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Implementing the Exercise Guidelinesfor Cancer SurvivorsKathleen Y. Wolin, ScD; Anna L. Schwartz, PhD; Charles E. Matthews, PhD, FACSM;
Kerry S. Courneya, PhD; and Kathryn H. Schmitz, PhDuris
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DDepartment of Surgery,Washington UniversitySchool of Medicine andSiteman Cancer Center,St. Louis, Missouri.
Dr Schwartz is from theBiobehavioral Nursingand Health Systems,University ofWashington, School ofNursing, Seattle,Washington and St.John’s Medical Center,Jackson, Wyoming.
Dr Matthews is from theDivision of CancerEpidemiology andGenetics, NationalCancer Institute,Bethesda, Maryland.
Dr Courneya is from theFaculty of PhysicalEducation andRecreation, University ofAlberta, Edmonton,Alberta, Canada.
Dr Schmitz is from theDepartment ofBiostatistics andEpidemiology, PerelmanSchool of Medicine andAbramson CancerCenter, Philadelphia,
I n oncology, there is a formal vetting processto introduce new standards of patient care.This process, managed by the National Com-
prehensive Cancer Network (NCCN, nccn.org),produces evidence-based guidelines to be imple-mented at the institution or practice level. Whilevariations in practice remain, even within thecontext of the guidelines, they provide a standardof care and a process for defining evidence-basedcancer care.
Medical and behavioral interventions havephysiologic effects, which necessitate their eval-uation for safety before widespread implementa-tion. Through this evaluation, providers under-stand whether the purported benefits of anintervention truly exist and outweigh any risks.As exercise has physiologic effects, it can beconsidered a therapeutic intervention, as it is inother clinical settings (eg, cardiac rehabilita-tion).1 Until recently, exercise as a therapeuticintervention in a cancer treatment and survivor-ship setting had not been evaluated. There is aneed for an evaluation of the risks and benefits ofexercise-based interventions for cancer survivorsby a body that understands clinical medicine,oncology, and exercise.
The American College of Sports Medicine(ACSM) has a long history of providing thiskind of evaluation as the organization is com-prised of clinicians, exercise physiologists, epide-miologists, behavioral scientists, and exercisespecialists. As such, in 2009, the ACSM con-vened an expert panel to provide such an eval-
Submitted for Publication: April 13, 2011; accepted Febru-ary 16, 2012.Published Online: May 10, 2012 (doi: 10.1016/j.suponc.2012.02.001)
Correspondence Author: Kathryn Schmitz, PhD, MPH,FACSM, Department of Biostatistics and Epidemiology, Perel-man School of Medicine and Abramson Cancer Center, 8thFloor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA19104-6021 ([email protected]).
tJ Support Oncol 2012;10:171–177 © 2012 Published by Elsevier Inc.doi:10.1016/j.suponc.2012.02.001
VOLUME 10, NUMBER 5 � SEPTEMBER/OCTOBER 2012
ation and invited a multidisciplinary team ofesearchers and practitioners to evaluate the ev-dence and issue guidelines on exercise for cancerurvivors.2
CSM GUIDELINES EXPERT PANELIn 2009, with support from the Siteman Can-
er Center and the Oncology Nursing Society,he ACSM convened an expert roundtable toeview the literature on exercise in cancer survi-ors and issue guidelines for activity, along withecommendations on exercise testing and pre-cription. The target audience for the resultingocument was the exercise professional, who wasxpected to develop an exercise program for can-er survivors. Such programs would take intoccount where the survivors were in the cancer-ontrol continuum (eg, on active treatment, sev-ral years past diagnosis, with existing disease) asell as their current health status and wouldssume that exercise professionals will work inonjunction with the survivors and cancer-careeams as necessary. The assembled evidence waseviewed by the panel and graded based on Na-ional Heart, Lung, and Blood Institute (NHLBI)ategories.3 The review was conducted for those
BSTRACT In 2009, the American College oened an expert roundtable to issue guidelineurvivors. This multidisciplinary group evaluatvidence for the safety and benefits of exerciseention for survivors. The panel concluded thffers myriad benefits for survivors including imunction, strength, fatigue, quality of life, and purvival. Recommendations for situations in whS Physical Activity Guidelines for Americansrovided. Here, we outline a process for implemlinical practice and provide recommendationsare provider can interface with the exerciseommunity.
