Eleven years ago, personal trainer and fitness instructor Judy Cerrito was diagnosed with breast cancer. When she looked for an exercise program to help her overcome the pain, stiffness and other side effects of treatment, she could not find anything specifically for breast cancer survivors. So as soon as she was back to work at the YMCA of Greater Providence, Rhode Island, she created something herself.
Starting Over, an exercise program for breast cancer survivors, has since helped hundreds of women regain function and well-being. Cerrito also coordinates the LIVESTRONG program at the YMCA, a 12-week, small-group training program for men and women with all types of cancer. “As difficult as it was to hear the words ‘You have cancer,’ I feel I was given a gift,” Cerrito says. “I now understand what so many others are going through, and I’m in a position to help.”
This article reviews the evidence indicating how exercise can benefit cancer survivors, as well as many of the challenges specific to working with this population. You will learn how you can best support cancer survivors in finding an exercise program that meets their needs, or even get started on developing a program yourself.
A Teachable Moment
This year, nearly 1.5 million Americans will hear those frightening words (Snowden 2009). Many more—1 in 2 men and 1 in 3 women—will receive a cancer diagnosis in their lifetime (Runowicz 2006). The good news: cancer is not a death sentence. For many of the most common forms of cancer—including breast, prostate and skin cancer—the 5-year survival rates following an early-stage diagnosis are close to 90% or higher (Ries et al. 2008).
As cancer survivors face the challenge of reclaiming their health, there is growing evidence that exercise can help. Unfortunately, most cancer survivors are not physically active. In a survey of more than 114,000 Canadian adults, fewer than 22% of cancer survivors exercise adequately (Courneya, Katzmarzyk & Bacon 2008). The statistics for Americans are equally dismal, with the majority of survivors not accumulating the recommended 150 minutes of
activity per week (Blanchard, Courneya & Stein 2008).
Nicole Culos-Reed, PhD, associate professor of kinesiology at the University of Calgary and founder of the Yoga Thrive program for cancer survivors, believes that fitness professionals can play a key role in supporting healthy lifestyle changes: “Cancer is a teachable moment and a wake-up call. It’s a real opportunity to help people change the behaviors we know are critical to survival.”
As more and more physicians recommend exercise, many cancer survivors, like Cerrito, will be looking for support from the fitness community. And many, again like Cerrito, will have trouble finding knowledgeable trainers who can work with them. “The worst thing that can happen is someone walks into a gym, says he has cancer, and the staff says, ‘Oh, we’re sorry,’” says Culos-Reed. “[People] don’t want you to be sorry—they want you to know what to do, how to keep it safe and how to work with them.”
Living Longer, Living Better
Following the shock of diagnosis, one of the first things cancer patients want to know is: What can I do to make sure this disease doesn’t come back, and doesn’t kill me? According to Culos-Reed, who also conducts research on the benefits of exercise for cancer survivors, “Physical activity is the single largest modifiable risk factor we know of to prevent recurrence.”
A recent review in the British Journal of Sports Medicine identified nine studies showing that physical activity reduced the risk of death in cancer survivors (Irwin 2009). Most striking was the finding, across a number of studies, that 3 hours a week of moderate-intensity exercise was associated with a 50%–53% lower risk of death in breast cancer survivors and a 39%–59% lower risk of death in colon cancer survivors. Although other forms of cancer have not been studied sufficiently to draw strong conclusions, there is no reason to suspect that exercise would not benefit people with other types of cancer.
Living longer is a powerful motivator, but quality of life can be equally important. A recent national survey of more than 9,000 cancer survivors found that for all types of cancer, meeting the recommended guidelines for physical activity was associated with a higher health-related quality of life, including less pain, fewer difficulties completing daily tasks, better physical functioning and better general health (Blanchard, Courneya & Stein 2008).
Is Exercise Safe During Treatment?
Many exercise programs for cancer survivors recommend that participants wait until after surgery, chemotherapy or radiation to begin. However, a review of 22 studies found that exercise during cancer treatment could enhance immune-system and physical functioning and improve the following symptoms and side effects: anxiety, mood swings, depression, fatigue, difficulty sleeping, pain, nausea, muscle weakness, reduced bone mineral density and poor body composition (Knols et al. 2005).
