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Exercise, Fatigue and Cancer
Presented by:
Tara Swanson PT, MSc (RS)
Marta Jelowicki, PT
McGill Cancer Nutrition and Rehabilitation Program
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PRESENTATION OVERVIEW
Section One:
Overview of Cancer-Related Fatigue
Section Two:Findings From Recent Study: PhysiologicalCorrelates in Cancer-Related Fatigue
Section Three:Practical Considerations Related to Exercisein Cancer Patients
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Section One:
Overview of Cancer-Related Fatigue
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WHY FATIGUE
Fatigue is often one of the first symptoms,
starting at the presentation of a cancer
diagnosis
This may be due to several factors including:
Tumour being metabolically active May have decrease in appetite/food intake
May have a decrease in activity levels, leading to
de-conditioning
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CANCER-RELATED FATIGUE(CRF)
a persistent, subjective sense of tiredness
related to cancer or cancer treatment thatinterferes with usual functioning.
(National Comprehensive Cancer Network 2003)
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DIMENSIONS of CRF
Affective Dimension
(irritability, anxiety, depression) Cognitive Dimension
(poor concentration & memory)
Physical Dimension
(muscle fatigue & weakness, breathlessness)
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MEASUREMENT of CRF
May take a multi-dimensional or
uni-dimensional approach
May use a specific tool or subscale on QOL
tools
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STATUS OF KNOWLEDGE
Fatigue during treatment seems to berelated to type of cancer, chemotherapy
regimen, psychological status, sleepdifficulties, pain, activity, anemia
Fatigue after treatment seems to be related
to age, gender, psychological status, sleepdifficulties, pain, activity and shortness of
breath
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STATUS OF KNOWLEDGE
Effective interventions include:
Education (energy conservation, stressreduction, distraction)
Sleep hygiene
Nutrition
Specific Medications
Exercise
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GAPS IN KNOWLEDGE
There are many, including a limited
understanding how physical factors beyond
pain and shortness of breath influence thefatigue experience and its impact on function
This information is essential to refining our
measurements and interventions to addressCRF
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Section Two:
Findings From Recent Study
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PHYSIOLOGICAL CORRELATES OFCANCER-RELATED FATIGUE
Swanson T, Dalzell MA, Small D, Kreisman H,MacDonald N, St-Pierre DMM
McGill University, School of Physical and Occupational Therapy
Jewish General Hospital, Department of Pulmonary Medicine
Montreal, Quebec Canada
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OBJECTIVES
OBJECTIVE 1: Identify the physical factorscontributing to CRF
OBJECTIVE 2: Determine to what extent these
factors contribute to CRF
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MEASUREMENT
Brief Fatigue Inventory (BFI)Cancer-Related Fatigue
TOOLVARIABLE
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Mendoza et al. Cancer (1999)
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Mendoza et al. Cancer (1999)
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MEASUREMENT
Hand Grip DynamometerMuscular Endurance
Routine Blood TestingHemoglobin & C-Reactive
Protein (CRP) Levels
30 second Chair Rise (CR)
Hand Grip Dynamometer
Muscular Strength
Pulse OxymeterO2 Saturation with Activity
2-Minute Walk Test (2MWT)Exercise Capacity
TOOLVARIABLE
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MEASUREMENT
Visual Analogue Scale (0-10)Sleep
Visual Analogue Scale (0-10)Weakness
Visual Analogue Scale (0-10)Overall Breathlessness
Visual Analogue Scale (0-10)Pain
TOOLVARIABLE
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STATISTICAL ANALYSIS
UNIVARIATE REGRESSION between variables and
cancer-related fatigue (as assessed by the BFI)
MULTIVARIATE REGRESSION to determine a
predictive model of cancer-related fatigue
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STUDY POPULATION
INCLUDED
Stage III or IV non small cell lung cancer
Referred to McGill Cancer Nutrition and Rehabilitation
Program
EXCLUDED
Unable to complete questionnaires Unable to complete the assessment tasks due to pain
or safety reasons
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RESULTS: PREVALENCE OF CRF
90% reported some degree of fatigue in the past
24hrs
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0 1-4 5-7 8-10
Worst Fatigue Score
10
20
30
40
50
%Respondents
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RESULTS: PREVALENCE OF CRF
84% reported fatigue to have interfered with at leastone function in the past 24 hrs
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Mendoza et al. Cancer (1999)
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RESULTS: IMPACT OF CANCER-RELATED FATIGUE
100
80
60
40
20
Generalactivity
WalkingAbility
NormalWork
MoodRelations
with OthersEnjoyment
Of Life
DIMENSION OF FUNCTIONING
%Respond
ents
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10
20
30
40
%Respondents
0 1-3 4-6 7-10
General Activity Score
50
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FACTORS RELATED TO CRF:UNIVARIATE ANALYSIS
0.21**Lower Limb Strength (CR)
0.30**Overall Breathlessness (VAS)
0.18**Exercise Capacity (2MWT)
0.29**Pain (VAS)
0.45**Weakness (VAS)
R2FACTOR
** p
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FACTORS UNRELATED TO CRF:UNIVARIATE ANALYSIS
0.02C-Reactive Protein (CRP)
0.03Sleep (VAS)
0.07Hemoglobin
0.04Upper Limb Endurance
0.03O2 Saturation - Exercise
0.07Upper Limb Strength
R2FACTOR
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MODEL BYMULTIPLE REGRESSION
Weakness (VAS)
Overall breathlessness (VAS)
Measurement of lower limb strength
(CR performance):
Combined R2 value 0.62(p
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CONCLUSIONS
Cancer-related fatigue is prevalent and interferes
with function of NSCLC patients
Lower limb strength (CR), weakness (VAS) and
overall breathlessness (VAS) explain 62% of the
variance in cancer-related fatigue scores
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CLINICAL SIGNIFICANCE
Management of breathlessness may improve CRF inthis population
Weakness, especially in the lower limbs, contributedto CRF in this population
Strength training programs, in combination withcardiovascular training, may lead to improvement inCRF and ultimately enhance patient QOL
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Section Three:
Practical Considerations Related to Exercise inCancer Patients
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Outline
Why exercise?
