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Clinicians Should Actively Promote Exercise in Survivors of Breast Cancer
Accepted Manuscript Clinicians should actively promote exercise in breast cancer survivors Ayush K. Kapila, MBBS(Lond) MRCS, Moustapha Hamdi, MD PhD, Ashraf Patel, MS FRCS PII:
S1526-8209(18)30124-1
DOI:
10.1016/j.clbc.2018.06.008
Reference:
CLBC 823
To appear in:
Clinical Breast Cancer
Received Date: 10 March 2018 Revised Date:
1 June 2018
Accepted Date: 11 June 2018
Please cite this article as: Kapila AK, Hamdi M, Patel A, Clinicians should actively promote exercise in breast cancer survivors, Clinical Breast Cancer (2018), doi: 10.1016/j.clbc.2018.06.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
Authors:
Moustapha Hamdi MD PhDb
a
TE D
Ashraf Patel MS FRCS a
M AN U
Ayush K Kapila MBBS(Lond) MRCS a,b
SC
RI PT
Clinicians should actively promote exercise in breast cancer survivors
b
AC C
EP
The Breast Unit Princess Alexandra Hospital Amstel Road Harlow United Kingdom CM20 1QX
Department of Plastic Surgery University Hospitals Brussels University of Brussels (VUB) Laarbeeklaan 101 1090 Jette
Keywords: breast cancer, exercise, recurrence, treatment adherence, group therapy, individualised therapy
ACCEPTED MANUSCRIPT
ABSTRACT
AC C
EP
TE D
M AN U
SC
RI PT
Breast cancer is the most common cancer affecting women causing 29% of all female cancers and afflicting 14% of all female cancer-related deaths worldwide. It remains a significant clinical, psychological and financial burden. Exercise has been suggested to reduce cancer recurrence and cancer-related mortality from research in the past decade. Recent American and European guidelines advise on exercise for breast cancer survivors, not only to improve quality of life and decrease fatigue, but also to aid in decreasing recurrence and improve breast cancer related to mortality. Nonetheless, adherence to guidelines remains low with lack of awareness and fatigue related to chemotherapy as the most common barriers. It remains to be elucidated whether a particular type of exercise, or whether group or individualised activity is most effective. The importance of exercise in avoiding recurrence and improving quality of life needs to be recognised and taken into account in the management of breast cancer survivors. Further patient awareness and education is essential towards this goal and the role of group exercise should be further explored.
ACCEPTED MANUSCRIPT
BODY OF TEXT Introduction
Evidence for exercise and guidelines
M AN U
SC
RI PT
Breast cancer is the most common cancer affecting women, compromising 29% of all female cancers and causing 14% of all cancer related deaths in women worldwide. In the UK, 55,222 new breast cancer cases were diagnosed in 2014 reflecting an incidence rate of 167 new breast cancer cases for every 100,000 females and 1 for every 100,000 males. The current lifetime probability of developing cancer is 12.3%, i.e. 1 out of 8 women will have a diagnosis of breast cancer at some stage in their life. As such breast cancer carries a significant social, psychological and financial burden. Breast cancer 5-year survival rates have improved to 91% in 2005-2011 from 75% in between 1975-1977 with the advent of more sophisticated chemotherapy, hormonal therapy and monoclonal antibodies such as Herceptin (1) (2) (3). Recurrence avoidance remains an important topic of research – not only from a purely medical perspective, but also to help avoid the psychological stress that occurs from it. More recently, exercise has been studied for its effects on reducing recurrence and mortality. As such, our analysis reviews the most notable evidence from the literature and the advice from the guidelines. It further assesses which different methods of exercise have been explored.
