Going the Distance After a Cancer Diagnosis

Teri Griege has always loved sports. She participated in high school sports but once she got married, built her career as a nurse and started her family — a son and a daughter — running took a back seat.

She started running again later on, kicking off with a marathon in 2006. Griege then shifted her interest to triathlon, which incorporates swimming, biking and running. She did her first Ironman Triathlon — a 2.4-mile open water swim, a 112-mile bike ride and a 26.2-mile run — in 2008 when she was 47. Griege placed fourth in her age group and just missed qualifying for the Ironman World Championship in Kona, Hawaii.

“I had no idea I was going to be fairly good at this,” Griege says.

She took the next year to train to qualify for the World Championship even though she was not feeling great.

“I wasn’t really sure what was going on. On some days, I’d feel really good. Other days, I’d feel bad,” Griege recalls. “I started having some bleeding. I thought maybe it was hemorrhoids. I’d get an injury; it seemed like it would take a long time to heal.”

Griege did another Ironman Triathlon in 2009 and was 10 minutes slower, completing it in 12:28:52. She also noted that her symptoms had gotten worse, with more bleeding and discomfort.

She finally went to the doctor in September 2009, who recommended she undergo a colonoscopy. She learned that she had a large tumor that had spread to her liver, meaning she had stage 4 colorectal cancer.

“This was all two weeks post having completed an Ironman at a very respectable time,” says Griege, who is now 61. “When I was diagnosed ... I used to say it was kind of like Lance Armstrong when he was diagnosed in the midst of his competitive cycling. But anyway, I was in fantastic (shape), best shape of my life. And I had cancer throughout my whole body.”

The Benefits of Exercise

Findings from several studies have demonstrated that patients with high levels of exercise before a cancer diagnosis may have better outcomes after a diagnosis compared with those who were sedentary before diagnosis.

“Typically, this has been looked at in things like breast cancer, prostate cancer — some of the more common diagnoses, as you can imagine — because there are more diagnoses there,” Lee Jones, chief of the exercise oncology service and attending physiologist at Memorial Sloan Kettering Cancer Center in New York, says in an interview with CURE®. “They appear to have — I wouldn’t say improved — but appear to have longer overall survival (the time when a patient with cancer is still alive) compared to those individuals who reported being sedentary.”

This benefit from exercising before a cancer diagnosis may be because these patients are in better shape, so they are able to tolerate therapies more effectively and are able to receive more of their treatments.

“(Elite athletes) have the perfect metabolism (and) they have the perfect (bodily) functions,” Dr. Inigo San Millan, assistant professor at the University of Colorado School of Medicine and an asso- ciate professor at the University
of Colorado in Colorado Springs, tells CURE®. “So when they have treatment for cancer ... they don’t suffer deterioration nearly as bad, in many instances, as other patients with cancer. For them, it’s like they have better tools to deal and cope with cancer.”

San Millan adds that the benefit a patient may obtain from exercise during cancer treatment may depend on the type of cancer they have.

“(In) stage 4 metastatic cancer, eventually most patients, whether you’re an elite athlete or not, they’re going to have the same outcome.”

These benefits may also depend on the type of treatment a patient is undergoing.

“That can really be everything, from taking an anti-estrogen pill for people with breast cancer,” says Dr. Jennifer A. Ligibel, director of the Leonard P. Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Institute in Boston, in an interview with CURE®. “People with prostate cancer also use endocrine therapy, and in that setting, exercise is so important because there can be a lot of muscle loss. ... But other people are getting really intensive chemotherapy and radiation, and the ability to remain active really does vary.”

Another explanation behind the benefits of exercise and cancer outcomes may also be a heightened immune system, which can lower circulating levels of metabolic growth factors and change other factors within the body that may aid in cancer cell growth.

“We want to convert our bodies to an inhospitable place for cancer cells to live,” Jones says. “If you think about exercising, it does that. It creates all these factors that cancer cells really don’t like. They like being in an environment where they’ve got lots of growth factors; it’s immune suppressed and all these other things.”

Upon receiving a diagnosis of stage 4 colorectal cancer, Griege initially underwent a short course of radiation and then six rounds of FOLFOX chemotherapy, a combination regimen commonly used to treat colorectal cancer that includes leucovorin calcium (folinic acid), fluorouracil and oxaliplatin.

“I was very fortunate that my body responded well,” she says. “I think this had to do with a lot of exercise and being in good shape.”

After completing the FOLFOX chemotherapy, Griege underwent a colon and liver resection, followed by six more rounds of FOLFOX and maintenance chemo with Avastin (bevacizumab) and Xeloda (capecitabine) for over nine years.

Side Effect Management

Exercise may also play a role in how patients tolerate the side effects of cancer treatment.

“(Exercise) has a lot of benefits for people,” Ligibel says. “They were less tired. They didn’t lose as much strength during their treatment because a lot of people do become deconditioned. And older people especially may be less able to take care of themselves after cancer treatment. So exercise really helped prevent that kind of decline.”

