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McGill Cancer Nutrition and Rehabilitation Program

Exercise, Fatigue and Cancer


Presented by:
Tara Swanson PT, MSc (RS)
Marta Jelowicki, PT
PRESENTATION OVERVIEW

z Section One:
Overview of Cancer-Related Fatigue
z Section Two:
Findings From Recent Study: Physiological
Correlates in Cancer-Related Fatigue
z Section Three:
Practical Considerations Related to Exercise
in Cancer Patients
Section One:
Overview of Cancer-Related Fatigue
WHY FATIGUE

z Fatigue is often one of the first symptoms,


starting at the presentation of a cancer
diagnosis

z This may be due to several factors including:


– Tumour being metabolically active
– May have decrease in appetite/food intake
– May have a decrease in activity levels, leading to
de-conditioning
CANCER-RELATED FATIGUE
(CRF)

“a persistent, subjective sense of tiredness


related to cancer or cancer treatment that
interferes with usual functioning.”

(National Comprehensive Cancer Network 2003)


DIMENSIONS of CRF

z Affective Dimension
(irritability, anxiety, depression)
z Cognitive Dimension
(poor concentration & memory)
z Physical Dimension
(muscle fatigue & weakness, breathlessness)
MEASUREMENT of CRF

z May take a multi-dimensional or


uni-dimensional approach

z May use a specific tool or subscale on QOL


tools
STATUS OF KNOWLEDGE

z Fatigue during treatment seems to be


related to type of cancer, chemotherapy
regimen, psychological status, sleep
difficulties, pain, ↓ activity, anemia
z Fatigue after treatment seems to be related
to age, gender, psychological status, sleep
difficulties, pain, ↓ activity and shortness of
breath
STATUS OF KNOWLEDGE

z Effective interventions include:


– Education (energy conservation, stress
reduction, distraction)
– Sleep hygiene
– Nutrition
– Specific Medications
– Exercise
GAPS IN KNOWLEDGE

z There are many, including a limited


understanding how physical factors beyond
pain and shortness of breath influence the
fatigue experience and its impact on function
z This information is essential to refining our
measurements and interventions to address
CRF
Section Two:
Findings From Recent Study
PHYSIOLOGICAL CORRELATES OF
CANCER-RELATED FATIGUE
Swanson T, Dalzell MA, Small D, Kreisman H,
MacDonald N, St-Pierre DMM

▪ McGill University, School of Physical and Occupational Therapy ▪


▪ Jewish General Hospital, Department of Pulmonary Medicine ▪
Montreal, Quebec Canada
OBJECTIVES

z OBJECTIVE 1: Identify the physical factors


contributing to CRF

z OBJECTIVE 2: Determine to what extent these


factors contribute to CRF
MEASUREMENT

VARIABLE TOOL
Cancer-Related Fatigue Brief Fatigue Inventory (BFI)
Mendoza et al. Cancer (1999)
Mendoza et al. Cancer (1999)
MEASUREMENT

VARIABLE TOOL
Exercise Capacity 2-Minute Walk Test (2MWT)
O2 Saturation with Activity Pulse Oxymeter
Muscular Strength 30 second Chair Rise (CR)
Hand Grip Dynamometer
Muscular Endurance Hand Grip Dynamometer
Hemoglobin & C-Reactive Routine Blood Testing
Protein (CRP) Levels
MEASUREMENT

VARIABLE TOOL
Overall Breathlessness Visual Analogue Scale (0-10)
Weakness Visual Analogue Scale (0-10)
Sleep Visual Analogue Scale (0-10)
Pain Visual Analogue Scale (0-10)
STATISTICAL ANALYSIS

z UNIVARIATE REGRESSION between variables and


cancer-related fatigue (as assessed by the BFI)

z MULTIVARIATE REGRESSION to determine a


predictive model of cancer-related fatigue
STUDY POPULATION

z INCLUDED
– Stage III or IV non small cell lung cancer
– Referred to McGill Cancer Nutrition and Rehabilitation
Program

z EXCLUDED
– Unable to complete questionnaires
– Unable to complete the assessment tasks due to pain
or safety reasons
PATIENT CHARACTERISTICS (n=58)

