Grief is a sacred journey

Strength When You Need It: Fitness and Cancer Therapy

Dew on a leaf rolls off easily - not unlike your physical ability during cancer treatment.Research shows that cancer patients do best when they get off the couch and move.  Most recently, resistance training is being suggested.  “Contemporary resistance training designs that provide strong anabolic effects for muscle and bone may have an impact on counteracting some of the side effects of cancer management, assisting patients to improve physical function and quality of life.” (1)  Research studies for specific types of cancer such as prostate and breast are showing that strength training improves outcomes and reduces side effects during treatment (2, 3), although there are no data for most types of cancer.

Unfortunately, there is no research about cancer patients who are fit when they become ill and continue exercising throughout.  How does exercise help a patient withstand life-saving but arduous therapies?  My story explains value of high levels of fitness for surviving cancer treatment with vitality and strength intact.

The Beginning

In the spring of 2006, my husband Vic Mansfield noticed lessening vitality and mild edema or swelling in his lower legs.  Vic had been a serious and disciplined resistance trainer for six years and an aerobic exerciser for much longer, but strength training was not going well.  It was hard to tell if this was a result of being 65, overtraining, overwork, lack of sleep, or something else.  By summer, Vic was stronger and feeling well, but his legs still had a tendency to swell.  I convinced him to see our internist before his usual yearly check-up.   Our doctor looked for circulatory problems, but instead found swollen lymph glands in the groin and elevated eiosinophils (a type of white blood cell).

Vic was referred to an oncologist and had a lymph node biopsy.  We waited for results for weeks.  The doctor felt sure that Vic had lymphatic cancer, but after sending tissue samples to four different labs, they failed to identify the specific type of cancer.  The oncologist could not offer treatment.  In the last weeks of waiting, Vic developed rashes, deep itching, and dripping sinuses.  Lymph glands throughout his body were swollen, making even the smaller lymph gland on his face and arms visible.  He was exhausted and his immune system was obviously in alarm.  Through it all, Vic kept exercising, telling himself that becoming weaker would only worsen his chances of healing.  The groin biopsy hampered squatting motions and finally the swelling lymph nodes made strength exercises impossible.  Fast paced aerobics turned into a slow walk.

A Nasty Diagnosis

In late August, Vic saw new doctors at Strong Memorial Hospital in Rochester, NY, fortunately one of the best lymphoma groups in the country.  The pathologist there made the diagnosis—angio immunoblastic T-cell lymphoma (AITL), a rare, aggressive, and incurable lymphoma.  The only known risk factors are aging and exposure to high dose radiation.   Still, Vic was finally in competent hands.  Doctors offered Vic a standard course of CHOP chemotherapy and asked if he would join an international study searching for the best way to treat non-Hodgkins or T-cell lymphoma.  Chemotherapy is often ineffective with AITL, but Vic had no doubt he wanted to try.

Vic had his first chemotherapy on Sept. 1, 2006.  He came home with anti-nausea medication and five days of high dose prednisone.  The day after the chemotherapy, his swollen lymph nodes were noticeably smaller.  Although Vic was exhausted, he took a long walk that day.

There is nothing worse for muscle mass and vitality than 100 mg of prednisone a day—it is like having the flu with 20 cups of coffee and no sleep—but after six days of treatment, Vic’s most alarming symptoms were gone.  He took long walks while on medication despite the side effects of prednisone.  We figured out what foods and supplementary therapies were supportive (I’ll discuss this in my next article).  He was able to eat throughout.  He drank lots of water and experienced mild nausea that was controlled by medication.

Eight days after the first chemo infusion and two days after the last prednisone dose, Vic tried strength training.  He was much weaker than he had been a few months before and exertion made him dizzy.  He did a light set of parallel grip deadlifts (PGDL), a set of heel raises, and had to quit—for a few days.  Inspired by Lance Armstrong’s book It’s Not about the Bike, Vic completed four strength training sessions before the next chemotherapy infusion.  It was joyful to lift weights without the swollen lymph glands and to find that he could still strength train, even though his strength was only 35% of his personal record (PR) in PGDL and 75% of his PR in the one-arm row.

Every three weeks from September to December, Vic had another chemotherapy infusion followed by five days of prednisone.  He kept walking, doing heavy chores like cutting and loading firewood, and stayed active throughout treatment. Nausea became a little worse with each round, but was manageable with medication.  Approximately eight days after each chemo infusion, he returned to strength and aerobic training.  His last chemotherapy was on Dec. 19, 2006, and by early January 2007, his most demanding lower body exercises like the squat and PGDL were about 60% of his PR, and his upper body strength was about 90% of his PR.  We were elated.

Randomized treatment options or the luck of the draw

As I mentioned, Vic enrolled in a study to find out the best treatment for non-Hodgkins lymphomas.  Fifty percent of participants would receive standard treatment—eight CHOP chemotherapy treatments followed by waiting and watching.  The other 50% would receive six CHOP treatments followed by high dose chemotherapy and autologous stem cell transplant.

