Jane Hill

	As director of Rocky Mountain Cancer Rehabilitation Institute at the University of Northern Colorado in Greeley, Colo., part of Reid Hayward’s mission is to investigate exercise and nutrition as an intervention for symptoms related to cancer treatment.

	Hayward and his students offer one-on-one coaching three days a week at the cancer center, he says. Think of them as cancer personal trainers. “Once we get the patients in here,” Hayward continues, “they’re hooked.”

	“Other centers give them a handout. We give them an initial assessment of balance, strength and endurance, and then reassess every three months.”

	He witnesses the benefits of working out during and after treatment, but he’s not surprised that patients aren’t lining up at the door before treatment starts. Most “are overwhelmed by too many other things with a higher priority.”

	So, when he doesn’t have enough trial participants, he and his team work with rats to study aerobic conditioning and the effects of chemotherapy.

	It’s difficult to apply lessons learned in animal trials directly to humans, although many physicians recommend light exercise to reduce certain treatment-related effects, such as fatigue and depression. Hayward is convinced that “the protective effect of exercise” can have a lasting impact. He suggests—only half-kiddingly&mdash;that patients receiving chemotherapy might be well served to “jog to treatment.”

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Exercise and nutrition intervention for patients with cancer could help with symptoms from treatment.

The Benefits of Personal Training

	Linda Rodrigue carries around a note card so she can recite accurately the various events in her recent cancer experience. March 7: Needle biopsy. March 11: Breast center visit for biopsy results (not good). March 15: Imaging scan. March 18: Meet surgeon. March 21: Ultrasound on the other breast. March 25: Oncologist appointment. March 27: Surgeon appointment. April 12: Lumpectomy. April 23: Post-surgery visit. April 26: Oncologist visit (recommends chemo and radiation). May 24: Chemo port inserted. May 29: First chemotherapy.

	The nearly three-month time frame between biopsy and treatment seems like a reasonable pace. In reality, however, it felt like “wham-bam,” says the 55-yearold South Carolina woman, leaving little time for much else, such as getting into peak shape for treatment.

	“I think in a perfect world, you’d want to do that,” she says.

	From their perspective, some professionals in the cancer rehabilitation field say the time between diagnosis and treatment, as imperfect as it may be, is a valuable window of opportunity for patients to begin “prehabilitation,” the physical and psychosocial interventions to better prepare them for the rigors of treatment.

	Lori McKitrick, who oversees the cancer rehabiliation program at Bon Secours St. Francis Health System in Greenville, S.C., says prehabilitation involves mental and physical assessments, as well as physical, occupational and speech therapies to shore up deficiencies.

	Following on the success of boot camps designed for individuals preparing for hip and knee replacements, experts are proving that cancer patients can reap similar benefits from such programs.

	“When prehabilitation was optional for joint patients, we saw a different outcome for those who had undergone the prehab, which included education and strengthening exercises,” says McKitrick, a certified speech therapist. Their length of stay, recovery time and satisfaction level were much better than those of people who didn’t participate. As a result, prehabilitation for joint replacement candidates is now mandatory at St. Francis, she says.

	Extending that concept, therapists trained in oncology at St. Francis invited men scheduled for prostate cancer treatment to obtain baseline assessments of their psychosocial and physical conditions, and then taught them appropriate therapeutic exercises in advance of treatment.

	The experience boosted not only the men’s physical capacity but also their mental and emotional resilience. It, too, helped reduce anxiety, McKitrick says. Patients gained a better idea of what to expect after surgery, as well as having “another place to get their questions answered.”

	“Once you get a cancer diagnosis, everything seems to be out of your control,” McKitrick says. “We are giving [patients] something to take control of, and it is having a positive outcome.”

	Exercise, in general, is good for anyone, and physically fit people usually fare better during treatment, but the comparison between the cancer and non-cancer patient populations is “apples to oranges,” says Michael Stubblefield, an attending physician in physical medicine and rehabilitation at Memorial Sloan Kettering Cancer Center in New York.

