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Chapter 4

Regaining Function

Promoting and maintaining health

    Unpack this topic

    There is no one giant step that does it, it’s a lot of little steps. Peter A. Cohen

    You have completed treatment for cancer and are now in recovery. Starting your recovery process and having to deal with post-treatment side effects and symptoms is not easy—but you can overcome these challenges. And always know that you don’t have to do this alone. Getting back on track can be difficult at the beginning, but It is extremely important to plan a healthy lifestyle in order to regain function, maintain health and deal effectively with possible side effects.

    This chapter is for:

    • People interested in learning how a healthy lifestyle will help them feel better and heal better.
    • People interested in information on regaining function and developing a healthy lifestyle.

    This chapter will guide you through a self-evaluation, taking into account both your physical and emotional status. It will offer recommendations, tips and strategies for healthy living, as well as ideas about how to get started—so that you can create a plan to regain function that is designed specifically for you. This can be your first step towards a healthy and active lifestyle after cancer treatment.

    The cancer diagnosis and its treatment may have brought changes to many aspects of your life. Perhaps you became more attentive to your health and self-care, and decided to incorporate good health habits during treatment. Now is an excellent opportunity to pursue these habits. And, even more, you can inspire people around you to do the same! Rosana Faria, psychologist

    Section 1

    A lifestyle for a healthy everyday life

    You play the starring role in your own life. During treatment you were supported by your healthcare team who helped you make important decisions about treating your illness. Now you are the one who can take charge of choices for your health that will help you regain your function after treatment. Perhaps this means looking at adjusting or changing your lifestyle to give you the best chance at recovery, and to feel better and healthier. Or, perhaps this means learning how to take steps to regain the healthy lifestyle you had before treatment. Having a healthy lifestyle after cancer treatment affects how you will heal. It will help make you feel stronger, boost your immune system, reduce cancer-related fatigue and post-treatment side effects that you may experience. With healthy living, you will also be able to more effectively manage any stress and enjoy life more.

    Living healthy is based on three pillars of support: nutrition, physical activity, and emotional wellbeing. All three of these items affect your mental and physical health.

    Living healthy means:

    • Having good nutrition
    • Maintaining a healthy weight
    • Limiting or avoiding ‘junk food’
    • Limiting the consumption of alcohol
    • Avoiding tobacco products
    • Being physically active

    Your recovery process is unique to you. Your lifestyle adjustments should be looked at in the same way. Listening to your body will help you decide what goals you would like to set for yourself — then you can draw up a plan of action for changes that you would like to make in your everyday life. Having a plan with realistic goals for healthy living will help motivate you to continue until the changes eventually become a normal part of your daily routine. Remember that being active and having a healthy diet can help you restore your energy.

    The World Cancer Research Fund offers many recommendations for healthy living on its website, including the importance of nutrition, a healthy body weight and physical activity, and the relationship to the prevention of certain cancers: www.wcrf.org/int/research-we-fund/our-cancer-prevention-recommendations.

    Getting on track: Finding a new rhythm

    Perhaps being diagnosed with cancer and going through treatment has changed how you see life. Identifying your values for living your life—and creating realistic goals and working towards them—could be a helpful way for you to establish your rhythm and lifestyle after treatment.

    As you put your plan for wellbeing into action, think baby steps. Add new changes gradually and let your body get used to its new rhythm. For example, if you smoke, you may first just want to focus on the possibility of quitting, and take small progressive steps toward your goal of stopping smoking. Speak with your healthcare team or your pharmacist about smoking cessation programs and available resources. You can find information on smoking cessation programs in Chapter 4: Regaining function / Section 5: On your way to recovery / Heading: Smoking Cessation.

    If there are any other habits you would like to change, think of the easiest possible action you could take to move towards that goal.

    Evaluating yourself: Think about your feelings and emotions, diet and activities

    Evaluating how you feel now, your current diet, physical routines and activities, and your lifestyle in general, is a good place to begin in your transition from treatment to recovery. Changing a lifestyle, diet or an everyday routine can be very challenging—get as much support as you need from family, friends and professionals as you move forward. See the list of professional support resources in Chapter 4: Regaining function / Section 5: On your way to recovery for more information.

    When you evaluate your diet and daily activities (such as going to the grocery store, climbing stairs, going to work, driving, etc.), take into consideration your emotions around these things. Below are some examples of questions you can ask yourself. You may think of some others depending on your normal daily activities:

    • Does washing dishes tire you out?
    • Are you exhausted when you return home from shopping or work?
    • Do you take pleasure in sitting down for dinner?
    • Do you feel good or better after you have eaten a meal?

    You may have noticed that your body has changed in the course of treatment, and you may need to get to know it again to understand how it functions now. This will help you adjust your diet and activities to get the most benefits possible.

    Assess your fatigue and sleep problems

    Fatigue and sleep problems are very common after cancer treatment. These side effects can interfere with making lifestyle changes, especially if you feel overwhelmed. Understanding your cancer-related fatigue can help you manage your symptoms effectively. How many of the following situations are true for you?

