Exercise and Pancreatic Cancer: Expert Guidelines
Dale Ischia is an accredited exercise physiologist and an ACSM cancer exercise specialist. She says that two of the most common side effects of pancreatic cancer and its subsequent treatment are deconditioning (a loss of physical condition and fitness) and fatigue. “We know that twelve weeks of chemotherapy creates a similar physical decline as seen in a decade of ageing,” she says. “This is 10 years of decline in your cardiovascular fitness, muscle strength and muscle mass, balance and mobility. In addition, cancer-related fatigue is common and debilitating. Exercise has been proven to be the most effective treatment for cancer related fatigue.” 1,2
Dale believes that exercise can halt, or even reverse the decline of function and energy that commonly occurs as a result of pancreatic cancer and subsequent treatment regimens. “Maintaining strength, cardiovascular fitness, balance and mobility throughout treatment is imperative to quality of life, 3 but we also know that exercise has other benefits. Recent research has further indicated that exercise can help to improve treatment tolerance and effectiveness.” 4,5
When is the best time to begin exercising after diagnosis?
As soon as possible. The more active you are the better. It is safe to exercise during treatment – provided you allow yourself time to recover from treatment and exercise.
Exercise helps ensure you are in the best possible physical condition when you undergo surgery. This will enhance recovery post surgery. Exercise during chemotherapy is also safe.
What kind of exercise is best?
Exercise should be prescribed according to your treatment side effects, other co-morbiditie and assessment findings. But in general, it should:
- Reflect your goals
- Be enjoyable
- Be done with a friend or group
- Cover all components of fitness, including cardiovascular, strength, balance and flexibility.
Walking outside is one of the simplest exercises you can do. It gets you in the fresh air, is free, can be done anytime and helps your cardiovascular system as well as the health of your mind.
What are your key recommendations?
It is well established that people diagnosed with cancer should avoid inactivity.
As a benchmark, patients should aim to perform 150 minutes of moderate intensity cardiovascular exercise per week, as well as two sessions of resistance exercise per week.6 This is a goal to work towards, and can be broken down into small chunks of 10-minutes, such as walking.
It is also advised that patients seek the advice of a qualified exercise professional such as an Accredited Exercise Physiologist who specialises in oncology. This practitioner will work out the best exercise program based on individual patient needs.
What should patients consider before starting an exercise program?
- Loss of muscle mass and strength. Go easy on yourself, you may not be able to do what you used to be able to do. Build up gradually.
- Are you absorbing enough nutrients to fuel your exercise program? You need enough fat, carbohydrates, proteins and vitamins and minerals.
- Check that your blood levels are with a safe range.
- If red blood cells are low, and this is causing you to be fatigued, you should only exercise at a very low level as tolerated.
- If neutrophils are low, resulting in suppressed immune systems, you avoid exercising in a public place.
- If your platelets are low, you should avoid any impact exercises.
- Cramps. These may be a sign of something else and you should check with your doctor, but can be common and are best managed by hydration (drinking 1.5-2.5L of water per day), stretching the affected area, and good nutrition, i.e, the correct sodium, potassium, calcium, and magnesium for smooth muscle function. A healthy diet will provide all of these nutrients and supplements are not required if you nutritional intake is sufficient.
- Peripheral Neuropathy. This is a common side effect of chemotherapy. It will not be worsened by exercise. It can reduce your balance, especially your proprioception. Moving your feet and hands can help with your proprioception. Massage can also help reduce the feeling that your foot is one block, and make it feel like individual bones and joints again.
- If you have a central port, there aren’t many limitations once it has healed, except when it is attached to chemotherapy. Please speak with your nurse, exercise physiologist or oncologist.
- Surgery. Patients must allow adequate time for your body to heal after surgery. Your surgeon will guide healing time. It is strongly recommended to improve your condition prior to surgery. Try to perform aerobic exercise every day, such as walking, swimming and bike riding leading up to your surgery.
- Recovery time. Your body needs to recover from chemotherapy or radiation sessions, and it needs time to recover from exercise. How you respond to treatment is very individual and depends upon many factors. You may find there are times in your cycle where you can’t manage much more than a walk to the bathroom.
What about exercising post-surgery?
- It is recommended patients get up and walk as soon as possible after your surgery to prevent blood clots. Going for a short walk every 2 hours is ideal. If this is not possible, pumping your feet up and down is a good alternative.