Practical considerations related to exercise incancer patients
Motivation and resources
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Why Exercise
Exercise training is safe and feasible for
cancer survivors following the completion of
primary therapy
[Exercise]may be associated with
potentially clinically meaningful
improvements in exercise capacity and
overall QOL
Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am 22 (2008)
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Why Exercise
Physical activity interventions may reduce
the risk of developing some cancers, help
cancer survivors cope with and recover from
treatments, improve the health of long-term
cancer survivors, and possibly even reduce
the risk of recurrence and extend survival
after a cancer diagnosis
Courneya, K.S. and Friedenreich, C.M., Seminars in Oncology Nursing, 2007
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Why Exercise
Physical Activity and Survival After BreastCancer Diagnosis
Prospective observational study
2987 women diagnosed with stage I-III breast cancerfrom the Nurses Health Study cohort
Patients were divided into groups depending on howengaged they were in physical activity
Physical activity was measured in MET-hrs per week
Holmes et al. JAMA, 2005
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Why Exercise
Physical Activity and Survival After BreastCancer Diagnosis
Results:Any category of activity higher than the reference
category of less than 3 MET-hrs per week wasassociated with a decreased risk of an adversebreast cancer outcome
Absolute unadjusted mortality risk reduction was6% at 10 yrs for women who engaged in 9 ormore MET-hrs per week
Holmes et al. JAMA, 2005
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Practical Considerations
Treatment Side-effects Chemo-induced
Radiation-induced
Surgical
Other treatments: eg: Stem-Cell Transplant, steroids
Disease-Related Site of tumor
Metastases Nutritional status
Psychosocial impact
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Chemo-Induced
Fatigue
Thrombocytopenia
Anemia Neutropenia
Loss of hair
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Chemo-Induced
Decreased appetite
Nausea and vomiting
Changes in bowel function Neuropathy
Altered mentation, Chemo-brain
Cardiotoxicity
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Radiation-Induced
Burns
Fibrosis
Fatigue
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Surgical
Pain
Anatomical changes
Scar mobility
Added management difficulties if followedclosely by radiation
Foot drop
Post-op restrictions due to type of surgery
Post-op restrictions suggested by surgeon
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Other Treatments
Stem Cell Transplant (SCT)
Decreased Immunity
Avoid public pools, lakes, and crowded areas
Graft vs Host Disease (allogeneic-SCT)
Sun exposure precautions
Sclerodermatic tissue changes with skin GvHD
Corticosteroids:
Used in many treatment regimens
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Site of Tumor
Gastroesophageal
Breast
Prostate Hepatobiliary
Lung
Hematologic
Other
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Metastases
Liver
Lung
Brain Bone
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Nutritional Status
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Psychosocial Impact
CognitiveCognitive
OccupationalOccupational
FinancialFinancial
PhysicalPhysical
RelationshipsRelationships
Spiritual
Religious
Spiritual
Religious
EmotionalEmotional
CopingCoping
PersonPerson
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Some Guidelines from Cancer ExerciseSpecialist Training Course
Individualize
Moderate intensity activity level
Full body exercise at each session 3x/wk Monitor blood counts
Progress slowly and vary workout with treatment
effects
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Some Guidelines from Cancer ExerciseSpecialist Training Course
50-60% HRR (starting);
RPE = 4-5
Active, moderate health,
average fitness
30-40% HRR (starting);
RPE = 1-3
Sedentary, poor health,
low fitness
Recommended Intensity LevelStatus
Exercise and Cancer Recovery, Schneider, C. M. et al., 2003
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Motivation
Some ideas. Patients have control: CHOICE
Prevention of complications or secondary
problems Potential benefits
Sense of achievement
Goal setting New habit: can take 30-60 times to develop
Exercise can be FUN, really
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Take-Home Message
Do not avoid, but be cautious when prescribing
Physical Exercise
MODERATE INTENSITY, slow progression
Keep in mind the whole person, the individual
Exercise is an important and integral part of life
prior to, with, and after cancer, have fun with it!
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Resources
Canadian and American Cancer Societies Comprehensive Health Improvement Program
(CHIP) at Atwater Club
Cummings Center
Jewish Rehabilitation Hospital
McGills Cancer Nutrition-Rehabilitation Programs
Wellness Center (CDN)
Yoga classes (Happy Tree) Many community activities, gyms, and.. the great
outdoors
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References
Demark-Wahnefried, W. and Jones, L., Hematol Oncol Clin N Am22 (2008) 319-342
Holmes et al., JAMA May 25, 2005, Vol 293, No. 20
Courneya, K.S. and Friedenreich, C.M., Physical Activty and
Cancer Control, Seminars in Oncology Nursing, Vol. 23, no. 4(Nov.) 2007 (pp 242-252)
Franklin, D. J. MD, PhD, Phys Med and Rehab Clin of N Am18899-924 (2007)
Exercise and Cancer Recovery, Schneider, C. M. et al., 2003