Oncology rehabilitation using a cardiac rehabilitation (CR) model is a promising intervention for cancer survivors. Wellness develops, as do physical and psychological functions. The application of oncological rehabilitation on a larger scale awaits the collection of controlled data on the value of oncological rehabilitation over normal care in contemporary populations. As the cancer survivor population grows due to oncological treatment, the importance of longer-term functional outcomes will be emphasized.
Individuals undergoing cancer treatment experience declines in fitness, strength, and physical function. Cancer and related treatments result in local symptoms such as range of motion and lymphedema, as well as systemic effects such as fatigue, deconditioning and pain syndromes. (1)
Survivors of certain types of cancer are also at increased risk for developing cardiovascular disease. (2,3) Undesirable outcomes of cancer treatments can be improved with rehabilitation interventions. She/He has documented improvements in exercise interventions, aerobic fitness, strength, and other enduring effects of cancer treatment. In addition, epidemiological evidence suggests that physical activity improves cancer-related outcomes, such as reducing recurrence and increasing survival, although no randomized controlled trial data are available. (4,5,6) Following a cancer diagnosis, oncological rehabilitation programs should become a standard component of cancer survivor care.
With a focus on preventing secondary diseases, reducing deaths and illness, and improving physical function and quality of life, Cardiac Rehabilitation (CR) provides an ideal framework for developing comprehensive oncology rehabilitation programs.
Cancer and the Impact of Cancer Treatment: Declines in Fitness, Strength, and Physical Function
The interplay of cancer and various cancer treatments results in physiological decline and persistent side effects, many of which can be improved with exercise and rehabilitation. Cardiovascular fitness is impaired in cancer survivors. (7) Significant reductions in the internal function of skeletal muscle myofilaments have recently been identified in cancer patients and have been found to be associated with reduced overall muscle strength and walking performance. (8)
Cancer and the Effect of Cancer Treatment: Permanent Side Effects
Surgery and radiation are common local treatment modalities that can impair mobility. Shoulder range of motion is limited to up to 45% of patients receiving sentinel lymph node assessment and 86% of patients receiving axillary dissection. (9) More importantly, this dysfunction translated into limitations on activities such as daily chores (44.2%) and lifting a gallon of milk (34.9%). Lymphedema can be acquired by disruption of lymphatic filtering from cancer-related surgery or radiation. Treatments to treat breast cancer are associated with a 21.4% sign of lymphedema23, and those with lymphedema experience strength and upper extremity impairment. (10,11)
The chemotherapeutic and targeted therapies used to treat cancer are associated with secondary harm that affects the quality of life of many cancer survivors. Fatigue is the most widely recognized lasting effect of cancer treatment and is found in 80% of cancer survivors. (12) Cancer-related fatigue is multifactorial and includes self-helpful effects such as decreased activity, deconditioning, depression, and sleep disturbance. (13,14) Depending on the diagnosis and interventions, weight gain or loss occurs with cancer treatment. Weight gain is more common in people receiving adjuvant therapy for breast and colon cancer. (15,16) Conversely, people with other malignancies such as the lung, head/neck, pancreas, and upper gastrointestinal tract often lose weight. This weight loss causes a reduction in skeletal muscle, often not reversed by diet alone and is accompanied by a decrease in strength. (17) Up to 35% of cancer survivors experience significant psychological distress. (18) Psychological factors appear to be associated with physical inactivity among cancer survivors. (19)
Benefits of Exercise and Rehabilitation for Cancer Survivors
Exercise and rehabilitation interventions have proven beneficial in improving the disorders experienced by cancer survivors. Aerobic interventions improve cardiopulmonary fitness in cancer survivors, with increases ranging from 10-15%. (20) Aerobic exercise has benefits for survivors of several different types of cancer, including lung, breast, prostate, lymphoma, and hematological malignancies. (21,22) Exercise and rehabilitative interventions result in improvement of shoulder motion disorder in women treated for breast cancer. (23) Resistance training doesn’t make lymphedema worse, it actually reduces flare-ups and symptoms. (24) A recent review of 56 studies with more than 4,000 participants identified the benefits of exercise interventions for fatigue management given during and after cancer treatment. (25) For cancer survivors, exercise results in reduced depression and improved quality of life. (26)
While a randomized controlled trial is lacking, observational studies find that overall survival is improved among cancer survivors who are more physically active. For breast cancer survivors, physical activity equivalent to 3 hours of moderate-intensity activity was associated with a 34% reduction in breast cancer-specific deaths and a 41% reduction in overall case deaths. (27)
Two large observational studies have shown that those who do 6 hours of moderate-intensity physical activity per week after a colon cancer diagnosis are associated with a reduced death rate from colon cancer and other causes compared to men or women who are physically inactive.
Cardiac Rehabilitation as an Oncological Rehabilitation Model
Cardiac Rehabilitation as an Oncological Rehabilitation Model
An effective oncology rehabilitation program will increase well-being and address physical and psychological deficiencies. CR provides an ideal model for bringing oncology rehabilitation to cancer survivors at academic and community medical centers nationwide.
The aerobic exercise component usually consists of 3-week ECG-monitored exercise sessions and a long-term exercise plan that progresses over time in frequency, duration, and intensity over 8-12 weeks.
