Exercise Oncology:Exercise Oncology:Improving Cancer Care OutcomesImproving Cancer Care Outcomes

Claudio Battaglini, Ph.D. FACSM Claudio Battaglini, Ph.D. FACSM

Get REAL & HEEL Breast Cancer Program DirectorGet REAL & HEEL Breast Cancer Program Director

Exercise Oncology Research Laboratory DirectorExercise Oncology Research Laboratory Director

Keeping FIt

“Cancer Survivorship: A New Challenge in Delivering Quality Cancer Care”

“Optimal care is care that allows you to maximize the costs of survival (Physical, emotional, social, economic), maximize your health outcomes and enable you to be as successful as possible in achieving your goals in the context of this illness”.

Dr. Julia Rowland (Director of NCI Office of Survivorship), JCO, 2007

Cancer and Quality of life – what is it?Cancer and Quality of life – what is it?

Global Quality of Life

Physical Well-Being

Social/FamilyWell-Being

FunctionalWell-Being

EmotionalWell-Being

Fatigue

Cognitive Function

Tumor siteSymptoms

Depression/Stress

Components of quality of life

Biological Mechanisms (Possible mechanisms involved in the relationship between exercise and cancer prevention)

Cancer Site Possible Mechanisms

Rationale

Colon ↓ gastrointestinal transit time; ↓ ratio of protsaglandis, etc.

PA ↑ gut motility and reduces mucosal exposure to carcinogens

Breast ↓ lifetime exposure to estrogen, etc.

PA delays menarche, ↓ ovarian estrogen production; ↓ %BF (↓ fat produced estrogens)

Prostate ↓ exposure to testosterone, etc.

↑ production of sex hormone-binding globulin

All Cancers ↑anti-tumor immune defenses; decrease IGFs, etc.

May ↑ # and activity of macrophages, lymphokine-activated killer cells (regulating cytokines)

Friedenreich & Orenstein J Nutr 2002

EXERCISE

Sex Hormones Oxidative

DamageImmune /

Inflammation

RECURRENCE / SURVIVAL

Other Metabolism

Exercise and survival after a cancer diagnosis: Exercise and survival after a cancer diagnosis: biologic mechanismsbiologic mechanisms

Purpose of the Exercise Oncology ProjectsPurpose of the Exercise Oncology Projects

Examine the effects of exercise on treatment-related side-effects;

Design of evidence-based exercise prescription guidelines for cancer survivors.

Treatment tolerability and enhanced chances for treatment success may be improved if individuals

are able to develop their psychological and physical strength, both of which have been shown

to combat the debilitating side effects of cancer and cancer treatment.

(Battaglini, 2007)

EXERCISE

Sex Hormones Oxidative

DamageImmune /

Inflammation

RECURRENCE / SURVIVAL

Other Metabolism

Get REAL & Heel Breast Cancer Research Program

CancerDisease-Treatment

Pro-inflammatory Cytokines

IL-1() IL-6. IFN-, TNF-, LIF, CNTF

Anorexia

Sarcopenia

Muscle Tissue Loss

Hackney & Battaglini, 2011

ExerciseTraining

Up - RegulationAnti-inflammatory Cytokines

IL-1ra, IL-4, IL-10, IL-15, sTNFR, sIL6R

Up-RegulationMuscle Protein Synthesis

FunctionalCapacity

FunctionalCapacity

Excitatory Inhibitory

AndrogenicHormones

EXERCISE

Sex Hormones Oxidative

DamageImmune /

Inflammation

RECURRENCE / SURVIVAL

Other Metabolism

Get REAL & Heel Breast Cancer Research Program

EXERCISE

Sex Hormones Oxidative

DamageImmune /

Inflammation

RECURRENCE / SURVIVAL

Other Metabolism

Get REAL & Heel Breast Cancer Program

The Impact of Acute Intermittent Aerobic Exercise on Natural Killer Cell, Catecholamine, and Cortisol Responses in Breast

Cancer SurvivorsEvans, E.,, Hackney, A.C., McMurray, R., Randell, S., and Muss, H., Battaglini, C.L.

