VOLUME 23 䡠 NUMBER 4 䡠 FEBRUARY 1 2005

JOURNAL OF CLINICAL ONCOLOGY R E V I E W A R T I C L E

Review of Exercise Intervention Studies in

Cancer Patients
Daniel A. Galvão and Robert U. Newton
From the School of Biomedical and
Sports Science, Edith Cowan Univer-
A B S T R A C T
sity, Joondalup, Australia.
Purpose
Submitted June 14, 2004; accepted
To present an overview of exercise interventions in cancer patients during and after
October 14, 2004.
treatment and evaluate dose-training response considering type, frequency, volume, and
Address reprint requests to Daniel A. intensity of training along with expected physiological outcomes.
Galvão, MS, School of Biomedical and
Sports Science, Edith Cowan Univer- Methods
sity, 100 Joondalup Dr, Joondalup, The review is divided into studies that incorporated cardiovascular training, combination of
Western Australia 6027, Australia; cardiovascular, resistance, and flexibility training, and resistance training alone during and
e-mail: d.galvao@ecu.edu.au.
after cancer management. Criteria for inclusion were based on studies sourced from
© 2005 by American Society of Clinical electronic and nonelectronic databases and that incorporated preintervention and postinter-
Oncology vention assessment with statistical analysis of data.
0732-183X/05/2304-899/$20.00
Results
DOI: 10.1200/JCO.2005.06.085 Twenty-six published studies were summarized. The majority of the studies demonstrate
physiological and psychological benefits. However, most of these studies suffer limitations
because they are not randomized controlled trials and/or use small sample sizes. Predomi-
nantly, studies have been conducted with breast cancer patients using cardiovascular
training rather than resistance exercise as the exercise modality. Recent evidence supports
use of resistance exercise or “anabolic exercise” during cancer management as an exercise
mode to counteract side effects of the disease and treatment.
Conclusion
Evidence underlines the preliminary positive physiological and psychological benefits from
exercise when undertaken during or after traditional cancer treatment. As such, other cancer
groups, in addition to those with breast cancer, should also be included in clinical trials to
address more specifically dose-response training for this population. Contemporary resis-
tance training designs that provide strong anabolic effects for muscle and bone may have an
impact on counteracting some of the side effects of cancer management assisting patients
to improve physical function and quality of life.

J Clin Oncol 23:899-909. © 2005 by American Society of Clinical Oncology

pears as the third most common cancer in

INTRODUCTION
the world, and it is ranked as the fifth most
A progressive increase of cancer burden, prevalent cause of death from cancer overall,
with an estimated 15 million new cases and being the leading cause of cancer mortality
10 million new deaths, is expected by the in women.2 Treatments for cancer include
year of 2020.1 In this context, prostate can- surgery as well as systemic and radiation
cer is the sixth most common cancer in the therapy and have successfully shown reduc-
world, representing 14.3% of cancers tions in mortality rates. However, for cancer
among men in developed countries with patients, the increased levels of fatigue dur-
more than 80% of the cases occurring in ing treatment remains a concern as it affects
men older than 65 years.2 Breast cancer ap- the majority of patients during radiotherapy