Exercise in any amount may also help with mood disorders during a patient’s cancer journey.

Griege says training for triathlons before her cancer treatment helped her break down how to approach each step of her cancer journey.

“There’s a certain mentality that goes along with (training and exercise),” Griege says. “It’s the perseverance and endurance. In an Ironman, if you look at that race, it’s a three-sport race, and then each one has quite a distance. ... So for me, the radiation was one sport, the surgery was a second sport and then chemotherapy was a third sport. You kind of get through one and then you move to the next. And even within the one (treatment), you have to break that down into something that most people are familiar with, (which) is a marathon. When you start a marathon, you don’t want to think about mile 26. You’re going to think about getting through mile No. 1.”

LISTEN: The Sport of Cancer: How One Survivor Linked Ironman Training and Colorectal Cancer

Griege exercised during cancer treatment and her cancer team understood how important movement was for her.

“I wanted to keep my life as normal as possible,” she recalls.

Although she had to stop exer- cising for a while after undergoing surgery, Griege would swim, bike and run, among other things, during the chemotherapy portion of her treatment. “I just would adapt to what my body felt I was able to do, what I could tolerate, but I continued,” she says.

Too Much of a Good Thing

Although it is understood that exercise offers benefits for patients with cancer while they are undergoing treatment, there is such a thing as too much, experts say.

Current guidelines recommend 150 minutes of moderate-intensity exercise a week, consisting of 30 minutes five days a week for people regardless
of cancer status. Exercise beyond 150 minutes per week may offer patients a benefit regarding heart disease and diabetes prevention, but Jones says it behaves differently for any cancer-related benefit.

“If you go from (no exercise) and then you start exercising 30 minutes or an hour a week, you do get this nice, linear decline in risk in general,” Jones says. “And if you go to about 150 minutes (a week), (the benefit) continues. But once you start to get past 150 to 200 minutes of exercise a week, it starts to plateau.”

One concern that many health care professionals have regarding exercise, especially in patients who have trained before receiving a diagnosis, is doing too much exercise during treatment.

“You’re not eating as well, you’re not sleeping as well, and you’ve got all these poisons in the system. And then you’re trying to exercise on top of that,” Jones says. “I think we normally think about exercise being in that context that it’s obviously going to be beneficial. ... I think we need to be a little bit careful with that, knowing full well what treatment is doing (to the body). It’s very easy, in that context, for exercise to start to become patho- logic. You can go over your body’s ability to recover.”

Jones says it’s important to keep in mind that a person benefits from exercise when the body is able to recover, not during exercise itself.

San Millan compares the dosing of exercise to the dosing of over-the-counter medications like ibuprofen. “You go to a doctor and they say, ‘You need to take ibuprofen,’ but they didn’t tell you how much and how often,” he says. “Then go you, ‘I think maybe half a bottle a day will work.’ And in one month ... you have liver disease or a big stomach ulcer. This is why I think that when you have to prescribe exercise, you need to tell the patient, ‘You need to do it this way, this intensity, this amount of days a week and for this duration.’”

This past fall, Griege was five years without treatment and considered to have no evidence of disease. Although she doesn’t train for Ironman competitions as much as she did when she was younger, she still runs, bikes and swims at least twice a week, what she calls “movement” instead of “training.” Griege uses this movement to raise money for cancer research and advocacy as her way to “pay it forward,” she says.

Taking It Slow

Whether a patient was training for marathons, for example, before receiving a cancer diagnosis or is interested in moving around more during treatment, experts say it is never a bad time to start exercising.

“It’s always time to improve your metabolic health and your own health through exercise,” San Millan says. “The important thing, though, is to do it correctly. ... It’s important to find the right professionals who can help you out with the right exercise prescription. ... You need to have exercise in the right, individualized way.”

Ligibel emphasizes the impor- tance of listening to one’s body during cancer treatment and learning when exercise may be ideal and when the body needs a break.

“If you’re finding that a day after your workout, you’re in bed for three days, that probably means that you need to modify your regimen a little bit,” she says. “Make sure that you’re getting enough hydration, enough food, enough sleep. It’s really a balance.”

If a patient did not have some sort of exercise regimen before a cancer diagnosis, Ligibel recommends starting slow. For example, patients can start by doing 10 minutes of exercise three or four times a week and building that up slowly. She also says it may help for patients to find out what kind of exercise they like to do so they keep up the routine.

Experts also advise patients to speak with their health care team before starting any type of exercise regimen to determine what they may be capable of.

“Movement is key,” Griege says. “Chemo was extremely tough, and my surgery was really, really tough. But you can just start by walking to the mailbox and getting the mail. Just inch by inch, little changes are so important. If it’s a beautiful day, go to the mailbox and go to the end of the street. ... Something is better than nothing.”

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