In autologous stem cell transplant, stem cells are harvested from the patient’s blood after six chemotherapy treatments.  Then there is a three-week hospitalization in a sterile, isolated environment where high dose chemotherapy is given to kill the existing white blood cells and destroy the immune system, followed by infusion of the stored stem cells.  If all goes well, the stem cells find their way to the bone marrow and begin producing new immune and other blood cells.

Without a stem cell transplant, only 30% of patients with Vic’s particular type of lymphoma, AITL, survive more than 22 months.  Nearly everyone with AITL who responds to CHOP chemotherapy gets a stem cell transplant eventually, because standard chemotherapy rarely holds the disease back for long.  The goal of the study is to find out if people have longer and healthier event-free remissions when given the stem cell transplant sooner rather than waiting for cancer to recur.  Early indications are that this is the case.  Following stem cell transplant, 45% of patients have at least a 5-year event-free remission.

In December, we hear that Vic has been randomized to the stem cell transplant group.  We’re grateful since this seems his best shot for long-term remission.  We’re also frightened by the arduousness of the procedure, as the side-effects promise to be devastating.   In preparation, Vic has a bone marrow biopsy to make sure his bone marrow is cancer-free.  It is.  A semi-permanent catheter is placed in his chest and stem cells are collected from his blood and stored.

Hospitalization

Vic is admitted to the bone marrow transplant unit on January 16, 2007 feeling relatively strong and amazingly positive.  We are given the long list of frightening symptoms he should expect during his hospital stay—extreme fatigue, nausea, diarrhea, mucositis or mouth sores that may extend into the stomach, inability to get out of bed, inability to eat and drink, extreme weight loss, and more.  He is told he will be attached to his IV pole full time for the next three weeks.  They encourage Vic to get out of bed daily, take a shower, sit in a chair for a while, and take a short daily walk within the transplant unit if possible. Vic names his IV machine R2D2, deciding to make it his buddy rather than his enemy.

Within a few hours of admission, Vic receives his first high dose chemotherapy.  I privately ask a nurse whether patients ever regain their vitality after this procedure.  She confides that they usually do not.

When I return to the hospital the following morning, I expect Vic to be a mess.  Instead he’s dancing along on the treadmill with a grin on his face.  He has four more high dose chemotherapy treatments over a period of five days.  High dose chemotherapy makes it impossible for the bone marrow to produce new blood cells, so the body can’t survive it without a “stem cell rescue.”  Two days after the last chemotherapy, Vic’s stored stem cells are infused into his blood.  Vic is told he will now experience the worst side effects.  They forecast that he’ll begin a slow recovery in about 10 days when the stem cells begin producing new white blood cells.  Full recovery is expected to take six to twelve months.

From the beginning of hospitalization, all fluids that go in and out of Vic’s body are measured.  Within a few days, Vic realizes that if he drinks enough, he does not have to be on the IV drip around the clock.  He easily drinks the 50 ounces of water a day they recommend—usually twice as much.  By day three, he’s hooked to his IV machine only when receiving medication.  The rest of the time, he’s free to walk in circles around the nurse’s station in the small 11 bed unit, and walk he does.  The first week, he’s strong enough to use the treadmill that stands in an uninviting spot behind equipment in the hallway.  As he grows weaker, he listens to music with his iPod, and walks in circles for several short sessions totaling about one hour a day.  He uses his bed only for sleeping.

On day ten of hospitalization, Vic’s white blood cell count is zero and his platelets and red blood cell numbers are dropping as expected.  He is now extremely vulnerable to infection.  He’s slow and sick, but he dons a surgical mask and leaves his room to keep walking.  The treadmill is too demanding.  He tries stretchy bands for a few strength exercises, but they make him dizzy.  One afternoon, he takes to his bed for the first time.  When a nurse checks his temperature, as they do at four-hour intervals, he has a fever of 101.5.  The nurse tells him that he’ll be on an antibiotic drip as soon as the pharmacy brings the medicine.  When Vic hears this, he gets out of bed, puts on his mask, and starts walking the circle.  His nurse is amazed that he’s walking with a fever.  He responds with a laugh, “I’m not going down that easily.”  That night the fever breaks and by the next day it is gone.

Twelve days into hospitalization, Vic’s white blood cell count and ANC (absolute neutrophil count) are still zero.  His hematocrit (percentage of red blood cells) has been dropping, but it stabilizes at 27 (normal range is above 42).  No blood transfusions are needed (it’s usual to need five or more during this procedure).  Vic receives one platelet transfusion.

On day 14, I walk into the bone marrow unit after an outdoor walk and see Vic circling the nurse’s station.  He’s been slow for days, but today he’s moving fast, elbows out, dodging through the nurses and cleaning carts.  Roller derby man is back!  By the next morning, Vic’s ANC and white blood counts are moving up.  By day 16, they are surging and he’s using the treadmill with a high incline, although he becomes winded easily.  His appetite improves and he’s still drinking lots of fluids.  They release him from the hospital on day 17.  Nurses tell us this is a record time.

