (no pun intended) two weeks later.
In the US most adults do not get the recommended 150 minutes of moderate intensity or 90 minutes of vigorous intensity physical activity per week. Nothing new about this, however, maybe it doesn’t accurately describe what is physical activity for cancer patients, particularly those in the midst of treatment. I argue that many cancer patients may be meeting the recommended guidelines but they just don’t know it.
There is a measure in exercise physiology called maximum aerobic capacity, which is recorded as maximum oxygen uptake, or VO2max for short (maximum volume of oxygen). Elite endurance athletes have values above 80 (it’s recorded as millilitres of oxygen per kilogram of body weight per minute: [ml/kg/min]). However, in many of the exercise and cancer studies I read, I often see average maximum oxygen uptake for cancer patients below 20. What does this mean and how does it relate to cancer patients meeting the physical activity guidelines?
Bear with me as I first translate VO2max into something easier to understand. I noticed one study where the cancer subjects had an average VO2max of 17.5 ml of oxygen/kg/min, this is a convenient number that converts into something we can relate to. An intermediate conversion is needed to something called a *MET, 1 ‘standard MET’ equals 3.5 ml of oxygen/kg/min, so a 17.5 VO2max = 5 METS. A 5 MET activity is walking at 4mph, one mile in 15 minutes (4 laps around a high school track).
So there we have it, our cancer subjects have a maximum aerobic capacity to walk 4mph. However, this doesn’t mean that they can actually walk the entire mile in 15 minutes, none the less, they should not feel inferior about it because an elite endurance athlete can’t go 15 minutes at their maximum aerobic capacity either. What? You see, maximum oxygen capacity can only be maintained for about 3-5 minutes regardless of who you are – cancer patient or elite endurance athlete.
For our cancer subjects, just one of those laps around that high school track at a speed of 4mph will take 3 minutes and 45 seconds. It is an interesting comparison then that the track & field world record for one mile is 3 minutes and 43 seconds (all four laps around that high school track). However, I guarantee you that the guy who set that world record could not have done another lap at his record pace – he was at his maximal oxygen capacity (actually a little above it as he sprinted the last part of the race, but he didn’t use any more oxygen to do that extra effort). So it would be no surprise if our cancer subjects also became exhausted after 3:45 of walking only one lap at their maximal oxygen capacity. This is just like the world record holder who is exhausted after running for 3:43 at his maximum oxygen capacity. What then can cancer patients do to get 150 or 90 minutes of exercise in a week? They can slow down.
If our 5 MET capacity cancer subjects slow down to 60% of their maximum, which is considered to be moderate intensity, they will be at 3 METs, and this intensity they will be able to sustain for longer than 5 minutes. The relative part of all this is that they can achieved 3 METs by walking a dog! Yep, according to the 2011 Compendium of Physical Activities, if our cancer subjects do this they are doing moderate intensity physical activity. Below are some other 3 MET activities from the Compendium:
Considering household and caregiving activities, some cancer patients may be getting close to meeting the physical activity guidelines just by maintaining a near normal work schedule or by puttering around their home while recovering between cycles of chemotherapy. There was a recent study that was critical of counting household activities as physical activity. This may be true for healthy adults, however, for cancer patients, some adjustments have to be taken into account.
One important consideration is that some chemotherapies can cause anemia. Other things too can affect our cancer subjects, some of them are mentioned in a previous blog: Mt. Everest and Cancer. So, during treatment, rather than our subjects having a maximum aerobic capacity of 5 METS, it may be lower than that. This means that if they want to sustain their physical activity beyond 5 minutes, their normal 60% intensity will now be at a slower pace, and this brings in even more Compendium activities. If they don’t slow down, they will find their normal pace is now more fatiguing and that they have to rest a little longer between activities. Unfortunately, and mistakenly, this causes many cancer patients to think they are too tired to ‘exercise’, so they nap a lot. Their old 60% pace is now a 70% or 80% intensity (vigorous), which is ok to do but they will need to walk for shorter periods of time and to rest a little longer.
I recently read an online post by a cancer patient who mentioned becoming fatigued from just walking across a room. I hope we can now understand that this could actually be viewed as part of a ‘workout’. The key may be for that patient to start treating a walk across the room as exercise and to mentally incorporate it into a modified ‘workout’ routine. This is not unlike how that world record miler might workout – he may do an effort at a specific intensity, recover, then repeat this pattern a number of times on a training day. For our subjects, walking across a room, up some stairs, down a hall, getting tired, resting for a bit, and then repeating this pattern, could be considered a type of workout called interval training. It may not be at the same pace as the world record miler but the relative intensity can be the same, cancer patients and clinicians just might not realize that it is.
Keep moving!
*MET Metabolic equivalent: one size does not fit all. Byrne, N.M., et al. J Appl Physiol 99: 1112–1119, 2005. Examining Variations of Resting Metabolic Rate of Adults: A Public Health Perspective. McMurray, R.G., et al. Med. Sci. Sports Exerc., Vol. 46, No. 7, pp. 1352–1358, 2014. The standard oxygen consumption value equivalent to one metabolic equivalent (3.5 ml/min/kg) is not appropriate for elderly people. M. Kwan, J. Woo and T. Kwok. International Journal of Food Sciences and Nutrition, Volume 55, Number 3 (May 2004) 179 /182. Activity-Related Energy Expenditure in Older Adults:A Call for More Research. Hall, K.S., et al. Med Sci Sports Exerc. 2014 Dec;46(12):2335-40. Errors in MET Estimates of Physical Activities Using 3.5 ml·kg–1·min–1 as the Baseline Oxygen Consumption. Kozey, S., et al. Journal of Physical Activity and Health, 2010, 7, 508-516.
