Have you heard about how exercise and ADT should go together like sausages and bread? Research has shown exercise can help to reduce side effects of this treatment (without influencing the effectiveness of the drug). Prostate cancer, unfortunately, needs male hormones (androgens such as testosterone) to thrive, so one of the main types of drug therapy for this disease is androgen deprivation therapy (ADT). These medications aim to reduce or block the effect these hormones have. Whilst it can be an effective treatment, reducing the amount of testosterone in a man’s body does have a significant impact in the form of confronting side effects such as weight gain, loss of muscle mass and menopause-like symptoms. Here is a look at 6 different ways exercise can help you deal with treatment side effects:
1. Exercise and ADT: Improving body composition whilst on ADT
As a typical side of effect of ADT, men may notice an increase in abdominal fat and reduction of your muscle mass. However, did you know that exercise can lessen the change in your body composition? Research shows that if men complete 2-3 sessions of progressive resistance training per week, they will minimise the loss in muscle mass and strength. If men were taking ADT for a short time (3 months), a combination of moderate to high intensity aerobic and resistance training will help prevent changes in fat mass. However, if men are using ADT over a long period of time, they will have to also make changes with their diet to see changes in your fat mass.
2. ADT can impact your strength and endurance: Exercise can help!
ADT and the lack of testosterone can impact their day-to-day capacity/endurance and as such can affect their ability to do the fun things in life (playing with grandchildren, working in the shed, catching up with friends etc). The great news is exercise can help! Whilst it is not new that exercise can help keep everyone feeling fit and capable, the interesting thing is that the sooner men start/continue once ADT is commenced, the less ADT related capacity you stand to lose.
3. ADT can lead to excessive fatigue, but did you know exercise is one of the best treatments?
Due to the decline in androgen production (ie: testosterone) and other cancer-related issues, men may notice an increase in their fatigue levels. This may mean they do not feel as able or motivated to live life as they used to. Whilst it may be counterintuitive, research shows that progressive exercise (building up to 150mins per week) is arguably the BEST medical management strategy to reduce fatigue. That being said, it is important to learn how to regulate how much they do depending on how they feel. One day they may find the walk to the letterbox is moderately hard, whereas another day they may be able to complete a full 30 min moderate intensity brisk walk. Interestingly, the higher the fatigue levels, the greater the benefits from exercising.
4. Keeping the bones strong is really important when on ADT
Another side effect of ADT is a possible reduction in bone mineral density (and may even lead to osteoporosis and bone fractures). Preliminary research shows that at least 2 sessions of resistance training per week can mitigate losses in bone density. However, this exercise needs to be reasonably heavy and “impact” the bone – we want to challenge the bone enough to increase its density. We recommend that exercise is slowly progressed to this impact exercise so as not to increase the risk of injury.
5. Exercise can reduce your risk of other diseases whilst on ADT
Men are already dealing with a lot thanks to a prostate cancer diagnosis. SO it is important to note that due to the changes in hormone levels and a combination of other factors, there is an increased risk of developing other metabolic conditions such as type 2 diabetes, cardiovascular disease and high blood pressure in men on ADT. There is preliminary research showing positive changes in blood sugar, cholesterol and triglyceride levels. In other cancer populations, they have shown that exercise can provide a protective effect against the cardiometabolic diseases. So to reduce the burden, get on your bike!
6. Other side effects from ADT can be impacted by exercise
There are a few other benefits, which are fantastic for men on ADT! Did you know that new evidence suggests that exercise may help to preserve sexual activity and libido and lessen declines in sexual function? It may improve mood and reduce psychological distress, anxiety and depression. Finally, observational data suggests that is may even reduce the risk of dying from prostate cancer and even improve overall lifespan. If we could put all these benefits into a pill, would you take it?
The when, where and how of exercise for men undergoing ADT?
For many men, they are not exactly sure where to start, so here are a few ways:
You can visit an accredited exercise physiologist who specialises in treating those with cancer who can set you up with an individualized program. This will help give you the tools and knowledge to exercise and get the benefits from it.
There are a few online programs that can guide you if you do not want to or do not have the resources to visit an exercise specialist. Check out online!
If you are comfortable exercising on your own, you can get straight into it. Much of the literature prescribes 2-3 resistance training exercise sessions per week plus building up to 150 minutes of moderate intensity aerobic exercise per week (but remember that you do not want to go to hard to quickly – building up is the best way!)
Chemotherapy is prescribed to do a great number of things: to cure, aid other treatments, control the cancer, and help with symptom relief. It is a powerful tool, but as everyone knows, it brings with it a vast array of challenges, both during your cycles and after. But where does tailored exercise fit into this? Is it possible to stay active whilst undergoing chemo, and why on earth would you want to?
