Dr Anna Campbell's keynote speech 'The Importance of Staying Active after a Cancer Diagnosis' at the SCPN's 'Be Active Against Cancer' conference, Tuesday 4th February 2014.

1. Physical Activity and Cancer:
Movement Matters!
Dr Anna Campbell
Lecturer in Clinical Exercise Science / Macmillan Physical Activity Advisor
Institute of Sport and Exercise
University of Dundee
a.k.campbell@dundee.ac.uk
Twitter: @canrehab

2. Outine of talk
• Rationale for research into exercise &
cancer survivorship
• Brief review of evidence
• Putting evidence into practice
• Future research and implementation

3. The number of people living with cancer is set
to double by 2030
Source: Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br J Cancer 2012; 107: 1195-1202.

4. Strong evidence base Modest evidence base Limited evidence base
6. Using the relevant evidence to inform programmes and policy
4. Characterising prevalence of and determinants of physical activity
behaviour in cancer survivors
5. Testing interventions to increase physical activity for cancer prevention
and survival
1. Identifying relations between physical activity and cancer risk
2. Identifying relations between physical activity, Tx side effects & survival
Physical Activity and Cancer Research:
Current State of the Science
3. Examining the biologic mechanisms involved in physical activity and
cancer risk
Adapted from Owen N et al. Amer J Prev Med 2011, 41, 189-196.

5. Physical Activity and
Cancer Risk / Recurrence
Physical Activity and Cancer. (2011). Courneya KS and Friedenreich CM (eds).
Recent Results in Cancer Research . Heidelberg:Springer-Verlag

6. Current Level of Evidence on Physical
Activity and Cancer Risk Reduction
Convincing or Probable
Colon
Breast
Endometrial
Insufficient or Null
Rectal *
Pancreatic
Gastric
Bladder
Testicular
Kidney
Hematologic cancers (non-Hodgkin
lymphoma, Hodgkin lymphoma,
leukemia, multiple myeloma)
Weaker evidence
Lung
Prostate
Ovarian * No association
Friedenreich et al. EJC, 2010; 46:2593-2604

7. Physical Activity and Cancer Recurrence
Breast cancer: 30% risk reduction
Systematic review of 9 prospective cohort studies: leisure
time physical activity is associated with a 30% reduced
risk of breast cancer mortality [Patterson, 2010; Ibramhim, 2011]
Colorectal cancer: 50% risk reduction
• Meyerhardt (2006) 6 hours/wk HR = 0.39 compared to no
PA 9.6 years later
• Meyerhardt (2009) 9 hours/wk HR = 0.47 compared to no
PA 8.6 years later
• Meyerhardt ((2006) 6 hours/wk HR = 0.51 compared to no
PA 3.8 years later
• Independent of sex, BMI, age, perfomance status or tx
Prostate cancer:
• 3+ hours vigorous activity per week = Cancer deaths
61% lower (Kenfield et al 2011)

8. What are the potential mechanisms of
the protective effect of PA?
• Insulin / IGF1 and binding proteins
• Sex steroid hormones
• Inflammation
• Adipokines
• Immune system
• Oxidative damage
• Direct effects on tumour cells - angiogenesis

9. What about living with cancer
and treatment side effect?

10. Total Prevalence - now
Total Prevalence - 2030
Diagnosis
&
Treatment
Rehabilitati
on
Early
Monitoring
Later
Monitoring
Progressiv
e Illness
End of Life
Care
(Year 1
Deaths)

11. The problem…
• Commonest problems were:
– Crouching / kneeling
– Standing for 2 hours
– Walking ¼ mile
– Lifting / carrying a load (10lb)
– Standing up out of a chair
These are all basis
daily activities needed for
– housework
– shopping
– childcare etc.
53%
Ness et al, 2006
21%

12. The problem….
• 4 million people living cancer by 2030 (Macmillan)
• Chronic or late appearing side effects:
– Fatigue
– Weight changes
– Osteoporosis
– Cardiotoxicity
– Lymphoedema
– Anxiety
– Depression
– Cognitive dysfunction
– Limited range of movement
– Lack of confidence

13. Systematic review evidence:
PA DURING adjuvant treatment
Outcome Evidence Grade
Physical
Function
Significant increase in C/V fitness
similar modest increases in muscular
strength [ES 0.33) ; 17RCTs]
A
Fatigue No difference in fatigue between
exercise and control groups [ES 0.18;
15RCTs ]
A
Well being Small improvements in anxiety [ES 0.21;
6RCT] self esteem [ES 0.25; 3RCT] No effect
on QoL [10 RCT] or depression [6RCTs]
A
Body
composition
Slight increase in lean body tissue,
significant reductions in body fat [ES 0.25;
7RCTs]
A
Effect sizes: 0.2 = small; 0.5 = moderate; 0.8 = large

