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1 신체활동과체력이암치료와생존에미치는효과 김연수 서울대학교체육교육과

2 CONTENTS PART Ⅰ 암발생률및생존율 PART Ⅱ 암경험자의신체활동량 PART Ⅲ 암과신체활동효과 PART Ⅳ 암과신체활동 ( 체력 ) 연구사례 PART Ⅴ 암경험자의신체활동지침

3 모든암연도별연령표준화발생률추이 만명당발생률 남자남녀전체여자 연령표준화발생률 : 우리나라 2000 년주민등록연앙인구를표준인구로사용 암경험자 : 1,234,879 명 / 41 명당 1 명암경험자 [ 국가암등록통계, 중앙암등록사업, 2012]

4 2012 년암생존율 / 5 년상대생존율 [ 모든암의 5 년상대생존율 : ] % 100 '93-'95 '96-'00 '01-'05 '06-'10 '08-' 전체남자여자 [ 국가암등록통계, 중앙암등록사업, 2012]

5 암경험자의사망원인 10 년이상암생존자사망원인 4 자살 6.2% 5 암 60.7% 1 심혈관질환 6.8% 3 당뇨 7.8% 뇌혈관질환 18.5% 2 [ 국가암등록통계, 중앙암등록사업, 2010] 20 년이상암생존자 62.7% 는암외질환으로사망 [Yi ming, AACR, 2012]

6 암경험자의신체활동률 Yonsei Univ. thesis, 2015 Physical Activity among Patients with High Risk of Cancer and Cancer Survivors Chae JS Total 503 patients who are at high risk of cancer(n=23) and cancer survivors(n=480) Age : 59.01±11.77 years Physical activity levels measured using the GPAQ questionnaire

7 암경험자의신체활동률 Type of Physical activity (MET-hour/week) Gastric(n=175) Colorectal(n=191) Breast(n=47) Gynecologic(n=20) Other Cancer(n=47) Work Vigorous 1.01± ± ± ± ±0.00 Moderate 13.18± ± ± ± ±16.35 Total work 14.19± ± ± ± ±16.35 Transportation 10.23± ± ± ± ±12.71 Leisure time Vigorous 6.23± ± ± ± ±22.65 Moderate 4.64± ± ± ± ±5.61 Total leisure time 10.87± ± ± ± ±22.55 Walking 5.70± ± ± ± ±7.68 Total physical activity 35.29± ± ± ± ±34.34 Sedentary time(min/da y) ± ± ± ± ± 암경험자 975 명운동강도를조사한결과, 격렬한신체활동 9.4%, 중등도신체활동 43.5%, 저강도신체활동 65.5 참여하는것과맥을같이함 [Blaney et al., psycho-oncology, 2013]

8 Health Behavior in Cancer Survivors(KNHANES Ⅳ, ) Cancer survivors Non-cancer chronic disease controls Non-cancer non-chronic disease controls p value n %(SE) n %(SE) n %(SE) Smoking status Never (2.55) 3, (0.74) 6, (0.56) <.001 Former (2.46) 1, (0.75) 1, (0.43) Current (1.58) 1, (0.69) 2, (0.53) OR(95%CI) a (1.26 to 2.90) 2.57(1.70 to 3.90) Heavy drinking No (1.57) 5, (0.55) 9, (0.44) <.001 Yes (1.57) (0.55) 1, (0.44) OR(95%CI) a (0.84 to 2.42) 1.26(0.74 to 2.15) Physical activity No (2.35) 4, (0.78) 8, (0.57).114 Yes (2.35) 1, (0.78) 2, (0.57) OR(95%CI) a (0.65 to 1.08) 0.84(0.65 to 1.08) a Adjusted for age, sex, education, marital status [Oh etl al., JJCO 2013]

9 암경험자의신체활동장벽 Treatment and disease-related physical and psychological side effects are very common Perceived physical activity barriers_multiple response 47.4% 42.9% 34.8% 19.2% 18.5% FATIGUE Lack of strength PAIN Poor condition Lack of time [Park et al., 2015]

10 암경험자의신체활동관련요인 Correlate and determinant [ + ] Health status(subjective, objective) Self-efficacy History of physical activity Intention to exercise Correlate but not-determinant [ - ] Age Overweight Perceived efforts Physical Activity Socioeconomic factors Marital status inconclusive Income, Education Occupation Determinant and inconclusive correlation Physical and psychological outcome Action planning Stress -? +? +? [Bauman et al., 2012; Kaewthumanukul & Brown, 2006]

