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Deconditioning: A Major Problem with Cancer Patients
Ernest H.Rosenbaum, MD
For many reasons - the diagnosis of cancer, its treatments and age - present a complex problem, where a person over even a short period of time can become weak and fatigued and deconditioned. This differs from fatigue. Deconditioning is frequently seen in ill patients, elderly, and the obese. Fatigue has many factors including chemical reactions, such as that of tumor necrosis factor, Interleukin-1, -6, and others, as well as cognitive, emotional and physiological components. It has been estimated to be present in 40% of cancer patients. 3
Deconditioning with debility and bed rest, muscles decline by an estimated 10% per week. Thus, in approximately five weeks, you could lose up to a quarter of your muscle strength, as well as getting joint capsule contracture.
Respirations change when supine as the diaphragm moves upward when recumbent, often leading to atelectasis.
Hypoxia when it occurs is often associated with hypertension, cardiovascular disease, and anemia.
When a person becomes partially or fully incapacitated with a loss of independence it can be looked upon as a rapid aging process, leading to frailty, which also goes along with the loss of vital capacity. It becomes harder to maintain daily functions, such as ambulation, with an altered oxygen capacity and increased lactic acid production affecting muscle strength and function. Normal activities of daily living, such as walking, increase the demands of oxygen consumption, leading to fatigue through deconditioning.
Cancer treatments also reduce functional status, especially when there are increased side effects of chemotherapy, radiation therapy, or surgery. Those with chronic obstructive pulmonary disease (COPD) or neurological problems have difficulty just walking or climbing stairs and doing daily functional tasks.
Aerobic exercises, such as bicycling, walking, or using a treadmill at least three times a week for twenty to thirty minutes can make a major difference with improved skeletal muscle strength, as well as cardiac muscle strength, with an improved stroke volume and cardiac output. It is difficult to get cancer patients, who are becoming more and more deconditioned, to exercise to help neutralize this problem as much as possible.
Cardiac and pulmonary rehabilitation programs have shown success but should be initiated as early as possible. Often, the problem is that reimbursements are lacking for many programs. Friends and family often say just taking it easy. But too much resting is the wrong message. With the use of a positive rehabilitation program, attitude and supportive guidance, it is possible to regain strength and improve quality of life.
There are often late side effects, including cardiovascular, gastrointestinal, hematologic, dental, pulmonary, renal, ophthmalogic, and bone and soft tissue damage early or as late side effects.
Heart failure, radiation, fibrosis, fatigue and cognitive, sexual, and urinary problems secondary to chemotherapy and hormonal therapy are not uncommon. 4
There are also problems with late side effects, including depression and psychological and cognitive effects, loss of fertility or potency, and concerns about one's future health and risk of a new cancer or a cancer recurrence and/or death.
Fatigue is a common problem and often goes along with cognitive changes and body deconditioning. There are chemical and biological changes, as well as emotional changes related to fatigue. Sleep problems are not uncommon and current studies are in progress to block tumor necrosis factor-alpha using imfliximab (Remicade).
Cancer survivors need follow-up examinations and reevaluations. This is best done in specialty clinics with nurses specially trained about survivorship and its problems. A treatment summary plan is also helpful for patients to better understand the disease process and possible consequences of the cancer and its therapy.
Remedies, as best as are available, should be provided for hot flashes, fatigue, shortness of breath, pain, and other cancer or treatment related problems.
A relationship has been shown between excess weight at diagnosis with an increased risk of cancer recurrence and death. Twenty-six of thirty-four studies showed increased body mass index (BMI) led to a poorer prognosis with larger tumors and more positive lymph nodes. An increase in recurrence and death was noted.5
There is some conflicting evidence showing that overweight might be protective for premenopausal women with adverse effects in postmenopausal women. 6
Of note is that following a diagnosis of breast cancer, those receiving chemotherapy typically gain two to six kilograms on anthracycline-based treatments. There is commonly a decrease in physical activity, which contributes to weight gain, which often continues post-treatment.
A healthy diet is essential. Diet and exercise also play a key role. Exercise can also make people not only feel better but increase muscle strength and produce other positive benefits.
Of note is in that the Nurses‚ Health Study of 2000 of 987 breast cancer patients followed over two years showed that three hours of moderate exercise per week was associated with a 50% reduction in cancer recurrence, breast cancer death, and total death rates.
Dietary factors are still under study, and the Women's Interventional Nutrition Study (WINS), which randomized early stage breast cancer patients to a low-fat diet or a usual diet control group, found they were able to decrease fat intake from 33% to about 20% over five years. Approximately five pounds were lost during this period, and although results are still under study, it appears that there is a decrease of breast cancer recurrence in the women on the low-fat diet.7 Of note is that the greatest benefits were in the estrogen receptor negative tumors.
Further results are being awaited.
3>Gillis, T. A., Graham, H. F., "Watch for Deconditioning in Cancer Patients and Prescribe, Exercise," Journal of Supportive Oncology, vol. 5, #2, February 2007, pg. 94-95.
4 Ganz, P., "Cancer Survivors: Issues in Symptom Management," Journal of Supportive Oncology, vol. 5, #2, February, 2007, pg. 73-75.
5 Chlebowski, R., et. al., J Clin Onc, 2002; 20: 1128-1143.
6 Michels, K. B., et. al., Arch Intern Med, 2006; 166: 2395-2401. 7 Chlebowski, R. T., et. al., Journ Natl Cancer Inst, 2006; 98: 1767-1776 - an ASCO presentation, 2006.
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