AC C
EP
TE D
A landmark prospective observational study from Harvard in 2005 studied 2987 female registered nurses in the Nurses’ Health Study who were diagnosed with stage I, II, or III breast cancer between 1984 and 1998 and who were followed up until death or till June 2002, whichever came first. They found decreases in relative risk of breast cancer-related mortality in women who engaged in more than 3 metabolic equivalent-hours per week (MET-h/wk) i.e. walking at an average pace of 2 to 2.9 mph for 1 hour. Women who exercised for 9 or more MET-h/wk had a relative risk which was approximately half of those who did not exercise (4). Similar results were observed by Bertram et al. in 2010 who studied 2361 post-treatment breast cancer survivors enrolled in the Women’s Healthy Eating and Living (WHEL) study and found a 35% lower mortality risk when physical activity guidelines were followed (5). Irwin et al. performed a longitudinal study of 4,643 women diagnosed with invasive breast cancer after entry into the Women’s Health Initiative study of postmenopausal women (6). The study found that women participating in ≥9 or more MET-h/wk of physical activity after diagnosis had 39% lower breast cancer mortality. Chen et al. followed up 4826 patients with stage 1 to 3 breast cancer identified 6 months after diagnosis and found a 40% reduction in breast cancer-specific mortality and 30% all-cause mortality at a median follow up of 4.3 years (7). Similar results were found by Bradshaw et al., Hollick et al. and Williams; all showing a reduction in breast cancer-related mortality (8) (9) (10). A meta-analysis performed in 2015 analysed 22 eligible studies looking at the effect of exercise on breast cancer. 7 of the 22 studies looked at the effects of lifetime recreational pre-diagnosis physical activity, 13 of the studies investigated more recent pre-diagnosis recreational physical activity, and 9 studies assessed post-diagnosis physical activity. From the 9 studies, it was found that if the physical activity guidelines from the study were met (i.e. ≥
ACCEPTED MANUSCRIPT 8 MET or metabolic equivalent hours/week) there was a 33% reduced risk of breast cancer related mortality and 46% reduction in all-cause mortality (11).
RI PT
A 2016 Cochrane review was performed as an update on a 2006 Cochrane review. It reviewed 32 studies with 2626 randomised female patients. Physical exercise during adjuvant treatment for breast cancer was found to improve physical fitness, cognitive function and cancer-site specific quality of life. It was further found to slightly reduce fatigue, and show little or no improvement in health-related quality of life, cancer-specific quality of life (different to cancer-site specific) and depression. Evidence varied from low to moderate quality and the follow-up seemed too short to make conclusions on recurrence (12).
AC C
EP
TE D
M AN U
SC
In line with this, the American Cancer Society recommends based on level I evidence to engage in at least 150 minutes of moderate exercise per week or 75 minutes of vigorous aerobic exercise per week with inclusion of strength training exercises at least 2 days per week. It further advises to avoid inactivity and return to normal daily activities as soon as possible following diagnosis (13) (14). Not only is this important because of suggested effects on decreasing recurrence, but also because of the beneficial effect of exercise on physical functioning, fatigue, and multiple aspects of quality of life whilst being safe both during and after cancer treatment (15). The European Society of Medical Oncology guidelines on breast cancer treatment also states that regular exercise should be recommended based on level IIb evidence to all suitable patients after treatment of breast cancer as it provides functional and psychological benefits and possibly reduces the risk of recurrence (16). In the United Kingdom, MacMillan guidance reports on the importance of NHS-led interventions on improving physical activity to prevent the decline of physical function. At the same time, significant events or transition points in a patient’s life (such as a cancer diagnosis) provide an opportunity and increased motivation from patients to change attitude and lifestyle. The Let’s Get Moving guidance from the Department of Health provides a framework for patients who would benefit from exercise interventions and delineates 5 steps: recruit – screen – intervene – active participation – review. These steps can be implemented at various stages of the treatment process; at diagnosis, prior to surgery, during treatment and following treatment. NICE Guidance on Improving Supportive and Palliative Care for Adults with Cancer, recommends a comprehensive rehabilitation service for cancer survivors if deemed necessary which reflects the importance of allied health professionals such as physiotherapy and occupational therapy (17) (18) (19).
