EX­ER­CISE AS MEDICINE

The Province - - FOCUS ON OPTIONS - GIL­LIAN SHAW

What if doc­tors could write a pre­scrip­tion that would slow the growth of cancer, treat de­pres­sion, pre­vent cog­ni­tive de­cline and help pa­tients live longer and stronger?

They can, ac­cord­ing to Aus­tralian phys­i­ol­o­gist and pro­fes­sor Prue Cormie, whose re­search has led the Clin­i­cal On­col­ogy So­ci­ety of Aus­tralia to rec­om­mend ex­er­cise be added to the treat­ment regime of cancer pa­tients. And not just any ex­er­cise, like strolling down the block or pop­ping into the gym once is a while, but an in­di­vid­u­al­ized pro­gram tai­lored to the dis­ease and de­liv­ered by phys­io­ther­a­pists or ex­er­cise phys­i­ol­o­gists.

“Based on the sci­en­tific lit­er­a­ture we now have avail­able we know with­hold­ing ex­er­cise from cancer pa­tients is harm­ful,” said Cormie, in Van­cou­ver re­cently to speak to on­col­o­gists and other med­i­cal pro­fes­sion­als at the in­vi­ta­tion of the Univer­sity of B.C. and Van­cou­ver’s Prostate Cancer Sup­port­ive Care pro­gram.

“We know they will ex­pe­ri­ence worse cancer-re­lated fa­tigue, worse func­tional de­cline, worse psy­cho­log­i­cal dis­tress and they’ll have a lower qual­ity of life.

“Un­doubt­edly if we could cap­su­late these ef­fects and put them into a pill you would pre­scribe it to ev­ery sin­gle one of your pa­tients,” she told an au­di­ence of health-care prac­ti­tion­ers at the B.C. Cancer cen­tre in Van­cou­ver.

Cormie’s field of re­search has a coun­ter­part in Bri­tish Columbia. Dr. Don McKen­zie, a UBC sports medicine pro­fes­sor, ex­er­cise phys­i­ol­o­gist and direc­tor of the Al­lan McGavin Sports Medicine Clinic, first chal­lenged the then widely held be­lief that vig­or­ous ex­er­cise — pad­dling a dragon boat — would be harm­ful to breast cancer sur­vivors. In 1996, a team of breast cancer sur­vivors com­peted in North Amer­ica’s first dragon boat fes­ti­val in Van­cou­ver.

McKen­zie’s work in­spired the global Abreast in a Boat, move­ment that has grown to 120 teams from all seven con­ti­nents.

“Phys­i­cal ac­tiv­ity has been over­looked and un­der­uti­lized in the man­age­ment of pa­tients with cancer,” McKen­zie, who was trav­el­ling in Eu­rope said in an emailed re­sponse to ques­tions.

“For­tu­nately ex­er­cise is gain­ing some trac­tion in the health care pro­fes­sions; phys­i­cal ac­tiv­ity should be stan­dard of care.”

McKen­zie said there is a also a very strong case sup­ported in med­i­cal lit­er­a­ture for ex­tend­ing the idea of ex­er­cise as medicine to other chronic con­di­tions and dis­eases. Cur­rently much of the re­search has in­volved pa­tients be­ing treated for breast, prostate or col­orec­tal cancer but ex­er­cise has proven to have a pos­i­tive ben­e­fit with other can­cers and in the gen­eral pop­u­la­tion.

In her pa­per on The Im­pact of Ex­er­cise on Cancer Mor­tal­ity, Re­cur­rence, and Treat­ment-Re­lated Ad­verse Ef­fects, Cormie re­viewed 100 stud­ies, in­volv­ing thou­sands of pa­tients whose ex­er­cise be­hav­iour was as­sessed fol­low­ing a cancer di­ag­no­sis of any type.

“Com­pared with pa­tients who per­formed no/less ex­er­cise, pa­tients who ex­er­cised fol­low­ing a di­ag­no­sis of cancer were ob­served to have a lower rel­a­tive risk of cancer mor­tal­ity and re­cur­rence and ex­pe­ri­enced fewer/less se­vere ad­verse ef­fects,” Cormie wrote.

De­spite Canada’s pi­o­neer­ing role in the field of ex­er­cise as medicine, in Aus­tralia it is more widely ac­cepted and rec­og­nized.

“I think that North Amer­ica has done, and con­tin­ues to do, a very good job con­duct­ing lon­gi­tu­di­nal tri­als and other re­search that sup­ports the in­te­gra­tion of phys­i­cal ac­tiv­ity into pa­tient care,” said McKen­zie. “What Aus­tralia has done is a ter­rific job of im­ple­ment­ing this in­for­ma­tion into prac­tice.

“You need both: ev­i­dence-based medicine ap­plied to pa­tient care.”

McKen­zie said Canada ur­gently needs to fol­low Aus­tralia’s ex­am­ple, where ex­er­cise is part of the treat­ment regime of cancer pa­tients and pub­lic health care cov­ers five ses­sions with an ex­er­cise phys­i­ol­o­gist or phys­io­ther­a­pist.

Train­ing is part of the so­lu­tion.

“We need to pro­vide the nec­es­sary train­ing for clin­i­cal ex­er­cise phys­i­ol­o­gists and es­tab­lish pro­fes­sional stan­dards and cre­den­tial­ing,” McKen­zie said. “These in­di­vid­u­als can then de­liver these ser­vices to the gen­eral pub­lic in com­mu­nity cen­tres, gym fa­cil­i­ties, fit­ness clubs, et cetera.”