Culos-Reed states that almost all oncologists now support starting physical activity as soon as patients are ready, including before or during treatment—something she says is a big change in medical opinion from even a decade ago. She recommends that patients get as much activity as they can during treatment, as long as they have clearance from their physician. This sometimes runs counter to patients’ instincts. “If they have physical side effects and fatigue, they think they have to protect the body. They don’t want to stress it, so they pull back and don’t engage.”
But the evidence suggests that appropriate exercise during treatment can restore energy, not deplete it. A recent meta-analysis of 28 studies—15 of which examined physical activity during treatment—found that exercise significantly improved fatigue in cancer survivors (Cramp & Daniel 2008). A wide variety of
exercise types, including cardiovascular exercise (e.g., walking, stationary cycling), strength training, flexibility training and yoga, helped boost energy.
Margaret Zuccotti, a 40-year-old mother of three with stage 4 breast cancer, is a perfect example of staying active during treatment. “Right from the beginning, running made chemo tolerable,” she says. “I ran or walked most days throughout my 7 months of weekly treatments, and felt like I was actively
going after my cancer in more ways than one.” Zuccotti has won the survivors’ division of the Philadelphia Susan G. Komen Race for the Cure 2 years in a row. “I am on Herceptin every 3 weeks from now until forever, but I run and compete to my heart’s content. Running helps me remember all that I am in addition to being a survivor.”
Finding Strength and Support
Zuccotti’s story points to another important benefit: exercise can give cancer survivors a sense of control and positive action. Doreen Puglisi, MS, founder and program director of the Pilates-based Pink Ribbon Program for breast cancer survivors, says, “This is
one thing they can choose to do that feels good to them.
All the other choices—chemo, surgery—they [also] have to make, but they don’t feel good. You do them because you want to survive. Exercise is the one thing that feels good both physically and mentally.”
Another key benefit of exercise programs for cancer survivors is social support. Cerrito agrees that the social component keeps people coming back to the Starting Over program. “It’s not a support group per se, but a supportive environment. The people in the program bond with each other because they have so much in common. People can take the program for one 8-week session, but many take it again and again, and several people have taken it for years. One woman’s doctor told her she’d be on chemo for the rest of her life. She was, but kept coming to class. When she got weaker, she just came to be with the supportive group.”
A Different Mindset
Working with cancer survivors requires a different mindset than working with a general population. Richard T. Cotton, MA, national director of certification for the American College of Sports Medicine, says, “If you always want your client to make progress and go further and faster, it doesn’t always happen, especially during treatment.” Sometimes a client’s abilities will improve, and sometimes they will decline. “So much has to be adjusted on the fly during the workout, and the exercise program will vary day to day.”
This is a lesson that Andrea Hall, coordinator of HOPE [Healing Through Optimism, Persistance and Exercise] Cancer Wellness at the Baptist Hospital in Nashville, Tennessee, learned from experience. “Initially, I tried to be too structured by having the 12-week plan all laid out. Not long after, I learned to create a program for the individual and take it week by week. If you have five women with breast cancer, they will have completely different health histories, emotions, personalities and backgrounds, and you will need to tailor their workouts accordingly.”
Cotton also points out that a trainer needs to think about different training outcomes when evaluating the program. “A trainer who is deeply invested in [muscle] sculpting, body composition, measuring tapes—that isn’t the best way to train a cancer survivor. A cancer trainer needs to be invested in quality of life,
fatigue, how the client feels 2 hours after the workout and the next morning.” Often, the training goal is simple: to feel better. Cancer survivors are not likely to be thrilled when they wake up the next morning too sore to move.
Puglisi, founder of the Pink Ribbon Program, agrees that this is the biggest difference when working with cancer survivors. “As personal trainers, we’re trained to motivate people to do things they might not want to do, and to push. With this population, there might be pain and real limitations. You have to be able to understand that this population has limitations, and it is not laziness.”
