Working out can reduce disease's spread and recurrence

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Maintaining an exercise routine may not be your top priority during cancer treatment, but there are benefits to being active. We'll hear about that from my guest, Dr. Kaushal Nanavati. He's an assistant professor of family medicine at Upstate, who is also the director of integrative medicine and survivorship at the Upstate Cancer Center. Welcome back to "The Informed Patient," Dr. Nanavati.

[00:00:37] Kaushal Nanavati, MD: Thank you, Amber. It's been a long time.

[00:00:39] Host Amber Smith: Several health organizations have general exercise recommendations. Dr. Nanavati, are there authoritative recommendations about exercise while undergoing cancer treatment?

[00:00:50] Kaushal Nanavati, MD: So there are, actually, several cancer organizations that have recommendations based on the best known current evidence. And the information and evidence change, and as they do, the recommendations do periodically change as well. So the American Cancer Society is kind of the premier organization that a lot of people look at for recommendations, but, there are recommendations from multiple societies.

[00:01:16] Host Amber Smith: Do we have evidence that it's actually safe to exercise during cancer treatment?

[00:01:22] Kaushal Nanavati, MD: Not only do we have evidence -- it's recommended. And for many people what they forget is that when you talk about some of the impact that cancer has on a person's life, if we just think about, so first of all, let's go back a step. When we say cancer, what that really means, it's a family of conditions. It's a whole compendium. And so one cancer does not equate to another. And someone who has cancer, during their journey through cancer, their body goes through different stages, different phases, and so even their body at different times will be able to tolerate different things.

All of that being said, as a broad stroke general recommendation, the value of exercise, if I put it in the cancer context, three main points to really bring up. One is that it's been known, through evidence, that exercise reduces the potential for onset of certain cancers, especially when you think about breast cancer, colorectal cancer, endometrial and gastric cancer, esophageal cancer, kidney cancer, and specifically with lung cancer, for people that smoke, exercise reduces their risk of lung cancer. So that's just the risk of getting it.

And for people who have cancer, exercise reduces the rate of recurrence, especially when it comes to things like certain types of breast cancer. So now we're talking about recurrence.

Then we think about cancer therapies. Exercise, through the literature, has been shown to actually enhance the benefit of the treatment and also benefit in actually helping to reduce the cancer burden on the body, whether it be reducing the spread of cancer, what we call metastatic disease. So high intensity exercise, in one study, actually showed that it reduced the potential for spread of cancer by nearly 72%. That's huge. Right? And high intensity activity isn't something that necessarily everybody does, but clearly there's some potential benefit for the right person in the right condition.

And then the idea of side effects of cancer chemotherapies, right? Whether it's immunotherapy or chemotherapy, or just going through the cancer journey. People experience mental fatigue, physical fatigue, emotional drain, and even the side effects of things like bone thinning, heart toxicity, cognitive decline, all of these things have been shown to benefit. When somebody has exercise, they actually experience less of the side effects and more of the benefits.

[00:04:03] Host Amber Smith: I want to ask you a little more specifically about the types of exercise, but I'm assuming maybe the recommendations are different depending on what type of cancer a person has, or how progressed it is, or where they are in their treatment.

[00:04:18] Kaushal Nanavati, MD: So that's exactly right. And on the other hand, as a baseline, we can say that anyone at any stage of any type of cancer can benefit from being physically active.

Physical activity includes basic things like going for a walk, riding a bicycle, going up and down the stairs, that type of stuff. And then there's more intense forms of activity. We think about exercise in terms of aerobic and anaerobic activity. So aerobic is the standard cardiovascular stuff that people think about, whether it's walking, jogging, treadmill, bikes, swimming, that type of stuff. And the anaerobic stuff relates to things like weight-based training.

So the current guidelines for exercise, which are -- it used to be that 150 minutes of aerobic exercise per week and then a couple of sessions of weight-based training. The latest guidelines actually encourage up to 300 minutes of aerobic exercise per week, along with two to three sessions of weight-based training per week.

So, ultimately, you end up looking at somewhere around anywhere between three to five or three to seven hours of exercise per week, if you include the weight-based training, to give the biggest kind of value for people who have cancer and for people who don't.

[00:05:38] Host Amber Smith: What about less vigorous things like relaxation exercises like yoga or even tai chi. Do those count as movement and exercise?

[00:05:48] Kaushal Nanavati, MD: They count and have their own value, actually, in terms of not only helping a person with things like balance and coordination, if they've had side effects of their treatment, but relaxation therapy has an impact on the biochemistry and hormones in the body. And so things like deep breathing exercise or practice.Some people meditate. Some people just do deep breathing. Walking in nature, as a reflective exercise. Tai Chi. Yoga. Pilates. All of these things actually have an impact biochemically in boosting the immune system, which is valuable in many instances and at the same time also have a benefit for reducing inflammation in tissues and muscles and joints, improving flexibility.

And so overall wellbeing improves, but specifically not only the physical, but the mental, emotional, biochemical and hormonal constitution of a person's body actually gets better as well.

