Coping with Cancer Through Exercise, with Sheila Lahijani, MD, and Sami Mansfield

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. Brielle Gregory Collins: Hi, everyone. I'm Brielle Gregory Collins, a member of the Cancer.Net content team, and I'll be your host for today's Cancer.Net podcast. Cancer.Net is the patient information website of ASCO, the American Society of Clinical Oncology. Today we're going to be talking about coping with the mental and emotional challenges of cancer through exercise. Our guests today are Dr. Sheila Lahijani and Sami Mansfield. Dr. Lahijani is an associate clinical professor of psychiatry and behavioral sciences at the Stanford University School of Medicine and the medical director of the Stanford Cancer Center Psychosocial Oncology Program. Dr. Lahijani is also an advisory panelist on the Cancer.Net Editorial Board. Thanks for joining us today, Dr. Lahijani. Dr. Sheila Lahijani: It's truly my pleasure to be here today, Brielle, with all of you. Brielle Gregory Collins: Thank you. Ms. Mansfield is the founder of Cancer Wellness for Life and the director of Oncology Wellness for the Sarah Cannon Cancer Institute at HCA Midwest Health. Thanks for joining us today, Ms. Mansfield. Sami Mansfield: Thanks, everybody, for having me. Excited to be here as well. Brielle Gregory Collins: Before we begin, we should mention that Dr. Lahijani and Ms. Mansfield do not have any relationships to disclose related to this podcast, but you can find their full disclosure statements on Cancer.Net. Now to start, Dr. Lahijani, how can a cancer diagnosis impact a person's mental and emotional well-being? Dr. Sheila Lahijani: Thanks for asking this question, Brielle. Usually, when people want to know the answer to this, what I preface it by saying is that there is a spectrum of responses. Many people find themselves to be quite distressed because cancer continues to have quite a lot of stigma, both in this country and as well as internationally. People oftentimes associate it with feelings of despair, anxiety, and helplessness. Having said that, many of these responses and reactions are normal. Some people can progress to have many more significant emotional responses and reactions that can become more disruptive to their lives and to the roles that they play a part in. We really try to meet patients where they're at to better understand how they've previously coped with past life challenges and/or traumas and to identify what strengths they have, what coping mechanisms they have to help them manage the distress associated with cancer. There are patients who also have a history of past psychiatric diagnoses and problems, in which case getting diagnosed with cancer and undergoing cancer treatment can cause a lot more difficulty. So each person is different. There are a lot of, quote-unquote, "normal" reactions, responses and reactions, that we as providers do validate and reflect back to the patients. And then there are those that can cause many more problems, and those are the ones we really need to address. Brielle Gregory Collins: Okay. And getting into some of those problems, what are some of the most common mental and emotional challenges that people face during cancer? Dr. Sheila Lahijani: The majority of people feel very anxious. And I've shared this with others and share this with my patients: being anxious means something. It means that you care about something. You care about yourself. You care about your life. You care about people in your life. And so it's a sign. It's something that needs to be tended to. People suffer from mood symptoms such as depression as well, difficulty coping, feelings of loss and despair. Those are the most common reactions. Some people can develop other difficulties related to side effects of cancer treatments as well. And also, there are people, as I mentioned, who previously have suffered from psychiatric symptoms, where things can become much more difficult and challenging, affecting their way of thinking: problems with cognition, memory, recall, things like that. So to summarize, largely mood disturbances and mood symptoms in the forms of anxiety and depression. Panic is also a part of that, as well as post-traumatic stress. And there are others who have previous symptoms that can become more problematic. So we really try to evaluate both mood and thinking in our patient population. Brielle Gregory Collins: Thank you so much for walking through those. And I want to talk a little bit now about exercise and how that can play a role in coping with some of these challenges. Ms. Mansfield, what is considered exercise, and what are some of the benefits of exercising during cancer? Sami Mansfield: Great question because there are so many different terminologies around exercise and physical activity and fitness. So I think we should start there. The terminology of physical activity is probably the most broad thing that we talk about. Physical activity is anything that we do to move the body, anything from rolling over in bed, getting up, brushing your teeth, etc. Exercise is a physical activity that is more defined or maybe has a purpose. And so it might be a goal to get stronger or a goal of rehab or prehab in this particular patient population. Or some people just want to be able to walk a 5k or run a 5k. So exercise is more intentional. And that's really how we try to define