Getting your ooomph back after cancer

Over recent years, the term “exercise oncology” has emerged to describe the idea that exercise could be considered a form of cancer treatment. The persuasiveness of evidence around the idea was reinforced in 2018 when the Clinical Oncology Society of Australia produced a position statement that hit the headlines globally.

They advised, based on scientific evidence, that exercise should be prescribed to all cancer patients, just like a drug. They went further than this, though: they stated that exercise should be embedded as part of standard practice in cancer care, and they said that to not do so would be harmful.1 Although it perhaps sounds counterintuitive, there is substantial evidence to show that exercise can help people to cope with cancer-related fatigue and, in some cases, to reduce the risk of developing fatigue or lessen the severity. 

There are consistencies within the data—particularly in encouraging people to exercise regularly rather than occasionally and at a manageable intensity and duration. 

There is also evidence about the positive effects of higher intensity exercise. 

There are many psychological and emotional advantages to taking regular exercise. It can help people cope with depression, anxiety and weariness. Running and gardening were my absolute saviors during my diagnosis of breast cancer and surgery. 

Part of the reason that exercise can be useful for cancer patients is because it can help restore appetite, thus increasing your nutritional intake, and it can help promote good sleep. Both factors, in turn, can help increase your sense of stability and ability to cope. 

Exercising outdoors can add further beneficial dimensions, and so-called “green exercise” is believed to offer even greater potential support to our mental and emotional wellbeing. Part of the reason for this is that exercise helps us generate endorphins—our ‘good time’ hormones that can give us a happy glow. 

If you’ve been out of action for a while, the chances are you’ll have lost some of your muscle strength, and this can be why simply climbing the stairs or getting out of a chair feels harder than it used to. Resistance training can help to rebuild your functional strength. 

Alongside muscle loss, cancer treatments can leave us with stiff or painful joints and with a reduced range of motion, and exercise can be used to help diminish pain and build strength in the connective tissue—the tendons and ligaments that support the joints and help them to remain mobile. 

Some of the hormones used in cancer treatment are linked to lowered bone density, and there’s very good evidence to show that weight-bearing exercise can help to slow down bone mineral loss and, in some cases, to actually increase bone density. Similarly there is specific evidence that exercise, when performed with good technique, can help prevent and manage lymphoedema. 

According to Cancer Research UK, each of the main forms of treatment (surgery, radiotherapy, chemotherapy and biological and hormone therapies) can cause cancer-related fatigue. 

Exercise can also help you to get back to normal, to feel more like yourself or to build your own ‘new normal.’ It can help you get your oomph back. 

Exercise should, however, feel like you are definitely doing something—for example, walking as exercise should not be an amble. Regardless of the speed you can reach, walking should be as purposeful and as fast as is comfortable for you. This is because the evidence that we’re using as a foundation for being more active is invariably based on “moderate exercise” unless it states otherwise. For example, one study suggested a specific link between walking pace and cancer survival.2 

Fatigue in cancer survivors is a significant issue—it is perhaps the most common side-effect. Not everyone calls it fatigue, but tiredness, exhaustion and lack of energy are reported by up to 95 percent of people with cancer.3 Moderate exercise often entails working at 70 percent of your maximum heart rate. It’s working at a level where you’re warm and you might want to take a layer of clothes off. You’re breathing deeper than usual, but you can still talk in short sentences. 

This might, of course, sound like far too much exertion for you, especially in the early days of getting fitter. If that’s the case, don’t worry; just make sure that you continue to push yourself gently to work as hard as you reasonably can. 

As you walk, or indeed as you start any cardio-based exercise after cancer, try to get used to maintaining a pace where you are lightly out of breath, for as much of the walk as you can. 

High-intensity interval training (HIIT) has become an extremely popular mode of exercise, and it’s been found that exercising in short, fast bursts might be as effective as more traditional moderate exertion. A 2018 study of men recovering from testicular cancer treatment found that “HIIT significantly improved post-intervention fatigue.”4 Similarly, a study published the following year found HIIT to be as effective as moderate exercise in addressing fatigue.5 

The importance of strength training 

There’s also a really important and often overlooked role for strength training in overcoming fatigue. Building stronger muscles will help to make daily life—climbing stairs, carrying shopping—feel less exhausting. Clinical studies show that a combination of cardio exercise and resistance training is your best bet in improving a sense of wellbeing after cancer.6 

Your strength training doesn’t need to be complicated or time-consuming: all you need to do is a routine where all your major muscles are worked against resistance. I highly recommend using resistance bands rather than weights at first—they’re easy, adjustable and cheap, and you’re less likely to get injured with them. 

A meta-analysis of 34 controlled studies on exercise and cancer noted reductions in fatigue and depression and improvements in quality of life among people who were physically active, with particular positive effects on psychological outcomes in those with breast cancer.7 

One Australian study examined psychological distress in men with prostate cancer, and its findings were very clear—exercise can help, but it’s better if we get the level of intensity right. Whether you do aerobic exercise or resistance exercise it doesn’t matter; as long as it’s at moderate to high intensity, exercise is beneficial for reducing symptoms of depression and anxiety.8 A much smaller-scale study found that exercise could improve the mental health of people with brain cancers.9 

Impact of cancer treatment on bones 

There are strong links between bone health and our hormone system, and therefore certain cancer-related hormone treatments can have an impact on bone density. This is particularly the case for breast cancer treatment in women that lowers estrogen levels, such as chemotherapy that causes early menopause, and drugs such as Zoladex or aromatase inhibitors (anastrozole, exemestane, letrozole). Radiotherapy or surgery to the ovaries can also affect bone density.10 

Similarly, hormone deprivation therapy in men with prostate cancer is known to cause reduced bone density, and people who had acute lymphoblastic leukemia (ALL) as children are known to have a higher risk of reduced bone density later in life. 