Adherence and type of activity Despite evidence and guidelines, adherence levels to physical activity in the United States are generally low. A study by Smith et al. found adherence levels of less than 5% (20), and in a multicentre study by Blanchard et al. only about 29.6-47.3% of patients were found to adhere to physical activity guidelines (21). To explore the reasons for this, a recent study was completed by exploring the beliefs and barriers to exercise in breast cancer survivors. It was found that a lack of knowledge on the benefits of exercise, along with extreme fatigue related to adjuvant chemotherapy were found to be barriers to exercise (22). This reflects that despite the benefits of exercise and despite guidelines promoting exercise after breast cancer treatment, patients are still very unaware of its effects (12).
ACCEPTED MANUSCRIPT
SC
RI PT
Concurrently, it is important to explore the type of activity or exercise programme required to achieve the goals set out by the American and European guidelines. Williams compared post-diagnosis running to walking in 986 patients and found that running was associated with a 40.9% risk reduction per MET-hr/day, compared to 4.6% per MET-hr/day in walking. This reflects the importance of moderate to vigorous exercise (10). The ENERGY trial measured weight loss in 692 cancer survivors divided in two groups - either a group-based behavioural intervention, supplemented with telephone counselling and newsletters or a less intensive control intervention and observed for 2 years. The trial showed a mean weight loss of 6% compared to 1.5% highlighting the importance of group-based intervention with counselling (23). A study by McCarroll et al. looked at using an interactive mobile application for reducing weight in endometrial and breast cancer survivors. They studied 50 patients and found significant reduction in weight, waist circumference and BMI, along with improved selfefficacy and ability to control their own diet. However, no significant differences were found in quality of life and physical activity using the app (24).
EP
TE D
M AN U
Desbiens et al. performed a randomised phase II pilot study comparing group-based exercise versus individual video-assisted physical activity. Of the 467 patients selected for eligibility, only 26 participated with 12 allocated to group physical activity and 14 allocated to individualised activity. Of these, only 6 and 9 participants completed the group and individualised programmes respectively. The study found improved quality of life parameters for patients in both activity programmes, however due to the low patient numbers no comparison could be drawn between the two different types of approach (25). This study reflected on the challenges posed in recruiting patients to exercise programmes and again underlined the importance of patient awareness which would help in increasing patient motivation. A further pilot study by Martin et al. looked at qualitative feedback from 28 breast and prostate cancer survivors undergoing an eight-week group exercise sessions followed by counselling. The patients felt the group exercise was helpful for them physically and psychologically again underlining how exercise and counselling in groups is useful for patients (26).
AC C
Our opinion and conclusions
Having reviewed the evidence and guidelines over the last few years, we feel that breast units should strongly consider incorporating exercise advice in clinical practice and explore avenues for group or individual exercise programmes. A recent example is from The Princess Alexandra Hospital Breast Unit (Harlow, United Kingdom) who invested in a 6 week supervised group exercise programme for post-operative breast cancer patients within a gym at the hospital. The project had good outcomes with 72% of the patients wishing to continue the programme after 6 weeks. This reflects the feasibility of group exercise with limited resources in a national health service (27). Group exercise can indeed be useful for patients; also demonstrated by Rock et al. in the ENERGY trial and by Martin et al. (23) (26). Where this is not possible, we feel that adequate education, patient awareness and support in individual exercise initiatives can already be a start in making a difference when compared to the status quo. Especially in the current climate where funding for supervised group or individualised sessions is limited,
ACCEPTED MANUSCRIPT by ensuring that we, as clinicians, inform patients about the benefit of exercise with evidence and guidelines mentioned above, we can already help in guiding them.
SC
RI PT
We strongly feel that exercise has a place in the prevention of recurrence of breast cancer and it is imperative that patients are aware of its effects. Ensuring patient awareness is the responsibility of the multi-disciplinary team and detailed explanation of the benefit exercise provides in cancer recurrence and mortality is essential for the patient. Highlighting further advantages such as decreased fatigue and improved physical functioning as mentioned above are of importance as well. In order for us to do this, a joint approach between primary and secondary services, and between nurses, physiotherapists and doctors is essential. Education on exercise should start in primary care for all patients diagnosed with breast cancer and for breast cancer survivors. It is only then that awareness regarding exercise will increase and patients will be able to include this as part of their daily routine.