The plain and simple fact is that there is a growing body of evidence that shows tailored exercise during chemotherapy can reduce unwanted side effects, limit de-conditioning, AND now it is also being found to aid treatment. So, why are we not prescribing exercise like a drug? Why are we still not using it to its potential? Well, let’s talk about the benefits first…
1. Exercise creates a reduction in chemotherapy related neuropathy symptoms
Neuropathy is a relatively common side effect of chemotherapy. Essentially, it effects the hands and feet, creating symptoms like numbness, tingling and pain, cramping, difficulty handling small objects, and issues with gait and balance. Unpleasant! Multi-modal exercise, such as resistance exercises coupled with low to moderate intensity aerobic exercise like walking, creates significant reductions in both the severity and prevalence of neuropathic symptoms. Now that sounds to me like a pretty useful treatment!
2. Exercise reduces cancer related fatigue
Chemotherapy is associated with a crippling fatigue, known as cancer related fatigue. This can have a sudden onset and can impose a significant physical burden. It is also psychologically draining as it often means you are unable to do the things you love, and can impose a financial burden due to missed days as work. There are now hundreds of studies that show that exercise reduced fatigue levels. If you would like to know more, read my previous blog “Cancer related fatigue: Does exercise help or hinder?”
3. Exercise reduces de-conditioning
Research has shown that the loss of rapid muscle mass is accelerated 24-fold during chemotherapy in comparison to healthy people. It is no wonder people undergoing chemo feel fatigued when they lose so much muscle, so quickly. Luckily we have a treatment for that! Specific resistance training has shown to minimise this loss of strength. Completing targeted strength training means that carrying your children, doing the shopping, getting out of the car doesn’t become so fatiguing. That has to improve your quality of life.
4. Exercise reduce risk of cardiovascular disease
Due to the direct toxic effects of anti-cancer therapies as well de-conditioning, people undergoing chemotherapy have a risk of developing cardiovascular diseases such as heart failure, stroke, and coronary heart disease. A study in 2016 found that post-diagnosis exposure to exercise was associated with substantial reductions in newly diagnosed cardiovascular diseases or cardiovascular related death. That is massive!
5. Improved completion rates of treatment
Now, oncologists provide treatment doses based on what they think will create the best chance on achieving the treatment goal. However, completion can depend on how well you can withstand the treatment and it’s side effects. So, given that exercise therapy can reduce general pain levels, cancer related fatigue, and neuropathy it makes sense that it allows more people to fully complete treatment. This can give you the best chance of survival!
6. Exercise reduces risk of death
If you exercise when diagnosed with cancer, you will reduce your chance of dying. I know that is a massive statement, but a review of 71 studies in 2015 found that exercise was linked to reduced mortality in breast, colorectal, and prostate cancers (those were the only cancers these studies focused on). In one of those studies they found mortality reduced by 24%, 32%, 39% and 40% when individuals participated in low, moderate, vigorous and very vigorous activities respectively. What they essentially found was that there was a dose response relationship with exercise and mortality. Therefore, some exercise is definitely better than none and more is better than less. It depends on personal side effects of your chemotherapy treatment.
7. There are always caveats to exercising whilst undergoing chemotherapy
It is important to be aware of the caveats to exercising while undergoing chemotherapy. Exercise must be tailored to the current functional status and capacity of each individual patient and then must be progressed and regressed based treatment cycles. Overstretching areas around catheters should be avoided. Stoma’s should be cleaned before and after sessions and if you are feeling feverish. It is also important to monitor acute changes in your pain levels, gastrointestinal disorders (nausea, vomiting diarrhoea etc), changes in heart rate, and blood pressure and breathing rates.
As we mentioned, exercise prescription must tailored to the current functional status and capacity of each individual patient. Typically you can exercise directly after each chemotherapy dose but usually once side effects really hit, intensities will need to be modified. For the same reported feelings of exertion, your exercise may change from being able to jog around the block, to being able to walk to the mailbox. Then, as you progress through your cycle, your intensity can increase. Just remember, exercise may sometimes feel like the last thing you want to do, but just like any good medicine, it will help when prescribed appropriately!
If you have any questions regarding how and when you can use exercise, please feel free to contact Holly on 8431 2111.
It can be really hard to be motivated to exercise. Much like most people in today’s society, we throw ourselves into a fast paced world where work, family and life are not always balanced. We are typically overtired, our to-do lists overflow and we tend to still say yes to things we maybe shouldn’t. On top of all this, we get told we need to look after ourselves. Eat well, move often, become more mindful etc etc. It is seriously tough stuff!
I know I should but I just don’t feel motivated to exercise!
