What to Know About Cancer-Related Fatigue and Exercise, with Anna Roshal, MD, Tarah Ballinger, MD, and Danielle Halsey, MS, EP-C

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. Fatigue is a common symptom of cancer and its treatment, and it can be very difficult to treat. However, exercise is one simple method that’s been shown to help people with cancer manage and cope with cancer-related fatigue. In this podcast, Dr. Anna Roshal talks with Dr. Tarah Ballinger and exercise physiologist Danielle Halsey about what people with cancer should know about cancer-related fatigue and the ways that exercise can help. Dr. Roshal is a medical oncologist and assistant professor of clinical medicine at the Indiana University School of Medicine. She is also a member of the Cancer.Net Editorial Board. Dr. Ballinger is a medical oncologist, an assistant professor of clinical medicine, and the Vera Bradley Foundation Scholar in Breast Cancer Research at the Indiana University School of Medicine. Ms. Halsey is the lead exercise physiologist at the Indiana University Melvin and Bren Simon Comprehensive Cancer Center. You can view disclosures for Dr. Roshal, Dr. Ballinger, and Ms. Halsey at Cancer.Net. Dr. Anna Roshal: Hello, my name is Dr. Anna Roshal. I am a medical oncologist at Indiana University, and I am very, very pleased to have 2 great guests today, Dr. Tarah Ballinger and Danielle Halsey, who is an exercise physiologist. And the topic of our podcast today is cancer fatigue. So before we start, I'm just going to disclose that none of us have any relevant conflicts to disclose today. So I will introduce our guests very briefly. So Dr. Ballinger is also a medical oncologist here at Indiana University. She is an assistant professor of medicine and also an associate director of our supportive oncology program. And like I said, Danielle Halsey is the lead exercise physiologist supporting our Multidisciplinary Oncology Vitality and Exercise (MOVE) program for patients with cancer. So my first question to start us, and I would direct to Dr. Ballinger, but Danielle, please jump in as well. We all know that cancer patients have a lot of fatigue, and there's many, many reasons why. And it's actually one of the most common, if not the most common concern and complaint that our cancer patients have as they're first diagnosed and as they're going through treatment, and also even after treatment. So it is something that specifically affects their quality of life, maybe more than any other symptoms. So, Dr. Ballinger, can you discuss what are some of the reasons cancer itself and cancer treatments can cause fatigue? Dr. Tarah Ballinger: Yeah, that's a great and somewhat difficult question. So as you mentioned, cancer-related fatigue is the most prevalent cancer-related symptom, both in patients going through treatment, but even for many years after experiencing cancer. Cancer patients have significantly more fatigue than someone who has not gone through the disease. The reason why it's so prevalent and so difficult to treat is because the causes of it are so multifactorial. There's, of course, physical symptoms from cancer that can cause fatigue, pain, shortness of breath, depending on where the cancer might be located. And there are psychological symptoms associated with cancer that can cause fatigue, like anxiety, depression. Definitely trouble sleeping is a big issue. But even beyond these symptoms from cancer, tumors themselves have direct effects that can cause fatigue. So cancer itself causes inflammation that can impact hormone production and other balances in the body that can certainly cause fatigue. And all of that is before we even start to talk about the other thing you mentioned, which is side effects of treatment. So that includes anemia, which means there's less red blood cells, so there's less oxygen delivery to tissues, and that can make people feel a lot more tired. We also have a lot of evidence that cancer treatments actually impact muscle function at the cellular level. Often what I hear from patients is that they feel sore, like they've worked out, but they haven't actually done anything. And that's really a real thing directly caused by cancer and its treatments. So again, the reason this is so hard to treat is because there are so many potential things that are kind of coming together to cause the problem. Dr. Anna Roshal: Yeah, that's certainly very interesting. And again, it's complex and lots and lots of factors contributing. I'm curious to hear how would you distinguish, we've all been tired, right? So there's regular tiredness and there is this relentless cancer fatigue that our patients experience. And it's, how do we tell the difference and how do our patients tell the difference? That's most important. How do your loved ones tell the difference of somebody just having a difficult day and they’re tired, or is this cancer fatigue that we're talking about? Dr. Tarah Ballinger: Yeah, cancer-related fatigue is different from the fatigue I might have if I stayed up late or was in clinic all day. That fatigue you can push through and probably will get better if you take a nap. Cancer-related fatigue, classically, it somewhat feels like moving through sand, like you just can't get through it. Taking a nap tends to not be