11 의사권고가암환자운동습관바꿔 Cancer, 2015 The effect of oncologists exercise recommendations on the level of exercise and quality of life in survivors of breast and colorectal cance : A randomized controlled trial Park JH, Lee J, Oh, M, Park H, Chae J, Kim DI, Lee MK, Yoon YJ, Lee CW, Park S, Jeon JY et al. 대상 : 유방암, 대장암환자총 162 명 그룹 1 그룹 2 대조군 : 운동권고하지않음 운동의중요성설명 주당 40분운동 한국의암전문의중 40% 만이운동을권고한경험이있음 그룹 3 운동의중요성설명 + 운동상담 15분 주당 87분운동 운동을권고하지못하는가장큰이유는? 진료시간이부족해서 (24%), 어떤운동을권고해야할지몰라서 (21%) 등

12 Physical Activity Across the Cancer Experience Framework Pre Diagnosis Post Diagnosis Prevention Detection Treatment Preparation Treatment Effectiveness Recovery Rehabilitation Disease Prevention Health Promotion Palliation Survival Prescreening Screening Pretreatment Treatment Survivorship End of Life [Courneya & Friedenreich, Sem Oncol Nurs, 2007]

13 Hypothesized mechanisms linking physical activity to cancer

14 Physical Activity Benefits across the Cancer Continuum Stage Improves Reduces Prevention [Screening] Immune surveillance Anti-inflammatory effect Insulin sensitivity Maintains normal growth factor production and activation DNA repair capacity Range of motion/flexibility Obesity and central adiposity Chronic inflammation Oxidative stress Bowel transit time Detection [Pre-treatment] Functional capacity - musculoskeletal, cardiorespiratory function Post-operative outcomes - health related quality of life Psychological benefits, opportunity to change health behavior Range of motion post-treatment Post-operative length of stay Stress, anxiety Post-operative complications - muscle atrophy - cardiopulmonary fitness

15 Physical Activity Benefits across the Cancer Continuum Stage Improves Reduces During Treatment Quality of life Maintains functional capacity Sleep Immune response Nausea Pain Fatigue Appetite Swelling Range of motion Self-esteem Muscle atrophy Balance Shortness of breath Body composition Risk of depression Survivorship Quality of life Length of survival Self-esteem and happiness Functional capacity -musculoskeletal strength, cardiopulmonary efficiency Energy levels Risk of recurrence Mortality Weight gain Cancer-related fatigue and pain Anxiety and depression Palliative Care Quality of life Circulatory function Strength Autonomy and indepencence Stress and Anxiety Fatigue Muscle atrophy Lymphedema

16 암과신체활동연구현황 PubMed Publication dates : 2005 to 2015 cancer 893 studies Breast 298 studies Colon 24 studies Lung 37 studies Prostate 60 studies Ovarian 34 studies Gastric 6 studies Thyroid 5 studies

17 암시기별신체활동효과 J Caner Surviv, 2010 An update of controlled physical activity trials in cancer survivors : a systematic review and meta-analys Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH Database : MedLine / 2005 to 2010 Keywords : exercise(or physical activity) and cancer randomized controlled trial, intervention studies, clinical tria Identify : 66 studies / 380 studies

18 Physical Activity Intervention_During treatment [Intervention length] 9% 6% [Activity frequency] 9% 6% 33% 21% 52% 64% [Activity mode] 6% 6% [Activity intensity] 21% 18% 88% 61%

19 Physical Activity Intervention_Post treatment [Intervention length] 10% [Activity frequency] 8% 18% 18% 45% 45% 55% [Activity mode] 14% 10% [Activity intensity] 35% 6% 76% 59%

20 Evidence of positive effects by during treatment Outcome Trial pooled Effect size 95% CI Heterogeneity Physical activity level to 0.61 Low Aerobic Fitness to 0.57 Moderate Upper body strength to 0.65 Moderate Lower body strength to 0.41 Moderate Body weight to Moderate % Body fat to Low Functoinal quality of life to 0.54 Low Anxiety to Low Self-esteem to 0.46 Low [Speck et al., J Cancer Surviv, 2010]

