Academic articles, May

Exercise in Patients with Gynecological Cancer

Raksina Winaitammakul, M.D.
Department of Obstetrics and Gynecology Faculty of Medicine Ramathibodi Hospital, Thailand

Gynecological Cancer Patients in Thailand
          The most prevalent cancer among women in Thailand is breast cancer, followed by cervical cancer, which recorded over 8,600 new cases in 2022 [1]. Other significant gynecological cancers include endometrial cancer, ovarian cancer, vaginal cancer, and choriocarcinoma. The five-year survival rates post-diagnosis vary significantly based on the type and stage of the cancer.
          Treatment options for cancer are diverse and generally associated with improved survival rates, typically involving surgery and adjuvant therapies. In some instances, chemotherapy, radiation therapy, targeted therapies, and immunotherapy may be employed either independently or in combination. Patients frequently experience side effects both during and after treatment, which can include fatigue, alopecia, changes in body composition (increased fat and decreased muscle mass), weight fluctuations, nausea, sleep disturbances, joint pain, loss of bone mass, lymphedema [2], and peripheral neuropathy [3]. Advances in medical science have led to increased survival rates among cancer patients, underscoring the importance of maintaining a good quality of life during and after treatment.

The Role of Exercise for Cancer Patients
          Exercise plays a critical role in both the treatment and rehabilitation of patients with gynecological cancer by mitigating the severity of treatment-related side effects and associated symptoms, such as pain, fatigue, and sleep disturbances [4]. Additionally, it helps maintain physical condition and enhances strength during and after treatment [5]. At the cellular level, exercise promotes angiogenesis and normalizes vascular structures by stimulating the production of angiogenic proteins and nitric oxide (NO). It also modulates the expression of key growth factors. Exercise enhances blood circulation within tumors, reduces hypoxia, and increases drug concentration, which aids in inhibiting metastasis and drug resistance. Furthermore, it increases immune cell counts and reduces lactic acid production within tumors [6].
          Studies have indicated that engaging in at least 150 minutes of aerobic exercise per week is most effective at alleviating chronic fatigue in cancer patients while also benefiting appetite and cancer-related cachexia (anorexia and cancer cachexia) [7]. Resistance training has been shown to reduce inflammatory markers associated with cancer and improve patient symptoms. Additionally, exercise can alleviate depression among cancer patients by preventing the entry of tryptophan metabolites, which are implicated in depressive symptoms, across the blood-brain barrier, thereby improving sleep, a common issue in cancer patients [6,8].

Recommended Types of Exercise for Cancer Patients
          1. Aerobic Exercise It is recommended that patients engage in at least 150 minutes of moderate-intensity aerobic exercise per week, which corresponds to maintaining a heart rate of 50-70% of the maximum heart rate. Various methods exist for measuring exercise intensity; however, two simple methods can be highlighted. Currently, the use of heart rate monitors is widespread, allowing individuals to maintain their heart rate within zones 2-3 based on the monitor’s settings. If a heart rate monitor is unavailable, patients can gauge their exertion level by their ability to speak in short sentences without excessive fatigue. It is advised to limit aerobic exercise sessions to no more than 60-90 minutes to avoid excessive fatigue, with a recommended distribution of 30 minutes of exercise on five days each week. For those new to exercise or unable to sustain 30 minutes in one session, activities can be broken down into 10–15-minute intervals, performed 2-3 times per day. Low-impact exercises such as brisk walking, jogging, swimming, or stationary cycling are ideal.
          2. Muscle Strengthening Exercise Resistance training is recommended 2-3 times per week, beginning with body weight exercises such as squats and push-ups, performing 10-12 repetitions per set for three sets. Additionally, patients may utilize free weights or machines designed for targeted muscle training. It is advisable to start with light weights to prevent injury. Patients should be attentive to their bodies, as excessive exertion may lead to fatigue, joint pain, or muscle injury. A proper warm-up with light weights is essential, and patients should avoid holding their breath during exertion—exhale during the effort and inhale during relaxation.
          3. Balance Exercises Balance training enhances stability both in static and dynamic situations, helping to prevent falls and related injuries. It is recommended to practice balance exercises approximately three times per week, incorporating activities such as Tai Chi, yoga, single-leg balance exercises, and heel-to-toe walking.
          **Safety Tips** If patients feel unsteady, they should utilize support for stability, with a sturdy chair or handhold nearby for safety. Exercises should be performed slowly and thoughtfully to minimize fall risk. If uncertain about exercise techniques, patients should consult a physician or physical therapist.     

