Transcript Slide 1

Exercise and cancer
Professor Robert Thomas
Consultant Oncologist
Addenbrooke’s, Bedford Cambridge University NHS Trusts
Cranfield University
The cancer problem
• 1 in 3 population will get cancer
• 1 in 4 die
• Most common cause of death in young
women
UK Ca breast
41,700 new women annually
Outcomes improving
2 million cancer survivors in the UK
Common symptoms and risk
amoung cancer survivors
 Fatigue and tiredness
 Mood, anxiety
 Depression
 Brain power and intellect
 Poor appetite
 Constipation
 Blood clots (thrombosis)
 Quality of life
 Hot flushes
 Bone density
 Poor sleep pattern
 Secondary cancers
 Bowel adhesions
 Weight gain
 Indigestion
Sore hands
Self help and lifestyle after Cancer
“Teachable moment”
What is the evidence?
Lifestyle and cancer news - Cancernet.co.uk
Exercise after Cancer
Reduce risks and side effects of treatment
Slow the growth of an established cancer
Prevent relapse after initial therapy
Improve overall chance of cure
Reduce side effects and
risks of treatments
Cancer Related Fatigue
• 28 RCT and 2 meta analysis reduces the severity of fatigue
• Supervised aerobic exercise programmes more effective.
• Adverse events during exercise were extremely low
Cramp and Daniel, 2008), Velthuis et al., 2009
Prostate Cancer
Patients on hormones
Progressive resistance and aerobic training 20 wk
• Improved muscle strength,
• Functional performance
• Balance in older men
• Mood, depression
• Metabolic syndrome (Adult Treatment Panel III criteria)
o Abdominal obesity,
High triglyceride, Hyperglycaemia
Daniel et al. Medicine & Science in Sports: Vol 38; 12 - pp 2045-52
Segal et al JCO, Vol 27, No 3 , 2009: pp. 344-351
.;
Prostate Radiotherapy Late
Toxicity and Lifestyle Study
Robert Thomas
Mea Holme
Madeleine Williams
Patricia Bellamy
Christine Steel
Jervoise Andreyev
Bedford, Addenbrookes, Cranfield
Oxford University
Bedford Hospital
Cranfield University
MacMillan Cancer Relief
Royal Marsden Hospital
Purpose
Do self help lifestyle factors correlate
with late toxicity after radiotherapy?
• Exercise
• Smoking
• BMI
• Age
Methods
470 live men sourced on the Lantis RXT data base
Referred from Bedford Hospital over 10 years
440 completed the study questionnaire (94%)
Approached in Clinic or via post +/- telephone calls
Toxicity
• Vaizey rectal toxicity score
• NCI common toxicity score
o Rectal bleeding
o Erectile function
o Urinary incontinence
Lifestyle
• Smoking habits
• BMI, age
• General practice physical activity questionnaire
Results
8% (35) smokers
1% were underweight (BMI <18.5)
36% normal weight (18.5-25),
38% over weight (25-29.9)
25% obese (>25%).
Results
58% inactive,
27% moderately inactive/active,
11% active
4% exercising more than 3 hrs a week
Results
GPPAQ
Smoker
(during
Rxt)
Smoker
(now)
Age
(time of
survey)
BMI

NS
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class
Rectal
toxicity
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
Incontinence



