Exercise and Cancer Research: Setting New Standards, Giving Patients Control

When someone would ask Harriette Royer if she was interested in joining a gym, her answer was usuallythe same: “Oh no, that’s not for me.”

Then cancer showed up and her thoughts changed. Royer volunteered for a Wilmot Cancer Institutestudy testing the value ofstrength training and walking during breast cancer treatment. Exercise contributed to her healing, she says, and now she’s a true believer.

In the five years since her diagnosis, Royer has been taking Pilates and yoga classes and walking to work. She’s an assistant director of career services for the Warner School of Education at the University of Rochesterand her daily jaunt, no matter what the weather, takes herabout a milefrom the city’s 19thWard to her UR office.She even purchased a pair of those funky FiveFinger shoes by Vibram.

“I’m that person who parks the farthest away. I take the stairs and I take walks in and around my building to increase my mileage.I just keepmoving,” Royer says. “It’s very important for me to keep my spirits up and stay healthy.”

Not only is Royer on the right path butshe’s in the right place—Rochester is a leader in the field of exercise oncology. Theprogram at Wilmot was founded byKaren Mustian, Ph.D., M.P.H., anindustrypioneer who has since mentored a cadre of junior scientists who are also studying the benefits of physical activity when cancer strikes.

Scienceis proving that exercise is an inexpensive, non-toxic way toalleviate the crushing fatigue that often accompanies cancer and its treatment, or to reduce sleep disturbances, brain fogginess, neuropathy in the limbs, or anxiety, for example.

“People tend to naturally think of taking a nap, or getting extra cups of coffee, or a pharmaceutical solution, if they’re feeling extra fatigue,” saysMustian,an associateprofessor in the URMC Department ofSurgeryand a Wilmot investigator since 2003.

“It’s very hard forcancerpatients and the medical community to wrap their heads around exercise because this intervention has not been front-and-center in the past. Nearly 15 years ago when we started this work a lot of people believed it wasn’t safe for most cancer patients to exercise,” Mustian recalls. “Now we know it can be safe when done correctly, and that it has measurable benefits.”

Building a powerhouse

Thegood news is thatcancer patients need not run a 5K, play vigorous sports, ortake part in strenuousclasses to benefit. Gentle walking, gentle yoga poses or stretching, and using elastic resistance bands athome, for example, are enough to help a person maintain strength and physical activity throughout chemotherapy or other treatments.

The hardest part is convincing people who do not exercise to buy into it,Mustian says, particularly when a newly diagnosed cancer patient is tired and overwhelmed with information.(Approximately 80 percent of the peoplewho’ve enrolled in Wilmot’s exercise studies are sedentary.)The field of cardiology was in the same position as cancer many years ago, but today exercise is usually expected and prescribed as part of rehabilitation after a heart attack.

Asthecancercommunitymarches toward similar goals,Mustian andcolleaguesareinfluencingthechanges.Wilmot’sExercise and Oncology Research Programisregularly featured at national meetings, anda recent studyfrom Mustian’s groupwas published in the high-impact journalJAMA Oncologyand featured on NBC Nightly News with Lester Holt.Because of its unique structure,the teamalsohas the capability to work with cancer clinics across the country, enrollinghundreds ofpatientsin large, randomized studiesto test innovative new approaches to care.

The exercise researchers arepart of theWCI Cancer Control and Survivorship Research Program, co-directed by Mustian and Gary Morrow, Ph.D.Primaryscientistsinclude Calvin Cole,Ph.D.;Richard Dunne,M.D.;Fergal Fleming,M.D.;Chunkit Fung,M.D.;MichelleJaneslins,Ph.D.;Charles Kamen, Ph.D.;IanKleckner,Ph.D.;Po Ju Lin, Ph.D.;Melissa Loh,MBBch;Supriya Mohile,M.D.,and Luke Peppone, Ph.D.

“Our program at the University of Rochesteris becoming a real powerhouse inexercise oncology,nationally and internationally,” says Mustian, noting that exercise as a way to control cancer’s side effects is also aresearch priority for the NationalCancerInstitute.​

Results of several large Wilmot studies discovered that:

• Exercise and/or behavioral-change therapy works better than medicationsto reduce cancer-related fatigue, the most common side effect during and after cancer treatment.

• Simple, low-cost exercise such as walking reduces chronic inflammation and protects against cognitive decline, known among patients as “chemo-brain.”

• Exercise reduces neuropathy (shooting pains, tingling, numbness, sensitivity to cold) in hands and feet, particularly in older cancer patients.

• Yoga benefits cancer patients by improving fatigue, anxiety, stress, depression, insomnia, memory loss, musculoskeletal pain, and overall quality of life.

