When Genevieve Hollis, MSN, CRNP, AOCN, ANP-BC, read a report recommending patients refrain from vigorous exercise, as well as other physical or psychological stress, in the days leading up to cancer treatments, she had an immediate response. "In general, this study will not at all influence my practice or that of my peers," stated the oncology nurse practitioner at the Abramson Cancer Center and advanced senior lecturer at the School of Nursing of the University of Pennsylvania, Philadelphia. "It was an in vitro study that may not translate to the live individual. The physiological process they addressed is extraordinarily complex, and just one factor will never regulate that practice."
Interpret Findings With Caution
According to Govindasamy Ilangovan, MD, associate professor of internal medicine at Ohio State University and lead author of the study, stress prior to cancer treatments can activate a stress-sensitive protein that triggers a cascade of events that enhances the ability of cancer cells to survive chemotherapy and radiation. Stress before cancer therapy could help deadly cells survive treatment and lead to disease recurrence (ScienceDaily, Sept. 22, 2010).
"One of the known inducers of this factor is exercise," he noted. "I am not against exercise, but the timing is critical. It looks like any intense or prolonged physical activity a couple of days before the start of cancer therapy is highly risky and has potential to reduce the benefits of the treatment."
Wendy Goldberg, MSN, APRN-BC, a nurse practitioner in psychiatry for the Henry Ford Health System in Detroit and a liaison to the Josephine Ford Cancer Center, shared her response to the author's recommendations. "The Ohio State study is in vitro and can only raise, but not answer, questions about in vivo vigorous exercise during cancer therapy," she said. "We have to be cautious about interpreting studies like this because we don't want to risk losing a certain benefit to avoid uncertain harm. For example, exercise is cytoprotective for the heart."
Goldberg noted many chemotherapy drugs may damage the heart muscle in ways that lead to heart failure 5 or 10 years down the line. "To date, there is zero evidence that exercise in the cancer setting is harmful and strong evidence that exercise is beneficial," she pointed out. "A number of cancers have excellent response rates to treatment. We wouldn't want to risk harming the heart in such a way that would limit completion of lifesaving cancer treatment or cause heart failure in an otherwise healthy cancer survivor."
Hollis pointed out there are a plethora of studies demonstrating the tremendous benefits of exercise for patients with cancer. "Regular exercise during cancer treatment decreases depressive moods, improves appetite, reduces side effects such as fatigue associated with cancer treatment, and increases functional status and the ability to perform activities of daily living," she said. "These benefits reduce the need for treatment breaks, so patients can receive their full therapy on schedule."
Jane Cosentino, BSN, RN, OCN, nurse navigator at Provena Saint Joseph Hospital, Elgin, IL, encourages patients with cancer to exercise moderation when making lifestyle choices. "To me, nothing is black and white; exercise should be part of a normal lifestyle," she noted. "Very few patients going through chemotherapy or radiation are engaged in vigorous exercise, but we do want them to continue regular physical activity to promote well-being and maintain a healthy weight. It's not unusual for women with breast cancer, for example, to gain weight because of some of the drugs they take and the temptation to overeat when they're worried about their disease."
Cosentino urges women to use common sense when making lifestyle choices. "If you have a healthy exercise routine, I tell my patients, 'You don't have to give it up while you're undergoing cancer treatment,'" she explained. "You may need to modify it a bit and limit some specific activities, but you can and should continue enjoying your regular physical activity."
A Matter of Balance
Kelly Gettings, BSN, RN, OCN, an oncology nurse clinician at the Brown Cancer Center at the University of Louisville in Kentucky, advocates a balanced lifestyle for patients undergoing chemotherapy. "I tell them to eat healthy; we don't want them to diet per se, but we do want them to choose healthy foods during their cancer treatment," she explained. "If they're not too tired, they should do some low cardio exercise like walking 3 times a day. They can choose low-impact aerobics like water exercises, but they shouldn't do high-impact exercises or weight-lifting activities that may dislodge their infusion ports."
Stress relief is a very personal choice. "Spend time with your family; have a family night if you have kids or go on a date night with your significant other," said Gettings. "Think about a girls' night out to get away from the whole cancer picture."
Speak up to let family and friends know what you need at any given time. "When people find out you have cancer, they bombard you with attention and concern," said Gettings. "While it's great to have a support system, it's OK to take some time out for yourself. Don't be afraid to say, 'I want to be alone for awhile to read a book or get a manicure.'"
The Ohio State study provides a foundation for future research on the impact of stress and exercise on cancer care.
"What this research really highlights is the value of future clinical studies that investigate whether behavioral interventions can actually affect the efficacy of cancer treatment," Goldberg explained. "Does it make a difference to teach guided imagery and relaxation to cancer patients before they begin chemotherapy, so they can do it at home and in the chemo room? What effect does a beautiful, organized, soothing environment have on molecular pathways? How about examining the impact of nurses who are warm, kind and skilled in therapeutic relationships?"
On the other hand, Goldberg concluded, "This beautifully designed study raises important questions about the potential effect of stress and exercise, [but] it would be totally wrong if patients used this data to stop exercising."
Sandy Keefe is a frequent contributor to ADVANCE.