Exercise Oncology in Pancreatic Cancer: Introduction – Jared Heitzenrater

The field of Exercise Oncology is growing rapidly with a large number of research articles coming out answering the important questions of the safety and efficacy of an exercise intervention to reduce treatment-related side effects, improve outcomes, increase treatment adherence, improve physical function, and so much more.

The majority of research in the exercise oncology field has been completed in breast, prostate, and colorectal cancer. A few case studies have been completed in a pancreatic cancer population with results that showed promising outcomes but had take-home message that in this population, exercise prescriptions need to be more targeted to the type of treatment and symptoms that these patients are experiencing to yield better outcomes. Before beginning an exercise program, it is important to consult your Physician or Oncologist to get their point of view on how a rehab program can fit into your care plan. Also, to improve safety as well as to get better results from your exercise program, it is recommended to complete a supervised program along with someone like an Exercise Physiologist trained in cancer rehab who would know how to tailor the exercise prescription to fit the needs of the patient as well as manage any comorbidities that they may be experiencing.

As soon as you know it is safe to exercise, find an Exercise Physiologist who specializes in cancer care to begin initial fitness assessments so that they can develop an exercise prescription specifically for you. There is no reason to be intimidated by the word exercise because every program will be tailored directly to the individual’s fitness level with treatment type and side effects taken into account as well. What specific benefits can someone expect to get from an exercise program? Exercise can lessen the harsh side effects of systemic chemotherapy treatment. Some chemotherapy types can be damaging to the heart putting patients at a higher risk for developing some sort of heart dysfunction or heart disease. Exercise has been shown to provide a cardioprotective effect to the heart meaning the chemotherapy will damage the heart muscle to a lesser extent than if an individual was sedentary during treatment. Also, chemotherapy can hinder the effect of the body’s immune system making an individual going through treatment more prone to getting sick. Exercising at a moderate intensity can boost the immune system to help prevent individuals from getting sick.

Side effects of radiation can depend on the type, dose, and location of the treatment. Like chemotherapy, radiation, if given to the chest area, can cause cardiotoxicity that exercise can work against to preserve the health of the heart (Brana, Zamora, Oristrell, & Tabernero, 2018). Radiation can also cause musculoskeletal issues such as a fibrotic tissue build up in the area of treatment that can cause weakness or range of motion issues that a flexibility and resistance training protocol can help to improve physical function of the affected area. Side effects of emotional fatigue and difficulty sleeping have also been shown to have had a lesser effect on those who participated in an exercise intervention (Canadian Cancer Society, 2019).

Surgery can be a very invasive procedure that can come with many complications and have a long recovery process. Exercising for a period of time before surgery is known as prehab. Prehab has been shown to reduce the number and frequency of complications caused by surgery, reduce recovery time, and hinder the negative effect on physical function that surgery can have on the body (Dimeo et. al., 2004).

Diabetes is known to be associated with pancreatic cancer, but the relationship is still unclear in some ways. However, it is known that some people with pancreatic cancer experience blood sugar problems because of insulin resistance that develops. Research has shown that exercise has an insulin-like effect that can improve insulin sensitivity and reduce some negative side effects or symptoms of type II diabetes that some patients experience as a comorbidity to their pancreatic cancer (Way et. al., 2016).

Individuals with pancreatic cancer also often suffer from cachexia which means that they are more predisposed to have extreme muscle wasting which can lead to decreased muscular strength, endurance, and functional capacity in general. This severe muscle wasting also causes a higher incidence of diminished quality of life, decreased treatment tolerance, reduced immunity, and higher mortality rates. This can be a tricky situation in terms of exercise as an intervention for cachexia. Exercise can increase lean muscle mass through resistance training specifically which will improve functional capacity and muscular fitness. However, the body cannot create muscle mass without the proper nutrients for building blocks of muscle such as protein as well as energy in the form of calories to create the muscle. This is why if you experience any form of cancer-related cachexia it is important to have a nutritionist on your care team so that they can ensure that you are receiving the right number of calories as well as nutrients to attenuate the cachexia. If you begin an exercise program while experiencing cachexia and begin to burn more calories without increasing your calorie intake to make up for the calories burned during exercise, the cachexia symptoms may get worse. This does not mean that you shouldn’t exercise to avoid this, just consult professionals about your nutritional needs before beginning a program so that they can adjust their recommendations for you.

