1. Physical Activity in Cancer
Dr Amelia Randle

2. A little about me A GP The Park Surgery Shepton Mallet
Macmillan GP lead for Cancer Somerset CCG
Clinical Champion for
Physical Activity Public Health
England South West A

3. Everybody Active, Every Day
Public Health England (2014) Everybody Active, Every Day

4. Getting to know you!
What setting are they working in?

5. Cancer Survival Worldwide

6. How inactive is England?
MAIN FOCUS/POINT OF THIS SLIDE IS THE ‘PHYSICALLY INACTIVE ‘ – TOP RIGHT IMAGE
30% OF THOSE WITH SMI ARE INACTIVE – NOTE SIGNIF WORSE THAN GEN POP’N
Define what we mean by ‘physically inactive’ - < 30 min/week of moderate intensity activity – this identifies those people on the extreme low end of movement (FYI - between is considered ‘insufficiently active’)
Physical inactivity is an issue across the population
1 in 3 men and almost half of all women (33% and 45%) are not physically active enough for good health (i.e. achieving the Chief Medical Officer’s recommended levels of physical activity.
The extent of this lack of activity is that almost 1 in 5 men and over a quarter of women (195 and 26% respectively) are classified as ‘physically inactive’ by not even doing 30 minutes of moderate or vigorous activity per week.
There are also significant inequalities, for example:
Disabled adults are half as likely to regularly take part in sport
Also we see issues across the lifecourse, for example:
Between the age of 5-7 and the teenage years the number of girls physically active enough for good health drops from 23% to 8%
Refs:
Health Survey for England 2012 (HSE)
Active People Survey 8, April 2103-April 2014 (APS)
National Travel Survey July 2014 (NTS)
Source: Health Survey for England 2012 (HSE); Active People Survey 8, April 2103-April 2014 (APS); National Travel Survey July 2014 (NTS)

7. Q2: How does the UK compare with the following countries for not being active?
USA
France
Netherlands
Germany
Australia
Finland A

8. Proportion who are not active
International comparison of physical inactivity (at ages 15 and over)
Prevalence of physical inactivity* among individuals aged 15 years or more
The graph shown here demonstrates one such study, which used data from 122 World Health Organization Member States and a specific criteria for inactivity (hence the distinction from the Health Survey for England and Active People Survey data).
Defined as not meeting any of the following criteria: (a) 5 x 30 minutes of moderate-intensity activity per week; (b) 3 x 20 minutes of vigorous-intensity activity per week; (c) an equivalent combination achieving 600 metabolic equivalent-min per week.
Reasons include Social, cultural and economic trends over decades have ‘designed’ physical activity out of daily life.
Less manual jobs
Technology
Over-reliance on cars and other motorised transport
Many features of our cities, towns and buildings – and even some of our parks – work against physical activity. The design of schools, public buildings and urban spaces prioritise convenience and speed instead of encouraging people to walk or cycle. People sit still all day, in offices where it is often easier to find the lift than the stairs. Rind E, Jones A, Southall H (2014) How is post-industrial decline associated with the geography of physical activity? Evidence from the Health Survey for England. Social Science Medicine 104: 88-97
Note: Comparator = Not meeting any of the following per week: (a) 5 x 30 mins moderate-intensity activity; (b) 3 x 20 mins vigorous-intensity activity; (c) equivalent combination achieving 600 metabolic equivalent-min.
Public Health England (2014) Everybody Active, Every Day (2014), based on WHO Observatory data

9. Physical activity: What counts?
Sleep is not considered a sedentary behaviour because it has a range of restorative functions that make it beneficial overall (despite the muscles being inactive for so long) – sleep is a fundamentally different state from when your muscles are inactive when awake – activities are only considered sedentary when you’re awake
Activities are classed based on the amount of energy they expend relative to laying quietly (units are metabolic equivalents - METs) – the same activity can have different intensities depending on how much effort/energy you expend (ie. Slow walking - light intensity activity vs brisk walking - moderate-vigorous activity) - Ainsworth et al. (2000 & 2011) Med Sci Sports Exerc
Sedentary (≤ 1.5 MET), Light (1.6 – 2.9 MET), Moderate (3 – 6 MET), Vigorous (> 6 MET)
* An activity which is vigorous intensity for one individual, may be moderate or light intensity for another, depending on factors such as age, mobility, and fitness.
Light
intensity
Moderate
intensity
Vigorous
intensity
Sleep
Sedentary A
Tremblay et al. (2010) Appl Physiol Nutr Metab

10. Q1: What are the UK Chief Medical Officers’ guidelines on physical activity for adults?
Department of Health (2011) Start Active, Stay Active

11. Q1: What are the UK Chief Medical Officers’ guidelines on physical activity for adults?
minutes of moderate intensity activity in durations of at least 10 minutes/week
Or 75 minutes of vigorous intensity activity
Or a combination of both
2. Muscle-strengthening activity at least 2 days/week
3. Limit time spent sitting for extended periods
4. For older adults (65+) - Balance and co- ordination activities at least 2 days/week
More is better. Some is better than none. A
Department of Health (2011) Start Active, Stay Active