it in the literature. From a cancer patient perspective, probably the most broadly impactful side effect management tool for exercise is actually fatigue because that is where we have a depth of evidence both in physical activity and inactivity differences. And related to fatigue from the mental health side, we see a strong benefit of both exercise and physical activity in anxiety, depression, stress management, sleep quality. So I think it's important for our audience to know that anything that you do for movement is good. Having a planned and structured movement program known as exercise is going to be ideal because the bottom line is we want you to reach your goal the quickest and without kind of feeling like you're not getting a lot of benefit to movement. And so that's why exercise really does have a significant role and why I think a lot of people really strive for, "What should I do? What does that specific exercise plan look like?" Brielle Gregory Collins: Got it. And I want to circle back to some of the challenges, Dr. Lahijani, that you outlined earlier. So how does exercise help address some of these challenges of cancer specifically? Dr. Sheila Lahijani: Well, I love this question. And I'm very informed by what my colleague, Ms. Mansfield, just described. Exercise and physical activity, in my opinion, are so beneficial to patients who are already diagnosed with cancer, as well as those patients who may be at risk for developing cancer-- any of us, really, to reduce our risk for certain kinds of cancer. There have been many studies that have been done that have demonstrated that intentional physical activity, as my colleague termed it, in the form of exercise can ramp up certain biological processes that contribute to improvements in cognition as well as memory function. There's a factor called a “brain-derived neurotrophic factor” which can get increased with physical activity and exercise. At the very molecular level, muscle cells can play a part in reducing the progression of disease and even potentially metastases. So there's a lot to be said biologically. As well as psychologically, it really can offer quite a lot of benefit to help people manage their distress through focusing on momentary breathing, momentary muscle relaxation. And there is also a social component to it. Even if someone is participating in an activity like this by himself, herself, or themself, there is something to be said about the communal experience of being up on your feet, moving yourself, and not being so isolated and alone, which is very much a problem for patients who undergo cancer care. Brielle Gregory Collins: That's a really good point. And Ms. Mansfield, I want to get a little bit into the specific things that people can do. So what kinds of exercise can help people with cancer cope with these challenges? Sami Mansfield: Now, it's a great question because that's what everybody wants. What should I do, right? And I tell everybody let's just start, number 1, with avoiding as much true sedentary behavior as possible. And I say true sedentary behavior because when you are just sitting and doing perhaps mindless activities, watching TV, there's a lot of exercises that can be done when you're seated, which is great for patients that have high amounts of fatigue or balance challenges. And I tell everyone, "Lift an arm. Lift a leg. Flex your toes and feet a couple of times, roll your shoulders, and you've just moved." It doesn't have to be vigorous or difficult. It just needs to be movement. So I think just thinking about these 1-minute, we call it “exercise snacks,” make a much more significant impact throughout the day than feeling like, "Oh, I've got to go to the gym and exercise for 30 minutes," or you might even have physical therapy. And the volume might be too high for people. So I want people to think first in small 1-minute movements. But the next piece of this is, we've studied the different modalities of exercise between aerobic exercise, thinking about things like walking, or chair-based, like marching in the chair, swimming, biking, whatever that may be. And resistance training exercises that use muscles. You could do something with weights, soup cans. You could do bodyweight exercises that build muscle. We've studied them separately and together. And what we've learned is that for the emotional side effects, specifically anxiety, depression, having a combination of these movements is going to give you the most significant benefit. So my advice is do a minute of marching, whether that's in your chair or standing, then maybe do a chair sit-to-stand 10 times and a couple of countertop pushups, and you've now hit a full-body routine exercise regimen in under 5 minutes. I do think that people need to remember although there are recommendations of how much you should strive for, there's no reason you have to do the whole recommendation of 150 minutes of moderate activity per week to see benefit. Start with just 1 minute at a time, 1 movement at a time, and try to mix it up. Make it fun. Add music. Make it a challenge. Make it something that you feel that you can attain because you will feel better and also accomplished. And that does improve your well-being, to feel like, "I did that. I did my 1 thing a day." And that's really phenomenal and goes a long way to how people feel mentally. Brielle Gregory Collins: Absolutely. And I