Posted on 28 Jan 19
By Dr Dane Vishnubala MBBS PGCME MRCGP DipSEM MFSEM DipSEM (UK & I) FHEA
With it being World Cancer Day, I am joined by some of the UK’s Physical Activity Cancer Experts to answer a few questions. Let me introduce you to them:
Dr Rebecca Robinson MBBS MRCP DipSEM (UK & I) MSc FFSEM
NHS and CHHP Consultant in Sport and Exercise Medicine with a Special Interest in Cancer and Physical Activity | Moving Medicine Cancer Lead. Web: www.movingmedicine.ac.uk
Jason Feavers MSc FRSPH
Health Professional Engagement Cancer Research UK | Physical Activity and Behaviour Change Specialist | Cancer Rehab Level 4 Instructor
Dr Anna Lowe BSc MSc MCSP PHD
Chartered Physiotherapist
Jason Minto BSc
Health Wise Manager GLL | Cancer Rehab Level 4 Instructor
Question 1: It's World Cancer Day and we are looking to find out more about the different health care professionals working in the field of cancer. Tell us about yourself and what you do?
Dr Rebecca Robinson: I am a consultant in Sports and Exercise Medicine. This relatively new, broad specialty is designed to help everyone to be as healthy and active as they can - from elite athletes to seriously ill patients. I have a role in elite sport but also work within the NHS as an exercise medicine consultant employed by the department of oncology in Sheffield Teaching Hospitals.
Jason Feavers: My original background was in the fitness industry. I spent over 15 years working in exercise referral roles which included managing an exercise referral scheme within a local authority public health team. During this time, I set up a cancer exercise scheme. I still instruct a weekly exercise class for people living with cancer. My current full-time role is working for Cancer Research UK as a Health Professional Engagement Facilitator. This involves working with health professionals, mainly within primary care, to improve cancer outcomes through earlier diagnosis and prevention of cancers.
Dr Anna Lowe: I'm a physiotherapist. Physiotherapists have a critical role in supporting people across the cancer pathway from the point of diagnosis, onward. The role of physical activity in cancer is being increasingly recognised and physiotherapists and support workers are well positioned to deliver personalised, progressive programmes that are safe and effective.
Jason Minto: I have spent the past 8 years developing my knowledge and qualifications in the healthcare sector, specialising in exercise referral. For the past 4 years I have coordinated the exercise referral scheme for the City of York; 3 years working with the council on the HEAL programme and for the past year working for Greenwich Leisure Limited (GLL) coordinating the Healthwise programme, its own exercise referral service.
Question 2: What are the most common cancers in the UK?
Dr Anna Lowe: According to Cancer Research UK, the most common cancers in the UK are breast, prostate, lung and bowel. These are increasingly being detected early due to advances in screening and early diagnosis, which improves outcomes.
Jason Feavers: These four cancer types accounted for 53% of all cancers diagnosed in the UK in 2015. Cancer survival is improving and has doubled in the last 40 years in the UK. More than half of people diagnosed with cancer in England and Wales survive their disease for ten years or more. Stage of diagnosis is a significant factor in survival rates. In the case of bowel cancer, if diagnosed at the earliest stage (stage 1) more than 9 in 10 people will survive their diagnosis for five years or more. If diagnosed at the latest stage (stage 4) less than 1 in 10 people will survive for five or more years. That's why it is so important to raise awareness of signs and symptoms of cancer and ensure patients have quick access to diagnostic tests and specific cancer pathways for diagnosis and treatment. National screening programmes exist for breast, bowel and cervical and are aimed at detecting potential cancers before any symptoms develop. For cervical and bowel cancer screening, the tests can also detect pre-cancerous changes that can be treated to reduce the risk of developing cancer in the future.
Dr Rebecca Robinson: As said by the others: Breast, prostate, lung, colon and melanoma skin cancer. There is strong evidence for physical activity in breast and colon cancer; also in prostate and current high-level research in all of these and lung, which will change the way we prescribe exercise. Melanoma is linked to sun exposure so actually we have to ensure people take precautions when they are involved in extensive outdoor sport, using sufficient sun protection. However, most people's activity levels in the UK are really low.
Question 3: What are the most important things you can do to reduce your risk of all cancers?
Dr Anna Lowe: Not all cancers are affected by lifestyle, but many of them are. To reduce your risk of getting these types of cancer it is helpful to do regular physical activity, to make healthy nutrition choices, to moderate your alcohol intake, avoid smoking, maintain a healthy weight and take care in the sun. The World Cancer Research Fund has produced some useful information on reducing your risk of cancer.
Jason Feavers: Around 4 in 10 cancer cases could be prevented, largely through lifestyle changes such as not smoking, keeping a healthy bodyweight, eating a healthy balanced diet, cutting back on alcohol, enjoying the sun safely and keeping active. Some cancers are more preventable than others. Lung cancer, bowel cancer, melanoma skin cancer and breast cancer together account for almost two-thirds of all preventable cancer cases in the UK. Physical activity is directly linked to reducing the risk of three cancer types (bowel, breast and womb). Being physically active can also help people to maintain a healthy weight, which is the second biggest factor for reducing cancer risk, with not smoking still being the most important thing you can do to reduce cancer risk.