M AN U
In the future, we look forward to comparison studies on whether a supervised group or individual exercise therapy has further advantages over education, awareness and exercise support alone. Before we progress to that stage, it is essential that we all work together towards increasing awareness. Much like the ancient mens sana in corpore sano, a healthy mind in a healthy body; we intrinsically know that exercise and lifestyle can help us in our quality and longevity of life, it is time we actively promote this for breast cancer patients.
AC C
EP
TE D
Bibliography 1. Cancer statistics, 2016. Siegel, Rebecca L., Miller, Kimberly D. and Jemal, Ahmedin. 1, 2016, CA: A Cancer Journal for Clinicians, Vol. 66, pp. 7–30. 2. Cancer Research UK. Breast cancer incidence (invasive) statistics. 2014. 3. Lifetime risk estimates calculated by the Statistical Information Team at Cancer Research UK. Office of National Statistics. s.l. : ISD Scotland, the Welsh Cancer Intelligence and Surveillance Unit and the Northern Ireland Cancer Registry, 2014. 4. Physical activity and survival after breast cancer diagnosis. Holmes, Michelle D., et al. 20, 2005, JAMA, Vol. 293, pp. 2479-2486. 5. Physical activity, additional breast cancer events, and mortality among early-stage breast cancer survivors: findings from the WHEL Study. Bertram, LA, et al. 3, s.l. : Cancer causes & control, 3 2011, Vol. 22, pp. 427-435. 6. Physical Activity and Survival in Postmenopausal Women with Breast Cancer: Results from the Women’s Health Initiative. Irwin, ML, et al. 4, s.l. : Cancer prevention research, 4 2011, Vol. 4, pp. 522-529. 7. Exercise After Diagnosis of Breast Cancer in Association with Survival. Chen, Xiaoli, et al. 9, 2011, Cancer Prevention Research, Vol. 4, pp. 1409-1418. 8. Post-diagnosis physical activity and survival after breast cancer diagnosis: the Long Island Breast Cancer Study. Bradshaw, PT, et al. 3, s.l. : Breast cancer research and treatment, 6 2014, Vol. 145, pp. 735-742. 9. Physical Activity and Survival after Diagnosis of Invasive Breast Cancer. Holick, CN, et al. 2, s.l. : Cancer Epidemiology and Prevention Biomarkers, 2 2008, Vol. 17, pp. 379-386.
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10. Significantly greater reduction in breast cancer mortality from post-diagnosis running than walking. Williams, PT. 5, s.l. : International journal of cancer, 9 2014, Vol. 135, pp. 1195-1202. 11. Physical activity, risk of death and recurrence in breast cancer survivors: A systematic review and meta-analysis of epidemiological studies. Lahart, Ian Matthew, et al. 2015, Acta Oncologica, Vol. 54, pp. 635-654. 12. Exercise for women receiving adjuvant therapy for breast cancer. Furmaniak, Anna C, Mening, Matthias and Markes, Martina H. 9, s.l. : Cochrane Database of Systematic Reviews, 2016. Art. No. CD005001. 13. Nutrition and physical activity guidelines for cancer survivors. Rock, Cheryl L., et al. 4, 2012, CA: A Cancer Journal for Clinicians, Vol. 62, pp. 242-274. 14. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. Runowicz, CD, et al. 6, s.l. : Journal of Clinical Oncology, 2 2016, Vol. 34, pp. 611-634. 15. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Schmitz, Kathryn H, et al. 2010, Medicine & Science in Sports & Exercise, Vol. 42, pp. 1409-1426. 16. Primary Breast Cancer: ESMO Clinical Practice Guidelines. Senkus, E, et al. 2015, Annals of Oncology, Vol. 26 (Supplement 5), pp. v8-v30. 17. Interventions to promote physical therapy for people living with and beyond cancer: evidence-based guidance. MacMillan Cancer Support. s.l. : MacMillan Cancer Support, 2017. 18. Let’s Get Moving – A physical activity care pathway. Commissioning Guidance. Physical Activity Policy Team. s.l. : Department of Health, March 2012. 19. Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise. National Institute of Health and Clinical Excellence. s.l. : NICE England, 2006. 