The question is no longer whether or not exercise is safe for cancer patients. Cancer care providers must now answer what type of exercise is best, when during treatment that program should start, and how to make sure patients can actually get the proper dose.

"This is the next natural step of the research," Karen Syrjala, PhD, Director of Behavioral Sciences and Co-Director of the Survivorship Program at Fred Hutchinson Cancer Research Center, said in a telephone interview discussing her latest findings about exercise in cancer survivors.

In their recent study, published online ahead of print in the Journal of Cancer Survivorship(DOI: 10.1007/s11764-011-0213-7), Syrjala's team concluded that community-based exercise programs focusing on strength training have both physical and psychological benefits.

"It's only now that we have enough research to demonstrate the safety in a controlled environment, that we can look to extend the safety and the focus of the intervention of exercise on survivors within their own communities," she said.

Evidence shows exercise can relieve symptoms like fatigue, protect bones, and enhance cardiopulmonary functions in cancer patients.

Historically, a lot of cancer patients are told they shouldn't exercise, unfortunately, and now we're sort of turned full circle," Melissa Hudson, MD, Director of the Cancer Survivorship Division, Co-leader of the Cancer Prevention and Control Program, and a member of the Department of Oncology at St. Jude Children's Research Hospital, said in a telephone interview. "It's going to help. It's been related to a better health-related quality of life."

A big foundation for this consensus is the American College of Sports Medicine's 2010 Roundtable on Exercise Guidelines for Cancer Survivors, which reviewed research on the benefits and risks for site-specific cancers, published in Medicine & Science in Sports & Exercise (2010;42:1409-1426). The report, which also outlines specific guidelines for certain cancer types, concludes that in general exercise is safe and beneficial both during and after cancer treatment.

These guidelines are a start, but cancer care providers still need to decode what the recommendations mean. "Each provider or cancer center has to look at the resources at their institution and their surrounding community to define how they would specifically implement those recommendations," Syrjala said.

Community-based Programs Work

Syrjala's latest research focused on the effectiveness of group exercise sessions, specifically tailored for cancer survivors, and supervised by personal trainers coached in cancer rehabilitation. All participants in the study attended sessions of "Exercise and Thrive," a 12-week program available to cancer survivors in the western Washington area who have completed cancer treatment piloted jointly by the YMCA of Greater Seattle and the Fred Hutchinson Cancer Research Survivorship Program.

These programs recognize and address specific needs of cancer patients when it comes to physical activity, Syrjala said. "We train the personal trainers in very extensive understanding of the specific cancer-related problems-such as scar tissue, lymphedema, neuropathy, reduced range of motion, so they understand those limitations and the safety issues. And, they're prepared to design an exercise program to reduce the risks from those limitations."

After attending the YMCA program for 12 weeks, the 221 cancer survivors of mixed age and diagnoses in the study reported improvements in overall quality of life, social support, pain, insomnia, fatigue, and overall musculoskeletal symptoms, along with improvements in blood pressure, upper and lower body strength, walking, endurance, and flexibility.

Another key takeaway from the study is recognizing the benefits of physical activity done outside of the cancer center.

"Our research was designed to really move exercise after cancer from specialized programs to the community-and make it both accessible and affordable for survivors, as well as to make it in the place they live and where they want to be focusing the rest of their lives, rather than staying within a cancer center," Syrjala said.

These findings highlight not only the effectiveness of exercise in improving quality of life for cancer survivors, but also shed light on the type of exercise most beneficial to cancer survivors. "The critical message is that oncologists need to begin recommending exercise from the point of diagnosis through the cancer treatment recovery, and that exercise needs to be in a safe environment with trainers who have the training to work with cancer survivors and the ability to individualize their programs," Syrjala said.

Better Understanding of Post-Cancer Needs

Syrjala's research adds to a growing body of knowledge about how to best prescribe exercise therapy to cancer patients specifically-which experts agree is the next hurdle to jump to start better physical activity habits.

