Cancer

Question 1

What factors define cancer and how may this effect treatment?

Answer 1

Anatomic location, causes, susceptibly to treatment - cancer has therefore become increasingly individualised.

Question 2

What was found about leisure time physical activity and cancer prevention and by what journal?

Answer 2

Moore (2016) JAMA: Prospective study of 12 trials including 1.44 million participants. Results: 90th vs 10th percentile showed 20% of more risk reduction of 13 cancer (Oesphageal, 42%, Liver 27%, Lung 26%) and 7% reduced risk across 26 with higher risk for melanoma (sun) and prostate (screening bias).

Question 3

What was about leisure time physical activity and secondary cancer risk and by what paper?

Answer 3

Friedenreich (2016) Clinical cancer research journal: 26 Prospective cohort studies showed 37% pooled risk reduction for cancer specific mortality for breast, colon, and prostate cancer

Question 4

What was found in the After Breast Cancer Pooling Project (2012)

Answer 4

• 25% reduced mortality risk for those meeting PA guideliens
• 22% increased risk for sedentary individuals (<1.5 MET hours/week)
• 35% pooled reduced risk for recurrence

Question 5

What are cancer survivors?

Answer 5

• Individuals with a history of cancer

Question 6

Why are randomized trials important in cancer research?

Answer 6

Reduce risk of reverse causation and confounding

Question 7

What is precision medicine?

Answer 7

Personalised or individualised medicine: Tailoring treatment based on individual’s genes, environment, and lifestyle. Greater exercise benefits for certain subgroups.

Question 8

What was found about the impact of exercise on treatment-related advsere effects and by what paper?

Answer 8

Cormie (2017) (Epidemiology review): The impact of exercise on cancer mortality, recurrence and treatment related adverse events. 100 studies.
Result: Fewer/less severe adverse effects, improved bone mineral density, improved psych distress (anxiety/depression), Improved quality of life in those exercised more.

Question 9

What are some ongoing clinical trials in cancer research and briefly describe the methods?

Answer 9

UK CHALLENGE Trial: Supervised 3 year multi-centre programme of exercise aiming to achieve 10-27 MET hour/week. Colon patients who have completed routine treatment.
INTERVAL-GAP4 Trial: High-intensity aerobic and resistance exercise routine over 12-months in 6 centres for metastatic prostate cancer.

Question 10

What was found about exercise training and VO2 peak in cancer patients and in what paper?

Answer 10

Jones (2011) Oncologist Journal: (2.90 vs -1.02 ml/kg/min) for exercise training group with 571 patients across 6 studies. Best for shorter duration (<4 months) and following completion of adjuvant therapy.

Question 11

Outline the methods and results from Sweegers and Colleagues and the journal their study was in?

Answer 11

Sweegers and colleagues (2018): 28 randomised controlled trials investigating exercise on upper body muscle strength, lower body muscle strength, lower body muscle function (LMBF) and CRF.
- Small effect on all but larger for when interventions were supervised (all), Session durations >60 minutes (RT) and when 3 sessions a week were included (RT).

Question 12

Why is promoting exercise important in cancer survivors?

Answer 12

1) 8% of caner survivors derived from accelerometer data met mod-vig PA guidelines
2) Significant comorbidities with 60% of cancer survivors being over 55 such as diabetes, CVD, arthritis, and obesity.
3) Combined effects of cancer-related side effects, aging, and other health conditions present as impaired cardiovascular fitness, functional limitations, and reduced quality of life.

Question 13

What are some considerations to factor in prior to exercise and exercise testing in and what is the adherence like and what’s the significance of this?

Answer 13

1) Low adherence to guidelines - do not create barriers
2) No testing prior to walking, resistance, or flexibility exercise
3) PAR-Q+
4) Brief cancer history

Question 14

What should a brief cancer history include in cancer survivors?

Answer 14

1) The type of cancer
2) Whether they are receiving treatment
3) Whether the cancer was removed
4) Treatment/Side effects: Neuropathy, Lymphedema, Ostomy, Bone Metastases. Any other symptom influencing their ability to exercise

Question 15

When should medical evaluation and/or testing be considered?

Answer 15

1) Those with persistent and significant cancer treatment related side-effects
2) Those with significant comorbidities
3) Those with metastatic disease

Question 16

What is are the four special groups that need medical evaluation for cancer and when should they be referred back?