20. Adherence to Physical Activity Guidelines in Breast Cancer Survivors. Smith, Savanna G and Chagpar, Anees B. 4, 2010, The American Surgeon, Vol. 76, pp. 962-965. 21. Cancer Survivors’ Adherence to Lifestyle Behavior Recommendations and Associations With Health-Related Quality of Life: Results From the American Cancer Society's SCS-II. Blanchard, Christopher M, Courneya, Kerry S and Stein, Kevin. 13, 5 2008, Journal of Clinical Oncology, Vol. 26, pp. 2198-2204. 22. Exploration of Exercise Outcome Expectations Among Breast Cancer Survivors. Hirschey, R, et al. 2, s.l. : Cancer nursing, 3 2017, Vol. 40, pp. 39-46. 23. Results of the exercise and nutrition to enhance recovery and good health for you (ENERGY) trial: a behavioral weight loss intervention in overweight or obese breast cancer survivors. Rock, CL, et al. 28, s.l. : Journal of Clinical Oncology, 8 2015, Vol. 33, pp. 31693176. 24. Feasibility of a lifestyle intervention for overweight/obese endometrial and breast cancer survivors using an interactive mobile application. McCarroll, ML, et al. 3, s.l. : Gynecologic oncology, 6 2015, Vol. 137, pp. 508-515. 25. Impact of physical activity in group versus individual physical activity on fatigue in patients with breast cancer: A pilot study. Desbiens, C, et al. s.l. : The Breast, 10 2017, Vol. 35, pp. 8-13.
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26. Breast and Prostate Cancer Survivor Responses to Group Exercise and Supportive Group Psychotherapy. Martin, E, et al. 6, s.l. : Journal of Psychosocial Oncology, 10 2015, Vol. 33, pp. 620-634. 27. Exploring the effects of an exercise programme on women with breast cancer. McCrea, Ruth and McNamara, Chris. 10, 2017, Cancer Nursing Practice, Vol. 16, pp. 22-26. 28. Early and locally advanced breast cancer: diagnosis and treatment. NICE (National Institute for Health and Care Excellence). 2, London : NICE, 2017, Vol. CG80, pp. 1-26.
S1526-8209(18)30124-1
DOI:
10.1016/j.clbc.2018.06.008
Reference:
CLBC 823
To appear in:
Clinical Breast Cancer
Received Date: 10 March 2018 Revised Date:
1 June 2018
Accepted Date: 11 June 2018
Please cite this article as: Kapila AK, Hamdi M, Patel A, Clinicians should actively promote exercise in breast cancer survivors, Clinical Breast Cancer (2018), doi: 10.1016/j.clbc.2018.06.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
Authors:
Moustapha Hamdi MD PhDb
a
TE D
Ashraf Patel MS FRCS a
M AN U
Ayush K Kapila MBBS(Lond) MRCS a,b
SC
RI PT
Clinicians should actively promote exercise in breast cancer survivors
b
AC C
EP
The Breast Unit Princess Alexandra Hospital Amstel Road Harlow United Kingdom CM20 1QX
Department of Plastic Surgery University Hospitals Brussels University of Brussels (VUB) Laarbeeklaan 101 1090 Jette
Keywords: breast cancer, exercise, recurrence, treatment adherence, group therapy, individualised therapy
ACCEPTED MANUSCRIPT
ABSTRACT
AC C
EP
TE D
M AN U
SC
RI PT
Breast cancer is the most common cancer affecting women causing 29% of all female cancers and afflicting 14% of all female cancer-related deaths worldwide. It remains a significant clinical, psychological and financial burden. Exercise has been suggested to reduce cancer recurrence and cancer-related mortality from research in the past decade. Recent American and European guidelines advise on exercise for breast cancer survivors, not only to improve quality of life and decrease fatigue, but also to aid in decreasing recurrence and improve breast cancer related to mortality. Nonetheless, adherence to guidelines remains low with lack of awareness and fatigue related to chemotherapy as the most common barriers. It remains to be elucidated whether a particular type of exercise, or whether group or individualised activity is most effective. The importance of exercise in avoiding recurrence and improving quality of life needs to be recognised and taken into account in the management of breast cancer survivors. Further patient awareness and education is essential towards this goal and the role of group exercise should be further explored.