    When I feel tired, overwhelmed and weak because of fatigue and sleep problems, I:

    • Have to stop what I enjoy doing.
    • Feel worried.
    • Snore loudly when I sleep.
    • Need more effort to do something I used to do easily.
    • Fall asleep during the day.
    • Have difficulties concentrating, making it difficult to work.
    • Feel these symptoms more than 3 times a week.

    If you answered ‘yes’ to most of these questions, or are concerned about your fatigue and quality of sleep in general, you may want to discuss these symptoms with your healthcare team. More information on fatigue and sleep problems can be found in Chapter 2: What to expect after treatment / Section 2: What are the possible side effects / Heading: Fatigue.

    We need to think . . . about what life is about, and what we can do during our life, what we can do better every day. José, recovering from follicular lymphoma, age 51

    Top tips

    • Evaluate your daily lifestyle. Think about the changes you would like to make and are capable of making at this time.
    • Start with small changes. Even something as basic as sitting or standing up straight—or buying a new vegetable or fruit every time you are at the grocery store—counts as a small change!
    • Listen to your body. Accept the limits that it may have right now, and move toward steadily increasing your activity level.
    • Respect your pace and acknowledge your accomplishments.
    • Make time to laugh and have fun. Enjoy good times with friends and family, watch a movie, take the dog for a walk. Laughing can reduce stress and put you in a positive mood.

    Section 2

    Nutrition

    Nutrition is one of the three pillars that support healthy living (the other two are physical activity and emotional wellbeing). Good nutrition doesn’t have to be complicated or time consuming—it could be as basic as making simple and practical changes to your eating habits.

    • Focusing on food after cancer treatment can be a challenge. You may have experienced eating problems and/or weight changes during treatment, and perhaps you are still dealing with these symptoms. How you feel about eating depends on the type of cancer you had and the treatment you received.
    • Incorporating new eating habits should be a gradual process and can be done in several ways. Tips and strategies are offered throughout the rest of this section.
    • If you are taking any medications, or still undergoing any treatments, be aware that certain foods may interfere with medications or make side effects worse. For example, for about the first six weeks after surgery for colon cancer, it is recommended to limit spicy, fatty or greasy foods as well as drinks with caffeine. Another example is grapefruit, which may interfere with medications. If you have any concerns about this, you should talk to someone in your healthcare team.
    • Depending on your situation, a dietitian may recommend a special diet. Share this information with your family, partner, friends and caregivers so that they can make healthy choices when grocery shopping.

    The importance of eating well

    Eating well after cancer treatment will give you energy and help strengthen your body. Healthy eating, along with physical activity and emotional wellbeing, can also help you reduce the risk of other health problems such as diabetes and osteoporosis. Also, according to the American Cancer Society, studies have suggested that food choices may help reduce the risk of recurrence. For more information, see www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-037186.pdf, page 16.

    The positive physical and psychological effects of eating well have been shown to be significant. If you would like to learn more about this subject, or get nutrition advice specifically designed for you from a professional, go to Chapter 4: Regaining function / Section 5: On your way to recovery / Heading: Nutrition, for information about health and nutrition workshops, and access to dietitians and nutritionists.

    Healthy eating

    Eating well—the main ingredients

    Eating well includes eating a variety of vegetables, fruits, whole grains and proteins. It is also important to keep your body hydrated by drinking a lot of fluids. The best way to begin is by taking control of the situation, and creating and preparing healthy meal options at home. Keep it simple to start and try to enjoy being creative.

    Make sure you get enough calories, proteins and nutrients in your diet. During your recovery process, you may need more calories to boost your energy. You can find them in carbohydrates and good fats. You can usually add these types of calories into your meals and snacks quite easily. For example, add avocado or olive oil to a salad, sandwich, sauce or cooked vegetables. Here are some examples:

    Carbohydrates:

    • Fruits.
    • Bread.
    • Pasta.
    • Legumes (e.g., beans, peas, lentils).

    Good fats:

    • Olive oil.
    • Nuts and seeds.
    • Avocados.

    Proteins play an important role in your body by helping maintain a healthy muscle mass and a healthy immune system. Certain foods help the body create proteins, which promote healthy function.

    High protein foods:

    • Nuts and seeds.
    • Legumes.
    • Cheese, milk and yogurt.
    • Tofu and soya.
    • Cooked meat, poultry, fish and eggs.

    Adding a variety of colourful vegetables to your stir fry, and sprinkling a variety of herbs and spices, such as turmeric, black pepper, and thyme, will provide an abundance of protective antioxidants. Anti-oxidants can help protect the body from damage caused by pollutants in our environment, such as dioxins and volatile organic compounds (VOCs). Sandra Grant, dietitian

    Combining healthy eating with a physical activity when you can (see Chapter 4: Regaining function / Section 3: Physical activity) may help your recovery process even more. Energy booster foods for before exercising, or for any time during the day, include:

    • Yogurt
    • Fruit milkshake and smoothies
    • Cereal bars
    • Whole grain crackers with peanut butter
    Drink water

    Drinking water every day is essential—it helps you to feel better and function better. The average intake for a healthy adult is between 1.5 and 2.5 litres a day, and more when you are active or in hot conditions.

