Laura Beil

Exercise can have such a profound impact on a person’s health that some doctors have started writing down instructions to get moving on a prescription pad. Physical activity may be as powerful as anything that comes from a bottle, but how much and how often is as individual as every pill in your medicine cabinet.

The American College of Sports Medicine makes a general recommendation for cancer survivors to do 150 minutes of moderate-intensity exercise each week. In issuing the guidelines in 2010, the group pointed out that while the long-term benefits are still unknown, “Exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups.”

Getting started can be the hardest part. While oncologists are great at treating cancer, they may not be the best specialists to offer specific guidance on how much exercise is best for individual patients, what type, and how often they should get out and do it, says Karen Mustian, a researcher at the University of Rochester Medical Center in Rochester, N.Y. “Start with your oncologist,” she says, “but that will probably not be enough. They will often just give general statements: ‘Of course you can exercise. Go ahead. Do something you like. Go walking.’ ”

She advises seeking out a cancer exercise trainer certified by the American College of Sports Medicine. This is a person who has special training in helping cancer survivors find—and stick with&mdash;the kind of activity that is best for them. The problem is, the certified cancer trainers are not yet in every area of the country. So it may be necessary to do some asking around to find an exercise specialist familiar with cancer.

A good trainer may also be cognizant of special considerations and risks. While cancer survivors can exercise safely the vast majority of the time—everyone can probably do something, Mustian says&mdash;some people may have complications even their doctors are unaware of. Certain treatments could have cardiac complications, or affect the immune system enough to warrant caution in crowded public gyms.

“What’s most important is you find someone you can be open with,” Mustian says. “They will listen and they will work with you to tailor an exercise prescription that meets your needs.”

[Read more about how exercise can reduce the risk of cancer recurrence in "

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Physical activity may be as powerful as anything that comes from a bottle, but how much and how often is as individual as every pill in your medicine cabinet.

The Motivation to Move

At 23, Lauren Parks was a newly minted college graduate a few months into her first job as a commercial underwriter at a San Diego bank. Lounging poolside at her apartment complex one day, she felt an itch in her right breast. When she reached to scratch it, she felt an unexpected lump.

Doctors assured her the odds of a malignancy were slim. She was too young for that. Then six months passed, and the tumor swelled to the size of an apricot, leaving no doubt an aggressive breast cancer was gathering strength. After chemotherapy, radiation and a double mastectomy, she had one singular determination: “I’m going to do everything I can to prevent this from happening again.”

But how? Parks’ oncologist advised staying active and keeping her weight under control. Treatment had left plump, unwanted curves on her naturally skinny frame. So the once uncommitted exerciser skipped the treadmill and Zumba and jumped straight into CrossFit, the fitness craze best known for its popularity among law enforcement officers, former professional athletes and suspected masochists.

Lauren Parks started her exercise regimen with the goal of preventing a recurrence of breast cancer. Photo by Megan Plenge. 

“It was so out of my comfort zone. I would have created every excuse not to go if I hadn’t gone through this,” she says. Her first time out, she found herself doing squats and throwing medicine balls. “I think I literally crawled into work the next day,” she says.

From the first burpee, she hoped to build up enough muscle for one pull-up. Today, at age 29, she can do six, a number that beats most Marine recruits. She conquered her first half-marathon this summer.

	It’s hard to say for certain whether exercise helped keep Parks cancer-free for six years. But there’s little doubt that physical activity is at the forefront of cancer prevention strategies. “A lot of patients will say, ‘What can I do to lower my odds of recurrence and increase survival?’ It’s really the question on the mind of most patients, and most oncologists as well,” says Kerry Courneya, director of the Behavioural Medicine Laboratory and Fitness Center at the University of Alberta in Edmonton. “Patients are looking for things they can do themselves. Exercise is a way to take back control over their lives.”

“He said, ‘You’re never going to get your breathing back.’ I proved him wrong.” 

	Most studies of exercise and cancer have focused on primary prevention—trying to determine whether physical activity plays a role in keeping cancer from occurring in the first place. Those data have tended to be encouraging. In general, according to Courneya, the most avid exercisers appear to have a risk of breast and colon cancer that is about 20 to 30 percent lower than that of their sedentary peers. (Protection probably exists for other types of cancer, he says, but colon and breast cancer have been studied more than other types.)