NS
NS
Erectile
function

NS
NS
NS
NS
Slow the growth of an established cancer
Lifestyle and cancer-mechanisms
Initial DNA
damage
Continuing DNA
damage,
Hormonal
environment
Immunity
Proliferation, de-differentiation, adhesion,
apoptosis, angiogenesis, invasion, metastasis
Lifestyle & tumour progression
93 men with indolent prostate cancer
Exercise (>20 mins brisk walking 6 days a week)
Yoga,
Vegan diet
High soy and antioxidant rich intake
Ornish, 2005 #92
PSA at 1 year
Exercise (>20 mins brisk walking 6 days a wk)
Yoga, Vegan diet
High soy intake
Control - increase by 6%
10% difference significant at P>0.01
PSA
Intervention - decrease by 4%
Trial entry
At one year
Ornish D, et al The Journal of Urology, 2005. 174: p. 1065-1070.
Cellular growth
Prostate cell lines
• Intervention - 70% growth reduction
• Control group – 6% growth reduction
• 64% difference highly significant at P>0.001
• Those with largest PSA reduction had highest reduction
Ornish D, et al The Journal of Urology, 2005. 174: p. 1065-1070.
Lifestyle / salicylate study
A randomised double blind phase II study of lifestyle
counselling and salicylate +/- dietary supplements in
patients with progressive prostate cancer.
Robert Thomas, Roger Oakes, Dr Simon Russell, Ms Madeleine Williams.
Thomas, et al. NCRN Conference proceeding 2008
Journal of Food and Science March 2009
3. Lifestyle / salicylate study
110 men with progressive
prostate cancer defined by 3
consecutive rises in PSA >20% over
the preceding 6 months were
randomised (50:50)
50
56 men
Lifestyle counselling and Sodium
Salicylate
50
54 men
Lifestyle counselling, sodium salicylate
vitamin C, copper and manganese
gluconates (CV247).
Prevent relapse after initial therapy
Improve overall chance of cure
Nurse’s Health Study (Breast cancer)
5204 registered nurses,
Breast cancer 1976 -2000
860 deaths (553 breast cancer)
BMI at diagnosis
= Overall survival
= Breast cancer relapse (nonsmokers)
Weight gain more than 0.5kg/m2 at 1yr (greatest if >2kg/m2)
= Overall survival
= Breast cancer specific survival
Kroenke CH, et al JCO 2005. 23(7): p. 1370-1378.
Fat intake after breast cancer
Lifestyle intervention study
2,437 postmenopausal women with early breast cancer
Randomised to nutritional and lifestyle counselling, or not.
Eight bi-weekly individual exercise and lifestyle counselling sessions for
median 60 months.
Results; In the Intervention group:
- Dietary fat intake reduction was significantly greater.
- Weight was lower
- Relapse rate was significantly lower (p=0.03)
- Overall survival greater.
Chlebowski RT, et al., JCO 2005(10): p. 3s
Exercise & Bowel cancer
relapse
Australian cohort study, 526 patients, colorectal cancer 1990-4,.
Exercisers def: recreational sport 1-2 week sweat and breathless
Results at 5 yrs
- 57% alive (non-exercisers)
- 71% alive (exercisers)
- statistically significant 14% (p<0.05)
- greatest benefit in stage III
Giles GG, IARC Sci Publ, 2002. 156: p. 69-70.
USA cohort study, 816, colon cancer, stage III. Exercise questionnaire, 18 or
more MET-hours of activity a week (6 hours walking at a mod pace)
- 35% difference in relapse rate between in the those in the
upper to lower quartiles of activity
- overall survival significantly different
Meyerhardt JA, et al., Proc Am Soc Clin Oncol, 2005. 24: 3534
Mechanisms - Exercise
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Lower IGF-1 and higher IGFBP-3 levels
Serum from exercisers encourage P53 activity
Prostaglandin and COX-2 inhibition
Reduce weight – and help hormonal mileau
Increases the bowel transit time
Reduce cholesterol and lipids
Exercise and breast
cancer relapse
• 933 BC survivors PE> 2.5 hrs/week 67% reduction in RR (Irwin M et
al 2007 JCO)
• 4482 BC survivors PE > 2.8 hrs/wk 35-49% reduction in RR (Holick C
et al Cancer Epidemiological Biomarkers Prev 2008)
• Nurses Health study 2987 BC survivors 3-5 hrs/wk better survival and
RR (Holmes et al JAMA 2005)
• 1490 BC survivors 30 mins 6 days a wk (+ >5 fruit/veg a day) greater
survival (Pierce JP Clin Onc)
Exercise and prostate
cancer relapse rates
2,686 men in the Health Professionals follow up study
986-2008 diagnosed with localised prostate cancer
554 died 122 (22%) of prostate cancer.
3 or more MET-hours per week reduced the risk of death by 35% (overall survival)
>90mins brisk walking had a 51% reduction in the risk of death
6 or more MET- hours (5 or more hours of vigorous exercise / week e.g. Jogging)
had a 56% reduction in the specifical prostate cancer risk of dying.
(Kenfield et al 2010)
Cancer Survivorship Exercise
Expert Advisory Group
Chair: Robert Thomas
Manager: Jo Foster
Aims?
Motivate
Educate
Convince
Research
Lobby
Cost effectiveness
Local exercise
programmes
Practical solutions
Hospital
based
programme
Hospital
based
programme
Lifestyle
counselling &
information
Discharge
Community
based
programme
Community
based
programme
Activity for Health Referral Scheme
• 2001 DoH white paper
• Run by PCT who pay for training of instructors
• Referral to one of 5,700 municipal leisure centres
80 referrals
Pilot evaluation
• No adverse events
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44% contacted gyms after initial referral
38% contacted gyms only after prompting
10% changed their minds
82% proceeded to exercise sessions
• 100% who started the programme finished (12wks)
R Thomas, Pei Ding, M Williams. Is the National activity for health referral scheme the practical solution
for exercise rehabilitation after cancer. www.ncri.org.uk/ncriconference/2010abstracts/abstracts/A68.htm
Cancer rehabilitation
National accreditation
Level 4
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Skills active (DoH)
Minimal standards - personal trainers
July 2010 agreed
Course designed April 2011
Evaluation of the cancer exercise
rehabilitation programme
400 Patients post initial therapies
(Breast, colorectal, prostate)
Lifestyle and exercise
advice
Lifestyle and exercise
advice & referral
Primary clinical end points:
Average weekly exercise - The General Practice Physical Activity Questionnaire
Secondary clinical end points:
Qol questionnaire - Psychological Flourishing Scale
Utilisation of health services (laxatives, BP, cholesterol)
Laboratory end points:
Serum IGF levels correlated against exercise levels
Ability of serum from participant to inhibit cancer cell line growth
Cost benefit analysis
More information
Lifestyle and cancer – the facts
Evidence review for the national
survivorship programme
cancernet.co.uk/lifetsyle-published-evidence.htm
Lifestyle and cancer evidence news summary
Sign up:
Cancernet.co.uk
Email:
[email protected]