There’s a great deal of evidence that exercise can noticeably help restore bone density. Weight-bearing exercise—where you transfer your body weight from one foot to another—is particularly helpful. This is because the effect of that weight transfer is to cause jolts to the bones, and these jolts stimulate the bones into repair mode. 

By far, your best bet is to combine aerobic, weight-bearing exercise (on your feet, getting out of breath) with strength training (getting strong). Schwartz et al. found that doing exactly this during chemotherapy helped preserve bone density in women being treated for breast cancer,11 and Almstedt et al. saw similar responses in women after treatment.12 

It’s the same picture for men, too: those taking hormone treatments for prostate cancers have improved their bone mineral density by combining aerobic exercise with strength training.13 

Yoga’s combination of stretching, breathing and relaxation can help lymphoedema wherever it is, as it is a holistic form of exercise, affecting the whole body. And there are yoga poses for the face, neck and shoulders that may help specifically with lymphoedema around the head and neck. Some yoga poses (such as downward dog and child’s pose) might be inappropriate for people with lymphoedema, depending upon the site of the swelling. 

Hormone treatments are used long term for people with breast, prostate and some gynecological cancers, to help prevent cancer recurrence or to slow down disease progression. The side-effects can leave us vulnerable to reduced bone density, muscle loss, weight gain and increased body fat. 

Cancer treatments can also cause “muscle wasting” in the short term, which can lead to a sense of weakness and fatigue. It is a common side-effect of hormone treatment for prostate cancer, and it’s one of the more compelling reasons for lifelong strength training for men who’ve had this cancer.14 

One condition that can arise from cancer-related weight loss is cachexia—a long-term loss of muscle that is experienced by many people, particularly those with pancreatic, gastric and esophageal cancers. It is linked to inflammation and metabolism. Several clinical trials recommend the use of progressive strength training to reduce cachexia and the risk of it.15 

Active daily living 

The American College of Sports Medicine (ACSM) states that we should all aim for: 

• at least 150 minutes of aerobic exercise (i.e., getting out of breath) per week 
• at least two sessions per week of resistance (strength) training on nonconsecutive days 
• stretching our major muscle groups every day when possible. 

Exercise ‘snacks’ 

One way to increase your activity levels in small amounts is to start doing ‘exercise snacks’—quite literally something small and light rather than a big feast! Exercise snacks are intended to be very brief—perhaps 20 to 60 seconds long—and to be done as frequently as you want to. Also sometimes referred to as ‘movement breaks,’ the idea is being studied by some of the scientists involved in devising HIIT,16 who found that physical activity in short, fast bursts can be surprisingly effective. Some examples are: 

• Practice controlling core muscles or doing pelvic floor exercises between stops if you’re standing on public transport.
• Sit with good posture and try to hold it for a given period of time.Sit on a Swiss ball. Stand on a Bosu balance trainer.
• Do squats while you’re washing the dishes, lunges while cleaning your teeth, stretches while you wait for the kettle to boil.
• Move during the ad breaks when you’re watching TV.
• Take a break while you’re working to climb the stairs or walk briskly to the end of the garden. 
• A few caveats. Exercising should not be painful: if it is, stop. Check that your posture and technique are correct and that you aren’t trying to increase the amount of resistance you are using by too much, too quickly. Start light and build up over time. 
• Avoid exercise if you have cellulitis. Avoid strength exercises if you’ve had surgery in the last eight weeks. 
• If your affected limb or area becomes heavy or more swollen quickly, or if you are experiencing pain, seek the advice of your specialist nurse, physiotherapist or doctor. 

Nordic walking—the perfect exercise 

Nordic walking is brilliant exercise in general, and near-perfect for people with cancer. It worked for me during my recovery from breast cancer, acting as a stepping-stone from gentle walking to running again. I’m convinced that it helped reduce the postsurgery swelling and helped get my arm moving fully again. 

Based on cross-country skiing, Nordic walking is an outdoor activity that will work your whole body without impacting too much on your back, knees and ankles. This is exercising at a level at which you can chat, have a giggle and at the same time become stronger and get a real sense of satisfaction. 

Nordic walking works the whole body. What’s more, it’s hard enough, but not too hard—it can be adapted to suit everyone’s individual fitness levels. For most people it will feel like a very spirited, energetic walk, but without that “I can’t breathe” feeling that sometimes happens with running. 

The difference between Nordic walking and walking briskly, or with trekking poles, lies in the way we use the poles to propel the body forward. Trekking poles, also called hiking poles, are used to support people’s balance while they walk, whereas Nordic poles are used to assist momentum. 

Nordic poles hit the floor by your feet, and you push them down and backward; they therefore cause your body to move up and forward. You wear a special strap that attaches to the pole, so there’s no need to grip it hard, and you can’t drop it. 

You strengthen your shoulders, arms and core with this movement, and it’s this propulsion that gives you the added oomph to walk faster and stronger. You then get into a fabulous cycle where the poles help you do more, and you use your body strength to push them, thus building your strength and fitness. 

I’ve known people who say they feel like they’re flying. It makes walking feel good. 

Adapted from the book Get Your Oomph Back by Carolyn Garritt (Hammersmith Health Books, 2021).