CME

“THE BENEFITS OF EXERCISE IN CANCER SURVIVAL: A LITTLE

GOES A LONG WAY”

Oleh:
Nadia Rezki Eliza 1810221011

Pembimbing :
dr, Wahyu Djatmiko, Sp.PD-KHOM

SMF ILMU PENYAKIT DALAM RSUD PROF. DR. MARGONO SOEKARJO

FAKULTAS KEDOKTERAN UNIVERSITAS JENDERAL SOEDIRMAN
PURWOKERTO

2019
 HALAMAN PENGESAHAN
CME
“THE BENEFITS OF EXERCISE IN CANCER SURVIVAL: A LITTLE
GOES A LONG WAY”

Disusun oleh:

Nadia Rezki Eliza 1810221011

Diajukan untuk Memenuhi Syarat Ujian Kepaniteraan Klinik di Bagian

Ilmu Penyakit Dalam RSUD Prof.Dr.Margono Soekarjo
Purwokerto

Telah disetujui,
Pada tanggal: 2019

Mengetahui,
Dokter Pembimbing

dr, Wahyu Djatmiko, Sp.PD-KHOM

Clinical Context

Many adults may consider exercise as a means to lose weight, or perhaps reduce their risk for
cardiovascular disease, but they often do not realize that recreational physical activity (RPA)
is an important tool in the prevention of cancer. A study by Moore and colleagues, which
appeared in the June 1, 2016, issue of JAMA Internal Medicine, pooled data from 12 cohort
studies of self-reported RPA and the risk for cancer among adults.[1] The study included data
from 1.44 million adults, with a mean age of 59 years.

High vs low levels of RPA were associated with significantly lower risks for 13 types of
cancer. The inverse association between RPA and the risks for breast and gastrointestinal
cancers are well-established, but RPA also reduced the risks for myeloid leukemia, head and
neck, kidney, and bladder cancers. Moreover, RPA had a preventive effect independent of
body mass index and smoking status for most of these forms of cancer.

There is some evidence that RPA can also reduce the risk for mortality among patients with a
known diagnosis of cancer, but this research has been focused on specific tumors. The
current study uses a large database to investigate the effect of RPA on mortality outcomes
across a broad range of adults with cancer.

Study Synopsis and Perspective

Exercise after a cancer diagnosis improves survival, even in patients who had not exercised
previously, concludes a new study.[2]

The findings come from an analysis of detailed epidemiological data collected over the
course of 14 years of a cohort of 5807 patients who were diagnosed with a variety of cancers.

A significant survival benefit of exercise was seen in patients with 1 of 8 specific tumors:
breast, colon, prostate, ovarian, bladder, endometrial, esophageal, and skin cancer (mostly
melanoma).

Regular exercisers had the biggest survival advantage over their sedentary peers. Patients
who exercised 3 to 4 times each week before and after their cancer diagnosis reduced their
all-cause mortality risk by 40% (hazard ratio [HR], 0.60) and their cancer-specific mortality
risk by 39% (HR, 0.61) compared with patients with cancer who remained "habitually
inactive."

However, patients who exercised just 1 or 2 days each week before and after their cancer
diagnosis also had significantly improved survival compared with sedentary counterparts.
They enjoyed a 32% reduction in both all-cause mortality and cancer-specific mortality (HR,
0.68), the study showed.

Astonishingly, even veteran couch potatoes experienced dramatically improved survival

when they exercised. The researchers found that patients who were sedentary in the decade
before diagnosis experienced a 28% drop in all-cause and cancer specific-mortality when
they exercised just 1 to 2 times a week in the year after cancer diagnosis (HR, 0.72).
The survival benefits were observed regardless of the patient's sex, age, weight, smoking
status, or cancer stage.

"In other words, the association was seen in obese patients, persistent smokers, and in
patients who were diagnosed with advanced-stage tumors," lead author Rikki A. Cannioto,
PhD, assistant professor of oncology at Roswell Park Comprehensive Cancer Center in
Buffalo, New York, told Medscape Medical News.

