From Cancer Patient to Triathlete

How Some Are Taking a Run at Cancer Fatigue

Laird Harrison

June 01, 2018

MINNEAPOLIS — Coaches are helping breast cancer survivors prepare for one of several local triathlon events in the Milwaukee area.

"It's about developing a group of cancer survivors who are encouraged to exercise together," said Linda Piacentine, PhD, from the Marquette University College of Nursing in Milwaukee. "It's not about just getting them started, it's about continuing together. We don't emphasize competing; we emphasize completing."

Previous studies have shown that only about half of all breast cancer survivors maintain exercise programs 6 months after initiation, and only 21% exercise at the recommended level 10 years after treatment.

Piacentine and her colleagues wanted to know if better results could be achieved with the unique triathlon program.

Over 14 weeks, they provide 5 sessions per week — 2 supervised and 3 unsupervised. The events vary slightly, but include a 0.25 to 0.5 mile swim, a 12 to 15 mile bicycle ride, and a 3.1 mile run.

The researchers mailed a survey to 156 breast cancer survivors 1 to 6 years after they had participated in a triathlon. Their ages ranged from 28 to 68 years.

Of the 106 respondents (68%), 80 (75%) had a leisure score index above 24, which is the cutoff for standard exercise guidelines, and works out to 150 minutes of moderate exercise per week.

It's about developing a group of cancer survivors who are encouraged to exercise together.

When asked how often they engaged in exercise that made them sweat, 51 (48%) of the respondents said often, and 10 (9%) said never. And 69 (65%) reported participating in an organized physical activity in the previous 12 months, such as another triathlon, a footrace, a group bicycling event, or a fitness class.

This study was subject to selection bias because those most likely to respond to the survey were also more likely to have continued exercising. But with a 68% response rate, even if those who did not respond were not exercising at all, "it still seems like we're making a difference," Piacentine explained at the American College of Sports Medicine 2018 Annual Meeting.

Many of those who participated in a triathlon are active members of a Facebook group and use it to organize group exercise activities, she reported.

This triathlon program might be more effective than others because of the bonding that occurs among the participants, Piacentine told Medscape Medical News. For example, breast cancer survivors are more comfortable undressing in front of each other than in front of a general group of gym users because they have similar scars, and often mastectomies, she said.

"I really think we can embed exercise in the core of cancer treatment," said Patricia Sheehan, a PhD candidate from the Waterford Institute of Technology in Ireland.

Fatigue is one of the most common symptoms of cancer, and it can persist for years after treatment. Yet cancer survivors feel more energetic when they exercise regularly, she explained.

In another study presented at the meeting, Sheehan and her colleagues assessed cancer survivors at least 6 weeks after they completed surgery, radiotherapy, or chemotherapy. All scored below 45 on the Functional Assessment of Cancer Therapy: Fatigue (FACT-F). The scale ranges from 0 to 52, and a score of 30 indicates severe fatigue.

Study participants had to be physically active fewer than 90 minutes per week. "When they came to me, there was nobody actually taking part in physical activity," Sheehan told Medscape Medical News. "These people had a huge fear of being physically active."

Getting Active

Of the 37 participants, 30 had survived breast cancer and the remaining seven were survivors of other types of cancer. Average age was 55 years, and average time since treatment was 2.3 years.

The 19 participants assigned to the exercise group met for exercise instruction twice a week for the first 5 weeks and then once a week for the second 5 weeks. Under the supervision of Sheehan, who is a personal trainer, they worked incrementally up to 65% to 85% of their age-adjusted maximum heart rate and to a score of perceived exhaustion of 11 to 13 on a 20-point scale, where 6 indicates no exertion and 20 is maximal exertion.

Most of the exercise was conducted in group sessions. From week 11 to week 26, although exercise classes were discontinued, Sheehan provided support to the participants through text messaging.

The other 18 participants, assigned to health education, met once a week with Sheehan to receive instruction about food and nutrition, cognitive behavior therapy, and sleep management. She discussed exercise with them only in response to their questions. She also provided support by text. After week 10, the members of this group were encouraged to enroll in the exercise program.

Improvement was seen in both groups, not only on the FACT-F index, but also on multiple measures of psychologic wellbeing, quality of life, and physical function.

In the exercise group, improvements on all domains measured were significant, except pulse wave velocity, a measure of arterial stiffness, and C-reactive protein, a measure of inflammation. In the education group, the only improvement that was significant was in the fatigue score (P < .05).

Table. Significant Changes After Health Education, Exercise
  Health Education Group Exercise Group
Measure Baseline Week 10 Baseline Week 10 Week 26
FACT-F 21.9 29.6 19.3 40.3 42.5
Global quality of life 48.1 50.5 50.0 69.3 69.3
Cognitive function 50.9 51.9 41.2 71.9 77.4
Insomnia 15.5 13.3 15.2 8.2 6.4
Physical activity fear 28.3 27.1 28.9 13.1 9.2
6 min walk test, m 462.0 496.3 438.3 601.8 625.8
30 s sit to stand, reps 11.6 12.6 13.4 23.8 27.7


Most of the fatigue score changes occurred in the first 4 weeks, Sheehan reported. And the improvements were greater than those documented by other researchers.

After the presentation, a member of the audience asked why the participants had such a fear of exercise, and how they were able to overcome it.

Many people with fatigue are afraid of "doing more harm than good" with exercise, she explained. "In Ireland, rest has been prescribed for fatigue." But fatigue is not the same as tiredness; it persists for years and doesn't improve with rest.

To overcome their fears, Sheehan gave the participants coping strategies, such as listing the pros and cons of exercise. She also taught them to gauge their level of exertion. Participants told her that their general practitioners tell them what they can't do, whereas she tells them what they can do.

Because the participants entered the study at different times, they were not randomly assigned to the different groups, which is a limitation of the study, she acknowledged.

Piacentine and Sheehan have disclosed no relevant financial relationships.

American College of Sports Medicine (ACSM) 2018 Annual Meeting: Abstracts 1101/6 and 1103/8. Presented May 31, 2018.

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