Precautions and Barriers to Exercise for Cancer Patients
1. Exercise During Treatment
          Assessing symptoms and determining the appropriate timing for exercise is crucial. Caution is advised during active treatment, especially if patients experience significant fatigue, nausea and vomiting, or low blood counts. Consultation with a physician is recommended in these cases. However, guidelines suggest that walking or resistance training with resistance bands can be performed safely when platelet counts exceed 50,000/uL [9,10].
              – platelets level 20,000-49,999/uL:  Strength training and aerobic exercise are generally considered safe, provided they are performed without excessive strain.
             – platelets level <20,000/uL:  Aerobic exercises (such as brisk walking, running, cycling, dancing) and weight training should be avoided due to the risk of severe hemorrhage.
             – platelets level 10,000-19,999/uL:  Strength training without weights (utilizing resistance bands) is permissible, along with aerobic exercises if patients can stand securely.
             – platelets level <10,000/uL:  Aerobic and strength training are contraindicated.
2. Lymphedema
          Lymphedema may arise from fluid retention due to low protein levels in the blood or complications following lymph node dissection. Symptoms can manifest in the calves, thighs, and extend to the genital region and lower abdomen [11]. Patients may worry that exercise could exacerbate swelling or perceive it as a barrier to physical activity. However, multiple studies have demonstrated that aerobic and resistance training do not worsen leg swelling or associated symptoms, such as pain or heaviness [12,13]. Water-based exercises, such as walking in water, aquatic cycling, or swimming, have been shown to effectively alleviate pain or heaviness in the legs compared to traditional aerobic exercises [14].
3. Peripheral Neuropathy
          Chemotherapy agents used to treat gynecological cancers often lead to peripheral neuropathy, characterized by varying degrees of numbness and pain that can affect fine motor skills and balance. While there is limited research on the efficacy of exercise in reducing chemotherapy-induced neuropathy, aerobic and resistance training during chemotherapy have been shown to lessen the severity of these symptoms [15,16]. Patients experiencing numbness should exercise with caution, favoring stationary cycling and resistance exercises using resistance bands for safety.
4.Overweight or Obesity
          Patients with endometrial cancer often have a direct correlation with obesity, particularly among younger patients. Exercise for this demographic may present challenges ranging from self-confidence issues to a higher risk of injury due to excess weight. It is thus recommended to engage in brisk walking on flat surfaces or treadmills while avoiding high-impact exercises and performing appropriate muscle stretching. Numerous studies indicate that exercise can improve various quality-of-life aspects for survivors of endometrial cancer [17] and positively influence weight management, which can impact recurrence risk [18].
          In conclusion, while the health benefits of exercise for disease prevention are well established, its role in enhancing the quality of life for patients with serious conditions such as cancer is equally significant. When appropriately structured, exercise can greatly improve the well-being of patients, although careful consideration and precautions must be taken for those with specific limitations to ensure safety and maximize exercise benefits.