Answer 16

1) Arm morbidity and lymphedema: Refer to physical therapy if shoulder morbidity makes unsafe for exercise (reduced range, flexibility, psychological distress, increased swelling)
2) Bone metastases: Fracture, Spinal Compression, and exacerbation of bone pain. Testing modalities should avoid loading of metastatic lesion or proximal location
3) Neuropathy: Instability, balance, and altered gait can increase risk of falls - assessing these useful for determining modality
4) Ostomy: Avoid Valsalva manoeuvre - based on expert opinion but ongoing EXPASS trial likely to show (Association of stoma care nurses)

Question 17

Outline the stages in physical activity assessment for cancer survivors?

Answer 17

1) Prior/Current participation in physical activity.

2) Focused clinical evaluation: Weight/BMI, Blood Pressure, Complete blood count (anaemia/thrombocytopenia), Functional status, Barriers to activity (Finance, Physical limit, Time, Social Support, Stress) Disease status, Review of systems (close ended questions to identify symptoms that haven’t come up)

3) Assessment of treatable contributing factors: Pain, Fatigue, Emotional distress, Nutritional deficit, Imbalance, Medications

4) Assessment of comorbidities and treatment effects: CVD, PD, Arthritis, Lymphedema, Peripheral neuropathy, Bone Health, Incontinence, Presence of stoma, Falls Risk, Need for assistive device, Steroid Myopathy (Muscle wasting)

5) Determine risk level of adverse event

Question 18

When might you liase with a patients medical team and why might you not?

Answer 18

• Barrier to entry in many

-Change in symptoms for lymphoedema, metastases, Arm/Shoulder morbidity, Nutritional concerns (muscle wasting), Cardiovascular symptoms

Question 19

What are 3 exercise training considerations in colorectal patients?

Answer 19

1) Physician recommendation for contact sports
2) Avoid excess intra-abdominal pressure
3) Start with low resistance progress slowly with stoma to avoid herniation

Question 20

What are 4 exercise specific recommendations for cancer patients?

Answer 20

1) Reduce infection risk
2) Intensity, duration and mode (bone metastases)
3) Exercise tolerance varies depending on treatment
4) Supervision to avoid fracture in metastases and if cardiac conditions

Question 21

What are 5 general contraindications to exercise in patients with cancer?

Answer 21

1) Fever
2) Extreme fatigue
3) Significant anaemia
4) Ataxia (lack of muscle coordination)
5) Cardiopulmonary contraindications

Question 22

What are 4 specific exercise training considerations in breast cancer patients including 2 for how resistance training may be manipulated?

Answer 22

1) Acute arm/shoulder issues need resolving: (manual lymphatic drainage, compression therapy, therapeutic exercise, education or medical evaluation
3) Fracture risk: Hormonal therapy
4) Reduce resistance by 2 weeks for each week missed
5) Supervised session of 16 with low resistance and working up with no upper limit

Question 23

What is a exercise consideration in patient with prostate cancer?

Answer 23

• Risk of fracture due to androgen deprivation therapy

Question 24

What are the FIIT recommendations for aerobic exercise in cancer patients UK and US

Answer 24

150-300 min mod or 75-150 vigorous aerobic - half this for UK

F: 3-5 days/ week (preferably 5)
I: 40-60% HRR
T: >30 minutes with modifications during treatment
T: Walking, cycling, swimming

Question 25

What are the resistance training FIIT principles for cancer patients?

Answer 25

F: 2-3 days/week with 48 hours between sessions
I: 60-80% 1RM or allow for 6-15 repetitions. Increase weight when repetitions >15
T: >1 set >8 repetitions set, 60 second rest between sets
T: 8-10 exercises focusing on major muscle groups

Question 26

What are 4 cancer specific exercise training recommendations in cancer survivors?

Answer 26

1) Arm morbidity/upper extremity lymphedema: No upper limit on weight lifted - need to wear compression garment. Progress weight and build slowly. Safety for lower extremity is unknown.
2) Bone metastases: No direct loading - bone pain monitored during and after exercise - if worsens exercise should be ceased - if doesn’t improve with stopping exercise refer to professional.
3) Neuropathy: Assessment of falls - weight bearing selected to reduce falls risk. Is symptoms worsen change exercise and if don’t improve with exercise cessation refer to professional.
4) Ostomy: Infection risk reduction, start low and go slow, Avoid contact sports and excess intra-abdominal pressure

Question 27

What 5 symptoms make it unsafe to exercise and what should you do if these present?

Answer 27

Ataxia, Severe fatigue, Profound weakness, and other worsening or changing physical conditions - these patients should be referred back.

Question 28

What is the blood cell count cut off values for exercise in cancer patients?

Answer 28

• Red blood cell <10 mg/dL
• Absolute neutrophil count <1000 cells per decilitre
• Platelets - 50,000-100,000 per microliter

Question 29

What does low red blood cell count lead to?

Answer 29

• Severe fatigue and weakness