Exercise in Cancer Prevention and Follow-up

9 Exercise in Cancer Prevention and Follow-up

Gerhard Uhlenbruck and Ilse Ledvina

Introduction

When we recommend exercise to cancer patients, we assume that there is a close correlation between cancer, physical activity, and the immune defense system. These interrelationships are clearly shown in Table 9.1.

Cancer imposes an enormously burdensome strain on those afflicted, weakening the immune defenses. Exercise, in contrast, ensures a certain tolerance or resistance to stress, which can be developed particularly through endurance training.

In this context, it is important to consider that stabilization of the patient’s mental state has a positive effect on the body’s immune defense mechanisms. The diagnosis of cancer exerts a maximum of stress that is processed in a variety of ways. Stress entails an adaptation syndrome of neurovegetative and psychoimmunological regulatory circuits as a result of an acute or chronic challenge to the physical and psychological capabilities of a person. The patient can be trained to successfully adapt to this burden by means of a coping strategy commensurate with the circumstances.

Therapies that follow the diagnosis (surgery, chemotherapy, radiotherapy, hormonal therapy) present an additional physiological and psychological burden, further weakening the immune defense system. Exercise creates stress resistance and has a beneficial effect on the psyche, thereby strengthening the immune defenses.

The topic of sports and cancer was first taken up by the German rural doctor Ernst Van Aaken in 1967. He claimed to have statistically proved that an endurance-training regimen designed by him led to a protective effect against cancer. He attributed a vital role to the increase in oxygen supply brought about by exercise. The role of exercise in this context was first indicated in 1973 (15), but it was only as of 1980 that exercise became an accepted rehabilitative procedure in cancer patients (6),(7),(10),(14).

Effect of Exercise

Exercise in the form of moderate endurance training strengthens the immune system mentally through fun, joy, and success on the one hand, and physiologically by inducing moderate inflammatory reactions on the other (Fig. 9.1).

Table 9.1 Cancer, exercise, and the immune system

Exercise as a cancer-triggering or cancer-promoting factor	• Is lymphogranulomatosis more frequently found in young, achievement-driven sports people? • Does an immune system that is weakened by high-level physical exertion promote the development of cancer? • How does psychological stress during physical exertion effect the immune defense, e.g., increased sufferance, overexertion, and excessive demands?
Exercise as a cancer preventive life style	• By strengthening the immune system, training immune defense • By development of a certain resistance to stress • Through reduction of fears and increase in well-being combined with experiencing success • Through changes in life style: changes in diet, avoidance of excess weight, improvement in sleep
Exercise in the cancer follow-up period	• Improvement in the immune defense, specifically activation of natural killer cells (NK cells), but also of T lymphocytes and macrophages • Through psychosocial effects within the group: contacts, talks, concerted undertakings • Improved acceptance of the body: increase in self-esteem, sex life is possible once again, feeling of fitness develops

Fig. 9.1 Exercise as inflammatory tissue-stress with immunologic consequences.

Diseases, injuries, losses, and handicaps often lead to chronic loss of self-esteem that can be effectively compensated for by physical activity.

It is important to achieve muscular tissue stress, be it by functional gymnastics, sports, and play or specific endurance training as set forth by the guidelines of national sport societies (NRM). The tissue trauma after an operation is also a stress for the immune system, which—in contrast to exercise—exerts a negative effect on the immune functions (Fig. 9.3).

The following immunological phenomena can be observed during exercise in the context of cancer follow-up, and are scientifically proved:

• activation of natural killer cells (NK), whose destructive effects on cancer cells are significantly improved 5,(10),(14)

• activation of macrophages (14)

• psychoneuroimmunologically exercise has an anti-depression effect (Fig. 9.2).

Table 9.2 Effect of exercise on the psyche durng cancer follow-up

• Mobilization of self-healing powers: support for selfhelp and finding of one’s self

• Reduced feeling of isolation and loneliness: the psychosocial net catches the soul’s needs and bodily discomforts

• Exchange of information: therapy, regimens, physicians, clinics, diet, complementary medicine

• Fewer fears and depressions: saving of medication for pain, sleep, and anxiety

• Mental fitness and strength for a new, intense life of one’s own responsibility and with realizable perspectives increase

• Chronic fatigue is reduced

Fig. 9.2 Psychoneuroimmunological aspects of exercise.

