As Health and Fitness Professionals, it is our responsibility to not only execute a well designed program, but also to educate our members on how/why that program was developed for them. Anyone can go online and find a 10-15 repetition program that looks at full body exercises. But understanding physiology and kinetic movement is incredibly important when we are looking at using exercise as an intervention to help increase range of motion, function, and prevent injury/improve recovery.
So when we look at cancer and exercise, we have to factor in what all is happening physiologically during, and after, treatment. One of the most common and well known treatments being Chemotherapy and Radiation. So let's start with what these two treatments have in common.
Overview on Chemotherapy and Radiation:
Chemotherapy is the administration of anti-tumor drugs that functions to destroy cancerous tumor cells. It can be given as the primary therapy for advanced cancers, or as an adjuvant therapy with other localized treatments such as radiation. The goal is to destroy the cancerous cells and minimize the damage and limit the normal function of regular cells. Unfortunately, since these two cells are very similar, it is difficult to destroy cancer cells without also damaging regular healthy cells. On the flip side, chemotherapy does destroy a higher percentage of cancerous cells over normal cells.
There are 4 types of Radiation: External Beam Radiation (EBR), Three-dimensional conformal radiation therapy (3D-CRT), Intensity-Modulated Radiation Therapy (IMRT), TomoTherapy, and Image-Guided Radiation Therapy (IGRT).
External Beam: Sends high energy rays directly to the tumor. Can be given after surgery is performed in an effort to wipe out any residual cells left behind.
Experimental treatment: Intra-operative radiation. This is when you use EBR during an operation. It is currently experimental for breast, colon, rectum, stomach, brain, pancreas, and gynecologic organs.
Three Dimensional conformal radiation therapy (3D-CRT): one of the most common types of external beam radiation treatments. It uses a special computer to map out exactly where the location of the cancer is. From there the patient is fitted with a plastic mold resembling a full body cast. Radiation is then administered directed at the target which minimizes the risk of damaging healthy surrounding tissue.
Intensity-Modulated Radiation Therapy (IMRT): May be used to decrease toxicity to normal tissue. IMRT is a type of 3D radiation therapy targeting tumors with greater precision than conventional radiation therapy. 3D images from CT scans help oncologists develop an individualized treatment plan delivering high doses of radiation to cancerous tissue while sparing the surrounding organs to reduce risk of injury to healthy tissues
TomoTherapy: combines IMRT with the accuracy of CT scanning technology in one machine. The doses can be designed to match the shape of the tumor while avoiding sensitive structures. These are custom made based on size, shape, and location on that specific day. This approach is also called "slice therapy" to treat tumors one layer at a time. Because it is very specific, there is generally lesser side effects than traditional radiation.
Image-Guided Radiation Therapy (IGRT): During the treatment, repeated images (CT, MRI, or PET) are done to identify changes in a tumor's size and location due to treatment which can allow the position of the patient (or planned location) to be adjusted. Repeating these imaging scans increase accuracy of treatment and lower the total volume of exposure to treatment when effective.
Precautions with Radiation:
Skin sensitivity following radiation. Those undergoing treatment should avoid hot or cold packs directly to the skin which may further irritate the sensitive skin. If you go into a swimming pool or salt water, you should rinse your skin well with fresh water. Avoid direct exposure to sunlight for at least 1 month after treatment
Chemotherapy and Radiation Side Effects
Immune System: Both these treatments compromise the immune system as the lymphocytes and T cells are vulnerable to damage during and after therapy. The degree of damage is based on 3 factors: Type, Dosage, and Localization of the treatment itself. Because lymphocytes and T cells are important for regular function of our immune systems, we should take extra precautions to keep the environment clean and avoid in person contact with people who are not feeling well to avoid general sickness.
