Athletes and Cancer

http://www.dcmsonline.org/jax-medicine/2001journals/augsept2001/athletescancer.htm Athletes and Cancer

Thomas D. Rizzo, Jr., M.D., Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, FL Associate Professor, Mayo Medical School, Rochester, MN

The message regarding the importance of exercise and physical activity may be muted by the diagnosis of cancer. Our efforts as physicians are directed toward treating disease and preventing complications from inactivity as well as disease. This paper will review current associations between athletic life choices and cancer as well as provide a framework for addressing the athletic patient's interests in the setting of a cancer diagnosis.

Athletes are one of the most visible groups of public figures in society today. Whether wittingly or not, they represent a physical ideal that many fans aspire to achieve. But, athletic individuals can be afflicted with the same diseases as the general population. Hypertension, diabetes, and ulcerative colitis are all examples of diseases afflicting athletes at the highest levels of sports. Many athletes have been able to participate in sports while managing their disease. Some diseases, like diabetes and hypertension, respond to exercise. Therefore the athlete with a disease becomes a role model for others with that disease and an example of what is possible despite an affliction.

At one time, we only knew that an athlete had cancer shortly before their death or by reading their obituary. Today, there are many athletes that continue to participate in their chosen sport despite being diagnosed with cancer. As these individuals are visible to the public, they set an example of what one can do in spite of such a diagnosis.

However, patients and their physicians may have questions about the relationship between physical activity and the development of a malignancy. Furthermore, as we promote physical activity for its health benefits we need to understand whether there are any undesired side effects of physical exercise.

It is not clear that there is any unusual relationship between sports and cancers involving the blood, solid organs or lungs. There are three types of behavior that can put an athlete at greater risk for certain cancers. It is not the act of being athletic that puts one at risk but the exposure to carcinogens that are associated with certain sports.

Skin Cancer

Many sports occur outdoors and, while there is greater awareness of the dangers of sun-exposure, the bulk of a person's sun exposure occurs in childhood and adolescence. A study that screened surfers in Texas provided a much higher yield of basal cell carcinoma when compared to screening of a self selected population.1 These authors recommended increased efforts to reach this population at risk to identify neoplasms earlier and to provide education about the risks of sun exposure.

Tobacco

A wad of tobacco in the cheek of a baseball player may be as much a part of the visual imagery of baseball as a batting glove or rosin bag. Smokeless or spit tobacco is quite common in baseball at all levels. However, the use of this tobacco product is associated with cancer of the lip and mouth. Athletes, particularly baseball players, need to be screened for these diseases and counseled about this association.2

Steroids

Anabolic steroids are performance-enhancing agents that are used by some athletes to improve strength. They may also have side effects including aggression and increased ability and effectiveness of training. Athletes may see these side effects as desirable. Among the known dangerous side effects are the developments of certain cancers. Hepatocellular and prostatic cancers, Wilms tumor and renal carcinomas have been reported in case studies to be associated with anabolic androgenic steroid use3 and supported by animal studies.4

While athletes are not at a greater risk for cancer compared to others with similar exposure, their lifestyle (sun-exposure, tobacco product use) may place them at greater risk than others without these exposures. Therefore, as physicians, we need to caution our athletic patients so that their healthy lifestyle is not linked to unhealthy behavior.

Exercise and Cancer: Can Someone with Cancer Exercise?

Before addressing whether a particular patient should exercise, we should first be clear on the characteristics of a particular patient's cancer, and its treatment. Any cancer will have a specific effect on a patient. They may have pain, they may lose a degree of function, and they may have a limitation of movement. (Table 1)

If a patient cannot safely participate in an activity, then an alternative needs to be identified. For example, a patient with a primary or metastatic cancer in the femur with an increased risk for fracture should not be running. They probably should not be walking or transferring from their bed to a chair using their full weight either.

