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In this episode, Dr. Diane Reidy-Lagunes welcomes MSK exercise scientist Dr. Lee Jones back to the show to discuss the most recent findings about the effects of exercise on cancer prevention, treatment and recovery. Dr. Jones provides advice for patients to stay physically fit and battle fatigue, as well as the most effective training regimen for anybody, with or without cancer.
Cancer Straight Talk from MSK is a podcast that brings together patients and experts, to have straightforward evidence-based conversations. Memorial Sloan Kettering’s Dr. Diane Reidy-Lagunes hosts, with a mission to educate and empower patients and their family members.
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Episode Highlights
Is there a difference between the terms, “exercise” and “physical activity”?
Physical activity is any bodily movement. That could be sweeping the yard, it could be walking up a flight of stairs or walking around the grocery store. It’s any bodily movement. Exercise is a sub-component of physical activity. It’s directed physical activity with the intention of improving health or fitness or wellbeing. In a lot of our research at MSK, we’re studying exercise – structured, defined physical activity that aligns with a prescription.
Does exercise help cancer patients live longer or better? Does exercise help during cancer treatment?
There’s good data to suggest that exercise training programs before surgery, particularly large surgeries, can be beneficial. If a patient improves their fitness level before going in for surgery, the tolerability and recovery from that surgery is enhanced. The caveat is that about 80% of the studies on this topic have only been performed in early-stage breast cancer of women undergoing chemotherapy.
People who have been through treatment often say they feel like they’ve aged many years, and MSK’s Exercise Oncology Service was one of the first groups to quantify that. Individuals who endured three months of chemotherapy experienced a 15% decline in their fitness levels, or the equivalent of a decade of aging within three to six months of treatment (a healthy person’s fitness would decline 10% every decade, or 1% per year).
MSK researchers found that exercise during chemotherapy – simple aerobic exercises such as biking on a cyclometer or walking on a treadmill, for three days a week at a moderate intensity (between 55 to 75% of someone’s baseline capacity) – significantly lessened that dramatic decline in physiological aging. It didn’t completely abrogate it, but it did lessen the decline as well as accelerated the patient’s recovery after treatment.
Can exercise help with treatment-related fatigue that so many cancer patients experience?
In 60+ MSK-led studies across a number of different cancer types and treatments, exercise had a very positive effect on patients with fatigue. While human bodies may be programmed to say, “I’m too tired. I don’t want to exercise. Exercise will make me more fatigued,” it’s actually the polar opposite. Exercise makes us less fatigued.
However, patients do need to know how much is too much for their bodies. If their energy levels are completely flat, they’re clinically exhausted or their resting heart rate is not where it normally is (sleep is the best time to measure this with a smart watch, to get a baseline) then it may be a potentially dangerous time to go out and expend energy. When patients feel rested and their heart rate is where it’s expected to be, it’s very appropriate to go out and maybe push themselves a little.
What’s better during cancer treatment, aerobic or anaerobic exercises? Should I combine aerobic and anaerobic workouts?
The generic guidelines recommend 150 minutes of moderate intensity aerobic exercise five days a week for at least 30 minutes (with three of those days including at least 25 minutes of vigorous intensity aerobic training and resistance training two or three times a week).
However, for a cancer patient going through treatment who hasn’t exercised for perhaps several years, that is not recommended. We would recommend walking. Whether it’s a brisk walk at 3.5 miles an hour or a slower pace but for a longer duration, walking is a great workout because there are many ways to manipulate it to fit different levels of intensity.
What’s the best intensity of exercise? Should I be doing low intensity, moderate intensity or high intensity workouts?
It is most beneficial to mix up your workouts, not just in terms of the type of exercise but also in duration and intensity. In MSK clinical studies, doctors prescribe exercise at low, moderate and high intensities. One session a week will be at low intensity, one session will be at moderate, and one will be at high intensity.
Many people prefer to do the same exercise routine with the same duration and intensity every time they work out. This is still more beneficial than doing nothing, but it is not as beneficial as doing a combination of durations, intensities and modalities.
To help people achieve this, take it easy on the weekend, do a new or highly intense workout on Monday, then do exercises you enjoy at milder intensities the rest of the week.
Does exercise prevent cancer? Which cancers does exercise prevent?
There are observational studies that show there is a link between your level of exercise and your risk of certain cancers. Decades ago, thousands of participants were polled on their fitness routines and then followed throughout their lives. This study showed that people who had fitness routines had significantly less occurrences of cancer than those who didn’t. It also showed a positive effect of exercise on many different organs throughout the body, preventing approximately 13 different types of cancer ranging from breast cancer to colon to esophageal to lung to bladder. However, these were observational studies and it should be kept in mind that people are not always great about self-reporting, quantifying exercises or agreeing to standard definitions.