love that term you use of “exercise snacks.” I think that's a really helpful way of looking at it. So for someone who's maybe just getting started with exercise, what is your advice for them as they manage their cancer diagnosis and are trying to look toward exercise as something that they want to incorporate into their lives? Sami Mansfield: That's definitely the question I love to answer. Because if somebody's motivated, we want to get them there quickly or get them to find a resource that helps them feel successful. I kind of go back to the whole “exercise snack” piece. I think it's more important that people realize it's better to do a little something every day than to think, "Oh my gosh, I need to hit 30 minutes today, and then for the next 3 to 5 days, I don't do anything." I really advise start small, start manageable, and look for something that you can do without having to add extra barriers to your life. As an example, if getting somewhere logistically on time doesn't work for you, start with 5 minutes of things that you can do from your home. I do think there is a really important resource within most of our cancer spaces. We have oncology rehab programs. We have trained exercise professionals that can guide you. But I think people don't realize that just moving around their house, maybe 1 flight of stairs if you can do that, is a really great way to get started. There's a lot of great YouTube videos you can try. There is definitely—talk to your physicians. They might have some great ideas. But starting daily, consistency really is going to make the biggest difference than just going, "Hey, Saturday is my day to exercise." I think we can all do a little bit in that snack fashion. And I don't know. I think we can all agree snacks are good. We all like a few snacks now and again. Definitely. And I also kind of have this thought about-- people say, "Well, if they have cancer, should they do yoga?"   And my answer is, "Well, do you like yoga?" I mean because yoga has a lot of really great resources for mental health and breath to movement and mindfulness and that grounding effect. But for someone who doesn't like yoga, which I will admit yoga is a little bit of my challenge so I push myself to do it, someone telling me to do yoga every day versus maybe exercises that I enjoy, I would be a little bit more down in the dumps about it, that you're taking away maybe what I love. So I think 1 thing, really thinking about what's the type of exercise you like to do, is it reasonable for you to continue that? If you used to run and maybe you have a lot of neuropathy in your feet, it might not be the most reasonable now. But what is the exercise that you enjoy? And that should also be part of that first thing that you do every day, not your, "Well, someone told me I should do yoga because they enjoy doing yoga," piece. And I think that's something that we need to think about in exercise. It still should be enjoyable and have good music. I think music is key as well.   Dr. Sheila Lahijani: I think it's really important to highlight as well that cancer causes so many life disruptions: disruptions to different roles, activities, functions, whatever it may be. And in speaking about intentional physical activity and exercise, it's an opportunity to create a routine and to try to lessen the impact that's caused by the disruptions. Sami Mansfield: The pandemic certainly accelerated that for those of us who don’t even have cancer. I don't know if anybody here also experienced this.  But I remember I was working out in a gym setting-- and we actually had our own-- we ran a gym space at the time in Kansas City for cancer survivors. So we took that virtual. But I struggled with my routine. I was like, "Wait a minute." And I could go to my own gym that was private, right? But I really struggled with the mentality of like, "It wasn't my routine." And when your routine slips, you just feel very out of control. I think 1 recommendation we should make for all of our listeners, physicians, or those of us that are working in the field is I recommend starting every day with a minute of movement. I don't care if you're doing a few arm circles where you're waiting for your coffee or whatever, but there is something about getting your blood flow moving quickly that makes a really big difference. So whether that's, "Before I brush my teeth, I'm going to just do a couple of leg swings or a couple of countertop pushups or something simple every single day." Or if you're in bed, you do something in bed, even if it's just your foot flexion or drawing the alphabet where you're doing something to stimulate movement." You bring up a really good point, that we need to make that ritualization or routine, but make it also very accessible for people. Brielle Gregory Collins: Absolutely. Thank you, Ms. Mansfield. That's really helpful. And Dr. Lahijani, in addition to exercise, what else can people with cancer do to cope with some of the mental and emotional impacts of their diagnosis? Dr. Sheila Lahijani: Thanks for asking this question. And I want to also preface this by saying so much of what we're talking about is essentially what is now a field of exercise oncology, right? And so there's more and more literature available and resources that emphasize the benefits of exercise in this patient population and how the effects of other treatment modalities, such