Treatments also will affect a patient's ability to exercise. (Table 1) Some effects, such as nausea, are immediate and temporary. Some effects, such as neuropathies following radiation or chemotherapy can occur over time. As neuropathic conditions can interfere with balance, proprioception or the ability to monitor the skin for injury, caution in bipedal activities should be exercised. This does not mean that all activities are eliminated. A patient with a peripheral neuropathy may not be safe to run, but may be able to jog in a pool. The appropriate precautions for a cancer patient are similar to those for other patients with similar conditions for different reasons. Patients with sepsis should avoid strenuous exercise, whether that sepsis is in the setting of leukemia or pneumonia. (Table 2)

However, in the absence of a contraindication to activity, due to organ involvement, disability, concomitant illness or treatment side effects, exercise is safe.

Exercise is also beneficial. Several studies have shown that exercise decreased fatigue in patients who were undergoing chemotherapy for cancer.7, 8 Others have shown improvement in a patient's ability to perform activities of daily living, regardless of whether they were regular exercisers before they received a cancer diagnosis.9

Benefits of Exercise

Cancer is a potentially devastating disease in and of itself. Many patients with cancer complain of fatigue and deconditioning.10 This is made worse by the side effects of radiation and chemotherapy. Advances in treatment and the use of adjuvant medications have helped lessen some of these side effects. Recent research also suggests that exercise can play a role in decreasing side effects. Cancer survivors who responded to a 1998 survey in sports magazines reported that they exercised regularly, and felt better.9

While this reflects a self-selected population, a 1997 study by Dimeo, had patients exercise after undergoing high dose chemotherapy. In this controlled study, those that exercised had a significant improvement in physical performance. They also had no reports of fatigue with their day-to-day activities, while 25% of the non-exercises reported fatigue.7

A recent study looked at whether exercise would reduce daily fatigue in women receiving chemotherapy for breast cancer. While one third were not able to keep exercising during chemotherapy, 61% of the exercisers improved their endurance as measured in a 12 minute walking test. The exercisers also reported less fatigue on the days they exercised. These positive effects were found in patients who were not exercisers (and presumably not fit) prior to their diagnosis of breast cancer.8

Training with Cancer

While exercise may be safe and beneficial in athletes with a cancer diagnosis, the effect of rigorous training is not clear. There are anecdotal reports of athletes competing at a high level while undergoing chemotherapy. I would think that one's ability to train would depend on the cancer and how the treatment made one feel. The athlete may have to been content with maintaining their fitness level as opposed to trying to increase this level. This is still a long way from inactivity and reflects a realistic reappraisal of an athlete's goals in the setting of an illness or injury.

What To Do and What To Tell Your Patient

Cancer is a devastating disease, and there is no underestimating the emotional and physical impact on an individual once they have received such a diagnosis. The disease itself may exhort a significant physical toll. Then the treatment, necessarily aggressive, may affect the patient's health, their appearance and their physical and "emotional" energy. The entire process is characterized by a loss of control: The patient does not have control over the disease that is harming them.

Unlike diseases such as hypertension, adult onset diabetes and obesity, they cannot alter their lifestyle to stop or slow the disease process. Once they have received a cancer diagnosis, they rely on information from their physician or physicians, as many can be involved. This is influenced and enhanced by the patient's own research and study, but ultimately, the patient will have to allow someone else to treat their disease.

Many individuals, regardless of age, define themselves in terms of their physical activity. They are not just co-workers, or neighbors, but golfers, tennis players, or runners. They take a degree of personal satisfaction from their participation in sporting activities. An injury to such an individual can be disruptive emotionally, as well as physically. Athletes have become depressed following their injuries.11 It may be very important to the athlete to feel that they are still involved in their chosen sport despite their injury and inability to participate fully.

For some athletes this is related to commitment. An individual may have decided to forgo certain aspects of their life to train for a marathon. An injury that interferes with that plan calls into question the worth of that commitment. The athlete may feel as though they have invested a tremendous amount of time and effort with no tangible return on that investment.

Other pressures in the face of injury relate to the short athletic "lifespan" and the urgency this creates. A "year" for a High School football player is not measured in 12 months but in 8 games. A "career" in High School football is only a few years. A small percentage of high school athletes go on to the next level, the chance to participate is truly limited by time.