ACCEPTED MANUSCRIPT
BODY OF TEXT Introduction
Evidence for exercise and guidelines
M AN U
SC
RI PT
Breast cancer is the most common cancer affecting women, compromising 29% of all female cancers and causing 14% of all cancer related deaths in women worldwide. In the UK, 55,222 new breast cancer cases were diagnosed in 2014 reflecting an incidence rate of 167 new breast cancer cases for every 100,000 females and 1 for every 100,000 males. The current lifetime probability of developing cancer is 12.3%, i.e. 1 out of 8 women will have a diagnosis of breast cancer at some stage in their life. As such breast cancer carries a significant social, psychological and financial burden. Breast cancer 5-year survival rates have improved to 91% in 2005-2011 from 75% in between 1975-1977 with the advent of more sophisticated chemotherapy, hormonal therapy and monoclonal antibodies such as Herceptin (1) (2) (3). Recurrence avoidance remains an important topic of research – not only from a purely medical perspective, but also to help avoid the psychological stress that occurs from it. More recently, exercise has been studied for its effects on reducing recurrence and mortality. As such, our analysis reviews the most notable evidence from the literature and the advice from the guidelines. It further assesses which different methods of exercise have been explored.
AC C
EP
TE D
A landmark prospective observational study from Harvard in 2005 studied 2987 female registered nurses in the Nurses’ Health Study who were diagnosed with stage I, II, or III breast cancer between 1984 and 1998 and who were followed up until death or till June 2002, whichever came first. They found decreases in relative risk of breast cancer-related mortality in women who engaged in more than 3 metabolic equivalent-hours per week (MET-h/wk) i.e. walking at an average pace of 2 to 2.9 mph for 1 hour. Women who exercised for 9 or more MET-h/wk had a relative risk which was approximately half of those who did not exercise (4). Similar results were observed by Bertram et al. in 2010 who studied 2361 post-treatment breast cancer survivors enrolled in the Women’s Healthy Eating and Living (WHEL) study and found a 35% lower mortality risk when physical activity guidelines were followed (5). Irwin et al. performed a longitudinal study of 4,643 women diagnosed with invasive breast cancer after entry into the Women’s Health Initiative study of postmenopausal women (6). The study found that women participating in ≥9 or more MET-h/wk of physical activity after diagnosis had 39% lower breast cancer mortality. Chen et al. followed up 4826 patients with stage 1 to 3 breast cancer identified 6 months after diagnosis and found a 40% reduction in breast cancer-specific mortality and 30% all-cause mortality at a median follow up of 4.3 years (7). Similar results were found by Bradshaw et al., Hollick et al. and Williams; all showing a reduction in breast cancer-related mortality (8) (9) (10). A meta-analysis performed in 2015 analysed 22 eligible studies looking at the effect of exercise on breast cancer. 7 of the 22 studies looked at the effects of lifetime recreational pre-diagnosis physical activity, 13 of the studies investigated more recent pre-diagnosis recreational physical activity, and 9 studies assessed post-diagnosis physical activity. From the 9 studies, it was found that if the physical activity guidelines from the study were met (i.e. ≥
ACCEPTED MANUSCRIPT 8 MET or metabolic equivalent hours/week) there was a 33% reduced risk of breast cancer related mortality and 46% reduction in all-cause mortality (11).
RI PT
A 2016 Cochrane review was performed as an update on a 2006 Cochrane review. It reviewed 32 studies with 2626 randomised female patients. Physical exercise during adjuvant treatment for breast cancer was found to improve physical fitness, cognitive function and cancer-site specific quality of life. It was further found to slightly reduce fatigue, and show little or no improvement in health-related quality of life, cancer-specific quality of life (different to cancer-site specific) and depression. Evidence varied from low to moderate quality and the follow-up seemed too short to make conclusions on recurrence (12).