I have recently gone back to study and I find myself sitting long periods attempting to use my brain (it’s hard work). By the end of the day, I am worn out. I am not sure what you feel like, but I feel like I have run a marathon. All from the confines of my small desk. Although I preach the joy and benefits you get from moving your body, to be honest sometimes it is the last thing I feel like doing. I want to go home, tick off annoying to-do list items and then if I have time I watch Netflix and cuddle with my dog.
Here comes the big but! I am a member of a pretty rocking hockey team and we train consistently on Tuesday and Thursday nights. So, no matter the weather, or how tired I feel, I peel myself off the couch and head out.
The tide turns once I move my body!
During the first 5 or so minutes, I am still not super excited to be running around but then a miracle happens. Slowly, I start feeling better, my energy returns, I don’t feel miserable and I am actually happy. We all tend to leave training in a better mood. I get home and tick off some to-do items and then I happily pass out for the night. I sleep really well, not only because exercise helps regulate my circadian rhythm, but because I know I have made my 10,000+ steps.
Acute changes to exercise: It is not a miracle, it’s science baby
Exercise acts directly on our central nervous system to increase energy and reduce fatigue. Notably, the improvements in energy and fatigue are not related to increases in aerobic fitness.
When your heart rate increases acutely it increase the brain’s blood supply. This makes you more alert, enhances your motivation to complete focused tasks, and improves mental clarity. It even creates neurons!
Acute stress levels decrease post one exercise session thanks to increases in hormones that makes us feel awesome (serotonin, norepinephrine and dopamine). If you want to know more, read Jacinta’s blog on exercise, mood and stress.
Also, psychologically we have achieved a mini-goal of exercising for that day so our confidence thanks to our sense of accomplishment (cue no internal guilt trip)
Some tips to help you beat the motivated to exercise fatigue barrier?
Get into your active wear. It helps.
Even if you don’t smash it, just show up. Something is better than nothing and you never know, it may become amazing.
Ask yourself: Are you really exhausted or are you just tired (exhaustion may need sleep, tiredness/fatigue may need exercise)?
Have an appointment – whether that is a group class, a specific time in your diary, an appointment with your EP/PT.
Think about what you will feel like both during and after. You won’t regret it!
During one of the group classes last week, I was engaged in a delightful conversation about a client’s 70th birthday. He was shocked he was turning the big seven-zero and when asked why he just responded…“Because I don’t feel it.”
Interested, we prodded him further, “well, how old do you feel?”
“I don’t know, I feel like David!”
The outcome of this conversation was a thought provoking statement. Training for him was not about getting stronger but more about enjoying retirement. Essentially, he now feels like he has a new lease on life. He never believed he would enjoy retirement as much as he does and he puts this down to staying mobile, strong, and injury free.
The road to retirement
From the age of five (give or take) where we start our official schooling through to the upper echelon of our middle age, we are expected to work in some shape or form! Apart from some in their twenties who go exploring, we are usually tied down to the monotony of work life. We all sit at our desks day-dreaming about the life we are going to have when we retire. However, we almost forget that when we arrive to this magical destination, we are 60-70 years of age. Over that time our bodies have been ignored, battered, bruised, sat sedentary and fed truckloads of processed foods.
In our field, we tend to see 60 to 80 year old clients with conditions such as osteoarthritis, diabetes, obesity, and heart conditions. All of whom still want to get out and live out their retirement dreams. Not just sit on a couch watching re-runs of “The Bold and the Beautiful”. However, the condition that their body has arrived to retirement in has made this difficult (but not impossible).
So how do we do we move well enough to start ticking things off our bucket lists?
Training for retirement – when you are retired!
Never fear! Just because you have spent a majority of your life working and caring for others doesn’t mean you may as well give up and switch the TV on. A majority of people want to walk around Europe, become grey nomads and see amazing sites like Machu Picchu. This involves feeling comfortable climbing stairs, walking long distances, balancing on uneven surfaces.
Hopefully we get to experience the joy of being a grandparent. Being about to get up and down off the ground, pick them up when they want a cuddle and kick a ball around the back garden is very difficult when you are not fit and active. Add to that, keeping a nice house and garden without aggravating injuries is a pretty big deal.
So therefore, we need to ensure we have adequate aerobic capacity to move for long distances. We need strength in our glutes, quadriceps, trunk and the list goes on to climb, hop and carry all sorts. Lastly, we know balance and reaction time does decrease with age so we need to challenge it (safely) as often as we can. We need to move well to retire well!
It is never too late to start!
Training for retirement – while you are still working!
Why wait till we get there to deal with the implications of a taxing work life? Improving your movement capacity and remaining injury free doesn’t just mean love retired life. It means you can love life in general! But it also means you can love life in general. Increasing your muscle strength, fitness and mobility ensures you can complete day to day life with decreased amounts of fatigue, you can hike without pain, you can umpire your children’s soccer games. Seriously, what more can you ask!!
