Exercise Oncology: Improving Cancer Care Outcomes

1. Exercise Oncology: Improving Cancer Care Outcomes Keeping FIt Claudio Battaglini, Ph.D. FACSM Get REAL & HEEL Breast Cancer Program Director Exercise Oncology Research Laboratory Director

2. “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

3. Cancer and Quality of life – what is it? Physical Well-Being Fatigue Functional Well-Being Global Quality of Life Social/Family Well-Being Cognitive Function Depression/ Stress Emotional Well-Being Tumor site Symptoms Components of quality of life

4. Biological Mechanisms (Possible mechanisms involved in the relationship between exercise and cancer prevention) Friedenreich & Orenstein J Nutr 2002

5. Exercise and survival after a cancer diagnosis: biologic mechanisms EXERCISE Sex Hormones Oxidative Damage Immune / Inflammation Metabolism Other RECURRENCE / SURVIVAL

6. Purpose of the Exercise Oncology Projects 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) • Examine the effects of exercise on treatment-related side-effects; • Design of evidence-based exercise prescription guidelines for cancer survivors.

9. Get REAL & Heel Breast Cancer Research Program EXERCISE Sex Hormones Metabolism Oxidative Damage Immune / Inflammation Other RECURRENCE / SURVIVAL

10. Cancer Disease-Treatment Exercise Training Pro-inflammatory Cytokines IL-1() IL-6. IFN-, TNF-, LIF, CNTF Up - Regulation Anti-inflammatory Cytokines Anorexia Sarcopenia IL-1ra, IL-4, IL-10, IL-15, sTNFR, sIL6R Androgenic Hormones Up-Regulation Muscle Protein Synthesis Muscle Tissue Loss  Functional Capacity  Functional Capacity Inhibitory Excitatory Hackney & Battaglini, 2011

11. Get REAL & Heel Breast Cancer Research Program EXERCISE Sex Hormones Metabolism Oxidative Damage Immune / Inflammation Other RECURRENCE / SURVIVAL

12. 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. (Peters 1994, Nieman 1995, Shore 1999, Na 2000, Fairey 2002, 2005, Lee 2010) EXERCISE Sex Hormones Metabolism Oxidative Damage Immune / Inflammation Other Heavy Sedentary Risk of Disease RECURRENCE / SURVIVAL Moderate Training volume

13. EQUAL (Exercise and Quality of Life in Leukemia/Lymphoma Patients) EXERCISE Sex Hormones Metabolism Oxidative Damage Immune / Inflammation Other Metabolism Immune / Inflammation Other RECURRENCE / SURVIVAL

17. Effects of Exercise on CRF

18. Effects of Exercise on PROs Concerning fatigue, Piper fatigue scores (used by 10 studies) decreased 1.1 points [95% CI, −0.2 to −2.1; p = 0.019] with exercise training and increased 0.2 points [95% CI, −1.4 to 1.7; p = 0.803] in the control group. Significant changes were indicated for FACT-Fatigue (FACT-F) (p = 0.055) and Linear Analogue Scale (LAS) (p = 0.012) *Lower scores reflect lower fatigue except where indicated Increased scores reflect lower fatigue; decreased scores reflect lower fatigue

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

20. Prescribing 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

21. Clinical 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.

22. Health Screening • Comprehensive health screening procedure should include: • Oncology physician consent for participation in physical activity • - Family physician consent 2. Intake Meeting - Informed consent form - PAR-Q - Medical History Questionnaire ??? - Lifestyle Evaluation (Physical Activity Levels) - Resting Vitals (BP, RHR, SPO2, ECG)

23. Exercise Testing Recommendations Chapter 5. Cardiorespiratory Fitness Testing in Clients Diagnosed With Cancer Jones, L & Battaglini, C. 2012

24. Exercise Testing Considerations • Max tests (w/ direct or estimated measurement of VO2peak) vs. Submaximal Tests • Purpose • Setting (clinical vs. non-clinical facility) • Type of cancer patient

25. Cardiorespiratory Endurance - CPET, Stress Tests, Sub-maximal Protocols (Modified Bruce Protocol, YMCA Bike Protocol, Rockport Walking Test, etc.) (Dependent on Functional Status of Patient)

26. Muscular 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)

27. Flexibility/ 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)

28. Exercise Prescription Recommendations Mode • 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

29. Frequency and Intensity • 2-5d/wk • Extreme caution w/ patients suffering extreme fatigue • Moderate intensity • 50-75% of VO2max • 40-80% HRR

30. Duration 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 overall health of patient

31. Special Precautions ComplicationPrecaution 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)

32. Special Precautions Continued ComplicationPrecaution Severe cachexia Loss of muscle mass limits exercise intensity - modify program accordingly Bone pain Avoid high impact exercises Extreme fatigue Exercise at lower power output, avoid high intensity exercise Dehydration Inability to efficiently thermoregulate

33. Exercise Session Example • Check resting vitals • Cardio Workout • Stretching (Whole Body) • Weight Training • Finals Stretches/ Relaxation Whole Body Stretches/ Specific Stretches Cardio Workout 20% 25% 15% Cool Down Stretches/ Relaxation 40% Weight Training Workout

34. 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)

35. Acknowledgements • All of the wonderful UNC physicians, cancer researchers, exercise physiology colleagues, and my students • Special thanks to: • Department of Exercise and Sport Science • Lineberger Comprehensive Cancer Center • UNC Cancer Hospital

36. THANK YOU! Contact Information: Dr. Claudio Battaglini Department of Exercise and Sport Science (919) 843-6045 claudio@email.unc.edu