1. Exercise and Cancer Outcomes Assoc Prof Sandi Hayes QUT, IHBI, School of Public Health

2. CRICOS No. 00213J

3. Reduced Functional status Gastro- intestinal side effects depression neuropathy fatigue depression arthralgia sleeping difficulties poor body image changes in BC Quality and quantity of survival Survivorship concerns

4. Function, quality of life and survival Fatigue depression Function al status CIPNArthralgias Bone outcomes CV late effects Survivorship concerns: common, do not sit in isolation and persist Schmitz et al; Cancer, 2012, 118(8):S2217-2225 (n=160) Post-diagnosis 6m12m18m6y 0 symptoms60 (37.5)80 (50.0)92 (57.5)68 (42.5) 1 symptom43 (26.9)38 (23.8)28 (17.5)41 (25.6) 2 symptoms26 (16.3)22 (13.8)21 (13.1)27 (16.9) 3+ symptoms31 (19.4)20 (12.5)19 (12.0)24 (15.0)

5. No cancer (%) < 5 year cancer survivor (%) 5+ year cancer survivor (%) A: Any physical restriction1331 B: Any limitation in physical performance 215354 Survivorship concerns: associated with cancer and its treatment Ness et al, AEP, 2006, 16:197

6. Limitations in physical performance and participation restrictions: Impacts all aspects of quality of life Associated with increased health care costs May influence survival Individual Impact Public health Impact So what?

7. Concerns following cancer

8. improves the function of all of our physiological systems being physically active = –Reduces risk of specific cancers by up to 60% –Reduces risk of heart disease and hypertension by 40% –Reduces risk of stroke by 27% –Reduces risk of type II diabetes by 58% –Is twice as effective in treating type II diabetes than insulin –Decreases depression as effectively as prozac or behavioural therapy Physical inactivity = greater risk of dying than smoking, obesity, hypertension, high cholesterol Relevance of exercise?

9. Exercise and cancer outcomes Preservation or improvements: Reductions: Muscle mass, strength, power Cardiorespiratory fitness Physical function Physical activity levels Range of motion Immune function Chemotherapy completion rates Body image, self esteem and mood Number of symptoms and side- effects reported, such as nausea, fatigue and pain Intensity of symptoms reported Duration of hospitalisation Psychological and emotional stress Depression and anxiety Hayes S, et al. (2009). J Sci Med Sport;12:428-34 ; Schmitz KH, et al. (2005). Cancer Epi & Biomarkers ;14.1588-95.

10. Cardiovascular disease Osteoporosis Diabetes Hypertension Other cancers Improves cancer survival: 4-18% Exercise and survival following cancer

11. Exercise prescription guidelines

12. Feasibility and clinical concerns Participation in exercise post-diagnosis is feasible Clinical concerns: –Immunosuppressive effect of exercise –Potential for exacerbating treatment- related side effects such as fatigue, lymphoedema, nausea, pain –Reduced exercise tolerance in cancer survivors Exercise is considered to be safe Adverse effects have been rare and mild

13. State of play Majority enter cancer diagnosis insufficiently active Majority stop exercising or experience declines in physical activity levels during treatment Majority never regain pre-cancer physical activity levels Majority enter cancer diagnosis insufficiently active Majority stop exercising or experience declines in physical activity levels during treatment Majority never regain pre-cancer physical activity levels Cancer diagnosis

14. Limits to our knowledge Evidence heavily derived from studying women with breast cancer Small samples with response bias –Representativeness? –Conservative estimate of effect Lack of understanding of mechanisms –Focus on specific outcomes in isolation Cost-effectiveness Survival

15. Exercise and Gynaecological Cancer Significant scope for advancing knowledge Name: ECHO Trial Design: a phase III, RCT evaluating the effects of an exercise intervention during chemotherapy for ovarian cancer Outcomes: physical wellbeing, chemotherapy-related side effects and adherence, physical function, QoL, progression-free survival, health resource use. Team: Hayes, Friedlander, Obermair, Mileshkin, Janda, Gordon, Barnes, Beesley, Sommeijer, Martyn App#: 1063509

16. Greatest challenge in exercise intervention trials is recruitment: Need for clinician support