Exercise medicine

Exercise medicine is a targeted prescription of exercise which acts to treat and prevent disease, ameliorate side effects and aid other treatments. Studies have shown the potential of exercise medicine to improve outcomes for people with cancer, by enhancing patient quality of life and reducing the impact of cancer on physical, physiological, social and economic function.1

As part of our unique and integrative approach to cancer care and in line with our commitment to offer every patient the best possible care, we have undertaken a centre-wide programme of investment to incorporate this evidence-based approach into our pathway as an opt-out basis for all GenesisCare patients. This has been based on the framework provided by the Exercise and Sports Science Australia position statement.2 We offer exercise medicine programmes delivered by specialist teams in purpose-built gyms at 8 centres across our network in the UK:

• Bristol
• Cambridge
• Chelmsford
• Elstree
• London
• Maidstone
• Milton Keynes
• Windsor

References

1. Campbell et al., 2019; MSSE
2. Hayes et al., 2019; JSAMS

Exercise medicine is complimentary and almost all patients will benefit, although each prescription is tailored to their specific cancer type, treatment and other comorbidities. The GenesisCare administration team will provide the patient with information about the exercise medicine programme and offer an assessment appointment.

At the initial assessment appointment and on completion of the programme, patients will complete validated, standardised tests to measure quality of life, fatigue, mental health, bio-electrical impedance, functional capacity and muscle strength.

Each patient is given a personalised exercise medicine prescription that is tailored to their specific needs, considering their cancer type, stage, grade, the side effects of their cancer and treatment, as well as the patient’s own goals for their health and recovery.

The programme is provided on-site in a purpose-designed exercise clinic containing a range of modern equipment for cardiovascular and resistance training, along with flexibility and balance activities. It typically involves a 12-week supervised programme, with two sessions per week of up to 45 minutes. Throughout each patient’s course, our physiotherapists work closely with them to monitor changes in their health and side effects. The prescription of exercise will be adjusted accordingly during treatment, to support and motivate each patient to achieve their goals.

A patient’s exercise medicine prescription is based on a thorough assessment that includes a 1RM (one-repetition maximum) test to measure strength capacity before the programme. We’re committed to offering a high-quality and patient-centric approach to help each patient enjoy the benefits of a safe exercise regimen. Compliance is not measured by attendance but by adherence to the prescribed activities and patients are encouraged to work at their own pace and explore the contribution that exercise can play in their overall health, as well as ameliorating side effects.

At the end of the 12-week programme, our goal is for patients to naturally embrace exercise as a lifestyle choice. We believe that this is an important and positive take away from their care experience.

GenesisCare Exercise Medicine app

Our teams are committed to keeping in contact with each patient beyond their treatment and will motivate and support them through the dedicated exercise medicine app. The GenesisCare Exercise Medicine app is available from the App Store and Google Play and allows patients to:

• Discover all the services that their GenesisCare centre provides and choose what interests them most
• Find their personalised and complete training programme including cardio, strength, and all types of activities with access to videos
• Check results and monitor progress
• Synchronise with other apps such as MyFitnessPal, Strava, Fitbit and Garmin

Tumour growth is encompassed by many processes including inflammation, angiogenesis, metabolic control, cell proliferation, and immune resistance. These processes are in turn modulated by several systemic factors including insulin/glucose metabolism, immune function, inflammation, sex steroid hormones, oxidative stress, genomic instability and myokines.

Physical activity affects these circulating factors (collectively known as the systemic milieu) in a way that influences cellular process and tumour growth.1 In a sedentary person, levels of sex steroid hormones and insulin are raised and the metabolism is less efficient.

Sudden, intense exercise can have a short-term positive effect by increasing blood flow to the tumour, thereby increasing oxygenation and delivery of vasodilators. This decreases hypoxia within the tumour. Sustained, repetitive exercise leads to permanent changes in metabolism and improved efficiency of physiological processes.