References:
1. Ferlay J, Ervik M, Lam F, Laversanne M, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2024). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. Available from: https://gco.iarc.who.int/today, accessed [4th April 2025].
2. Armbrust R, Auletta V, Cichon G, Vercellino G, Yost K, Sehouil J. (2023).Lymphedema after pelvic and para-aortic lymphadenectomy-results of a systematic evaluation in patients with cervical and endometrial carcinoma. Arch Gynecol Obstet, . 307(5),1557-65.
3. Viswanathan, A.N, Larissa JL, Eswara JR, Horowitz NS, Konstantinopoulis PA, Mirabeau-Beale KL., et al. (2014) Complications of pelvic radiation in patients treated for gynecologic malignancies. Cancer. 120(24),3870-83.
4. Contreras, L.B, Cuevas-Cid R, Lorca LA, Ribeiro IL. (2022) Effectiveness of Resistance Training on Fatigue in Patients Undergoing Cancer Treatment: A Meta-Analysis of Randomized Clinical Trials. Int J Breast Cancer, 9032534.
5.Rose, G.L., et al, Stewart EM, Clifford BK, Bailey TG, Rush AJ, Abbott CR., et al (2023). Efficacy of exercise interventions for women during and after gynaecological cancer treatment – a systematic scoping review. Support Care Cancer, 31(6),
6. Zhu, C., Ma, H., He, A., Li, Y., He, C., & Xia, Y. (2022). Exercise in Cancer Prevention and Anticancer Therapy: Efficacy, Molecular Mechanisms, and Clinical Information. Cancer Letters, 544, 215814.
7. Mustian KM, Sprod LK, Janelsins M, Peppone LJ, Mohile S.(2012) Exercise Recommendations for Cancer-Related Fatigue, Cognitive Impairment. (2012), Sleep problems, Depression, Pain, Anxiety, and Physical Dysfunction: A Review. Oncol Hematol Rev,8(2),81-88.
8. Alizadeh Pahlavani, H.(2024) Possible role of exercise therapy on depression: Effector neurotransmitters as key players. Behav Brain Res. 459,
9. Melo-Diaz, L.L.(2017) Thrombocytopenia and Physical Activity among Older Adults: The Tenuous Line between Bleeding Preventiona Physical Functional Decline. Open Access Journal of Gerontology & Geriatric Medicine.1(5),12-4.
10. Morishita, S, Nakano J, Fu JB, Tsuji T. (2020) Physical exercise is safe and feasible in thrombocytopenic patients with hematologic malignancies: a narrative review. Hematology. 25(1), 95-100.
11. Dunberger G, Lindquist H, Waldenstrom AC, Nyberg T, Steineck G, Avall-Lundqvist E. (2013). Lower limb lymphedema in gynecological cancer survivors–effect on daily life functioning. Support Care Cancer. 21(11),3063-70.
12. Do, J.H, Choi KH, Ahn JS, Jeon JY. (2017). Effects of a complex rehabilitation program on edema status, physical function, and quality of life in lower-limb lymphedema after gynecological cancer surgery. Gynecol Oncol.147(2),450-5.
13. Katz, E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. (2010). Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil. 91(7),1070-6.
14. Dionne, A, Goulet S, Leone M, Comtois AS. (2018). Aquatic Exercise Training Outcomes on Functional Capacity, Quality of Life, and Lower Limb Lymphedema: Pilot Study. The Journal of Alternative and Complementary Medicine. 24(9-10),1007-9.
15. Scheffer, D.D.L. and A. Latini. (2020). Exercise-induced immune system response: Anti-inflammatory status on peripheral and central organs. Biochim Biophys Acta Mol Basis Dis. 1866(10),
16. Brett Whalen L, Wright WZ, Kundar P, Angadi S, Modesitt SC. (2022). Beneficial effects of exercise on chemotherapy-induced peripheral neuropathy and sleep disturbance: A review of literature and proposed mechanisms. Gynecol Oncol Rep. 39,100927
17. Robertson, M.C, Lyons EJ, Song J, Cox-Martin M, Li Y, Green CE.,et al.(2019). Change in physical activity and quality of life in endometrial cancer survivors receiving a physical activity intervention. Health Qual Life Outcomes.17(1),
18. Laskov I, Zilberman A, Yacobi LM, Hasson SP, Cohen A, Safra T, Grisaru D, Michaan N.,et al.(2023). Effect of BMI change on recurrence risk in patients with endometrial cancer. Int J Gynecol Cancer. 33(5),713-8.