f Sports Medicine con-s on exercise for cancered the strength of theas a therapeutic inter-at exercise is safe andprovements in physicalossibly recurrence andich deviations from theare appropriate were
enting the guidelines infor how the oncologyand physical therapy
umor sites where sufficient evidence was avail- P
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Implementing Exercise Guidelines for Cancer Survivors
able in adults: breast, prostate, colon, gynecologic, and he-matologic. Data on exercise programs in children do exist,largely in hematologic cancers, but were not included andhave been reviewed elsewhere.4 The ACSM guidelines re-view included evaluation of the risk-benefit equation; ques-tions of both safety and benefits of exercise were considered.“Survivors” were defined according to the National Coalitionfor Cancer Survivorship recommendation as “from the time ofdiagnosis until the end of life.”5
ACSM GUIDELINES ON EXERCISE FORCANCER SURVIVORS
The ACSM physical activity guidelines for cancer survi-vors have at their foundation 2 existing documents: first, theUS Department of Health and Human Services 2008 PhysicalActivity Guidelines for Americans (PAGA) provided direc-tion with respect to the recommended types and amounts ofphysical activity;6 second, the ACSM Guidelines for ExerciseTesting and Prescription were relied upon to address safetyissues for medical conditions other than those associated withcancer, as well as general principles for exercise prescription.7
The PAGA notes that all individuals should strive to avoidinactivity and that any level of physical activity may providehealth benefits. The same recommendation was made forcancer survivors in the ACSM guidelines, with an emphasison returning to normal daily activities as quickly as possibleafter surgery and continuing these activities as much as pos-sible during any adjuvant treatments (Table 1). For adults togain substantial health benefits, the PAGA suggests at least150 min/week of moderate-intensity activity or 75 min/weekof vigorous-intensity activity (or an equivalent combination).Additional benefits are gained with greater amounts of activ-
Table 1
Summary of the ACSM Exercise Guidelines for CancerAEROBIC
US Physical ActivityGuidelines forAmericans (PAGA)b
150 min/week of moderate-intensityor 75 min/week of vigorous-intensity activity or an equivalentcombination
Breast Follow US PAGA
Prostate Follow US PAGA
Colon Follow US PAGA
Gynecologic Morbidly obese women may requireadditional supervision
Hematologic, no HSCT Follow US PAGA
Hematologic with HSCT Recommend starting with lighterintensity and slower progression togreater intensity and duration
Abbreviations: ACSM, American College of Sports Medicine; HSCT, human stem cell transpaAdapted from Schmitz et al.2
b Physical Activity Guidelines Advisory Committee.6
ity. The PAGA applies the same prescription to older adults, m
172 www.SupportiveOncology.net
ith the addition that those whose physical conditions pre-lude participation in 150 min/week of moderate-intensityctivity, such as cancer survivors, should be as active as theyre able. For resistance training, the PAGA recommendsoderate- or high-intensity activities for all major muscle
roups at least twice per week. To improve flexibility, theAGA recommends that adults stretch major muscle groupsnd tendons on days they participate in other types of activ-ty. The PAGA also notes that older adults benefit fromalance exercises.
For aerobic training, the ACSM guidelines for cancerurvivors recommend following the age-appropriate PAGAecommendations. The ACSM guidelines note that modifi-ations of varying degrees to the PAGA are sometimeseeded for many cancer survivors to safely participate inesistance training. Similarly, the ACSM guidelines for flex-bility in cancer survivors are the same as those for all adults,ith some modifications based on survivors’ conditions. Forxample, the ACSM guidelines note that colon cancer sur-ivors with ostomies should take care to avoid excessivebdominal pressure. Many other conditions may also requirerecautions, as with breast-tissue expanders, peripherally in-erted central catheter lines, intraperitoneal catheters, andther postsurgical limitations.