	Stubblefield says most of the published research that discusses results of prehabilitation involves patients who have a medical condition other than cancer. He notes that the window of opportunity between diagnosis and treatment for people with COPD (chronic obstructive pulmonary disease) or damaged joints, for example, is much greater than for people who have cancer.

	“We have a massive race occurring,” he says. “Changes in physical conditioning take more than a few days or a week. When you have cancer, it needs to be dealt with now. If you have lung cancer, you want to take it out this week, not in four to six weeks.”

	One study that looked exclusively at the effect of prehabilitation on functional recovery after colorectal cancer surgery was inconclusive, Stubblefield says. The findings showed that tougher exercise could have had a harmful effect, while simple walking could have benefited an elderly subset of the test group.

	Advocating for prehabilitation is premature, especially when resources are insufficient for rehabilitation, says Stubblefield, who has dedicated his medical career to restoring cancer survivors’ quality of life.

	Currently, even at prestigious cancer institutions that are recognized for evaluating and taking care of posttreatment complications, too many people who need therapeutic rehabilitation don’t receive it, he adds.

	Julie Silver, a cancer survivor, physiatrist and associate professor at Harvard Medical School in Boston, agrees with Stubblefield about the wide gap between cancer survivors who need rehabilitation and those who actually receive it. But she is a strong proponent of prehabilitation.

	The company she cofounded, Oncology Rehab Partners, developed STAR (Survivorship Training and Rehabilitation), a program designed to help hospitals and cancer centers implement rehabilitation protocols that focus on improving outcomes. This includes prehabilitation protocols to help patients with newly diagnosed cancer get ready for upcoming treatments. Among the healthcare centers that have adopted the prehab program is St. Francis Health System, where McKitrick is a certified STAR clinician.

	Regardless of the time frame between diagnosis and start of treatment, it’s smart to obtain a baseline screening to identify the targeted interventions that could improve recovery and enhance a survivor’s quality of life, Silver says. These could involve swallowing exercises before surgery for head and neck cancers, smoking cessation to improve breathing function prior to lung cancer surgery or pelvic floor exercises to reduce urinary incontinence after prostate cancer surgery. Interventions also could take the form of a nutritional boost to fight fatigue or balance training exercises to help prevent falls.

	A psychological health assessment is also important because, among other reasons, mental health and attitude can affect whether a patient will adhere to a treatment regimen, she adds.

	“It’s reasonable to assume that patients will have some level of distress that changes with time,” Silver says. By giving them cognitive-behavioral coping skills, such as guided imagery and muscle relaxation techniques, they can learn to reduce their stress response, which could result in lowering their heart rate and blood pressure before going into surgery, she says.

	Though prehabilitation is relatively new for people with cancer and its potential is yet unknown, few would argue against supporting patients prior to treatment in an effort to enhance their recovery. Future studies might show whether early intervention could reduce hospital readmission or lower overall healthcare costs.

	Meanwhile, patients should ask their oncologist or other members of their healthcare team if prehabilitation services are available where they are being treated, Silver says. If they are offered, patients should ask how they can access those services as soon as possible, she adds, even if the period between diagnosis and the start of treatment is packed with appointments.

Editor’s Note: During the formation of this article, McKesson Specialty Health,

parent company, purchased a majority stake in Oncology Rehab Partners.

is editorially independent from McKesson.

Preparing physically for treatment could play a role in recovery of cancer.

Prehabilitation Aims to Prepare Patients for What Lies Ahead

John Nidecker is a devoted cyclist, logging up to 100 miles a week near his home in Santa Rosa, Calif. He’s also a careful rider, knowing that accelerated bone loss is a side effect of intermittent hormone therapy for prostate cancer, a part of his life for the past 14 years.

“I’m conscious of the risk of falling, but it doesn’t hold me back too much,” says Nidecker, whose bone density scans consistently show low bone mass but above the osteoporosis range.

Osteoporosis, or thinning bones, is worrisome for people with cancer because it doesn’t necessarily take a fall off a bike to fracture a bone. Something as simple as a sneeze or a coughing fit can break a weakened rib. Vertebrae can break for no reason, causing a curved spine or, more ominously, a hip could get broken, leaving a patient bedridden for a time.

