In this episode of the ASCO eLearning Podcast, Gregory Masters, MD, and Christina Dieli-Conwright, PhD, MpH, dive into the exciting benefits of exercise for patients with early-stage cancer, advanced disease, and how exercise could preemptively lower risk.
To hear the latest eLearning Podcast episodes as soon as they are available, please subscribe on Apple Podcasts. To access our entire library of podcasts and other amazing eLearning content, visit elearning.asco.org.
CLIFFORD HUDIS: Hello, I'm Dr. Clifford Hudis, CEO of ASCO, dropping into your feed to let you know about a special episode of the ASCO in Action podcast featuring the extraordinary career of Dr. Richard Schilsky, ASCO's chief medical officer. Rich and I discuss the advances that have revolutionized cancer care over the last 50 years and much, much more. Here's a preview of the episode.
RICHARD SCHILSKY: The 1980s, in many respects, were the doldrums of progress in clinical oncology. There really was not a lot of innovation in the clinic. But what was happening and what was invisible to many of us, of course, was that was the decade of discovery of the fundamental biology of cancer. That's when oncogenes were discovered, when tumor suppressor genes were discovered, when it became clear that cancer was really a genetic disease. And that is what transformed the field and put us on the path to targeted therapy and precision medicine as we think of it today.
CLIFFORD HUDIS: You can find the ASCO in Action podcast on Apple Podcasts or wherever you are listening to this show. And you can find all nine of ASCO's podcasts, which cover a wide range of educational and scientific content and offer enriching insight into the world of cancer care at podcast.asco.org.
SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
GREGORY MASTERS: Hello, I'm Dr. Gregory Masters. I'm a medical oncologist at the Helen F Graham Cancer Center in Delaware.
CHRISTINA DIELI-CONWRIGHT: And my name is Christina Dieli-Conwright. And I'm a member of the faculty at the Dana-Farber Cancer Institute in the division of population sciences and department of medical oncology.
GREGORY MASTERS: We would like to discuss the role that exercise and physical activity can play in providing excellent cancer care to your patients. And we'll start with a brief case presentation to review how exercise can improve the care in patients with early-stage cancer. The first patient is a 51-year-old postmenopausal female who presented with stage IB hormone receptor positive, HER2 negative breast cancer. Sentinel lymph node biopsy was negative. And she underwent lumpectomy, followed by radiation therapy.
She had a low recurrence score on the 21-gene expression assay and saw a medical oncologist to consider additional therapy. She agreed to take anastrozole off for five years. At the end of the office visit, she poses the question, besides surgery, radiation, and hormonal therapy, what else can I do to improve my chances?
CHRISTINA DIELI-CONWRIGHT: What is the role for exercise in patients with early-stage cancer?
GREGORY MASTERS: Well, Christina, it's important to understand that exercise can help improve and maintain a healthy lifestyle in most patients, regardless of a cancer diagnosis. But there's a particular benefit in cancer patients and, also, in helping to reduce the risk of cancer as well. Studies show a decreased risk of getting certain cancer in patients who exercise on a regular basis.
There's a decreased risk of developing cancer of the breast, colon, endometrium, kidney, bladder, esophagus, and stomach. The hazard ratio is 0.6 to 0.9 for developing these cancers. That is, there's a 10% to 40% reduction in the risk of getting one of these cancers. The evidence is convincing, with both statistically and clinically significant reductions in developing cancer.
There's also evidence that sitting time or complete inactivity may increase the risk of cancer. Multiple types of exercise can help, including both recreational or leisure time exercise and occupational physical activity. Those who are very active at work may achieve a similar benefit.
CHRISTINA DIELI-CONWRIGHT: How does this affect quality of life and cancer outcomes?
GREGORY MASTERS: So exercise can help reduce the risk of developing cancer. But exercise also improves health in patients who are being treated or have been treated for early-stage cancer. Physical activity has been correlated with improved cancer-specific and all-cause mortality. That means physically active patients are less likely to die of their cancer or other causes.
A hazard ratio for death is 0.67 to 0.7 for breast, cancer, and colorectal cancer patients. That means there's a 30% reduction in the risk of death in those who exercise regularly. This holds for both prediagnosis exercise and postdiagnosis exercise. So patients who are already in an exercise routine when diagnosed and those who begin an exercise program after their cancer diagnosis can achieve benefits from exercise.
