Join Fight CRC and Dr. Erin Van Blarigan, ScD, in this webinar discussing exercise, research, and colorectal cancer.

1. Research Trends in Exercise and Colorectal
Cancer

2. TODAY’S WEBINAR
 SPEAKER(S)
 Erin Van Blarigan, ScD
 QUESTIONS
 Ask a question in the panel on the RIGHT SIDE of your
screen
 WEBINAR ARCHIVE
 FightCRC.org/webinar
 TWEET ALONG
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3. RESOURCES
TABOO-TY PODCAST MINI MAGAZINES CLINICAL TRIAL FINDER

4. FIGHTCOLORECTALCANCERDISCLAIMER
The information and services provided
by Fight Colorectal Cancer are for
general informational purposes only.
The information and services are not
intended to be substitutes for
professional medical advice,
diagnoses or treatment.
If you are ill, or suspect that you are
ill, see a doctor immediately. In an
emergency, call 911 or go to the
nearest emergency room.
Fight Colorectal Cancer never
recommends or endorses any specific
physicians, products or treatments for
any condition.

5. ErinVanBlarigan,ScD
Dr. Van Blarigan earned her doctor of science in Epidemiology and
Nutrition from the Harvard School of Public Health. Her doctoral
dissertation was titled, “Diet and physical activity in relation to
prostate cancer progression and survival,” and her thesis committee
included: Drs. Meir Stampfer, Edward Giovannucci, and June Chan.
Dr. VanBlariganalso completed a postdoctoral scholarship at UCSF
where she participated in the NIH Training Program in Molecular and
Genetic Epidemiology of Cancer. She is now an Assistant Professor in
the Departments of Epidemiology and Biostatistics and Urology.

6. Research Trends in Exercise
and Colorectal Cancer
July 25, 2019
Erin Van Blarigan, ScD
erin.vanblarigan@ucsf.edu

7. Outline
Physical activity and colorectal cancer survival
Physical activity and quality-of-life in people with colorectal
cancer
Exercise during treatment for colorectal cancer
7

8. Physical activity and colorectal cancer survival
8

9. 9

10. Physical activity after diagnosis and survival
 Data from 6 meta-analyses:
• Higher physical activity after diagnosis consistently associated with
lower risk of all-cause and colorectal cancer-specific mortality
 High vs. low physical activity  40% lower risk of all-cause and
colorectal cancer-specific mortality
 Difficult to determine dose in observational studies
• ~5 hours walking per week = 35% lower risk of death
Any level of physical activity likely confers some benefit
10
McTiernan et al. Med Sci Sports Exerc. 2019.

11. Post-diagnosis physical activity and colorectal
cancer-specific mortality
11
“High” vs. ”low” activity  44% lower risk Wu et al. Oncotarget, 2016.

12. Post-diagnosis physical activity and all-cause
mortality
12
“High” vs. ”low” activity  42% lower risk Wu et al. Oncotarget, 2016.

13. Change in activity from pre- to post-diagnosis
and mortality in women with stage I-III CRC
13
Meyerhardt et al. J Clin Oncol, 2006.

14. Joint effects of postdiagnosis leisure-time physical
activity and TV watching and mortality among people
with colorectal cancer
14
1+ hour per week of activity
& 0-2 hours per day of TV
 29% lower risk of
all-cause mortality
Arem et al. J Clin Oncol, 2015.

15. Post-diagnosis physical activity and overall
survival in people with metastatic colorectal cancer
0
0.2
0.4
0.6
0.8
1
1.2
<3 3-8.9 9-17.9 18+
AdjustedHazardRatio
MET-hours per week
15
Guercio et al. ASCO GI 2017.
19% lower risk

16. CHALLENGE Trial (CO.21)

18. CHALLENGE Trial Update
≈20 centers in Canada
≈22 centers in Australia
UK, US, Israel, France
>710 of 962 randomized
3 more years of accrual
early efficacy (125 events)
Slide from K. Courneya 2019

19. Physical activity and colorectal cancer survival:
biological mechanisms
19

20. Mechanisms relating physical activity to cancer survival
20
Friedenreich et al. J of Molecular Medicine, 2017.

21. Dose response of 6-months of aerobic exercise
on change in fasting insulin in colon cancer
21
Brown et al. Endocr Relat Cancer. 2018.

22. Dose response of 6-months of aerobic exercise
and change in body composition in colon cancer
22
Brown et al. Br J Cancer. 2017.

23. Physical activity and quality-of-life
23

24. Associations between replacing sedentary time with standing
or physical activity and quality-of-life among people with
colorectal cancer
24
Van Roekel et al. Cancer Causes Control, 2016.

25. Dose-response of 6 months of aerobic exercise on
change in quality-of-life in 39 people with colon cancer
-25
-20
-15
-10
-5
0
5
10
Physical
health
Mental health CRC QOL Sleep quality Fatigue Fear of cancer
recurrence
Bowel
function
Control 150 min/wk 300 min/wk
25
*
*
*
* Group effect p<0.05
Brown et al. Psychooncology, 2018.