Working with survivors also means learning how to handle emotions when clients get sicker. Cerrito says, “It is heart-wrenching when they don’t do well, when they die, and you’re grieving. That is a component of this program. We talk to our staff about this, and we have made arrangements that they can call any one of us, or counselors, 24-7.”
Understanding Symptoms and Side Effects
The symptoms of cancer and side effects of its treatment are far-ranging (see the sidebar “Common Symptoms and Side Effects During Cancer Recovery”). They influence what clients are able to do safely and what they need from an exercise program. To work with cancer survivors in or recently out of treatment, you must learn about the symptoms and side effects, and how to address them.
Take, for example, lymphedema, a buildup of lymphatic fluid in the arms or legs that is a common side effect of radiation, chemotherapy or surgery. Exercise can help lymphedema but also make it worse, and precautions are necessary to avoid harming a client. According to the National Lymphedema Network (2008), aerobic exercise, gentle stretching, and slow, repetitive movements without extra resistance may be helpful for reducing
or preventing lymphedema. To avoid harm, a compression garment should be worn during exercise to prevent additional swelling. Clients should begin resistance exercise with a low load, and progress gradually, allowing adequate rest between sets. Aggressive stretching should be avoided.
In practice, these recommendations can look quite conservative. Cerrito says, “Instead of going on a machine with a minimum weight of 20 pounds, we start with 1-pound hand weights. If [clients] do well, maybe next week or so we’ll try 2-pound weights. If there are any adverse symptoms, such as pain, tingling or more swelling, then we back off.”
Another common side effect of chemotherapy is cognitive
impairment—what survivors call “chemo brain.” “Chemo brain really affects their memory and coordination skills,” says Hall. “They’re aware of it and will often joke about it or get really frustrated. I am very patient with them and try my best to make the workouts a positive experience.” Cerrito agrees that patience is key. “If you’re teaching someone how to use a particular type of equipment, you can’t expect them to remember how to use it during the next session. Maybe they will, but be ready to gently show them again.”
Fatigue, the most common side effect of cancer treatment, can be quite unlike the kind of tiredness most of us are familiar with. Laura Thatcher, MS, exercise physiologist for the Cancer Wellness Program at McConnell Heart Health Center in Columbus, Ohio, says, “During treatment, individuals have a different level of
fatigue. It is not the fatigue of ‘I had a hard day at work,’ but more like, ‘I am completely exhausted.’ You have to be aware that on certain days after their treatment, they may not be able to even come close to what they would normally do.” Her program helps survivors find their “new normal” and overcome any frustrations that arise if they cannot do as much as they could before the
diagnosis. “We remind them that they will get there eventually, but we have to gradually build up their stamina.”
Lymphedema, chemo brain and fatigue are just a few of the new challenges you will encounter when training cancer survivors. For this reason, it is important to familiarize yourself with the most common symptoms and side effects and to investigate the best practices for each.
Connecting With the
Cancer Support Community
No program for cancer survivors can succeed without being connected to the local cancer support community. Puglisi, founder of the Pink Ribbon Program, advises, “Reach out to all cancer support groups. Ask to come and give a 10-minute class. Show them some seated exercises. Talk about how treatment can change the body, and how exercise can help them return to pretreatment function.”
Puglisi also encourages instructors to introduce themselves to medical professionals, such as radiation oncologists and plastic surgeons. “Many instructors feel uncomfortable reaching out to the medical community, but the key to a program’s success is networking. With this population, you can’t just put an ad in the paper.” She suggests making presentations, not just to physicians, but to anyone in a position to refer cancer survivors. For example, the patient-care coordinator at the plastic surgeon’s office may have more time than the doctor to discuss the benefits of postsurgery exercise.
Promoting Lasting, Positive Change
According to Culos-Reed, an 8-week exercise program can be a big success, but “maintenance is a huge challenge.” There are many things you can do to support commitment. “Encourage [clients] to do the kind of exercise they want to do,” she recommends. “The doctor might say walking is good for you, but unless you enjoy it, it doesn’t matter, because you won’t do it.”