AGE 68 yrs (42-88)


MALE/FEMALE 30/28
STAGE AT ASSESSMENT
Stage IIIA 5
Stage IIIB 18
Stage IV 35
CURRENTLY RECEIVING
TREATMENT
Chemotherapy 22
Chest Radiation 3
RESULTS: PREVALENCE OF CRF

z 90% reported some degree of fatigue in the past


24hrs
50
% Respondents

40

30

20

10

0 1-4 5-7 8-10


Worst Fatigue Score
RESULTS: PREVALENCE OF CRF

z 84% reported fatigue to have interfered with at least


one function in the past 24 hrs
Mendoza et al. Cancer (1999)
RESULTS: IMPACT OF CANCER-
RELATED FATIGUE

100
% Respondents

80

60

40

20

Walking General Normal Relations


Mood Enjoyment with Others
Ability activity Work Of Life

DIMENSION OF FUNCTIONING
50
% Respondents

40

30

20

10

0 1-3 4-6 7-10


General Activity Score
FACTORS RELATED TO CRF:
UNIVARIATE ANALYSIS

FACTOR R2
Weakness (VAS) 0.45**
Overall Breathlessness (VAS) 0.30**
Pain (VAS) 0.29**
Lower Limb Strength (CR) 0.21**
Exercise Capacity (2MWT) 0.18**
** p<0.01 level
FACTORS UNRELATED TO CRF:
UNIVARIATE ANALYSIS

FACTOR R2
Upper Limb Strength 0.07
Upper Limb Endurance 0.04
O2 Saturation - Exercise 0.03
Hemoglobin 0.07
C-Reactive Protein (CRP) 0.02
Sleep (VAS) 0.03
MODEL BY
MULTIPLE REGRESSION

z Weakness (VAS)
z Overall breathlessness (VAS)
z Measurement of lower limb strength
(CR performance):

Combined R2 value 0.62


(p<0.01)
CONCLUSIONS

z Cancer-related fatigue is prevalent and interferes


with function of NSCLC patients

z Lower limb strength (CR), weakness (VAS) and


overall breathlessness (VAS) explain 62% of the
variance in cancer-related fatigue scores
CLINICAL SIGNIFICANCE

z Management of breathlessness may improve CRF in


this population

z Weakness, especially in the lower limbs, contributed


to CRF in this population

z Strength training programs, in combination with


cardiovascular training, may lead to improvement in
CRF and ultimately enhance patient QOL
Section Three:
Practical Considerations Related to Exercise in
Cancer Patients
Outline

z Why exercise?
z Practical considerations related to exercise in
cancer patients
z Motivation and resources
Why Exercise

z Exercise training is safe and feasible for


cancer survivors following the completion of
primary therapy
z [Exercise]…may be associated with
potentially clinically meaningful
improvements in exercise capacity and
overall QOL

Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am 22 (2008)


Why Exercise

z “Physical activity interventions may reduce


the risk of developing some cancers, help
cancer survivors cope with and recover from
treatments, improve the health of long-term
cancer survivors, and possibly even reduce
the risk of recurrence and extend survival
after a cancer diagnosis”

Courneya, K.S. and Friedenreich, C.M., Seminars in Oncology Nursing, 2007


Why Exercise

Physical Activity and Survival After Breast


Cancer Diagnosis

z Prospective observational study


z 2987 women diagnosed with stage I-III breast cancer
from the Nurses’ Health Study cohort
z Patients were divided into groups depending on how
engaged they were in physical activity
z Physical activity was measured in MET-hrs per week