There appears to be a dose-response relationship. So the more one exercises, the better, within reasonable guidelines. The American Cancer Society estimates that about 15 million cancer survivors alive in the United States may benefit from exercise. But there are some limitations to these studies. There may be patient recall bias, meaning that some patients may overestimate their activity to please questioners.
These data also come from nonrandomized studies for the most part. So other factors, such as a healthy lifestyle, may also be at play. Some studies compare the highest to the lowest risk groups to calculate the risk ratio. So the data may overestimate risk reduction in some patient groups.
Another benefit is that symptoms can improve with exercise, leading to a better overall quality of life. Studies have shown an improvement in fatigue, physical functioning, and physical fitness, and a reduction in depression and anxiety. And of course, the added benefit comes that overall cardiovascular risk may be reduced with exercise.
CHRISTINA DIELI-CONWRIGHT: Is it safe to exercise during chemotherapy and/or radiation therapy?
GREGORY MASTERS: Exercise is safe in the cancer population. In studies looking at adverse events in patients enrolling in a postdiagnosis physical activity program do not show unexpected safety concerns. Nonetheless, there remain major challenges in implementing these recommendations in the broad cancer patient population.
One problem can be getting providers to adopt the recommendations. Another issue is time constraints for both patients and health care providers. There may be knowledge deficits in providers. And although 79% of oncologists agree that referral to an exercise program is important, in one ASCO survey, only 10% to 20% of providers actively refer patients to these programs.
One strategy for getting providers and their patients engaged may be to assess, advise, and refer. This is one way to support providers in the steps needed to boost participation. There can also be constraints from a patient-care side. Getting patients to follow through on our recommendations can be a challenge.
And we need to focus on behavioral changes. Patients need a strong support system, including not only their oncologist, but also family and caregivers, oncology, nurses, physical therapists, occupational therapists, and trainers to help them with their routines. Specific programs can be helpful, such as Livestrong at the YMCA.
A patient's access to this care can be limited for various reasons, socioeconomic or otherwise. But we know that cost, insurance coverage, and time out of work can be a challenge. It may be difficult for these patients to commit more time and effort to an exercise routine after going through extensive treatment. And we know there's a dire need to reach underserved populations.
This is a perfect time to remember the focus of Dr. Lori Pierce, the current ASCO president, who has as her theme, equity, every patient, every day, everywhere. Remember, we can all work together to help our patients strive for their best health through exercise. And for our early-stage breast cancer patient, to help her improve her chances, in addition to standard care, I would recommend a regular exercise routine, perhaps with referral to a specialist in exercise physiology.
CHRISTINA DIELI-CONWRIGHT: Greg, are there specific clinical concerns to address?
GREGORY MASTERS: As a medical oncologist, before I refer a patient for exercise, I consider comorbid medical conditions, such as cardiac, pulmonary, orthopedic, central nervous system, and neurologic complaints, and any post-operative limitations that may be appropriate. Thank you.
CHRISTINA DIELI-CONWRIGHT: I have the pleasure of discussing a second case with you today. And this case is a 60-year-old male who underwent surgery five years ago for stage II colon cancer. Earlier this year, his CA tumor marker was elevated. And a CT scan showed new metastatic disease in the liver and lung.
Biopsy confirmed metastatic adenocarcinoma. Molecular testing shows the cancer is KRAS mutation positive. Symptoms include fatigue, anorexia, and mild cough. And he still gets occasional diarrhea since surgery.
He begins chemotherapy with FOLFOX and bevacizumab. At the next visit, he has increased complaints about his energy level and mild depression. He asks, besides chemotherapy, what more can I do to improve my quality of life? So I'm here to share with you today the role of exercise and its benefits in a case just like this, with patients with metastatic cancer.
GREGORY MASTERS: What is the role for exercise in patients with advanced cancers? And how does it affect their quality of life, symptom management, and prognosis?
CHRISTINA DIELI-CONWRIGHT: So this is a very interesting question, given that very few studies, intervention studies specifically with exercise, that have actually targeted specifically patients with metastatic disease. However, there are pilot studies that have smaller patients enrolled that have shown that exercise is feasible and safe for patients with metastatic disease. And to date, exercise in patients with metastatic disease, although few, have shown to improve quality of life and physical function. And by physical function, I'm referring to how quickly an individual is actually able to walk and the distance by which they're able to walk over a certain period of time.
So importantly, we need to emphasize that research is actually heavily lacking in this population. So further and ongoing research that has yet to be published is underway and needed to determine whether exercise can impact symptom management and also improve prognosis in patients with metastatic disease.
