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How exercise can boost health and recovery of people with cancer

Evidence shows physical exercise has a positive effect on cancer patients before, during and after treatment
Picture shows a group of hikers going through a wood. Evidence shows physical exercise has a positive effect on patients before, during and after treatment.

Evidence shows physical exercise has a positive effect on cancer patients before, during and after treatment

  • Expert group urges people with cancer to be as active as possible at all stages of cancer pathway
  • Activity can help cope with side effects as well as fatigue, anxiety and depression
  • It also improves health-related quality of life, bone health and sleep

International cancer experts are calling for exercise prescriptions to encourage people living with and beyond cancer to get the benefits of physical activity.

A global expert group, convened by the American College of Sports Medicine (ACSM), says exercise can help cancer patients to cope with side effects of treatment and lower

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Evidence shows physical exercise has a positive effect on cancer patients before, during and after treatment

  • Expert group urges people with cancer to be as active as possible at all stages of cancer pathway
  • Activity can help cope with side effects as well as fatigue, anxiety and depression
  • It also improves health-related quality of life, bone health and sleep
Picture shows a group of hikers going through a wood. Evidence shows physical exercise has a positive effect on patients before, during and after treatment.
Picture: iStock

International cancer experts are calling for ‘exercise prescriptions’ to encourage people living with and beyond cancer to get the benefits of physical activity.

A global expert group, convened by the American College of Sports Medicine (ACSM), says exercise can help cancer patients to cope with side effects of treatment and lower the risk of some cancers returning.

Their statement is the latest step in a growing move to encourage patients to be as active as possible at all stages of the cancer pathway.

Evidence suggests exercise is particularly beneficial for several forms of cancerPicture shows a 'Get Active' logo produced by Macmillan Cancer Support. Evidence shows that physical exercise has a positive effect on patients before, during and after treatment.

The ACSM group, which includes Macmillan Cancer Support, says there is evidence that exercise can help with cancer-related fatigue, anxiety, depression and physical function, as well as improving health-related quality of life, bone health and sleep.

Physical activity can have a positive effect on patients before, during and after treatment, and even in the palliative care phase, Macmillan says. In some cases, being physically active has been shown to slow progression of the disease, improve survival chances and reduce the chance of recurrence.

Evidence suggests exercise is particularly beneficial for several forms of the disease, including breast and prostate cancer, and nurses should tell their patients this, Macmillan adds.

‘A cancer diagnosis and treatment is a teachable moment and a chance to get people to think about their health differently’

June Davis specialist adviser for allied health professionals at Macmillan Cancer Support

For many patients, increasing activity could be more powerful than drugs. Gradually boosting activities that patients already enjoy is a good approach, says Macmillan specialist adviser for allied health professionals June Davis.

Benefits of encouraging people with cancer to exercise

  • For all adults, exercise is important for cancer prevention and specifically lowers the risk of seven common types of cancer: colon, breast, endometrial, kidney, bladder, oesophagus and stomach
  • Incorporating exercise can help improve survival chances after a diagnosis of breast, colon and prostate cancer
  • Exercising during and after cancer treatment has a positive effect on fatigue, anxiety, depression, physical function and quality of life, and does not exacerbate lymphoedema
  • There is an increasingly robust evidence base about the positive effects of exercise for cancer patients

(Source: American College of Sports Medicine)

The evidence of benefits to patients is now so strong that these conversations must take place, Ms Davis says, adding that for many patients increasing activity could be more powerful than drugs.

‘A cancer diagnosis and treatment is a teachable moment and a chance to get people to think about their health differently,’ she says.

Only 23% of people living with cancer are active to recommended levels

‘Nurses need to understand what people like to do in their day-to-day lives and what they can do more of. If it is walking around the supermarket, make it a longer walk to the shops or take the grandchildren to the park. For nursing colleagues it is about having these conversations about what they are doing that they could change a bit, and keeping it low-key.’

Ms Davis adds that the free NHS Active 10 app is a good way for people to set achievable goals for ten minutes of activity a day.

Picture of screen pages in the NHS Active 10 app. Evidence shows that physical exercise has a positive effect on patients before, during and after treatment.
Pages in the NHS Active 10 app

Despite the proven benefits, only 23% of people living with cancer are active to recommended levels, according to a 2012 NHS report.