    If you have fever, diarrhea or any other health condition, the amount of water you need to drink, and how often, may need to be adjusted.

    Foods to avoid

    For healthy living, certain foods should be limited or avoided.

    • Limit eating red meats to less than 18 ounces (510 grams) a week.
    • Avoid processed meats like deli meats and bacon.
    • Avoid frying, broiling and grilling meats at very high temperatures to avoid charring. Certain types of cooking can create chemicals that may increase the risk of cancer.
    • Limit your intake of ‘fast foods’ and sugary drinks.
    • Limit your consumption of alcohol. The World Cancer Research Fund advises that if you drink alcohol, limit consumption to 2 drinks a day for men and 1 drink a day for women.

    Challenges to eating well

    If you are unable to cook, try making very simple meals. Or ask a family member or caregiver to prepare meals for you. Plan ahead—with help if necessary—and fill your pantry, fridge and freezer with healthy foods that can be easily and quickly transformed into balanced meals and snacks. Some suggestions are:

    • Soups
    • Dried fruits and nuts
    • Cereals with milk
    • Crackers or rice cakes with cheese
    • Pasta or rice with vegetables or meat sauce
    • Peanut butter and jam
    • Seeds, honey and pickles
    • Canned tuna, salmon and sardines

    Try to feel comfortable asking for help from others with shopping or cooking. While it may have been obvious to the people caring for you that you needed this help while you were in treatment, people often forget that recovery can sometimes be challenging as well. Friends and family members are usually happy to be able to make these tasks easier for you—and perhaps share a good meal and conversation at the same time!

    If eating is a problem due to dry mouth and/or difficulties swallowing, talk to your doctor or dietitian about alternatives that would be right for you at this time. Then you can gradually add in your usual foods when you feel comfortable.

    Food safety

    Eating well includes food safety. It is important to avoid adding germs to your body, especially within one month of finishing your treatment, since your immune system is recovering.

    • Wash your hands before eating and cooking.
    • Wash vegetables and fruits before eating or cooking them.
    • Separate food that will be eaten raw from food that will be cooked.
    • Use separate grocery bags and cutting boards for items that need to be cooked before eating, such as meats, fish, poultry, eggs and vegetables.
    • If you are eating out, avoid buffet meals and raw or under cooked meat, poultry, fish and eggs—these foods may contain higher levels of germs and bacteria.

    People are asking about . . .

    GMOs—genetically modified organisms

    GMOs are plants or animals that have had their genes changed in some way, or have had genes from another plant or animal added to their own. GMOs are commonly used in the food industry and are considered safe according to Health Canada. Here are pros and cons according to Christy Brissette, clinical dietitian at Princess Margaret Hospital (www.ellicsr.ca).

    • Pros: Genetically modifying crops increases their resistance to pesticides, plant diseases, cold and drought. GMOs ripen slower and are also used to maximise nutrients in a crop.
    • Cons: GMOs can cause allergies. No studies have been done on their long-term effects on human health.

    Organic foods

    Organic describes foods that haven’t been grown with pesticides and/or GMOs. It is also a term used for meat, eggs, dairies and poultry that are not from animals that have been raised on antibiotics or hormones. While it is thought that organic foods reduce the risk of exposure to certain chemicals and may have better nutritional value, according to the American Cancer Society there are no current human studies showing that organic foods are better at reducing the risk of cancer or cancer recurrence (www.cancer.org/treatment/survivorshipduringandaftertreatment/nutritionforpeoplewithcancer/nutrition-and-physicalactivity- during-and-after-cancer-treatment-answers-to-common-questions).

    Milk and dairy products

    We grew up being told that dairy products are good for our health and bones; however, there are now many conflicting messages about this advice. Dietitians currently recommend drinking or eating dairy products with lower percentages of milk fat, such as skim (0%) or 1% milk.

    Contrary to popular belief, Canadian dairy products do not contain hormones. Although American dairy farmers are allowed to use hormones to increase the milk production of their dairy cows, this practice is banned in Canada. So you can enjoy a refreshing glass of low fat milk without worrying about hormones. Sandra Grant, dietitian

    Special diets

    If you would like more information about special diets, such as gluten free, juicing or macrobiotics, visit www.ellicsr.ca/en/connectwithELLICSR. Have a look at their blog and read the posts from Christy Brissette, clinical dietitian at Princess Margaret Hospital.

    Weight change

    Your eating habits and your weight may have changed during or after treatment. Some people gain weight while others lose weight, depending on the type of cancer and treatment. Significant changes in weight may have physical and/or emotional health consequences. If you have concerns, and would like help and guidance, speak with the dietitian at your cancer centre.