21 Evidence of positive effects by post treatment Outcome Trials pooled Effect size 95% CI Heterogeneity Physical activity level to 0.54 Moderate Aerobic fitness to 0.59 Moderate Upper body strength to 1.32 Low Lower body strength to 1.68 High Body weight to 0.06 Low Body fat percentage to 0.05 Low Overall quality of life to 0.54 High Fatigue to High Depression to 0.05 Moderate Anxiety to 0.03 Moderate IGF to Low Symptoms / side effects to Low [Speck et al., J Cancer Surviv, 2010]

22 PA and incidence of specific cancers CANEP, 2015 Prevention European code against Cancer 4 th Edition : Physical activity and cancer Michael Leitzmann, Hilary Powers, Annie SA, Chiara Scoccianti, Franco Berrino et al. Cancer type Number of studies Relative risk 95% CI Substantial evidence Colon to 0.80 Endometrial to 0.90 Breast to 0.91 Weak or moderate evidence Prostate to 0.98 Stomach to 1.06 Ovary to 1.01 Kidney to 0.99 Lung to 0.81

23 Leisure time physical activity and cancer risk BJSM, 2015 Prevention Leisure time physical activity and cancer risk : evaluation of the WHO s recommendation based on 126 high-quality epidemiological stud Li Lie, Yun Shi, Tingting Li, Qin Qin, Jiyun Yin, Shuo Pang, Shaofa Nie, Sheng Wei Data base : Medline and Web of Science / until 2014 Methods : MOOSE(Meta-analysis of Observational Studies in Epidemiology) guidelines Keywords : Exercise(OR physical activity OR walking) AND cancer(or neoplasm OR tum

24 Dose-response analysis of RR for cancer in relation to LTPA 구분 Number of comparison s Overall Sex Leisure time physical activity(met-h/week) (0.91 to 0.95) 0.91(0.88 to 0.93) 0.90(0.88 to 0.91) 0.89(0.87 to 0.92) 0.89(0.85 to 0.94) P for nonlinearity <.001 Male (0.92 to 1.02) 0.94(0.90 to 0.98) 0.92(0.88 to 0.97) 0.93(0.87 to 1.02) -.25 Female (0.93 to 0.98) 0.95(0.92 to 0.97) 0.93(0.90 to 0.95) 0.89(0.85 to 0.93) 0.86(0.79 to 0.93).10 Cancer types Breast cancer (0.94 to 0.99) 0.95(0.93 to 0.98) 0.93(0.90 to 0.96) 0.90(0.86 to 0.95) 0.88(0.81 to 0.95).41 Colorectal cancer (0.85 to 1.00) 0.85(0.79 to 0.92) 0.86(0.80 to 0.94) Endometrial cancer (0.93 to 1.15) 0.97(0.87 to 1.08) 0.91(0.81 to 1.02) Pancreatic cancer (0.77 to 1.14) 0.90(0.73 to 1.09) 0.87(0.73 to 1.05) 0.88(0.69 to 1.12) -.72 Ovarian (0.75 to 0.91(0.76 to 0.99(0.81 to 0.97(0.76 to 0.91(0.68 to.28

25 MET(metabolic equivalent, 대사당량 ) 활동의강도및에너지소비량의지표 1MET (equals 3.5 ml/kg/min) 는휴식하는동안의산소소비량으로 이를통하여활동을할때이에비해얼마나더산소를소비하는가를통하여 운동강도를알수있다. 저강도 : 3 METs 미만, 노래를부를수있다 MET 중강도 : METs, 말은하지만노래를부르지는못한다 고강도 : 6 METs 이상, 문장을이어서말하기가어렵다 25

26 신체활동강도목록 신체활동평가를위한한국어판신체활동목록과컴퓨터프로그램개발 박재현등한국체육학회지 44 권 2 호 pp

27 Colon Transit Time and Physical Activity J Neurogastroenterol Motil 2015 Prevention Colon Transit Time According to Physical Activity Level in Adult Song BK, Cho KO, Oh JW, Kim YS Participants : male(n=24), female(n=25) Age : 37.4±8.3years Physical activity levels measured using accelerometer Male(n=24) Female(n=25) LPAG MPAG HPAG Total LPAG MPAG HPAG Total RCTT(hr) 4.0± ± ± ±5.7* 10.4± ±15.2 * 2.4± ±12.7 LCTT(hr) 0.8± ± ± ± ± ± ± ±3.1 RSCTT(hr) 4.4± ± ± ±7.1* 21.8± ± ±7.0* 14.0± ± ±22.1 RCTT : right colon transit time, LCTT : left colon transit time, RSCTT : Recto-sigmoid colon transit tim TCTT(hr) 9.2± ± ± ±9.3* 2.8±3.4* 25.8±24.1 TCTT : total colon transit time, * : <.05 * *