12. Top 5 non-communicable disease risk factors for mortality
IN PSYCH SESSIONS, MENTION ALL LIFESTYLE FACTORS AS GENERALLY HAVE POORER DIET, NOT ENOUGH FRUIT/VEG (NOT MEETING GUIDELINES), OBESITY (PARTLY DRUG-RELATED), HIGHER RATES OF SMOKING AND HIGHER RISK OF HYPERTENSION/CVD
For clarification – this data is referring to ‘Mortality only’ – see page 9, second paragraph of the document cited
Also note that physical activity is the only risk factor that, if improved, could reduce all of the other risk factors (even smoking since people who become more active are more likely to stop smoking) A
WHO (2009) Global health risks: mortality and burden of disease attributable to selected major risks

13. Inactivity vs. smoking Global mortality
Authors of this paper suggest that doctors could stress the harms of inactivity, and not simply the benefits of exercise, to have a more motivating effect. For example to combat smoking – we stress the harms of smoking, and not the benefits of not smoking – the message is more effective at avoiding the behaviour
Also note how little has been done to combat inactivity relative to smoking
These are based on prevalence and adjusted relative risks of inactivity on mortality from meta-analyses and a collection of country-level data
Inactivity defined as not meeting WHO recommendations of 150 min/week of moderate physical activity/week or 75 min of vigorous activity/week or equivalent combination A
Reprinted from The Lancet, Jul 21;380(9838), Wen CP, Wu X, Stressing harms of physical inactivity to promote exercise, Pages , Copyright 2012, with permission from Elsevier

14. Physical activity: Who gains the most?
Mortality after age 40
Years gained after age 40
Biggest drop
in mortality
Biggest gain
in years
MAIN POINT (avoid explaining METs)
Dose response curve of physical activity. Biggest gains are in those doing nothing to doing something, even if just a small amount.
The red bar represents the approximate cut off for 150mins/moderate intensity (10MET-hr/week = 180m brisk walking)
The ones with the most to gain are those going from nothing to something, rather than from something to more - We need to target those who are currently inactive and get them to do something, even if it’s not a lot/vigorous – that can make a big impact on the population level
BACKGROUND INFO
This is based on pooled data from six prospective cohort studies in the National Cancer Institute Cohort Consortium, comprising 654,827
individuals, 21–90 y of age
MET – physiological msr of energy cost of physical activity - Metabolic Equivalent of Task ( 1 MET (3.5ml oxygen/kg/min) = sitting at rest for one hour, Mod 3-6 METS, Vig 6+ MET)
Looking at mortality risk - the biggest drop in risk/ gain in life is for those going from completely inactive to 10 MET-hrs/week – the equivalent of walking at a moderate pace for about 3 hours/week (3 METs * 3.3 hrs = ~ 10 MET-hrs/wk) or walking at 5 miles/hr for just over 1 hour/week (8 METs * 1.3 = ~10 MET-hrs/week).
Adjusted for gender, alcohol consumption, education, marital status, history of heart disease, history of cancer, BMI, and
smoking status (age was used as the time scale) A
Moore et al. (2012) PLOS Medicine

15. Q3: Physical activity reduces risk of which of the following conditions by at least 20%?
Early death CHD and stroke Type 2 diabetes Colon cancer Breast cancer Hip fracture Depression Hypertension Alzheimer’s disease Functional limitation, elderly A

16. Physical activity: Our greatest defence
Physical Activity contribution to reduction in risk of mortality and long term conditions
Disease
Risk reduction
Strength of evidence
Premature Death
20-35%
Strong
CHD and Stroke
Type 2 Diabetes
35-40%
Colon Cancer
30-50%
Breast Cancer
20%
Hip Fracture
36-68%
Moderate
Depression
20-30%
Hypertension
33%
Alzheimer’s Disease
Functional limitation, elderly
30%
Prevention of falls
Osteoarthritis disability
22-80%
PSYCH: POINT OUT TOP 5 ON THE LIST ARE ESPECIALLY IMPORTANT FOR THOSE WITH SMI AS HAVE INCREASED RISK AND EVEIDENCE FOR PA TO REDUCE RISK IS STRONG
Now pay attention to the size of effects – the degree of protection that physical activity gives is greater for all conditions than what we’d consider to be good for drugs? (about 20% risk reduction on average?)
PA is our first line of defence against:
Mortality
The big killers - Cardiovascular disease, cancer
Disabling conditions - Type 2 diabetes, Dementia (Beydoun et al., 2014; BMC Public Health), Depression, Musculoskeletal ill-health
Poor quality of life - Subjective wellbeing, functional limitations - independence
Also links with: Ovarian cancer, Endometrial Cancer, Prostate cancer, Lung cancer
Physical activity is healthier, safer, cheaper, more effective and efficient than drugs for preventing (and treating?) disease A
Start Active, Stay Active (2011) based on US Department of Health and Human Services Physical Activity Guidelines Advisory Committee Report (2008), Washington D.C.

