Prior to Ira’s glioblastoma (GBM) diagnosis in July 2020, our weeks were filled with indoor and outdoor activities. Fortunately, neither the craniotomy nor the chemo/radiation treatments have impacted Ira’s ability to perform traditional exercises like walking and strength training, or fun activities like downhill skiing, hiking in the mountains, snowshoeing at altitude, or swimming in the ocean. Ira has remained determined to maintain his quality of life.
Ira’s first step was to take periodic walks around the post-surgical floor of the hospital. Before being discharged from the hospital, my Apple watch accumulated more than six miles. After returning home, we instituted a daily routine of walking a minimum of 30 minutes a day, weather permitting. We frequently take hikes lasting several hours.
While we consider overall fitness to be just one of our cancer fighting strategies, I was curious to see whether researchers have investigated the link between physical activity and the well-being and longevity of GBM patients. While there are an abundance of studies focusing on healthy individuals and people with more common cancers, researchers have spent far less time examining whether exercise has an impact on the GBM population. Lack of funding, minimal interest in the topic, and a relatively small group of active GBM participants are plausible reasons why this subject has been neglected. The fact that researchers have not devoted much attention to this topic should not dissuade anyone from adding enjoyable exercises into their weekly schedule.
Consistent exercise has shown remarkable benefits for other cancer patients by enhancing the quality of life, reducing the side effects of chemotherapy and radiation, improving brain function, minimizing fatigue, reducing the likelihood of depression and anxiety, relieving episodes of insomnia, adding muscle strength, improving bone density, expanding range of motion, strengthening the immune system, increasing appetites, and maintaining healthy weight.
Two of the healing factors— taking control and exercise— highlighted in Kelly A. Turner’s award-winning book, Radical Remission: Surviving Cancer Against All Odds, can be accomplished when GBM patients take the initiative to set up an exercise routine.
Since each GBM patient’s journey is unique, it is not possible to create a one size fits all approach to exercise. Some people respond favorably to the treatments while many other GBM patients have serious repercussions which may prevent or limit them from engaging in physical activity. Hopefully, the takeaway points from the articles summarized below will motivate GBM patients to get off the couch and start moving at whatever level is possible.
Exercise Guidelines for Cancer Survivors: Consensus Statement for International Multidisciplinary Roundtable
In the November 2019 issue of Medicine & Science in Sports & Exercise, one can read the article Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable to find evidence-based exercise suggestions to minimize the ill effects of cancer treatments—anxiety, depressive symptoms, fatigue, quality of life, physical function, bone health, sleep, cardiotoxicity, chemotherapy induced peripheral neuropathy, cognitive function, falls, nausea, pain, sexual function, and treatment tolerance.
The report recognizes that “during active treatment, an individual’s ability to tolerate exercise may fluctuate from day to day or week to week.” Thus, the study’s evidence-based prescriptions for frequent, intensity, time, and type (FITT) may or may not apply to all cancer patients, especially those who lack mobility from debilitating cancer side effects.
Often the people included in these studies were healthier and exhibited more motivation than most cancer patients. GBM patients who exhibit deficiencies in the aftermath of their diagnosis and treatments, or have underlying health issues that may be adversely affected by an exercise routine, should seek the advice of a medical professional before starting an exercise program.
Exercise Behavior, Functional Capacity, and Survival in Adults with Malignant Recurrent Glioma
The 2011 Duke University Medical Center study Exercise Behavior, Functional Capacity, and Survival in Adults with Malignant Recurrent Glioma monitored 243 glioblastoma patients with a Karnofsky Performance Score (KPS) greater or equal to 70 to determine whether exercise affected the survival of patients with recurrent glioblastoma. Exercise was defined as “a planned, structured, and repetitive physical activity performed in leisure (ie, nonoccupation) time.”
(Health professionals assess patients’ overall performance with the Karnofsky Performance Scale or KPS. 100= normal with no complaints; 90= able to perform normal activity with only minor symptoms; 80= normal activity with effort and some symptoms; 70= able to care for self but unable to do normal activities.)
If you are trying to determine whether you should consider implementing a customized exercise routine, consider this statement.
…increasing exercise behavior levels after a cancer diagnosis is an important clinical goal. Randomized trials demonstrate that structured exercise training is a safe and well-tolerated therapy associated with significant improvements in several clinically relevant outcomes, such as cardiorespiratory fitness, quality of life, and fatigue in patients with cancer both during and after primary adjuvant therapy.24,25
In a June 21, 2011 Science Daily story reviewing this Duke University Medical Center study, the authors offered a noteworthy detail,
The patients who reported participating in regular, brisk exercise – the equivalent of an energetic walk five days a week for 30 minutes — had significantly prolonged survival, living a median 21.84 months vs. 13.03 months for the most sedentary patients.
This Duke University Medical Center study concluded by stating,
Exercise behavior is a strong independent predictor of survival that provides incremental prognostic value to KPS as well as traditional markers of prognosis in malignant recurrent glioma.