Culos-Reed also encourages clients to have a workout buddy and recruit the social support they need to make exercise a priority. For example, the Yoga Thrive program invites cancer survivors to bring a support person to class. Like survivors, caregivers are often exhausted and stressed out by the experience of cancer treatment. They can benefit from exercise while supporting the survivors in staying active—and with this support, survivors may be more likely to continue exercising after the program has ended.
The Yoga Thrive program also gives participants the tools they need to work out on their own. “We give them a DVD so they can work out after the program ends,” says Culos-Reed, “and we give them home-based equipment—like balls, bands and flashcards—so they can remember the poses despite chemo-brain fog.”
Cerrito stumbled on another solution to the maintenance problem when graduates of the LIVESTRONG program started showing up at the YMCA even after their 12-week session ended. They worked out alongside the current participants and offered them support. “It has spread to all of our branches. So many people finish the program, become members of the Y and join this graduate club. We hear over and over again that people in this program want to give back. Being in this graduate program and mentoring new people means giving back.”
If you are interested in working with cancer survivors, it may be easier to join an existing wellness or fitness program than to start your own. A program that is up and running may even provide or pay for your training. Find out what is available by searching online and contacting local cancer centers, wellness centers and gyms. Observe programs in your area. Attend more than one session to get a sense of how the trainer assesses clients’ needs on a daily basis and adapts a session to meet clients’ needs.
If a program is not available in your area, start connecting and looking for opportunities to collaborate. A fitness facility or cancer support center may be interested in sponsoring or hosting a program. Mention your goals to your existing client base—you might be surprised to discover who among them are cancer survivors or whose lives have been touched by cancer in other ways. These clients can give you feedback on your ideas and help connect you with organizations that could support your work.
Most important is your personal commitment to this population. As Thatcher says, “It really helps if you have a passion for it. These participants can see your passion, and they thrive off it.”
Anemia: low levels of oxygen-transporting hemoglobin or a red blood cell count below normal; can be caused by both cancer and its treatment, and can produce symptoms of fatigue and depression.
Cardiopulmonary weakness: impaired cardiac and respiratory function; can result from some cancer treatments. Cardiorespiratory exercise can improve function but must be offered at the level comfortable to the individual.
“Chemo brain”: the common term for cognitive impairments and memory loss associated with chemotherapy; can affect a client’s ability to concentrate and recall exercises.
Dehydration: can be caused by treatment itself or its side effects, such as vomiting or diarrhea. Hydration during training is important.
Depressed mood: can include feelings of sadness or hopelessness, loss of pleasure, and difficulty concentrating or sleeping.
Fatigue: one of the most common symptoms of cancer and side effects of cancer treatment; must be taken into account when leading an exercise session or recommending home exercise.
Immune system suppression: can occur to such a degree during treatment that engaging in aquatic exercise and visiting a public gym with shared equipment and close quarters are contraindicated for some people. Patients should ask their physicians for clearance to exercise in a pool or public facility.
Lymphedema: a buildup of lymphatic fluid that causes swelling in the arms or legs—a possible side effect of radiation, chemotherapy or surgical removal of lymph nodes. Lymphedema may be helped or worsened by exercise; caution is required.
Muscle weakness or imbalances: common side effects of radiation, chemotherapy and surgery; may be improved through well-targeted, gentle stretching and resistance exercises that progress over time.
Nausea: a common side effect of chemotherapy and radiation; may interfere with appetite, energy and quality of life.
Peripheral neuropathy: tingling, burning, loss of sensation, pain or other unusual sensations that can persist following chemotherapy; may impair coordination and make exercising uncomfortable or more difficult.
Reduced bone mineral density: a possible side effect of chemotherapy that can increase risk of fracture during training or everyday activities.
Sarcopenic obesity: an increase in adipose tissue with a loss of lean body mass—a possible side effect of chemotherapy and hormonal therapy. Regular exercise can help improve body composition in cancer survivors.*
* Evidence cited in this article suggests that exercise can improve or reduce this symptom/side effect.
Visit www.cancersymptoms.org for more information about common symptoms and side effects. Additional source: Sprod 2009.