17. Primary prevention Evidence of reduced risk from physical activity
Convincing
Colon
Probable
Breast (post-menopausal)
Endometrium
Limited but suggestive
Lung
Pancreas
Breast (pre-menopausal)
The leading authority on the links between physical activity as an independent risk factor for the primary prevention of cancer is the World Cancer Research Fund’s Continuous Update Project. This evidence is from their 2007 report, however findings remain unchanged from the continuous update project.
The evidence here is for physical activity as an independent risk factor only, other cancers also have weight as a risk factor which includes both weight and healthy eating as a modifiable risk factor e.g. prostate cancer. This evidence is not included here. All information on the CUP can be found
Examples of the relative risk reduction by physical activity as a modifiable independent risk factor include:
Colon relative risk reduction of 30-40%
Post menopausal breast relative risk reduction of 20-30%
Endometrial relative risk reduction of 30%
To bring home to you what that actually means, given the prevalence of inactivity in the UK/globally 15% of colon cancers are directly attributable to not being active enough.
Background
The Continuous Update Project (CUP) lead by the World Cancer Research Fund is an analysis of global scientific research into the links between diet, physical activity, weight and cancer.
(Background information: The CUP is based on a live system of data managed by a team of WCRF-funded researchers at Imperial College London, who collate and analyse individual research studies from around the world. An expert panel of the world’s leading scientists then reviews the findings and evaluates the evidence. They use their conclusions to develop the best cancer prevention advice and make further Recommendations for Cancer Prevention, which World Cancer Research Fund UK then communicates to the public, health professionals and key organisations.)
Additional references:
Boyle T, Keegel T, Bull F, Heyworth J, Fritschi L (2012). Physical activity and risks of proximal and distal colon cancers: a systematic review and meta-analysis. J Natl Cancer Inst 17;104(20):
Wu, Y., D. Zhang, et al. (2013). "Physical activity and risk of breast cancer: a meta-analysis of prospective studies." Breast Cancer Research and Treatment 137(3):
Moore, S. C., G. L. Gierach, et al. (2010). "Physical activity, sedentary behaviours, and the prevention of endometrial cancer." British Journal of Cancer 103(7):
Tardon A, Lee WJ, Delgado-Rodriguez M, Dosemeci M, Albanes D, Hoover R, Blai A (2005) Leisure-time physical activity and lung cancer: a meta-analysis. Cancer Causes Control 16:389–397.
O’Rorke MA, Cantwell MM, Cardwell CR, Mulholland HG, Murray LJ (2010) Can physical activity modulate pancreatic cancer risk? A systematic review and meta-analysis. Int J Cancer 126:
Parkin, M., et al., The fraction of cancer attributable to lifestyle and environmental factors in the UK in BJC (Supp 2): S38-S41.
Conclusions of World Cancer Research Fund (WCRF) expert report (2007) and continuous update project (CUP) 17

18. Primary prevention
Magnitude of risk reduction approximately % at highest levels of physical activity
Emerging evidence for ovarian, oesophageal, and prostate cancers
Excess body weight and adiposity also major risk factor for multiple cancers
References
Olsen CM, Bain CJ, Jordan SJ, Nagle CM, Green AC, Whiteman DC, Webb PM (2007) Recreational physical activity and epithelial ovarian cancer: a case-control study, systematic review, and meta-analysis. Cancer Epidemiol Biomarkers Prev 16:
Singh, S., S. Devanna, et al. (2014). "Physical activity is associated with reduced risk of esophageal cancer, particularly esophageal adenocarcinoma: a systematic review and meta-analysis." BMC Gastroenterology 14(1): 101.
Lui YP, Hu FL, Li DD, Wang F, Zhu F, Zhu L, Chen WY, Ge J, An RH, Zhao YS (2011). Does physical activity reduce the risk of prostate cancer? A systematic review and meta-analysis. Eur Urolog 60: 18