There isn’t a randomized-control trial yet showing that exercise lowers your risk of any form of cancer or reduces your risk of recurrence of any form of cancer. Those trials are ongoing and results should hopefully be published in the next five years.
At MSK’s Exercise Oncology Service, researchers found that exercising a mouse with cancer led to the cancer growing 30% slower. Exercise didn’t stop cancer growth, but it did slow it down. MSK also did a study combining exercise with chemotherapy in mice, to see if the combination was better than just chemotherapy alone. The findings showed that tumor growth was the slowest in the animals that got exercise plus chemotherapy versus those that got chemotherapy alone. Studies are now underway in humans.
What is the ideal exercise regimen for a cancer patient?
It depends on how much you’re doing right now. For individuals who are thinking about starting but haven’t done much exercise in the past year or longer, start doing something physical three days a week, whether that’s walking or biking or yoga. Start slowly, 10 to 15 minutes a day for three days a week, and it will be incredibly beneficial.
After two weeks, start thinking about adding an additional day or increasing the duration. Then consider replacing one of the days or activities with a bike ride instead of a walk, or a resistance training session instead of a walk. Continue mixing it up – in duration, modality and intensity – from there.
Yoga is also great, especially if your goal is improving your quality of life or fatigue. Stretching and any kind of movement can be beneficial to cancer patients because the toxicities of treatments so often include muscles and nerve damage. Working to preserve muscle strength and flexibility through yoga is very beneficial.
Overall, try and be as physically active as possible. Take every opportunity. Park further away when you go to the grocery store. Do a couple of extra laps in the mall. If you hit your 10,000 steps in physical activity, that doesn’t mean that you don’t have to exercise that day. The physiological benefits of those are very different so try to do both.
The beauty of exercise is that it isn’t one size fits all. We can tailor it in many different ways depending on what the current scenario is. Talk to your doctor and care team to determine the best regime for you. Slow and steady wins the race.
Show transcript
Dr. Diane Reidy-Lagunes:
Exercise. It's up there with "take your medicine" and "eat healthy" when it comes to your doctor's orders. We know it's good for us, but when we're dealing with cancer, does it hold the same power? Do we know the exercise prescription that is best for us as individuals? We do know that growing research suggests that consistent exercise plays a critical role in cancer prevention and disease management. It will lessen the side effects and even extend survival, and we're going to talk about it today.
Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcasts.
Today I am thrilled to welcome back Dr. Lee Jones to the pod to talk more about the role of exercise in cancer prevention and treatment. Lee is an exercise scientist who developed the Exercise Oncology Service here at MSK and a major focus of his lab is studying the role of exercise and how it actually helps suppress cancer, from prevention to advanced disease. Lee, welcome to the show.
Dr. Lee Jones:
Thank you Diane. It's a pleasure to be here.
Dr. Diane Reidy-Lagunes:
And Lee, as you know, a lot has changed since we last spoke. That was pre-pandemic when we were just starting the pod and thankfully, there's been a lot more research out there as it relates to exercise and cancer. So I want to start off with definitions because when we talk about exercise in our overall wellbeing, you know, sometimes we talk about exercise, movement, physical activity. Is there a difference in those terms and does it matter?
Dr. Lee Jones:
I'm glad we started with that because I think it's important just to kind of set the stage so we're all on the same page. So physical activity essentially is any bodily movement. That could be sweeping the yard, it could be walking up a flight of stairs, walking around the grocery store, literally any bodily movement. Exercise is a sub-component of physical activity. It's directed physical activity with the intention of improving health or fitness or wellbeing. So, very often people will talk about exercise and physical activity being the same things and they're not. I'll talk about both of those things, but in a lot of our research we're studying exercise – really structured, defined physical activity – that aligns with a prescription, as opposed to advice like, "Oh, you need to get out there and move more."
Dr. Diane Reidy-Lagunes:
A hundred percent. So to reiterate, it may be helpful for you to go out and rake the leaves, but when we talk about the data that you are trying to generate and the scientific discovery of exercise and its role in cancer prevention and treatment, it's really regimented exercise programs that you're testing. I'm going to start with the most important question. So in 2023, can you tell us about the available data on exercise as it relates to cancer? And taking it a step further, can we show that exercise can help our patients live longer or better when they're getting cancer treatment or when they have this diagnosis?