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 Galvão and Newton

and/or chemotherapy periods compromising their physical cal and psychological adaptations increasing quality of life
function and quality of life.3-9 Dimeo7,8 has proposed that in this population.
the lack of physical activity during treatment may affect the The purpose of this article is to present a descriptive
increased levels of fatigue observed during and after cancer overview and chronological perspective of developments of
management. As such, several studies examining the role the experimental exercise intervention studies undertaken
of exercise with cancer patients have linked the increased during and after cancer management. The second aim of
levels of physical activity during10-23 and after cancer this review attempts to establish a dose response of training
treatment24-32 with positive effects on decreasing rates of for this population considering type of exercise, frequency
fatigue, enhancing physical performance, and improving of training, volume of training, intensity of training and
quality of life. However, the majority of the exercise inter- expected physiological outcome measures. In addition, we
ventions undertaken with this population have focused on also highlight specific points that should be examined in the
cardiovascular training,10,11,15,17-19,22-24,33-36 with few stud- future with the goal of obtaining more information on
ies using the combination of aerobic and resistance exercise prescription for this population. This review re-
exercises12,16,25,29-31 or resistance exercise alone.20,37 There- ports 26 published studies appearing in the Medline (elec-
fore, little is known as to the effect of resistance training tronic version of Index Medicus) database, published by
being a primary exercise choice to counteract some of the June of 2004 and searched by the terms: exercise; cardiovas-
physiological conditions accompanied by cancer disease and cular training; resistance training; rehabilitation; and can-
the traditional treatments. Considering that most of the exper- cer. Secondary searching involved scanning the reference
imental exercise studies have incorporated breast cancer lists from the papers identified above and then locating
patients11,18,19,21,38-40 and other types of cancer10,17,23,24,37 papers that appeared useful in reviewing the topic. A key
but not prostate cancer, there is a particular lack of infor- criterion throughout this process was identifying studies
mation on how prostate cancer patients undertaking tradi- that incorporated preintervention and postintervention as-
tional treatment would respond to an exercise program. sessment with statistical analysis of the data.
Yet, given the documented effects of androgen deprivation
therapy (ADT),41-49 these patients should benefit particu- EXPERIMENTAL EXERCISE STUDIES DURING
larly from resistance exercise. To date, only one published CANCER TREATMENT
report has examined the effects of a short-term resistance
exercise program on patients diagnosed with prostate can-
A summary of the published studies examining the effect of
cer undertaking ADT.20 Interestingly, they reported quite
exercise on cancer patients undertaking treatment is shown
promising results. In view of the extensive scientific litera-
in Table 1. Of the 18 experimental exercise interventions
ture supporting resistance training as being the most effec-
under cancer treatment, 14 had used some type of cardio-
tive method available for improving muscle strength and
vascular training,10,11,13-15,17-19,21,23,33-35,38,40 two had used
increasing lean tissue mass in different populations ranging
a mixed training program using cardiovascular, resistance,
from athletes to frail older adults,50-60 resistance exercise
and flexibility exercises12,16 while the other two studies ap-
may also have a great potential to counteract the side effects
plied a structured resistance training program.20,37 The
of prostate cancer during ADT by increasing muscle func-
main outcome measures from these studies include: levels
tion, lean tissue mass, and bone mineral density with sub-
of fatigue,11,20,35,40,69 quality of life, emotional-related dis-
sequent reduction in levels of fatigue.
tress,11,12,15,16,19,23,33,35 immunological parameters,13,14,17,24, aer-
There are specific training variables involving resis-
obic capacity,10-12,14-19,21,23,33,35,39,40 and muscle strength.12,16,20
tance exercise prescription that include number of sets and
repetitions (volume), intensity of training (load), duration Cardiovascular Training
of rest between sets and exercises, frequency of training, and The first study by Winningham et al38 examined the
repetition velocity.39,61,62 Currently, there is no informa- effect of a 10-week aerobic program performed three times
tion with regard to such training variables and possible per week on nausea responses of patients with breast cancer
variations with cancer patients undertaking resistance undertaking chemotherapy. Subjects were randomly as-
training programs. Interestingly, some of these variables signed to a supervised aerobic exercise group three times
have been examined in untrained older adults54,63-66 and per week, a placebo group that performed low-intensity
favorable responses in strength and function result from a supervised flexibility training once weekly, or a control
variety of training regimens, even those that involve rela- nonexercise group. Nausea responses to training were as-
tively low intensities,54,64,67 frequencies,65 and volume.63,68 sessed by a self-report system inventory (Symptom Check-
Considering the detrained state and high levels of fatigue of list-90-R; Pearson Assessments, Eagan, MN). The exercise
many cancer patients, it may be expected that even a train- group improved significantly more on symptoms of nausea
ing program consisting of lower intensity, volume, and compared with control and placebo groups (P ⬍ .05). Con-
frequency could significantly promote positive physiologi- sidering that nausea is a consistent symptom experienced by

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 Exercise in Cancer Patients

Table 1. Experimental Design Exercise Studies During Cancer Treatment

Study Frequency No. of Age
(Reference Number) Duration (weeks) Patients Sex (years) Type of Cancer Exercise Program Intensity Outcome Measures

Cunningham et al, 5 3-5/week 40 M, W 14-44 Leukemia Resistance training Unspecified 2 Nitrogen balance
198649 7 Creatinine excretion
7 AC
Winningham et al, 12 3/week 42 W 45-48 Breast Cardiovascular cycling 60-85% MHR 2 Nausea
198850 IT 20-30 minutes
Winningham et al, 12 3/week 24 W 45 Breast Cardiovascular cycling 60-85% MHR 1 Lean tissue mass
198948 IT 20-30 minutes 2 0.5% Body fat
2 Skinfold sites
Macvicar et al, 10 3/week 45 W 43-46 Breast Cardiovascular cycling 60-85% MHR 1 42% VO2max
198930 IT
Mock et al, 6 4-5/week 46 W 35-64 Breast Cardiovascular walking Self-paced 1 4% 12-MWT
199723 20-30 minutes 2 Fatigue
2 Symptom experience
Dimeo et al, ⵑ2 Daily 70 M, W 39-40 Breast, sarcoma, Cardiovascular cycling 50% HRR 2 14% MP, 2 Thro
199729 carcinoma, IT 30 minutes 2 Neutro, 2 Hosp
adenocarcinoma,
neuroblastoma
Dimeo et al, 6 5/week 5 M, W 18-55 Hodgkin’s lymp., Non- Progressive treadmill 3 mmol/L (LC) 2 100% LC
199822 Hodgkin’s lymp., walking 30-35 80% MHR 2 18% Heart rate
bronchial, breast, minutes 1 101% TD
medulloblastoma 1 12% MP
Dimeo et al, * Daily 59 M, W 40 Breast, lung Cardiovascular cycling 50% HRR 2 Psychologic distress
199935 Carcinoma, IT 30 minutes
seminoma,
Adenocarcinoma,
Hodgkin’s lymp.
Schwartz et al, 8 4/week 27 W 35-57 Breast Cardiovascular walking Self-paced 1 10.4% 12-MWT
1999, 200046,47 35 minutes accelerometers 2 Fatigue
Na et al, 200025 2 5/week 35 * 28-75 Stomach Cardiovascular arms and 60% MHR 1 28% NKCA
cycling ergometers
30 minutes
Schwartz et al, 8 3–4/week 72 W 27-69 Breast Cardiovascular walking Self-paced 1 15% 12-MWT
200152 12 minutes accelerometers 2 Fatigue
Mock et al, 6-24 5-6/week 52 W 28-75 Breast Cardiovascular walking Self-paced 1 6% 12-MWT
200131 10-30 minutes 2 Fatigue
2 Emotional distress
Segal et al, 26 5/week 123 W 51.4 Breast Cardiovascular walking, 50–60% VO2max 1 Physical functioning
200145 home vs. non-home 7 Quality of life
based 7 VO2max
Kolden et al, 16 3/week 40 W 45–76 Breast Cardiovascular walking, Unspecified 1 11% Flexibility
200224 cycling, stepping, 1 15.4% VO2max
resistance training, 1 34.5% UB
flexibility 1 37% LB
2 5% RSBP
1 Quality of life
Segal et al, 12 3/week 155 M 68.2 Prostate Resistance training, 2 60–70% 1-RM 1 42% UB
200332 sets, 12 repetitions 1 36% LB
7 Body composition
7 PSA, 2 Fatigue
1 Quality of life
Dimeo et al, ⵑ2 Daily 66 M, W 20–73 Leukemia, Hodgkin’s Cardiovascular walking 70% MHR 7 Walking speed
200326 lymp., non- 2 6.7% HEM
Hodgkin’s lymp.,
myeloma
Courneya et al, 16 3–5/week 102 M, W 61.1 Colorectal Cardiovascular walking, 65–75% MHR 7 Quality of life
200327 flexibility 7 Cardiovascular capacity
Adamsen et al, 6 4/week 23 M, W 18–63 Leukemia, breast, Resistance training, 3 60–100% MHR 1 32.5% WB
200328 colon, ovary, testis, sets, 5–8 repetitions; 85–95% 1-RM 1 16% VO2max
cervix, Hodgkin’s cardiovascular 7 Quality of life
lymp., non- cycling; relaxation
Hodgkin’s lymp.