19. Pre-diagnosis (prevention) Pre-treatment (prehabilitation)
Treatment (symptom control)
Survivorship (health promotion)
Post-treatment (rehabilitation)
End of life
(palliation)
Physical activity pre-treatment
Results
Emerging evidence that exercise pre-treatment is important since fitter individuals tolerate treatment better. This was reported in a systematic review of 18 intervention trials of pre-surgery exercise prescriptions (mainly lung or prostate cancer)
Improved pulmonary and cardiovascular parameters
Shorter hospitalisations
Reversed incontinence after prostatectomy
Aerobic and muscular fitness preserved or slightly increased
Aimed at maintaining functional abilities and well-being
Physical activity during treatment
Body composition improved (via fat loss)
Fatigue controlled or slightly reduced
Well-being and quality of life enhanced
Physical activity after treatment
Aerobic and muscular fitness moderately increased
Aimed at restoring functional abilities and well-being
Well-being includes depression and anxiety as improved outcomes, as well as self-esteem and body image.
Fatigue moderately reduced
Majority of patients surveyed are interested in physical activity
Physical activity in palliative care
Some benefits demonstrated from intervention trials
Less severe symptoms (dyspnoea, appetite loss)
Preserved functional outcomes (walking ability, muscular strength)
Slowed decline in quality of life
Elevated risk of other chronic diseases following cancer treatment (e.g. cardiovascular disease, type 2 diabetes, osteoporosis)
Physical activity and health promotion
Lack of physical activity is a risk factor for several major chronic diseases, including coronary heart disease, stroke, diabetes mellitus, osteoporosis, obesity, some cancers and dementia. Risk reductions of 20–50% are possible for people who are active at the recommended levels relative to those who are inactive.
Consequences of treatment including bone problems, cardiac problems, metabolic syndrome, psychosocial problems and subsequent primary cancers can be reduced with the adoption of healthy lifestyle choices.
Equally important is the role of physical activity in helping to manage existing chronic conditions in cancer survivors.
References:
Silver JK, Baima J. (2013) Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American Journal of Physical Medicine & Rehabilitation 92,
Singh F, Newton RU, Galvão DA, Spry N, Baker MK (2013). A systematic review of pre-surgical exercise intervention studies with cancer patients. Surgical Oncol 22,
Speck RM, Courneya KS, Mässe LC, Duval S, Schmitz KH. (2010) An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Journal of Cancer Survivorship 4,
Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. (2012) Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Systematic Reviews 8, CD
Cramp F, Byron-Daniel J. (2012). Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews 11, CD006145
Fong DY, Ho JW, Hui BP, Lee AM, Macfarlane DJ, Leung SS, Cerin E, Chan WY, Leung IP, Lam SH, Taylor AJ, Cheng KK. (2012). Physical activity for cancer survivors: meta-analysis of randomised controlled trials. British Medical Journal 344:e70, doi: /bmj.e70.
Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, Gotay CC, Snyder C. (2012). Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Systematic Reviews 8, CD
Craft LL, Vaniterson EH, Helenowski IB, Rademaker AW, Courneya KS. (2012). Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiology Biomarkers & Prevention , 3-19.
Cramp F, James A, Lambert J. (2010). The effects of resistance training on quality of life in cancer: a systematic literature review and meta-analysis. Supportive Care in Cancer 18,
Lowe SS, Watanabe, SM, Courneya, KS. (2009). Physical activity as a supportive care intervention in palliative cancer patients: a systematic review. Journal of Supportive Oncology 7,
Lowe SS, Watanabe SM, Baracos VE, Courneya KS (2010). Physical activity interests and preferences in palliative cancer patients. Support Care Cancer 18:
Maddocks M, Armstrong S, Wilcock A (2011). Exercise as a supportive therapy in incurable cancer: exploring patient preferences. Psychooncology 20:
Headley JA, Ownby KK, John LD (2004) The effect of seated exercise on fatigue and quality of life in women with advanced breast cancer. Oncol Nurs Forum 31:
Oldervoll LM, Loge JH, Lydersen S, Paltiel H, Asp MB, Nygaard UV, Oredalen E, Frantzen TL, Lesteberg I, Amundsen L, Hjermstad MJ, Haugen DF, Paulsen Ø, Kaasa S. (2011) Physical exercise for cancer patients with advanced disease: a randomized controlled trial. Oncologist 16,
Oldervoll LM, Loge JH, Paltiel H, Asp MB, Vidvei U, Wiken AN, Hjermstad MJ, Kaasa S (2006) The effect of a physical exercise program in palliative care: A phase II study. J Pain Symptom Manage 31:
Scottish Intercollegiate Guidelines Network (SIGN). Long term follow up of survivors of childhood cancer. Edinburgh: SIGN;
Smith, W. A., Li, C., Nottage, K. A., Mulrooney, D. A., Armstrong, G. T., Lanctot, J. Q., Chemaitilly, W., Laver, J. H., Srivastava, D. K., Robison, L. L., Hudson, M. M. and Ness, K. K. (2014), Lifestyle and metabolic syndrome in adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort Study. Cancer, 120: 2742–2750. doi: /cncr.28670
Macmillan Cancer Support (2012). The importance of physical activity for people living with and beyond cancer: A concise evidence review.
Macmillan Cancer Support Cured – but at what cost? 19

20. HOW PHYSICAL ACTIVITY CAN HELP?
It is important to be aware that supporting people to be physical activity at each stage of someone’s cancer journey can bring clinical and quality of life benefits.
Excitement for the benefits of physical activity is increasing among clinicians as a steady stream of well-conducted randomised controlled trials (RCT) are published in established medical and sports journals on the impact of a physically active lifestyle on cancer survivors. Most notably, two large meta-analyses have left little doubt of the benefit of exercise programmes. The first, analysed 34 RCT’s, published in the British Medical Journal and the second, a comprehensive reviewed of 85 RCT’s conducted by the American College of Sports Medicine. They both report significant improvement for cancer-related fatigue, weight gain, joint pain, hot flushes, muscle power, overall quality of life, mood, anxiety and depression fatigue, exercise capacity and quality of life. In addition to these meta-analysies, other important studies have reported the benefits of exercise programmes particularly in the following areas:
Cancer-related fatigue (CRF) The role of physical activity to help reduce the trauma of CRF was reviewed in two meta analysis. These showed that exercise had a small but significant improvement in CRF.
Anxiety and depression. It has major knock-on benefits for general health, damages relationships, sleep patterns and some studies have linked psychological distress with reduced survival. Exercise programmes reduce levels of psychological morbidity; improve self-esteem, feelings of hopelessness and loneliness especially in those involved in group activities.
Weight gain
Arthritis The landmark HOPE study, from New York, reported significantly better joint function in those randomised to an exercise and stretching programme involving women taking Aromatase inhibitors.
Other conditions helped by exercise include a reduced risk of thromboembolism, constipation caused by immobility and drugs, cognitive impairment from chemotherapy (Chemo-brain) and hormones, peripheral neuropathy, cardiac impairment, erectile dysfunction and incontinence after pelvic radiotherapy and accelerated bone loss.
Reduces co-morbidities
Physical activity is also an independent risk factor for over 20 long term conditions.
Reduce disease progression / mortality / recurrence
There is emerging evidence that being active at recommended levels may help reduce the relative risk of recurrence and mortality for breast, colorectal, prostate, lung and brain cancers.
References:
Thomas, R.J., Holm, M., & Ali-Adhami, A. (2014). Physical activity after cancer: An evidence review of the international literature. BJMP; 7(1)
Macmillan Cancer Support. (2011). The importance of physical activity for people living with and beyond cancer - a concise evidence review. London: Macmillan Cancer Support. Primary sources are included within this publication
Information taken from:
UK Government. (2011). Start active, stay active – a report on physical activity for health from the four home countries’ chief medical officers. London: Crown Publishing 20

