Sports and cancer.
After two years of participation in the SBAC cancer exercise program, we reported the health status, physical function, and psychosocial benefits of cancer patients, obtained through a 20-week supervised exercise program followed by self-reported exercise. In this program, the participants were categorized according to the type of cancer: Prostate Cancer [Pr] (n = 12), and Carcinoma / Leukemia [C / L] (n = 13). The demographic information on these groups was: Age (years): 71 ± 7.3 [Pr], 44.6 ± 17 [C / L], Cancer Stage: 2.0 ± .6 [Pr], 2.5 ± .7 [C / L] , and years after diagnosis: 4.7 ± 2.3 [Pr], 2.4 ± 2.5 [C / L]. The exercise lasted 20 weeks, and consisted of exercise on aerobic machines, progressive strength training, and special exercises. After the exercise program the participants completed a quality of life survey (QOL). At two years, a follow-up survey on cancer status, health care information, and alternative health practices was requested. Physical fitness results indicated changes in total strength in both groups (+ 40% for Pr, + 52% for C / L).
The strength gain in the C / L group was significant (p = 0.05). The time of aerobic exercise on machines also increased in both groups (+ 20% for Pr, + 30% for C / L). The results regarding quality of life indicated that the Pr group did not perceive any change in 8 selected categories (ADL, perceived physical fitness, and pain level), but significant changes were observed in all categories for the C / L group. . In two years, the vigor level (on a 10-point scale) was 8.5 for Pr and 9.0 for C / L. 77% of Pr and 84% of C / L received vitamin supplements. 92% of the C / L group used alternative medicine (mainly meditation), but only 23% of the Pr group used these modalities. One hundred percent of the Pr group and 65% of the C / L group continued exercising for two years. Compared to other cancer groups, there were no out-of-pocket medical expenses for either group.
There was one case of cancer recurrence and one report of death in the Pr group, while none occurred in the C / L group. This study suggests that long-term exercise could improve both the physical and psychological components of recovery from cancer. Over time, patients continue to incorporate physical activity and other quality of life practices into their lives. Changes in physical fitness and quality of life are more pronounced in the C / L group, due in part to the stage of cancer, time elapsed after diagnosis, and the severity of medical treatments prior to the start of exercise.
Key Words: rehabilitation, quality of life, follow-up survey, physical fitness.
INTRODUCTION
According to 1997 statistics from the American Cancer Society, 335,000 men between the ages of 45 and 85 will be diagnosed with prostate cancer this year. Of this total, almost 42,000 men will die (1). In terms of morbidity and mortality, prostate cancer ranks third behind lung and breast cancers. Outside the aspects related to nutrition, there are no strongly identifiable risk factors that can be modified for the prevention of prostate cancer.
ACS statistics for 1997 counted 35,500 people diagnosed with leukemia (of all subtypes), and this cancer consumed 34,000 lives. The overall survival rate after 5 years for all types of cancers in the United States is 40%. When this rate is adjusted for life expectancy factors (heart disease, accidents, etc.), it increases to 56%. General recommendations for most of these patients are to undergo surgery, radiation, and / or chemotherapy as part of their initial medical treatment, but long-term therapies are often not routinely prescribed. However, in the field of cancer treatment, survival and quality of life are perhaps the two most important issues facing physicians who work with recovering patients. Over the past decade, the most effective type of therapeutic intervention to increase survival in breast cancer patients has been the psychotherapy used by Fawzy (2) and Spiegal (3). Unlike breast cancer, prostate cancer is generally diagnosed in older men (about 80% of prostate cancers are diagnosed in men older than 65 years (1)), in which aspects related to quality of life are different. Leukemia patients sometimes experience large doses of chemotherapy, anticancer drug combinations, blood transfusions with antibiotics, and bone marrow transplantation, because this type of cancer originates in the blood and is more likely to metastasize .
Exercise has been used as an adjunct therapy in cancer patients since the early 1980s when Winningham et al. Developed the WAIT (Winningham Aerobic Training Interval) scale while reporting the effects of low-intensity aerobic training in patients with cancer (4-6). Most of the research related to physical activity has been epidemiological, and regular physical activity has been shown to increase the incidence rates of primary prevention in certain cancers, such as breast and colon (9-12).
With few research reports on cancer rehabilitation (13-15,17) and on exercise programs (7,18) it has not been possible to standardize so far, the information on the type of exercise programs, the dose-response , and the long-term consequences of physical conditioning in people diagnosed with cancer. To date, no specific exercise protocols are known for individuals with prostate cancer or leukemia.
Therefore, the purpose of this research was to report the health status of participants in an outpatient exercise and wellness program after their cancer diagnosis and treatment. We include information on the physical condition of the participants, personal assessment of the psychosocial benefits of their participation, and relevant information about health care that could be modified by participation in a community program like this one. A second purpose of this report was to conduct a two-year follow-up study of the exercise and wellness program participants and to describe the health status of the participants over time.