References:
Scientists Explore Effect of Exercise on Prostate Cancer Patients
From the article:
‘In this study, researchers looked at 572 prostate cancer patients and found that those who walked at a faster pace before their diagnosis had more regularly shaped blood vessels in their prostate tumors than those who walked slowly.’
This is initial evidence of a hypothesis that I’ve been advocating, that exercise ‘normalizes’ tumor blood vessels, and that this is a good thing, particularly before chemotherapy or radiation which both work better with more oxygen. This is contrary to the anti-angiogenic (choke off the blood supply of tumors) dogma that is dominant in oncology. Although, some anti-angiogenic drugs do temporarily ‘normalize’ tumor blood flow, I think exercise will be found to do it better and also with less side effects, which many of the anti-angiogenic drugs cause.
Rakesh Jain at the Harvard Medical School is a pioneer in this vascular normalization area but with drug interventions. Therefore, it is encouraging to read the results from this human study that suggest that exercise may be doing the same thing. There have been some animal studies showing this but to my knowledge, this is the first one from tumors in humans.
For what it is worth, my advice, and what I applied to my own treatments (including exercising during chemotherapy infusion), is to exercise before first cancer treatment (as soon as you are diagnosed, or symptomatic if experiencing a recurrence) in order to improve tumor blood flow, which in theory should improve drug perfusion or the response to radiation. This should improve treatment response rates, which I hope this study will spur many investigations on.
Keep moving, even if feeling fatigued on some days. Do not let tumors gain any more advantage than they already have, influence their dysfunctional vasculature growth by normalizing it with exercise!
References
Rakesh Jain:
Animal studies:
Mt Everest and cancer?
Does there need to be a paradigm shift in how exercise is used in oncology (if it’s being used at all)? I was reviewing my blood work after my recent stem cell transplant and noticed that my hemoglobin and red blood cells had dropped 47% from my normal health to their lowest values two weeks after my transplant. I then checked what altitude a 50% drop in oxygen would correspond to. A 50% drop in oxygen represents an altitude of over 19,000 feet. Mt. Everest south base camp is 17,598 feet. I spoke with a couple of altitude and exercise experts to confirm my comparison. They suggested that in many ways a chemotherapy related drop in hemoglobin (carries oxygen) would be more difficult than the physical challenge of a drop in the partial pressure of oxygen due to ascending to high altitude. No wonder many cancer patients have a difficult time with some chemotherapies, even more so sedentary patients.
Furthermore, if one is to factor in cachexia (the muscle wasting common among symptomatic cancer patients), decreased activity due to cancer related fatigue and hospital bed rest, then by the time some patients’ hemoglobin drops below 8.0 (the level at which they might need a transfusion) their cardiovascular fitness has already been significantly impacted. Lower this capacity further with some chemotherapies and you have some patients in their fitness training zone (if not maxed out) just walking across a room. Additionally, some drugs used during cancer treatments, like corticosteroids, can cause muscle weakness, further impacting physical function. All of these things can significantly contribute to the downward spiral of ongoing cancer treatment related fatigue.
It would be irresponsible to send someone to Mt. Everest base camp without training them first, but it is common practice in oncology to physically challenge patients in a similar manner without training them for the difficulty to come. Instead, we nurse patients through the treatment challenge, cheer when they are finished, then send them off to physical therapy to address the injuries. This is not a success story, this is poor survivorship care planning. The emphasis on post-treatment survivorship care plans in oncology is like having someone train for Mt. Everest after they return from climbing it – clearly, some of the training must occur before the ordeal. Cardiology figured out decades ago to get patients moving as soon as possible in order to improve survival. Currently, in oncology we provide recliners for patients during chemotherapy. Does this need to change? After all, they do let us walk out of the chemo infusion wards.
There often is time between cancer diagnosis and first treatment to implement a survivorship care plan that includes exercise. One might even go farther back, possibly to the first encounter with a primary care physician because of symptoms, or perhaps to the first biopsy. Additionally, patients frequently seek second opinions, get an additional whole node biopsy, consult with another specialist, and weigh treatment options before finally having their first cancer treatment scheduled. All of this can take weeks. Is this enough time for an exercise intervention to significantly affect treatment outcomes – including response rates, or at least to maintain fitness and avoid detaining? If the focus in oncology remains on post-treatment rehabilitation we may never know, and patients will continue to struggle more than they may have to through treatments that may be more demanding than we currently realize.
If patients are willing to have their bodies ravaged by surgery, radiation, and chemotherapy, all of which can decrease physical function, then it shouldn’t be too much to do 30 minutes of walking a day, however one wants to carve that time up, as a part of cancer treatment plans or at least as a part of survivorship care planning. With better planning prior to first treatment maybe exercise can improve cancer treatments and reduce treatment side effects, including cancer related fatigue, which appears to be more debilitating than we thought. First, we need more pre-habilitation research.
NOTE: 12/16/14. The abstract below from ASH 2014, San Francisco, provides evidence supporting the importance of fitness going into stem cell transplant.
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