Special Considerations for Cancer

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This chapter presents background information and special considerations for exercise testing, prescription, and progression for individuals with cancer. The case study that follows outlines the personal and health history of a middle-aged woman diagnosed with and treated for breast cancer. This background information will be used as a guide for exercise testing and development of a progressive aerobic and resistance training program with the primary goal of return to work and recreational activities for this patient.

Case Study 20-1

Mrs. Case Study-CA

Mrs. Case Study-CA is a 58-year-old woman weighing 89.5 kg (197 lb) with a height of 165 cm (5 ft 5 in). She has a history of stage IIA hormone receptor–positive breast cancer, diagnosed 7 months ago. She also has a family history of breast cancer in her maternal grandmother and in an older sister. Mrs. Case Study-CA has a history of prediabetes and is taking a stable dose of metformin. She does not smoke and drank alcohol moderately (four to six drinks per week) up to the time of her breast cancer diagnosis. As her course of treatment, Mrs. Case Study-CA received neoadjuvant chemotherapy for the first 3 months to shrink the breast tumor followed by breast-conserving surgery (BCS; sometimes called lumpectomy or partial mastectomy) in the left breast. She then received local radiation therapy during months 5 and 6. Adjuvant hormone therapy (tamoxifen, an estrogen receptor antagonist) was initiated at the time of surgery and will continue, once daily, for at least 5 years.

Prior to her cancer diagnosis, Mrs. Case Study-CA was working full-time as an accountant at a large corporation. Although she regularly worked 10 hours per day, 5 days per week, Mrs. Case Study-CA made an effort to go for daily 15-minute walks on her lunch break and tended to her garden 1 hour per night, 3 days per week. Since her diagnosis, she has not had the energy for her daily walks, and her husband has taken over gardening duties in addition to cooking and cleaning, adding stress to the marriage. Mrs. Case Study-CA’s primary goals for an exercise program are to facilitate her return to work and to mitigate the side effects of treatments, allowing her to return to gardening and cooking.

At a recent visit with her primary care physician, Mrs. Case Study-CA expressed interest in returning to work, adding in her daily walks, and starting to garden again. Her physician conducted a physical exam and noted mild swelling in her left axillary lymph nodes (lymphedema; localized fluid retention and tissue swelling), reduced range of motion (ROM) in the left shoulder, and muscular weakness in the left arm compared with the right arm. Mrs. Case Study-CA did not report any dizziness or shortness of breath when walking but did report being easily fatigued when climbing stairs and doing housework.

While in the clinic, Mrs. Case Study-CA’s physician sent her to the heart center for exercise testing. Before testing, she was fitted with a compression sleeve to help control the lymphedema in her left arm. After a warm-up, she completed a submaximal exercise test on the treadmill using the modified Bruce protocol. The results of the exercise test are presented in Table 20.1. The test was stopped after 2 minutes of stage 3 due to patient-reported fatigue.

Table 20.1

Results of Graded Exercise Treadmill Test (Modified Bruce Protocol)

Stage	Time (min)	Speed (mph)	Incline (%)	Heart Rate (bpm)	Blood Pressure (mm Hg)	Rating of Perceived Exertion
Rest	3	0	0	74	118/82	6
0	3	1.5	0	98	130/82	8
0.5	3	1.5	0	106	138/82	9
1	3	1.7	0	112	150/82	12
2	3	1.7	5	146	168/82	13
3	2	1.7	10	162	176/82	15
Recovery	2	0	0	116	136/82	6
Recovery	3	0	0	80	122/82	6

Mrs. Case Study-CA’s physician told her that it was safe for her to begin light- to moderate-intensity exercise, such as walking. She sought guidance from an exercise professional to help her safely add exercise back into her routine. During the initial consultation, Mrs. Case Study-CA performed simple ROM exercises to determine her ability to perform different exercises. Then, she completed one repetition maximum (1-RM) testing on the bench press, leg press, and lateral raise. Her estimated 1-RM was determined to be 85.0 kg (187 lb) for the leg press, 31.5 kg (69 lb) for the bench press, 8.0 kg (17 lb) for the right lateral raise, and 5.5 kg (12 lb) for the left lateral raise based on workload from 8-RM.

Description, Prevalence, and Etiology

Cancer is a general term encompassing over 200 unique disease states. Cancer is broadly defined as uncontrolled cell growth, usually as a result of genetic or single-nucleotide mutations, which can occur in epithelial tissue (carcinoma), connective tissue (sarcomas), bone (blastoma), blood (leukemia), or lymph nodes (lymphoma) (21). Each cancer is further classified by the size and spread of the tumor(s), indicated by a staging system. There are several staging systems, but a five-stage system is often used (1). Stage 0 indicates presence of abnormal cells that are localized. Stages 1–4 indicate the presence of tumors, with increasing size and spread represented by a higher stage number. Stage 4 indicates that tumors have spread to other tissues or organ systems in the body from the primary tumor site called metastasis. Each tumor may also be evaluated for appearance and assigned a grade based on cellular differentiation within the tumor. In general, tumor grading systems range from 1 to 4, with “1” indicating well-differentiated tumor cells that are likely to grow and spread slowly and “4” indicating undifferentiated cells that are likely to grow and spread rapidly. The grade of the tumor, along with the organ or tissue site and stage, will determine the timing and aggressiveness of cancer treatment. Thus, these tumor characteristics should be considered when developing an exercise prescription.