Abbreviations: M, men; W, women; 7, no change; 1, increase; 2, decrease; *, not described; PSA, prostate-specific antigen; LC, lactate concentration;
VO2max, maximum concentration of oxygen consumption; lymp., lymphoma; IT, interval training; TD, training distance; MHR, maximum heart rate; MP,
maximal performance (MET); HEM, hemoglobin; AC, arm circumference; UB, upper body strength; LB, lower body strength; WB, whole body strength; RSBP,
resting systolic blood pressure; NKCA, natural killer-cell cytotoxic activity; HRR, heart rate reserve; Neutro, duration of neutropenia; Thro, duration of
thrombopenia; Hosp, duration of hospitalization.

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 Galvão and Newton

cancer patients during treatment, these preliminary data A progressive walking treadmill program up to 30 to 35
showed that cardiovascular training can safely be incorpo- minutes with intensity set to elicit a blood lactate level of 3
rated during breast cancer traditional treatment and may mmol/L in capillary blood was prescribed. At the end of the
decrease symptoms of nausea. Winningham et al36 also pre- intervention, walking distance, walking maximal perfor-
sented data related to a subgroup of their earlier report,38 mance, heart rate, and lactate concentration were improved
which examined the effect of a 10- to 12-week aerobic training (P ⬍ .05) demonstrating once more the positive physiolog-
program on body composition responses of breast cancer sub- ical responses accrued with cardiovascular training. In ad-
jects undertaking chemotherapy. Subjects were randomly al- dition, the authors also noted a clear decrease in levels of
located to an exercise group that trained three times per week fatigue at post-test. Subsequently, in 1999, the same group
for 20 to 30 minutes with intensity set at 60% to 80% of of investigators23 also examined a daily exercise protocol
maximal heart rate or a control group that did not receive the consisting of a supine bike program followed by an interval
exercise treatment. Although elementary techniques for body training pattern for 30 minutes in cancer patients receiving
composition determination, such as skinfold measurement, high doses of chemotherapy. Outcome measures included
were used in this intervention, the results were an increase in psychological distress and levels of fatigue. It was demon-
lean tissue mass for the training group compared with the strated at the end of the intervention that subjects under-
control group. Considering the specificity of the training taking the exercise program significantly decreased
program in this study (aerobic exercise only), the relative in- psychological distress with no changes in fatigue levels.
crease in lean tissue mass may be attributed to the decreased fat Schwartz et al34,35 reported results from a 8-week
tissue. exercise intervention in 27 women with breast cancer un-
The effect of a 10-week aerobic interval training pro- dertaking chemotherapy. The exercise program included a
gram was also investigated by MacVicar et al.18 Forty-five home-based walking program with self-paced intensity
women with breast cancer receiving chemotherapy were measured by an accelerometer. Subjects who underwent the
randomly assigned to an aerobic exercise group (cycling exercise program demonstrated greater response in the
training), a flexibility training group, or a control group. physical performance assessment (12-minute walk test), as
Exercise intensity was set at 60% to 85% of the maximum well as decreasing levels of fatigue compared with subjects
heart rate reserve. Results demonstrated differences for who did not adopt the training program (P ⬍ .05).
maximum oxygen uptake (VO2MAX) and testing time The short-term effect of cardiovascular training on
among groups; the aerobic training group improved signif- natural killer-cell cytotoxic activity (NKCA) in patients
icantly more than the flexibility and control groups. with stomach cancer were reported by Na et al.13 Subjects
Mock et al11 examined the effect of a randomized were assigned to an exercise group that performed 30 min-
controlled-trial home-based exercise program on 46 utes of supervised cardiovascular training using arm and
women with breast cancer undertaking radiotherapy. The cycle ergometer or a nonexercise control group. Blood sam-
exercise program consisted of a 20- to 30-minute self-paced ples were collected at baseline, day 7, and day 14. At post-
walking program, four to five times per week over 6 weeks. test, a significantly greater increase in NKCA was noted for
A 12-Minute Walk Test, Symptom Assessment Scales, and the exercise group (27.9%) compared with the control
the Piper Scale were used to assess physical function, symp- group (13.3%; P ⬍ .05). Although the training period was
toms experience, and fatigue, respectively. Results showed short in duration, it is interesting to note that both groups
that subjects undertaking the exercise program improved had similar values for NKCA at the midpoint of interven-
significantly more in walking distance, symptom experi- tion, with the differences between groups occurring during
ence (anxiety, depression, and difficulty sleeping), and fa- the second half of the training period.
tigue compared with controls. Schwartz et al40 also investigated the relationship of
The effect of a daily bed cycling program during high- fatigue and exercise through a home-based aerobic exercise
dose chemotherapy treatment in cancer patients followed program consisting of a 12-minute walk in women under-
by autologous peripheral blood cell transplantation was going chemotherapy treatment for breast cancer. Func-
reported by Dimeo et al.17 Subjects from the control group tional abilities were assessed through a 12-minute walk test
experienced significantly higher loss of physical perfor- and fatigue levels by a self-reported instrument. The exer-
mance levels during hospitalization than the exercise group cise program increased functional ability by 15% whereas
(P ⬍ .05). Moreover, other physiological parameters such the nonexercisers decreased performance by 16%. In addi-
as duration of neutropenia, thrombocytopenia, and sever- tion, decreased levels of fatigue (P ⬍ .01) for the exercise
ity of diarrhea were significantly reduced after the exercise group were observed after the intervention. It is interesting
intervention (P ⬍ .05). Dimeo et al10 also reported the to note that the exercise program was unsupervised with
response of a 6-week cardiovascular exercise program on none of the sessions being accompanied by an exercise
fatigue and physical performance in a small sample of can- physiologist. Considering that training program variables
cer patients (n ⫽ 5) experiencing fatigue during treatment. were not well controlled during training, the results are