Holmes et al. JAMA, 2005


Why Exercise

Physical Activity and Survival After Breast


Cancer Diagnosis
Results:
“Any category of activity higher than the reference
category of less than 3 MET-hrs per week was
associated with a decreased risk of an adverse
breast cancer outcome”
“Absolute unadjusted mortality risk reduction was
6% at 10 yrs for women who engaged in 9 or
more MET-hrs per week”
Holmes et al. JAMA, 2005
Practical Considerations

z Treatment Side-effects
– Chemo-induced
– Radiation-induced
– Surgical
– Other treatments: eg: Stem-Cell Transplant, steroids

z Disease-Related
– Site of tumor
– Metastases
– Nutritional status
– Psychosocial impact
Chemo-Induced

z Fatigue
z Thrombocytopenia
z Anemia
z Neutropenia
z Loss of hair
Chemo-Induced

z Decreased appetite
z Nausea and vomiting
z Changes in bowel function
z Neuropathy
z Altered mentation, “Chemo-brain”
z Cardiotoxicity
Radiation-Induced

z Burns
z Fibrosis
z Fatigue
Surgical

z Pain
z Anatomical changes
z Scar mobility
z Added management difficulties if followed
closely by radiation
z Foot drop
z Post-op restrictions due to type of surgery
z Post-op restrictions suggested by surgeon
Other Treatments

z Stem Cell Transplant (SCT)


– Decreased Immunity
z Avoid public pools, lakes, and crowded areas
– Graft vs Host Disease (allogeneic-SCT)
z Sun exposure precautions
z Sclerodermatic tissue changes with skin GvHD

z Corticosteroids:
– Used in many treatment regimens
Site of Tumor

z Gastroesophageal
z Breast
z Prostate
z Hepatobiliary
z Lung
z Hematologic
z Other
Metastases

z Liver
z Lung
z Brain
z Bone
Nutritional Status
Psychosocial Impact

Coping
Coping
Cognitive
Cognitive Emotional
Emotional

Spiritual
Spiritual
Occupational
Occupational Person
Person Religious
Religious

Financial
Financial Relationships
Relationships
Physical
Physical
Some Guidelines from Cancer Exercise
Specialist Training Course

z Individualize
z Moderate intensity activity level
z Full body exercise at each session 3x/wk
z Monitor blood counts
z Progress slowly and vary workout with treatment
effects
Some Guidelines from Cancer Exercise
Specialist Training Course

Status Recommended Intensity Level

Sedentary, poor health, 30-40% HRR (starting);


low fitness RPE = 1-3
Active, moderate health, 50-60% HRR (starting);
average fitness RPE = 4-5

Exercise and Cancer Recovery, Schneider, C. M. et al., 2003


Motivation

z Some ideas….
– Patients have control: CHOICE
– Prevention of complications or secondary
problems
– Potential benefits
– Sense of achievement
– Goal setting
– New habit: can take 30-60 times to develop
– Exercise can be FUN, really…
Take-Home Message

z Do not avoid, but be cautious when prescribing


Physical Exercise
z MODERATE INTENSITY, slow progression
z Keep in mind the whole person, the individual
z Exercise is an important and integral part of life
prior to, with, and after cancer, have fun with it!
Resources

z Canadian and American Cancer Societies


z Comprehensive Health Improvement Program
(CHIP) at Atwater Club
z Cumming’s Center
z Jewish Rehabilitation Hospital
z McGill’s Cancer Nutrition-Rehabilitation Programs
z Wellness Center (CDN)
z Yoga classes (Happy Tree)
z Many community activities, gyms, and….. the great
outdoors
References

Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am


22 (2008) 319-342
Holmes et al., JAMA May 25, 2005, Vol 293, No. 20
Courneya, K.S. and Friedenreich, C.M., Physical Activty and
Cancer Control, Seminars in Oncology Nursing, Vol. 23, no. 4
(Nov.) 2007 (pp 242-252)
Franklin, D. J. MD, PhD, Phys Med and Rehab Clin of N Am 18
899-924 (2007)
Exercise and Cancer Recovery, Schneider, C. M. et al., 2003

marta.jelowicki@muhc.mcgill.ca

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