While there are no official guidelines on physical activity for people with cancer, Macmillan says that otherwise healthy cancer survivors should be encouraged to build up to the level set out in physical activity guidelines produced by the UK’s four chief medical officers.

These guidelines state that adults should do at least 150 minutes of moderate intensity activity such as brisk walking or cycling a week, or 75 minutes of vigorous activity, such as running, or a combination of both. Strengthening exercise should be carried out twice a week.

‘Patients are advised to avoid inactivity and return to normal daily activities as soon as possible after surgery, and during adjuvant cancer treatments’

American College of Sports Medicine

The ACSM round table consensus statement on activity guidelines for cancer agreed that standard guidance for all adults should be followed. ‘Exercise is safe both during and after cancer treatment,’ the group said. ‘Patients are advised to avoid inactivity and return to normal daily activities as soon as possible after surgery, and during adjuvant cancer treatments.’

While many patients have co-morbidities, a Macmillan review of evidence showed that exercise would generally also be helpful for these conditions, the most common being cardiovascular, metabolic, musculoskeletal and psychological disorders.

‘Physical activity has a role in the prevention and management of these conditions, thereby strengthening the need for greater focus on helping those affected by cancer to maintain healthy active lifestyles,’ it said.

Seven ways to encourage people with cancer to get more active

  1. Encourage people to set goals they can achieve at their own pace. Whether it’s being more active around the house, going for a walk or participating in a class, make sure it’s the right goal for them
  2. Gradually build up activity levels
  3. Encourage patients to keep a record of how active they’ve been and how they feel afterwards, so they can see progress
  4. Suggest they share their plans with other people who are supportive
  5. Suggest people try being active with other people, such as family or friends, or join a group or a club
  6. Make sure the activities they do are fun and enjoyable
  7. As people find they can do more, try a new activity – some people find trying a variety of activities helps

Source: Macmillan Cancer Support – Get Active, Feel Good

The benefits of exercise have prompted the Royal Marsden NHS Foundation Trust in London to develop a physical activity strategy for patients and staff.

Oncology lecturer and physiotherapist Katharine Malhotra has led the strategy development as part of a Darzi Fellowship based on consultation with patients and staff, and is currently implementing it at the specialist cancer trust.

‘Just like the general physical activity guidance for the whole population says, any activity is better than none, but more is better still,’ says Ms Malhotra. ‘This applies to people with cancer as well as the rest of the population. We have focused on how we can make every contact count when it comes to promoting physical activity.’

Healthcare staff need to give people the confidence and empower them

Training for staff is important so that they feel able to encourage activity, Ms Malhotra says.

‘For healthcare staff it is about being confident to talk about physical activity, understanding that it is beneficial and knowing the national guidance. If there are barriers from patients, it is about listening to them and finding out what is important to them. For a lot of people there is anxiety about whether it is safe to be doing it. Staff need to give people the confidence and empower them. It’s about giving them some control.’

How and when to bring up the issue of increasing activity can worry nurses. During training sessions on physical activity and cancer, healthcare professionals will often raise concerns about when is the right time, as patients may be trying to cope with a recent diagnosis or the challenges of treatment, Ms Malhotra says.

But research carried out at the hospital suggests that patients want to know about the benefits of exercise early in their cancer journey, not after their treatment has finished.

An evidence review by Macmillan in 2017 found healthcare professionals are well-placed to promote physical activity with their patients. Studies have demonstrated that patients are receptive to advice about lifestyle factors, particularly soon after diagnosis, with even brief conversations effective in changing attitudes and behaviour.

‘There is a recognition of the challenge of timing,’ Ms Malhotra says. ‘Professionals also talk about not wanting to seem like they are placing blame on people for not being active. But we have found that people want to hear this message early, alongside treatment, and to use it as part of treatment.

‘Staff can ask people: “How active are you? Are you aware of what the physical activity guidelines are and what the benefits can be? What could help you to be more active now?” Then you can help support them through treatment. We know it can potentially have an impact on treatment adherence, as research has shown that people who are active are less likely to need breaks or pauses in their treatment.’

Picture shows a female physiotherapist with an older male patient who is on a static bicycle. Evidence shows that physical exercise has a positive effect on patients before, during and after treatment.
Picture: iStock

Ms Malhotra encourages patients to start gently when introducing physical activity, build up levels gradually and be attuned to their body.

