Latest research shows that if you are born after 1960, your lifetime risk of being diagnosed with cancer is now 1 in 2. There are over 360,000 new cancer cases in the UK every year – that's nearly 1000 every day (CRUK).
On a more positive note, new effective cancer detection methods and sophisticated treatments have resulted in cancer survival rates doubling in the last 40 years. Currently, over 50% of people diagnosed with cancer will survive for more than 10 years and the prognosis increases to 80% survival rate with cancers such as breast, prostate, testicular, melanoma and Hodgkin lymphoma.
Unfortunately, with some cancers – such as stomach, brain, oesophageal, lung and pancreatic cancers, which are difficult to diagnose and/or treat – the 10-year survival rate is less than 20%.
The importance of exercise
Over four million people will be living with or beyond a cancer diagnosis in the UK by 2030 (Maddams et al., 2012) and it is important to try to ensure that they are living well, but this is not always the case.
For many cancer survivors, treatments such as surgery, chemotherapy, radiotherapy and hormone treatments lead to chronic or late-appearing side effects such as fatigue, cardiorespiratory and muscular weakness, metabolic syndrome, osteoporosis, lymphoedema and depression (Khan et al., 2011). This can have a profound effect on their quality of life.
One way to combat these side effects is to stay active. There is now convincing evidence that being active at all stages of the cancer journey (pre-surgery, during cancer treatments, in the survivorship phase with advanced cancer and during palliative care) can provide significant physical and psychological benefits (Stevinson et al., 2017).
Strong observational evidence shows that higher levels of physical activity are associated with lower risk of cancer recurrence and mortality following breast, colon and prostate cancer (Li et al., 2016). Furthermore, specific doses of exercise have been shown to effectively address anxiety, depression, physical function deficits, cancer related fatigue, bone health, sleep, lymphoedema and quality of life (Winters-Stone, 2018).
In addition, exciting new evidence supports the concept that exercise may directly improve the effectiveness of chemotherapy treatments (Cheville et al., 2015, van Waart et al., 2015, Courneya et al., 2007, Hayes et al., 2018), which may partly explain the cancer survival benefits (Moore et al., 2016).
In summary, the evidence is strong enough to consider exercise/physical activity rehabilitation programmes as an integral additional cancer treatment and it should be embedded as a standard part of cancer care, similar to that offered in cardiac rehabilitation.
Training in exercise oncology for fitness instructors
In 2007, Professor Anna Campbell (pictured) published a paper showing that it was feasible, safe and effective for women diagnosed with breast cancer to exercise during chemotherapy / radiotherapy in a community-based group setting (Mutrie et al., 2007). This study was one of the first to demonstrate how to implement a pragmatic exercise programme “in the real world” – all the circuit class classes took place in local council leisure centres.
As a consequence, Professor Campbell established CanRehab in order to facilitate the training of fitness instructors to a competency level where they could confidently provide safe, effective and individualised programmes for people during and after cancer treatment.
One of CanRehab’s main strengths is that it consists of a small, dedicated team of specialist advisors, tutors and assessors who are oncologists, surgeons, palliative care physiotherapists and university lecturers working in exercise oncology, exercise physiologists and exercise oncology.
Professor Campbell is part of an international task force of cancer exercise researchers and this helps ensure that CanRehab’s teaching materials are constantly reviewed to reflect the most up to date evidence-based guidelines for exercising safely after a cancer diagnosis. CanRehab has now trained over 700 fitness and health professionals throughout the UK and Northern Ireland, and in 2017 won the prestigious UKActive Active Training Awards Specialist Training Programme of the Year accolade. CanRehab training courses are now being used as a template for similar training courses in Spain, Portugal, Denmark and Holland.
CanRehab’s Level 4 Cancer Exercise Training Course
During the Level 4 CanRehab course, students learn from a cell biology perspective how cancer can occur and what factors increase risk of cancer development. The course includes a review of the latest cancer statistics, how to classify cancers and the current ways of treating different cancers.
Cancer treatment regimens are constantly changing to include new and more sophisticated tools to combat the cancer and it is important that CanRehab students are aware of these treatments and how they work and are able to confidently discuss these with their clients.
The course teaches the students how to identify the relevant side effects of surgery, chemotherapy, radiotherapy, hormone treatment and other treatments that potentially can have an impact on an exercise prescription. With the help of a number of practical sessions during the course (with case studies based on real people who have had cancer), the students gain confidence in knowing how to modify the exercise prescription to ensure it is safe and effective.
At each course, the students also have a session with a local cancer survivor who voluntarily comes to talk about what it is like to experience cancer and its treatments and how they managed to remain or become active. Another unique component of the course is guidance on how to set up a bespoke circuit class (which was used successfully in Professor Campbell’s studies).
Exercise guidelines for cancer
To date, no formal guidelines for cancer survivors have been published in the UK. However, in Macmillan’s concise evidence review (Stevinson et al., 2017) general recommendations based on published US and Australian guidelines are:
- Avoid inactivity and try to return to some activity as soon as possible after surgery.
- Aim to continue to be physically active as far as possible while undergoing cancer treatments such as chemotherapy, but be aware that treatment-related toxicities can increase risk of anemia, infection and affect cardiorespiratory fitness and bone health.
- After cancer treatments, most cancer survivors should build up to age-appropriate guidelines for health-enhancing physical activity (typically aerobic exercise for two and a half hours per week, resistance exercise twice weekly, and balance/coordination exercise twice weekly).
- For those clients with cancer complications or co-morbidities that prohibit moderate-intensity exercise, avoidance of total inactivity is nonetheless advised.
During chemotherapy and radiotherapy, and with some of chronic or late-appearing side effects of cancer treatment, it is essential to acquire further knowledge on how to recognise contra-indications and/or which exercises have to be modified or excluded. For example, there are essential modifications to strength training exercises required if:
- a woman has developed lymphoedema after breast cancer surgery and radiotherapy
- a client diagnosed with colon cancer has a colostomy bag – when it is important to improve the client’s confidence by incorporating safe and effective exercises for core muscle stability
- a prostate cancer survivor is on hormone treatment – when they will need to incorporate specific weight-bearing exercises to decrease risk of bone thinning.
This level 4 course provides the students with a list of potential issues to look out for at each session with a client and guidelines on when to stop, reduce or alter an exercise or activity and when to refer back to the appropriate health care professional.
As the evidence builds on the effectiveness of cancer specific community-based programmes presurgery, during treatment and post treatment, Clinical Commissioning Groups are looking to fund programmes with a clear referral pathway from the health setting to the community.
Indeed, the Level 4 CanRehab course has also been attended by GPs, oncologists and physiotherapists, who stated that not only did it enhance their knowledge of exercise prescription but also helped them understand the relevant skills that the CanRehab fitness instructors gain, and therefore enabled them to confidently refer their patients to community-based programmes supervised by cancer exercise experts.
Some of the CanRehab graduates now work in NHS settings as key team players in cancer prehabiitation or rehabilitation cancer programmes.
If you are interested in training with CanRehab to become a specialist fitness instructor in cancer and exercise rehabilitation – either at one of the regular venues around the UK or possibly as a course at your own venue; or finding out about our other future CPD programmes for health and fitness instructors, you should e-mail email@example.com or visit the website for more information.
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