The study was published online November 28 in Cancer Causes & Control.

These findings indicate that "it is never too late to make healthy lifestyle changes that may
affect the survival trajectory," said Dr Cannioto. "This is good news for all cancer patients."

"Collectively, these observations solidify the clinical and public health importance of the
message that any amount of regular weekly activity is better than inactivity," the authors
write. This is "particularly encouraging," they add, "given that cancer patients and survivors
can be overwhelmed by the current physical activity recommendations of 30 min per day of
moderate-intensity physical activity."

The study population, which was primarily white, included more women than men (55% vs
45%). A total of 1390 patients (24.4%) said they did not exercise regularly before diagnosis,
and 2400 (41.9%) said they did not exercise after cancer diagnosis.

The authors acknowledge that this self-reporting of physical activity is a "primary limitation
of our study," as it may be subject to recall error and misclassification, especially for the
decade before diagnosis.

Implementing Exercise Into Supportive Care?

"These data demonstrate the potential value of implementing exercise into the supportive care
continuum of cancer patients and can inform targeted intervention trials designed to improve
clinical outcomes among patients diagnosed with a variety of malignancies," the authors note.

Oncologists should counsel patients about the survival benefits of physical activity and
encourage them to take advantage of resources within the healthcare system and in the
community, Dr Cannioto suggested. A referral to physical therapy can address specific
mobility issues, and there are many community resources such as the YMCA, which offers a
free exercise program for patients with cancer, she noted.

However, there has been some concern expressed about how the exercise needs of seriously
ill patients with cancer can be balanced without creating additional health risks, as for
example, in an editorial published early this year in the Lancet Oncology.[3]

The unnamed editorialists noted that when the Clinical Oncology Society of Australia
released its position statement in May recommending that all patients with cancer be
prescribed exercise as part of their treatment regimen, the move was endorsed by no fewer
than 25 leading healthcare institutions.[5]
 Despite widespread endorsement for incorporating exercise into cancer survivorship, "it
would be naive to think that there can, or should, be a one-size-fits-all approach to suit all
patients," the editorialists write.

"[P]atient comorbidities and fragility...need to be adequately considered when recommending

the feasibility of any physical activity regimen," they add.

In an accompanying correspondence column, a research team from the Princess Margaret

Cancer Center, University Health Network, Toronto, Ontario, Canada, agreed that common
comorbidities and treatment adverse effects can increase risk in patients who would
otherwise benefit from exercise.[6]

Current exercise guidelines for cancer patients are geared primarily to the general public,
"with some cancer-specific caveats," write Daniel Santa Mina, PhD, assistant professor in the
Faculty of Kinesiology and Physical Education, University of Toronto, Ontario, Canada, and
colleagues.

As such, these guidelines "fall short of effectively advising clinicians and qualified exercise
professionals...about how to identify and manage many potential exercise contraindications,
especially given the high degree of heterogeneity in patient risks and comorbidities," the
authors emphasize.

To address these barriers to exercise, the researchers have developed a clinical "if yes, then"
tool that provides clinicians with evidence-based directives for common exercise
contraindications.

The Safety Reference Guide can be used in conjunction with guidelines from the American
College of Sports Medicine and the Clinical Oncology Society of Australia to standardize
risk management and determine exercise precautions. Ultimately, it allows clinicians to tailor
safe, individualized workouts for patients with cancer who might otherwise be excluded from
the full benefits of an exercise prescription.

The guide is now part of an 8-week, medically supervised Cancer Rehabilitation and Exercise
program at Princess Margaret Hospital for patients with active cancer-related impairments
such as fatigue, deconditioning, lymphedema, or general or localized dysfunction.

The study of the cancer survival benefits of exercise was funded by the Roswell Park Cancer
Center and National Cancer Institute. Dr Cannioto, Dr Santa Mina, and coauthors have
reported no relevant financial relationships.

Cancer Causes Control. Published online November 28, 2018.

