The role of exercise during & after treatment for colorectal cancer

Outline of talk What is the rationale behind exercise programmes after colorectal cancer diagnosis What is the evidence that exercise is beneficial What are the current guidelines with respect to exercise prescription for this population What are the contra-indications? Are there any programmes currently out there?

Males Colorectal (415) (572) (783) (1048) Lung (127) (121) (118) (116) Prostate (835) (1264) (1771) (2306) Other (1401) (1759) (2178) (2684) All (2777) (3717) (4850) (6153) Females Colorectal (368) (451) (561) (697) Lung (81) (120) (179) (261) Breast (1803) (2500) (3406) (4598) Other (1635) (1999) (2434) (2983) All (3887) (5071) (6579) (8538) Projections of Cancer Prevalence in the UK Maddams et al BJC 2012

The problem…. 4 million people living cancer by 2030 (Macmillan) Chronic or late appearing side effects: –Fatigue –Weight changes –Limited range of movement –Cardiotoxicity –Hernia –Anxiety –Depression

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.

Health behaviours in older cancer survivors in the English Longitudinal Study of Ageing Grimmet et al (2009) EJC Fewer cancer survivors reported being moderately or vigorously active on more than one day per week compared to those with no history of cancer (51% versus 59%). The difference was significant after adjusting for age and sex (p <.05) and remained after additional adjustment for education and arthritis status (OR 0.82, CI 0.70–0.96, p <.05).

Cancer Rehabilitation: The key ‘drivers’ Guidance on Cancer Services: Improving Supportive and Palliative Care (NICE 2004) Cancer Reform Strategy (DH 2007) 2 million reasons (Macmillan 2008) National Cancer Survivorship Initiative Vision Document (2010) Cancer Rehabilitation Pathways (NCAT 2010) Improving Outcomes: a strategy for cancer (DH 2011)

NCSI Vision for future Survivorship Care (Jan 2010) Assessment, information provision & care planning Support for self-management Tailored support for potential consequences of treatment or further disease Measuring outcomes and experience This is a shift from a predominant focus on cancer as an acute illness treated in the acute sector to a greater focus on recovery, health, well- being and return to work after cancer treatment. This shift will enable people affected by cancer to be prepared for the long term– for living with and beyond cancer

Rationale for exercise based cancer rehabilitation: Reduces functional loss (CV and muscular) May reduce chronic and late appearing side effects (e.g. fatigue, depression, weight gain, osteoporosis, lymphoedema) Reduces long term reliance on NHS Reduces the risk of colorectal cancer recurrence and all cause mortality No need to “reinvent the wheel” – use rehab programmes with other chronic conditions – CHD, diabetes, COPD as a template

Systematic review evidence: PA during adjuvant treatment OutcomeEvidenceGrade 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

Systematic review evidence: PA after adjuvant treatment OutcomeEvidenceGrade 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 EfEf

Other benefits of exercise... Bone healthB Range of movementB LymphoedemaB Positive moodB Chemo-brainC CardiotoxicityC Immune system / inflammationC Bone Health B Range of Movement B Lymphoedema B Positive Mood B Insulin regulation B Cardiotoxicity C Immune system C Outcome Grade

Cancer diagnosis can signal an enhanced motivation to change lifestyle behaviours – become more receptive to health behaviour change interventions. “What can I do to stop the cancer coming back?”

active living exercise sport dance play recreation activities

Guidelines Cancer survivors with curative intent should aim to do the standard recommended amount of physical activity required to get the health benefits

How often each week? How long each time? What type of exercise? What intensity must it be?

All healthy adults All healthy adults aged 18–65 years should aim to take part in at least 150 minutes per week of moderate-intensity aerobic activity, or at least 75 minutes of vigorous-intensity aerobic activity, or equivalent combinations of moderate- and vigorous-intensity aerobic activities. All healthy adults should also perform muscle- strengthening activities on two or more days of the week.

Beginners Beginners should steadily work towards meeting the physical activity levels recommended for ‘all healthy adults.’ Even small increases in activity will bring some health benefits in the early stages and it is important to set achievable goals that provide success, build confidence and increase motivation. For example, a beginner might be asked to walk an extra 10 minutes every other day for several weeks in order to slowly reach the recommended levels of activity for all healthy adults. It is also critical that beginners find activities they enjoy and gain support in becoming more active from family and friends.

Conditioned individuals Conditioned individuals who have met the physical activity levels recommended for ‘all healthy adults’ for at least six months may obtain additional health benefits by engaging in 300 minutes or more per week of moderate- intensity aerobic activity, or 150 minutes or more per week of vigorous-intensity aerobic activity, or equivalent combinations of moderate- and vigorous-intensity aerobic activities.

Putting evidence into practice

Putting evidence into practice... Twelve year process 2000: Pilot study with 23 women 2003: CRUK Glasgow Study - randomised control trial 2007: BMJ paper on Glasgow Study 2008: Masters in exercise and cancer survivorship 2009 Active ABC started in Glasgow 2010 Macmillan funded 5 year follow up 2010 NVQ qualification for fitness instructors approved 2011 Move More campaign and CANmove programme 2012 J Cancer Survivorship paper on 5 year follow up

Results of the Glasgow Study 1054 women were informed of study – main reason for not taking part was travel (425 women) 203 women were 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.