28 Gastrointestinal Motility and Aerobic Exercise World J Gastroenterol, 2011 Prevention Aerobic Exercise improves gastrointestinal motility in psychiatric inpatients Song BK, Cho KO, Oh JW, Kim YS Participants : exercise group(n=23), control group(n=19) Intervention : aerobic exercise program vs. ordinary daily activities Aerobic exercise program Frequency 60min, 3times/week, 12weeks Exercise program Warming-up Stretching(10min) 1-4week 5-8week 9-12week Main exercise 50%HRR 60%HRR 70%HRR Walking & Running(40min) Cooling-down Stretching(10min)

29 Effects of a 12-week aerobic exercise program on segmental and total colon transit time in psychiatric inpatients A : right colon, B : left colon, C : recto-sigmoid colon, D : total colon, b : p<.01, baseline to study-end change in total colon transit time for Exercise vs. Control group

30 CardiorespiratoryFitness(CRF) and Risk of Incident Cancer JAMA Oncol, 2015 Prevention Midlife Cardiorespiratory Fitness, Incident Cancer, and Surviva After Cancer in Men Lakoski SG, Willis BL, Barlow CE, Leonard D, Gao A, DeFina LF, Jones LW et al. Cance r Events, No. Low CRF Hazard Ratio(95% CI) Moderate High CRF CRF 1-MET Increase Lung ( ) 0.68) 0.45( ( ) Colon ( ) 0.87) 0.56( ( ) Prosta te 1, ( ) 1.46) 1.22( ( ) Adjusted for age, visit date, BMI, smoking

31 Association between CRF and Late-life Incident cancer and Cause-Specific Mortality Survival Health Status Events, No. Hazard Ratio(95% CI) Low CRF Moderate CRF High CRF 1-MET Increase Healthy to Cancer diagnosis 1, ( ) 1.07( ) 1.01( ) Cancer to cancer-related death ( ) 0.68( ) 0.90( ) Cancer to CVD-related death ( ) 0.32( ) 0.75( ) Healthy to Cancer-related death ( ) 0.66( ) 0.96( ) Healthy to CVD-related death ( ) 0.38( ) 0.84( ) Healthy was defined as having no observed incident cancer or CVD at baseline Adjusted for age, visit date, BMI, smoking

32 Exercise in Men Receiving ADT for Prostate Cancer Treatment 가정기반복합운동프로그램이 ADT 를받는전립선암환자의 신체활동량, 체력, 그리고삶의질에미치는영향 김연수, 임정준, 문홍상, 최홍용 Participants : 호르몬차단요법 (ADT) 를받는전립선암환자 - randomly assigned 가정기반복합운동프로그램그룹 (n=20), usual care(n=9), Intervention : total 12weeks, 주 1 회 supervised by exercise specialists, 운동처방과상담 가정기반운동 : 만보계, 탄력밴드, 운동일지, 문자메세지주 2 회 - 근력운동 : 탄력밴드프로그램교육후 3 times / week, 2set, 8-12reps of 10 different exercise - 유산소운동 : 1 일 30 분이상 5 times/week 걷기, 만보계활용 Primary outcome : 신체계측, 체력, 신체활동량, 삶의질, 피로도, 우울증, 낙상두려움, 혈액변인

33 Physical activity program 가정기반신체활동프로그램 그룹종류강도시간, 빈도사용도구비고 실험군 유산소운동운동자각도 11~13 근력운동운동자각도 12~15 1회 30분주 5회이상 1회 30분주 3회이상 만보계 저항성밴드 걷기위주점진적증가대근육위주점진적증가 통제군교육 - 2 회 - 스트레칭, 신체활동 교육

34 Physical activity program 주 1 회그룹신체활동프로그램 ( 실험군 ) 스트레칭을통한 Warm-up 난이도별 24 가지체중부하운동과 22 가지의밴드운동 (0-6 주 : Green, 7-12 주 : Blue) 유산소운동은걷기, 조깅, 싸이클등으로환자선호에따라일상생활에서의실천권고

