Role of Exercise During the Cancer Journey
During the time period just before and after a cancer diagnosis, exercise may be most useful for reducing the anxiety associated with waiting for test results. The journey continues with the active treatment period. For many people, the first type of cancer treatment is surgery, which sometimes occurs within weeks of diagnosis. Exercise can often continue right up until the day of surgery. The specific benefits of presurgical exercise are just beginning to be explored. The hypothesis is that exercise for even a few weeks before surgery may improve immediate surgical outcomes and decrease recovery time, including less time in the hospital.
During the time period immediately following surgery, the body needs to spend all of its energy healing. The rule of thumb for returning to exercise is anywhere from four to eight weeks after surgery, depending on your condition and the extent of the surgery. If adjuvant treatments such as radiation and chemotherapy are recommended, exercise can and should continue during this period. Exercise tolerance varies throughout the cycles of treatment. For example, if chemotherapy is received every three weeks, there may be a few days immediately after the infusion when exercise needs to be curtailed or even stopped. However, the recommendation from multiple leading organizations is that cancer patients continue to exercise throughout their treatment. At the end of chemotherapy or radiation treatment, some oral therapies may still be used. From this point and to the end of life, exercise is recommended and may be undertaken in a manner specifically designed to minimize adverse effects of treatment and maximize survival.
Focusing on Physical Activity during Cancer Treatment
The benefits of exercise for persons who have had a diagnosis of cancer have been broadly documented and include both physical and psychosocial benefits). Hundreds of randomized controlled trials have been completed that document benefits of specific exercise regimens for specific outcomes. Exercise is like medicine in that it must be prescribed and dosed specifically for the outcome of interest. For example, low-intensity aerobic activity has been shown to improve fatigue and quality of life. However, to improve function and bone health may require strength training. To improve balance may require yet another type of activity (e.g., yoga). There is research to support the benefit of exercise on reducing the risk for recurrence of breast and colon cancer as well.
Guidance for exercise after a diagnosis of cancer:
- Avoid inactivity, and return to activity as soon as possible after surgery.
- Build to 150 minutes per week of aerobic activity (e.g., walking, biking, swimming, dancing).
- Perform progressive strength training two to three times per week.
- Do flexibility activities on most days of the week.
The overall recommendations after therapeutic interventions (e.g., surgery) are to avoid inactivity and return to regular activity as soon as possible, including aerobic activities, resistance training, and flexibility exercises. With regard to aerobic exercise, low intensity is typically recommended. The ACSM guidelines are the only ones that specify an intensity of moderate to vigorous intensity, and this is based on the documentation of benefits from aerobic exercise at higher intensity levels.
Precautions for Exercise
As discussed earlier, many cancer survivors experience one or more persistent adverse effects of their cancer treatments. Some of these may alter the safety of certain types of exercise, which would suggest that survivors with these issues undergo a preexercise evaluation before getting started to avoid the potential that exercise might do more harm than good. In addition, most cancer survivors are older adults who enter their cancer journey with one or more chronic disease diagnoses, which also may alter the safety profile of exercise. This section discusses whether survivors should seek a preexercise evaluation by a well-trained exercise professional or physical therapist before starting exercise and then whether supervised or home-based activities are recommended.
Where can I find a fitness professional to help guide me in my exercise program?
How do you know whether you can proceed with exercise in a community or home-based, unsupervised setting versus needing a more structured, supervised exercise program after cancer? First, if you would like a supervised, structured program, go find that supervised program! Second, if you are going to do low-intensity activity such as walking, you can likely proceed without supervision or evaluation. However, if you intend to progress beyond low intensity, to include strength training or to do sports and higher-intensity outdoor activities (e.g., hiking mountains, skiing), it would be useful to understand your risk level. There are three categories in both sets of guidelines: low-risk individuals who can exercise unsupervised without prior evaluation, moderate-risk individuals who are advised to undertake an evaluation to determine whether they need supervision, and high-risk individuals who are advised to find a supervised exercise program for their own safety. Anyway, you should consult a physician before exercise and have an evaluation by an outpatient rehabilitation clinician.
The majority of individuals diagnosed with cancer are over age 65 and have at least one other chronic disease diagnosis at the time of cancer diagnosis (e.g., hypertension, obesity, asthma, arthritis). Therefore, the beginning exercise program draws heavily from the advice in chapters that focus on those specific conditions and the chapter on exercise for older adults. Ideally, starting an exercise program in a supervised setting helps to ensure that the exercises are being done properly before one continues the program in a community or home setting.
