Steven Harulow looks at the impact of exercise in cancer rehabilitation and the challenges and rewards for personal trainers working in this growing area of expertise.
According to Cancer Research UK (CRUK), someone is diagnosed with cancer in the United Kingdom approximately every two minutes. That’s a staggering 363,000 new cancer diagnoses every year; more than 990 every day. It is very likely that you will know of or meet someone with cancer. You may even develop cancer yourself.
That’s a pretty depressing thought, I know, but it’s important to realise that improvements in cancer detection and treatment advances mean more people are living longer and cancer free after treatment. Overall cancer survival in the UK has doubled in the past 40 years and in 2010-2011 half of those diagnosed with cancer in England and Wales had survived their disease for 10 years or more (CRUK).
The trend is set to continue with the introduction of new therapy techniques and treatments personalised to an individual’s own particular cancer. This means that there is a growing population for whom cancer represents a controllable long-term condition, along the lines of diabetes, arthritis and chronic respiratory problems.
Like other groups with chronic health problems, cancer survivors have their own particular issues that impact on their wellbeing.
Adjusting to life as a cancer survivor
There is no doubt that dealing with the physical and psychological effects of cancer and cancer treatments – for example, surgery, chemotherapy, radiotherapy and hormone therapy – can be a tough challenge. There may be short-duration symptoms that develop during therapy, those that continue for months or years during treatment, and the so-called late effects that emerge after therapy has ended (Ellaham, 2019).
Many cancer survivors talk about their all-consuming fatigue after treatment – associated with poor cardiovascular conditioning, sarcopenia, decreased muscle strength and loss of physical function due to pain and restricted joint mobility. They also comment routinely on their unwelcome weight gain, either due to inactivity and poor dietary choices or as the result of medications, such as corticosteroids.
For some individuals – for example, those who were treated for breast cancer and lymphoma – they are at higher risk of developing long-term cardiac effects linked to their treatment (National Cancer Institute, 2018). Others risk developing enduring health problems associated typically with a lack of physical activity, such as obesity, hypertension, diabetes, cardiovascular disease and cancer recurrence.
Then there are condition-specific problems, such as blood abnormalities, low platelet counts and anaemia; early onset osteoporosis; peripheral neuropathy (often due to the side effects of certain chemotherapy drugs); and lymphoedema (the swelling in limbs that can occur after the removal of some or all of the associated lymph nodes).
The presence of any of these problems, if not addressed appropriately, can greatly hinder an individual’s ability to return to and participate in physical activity.
Cancer survival can also take its toll on a person’s mental health. Clients discuss depression related to their poor quality of life post cancer and anxiety caused by loss of income, fear of cancer recurrence and death. Some also comment on the sense of loss and the poor self-esteem they feel because they are unable to participate in the active lifestyle they had prior to their diagnosis and treatment.
Cancer and exercise
By now some of you will be saying to yourselves that many of these problems can be addressed through an exercise programme sensitive to the physical needs of the individual. After all, that’s what we do with clients referred for exercise by their doctors.
As fitness professionals, we extol the virtues of physical activity and the beneficial effects that exercise has on the health of our general clients. International health guidelines emphasise the need to undertake regular moderate intensity exercise to increase cardiovascular efficiency and regular resistance activities to prevent muscle loss, develop muscle strength, increase bone density and improve metabolism. Not to mention the positive effects exercise can have on mood, stress and cognitive abilities (US Department of Health and Human Services, 2018).
However, until recently it was rare to see the words “cancer” and “exercise” on the same page, never mind in the same sentence.
With limited evidence to the contrary, the traditional medical message to people living with cancer and the side effects of cancer therapy was to put their feet up and rest. The thinking behind this was that excessive physical activity would make the effects of fatigue worse by placing an extra burden on a body that had already endured intensive treatment.
In the past decade, however, a growing raft of evidence has emerged to support the role of exercise in cancer treatment and cancer survival (Ellaham, 2019). This has driven a turnaround in medical thinking regarding the physical and psychological benefits of exercise in cancer therapy, and the role that lack of physical activity plays in the development of some cancers (Patel et al, 2019).