35 Physical activity program 신체활동프로그램 ( 실험군 )

36 Physical activity program 신체활동프로그램 ( 실험군 ) 월 2회신체활동프로그램교육 한주동안의신체활동기록지분석및운동처방 주 2회신체활동증진을위한문자발송

37 Physical activity program 신체활동프로그램 ( 통제군 ) 스트레칭및신체활동교육 2 회제공 월 2 회안부문자발송

38 Measurements 측정항목 구분 측정항목 측정도구 신체계측 신장, 체중, 혈압, 허벅지 / 허리둘레, 신체조성 신장계, 혈압계, 줄자, Inbody 체력악력, 하지근력, Senior Fitness Test 악력계, MMT, 줄자, 초시계 설문지 삶의질 우울증 낙상두려움 FACT-Prostate. FACIT-Fatigue Beck Depression Index Korean Fall Efficacy Scale -International 혈액변인 PSA, TC, HDL-C, LDL-C, TG, Glucose -

39 Anthropometric characteristics < 표. 1> 인구통계학적자료 Variable Con G Mean ± SD(n=8) Ex G mean ± SD(n=11) P value Age (yrs) 78.38± ± Height (cm) ± ± Weight (kg) 64.41± ± Lean body mass (kg) 24.58± ± Body fat mass (kg) 23.43± ± Waist circumference (cm) 89.72± ± Thigh circumference (cm) 48.15± ± PSA (ng/ml) 1.35± ± ADT duration (month) 43.66± ± Gleason score 7.63± ± Prostate Specific Antigen: PSA Androgen Deprivation Therapy: ADT Values are Mean±SD, *p<.05, **p<.01

40 Results < 표. 2> 12 주간의신체활동프로그램이신체계측에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group Weight (kg) Lean body mass (kg) Body fat mass (kg) BMI (kg/m²) Waist circumference (cm) Thigh circumference (cm) SBP (mmhg) DBP (mmhg) Con(n=8) 64.41± ±7.25 Ex(n=11) 65.38± ±7.85 Con(n=8) 23.43± ±3.08 Ex(n=11) 25.31± ±3.61 Con(n=8) 21.03± ±7.18 Ex(n=11) 19.06± ±5.42 Con(n=8) 24.58± ±2.62 Ex(n=11) 24.55± ±2.46 Con(n=8) 89.72± ±5.45 Ex(n=11) 89.64± ±5.45 Con(n=8) 48.15± ±3.11 Ex(n=11) 50.35± ±3.47 Con(n=8) ± ±15.58 Ex(n=11) ± ±19.68 Con(n=8) 73.75± ±8.84 Ex(n=11) 70.73± ± ** Body Mass Index: BMI, Systolic Blood Pressure: SBP Diastolic Blood Pressure: DBP Values are Mean±SD, *p<.05, **p<.01

41 Results < 표. 3> 12 주간의신체활동프로그램이체력에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group Grip Strength (kg) Chair stand (count/30 sec) Arm curl (count/30 sec) Chair sit and reach (cm) Back scratch (cm) Up and go (sec) Single leg stance (sec) 2-min step (count/2 min) Con(n=8) 26.45± ±4.49 Ex(n=11) 30.08± ± * Con(n=8) 21.13± ±6.55 Ex(n=11) 23.00± ± <.001** Con(n=8) 25.87± ±5.92 Ex(n=11) 28.1± ± <.001** Con(n=8) 0.88± ±11.91 Ex(n=11) 7.50± ± Con(n=8) ± ±10.74 Ex(n=11) ± ± Con(n=8) 5.93± ±1.05 Ex(n=11) 6.71± ± ** Con(n=8) 6.41± ± Ex(n=11) 19.43± ±21.17 Con(n=8) ± ±45.71 Ex(n=11) ± ± ** Values are Mean±SD, *p<.05, **p<.01

42 Results < 표. 4> 12 주간의신체활동프로그램이각근력에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group Left knee extensor (Nm/kg) Con(n=8) ± ±28.57 Ex(n=11) ± ± ** Left knee flexor (Nm/kg) Con(n=8) 99.40± ±13.67 Ex(n=11) ± ± <.001** Right knee extensor (Nm/kg) Con(n=8) ± ±23.06 Ex(n=11) ± ± * Right knee flexor (Nm/kg) Con(n=8) ± ±11 Ex(n=11) ± ± <.001** Values are Mean±SD, *p<.05, **p<.01