There is little evidence that any one form of exercise is superior to others for cancer survivors. The existing research supports the benefits of a wide variety of exercise types, from cardiovascular training to yoga. That said, a 2006 review by Conn et al. found that almost all supervised exercise interventions for cancer survivors included some form of aerobic exercise (e.g., walking, treadmill, stationary cycling). Most interventions were designed to provide moderate-intensity exercise (30%–70% VO2max). About half of the programs included resistance training and flexibility training. Interventions tended to be 10 weeks or longer, with three sessions per week. Findings on mind-body approaches are not as far along as the research on more traditional fitness approaches. However, a 2009 review by Smith and Pukall found some positive evidence that yoga could improve health-related quality of life, stress and mood in cancer survivors.
The information in this article will help you understand the benefits and challenges of physical activity for cancer survivors. To become fully trained in specific assessment and exercise strategies for cancer survivors, the following resources can help you take the next step.
The American College of Sports Medicine, www.acsm.org, offers a certified cancer exercise trainer (CET) specialty certificate and provides workshops, reading recommendations and online webinars to prepare for the exam.
The Cancer Exercise Training Institute, www.thecancerspecialist.com, offers workshops and home study programs.
OM Yoga,www.omyoga.com/teachertraining/2008/SurvivorTT.htm, offers a 45-hour training program in how to teach yoga to cancer survivors.
The Pink Ribbon Program,www.pinkribbonprogram.com, offers a 2-day training to teach a post-operation recovery workout for breast cancer survivors.
The Rocky Mountain Cancer Rehabilitation Institute, www.unco.edu/rmcri, offers a 1-week cancer exercise specialist training course.
Yoga Bear, www.yogabear.org, connects cancer survivors with free yoga classes at studios around the United States.
- Engage in at least 30 minutes, and preferably 45–60 minutes, of moderate-to-vigorous activity 5 or more days a week.
- Balance caloric intake with physical activity.
- Achieve and/or maintain a healthy weight.
- Eat five or more servings of vegetables and fruits each day.
- Choose whole grains over processed grains.
- Limit consumption of processed and red meats.
- Limit alcohol to one drink per day for women or two per day for men.
Meeting these guidelines (Doyle et al. 2006) may be quite challenging for your clients. A survey by the American Cancer Society found that the majority of cancer survivors do not meet the physical activity guidelines, and only 5% meet the guidelines for both physical activity and nutrition (Blanchard, Courneya & Stein 2008). Nicole Culos-Reed, PhD, associate professor of kinesiology at the University of Calgary and founder of the Yoga Thrive program for cancer survivors, recommends making these guidelines the ultimate goal, but not an all-or-nothing demand. “It has to be a gradual progression. If they try 30 minutes and are sore the next day, they might decide, ‘That’s it, I’m done, I quit.’ We tell participants that 30 minutes a day is the goal, but they might not be there yet. Five minutes a day is okay. Ten minutes a day is okay.”
In 1980, Sherry Lebed Davis was not thinking about launching a worldwide program for breast cancer survivors. She wanted to help just one person: her mother. Lebed Davis, a former professional dancer and owner of two dance studios, and her two brothers, both physicians, were concerned about how their mother was healing from breast cancer surgery. They teamed up to create a dance-based therapeutic practice that would help their mother recover from the physical and emotional side effects of cancer treatment. The simplified dance movements focused on improving lymphatic-system function, balance, range of motion, strength and endurance. Carefully chosen music and props—including hats, boas and scarves—brought in the healing elements of play and joy.
The experiment—along with her mother’s recovery—was so successful that her mother’s doctor, head of the cancer center at the Albert Einstein Medical Center in Philadelphia, asked Lebed Davis to present the program to the cancer center surgeons. The program soon became standard care for every woman treated for breast cancer at the center. Research showed that, among breast cancer survivors, the method reduced swelling; increased energy level, range of motion and flexibility; and decreased depression.
For 10 years, Lebed Davis continued to teach the program—then called the Lebed Method—at two hospitals in Philadelphia. When she moved to Seattle, she thought she was leaving the method behind. But in 1996, she was diagnosed with breast cancer herself. As she went through a difficult recovery, her brother Marc reminded her of their program. He told her to bring it back, this time for her own healing.