	Fewer studies have specifically examined recurrence, but those, too, generally provide reason for encouragement. For example, a study published in 2005 in the 

found that breast cancer survivors who walked three to five hours per week were about 50 percent less likely to die from breast cancer over the next four to 18 years, and the benefit tended to increase the more hours they walked. More recent research, published last year in the 

, found that among more than 3,000 women studied, those who were more active before their diagnosis were less likely to see a return of breast cancer, assuming their tumor was not driven by estrogen or progestin. Another study, this one a 2006 look at survivors of stage 3 colon cancer published in the 

, found that people who engaged in more than three hours of exercise per week were about half as likely to see a return of their disease as survivors who were inactive.

	Studies have also measured survival generally—how exercise affects the odds of dying, rather than specifically looking at cancer recurrence. A review published this year in the journal

concluded that survivors of breast cancer who engaged in at least 150 minutes per week of moderately intense exercise had a 24 percent reduction in mortality compared with their sedentary peers. For survivors of colorectal cancer who exercise at that level, mortality reduction was 28 percent.

	Sounds great, but before buying a treadmill or springing for $100 running shoes, know that doctors can’t yet say with certainty that exercise will dramatically reduce the odds of cancer coming back. For one thing, studies have been observational, meaning that the health of survivors who exercise is compared with the health of those who don’t. While a scientifically valid way to answer a question, this kind of research produces only statistical correlations— as physical activity goes up, cancer goes down.

	A good sign, but as scientists often say, correlation is not causation. Those who remain cancer-free could be making other lifestyle choices that might be improving their health and affecting recurrence. For example, those who exercise may also tend to follow a healthier diet and be more compliant with their treatment. Also, the problem with looking at survival alone is that being active conveys benefits that go beyond fighting malignancy. Exercise is well known for protecting against heart disease and diabetes, so cancer survivors might live longer because they are less likely to die from other common problems that rise in likelihood with age.

	What’s lacking is a randomized trial, in which one group of cancer survivors is assigned to do regular exercise while another is simply provided standard follow-up care. Courneya is heading up one of the few such studies. For that research, 1,000 people with colon cancer are being randomly assigned to exercise for three years while doctors note which participants see a return of cancer. The research is costing more than $6.5 million, and is being paid for by the Canadian Cancer Society and the Australian government. Unlike observational studies, the Canadian trial will be able to show cause and effect and will also estimate how effective exercise is—by what degree it actually lowers recurrence and cancer death risks. But it will not provide data for perhaps a decade.

	Still, cancer survivors don’t need to wait around in the La-Z-Boy for the results to come in. Exercise as cancer prevention makes biological sense, experts say. To begin with, physical activity helps control obesity, which a long line of evidence suggests increases the risk of cancer. In prostate cancer, for example, obesity is thought to raise the risk of aggressive malignancy. The reasons aren’t known, but fat tissue might be an accomplice to tumors by producing certain hormones that stimulate cell growth. Inflammation is another prime suspect that is reduced by exercise and elevated in obesity. Adipose tissue provokes the body’s white blood cells into a low level of activation. This quiet simmering of the immune system might damage DNA, perhaps ultimately triggering the growth of tumors.

	There’s one hitch to pointing a finger at fatness, though. Exercise alone doesn’t necessarily lead to weight loss, says Jeffrey Meyerhardt, a gastrointestinal cancer specialist at the Dana- Farber Cancer Institute in Boston. “Most people who exercise will make up their calories.” To lose weight, people have to also eat less, which doesn’t always happen.

	So physical activity might bring about other changes in the body that somehow nip the earliest buds of a tumor. The leading theory concerns how exercise affects insulin. The hormone is produced after you eat to get calories out of the bloodstream and into tissues. People develop type 2 diabetes—the most common kind&mdash;when the body becomes resistant to the effects of insulin, allowing glucose to build up in the blood. Often the body keeps pumping out higher and higher amounts of insulin in a desperate attempt to lower blood sugar, which only makes things worse.

	During exercise, the body needs calories for fuel. Insulin sensitivity increases, and levels of the hormone drop. Along with insulin, exercise lowers the body’s level of a chemical called IGF (insulin-like growth factor). Exactly how insulin and IGF fuel the growth of tumors is still being worked out, but the connection is strong enough that scientists are experimenting with using diabetes medications for cancer treatment.	

