Physical Activity and Cancer: Movement Matters!

Dr Anna Campbell Lecturer in Clinical Exercise Science / Macmillan Physical Activity Advisor

Institute of Sport and Exercise University of Dundee

a.k.campbell@dundee.ac.uk Twitter: @canrehab

Outine of talk

• Rationale for research into exercise & cancer survivorship

• Brief review of evidence • Putting evidence into practice • Future research and implementation

The number of people living with cancer is set to double by 2030

Source: Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br J Cancer 2012; 107: 1195-1202.

Strong evidence base Modest evidence base Limited evidence base

6. Using the relevant evidence to inform programmes and policy

4. Characterising prevalence of and determinants of physical activity behaviour in cancer survivors

5. Testing interventions to increase physical activity for cancer prevention and survival

1. Identifying relations between physical activity and cancer risk

2. Identifying relations between physical activity, Tx side effects & survival

Physical Activity and Cancer Research: Current State of the Science

3. Examining the biologic mechanisms involved in physical activity and cancer risk

Adapted from Owen N et al. Amer J Prev Med 2011, 41, 189-196.

Physical Activity and Cancer Risk / Recurrence

Physical Activity and Cancer. (2011). Courneya KS and Friedenreich CM (eds).

Recent Results in Cancer Research . Heidelberg:Springer-Verlag

Current Level of Evidence on Physical Activity and Cancer Risk Reduction

Convincing or Probable

Colon Breast

Endometrial

Insufficient or Null Rectal * Pancreatic Gastric Bladder Testicular Kidney Hematologic cancers (non-Hodgkin lymphoma, Hodgkin lymphoma, leukemia, multiple myeloma)

Weaker evidence Lung

Prostate

Ovarian * No association

Friedenreich et al. EJC, 2010; 46:2593-2604

Physical Activity and Cancer Recurrence Breast cancer: 30% risk reduction Systematic review of 9 prospective cohort studies: leisure

time physical activity is associated with a 30% reduced risk of breast cancer mortality [Patterson, 2010; Ibramhim, 2011]

Colorectal cancer: 50% risk reduction • Meyerhardt (2006) 6 hours/wk HR = 0.39 compared to no

PA 9.6 years later • Meyerhardt (2009) 9 hours/wk HR = 0.47 compared to no

PA 8.6 years later • Meyerhardt ((2006) 6 hours/wk HR = 0.51 compared to no

PA 3.8 years later • Independent of sex, BMI, age, perfomance status or tx Prostate cancer: • 3+ hours vigorous activity per week = Cancer deaths

61% lower (Kenfield et al 2011)

What are the potential mechanisms of

the protective effect of PA?

• Insulin / IGF1 and binding proteins • Sex steroid hormones • Inflammation • Adipokines • Immune system • Oxidative damage • Direct effects on tumour cells - angiogenesis

What about living with cancer and treatment side effect?

Total Prevalence - now

Total Prevalence - 2030

Diagnosis & Treatment

Rehabilitation

Early Monitoring

Later Monitoring

Progressive Illness

End of Life Care (Year 1 Deaths)

The problem…

• Commonest problems were: – Crouching / kneeling – Standing for 2 hours – Walking ¼ mile – Lifting / carrying a load (10lb) – Standing up out of a chair

These are all basis daily activities needed for

– housework – shopping – childcare etc.

53%

Ness et al, 2006

21%

The problem….

• 4 million people living cancer by 2030 (Macmillan) • Chronic or late appearing side effects:

– Fatigue – Weight changes – Osteoporosis – Cardiotoxicity – Lymphoedema – Anxiety – Depression – Cognitive dysfunction – Limited range of movement – Lack of confidence

Systematic review evidence: PA DURING adjuvant treatment

Outcome Evidence Grade

Physical Function

Significant increase in C/V fitness similar modest increases in muscular strength [ES 0.33) ; 17RCTs]

A

Fatigue No difference in fatigue between exercise and control groups [ES 0.18; 15RCTs ]

A

Well being Small improvements in anxiety [ES 0.21; 6RCT] self esteem [ES 0.25; 3RCT] No effect on QoL [10 RCT] or depression [6RCTs]

