A large body of work has shown a clear benefit of exercise in reducing the risk of cancer and improving quality of life. But does perception of the exercise experience as enjoyable, or at least palatable, affect adherence or outcomes?
A large body of work has shown a clear benefit of diet and exercise in reducing the risk of a first cancer, lowering the risk of recurrence and improving quality of life.
But does perception of the exercise experience as enjoyable, or at least palatable, affect adherence or outcomes? A new study investigated that question by turning its attention to dyadic exercise — exercise with another person — in both heterosexual and lesbian, gay, bisexual and transgender (LGBT) survivors and their caregivers.
Findings from this study of approximately 40 individuals who participated in a six-week program of walking and using gentle training with resistance bands at home were presented during the 2016 Annual Meeting of the American Society of Clinical Oncology (ASCO), a gathering of 30,000 oncology professionals in Chicago.
Could you give me some background about this study?
CURE spoke with Charles S. Kamen, the lead author on the study and an assistant professor in the Cancer Control unit in the Department of Surgery at the University of Rochester Medical Center, to gain insight into the study and his plans for future research.It's been a winding journey. I'm a clinical psychologist by training and my research has been focused on couples broadly, but I have a specific interest in same-sex couples.
This study looked at couples-based exercise, where we have the cancer survivor and the caregiver exercise together as a dyad, or a traditional exercise protocol, where we have the cancer survivor exercise alone and the caregiver did not change their behavior. That was my initial idea. I then expanded the concept to include LGBT survivors and their caregivers and heterosexual survivors and their caregivers.
What have you found so far?
My basic hypothesis is that, although some people like it, exercise is tough. When you tell people to exercise more, it's tough, but having someone else to do it with you makes the whole process more palatable. By having two people exercise together, I'm hoping to increase adherence to the exercise prescription. This is particularly important to LGBT survivors' caregivers, because they often are not acknowledged in oncology care — typical questions are: "Is this your brother or sister? Is this a friend?" The immediate assumption isn't that the person is a partner.I did a pilot study, where I collected data from 10 LGBT survivors and their caregivers and 10 heterosexual survivors and their caregivers. This was a very small study — there are no real conclusions we can draw from this. It looks like, though, compared to survivor-only exercise, exercising with a partner did significantly reduce reports of depression over the course of six weeks. This was true for survivors, but not caregivers. Caregivers were pretty much a flat line.
In the general population, how prevalent is depression among LGBT people?
What are the next steps in this area?
I thought the most important finding was that at baseline, LGBT survivors had a higher rate of depression than heterosexual survivors. After the six-week intervention, whether they exercised with a partner or not, their depression decreased and there was no difference between LGBT and heterosexual survivors post-intervention. This indicates to me that exercise may be a viable strategy for reducing health disparities for LGBT survivors.It's much higher, in general — between one-and-a-half to three times higher based on the study. My basic hypothesis is that cancer is stressful for everybody, and there is about a 40 percent rate of distress or depression in cancer survivors. If you're LGBT, you may have this chronic level of ongoing stress that can cause depression just from going about your daily life — worrying about people discriminating against you or worrying about coming out to a health care provider. Layer cancer on top of that and you'll have even more stress.I want to study specifically the LGBT population and learn about the mechanisms by which this intervention works. I would think that part of why dyadic exercise works is because you're supporting your partner — social support, helping to bolster their adherence to exercise — but my first study was so small I couldn't see any of those effects. I'm hoping my next study, of 70 people, will provide some answers. I also applied for a grant to recruit a heterosexual arm for the study.
What have you heard from some of the survivors on your first pilot study?
I think we just need more data on the experience of LGBT survivors in general, because we know almost nothing. We have some data on prevalence rates of cancer in LGBT populations, but we know very little empirically about the experience of an LGBT patient going through care. I'd like to actually back up and see if being LGBT affects cancer care long-term, if it affects outcomes after care and see what additional services and interventions are still needed to optimize care.I've heard a lot of different things. Even in a trial like this, adherence to exercise is a problem — I hear from people that it's hard to work exercise into their daily routine.
What about the effect of this exercise on the caregiver? Do you collect data on that?
I've heard some nice things about the dyadic component of my study, too. A male survivor told me that his partner is really bossy and will tell him what to do, but when they were exercising together, it was more like his partner and caregiver was coaching him — it was reinforcing. I heard from another same-sex couple who was together for 35 years and it wasn't until one partner was diagnosed with cancer that they decided to get married and legalize their relationship. I think that reinforces how important it is that there is legal recognition of same-sex relationships because it covers so many parts of life, up to and including a cancer diagnosis.Yes, I collected data from both the caregiver and the survivor. In the pilot study, the rate of depression was very low, so we didn't see much change. Dyadic exercise, though, makes the caregiver feel like they're part of the process and actually doing something, as opposed to just driving the patient to an oncology visit or sitting in the waiting room.
And it's a shared experience. It's shared from both sides. I've talked to survivors who are really concerned about their caregivers — even patients with stage 4 disease — who said, "I'm not worried about me, I've made my peace with the illness. I'm worried about my husband and my children." The caregiver, then, may say that of course they're worried about their partner because the partner is going through a terrible process.
If you look at the literature, there aren't many interventions that focus on both the survivor and the caregiver. My hope is that we can create a shared experience and make it active so they can take it home and do it every day if they want. There's no real disadvantage to walking every day and, in fact, you probably should.