21. Physical activity and survival
Emerging evidence of physical activity post-diagnosis as an independent predictor of survival time/disease progression
Cancer
Studies
Risk reduction
Breast 4
>20% cancer mortality/progression
Colorectal 6
>30% cancer mortality/progression
Prostate 2
>50% cancer mortality/progression
Lung 1
>30% total mortality
Brain
Reduce disease progression / mortality / recurrence
Large cohort studies have linked a reduced relapse rate and improved survival benefit with greater physical activity.
There is emerging evidence of physical activity post-diagnosis as an independent predictor of survival time/disease progression
Breast – RCT involving 2437 breast cancer patients showed that in the group receiving nutritional and exercise advice had better overall survival and reduced relapse rates compared to controls. A cohort study of 933 breast cancer survivors – those who exercised greater than CMO guidelines 67% lower risk of all deaths compared to sedentary women. Prospective observational study of 4482 breast cancer survivors found those who exercised >2.8hours per week had a 35%-49% lower risk of dying from breast cancer.
Colorectal – RCT 31% reduction in relapse rate in stage 3 bowel cancer. Cohort study of 526 patients showed that those exercised 2 days a week compared to non exercisers had a 5yr survival rate of 71% vs 57%
Prostate – Cohort study of 2686 men with prostate cancer showed that those who walked at a brisk pace for >90mins a week had a 51% lower risk of overall death.
Lung – small study using a prospective design (this study identifies a group of people and follows them over a period of time to see how their exposures affect their outcomes), 118 consecutive participants - >30% total mortality
Brain - Using a prospective design, 243 patients - >30% total mortality
Reference:
Betof AS, Dewhirst MW, Jones LW. (2013). Effects and potential mechanisms of exercise training on cancer progression: a translational perspective. Brain Behaviour & Immunity 30, S75-87.
Je Y, Jeon JY, Giovannucci EL, Meyerhardt JA. Association between physical activity and mortality in colorectal cancer: A meta-analysis of prospective cohort studies. Int. J. Cancer: 133, 1905–1913 (2013)
Richman EL, Kenfield SA, Stampfer MJ, Paciorek A, Carroll PR, Chan JM. (2011).
Physical activity after diagnosis and risk of prostate cancer progression: data from the cancer of the prostate strategic urologic research endeavor. Cancer Research 71,
Kenfield SA, Stampfer MJ, Giovannucci E, Chan JM. (2011) Physical activity and survival after prostate cancer diagnosis in the health professionals follow-up study. J Clin Oncol 29:
Jones LW, Hornsby WE, Goetzinger A, Forbes LM, Sherrard EL, Quist M, Lane AT, West M, Eves ND, Gradison M, Coan A, Herndon JE, Abernethy AP. (2012). Prognostic significance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer. Lung Cancer 76,
Ruden E, Reardon DA, Coan AD, Herndon JE 2nd, Hornsby WE, West M, Fels DR, Desjardins A, Vredenburgh JJ, Waner E, Friedman AH, Friedman HS, Peters KB, Jones LW. (2011). Exercise behavior, functional capacity, and survival in adults with malignant recurrent glioma. Journal of Clinical Oncology 29,
Macmillan Cancer Support. (2012). The importance of physical activity for people living with and beyond cancer - a concise evidence review. London: Macmillan Cancer Support.
Ramblers. (2013). Walking works - making the case to encourage greater uptake of walking as a physical activity and recognise the value and
benefits of walking for health. London: Walking for health
Schmid D, Leitzmann MF. Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis. Annals of Oncology 25: 1293–1311, 2014

22. Health risks of sitting, independent of physical activity
These are summary estimates of sitting time on risk of each health outcome based on a recent meta-analysis – all adjusted for demographics and physical activity (the effect of self-reported sitting time on each outcome regardless of engagement in self-reported moderate-to-vigorous activity)
Measures of physical activity and sitting differ for each study - this aims to pool different estimates and get an overall picture / summary estimate of effects
“In the example given in previous slide for GP’s a calling system may double risk of Diabetes”
Biswas et al. (2015) Annals Intern Med