To encourage people who are uncertain how to start, patients at the Royal Marsden NHS Foundation Trust can be referred or self-refer to the physiotherapy team, Ms Malhotra says.

Cancer teams should generally have access to physiotherapists, and there are wider charity and NHS services available, such as Walking for Health groups, run by the Ramblers. This provides 1,800 free short walks every week.

Another option is 5k Your Way, a community-based initiative to encourage those living with and beyond cancer, families, friends and those working in cancer services to walk, jog, run, cheer or volunteer at a local Parkrun event on the last Saturday of every month.

Safety precautions when exercising with cancer

Macmillan Cancer Support says vital safety precautions include the avoidance of high-intensity activities when immunosuppressed or experiencing pain, severe fatigue or compromised bone health, and avoiding activities requiring balance when frail or experiencing dizziness or peripheral sensory neuropathy.

In addition, anyone with a stoma should start with low-resistance exercise and progress slowly to avoid herniation.

Specific advice about people with or at risk of metastatic bone disease (MBD) has been produced for healthcare professionals by Macmillan. People whose cancer has metastasised to the bones are at increased risk of fracture, but can still benefit from exercise.

The charity advises nurses to inform people at risk of or with confirmed MBD of the benefits of being physically active throughout their cancer care journey.

Ensure that people at risk of or with confirmed MBD are aware of ‘red flag’ or worrying symptoms that should lead them to seek urgent or immediate medical advice.

(Source: Macmillan Cancer Support – Physical Activity and Cancer and Physical Activity for People with Metastatic Bone Disease: Guidance for Healthcare Professionals)

There is also now a greater focus in cancer care on getting fitter before beginning cancer treatment, called ‘prehabilitation’.

Chloe Beard, an enhanced recovery nurse at the Christie NHS Foundation Trust in Manchester, supports patients to increase activity to maximise their well-being before undergoing cancer surgery at the specialist hospital.

Support for patients to boost activity within their own capabilities

‘Even without complications, we know that 20-40% of people undergoing surgery lose some functional capacity, and that is significant,’ she says. ‘It can be the difference between patients being able to go up and down stairs or not, and the difference between independence and dependence.’

She supports patients to boost activity within their own capabilities. It could mean going to the gym, standing and sitting repeatedly in their chair or even lifting tins of food.

‘We give people permission to exercise, which people are sometimes worried about doing,’ she says.

Prehabilitation focused on exercise, nutrition and emotional well-being

People newly diagnosed with bowel cancer in Manchester can access an innovative project run by Greater Manchester Cancer called Prehab4Cancer. The project plans to support 2,000 people to engage in prehabilitation focused on exercise, nutritional screening and improved emotional well-being.

Patients are open to hearing messages about increasing activity at that point, Ms Beard says. ‘We want these conversations as soon as possible, and no one has ever been negative about it. People are keen to help themselves in this situation.’

Picture of Esther Parkinson. Evidence shows that physical exercise has a positive effect on patients before, during and after treatment.Esther Parkinson: ‘Being active helps me to maintain a good healthy balance’

Esther Parkinson has found that running, Pilates and ballroom dancing have all boosted her physical and mental health following her treatment for breast cancer.

Ms Parkinson, from Lytham St Annes in Lancashire, was diagnosed with primary breast cancer in 2013 at the age of 39.

She underwent chemotherapy, two lots of breast surgery and 15 sessions of radiotherapy at the Christie NHS Foundation Trust in Manchester, where the disease was successfully treated.

Once Ms Parkinson had finished her treatment she discovered that exercise was linked to better bone health, which was important as her treatment had caused her bones to begin to weaken, and could reduce the risk of breast cancer returning.Picture of Esther Parkinson. Evidence shows that physical exercise has a positive effect on patients before, during and after treatment.

Ms Parkinson, who works for the procurement team at Blackpool Council, says: ‘Your world falls apart when you hear the three words, “You have cancer.” It is pretty shocking stuff.

‘While I had run before, I started to take it seriously after my treatment. I run two or three times a week. I’m outside in the fresh air and I always feel so much better after a run. I live by the coast and the view is different for every run.’

She now regularly takes part in races, does Pilates twice a week and has taken up ballroom dancing, which also has a social aspect. 

Ms Parkinson, who takes tamoxifen, says: ‘Being active helps me to maintain a good healthy balance. It helps me sleep well and is good for my mental health too.’


Erin Dean is a health writer

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