By Dennis Kerrigan, PhD, FACSM, ACSM-CEP

While the advancements in cancer treatments have drastically changed over the years, what has not changed are the challenges clinicians face with respect to balancing the benefits of treatment with the possible adverse effects. This is especially concerning given that many patients with cancer are older and have multiple comorbidities, which increase the likelihood of both short-term and longer-term adverse effects following cancer treatment (Figure 1, below).  

Because of the many parallels that exist between patients with cancer and those seen in cardiopulmonary rehabilitation, the idea of exercise oncology is not a difficult concept for most individuals to comprehend. What still needs to be elucidated, however, are the specific details concerning:

• Which individuals with cancer would benefit the most
• How to best deliver this service

This article briefly covers the mounting evidence for a medically supervised exercise oncology program and shares the experiences from our Henry Ford ExCITE program in Detroit, Michigan. Specifically, we share how the development of our exercise oncology program was created from the existing foundation of our cardiac rehab program.

While research exploring the relationship between exercise and the primary prevention of cancer is well established, during the late 1990s and early 2000s researchers began looking at the effects of exercise during (and after) treatment. And while these studies were small and looked mainly at physical function and patient-reported outcomes, many of these papers did report benefits.¹

An EXCITE-ing Step Toward the Future

In 2008, Henry Ford Health launched the Exercise and Cancer Integrative Therapy Education Program (ExCITE) pilot study as both a research initiative, but to also establish a permanent exercise oncology program. The goal was to initiate exercise training for individuals with breast and prostate cancer at the time of diagnosis and to continue supervised exercise throughout treatment(s), up to 1 year. Patients were enrolled into our existing Phase 3 cardiac rehab maintenance program, where they exercised alongside our cardiac patients. The exercise protocol consisted of heart-rate based aerobic training similar to our cardiac rehab patients, but with the addition of strength and stretching exercises specific to the cancer location.

We quickly learned that, unlike the cardiac rehabilitation patient, the exercise progression for the exercise oncology patient was not linear, especially during certain chemotherapy regimens when exercise workload was often titrated down and patients sometimes would need to pause their exercise due to certain side effects (e.g., anemia, neutropenia, neuropathy). However, patients did enjoy the group exercise model and social support from other patients, which kept them engaged despite some side effects. And similar to some of the preliminary cancer research conducted by others, Henry Ford patients in the ExCITE pilot showed improvements overall in cardiopulmonary fitness and strength.

Over the decade of the 2010s, the number of exercise oncology papers grew exponentially, providing supportive evidence for exercise to improve many cancer-associated side effects (e.g., fatigue, pain, deconditioning, anxiety).² Importantly, the first American College of Sports Medicine (ACSM) guidelines for exercise in patients with cancer were published, providing more evidence as the ExCITE program grew out of the original pilot study. The initial program was housed in our Phase 3 Cardiac Rehabilitation location at Henry Ford and operated by the cardiac rehab staff. And while growth was slow at first, thanks in large part to philanthropic support from the Detroit Lions and Detroit Pistons through a program called “Game on Cancer,” the number of patients participating grew from roughly 20 to over 140 by 2019.

At the close of the decade, in addition to a second ACSM guidelines paper, an important paper published in Circulation gave shape to the structure of what author Susan Gilchrist, MD, described as Cardio-Oncology Rehabilitation (CORE).^3,4 Because of the many shared risk factors between cancer and heart disease (e.g., diabetes, obesity, smoking, hypertension), many individuals with cancer are at high risk of heart disease and vice-versa. The idea of CORE is to stratify those most vulnerable based on CV risk profile, poor functional status, and/or exposure to cardiotoxic cancer treatment, thus providing solid rationale for having these individuals participate in a medically supervised exercise oncology program. Recent studies examined the effect of exercise in cancer patients exposed to cardiotoxic treatments, including one we have recently published in the Journal of Cardiopulmonary Rehabilitation and Prevention^.5 And while the effect of exercise on cardiac function itself has been equivocal, the effect of exercise on cardiopulmonary fitness (i.e., peak VO2), which is an important predictor of clinical outcomes, has supported the use of supervised exercise in this population.

Similar to many cardiac and pulmonary rehabilitation programs throughout the country, the ExCITE program was affected greatly by the COVID-19 pandemic. Considering the compromised immunity of many cancer patients, all exercise oncology programs took a large step back at that time. However, in 2021 the ExCITE program relocated to the new Henry Ford Cancer Pavilion and became a stand-alone location separate from cardiac rehabilitation. Ironically, as ExCITE physically moved away from its cardiac rehabilitation origins, the structure began looking more like cardiac rehabilitation, with set scheduled classes needed to meet increased demand.

With the new site came opportunities to collaborate with many of the oncology team members who observed firsthand the benefits in their patients. The new location also resulted in a greater range of cancer types being involved, including more complex patients with advanced disease. These patients, while presenting with some similar issues to what cardiac and pulmonary patients have, also bring new challenges to be aware of, such as bone metastasis, presurgical risk reduction, and learning new drugs and drug side effects on a daily basis.

How CR/PR Programs Can Contribute

As the research in this field continues to grow and likely support the beneficial effects of exercise in this population, the need to establish programs becomes paramount. The use of existing frameworks provided by cardiac and pulmonary programs can provide the spark to initiate more exercise oncology programs across the country. If done correctly, by selecting those individuals who may incur the most benefits, this could provide a pathway to allow many patients with cancer to receive many of the same benefits that patients with cardiac and pulmonary disease have enjoyed for decades.

REFERENCES:

1. Galvao DA and Newton RU (2005). Review of Exercise Intervention Studies in Cancer Patients. Journal of Clinical Oncology (23) 899-909
2.  Schmitz KH et. al (2010). American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise (42) 1409-1426
3. Campbell KL et. al (2019). Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Medicine & Science in Sports & Exercise (51) 2375-2390
4. Gilchrist SC et. al (2019). Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association. Circulation (139) 997-1012
5. Kerrigan DJ et. al (2023). Cardiac Rehabilitation Improves Fitness in Patients With Subclinical Markers of Cardiotoxicity While Receiving Chemotherapy: A RANDOMIZED CONTROLLED STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention (43) 129-134

Dr. Kerrigan is a Bioscientific Medical Staff and Senior Exercise Physiologist in Preventive Cardiology. His current role is as the Director of the Henry Ford ExCITE program, a comprehensive, evidence-based clinical exercise program for patients both during and after cancer treatments. In addition to his clinical duties, Dr. Kerrigan also conducts research in patients with heart disease, cancer, and obesity.