Week 13- Exercise and Cancer

What are the five learning objectives of the Exercise and Cancer lecture?

1. Understand pathophysiology of common cancers.

2. Identify the cancer-care continuum and the role of exercise across it.

3. Identify cancer risk factors and exercise management.

4. Plan exercise and lifestyle changes to address risk factors.

5. Recognise exercise risks in cancer cohorts.

Lecturer emphasis: Individualise exercise to current and previous treatment and refer when risk exceeds exercise-scientist scope.

Why is exercise described as medicine rather than simply a fitness trend?

Exercise can help prevent disease and manage chronic conditions, including cancer. Benefits depend on the patient, current capacity and treatment risks; one exercise plan does not suit all patients.

DIAGRAM ON SLIDE 3

What is the scope of exercise medicine in chronic conditions?

Primary prevention: evidence for at least 35 chronic conditions.

Treatment/management: evidence for 26 common chronic diseases, including cancer.

Examples:

• Psychiatric: depression, anxiety, stress, schizophrenia.

• Neurological: dementia, Parkinson's disease, multiple sclerosis.

• Metabolic: obesity, hyperlipidaemia, metabolic syndrome, polycystic ovarian syndrome, type 1 and type 2 diabetes.

• Cardiovascular: hypertension, coronary heart disease, heart failure, cerebral apoplexy/stroke, claudication.

• Pulmonary: COPD, asthma, cystic fibrosis.

• Musculoskeletal: osteoarthritis, osteoporosis, back pain, rheumatoid arthritis.

How do normal cell division and apoptosis prevent cancer?

Healthy cells divide in a controlled way; injured, damaged or aged cells may undergo apoptosis (programmed cell death) or immune removal. This prevents abnormal cells from persisting.

DIAGRAM ON SLIDE 5

How can mutations lead to cancer, and what are the main causes of mutations?

1. DNA mutation occurs.

2. Some abnormal cells evade apoptosis and immune surveillance.

3. Apoptosis malfunction permits uncontrolled cellular growth.

Causes named: physical, chemical, biological, genetic, ageing and hormonal factors.

Examples from existing notes: UV radiation; tobacco/asbestos; infections; inherited predisposition such as BRCA-related risk.

DIAGRAM ON SLIDE 6

How do benign and malignant tumours differ?

Benign: non-cancerous, localised, often has a fibrous capsule, limited growth potential, regular shape and well-differentiated cells; does not invade or metastasise. Can still cause local harm (e.g. in brain).

Malignant: cancerous, characteristically invades surrounding tissues, may metastasise to distant sites, contains anaplastic/poorly differentiated cells and can cause death without treatment.

DIAGRAM ON SLIDE 7

Which six classes of cancer are named by the cell or tissue of origin?

• Carcinoma: epithelial cells (skin, body cavities, organs).

• Sarcoma: bone and soft tissues.

• Myeloma: plasma cells (antibody producers).

• Leukaemia: blood cells originating in bone marrow.

• Lymphoma: immune/lymphatic tissues (e.g. lymph nodes, spleen, stomach, testicles).

• Mixed types: several cell/tissue types.

Lecturer explanation: Oncology often treats solid tumours; haematology focuses on blood-related cancers. Treatment exposure is often more important than cancer name for exercise safety.

DIAGRAM ON SLIDE 8

What historical Australian cancer burden and survival figures are shown?

2021: 151,000 new cancer cases (413/day).

Five-year survival: 70%, up from 51% about 30 years earlier.

Approximately 49,000 annual cancer deaths (lecture estimate).

Common cancers in men: prostate, melanoma, colorectal, lung.

Common cancers in women: breast, colorectal, melanoma, lung.

Lecturer explanation: These illustrate burden rather than numbers to memorise; 5-year survival does not rule out later recurrence.

What seven cancer treatment options are identified?

1. Hormone therapy

2. Surgery

3. Bone marrow transplantation

4. Chemotherapy

5. Targeted therapy

6. Radiation therapy

7. Immunotherapy

DIAGRAM ON SLIDE 10

How do local cancer therapies differ from systemic therapies?