AC C
EP
TE D
M AN U
SC
In line with this, the American Cancer Society recommends based on level I evidence to engage in at least 150 minutes of moderate exercise per week or 75 minutes of vigorous aerobic exercise per week with inclusion of strength training exercises at least 2 days per week. It further advises to avoid inactivity and return to normal daily activities as soon as possible following diagnosis (13) (14). Not only is this important because of suggested effects on decreasing recurrence, but also because of the beneficial effect of exercise on physical functioning, fatigue, and multiple aspects of quality of life whilst being safe both during and after cancer treatment (15). The European Society of Medical Oncology guidelines on breast cancer treatment also states that regular exercise should be recommended based on level IIb evidence to all suitable patients after treatment of breast cancer as it provides functional and psychological benefits and possibly reduces the risk of recurrence (16). In the United Kingdom, MacMillan guidance reports on the importance of NHS-led interventions on improving physical activity to prevent the decline of physical function. At the same time, significant events or transition points in a patient’s life (such as a cancer diagnosis) provide an opportunity and increased motivation from patients to change attitude and lifestyle. The Let’s Get Moving guidance from the Department of Health provides a framework for patients who would benefit from exercise interventions and delineates 5 steps: recruit – screen – intervene – active participation – review. These steps can be implemented at various stages of the treatment process; at diagnosis, prior to surgery, during treatment and following treatment. NICE Guidance on Improving Supportive and Palliative Care for Adults with Cancer, recommends a comprehensive rehabilitation service for cancer survivors if deemed necessary which reflects the importance of allied health professionals such as physiotherapy and occupational therapy (17) (18) (19).
Adherence and type of activity Despite evidence and guidelines, adherence levels to physical activity in the United States are generally low. A study by Smith et al. found adherence levels of less than 5% (20), and in a multicentre study by Blanchard et al. only about 29.6-47.3% of patients were found to adhere to physical activity guidelines (21). To explore the reasons for this, a recent study was completed by exploring the beliefs and barriers to exercise in breast cancer survivors. It was found that a lack of knowledge on the benefits of exercise, along with extreme fatigue related to adjuvant chemotherapy were found to be barriers to exercise (22). This reflects that despite the benefits of exercise and despite guidelines promoting exercise after breast cancer treatment, patients are still very unaware of its effects (12).
ACCEPTED MANUSCRIPT
SC
RI PT
Concurrently, it is important to explore the type of activity or exercise programme required to achieve the goals set out by the American and European guidelines. Williams compared post-diagnosis running to walking in 986 patients and found that running was associated with a 40.9% risk reduction per MET-hr/day, compared to 4.6% per MET-hr/day in walking. This reflects the importance of moderate to vigorous exercise (10). The ENERGY trial measured weight loss in 692 cancer survivors divided in two groups - either a group-based behavioural intervention, supplemented with telephone counselling and newsletters or a less intensive control intervention and observed for 2 years. The trial showed a mean weight loss of 6% compared to 1.5% highlighting the importance of group-based intervention with counselling (23). A study by McCarroll et al. looked at using an interactive mobile application for reducing weight in endometrial and breast cancer survivors. They studied 50 patients and found significant reduction in weight, waist circumference and BMI, along with improved selfefficacy and ability to control their own diet. However, no significant differences were found in quality of life and physical activity using the app (24).
EP
TE D
M AN U
Desbiens et al. performed a randomised phase II pilot study comparing group-based exercise versus individual video-assisted physical activity. Of the 467 patients selected for eligibility, only 26 participated with 12 allocated to group physical activity and 14 allocated to individualised activity. Of these, only 6 and 9 participants completed the group and individualised programmes respectively. The study found improved quality of life parameters for patients in both activity programmes, however due to the low patient numbers no comparison could be drawn between the two different types of approach (25). This study reflected on the challenges posed in recruiting patients to exercise programmes and again underlined the importance of patient awareness which would help in increasing patient motivation. A further pilot study by Martin et al. looked at qualitative feedback from 28 breast and prostate cancer survivors undergoing an eight-week group exercise sessions followed by counselling. The patients felt the group exercise was helpful for them physically and psychologically again underlining how exercise and counselling in groups is useful for patients (26).