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 Exercise in Cancer Patients

somewhat attractive and one would expect even greater program on quality of life and cardiovascular capacity of
adaptations for an exercise program that incorporates a colorectal cancer patients undertaking adjuvant therapy.
more controlled setting resulting in an enormous impact on The exercise group was instructed to perform cardiovascu-
the outcome measures with this population. lar and flexibility activities three to five times per week over
The effect of a similar home-based walking exercise 16 weeks whereas the control group was advised to not
intervention on patients with breast cancer undertaking participate in any exercise activity during the study period.
either radiotherapy or chemotherapy was also examined by No significant differences were observed between groups
Mock et al.19 The exercise program consisted of a progres- for quality of life and cardiovascular capacity at the end of
sive walking (10 to 30 minutes) program 5 to 6 days per the intervention. The failure to detect differences between
week with an unspecified training intensity. Similar to groups is primarily explained by the fact that 51.6% of the
Schwartz et al40 and their previous report,11 physical func- control group did not comply with the study and exercised
tion was assessed by the 12-Minute Walk Test. In addition, during the study period. The nature of the exercise itself
fatigue and emotional distress were measured by the Piper (home-based program) was pointed out by the authors as
Scale and Profile of Mood States (POMS), respectively. Con- being one possible reason of the high contamination during
sistent with their previous findings,11 the exercise intervention the intervention with little effectiveness.
lead to a significant improvement in physical performance by
increasing walking distance. Additionally, fatigue and emo- Cardiovascular, Resistance, and
tional distress were enhanced at post-test, indicating once Flexibility Training
more that positive psychological outcomes may be achieved Kolden et al12 examined the effect of an exercise train-
with a simple home-based walking exercise program. ing intervention including cardiovascular, resistance, and
Segal et al33 conducted a randomized controlled trial flexibility training over 16 weeks in patients with breast
examining the effect of a supervised and unsupervised walking cancer undertaking some type of adjuvant therapy (radio-
program on patients with breast cancer undertaking treatment therapy, chemotherapy, or hormonal therapy). Subjects
(radiotherapy, hormonal therapy, or chemotherapy) over 26 were tested for resting blood pressure, body composition,
weeks. Aerobic capacity, body weight, and generic and disease- aerobic capacity, flexibility, and strength. In addition, nu-
specific health-related quality of life were assessed (MOS SF- merous psychological outcomes were also examined using
36) at baseline and post-test. Results demonstrated that the Beck Depression Inventory, State-Trait Anxiety Inven-
physical function measured by the MOS SF-36 decreased in tory, Positive and Negative Affect Schedule, Hamilton Scale
the control group while it increased in both training groups for Depression, Quality of Life, and Global Assessment
(P ⬍ .05). At post-test, no differences among groups were Scale. At the end of the intervention, there was an observed
detected for quality of life, aerobic capacity, or body weight. effect for time for upper and lower body strength, cardio-
However, when groups were stratified by type of adjuvant vascular capacity (estimated VO2max), flexibility, and resting
therapy, in this case not receiving chemotherapy, differences in systolic blood pressure (P ⬍ .05). Additionally, subjects
improvement were observed between the supervised and con- experienced positive psychological adaptations with train-
trol group for aerobic capacity (P ⬍ .01). It is relevant to point ing improving some of the quality-of-life measures.
out that the small changes in aerobic capacity (3.5%) may be Recently, Adamsen et al,16 examined the effect of a high-
related to the nonspecific aerobic capacity test protocol (step- intensity supervised exercise program on a mixed cancer pop-
ping ergometer) utilized by the authors to assess chronic re- ulation over 6 weeks. The training program included interval
sponse of a walking program. training with intensity set at 60% to 100% of the maximal heart
The effect of 2 weeks of cardiovascular training on a rate, resistance exercises performed at 85% to 95% of 1 repeti-
mixed cancer population undergoing conventional or high- tion maximum (RM) for five to eight repetitions, and relax-
dose chemotherapy during hospitalization was examined ation training. The results demonstrated an increase of 32.5%
by Dimeo et al.14 The training program consisted of a daily in maximal strength (P ⬍ .0001) and 16% improvement in
walking treadmill interval training program with intensity VO2max (P ⬍ .001). Several measures of quality of life were also
set at 70% of the maximum heart rate. Submaximal stress improved; however, no statistically significant values were
test results demonstrated that physical performance re- noted. It is relevant to highlight that this is the first study that
mained unaltered during treatment with significant reduc- incorporates a higher intensity training design; however, the
tions in hemoglobin levels at hospital discharge (P ⬍ .05). absence of a control group and the short duration of the inter-
Although physical performance did not change at post- vention limited the interpretation of the data.
test, results demonstrated that cardiovascular training Resistance Training
may assist on preserving performance status during inten- The earliest published study examining the effects of
sive chemotherapy. resistance exercise was a short-term intervention involving
Finally, Courneya et al15 conducted a randomized con- patients with acute leukemia undertaken by Cunningham
trolled trial examining the effect of a home-based exercise et al.37 Subjects were randomly assigned to two exercise