		There are still other theories to explain the connection between exercise and cancer. Meyerhardt points out that vitamin D, which the body produces naturally with sunlight exposure, is thought to be a cancer suppressor. A lot of people get their exercise by running, cycling and engaging in other outdoor sports.

		And finally, exercise could reduce recurrence by enhancing the effectiveness of cancer treatment, an idea that Courneya puts in the category of speculative, but possible. People who stay active after cancer may well have been exercising before diagnosis. “Patients who exercise during their chemotherapy may complete more of their treatment,” he says. “The other thing is that there could be some sort of synergistic effect— exercise may act as a chemosensitizer.”

		Until more answers are known, experts like Karen Mustian of the University of Rochester Medical Center in Rochester, N.Y., prefer talking about the more immediate benefits that exercise can bring to cancer survivors. “When you say the word ‘survival’ or ‘recurrence,’ those are really important words,” she says. “I’m hesitant to make any strong statements.”

		Exercise can nonetheless make life better in the short term, she says, like combating fatigue and weight gain that can be side effects of treatment. In a study Mustian and her colleagues published last year in the 

, two 75-minute yoga sessions per week improved the quality of sleep in cancer survivors. In other studies, she’s found that patients who exercise during treatment experience less memory loss and fewer problems breathing. “These are things that they feel during their treatment,” Mustian says. “I really talk about something specific.”

		It was the immediate improvement—not the specter of recurrence&mdash;that inspired Ilene Barth’s dedication to exercise after her diagnosis of lung cancer at age 53. She had been a smoker, but had given up the habit a decade earlier. She chose to have a baseline imaging scan to see if her lungs had suffered any lasting damage. The results revealed a tumor the size of a nickel. As part of the treatment, doctors removed a portion of her lung, which left her straining even to blow up a balloon for her daughter’s birthday party. “I had very good lung capacity, and then suddenly I didn’t have any,” she says. “It was scary.”

Exercise helped Ilene Barth regain lost lung capacity after surgery for lung cancer. Photo by Rita Rosenblit.

		A New York book publisher who enjoys a summer home in the mountains of Telluride, Colo., she didn’t want to give up cool, peaceful summers at 10,000 feet. “If I wanted to go home, I had to be able to breathe better,” she says. Even her doctor was not optimistic. “He said, ‘You’re never going to get your breathing back.’ ” She didn’t accept his skepticism, starting with high-altitude walks to neighbors’ houses or the local farmer’s market. She now plays tennis regularly and skis every winter. Simply put, she says, “I proved him wrong.” In fact, her pulmonary capacity is higher than it was before her surgery.

		Her cancer has stayed away for 11 years. Whether physical activity has had anything to do with it, Barth’s motivation to keep moving is more immediate: Exercise is what allows her to live like she never had cancer in the first place.

		> Exercise appears to help prevent cancer and recurrence, although research to test this idea is continuing.

		> Physical activity can help alleviate symptoms including fatigue, memory loss, sleep disturbances, weight gain and breathing problems.

To reduce the risk of cancer recurring, exercise may be just what the doctor orders.

The Fitness Factor

This kind of East-meets-West approach to cancer treatment could eventually become the norm. As more research supports the use of certain complementary methods, medical centers across the country are integrating them into everyday practice in both treatment and survivorship, giving rise to one of the newest frontiers in patient care: integrative oncology.

“There’s been a sea change in the way oncology is practiced in major centers,” says Barrie Cassileth, chief of integrative medicine service at Memorial Sloan Kettering Cancer Center in New York, author of the new book 

 advisory board. “The emphasis now in oncology is not only the best possible path to cure, but how can we control the symptoms that result from cancer treatment.”

Some doctors believe that oncology has often suffered from a loss of perspective—an almost singular focus on killing the cancer, while losing sight of patients themselves. Integrative oncology is one means of restoring balance, enabling conventional treatments to remain relentless on the malignancy but as gentle as possible on the patient. Often, that involves acupuncture, massage, yoga and even some lesserknown practices, such as music therapy and the feather touch of reiki.