The current U.S. prevalence for all types of cancer is 13.7 million (20). The most common cancer sites are female breast, lung, male prostate, and colon and rectum (20). These cancers result from a combination of exposures, including environmental agents (e.g., cigarette smoke), lifestyle factors (e.g., diet, physical activity), and host factors (e.g., genetics, body weight). Understanding how these risk factors have an impact on disease progression and recurrence is important for developing exercise prescriptions for individuals with cancer. The National Coalition for Cancer Survivorship’s definition of cancer survivor, identified from time of diagnosis to the rest of life, including cancer treatment, will be used in this text (13).

Engaging in a regular physical activity program has been shown to reduce risk for recurrence, cancer-specific mortality, and all-cause mortality among adults with a history of cancer (2,8,12,23). A regular exercise program can also help delay or control other chronic conditions which are common among cancer survivors (4,6,7,10,11,14,25), such as diabetes or cardiovascular disease (CVD), discussed in more detail in other chapters of this textbook. There is ample evidence that exercise training can help mitigate cancer-related fatigue and can improve physical function and quality of life for cancer survivors (5,15,16,17). Recently, the short- and long-term cardiovascular health benefits of exercise among cancer survivors have been investigated (18).

Overview of Preparticipation Health Screening, Medical History, and Physical Examination

The American College of Sports Medicine (ACSM) recommendations for exercise preparticipation health screening (1) can be followed for patients with a personal history of cancer. Each patient’s current physical activity levels, time since diagnosis, course of treatment, symptoms and side effects, and other personal health factors will determine what steps should be taken prior to beginning an exercise program.

The patient’s health history should be considered when determining if additional evaluation is necessary. Cancer-related side effects will vary by treatment modality (e.g., chemotherapy, radiation, surgery, immune therapy, hormone therapy) and host factors, such as age and presence of comorbidities. The number of treatment options and agents, and their potential side effects, is as varied as the cancers themselves. Common immediate side effects of treatment include pain, fatigue, nausea and vomiting, change in appetite, and localized swelling or lymphedema (19). Long-term effects, or side effects that occur during or shortly after treatment is completed, can include changes in cognition, body weight and composition, cardiovascular health, immune function, and nerve function. Cognitive side effects are often referred to as chemo brain by patients and can include changes in memory and comprehension. Patients may experience unintentional increases or decreases in body weight depending on their phase of treatment, type of therapy, or experience with other symptoms or side effects. Loss of muscle mass, or cachexia (wasting), or increases in fat mass may occur with or without changes in body weight. Cardiovascular health can be affected by changes in metabolic profile (e.g., dyslipidemia), in body composition, or in vascular structure and function resulting from treatment. Treatment agents that target the immune response, such as inflammation, or specific immune receptor cells can have an impact on a patient’s ability to respond to antigens or recover from infection. Peripheral neuropathies may result from damage to nerves during surgery and can manifest as pain, numbness, or ataxia in the affected tissues or joints. Patients may experience muscle weakness and/or balance issues related to treatment incurred neuropathies. Reduced ROM around affected joints during and after treatment (e.g., shoulder joint following breast surgery) is also common. Patients undergoing hormone therapy can experience loss in bone mass and bone mineral density, thus increasing risk for bone break and fractures. Hormone therapy for cancer is aimed at reducing circulating hormones (e.g., androgen deprivation therapy for prostate cancer, estrogen reduction for breast cancer) in order to deprive the tumor cells. This has an opposite effect on bone health than hormone replacement therapy used to relieve symptoms of menopause in women. Additionally, surgical removal of hormone-producing glands or organs as part of cancer treatment can result in reduction in bone mass and density.

Advances in treatment, screening, and diagnosis have led to increased 5- and 10-year survival rates for a number of cancer sites (2). Due to these improvements, new late effects, or side effects appearing months to years after the end of treatment, are appearing in patients with a history of cancer. The cardiotoxic effects of chemotherapies are being increasingly recognized and can lead to complications such as cardiomyopathy, left ventricular dysfunction, and heart failure (HF) (3,17). Factors increasing the risk of chemotherapy cardiotoxic effects include the presence of other CVD risk factors (e.g., age, family history, hypertension, smoking) and the number and dose of concomitant chemotherapy agents administered (3). Patients who display or report signs or symptoms of cardiac arrhythmias or HF such as shortness of breath, rapid onset of fatigue, or light-headedness/dizziness with moderate-intensity activity should undergo additional medical evaluation before beginning an exercise program in order to determine exercise safety. If the patient has confirmed HF, the guidelines for exercise testing and prescription for HF should be followed (see Chapter 12).

The immediate and long-term side effects of treatment should be assessed prior to or during medical examination in order to guide exercise testing, prescription, and progression. A medical examination may need to be repeated after completion of cancer treatments, after any major changes in medication (type or dose), or if the patient reports changes in symptoms or side effects. Furthermore, exercise should be discontinued temporarily after major changes in symptoms or side effects and until a medical evaluation is performed and the patient is cleared to safely resume exercise.

Case Study 20-1 Quiz:

Preparticipation Health Screening, Medical History, and Physical Examination

1. What type of preparticipation health screening is necessary for this patient prior to engaging in moderate-intensity exercise?

2. What specific host factors should be considered for their impact on cancer treatment and exercise tolerance?

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