    Weight gain

    During your cancer treatment, you may have eaten more to help with nausea, to deal with stress and anxiety, or because you were less active and tended to snack more often. There are also other reasons for weight gain during or after treatment. For example, menopause, hormone therapy and steroid medication can all contribute to weight gain.

    Tips for managing weight gain include:
    • Eat plenty of vegetables, fruits and whole grains.
    • Try to eat smaller portions.
    • Limit fat, sugar, refined flour and salty foods (which make your body retain water).
    • Steam or bake food instead of frying.
    • Avoid skipping meals. This will not help you lose weight more quickly and it is not healthy.
    • Drink lots of fluids.
    • Exercise. Walking, cycling and other muscle strengthening exercises can help maintain a healthy weight.

    Find interesting recipes in the ELLICSR Kitchen at Princess Margaret Hospital’s Health, Wellness and Cancer Survivorship Centre: www.ellicsr.ca/en/clinicsprograms/ellicsrkitchen/Pages/recipe_archive.aspx.

    Weight loss

    Cancer itself can be a direct cause of weight loss. Or your appetite and tastes may have been affected during treatment and you may be eating less and losing weight as a result. Also, after-treatment side effects, such as nausea, vomiting, mouth sores, trouble swallowing, fatigue and depression can lead to weight loss. Find more information on these side effects in Chapter 2: What to expect after treatment / Section 2: What are the possible side effects.

    After treatment, it is important to get back to a healthy weight in order to have more energy, feel better, and manage and reduce side effects effectively. To help you regain weight, it is essential that you eat healthy food on a daily basis, including foods that contain more calories. Eating smaller portions more often may make this easier for you. Try to eat your main meal of the day when you feel hungry. Also, drink fluids throughout the day to stay hydrated. If you had weight loss during treatment and are now unable to gain weight, you may want to speak to a dietitian at your cancer centre for an assessment. They can help you find the best approach to get back to a healthy weight.

    Tips for managing weight loss include:
    • Choose foods containing more calories and proteins. You can add extra protein to your diet with foods like peanut butter, cheese and eggs.
    • Eat high protein/low fat foods, such as fish, poultry, nuts, seeds and legumes.
    • Eat healthy fats (fatty acids, omega-3 fatty acids), such as olive oil, avocados, flax seeds and walnuts.
    • Eat when you are most hungry.
    • Make a rainbow on your plate! Eat foods of different colours.
    • Eat high calorie foods first. This is a good strategy if you fill up quickly at meal time.
    • Set goals for your weight gain. For example, eating 500 calories more a day usually results in a weight gain of approximately 1 pound a week.

    Managing side effects with food

    Depending on what type of cancer and treatment you had, you may experience side effects and symptoms that affect your relationship with food: what you can eat, how much you can eat, and if you have difficulty eating (e.g., swallowing). Side effects and symptoms can vary from person to person, and can change over time. With the right plan and follow-up with your healthcare team, you should gradually be able to get back to eating the way you did before treatment.

    Anemia

    Anemia is a lack of healthy red cells in your body. The main symptoms of anemia are fatigue and dizziness.

    • Eat more foods high in iron, such as red meat or from plant sources, such as dried beans, spinach, pumpkin seeds and almonds.
    • For high iron foods from plant sources, be sure to combine them with a vitamin C source, such as oranges, red or green peppers or tomatoes.
    • To treat the anemia directly, your doctor may prescribe iron supplements, folic acid pills or vitamin B12.
    Changes in taste or smell

    If you are experiencing changes in taste or smell, this can affect your eating habits. You may want to try adding extra seasoning or sauces to your meals to give them more flavour. Serve your dishes at room temperature—this will help to bring out the flavours in the food.

    Constipation

    Some medicines and cancer treatments cause constipation. Foods like prunes, rhubarb and papaya are natural laxatives. In general, adding more fibre progressively to your meals, such as whole grains, cereals, brown rice, dried fruits, seeds and nuts, usually helps relieve constipation. Make sure to also drink lots of fluids. In some situations, you may need a prescription for a laxative or stool softener.

    Diarrhea

    On the flip side, some cancer treatments and medicines cause diarrhea. Drink lots of non-carbonated, caffeine-free fluids, eat small meals more often during the day, and reduce the fibre in your meals. Eat more foods like pasta, bananas, melons, potatoes, meat, poultry and fish. Limit your intake of greasy, fried, sugary and spicy foods, as well as the natural laxative foods listed in the information on constipation. Choose instead salty foods, such as soups, sports drinks, crackers and pretzels. If you have diarrhea for more than 24 hours, or if you have pain or cramps in your stomach, you should talk to your healthcare team.

    Dry mouth or thick saliva

    If you are experiencing dry mouth or thick saliva, try adding more moisture to your meals with foods such as broth, soups, sauces, gravy, creams and butter or margarine. You can also try pureed foods, which generally contain more liquid. Drink lots of fluids during the day, avoiding caffeine, which can make your mouth even dryer. Keep your favourite fluid with you in a bottle or thermos so that you can drink regularly throughout the day. You can also try chewing gum or sucking on candies.