23. Safety considerations
Potential risk
Precaution
Exacerbate symptoms
Avoid high intensity; modify based on site of treatment
Immune suppression
Avoid high intensity/volume & public places while white blood cell counts are low
Bone fractures
Avoid high impact/contact with bone metastases/osteoporosis risk
Falls
Avoid activities needing balance with dizziness/frailty/peripheral neuropathy
Exercise programs should be tailored to the individual patient. For patients who were physically active prior to chemotherapy or radiation treatment, a decrease in the intensity of exercise may be necessary.
Patients who were sedentary prior to treatment should begin with low-intensity activities (eg, slow walking) and gradually increase the pace.
With physician approval, those who have completed treatment are recommended to engage in activity to the CMO guidelines.
Certain patients may require special precautions with regard to physical activity. For example, older patients and those who have balance issues due to peripheral neuropathy may be advised to avoid exercising on a treadmill. Patients receiving radiation treatment should avoid exposing irradiated skin to the chlorine in swimming pools. Additional safety precautions may also be necessary for patients who have bone disease, severe anemia, compromised immune functioning, or medically comorbid conditions (eg, arthritis) that affect their physical functioning.
General advice
•Stop if you experience any sudden symptoms, including feeling dizzy, chest pain, a racing heart, breathing problems, feeling sick, unusual back or bone pain, muscle weakness or a persistent headache. Contact your doctor if you notice any of these, or any other symptoms.
•Don’t exercise if you feel unwell, have an infection or high temperature, or have any symptoms that worry you.
•Wear well-fitting trainers – don’t risk an injury by wearing the wrong shoes.
••Drink plenty of water so you don’t get dehydrated.
•Have a healthy snack such as a banana after exercising.
•Avoid uneven surfaces and activities that increase the risk of falling or hurting yourself, especially if you have bone problems.
Which activities are best for you can depend on the type of cancer you have, your treatments and any other conditions you have. If you are in any doubt, get advice from your doctor.
Being physically active has fewer risks than being inactive. But, it’s important to know how to take care of yourself when you begin to be more active.
All of this information is in the Physical Activity and Cancer Treatment booklet on pages
Chemotherapy lowers the number of blood cells in your blood. If your white blood cells are low, you are more at risk of getting an infection. Your cancer doctor might advise you to avoid public places such as swimming pools or gyms until your white blood cells are back to a normal level.
If you have a central or PICC line, avoid swimming because of the risk of infection. You should also avoid vigorous upper body exercises, which could displace your line.
Platelets are cells that help the blood to clot. If your platelets are low, you are more at risk of bruising or bleeding. Your doctor may advise that you take gentle exercise until your platelets recover. If your red blood cells are very low (anaemia), you will feel very tired and sometimes breathless. Your doctor might ask you to only do day-to-day activities until the anaemia improves.
Radiotherapy
If you have a skin reaction or redness due to radiotherapy, avoid swimming as the chemicals in the water can irritate your skin. After treatment, when any redness or skin reaction has gone, it’s fine to swim again.
Surgery
It’s important to start moving around as soon as possible after surgery. This reduces the risk of complications such as blood clots and helps with recovery. Depending on the operation, your surgeon will tell you which activities you should avoid and for how long.
Other safety issues
Some treatment side effects or other medical conditions can affect which physical activities are right for you.
Bone problems
If you have bone thinning or cancer in the bones, avoid high impact activities. With these, there is more risk of you falling and breaking (fracturing) a bone. High-impact activities are things that involve pounding actions (for example, feet hitting the floor or hitting a ball with a racket). They include running, jogging, football, tennis, squash and hockey. You should also avoid exercises where you bend forward at the waist, such as
toe-touching and sit-ups. Good activities include walking, dancing, climbing stairs, swimming and resistance exercises. It’s also a good idea to do some exercises that improve your coordination and balance, to reduce your risk of falling. These include dancing, exercising to music and Tai Chi.
Peripheral neuropathy (nerve damage)
Some chemotherapy drugs can damage the nerves. This causes numbness or tingling in your hands or feet, muscle weakness or difficulty with balance and coordination. If your feet or balance are affected, then running or brisk walking (especially on uneven surfaces) may not be the best activity for you. Cycling or swimming may be more suitable. Remember to check your feet regularly for cuts or blisters.
Lymphoedema
If you have lymphoedema, always wear a compression garment when you exercise. Avoid doing lots of repetitive action with the affected limb. Swimming can be helpful if you have lymphoedema as it gently massages the lymphatic vessels. Ask your lymphoedema specialist for advice. Build up the physical activity involving that arm or leg slowly. We have a booklet about lymphoedema, which we can send you.
Heart or lung problems
Most people with heart or lung problems can benefit from regular physical activity. Check with your doctor or specialist before you start any exercise programme. Medicines to thin the blood If you’re taking medicine to thin the blood, you will bruise more easily. Avoid high-impact activities (see previous page), as you could get knocked or fall over.
References:
Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer
treatment: an American Cancer Society Guide for Informed Choices. CA Cancer J Clin. 2006;56:
Macmillan Cancer Support. Physical Activity and Cancer Treatment London. Macmillan. 23

24. Physical activity guidelines
Exercise is safe both during and after most cancer treatments
Patients are advised to avoid inactivity and return to normal daily activities as soon as possible after surgery, and during adjuvant cancer treatments
The standard age appropriate guidelines are also appropriate for cancer patients
Although no formal physical activity guidelines exist in the UK for people living with and beyond cancer, we can be confident that advising and supporting people living with and beyond cancer to gradually build up to the health-related physical activity guidelines for the general population are appropriate.
An excerpt from the American College of Sports Medicine round table consensus statement on exercise guidelines for cancer survivors supports this: ‘Exercise is safe both during and after most types of cancer treatment ... Patients are advised to avoid inactivity and return to normal daily activities as soon as possible after surgery, and during adjuvant cancer treatments. The standard age appropriate guidelines are also appropriate for cancer patients.’
The more recent expert consensus statement from the British Association of Sport and Exercise Sciences on exercise and cancer survivorship also highlights the importance of avoiding total inactivity for all cancer patients. Those with cancer complications or co-morbidities, which prohibit moderate-intensity exercise should nonetheless aim to be as active as their abilities and conditions allow.
References
Macmillan Cancer Support (2012). The importance of physical activity for people living with and beyond cancer: A concise evidence review.
ACSM Position Statement of Cancer:
BASES 2011: Conclusions and recommendations: 24