MPLEMENTING EXERCISE RECOMMENDATIONSN CANCER SURVIVORS
The ACSM panel noted numerous potential benefits forxercise in the cancer survivor population (Table 2), whichave also been summarized in other reports.8�12 Exercise hashe potential to improve physical function, aerobic capacity,trength, and flexibility. Data exist for a key role of exercise in
vivorsa
RESISTANCE FLEXIBILITY
Muscle-strengthening activitiesof at least moderate intensityat least 2 days/week for eachmajor muscle group
Stretch major muscle groups andtendons on days other activitiesare performed
Start with supervised programand progress slowly
Follow US PAGA
Follow US PAGA Follow US PAGA
Follow US PAGA except withstoma, where lower resistanceand slower progression arerecommended to avoidherniation
Follow US PAGA, taking care toavoid excess abdominal pressureif patient has ostomy
Data on safety and benefitsare not available for womenwith lower limb lymphedema
Follow US PAGA
Follow US PAGA Follow US PAGA
Follow US PAGA; resistancetraining may have particularbenefits in this population
Follow US PAGA
Sur
lant.
aintaining a healthy body composition as well as a healthy
THE JOURNAL OF SUPPORTIVE ONCOLOGY
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body image. Exercise has benefits on quality of life (QOL),including fatigue, and may reduce the anxiety associated withrecurrence. In addition to the documented benefits, ongoingresearch is exploring the role of exercise in prolonging dis-ease-free survival and reducing risk of recurrence anddeath.13�19 Exercise may improve survivors’ physical andpsychological ability to complete treatment. Finally, exercisemay reduce or prevent long-term and late effects oftreatment.2
The ACSM guidelines for survivors were written to beapplicable to both clinical exercise physiologists who may beworking within a cancer center as well as exercise profession-als who work in the community setting. Exercise professionalswere encouraged to work with the cancer-care team whennecessary to understand the survivor’s treatment and medicalrisks. Here, we outline what evaluations were recommendedin those guidelines and the kind of information that exerciseprofessionals need from the clinical care team to develop asafe and effective exercise program for survivors, as well as theinformation that survivors need to exercise without supervi-sion. Ideally, survivors would work with a certified exerciseprofessional (eg, a trainer with ACSM Cancer ExerciseTrainer certification) when they undertake a new exerciseprogram. However, we recognize that numerous circum-stances (eg, physical location, financial ability) may precludethis, and it should not serve as a barrier to a survivor’sfollowing the key component of the guideline: Avoid inac-tivity. Thus, the clinical care team should be prepared toprovide survivors with enough information to move safely,which nearly every survivor can do.
The rich evidence base that informed the ACSM guide-lines shows that exercise is safe for survivors and that thereare morbidities for which exercise is a useful therapeuticintervention. However, implementation of the guidelines
Table 2
Rating1 the Evidence Base Supporting the ACSM Exer
BREAST (DURING) BREAST (AFT
Safety A A
Fitness A A
Strength A A
Body composition B B
QOL B B
Fatigue B B
Anxiety B B
Flexibility A
Physical function A
Lymphedema A (is safe
Body image B
Abbreviations: ACSM, American College of Sports Medicine; HSCT, human stem cell transpaAdapted from Schmitz et al.2 Evaluation of the evidence was based on NHLBI categories,3
randomized controlled trials exist or they are small and results are inconsistent; C indic
indicates evidence insufficient for categories A–C. Blanks (as well as the nonlisting of a s
among survivors poses challenges. Connecting survivors to s
VOLUME 10, NUMBER 5 � SEPTEMBER/OCTOBER 2012 w
ppropriate programs and identifying survivors for whomommunity-based programs may not be appropriate remainhallenges. The ACSM guidelines detail considerations thatight guide such decision making. However, one of the major
hallenges in this process is the lack of evidence-based thresh-lds for most of the clinical indicators that are recommendeds considerations.