AC C
Our opinion and conclusions
Having reviewed the evidence and guidelines over the last few years, we feel that breast units should strongly consider incorporating exercise advice in clinical practice and explore avenues for group or individual exercise programmes. A recent example is from The Princess Alexandra Hospital Breast Unit (Harlow, United Kingdom) who invested in a 6 week supervised group exercise programme for post-operative breast cancer patients within a gym at the hospital. The project had good outcomes with 72% of the patients wishing to continue the programme after 6 weeks. This reflects the feasibility of group exercise with limited resources in a national health service (27). Group exercise can indeed be useful for patients; also demonstrated by Rock et al. in the ENERGY trial and by Martin et al. (23) (26). Where this is not possible, we feel that adequate education, patient awareness and support in individual exercise initiatives can already be a start in making a difference when compared to the status quo. Especially in the current climate where funding for supervised group or individualised sessions is limited,
ACCEPTED MANUSCRIPT by ensuring that we, as clinicians, inform patients about the benefit of exercise with evidence and guidelines mentioned above, we can already help in guiding them.
SC
RI PT
We strongly feel that exercise has a place in the prevention of recurrence of breast cancer and it is imperative that patients are aware of its effects. Ensuring patient awareness is the responsibility of the multi-disciplinary team and detailed explanation of the benefit exercise provides in cancer recurrence and mortality is essential for the patient. Highlighting further advantages such as decreased fatigue and improved physical functioning as mentioned above are of importance as well. In order for us to do this, a joint approach between primary and secondary services, and between nurses, physiotherapists and doctors is essential. Education on exercise should start in primary care for all patients diagnosed with breast cancer and for breast cancer survivors. It is only then that awareness regarding exercise will increase and patients will be able to include this as part of their daily routine.
M AN U
In the future, we look forward to comparison studies on whether a supervised group or individual exercise therapy has further advantages over education, awareness and exercise support alone. Before we progress to that stage, it is essential that we all work together towards increasing awareness. Much like the ancient mens sana in corpore sano, a healthy mind in a healthy body; we intrinsically know that exercise and lifestyle can help us in our quality and longevity of life, it is time we actively promote this for breast cancer patients.
AC C
EP
TE D
Bibliography 1. Cancer statistics, 2016. Siegel, Rebecca L., Miller, Kimberly D. and Jemal, Ahmedin. 1, 2016, CA: A Cancer Journal for Clinicians, Vol. 66, pp. 7–30. 2. Cancer Research UK. Breast cancer incidence (invasive) statistics. 2014. 3. Lifetime risk estimates calculated by the Statistical Information Team at Cancer Research UK. Office of National Statistics. s.l. : ISD Scotland, the Welsh Cancer Intelligence and Surveillance Unit and the Northern Ireland Cancer Registry, 2014. 4. Physical activity and survival after breast cancer diagnosis. Holmes, Michelle D., et al. 20, 2005, JAMA, Vol. 293, pp. 2479-2486. 5. Physical activity, additional breast cancer events, and mortality among early-stage breast cancer survivors: findings from the WHEL Study. Bertram, LA, et al. 3, s.l. : Cancer causes & control, 3 2011, Vol. 22, pp. 427-435. 6. Physical Activity and Survival in Postmenopausal Women with Breast Cancer: Results from the Women’s Health Initiative. Irwin, ML, et al. 4, s.l. : Cancer prevention research, 4 2011, Vol. 4, pp. 522-529. 7. Exercise After Diagnosis of Breast Cancer in Association with Survival. Chen, Xiaoli, et al. 9, 2011, Cancer Prevention Research, Vol. 4, pp. 1409-1418. 8. Post-diagnosis physical activity and survival after breast cancer diagnosis: the Long Island Breast Cancer Study. Bradshaw, PT, et al. 3, s.l. : Breast cancer research and treatment, 6 2014, Vol. 145, pp. 735-742. 9. Physical Activity and Survival after Diagnosis of Invasive Breast Cancer. Holick, CN, et al. 2, s.l. : Cancer Epidemiology and Prevention Biomarkers, 2 2008, Vol. 17, pp. 379-386.
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