    Fatigue

    Fatigue is one of the most common after-treatment side effects, and can significantly affect the basics of your everyday life, including eating. To manage cancer-related fatigue, try eating foods with more calories and proteins. This may help you restore energy. See Chapter 4: Regaining function / Section 2: Nutrition / Headling: Healthy Eating for how to get more calories and proteins into your meals.

    To help with fatigue:

    • It is important to keep your body hydrated by drinking lots of fluids.
    • Think about eating when you have the most energy.
    • Do not hesitate to ask for help with shopping or to prepare meals.
    Nausea and vomiting

    If you are experiencing nausea and vomiting, try the following approaches to help prevent and manage these side effects:

    • Eat slowly and eat smaller portions.
    • Take your time after eating—relax while sitting up.
    • Drink fluids in small sips. But remember to keep drinking plenty of fluids during the day.
    • If you can’t cook because the smell makes you nauseous, ask people to cook for you. Or heat up a prepared meal from the freezer.
    • Avoid greasy, fried, sugary or spicy foods. Also, cold foods are easier to tolerate.

    Top tips

    • Vary your diet. Test new recipes using items from all the food groups. Eat at least 8-10 servings of fruits and vegetables each day: 1 serving is equal to ½ cup of vegetables or fruit (fresh, frozen or canned) or 1 cup of leafy raw vegetables or salad.
    • Snack on vegetables and fruits.
    • Limit red meat (beef, pork and lamb) to a maximum of 3 to 4 servings a week (18 ounces/510 grams).
    • Avoid smoked, salt-cured and pickled foods, such as bacon, sausage and deli meats.
    • Choose low-fat dairy products and high-fiber foods, such as whole-grain and cereals.
    • Check out Health Canada’s Food Guide. You will find information on the recommended number of servings you should eat per day from the different food groups: food-guide.canada.ca/en.

    Section 3

    Physical activity

    Physical activity is one of the three pillars that support healthy living (the other two are nutrition and emotional wellbeing). It is strongly recommended that you try to incorporate some physical activity into your life after your cancer treatment, to help you heal and regain function.

    Being physically active positively affects your physical and mental health. It reduces cancer-related fatigue and increases muscle strength—which improves your body composition by balancing fat, bone and muscle. Research has shown that exercise can help reduce the risk of heart and blood vessel disease, diabetes and osteoporosis. Also, studies of breast, colorectal, prostate, and ovarian cancer survivors showed that people with higher levels of physical activity after diagnosis tended to live longer, and were less likely to experience a recurrence of cancer. For more information about this, visit the American Cancer Society: www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-037186.pdf, page 28.

    In addition to helping you regain strength and improve the recovery process after your treatment, physical activity also helps you sleep better, helps reduce stress and anxiety, and may help boost self-esteem.

    • The World Cancer Research Fund (2016) recommends 30 minutes of moderate physical activity a day, most days, increasing to 60 minutes as fitness levels improve.
    • Recent advice from The American Cancer Society and the American College of Sports Medicine recommends 150 minutes of exercise per week, including strength training at least 2 days a week.

    Check out My Cancer Fatigue (www.mycancerfatigue.ca) to create a fitness plan to help improve your physical energy. The site includes tools, such as a physical activity goal setter and tracker, and a list of resources for all of the provinces.

    What is being active?

    Being active means moving your body. You can begin with any activity that you enjoy—something that can be done at a light to moderate intensity, depending on your health and fitness level. If you were active before your treatment, you may not be able to pick up where you left off. Take into account what kind of activities or exercise you used to do, what you are capable of doing now without over-exerting yourself, and if you have any physical challenges post-treatment. Focus on building your fitness gradually and be patient with yourself.

    Activity intensity levels

    • Light (easy): This level of activity does not cause sweating unless it’s a hot, humid day. There is no noticeable change in breathing (the activity doesn’t cause you to breathe harder). Examples: walking on a flat surface at a slow pace, or strolling.
    • Moderate (somewhat hard): This level of activity will cause sweating after performing the activity for about 10 minutes. Breathing becomes deeper and more frequent. You can carry on a conversation but not sing. Examples: walking at a moderate or brisk pace, 3 to 4.5 mph, bicycling on level ground 5 to 9 mph, water aerobics, yoga, ballet exercises, golf, light weight training or light aerobic exercises.
    • High (hard): This level of activity will cause sweating after 3-5 minutes. Breathing becomes deep and fast. You can only talk in short phrases. Examples: Jogging, running, high impact or step aerobics, tennis, backpacking, bicycling on steep hills, and most competitive sports such as football or hockey.

    To help assess the level of intensity of your activity at any time, you can use the ‘talk test’. While exercising, try to talk and say a full sentence. If you succeed, you are in the right range of light to moderate intensity. If talking is too difficult or if you are breathing hard, you should lower the intensity. However, if you can sing a song, your level of intensity is too easy and you can ramp it up a bit! With time, you will be able to continually increase the level of intensity of your chosen activity.