Study Highlights

 Study data were drawn from the Roswell Park Data Bank and Biorepository, which collects
information on adults with cancer.
 The current study includes 5807 participants who provided data between 2003 and 2016.
 All patients in the database complete an extensive health questionnaire, which includes
information on RPA.
 The current study investigates the effects of persistent RPA, RPA limited to the time after
cancer diagnosis, and sedentary behavior on the risk for mortality.
 Regular precancer RPA was defined by a minimum of 1 to 2 exercise sessions per week for a
minimum of 1 year. Post diagnosis RPA was defined by at least 1 to 2 sessions per week.
 The main study result was adjusted to account for demographic, health habit, and cancer
variables.
 The mean age of participants at the time of cancer diagnosis was 60.6 years, and 54.8% of the
cohort was women. There was a wide range of cancer sites in the cohort, with the most
common being breast and prostate.
 18.7% of the study cohort was habitually active, and 5.7% of adults became active after the
diagnosis of cancer; 23.2% reduced RPA after the diagnosis of cancer, and 52.3% were
habitually inactive.
 The hazard ratios for all-cause and cancer-specific mortality in comparing habitually inactive
adults with adults with any prediagnosis RPA were 0.74 (95% CI, 0.70-0.81) and 0.78 (95%
CI, 0.70-0.87), respectively.
 Exercising for 3 to 4 days per week was associated with the greatest survival advantage. The
pace of walking was the only variable that produced a linear effect in reducing the risk for
death.
 Comparing patients who reported postdiagnosis RPA with habitually inactive adults, the
hazard ratios for all-cause and cancer-specific mortality were 0.68 (95% CI, 0.62-0.75) and
0.68 (95% CI, 0.61-0.75).
 Formerly inactive patients who initiated RPA only after the diagnosis of cancer experienced a
28% reduction in all-cause and cancer-specific mortality.
 Subgroup analyses based on the site of cancer, type of cancer treatment, body mass index,
and educational attainment generally failed to alter the main study conclusions.
 RPA appeared effective at improving mortality across cancer stages I, II, and III, but not
stage IV.
 Excluding adults with breast and colon cancer also failed to alter the main study findings.

Clinical Implications

 A previous study found that RPA was associated with lower risks for 13 different types of
cancer, including myeloid leukemia, head and neck, kidney, and bladder cancers. Moreover,
RPA had a preventive effect independent of body mass index and smoking status for most of
these forms of cancer.
 The current study finds that even infrequent RPA initiated only after the diagnosis of cancer
can reduce the risk for mortality among adults with cancer. Prediagnosis RPA also helped
reduce the risk for cancer, and these findings were generally true regardless of cancer site or
treatment.
 Implications for the Healthcare Team: The healthcare team should encourage RPA among
adults at risk for cancer and among patients diagnosed with cancer.

Below are all the test questions with an explanation of the correct answer.

1. You are seeing a 60-year-old woman for a health maintenance visit. The patient reports that she
does brisk walking for 1 hour twice weekly for RPA. According to the previous study by Moore
and colleagues, what can you tell her regarding the association between RPA and the risk for
cancer?
 Answer: RPA was effective at reducing the risks for 13 different types of cancer
This previous study found that RPA was associated with lower risks for 13 different types of
cancer, including myeloid leukemia, head and neck, kidney, and bladder cancers. Moreover, RPA
had a preventive effect independent of body mass index and smoking status for most of these
forms of cancer.

2. The patient is diagnosed with breast cancer after routine mammography. What should she consider
regarding the association between RPA and mortality among adults with cancer in the current
study by Cannioto and colleagues?

Answer: Mild to moderate RPA initiated after the diagnosis of cancer was associated with lower
mortality
The current study finds that even infrequent RPA initiated only after the diagnosis of cancer can
reduce the risk for mortality among adults with cancer. Prediagnosis RPA also helped reduce the
risk for cancer, and these findings were generally true regardless of cancer site or treatment.