Exercising straight after diagnosis – ‘Prehab’

You could be forgiven for thinking that getting fit might be the furthest thing from someone’s mind if they’d just been diagnosed with cancer. If you’re reading this as somebody that’s going through diagnosis right now then yes, it might not feel like going to the gym is top of your ‘to-do’ list. However, just as with many other aspects of exercise and cancer, there are two huge reasons why it’d be a really good idea.

Firstly, it can be an immense help in people’s sense of wellbeing as they go through that ‘in limbo’ stage between diagnosis and the beginning of treatment. Exercise can help you keep your head together during difficult times. It can help distract you, help you sleep, help stimulate your appetite. It can really help how you feel.

There are several reasons for this. One thing that emerges from all the growing evidence and practice in this area is that, from a patient perspective, it can help you feel like you’re taking back some control. Going through a cancer diagnosis is often a time of great worry, and a time of waiting. Waiting for appointments, waiting for scans and biopsies, and of course, waiting for results. And then waiting for treatment to start, which is often a period of several weeks. Patients may find themselves having to play a relatively passive role, waiting and then listening, being told their results and their treatment options.

For many it is terrifying, or at least deeply unsettling. Waiting for treatment to start can feel like you’re in No Man’s Land. ‘There’s a myth that adopting a positive attitude can help. Well it might, but you might want to rant and rave…, weep daily tears, or withdraw from the world’.[1]

The second significant argument for cancer prehab is that it can help your body to be able to tolerate what’s coming, and to recover more quickly from the treatment itself. If you’re active in the run-up to treatment, you’re likely to stay less time in hospital and are less likely to be readmitted.[2]

And you don’t need months of preparation. Macmillan say: ‘The benefits of prehabilitation can be seen in as little as two weeks. Prehabilitation empowers people with cancer to enhance their own physical and mental health and well-being and thereby supports them to live life as fully as they can.[3]

Building the evidence base

The idea that people could, and perhaps even should, be physically active straight after a cancer diagnosis has been around for a little while but has gained significant traction recently, as the evidence base around exercise and cancer in general has grown and flourished.

Macmillan Cancer Support spearheaded this in the UK by bringing together an international body of experts to consider and develop guidance for what’s become known as cancer ‘Prehab’. The Macmillan group have designed guidance on how it should be delivered and there are currently several trials underway across the UK. Once such trial is across Greater Manchester, and the results so far have been startling. It received widespread media attention in December 2019.

The Manchester project works like this:

  • Patients are offered the prehab service within 48 hours of being diagnosed
  • The service has three distinct aspects: Exercise, nutritional advice and mental health and emotional support. It is strongly believed that the three components are essential, and that they each contribute to the overall success of the programme.
  • For the exercise part, participants do three exercise sessions each week which consist of High Intensity Interval Training (HIIT) and strength training.
  • Family and carers are encouraged to join in, partly so that they can then support the patient to be active outside the structured classes, and because they themselves are going through a difficult time and the programme may benefit them too.

How Hima[4] got fit for surgery

Hima was diagnosed with lung cancer, and although surgery was the best treatment option, her surgical team felt that she would find it difficult to tolerate. So, aged in her mid-eighties, she was advised to get fitter, so that she could safely have her surgery. She started coming along to the gentle exercise class that I run at Maggie’s. I don’t think she’d done anything like it before in her life. Neither of us spoke each other’s language, but by mirroring exercises as I demonstrated them, she learnt strength training.

At the end of each class, the whole group does as many ‘sit-to-stand’ as they feel they can. This exercise gets you properly out of puff, sends the heart rate right up, and is helpful for building strength in your lower body and confidence in your own ability. It’s the one exercise, more than any other, that I urge people to do at home as well as in the class, and Hima did her home study with considerable gusto. She just got completely into doing them, and would bob up and down, grinning. The number she could do increased massively over the weeks until she reached the magnificent point that she outdid everyone else in the room, keeping going longer than any of her classmates, most of whom were 20, 30, 40 years younger than her. She was able to stand up out of a chair and sit down again more than 60 times. The average for her age is 9-14.

And then she disappeared from the class. Her family got in touch a little later to say that she’d had her surgery.

Sit to stand looks like this…

How to start your own prehab

I think it’s important that any prehab plans are simple, structured and manageable. I’d keep it simple because the period immediately after a diagnosis is one in which people are bombarded with information. There’s often a great deal to do in preparation, around people’s workplaces, childcare arrangements, finance. People can feel they need to get their ‘house in order’, anticipating a time where they may well feel too tired or unwell to do it.

So, my first recommendation is for a brisk daily walk, ideally outdoors. You might not feel like it every single day but try to make it something that you do as part of your regular routine. If you can, do this in a natural environment, because looking at trees and birds and seasonal change can really calm the mind. But it may well be that, in order to be practical, this is a part of a commute, or the school run.

If you can move faster than a walk, then go for it, or it might be that cycling’s your thing. It just needs to be something to get you out of the front door, out of puff, and warm. If you’re not able to get outdoors, there’s a home-based HITT routine here.