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 Galvão and Newton

groups performing the program either three or five times 2. Four studies had used cardiovascular exercise pro-
weekly or a nonexercising control group. The training pro- grams24,26-28,32 whereas the other four implemented a
gram consisted of several upper and lower body exercises mixed training program using cardiovascular, resistance,
including the chest press, biceps curl, triceps extension, and flexibility exercises.25,29-31 Levels of fatigue, muscle
straight leg raises, knee extension, hip extension, hip abduc- strength,29,31 cardiovascular function,24,26-31 immunologi-
tion, shoulder retractors, and sit-ups performed with 15 cal parameters,24,27,28,31 symptoms of emotional-related
repetitions at an unspecified intensity. Outcome measures distress, and quality of life25,27,29,30,32 were the major out-
included skinfold measures, arm circumference, nitrogen come measures from these studies.
balance, and creatinine excretion. Results indicated that
groups did not change arm circumference and skinfold Cardiovascular Training
measures over the course of the intervention. Although Sharkey et al26 conducted the first experimental exer-
there were no differences among groups for nitrogen bal- cise study examining the chronic response of a 12-week
ance during the course of the study, the authors suggested cardiovascular training program on children and young
that the exercise program favored both training groups with adults with mixed cancer diagnosis who had completed
the control group decreasing levels of creatinine excretion chemotherapy for at least 1 year. Outcome measures in-
from pretest to post-test (P ⬍ .05). cluded cardiovascular and pulmonary physiological re-
Recently, Segal et al20 reported the results from a 12- sponses. Although none of the physiological parameters
week whole body resistance training intervention in pa- changed with training, exercise tolerance assessed by exer-
tients with prostate cancer undergoing ADT. The resistance cise time was increased significantly (P ⬍ .05).
training program consisted of two sets of 8 to 12 repetitions The effect of cardiovascular training on NKCA, mono-
at 60% to 70% of 1 RM for six upper body and three lower cytes, and personality was examined in a group of breast
body exercises performed three times per week. Outcome cancer survivors by Peters et al.27,28 Their training program
measures included fatigue, disease-specific quality-of-life consisted of 30 to 40 minutes of cycling at approximately 60%
assessment, and muscle strength and body composition. of maximum heart rate performed five times per week during
Results showed positive effects of resistance training on the first 5 weeks of training with a subsequent reduction of
decreasing fatigue levels, health-related quality of life, and training frequency for the following 6 months completing a
muscle strength with no changes in body composition by total 7-month training period. Although NKCA cell numbers
the subjects embarking on the exercise program. The fact were unaltered over the course of the intervention, an increase
that body composition was unaffected by the training pro- in the cytotoxic activity was noted at post-test. While the total
gram may be related in part to the elementary body composi- number of leukocytes was unchanged after the training pro-
tion methods used to assess changes in muscle and fat tissue. In gram, significant changes in leukocyte subpopulations were
addition, it is well known that strength gains during the first detected with an increased number of granulocytes and a de-
stages of resistance training are predominantly caused by neu- creased number of lymphocytes and monocytes (P ⬍ .05). The
ral factors with gains in muscle size becoming dominant as authors suggested that cardiovascular training would possibly
training continues.70-72 Consequently, the shorter duration of alter the number of specific receptors in the surface membrane
the intervention and the limitations on body composition on monocytes. Moreover, satisfaction of life increased in the
assessment methods indicated that increases in strength were first 5 weeks of training with a subsequent decrease during the
likely to be related to neural alterations rather than muscle other 6 months of the intervention.
morphological changes. These preliminary data showed opti- Dimeo et al24 examined the effects of a cardiovascular
mistic outcomes with a resistance training program that is training program on maximal performance and hemoglo-
characterized primarily by anaerobic rather than aerobic en- bin levels of cancer patients directly after hospital discharge.
ergy sources. Taking into consideration that immunological The exercise program consisted of 6 weeks of treadmill walking
parameters were not assessed in this particular study, it re- every weekday with intensity set to elicit a blood lactate level
mains to quantify if resistance training may positively alter the of 3 mmol/L in capillary blood. Results indicated that sub-
immune system of patients under cancer treatment. In addi- jects that underwent the exercise program showed a significant
tion, it would be interesting to examine how other types of increase in maximal performance and hemoglobin concentra-
cancer patients would respond with resistance exercises. tion compared with controls (P ⬍ .05).
The effects of 10 weeks of cardiovascular exercises on
women who had undergone breast cancer treatment were
EXPERIMENTAL EXERCISE STUDIES AFTER examined by Segar et al.32 Subjects were randomly allocated
CANCER TREATMENT
to an exercise group, exercise plus behavior modification
group, or a control group in an experimental crossover design.
Experimental studies examining the effect of exercise on Symptoms of depression, state of anxiety, and self-esteem
patients with cancer after treatment are presented in Table were assessed by the Beck Depression Inventory, the State