In May 2018, the Clinical Oncology Society of Australia (COSA) launched its position statement on the role of exercise alongside surgery, chemotherapy and radiation in cancer care. According to COSA: “All people with cancer should avoid inactivity and return to normal daily activities as soon as possible following diagnosis (ie, be as physically active as current abilities and conditions allow).”
Writing in the online publication, The Conversation, COSA lead author Professor Prue Cormie said: “Research shows exercise can help cancer patients tolerate aggressive treatments, minimise the physical declines caused by cancer, counteract cancer-related fatigue, relieve mental distress and improve quality of life.”
Professor Cormie also made international headlines when she added: “If the effects of exercise could be encapsulated in a pill, it would be prescribed to every cancer patient worldwide and viewed as a major breakthrough in cancer treatment.”
Physical activity is now also considered to be an important step that individuals can take to prevent the development of cancer and reduce the risk of recurrence (Ellaham, 2019). In 2018, an expert panel convened by the America College of Sports Medicine (Patel et al, 2019) concluded that physical activity is associated with reduced risks for seven common types of cancer – colon, breast, kidney, endometrial, bladder, stomach and oesophageal.
According to the panel: “Fitness and public health professionals and health care providers worldwide are encouraged to spread the message to the general population and cancer survivors to be physically active as their age, abilities, and cancer status will allow.”
In November 2019, Penn State Cancer Institute Professor Kathryn Schmitz outlined the latest activity guidelines for cancer survivors and called on oncology professionals to make exercise assessment, advice and referral a standard practice within clinical oncology. The new activity guidelines recommend 30 minutes of moderate aerobic exercise three times each week, plus 20–30 minutes of resistance exercise twice a week. Importantly, Professor Schmitz emphasises that the optimal amount of activity depends on the individual's physical abilities. This is key to the effectiveness of any cancer-related exercise programme.
With hundreds of events held throughout the country every year, the Race for Life raises money for Cancer Research
Working with cancer survivors
Like many personal trainers, I joined the fitness industry later in life after a number of careers. As a former registered nurse, I have always been drawn to the health aspects of fitness, particularly for people affected by disease and medical interventions, such as surgery and drug therapy.
After gaining my Level 3 Advanced Diploma in Personal Training through YMCAfit in 2016, I developed a niche role working with older clients. Many of these people had the typical lifestyle-related conditions – including metabolic disorders, musculoskeletal problems and cardiovascular issues – that exercise referral schemes address. It seemed a natural progression to complete the Level 3 Diploma in Exercise Referral and this led to related experience at the Central YMCA in London.
Continuing in the health vein, I completed a Level 4 Qualification in Cancer Rehabilitation through the Wright Foundation in early 2018. Since then I have had the opportunity to work with Trekstock, a charity that aims to help young adults with cancer to, “thrive with, through and beyond a diagnosis of cancer”.
As part of Trekstock’s “Renew” programme, I work with individual clients who have had or are undergoing treatment for a range of cancers – including brain, breast, bowel, melanoma, sarcoma and a variety of blood cancers.
The programme involves an initial health assessment looking at body composition, overall health and fitness parameters, and specific condition-related issues. With this information, I develop a tailored exercise plan to meet each client’s goals and take it from there gradually over a 12-week period.
Rewards and challenges
It’s such a pleasure to be part of this successful and rewarding programme. Clients with a cancer diagnosis are pretty special people and it’s a privilege to be a part of their health and fitness journeys.
Some of the individual progress has been amazing, both in terms of physical and psychological development, and in regards to the improvements clients report in their wellbeing and quality of life.
Remember, for some people who have been through months of chemotherapy, extreme fatigue and balance issues can make even walking on a treadmill for a few minutes a major challenge. To go from that situation in week one to light jogging and beyond in subsequent weeks is such a big achievement. I’ve seen huge smiles and tears of joy at the end of sessions when clients realise what they have just accomplished.
We’re not talking about massive muscle gains and huge improvements in aerobic capacity after 12 weeks, but we are talking giving people the tools, knowledge and confidence to go out and manage their own condition, so that their fatigue improves, and they can they can go back to work and carry on with their active lives.
One of the consistent client feedback comments at the end of the programme is that it is has literally been “life changing”.