Risk of Disease

Sedentary

Training volume

Moderate

Heavy

(Peters 1994, Nieman 1995, Shore 1999, Na 2000, Fairey 2002, 2005, Lee 2010)

EXERCISE

Sex Hormones Oxidative

DamageImmune /

Inflammation

RECURRENCE / SURVIVAL

Other Metabolism

EQUAL (Exercise and Quality of Life in Leukemia/Lymphoma Patients)

Metabolism Other Immune / Inflammation

Effects of Exercise on CRF

*Lower scores reflect lower fatigue except where indicated Increased scores reflect lower fatigue; decreased scores reflect lower fatigue

Effects of Exercise on PROs Baseline Postintervention Change

Measure* No. of studies

N Mean SD Mean SD Mean 95% CI P 

Piper, 0 - 10  Exercise 10 483 4.6 1.0 3.5 1.4 1.1 0.2 to 2.1 .019  Control 4 114 3.8 1.3 4.0 0.5 +0.2 1.4 to 1.7 .803  

FACT-F, 0-52  Exercise 8 472 35.1 6.8 38.5 4.2 +3.4 0.9 to 7.8 .103  Control 5 305 37.4 4.5 37.4 2.9 0.0 2.6 to 2.6 .984  

FACT-F, 0-52  Exercise 4 146 21.9 11.0 16.1 10.3 5.8 0.2 to 11.9 .055  Control 2 61 11.4 0.8 10.5 2.3 0.9 14.9 to 13.1 .563  

, 6 - 30  Exercise 2 73 13.2 3.5 11.1 1.2 2.1 23.1 to 18.8 .417  Control 2 56 13.7 4.0 15.4 2.8 +1.7 9.1 to 12.6 .288  

EORTC, 0 - 100  Exercise 1 69 39.5 33.7 5.8  Control 0 70 42.9 25.9  

LAS, 0 - 100  Exercise 2 55 35.9 9.3 20.8 8.9 15.1 18.8 to 11.3 .012  Control 2 49 35.3 8.9 37.3 7.1 +2.0 13.9 to 17.8 .363  

BFI, 0 – 10  Exercise 2 83 4.7 0.4 4.5 0.2 0.2 5.3 to 4.9 .705  Control 1 22 2.1 4.8 +2.7  

MFI, 4 - 20  Exercise 1 49 13.1 9.2 3.9  Control 0 22  

FSI (Severity), 0 - 10  Exercise 1 17 3.9 1.7 3.3 2.0 6.0  Control 0  

Norwegian, 0 - 33  Exercise 1 12 21.5 12.1 9.4 6.0  Control 0  

SympASF, 0 - 100  Exercise 1 23 14.0 26.0 +12.0  Control 1 23 25.0 45.0 +20.0  

Concerning fatigue, Piper fatigue scores (u

sed by 10 studies) d

ecreased 1.1

points [95% CI, −

0.2 to −2.1; p = 0.019] with exercise tra

ining and increased

0.2 points [95% CI, −

1.4 to 1.7; p = 0.803] in the control group. Signific

ant

changes were indicated for FACT-Fatigue (FACT-F) (p

= 0.055) and Linear

Analogue Scale (LAS) (p

= 0.012)

Exercise and Cancer: becoming aware of the Exercise and Cancer: becoming aware of the implications of working with a cancer patientimplications of working with a cancer patient

Prescribing Exercise for Cancer PatientsPrescribing Exercise for Cancer Patients

• Cancer dx affects all aspects of physical functioning

• Unique manifestations

-Tumor

-Treatment

-Side-effects

• ACSM / ACS guidelines

• Optimal guidelines yet to be established

Clinical ConcernsClinical Concerns

• Unwillingness of cancer patients

• Immunosuppressive effects

• Pathological bone fractures

• Cardiotoxicity (RT & CT)

Kang, J. Environmental Health Perspectives Suppl. (109) S1, 2001;

Courneya,Mackey, & Jones. Phys SportsMed, 2000.

Comprehensive health screening procedure should include:

1.1. Oncology physician consent for participation in physical activityOncology physician consent for participation in physical activity

- Family physician consent

2. Intake Meeting2. Intake Meeting

- Informed consent form

- PAR-Q

- Medical History Questionnaire ???