    Here are some other tips to keep in mind when you are thinking about starting to exercise.

    • Be active when you have the most energy. Use your energy wisely—don’t overdo physical activity at the beginning.
    • Incorporate physical activity into your regular activities. For example, try parking further from the door to your work than usual, to walk a few extra steps.
    • Begin slowly, even if it’s only a few minutes a day. Your body will let you know when you should slow down and rest.
    • Try exercising for short periods and rest in between. For example, walk briskly for a few minutes and then slow down. Continue until you have walked briskly for a total of 30 minutes.
    • Remember the 4 important parts of exercise: stretching, strengthening, aerobics, and balance. Consider gradually including these types of exercises to your routine: stretching to improve flexibility, muscle strengthening with light weights or resistance bands, aerobic activity to increase your heart rate, and techniques like heel raises to improve balance.

    It’s possible that at times you may feel you do not have enough energy to be physically active. Try doing something that will match your energy level that day. You can set yourself small goals and do activities more often, rather than setting a big goal and being discouraged when you cannot reach it. It’s important to enjoy your activity of choice, whether it be dancing, gardening, or practicing Qi-Gong, for example. And why not participate in a group or ask others to join you, so that it can be even more pleasurable! Maria Milioto, physiotherapist

    Breathe into it

    It is impossible to play down the importance of breathing. Stress and anxiety can cause breathing to become tight and irregular, leading to more stress and anxiety! Relaxing and breathing can help reduce stress and anxiety, and improve overall flexibility. Breathing exercises are a great way to become more aware of the benefits breathing has on your body. They also help increase the oxygen flow throughout your body. Try practicing with small, deep breathing exercises: breathe in slowly through your nose, hold your breath for a few seconds, then breathe slowly out through your mouth. Repeat the cycle at least 3 times. For more details on how to practise deep abdominal breathing exercises, visit www.healthlinkbc.ca/health-topics/uz2255.

    Precautions for exercise

    Talk to your healthcare team before starting any physical activity or exercise program if any of the following situations apply to you.

    • If you have anemia (low red blood cell count).
    • If you have a low white blood cell count, or take medicine that makes it harder for your body to fight infection, your should avoid places where you are more at risk for infections, such as at public gyms.
    • If you have vomiting or diarrhea, swelling anywhere on your body, unrelieved pain, or other symptoms that concern you.
    • If you have shortness of breath with small amounts of exertion, or extreme fatigue.
    • If you have balance problems. Make sure to exercise on an even surface to avoid falls or injuries.
    • If you have osteoporosis, arthritis, nerve damage, poor balance, poor vision, or overall weakness—to not injure yourself or break a bone, do not exercise with heavy weights. Ask for advice from a professional for exercises that will not put too much stress on your bones.

    Need extra help?

    While some people will be able to begin an exercise routine safely on their own, others will see better results working with an exercise specialist. A physiotherapist or a kinesiologist can assess your fitness level and create a progressive plan that will work best for you. The objective is to move forward with recovery and to have fun—and especially to enjoy your chosen activity. For information on community programs in the community and exercise specialists, see Chapter 4: Regaining function / Section 5: On your way to recovery.

    If you are experiencing physical limitations due to treatment or surgery, you can ask for a referral to a physiotherapist. This therapy may be covered by provincial health insurance or private insurance, if you have private coverage. A physiotherapist will assess your current abilities and functional needs, and develop a plan to help you reach your physical health goals. For information on how to find a physiotherapist that will fit your needs, go to Chapter 4: Regaining function / Section 6: On your way to recovery / Heading: Physiotherapists.

    If you have serious physical limitations, which are affecting your daily living or your ability to return to work, an occupational therapist can teach you how to work with these challenges to carry out your daily activities. They may also recommend changes to your home or work environment. For example, an occupational therapist may recommend voice recognition software for a person with limited use of their hands or arms, or the installation of a shower seat for people with reduced mobility. For information on how to find an occupational therapist, go to Chapter 4: Regaining function / Section 6: On your way to recovery / Headling: Occupational therapists.

    Managing side effects with physical activity

    Fatigue

    If you are experiencing cancer-related fatigue, it can be hard to imagine yourself being active. When you understand what your body is able to do at this time, you should be able to add the right type of activity to your routine. Being active in some way will help counteract the effects of fatigue.

    • Try to be more active in your daily routine. Use the stairs instead of the elevator if you can, park further away from the door of your work or a shopping centre, so you can take a short walk. Be careful not to overdo it—a little goes a long way.
    • Aim to eventually exercise at least 150 minutes per week, focussing on bone and muscle strengthening exercises twice a week.
    • Avoid exercising 4 hours before going to bed, to improve your chances of sleeping well.

    It may be helpful to use a 0-10 scale when discussing the level of your fatigue with your healthcare team. For example:

    • 0 = no fatigue
    • 1,2,3 = mild
    • 4,5,6 = moderate
    • 7,8,9 = extreme
    • 10 = the worst

    My Cancer Fatigue (www.mycancerfatigue.ca) can help you create an action plan for managing your fatigue with physical activity. For more information, also see Chapter 2: What to expect after treatment / Section 2: What are the possible side effects / Heading: Fatigue.