Local treatment principally targets a site: surgery and radiation therapy. Surgery may remove a tumour, biopsy, or debulk it; radiation effects depend on irradiated tissue.

Systemic therapies act throughout the body: hormone therapy, bone marrow transplantation, chemotherapy, targeted therapy, immunotherapy.

Lecturer explanation: Treatments may be given before surgery, after surgery or for a prolonged period; their short- and long-term toxicity matters for exercise.

DIAGRAM ON SLIDES 11-12

What acute side effects can cancer surgery cause?

• Pain

• Swelling

• Reduced range of motion (ROM)

• Inflammation

• Bleeding

Example: reduced shoulder/chest ROM after breast surgery.

What chronic side effects can cancer surgery cause?

• Persistent pain

• Loss of ROM and function

• Blood clots, including deep-vein thrombosis (DVT) and pulmonary embolism (PE)

• Lymphoedema

Exercise implication: Assess movement restrictions, swelling and thrombotic warning signs.

What are the acute side effects of radiotherapy?

• Fatigue

• Skin irritation and burns

• Hair loss

• Pain

• Loss of appetite

• Diarrhoea

What are the chronic side effects of radiotherapy?

• Secondary malignancy within radiotherapy field

• Cardiac or lung scarring

• Loss of ROM

• Fractures

• Fertility problems

• Incontinence

• Sexual-function issues

Lecturer explanation: Risks are related to the irradiated region, and may emerge long after treatment.

What are the acute side effects of chemotherapy?

• Nausea; vomiting

• Fatigue

• Diarrhoea; constipation

• Mucositis

• Myelosuppression

• Cognitive changes

• Weight gain or weight loss

• Peripheral neuropathy

• Muscle, bone and joint pain

What are the chronic side effects of chemotherapy?

• Cardiomyopathy

• Lung fibrosis

• Decreased bone mineral density (BMD)

• Chronic fatigue

• Myopathy

• Infertility

• Hearing loss

• Peripheral neuropathy

Lecturer explanation: The specific drug matters; past anthracycline exposure can have delayed cardiac consequences.

What does the highlighted treatment-toxicity table identify as particularly important for exercise screening?

Surgery: inflammation, bleeding; later DVT/PE and lymphoedema.

Radiotherapy: later cardiac/lung scarring, fractures and incontinence.

Chemotherapy: myelosuppression, peripheral neuropathy, muscle/bone/joint pain; later cardiomyopathy, lung fibrosis, myopathy and neuropathy.

Implications: Assess blood counts/bleeding, balance or sensation, heart/lung function and bone fragility, even in apparently well survivors.

DIAGRAM ON SLIDES 13-15

What proportions of cancer burden are attributed to modifiable factors in the lecture?

• 42% of cancer burden attributed to personal/behavioural risk factors, including smoking, overweight and inactivity.

• Smoking, ultraviolet radiation, body weight, poor diet and alcohol account for 90% of preventable cancers (lecture estimate).

Lecturer emphasis: These are opportunities for lifestyle risk reduction, while genetics and other non-modifiable risks also matter.

How are behavioural, biomedical and environmental cancer risk factors defined?

Behavioural: individual behaviours amenable to change, e.g. diet, tobacco smoking, alcohol.

Biomedical: physiological states that affect disease risk, e.g. diabetes or excess body fat.

Environmental: exposure to substances, pollutants or energies, e.g. UV radiation.

How should the Australian cancer risk-factor matrix be interpreted?

Rows represent different cancer types; columns represent risk factors grouped as behavioural, biomedical and environmental. Highlighted intersections identify recognised associations. The pattern differs by cancer type, so no single risk factor applies to all cancers. Physical inactivity, dietary factors, tobacco and alcohol are important in prevention discussions.

DIAGRAM ON SLIDE 17

How extensive was the evidence base summarised in the ESSA exercise-oncology position statement?

• 140 meta-analyses

• More than 150 systematic reviews

• More than 90 non-systematic reviews

Lecturer explanation: This illustrates a sizeable evidence base, but the appropriate prescription still depends on cancer and treatment characteristics.

DIAGRAM ON SLIDE 18

Which populations, cancers and stages are represented in exercise-oncology research?