This was the push Lebed Davis needed, not just bring to back the program, but to expand it and offer it to the world. She started teaching in six local hospitals, and as word got out, people from all over the United States began asking how they could learn the method. So Lebed Davis and her brother Marc Lebed launched a teacher-training program.
Although the program was designed for cancer survivors, the classes provided such a valuable experience—unintimidating, fun and healing on many levels—that individuals with other health challenges kept asking to join the classes. This led Lebed Davis to expand the method, and with her brother, she developed specialized programs for other conditions, including multiple sclerosis, chronic fatigue syndrome, Parkinson’s disease and diabetes, as well as a program for children with cancer or disabilities. “Healthy-Steps” was added to the name of the program to reflect the new, broader scope of its mission.
Healthy-Steps/The Lebed Method is now offered in more than 700 locations. The program is available in 14 countries apart from the U.S., with 18,000 classes taking place every week. Lebed Davis says, “Our program is really for special populations now. So many people are left out of the fitness market. I’ve seen students leave even basic fitness classes crying because they thought it was the one thing they’d be able to do, but they couldn’t. This is something everyone can do. There are too many people with illnesses or chronic conditions who need fitness. We shouldn’t leave people out. It’s too important.”
Learn more about Lebed Davis’s program through the following resources:
- The Lebed Method: Focus on Healing Through Therapeutic Exercise and Movement, DVD by Sherry Lebed Davis and Michelle Mansfield (2006)
- Thriving After Breast Cancer: Essential Healing Exercises for Body and Mind, by Sherry Lebed Davis, Stephanie Gunning, Ann Campbell and David Ehlert (Broadway 2002)
Conn, V.S., et al. 2006. A meta-analysis of exercise interventions among people treated for cancer. Support Care Cancer, 14 (7), 699–712.
Courneya, K.S., Katzmarzyk, P.T., & Bacon, E. 2008. Physical activity and obesity in Canadian cancer survivors: Population-based estimates from the 2005 Canadian Community Health Survey. Cancer, 112, 2475–82.
Cramp, F., & Daniel, J. 2008. Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, Issue 2, CD006145.
Demark-Wahnefired, W., et al. 2005 Riding the crest of the teachable moment: Promoting long-term health after the diagnosis of cancer. Journal of Clinical Oncology, 23 (24), 5814–30.
Demark-Wahnefired, W., & Jones, L.W. 2008. Promoting a healthy lifestyle among cancer survivors. Hematology/
Oncology Clinics of North America, 22 (2), 319–42.
Doyle, C., et al. 2006. Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA: A Cancer Journal for Clinicians, 56 (6), 323–53.
Irwin, M.L. 2009. Physical activity interventions for cancer survivors. British Journal of Sports Medicine, 43, 32–38.
Irwin, M.L., et al. 2003. Physical activity levels before and after a diagnosis of breast carcinoma: The Health, Eating, Activity, and Lifestyle (HEAL) study. Cancer, 97 (7), 1746–57.
Knols, R., et al. 2005. Physical exercise in cancer patients during and after medical treatment: A systematic review of randomized and controlled clinical trials. Journal of Clinical Oncology, 23 (16), 3830–42.
National Lymphedema Network. 2008. Position statement of the National Lymphedema Network: Exercise. www.lymphnet.org/pdfDocs/nlnexercise.pdf; retrieved July 15, 2009.
Ries, L.A.G., et al. 2008. SEER Cancer Statistics Review 1975–2005. Bethesda, MD: National Cancer Institute.
Runowicz, C.D. 2006. Investment in cancer control and research: A sure bet. CA: A Cancer Journal for Clinicians, 56 9–10.
Smith, K.B., & Pukall, C.F. 2009. An evidence-based review of yoga as a complementary intervention for patients with cancer. Psycho-Oncology, 18, 465–75.
Snowden, R.V. 2009. Cancer death rate steadily declining. American Cancer Society: ACS News Center, May 27.
Sprod, L.K. 2009. Considerations for training cancer survivors. Strength and Conditioning Journal, 31 (1), 39–47.
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