    Digestion

    Physical activity can also help your digestion. It may also help with side effects after colon, rectal or thyroid cancer treatments.

    • Sip water while exercising—the more you sweat the more you should drink.
    • Wear comfy clothes in layers that can be easily taken off.
    • Take your medicine for diarrhea (if any) before you exercise.
    • Go to the bathroom prior to starting your session.

    Even though I was active before, I always had a heavy feeling with the chemo and the radiotherapy. It’s like you’ve been run over by a truck. I felt a physical change after starting at the gym, however. I regained muscle and I got my physical energy back. When you feel physically well, you confront challenges differently. You know, you are stronger, physically and mentally. Alice, recovering from rectal cancer, age 71

    Top tips

    • Think gradual. Start small, especially if you have been inactive, and make your activity sessions longer gradually.
    • Pace yourself according to your level of energy.
    • Schedule your choice of activity in your calendar for when you usually have the most energy.
    • Warm up (with shoulder shrugs, lifting arms above the head, knee lifts, for 2 to 3 minutes) and cool down (with some stretching, holding stretches for 15 to 30 seconds at a time). These are two important steps to include at the beginning and at the end of each exercise program.
    • Focus on having fun.
    • Ask family or friends to join you in your activity.
    • Recognize and reward your achievements.

    Section 4

    Emotional wellbeing

    Emotional wellbeing is one of the three pillars that support healthy living (the other two are nutrition and physical activity). As you face the many challenges that come with life after cancer treatment, you may find complementary therapies an interesting area to explore. The focus of complementary therapies is on health and healing, and overall wellbeing of the body, mind, and spirit.

    Complementary therapies

    Common complementary therapies include: meditation (including mindfulness meditation), reflexology, aromatherapy, art therapy, music therapy, healing touch, massage therapy, reiki and biofeedback. Many people have found that these kinds of activities have had a positive impact on their emotional wellbeing. In some cases, these therapies may be able to help relieve post-treatment side effects such as fatigue, nausea and pain. For more detailed information about complementary therapies and how they can help, see the Canadian Cancer Society website: www.cancer.ca/en/cancer-information/diagnosis-and-treatment/complementary-therapies/?region=on. Community resources for complementary therapies can be found in Chapter 4: Regaining function / Section 5: On your way to recovery.

    Section 5

    On your way to recovery: Resources to help you regain function

    There are many services, programs and organizations that can provide you with the information and help you may need, depending on your situation. Below are some of the resources available in general and in some of the provinces. Use this as a guide to search for more information, or for resources available in your particular area. Depending on the topic (e.g., nutrition), some of the regional sites have general information and tips that would be helpful for anyone.

    For information on lymphedema therapy resources, see Chapter 2: What to expect after treatment / Section 2: What are the possible side effects / Heading: Lymphedema.

    For more information on programs, services, support groups, psychosocial support and/or educational information, also check out the last section of Chapters 2, 3, 6 and 7.

    Wellness and physical activity programs, and services

    • Canadian Cancer Society community services locator: csl.cancer.ca/en. Helps you find resources on nutrition, physical activity and complementary therapies available in your area. Call 1-888-939-3333 to talk to an information specialist.
    • My Cancer Fatigue: www.mycancerfatigue.ca. Helps you create an action plan for managing fatigue focusing on physical activity, sleep strategies, nutrition, psychological interventions and spiritual practices. Also includes a list of available resources across Canada.
    • American Cancer Society – Guidelines on Nutrition and Physical Activity for Cancer Prevention: www.cancer.org/acs/groups/cid/documents/webcontent/002577-pdf.pdf. Provides advice on diet and exercise to reduce cancer risk.
    • Cancer.net–The American Society of Clinical Oncology: www.cancer.net. Offers advice and strategies regarding nutrition, prevention, exercise and emotions, including a program called 8 Steps to Starting Exercise After Cancer Treatment.

