Patient Preference And Timing For Exercise In Breast Cancer Care
Treatments for cancer vary and depend on many individual factors. However, there is one universal recommendation for cancer patients: avoid inactivity (1). Several national and international agencies recommend exercise participation for all persons following a cancer diagnosis. It is safe, reduces fatigue, elevates mood, and increases general well-being. For some cancer patients, particular types of exercise may be more advantageous than other types of exercise.
For breast cancer patients, consistent aerobic exercise (walking briskly, going up stairs, using a bicycle, etc.) is important because activities that increase heart rate also increase fitness level. Many breast cancer patients have a low fitness level when they are diagnosed, and fitness level can decrease further due to cancer treatment. Fitness level is highly predictive of cardiovascular death, and breast cancer survivors have an increased risk of heart failure and coronary artery disease compared to women whom never had breast cancer.
One cancer treatment known to damage the heart and blood vessels is the cardiotoxic chemotherapy drug doxorubicin, or its brand name, Adriamycin®. Animal studies have shown that exercise prior to receiving cardiotoxic chemotherapy protects the heart from damage. Therefore, we asked breast cancer patients if they would be interested in an exercise program that was complementary to their traditional breast cancer care. Breast cancer patients already face significant burden with traditional treatment plans, thus it was unknown if women would be interested in an additional therapy, or if there were windows of opportunity were time was available to prescribe a meaningful exercise program.
Sixty-seven newly diagnosed breast cancer patients completed our questionnaire. The questionnaire consisted of 4 multiple choice questions. Women were asked if they would be interested in participating in an exercise program before chemotherapy initiation (should chemotherapy be recommended), if they would be willing to put off their chemotherapy treatment (should chemotherapy be recommended), who they would like to hear information about exercise programming from, and when they would like to know information about exercise programming in relationship to their cancer treatment.
Most women absolutely wanted to or were interested in participating in an exercise program before treatment (76.2%). As exercise initiated before cardiotoxic chemotherapy and radiation may be beneficial, we asked women if they would be willing to delay their treatment in order to implement an exercise program as part of their clinical care. Forty-nine percent of the study cohort was amenable to delaying treatment, with the important caveat that they would only put off treatment if their physician recommended doing so. A physician may not need to be the gatekeeper to deliver detailed exercise programming information though, as 58.5% of participants would be open to hearing such information from a cancer exercise specialist. Lastly, the majority of women were interested in receiving the information about exercise programming in their cancer care when they were diagnosed (61.9%), compared to when they were first told about an abnormal screening (15.9%), or compared to hearing this information yearly from their gynecologist (22.2%).
Given breast cancer patient interest in exercise programming before treatment, and the preference for this modality to be introduced at cancer diagnosis, we investigated the length of time between diagnosis of breast cancer and initiation of cardiotoxic chemotherapy. After chart review of 500 random patients diagnosed with breast cancer and treated at the University of Pennsylvania, we found that 14.4% of breast cancer patients received cardiotoxic chemotherapy (doxorubicin/Adriamycin®) following their surgery. On average, there were 72.6 ± 34.6 days (median 68 days, range 17-164 days) between cancer diagnosis and initiation of cardiotoxic adjuvant chemotherapy treatment. No clinical trial to date has been done to investigate whether exercise and increasing fitness level prior to chemotherapy initiation is effective in preventing damage to the heart from cardiotoxic chemotherapy. However, studies in humans have shown that as a little as 4 weeks (28 days) of consistent exercise can improve how the heart works and cause cellular changes that may protect the heart from damage caused by cardiotoxic chemotherapy.
These findings are described in the article entitled Patient preference and timing for exercise in breast cancer care, recently published in the journal Supportive Care in Cancer. This work was conducted by Kathleen M. Sturgeon and Kathryn H. Schmitz from Pennsylvania State University and Carla Fisher, Gina McShea, Susan Kruse Sullivan, Dahlia Sataloff from the University of Pennsylvania.
- Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and science in sports and exercise 2010;42(7):1409-26