Dr. Lee Jones:
The answer to that is yes, with some caveats. We've really been looking at exercise both before cancer treatment (before surgery or before the initiation of therapy), during therapy, and then following the completion of therapy. There's actually pretty good data to suggest that exercise training programs before the surgery, particularly these pretty large surgeries, can be beneficial. If you improve somebody's fitness level before they go for surgery, then the tolerability and recovery from that surgery is enhanced. There's a number of trials that have shown those kind of benefits. The caveat here is most of these studies, probably 80% of these, have been performed in early stage breast cancer of women undergoing chemotherapy. So I'm not saying what I'm going to talk about applies to every single type of therapy, every single different type of cancer. We know that in people who've been through treatment – they obviously know this – you'll feel like you aged. People will tell you this, "I feel like I've aged 10 years," and we actually were one of the first groups actually to quantify that. And we did show that individuals who go through different types of treatment, we do have this kind of accelerated aging. And from a physiological perspective, that was anywhere from 10 to 15 years.
Dr. Diane Reidy-Lagunes:
10 to 15 years?
Dr. Lee Jones:
Yeah. We would see a 15% decline in somebody's fitness level during three months of chemotherapy. And now people would say, "Well yeah. You're going through chemotherapy. That's what you might expect." But what's important about that is context. Normally your fitness would decline 10% every decade, 1% per year. So you're seeing the equivalent of a decade of aging within three to six months of treatment. We then went in and started to intervene with exercise during treatment to see if we could mitigate this impact. There's a little bit of conflicting data, but on the whole it does seem that exercise – and typically this has been endurance training, either on a cyclometer or it's been treadmill walking—
Dr. Diane Reidy-Lagunes:
So aerobic.
Dr. Lee Jones:
Aerobic activity, typically three days a week at a moderate intensity (so that would be anywhere between 55 to 75% of someone's baseline capacity) – if you do that kind of training during your chemotherapy, it will significantly lessen that dramatic decline. It doesn't completely abrogate it, but it does significantly lessen that decline, which is incredibly important for a lot of different things, not only during treatment but it also then accelerates the recovery after treatment.
Dr. Diane Reidy-Lagunes:
Incredible. So for patients undergoing chemotherapy treatment, at least in these breast cancer patients in that study, it was aerobic physical activity – exercise – that really helped mitigate that aging process. Was it the same for the surgery as well, prior to surgery?
Dr. Lee Jones:
Yeah, surgery's typically been aerobic training as well. Endurance training.
Dr. Diane Reidy-Lagunes:
Treatment-related fatigue is one of the most debilitating side effects that our patients can endure, in addition to, like you were saying, just maintaining your physical strength. Are those side effects things that you saw on that data that were actually improved?
Dr. Lee Jones:
Yeah, that's probably where we have some of the best data, is exercise on fatigue. And this is either during therapy or after the completion of therapy. There's probably 60 plus studies, not just in breast cancer but across a number of different cancer types during cancer treatment, and fatigue is where you see some of the most robust effects of exercise. And this is self-reported fatigue of course, which is extremely important. It's kind of interesting. When we first got into this field – I don't want to date myself, but we've been doing this research for a while – when we first spoke to the oncologist about exercising individuals doing their treatment, their first response was, "You can't exercise people! They feel extremely tired. Exercising them is going to make them feel more tired, more fatigued." And of course it's the complete opposite.
Dr. Diane Reidy-Lagunes:
It's the complete opposite. And I would say even for all of us, right? It's like our bodies are programmed to say, "I don't want to exercise. I'm too tired." But when you get yourself off the couch and you actually go out there and then you do it, you don't have the fatigue like you had before, right?
Dr. Lee Jones:
Yeah, that's right. This is something that's extremely important, that fine margin between when is that time where you feel fatigue and exercise is going to be a benefit, versus when you're completely flat-out.
Dr. Diane Reidy-Lagunes:
Is there a point for which you could have an objective sign to say, "You know what? This is too much for my body." Like we're all tired, we don't want to get up off the couch, but when do we know that there really is no more what we call "residual capacity" left? And that is potentially a dangerous time for which you're going to go out and, you know, use that energy when you might not have a lot of energy to even expand at that point.
Dr. Lee Jones:
It's a great question and I think one that's not really talked about enough. The mentality with exercise, particularly in New York actually is, "I need to be going to a Soul Cycle class five days a week. If I'm not then I'm not fighting it in the way I should." Where I think, as physiologists, we think of it actually almost the polar opposite. If you think about individuals who might be starting therapy, they might not be sleeping as well, they might not be eating as well, they're getting the toxic effects of therapy, they're traveling to their appointments. There's a lot of stresses to the system. So if you now add exercise as another form of stress in that context, it could just simply add to the many stresses that an individual's already receiving.