43 Results < 표. 5> 12 주간신체활동프로그램이신체활동정도에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group TEE (kcal/day) Step (count/day) Light activity (min/day) MTV (min/day) Sedentary ratio (%/day) Sedentary break (count/day) Con(n=7) ± ± Ex(n=11) ± ± Con(n=7) ± ± Ex(n=11) ± ± Con(n=7) ± ±79.02 Ex(n=11) ± ±67.44 Con(n=7) 36.13± ±25.54 Ex(n=11) 30.49± ± Con(n=7) 65.96± ±10.32 Ex(n=11) 68.56± ±5.36 Con(n=7) 17.62± ±6.71 Ex(n=11) 18.69± ± * * Total Energy Expenditure: TEE Moderate To Vigorous: MTV Values are Mean±SD, *p<.05, **p<.01

44 Results < 표. 6> 12 주간신체활동프로그램이혈액변인에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group PSA TC HDL-C LDL-C TG Glucose Con(n=8) 6.71± ±6.09 Ex(n=10) 1.49± ±2.57 Con(n=8) ± ±38.61 Ex(n=11) ± ±38.36 Con(n=6) 46.83± ±13.47 Ex(n=7) 49.14± ±11.26 Con(n=6) 92.33± ±24.52 Ex(n=7) ± ±33.11 Con(n=5) ± ±32.58 Ex(n=7) ± ±39.12 Con(n=8) ± ±61.25 Ex(n=11) ± ± * Prostate Specific Antigen: PSA, Total Cholesterol: TC, Triglycerides: TG High Density Lipoprotein: HDL-C, Low Density Lipoprotein: LDL-C Values are Mean±SD, *p<.05, **p<.01

45 Results <Table. 7> 12 주간신체활동프로그램이삶의질에미치는영향 Variable Group Pre Mean±SD Post Mean±SD F Time*Group FACT-P Con(n=8) ± ±12.23 Ex(n=11) 95.36± ± <.001** FACIT-F Con(n=8) 41.12± ±8.60 Ex(n=11) 28.27± ± * BDI Con(n=8) 10.50± ±8.27 Ex(n=11) 13.63± ± * KFES-I Con(n=8) 24.75± ±11.26 Ex(n=11) 24.09± ± * Functional Assessment of Cancer Therapy-Prostate: FACT-P Functional Assessment of chronic Illness Therapy-Fatigue: FACT-F Beck Depression Inventory: BDI, Korean Fall Efficacy Scale-International: KFES-I Values are Mean±SD, *p<.05, **p<.01

46 summary PA program minimize ADT syndrome

47 신체활동연구사례 _ 대장암 J Clin Oncol, 2006 Recurrence Impact of physical activity on cancer recurrence and survival in patients with stage Ⅲ colon cancer : finding from CALGB Meyerhardt JA, Heseltine D, Niedzwiecki D, Hollis D, Satiz LB, Mayer RJ, Fuchs CS et al. Sample size for physical activity(n=832) in the Cancer and Leukemia Group B(CALGB) Physical activity assessment : During the past 2 months, what was your average time per spent at each of the following recreational activities? - walking, bicycling, swimming, racket sports, other aerobic exer Follow-up period : 2.7 years

48 Impact of PA on Colon Cancer Recurrence and Mortality Outcome Cancer recurrence or death from any cause Total MET-hours per week < p for HR(95%CI) HR(95%CI) HR(95%CI) HR(95%CI) HR(95%CI) trend No. of events Unadjusted ( ) 0.89( ) 0.51( ) 0.58( ).01 Adjusted ( ) 0.90( ) 0.51( ) 0.55( ).01 Cancer recurrence No. of events Unadjusted ( ) 0.87( ) 0.50(0.26) 0.63( ).03 Adjusted ( ) 0.89( ) 0.51( ) 0.60( ).03 Overall mortality No. of events Unadjusted ( ) 0.75( ) 0.79( ) 0.50( ).05 Adjusted ( ) 0.71( ) 0.71( ) 0.37( ).01 Participation of PA over 18 MET-h/week would prevent recurrence of cancer by about 50%, Adjusted for sex, age, baseline performance status, weight change, BMI however, more than 27 MET-h/week exercise does not warrant better outcome.