Recovery at Home

Despite his relative vigor, Vic has taken a hit.  He’s anemic and vulnerable to every virus, mold, and bacteria since his immune system is starting from zero.  He has lost childhood immunities to measles, chicken pox, etc.  He is advised to rest, eat, stay home, and avoid sick people.  Within 10 minutes of arriving home, Vic dons his surgical mask and rubber gloves and loads the wood stoves.  A friend advises me to tie him down.

Vic naps a few times a day, but he’s also taking walks in frigid weather, handling firewood, and using the rowing machine.  We had been warned he wouldn’t have much appetite for months, but his appetite recovers quickly.  Two days after returning from the hospital, he puts two 45 lb plates on the trap bar and tries a PGDL (parallel grip dead lift).  (I really should have tied him down!)  After six reps, he is dizzy and admits that he is too bull-headed for a 65 year-old guy who just went through high dose chemotherapy.  Six days later, he completes a full workout with 20% of his PR in lower body exercises and 60% in upper body exercises—and it was a challenging workout.  He’s been adding 5-10 lbs a week to all major exercises since.  He’s also speeding up on intense up-hill hikes and snow shoe walks and aerobic fitness is returning.

Seven weeks out of the hospital, Vic is using similar loads to those he used just before hospitalization—about 60% of his PR in lower body work and 90% of his PR in upper body exercises.  He lost more ground in lower body exercises, probably because they are most systemically demanding but also because he isn’t pushing as hard as he used to.  He is still slightly anemic, although his vitality is strong and growing stronger.  White and red blood cell counts have all risen to normal or near normal in record short amounts of time.  He has some neuropathy in his feet with tingling and a sense of numbness.  His knuckles are stiff and a bit painful.  He tends to have swollen elbows and poor drainage in the pectoral area, probably due to scar tissue in the lymph system.  His digestion is not what it used to be.  Doctors say there will be improvement in most symptoms over the next year, but we continue to pursue alternative solutions.

Vic most recent doctor’s visit included reports on blood cell counts and a PET/CAT scan.  Blood work is excellent, but the scan found some residual activity in a few lymph nodes.  Because the combined PET/CAT scan is new and because Vic’s cancer is so rare, the doctors simply do not know if the activity is a problem.  Of course, we’d be happier if the scan were 100% clear, but as we’ve known all along with this cancer, we’ll have to watch and wait.  Vic’s doctor feels cautiously optimistic and said: “You’ve done as well as anyone could possibly do with this procedure.”  I hope more medical people become interested in why that’s so.

Lessons learned

1. Exercise is physically and psychologically empowering.  Vic made it through stem cell transplant in the briefest time possible with great blood counts and a hopeful attitude.  All the way through, he did all he could to help himself.  (A later article will cover nutrition and other supportive therapies that were helpful.)

2. The discipline of exercise trains us to deal with the challenges of catastrophic illness.  Doctors told patients they should move, but nurses lamented that most patients refused to get out of bed.  If we don’t have the discipline and habit of exercise, it’s difficult to develop it while sick.  It is so unusual to see a stem cell transplant patient moving that, at check-ups, Vic is greeted by the staff as “the man who walked.”

3. Sixty percent of your PR may sound discouraging, but it is strong compared with people who don’t exercise.  Vic joked that he could do a better squat than his doctor, even at his weakest.

4. Experience with over-training comes in handy for recovery from illness.  Vic over-trains easily now and has to avoid pushing against muscle soreness and fatigue in strength and aerobic exercise.

5. There is much pleasure in being a beginner again and adding 10 lbs to the bar each week for lower body exercises.

6. There is even more pleasure in surviving this procedure with excellent vitality and to still enjoy exercising.  Whatever the future brings, being fit will clearly help meet any challenges.  Our goals now are to help Vic set new records for long-term survival and remission.  Lance Armstrong did it.  So can Vic.

This essay was published in Master Trainer: Lifetime Bodybuilding and Masters Athletes, June 2007.

References

1. Galvão DA, Newton, RU A review of exercise intervention studies in cancer patients. Journal of Clinical Oncology. 2005; 23: 899-909.

2. Ohira T, Schmitz KH, Ahmed RL, Yee D. Effects of Weight Training on Quality of Life in Recent Breast Cancer Survivors. The Weight Training for Breast Cancer Survivors (WTBS) Study. Cancer. 2006; 106(9), 2076-2083.

3. Galvão DA, Nosaka K, Taaffe DR, Spry N, Kristjanson LJ, Mcguigan MR, Suzuki K, Yamaya K, Newton RU. Resistance Training and Reduction of Treatment Side Effects in Prostate Cancer Patients. Medicine and Science in Sports and Exercise.  2006; 38(12): 2045-2052.