26. Moderate-to-vigorous physical activity and depression, anxiety,
and satisfaction with life in people with colon cancer
26
0
1
2
3
4
5
1 2 3 4
Adjustedmeandepressionscore
Quartile of MVPA
Depression
16
17
18
19
20
1 2 3 4
Adjustedmeananxietyscore
Quartile of MVPA
Anxiety
22
23
24
25
26
27
28
29
1 2 3 4
Adjustedmeansatisfactionwithlife
Quartile of MVPA
Satisfaction with life
Vallance et al. J Cancer Surviv, 2015.

27. Exercise during treatment for colorectal cancer
27

28. Relationship between exercise & cancer
treatment is an active area of research
 Physical activity often declines during treatment
 Many do not return to their pre-diagnosis level of activity after
treatment ends
 Functional capacity before surgery strongly predicts morbidity and
mortality
 Exercise may impact the efficacy of cancer therapies
28

29. Systematic review of exercise during treatment
 Systematic review through 2015 identified 7 studies:
• Supervised multimodal exercise during adjuvant treatment may
improve functional capacity and muscle strength
• No adverse events reported
• No studies examined neoadjuvant treatment
‒ Exercise before surgery may be optimal since it avoids post-
surgery limitations
29
van Rooijen et al. Scand J Med Sci Sports. 2018.

30. Feasibility of exercise during neoadjuvant
chemoradiation for rectal cancer
 10 rectal cancer patients (7 men, aged 27-70 y)
 Supervised resistance and aerobic exercise 2x/week for 10 weeks
 Exercise was feasible and well-tolerated
 May improve physical function while minimizing adverse changes in
body composition and cancer-related fatigue
30
Singh et al. Integrative Cancer Therapies 2018.

32. 32

33. FORCE: Focus on Reducing Dose-limiting Toxicities in
Colon Cancer with Resistance Exercise
 Low muscle mass associated with chemo toxicity and higher risk of colon
cancer and overall mortality
 Maintaining dose intensity may improve colon cancer outcomes
 In-person exercise 4-6 times, every 2-3 weeks for first 3 months
 At-home resistance exercise 2x per week, 45 min sessions
33
Stage II-III colon cancer patients
receiving post-operative
chemotherapy with curative-intent
Arm 1:
Resistance Training (RT)
Arm 2:
Usual Activity Group
Meyerhardt et al. 2017

34. Exercise during palliative treatment for
metastatic colorectal cancer
 8-week supervised multimodal exercise program (2x/week for 1 hour)
34
Zimmer et al. Support Care Cancer 2018.
*p<0.05
TrialOutcomeIndex
Intervention
Control

35. Self-Monitoring and Reminder Texts for Physical
Activity after Cancer (Smart Pace II)
35
Open for Enrollment
alexandra.milloy@ucsf.edu
Funded by Osher Center for Integrative Medicine (PI: Van Blarigan EL)
Good morning! How is your
energy level today? Text
back ‘H’ if you feel great, ‘M’
if you feel ok, and ‘L’ if you
feel very tired.
M
Ok – try to get at least 30
minutes of moderate
exercise today. The
exercise doesn’t have to be
intense – just move your
body and you might feel
more energized afterward!
Fitbit Flex 2

36. Summary and Conclusions
Physical activity is associated with longer survival and higher
quality-of-life in people with colorectal cancer
Data from randomized controlled trials show that exercise:
• Improves insulin sensitivity, body composition, and physical
function in people with colorectal cancer
• Is feasible and well-tolerated during treatment
36

37. Summary of Active Research Studies
Effect of exercise on risk of recurrence in stage II-III colon
cancer (CHALLENGE trial in Canada & Australia)
Effect of exercise on treatment toxicity and efficacy
Digital health solutions to help patients and survivors achieve
the recommended amount of physical activity
37

38. 2018 US Physical Activity Guidelines for People with
Chronic Conditions, including Cancer
 Engage in regular physical activity according to your abilities and avoid
inactivity
 Aim for:
• 150-300 minutes per week of moderate-intensity or 75-150 minutes
per week vigorous-intensity or an equivalent combination
• Aerobic activity should be spread throughout the week
• Perform muscle-strengthening activities that involve all major muscle
groups 2 or more days a week
38

39. THANK YOU!
39
Alan Venook, MD
Jeffrey A. Meyerhardt, MD MPH
Katherine Van Loon, MD MPH
Chloe Atreya, MD PhD
Angela Laffan, NP
June M. Chan, ScD
Stacey A. Kenfield, ScD
Greta Macaire, RD CSO
Yoshimi Fukuoka, RN PhD FAAN
Christine Miaskowski, RN PhD FAAN
Kerry Courneya, PhD
Funding
National Institutes of Health / National
Cancer Institute
UCSF Helen Diller Comprehensive
Cancer Center
Osher Center for Integrative Medicine
http://cancer.ucsf.edu/gi/survivorship-program

41. Skeletal muscle radiodensity at diagnosis and
survival in people with colorectal cancer
41
Kaplan-Meier curve of skeletal muscle radiodensity and overall mortality
SMD = skeletal muscle radiodensity
Years since diagnosis
Kroenke CH et al. Cancer. 2018.

42. (Friedenreich et al. Clin Can Res 2016;22:4766-75)

43. Q
&
A
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