Cancer related fatigue (CRF) is something that almost all patients with cancer experience in some way shape or form and is the most debilitating complaint that affects their daily life. Aerobic exercise has been shown to be the most effective form of exercise to try to combat cancer related fatigue. Research has shown that 20-30 minutes of supervised exercise has a small effect on CRF, whereas aerobic exercise in 50-minute sessions had a large effect on CRF. Fifty minutes is a long time for an untrained individual to exercise so if you are new to exercising, start out shorter and work your way up to longer durations.

In addition to directly influencing the degree of impact that side effects of treatment have on an individual, exercise can also improve activities of daily living and independence. A common exercise intervention will have an aerobic component like walking on the treadmill or pedaling a recumbent bike that will increase endurance and help a patient get around the house, store, or social event longer without feeling tired as quickly. An exercise program will also have a resistance training component that will most likely have functional movements that directly relate to things an individual may do at home. For example, a patient may complete a stair walking or sit to stand motion from a chair to help them get better at doing those movements at home. Lastly, a flexibility portion will also be included which will work to make things such as reaching for items off the ground easier.

In conclusion, what can you expect from an exercise program? If you are joining a supervised exercise program which is what is recommended for safety and efficacy, you should expect some initial meeting where you will discuss your diagnosis, health history, and exercise history. From that point on an initial fitness assessment will be completed to create baseline data. This information will serve as the foundation for the exercise oncologist to create an individualized exercise prescription for you. You will then complete the program which in most cases is 12-15 weeks and will include stages of progression from your initial levels of fitness to higher levels when deemed appropriate. You may also expect some modifications when necessary to ensure that you get the most benefits possible. It is important to keep an open line of communication between your trainer, oncologist, and the rest of your care team so that they can all adjust your treatment plan based on you beginning an exercise program. There are many potential benefits to beginning an exercise program that can work towards improving treatment tolerance, quality of life, and so much more.

References

Braña, I., Zamora, E., Oristrell, G., & Tabernero, J. (2018). Cardiotoxicity. In Side Effects of Medical Cancer Therapy (pp. 367-406). Springer, Cham.

Dimeo, F. C., Thomas, F., Raabe-Menssen, C., Pröpper, F., & Mathias, M. (2004). Effect of aerobic exercise and relaxation training on fatigue and physical performance of cancer patients after surgery. A randomized controlled trial. Supportive care in cancer, 12(11), 774-779.

Mock, V., Dow, K. H., Meares, C. J., Grimm, P. M., Dienemann, J. A., Haisfield-Wolfe, M. E., … & Gage, I. (1997, July). Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. In Oncology nursing forum (Vol. 24, No. 6, pp. 991-1000).

Side effects of radiation therapy – Canadian Cancer Society. (2019). Retrieved from https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/radiation-therapy/side-effects-of-radiation-therapy/?region=on

Solheim, T. S., Laird, B. J., Balstad, T. R., Stene, G. B., Bye, A., Johns, N., … & Kaasa, S. (2017). A randomized phase II feasibility trial of a multimodal intervention for the management of cachexia in lung and pancreatic cancer. Journal of cachexia, sarcopenia and muscle, 8(5), 778-788.

Tian, L., Lu, H. J., Lin, L., & Hu, Y. (2016). Effects of aerobic exercise on cancer-related fatigue: a meta-analysis of randomized controlled trials. Supportive Care in Cancer, 24(2), 969-983.

Way, K. L., Hackett, D. A., Baker, M. K., & Johnson, N. A. (2016). The effect of regular exercise on insulin sensitivity in type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetes & metabolism journal, 40(4), 253-271.

Bio:

Jared Heitzenrater (Erie, Pa) is a 2nd year Masters Student at Saint Francis University studying Cancer Care with a specialization in Exercise Oncology. He graduated in 2018 with a Bachelor’s degree in Exercise Science from Slippery Rock University and completed a clinical internship at Butler Memorial Hospital’s Cardiovascular Rehabilitation. Jared is also a Certified Exercise Physiologist through the American College of Sports Medicine. Jared is currently working on his Masters Thesis project looking at Balance and Quality of Life in a Cancer Population as well as completing a second clinical internship at Maple Tree Cancer Alliance in Sharron, Pa.