METHODS
Features of the Exercise Program
At the Santa Barbara Athletic Club in California, cancer patients performed a combination of aerobic exercises, special exercises, and progressive strength exercises on machines twice a week for 20 weeks.
Demographic data are presented in Table 1.
Table 1. Patient characteristics (mean ± SD).
The goal of the exercise was to improve aerobic capacity, functional strength, and movement limits without causing pain. The patients also participated in specific wellness activities (yoga, relaxation techniques and movement) in a group made up of their peers.
Patients were referred to the SBAC exercise program from a local cancer treatment center after completing an initial questionnaire that was provided to those patients who were interested in participating in an outpatient program. The reference criterion was a Karnofsky classification scale greater than 70, with no apparent orthopedic limiting factors. There were no restrictions from the point of view of ongoing chemotherapy status or contraindicated medication use. 16% of the prostate cancer participants (2/12) and 15% of the carcinoma / leukemia participants (2/13) were undergoing chemical or ray therapy during the exercise program. All participants also completed a questionnaire in the last week of the exercise program. This post-conditioning questionnaire was modified from a Rotterdam quality of life survey given to cancer patients after they have undergone radiation therapy or chemotherapy (19). This version of the survey contains two sections on exercise and rehabilitation and wellness components. The components of the aerobic and strength evaluations as well as the characteristics of the survey can be consulted in another study (18). Participants did not perform 1RM or VO2 max. for aerobic capacity. Participants exercised to voluntary fatigue on aerobic machines during the first week, and power output data was recorded. That same week, functional strength was assessed using an estimated MR scale developed by Hatfield (22).
Characteristics of the Follow-up Survey
The follow-up survey was conducted by telephone in both groups of cancer patients who participated in the exercise program for 20 weeks. The program began in the spring of 1994, and since its inception about 75 participants have participated. Each survey lasted approximately 10 minutes and included 33 questions grouped into four information sections: general, cancer, health care, and exercise.
Each participant was asked all the questions and the responses were recorded. If the question was not known, the answer was not recorded. In general, all questions were answered and there was no confusion regarding any section. The response rate of the 2-year follow-up survey was 100% for both groups.
Statistical analysis
The demographic data of the participants were analyzed using descriptive statistics. The pre and post data on both physical fitness criteria and the questions of the follow-up survey were analyzed using the Student’s t test for paired data, the averages of the t tests used in Tables 2 and 3 were corrected for the use of the Dunn’s multiple comparisons test (20).
RESULTS
Improvements in Physical Condition
At the conclusion of week 20 of the supervised exercise program, participants in the prostate group showed an average increase of 38% in total body strength (upper and lower body exercises). However, these results were not statistically significant (p = 0.17). The time on the aerobic machines increased by 24% (8.4 to 10.4 minutes, p = 0.17) and the functional aerobic capacity (measured in METS) improved by 5% (p = NS). In contrast, members of the carcinoma / leukemia group increased total body strength by 52% with a significant increase for three of the four categories (p = 0.05). In this group, a 30% increase was also observed in the time in the aerobic machines (p = NS) and in the MET value from 4.15 to 6.32 (p = NS).
In 7 of the 8 categories of the modified Rotterdam survey, the prostate group had no significant changes in their psychosocial responses (Table 3). The only category that presented statistically significant differences was the force perception section (25% change), which showed a strong correlation with the real gain in total strength observed for this group (38%) – Pearson’s correlation coefficient of r = 0.53.
In contrast, the group of patients with carcinoma / leukemia showed an average increase of 52% in total strength and significant changes in each of the eight categories of the modified Rotterdam survey. The changes that this group presented in the first three sections (which detail activities related to daily life) were higher by an average of 13% with respect to the previous responses to the exercise program (Pre). Regarding the areas of perception of change in strength and endurance, here again a different response of approximately 33% was observed. The final three questions, related to pain management aspects, showed an average increase close to 19%.
The percentage of patients in the prostate cancer group who continued to participate in exercise groups in health clubs or on their own over 2 years (at least 3 days per week) was 100% (12/12). The percentage in the group of participants with carcinoma leukemia was 61% (8/13).
Table 2. Physical Fitness Results for the Prostate Cancer and Carcinoma / Leukemia Groups
Table 3. Results of the modified Rotterdam survey. * Significant # Based on a 9 point scale, n = 15 observations for each question, 46-49 total observations for each section. ^ Survey data corrected using Dunn’s multiple procedure test. NS = non-significant values.
Physical characteristics
Aun cuando se lo ha señalado como un elemento importante en la sobrevivencia del cáncer (12), otra observación importante es la falta de indicación hacia la realización de Terapia Física para los participantes. Solo a uno de los participantes en cada grupo le fue indicada esta terapia. Esto parecería contradecir las recomendaciones hechas a los pacientes en etapas postquirúrgicas cuando están internados (21).