Paediatric and adult populations; all cancer-care continuum stages.

Cancer types: breast, prostate, colorectal, lung, haematological, head and neck, gynaecological, brain, testicular, pancreatic and childhood/adolescent-specific cancers.

Lecturer explanation: Evidence is not equally extensive for rare cancers.

DIAGRAM ON SLIDE 19

What are the six main phases of the cancer-care continuum?

1. Prevention and risk reduction

2. Screening

3. Diagnosis

4. Treatment

5. Survivorship

6. End-of-life care

The continuum moves from acute through chronic to end-of-life care; exercise goals change across phases.

DIAGRAM ON SLIDE 20

Which activities belong to cancer prevention/risk reduction and screening?

Prevention/risk reduction: tobacco control, diet, physical activity, managing sun/environmental exposure, chemoprevention, immunisation.

Screening: age- and gender-specific screening and genetic testing.

DIAGRAM ON SLIDE 20

Which activities belong to cancer diagnosis and treatment?

Diagnosis: biopsy, pathology reporting, histological assessment, staging, biomarker assessment and molecular profiling.

Treatment: systemic therapy, surgery, radiation.

DIAGRAM ON SLIDE 20

Which activities belong to cancer survivorship and end-of-life care, and which supports span the continuum?

Survivorship: surveillance for recurrence, screening for related cancers, hereditary cancer predisposition/genetic assessment.

End of life: advance care planning, hospice and bereavement care.

Across all phases: care planning, psychosocial support, family/caregiver support, prevention and management of long-term effects and palliative care.

DIAGRAM ON SLIDE 20

What role does physical activity play in primary prevention of cancer?

The lecture estimates 30-50% of cancers may be preventable through behavioural changes.

Regular physical activity is associated with lower incidence of colon, breast, endometrial, lung, oesophageal, pancreatic cancers and meningioma.

A dose-response relationship is described between exercise and cancer prevention (especially discussed for breast cancer).

DIAGRAM ON SLIDE 21

What are the main goals of exercise during cancer diagnosis and active treatment?

• Preserve or improve physical function.

• Maintain body composition and cardiovascular fitness.

• Manage cancer-related fatigue and psychosocial distress.

• Help manage treatment toxicities: blood counts, peripheral neuropathy symptoms, cardiovascular changes, lymphoedema and chemo-brain.

• May inhibit tumour growth or improve chemotherapy tolerance (emerging evidence).

Lecturer explanation: Preserving baseline independence during therapy is itself a meaningful success.

DIAGRAM ON SLIDE 22

What association is described between physical activity and cancer recurrence/progression?

Higher activity after diagnosis/treatment was associated with lower recurrence than little or no activity in breast, colorectal and prostate cancer cohorts.

Prostate cancer progression showed an inverse association with walking speed and walking volume.

Lecturer explanation: These are associations, not guaranteed prevention of recurrence.

DIAGRAM ON SLIDE 23

What mortality associations are reported for higher exercise levels in cancer survivors?

The lecture reports 23-69% lower cancer-specific mortality risk in high- versus low-activity groups for breast, prostate and colorectal cancer.

Similar trends were reported for all-cause mortality.

Exercise before diagnosis may be associated with lower risk of death from breast and colon cancer.

Lecturer explanation: Evidence for rare cancers is less developed.

DIAGRAM ON SLIDE 24

What are appropriate exercise goals during end-of-life cancer care?

• Restore or maintain comfort.

• Preserve independence and autonomy.

• Reduce pain.

• Support psychological wellbeing.

Lecturer explanation: Goals need not focus on increasing fitness; independence, dignity and symptom relief can be the priorities.

DIAGRAM ON SLIDE 25

What is cancer-related fatigue (CRF) and how common is it according to the lecture?

The lecture estimates 90% of patients experience CRF. It can impair daily activities and persist long term; unlike ordinary tiredness, rest does not always resolve it.

Explain the downward deconditioning spiral in cancer-related fatigue.

Cancer-related fatigue → more rest/inactivity → loss of muscle → loss of fitness → greater fatigue → further inactivity.

Lecturer explanation: Even manageable activity such as a short walk can help interrupt this cycle.