14. Systematic review evidence:
PA AFTER adjuvant treatment
Outcome Evidence Grade
Physical
Function
Significant increase in C/V fitness [ES
0.32) ; 14RCTs] large increases in muscular
strength [ES 0.90) ; 7RCTs]
A
Fatigue Significant lowering of fatigue [ES 0.54;
14RCTs ]
A
Well being Significant improvements in QoL [ES 0.29;
16RCT] anxiety [ES 0.43; 7RCT] and
depression [ED 0.30; 10RCTs]
A
Body
composition
Significant small reductions in body fat
[ES 0.18; 15RCTs] and increases in muscle
mass [ES 0.13; 5RCTs]
A
Bone Health Some encouraging findings on bone health density
were reported but overall results from 8 trial of
various designs were inconsistent
B

15. Recent reviews
15
Evidence-based physical activity
guidelines for cancer survivors:
Current guidelines, knowledge gaps
and future research directions
L.M. Buffart, D.A. Galvão, J. Brug,
M.J.M. Chinapaw, R.U. Newton
Cancer Treatment Reviews (2014)
40(2):327-40.

16. Reviews side effects:
Exercise intervention
Bone Health (Winters-Stone et al, 2012)
Lymphoedema (Cormie et al 2013)
Depression (Craft et al, 2011)
Biomarkers (Ballard Barbash, 2012)
Cardiotoxicity Scott et al (20130
Quality of life (Ferrer et al,2010)

17. Physical activity interventions
during palliative care
Systematic review of 6 small studies [Lowe, 2009]:
Findings included:
– home based seated exercises prevented decline in QoL in
RCT [Headly, 2003]
– Supervised group exercise for 6 weeks (uncontrolled trial)
[Oldervoll, 2006] improved:
• fitness,
• functional ability,
• emotional well being
• Fatigue
• dyspnea
• anorexia
“Patient preference is important, PA may be
recommended to maintain independence and
wellbeing towards end of life.”

18. Two new studies by Jones et al
• “too sick not to exercise”
– 6 week home based exercise programme
post surgery
– Nintendo wii fit plus
– Improvements: less tired, more confident,
better functional activities and balance,
more steps per day
• Cancer Nursing, Vol 36 (3) 175 (2013)

19. Results of the Glasgow Study
(2007)
• 203 women with breast cance recruited into study in one year (age
38-75)
• 177 women completed the study
• After 12 weeks: those in exercise programme improved significantly
more than the usual care group in:
– Walking faster and more weekly activities
– Shoulder mobility
– Breast cancer specific quality of life
– Positive mood
• 6 months later, those in exercise group still benefited more in terms
of improved
– Overall quality of life,
– Physical functioning,
– Positive mood,
– Less fatigue and depressed.
• Cost benefit analysis
• Behaviour change model base to intervention

20. Quotes from focus groups:
Emslie et al , Health Education Research 2006
• Perceived benefits of the exercise intervention
You felt better after it.. lifted. I just felt generally that my
health had improved in that hour. Aye, I think I was on a high
possibly! (Respondent 3, group 3, intervention arm)
I might have had to crawl down (to the class) but when I came out
after it was over I felt totally different. I had so much more
energy. (Respondent 1, group 6, intervention arm)
• The importance of the group context of the exercise
intervention
It was a wee kind of light for me at the end of a big long tunnel.
And I just think having contact with other women.. that was what
really appealed to me (Respondent 4, group 1, intervention arm) I
really looked forward to it..you were meeting people that were
the same as yourself. And you could get on with your exercise and
have a laugh at the same time (Respondent 1, group 6,
intervention arm)

21. 5 year follow up
• Of the 203 women in the original study, 114 attended the 18
months follow up and 87 at 5 years.
• Women in the original exercise group still reported
significantly more leisure time physical activity (2 and a half
hours more) and a more positive mood than women in the
original control group.
• Those engaging in sufficient physical activity recorded a larger
decrease in depression levels at all follow-up points.
Mutrie, N., Campbell, A., Barry, S., Hefferon, K., Mcconnachie, A., Ritchie, D. & Tovey,
S. (2012) Five-year follow-up of participants in a randomised controlled trial showing
benefits from exercise for breast cancer survivors during adjuvant treatment. Are there
lasting effects? Journal of Cancer Survivorship Volume 6, Issue 4, pp. 420 - 430