49 Physical Activity and Breast Cancer JAMA, 2005 Recurrence Physical Activity and Survival After Breast Cancer Diagnosis Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA Total (n=2,987) <3 (n=959) Physical activity after diagnosis, MET-h/week (n=862) (n=335) (n=428) Total deaths (n=403) p for trend Age-adjusted RR(95%CI) ( ) 0.53( ) 0.56( ) 0.67( ).004 Multivariable-adjusted RR(95%CI) ( ) 0.59( ) 0.56( ) 0.65( ).003 Breast cancer deaths Age-adjusted RR(95%CI) ( ) 0.47( ) 0.60( ) 0.64( ).01 Multivariable-adjusted RR(95%CI) ( ) 0.50( ) 0.56( ) 0.60( ).004 Recurrence Age-adjusted RR(95%CI) ( ) 0.53( ) 0.66( ) 0.76( ).05 Multivariable-adjusted RR(95%CI) Breast cancer survival benefit from more than 9 MET-h per week physical activity. Adjusted for age, smoking status, BMI, menopausal status, hormone therapy use, age at first birth and parity, disease stage ( ) 0.57( ) 0.66( ) 0.74( ).05

50 심폐체력연구사례 _ 유방암 MSSE, 2009 Survival A prospective study of cardiorespiratory fitness and breast cancer mortality Peel JB, Sui X, Adams SA, Hebert JR, Hardin JW, Blair SN Participants : Age 43.0±10.5 years, Mean maximal METs 9.5 ± 2.2, Total n=14,811

51 심폐체력연구사례 _ 폐암 CANCER, 2010 Survival Peak oxygen consumption and long-term all-cause mortality in nonsmall cell lung cancer Jones LW, Watson D, Herndon JE, Eves ND, Haithcock BE, Loewen G, Kohman L Participants : stage Ⅰto ⅢA lung cancer(n=398) Age : 64 ± 9 years Determine VO 2peak : began cycling at 20W, workloads were increased 5 to 20W/min until volitional exhaustion or until a symptom limitation was achieved VO 2peak, ml/kg/min : 15.8 ± 0.43

52 Association between VO 2peak (ml/kg/min) and all-cause mortality VO 2paek (ml/kg/min) Analysis < >17.3 P trend All patients No. of events Median, mo 30.5( ) 42.7( ) 39.1( ) Unadjusted HR Reference 0.80( ) 0.74( ).0403 Adjusted HR Reference 0.79( ) 0.76( ).0837 Resected patents No. of events Median, mo 44.0( ) 43.9( ) 46.2( ) Unadjusted HR Reference 0.91( ) 0.84( ).2888 Adjusted HR Reference 0.88( ) 0.86( ).3937 Nonresected patients No. of events Median, mo 11.4( ) 23.1( ) 19.5( ) Unadjusted HR Reference 0.45( ) 0.57( ).0385 Adjusted HR Reference 0.34( ) 0.32( ).0015 Adjusted for age, sex, age, performance status

53 ACS, WCRF/AICR, ACSM 신체활동대한기본원칙 ACS WCRF/AICR ACSM [ 활동적인생활습관을가져라 ] 성인 : 일상적인활동에추가로하 루 활동을 최소 30 분이상중등도강도신체 주당 5 일이상유지 (45-60 분활동 [ 매일일상에서활동적이되어라 ] 매일하루최소 30 분이상중등도 강도신체활동유지 [ 비활동성을피하라 ] 수술이후최대한빨리정상적인 활동으로돌아가도록노력 권고 ) 어린이와청년 : 일주일에 5일이상하루최소 60분이 상 ACS : American Cancer Society WCRF : World Cancer 중등도 Research 강도신체활동 Fund 유 AICR : American Institute for Cancer Research ACSM : American College of Sports Medicine 지, 모니터앞의시간한 신체적적합성이향상된다면중등도활동 60분이상또는고강도활동 30분이상으로목표상향 TV 시청과같은정적인습관제 비수술적치료의도중 / 이후정상적인일상활동운동을최대한지속 유산소운동, 저항성운동, 유연성운동권장사항은일반인을위한가이드라인과동일 - 중강도 (150 분 / 주 ) 또는고강도 (75 분 / 주 ) 신

54 ACSM 암생존자를위한운동가이드라인근거수준분류 구분 유방암 ( 치료도중 ) 유방암 ( 치료이후 ) 전립선암 혈액암 (HSCT 도중 / 이후 ) 혈액암 (HSCT 하지않음 ) 안전성 A A A A 신체적적합성 A A A C B 근력 A A A C 신체조성 B B B QOL B B B C 피로 B B A C B 긴장 B B 신체적기능 A B 림프부종 A A : RCT 기반수준높은데이터 ; B : RCT 연구적거나, 규모가작고일관되지않은결과 ; C : uncontrolled, unrandomized, 그리고 / 또는관찰연구 ; D : 근거불충분 ; 빈칸 : 데이터자체불충분 HSCT(Hematopoietic stem cell transplantation)