In clinical practice, thresholds for defining risk and safetyre necessary for consistent care and are often implementedn an institution-specific basis, based on the clinical experi-nce of a few individuals, particularly when the research bases limited or nonexistent. Such practices can be set withoutuch evidence but change only with substantial contrary
vidence, often only from large, randomized, controlled trials.hus, thresholds and therapeutic intervention plans shoulde set with caution.
REEXERCISE EVALUATIONSExercise testing is not required for survivors who plan to
articipate in low- to moderate-intensity activity, such asalking, flexibility exercises, or resistance training. Prior toore vigorous-intensity exercise, survivors should follow the
eneral ACSM guidelines for exercise testing and prescrip-ion, which may include formal clinical exercise test admin-stration by an exercise professional for individuals at in-reased risk for complications associated with risk factorsnrelated to cancer and/or other preexisting health condi-ions, such as heart disease.
The challenge for implementation of the medical evalua-ion is to determine the thresholds for risk indicators. Exerciserofessionals will look to the oncology care team to provideuidance. Thus, as noted, there is a need to balance the risksssociated with disease versus the risks associated with a
Guidelines for Cancer Survivorsa
PROSTATE
HEMATOLOGIC(DURING ORAFTER HSCT)
HEMATOLOGIC(NO HSCT)
A A
A C B
A C
B
B C
A C B
B
OL, quality of life.
in A indicates overwhelming data from randomized controlled trials; B indicates that few
at results stem from uncontrolled, nonrandomized, and/or observational studies; and D
type of cancer) indicate that there was insufficient evidence to rate the data.
cise
ER)
)
lant; Q
where
ates th
edentary lifestyle. Relying on a symptom-based approach is
ww.SupportiveOncology.net 173
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Implementing Exercise Guidelines for Cancer Survivors
recommended when exercise recommendations and prescrip-tions are provided.
The ACSM guidelines for cancer survivors were intendedto address cancer-related issues; they come within the broadercontext of conventional exercise guidelines and evaluationsfor managing other conditions.6,7,20�22 The guidelines thusrecommend evaluation for other conditions, such as periph-eral neuropathies and musculoskeletal morbidities secondaryto treatment. For individuals who have received hormonetherapy, evaluation of fracture risk is recommended. Survivorswith known metastatic disease to the bone are recommendedfor evaluation, and individuals with known cardiac conditionsshould receive a medical evaluation per existing guidelines.7
The ACSM guidelines suggest that exercise professionals con-sult with the survivors’ medical teams in this phase of exerciseplanning. As a result, the oncology professional should antic-ipate questions about the presence of, or risk posed by, thesefactors.
Additional tumor site-specific assessments are also recom-mended in the ACSM guidelines. Breast cancer survivorsshould have arm and shoulder morbidity assessed. Prostatecancer survivors, in particular, require evaluation of musclestrength and wasting. Colon cancer survivors who have anostomy need to have established practices for the manage-ment of infection risks in place before undertaking an exerciseprogram. Morbidly obese survivors may require additionalmedical clearance and supervision for exercise due to weight-related risks. This may be particularly pertinent for the en-dometrial cancer survivor population.
