Cancer Rehabilitation

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Cancer Rehabilitation

• Barbara L Francis
• Navitas Cancer Rehabilitation

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Institute of Medicine Report

• The scope of quality cancer care must be
  broadened beyond what is presently provided to
  one that fosters health prevention and minimizes
  dysfunction or disability from illness.

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Cancer Rehabilitation

• A process to restore mental and/or physical
  abilities lost to injury or disease, in order to
  function in a normal or near-normal way.
• (Definition from National Cancer Institute)

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The Cancer Patient
Cancer Diagnosis
Comorbidities
Cancer Treatment
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Common Side Effects

• Fatigue
• Immune suppression
• Thrombocytopenia
• Anemia
• Leukocytopenia
• Loss of appetite
• Weakness/tiredness
• Neuropathy
• Shortness of breath
• Aching/stiffness in the joints
• Loss of muscle mass and cachexia
• Change in blood pressure
• Change in heart rate
• Insomnia
• Diminished concentration and motivation
• Emotional reactivity

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Integrated Therapies

• Physician
• Physical Therapy
• Occupational Therapy
• Cardiopulmonary Exercise Therapy
• Nutritional Counseling
• Psychological Counseling
• Other Therapies
• Massage
• Acupuncture
• Relaxation Techniques
• Lymphatic Drainage

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Integrated Supportive Care
Recovery and Restorative Therapies
Symptoms Management
Fatigue Immune suppression Thrombocytopenia Anemia
Leukocytopenia Neuropathy Insomnia Emotional
reactivity Loss of appetite High levels of
stress Pain Decreased range of
motion Gastrointestinal issues
Fatigue Muscular Strength Balance Bone
Density Stress Endurance Lymphedema
Nutrition Emotional Wellbeing
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Exercise Research

• Adamsen et. al., Supportive Care in Cancer, Feb.
  2006
• Increases in muscular strength, physical
  performance, physical activity levels
• Reduction in fatigue and pain
• Improvements in physical functioning and role
  functioning

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Exercise and Cancer Related Fatigue

• Van Weert et. al., Oncologist, Feb 2006
• Rehabilitation reduces fatigue
• Change in fatigue was mainly associated with
  change in physical parameters (e.g. muscle force,
  exercise capacity)

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Exercise and Fatigue in Stem Cell Patients

• Carlson et. al., Bone Marrow Transplant, May 2006
• Decreased fatigue
• Increase in muscle power output
• Increase in cardiac stroke volume
• Decrease in heart rate, blood lactate and
  perceived exertion
• Findings immediately after and at 3,6,9 and 12
  month post-program

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Activities of Daily Living Performance in Cancer
Patients Undergoing Treatment

• 30 cancer patients (M F various diagnoses
  surgery and treatment chemo and/or radiation)
• 17 exercise 13 non-exercise
• Evaluated on fatigue, QOL, balance, sit to stand,
  stair climb/descent, treadmill walking, lift and
  carry
• 17 weeks of exercise (combo resistance, aerobic,
  flexibility, balance)
• Low/moderate intensity 2 sessions/week 1
  hour/session
• Results
• significant difference on all study variables
  between exercise and non-exercise (exercisers
  improved non-exercisers declined)
• High adherence rate for exercisers
• Conclusions
• Cancer patients are able to attenuate declines in
  ADL performance, QOL and fatigue and improve in
  most cases (even during treatment)

Anton, et. al., 2006
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Brief Review Exercise and Cancer Research
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Battaglini et al. (2006)
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Exercise and Breast Cancer

• Courneya, et. al., Journal of Clinical Oncology,
  Oct. 2007
• Randomized controlled trial
• 82 usual care subjects
• 82 resistance exercise subjects
• 78 aerobic exercise subjects

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Exercise and Breast Cancer

• Courneya, continued
• Aerobic exercise
• Improved self-esteem (P.015), aerobic fitness
  (P.066), body fat (adjusted P.076)
• Resistance exercise
• Improved self-esteem (P.018), muscular strength
  (P
  completion rate (P.033)
• Changes in QOL, fatigue, depression and anxiety
  were higher in exercise groups but did not reach
  statistical significance.
• No lymphedema or adverse events.