An injury steals some of that time. An athlete's physician will first have to help the injured player understand why they cannot participate currently, and then help them find alternative ways to stay fit and mentally involved. This has to be done within the context of their injury. A wide receiver in a leg brace may be able ride a bike, but they are not likely to be running wind sprints, regardless of their interest, motivation and desire.

As physicians, we are in a unique position with regards to cancer. We have seen it's ravages, we understand the effects and the complications regarding treatment and we know when it should be treated aggressively. We have also seen the remarkable strides made in its treatment. Fifteen years ago we anticipated cures, now we actually use this word to describe eliminating the disease in an individual. However, the probability of a cure does not minimize the severity of the disease and the need for the patient and his or her physicians to be committed to its treatment.

It can be surprising, and somewhat frustrating, when a patient, having been presented with a cancer diagnosis, seems more interested in whether they can keep playing tennis, or whether chemotherapy can be put off until after the upcoming road race.

It is valuable for us as physicians to remember that the patient/athlete is basically asking whether they can keep "living" while they are fighting this disease with you. Their question is not unlike a person asking whether they should keep working while they are receiving cancer treatment.

So, If An Athlete Has A Cancer Diagnosis Can They Continue To Participate In Their Sport?

We must first know if there are any conditions associated with the cancer or side effects associated with the treatment of the cancer that would put the patient at increased risk by being active. (Table 2)

Once you have determined the potential risks of physical activity, you can explore the athlete's goals of sports participation. In many cases the goals will be realistic, attainable and ultimately, beneficial to the patient. In a few cases the goals will be very unrealistic. These individuals will need further education regarding their disease. Many patients have realistic goals but will need help in reaching their goals while undergoing treatment for their cancer. Referral to a specialist, either a physician or physical therapist with an interest in athletes with malignancies may be helpful. (Table 3)

For those few patients who can no longer participate in their chosen activity, alternative activities may be helpful. There are many sports that have complementary versions from a wheelchair base. Others can still enjoy the camaraderie of athletic events as non-participants. The competitive may choose to find their outlet in other activities entirely.

The important point is to realize that the active patient with cancer may be able to continue to be active, safely and satisfyingly, despite their diagnosis.

References

1. Dozier S. Wagner RF Jr. Black SA. Terracina J. Beachfront screening for skin cancer in Texas Gulf coast surfers. Southern Medical Journal. 90(1): 55-8, 1997 Jan 2. Cummings KM. Michalek AM. Carl W. Wood R. Haley NJ. Use of smokeless tobacco in a group of professional baseball players. Journal of Behavioral Medicine. 12(6):559-67, 1989 Dec. 3. Martorana G, Cancetti S, Manferrari F, Creti S. Anabolic steroid abuse and renal cell carcinoma. J Urol 162(11): 2089, 1999, Dec. 4. Bronson FH, Matherne CM Exposure to anabolic-androgenic steroids shortens life span of male mice. Med & Sci in Sports & Ex 29 (5): 615-19, 1997. 5. LaBan MM "Rehabiltation of patients with cancer." in Krusen's handbook of PM&R 4th ed, edited by Kottke, FJ, Lehmann JF, W B Saunders, Co., Philadelphia, 1990. 6. From Vargo, M, Cleveland, OH "Prevalence of cancer and scope of need for rehabilitation" presented at AAPM& R Annual Assembly, 1999. 7. Dimeo FC, et al, "Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation" Cancer, 79(9): 1717-22, 1997. 8. Schwartz AL, et al., "Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy" Med & Sci in Sports & Ex, 33(5): 718-723, 2001. 9. Schwartz AL, Patterns of exercise and fatigue in physically active cancer survivors. Oncology Nursing Forum, 25(3): 485-91, 1998. 10. Marciniak C,et al "Functional Outcome Following Rehabilitation of the Cancer Patient" Arch PM&R Vol77, 1996 11. Smith, AM, Milliner, EK Injured athletes and the risk of suicide. Journal of Athletic Training 29 (4): 337-341, 1994.

Jacksonville Medicine / August/September, 2001