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 Exercise in Cancer Patients

Table 2. Experimental Design Exercise Studies After Cancer Treatment

Frequency No. of Age
Study Duration (weeks) Patients Sex (years) Type of Cancer Exercise Program Intensity Outcome Measures

Sharkey et al, 12 2/week 10 M, W 19 Leukemia, Ewings Cardiovascular 60–80% MHR 10% ET, 7 AT
199338 tumor, * 7 Peak OX
neuroblastoma 7 Peak HR
Wilms’ tumor,
rhabdomyosarcoma
Peters et al, 28 2-5/week 24 W 49 Breast Cardiovascular ⵑ 60% MHR 12 Satisfaction of life
1994, cycling 7 NKCA
199539, 40 7 Leukocytes
2 2.1% Lymphocytes
2 1.1% Monocytes
1 4.1% Granulocytes
Nieman et al, 8 3/week 12 W 61 Breast Cardiovascular 75% MHR 7 NKCA
199543 resistance 7 LB
training 1 6-minute Walk Test
Dimeo et al, 6 5/week 36 M, W 39–42 Non-Hodgkin’s Cardiovascular 3 mmol/L (LC) 1 32% MP
199736 lymp., breast, walking 30 1 30% HEM
sarcoma, minutes
seminoma, lung
Segar et al, 10 4/week 24 W 30–65 Breast Cardiovascular ⫽ 60% MHR 2 Depression
199844 30–40 minutes 2 Anxiety
Durak et al, 10 2/week 20 M, W 50 Carcinoma, Cardiovascular Own RPE 1 43% WB, 41.4% 1 MP
199841 lymphoma, resistance 1 Quality of life
leukemia training,
flexibility
Durak et al, 20 2/week 25 M, W 44-71 Prostate carcinoma, Cardiovascular Unspecified 7 Aerobic capacity
199942 leukemia resistance 1 45% WB
training
Porock et al, 4 * 9 M, W 51-77 Bowel, breast, oral, Cardiovascular Unspecified 2 Depression
200037 pancreas, resistance 2 Anxiety
melanoma training 7 Fatigue

Abbreviations: M, men; W, women; 7, no change; 1, increase; 2, decrease; 1 2, increased at week 5 and decreased at posttest; *, not described; LC,
lactate concentration; MHR, maximum heart rate; MP, maximal performance (MET); HEM, hemoglobin; LB, lower body strength; WB, whole body strength;
NKCA, natural killer-cell cytotoxic activity; ET, exercise tolerance; AT, anaerobic threshold; peak OX, peak oxygen uptake; peak HR, peak heart rate.

Anxiety Inventory, and the Rosenberg Self-Esteem Inventory, distance test compared with controls (P ⬍ .05). However,
respectively. At post-test, it was observed that the exercise differences between groups were neither observed for lower
group had significantly less depression and state of anxiety body strength nor for NKCA. It should be noted that the small
compared with controls with no differences between exercise sample size (n ⫽ 6 per group) limited the ability to detect
and exercise plus behavior modification groups. After the significant difference between groups.
crossover, the controls also showed optimistic changes by de- Durak et al29 conducted an exercise intervention in a
creasing depression and state of anxiety showing positive psy- mixed cancer patient population over 10 weeks. The exer-
chological response accrued with cardiovascular training. cise program was performed twice weekly and consisted of
Cardiovascular, Resistance, and cardiovascular training at their own perceived exertion,
Flexibility Training resistance training machines using unspecified intensity,
The effects of an exercise program on breast cancer and flexibility exercises. Outcome measures included qual-
survivors who had undergone surgery, radiation, and che- ity of life (Modified Rotterdam Quality of Life Survey),
motherapy were examined by Nieman et al.31 Subjects were endurance capacity, and a four- to six-repetition maximum
randomly assigned to an exercise or control group. In addi- strength test. Results demonstrated an average increase of
tion to physical performance measures that included 43% for both upper and lower body strength combined and
symptoms-limited exercise testing on the treadmill, 6-minute a 41.4% increase in MET level from the first to the last
walk test and lower body strength, immunological training session of the exercise program. In addition, the quality of
response was also assessed by measuring NKCA and concen- life assessment indicated a significant improvement in par-
trations of circulating immune cells. The training program ticipants’ ability to perform daily functions. The same
included 30 minutes of walking at 75% of heart rate maximum group of investigators30 also examined the effect of a 20-
and seven different resistance exercises performed for 12 rep- week cardiovascular and resistance training program on
etitions at an unspecified intensity. Results indicated signifi- survivors of prostate cancer, carcinoma, and leukemia. The
cant improvement for the exercise group on 6-minute walk exercise protocol was described with little detail in the

