“Don’t take it personally, doctor, but it has been a dreadful experience.”
I tell her that far from taking offence, I am sympathetic because in the 15 months since her cancer diagnosis, she has weathered surgery, chemotherapy, and radiation, not to mention hospitalisations and hiccups. This, on top of the psychological suffering and the spillover effect on the whole family that no healthcare system ever fully mitigates.
“What if I have done all this and it returns?”
I squeeze her hand to acknowledge the pulsating fear in the heart of every patient who has sacrificed greatly to see the back of a dreaded diagnosis. From experience, I know what not to say, particularly in the immediate aftermath of a diagnosis. You don’t promise a cure; instead, you highlight good prognostic features and sound therapeutic advances while reassuring patients that you and your team will stand by in the years ahead.
Sometimes I can’t help thinking how tepid this reassurance must sound, until I note the sheer relief of patients who somehow thought that the end of chemotherapy was the end of our relationship.
If cancer is a “journey”, then patients are right to expect instructions along the way rather than being overwhelmed early and cast aside later. But truth be told, oncologists handle treatment well and survivorship poorly. Typically, we provide cursory advice to quit smoking and curb drinking and direct patients to their GP to rehabilitate the rest of their life. If only it were so easy.
But there is a prescription that every cancer patient deserves: a prescription supported by evidence for an action controlled by the individual. That prescription would be for exercise.
Many cancer patients endure the rigours of chemotherapy for small gains at the risk of significant toxicity. There is mounting evidence that when it comes to risk reduction, even moderate exercise can match the benefit of the most promising cancer treatments. Therefore, while exercise does not replace cancer treatment, it is an unquestionably valuable and underutilised companion.
The 2018 Physical Activity Guidelines for Americans recommend 150 minutes of moderate intensity or 75 minutes of vigorous aerobic exercise, spread throughout the week, with additional benefit derived from two days of muscle-strengthening exercises.
The most recent backing for the benefit of exercise comes from a study of nearly 12,000 cancer patients whose self-reported exercise habits were divided into four categories – no exercise, below guidelines, meeting guidelines, and exceeding guidelines.
The study yielded some important takeaways.
First, only 38% of patients were defined as exercisers and across the study population, median time spent doing moderate (worked up a light sweat) and strenuous exercise (increased heart and breathing rate to very high levels) was just 44 and 19 minutes a week, respectively.
This finding did not surprise me; it may be explained from inertia and fatigue combined with poor health literacy. It is not uncommon to find that patients stop exercising during cancer because of a perceived need to conserve energy. But sedentary patients end up gaining weight and losing muscle mass and aerobic capacity, which affects them for years. Indeed, patients are frequently surprised to hear that one of the best ways to manage the side effects of cancer treatment and reduce complications is to continue or adopt a habitual exercise.
The study’s second finding was truly striking. Meeting versus not meeting the exercise guidelines was associated with a 25% reduced risk of mortality. Compared with no exercise, every level of exercise (from below guidelines to exceeding guidelines) was beneficial. Exercisers lived an extra five years with the difference in survival appearing within five years and persisting for at least 20 years after diagnosis. Given the modest survival benefit associated with a range of treatments, frankly it would be every oncologist’s dream to prescribe something with the potential to deliver such impressive results.
These findings underline the oft-repeated mantra that any exercise is better than no exercise. In addition to standard treatments, exercise really is one of the best daily “pills” cancer patients can take to improve their life expectancy. Indeed, if exercise could be marketed as a pill, it would be an outright blockbuster.
Some limitations of the study were that exercise was assessed only once over a follow-up period of 11 years and exercise changes over this period were not captured. It is possible that some people who had been exercising all their life still developed cancer and survivors who increased their exercise experienced greater benefit. But incomplete knowledge need not stop us from acting on what we know and advocating for a more holistic approach to cancer that includes exercise, not as an optional pillar, but an essential one.
Exercise influences the body in many ways through affecting inflammation, immunity, cellular stress and insulin regulation, each of which can influence cancer progression. Future studies using wearable devices and artificial intelligence to interrogate data might help shed light on new ways to incorporate exercise into treatment regimens and elicit behaviour change.
So where to from here?
Just as they urge compliance with drug treatment, oncologists as trusted providers must encourage patients to embrace exercise. Pragmatically, it will be hard to find time to discuss the ever-expanding items on a doctor’s list, which is why assistance from exercise physiologists and other experts is indicated as a matter of routine.
In the same way as they receive chemotherapy based on individual parameters, patients should receive a tailored exercise prescription at the start of their treatment.
An exercise prescription is the start; infrastructure is crucial. Fixing the gap between recommendation and implementation requires patients to have affordable access to community facilities. When I think of all my deconditioned patients and their lost productivity, not to mention the related despondency, I can’t help thinking that subsidising the cost of exercise during cancer treatment might well reduce the ultimate cost to society.
However, patients should note that exercise does not have to be expensive: a brisk walk, a gentle jog or a bike ride are easily accessible to most people.
All too often in cancer medicine, it is easy to be seduced by the next new thing, only to realise that the hype outlived the hope. Fortunately, when it comes to exercise the good news keeps getting better. This is the prescription that every cancer patient deserves.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