Health costs/benefits of exercise intervention  NHS costs for intervention was £400 per women  Safe and effective intervention  Provided short term and long term physical, functional and psychological gain  Participants spent less nights in hospital and visits to GP – an economic saving to NHS of £1507 per person  Intervention achieved conventional standards of cost-effectiveness

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 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.

Train fitness instructors to a level that ensures all participants are provided with individualised, safe standard and effective programmes Ensure classes are delivered in areas easily accessible to cancer survivors from more deprived communities Link with MDT in all participating hospitals to ensure all eligible patients are aware of the programme Produce appropriate screening materials to ensure a safe and appropriate referral process Encourage participants to move to being independent exercisers – other main stream and long term condition programmes

CanRehab Level 4 training programme Supported by CRUK, Macmillan and Breast Cancer Care 4 days lectures and workshops Written exam Practical exam Case study Glasgow, London, Birmingham, Wales, Dundee and Manchester.

Referral Pathway Diagnosis During treatment After treatment Follow up clinic

GOALS OF EXERCISE PROGRAMME Improve functional status prior to treatment or prevent/attenuate functional decline during treatment Maintain muscle mass (lean body mass) and strength  Maintain / optimise cardiorespiratory function  Maintain joint range of motion/ muscle/connective tissue length Improve functional status prior to treatment or prevent/attenuate functional decline during treatment Maintain muscle mass (lean body mass) and strength  Maintain / optimise cardiorespiratory function  Maintain joint range of motion/ muscle/connective tissue length Address treatment-specific impairments during and following treatment: Pain Fatigue/ anaemia Muscular weakness (specific) Deficits in joint range of motion Poor balance or coordination Lymphoedema/ oedema/ swelling Peripheral neuropathy Bone: oesteopenia, osteoporosis Steroid-induced myopathy Optimize general health in the Recovery period following cancer treatment: Improve body composition: reduce fat mass, increase lean body mass Improve muscular endurance Improve muscular strength Improve cardiorespiratory fitness Improve flexibility Improve physical functioning

During Cancer Treatment exercise to tolerance. depends on fitness and treatment toxicities. 3-5/wk, minutes, RPE walking will most likely meet this prescription. progression is not always linear. © CanRehab

Mode:  Most exercises will involve large muscle groups e.g. walking and cycling because they are safe and tolerable for patients. Exercises will be modified based on acute or chronic treatment effects from surgery, chemotherapy, and/or radiotherapy. Frequency:  At least 3-5 times/wk, but daily exercise may be preferable for deconditioned patients who do lighter intensity and shorter duration exercises. Intensity:  Moderate, depending on current fitness level and medical treatments. Guidelines recommend 50% to 75% HRreserve, 60% to 80% HRmax, or an RPE of 11 to 14 © CanRehab

Duration:  At least min of continuous exercise; however, deconditioned patients or those experiencing severe side effects of treatment may need to combine short exercise bouts (eg, 3-5 min) with rest intervals. Progression:  Patients should meet frequency and duration goals before they increase exercise intensity. Progression should be excluded those who are experiencing severe side effects of treatment or slower and more gradual for deconditioned patients.

Individualise the programme based on information gathered from referral Consider needs, goals and exercise preferences of the survivor Identify any potential barriers to exercise including long-term treatment and disease-related side effects that may compromise ability to exercise Consider the principles of exercise prescription: overload, adaptation, specificity and reversibility Set prescription variables for components of exercise programme (e.g. frequency, intensity, type & time) Re-evaluate and modify programme to address changes in medical status and physical fitness and functioning Designing an exercise programme for the client

Cancer-specific contraindications for colorectal cancer patient Advisable to avoid intra-abdominal pressures for patients with ostomy. Contact sports (risk of blow) and weight training (risk of hernia) not recommended for patients with an ostomy Individuals with known metastatic disease to the bone will require modifications to their exercise programme concerning intensity, duration, and mode and increased supervision to avoid fractures. Individuals with cardiac conditions (secondary to cancer or not) will require modifications and may require increased supervision for safe exercise Refer back if unusual fatigue, muscle weakness, head, neck or back pain.

3 Levels of care and support

HCP refers patient using CANmove guidelines. Patient completes CANmove programme & referred on to local community facilities Patient attends CANmove Programme* Proposed referral pathway for all cancer patients to access rehabilitation Aim to develop an opt-out electronic system. Aim to develop an information sharing agreement allowing fitness instructors to be part of MDT (NHS) Aim to develop a risk stratification process Patient CANmove consultation * Patient *contacted by ISE Exe consultation: -Home P -Walk P -sign post to other PA venue. Cons ? Pros Opt - out Not hospital based. Large volumes patients can access service. HCP input needed if required. Reduces NHS burden Normalises living with cancer/LTC. Protects patient data. Cost effective Offers an evidenced based service not currently available elsewhere Free Patients can access PA services Promotes self- management Patient *contacted by CRT/SPCS Contra- indications to exercise: -re-refer *

Future Plans... Expand access to classes for all cancers, where possible in 2013, focusing promotion on Prostate, Breast and Colorectal which have the strongest evidence base relating to the positive effects of exercise Expand the programme across Scotland Develop a clearer referral pathway for NHS and relevant charities Deliver more classes to ensure areas of deprivation have equal access. Establish the exit strategy for participants to maintain an active lifestyle. Ultimate goal Opt out - not opt in... Let’s make an exercise based rehabilitation programme a sustainable part of every cancer survivors’ care pathway