DIAGRAM ON SLIDE 26

How can exercise reduce cancer-related fatigue and related symptoms?

• Maintain/improve muscle mass and fitness, making activities of daily living (ADLs) easier.

• Potentially reduce fatigue-associated inflammation and increase tolerance.

• Improve nausea.

• Improve mood.

DIAGRAM ON SLIDE 26

How do functional exercise goals change from cancer treatment to later survivorship?

During treatment: minimise decline in strength, functional capacity and cardiovascular fitness; preserve independent ADLs.

Years after treatment: recover strength and fitness towards premorbid levels; return to full activities/sport; improve function for ADLs and work.

DIAGRAM ON SLIDE 27

How does exercise help regulate body composition during treatment versus years later?

During treatment: complement dietary intervention for weight management; preserve muscle or slow deterioration; support body confidence.

Years after treatment: assist fat loss, rebuild lean muscle mass and reduce chronic disease risk.

Lecturer explanation: Corticosteroids and inactivity may alter body composition.

DIAGRAM ON SLIDE 28

Which psychosocial and quality-of-life outcomes can exercise improve in cancer care?

↓ Fatigue; ↓ nausea; ↑ fitness → ↑ ADLs; ↑ treatment tolerability; ↑ muscle mass → ↑ strength; ↑ body confidence; ↑ emotion and mood; ↑ endorphins; ↑ memory.

Lecturer explanation: Improvements in function and confidence can restore a sense of control; a cancer diagnosis does not automatically imply a need for psychological counselling.

DIAGRAM ON SLIDE 29

What treatment-related toxicities might exercise help manage?

• May protect against anthracycline-induced cardiotoxicity.

• May improve taxane chemotherapy-related neurological symptoms/peripheral neuropathy.

• Vascular remodelling may improve chemotherapy drug delivery.

• May improve cognitive function (chemo fog).

• May improve immune function.

Lecturer explanation: Some mechanisms and benefits remain emerging research and should not be treated as guaranteed effects.

What does the COSA position statement say about exercise during cancer care?

• Exercise should be prescribed as a routine part of cancer care.

• Discuss exercise as an adjunct to cancer treatment.

• Prescribe exercise to people with cancer.

• Refer to an exercise specialist experienced in cancer care.

Lecturer emphasis: Individual risk screening and appropriate referral are crucial.

DIAGRAM ON SLIDE 31

What exercise frequency is shown by the cancer exercise prescription graphic?

• Moderate-intensity aerobic activity: >3 × 30 min/week.

AND

• Muscle-strengthening activity: 2 days/week.

Lecturer explanation: These targets differ from the earlier generic 150-minute target; build towards them according to symptoms, treatment burden and capability.

DIAGRAM ON SLIDE 32

Which treatment-related red flags must be assessed before prescribing exercise in a cancer cohort?

• Cardiotoxicity (including prior anthracycline treatment)

• Bone mineral density loss and bone metastases

• Lung fibrosis

• Abnormal blood counts/myelosuppression and bleeding risk

• Peripheral neuropathy (balance/sensation/grip)

• Lymphoedema

• Post-surgical ROM loss

• Severe fatigue

Review current and past chemotherapy, radiotherapy and surgery; complications can persist or emerge after treatment.

How should exercise be adapted to cancer treatment side effects?

Tailor activities to current capacity, cancer treatment and toxicities.

Examples: address post-surgical ROM limitations; adapt for neuropathy-related sensory or balance loss; scale exercise for fatigue; avoid inappropriate loading with bone fragility; consider cardiopulmonary injury and blood counts.

Lecturer explanation: Seek specialist input when risks are unclear; medical clearance is not a substitute for ongoing clinical judgement.

What are the lecture's overarching takeaways about cancer and exercise?

• Cancer is a leading cause of death in Australia, and disease plus treatment creates substantial burden.

• The lecture estimates 30-50% of cancers may be preventable with lifestyle modification.

• Activity, diet and smoking cessation can reduce risk.

• Exercise contributes to prevention, care, rehabilitation and recovery.

• Safety, treatment history, individualisation and scope of practice remain essential; exercise scientists have a strong role in prevention.