Immunotherapy, Training, and Athletic Performance

I’ll try and keep this concise.
In June, I was diagnosed with a 3b melanoma.
In July, 14 lymph nodes were removed along with a large patch of skin.
In August, an infection and subsequent admission to hospital set back recovery significantly.
In September, I started a year long course of Pembrolizumab (immunotherapy).
In October I got back on the bike.
In November I began structured training.

As part of recovery I’ve chosen a couple of events in the new year to focus on … Paris Ancaster (75 km field, gravel, singletrack) in April, and the Epic 8 Hour in May. I’m not really chuffed about being competitive for either (hell, being on the bike next spring will be reward in itself all things considered), but I do want to enjoy the events. Should they go well and if the borders re-open I focus on some more competitive events later in the season.

Anyway, my program isn’t particularly heavy … 350 to 400 TSS/week spread over 3 to 4 rides indoors and out (trainer, mountain and fat bike). Two weeks on, 1 week off. It’s well within what I would have tolerated pre-surgery. I’m 58, had an CTL of probably around 50 before surgery and Training Peaks pegs it at 30 now.

Anyway, I’m toast … resting heart rate is way up, legs are jello, I’m sleeping an hour or two more a day than I would expect, and it takes probably double the recovery time that it would have 6 months ago. I’m experienced enough to know that I need to reduce the load and scale back.

In the normal course of things, I’d presume that I went in too hard, and my body and age were both conspiring to tell me to slow down. But given my performance and ability to recover in the past, I can’t help but think the Pembro (immunotherapy) treatment is contributing to the fatigue. Yesterday for instance I napped for an hour after 30 minutes shoveling snow. Urgh.

A search for insight hasn’t been particularly useful; Google turns up zero results linking immunotherapy, training and athletic performance and my oncologist is frustratingly obtuse … he says, yes Pembro can cause fatigue and yes keep exercising. Likewise, the published literature that IS available indicates that 35% of patients on Pembro experience SOME symptoms of fatigue and exercise can help mitigate those symptoms but they’re talking about modest exercise in largely deconditioned patients. Regrettably, I’m drawing a blank …

My questions therefore are this …
Are there folks amongst you who have trained through immunotherapy. And what have your experiences been?
Are there professionals here (an oncologist perhaps) who have trained athletes recovering from cancer or during treatment? Or might some here know of resources available to those in similar situations to mine?

And more specifically, I guess what I’d really like to know is …
Is it reasonable to train through immunotherapy.
What might the expected load reduction be? Expected outcomes?
And am I being a damn fool thinking I’ll be ready for the spring season?

Thanks all,
T

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Hi, I had a friend that had a brain tumor, required surgery and Immunotherapy.

18 months on, he is doing well, started back his cycling small stuff to begin with and built up to cycling 60-70mile rides and some big hills. He has to be careful with COVID 19 around due to his immune system being compromised with the continued treatment. His main feedback was take it in small steps and listen to what your body tells you.

Found this link also.

Take care of yourself!!

Anyone else fighting cancer or coming back from cancer?

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My second cancer diagnosis was a stage 3b melanoma as well. Surgery followed up with a year of immunotherapy (nivolumab) . I trained through the year of immunotherapy but give yourself a break. Everyone responds to immunotherapy different but I had a few issues. It really did a number on my thyroid so I had to get that under control and the fatigue was a real issue. Five days after the infusion of the immunotherapy I would feel like I had the flu for 5 days after. It’s hard to make real progress when you are training 3 weeks a month. There were other side effects too but it’s a hard course and remember your priority is to beat the cancer then training can be a focus.

I’m one year off my immunotherapy and I do feel better. My thyroid is still off but I take medicine to balance that out.

The bike training was more to keep me sane after the surgery and immunotherapy. Keep an eye on anything that seems out of the ordinary because there are a ton of side effects with different immunotherapy treatments.

Keep up the fight

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Hi T,

I am sorry you’re going through this. I am a physician-scientist who has been in the immuno-oncology field for about a decade.

I am an expert in checkpoint blockade drugs such as Pembro. I primarily do research and this is not medical advice, however I’m familiar with the clinical literature and feel qualified to give an additional opinion here from this perspective.

To the best of my knowledge, there is no useful and rigorous literature to guide you with respect to immunotherapy specifically. As you’ve discovered, adverse effects of Pembro differ dramatically across individulous and our ability to meaningfully predict or track effects is limited. Listening to your body and managing the symptoms, as jasonmayo did, is what I would do.

No reason you can’t go for it when you feel good, provided you’re not fatiguing yourself to the point of getting sick. Happy to discuss further.

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Thanks for this, folks.
Like you, @jasonmayo, the second week does seem to be the most difficult. I’ve adjusted my schedule accordingly and lowered expectations a whole lot … I too recognize the experience of feeling flu-like but hadn’t put it into those words until you mentioned it; sans cough/fever it’s exactly what it feels like … soreness, fatigue, brain fog etc …

Thank you for that link @C10oky ; it’s lead to further reading which contextualizes the challenge for me. Many on treatment are impacted far worse, fatigue being the least of the potential impacts. I wonder if at some point some clever grad student will start gathering stats and give more rigorous context to what it means to train through the ordeal.

Your offer to further discuss @HeiL1Ofu is very kind. I guess the one question that nags most is whether training has the potential to negatively impact the work of the Pembro … I don’t mind pushing myself with an end-goal in sight, but what I DON’T want to do is go thru a year of treatment/training and work against myself by over-stressing the immune system or trigger any other unintended consequences.

Kind regards,
T

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I apologize for the delay in responding, which was in part because I have nothing useful to say, unfortunately.

Despite the success of this class of drugs, we actually do not understand what global health factors are important for the best responses. Exercise? Diet? Sleep? These questions have not been answered with a degree of rigor that is clinically actionable. Understanding the effect of global health factors on “inflammation” generally and the effect of inflammation generally on a therapeutic anti-tumor response is definitely frontier medicine.

Personally, if it were me, I’d speculate that taking care of yourself as you would to avoid getting a cold is probably helpful. So avoiding the extremes of stress, sleep deprivation, or caloric deprivation, are probably more impactful than some strenuous exercise. I really doubt strenuous exercise, within reason, would have a negative impact.

Personally, I would train without limitation, but listen to my body to avoid deep fatigue. Personally, I would train through a bit of fatigue because I love cycling and there is no good evidence to the contrary.