something that actually makes it better. And I think that can be a real struggle for patients in terms of their loved ones relating to them because a lot of people will think, oh, well just get some rest and you'll feel better. But that's not really how it works for cancer-related fatigue, which is why we try to look for other ways to try to improve this symptom. Dr. Anna Roshal: That's a great point. I certainly noticed that in my patients and certainly noticed it in my interactions with the loved ones of patients because that's one of the most common responses. So they just didn't get enough sleep or maybe they didn't drink enough water or anything like that. But we do know that it's much more complex than that. So maybe this is a good jumping point to talk about what kind of research has been done to look into how we can make this better. You know, since fatigue is this very complex symptom affecting our patients’ quality of life, what can we do to make this better? Dr. Tarah Ballinger: Yeah, so that's one of the reasons I'm really excited that we're talking about this prevalent symptom today because one of the, or the best thing that we have found to help with cancer-related fatigue is actually exercise. And that can seem a little bit counterintuitive if you're fatigued that you should exercise, but even light movement can help. So what's really awesome about exercise is that it can target all of those different mechanisms for cancer-related fatigue that I mentioned. And that's really different from what we typically think of in treatment, which is medications. Medications have kind of 1 mechanism of action. They might treat 1 cause of something, but exercise is able to actually treat all those different potential causes of cancer-related fatigue. So it can help with physical symptoms from the cancer, the psychological symptoms from the cancer, and even those direct effects of the tumor and the treatment. So exercise, it's really one of the only things that's been proven to improve the symptoms of cancer-related fatigue. It helps with our muscle function. It helps improve oxygen delivery to tissues. And when you exercise, it actually changes your body's immune system and it's anti-inflammatory. So there are true scientific mechanistic reasons for why exercise can be helpful. And again, it's one of the only things that we've proven over and over again can and does improve these symptoms. Dr. Anna Roshal: That's great. And that's, yeah, like you said, it does seem counterintuitive. And I find that as an oncologist discussing this with patients in the clinic can be quite challenging. Because like, yeah, I'm tired. And you really want me to do what? So yeah. So maybe this would be a great point for Danielle to jump in and talk about what kind of exercise, right? Because when we talk exercise, there are so many different ways people can exercise and do exercise. So what kind of exercise? Is this walking? Is this weights? And can we talk about, maybe in detail, of what kind of exercise has been looked at and found beneficial or what you recommend for patients? Danielle Halsey: Yeah, of course. So exercise walking and resistance training have both been proven in lots of research that it is beneficial to patients and their cancer-related fatigue, but also in combination. And one of the big things that I talked to you about with patients is just finding the exercise that works best for them and something that they're going to stick to. And so the actual “dosage,” and I say that with air quotes as I say it, but what the research has shown or what strong evidence has shown is that at least 3 times a week of some sort of aerobic activity, so that can be swimming, walking, if you like running, running, if it's biking, some sort of aerobic activity at a moderate intensity that will get your heart rate up for 30 minutes, has been linked to a decrease in cancer-related fatigue. And then at least 2 days a week of resistance training for at least 2 sets at 12 to 15 reps is going to have a positive impact on cancer-related fatigue as well. Dr. Anna Roshal: So speaking of types of exercise, you have mentioned walking and resistance training, and even swimming. Are there any other exercises? I know a lot of people like to do yoga or Pilates, especially before, and that's a different form of exercise than maybe going for a walk. What are the patients or people enjoy this more? Is there data for doing more of that type of exercise rather than traditional, let's go for a walk? Dr. Tarah Ballinger: Yeah, there is data that exists for some of these other forms of movement to improve cancer-related fatigue. So we do have evidence that yoga can help with cancer-related fatigue. Even massage therapy can help with cancer-related fatigue. Tai Chi, we have data for that as well. So I think those are important adjuncts. I think whether or not they can replace traditional aerobic exercise depends a little bit on how you're doing it. For a lot of the benefits of aerobic exercise, like Danielle mentioned, it's just about increasing your heart rate a bit or increasing your breathing a bit. So for some patients, that's happening when they're doing something like yoga, but for others it's not. So I still think that while those things can be important adjuncts and they