A

Body composition

Slight increase in lean body tissue, significant reductions in body fat [ES 0.25; 7RCTs]

A

Effect sizes: 0.2 = small; 0.5 = moderate; 0.8 = large

Systematic review evidence: PA AFTER adjuvant treatment

Outcome Evidence Grade

Physical Function

Significant increase in C/V fitness [ES 0.32) ; 14RCTs] large increases in muscular strength [ES 0.90) ; 7RCTs]

A

Fatigue Significant lowering of fatigue [ES 0.54; 14RCTs ]

A

Well being Significant improvements in QoL [ES 0.29; 16RCT] anxiety [ES 0.43; 7RCT] and depression [ED 0.30; 10RCTs]

A

Body composition

Significant small reductions in body fat [ES 0.18; 15RCTs] and increases in muscle mass [ES 0.13; 5RCTs]

A

Bone Health Some encouraging findings on bone health density were reported but overall results from 8 trial of various designs were inconsistent

B

Recent reviews

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Evidence-based physical activity guidelines for cancer survivors: Current guidelines, knowledge gaps and future research directions L.M. Buffart, D.A. Galvão, J. Brug, M.J.M. Chinapaw, R.U. Newton Cancer Treatment Reviews (2014) 40(2):327-40.

Reviews side effects: Exercise intervention

Bone Health (Winters-Stone et al, 2012)

Lymphoedema (Cormie et al 2013)

Depression (Craft et al, 2011)

Biomarkers (Ballard Barbash, 2012)

Cardiotoxicity Scott et al (20130

Quality of life (Ferrer et al,2010)

Physical activity interventions during palliative care

Systematic review of 6 small studies [Lowe, 2009]:

Findings included: – home based seated exercises prevented decline in QoL in

RCT [Headly, 2003]

– Supervised group exercise for 6 weeks (uncontrolled trial) [Oldervoll, 2006] improved:

• fitness, • functional ability, • emotional well being • Fatigue • dyspnea • anorexia

“Patient preference is important, PA may be recommended to maintain independence and wellbeing towards end of life.”

Two new studies by Jones et al

• “too sick not to exercise” – 6 week home based exercise programme

post surgery – Nintendo wii fit plus – Improvements: less tired, more confident,

better functional activities and balance, more steps per day

• Cancer Nursing, Vol 36 (3) 175 (2013)

Results of the Glasgow Study (2007)

• 203 women with breast cance recruited into study in one year (age 38-75)

• 177 women completed the study • After 12 weeks: those in exercise programme improved significantly

more than the usual care group in: – Walking faster and more weekly activities – Shoulder mobility – Breast cancer specific quality of life – Positive mood

• 6 months later, those in exercise group still benefited more in terms of improved – Overall quality of life, – Physical functioning, – Positive mood, – Less fatigue and depressed.

• Cost benefit analysis • Behaviour change model base to intervention

Quotes from focus groups: Emslie et al , Health Education Research 2006

• Perceived benefits of the exercise intervention You felt better after it.. lifted. I just felt generally that my

health had improved in that hour. Aye, I think I was on a high possibly! (Respondent 3, group 3, intervention arm)

I might have had to crawl down (to the class) but when I came out after it was over I felt totally different. I had so much more energy. (Respondent 1, group 6, intervention arm)

• The importance of the group context of the exercise

intervention It was a wee kind of light for me at the end of a big long tunnel.

And I just think having contact with other women.. that was what really appealed to me (Respondent 4, group 1, intervention arm) I really looked forward to it..you were meeting people that were the same as yourself. And you could get on with your exercise and have a laugh at the same time (Respondent 1, group 6, intervention arm)

5 year follow up • Of the 203 women in the original study, 114 attended the 18

months follow up and 87 at 5 years.

• Women in the original exercise group still reported significantly more leisure time physical activity (2 and a half hours more) and a more positive mood than women in the original control group.

• Those engaging in sufficient physical activity recorded a larger decrease in depression levels at all follow-up points.