The effects are believed to be wide‑ranging and include reduced circulation of insulin, glucose and sex steroid hormones, a reduction in inflammation and enhanced immune function. These all create an unfavourable tumour micro‑environment (TME), depriving the tumour of the resources needed for growth.

References:

1. Patel et al., 2019; MSSE

In 2010 and again in 2019, the American College of Sports Medicine International Multidisciplinary Roundtable reviewed available evidence in support of developing prescriptive exercise medicine programmes for people with cancer.1 They concluded that specific doses of aerobic training, resistance training, or combined aerobic and resistance training could all improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning and health related quality of life (HRQoL).

The following exercise related outcomes can be achieved before and after cancer treatment:

Can be significantly reduced by moderate-intensity aerobic training performed three times per week and for at least 12 weeks, or twice weekly combined aerobic plus resistance training lasting 6 to 12 weeks.

Can be significantly reduced by moderate-intensity aerobic training three times per week for at least 12 weeks.

Can be improved by combined moderate intensity aerobic and resistance exercise performed two to three times per week for at least 12 weeks.

Can be significantly improved by moderate-intensity aerobic training, resistance training or combined aerobic plus resistance training performed three times weekly for 8 to 12 weeks.

References:

1. Campbell et al., 2019; MSSE

We are delighted that many of our patients have participated in our exercise medicine programme during the first 12 months – even through lockdown. We have been collecting PROMs data and will be sharing our learnings with clinicians and patients, detailing how exercise medicine is benefiting patients in particular tumour groups.

The below case studies are accounts from two patients who participated in our pilot exercise medicine study at our Windsor centre.

Patient A was a 55-year-old female with breast cancer who had radiotherapy at our Windsor centre. Although she was not a regular exerciser before, she was exceptionally motivated to complete her prescribed programme which concentrated on reducing fat and increasing muscle strength.

At her re-assessment on programme completion, she showed outstanding improvements in functional capacity, moving up three levels from “below average” to “good” in the three-minute step test. She also greatly improved her muscle strength; in one-repetition maximum (1RM) tests she went from a 66kg seated row to 86kg and an 80kg leg press to 89kg.

As well as physical improvements, Patient A also showed a reduction in fatigue (from 31 before the programme to 41 on completion in the FACIT Fatigue Scale – a higher number indicating improved energy levels), depression and, significantly, anxiety (from 10 to 8 and 13 to 3 respectively in the HAD Scale).

Her scores in the SF-36 questionnaire showed improvements in various quality of life areas. These included role limitations due to emotional problems or physical problems (from 0% to 67% and 0% to 100% respectively), emotional wellbeing (28% to 84%) and social functioning (50% to 88%).

During the programme, Patient A changed her lifestyle to clean up her diet and make exercise an integral part of her life. She has moved from the contemplative stage of exercise behavioural change to the action stage, having now joined a gym with confidence to continue her strength and cardiovascular programme.

The exercise medicine programme motivated me to make positive changes to my future health and life

- Patient A

Patient B was a 58-year-old male with prostate cancer who initially started an exercise medicine programme alongside his chemotherapy treatment at our Windsor centre. Unfortunately, he was unable to complete the full course due to the heavy side effects he experienced. His initial programme was focused on improving fatigue and he showed improvements in the FACIT Fatigue Scale from 15 to 33. However, between starting the programme and initial discharge, he lost muscle mass (3.8kg) and muscle strength (with his 1RM chest press changing from 50kg to 41kg), despite a weight loss of only 0.8kg.

He started the programme again while later undergoing radiotherapy. This course was tailored to reduce fat while building up his muscle mass and maintaining earlier improvements in fatigue. His body fat dropped from 33.1% to 29.9% and he gained 2.9kg of muscle mass. His fatigue improved further from 33 on initial discharge to 38.

He also improved his functional capacity and his SF-36 scores showed improvements in quality of life, particularly with regards to social functioning and health change.