can help with a whole comprehensive plan to treat cancer-related fatigue, I think traditional forms of aerobic exercise are still important and getting your heart rate up is important. However, things like yoga, they're still resistance exercise depending on how you're doing them because you are loading parts of your body with your body weight. So there are muscular benefits to doing that as well. So it's all, again, it's all an individualized thing depending on how people are doing it, what they like to do, what they're able to achieve in each of those exercises. Dr. Anna Roshal: So anything that they can do, but definitely having that emphasis on increasing the heart rate and using your muscles, regardless what that is. Yeah. Dr. Tarah Ballinger: Yep, exactly. Exactly. And that's really the difference. A lot of times people, we debate as exercise oncology researchers and a lot of people debate the difference between the term “physical activity” and the term “exercise.” So both of them are important in different ways. So physical activity is really any type of movement. So if I walk from my office to clinic, I'm doing physical activity. But I'm not doing exercise because exercise is done with a specific purpose to achieve a specific goal. So to really be exercising, I have to go out for a walk and say, “I'm gonna do this for 5 minutes because I know it's gonna make my cancer-related fatigue better.” Then that becomes exercise. So that's an important nuance and a different way to think about it, again, more like a prescription, a medication, something you're doing for a specific purpose. Danielle Halsey: Yeah, adding that intention where like going for a walk is, you know, a very important thing and being more active throughout the day and getting up and getting steps and things like that, it's going to benefit you. It's going to be a good thing. But adding intentional movement with a goal in mind of that 5-minute walk that is a challenging 5-minute walk versus the 5-minute walk with your, you know, dog who's stopping and sniffing every 2 minutes is going to have a different impact than the exercise that is intentional to get that heart rate up and you're like, speed walking to the stop sign and speed walking back to your door and, you know, little things like that where it's just intentional movement. Dr. Anna Roshal: Got you. And are there any guides for patients for the information that you just mentioned? Where can they go to find this? Danielle Halsey: Yeah, there's some really good resources using the American College of Sports Medicine, both their website and finding a health care provider that can get them more information as well. There's actually, on their website, a search bar to find different exercise physiologists or cancer exercise programs like myself that are in your area. Dr. Tarah Ballinger: I agree. The American College of Sports Medicine probably has the most good resources available online for patients. They have a program called Exercise is Medicine, which is perfect in terms of what I was explaining for how exercise can actually work like a medicine to help with cancer-related fatigue. If you just Google “Exercise is Medicine from the American College of Sports Medicine,” you'll find it. And then they have a search area where you can look for professionals like Danielle that might be in your area. There are a couple of other national programs. The YMCAs have a program called Livestrong. Most all of them carry that program, and they have trainers that will work with cancer survivors at any point in their disease journey. I also work with another program called Maple Tree Alliance. If you Google that resource as well, they have several cancer exercise programs across the country. They also have some exercise videos available online. But like Danielle said, I think the first thing to do is advocate for this resource for yourself and ask your oncology care team about where you might be able to get help with this type of thing. Oftentimes, I think patients can get a little frustrated because they need the type of specific information that someone like Danielle can provide rather than just, oh, you should move around, or you should do aerobic exercise. A lot of patients need to know, how long can I do this? How long should I be doing it? How high should my heart rate be getting? And a lot of those more specific questions need to be answered by a specialist. Dr. Anna Roshal: Yeah, that's definitely true. And that's, yeah, like you mentioned, it's difficult maybe for just oncology professionals in the clinic to know all of this and have time to consult patients on this. So maybe, Danielle, I know we mentioned a few times that you're an exercise physiologist, but can you explain what you do on a regular basis and who is the exercise physiologist? How is it different maybe from a trainer at the gym? Which is maybe more patients are maybe associating that, but I know that's not what you do. Danielle Halsey: Yes, yes. It's very funny because when I want to tell people what I do, like random people I meet on the street, I say, “I'm an exercise physiologist.” I do put it in layman terms. I say, “I'm a very fancy, well-educated personal trainer some days.” But you're not totally off. But generally, what it is, is exercise