A high percentage of patients in the carcinoma / leukemia group (92%) used some complementary or alternative therapy as part of their recovery process, the main ones being meditation or visualization. 84% of this group also took vitamin supplements. 77% of patients in the prostate group consumed vitamins and resorted less to the use of alternative therapies. Only 23% of these patients performed meditation or visualizations on a regular basis. Compared to other reported groups, neither group reported having incurred out-of-pocket expenses during the two years of participation in the exercise program.
Cancer Recurrence / Survival
Statistics from the American Cancer Society state that the average 5-year survival rate for Caucasian cancer patients is 50%. In two years of follow-up, we reported one case of cancer recurrence in the prostate group and one death. There were no reports in the carcinoma / leukemia group. The vigor level in the prostate group was 8.5 on a scale of 10 and 9 for the carcinoma / leukemia group. In fact, of a total of 75 SBAC participants who have completed the 20-week exercise program, the only reported death in the two years was in the prostate cancer group.
DISCUSSION
The results of this report show that the improvements made in aerobic conditions and strength in men with prostate cancer (38% in strength and 24% in time on aerobic machines) were not enough to produce significant results. Due to the small sample size of this group, it might initially be thought that a larger number of participants would have produced significant results. Also when considering the real numbers of the improvements obtained; time on aerobic machines increased by 2 minutes and strength by 7.4 kg (16lb). While any improvement in aerobic capacity and strength is significant, these changes numerically are not sufficient to produce statistically significant differences.
Since the prostate group was diagnosed twice as early as the carcinoma / leukemia group, they also had more time to heal. Therefore, changes related to the quality of life could be due to the passage of time and with it to a more complete recovery. The 38% improvement in the prostate group is remarkable given the age of the participants regardless of statistical significance. They obtained improvements with respect to the risks of falls, the probability of developing osteoporosis and sarcopenia. The lack of statistically significant differences in the responses related to quality of life indicates that the quality of life of the participants was good before entering the exercise program. They, unlike members of their class, they did not have any of the problems associated with medical treatment, such as response to chemotherapy, residual effects of medical treatment, surgical scar tissue, and difficulties in moving. While they were on average 27 years older than the average for the Carcinoma / Leukemia group, it is likely that medical differences played more than one role in the ability to perform (and excel) in exercise. Participants in the prostate group had no obvious orthopedic problems and were not under medical treatment. The ability to exercise (100% participation after two years) is proof of the fact that their quality of life was good enough to help them continue with the physical fitness program. \Members of the carcinoma / leukemia group were still involved in medical treatments and this may have prevented some from exercising over time (65% continued to exercise after two years). Your physical condition could also be correlated with your statistical improvements in quality of life and fitness functions. This information agrees with data presented by Dimeo et al. (23) who established that patients with high dose chemotherapy and stem cell transplantation (strong medical interventions) had improvements in physical parameters (hematocrit) and in aerobic conditions (increase in VO2 max.).
Your physical condition could also be correlated with your statistical improvements in quality of life and fitness functions. This information agrees with data presented by Dimeo et al. (23) who established that patients with high dose chemotherapy and stem cell transplantation (strong medical interventions) had improvements in physical parameters (hematocrit) and in aerobic conditions (increase in VO2 max.). Your physical condition could also be correlated with your statistical improvements in quality of life and fitness functions. This information agrees with data presented by Dimeo et al. (23) who established that patients with high dose chemotherapy and stem cell transplantation (strong medical interventions) had improvements in physical parameters (hematocrit) and in aerobic conditions (increase in VO2 max.).
With an average age of 44 years, participants in the carcinoma / leukemia group experienced improvements of approximately 52% in strength and 30% in time on aerobic machines. These improvements could be due to being younger or perhaps to the level of medical intervention involved. In this group, all underwent chemotherapy, while in the prostate group, only one of them performed this therapy. Furthermore, two participants in the carcinoma / leukemia group were still under treatment when they participated in the exercises. This makes its benefits even more remarkable.
It is interesting to contrast the changes in these groups of participants of the SBAC wellness program. On the one hand, it appears that exercise has a small effect on both quality of life and physical functions in patients with prostate cancer. In a more detailed observation we must pay attention to the relative changes achieved in each category based on a few factors such as: age at which the program was entered, previous physical functions, sex and cancer treatment, which would be the most influential controversial progress.
Conclusions
In conclusion, we describe the health and fitness status of cancer patients who participated in an exercise and wellness program at a community health club. Improvements in physical fitness were observed in both groups, the changes observed in the group of patients with carcinoma and leukemia being significant. In the complementary treatment survey at two years we reported: lack of referral of physical therapies, no cash expenses for any of the groups, use of some type of alternative therapy (meditation, prayer, etc.) and use of vitamin supplements in most patients. One case of death and one case of cancer recurrence were reported in the prostate group and none of them in the carcinoma / leukemia group. The importance of this report is that it is possible to include people with cancer in a supervised program. Most of these groups will continue to exercise over time. We conclude that exercise brings both physical and psychosocial benefits to cancer patients over time. However, the changes are observed in those patients who begin exercise close to their medical interventions.