[00:06:46] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking to director of integrative medicine, Dr. Kaushal Nanavati from the Upstate Cancer Center, and we're talking about the benefits of exercise during cancer treatment.

So let's get a little more specific about exercises that would be good for someone who is maybe new to exercise, that hasn't really done a whole lot of activity in the past and now they're in cancer treatment. What types of things would you recommend for that person?

[00:07:17] Kaushal Nanavati, MD: Start low and go slow. Right? And I'm smiling as they say that for those that really can't see us anyway. You know, the key is what you want to do is be consistent. There was a study that was done that showed that people who exercise 30 minutes three times a week versus people who did 10 minutes a day, the ones that did 10 minutes a day were more likely to make it a habit.

So the key is really to get started. This morning my thought was to embark, right, to begin the journey. The most important thing is taking that first step. So for those people that haven't exercised regularly, make it a part of your routine. Make it a non-negotiable so that everything else works around that.

For me, before I go to work in the morning, I have my exercise time. And then if I have time later in the day, I may exercise more or go for a walk in the evening with my wife or my family, et cetera. But fundamentally, I get my self-care time in in the morning because I know that once the day gets going, sometimes we get busy, things come up, et cetera. But first thing in the morning, we can actually plan for it. So I encourage people who haven't started to even plan for five or even 10 minutes, depending on their physical ability.

And more importantly, I will put the caveat that if you haven't exercised regularly, make sure you work with your healthcare provider and ensure that you're healthy enough to begin exercising. And then they, or they can connect you with somebody who can guide you on how to optimally exercise. At Upstate, we actually have the advantage of having multiple specialties and specialists available. And we even have a physical therapist who is specifically now focused on physical activity in cancer patients. So we're going to have more and more resources available, which I'm really excited about because everyone has different ability. At the same time, every cancer type has a different impact on the body. And depending on how it's impacting one person versus the other, we can be more specific about the types of recommendations we make and the approach that people can take.

But there are fundamental things we all do during the day. And as long as we're more active than we are sedentary, there's value. One of the things that exercise does, actually, which I think is fascinating biochemically, is it actually has an impact on reducing cancer metabolism. So what I mean by that is, if you exercise very vigorously, what happens is your muscles need the blood flow, which kind of steals it away from those cancer cells that are starving for it and clamoring and competing for it. And so if you're exercising and the muscles are getting the blood flow, the cancer cells are getting less of it, which can eventually lead to starving them out. And, biochemically exercise actually works inside the cells to induce natural kind of cancer cell death, so that we can actually get rid of them faster. So that is amazing stuff that we don't even think about.

[00:10:15] Host Amber Smith: What about athletes who are used to working out at a high level? Do they ever have to take it down a few notches?

[00:10:22] Kaushal Nanavati, MD: So the best answer in medicine that we always teach our students is, "it depends."

So it depends, Amber. And what I mean by that is that it depends on the person, depending on what type of cancer they have. In many instances, they may have to take it down a notch, especially if they're experiencing fatigue, bone pain, if there's stress on their heart because of the treatment or the therapy that they're getting, if they're having impact on their cognitive function, et cetera. Or it's metastasized somewhere else, let's say, to the bone or muscle.

Definitely I think across the spectrum from the sedentary person to the person who's an experienced athlete or a competitive athlete, fundamentally we have to make sure that what they're doing is not increasing stress load on their body, on their heart, and on their skeletal structure as well. And then give them a green light as to the degree of intensity, frequency, duration, all those things they can do. But that doesn't mean that they can't be active and doesn't mean that they still can't compete and / or engage in activity as they're able to tolerate and as is dictated by the type of cancer they have.

[00:11:31] Host Amber Smith: Does it matter whether the person exercises indoors or outdoors?

[00:11:36] Kaushal Nanavati, MD: So if they're exercising, I'm smiling, right? Because they're already doing the thing. Outdoors and indoors, in terms of what the evidence suggests, as long as they're doing it, there's value.

We know that there's benefit to daylight, in terms of mood, cognition, attention and feelings of joy. At the same time, if it's February in Syracuse, then you've got to be careful as to what the weather is outside as well.

So, it is variable. At the end of the day, doing the exercise is where the greatest value is. And then the environment should be one that supports somebody's sense of joy, versus stresses them out. And that's the way they can kind of figure it out as to what works best for them.

[00:12:19] Host Amber Smith: I've heard that oncology treatments can weaken the immune system, so do you have any concerns regarding group exercise classes, where the person would be surrounded by other people who are exercising?

[00:12:33] Kaushal Nanavati, MD: Yeah, actually that is something to consider, and that is something to pay attention to because the potential for infections such as viral infections, et cetera, is higher, especially if you're sharing equipment or it's not cleaned properly from user to user. Then we have to be careful.

Also, oftentimes when you're in physical exercise environments with groups, not everybody is necessarily practicing optimal hygiene. And even if they are, if they have a cough or they have a cold, then the potential for risk is higher for a cancer patient, especially if they're on some type of immune suppressing treatment.