physiologists are individuals that are highly trained, I have a background in chronic diseases. I have a background in physiology. I have a background in chemistry and all of the similar education as a physical therapist might have had, but my education stopped at a master's comparative to physical therapists who go into a DPT school. And they are more focused on injury where exercise physiologists are going to be more focused on chronic illness and patients who have chronic illnesses. Or, where we typically see exercise physiologists working in health care systems is in cardiovascular departments. My job on the day to day is utilizing the structure of cardiac rehab to develop a cancer rehabilitation program here at IU. And we've seen how beneficial that exercise can be in the cardiac population. And we've also seen how beneficial exercise can be in cancer rehabilitation, but it's not as well known or established. And so my day to day can vary dependent upon the number of patients that I have coming in, but in an ideal day, I'll see 4 to 5 patients individually. I help them with aerobic endurance. So, we do have a target heart rate and duration on a treadmill or a bike if they prefer one or the other. And then we do about 20 to 30 minutes of resistance training based off of where their baseline is and their overall comorbidities and range of motion and things like that. I spend time in clinic also talking to patients about different exercise modalities that might be beneficial for them, doing a little bit of health coaching, I guess you could say, in the sense of talking to them about what they're currently doing, what they might be able to add to their day-to-day activities, and what would help them maintain their physical activity if they're doing that outside of our program. And then I do assessments with all of our patients as well to just see where their baseline physical function is. And we use that as the means to build them an exercise program and an exercise prescription to make sure we get them either maintaining their physical function throughout treatment or improving and exceeding their goals, I guess you could say, in the stages after treatment. Dr. Tarah Ballinger: Ideally, we want to be identifying patients and working with them from the time of diagnosis. So we think of it more like prehabilitation rather than rehabilitation, because if you're able to integrate physical activity and exercise as part of your cancer treatment from the very beginning, we know there are so many benefits to that, not just in terms of your fatigue and quality of life, but also a lot of other cancer outcomes in terms of responding to treatment. So it's really important, but I think the onus is on us as the health care team to help be able to deliver those services directly to patients. And again, we want to do this in a way that is almost like a prescription, very individualized. Like Danielle mentioned, there are guidelines for 30 minutes, 3 times a week, resistance exercise, this many reps of this many things. But for a lot of patients, that might be something they can't do. So your prescription, maybe 5 minutes of walking is enough to get your heart rate up. So you're just doing that every day. Next week, maybe a couple of the days, you can increase to 7 minutes or 10 minutes. So for every single patient, it's different, and we need to provide that support so patients know what to do and have a prescription to follow. Dr. Anna Roshal: Great description. And then hopefully those services will be available, are available to more of the patients around the country and around the world. Can you speak to other certain types of patients that in your experience benefit more from this exercise-based prehabilitation and rehabilitation? Or is that really all cancer patients? Dr. Tarah Ballinger: Yeah, so like most things, most of the evidence that exists for the support of exercise and cancer-related fatigue exists in breast cancer, but that's primarily because breast cancer is so prevalent. So it's more well-studied in breast cancer. There's good evidence for exercise preventing or treating cancer-related fatigue when it's done during chemotherapy, when it's done after chemotherapy. But also there's a lot of evidence in patients with lung cancer who have unique reasons for cancer-related fatigue, especially with all of the respiratory symptoms that those patients can have. But I think ultimately, the patients who benefit are the patients who do it. So the patients, yeah, the patients who do it benefit. What we find the barrier is, is just getting patients through the door in the first place and getting them over that hurdle of understanding the importance of this, not being afraid to do it and kind of trying to find a reason to make this a part of their treatment plan. I always encourage people, again, I sound like a broken record, but I think thinking of this as a medication or a prescription is really important because it should just be a habitual part of what you're doing as part of your treatment. I think cancer patients and people in general wait for some type of magical motivation to exercise. And people always say, “I'm not motivated today. I can't find the motivation.” But if you think about it as just something that you need to do