Resistance training is typically given with the aim of increasing strength, skeletal muscle endurance and ultimately functional capacity. (28) Because of the frequency with which oncological treatments cause musculoskeletal disorders, a physical therapist (PT) evaluates function before individuals enter the program. Physiotherapist; evaluates lymphedema in terms of range of motion and balance disorders. If there is adequate clearance or severe deconduction occurs, one-on-one physical therapy is provided. Alternatively, if physical limitations exist but participants are able to initiate the program, the physical therapist instructs the exercise physiologist about necessary changes. With the help of a cardiologist specializing in onco-cardiology, participants participating in oncology rehabilitation undergo cardiopulmonary exercise tolerance testing (ETT).
The utility and safety of the ETT test is based on previous review of cardiovascular fitness testing in the cancer setting. (29)
1) De Moor JS, Mariotto AB, Parry C, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epi Bio Markers Prev. 2013;22(4):561–670.
2)Hooning MJ, Botma A, Aleman BM. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst. 2007;99(5):365–375.
3)van den Belt-Dusebout AW, Nuver J, de Wit R, et al. Long-term risk of cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol. 2006;24(3):467–475.
4) Holmes MD, Chen WY, Faskanich D, Kroenke C, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA. 2005;293:2479–2486
5) Meyerhardt JA, Giovannucci EL, Holmes MD, et al. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol. 2006;24:3527–3534.
6) Meyerhardt JA, Heseltine D, Niedzwiecki D, et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol. 2006;24:3535–3541.
7) Lakoski SG, Eves ND, Douglas PS, Jones LW. Exercise rehabilitation in patients with cancer. Nat Rev Clin Oncol. 2012;9(5):288–296.
8) Toth MJ, Miller MS, Callahan DM, et al. Molecular mechanisms underlying skeletal muscle weakness in human cancer: reduced myosin-actin cross-bridge formation and kinetics. J Appl Physiol. 2013;114(7):858–868.
9) Leidenius M, Leppänen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185(2):127–130.
10) DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500–515.
11) Smoot B, Wong J, Cooper B, Wanek L, Topp K, Byl N, et al. Upper extremity impairments in women with or without lymphedema following breast cancer treatment. J Cancer Surviv. 2010;4(2):167–178.
12) Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR. Cancer-related fatigue: the scale of the problem. Oncologist. 2007;12 (Suppl 1):4–10.
13) Meeske K, Smith AW, Alfano CM, McGregor BA, McTiernan A, Baumgartner KB, et al. Fatigue in breast cancer survivors two to five years post diagnosis: a HEAL Study report. Qual Life Res. 2007;16(6):947–960.
14) National Comprehensive Cancer Network. [Accessed February 6, 2014];Cancer-Related Fatigue (Version 1.2014)
15) Vance V, Mourtzakis M, McCargar L, Hanning R. Weight gain in breast cancer survivors: prevalence, pattern and health consequences. Obes Rev. 2010;12(4):282–294.
16) Meyerhardt JA, Niedzwiecki D, Hollis D, Saltz LB, Mayer RJ, Nelson H, et al. Impact of body mass index and weight change after treatment on cancer recurrence and survival in patients with stage III colon cancer: findings from Cancer and Leukemia Group B 89803. J Clin Oncol. 2008;26(25):4109–4115.
17) Gould DW, Lahart I, Carmichael AR, Koutedakis Y, Metsios GS. Cancer cachexia prevention via physical exercise: Molecular mechanisms. J Cachexia Sarcopenia Muscle. 2013;4(2):111–124.
18) Zabora J, Brintzenhofer K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psychooncology. 2001;10(1):19–28.
19) Chambers SK, Lynch BM, Aitken J, Baade P. Relationship over time between psychological distress and physical activity in colorectal cancer survivors. J Clin Oncol. 2009;27:1600–1606.
20) Schmitz KH, Holtzman J, Courneya KS, Mâsse LC, Duval S, Kane R. Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2005;14(7):1588–1595.
21)Quist M, Rørth M, Langer S, Jones LW, Laursen JH, Pappot H, et al. Safety and feasibility of a combined exercise intervention for inoperable lung cancer patients undergoing chemotherapy: a pilot study. Lung Cancer. 2012;75(2):203–208.
22) Persoon S, Kersten MJ, van der Weiden K, Buffart LM, Nollet F, Brug J, et al. Effects of exercise in patients treated with stem cell transplantation for a hematologic malignancy: a systematic review and meta-analysis. Cancer Treat Rev. 2013;39(6):682–690.
23) McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, et al. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database Syst Rev. 2010;16(6):1–48.
24) Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361(7):664–73.
25) Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012;14:11:1–84.
26) McClellan R. Exercise programs for patients with cancer improve physical functioning and quality of life. J Physiother. 2013;59(1):57. doi: 10.1016/S1836-9553(13)70150-4.
27) Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published studies. Med Oncol. 2011;28(3):753–765.
28) Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(5):572–584.
29) Jones LW, Eves ND, Peppercorn J. Pre-exercise screening and prescription guidelines for cancer patients. Lancet Oncol. 2010;11(10):914–916.