“The consequences of osteoporotic fracture can lead to death,” says Catherine Hall Van Poznak, an associate professor of medical oncology who studies osteoporosis and breast cancer at the University of Michigan in Ann Arbor. Nothing good comes from a bent skeletal frame that prevents organs from “maximizing their abilities,” she says. For example, when lungs aren’t expanding fully, they are more vulnerable to pneumonia. “The frailty that follows fractures increases an individual’s risk for additional illnesses.”

Many therapies used to treat breast and prostate cancers work by suppressing hormones that can fuel cancer, such as testosterone and estrogen. There’s a trade-off, though, because bodies need these hormones to keep bones strong.

Bones are living tissue in a constant cycle of renewal. In healthy bones, one category of cells (osteoclasts) dissolves bone tissue, while other cells (osteoblasts) rebuild, replacing the removed bone with new bone. The body needs calcium and vitamin D for the rebuilding process. As the body ages, osteoblasts fall behind, and ultimately there is a net loss of bone, increasing the risk for osteoporosis.

The consequences of osteoporotic fracture can lead to death. The frailty that follows fractures increases an individual’s risk for additional illnesses.”

One of estrogen’s important jobs is to maintain proper balance between bone buildup and breakdown, according to the National Cancer Institute. Yet, medicines used to treat hormone receptorpositive breast cancers affect bone density in different ways. Aromatase inhibitors (AIs) block the production of estrogen and are associated with an increased risk of osteoporosis and fracture. Selective estrogen receptor modulators (SERM), such as tamoxifen, work by blocking the effects of estrogen on cancer cells and some other tissues, but have the balancing effect of estrogen on bones.

“When discussing toxicity of aromatase inhibitors with postmenopausal women, we counsel them on the importance of calcium and vitamin D daily intake and doing weight-bearing exercise to mitigate the risk of bone loss,” Van Poznak says. “Diet and exercise are the foundation. Intervention with a prescription medication is only for those at greatest risk of osteoporotic fracture.”

A recent study concluded that all patients starting AIs “need advice regarding exercise and calcium/ vitamin D supplements.” In addition, they need bone mineral density monitoring and bone-building medication if bone mass numbers are below a certain threshold or they have at least two other fracture risk factors, such as a smoking history or family history of fractures.

Osteoporosis medications that slow bone loss include bisphosphonates, such as risedronate, ibandronate, Fosamax (alendronate) and Zometa (zoledronic acid), as well as the biologic drug Prolia (denosumab), also known as Xgeva.

However, the Food and Drug Administration (FDA) issued a consumer update in 2012 suggesting that “some patients may be able to stop using bisphosphonates after three to five years and still continue to benefit from their use.” It also mentions that bisphosphonate labels have carried safety warnings about the rare side effect of severe jawbone decay (osteonecrosis of the jaw) since the early 2000s, and increased risk of unusual thigh bone fractures since 2010. The update cautions that the “FDA continues to evaluate a possible association of bisphosphonates with esophageal cancer.”

Though different types of cancer treatments create different levels of risk for bone loss, the National Comprehensive Cancer Network’s (NCCN) Task Force on Bone Health in Cancer Care recommends that cancer patients have bone density screening, regardless of age or gender, because patients “typically have several additional osteoporosis risk factors.”

The NCCN recommendation is welcome news to Nidecker, who requested a bone density baseline scan when he started receiving hormone deprivation treatments 14 years ago, after learning about it online. “Very little was explained to me,” he says. “I am kind of disappointed that none of the dozen doctors I talked to, with one exception, suggested a scan.”

Little has changed since then, if the men in his prostate cancer support groups are typical. Most are unaware of the side effects of hormone therapy. “Bone density in particular is not on anyone’s radar screen,” says Nidecker, who leads support groups at the University of California, San Francisco Medical Center at Mount Zion and at Sutter Health. His advice for anyone joining a group is to get a baseline test, especially those who are starting hormone therapy.