- You should avoid lifting anything heavier than 2kg for around 6 weeks, but check with your doctor. After you are given the all clear from your doctor that it is safe for you to commence more strenuous exercise and lift heavier things, ensure you gradually increase the load and intensity over a number of weeks. Don’t do it all at once. Your body needs time to adapt to new loads.
- You will need to regain your overall strength, but areas to focus on are your abdominal strength and leg strength in order to keep you as functionally independent as possible.
- Always breathe throughout all types of exercise. Don’t hold your breath.
- If you had surgery involving any of the main blood vessels in your abdomen you should avoid straining, breath holding and heavy weights until your doctor tells you it is safe to do so.
- You may develop diabetes as a result of your surgery as your remaining pancreas isn’t making enough insulin, so your blood sugar becomes too high. If so, your diabetes needs to be appropriately managed in order for you to exercise safely.
- An Accredited Exercise Physiologist specialising in Oncology is the best person to seek advice from if you have any further questions regarding exercise.
Is exercise safe during chemotherapy?
- Exercising during chemotherapy is recommended. It should be performed to tolerance, keeping all the considerations above in mind.
- Your ability to exercise will fluctuate throughout your chemotherapy cycle. Perform gentle range of movement exercises lying down, if that is all you can tolerate. Keeping active in some capacity is important. Do several short walks in a day and a longer walk on days you have more energy.
When should patients stop exercising and consult a doctor?
Patients should stop exercising and consult a doctor if they experience any of the following:
- Dizziness or fainting while exercising
- Swelling in your ankles, neck, face or arms – seek immediate medical help
- Shortness of breath with only a small amount of exertion
- Chest pain or palpitations
- Sudden onset of nausea during exercise
- Chills/shaking during exercise
- Severe diarrhoea or vomiting.
- High temperature
Aerobic exercise helps maintain your cardiovascular system (heart, lungs, muscle and blood)
- At least 150 mins of moderate activity per week (30 mins/day)
- It is ok to begin in 10-minute blocks and progress as you improve.
- Start low, progress slow.
- Have exercises planned for low energy days after chemo. For example stretching, walking slowly for 5 minutes.
Definition of ‘moderate intensity exercise’
- 50-70% of maximum heart rate (Max heart rate is 220 minus your age)
- Talk test. Breathing rate is such that you can talk, but not sing
- Examples of moderate exercise include: walking, hiking, biking, swimming, dancing, gardening, housework
- Strength Training
- Strengthening exercises increase your muscle mass. Your muscle mass is a good indicator of survival; the more muscle mass the better
- Resistance exercise increases your muscle mass. This includes body weight exercises, free weights, and machine weights
- If you have recently had surgery you must get the okay from your surgeon before lifting heavy weights
- Aim for 2 -3 strength sessions weekly for major muscle groups
- Begin with 1 set of 10 – 12 reps of 8 different strength-training exercises
- Build to 2-4 sets of 6-8 reps and increase load
- Poor balance is a common side effect of chemotherapy.
- Having surgery through the abdominal wall can also have a negative impact on your balance.
- Working on your balance will help maintain and improve your balance and prevent you from falling.
- Simple balance exercises such as standing on one leg with help challenge and maintain your balance.
Flexibility/Range of Movement Exercise
- Range of movement exercise minimises muscle and joint pain and allows you to move more freely.
- It is important to including stretching after your strengthening exercises in order to assist in recovery and minimise muscle and joint pain.
- Mustian KM, Alfano CM, Heckler C, et al. Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-analysis. JAMA Oncol 2017.
- Zou LY, Yang L, He XL, et al. Effects of aerobic exercise on cancer-related fatigue in breast cancer patients receiving chemotherapy: a meta-analysis. Tumour Biol 2014; 35(6):5659-67.
- Scott K, Posmontier B. Exercise Interventions to Reduce Cancer-Related Fatigue and Improve Health-Related Quality of Life in Cancer Patients. Holist Nurs Pract 2017; 31(2):66-79.
- van Waart H, Stuiver MM, van Harten WH, et al. Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol 2015; 33(17):1918-27.
- Pedersen L, Idorn M, Olofsson GH, et al. Voluntary Running Suppresses Tumor Growth through Epinephrine- and IL-6-Dependent NK Cell Mobilization and Redistribution. Cell Metab 2016; 23(3):554-62.
- Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 2010; 42(7):1409-26.
- Yeo TP, Burrell SA, Sauter PK, et al. A progressive postresection walking program significantly improves fatigue and health-related quality of life in pancreas and periampullary cancer patients. J Am Coll Surg 2012; 214(4):463-75; discussion 475-7.