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Exercise As Therapy

• Best before or early into treatment
• Exercise interventions are low to moderate
  intensity (40-70 of predicted maximum heart
  rate)
• Interventions are progressive, dosage is varied
  and individualized (mean frequency is 2X/wk, mean
  duration is 40 min, for 12 to 16 weeks).
• Interventions involve cardiovascular and muscular
  endurance, strengthening, ROM, flexibility and
  static/dynamic balance.
• Balance between anaerobic and aerobic work is
  tilted in the direction of anaerobic activities.

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Exercise as Therapy

• Physical training in patients with chronic heart
  failure enhances the expression of genes encoding
  antioxidative enzymes. PV Ennezat, et.al. J AM
  Coll Cardio 200138 194-8
• Exercise training increases capacity of skeletal
  muscle to buffer increased reactive oxidative
  stress (ROS). Decreased ROS-decreased
  inflammation-decreased skeletal muscle
  catabolism-increased skeletal muscle function

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Exercise as Therapy

• Low intensity exercise training (LIET) during
  doxorubicin treatment protects against
  cardiotoxicity. AJ Chicco, et.al. J Applied
  Physiology 2006100 519-527
• LIET during Dox treatment protects against
  cardiac dysfunction following treatment by
  enhancing antioxidant defenses and inhibiting
  apoptosis

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Exercise as Therapy

• Exercise therapy effect on natural killer cell
  cytotoxic activity in stomach cancer patients
  after curative surgery. Y Na et.al. Arch PMR
  200081 777-779
• Early moderate exercise beneficial effect on
  function of in-vitro NK cells

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Exercise and Stage III Colon Cancer

• Meyerhardt, et. al. Journal of Clinical Oncology,
  2006
• Subjects compared with patients who engaged in
  less than 3 MET hours per week of physical
  activity
• The adjusted hazard rate for disease-free
  survival was 0.51 for 18-26.9 MET-hours per week,
  0.55 for 27 or more MET-hours per week.
• Post diagnosis activity was associated with
  similar improvements in recurrence-free survival
  (P for trend.03) and overall survival for trend
  .01)

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Treatment-Related Side Effects and Exercise
Benefits
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Exercise Therapy Value

• Reduce work of breathing
• Improve pulmonary function
• Normalize arterial blood gases
• Alleviate shortness of breath
• Increase efficiency of energy use
• Correct poor nutrition
• Improve participation in physical functioning and
  activities of daily living
• Restore a positive outlook
• Improve emotional state
• Decrease health-related costs
• May impact lengthen survival

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Cardiovascular Analysis
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9 News Coverage
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Integrated Supportive Care

• Nutritional Counseling
• Helps maintain healthy weight
• Healthy nutrition habits for transition from
  treatment
• Maximize cancer preventive potential of the diet
• Evaluate the risks and benefits of
  nutrition-related supplements
• Massage
• Decrease pain, stress
• Increase sense of well being

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Integrated Supportive Care

• Psychological counseling
• Decrease stress
• Regain a sense of control
• Mitigate family/work issues
• Increase sense of well being
• Acupuncture
• Decrease nausea, pain, stress
• Reiki
• Decrease stress

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Integrated Supportive Care

• Manual Lymphatic Drainage
• Improve function
• Decrease lymphedema
• Decrease pain

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Starting an Exercise Program

• Physician approval
• Finding professional assistance
• One Size Does Not Fit All
• Developing an individualized program
• Starting and progressing slowly
• Exercise Program components
• Cardiovascular
• Strength
• Flexibility
• Relaxation

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Summary

• Safe and feasible to exercise during treatment to
  improve physical functioning and various aspects
  of quality of life
• Moderate exercise improves fatigue, anxiety,
  self-esteem, cardiovascular fitness, muscle
  strength and body composition
• Goal maintain/improve activity level

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Summary

• Rehabilitation
• Full integration of multiple disciplines
  (physical therapy, psychology counseling,
  acupuncture, cardiopulmonary exercise, nutrition,
  occupation therapy, massage, acupuncture,
  lymphatic drainage
• Improve quality of life
• Healing and caring environment

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• To be healthy does not mean to be free
• of disease it means that you can function, do
  what you want to do, and become what you want to
  become.
• Rene Jules Dubos1901 - 1982

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• You must do the things
• you think you cannot do.
• -Eleanor Roosevelt

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Thank YouQuestions?
bfrancis_at_navitasinc.com