GREGORY MASTERS: What safety precautions should a patient be aware of when performing exercise?
CHRISTINA DIELI-CONWRIGHT: So it is advised to have an understanding of one's own physical personal strengths and weaknesses as well as prior medical history before initiating exercise. And perhaps this is even more important in an individual with a metastatic diagnosis. Importantly, consideration of daily aches and pains, overall well-being, time since last exercise was performed regularly are important, but just a few examples of considerations to understand. This basic information will really help to determine which forms of exercise are safe and which forms of exercise should be future recommended.
Consulting with a medical oncologist prior to starting an exercise program is advised. And subsequently, that physician may also refer that patient to see a professional exercise specialist. In line with this recommendation, there actually are specialized exercise professionals with unique training in exercise for cancer patients, who can assist in providing personalized exercise guidance for patients with cancer. And it is possible to seek out those recommendations using a website provided by the American College of Sports Medicine.
GREGORY MASTERS: Will exercise during treatment aid in how well a patient tolerates treatment?
CHRISTINA DIELI-CONWRIGHT: Exercise during treatment may aid in how well a patient tolerates treatment. However, there is no scientific evidence yet to support this, specifically within the metastatic population. Logically, we do know that exercise during treatment has many physical health benefits, such as maintaining strength and physical endurance. And that may help to keep the patient fit so that they're able to better withstand the treatment as opposed to if they were not fit. However, studies are underway to help to continue to support this logic.
GREGORY MASTERS: What are the best ways to help patients understand this information and to get them to initiate and stick with an exercise routine?
CHRISTINA DIELI-CONWRIGHT: So this is a fantastic question and this is a question that highlights the challenges of individuals difficulties adhering to regular exercise, in general, throughout the lifetime. However, there are some great resources specific to individuals diagnosed with cancer that are worth mentioning. For example, website and organization referred to as cancer.net offers a number of brief articles focused on exercise that provide great readings around the benefits of exercise before, during, and after treatment, et cetera.
Often the easiest way to get started and to stick with exercise is to start with an enjoyable activity that will be based on one's personal preference and to start small. It's not necessary to choose an activity that is completely unenjoyable or for an excess amount of time because then that will often result in a person not adhering to what they're trying to achieve. Exercise can often appear very daunting when it's examined in a very high volume or at a very high intensity if that's the only way that it's thought to be able to be performed.
So starting simple by taking short walking breaks to reduce sitting time can actually go a long way. And there's more and more research to support the benefits of reducing sitting behavior. Individuals are also more likely to stick with an activity when they enjoy the activity and when it is not too time consuming. Another tidbit is exercising with family, friends, or in a group setting when it's safe can also promote consistency with exercise.
Nowadays, there are a lot of virtual exercise programs in light of the COVID pandemic that actually can involve exercising in a group with family or with friends but being socially distant via virtual platform. Also important to note, when approaching more advanced forms of exercise, such as weightlifting or training for a specific event, such as a running event like a half marathon or a 3K, 5K, it is definitely helpful to seek professional assistance, even if for a single consultation. This way you're on a straight and clear path of how to safely go about performing the exercise.
And specifically, with our patient diagnosed with metastatic disease, exercise is safe and feasible. However, relying on consultations by medical oncologists and also exercise professionals will really help to put that individual in safe hands to get off on a safe start in order to perform the exercise and help to benefit the improvements of quality of life and strength and physical function that we know are well-established among cancer survivors. Thank you so much for your time.
GREGORY MASTERS: Now that we have reviewed these two cases, let's consider how these cases are related. There's evidence that exercise benefits patients with both early-stage cancer and advanced disease. There's also evidence that exercise can help reduce the risk of cancer prior to diagnosis.
Based on these studies, there's strong evidence supporting our recommendations to patients that they become more active. Beyond understanding the data, sometimes the hardest component of this is getting patients to implement our recommendations. The take-home point should be that exercise helps both groups of patients and that we should be recommending exercise for this patient population.
CHRISTINA DIELI-CONWRIGHT: The key teaching points from our session today should be recommending exercise for patients with early-stage or advanced cancer is evidence-based and will improve multiple health outcomes. The goals, therefore, are coming up with the best way to teach our patients this information and helping them to act on that knowledge. Barriers may include lack of energy, which limits patients initial interest to pursue exercise as therapy.
GREGORY MASTERS: Thank you for listening to this week's episode of the ASCO eLearning Podcast.
SPEAKER: To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning center at elearning.asco.org.