22. Notable differences between original
intervention and control group
5 years later
Intervention Control
More aware of the importance of
physical activity to health and well
being
Understood importance – not to
same extent
More knowledgeable how to exercise
safely
Felt lost as to how to start
exercising safely
More self assured in engagement in
different types of physical activity
(weights, classes)
More likely to be a ‘contemplative’
stage of change
More likely to be gym goers More likely to be walkers
Integrated exercise into lifestyle
Hefferon, K., Murphy, H., Macleod, J., Mutrie, N., Campbell A. (2013)
Understanding Barriers to exercise implementation 5-years post Breast cancer
diagnosis: A large-scale qualitative study. Health Education Research

23. Future research on physical
activity and cancer
• Cancers other than breast, prostate and
colorectal
• Dose (FITT) required for benefits
• Mechanisms of protection
• Determinants and predictors of behaviour
change
• Chronic and late appearing side effects
• Implementation studies
23

25. Integrating evidence based care
Physical Activity Care Pathway

26. Royal Bournemouth and Christchurch Hospitals
CNS assess
patient
needs and
complete
formal
referral into
leisure
centre.
Exercise
professionals
trained in
motivational
interviewing
lead
behaviour
change
intervention
.
3 week
supportive
phone call
6 and 12
week face
to face
review
6 month
follow up
phone call.
Specialised
exercise
referral
classes (wet &
dry), gym
work,
swimming,
Nordic
walking,
dance classes,
ladies
swimming
sessions,
dragon boat
racing and
more.
Clinical
Nurse
Specialists
identify
cancer
patients at
end of
treatment.

27. Cancer and Physical Activity
Standard Evaluation
Framework
•Consistent approach to collection of data
•Learn from existing practice
•Collect evidence to present to partners

28. Evidence to Practice:
Move More Programmes

29. The Move More Dundee
Programme
• Anyone who has been diagnosed with cancer and still under
clinical care
• Exercise champion or any of MDT – 5 min brief intervention
training
• Approved referral process
• Referred to Move More manager at ISE
• Phone call
– Exercise consultation
– Home based programme
– Gym programme
– Group exercise
– Water based programme
– Hospice programme
– Walking
– Chi gung
• Classes led by Qualified Cancer Exercise Fitness instructors

30. Move More Dundee
HCP refers patient
(Move More Dundee
information & Referral
Form)
Patient contacted by telephone by Move More team at ISE
Patient attends Move More Programme
at ISE for exercise consultation
Patient given:
• advice only
• home programme
• other PA (e.g. walking group)
or signposted to:
• other local PA programme
• Macmillan day care.
• Maggies.
Move More participant is provided with an
exit consultation into independent
physical activity programme.
Patient has a telephone consultation
with the Move More team.
Patient joins Move More Programme
(gym-based, group exercise, other ISE
classes & PA)

31. 3 Levels of care and support

33. What can you do?

34. BENEFITS OF PHYSICAL ACTIVITY PROGRAMME
Improve
functional status
prior to
treatment or
prevent/attenuate
functional decline
during treatment
Address treatment-
specific impairments
during and following
treatment: Optimize general
health in the
recovery period
following cancer
treatment:

35. Activity Recommendations
Exercise can be safely performed during and after cancer
treatment, if individual limitations are considered.
All cancer survivors, including those with existing disease
or who are undergoing difficult treatments, should be
encouraged, as a minimum, to avoid being sedentary.
Unless advised otherwise, follow the physical activity
guidelines provided for the general UK population

36. Guidelines for keeping active!
• How often?: 5 times a week
• How hard?: moderate intensity – it should
feel slightly hard
• What type of activity?: using large
muscle groups e.g. walking, cycling,
swimming, low level aerobics, include
weight bearing exercises
• How long?: at least 30 min continuous or a
number of shorter bouts

37. © CanRehab

39. Exercise
deficiency
increases
cancer risk

40. Strong evidence base Modest evidence base Limited evidence base
6. Using the relevant evidence to inform programmes and policy
4. Characterising prevalence of and determinants of physical activity
behaviour in cancer survivors
5. Testing interventions to increase physical activity for cancer prevention
and survival
1. Identifying relations between physical activity and cancer risk
2. Identifying relations between physical activity, Tx side effects & survival
Physical Activity and Cancer Research:
Current State of the Science
3. Examining the biologic mechanisms involved in physical activity and
cancer risk
Adapted from Owen N et al. Amer J Prev Med 2011, 41, 189-196.