Muscle Wasting:
During treatment we can expect damage to the muscle tissue which leads to wasting. A low to moderate intensity is important in order to stimulate regular protein synthesis for tissue repair, but also not too high of an intensity that would overly stress the muscle into further damage. A low to moderate intensity example would be lifting weights light enough to lift it at least 10 times with ease, but no more than 15 repetitions without straining. Too high of an intensity would be something you could barely lift 10 times without straining or compensating in other muscle groups. Checking for soreness is also a good indicator of how much is "too much". If you feel like you can barely lift your arms or walk around then it's definitely too much
Lymphatic Swelling/Lymphedema:
Another indicator of "too much" would be fluid swelling in the extremities. Part of the function of the lymphatic system is to process and move fluids through out the body. When some of the lymph nodes are damaged or removed during treatment, we are slowing down our body's natural ability to process and move bodily fluids. This causes symptoms like pain and swelling at the extremities because of the fluid build up. This would require medical attention and a return to your doctor to address the lymphedema and is something to take into strong consideration when addressing your training program. For these reasons, that is why we don't want to overly "stress" the body with heavy lifting exercises that may cause pooling. Less intensive and repeated muscle contractions such as walking, swimming, rowing for cardiovascular health and lighter weights (10-15 repetitions without major strain) are the best exercises to promote blood flow because the repeated smaller movements help casually push fluids with each contraction. What's important is to note the volume of exercises you are doing so start off with a smaller volume and then gradually work your way up to see how well your body is tolerating the exercises
Infertility:
Both sexes can experience this during and after chemotherapy and/or radiation treatment
Neuropathy:
feeling a tingly or burning sensation in the hands and feet may be a sign of nerve damage
Fatigue:
The most common reported side effect of cancer survivors (1). Even with plenty of sleep, fatigue is still reported and those experiencing fatigue should exercise 3-4 times per week for 20-30 minutes.
Disruptions to the normal cell reproduction cycle:
Damage to the cells can disrupt it's normal reproduction which can lead to acute changes to the intestinal mucosa. Bowel segments, ulcerations, diarrhea, and a decrease in digestive enzymes that would normally absorb fat, carbs, vitamins, and electrolytes. As a result, people would present as malnourished even if they are eating regularly since the body is not absorbing nutrients effectively.
Acute or Chronic Pulmonary Toxicity:
Following chemo and radiation, the formation of scar tissue and abnormal pulmonary tissue may cause coughing, low grade fever, low tolerance to exercise, restlessness, and severe fatigue. shortness of breath and colds can be more frequent as a result of poor breathing, or excessive coughing
Chemotherapy Side Effects
Memory loss: during and after treatment you can experience brain fog or difficulty recalling short term information. Long term memory tends to improve after treatment ends in time.
Heart Damage:
Cardiomyopathy typically appears after 4 weeks of chemotherapy treatment which has a higher fatality rate than radiation induced cardiomyopathy. Signs of chemotherapy induced cardiomyopathy include the following
Sinus tachycardia - Resting heart rate greater than 100 beats per minute
Premature Atrial Contractions - irregular heartbeat which starts in the upper 2 chambers of the heart. It may feel like their heart "stops" after a symptom. Another common word for this would be "heart palpitations"
Premature Ventricular Contractions - Irregular heartbeat that starts in the lower chambers of the heart - more serious than Premature Atrial Contractions
Supra-Ventricular Arrhythmias - early extra beat that originates in the upper chamber of the heart
For these reasons, it's important to regularly check your resting heart rate before starting any exercise. If it is over 100, the session should be postponed and you should contact your doctor for further evaluation. The same precautions would apply if you are experiences heart palpitations or unusual shortness of breath
Drug Therapy: Cisplatin, Methotrexate, and Mitomycin
These drugs can lead to uricemia (abnormal uric acid in the bloodstream). This can cause kidney and bladders problems, hemolytic anemia, and edema/swelling in the upper and lower limbs. a decrease in magnesium, potassium, calcium, and sodium can be experienced.
Methotrexate is also hepatoxic and is known to cause liver damage that can lead to cirrhosis/liver disease, and cholestasis/loss of bile excretion. Liver damage symptoms include: dark urine, pale stools, yellowing of eyes/skin, pain or swelling in the abdomen, flu like symptoms, or severe fatigue. Weight gain, anorexia, fatigue, and abdominal growth/pain are common symptoms.
