Colorectal cancer is the second most prevalent within the UK, and incidence is increasing as the population ages and people adopt more sedentary lifestyles and risky health behaviours such as smoking and fatty diets but despite this, survival rates are increasing (NICE 2004, Slattery 2004, Ganz 2005, National Cancer Intelligence Network 2009).

Encouraging patients and those at risk of developing bowel cancer to adopt a healthier lifestyle is gaining more and more weight. A review by Slattery (2004) identifies the protective effect of physical activity against colorectal cancer, with the risk being reduced by 30-40% in more active adults. There also appears to be a ‘dose response’, with more intensive activities being associated with a bigger risk reduction, all though this is widely debated within the literature. Slattery (2004) does not discuss the selection criteria imposed on studies included in her review, which could influence the strength of the conclusions made.

There is also plenty of evidence supporting the use of exercise in the management of symptoms, for both colorectal survivors and cancer survivors in general. Courneya, Friedenreich et al (1999b) found that a mild increase in exercise frequency was associated with improved quality of life in colorectal cancers. However, a questionnaire response rate of only 42% was recorded, the main reason for non-response being lack of interest. This could indicate that only those who were regular exercisers responded, skewing the results. Despite these limitations, Peddle, Plotnikoff et al (2008), Blanchard, Courneya et al (2008) and Korstjens, May et al (2008) also note a better quality of life in cancer survivors who exercise. This is further supported by Lynch, Cerin et al (2008) who found that colorectal patients achieving 150 minutes of physical activity per week had an 18% higher quality of life score than those who reported none.

A randomised controlled trial by Courneya, Friedenreich et al (2003) comparing quality of life, fatigue, anxiety, depression and fitness outcomes in colorectal survivors who exercised with a control group, found that there was no difference in outcomes between the two. These findings were attributed to contamination as 52% of the control group reported exercising, and there was poor compliance in the intervention group. Another trial by May, Van Weert et al (2008) found that physical fitness was significantly increased with exercise, but unfortunately the sample included relatively few colorectal patients, making it unclear if similar results would be seen exclusively in colorectal patients.

Morey, Snyder et al (2009) compared a home-based diet and exercise intervention in older survivors, including those with colorectal cancer. Results indicate that those in the intervention group had clinically and statistically significant changes in physical functioning, quality of life and lower limb strength. This is supported by Mosher, Sloane et al (2009) who found that higher levels of exercise and healthier diets were associated with better quality of life scores in older survivors.

There is also convincing evidence that survivors who engage in regular physical activity have improved survival rates (Demark-Wahenfried and Jones 2008, Irwin 2009). Meyerhardt, Giovannucci et al (2006) found that greater post diagnosis physical activity was associated with a 50% decrease in colorectal cancer specific and overall mortality. Haydon, MacInnis et al (2006) concur with these conclusions, reporting that regular exercisers had a five year survival rate of 71% in comparison with non-exercisers, whose five year survival rate was 57%. However, activity levels were estimated based upon participant’s recall of their average weekly exercise levels over six months, which may have led to inaccuracies. Barbaric, Brookes et al (2010) report an increased survival rate in more active colorectal cancer survivors, but the studies included in their review were only of moderate quality, and the best protective effects were only seen in those with stage II-III cancers. No link was found between survival and activity levels prior to diagnosis, although Irwin (2009) suggest that patients who exercised more post diagnosis were more likely to have always adopted exercise behaviours, leading them to develop less aggressive forms of colon cancer, that had better prognoses.

Despite the evidence currently available, many colorectal cancer survivors are relatively inactive, their exercise levels being lower than the recommended guidelines for health benefits, indicating that although a cancer diagnosis may provide a ‘teachable moment’, where patients may be more susceptible to health promotion messages, this is not indicative of long term behaviour change. Cancer survivors access healthcare services much more frequently than the rest of the population, and they are at greater risk of additional co-morbidities, secondary malignancies and psychological problems, although the majority are unaware of these potential issues. This indicates that a physical activity intervention would have a positive impact on the prevention of co-morbidities and enhance self-management, and as it is relatively low cost, may also ease the burden on hospital services. The overall message to get more active is clear for those with and at risk of colorectal cancers; even if the specifics of how to do this are still becoming evident. It is up to us, as physiotherapists, to deliver these messages and the support patients need to help them reap the health and psychological benefits. (Ganz 2005, Bellizzi, Rowland et al 2005, Demark-Wahenfried 2006b, Spence, Heesch et al 2007, DOH 2007, Sabatino, Coates et al 2007, Stull, Snyder et al 2007, Demark-Wahenfried and Jones 2008, Blanchard, Courneya et al 2008,ACSM 2009, Morey, Snyder et al 2009, Irwin 2009, NCSI 2009, NCSI 2010b).

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