    Quebec/Montreal

    • Quebec Cancer Foundation: intranet.fqc.qc.ca:8080. Look at the virtual library for information on healthy living or speak with the librarian at 1-800-363-0063.
    • The Quebec Cancer Foundation also offer a kinesiology service for up to one year post-treatment: www.fqc.qc.ca/en/need-help/kinesiology.
    • Hope and Cope Wellness Centre–Lou’s House: www.hopeandcope.ca/wellness. The Hope and Cope Wellness Centre offers many programs and services, including stress reduction courses and relaxation techniques. The centre also offers ActivOnco, which is a rehabilitation program that includes a team of physiotherapists and exercise physiologists. Patients can take advantage of this program for up to one year post-treatment.
    • Cedars CanSupport: www.cansupport.ca. This program supports cancer patients with numerous programs and activities, including reiki, meditation and relaxation, yoga, fitness classes and dragon boating.
    • Fondation Virage–Notre Dame Hospital: www.viragecancer.org. The foundation offers personalized exercise programs for up to one year post-treatment. The program includes assessment and individual follow-up with a physiotherapist, as well as group classes.
    • The McGill Cancer Nutrition-Rehabilitation Program: www.mcgill.ca/oncology/divisions-programs/cancer-nutrition-rehabilitation. This program at the Jewish General Hospital and the MUHC provides nutritional counseling and physical rehabilitation to help manage common symptoms associated with cancer. Patients must be referred to this program by their oncologist.
    • McGill Comprehensive Health Improvement Program (CHIP): www.chiprehab.com/english/main.html. Health professionals from the McGill University teaching hospitals work with recovering patients to help them improve long-term health and quality of life through exercise, nutrition, and psycho-social programs. Check with your insurance company about coverage, or contact CHIP to inquire about financial assistance.
    • Cancer Rehabilitaton and Cachexia Clinic at the MUHC: www.muhc.ca/cancer/page/cancer-rehabilitation-and-cachexia-clinic. This clinic offers rehabilitation, nutritional counseling, and psycho-social services. Patients must be referred to the program by their oncologist.
    • West Island Cancer Wellness Centre: www.wicwc.org. The West Island Cancer Wellness Centre offers free wellness services for up to one year after cancer treatment, including reflexology, healing touch and acupressure.
    • Happy Tree Yoga: www.happytreeyoga.com. Happy Tree’s gentle yoga classes are free for anyone undergoing or recovering from cancer treatment.

    Ontario/Toronto

    Alberta/Calgary

    British Columbia/Vancouver

    Nutrition

    Most cancer centres have a dietitian on staff—your doctor can refer you if you are interested. Below are some of the resources available in general and in some of the provinces. Use this as a guide to search for more information, or for resources available in your particular area. Many of the regional resources listed below have general nutritional information and strategies that would be helpful regardless of your location.

    Quebec/Montreal

    • The McGill Cancer Nutrition-Rehabilitation Program: www.mcgill.ca/oncology/divisions-programs/cancer-nutrition-rehabilitation. This program at the Jewish General Hospital and the MUHC provides nutritional counseling and physical rehabilitation to help manage common symptoms associated with cancer. Patients must be referred to this program by their oncologist.
    • Cancer Rehabilitaton and Cachexia Clinic at the MUHC: muhc.ca/cancermuhc.ca/cancer/page/cancer-rehabilitation-and-cachexia-clinic.
    • The clinic offers rehabilitation, nutritional counseling, and psycho-social services. Patients must be referred to this program by their oncologist.
    • Hope and Cope Wellness Centre–Lou’s House: www.hopeandcope.ca/wellness/#nutrition. The Centre’s nutrition program has been developed by an experienced cancer dietitian, and includes weekly cooking classes, lectures on specific cancer nutrition topics and a weight loss series for patients who have completed cancer treatment..
    • West Island Cancer Wellness Centre: www.wicwc.org. The Centre provides patients with access to a naturotherapist and a food coach and culinary instructor.

    Ontario/Toronto

    Alberta/Calgary

    British Columbia/Vancouver

    Smoking Cessation

    Quebec/Montreal

    Ontario/Toronto

    Alberta/Calgary

    British Columbia/Vancouver

    • BC Smoking Cessation Program: www2.gov.bc.ca. Provides information regarding treatment options, and a list of resources and programs available.
    • Quit Now: www.quitnow.ca. Provides advice and counselling from experts and peer support groups.
    • The University of British Columbia Smoking Cessation Clinic at The Vancouver General Hospital:
      www.ubccardio.com/specialty-clinics/smoking-cessation-at-vgh. Offers individualized treatment according to the patient's needs.

    Physiotherapists

    You can speak to your healthcare team about a referral to a physiotherapist. For access to a physiotherapist at a private clinic, you may want to check that your personal insurance plan covers the treatment, as well as what conditions must be met for the treatments to be reimbursed.

    Quebec/Montreal

    • The Ordre professionel de la physiothérapie du Québec provides a list of physiotherapists and physical rehabilitation therapists who are members of the order: oppq.qc.ca/en. You can search the site for a therapist with experience in the area that is a concern to you.

    Ontario/Toronto

    • College of Physiotherapists of Ontario: www.collegept.org. Search the College listings to find a therapist in your area.

    Alberta/Calgary

    British Columbia/Vancouver

    • Physiotherapy Association of British Columbia: bcphysio.org/find-a-physio. Search for a therapist in your area according to your needs.

    Occupational therapists

    Quebec/Montreal

    • Ordre des ergothérapeutes du Québec: www.oeq.org/ordre/repertoire.fr.html. Provides a list of licensed occupational therapists who are members of the order:
    • Physiothérapie universelle: physiotherapieuniverselle.com/en. This site explains the benefits of follow-up by an occupational therapist and allows you to make an appointment with a professional.

    Ontario/Toronto

    Alberta/Calgary

    British Columbia/Vancouver