The Potential Role of Exercise in Neuro-Oncology
A few years later (2015), researchers from Australia and Hong Kong studied The Potential Role of Exercise in Neuro-Oncology and shared their findings in Frontiers in Oncology. By recognizing the possibility that exercise could be used to counteract the devastating symptoms associated with brain and central nervous system cancers, they tried to identify potential exercises that would address the common symptoms of fatigue, functional decline, cognitive impairment, depression, and anxiety. They theorized that the clinical research highlighting the overall benefits of exercise can be applied to the GBM population.
A considerable body of literature including neuroimaging, human, and animal studies outside the cancer setting has elucidated the main mechanisms believed to be responsible for the preventative and restorative effects of exercise on cognition (52–55). Specifically, exercise mechanistically drives improvements in brain function and structure through stimulating neurogenesis and neural plasticity, up-regulating growth factors including brain-derived neurotropic factor, reducing levels of endogenous corticosteroids and pro-inflammatory cytokines, reducing oxidative stress, preserving brain volume, improving vascularization and increasing blood flow throughout the central nervous system, and increasing levels of hormones beneficial to neural structure and function (52–55). Despite clear differences in the pathophysiology of cognitive declines experienced by brain cancer patients, this establishes exercise as a promising intervention to counteract the cognitive effects experienced by patients.
This article also advocates that
patients avoid inactivity even when undergoing difficult treatments and aim to participate in regular aerobic (e.g., walking, cycling) and resistance (i.e., lifting weights) exercise. To realize significant health benefits, patients should perform at least 150 min of moderate intensity aerobic exercise and two to three moderate intensity resistance exercise sessions weekly (95, 96).
I realize that this may be a tall order for many who are undergoing the Standard of Care treatments for GBM or are experiencing medical issues. Nevertheless, I encourage GBM care partners to become an exercise buddy with their loved one. It is much easier to take a walk with someone than to walk or exercise by yourself. Even a five minute walk is better than remaining sedentary.
Reductions in exercise behavior and tumor progression in newly diagnosed glioblastoma (GBM) patients
In another Duke University Medical Center study, researchers worked with 68 newly diagnosed GBM patients with a KPS score ranging from 70 to 100. The participants completed the Modified Godin Leisure Questionnaire at six-month increments. This study reached the following conclusion:
Our observations of exercise behavior over time suggest that poorer baseline exercise behavior is associated with a disease progression within 6 months of chemoradiation completion in newly diagnosed GBM patients. Moreover, this exercise behavior continues to decline after progression. Based on these observations, a greater understanding of the role of physical functioning is merited in GBM patients.
Even though this study admits that more data needs to be collected, it points out the relationship between activity and longevity.
The Role of Exercise in Brain DNA Damage
A 2020 international study examined The Role of Exercise in Brain DNA Damage. While the findings shed some light on how exercise affects the brain, this study also calls for more research.
The DNA damage is a common feature of neurodegenerative illnesses and the ability to repair this damage is crucial for neuronal survival. Data from previous studies have revealed clear evidence that physical exercise induces profound genetic alterations that regulate synaptic and brain plasticity. Furthermore, exercise may be fundamental in the control of the neurological disease; however, a better understanding of the effects of different types of exercise is required. Future studies in animals and humans may address these gaps in knowledge and contribute to understanding the effects of physical exercise on the brain.
Now that you know that your brain health is dependent on activity, are you more inclined to start moving?
Physical Activity and Exercise in Adults Diagnosed with Primary Brain Cancer: A Systemic Review
More facts are in the April 28, 2021, edition of the Journal of Neuro-Oncology. In the article Physical Activity and Exercise in Adults Diagnosed with Primary Brain Cancer: A Systematic review, the researchers analyzed fifteen peer-reviewed studies focusing on primary brain cancer, physical activity, and exercise. These studies were published prior to May 1, 2020. One of the noted shortcomings of this review was that glioblastoma patients tend to be “insufficiently active from diagnosis through to post-treatment.” Thus, the people included in these small studies experienced more active lifestyles than other GBM patients.
While advances in treatments such as a combined radiotherapy and chemotherapy (temozolomide) have contributed to improvements in survival , treatment-related complications and side-effects that impact physical, cognitive and psychosocial functioning remain throughout all phases of survivorship (from cancer diagnosis until end-of-life) [5,6,7,8].
The results from this small cohort indicate that exercise can improve symptoms, aerobic capacity, and body composition. However, the data is limited. Like the previously mentioned studies, the participants were in better overall shape compared to most GBM patients. Despite the small number of studies, the article encourages GBM patients to be as active as possible but simultaneously acknowledges that guidelines should be designed to accommodate individual needs.
In line with exercise prescription guidelines, a tailored, individualized approach to exercise prescription which accommodates fluctuating symptoms and unique circumstances (e.g. stage of diseases, functional capacity, treatment toxicity) that present alongside brain cancer is necessary [45,46,47].