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 Galvão and Newton

original manuscript; therefore it is unclear what intensity should be taken of the recent report from Segal et al20 who
and volume were applied during the exercise intervention reported positive effects of resistance exercises alone on
for both cardiovascular and resistance exercises. In addi- rates of fatigue, health-related quality of life, and muscle
tion, neither strength maximum nor cardiovascular capac- strength in patients with prostate cancer undertaking ADT.
ity tests were implemented at pretest and post-test; Although these results support positive psychological and
therefore it was extremely difficult to analyze the authors’ physical outcomes, it remains to be examined how specific
presented data. At post-test, subjects completed a quality- physiological parameters such as muscle tissue mass and
of-life survey with the same questionnaire being reassessed bone mineral density would respond with resistance exer-
in a 2-year follow-up period. It was reported that the train- cises in this population, especially in long-term trials. Re-
ing protocol induced an increase of 38% and 52% for over- cently, Smith et al43 reported an increase of 11% of fat mass
all strength in the prostate cancer and carcinoma/leukemia and a decrease of 3.8% of lean-free bone tissue mass from a
groups, respectively. No significant change was noted for aer- year-long prospective assessment of the effects of ADT on
obic capacity. It is interesting to point out the high level of body composition responses evaluated by dual energy x-ray
adherence to the exercise program from both groups with absorptiometry. Further, the concern related to the negative
subjects from the prostate cancer group having 100% compli- effects of ADT on accelerating bone loss has been exten-
ance to the training program whereas the carcinoma/leukemia sively reported in the literature.46,75-83 As an alternative,
group recorded 65% of adherence over the 2-year period. resistance exercise studies in older adults have consistently
Finally, Porock et al25 investigated the effect of a short- shown it to be a safe and effective strategy to counteract
term home-based exercise intervention in a mixed popula- sarcopenia50,54-57,59,84,85 and preserve or induce gains in
tion of cancer patients. The training program appears to bone mineral density84,86-88. Recently, Villareal et al86 re-
include both cardiovascular and resistance exercises but ported positive effects of a 9-month resistance training pro-
lacked an exact description of training program variables gram on bone mineral density in older women undertaking
(intensity, frequency, and volume). Outcome measures in- hormonal replacement. A meta-analysis undertaken by
cluded fatigue, anxiety, depression, symptoms of distress, Wolff et al89 also proposes that resistance training preserves
and quality of life. Results indicated positive adaptations for or reverses bone loss of up to 1% per year in both femoral
depression and anxiety with no change in fatigue levels. It neck and lumbar spine sites for pre- and postmenopausal
should be noted that the short-term duration of the inter- women. Taking into consideration the long-term benefits
vention and the small sample size (n ⫽ 9) limited the ability of this exercise modality on bone response, resistance train-
to detect significant changes with training. ing may have an important role on reducing the effect of
bone loss rate in men with prostate cancer undertaking
ADT. Moreover, considering that, traditionally, ADT varies
DISCUSSION
from 2 to 3 years but can also take up to 20 years,90 the role
of resistance exercise may be even more relevant by improv-
The primary aim of this article was to present an overview of ing psychological and physiological parameters and, there-
published studies undertaken with any cancer population fore, improving quality of life.
during and after treatment. Unfortunately, most of these In the context of maintaining or increasing lean tissue
studies suffer limitations because they are not randomized content in healthy elderly and various patient populations in
controlled trials, use small sample sizes, and/or report in- which muscle and bone loss are problematic, resistance exer-
sufficient scientific methodological criteria. Despite this, it cise might be more appropriately termed “anabolic exercise.”
appears that there is a reasonable amount of data in the It is not surprising, therefore, that the many cardiovascular
literature that underline preliminary positive physiological exercise interventions with cancer patients have produced
and psychological benefits from exercise when undertaking mixed results as such exercise does not provide a strong ana-
during or after traditional cancer treatment. It is interesting bolic effect for muscle and bone and may not elicit the changes
to point out that the early published report on cancer and in endocrine status that are desirable in these patients.
exercise by Cunningham et al37 used resistance exercises as It is interesting to note that, among the different cancer
the training modality that was based on the original work by types, breast cancer has been the most common cancer type
Delorme,73,74 who introduced the model of progressive examined during exercise trials. Of the 18 studies undertaken
workload with resistance exercises. Subsequently, the ma- during treatment, nine had used exclusively breast cancer
jority of studies examining the effect of exercise on cancer subjects11,12,18,19,21,33-35,38,40 with three studies including
patients undertaking treatment completed from the late breast cancer plus a mix of cancer populations10,17,23 and few
1980s to 2003 implemented the cardiovascular training other experiments using leukemia, stomach cancer, prostate,
modality10,11,13,15,17-19,23,33-36,38,40 with only two interven- colorectal, and a mix population of cancer types.13,15,16,20,37
tions using the combination of resistance, flexibility, and A similar figure can be observed with the experimental trials
cardiovascular training.12,16 Therefore, particular attention undertaken after cancer treatment where three studies were