I'm a big believer in thinking about what is – you know, you just mentioned this reserve capacity – how much reserve capacity do we have? What is a good way to try and measure that? One is, obviously people know their own bodies better than I ever will. So I think it's really important to listen to your body and truly, you know, identify those days where you are wiped out versus the ones where you feel like, "Oh you know, I actually could get up and do something today." Objective metrics-perspective, I'm a big fan of things like resting heart rate. If you've got a smart watch or something else, it will tell you your resting heart rate as you sleep, and that's basically an indication of how rested you are. So if you see that's a little bit out of whack, then the next day you wouldn't really want to go out and try to do a really intense workout on that day – you might actually take it off or you might actually just take it easy – versus on a day where you feel very rested, your heart rate's exactly where you'd expect it to be, and then on that day it's very appropriate to go out and maybe push it a little bit more.
Dr. Diane Reidy-Lagunes:
That's super helpful. Do we have any data on aerobic, anaerobic versus yoga – and I think probably anaerobic and yoga would go together – but is it important to mix those? Focus on one? The other?
Dr. Lee Jones:
I will start with what the guidelines say and then I'll give you my opinion. The guidelines are essentially the same for individuals who are going through cancer treatment as they are for somebody who's just had cardiovascular disease or somebody who doesn't have any conditions, which is: 150 minutes of moderate intensity exercise, aerobically – or five days a week of at least 30 minutes – three days a week with at least 25 minutes for vigorous intensity aerobic training. And the recommendation is two to three times per week of resistance training. So there are the generic recommendations. The nuance comes of course, is somebody who's going through treatment who hasn't exercised maybe for several years going straight to 150 minutes would be probably not recommended. That's a huge, huge ask and that's a huge difference. Versus somebody who's been running marathons and training, I wouldn't say just do 150 minutes, right? So I think within that, nuance and context are important.
If there was one exercise that I would recommend, it would be walking. And people think "Well, walking? That's just low intensity exercise." It isn't. Walking – you can do the New York brisk walk – if you're walking at 3.5 miles an hour and you've got a 4% grade, that is a great workout. Just in the same respect, you could walk at a slower pace for 45 to 60 minutes. So there's lots of ways that we can manipulate walking to get to these different levels of exercise.
People will ask me, "Okay, what's the best intensity of exercise to work out? Should I be doing just low intensity, moderate intensity or high intensity?" In our clinical studies, what we do, we prescribe exercise at low, moderate and high intensity. One session a week or three sessions a week will be at low intensity, one session a week will be at moderate, and one will be at high intensity. And as we know, many people in their exercise will do the same modality, the same duration, the same intensity every single time they do it. Now I'm not saying that's not beneficial. It is. That's more beneficial than doing nothing. But I think, if you think about trying to optimize your time, we can actually do sessions that are at a lower intensity but for a longer duration, or shorter duration at higher intensity. So rather than gravitating to the mean, can we start to exercise a little bit more in the extremes? This is probably the number one piece of advice that I give, is trying to mix it up a little bit not just in terms of the type of exercise we do, but also in their duration and intensity.
Dr. Diane Reidy-Lagunes:
A hundred percent. And I think that's probably why for some people the help of a trainer could be so critical, right? Because we're just not programmed to just sort of say, "Let's do something different and push ourselves in a different way."
Dr. Lee Jones:
It's hard. It's hard. I find it hard myself. What we try to do in our studies actually is have the harder days at the beginning of the week when you feel the freshest. Take it easy on the weekend, come into that Monday, do your more intense, harder session, and then the rest of the week is all icing on the cake.
Dr. Diane Reidy-Lagunes:
Beautiful. Another question from our listeners: Is it true that exercise can in fact prevent certain cancers? And if so, which ones?
Dr. Lee Jones:
A great question. The question of exercise and prevention, believe it or not, has been around for like a hundred years. The reality is all the data we have of exercise linking to either the risk of certain types of cancer or recurrence or mortality after cancer come from clinical epidemiological studies, observational studies. So what does that data show? The data will show that the link between your level of exercise and the risk of certain points of cancer, there does appear to be a reduction in multiple types of cancer – probably 13 different types of cancer ranging from breast cancer to colon to esophageal to lung to bladder, lots of different organ sites in the body – which is kind of interesting, right? It shows that exercise is having multi-organ benefits, which is incredible.
But you have to keep in mind the data that that is coming from. People are not great when it comes to recalling how much exercise they do, not because they're trying to be dishonest, just because it's very hard to quantify exactly what an individual did. And my quantification and definition of that might be completely different than yours, right? There isn't a single randomized-control trial yet showing that exercise lowers your risk of any form of cancer or reduces your risk of recurrence of any form of cancer. Those trials are ongoing in the post-diagnosis side. Results should be hopefully coming out in the next five years or so.