Of course, it’s not all positive and some clients have to leave the programme because of further medical problems or cancer recurrence. Unfortunately, some clients have a life-limiting diagnosis and are approaching the end of their lives. However, even for these individuals a programme of appropriate exercise can make the world of difference to their symptom management and, as they say, gives them a form of control they can exert at a time when this is becoming a scare commodity.
Level 4 Specialist Qualifications and professional recognition
The field of cancer rehabilitation is one of the most complex areas that fitness professionals work in. Cancer treatment is by its nature complicated and many cancer survivors present with anatomies that have not only been altered directly by medical intervention, but also through the associated effects of therapy and sometimes the cancer process itself.
Add to that the enormous psychological elements involved in cancer survival and it becomes clear that personal trainers need to be at a level of competence where they can work confidently, safely and effectively.
In the UK, a Level 4 Cancer Rehabilitation Qualification is an essential prerequisite for fitness professionals aiming to work formally in this area. The qualification provides an overview of how cancers occur at the cellular level and the various risk factors involved in their development. It also examines common types of cancer and looks at cancer classifications and their implications for the individual.
The examination of contemporary treatment methods and their potential side effects helps to explain why people may need a modified exercise prescription to address their particular limitations. Discussion of real-life case studies helps to bring FITT programming adaptations to life and of course there are practical gym-based sessions to consolidate theory into practice.
A growing area for fitness professionals
The field of cancer rehabilitation is a potentially huge area of involvement for fitness professionals.
As the evidence base continues to support the inclusion of exercise and physical activity as part of the pre and post treatment cancer care pathway, oncologists are increasingly referring their patients for exercise. Admittedly, there is still a strong health flavour to this activity, with many programmes delivered under the auspices of physiotherapy, but there are growing opportunities for fitness professionals.
My advice to anyone wanting to work in this field is to go out and meet health and fitness professionals who already work in this area. Most UK regions have a network of activity centres and Macmillan Cancer Support provides comprehensive information on local schemes and opportunities.
It’s also important to meet and talk to people who have had a cancer diagnosis. What better way to find out what it’s like to live with cancer and to appreciate the many complexities that they face?
Cancer Research UK. Cancer Statistics for the UK. https://www.cancerresearchuk.org/health-professional/cancer-statistics-for-the-uk
Clinical Oncology Society of Australia. COSA position statement on exercise in cancer care. April 2018. https://www.cosa.org.au/media/332488/cosa-position-statement-v4-web-final.pdf
Collins F. Panel finds exercise may lower cancer risk, improve outcomes. National Institutes of Health Director’s Blog. October 2019. https://directorsblog.nih.gov/2019/10/16/panel-finds-exercise-may-lower-cancer-risk-improve-outcomes/
Cormie P. Every cancer patient should be prescribed exercise medicine. The Conversation. May 6 2018.
Ellahham SH. Exercise before, during, and after cancer therapy. Journal of the American College of Cardiology. Expert analysis. 4 December 2019.
Macmillan Cancer Support. In your area. https://www.macmillan.org.uk/in-your-area/choose-location.html
Macmillan Cancer Support. Move more. Physical activity the underrated ‘wonder drug’. http://www.canexercise.co.uk/wp-content/themes/canexercise/images/pdf/Physicalactivityreport.pdf
National Cancer Institute. Higher risk of heart failure seen in some cancers. 26 March 2018. https://www.cancer.gov/news-events/cancer-currents-blog/2018/increased-heart-failure-risk
Patel AV, et al. American College of Sports Medicine Roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Medicine and Science in Sports and Exercise. November 2019. Volume 51: 11, p 2391–2402.
Schmitz KH. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA: A Cancer Journal for Clinicians. November/December 2019. 69: 6. https://onlinelibrary.wiley.com/doi/abs/10.3322/caac.21579
Trekstock Renew Programme. https://www.trekstock.com/renew
US Department of Health and Human Services. Physical activity guidelines for Americans 2nd edition. 2018. https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
Zahid N. An international group of experts releases new exercise guidelines for cancer survivors. 19 October 2019. https://speciality.medicaldialogues.in/an-international-group-of-experts-releases-new-exercise-guidelines-for-cancer-survivors/