A study that compared the results of an exercise intervention in breast cancer patients initiated at various stages of treatment found that women who began exercise at the start of chemotherapy maintained the frequency of their workouts during therapy more, and continued the habit more consistently after treatment, than the women who started exercise after chemotherapy treatment. The bottom line: starting exercise at the beginning of chemotherapy had a better overall sustainability, coauthor Fang-yu Chou, PhD, RN, Assistant Professor in the School of Nursing at San Francisco State University, said via email.

"The longer patients can maintain exercise behaviors, the greater the overall benefit," Chou said. But, because of side effects of treatment and adverse symptoms, many patients lack the motivation to exercise. "There will need to be more studies to explore other innovative approaches to help support and sustain the exercise habits of these women, particularly in the post-treatment period."

In conclusion, Chou and her coauthors recommend that clinicians encourage breast cancer patients to start exercise at the beginning of chemotherapy, and communicate routinely the benefits of exercise as described in the American College of Sports Medicine guidelines, according to the study published in Oncology Nursing Forum (2012;39:91-96).

"Cancer survivors have very distinct needs that are a result of both-for most people-a high level of inactivity with a lot of muscle loss, as well as very specific problems that may result from their cancer treatment, such as scar tissue that forms through surgery, or treatment that's very localized or that increases the risk of lymphedema," Syrjala said.

Another study found that a program of controlled exercise through twice-weekly progressive weight lifting in 141 breast cancer survivors with stable lymphedema of the arm reduced lymphedema symptoms and increased strength (NEJM 2009;361:664-673). The research reversed previous thinking that recommended breast cancer survivors with lymphedema avoid unnecessary lifting-and suggests that this population can benefit from supervised weight-lifting programs that aim to gradually increase strength in a controlled way, the authors noted. The program used was part of the YMCA's and Lance Armstrong Foundation's LIVESTRONG collaborative program.

Continuing Research

"Some of the big questions are when do you begin to introduce the concept of how a lifestyle change like physical activity can help you," Hudson said. "Often at the beginning, at diagnosis, and early in treatment is when patients might be feeling more vulnerable, and actually more accustomed to making a lifestyle change that can be sustainable."

And how can that safely be implemented? "How can you take into account some unique health issues associated with a specific health treatment or intervention for that cancer?" Hudson said is the question that still needs to be answered. "That's working with our physical therapy colleagues and our exercise specialists to study these patients and learn and establish these parameters of safety."

Roadblocks to Better Routines

Despite the new consensus on exercise for cancer patients and survivors, delivering the message to those specific populations that will most benefit may prove the toughest puzzle to solve.

"How do you get people moving?" Melissa Hudson, MD, asks. "I will still have patients in the hospital who will come in and say, 'I'm not supposed to do certain things-I was told I can't do that safely.'"

A team of Canadian researchers designed a study to answer how young adult cancer survivors would best receive physical activity counseling (Cancer Nursing 2012;35:48-54). Their survey of 588 young adult cancer survivors found that 81 percent would have preferred receiving physical activity information after their diagnosis-and 50 percent would have preferred counseling from a fitness expert at a cancer center.

"There's a big need for cancer research in young adults because [young adult cancer survivors] are being grouped in with everybody else, which is the typical 65-year-old diagnosed with cancer," said study coauthor Lisa Belanger, MSc, a PhD candidate at the University of Alberta.

Beyond barriers specific to cancer patients that make exercise more difficult, cancer patients face the same roadblocks that prevent healthy individuals from adopting exercise routines and a healthy lifestyle.

"Our built environment doesn't encourage movement," said Kiri Ness, PhD, PT, Associate Member in the Department of Epidemiology and Cancer Control at St. Jude Children's Research Hospital. "You don't have to walk anywhere; you take a car...the sedentary job-sitting in a desk all day."