What we've done in our program is tested whether this was actually biologically plausible in mouse models. And we have found within our studies that if you exercise a mouse that has cancer, that cancer does grow slower. There's no doubt about it. About 30% slower. Now it doesn't eradicate it, but it slows it down. We had a study where we combined exercise with chemotherapy to see if the combination was better than just chemotherapy alone, and in mouse models it was. So, tumor growth was the slowest in the animals that got exercise plus chemotherapy versus those that got chemotherapy alone. Now we have studies in people where we're now looking to test that.
Dr. Diane Reidy-Lagunes:
Absolutely amazing. Just to reiterate, because this is one of the most common questions that our listeners have been asking: In your opinion, based on the best available data, what would be the ideal weekly regimen for a patient, whether they are being treated for cancer, they have been, or they're a caregiver and they don't have cancer, but they want to prevent it?
Dr. Lee Jones:
So anytime I get asked this question, I'm reluctant to say, "Everyone should do this." It really depends on how much you're doing right now. For those individuals who are thinking about starting but you haven't really done anything for the past maybe year or even longer, if you could start doing something three days a week, whether that's walking or biking or it's yoga. Starting off nice and slow, 10 to 15 minutes three days a week, will be incredibly beneficial. If you can get into the habit of that for two weeks, once you've hit that two-week mark, then you can start thinking about, "Well, can I add an additional day? Now if I'm doing three days a week, can I do four days a week?" One of those sessions, as I talked about, might be a bit longer. One of those sessions might be a bit shorter, but now you're putting your foot down a little bit. And then as you get into that groove, then you can start considering substituting in maybe a bike session instead of walking, or resistance training session. So you build as appropriate.
Dr. Diane Reidy-Lagunes:
Right, because it's not just movement, you're really talking about exercise now.
Dr. Lee Jones:
Yeah, exactly. Beyond that, try and be as physically active as possible. Take every opportunity. Park further away when you go to the grocery store. Take the opportunity to do a couple of extra laps in the mall. If you hit your 10,000 steps in physical activity, that doesn't mean that you don't have to exercise that day. The physiological benefit of those are very different. So trying to hit both is important.
Dr. Diane Reidy-Lagunes:
What about yoga?
Dr. Lee Jones:
Yoga's great. We talk about aerobic training, resistance training, and yoga is another form of training. It comes back to, "What is the endpoint that we're trying to improve or focus on?" And if it's quality of life, fatigue, things like that, then stretching and any kind movement can be beneficial. If we're specifically talking about, "I want to improve my fitness level," probably aerobic. If I want to improve my balance, my posture, my core, then yoga. If you can do all of those in a nice balanced way, that's always my goal. I don't necessarily achieve it every week, but I would love to be able to do that.
Dr. Diane Reidy-Lagunes:
A hundred percent. Mine as well. Yeah, and I mean, particularly we know some of our patients who undergo radiation therapy, while it could be curative, that type of therapy may induce what we call fibrosis. And just the ability to try to stretch and encourage that flexibility and balance that's associated, like you said, with your core. And some of our chemotherapies can cause what we call neurotoxicity, where you may have numbness and tingling. And so I think those types of exercises, like you said, from a quality of life perspective, can be critically important for our patients to be able to make sure that that muscle strength and that flexibility is still there, since some of the treatments can actually cause harm to those muscles.
Dr. Lee Jones:
Yeah, and I think what you're really honing in on is the personalization element. That's the beauty of exercise. It isn't one size fits all. We can tailor it in many different ways depending on what the current scenario is.
Dr. Diane Reidy-Lagunes:
I think that's a beautiful way to end. You're absolutely right. I think it's so critically important to talk to your primary team – the nurses, nurse practitioners, and docs – to ask about those therapies and then think about what exercises and prescription might be best for you. And certainly if you're starting slowly in the beginning, that's okay – like you said, slow and steady wins the race – and making sure that that's in a safe environment.
Dr. Lee Jones:
Precisely.
Dr. Diane Reidy-Lagunes:
Awesome. Lee, thank you so much for joining us. I learned a lot from you today.
Dr. Lee Jones:
Diane, it's always my pleasure. It was great. Thank you.
Dr. Diane Reidy-Lagunes:
Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information, or just send us any questions you may have, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing this podcast at Apple Podcasts or wherever you listen to your podcasts. Any products mentioned on this podcast are not official endorsements by Memorial Sloan Kettering. These episodes are for you but are not intended to be medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.