25. The potential biochemical pathways
Class of effector molecule
Effector molecule
Effects of physical activity on the effector molecule
Cell growth regulators
IGF1
IGFBP3
Decreased levels
Increased levels
Proteins involved in DNA damage and repair
BRCA1
BRCA2
Increased expression
Regulator of apoptosis and cell cycle arrets
p53
Enhanced activity
Hormones
Oestrogen
Vasoactive intestinal protein
Leptin
Decreased levels (indirect)
Immune system components
NK cells
Monoocyte function
Circulating granulocytes
Increased proportion
While the emerging literature base suggests that both self-reported exercise behaviour and objective measures of exercise capacity/functional capacity are associated with survival in select cancer populations, the underlying biological mechanisms remain to be elucidated. Postulated mechanisms underlying the potential effects of exercise and/or fitness on cancer progression include modulation of metabolic (e.g. markers of glucose–insulin homeostasis)
and sex-steroid (e.g. estrogens) hormone levels, improvements in immune surveillance, and reduced systemic inflammation and oxidative damage (McTiernan, 2008).
Exercise has also been shown to have a large impact on gene expression, although the mechanisms through which the patterns of gene expression are affected remain to be determined. In a recent study of the mechanisms through which exercise impacts prostate cancer survival, it was found that 184
genes are differentially expressed between prostate cancer patients who engage in vigorous activity, and those who do not. Amongst the genes that were more highly expressed in men who exercise were BRCA1 and BRCA2, both of which are involved in DNA repair processes.
The body’s chemical environment significantly changes after exercise. The precise chemical mechanisms, which the anti-cancer effect remains incompletely understood but one of the most likely mechanisms involving growth factors such as insulin-like growth factors and it’s binding proteins, due to the central role of these proteins in regulation of cell growth.
Another neuropeptide which changes after exercise is Vasoactive Intestinal Protein (VIP). Breast and prostate cancer patients have been found to have higher VIP titres compared to individuals who regularly exercise, and who have increased production of natural anti-VIP antibodies. In hormone related
cancers such as cancers of the breast, ovaries, prostate and testes, the association between high levels of circulating sex hormones and cancer risk is well established. Another mechanism through which exercise may affect cancer, is through decreasing the serum levels of these hormones. For
breast cancer survivors, the link between exercise and lower levels of oestrogen has been shown. An indirect, related mechanism is that exercise helps reduce adiposity, and adiposity in turn influences the production and availability of sex hormones. In addition, greater adiposity leads to higher levels
of Leptin, a neuropeptide cytokine with has cancer promoting properties.
Other pathways include the modulation of immunity, such as improvements in NK cell cytolytic activity; the modulation of apoptotic pathways through impacting on a key regulator, p5351, and an exciting recent discovery, the messenger protein irisin, which is produced in muscle cells in response to exercise and is found is to be an important molecule in linking exercise to the health benefits , However, we are only beginning to scratch the surface with these and the other mechanisms discussed here, and much more research needs to be done to in this area.
References:
Thomas, R.J., Holm, M., & Ali-Adhami, A. (2014). Physical activity after cancer: An evidence review of the international literature. BJMP; 7(1) 25
Thomas, R.J., Holm, M., & Ali-Adhami, A. (2014). Physical activity after cancer: An evidence review of the international literature. BJMP; 7(1)

26. Different visceral fat for the same BMI
More healthy
Less healthy
Favourable fat distribution among obese adults can be termed ‘metabolically healthy’
Prospective evidence indicates that healthy obesity is a state of relative health, not of absolute health (disease risks are intermediate between healthy normal-weight and unhealthy obese – but ‘healthy obesity’ usually defined as obesity in the absence of metabolic risk factor clustering, and does not usually consider visceral fat itself - some healthy obese adults do have favourable fat distributions, and their long-term health risks may be lower) A
Reprinted from Lancet Diab Endocrinol, Volume 1, Issue 2, Stefan, Häring et al., Metabolically healthy obesity: epidemiology, mechanisms, and clinical implications, Pages 152–162, Copyright 2013, with permission from Elsevier

27. Getting your patients more active
Research has shown that ‘permission’ from a healthcare professional can be an important trigger for activity
Lower mood/negative symptoms reduced motivation (need more support to take up/sustain PA)
Acknowledge impact of meds on tiredness/sleep/weight
Something is better than nothing!
Remember everyday activities eg shopping/housework/walking to shops count as PA: get support workers to encourage/accompany active behaviour rather than commissioning someone to do shopping/housework for the patient