every day, like brushing your teeth and taking your medicines, and just get out and go for your walk and try to reframe it a little bit differently, that can be very helpful and very important. Dr. Anna Roshal: That’s great advice. I was thinking about this, making this part of routine, not just in cancer patients, but in all of us. For some reason, the image of the pill box, like many of our older patients use, came to mind. So your morning pills, your evening pills, and there is a box, go out for a walk. Something like that. We need to design that. Dr. Tarah Ballinger: Yes. Danielle Halsey: Yeah, I would say that's a big thing. Like in the general population, it's this, a lot of the barriers that general population have to exercise, you'll see the same exact thing with cancer patients. And they're just, they just might be exacerbated a little bit more by this fatigue and the amount of appointments they have and other aspects of their life adding on to, oh, this is one other thing I have to do. And it is extremely interesting to see the differences in some of my patients who have been active prior to treatment and their diagnosis compared to those who were not active before. And I have 1 patient in particular who was not active before her treatment and any other patient that she's met who was active before her or who was active before their diagnosis, I hear her say, “I wish I had been active sooner. I wish I had been active prior to being diagnosed because I think it would have made a world of a difference in coming back.” And so I love the idea of making it a habitual thing. I like the idea of making physical activity something that isn't necessarily like a, “I have to do it” kind of thing, but something I get to do because I need to do it or it's something that's going to help me in the long run as well. And it's something that all of us, no matter our disease status, could benefit from making more of a habitual thing and an everyday task. Dr. Anna Roshal: Thank you, both of you. I know we talked mostly about exercise as a prescription for cancer fatigue. And I know in the beginning, Dr. Ballinger, you mentioned that really that's the only proven way to really reduce cancer fatigue. Are there any other things that our patients can do to try to cope with the fatigue in addition to the exercise? Obviously not instead, but in addition, are there any other tips that you have? Dr. Tarah Ballinger: Yeah, so like I mentioned, there are a lot of causes of cancer-related fatigue. So I think thinking about some of those other causes. So mental health is a huge one. So if depression or anxiety are something that you're experiencing, then treating that is going to make your cancer-related fatigue improve. So I always encourage talking to a therapist, a psychologist, if you want to consider taking a medication to help with depression or anxiety, all of those things can help. Sleep hygiene is really important. So again, thinking back to the naps, I encourage people to go for a short walk when they're tired as opposed to taking a nap so that it doesn't disrupt their nighttime sleep quite as much. Better sleep hygiene can help a lot with cancer-related fatigue. We mentioned other things like yoga, acupuncture, massage therapy. For some patients, there are stimulant medications that can help with severe cancer-related fatigue. I've certainly had some patients with debilitating cancer-related fatigue who have benefited from those as additional parts of their treatment. And that brings up the point that I think if the cancer-related fatigue is really severe, then it's definitely something that you need to discuss with your oncologist. You might need other blood work to make sure there's not something else causing you to be very fatigued. Or even sometimes we have to adjust the doses of a patient's medication so that they can better tolerate the treatment if the treatment is causing a lot of the cancer-related fatigue. So I think, again, this is a very complicated, difficult symptom, but there are a lot of ways to address it from multiple aspects that can make things better for patients. Dr. Anna Roshal: I think that's a very important point, right? Because there could be other reasons besides what we talked about, just the cancer diagnosis and its physiological effects. So I definitely agree with the comprehensive evaluation by the patient’s oncologist who then can determine how it was really causing the fatigue and make the appropriate determination for other things, maybe in addition to exercise. Well, I think this has been very wonderful and extremely informative. I learned a lot. Are there any other things that, Dr. Ballinger or Danielle, you guys want to add for listeners? Dr. Tarah Ballinger: I think this is really important, and would encourage everyone to empower themselves and believe that they can and should be doing exercise and every little bit counts. Dr. Anna Roshal: Well, thank you very much, both of you. That's been wonderful. Thank you. Danielle Halsey: Thank you. Dr. Tarah Ballinger: Thank you. ASCO: Thank you, Dr. Roshal, Dr. Ballinger, and Ms. Halsey. You can learn more about exercise during cancer on the Cancer.Net Blog. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. 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