• Only four weeks of walking and resistance-band strength training during radiation therapy results in better fitness and less fatigue.

• Tai chi is effective for improving self-esteem, physical function and quality of life in breast cancer survivors.

The bedrock of many of Wilmot’sclinical studies istwospecialized, copyrighted exercise programs developed by Mustian:EXCAP (Exercise for CancerPatients)and YOCAS (Yoga for Cancer Survivors). They were designed for any ageand can be adapted to nearly any situation. Inaddition, research participants are evaluated at URMC’s PEAKHuman Performance Lab, also foundedby Mustian. The Lab measures a patient’s metabolism, heart and lung function, range of motion, strength, balance,functional capabilitiesand other outcomes such as inflammation and gene expressionbefore, during, and after treatment.

“The fact that we can take a person who’s never really exercised and get them moving during cancer treatment is really remarkable,” Mustian says.

Teachable moments

Despite the strides made, however, a lot of questions are still unanswered.Should exercise be doledout in personalized doses,like medications? Is more necessarily better? What biological pathways are impacted by exercise in a cancer patient? And, what about timing?

Wilmot surgeonFergal Fleming, M.D., observed something that sparked his interest in the timing question.Flemingcorrectsbowel disorders, including colon and rectal cancer and non-cancerous conditions such as Crohn’s disease. In a pilot study he tracked a small number of patients who were minimally active before surgery, taking about 4,000 steps a day, and discovered that their activity level plunged to 1,800 steps a day after surgery, with no improvement over the next four weeks. (Healthy people need to walk about 5,000 steps daily to be considered low-active, 7,500 steps to be somewhat active, 10,000 steps to be activeand 12,500 steps to be highly active.)

Fleming says that three months after surgery, 30 percent to 40 percent of adults stillaren’tback to their pre-operative fitness level.

This concernshim and he wondered: If a patient starts an exercise program in the days and weeks leading up to surgery, can you reduce the fitness plunge and improve outcomes?

He designed a formal study, which will be enrolling patients for the next year, to assess the impact of exercise on patients undergoing colon and/or rectal cancer surgery. Most of his patients receive chemotherapy or radiation before surgery, and then recover for about eight weeksprior totheir operation. During that eight-week rest period, the study participants are offered a version of the EXCAP program that includes in-home strength training and walking.

So far, Fleming says, the patients who’ve signed up are enthusiastic. They range in age from the 30s to 80s. His objective is to find out if individualswho exercise during the rest period have better surgical recoveries and are in better shape—both physically and psychologically—to cope with a second round of chemotherapy after surgery.

“People are overwhelmed with information when they learn they have cancer and talking about exercise can seem like just one more thing,” Fleming says. “But ironically, people are also more open to lifestyle changes at the time of diagnosis. They want to know what they can do to improve their outcome and they want a sense of control. I look at this as a teachable moment.”

Fleming also believes that for many people, such as Royer, exposure to exercise while sick will have a lasting effect.

A perfect gift

Some cancer patientsdon’t need to be sold on exercise because they’ve always done it.

Joe Mercik, 42,an Irondequoitresident and former professional soccer player for the Rochester Rhinos, did strength training, sit-ups and push-ups at home throughout his chemotherapy treatment for testicular cancer in 2010.Exercise has defined him since he was a youngster, he says, and it still gives him energy, focus, confidence, and motivation.

These days, he sometimesexerciseswith his two small children, Luke, 3,and Harleigh,1,in tow.

“Staying positive through the diagnosis, treatments, and post therapy is vital to beating this terrible disease,” Mercik says.“Exercise and physical fitness is a close second.It helped me prepare for what was ahead, and gave me strength and courage.”

The same is true for another young patient, Amy Schnitzler, 27, of Henrietta, who recently completed several rounds of chemotherapy for metastatic breast cancer.She was afrequent five-mile-a-day outdoor runner before she was diagnosed with cancer in 2016,andSchnitzler’s family chipped in and bought her a treadmill to use indoors when she wasn’t feeling wellenough to go outside.

“It was so awesome,” she says. “A lot of times people don’t know what to do or say when someone they love has cancer, but this was the perfect gift.”

During treatment she walked orjoggedslowlyon the treadmill, and on her worst days she did simple stretches to keep the blood flowing.As she regains strength, she has her eye onkick-boxing class.

“I exercise to feel like myself,” Schnitzler says. “One of the biggest things I felt after the cancer diagnosis was a huge lack of control. And my recurrence was dismantling. I needed to be able to say: I can control the food I put into my body and I can keepmoving. I can participate in myownhealth.’ “