The Benefits of Exercise for People Living With Metastatic Disease

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here's your host, Breastcancer.org Senior Editor, Jamie DePolo. 

Jamie DePolo: Hello, I’m Jamie DePolo, senior editor at Breastcancer.org. I’m podcasting live from the 2023 San Antonio Breast Cancer Symposium.

My guest is Dr. Anne May, professor at the Julius Center for Health Sciences and Primary Care at the University Medical Center Utrecht, in the Netherlands.

At this conference she presented the results from her study looking at how exercise can help people diagnosed with metastatic breast cancer.

As background, Dr. May was part of the expert group that developed the American Society of Clinical Oncology guidelines on exercise for people being treated for early stage cancer. But when those guidelines were developed there wasn’t enough research on exercise in people with metastatic cancer to make any recommendations, so she decided to do this study.

Dr. May, welcome to the podcast.

Dr. Anne May: Thank you.

Jamie DePolo: So, first of all could you describe the study design for us?

Dr. Anne May: Yes. What we did in the PREFERABLE-EFFECT study, we recruited patients from eight centers all around Europe and also centers in Australia, and all patients with metastatic breast cancer who had stable metastasis were allowed to enter our trial. And then when patients provided consent we randomized them, so it was a random process whether you get the intervention, the exercise intervention or the control group. And we included 357 women with metastatic breast cancer. Oh, I’m sorry, I need to say that we have two men in our study and we were happy about that because we opened the study for men as well.

And at the end half of them received the exercise intervention and the other half the control group. 

Jamie DePolo: Okay. And what kind of exercise did the people do?

Dr. Anne May: The exercise intervention group received a nine-month exercise program that was supervised by a physical therapist or exercise trainer and every session consisted of endurance training, resistance training, and balance training.

And that means that patients cycled on a cycle ergometer with quite high intensities, and the resistance exercises were done on machines, and then all the muscles of the body, the large muscles were trained. And the program was offered twice per week for six months and then in the last three months of the program, so from six to nine months, patients did one of the supervised sessions on their own, at home. 

Jamie DePolo: Okay, great. And what treatments were people receiving? Did you look at that?

Dr. Anne May: Yes, we looked at that. So, at the start of our intervention, over half of all patients received endocrine treatment and for the other patients it was a mixture of other treatments patients received. But we opened the study to everyone, so it was not that only patients with; undergoing one certain treatment were allowed to enter. Now, it was for us very important that this was a study that would also, yeah, include a broad sample of patients with metastatic breast cancer.

Jamie DePolo: Sure. So, basically anybody with metastatic disease was eligible.

Dr. Anne May: Yes.

Jamie DePolo: Okay. And then I want to ask about modifications to the exercise. Were those allowed for people who couldn’t do certain movements? Or if they had bone metastases and maybe something wasn’t safe?

Dr. Anne May: Yeah. So, our exercise program was, we had a protocol, but already in the protocol we specified that, for example, if patients have bone mets in their lower spine that then some of these exercises who put burden on the spine should be adapted. So, it was clearly described and also the program was always adapted to how patients were feeling. So, if they had just a tough treatment period then, of course, we adjusted the program for them, so it was really individualized.

And also at the start of the intervention, we did a fitness test, so that every patient started the program at her or his own level.

Jamie DePolo: Oh, that makes sense. So, then, and they could progress at their own level as well.

Dr. Anne May: Yes, yes. 

Jamie DePolo: Perfect. And now what were the results? I know that they were good, so I’m very excited for you to share them with us.

Dr. Anne May: Yes, we were also very excited when we saw our results at first. So, we found that patients in the exercise intervention had lower levels of fatigue as compared to our control group. Also, their quality of life was better, we found better physical functioning, we found better physical fitness, and also patients reported that they were better able to meet friends, their family, and if patients were still working, also their working life was improved.

And last and that I thought, we think is very important, we also looked into symptoms. So, we found, for example, that almost 60% of our patients at baseline, so at start of the study, reported levels of pain and dyspnea [shortness of breath] that were above the clinical relevant threshold, so quite distressing. And then we found that while exercising pain and dyspnea decreased in the intervention group. 

And why do we think this important? Of course, because this is a huge benefit for patients, but also we learned from a questionnaire study we did in patients with metastatic breast cancer in Europe, where we asked patients what are barriers and facilitators for you to start exercising? And one of the barriers that was, that was mentioned, was that patients had worries that their pain or their fatigue would increase while exercising. And now this study shows the opposite, that both fatigue and pain decrease, and I think this is something that is an important message that should also oncologists tell their patients when they recommend exercise to them, that it’s, it’s, also it’s safe and it decreases distressing symptoms. 

Jamie DePolo: And I have to ask, just for those of us who aren’t doctors, dyspnea, what is that in plain language?

Dr. Anne May: Oh, yes, I’m sorry that is shortness of breath.

Jamie DePolo: Oh, got it. Okay, perfect, thank you. Now, was it hard for people to stick with the exercise program? I know you said that some people thought, oh, you know I can’t start because of pain or fatigue. Did you have pretty good compliance?

Dr. Anne May: Yes, we were very content with the compliance. We had a median of 77 session, percent of all sessions were attended by patients and the main reason for not attendance were medical reasons, so hospital visits, for example, and also a vacation, which is quite logical if you follow a nine months program then you always have some vacations. So, no, we really saw good adherence to the program and I think that what helped to adhere is that it was supervised, so you have a trainer. Some patients trained in groups, so we have other group members that were sometimes patients, but sometimes also other people with other complaints. And what also motivated them was that the program was really adjusted to their needs. 

Jamie DePolo: That makes sense. And it also reinforces the research and opinions that say if you work out with a friend or a buddy you’re much more likely to stick to the program.

Dr. Anne May: Yes. I guess that’s something that, that counts for all of us.

Jamie DePolo: Sure, yeah. Now, during the media briefing on your study you shared some quotes from people who participated in the study. So, I wondered if you could just summarize those for us, because that was very powerful. 

Dr. Anne May: Yeah, we had included quotes of two patients and one of the patients said that, and that was actually what we just discussed, that the coach helped her a lot, that she motivated her to come and that was very powerful for her.

And the other quote was a woman who was treated with chemotherapy during the exercise intervention and she said that every time she came, sometimes she was too fatigued to come, but she decided to come, and at the end she felt better and therefore she was very grateful to getting this intervention. 

Jamie DePolo: Yeah, that’s wonderful. Now, if someone diagnosed with metastatic breast cancer is listening to this and wants to start exercising and maybe doesn’t know how or is scared, what advice would you give them?

Dr. Anne May: My advice is always first talk to your treating physician or oncology nurse about it, because they know you best and can also point out some contraindications if they are. So, that is the first thing that should be done. And then look for a certified, or in any case, an exercise training trainer who has experience working with patients with cancer.

And also what’s very, what we think is very important, is that the oncologist provide the physical fitness trainers with information on the patients so whether, for example, the location of bone metastases. So, because, so then the physical trainers are, yeah, could adjust the program. Yeah, I think that is, that is the advice I have.

Jamie DePolo: Okay. And in that case would it make sense for, obviously you said that people should talk to their doctor, but maybe say, hey, you know I’m thinking about starting exercising, could you give me a quick summary for the trainer I’m going to work with just so that person’s aware.

Dr. Anne May: Yes. So, that is what I think is, would be great and also necessary.

Jamie DePolo: Perfect. Dr. May, thank you so much. 

Dr. Anne May: Thank you.

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