Mutrie, N., Campbell, A., Barry, S., Hefferon, K., Mcconnachie, A., Ritchie, D. & Tovey,

S. (2012) Five-year follow-up of participants in a randomised controlled trial showing benefits from exercise for breast cancer survivors during adjuvant treatment. Are there lasting effects? Journal of Cancer Survivorship Volume 6, Issue 4, pp. 420 - 430

Notable differences between original intervention and control group

5 years later

Intervention Control

More aware of the importance of physical activity to health and well being

Understood importance – not to same extent

More knowledgeable how to exercise safely

Felt lost as to how to start exercising safely

More self assured in engagement in different types of physical activity (weights, classes)

More likely to be a ‘contemplative’ stage of change

More likely to be gym goers More likely to be walkers

Integrated exercise into lifestyle

Hefferon, K., Murphy, H., Macleod, J., Mutrie, N., Campbell A. (2013) Understanding Barriers to exercise implementation 5-years post Breast cancer

diagnosis: A large-scale qualitative study. Health Education Research

Future research on physical activity and cancer

• Cancers other than breast, prostate and colorectal

• Dose (FITT) required for benefits • Mechanisms of protection • Determinants and predictors of behaviour

change • Chronic and late appearing side effects • Implementation studies

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Integrating evidence based care

Physical Activity Care Pathway

Royal Bournemouth and Christchurch Hospitals

CNS assess patient needs and complete formal referral into leisure centre.

Exercise professionals trained in motivational interviewing lead behaviour change intervention.

3 week supportive phone call 6 and 12 week face to face review 6 month follow up phone call.

Specialised exercise referral classes (wet & dry), gym work, swimming, Nordic walking, dance classes, ladies swimming sessions, dragon boat racing and more.

Clinical Nurse Specialists identify cancer patients at end of treatment.

Cancer and Physical Activity Standard Evaluation

Framework

•Consistent approach to collection of data •Learn from existing practice •Collect evidence to present to partners

Evidence to Practice: Move More Programmes

The Move More Dundee Programme

• Anyone who has been diagnosed with cancer and still under

clinical care • Exercise champion or any of MDT – 5 min brief intervention

training • Approved referral process • Referred to Move More manager at ISE • Phone call

– Exercise consultation – Home based programme – Gym programme – Group exercise – Water based programme – Hospice programme – Walking – Chi gung

• Classes led by Qualified Cancer Exercise Fitness instructors

Move More Dundee

HCP refers patient (Move More Dundee

information & Referral Form)

Patient contacted by telephone by Move More team at ISE

Patient attends Move More Programme at ISE for exercise consultation

Patient given: • advice only

• home programme • other PA (e.g. walking group)

or signposted to: • other local PA programme

• Macmillan day care. • Maggies.

Move More participant is provided with an exit consultation into independent

physical activity programme.

Patient has a telephone consultation with the Move More team.

Patient joins Move More Programme (gym-based, group exercise, other ISE

classes & PA)

3 Levels of care and support

What can you do?

BENEFITS OF PHYSICAL ACTIVITY PROGRAMME

Improve functional status prior to treatment or prevent/attenuate functional decline during treatment

Address treatment-specific impairments during and following treatment:

Optimize general health in the recovery period following cancer treatment:

Activity Recommendations Exercise can be safely performed during and after cancer

treatment, if individual limitations are considered. All cancer survivors, including those with existing disease

or who are undergoing difficult treatments, should be encouraged, as a minimum, to avoid being sedentary.

Unless advised otherwise, follow the physical activity

guidelines provided for the general UK population

Guidelines for keeping active!

• How often?: 5 times a week

• How hard?: moderate intensity – it should feel slightly hard

• What type of activity?: using large muscle groups e.g. walking, cycling, swimming, low level aerobics, include weight bearing exercises

• How long?: at least 30 min continuous or a number of shorter bouts

© CanRehab

Exercise deficiency increases cancer risk

Strong evidence base Modest evidence base Limited evidence base

6. Using the relevant evidence to inform programmes and policy

4. Characterising prevalence of and determinants of physical activity behaviour in cancer survivors

5. Testing interventions to increase physical activity for cancer prevention and survival

1. Identifying relations between physical activity and cancer risk

2. Identifying relations between physical activity, Tx side effects & survival

Physical Activity and Cancer Research: Current State of the Science

3. Examining the biologic mechanisms involved in physical activity and cancer risk

Adapted from Owen N et al. Amer J Prev Med 2011, 41, 189-196.