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 Exercise in Cancer Patients

Table 3. Guidelines and Possible Physiological Outcomes from Exercise in Cancer Patients
Frequency
Exercise Modality Intensity (/week) Volume Dosage Cancer Relevant Expected Outcomes

Cardiovascular exercises 55-90% MHR 3-5 20-60 minutes Continuous or intermittent 1 Cardiopulmonary function
40-85% MHRR 1 Insulin sensitivityⴱ, 1 HDLⴱ, 2 LDLⴱ
2 Fat mass, 2 Fatigue
Anabolic/resistance 50-80% 1-RM 1-3 1-4 sets per muscle 1 Muscle massⴱ, 1 Muscle strength
exercises 6-12 RM group 1 Muscle powerⴱ, 1 Muscle endurance
1 BMDⴱ, 1 FP, 2 Fatigue
1 Resting metabolic rateⴱ, 2 Fat massⴱ
Flexibility exercises ? 2-3 2-4 sets per muscle 10-30 seconds 17 Range of motion
group

Abbreviations: 1, increase; 2, decrease; 7, no change; MHR, maximum heart rate; MHRR, maximum heart rate reserve; HDL, high-density lipoprotein;
LDL, low-density lipoprotein; BMD, bone mineral density; FP, functional performance; RM, repetition maximum.
ⴱ
Data not available with cancer population, recommendation based from studies undertaken with noncancer population.

conducted with breast cancer patients,27,28,31,32 three in a spite the work by Segal et al33 and Cunningham et al,37
mixed cancer population including breast cancer,24,25,29 which compared a home-based versus supervised exercise
and two in a mixed cancer population not including breast and five times versus three times weekly resistance exercises,
cancer.26,30 Therefore, future studies aiming to examine the respectively, none of these studies had actually used more
role of exercises in cancer populations should also include than one training protocol, attempting to compare differ-
other cancer types than breast to reveal possible physiolog- ences in training response due to various intensities, fre-
ical and psychological benefits from exercise among other quencies, volume, and type of training. Consequently, a
cancer groups. requirement for future studies on this topic should include
As a secondary purpose of this review, we attempted randomized controlled trials comparing how various types
to establish a training dose-response with this population of cancer undergoing different treatments and stages of the
based on the existing literature. The importance of scientific disease would respond to different training stimuli.
exercise principles has been extensively reported.39,61,62,91 Finally, the majority of the studies involving resistance
It is well known that manipulation of the training pro- training did not draw on the wealth of scientific research that
gram variables of frequency of training, intensity of has been published in regard to resistance training for muscle
training, specificity of training, and rest period between hypertrophy and strength gain. In all cases excepted one,16 the
sets and exercise sessions produces clearly differentiated intensity of exercise in particular was inferior to the 6 to 10 RM
effects on specific physiological adaptations for both car- load that has been deemed optimal for muscle growth and
diovascular and resistance exercise. Nevertheless, long-
strength enhancement.61,62 One of the better designed resis-
term trials comparing different training models are rare
tance training interventions addressed in this review was by
even in healthy adult populations as reported by the
Cunningham et al37 and yet their model was based on research
American College of Sports Medicine position stand on
completed around 1950.73,74 Moreover, the only study that
the recommended quantity and quality of exercise pre-
incorporated a better-quality training intensity limited the
scription in healthy adults.39 Therefore, most of the stud-
program to 6 weeks and performed no more than three resis-
ies presented in this review that aim to elucidate training
tance exercises.16 Although much more research is required in
response for cancer patients during and after treatment,
were short in duration10,13,14,16,18,20,24,25,29,31,32,34-38,40 this important area, some guidelines and possible physiologi-
with some interventions still not controlling elementary cal outcomes are provided in Table 3. Future research into
training variables.12,25,29,30,92 The short-term nature of exercise interventions with cancer patients should involve con-
these interventions would likely limit the ability to detect temporary resistance training program designs incorporating
specific physiological responses with training. Moreover, adequate intensity, periodization, selection of functional exer-
considering that exercise has been endorsed as a crucial cises involving large muscle groups, and manipulation of rest
component of a healthy lifestyle and is viewed as a lifelong period and recovery strategies to maximize the anabolic effect
behavior that may prevent and control various disease on muscle and bone as well as positive endocrine responses.
conditions,93-96 further studies undertaken for longer peri- ■ ■ ■
ods are needed. Additionally, the specific training dose for
this population and how it would differentiate from many Authors’ Disclosures of Potential
of the cancer types, treatment modalities, and stages of Conflicts of Interest
treatment remains an open area for prospective trials. De- The authors indicated no potential conflicts of interest.

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 Galvão and Newton

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