The ACSM guidelines for survivors suggest a preexerciseevaluation for fracture risk in survivors on hormone therapy.The NCCN treatment guidelines for men with prostate can-cer who are on hormone therapy (androgen deprivation ther-apy [ADT]) recommend screening and treatment for osteo-porosis according to the general National OsteoporosisFoundation guidelines.23 It is suggested that fracture risk beassessed using the World Health Organization Fracture RiskAssessment Tool (FRAX), with ADT considered as equiva-lent to secondary osteoporosis. The NCCN prostate cancerguidelines as well as Medicare guidelines recommended treat-ment for those with a 10-year hip fracture risk of at least 3%or a 10-year major osteoporosis fracture risk of at least20%.24,25 While the NCCN breast cancer-treatment guide-lines recognize that certain treatments (eg, aromatase inhib-itors) increase fracture risk and women may require treatment(eg, with bisphosphonates), no guidelines for fracture riskevaluation are provided.26 However, the bone-health guide-line notes, “The NCCN Clinical Practice Guidelines in On-cology: Breast Cancer and Prostate Cancer recommends thatpatients for whom planned therapy includes medications thatlower sex steroids should be evaluated both at baseline andwith periodic follow-up dual-energy X-ray absorptiometry(DXA) scans to evaluate risk of fracture.”24 The US Preven-tive Service Task Force guidelines recommend bone-densityscreening for all women aged 65 years and above and for
women aged 60 to 64 who are at high risk for bone loss.27 The L174 www.SupportiveOncology.net
merican Society of Clinical Oncology (ASCO) guidelinesuggest bone-density screening for women with breast cancerho have high-risk factors such as a family history of frac-
ures, body weight less than 70 kg, and prior nontraumaticracture; for postmenopausal women of any age receivingromatase inhibitor therapy; and for premenopausal womenith therapy-induced ovarian failure.28 The NCCN guide-
ines recognize that bone-density evaluation via DXA posesome challenges and risks and, thus, recommend assessmentsing the FRAX algorithm in survivors who are at increasedisk for bone loss and fracture. No fracture risk level has beenefined as indicating that exercise is unsafe. The ACSMxercise prescription guidelines also provide guidance on ex-rcise in osteoporotic individuals. Finally, multiple myelomaurvivors should be treated as if they were osteoporotic, givenhat some proportion of these survivors will have bony lesionshat place them at high fracture risk.
Loss of muscle strength and wasting may be issues for someancer survivors. The ACSM guidelines note that this isarticularly so for prostate cancer survivors, who may loseuscle mass during ADT. Given the exercise pathology ex-
ertise of certified exercise specialists and physical therapists,ncology care providers should feel comfortable referring as-essment of strength and wasting to these individuals. How-ver, there is not sufficient reason to send every prostateancer survivor for such an evaluation, particularly if the menesire to begin walking or using a stationary bicycle, both ofhich are lower-risk activities. Criteria for defining weaknessnd wasting are not given in the ACSM guidelines. It is notlear under what circumstances weak individuals should avoidxercise; in fact, weakness in cancer survivors may be seen nots a contraindication to exercise but as an indication forxercise as a therapeutic intervention, although it should betarted slowly and should progress slowly, in line with the “asble” approach to physical activity recommended in theCSM/American Heart Association physical activity recom-endations for older adults.22
To ensure survivor safety, the ACSM guidelines recommendhat cancer survivors undergo neuropathy evaluation prior tonitiating an exercise program. Neuropathy can range from mildo severe, with most survivors initially experiencing sensations ofingling, pain, or numbness.29 Survivors often complain of walk-ng difficulty and of dropping items, both of which can poseafety risks in an exercise setting. Chemotherapy-induced pe-ipheral neuropathy (CIPN) manifests as sensory symptoms (eg,umbness or tingling), cold sensitivity, and pain. Diagnostic
eatures of CIPN include symmetrical, distal, length-dependent,glove-and-stocking” distribution; predominantly sensory symp-oms (especially pain), both in frequency and in severity, ratherhan motor symptoms; onset after the administration of chemo-herapy, which may be progressive, rapid, or “coasting”; and doseependence. Survivors who report CIPN symptoms should beginith a supervised exercise program, such as the one offered by
he LIVESTRONG at the YMCA program (http://www.ivestrong.org/What-We-Do/Our-Actions/Programs-Partnerships/
IVESTRONG-at-the-YMCA), currently available in 17 states,THE JOURNAL OF SUPPORTIVE ONCOLOGY
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to manage survivor safety. Survivors may also benefit fromchoosing an activity with greater stability relative to other ac-tivity options, such as riding a stationary bike rather than walk-ing. Exercise professionals are best equipped to make exerciseprescriptions in this scenario.