as antidepressants and psychotherapy, can be further enhanced when someone is also being physically active or having an exercise snack. So to answer your question, what I'm saying is there are many ways we can support our patients and many ways we can encourage them to have better management and control over their distress-- why there is anxiety, depression, sleep disturbances. It's really meeting people where they're at-- which Ms. Mansfield also mentioned, starting somewhere. So when we see patients in our clinic-- and I've been known to do this, and I've done this back in the day where we would really write a lot more paper prescriptions. But even as part of my discussion points and patient instructions, I always make a point of writing, "Do some physical activity, even minimum opportunity to get yourself moving." Because what we're trying to really do is help with the circulation-- help with the circulation in the body, in the brain, really ramp up those neurotransmitters that help people feel better, remove the unhealthy oxygen, introduce the healthier oxygen. And that, in conjunction with medications, in conjunction with different psychotherapy modalities, in conjunction with progressive muscle relaxation, mindfulness, grounding techniques, can really help people feel less helpless, less stuck, less tired-- again, as I mentioned earlier, less alone, and find opportunities where they have more of a sense of control because that's part of what we're talking about here. There's a strong feeling of helplessness and lack of control when someone is diagnosed with cancer and undergoes cancer care. And this is an opportunity to help them find ways to manage their health physically, mentally, cognitively, spiritually, and feel less a sense of helplessness. It’s really encouraging me to say that there are many patients who are physically really suffering, whether it's from neuropathic pain, cancer-related fatigue, any kinds of deconditioning related to surgical interventions, other effects of chemotherapies, from depression. And it is much, much harder. And people sometimes cannot physically move. And it requires a lot more activation energy to take those steps. So part of what we do in my clinic and how we partner with our colleagues in palliative medicine as well is how can we manage people's symptoms? How can we manage their depressive symptoms, their physical symptoms? How can we help them be more cognitively stable and intact to be able to safely take those steps or to have more of that motivation or that energy or that pain relief to be able to participate in the things that we're talking about? I'm cognizant of the fact that when we have our patients and family members and caregivers listen to this, there may be some folks who are like, "But I just can't." And I have patients who tell me, "I get it, Dr. Lahijani. I understand. And I appreciate this guidance that you've offered me and the recommendations to use this medication or to consider this, but I just can't." So that problem with motivation and lack of optimal symptom management really has to be addressed in parallel, in my opinion, to really help support patients in actually participating in what we're suggesting here. Sami Mansfield: I think that's not only an excellent point, I think you really reiterate the partnership that needs to happen with the clinicians and the exercise oncology field or oncology rehab field because the only way to really do this effectively again, and especially a more complex patient, is in conjunction with one another. And I think that we need to be mindful and remind the patients, and like you said, the family members listening, that the conversation should be had, but the clinicians really can help manage the clinical symptoms so that the exercise or rehab professionals can really get in with that, the more implementation piece, when reasonable. But I think we need to take the guilt off our patients that it's not going to be every day, even though they want to. And that's the reality, and that is okay. And some days, it is a rest day or a rest week. And that is part of the healing process of the body and a really important way to recover. And that's okay, too. I think recommendations are nice as an example. But at the end of the day, if they're not reasonable for people, we need to also take that next layer of guilt away. And they just need to be able to feel comfortable and pain-free and symptoms-managed. And that's quality of life as well. Brielle Gregory Collins: Wow, what a great discussion. And I think the main takeaway here for anyone listening is your health care team is there to help you, and they'll work with you to figure out what's best for you, whatever that might be. So thank you so much. That was wonderful to hear both of your perspectives. And I want to talk a little bit about resources that people listening can turn to to learn a little bit more about this. So I'd like to direct this to both of you. Ms. Mansfield, we'll start with you, but where can people go to learn more about exercise and managing the mental and emotional effects of cancer? Sami Mansfield: Absolutely. That is the key question is, what next? Really, Cancer.Net is a wonderful and evolving resource and is continuing to progress its information. So no matter when you're listening to this podcast, check out Cancer.Net. I know that the information is