• improvement of antibacterial characteristics of neutrophilic granulocytes, reducing susceptibility to infections

• overall, the condition of the immune system is improved, which has been demonstrated by functionality tests of the various immune cells, in particular T lymphocytes.

• all rules of exercise immunology have been proved. Initially a mass of undifferentiated immune cells is mobilized, after which smaller groups of immune cells with a specific functional ability are produced. One can trace the cancer-protective effect of exercise back to this phenomenon in retrospective studies. The same seems to hold true for exercise within follow-up for cancer patients. However, too much exercise is not healthy, and too much training can harm the immune system (4), (6), (7).

• the immune fitness of patients who are exercising can be determined and followed with the help of a simple immunology skin test (11). Psychooncological effects of exercise in cancer survivors are listed in Table 9.2 and Table 9.3; the latter also summarizes an optimistic perspective.

Table 9.3 Psycho-oncology effects of exercise as an enhanced measure in the follow-up of cancer

• Individual fitness: exercise and physical activity three times a week for one hour

• Hobbies: mental training, arts and culture

• Change in diet: fresh fruit and vegetables; fish instead of meats

• Ecoimmunology: family, friends, sexuality (more sense of comfort and love and security)

• Meaningful duty requirements, reachable goals in the job and family or, for example, also volunteer work

Fig. 9.3 Exercise as muscle tissue stress with effects on thecentral nervous system and the immune system. Since the immune system as the sixth perceptive sense is derived from the brain, mediator substances from the brain are also “understood” by the cells of the immune system and vice versa (“concerted action”).

Clinical Examinations

• Statistical investigations have shown, that with respect to prevention regular endurance training significantly reduces the risk for individual types of cancer including breast (see Fig. 9.4) and colorectal cancer (see Fig. 9.5). It probably offers some protection against prostate, testicular, and lung cancer, as well as endometrial and ovarian cancer (9) and also other forms of cancer (4,6, 7, 12).

• Not merely animal experiments (13), but also clinical experience and studies (which have not yet been scientifically evaluated on the topic of remission prophylaxis through moderate endurance training) indicate a postoperative cancer-protective effect, mediated by activation of immunological and psychoimmunological circuits. Further research in this direction is highly recommended. Informal studies done so far indicate that this will be a fruitful area of investigation.

Fig. 9.4 Four hours of physical exercise per week suffice to drastically reduce the risk of breast cancer (7).

Fig. 9.5 People who are physically active reduce markedly their risk of developing colon cancer (7).

• For some types of tumors, the protective effect of regular exercise has been demonstrated. This is true for breast cancer (Fig. 9.4), colorectal cancer (Fig. 9.5), but also for prostate cancer seminal (testicular) and lung cancer (9).

• Regular physical exertion in the form of endurance training not only activates NK cells but also improves the psychological state as well as the stress resistance, even in the elderly age groups (Fig. 9.6)(7,10, 14).

There are also other forms of well-being that can be enhanced through sports, vacation, successes, and rehabilitation. the term “training” should be explained in this context.

Fig. 9.6 Comparison of women exercising (average age 73 years) and women that are not physically active (7).

Training signifies daily repetitive physical exercise, as well as physiological and mental exertion with the goal of improving the physical and intellectual capabilities, in order to achieve a meaningful and fulfilled life through adaptation.

Training in the form of moderate exercise and endurance brings all bodily functions back to a healthy stable middle ground: poorly performing systems are restored to normal function (immune system), malfunctions are corrected (blood fats, blood pressure), and excessive overload of physical and psychological stress (stress hormones) are down-regulated.

The sick patient has limitations that he must learn to recognize, since disease results in restricted physical and mental well-being through reduced or impaired biological and ecological conditions. Achieving a positive sense of self is not only realized through free development of genetically predetermined dispositions within the constraints imposed by the disease, but can also be achieved via completely new possibilities. This range of new possibilities includes not only exercise, but also activities such as music, art, literature, painting, reading, and writing, in other words activities that are mentally stimulating and that result in an individual and highly creative healing process.

Regarded in this way, the immune system can be stabilized in multiple ways, as demonstrated in the following figures (Figs 9.7 and 9.8), in which psychological and immunological factors are integrated, while co-stimulating and influencing each other.