UBC as­so­ciate pro­fes­sor Kristin Camp­bell is in the Univer­sity of BC’s Fac­ulty of Medicine phys­i­cal ther­apy de­part­ment. Her re­search, which has fo­cused on women un­der­go­ing treat­ment for breast cancer, has shown pa­tients who are pre­scribed ex­er­cise and a healthy eat­ing pro­gram as part of their cancer treat­ment ben­e­fited in phys­i­cal, emo­tional and men­tal well-be­ing.

“For some peo­ple, head­ing to the gym was def­i­nitely not the first thing they wanted to do,” Camp­bell said. “But what we hear from women is that even if ex­er­cise wasn’t top of mind and they were a bit con­cerned about do­ing it in the first place, they found it to be re­ally ben­e­fi­cial.

“They had a lot more en­ergy than they thought they would have oth­er­wise, even on days when they were feel­ing ter­ri­ble they didn’t want to go to the gym. They left with a lot more en­ergy once they were there.”

The ef­fect was more than phys­i­cal. For women in the pro­gram it was a chance to get to­gether with oth­ers go­ing through the same ex­pe­ri­ence, or sim­i­lar ex­pe­ri­ences.

“As much as fam­ily and friends are well mean­ing and they want to be sup­port­ive they don’t know ex­actly what it’s like to be in their shoes,” Camp­bell said. “At the gym, they are with women who are go­ing through the same jour­ney.”

Cheri Van Pat­ten, a re­search and clin­i­cal prac­ti­tioner at B.C. Cancer in on­col­ogy nutri­tion, was co-lead with Camp­bell in the study on

the im­pact of ex­er­cise and nutri­tion on women un­der­go­ing breast cancer treat­ment.

“We’re try­ing to help bridge the gap be­tween lit­er­a­ture that shows ex­er­cise and nutri­tion is ef­fec­tive as an ad­junct to cancer treat­ment and the lack of pro­grams in place,” she said. “It is in­spi­ra­tional to show that other coun­tries have moved the nee­dle over to ac­tu­ally em­bed­ding this ser­vice into com­pre­hen­sive care, such as Aus­tralia.

“They’re def­i­nitely lead­ing the way and it’s a model we would like to em­u­late here.”

It’s is not a one-size-fits-all pre­scrip­tion, nor does just any ex­er­cise do.

Cormie said stud­ies show there is a re­la­tion­ship be­tween the qual­ity of the ex­er­cise — how good it is and how hard it is — and the ben­e­fit.

“The faster some­one does a walk or a run, the bet­ter the ac­tual sur­vival ben­e­fit,” she said.

Ex­er­cise that would be pre­scribed to a pa­tient suf­fer­ing

loss of mus­cle mass as a side-ef­fect of treat­ment would for ex­am­ple, dif­fer from that pre­scribed for a pa­tient suf­fer­ing other side ef­fects.

In Van­cou­ver, Camp­bell is con­duct­ing a study into the im­pact of a struc­tured ex­er­cise pro­gram, ei­ther dur­ing or after chemo­ther­apy, on cog­ni­tive func­tion. In what of­ten is re­ferred to as “chemo brain,’’ cancer pa­tients have re­ported cog­ni­tive side ef­fects from treat­ment.

“Women who are go­ing through chemo­ther­apy for breast cancer tend to re­port changes in cog­ni­tion,” Camp­bell said. “They can’t multitask the same way, word find­ing is a bit dif­fi­cult they just have prob­lems re­call­ing names, things like that, they just don’t feel as sharp.

“Whether it’s the chemo­ther­apy it­self, anx­i­ety around hav­ing the di­ag­no­sis, all these things play a role po­ten­tially.”

Camp­bell said her re­search team has done one proof-of­con­cept study to see if ex­er­cise would be a ben­e­fit and a se­cond larger study is un­der­way now, aim­ing to en­rol 84 women,

Aaliya Mer­ali-Dewji is an ex­er­cise phys­i­ol­o­gist and the co-or­di­na­tor of the cog­ni­tive study. Women in the study go to a gym in Van­cou­ver three days a week and carry out in­di­vid­u­al­ized pro­grams un­der su­per­vi­sion. For Mer­ali-Dewji, the pos­i­tive ef­fects are ob­vi­ous in the gym.

“It’s like a medicine in that it can im­prove the ef­fi­cacy of the chemo, the drugs they are tak­ing, their re­cov­ery, their over­all mood and fa­tigue,” she said. “Fa­tigue is a big thing when you are get­ting chemo and ex­er­cise can at­ten­u­ate that.”

Cormie said based on all the sci­en­tific ev­i­dence, it is clear ex­er­cise “should be on the agenda of spe­cial­ists.”

“It would be mal­prac­tice if we had a drug like this and it wasn’t be­ing used.”

— REID LUCIER

Left to right Tr­ish Schulte, UBC stu­dent Lau­ren Bar­nett, Tara Buck­ley, Stephanie Knox and Kristin Camp­bell.

— PHO­TOS: REID LUCIER

Les­ley Zhao gets her ex­er­cise in.

Tr­ish Schulte says ex­er­cise gives her more en­ergy.

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