Arm and shoulder morbidities may make some types ofexercise less safe, particularly for breast cancer survivors whoare at increased risk of these morbidities even in the absenceof exercise. As a result, prior to the patient’s beginning anupper body exercise program, an evaluation for range of mo-tion, scapular stability issues, weakness, pain, and lymph-edema is of value. Ideally, such evaluations would be done bya lymphedema specialist with the level of training recom-mended by the National Lymphedema Network.30 However,inability to access such expertise should not be translated intoavoiding exercise for the upper body. Even in the absence ofany upper body morbidity evaluation, exercise for the upperbody can be started at a very light intensity and progressedaccording to symptom response. Again, survivors may benefitfrom a supervised program in the community, physical ther-apy, or clinical exercise-specialist setting. There is tremen-dous value to establishing clear links from community-basedexercise programs back to the clinical rehabilitation medicalprofession so that if any problems arise, breast cancer survi-vors can be easily referred, treated, and returned quickly toexercise.
CONTRAINDICATIONS TO EXERCISEIn addition to the need for preexercise evaluations in some
survivor groups, the ACSM guidelines specify some conditions inwhich exercise is contraindicated. These include extreme fatigue oranemia, initial wound healing following surgery, cases of cardiopul-monary disease, and survivors who experience noticeable changes inswelling, such as during lymphedema. Certain types of exercisemight also be contraindicated in survivors with ostomies. TheACSM guidelines were created within a context of existing clinicaltreatment and supportive care guidelines, which address overlappingindications. Thus, we believe that successful implementation looksat the totality of expertise available in the cancer-care community.
The NCCN guidelines recommend that certain survivorgroups (eg, patients with comorbidities, recent major surgery,functional or anatomical deficits, or substantial deconditioning)obtain referral to physical therapy to facilitate exercise duringfatigue. The NCCN guidelines offer tools for the evaluation offatigue, such as the Functional Assessment of Cancer Therapy–Fatigue (FACT-F) instrument, with thresholds for defining ex-treme fatigue (eg, a score of 7�10 in response to a general,single-question, self-reported fatigue rating).31 It is also impor-tant to note that an exercise program is a recommended treat-ment (category 1–level evidence: high-level evidence and uni-form NCCN consensus) for fatigue in the NCCN fatigueguidelines. The ACSM guidelines state that “it is reasonable toencourage all patients to engage in a moderate level of physicalactivity during and after cancer treatment,” and they note thatsurvivors may require referrals to exercise specialists. The NCCN
guidelines indicate that exercise should be used with caution in cVOLUME 10, NUMBER 5 � SEPTEMBER/OCTOBER 2012 w
urvivors with bony metastases, thrombocytopenia, anemia, fe-er, active infection, or limitations due to metastases or otherllness. While not all explicitly noted in the ACSM guidelines,his symptom-based approach to proceeding with caution—be-inning at a low-intensity level and progressing slowly as survi-ors are able—is consistent with the ACSM guidelinespproach.
The NCCN guidelines define anemia as hemoglobin noreater than 11 g/dL or at least 2 g/dL below baseline, but theCCN guidelines do not give a definition for extreme ane-ia.31 At present, there are no data to indicate that low- oroderate-intensity aerobic exercise, such as walking, is unsafe
n survivors with (nonextreme) anemia; and one study indi-ates that it is safe in mild-to-moderate anemic survivors.32
s noted, implementing thresholds in such a setting may keepancer survivors from accessing the myriad benefits that ex-rcise can offer. However, oncology providers should makeurvivors and their exercise professionals aware of symp-oms (eg, sustained tachycardia, chest pain, dyspnea onxertion, or syncope) that may indicate an increase in risknd suggest the need to temporarily suspend exercise untilhe anemia is treated. Symptoms may appear below com-on severe anemia thresholds (eg, at �8 g/dL), and as
uch, a symptom-based approach to anemia-associated ex-rcise risks may be preferable.