55 암경험자의권장운동 유연성운동 스트레칭, 요가 관절가동범위를유지하거나늘리는동작 관절유연성, 통증감소 유산소운동 걷기, 달리기, 자전거타기 전신근육을규칙적으로움직여심폐기능회복 근력운동 체중부하운동, 저항밴드운동 암치료과정중소실된근육과근력회복 균형운동 하지근력단련 낙상위험감소 [Garber et al., MSSE, 2011; WHO, 2010]

56 10,000steps Fig.1 Steps/day scale schematic linked to time spent in MVPA

57 Physical Activity and Cancer Recommendations Stage Type Intensity Frequency Time Prevention Aerobic -Brisk walking Moderate-Vigorous Bouts of 10min more 150min per week -Cycling -Swimming Resistance 1 set of reps 2 times pre week Ensure 1-2 min rest -Free weights between each set -Elastic resistance bands Gradually work to Rest muscles at least 2 sets of reps one day between sessions Pre-treatment Aerobic Resistance Maintain 2 times per week For a duration that suits the unique need of the individual Flexibility

58 Physical Activity and Cancer Recommendations Stage Type Intensity Frequency Time During Treatment Aerobic Resistance Maintain As often as able For a duration that suits the unique need of the individual Flexibility -Gentle stretching Survivorship Aerobic -Brisk walking / Jogging -Cycling Moderate Vigorous 3-5 days per week 150min per week 75min per week -Swimming Resistance -Resistance -Free weights machines -Weight -Elastic resistance Bearing bands 1 set of reps Gradually work to 2 sets of reps 2-3 days per week Ensure 1-2 min rest between each set Flexibility -Stretching Target all muscle group Daily Hold each stretch for 30s repeat on opposite site

59 Physical Activity and Cancer Recommendations Stage Type Intensity Frequency Time Palliative Care Aerobic -Brisk walking / Jogging Light to moderate 1-2 times per week For a duration that suits the unique need of -Cycling the individual -Swimming -Yoga -Tai Chi Resistance 1-2 times per week For a duration that -Body weight suits the unique need of -Elastic bands the individual -Free weight Flexibility -Stretching -Range of motion activities Target all muscle group Daily Hold each stretch for 30s repeat on opposite site [ACSM s guidelines for exercise testing and prescription 9 th, 2014] [National comprehensive cancer network s physical activity survivorship guidelines, 2 [Bouillet T, Oncol Hematol, 2015] [Silver JK & Baima J, Am J Phys Med Rehabil, 2013]

60 ACSM Cancer Survivors Exercise Guidelines 구분유산소운동저항성운동유연성운동 Physical activity guideline for american;pag A 중등도운동 150분 / 주또는고강도운동 75분 / 주 주요근육군에대해최소중등도이상으로최소주당이틀이상의근력강화운동 다른신체활동을시행하는날주요근육군과건을함께스트레칭실시 유방암 PAGA와동일 골절발생위험성에유의 최소 16반복이상의낮은저항운동으로시작하여점진적증가 림프부종및저항성 PAGA와동일 상지 / 견관절병증에유의하여시행시요가도안전 대장암 PAGA와동일 장루를가진경우접촉운동전의사의승인권장 PAGA와동일 장루가있는경우낮은저항에서부터점차늘려서탈장을방지할수있도록함 PAGA와동일 장루가있는경우수영등접촉운동조정필요 성인혈액암 (no HSCT) PAGA 와동일 PAGA 와동일 PAGA 와동일 성인 HSCT 운동의면역효과를고려하여과도한운동은제한 골수이식환자의경우유산소운동보다저항성운동이더중요할수있음 PAGA 와동일 PAGA 와동일 전립선암 PAGA와동일 골절발생위험성에유의 근치적전립선절제술을받은경우골반저운동포함 PAGA 와동일 골절발생위험성에유의 부인과암으로인한 2 차적하지림프부종의 경우 부인과암 말초신경병증이있는경우자전거운동이체중 부하운동보다선호될수있음 저항운동의안전성에대한연구부족 PAGA와동일 림프절절제술또는림프절에방사선치료

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