Have you ever been too tired to walk up your stairs, eat, or even go to the toilet? Welcome to the life of individuals with cancer related fatigue.
Fatigue is one of the most common and debilitating side effects of cancer treatments that presents itself before, during, and after treatment. A 2007 study found that 80-90% of people undergoing radiotherapy and chemotherapy reported experiencing incapacitating fatigue. Of those, approximately 91% felt they could not lead a normal life, participate in social activities or perform simple intellectual tasks. 75% had to change employment status and 65% needed their caregivers to take at least one day off per month. Worse still, many of these people can suffer similar symptoms long after the treatment has ceased.
What is cancer related fatigue?
Cancer related fatigue is unlike anything the apparently healthy individual has usually ever felt. The sense of utter exhaustion that you feel is disproportionate to the amount of effort produced. For a once fit individual, that can mean that a walk to the letter box produces the fatigue levels that are only imagined after completing an Ironman event (1 x 3km swim, 1 x 180km bike ride topped off with a marathon). The most disconcerting thing about cancer related fatigue is that rest or sleep does not always help alleviate symptoms. On top of that, because the causes are not well understood, treatment is not always straight forward.
If that is that case, shouldn’t I rest rather than exercise?
Well this is where it gets interesting! Research has now shown that exercise should be used as part of a patient’s oncology treatment schedule. Not surprisingly, results show an increase in strength and capacity, especially in cases of breast, prostate, haematological, and colorectal cancer. However, one of the unexpected outcomes of these studies has been the effect of exercise on fatigue levels. It was first measured due to concern that exercise would exacerbate cancer related fatigue levels, BUT the results proved very interesting… It in fact showed the opposite!
A systematic review from South Australia showed that out of the 47 studies identified relating to exercise and cancer related fatigue, 32 found exercise to significantly reduce cancer related fatigue! In fact, there were no significant studies that didn’t favour an exercise intervention for improving cancer related fatigue.
So… exercise reduces your levels of cancer related fatigue!!
How exactly can exercise help?
As there is still no single definitive cause of cancer related fatigue, determining the physiological reasons as to why exercise is so effective is pretty difficult. When you begin treatment, just the thought of exercise would probably make you feel exhausted. However, if we look at the flip side, we know that without a doubt inactivity leads to increased fatigue. Exercise reduces the distance you can walk without puffing and also the amount you can lift. So therefore, movement allows you to complete all those activities quicker and for a longer period of time.
There are also theories around surmising that resistance training can prevent the dysregulation of our immune system and helps maintain our energy currency (ADP). All of which can be disrupted when we begin muscle wastage. Big words I know! The main take away message is that moderate exercise can increase your capacity to function, improve your quality of life, decrease risk of depression and anxiety, and decrease cancer related fatigue!
What exercise should I do to reduce fatigue levels?
Before we answer this question, I would like to make a caveat… The definition of exercise (and its intensities) is very broad. What a healthy individual calls exercise can be different to what someone undergoing treatment or who is now a survivor does. Also, no two cancers are the same and so no two exercise prescriptions are the same. It should be based on factors such as your cancer diagnosis, side effects, and treatment type, timing and trajectory. Plus your age, current activity levels prior to diagnosis and previous injuries and illnesses.
With all that in mind, research has shown that a combination of both types of training is recommended for you during and post treatment. So far the evidence says that best case scenario is twice a week progressive (60-80% 1RM) resistance training (lifting/moving heavy objects). Adding to two-four times of moderate aerobic (huff and puff) exercise (40-60% max). If you have just undergone a chemo cycle that may be 2 x 5 minutes of a home-based program. This may include sit to stands, wall push ups and a single leg dead lift. If you are feeling strong that maybe 2 x 45 minutes of supervised gym using weights.
Do I need to train throughout my whole treatment?
Interestingly, timing and duration of the activity may be important since one of the biggest effects on fatigue was observed when the exercise intervention lasted until the end of the treatment. So, ensuring you move throughout the entire treatment period/s can decrease your cancer related fatigue by up to 50%. That could mean the difference between getting to the toilet, being capable to watch your children play sport, or even feeding yourself.
If you are unsure about how to begin or keep exercising as you undergo treatment, please feel free to give us a call or an email and we are happy to chat!
Brown 2010, Efficacy of Exercise Interventions in Modulating Cancer-Related Fatigue among Adult Cancer Survivors: A Meta-Analysis. The Journal of Cancer Epidemiology and Biomarkers
Curta et al 2000, Impact of Cancer-Related Fatigue on the Lives of Patients: New Findings From the Fatigue Coalition. The Oncologist vol. 5 no. 5 353-360
Maloney, L 2016, A summary of meta-analytic evidence on the impact of exercise on cancer related fatigue: An umbrella review.