But, she said research like that of the study by Syrjala et al that points to the benefit of specific exercise programs-like the YMCA program and community-activity-has the potential to help get cancer patients moving. "The people who lead these groups have special training," she said. "If you have some health impairment that makes it difficult for people to exercise and if you have a group leader who understands how to deal with that or incorporate it into the program, you're going to do better."

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The American Society of Clinical Oncology has issued a new clinical practice guideline recommending that obese adult cancer patients receive the full chemotherapy dose their actual weight would dictate, rather than using an "ideal weight" or an upper limit to the amount of drug that is administered. The report is the first major recommendations for obese cancer patients, the Society notes, and was published ahead of print in the Journal of Clinical Oncology (DOI:10.1200/JCO.2011.39.9436).

"There's just not an upper limit as has sometimes been arbitrarily put on the dose of chemotherapy," the Co-Chair of the ASCO panel that wrote the report, Gary Lyman, MD, MPH, Professor of Medicine at Duke University and Duke Cancer Institute, said in a phone interview. "The dose should be matched to the patient's weight and size, and should be based on the patient's weight and body surface area (BSA)-and when you do that, you do have a better chance of controlling the disease."

Studies have tracked the effect of this under-dosing, and show that as many as 40 percent of obese adult cancer patients get undertreated as a result, an ASCO news release notes. In many cases, clinicians administer a smaller amount of chemotherapy than an obese cancer patient's actual weight would require because that full dose (calculated based on BSA) is so much higher than doses usually given, Lyman explained. "So, there's either a use of an idealized weight instead of the actual weight, or sometimes there's a capping of the dose."

Key Points

The key recommendations in the guidelines listed first in the report are:

* Actual body weight should be used when selecting cytoxic chemotherapy doses regardless of obesity status.

* Full weight-based chemotherapy dosing should be used for morbidly obese patients with cancer, subject to appropriate consideration of other comorbid conditions.

* Full weight-based chemotherapy doses should be used in the treatment of the obese patient with cancer, particularly when the goal of treatment is cure.

The same results were found in the morbidly obese-full, weight-based chemotherapy doses (with no upper limit) did not yield any worse or increased frequency of side effects than in healthy-weight individuals. The panel wanted to specify that even in the extreme cases, for the morbidly obese patient whose accurately calculated chemo dose (based on BSA) is very high, there is no proven risk of harming the patient, or increased side effects, Lyman said. "Again, obesity at any level seems to be a setting where if you dose patients based on their actual weight-no matter how high it is-they won't have any greater side effects than a healthy weight patient."

The evidence in the panel's review also shows that the chance of the cancer not being treated effectively increases for obese and overweight cancer patients who are not given the full dose their weight dictates, and those patients have a greater chance of the cancer returning. "The data do suggest that reducing the dose delivery is associated with a higher mortality both in obese patients and non-obese patients," Lyman said. "If you reduce the dose, it may well compromise the chance of long-term survival."

The guidelines specify that other illness and comorbidities (such as heart disease or lung disease) may cause the need for adjusting doses. And, the report also recommends two known exceptions to using BSA-calculated doses: when administering the cytoxic agents carboplatin and bleomycin, fixed doses should be used for all patients, regardless of weight.

Areas for More Research

The report's final recommendation calls for further research in the role of pharmacokinetics and pharmacogenetics in dosing obese adult cancer patients. Lyman said these fields that investigate the way drugs get distributed and eliminated in the body (pharmacokinetics), and the gene patterns and mutations that affect how the drug works (pharmacogenetics), are evolving fields of study, but early research suggests they do play a role in treatment, and more personalized therapies will be key to more effective treatment. "We do hope that in the future there are more ways we can specifically target the drugs in doses that are very individualized-that will optimize treatment for that individual," he said.

ASCO was prompted to write the guidelines, Lyman explained, by the epidemic of obesity in the country, the increased risk of cancer associated with obesity, and the history of poorer outcomes among obese cancer patients. "ASCO decided a couple of years ago that we needed to review all the evidence and we needed to come up with guidelines because there's enormous variation in practice-there is a lot of confusion and uncertainty," he said.