Cancer treatment often results in people feeling that they aren’t as strong as they were beforehand. I see it a lot, especially in people’s lower body strength, so that climbing the stairs becomes more difficult. It can arise simply from having to sit or lie down much more than you’re used to. People who’ve had surgery or radiotherapy around their upper body often report reduced strength in their arms and shoulders, and those having surgery or radiotherapy in the pelvic area often talk of reduced strength in their core. So, a useful part of prehab is strength training so that you begin treatment in the strongest position possible.

A little structure here is helpful, because strength training works best when it is performed well and with regularity. So, three times a week, on non-consecutive days (i.e. Monday, Wednesday, Friday) do something that challenges your muscles. There’s a gentle strength programme here. This doesn’t need to be time consuming or costly but getting as strong as you can might well be useful later on.

How Paul*[5] coped with watchful waiting

Paul was diagnosed with leukaemia, and although the type he had was aggressive, it was diagnosed early, and he did not have enough leukemic cells in his blood (at the time of diagnosis) for treatment to start. So, he was put onto ‘watchful waiting’, a period after a definitive diagnosis and before treatment starts, where you return to your cancer team regularly to monitor the disease’s progress.

Also known as Active Surveillance, it’s not easy to go through a period of repeated testing, in the knowledge that you will become increasingly ill and that only then will you have treatment. ‘It is normal for watchful waiting patients to feel anxiety and a sense of helplessness’.[6]

Exercise is recommended for people on watchful waiting, for all the reasons outlined already. With Paul, we mixed interval running (short bursts, interspersed with walking breaks) and strength training. Prehab for leukaemia is still – as far as I could find- a relatively new concept. So that I could plan the best programme for Paul I sought the advice of the international exercise oncology community through the power of twitter. They told me to help Paul to build up his muscular power, so that his physical strength could help him tolerate the drug regimens and transplant that he’d need later.

His strength training was specific – small numbers (repetitions) of strength moves with the highest resistance he could manage. We used a heavy-duty resistance band outdoors, but in bad weather headed indoors and used weights in a gym. For Paul it was important to manage his increasing sense of tiredness as his illness progressed and he got nearer to treatment. We were also very mindful of his exposure to infection risk.

He’s having treatment now.

A note of caution – when prehab might need a rethink

For most people diagnosed with cancer, prehab is a great idea, but there are some situations that require a little caution. As with exercise during and after treatment, prehab activities need to be made extra safe for people with metastatic spread to the bones, simply to ensure that any risk of fracture isn’t increased. There are still all of the potential benefits of exercise, of course, but just a few considerations:

  • Avoid activities where there’s a greater risk of falling. Avoid contact sports
  • Avoid putting increased strain on the spine
  • Avoid excessive twisting and bending of the spine. You can still train your back and core muscles, just with some caution

Similarly, there are some considerations when embarking on a prehab programme if you’ve got reduced immunity. Just as Paul and I did, avoid situations that could increase your risk of infection, such as public gyms, yoga studios and swimming pools[7].

What else can you do to prepare for cancer treatment?

I would take a leaf out of Manchester’s book, and combine exercise with the best nutrition you can. Clinical teams, and support organisations like Macmillan and Maggie’s, can help advise those who have inadvertently lost weight in the run up to diagnosis on how you can keep your strength up as much as possible by eating well. Exercise professionals can help with nutritional advice if you feel you’d like to lose body fat ahead of treatment.

Also, if it’s not stating the obvious, care for your mental health. Again, there’s support available from many sources, such as Macmillan Cancer Support, and organisations that focus on one specific type of cancer. Paul and his family found a great deal of support through leukaemia organisations.

One of the things I see in many of the training sessions I do with people going through diagnosis and treatment, is that an outlet for emotions and stress is terribly important. Exercise can provide it – I often bring out the boxing gloves specifically to help people let off steam. But so can the ‘talking therapies’ and peer support. If you’re near to one, drop into a Maggie’s Centre because the support you can find there is superb.

You might also seek out some calm, amidst the chaos. I’ve focused on physical activity that gets you out of puff and helps you to be physically stronger, because prehab evidence shows that it’s effective. But there’s also a really important role for yoga, tai chi, Pilates – activities that can help you to relax and hopefully to feel calm. They’ll also help you to stay physically strong and balanced.

More than anything, let the time in the run up to treatment be for you. Self-care, as some may call it. Allow yourself time and energy, even if it’s in small amounts, to wrench back a little control and devote some time to yourself. As someone once said: ‘because you’re worth it’.

[1] Prehabilitation for People with Cancer. Macmillan Cancer Support 2019

[2] Wrexham Maelor NHS Trust, BBC News 28.11.2019

[3] Prehabilitation for People with Cancer. Macmillan Cancer Support 2019

[4] People’s names have been changed

[5] Name has been changed

[6] https://blood-cancer.com/treatment/watch-wait/ 17/01/2020

[7] https://www.cancerresearchuk.org/about-cancer/coping/physically/exercise-guidelines 28.01.2020

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