Gastrointestinal: Diarrhea, constipation, vomiting, nausea, and appetite changes. Depending on the severity of GI symptoms, it is recommended to post-pone exercise sessions when experiencing GI side effects
Osteoporosis: Mindful of bone density damage during treatment. Precautions for current state would involve load bearing exercises. This depends on doctor's recommendations as well as how advanced the bone disease state has gone
***** Immediate red flags to inform your doctor of Low blood cell counts signs and symptoms
Unexpected bruising
Small red spots under the skin
Pink or reddish urine
Black or bloody bowel movements
Bleeding from gums or nose
***** Immediate red flags to inform your doctor of an infection signs and symptoms
Fever
Chills, cough, sore throat
Sweating excessively
Loose bowels or burning feeling with urination
Unusual vaginal discharge or itching
Redness or swelling
Radiation Side Effects
Pericarditis:
Inflammation of the membranous sac that encloses the heart. This may take 2-5 months to recover from following treatment. For others, it may require surgery to prevent restrictive inflammation that surrounds the heart.
Thyroid tissue:
Thyroid malfunction as a result of radiation influencing the hypothalamus and the pituitary glands. This can cause abnormalities in the release of HGH (Human growth hormone)
Other misc. side effects
Skin changes: Sensitive skin may have damage that makes holding things like weights difficult and may break skin. weight gloves would be recommended in this sense. Also, with lymphedema being a risk factor you also want to make sure you aren't creating any blood flow restrictions. One example would be using an exercise band, but wrapping it around the hands in an effort to make it easier to grip. While it may solve the grip problem that could be related to skin tenderness, it inadvertently can cause swelling as the band prevents blood flow from returning to the heart.
This is just a generalized list of side effects, there are more dependent on the type of therapy used and where it is administered. For now, we are only reviewing the main ones that likely will influence a fitness program.
Chemotherapy Cycles:
Adjuvant therapy may last 4-6 months. This is common in cancers of the breast and colon. The length of chemotherapy treatment depends on the response of the disease to the therapy itself(2). If it goes away entirely, chemotherapy may continue for 1-2 cycles after that fact to maximize the chance of having attacked all microscopic levels of the disease.(3) If it shrinks, but does not disappear, chemotherapy will continue if it is tolerated, and the disease continues to not grow. If it does grow, chemotherapy will be stopped and an attempt of different drugs can be given to try and kill the cancer.
Exercise and Chemotherapy:
If Adriamycin (doxorubicin) is part of your chemotherapy regimen, you should NOT exercise the same day as your Chemotherapy treatment. Adriamycin can make your heartbeat irregular for about 24 hours after receiving treatment.
Only low intensity exercise (no more than 15-20 bpm over resting heart rate) for 24-48 hours following chemotherapy
If you have severe fatigue it is recommended to exercise 3-4 times per week for 20-30 minutes at a very low intensity (15-20 bpm above resting). If 20-30 minutes at one time is too much, then break it into smaller, more manageable increments until you reach 20-30 minutes 3-4 times per week.
Regardless of treatment, if you are vomiting or have diarrhea, you should not exercise for 24-26 hours. The priority should be rest, rehydrate, and replenish electrolytes.
If an external catheter has been placed, patients should avoid activities that may dislodge the catheter. Anything with higher risk of falling, contact sports, and any exercises that use the same part of the body where the catheter is placed. A medical clearance is necessary before trying to swim with a catheter.
Final Comments
From an initial diagnosis to treatment, the information available can be overwhelming. Our goal here is to break down some of the common treatments for cancer and make it easier to understand from the patient's perspective. While it is commonly recommended that cancer patients should exercise, it is also important to understand what types of exercises are the most beneficial for the individual patient based on the treatments involved. In our next blog we will plan to go over surgical interventions for breast cancer and how that effects range of motion, muscular anatomy, and recovery timeframes.
Disclaimer: The recommendations for this article are pulled directly from the Cancer Exercise Training Institute (CETI). Although they are the most current research based recommendations, they do not constitute an exercise prescription. You should speak with your doctor prior to engaging in any sort of diet or exercise program. There is no one-size-fits-all approach to exercise, but working with a Medical and/or Cancer exercise specialist and your doctor can help create a one-size-fits-you approach based on your unique situations.
Sources:
(1) Cancer.Net Editorial Board. Cancer Prevention Vaccines. June 2018. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/immunotherapy-and-vaccines/what-are-cancer-vaccines
(2) Chemocare. How long is chemotherapy given? https://www.chemocare.com/chemotherapy/what-is-chemotherapy/types-of-chemotherapy.aspx
(3) Chemocare. How long is chemotherapy given? Https://www.chemocare.com/chemotherapy/what-is-chemotherapy/how-long-is-chemotherapy-given.aspx
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