Dr Rebecca Robinson: The best thing everyone can do for themselves is to look after their health as well as possible: being active, stopping smoking and being a healthy weight with a good diet. However, sadly many people have a higher risk, for example a genetic risk. You should have the screening tests like cervical screening that your GP will offer, learn for yourself how to spot the early signs and get a medical check if something isn't right. These are really important, because early detection of cancers saves lives.
Question 4: How does physical activity help those who have or have had cancer?
Dr Anna Lowe: Physical activity is really important across the cancer pathway, from the point of diagnosis onward. The evidence for "prehabilitation" that is, using the time between diagnosis and treatment to optimise physical and psychological wellbeing is building. Studies have shown that it can help to reduce time in hospital and improve treatment outcomes. Physical activity is also a critical part of rehabilitation after treatment, it helps to restore function so that people can get on with their lives and it also helps to optimise long term wellbeing.
Dr Rebecca Robinson: From 20 plus years of research: we think that it helps a lot. Cancer is not just one, but many diseases, and of course exercise has lots of types and benefits. So it is a complex area and the exact science is still evolving: we can't prescribe a 'dose' yet. But from what we know, exercise in cancer is really exciting: it can help in survival and we think in reducing risk of recurrence. It is a cruel fact that patients with a diagnosis of cancer have higher risk of other diseases too, which might be a result of their illness or a side-effect of important treatment, but in many cases, from risk of heart disease to diabetes, physical activity can reduce that risk. Exercise can help to strengthen the heart and lungs, build-back muscle, stimulate immunity... even fight fatigue, which is a major problem in the condition. What's more it makes you feel good, you can exercise with friends and family and it's something you can take back ownership of.
Jason Minto: In the Healthwise programme we facilitate a number of classes that help those living with and beyond cancer. These classes are both within a gym environment as well as community outbound classes. Exercise for cancer patients needs to be tailored to individuals and research shows activities that can help with fatigue, osteoporosis, weight loss and other specific benefits to patients. For example, Nordic Walking has been shown to help individuals with breast cancer, and the research evidence suggests that Nordic Walking, or similar pole walking, is a safe form of rehabilitation for individuals with breast cancer-related lymphoedema in the arm and may improve arm strength. Pole walking may also benefit muscular shoulder function in breast cancer survivors. In general there are very good reasons for exercising. It can improve your quality of life and help you feel better. Some studies show that it can help to speed up recovery after cancer treatment. Regular exercise can reduce stress and give you more energy, increase mood and help with fatigue.
Jason Feavers: Physical activity can help to alleviate many of the effects of cancer treatment. As well as psychological benefits, such as reduced anxiety and depression during and following treatment, physical activity can help manage fatigue, improve body composition and maintain bone density – particularly important for prostate and breast cancer patients on hormone treatment to reduce the risk of cancer recurrence. For bowel, breast and womb cancers, physical activity can reduce the risk of recurrence and a research study is ongoing, investigating the effectiveness of physical activity as a treatment for localised prostate cancer.
Question 5: How much physical activity should people with cancer be aiming for?
Dr Anna Lowe: Physical activity should be embedded across the cancer pathway and people with cancer should be supported to make activity a life-long habit. The amount that people can do will vary from individual to individual and will be influenced by where they are in their cancer journey. The general rules are to start small and build up gradually. People with cancer should aim to do moderate intensity physical activity. A general rule of thumb is that if you are getting a bit warm and a bit out of breath then you are working at moderate intensity. It's important to remember the role of muscle strengthening too, building in some challenge to your muscles each week will help to maintain strength, and this is critical in supporting healthy ageing.
The Chartered Society of Physiotherapy is supporting people with long-term conditions to be active through its ‘Love Activity, Hate Exercise?’ campaign. They have produced lots of useful resources to help people overcome barriers to becoming more active.
If you are having treatment or have recently finished, it is fine to start exercising if this is something that feels right for you… how much you do really depends on you. If exercise is new to you, then a slow progression would be the right way forward for you because you would need to build up gradually.
Jason Minto: NICE guidelines advise at least 30 minutes a day, 5 days a week, of moderate paced activity such as walking. This level of activity is helpful for people even during cancer treatment, but it must be noted that everyone is different and exercise needs to be tailored to the individual, taking into account their overall fitness, diagnosis and other factors that could affect safety.
Jason Feavers: The recommendation for activity levels for people with cancer is the same as the general population, but taking account of an individual’s effects of treatment and cancer diagnosis. The key messaging is that previous outdated advice to rest and conserve energy during cancer treatment has now been replaced with advice to engage in physical activity, as able, both during and following treatment.