These practices have long been popular and patients often use them on the side without telling their doctors. Still, experts such as Cassileth say there’s been a philosophical shift: Today doctors not only give nodding acceptance to complementary care but outright encouragement.

This new approach often surprises patients. When Joan Pouch was undergoing chemotherapy at Penn Medicine’s Abramson Cancer Center in Philadelphia in mid2011, a volunteer asked if she wanted a reiki session. “I said, ‘What is it?’ ” Pouch recalls. Until then, she hadn’t known that treatment for her stage 3 breast tumor would involve anything other than the surgerychemoradiation triple play she anticipated. That day, the volunteer gently placed her hands on Pouch’s arms and head in a practice that promotes balance and stress reduction through touch. Reiki comes from Japanese terms that translate as “universal life force.” While the scientific basis for many of these practices remains unclear, the apparent benefits are starting to attract attention among conventional researchers.

When a routine mammogram revealed Marie Jackson’s breast cancer in February 2013, she set two immediate goals. First, she wanted to spend as much time as she could behind the counter at The Flaky Tart, the Parisian bakery she owns in Atlantic Highlands, N.J. Second, she wanted to use whatever medical science she could to rid herself of the grape-size, aggressive tumor. But when the side effects of treatment started affecting every aspect of her life, she realized she needed to regain control.

Felt like I had food poisoning, a really bad hangover and the flu at the same time,” she says. “I was flat on my back.” Nauseated, worn out and more bedridden than a 47-yearold should be, she was determined to do something about it.

The emphasis now in oncology is not only the best possible path to cure, but how can we control the symptoms that result from cancer treatment?

“It was amazing,” Pouch says. After 15 minutes, she felt her anxiety begin to lift. In its place, she felt an enhanced sense of balance she had not known since receiving her diagnosis.

Not that integrative medicine is always unfamiliar. One of its mainstays is an emphasis on diet and physical activity. Studies have found that patients who exercise during and after treatment and maintain a healthy body weight tend to recover faster, feel stronger and even live longer than their sedentary peers.

“There’s a huge amount of research on the benefits of a healthy diet, physical activity and healthy body weight,” says Heather Greenlee of Columbia University in New York, president of the Society for Integrative Oncology. “Those are some of the best things patients can do to take care of themselves. But a lot of people want quick fixes. Dietary and behavioral change takes time.”

The emphasis on diet and physical activity underscores an important distinction between integrative oncology and alternative medicine. Alternative medicine choices lack scientific validity and are used in place of conventional treatment, says Lorenzo Cohen, director of the integrative medicine program at MD Anderson Cancer Center in Houston and a member of 

 advisory board. “Integrative medicine is more of a philosophy of how we treat patients,” he says. It incorporates treatments that have held up under scientific challenges, with a focus largely on improving quality of life.

Why has integrative oncology finally taken hold? Partly because of demand. The rise of integrative medicine mirrors a trend in the general population, where complementary therapies have become part of the social fabric. Data show that about four in 10 adults in the U.S. use some kind of complementary or alternative medicine—but the figure is higher among people with cancer&mdash;a huge jump from just a few decades ago. For example, one 1992 study estimated that only about 9 percent of people with cancer used complementary or alternative medicine. More recent studies put the prevalence among them in a range of 40 to almost 90 percent, particularly when prayer is included.

A study of data from more than 31,000 adults, published in 2007 in the journal 

, found that even after the cancer is behind them, survivors were still more likely than people without a chronic illness to seek complementary medicine and prayer.

Integrative medicine is more of a philosophy of how we treat patients.

The trend toward integrative therapies is also due to an unmet need in conventional medicine for more comprehensive management of symptoms and side effects, says Jeffrey White, director of the Office of Cancer Complementary and Alternative Medicine, which is part of the National Cancer Institute. Not only are people with cancer beset with immediate side effects of their treatment, but also the fierceness of the symptoms can make them feel helpless in the face of disease.

“I’ve always been very healthy,” Jackson says, so her cancer diagnosis presented not only a physical challenge but a psychological one, as well. By giving people more choices and strategies for action, integrative oncology can help restore a feeling of control.