- Lifestyle Evaluation (Physical Activity Levels)

- Resting Vitals (BP, RHR, SPO2, ECG)

Health ScreeningHealth Screening

Exercise Testing Recommendations

Chapter 5. Cardiorespiratory Fitness Testing in Clients Diagnosed With CancerJones, L & Battaglini, C. 2012

Exercise Testing Exercise Testing ConsiderationsConsiderations

1. Max tests (w/ direct or estimated measurement of VO2peak) vs. Submaximal Tests

2. Purpose

3. Setting (clinical vs. non-clinical facility)

4. Type of cancer patient

Cardiorespiratory EnduranceCardiorespiratory Endurance

- CPET, Stress Tests, Sub-maximal Protocols (Modified Bruce Protocol, YMCA Bike Protocol, Rockport Walking Test, etc.)

(Dependent on Functional Status of Patient)(Dependent on Functional Status of Patient)

Muscular Strength/ EnduranceMuscular Strength/ Endurance

- 1RM, Sub-maximal Protocols [Rocky Mountain Cancer Rehabilitation Protocol (“Exercise and Cancer Recovery”, Schneider,

C., Dennehy, C., and Carter, S., 2003)], Partial curl-ups, Push-ups, etc.

(Dependent on Functional Status of Patient)(Dependent on Functional Status of Patient)

Flexibility/ BalanceFlexibility/ Balance

-Goniometry, Sit-and Reach, more sophisticated tests for specific deficiencies (i.e.: shoulder function, ROM)

- Balance (Static and Dynamic Tests; Single limb stance, Timed 360o turn, Four square step test)

(Dependent on Functional Status of Patient)(Dependent on Functional Status of Patient)

ModeMode

Exercise Prescription RecommendationsExercise Prescription Recommendations

• Walking/ cycle ergometry (natural choice)

• Account for specific impairments (e.g., colorectal, breast cancer)

• Resistance training (upper body concerns i.e lymphedema (unfounded)

• Combined aerobic and resistance training optimum

Frequency and IntensityFrequency and Intensity

• 2-5d/wk

• Extreme caution w/ patients suffering extreme fatigue

• Moderate intensity

• 50-75% of VO2max

• 40-80% HRR

Duration and ProgressionDuration and Progression

• 20-45 min (continuous)

• Multiple short exercise bouts during the day

• Initially work on frequency and duration – then intensity

• Progression slower for patients suffering severe side-effects

All dependent of the disease stage and All dependent of the disease stage and overall health of patientoverall health of patient

ComplicationComplication PrecautionPrecaution

Hemoglobin <8.0 g/dl Avoid high intensity exercise

Absolute neutrophil count Avoid exercises that may increase chance of infection

(swimming)

Ataxia/dizziness Avoid exercises that require significant balance &

coordination (treadmill)

Special PrecautionsSpecial Precautions

ComplicationComplication PrecautionPrecaution

Severe cachexiaSevere cachexia Loss of muscle mass limits Loss of muscle mass limits exercise intensity - exercise intensity -

modify modify program accordinglyprogram accordingly

Bone painBone pain Avoid high impact exercisesAvoid high impact exercises

Extreme fatigueExtreme fatigue Exercise at lower power output, Exercise at lower power output, avoid high intensity exerciseavoid high intensity exercise

DehydrationDehydration Inability to efficiently Inability to efficiently thermoregulatethermoregulate

Special Precautions ContinuedSpecial Precautions Continued

1.1. Check resting vitalsCheck resting vitals

2.2. Cardio WorkoutCardio Workout

3.3. Stretching (Whole Stretching (Whole Body)Body)

4.4. Weight TrainingWeight Training

5.5. Finals Stretches/ Finals Stretches/ Relaxation Relaxation

Cardio Cardio WorkoutWorkout

Weight Training Weight Training WorkoutWorkout

Whole Body Whole Body Stretches/ Stretches/ Specific Specific

StretchesStretches

Cool Down Cool Down Stretches/ Stretches/ RelaxationRelaxation

40%40%

25%25%20%20%

15%15%

Exercise Session ExampleExercise Session Example

• No evidence that one type of exercise is superior

• Safety is the primary concern

• Optimal program may combine resistance and aerobic exercises

• Key point: be flexible with prescriptions; modify prescription based on response to treatment(s)

AcknowledgementsAcknowledgements

• All of the wonderful UNC physicians, cancer researchers, exercise physiology colleagues, and my students

Special thanks to:Special thanks to:

• Department of Exercise and Sport Science

• Lineberger Comprehensive Cancer Center

• UNC Cancer Hospital

THANK YOU!THANK YOU!Contact Information:

Dr. Claudio Battaglini

Department of Exercise and Sport Science

(919) 843-6045

claudio@email.unc.edu