Question 6: Are there any major things that people with cancer should avoid doing when taking part in physical activity?
Dr Rebecca Robinson: The benefits altogether outweigh the risks, but if you're concerned ask your health professional. We should as health professionals now be able to help individuals plan how to build up to overcome fatigue, how to train core and pelvic muscles after bowel surgery and get back to swimming after breast surgery.
If your blood counts are low, ask your doctor and take precautions to avoid infection such as extra hand hygiene and avoiding crowds, but you don't always have to avoid the gym. If you have a PIC line or stoma, don't be afraid to ask for advice.
If cancer has affected your bones, it's good to have a health professional's advice. During some types of chemotherapy, patients can be very sensitive to cold air, so having a buff or scarf over the mouth and throat can help.
Some people may have received drugs that can affect heart muscle, so measuring the heart's function to enable you to train and progress, can guide you and your doctors.
The bottom line here is that many health professionals, including specialist nurses, now have knowledge that exercise is good. If you're struggling to find the answers, or meet with negative ones, do ask for exercise medicine advice and our specialty is available on the NHS. And I can highly recommend the website http://www.cancerfit.me/site/index.php run by some great specialist doctors and fitness experts.
Dr Anna Lowe: The vast majority of people with cancer can engage in physical activity and it will improve their health and wellbeing. There are occasions when it's not recommended and in these circumstances, activity should be discussed with a member of the medical team. These include (but are not limited to) if you are acutely unwell, have a temperature, have new, severe or worsening pain.
Jason Feavers: This depends so much on an individual’s diagnosis and treatment. Pacing activity to manage fatigue is really important. Chemotherapy can suppress the immune system so there is often a need to avoid areas with an increased infection risk such as swimming pools, during chemotherapy cycles. If a central line is fitted for chemotherapy there are certain restrictions to activity to avoid the line getting dislodged. Specific advice should be sought on exercises to avoid or focus on following surgery and for patients with longer term effects of treatment such as a stoma, lymphoedema or chemotherapy induced peripheral neuropathy.
Question 7: What is, in your opinion, the key thing we need to change (or solve) to get people (on a large scale) more active?
Jason Feavers: From the perspective of health-related exercise including cancer, making exercise more ‘accepted’ for managing medical conditions would be the key thing to change. This includes providing more information and education to health professionals. Moving Medicine (www.movingmedicine.ac.uk) is a great example of how the Faculty of Sport and Exercise Medicine, Public Health England and Sport England are working together to provide resources to health professionals to address this. Medical colleges including FSEM and the Royal College of General Practitioners are also working to include training on exercise and physical activity within medical training programmes and through clinical champions programmes.
Supporting people to overcome barriers to physical activity is essential. There is sometimes an assumption that people are either motivated or not motivated to change. People are often ambivalent to change. They know there will be benefits of being more physically active, but have fears or concerns or other priorities that need addressing to support commitment to
change. We also need to focus on individual motivation and not assume that improving health will be the main motivator for someone with a medical condition to increase physical activity levels.
Improved confidence in the role of the fitness industry to work with medical referrals is needed, as well as more instructors completing exercise referral and level 4 specialist instructor qualifications. Ongoing reviews of the content of exercise referral and level 4 qualifications should include consideration of how to embed exercise instructors within NHS services and ensuring training provided is adequate for such roles. In sports medicine, multidisciplinary teams including clinicians, such as medics and physiotherapists, supported by non-clinical staff including strength and conditioning coaches and sports psychologists, provide the most effective treatment and return to full fitness for athletes within their care. A similar approach could be considered within the NHS incorporating specific pathways to health trainers and exercise instructors as part of treatment.
Dr Rebecca Robinson: We need to make everyone feel that being active is for them, and help people reach their goals. Many of the patients I see in the general oncology clinic know this and most wouldn't say that they are 'sporty.' They are active and want to do more, even later in their disease journey.
However, as health professionals we struggle to answer, or even ask, about physical activity in a busy clinic. Even though in the long run it could help our patients so much! I believe making activity accessible for all our patients is really important. Some patients could be active in the hospital, when it's waiting time for a clinic for example. We as health professionals need to make physical activity part of the conversation for all patients with cancer. However, many would like to do their activity away from their place of medical treatment, so I am not sure how feasible waiting room activities will be.
A fantastic charity called Move! has launched '5k your way,' where patients living with and after cancer diagnosis can join for 1, 2 or 5k-whatever they can do, within a growing number of Park Runs, nationally. Initiatives like these are brilliant, but we've a long way to go to reach everyone!
Dr Dane Vishnubala: I hope you found our interview with these cancer physical activity experts useful. With regards to useful resources, please check out the links below.
Resources:
As always do get in touch with us should you have any questions,
Best wishes,
Dr Dane Vishnubala | Active IQ Chief Medical Advisor
MBBS PGCME MRCGP MSc SEM PGCert (MSKUS) DipSEM (UK & I) MFSEM FHEA
@danevishnubala