online. There's a ton of resources right there. There are some other really great programs and resources. I would talk to your clinicians about things like cancer-specific rehab programs that you may have access to, which many have insurance coverage. And I tell people you don't have to feel broken to get cancer rehab. There are a lot of ways that cancer rehab can help you even just manage general fatigue or cognition. Referral to a speech-language pathologist can be helpful with some of those techniques about memory and chemobrain. So those are resources. In addition, there are qualified exercise professionals through the American College of Sports Medicine that have training and certifications and have experience. That can be another resource that can help you. I would also advise people to think, "You don't always have to have a cancer professional." There are great fitness professionals that may fit-- yoga professionals or other types of exercise modalities. So don't always feel like you have to find the “cancer person.” But depending on your symptoms or side effects, having a professional that understands what it means when you say neuropathy can be very helpful. So I would definitely start with those resources first and then branch out as you feel comfortable. Dr. Sheila Lahijani: She responded to that question beautifully. And to add to what she just shared, looking at what your own cancer center, your place of health care where you receive it, what's available. There are many websites through the different cancer centers and medical centers that have wonderful patient-facing and family-facing educational resources. The American Cancer Society also has a lot of helpful information. As Ms. Mansfield mentioned, Cancer.Net is a wonderful resource. And also to emphasize that there are programs that can be done virtually, especially in this era of this pandemic. While we encourage in-person interactions, however it's safe and feasible because there's so much benefit to feeling less alone and isolated and maybe having that direct 1-on-1 attention, we recognize that many patients because of their immune compromise or because of whatever challenges they may have with respect to support or transportation or finances, whatever it may be, it might be harder to access care or services where someone lives. And so there are programs and services that are available online. And that shouldn't be limiting. That should be something to really think about and consider. Actually, I was in a meeting recently where I learned about an organization called the Maple Tree Cancer Alliance, which has programs available through different cancer centers as well, among which is my center, Stanford. And so there are plenty of resources available. And with that, I will also say pick something. Choose something. You don't need to look at everything and try to do everything. Take a look at what's available to you, what's accessible to you, what makes sense, and just try it out, and see if it helps. And if it doesn't help or if it's not providing you any kind of immediate benefit, look to see what other options there are. We have so many patients tell us that they're trying to follow through on our recommendations, and people want to be, quote-unquote, "good patients." And that can get very overwhelming. People in large part want to feel better. They want to get better. That doesn't mean you have to take advantage of every single resource or recommendation that's being offered to you. Take a look at what's close to you, what you can access, and how you can make it work, and start somewhere. Brielle Gregory Collins: Absolutely. Sami Mansfield: And on that start somewhere, the other thing to really think about too - and Dr. Lahijani really said this - is you don't have to do-- everything at once can be so overwhelming. This is the long game. And so this exercise piece should be a lifestyle behavioral change piece that works for you in the long-term. It isn't about just, "Here I am. I want to get through just this 1 specific piece in my life." Look for something that you enjoy because you're going to be much more likely to continue. And then thinking about that support circle, it may be someone that has a similar diagnosis or understands what you're going through or have gone through. And it may be somebody that you have met or a family member that has never experienced this but is that person that you can vent to or is your accountability partner or your meet-for-a-walk or a virtual walk partner. I think we need to be really mindful, be creative about this. It should be enjoyable. It should be something that fits you. And at the end of the day, there's no right way to exercise. I think we'd all do something different here today if we all could choose. And that's okay too. Cancer is very individual, and so is this piece of that. So I think that's really empowering for all of our listeners to remember. Brielle Gregory Collins: Definitely. And that's so nice to hear, as far as there's no right way to exercise, I think that's a really helpful way of looking at it. Well, thank you both so much for your time today and for sharing your expertise, Dr. Lahijani and Ms. Mansfield. It was so great having you both. Sami Mansfield: Thank you so much for having us. ASCO: Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. 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