When Nidecker learned his Internet and discovered that one remedy is to increase calcium, vitamin D and a few other minerals through diet and supplements. “I also shifted to a more plantbased diet and put more emphasis on fitness.” He took Fosamax to counter bone loss for about five years, but stopped upon learning the potential longterm side effects of bisphosphonates.

Bone density in particular is not on anyone’s radar screen. We suggest they talk to their doctor about getting a baseline test, especially those who are starting hormone therapy.”

fear is staying alive and second is sexual function,” says Barbara Zoltick, an oncology nurse practitioner at the Abramson Cancer Center in Philadelphia. “My feeling is now that men are living longer with prostate cancer, they want to live better.”

Historically, there hasn’t been an emphasis on bone density testing for men, she says, but she sees that changing. In addition to receiving a DEXA (dual energy Xray absorptiometry) scan both before starting hormone deprivation therapy and again a year later, men are encouraged to pay attention to bone health, she says.

They should continue physical activity or take up weight-bearing activity, such as dancing or jogging, under guidance from a primary care doctor or a physical therapist, Zoltick adds. They also should follow current National Osteoporosis Foundation guidelines regarding calcium and vitamin D intake, either through food or over-the-counter supplements, and avoid excessive caffeine, smoking and alcohol consumption. Chronic steroid use can also contribute to thinning bones.

Few clinical studies of men receiving hormone therapy have been run to evaluate the effectiveness of calcium and vitamin D on bones, but their usefulness is “inferred from other studies,” Zoltick says. “Anecdotally, it’s hard to tell whether these lifestyle changes make a definitive change on bone because of so many variables,” which is why more clinical trials are needed, she says.

To stress the importance of shoring up bone health for men in treatment, she has teamed up with other nurse practitioners and a dietitian at the University of Pennsylvania to create clear instructions that are evidencebased and in accord with current guidelines. They want to ensure that patients are receiving consistent instructions from their medical team.

“Sometimes, giving patients too much paper to read is overwhelming,” Zoltick says. “We are trying to send them home with something very basic.”

Maintaining bone health is essential throughout cancer treatment.

Bone Basics

Genes. Exercise. Medication. A combination of factors probably saved Stan Rosenfeld’s bones during prostate cancer treatment. Receiving his diagnosis at age 59 and learning that the cancer may have spread, he secured “a second, third and fourth medical opinion” and then opted for hormone therapy to reduce testosterone levels right away. Surgery, radiation and more hormone therapy followed.

Because loss of bone density and increased fracture risk are possible side effects of reduced testosterone, Rosenfeld was given a scan with low-dose radiation, or DEXA (dual energy X-ray absorptiometry), to establish his baseline bone density. He also took medication to build bone mass.

The baseline result was fine, he says. At the end of 14 months of hormone therapy, he had another DEXA scan that again showed healthy bones.

A DEXA scan, usually of the femoral neck or spine, takes up to 30 minutes. A patient’s bone density is compared against young, healthy adults, and the result is expressed as a T-score.

A T-score of 0 means that an individual’s bone mineral density (BMD) is equal to the norm for a young adult. Any BMD score between +1 and −1 is considered normal or healthy. A T-score between −1 and −2.5 indicates low bone mass, called osteopenia, but not low enough for an osteoporosis diagnosis. Healthier habits are generally encouraged for all patients, such as a calcium-rich diet or mineral supplements, weight-bearing exercises, limited alcohol and no smoking. A T-score of −2.5 or lower indicates osteoporosis and high risk of fracture. Medication may be prescribed for this group.

The World Health Organization developed a Fracture Risk Assessment Tool, or FRAX, based on data collected from populations worldwide. Using the T-score (although this is not required) and other measures, as well as answers to questions about clinical risk factors related to age, family history and lifestyle, the FRAX model calculates a patient’s risk for a hip fracture or other major skeletal incident, such as a break to the spine, hip, forearm or shoulder.

What you should know about bone density during cancer treatment. 

Jane Hill

The Benefits of Personal Training

Prehabilitation Aims to Prepare Patients for What Lies Ahead

Bone Basics

Assessing the Risk

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