Physical Activity Recommendations
There are six elements common to all of the exercise components, toward the goal of ensuring that exercise is both safe and beneficial: frequency, intensity, time, type, volume, and progression (FITT-VP). Frequency refers to the number of times the activity occurs per week. Intensity refers to the degree of difficulty. This can be stated in absolute terms (e.g., lifting a given weight such as a 5-pound [2.3 kg] dumbbell) or in relative terms (50 percent of maximum effort). Time refers to the duration of a given exercise or session of exercise. Type refers to the mode of exercise, such as stationary bicycling, walking, or jogging. Volume is defined as the total amount of exercise done, which is a combination of intensity and time. Finally, progression refers to the need for exercise to progress with regard to volume in order for benefits to continue to accrue. One can increase the volume by increasing intensity or time.
To start an aerobic exercise program as a beginning exerciser, the frequency should be two to three times per week. Once you are comfortable with this frequency (e.g., no increase in fatigue or other adverse effects), another session can be added per week up to six sessions per week. There should always be at least one day of rest from aerobic exercise.
As to intensity, one easy way to determine this is to use the “talk but not sing” rule. If you can sing (hold a note) while doing your aerobic exercise, you are not working hard enough. By contrast, if you cannot talk while doing aerobic exercise, you are working too hard. Intensity needs to progress, however, for benefits to continue to accrue. Thus, it would be advisable to take note of your pace on a track or pathway or of your workload on any gym equipment you are using. For example, you could note how many blocks you can walk in your daily walking sessions and increase the number of blocks walked within a given time period as you continue. Tracking this information is helpful for ensuring that you get the most out of your workouts.
Regarding time per aerobic exercise session, a beginning exerciser who is starting after a cancer diagnosis might want to begin with as little as 5 to 10 minutes per session to be sure that the activity is tolerated. This is increased by 10 percent per week. For example, if you choose to do three 10-minute sessions in your first week of a walking program, the next week you would do 33 minutes or 11 minutes per session. Within several months, you would be up to 30 minutes per session.
Typically with respect to the volume and progression of aerobic exercise for beginning exercisers after cancer, 30 minutes per week is a starting point, and then the time or intensity can be increased. The intensity can be increased by 10 percent per week, as can the time. However, it might be advisable to increase one of these per weeks, not both. That could mean increasing time one week and intensity another week.
Various types of aerobic exercise can be included in your exercise program. One common approach is a walking program. For those with balance or peripheral neuropathy, however, a stationary bicycle might be the best first step to aerobic fitness. The most important aspects of choosing a type of aerobic exercise are safety and enjoyment. If you get hurt or don’t enjoy the activity, you won’t keep doing it regularly.
Resistance (strength) training is not just for young people and isn’t just about lifting heavy weights in order to create bigger muscles and look better on the beach. Strength training can help cancer survivors regain the strength that is lost during active treatment and is also helpful for promoting bone health. Strength training can help older adults by ensuring that they continue to have the strength to get on and off the toilet, climb stairs, carry groceries, and do other common functional tasks. Older adults lose muscle mass as they age, and cancer treatment can exacerbate that process. Strength training may be more important than aerobic exercise for some survivors.
The recommended frequency of strength training is two to three times per week. The time it takes per session may vary, but 20 to 30 minutes is adequate. The type could include dumbbells, variable-resistance machines, or strength training activities performed in a class.
Even if you have done strength training in the past, it would be advisable to start with very low levels of resistance during and after your cancer treatment. There is often a period of inactivity during active cancer treatment. This can result in loss of muscle mass and strength. Adjuvant treatments (e.g., chemotherapy and radiation) may also result in loss of muscle mass and strength. Thus, to avoid injury, it is recommended that those living with and beyond cancer start with low resistance. If you are using dumbbells, this would translate to 1 to 5 pounds (0.45 to 2.3 kg) per exercise. If you are using variable-resistance exercise machines at a fitness facility, start with one or two plates on each machine.
The type of strength training you do is not as important as doing it regularly. If you prefer to exercise at home, you might want to get a set of dumbbells or adjustable-weight dumbbells. If you enjoy exercising with others, you might like using variable-resistance machines in a circuit or in a class led by an instructor.