The field also tries to steer patients to methods that are most likely to bring results. Left on their own, patients might rely on advice that isn’t always correct. (In fact, experts often lament Internet sites that make either exaggerated or wholly unproven claims.) One study of patients entering clinical trials at MD Anderson found that the most common choices for complementary therapy were vitamins, herbs and prayer. Yet, in practice, acupuncture is one of the most beneficial treatments in integrative oncology for nausea and other complaints.

“Acupuncture stands out on its own to help control symptoms,” Cohen says. “There’s good evidence in the area of controlling nausea.” This past year, in the

, Cohen and his colleagues reviewed all the studies published so far on the effectiveness of acupuncture for symptom management in cancer care, finding support for nausea relief and possibly pain. However, the jury is still out on its effectiveness for a host of other symptoms, such as fatigue and sleep disturbances. Nonetheless, he says, acupuncture’s moderate cost and few side effects make it an attractive option.

The same can be said for yoga: it’s cheap and has little chance of side effects. Yoga has also fared well in scientific studies of its value, at least during active treatment. A 2012 review published in the journal 

 of twelve randomized trials concluded that breast cancer patients who practiced yoga reported better short-term quality of life and improvement in other measures, such as anxiety, depression and stress.

Vitamin and herbal supplements, among the most common choices for people with cancer, are more difficult options for doctors to endorse beyond the level of a plain multivitamin. And unlike many of the mind-body approaches, supplements carry a more tangible risk of side effects due to their numerous biologic effects. “The most concerning area is that those particular agents may have a negative effect on conventional treatments,” Cohen says. “An example of this that is often used, but salient, is Saint John’s-wort.” Taking the herb, which might relieve mild or moderate depression, can reduce the effectiveness of some anti-cancer drugs. Studies of individual vitamins and herbs are inconsistent, Cohen says, and there are safety concerns about contamination and doses listed on the labels that do not reflect what is actually in the bottle.

Conventional medicine and complementary therapies are two worlds that still don't really intersect very well.

If there is one common wish among integrative oncology specialists, it is for more data on just about all the methods in their toolbox. “We don’t understand enough about the mechanism of action of these approaches,” White says. They can be difficult to study because of the complexity that has evolved over generations of use.

“Many of these interventions sound simple and can be described in a few words, like acupuncture,” he says. “There are more than 300 anatomical points that are used by acupuncturists in different combinations with different stimulation techniques. The effectiveness of an acupuncture treatment may depend on the choice of the points, the type of stimulation used, the skill of the acupuncturist and the frequency with which it’s done.”

Still, effectiveness data is needed to help achieve insurance coverage and relieve the financial barriers that could prevent patients from access. Some methods are provided as a part of cancer care, but many patients still pay for them out of their own pockets. And unless it’s covered by insurance, integrative oncology could remain confined to major cancer centers and not reach into communities. White still reserves one day each week for practice in a small hospital in suburban Washington, D.C., where, he says, a position such as a staff acupuncturist is unthinkable. Doctors in smaller hospitals must have some education, awareness and an interest in integrative medicine to pursue it; otherwise their patients remain mostly unaware. “Conventional medicine and complementary therapies are two worlds that still don’t really intersect very well,” he says.

[CURE-recommended integrative oncology resources]

Luckily for many patients, sometimes care is provided by volunteers, like the one who brought reiki to the bedside of Joan Pouch. Once her cancer treatments ended, she had trouble locating a practitioner near her suburban Philadelphia home. So, at age 61, she decided to learn the skill herself. Today, she volunteers at the Abramson Cancer Center every Tuesday, offering reiki to those who occupy the floors she once knew as a patient. She is not surprised to find herself delivering the care that was foreign to her just a few years ago. From the time she received her diagnosis, she looked at cancer as a journey. “I think your life is taken to the areas where you are needed.”

Patients, physicians and researchers are learning that integrative therapies have a place in cancer care.

Integrative Therapies Can Complement Conventional Cancer Treatments

Although integrative medicine includes many approaches to complement conventional therapies, according to the Society for Integrative Oncology they can be described by five categories:

3. MANIPULATIVE AND BODY-BASED PRACTICES 

Integrative medicine can be described by five categories, including mind/body, energy and ancient medical systems.

Laura Beil

The Motivation to Move

The Fitness Factor

Integrative Therapies Can Complement Conventional Cancer Treatments

Integrative Modalities

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