A little exercise for me, a lot for you?


bikes,vintage  Cycling on twilight time

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:

  • Improve survival in breast (1) and colorectal cancers by 50% (2).
    • Brisk walking of 2 1/2 hours per week produced the breast cancer results, but more vigorous exercise of 6 hours per week was needed for colon cancer;
  • Other researchers found moderate intensity physical activity to reduce risk of death from all causes by 60% among breast cancer patients (5);
  • and, cancer specific mortality from brain (4),andhigh grade, advanced, or fatal prostate cancers (3), were also reduced 43% and 70% respectively.
    • running 7.5 to 15.5 miles per week or walking briskly 12 to 23 miles per week for the brain cancer results, and 3 hours per week of vigorous exercise for prostate cancer.

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.

African American Family Parents and Children Cycling  Walking_2

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.

senior man exercising in wellness club

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.Exercising on gym bikes.

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.

Swimming competition  Young Couple Jogging in Park



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.



The Future of Medicine Is in your Smartphone.  Eric J. Topol, MD.  The Wall Street Journal, 1/9/2015.


Cancer and me: a bike and the psychiatric ward.


Almost a year ago, after being diagnosed with my third cancer in as many years, I was admitted to hospital to start chemotherapy.  This new cancer, Diffuse Large B Cell Lymphoma (DLBCL), was aggressive and required an aggressive treatment protocol that consisted of being hooked up to a chemotherapy infusion pump 24 hours a day for nearly 7 days straight.

An IV line was put into my arm (PICC line) near the crook of my elbow and it ran through the vein up 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.  But this turned out to not be my real problem, 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 to exercise on a stationary bike.  This was an MD Anderson affiliated hospital, and MD Anderson is 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 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 the 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.

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 in my right arm.  Plus, my left arm was also sore from the recent biopsy surgery done 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.


A summary of my exercise intentions regarding cancer treatments (with scientific references at the end)


US News and World Report, Hospital, specialty – cancer


A pilot study of aerobic exercise performed in breast cancer patients during chemotherapy infusion.


Cycling through cancer