Fig. 9.7 Stabilizing effects on the immune defense mechanisms in cancer patients.

The immune system should be regarded today as the sixth organ of perception; see current overview under (9). When we strengthen our senses by “exerting” them, we are also strengthening our immune system. Exercise has a positive effect on the psychological and physical defense mechanisms and promotes stress resistance. Such defenses, however, depend on the autonomic nervous system. It is therefore an important question whether a person has inherited a vagotonic or a sympathetic nervous system dominance. Vagotonic persons have a higher stress resistance, while sympathetic persons react more sensitively to stress. Through exercise, stress resistance can be positively influenced. The sympathetic system is particularly heavily activated during cancer. Stress hormones are released and the immune system is weakened. An immune system that is markedly weakened, not only because of disease but also by unnecessary and intrusive therapeutic procedures (see Fig. 9.3), requires stabilization. In this respect, the development of stress resistance through exercise is particularly important.

There are exceptions for exercising during cancer follow-up. These are the contraindications (2):

• metastases of the bone

• disease that puts heavy strain on the cardiovascular system (e. g., cardiac insufficiency)

• strongly weakened immune system creating danger of infection.

For the training of the immune system, it is sufficient to continually exert oneself for one hour (heart rate: 180-age) or 4×45 minutes. One should choose the type of exertion that one enjoys most (walking, jogging, hiking, swimming, bicycling, tennis, inline skating, and so on). A suggested regime for cancer follow-up would be 1–1.5 hours once a week to start with, leaving more extensive regimens (at least two more training entities) up to the individual after consultation and discussion.

Fig. 9.8 Influence of endurance training on the immune system and the psyche.

In total, about 2000 calories are to be consumed through exercise each week (one minute of jogging consumes 10 calories). Emphasis should be placed on regularity and endurance of exertion. Certain courses given by licensed trainers in weekend seminars or sports institutes are normally offered. Functional gymnastics, endurance training, sports, and fun activities, as well as relaxation exercises can be included. It would be good before starting such a complementary measure to consult the family practitioner in order to ensure fitness for performing sports (stress ECG).

Exercise regimens for cancer follow-up can reduce the need for anxiety-reducing, sleeping, and pain medication. At the same time, mental agility is increased and reintegration into work or family circles is facilitated.

With increasing customization to a training program, patients are motivated to exercise more continuously. In addition, one should make it clear to the patient that exercise not only helps to prevent a cancer recurrence, but also lowers the risk for other diseases:

• cardiovascular diseases (heart attack, stroke)

• infections and aging processes (there are close correlations between the two)

• metabolic disturbances (type II diabetes)

• osteoporosis.

At the center of all these diseases is the process of inflammation. Inflammation also plays a pivotal role in aging as well as arteriosclerosis. In contrast to that, slight infections and moderate endurance exercise strengthen our immune system. Paradoxically, this can also be seen as a beneficial effect of the inflammatory process. With heavy and chronic infections the immune system is overburdened, however. The correlations between cancer and infections are interesting: while smaller infections strengthen the immune defenses, chronic infections seem to promote the development and growth of cancer (e. g., prostate cancer).

Also, metabolic disturbances, such as overweight and metabolic syndrome, can exert a negative influence on cancer: on the one hand insulin and related growth hormones stimulate cancer cells (breast cancer) to increased multiplication, on the other hand fat-soluble carcinogens can be stored or produced (estrones) in fatty tissues.

The diabetic patient poorly supplies a newly developing tumor with blood, due to pathological vessels and new vessel growths (diabetic microangiopathy). In a professional athlete the exact opposite would be expected. Calcium antagonists reduce the blood pressure and the number of adhesion molecules in endothelial cells. These, however, are necessary for the metastases of cancer cells. It can be demonstrated that various diseases are correlated with each other and are able to influence one another.

We must passively endure diseases. However, moderate exercise gives us an active strategy to combat it, that is even fun. Exercise can prolong our lives, and it is even more certain that exercise improves our quality of life. It is precisely this aspect that should be emphasized for cancer patients. Exercise is of great value when the family and work environment of the patient shows understanding for the “change in lifestyle” and lends support in this matter.