Daily Lifestyle Modifications to Improve Quality of Life and Survival in Glioblastoma: A Review
Daily Lifestyle Modifications to Improve Quality of Life and Survival in Glioblastoma: A Review was published in Brain Science (March 21, 2021). This study performed by the Division of Neurosurgery at the University of Missouri School of Medicine reviewed recent laboratory animal studies, human studies, and ongoing clinical trials to determine if there are any effective non-surgical and patient-controlled methods.
Some animal studies illustrate the benefits of exercise when performed in conjunction with temozolomide. While human results are limited, the authors did share a few studies outlining the positive effects of activity.
In humans with glioma, implementation of a regimented exercise program improves motor function and cognitive functioning and reduces depression, anxiety, headaches, fatigue, and communication deficits compared to those who do not participate [38,39,40]. One study even showed that exercise behavior in patients with grades III and IV glioma was an independent predictor of survival, with those participating in >9 metabolic-equivalent hours/week having a median survival of 7.8 months longer than those participating in <9 metabolic-equivalent hours/week of exercise .
(Endnotes 38 and 40 reference two different 2016 studies. Endnote 39 refers to a 2020 study and endnote 41 pertains to the Duke University Medical Center study. Thirty minutes of brisk walking for five days a week is ≥ 9 metabolic equivalent.)
The article alerted me to two studies that will conclude later this year. Canadian Clinical Trial (NCT03390569) examining Exercise in Patients with Glioblastoma and the Glioma and Exercising (NCT03775369) at the University Hospital in Basel, Switzerland. I look forward to seeing the outcomes of these studies.
The researchers at the University of Missouri concluded,
In glioblastoma patients who are motivated to make lifestyle adjustments to improve their outcomes, dietary restriction of sugar and caloric intake in particular seems to have the most promise, with exercise, vitamin supplementation, and cannabis use showing potential benefits as well.
Exercise Improves Health-Related Quality of Life Sleep and Fatigue Domains in High- and Low-Grade Glioma Patients
I located this study published in September 2021. In Exercise Improves Health-Related Quality of Life Sleep and Fatigue Domains in High- and Low-Grade Glioma Patients, the researchers surveyed thirty-eight patients from one tertiary care institution by using telephone surveys.
The results state that
glioma patients with low tolerance to exercise had more sleep disturbances and greater fatigue than glioma patients with high tolerance to exercise. Furthermore, exercise tolerance in the adult glioma population does not appear to impact plasma BDNF secretion.
(BDNF is the abbreviation for brain-derived neurotrophic factor. It is a neurotrophin protein that supports neuronal growth and survival)
Daily activity offers tremendous benefits that cannot be replicated. Trying to find the right formula may be tricky, especially when a GBM patient led a sedentary pre-diagnosis lifestyle. The simplest way to start is by adding a daily walk. The length of the walk, as well as the pace, will be dependent on one’s strength and stamina. If necessary, start out slow and then gradually increase the duration and the speed. GBM patients with a higher KPS score can consider resistance training and/or participating in their favorite sports.
In addition to our daily walks, Ira does resistance training and full body workouts a few times a week. Whenever possible, we hike in the mountains, swim, snowshoe, downhill ski, go horseback riding. and also try new activities. In August, we both participated in an aerial yoga class. Even though this was outside my comfort zone, I followed Ira’s lead. By incorporating active, daily lifestyle habits, GBM patients can become more empowered to embrace life and defeat glio. #embracelifedefeatglio
Has your opinion about the importance of an active lifestyle changed after reading this story? Please leave a comment below.
Are you looking for ways to improve the quality of life during chemo and radiation? Check out these useful cookbooks filled with easy to follow healthy recipes.
Anyone who is looking for ways to beat the odds, should read this.
To bring attention to Glioblastoma, Sandy highlighted the ability to embrace life after a glio diagnosis.
Do you avoid exercising? Here are a few tips to help you get motivated.
To celebrate their 46th wedding anniversary and life, Sandy and Ira explored Kauai.
A late spring getaway took us to romantic and picturesque Captiva Island.
Yes, you can maintain a healthy diet while traveling.
Can you believe that until spring 2021, I had never skied at Vail? Thanks to a media trip hosted by the Grand Hyatt Vail, Ira and I explored this amazing terrain. Our youngest son, Jordan, led the way to their famous back bowls.
While Ira was undergoing chemo, we went horseback riding, snowshoeing, and learned archery at Vista Verde Ranch, a luxury dude ranch near Steamboat, Colorado.
Glioblastoma and chemo did not stop Ira from skiing more than 20 times with glioblastoma.
Sandra Bornstein is the author of May This Be the Best Year of Your Life. Sandra’s memoir highlights her living and teaching adventure in Bangalore, India. She was a licensed Colorado teacher who taught K-12 students in the United States and abroad. Sandra also taught college-level courses at Front Range Community College and the University of Colorado-Boulder.
In addition to reviewing books and interviewing authors, Sandra is an award-winning author and lifestyle and travel journalist. Many of Sandra’s travel stories appear on the For Readers Page. To follow Sandra’s travel adventures, visit TheTravelingBornsteins website.