28. Drivers of physical activity
Healthcare professional have potential for strong influence
Physical environment
Physical symptoms
Social network
Individual
Physical/health limitations, as well as availability of local assets will shape what is possible
Social relationships and support (or lack thereof) have a strong influence on behaviour
Individual identity, attitude to cancer and physical activity are key to how barriers work in practice
Physical environment
Social network
Physical symptoms
This is reinforced by qualitative research conducted by macmillan which identified the key drivers of being active.
Key finding was that an individual’s emotional response to cancer is key to whether or not they were active.
The second key driver relates to people’s relationships – the level of social support people had.
Physical symptoms – things like fatigue, consequences of surgery, etc. were less important, shaping what might be possible but not being the biggest influencer on behaviour
Finally – healthcare professionals had a significant role in the story – what they say, or more accurately what they don’t say about physical activity was a crucial driver in what people considered was appropriate, expected or normal for them as a cancer survivor. 28

29. In the UK, health care professionals are well placed to offer physical activity advice to cancer patients during their many interactions throughout treatment and observation at a time when a cancer patient may be motivated to make a lifestyle change. This has been defined as a ‘teachable moment’ which is usually the period following a significant health event.
THE TEACHABLE MOMENT
It has been suggested that to motivate behaviour change, a health event must
Increase perceptions of vulnerability to a health treat and that changing behaviour can address that treat
Be associated with positive or negative emotions which will increase the perceived meaningfulness of the event
Challenge an individual’s social role or self-concept.
It seems likely that a cancer diagnosis would satisfy this criteria.
Behavioural interventions capitalizing on the teachable moment have demonstrated success at promoting healthy behaviours. For example a nurse-led
intervention enrolling patients 2 to 4 days after admission to hospital for a cardiac issue significantly increased smoking cessation rates. Using intention to
treat analysis 50% were not smoking at 12months vs 37% in controls.
A US intervention by Vallance, Courneya, Taylor, Plotnikoff, & Mackey (2006), made use of print based materials for breast-cancer survivors.
A randomised control trial followed with 377 breast-cancer survivors randomised to three intervention arms. Only those not meeting the recommended guidelines for physical activity were eligible. Physical activity levels increased by 30-minutes per week at 12-week follow-up in those receiving a recommendation from a physician (control group); by 70-minutes per week in those using the guidebook (although not significant, p=0.12); and by 87-minutes per week in those using guidebook in combination with a pedometer (p=0.022). This combined group was the only cohort to see a significant improvement in quality of life and fatigue scores when compared to a standard recommendation (Vallance et al., 2007).
Healthcare professionals are uniquely suited to recommend and facilitate healthy behaviour changes.
18% of those involved in the PROMS Survey stated that they would have liked more information on physical activity. If they have received advise and information they are likely to have been ready to improve their physical activity levels.
A survey of 1011 people living with cancer in 2015 asked the question “who do you consider to be an expert in physical activity and cancer” – 76% said oncologists.
References:
Rabin, C. (2009). Promoting Lifestyle Change Among Cancer Survivors: When Is the Teachable Moment? American Journal of Lifestyle Medicine;3:369–78.
Chambers, R, Chambers, C and Campbell I (2000). Exercise promotion for patients with significant medical problems. Health Education Journal, 59 (90). DOI: /
Demark-Wahnefried, W. (2005). Riding the Crest of the Teachable Moment: Promoting Long-Term Health After the Diagnosis of Cancer. Journal of Clinical Oncology, 23(24), 5814–
McBride, C. M., & Emmons, K. M. (2003). Understanding the potential of teachable moments: the case of smoking cessation. Health Education Research, 18(2),
Rosenstock, I.M. (1974). Historical origins of the health belief model. Health Education Monograph. 8(2):
Behaviour change individual approaches. National Institute of Health and Care Excellence; 2014.
Department of Health. Improving Outcomes: A Strategy for Cancer. Second Annual Report. London: Stationery Office; 2012.

30. “To ensure everyone living with and beyond cancer is aware of the benefits of physical activity and enabled to choose to become and to stay active at a level that is right for them.”
VISION
Our vision is
“To ensure everyone living with and beyond cancer is aware of the benefits of physical activity and enabled to choose to become and to stay active at a level that is right for them.”
The level is patient centred and the message will be different depending upon the stage of the cancer journey. Something really is better than nothing.
Prevention & Diagnosis
Preventive -“build up to age appropriate physical activity guidelines”
Treatment & Recovery
Restorative - “reduce sedentary activity”
Living With and Beyond
Supportive - “build up to age appropriate physical activity guidelines”
End of Life
Palliative - “reduce sedentary activity”
We want to help people to move more.
How? By informing people about how physical activity can put them back in control using our experience, knowledge and the positive experiences of others. By giving them the confidence to embrace change and by encouraging and enabling them to reach for a better quality of life and by activating them through opportunities that provide the right level of movement just for them supporting them to do so.
Hopefully from today you see physical activity as a vital part of treatment and care, and can confidently recommend physical activity to people living with cancer.

31. Summary
Consider mentioning physical activity in all consultations A disease diagnosis does not = ‘become a couch potato’, need to stay active everyday ‘Moderate’ activity differs by individual- make it achievable
Give them
permission!

32. Available resources Free modules on physical activity
by Dr William Bird, GP
Free module on motivational interviewing in brief consultations by Prof Stephen Rollnick
English Physical Activity Clinical Champions Network
For clinicians
Physical Activity in England Forum
For researchers, policymakers, activists

33. Everybody Active, Every Day Be a clinical champion!
Everybody Active, Every Day (2014)