And so they do have to be careful about that. And yeah, sometimes you love that emotional support, and the support of a group can be uplifting. And at the same time, in terms of exercise itself, you still have to be careful.

[00:13:23] Host Amber Smith: Well, on that note, are there things to watch out for so that you're not overdoing it or is there anything risky about this, just to be aware of?

[00:13:33] Kaushal Nanavati, MD: I think the most important thing one has to gauge is, 1, their ability,and 2, pair that with their health providers' recommendations, specifically their oncology team and their primary care providers, since between the two of them, their health is assessed, not just in terms of their cancer diagnosis, but their overall health in the context of their life, in terms of their goals.

And so that becomes the important thing. You know, people will hear exercises good for you, and then just start doing it. But, you know, when you jump start the system, sometimes there's a little bit of stress that comes with that. So, taking a gradual approach to increasing it, but being consistent.

There's a great quote by (actor) Denzel Washington that talks about dreams are just dreams, but in order to achieve those dreams -- I'm paraphrasing -- it requires discipline. It requires consistency. And I think when it comes to physical exercise, the key is consistency, just as it is with nutrition. And I do have to put a plug in that exercise and nutrition go hand in hand. So when people do better with both, it enhances their overall wellbeing and clearly creates an environment that gives them better opportunity to have an anti-cancer environment within their body as well.

[00:14:55] Host Amber Smith: We talked about sort of the ideal amount of time being three to five to seven hours a week, kind of spread across the week. But what about the person who's battling fatigue and struggling just to get through the day sometimes. Do you have any advice for that person?

[00:15:14] Kaushal Nanavati, MD: Yeah, actually it is exercise, because what happens is when it comes to cancer-related fatigue, we know that people that exercise actually have improved energy. And so, they may not start with an hour a day. But what they can do is start with two minutes or five minutes, get up to 10 minutes.

We also know from other studies that if you get 10 minutes of cardiovascular exercise, aerobic exercise that's actually good for your heart. We also know that people that tend to exercise more consistently actually have improved energy.

So, it's kind of like, if I don't do it, I'll remain tired, but if I do it, I might be tired in the moment, but over time I'll actually have better and better energy, improved stamina, and that actually helps in the long term.

[00:16:01] Host Amber Smith: Is there a value to building in a rest day where you don't do aerobic stuff, or you don't do weight training, you just sort of let your body rest?

[00:16:12] Kaushal Nanavati, MD: That depends on the person and depends on the intensity of what you're doing. If you're going for walks every day you can go for walks every day. If you are going to be doing a power lifting competition, or you're going to be doing something engaged competitively or training for a marathon, then you have to kind of do what's right for your body, giving moments of rest. Especially when you do longer endurance or strength-based more intense activities, then your body does need time to recover, depending on how intensely you're doing it. For people that are doing moderately intense activity and / or low intensity activity, generally speaking, they can remain consistent throughout the week.

[00:16:53] Host Amber Smith: At the beginning of this interview, we talked about the benefits really of adopting an integrative approach that combines medical treatment with exercise, and you also brought up nutrition. Do we understand, in the body, what it is that is happening that helps reduce the spread of cancer, potentially, or reduce the risk of cancer? What is happening, like, at a cellular level?

[00:17:18] Kaushal Nanavati, MD: A ton of stuff, I'll tell you. Everything from impact on dopamine to immunoglobulins, to actually impacting cellular structures that lead to kind of advanced cell death and slow down the progression of cancer, slow down the spread of cancer, what we call metastatic disease, what we call proliferation or growth of the cancer.

There are multiple, multiple enzymes and hormones and chemicals that are affected, including what we call cytokines and the VEGF (vascular endothelial growth factor) protein that some people have heard of, something called mTOR, (mammalian target of rapamycin) multiple, multiple enzymes that get affected.

In fact, the other thing that ends up happening is, it actually has an impact even on the blood supply to cancer cells and reducing that, as I mentioned, with higher intense activity. So, everything from regulating the metabolism of cancer, how much it gets for nourishment, to regulating the immune environment in the body to keep our immune system stronger, to reducing the cancer risks, as I mentioned, to reducing the cancer related side effects. And all of that, combined, is happening simply by staying physically active on a consistent basis.

[00:18:34] Host Amber Smith: Well, this is really good to know and very important information. I appreciate you making time for this interview.

[00:18:40] Kaushal Nanavati, MD: I really appreciate it because I agree that this is really the stuff that puts the power back into a person's hands to be able to navigate their living experience, even with a diagnosis of cancer, recognizing that you want to be, you want to live like you're living, and you want to have the best quality of life moving forward, regardless of the diagnosis, to the best of your ability.

[00:19:02] Host Amber Smith: My guest has been Dr. Kaushal Nanavati, an assistant professor of family medicine at Upstate, who is also the director of integrative medicine and survivorship at the Upstate Cancer Center. "The Informed Patient" is a podcast covering health, science, and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you're listening. This is your host, Amber Smith, thanking you for listening.