The ACSM guidelines caution that survivors should allowdequate time to heal after surgical treatments. The time andlinical indicators that define “adequate” will clearly vary by typef surgical procedure (eg, open versus laparoscopic) and theurvivor’s presurgical health. At the time the survivor is clearedo resume normal activities of daily living, he or she should beounseled to begin a progressive exercise program. Survivors whoave an ostomy should be counseled to avoid contact and waterports but can safely participate in many forms of exercise, in-luding brisk walking and cycling. These survivors should alsoake care to avoid excessive intra-abdominal pressure. Survivorsith ostomies are also indicated to get physician clearance beforengaging in weight training because of the risk of herniation.linicians may want to suggest that survivors with ostomiesegin with supervised resistance exercise, particularly if theyave not previously been active.
Individuals with cardiac conditions that contraindicatexercise, regardless of their cancer survivorship status, shoulde counseled accordingly. However, many cardiac patientsan safely exercise, and guidelines have long been in place toirect exercise testing and prescription in this population.7
If survivors, regardless of tumor site, begin to experiencewelling, they should stop exercising and seek medical treat-ent for the swelling. Evidence indicates that breast cancer
urvivors with lymphedema can safely exercise, including re-istance training with proper compression, and that suchxercise does not cause lymphedema in women at risk for theondition.33,34 However, there are limited parallel data inndividuals with lower extremity lymphedema secondary to
ancer treatment.35 Home exercise programs have been foundww.SupportiveOncology.net 175
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Implementing Exercise Guidelines for Cancer Survivors
to be a useful adjunct to physical therapy programs for treat-ing arm and shoulder morbidities in breast cancer survivors.36
In general, there is a limited amount of evidence on which toissue specific guidelines on contraindications and precautions toexercise. As noted by Wolin et al,37 the implementation of survivorprogramming in the absence of conclusive evidence is a necessaryreality, and clinicians will make judgments based on their previousclinical experience. However, the key conclusion of the ACSMguidelines on exercise for survivors is that exercise is safe and offersa multitude of benefits.2 As noted, there are survivor groups whorequire modifications to the general guidelines, particularly for re-sistance training. For example, adults who have undergone humanstem cell transplant will initially require a lighter intensity andslower progression. Moreover, morbidly obese cancer survivors, as iscommon in endometrial cancer, may also require greater supervi-sion. Colon cancer survivors with a stoma may need to start at a lowresistance and progress slowly to avoid herniation. Hematologic andprostate cancer survivors may otherwise follow the PAGA. Forgynecologic cancer survivors, data on the safety of resistance train-ing in women with lower limb lymphedema do not exist andsurvivors should proceed with caution. In breast cancer, women arerecommended to begin with a supervised program and progressslowly at low resistance.
PRESCRIPTION AND REFERRALIn providing an exercise prescription to cancer survivors, the
risks of inactivity must be balanced against the risks of activity.As such, at the very least, oncology clinicians should counselsurvivors to “avoid inactivity.” However, many survivors willseek a greater amount of guidance and prescription from theirclinicians to achieve the health benefits offered by activity.While exercise specialists, including physical therapists andACSM Certified Cancer Exercise Trainers, are best equipped toprovide such a prescription, geographic or financial access tothese specialists should not serve as a barrier to exercise. Forexample, walking, particularly when begun at a low level andprogressing to a moderate pace, is a safe activity for most cancersurvivors. Similarly, the use of a stationary bicycle or cycleergometer allows for stable and safe exercise that can progress asan individual’s functional capacity allows. For survivors whorequire supervision or who may need guidance on safe proce-dures, referral to a local physical therapist or exercise specialistcan help. The ACSM allows individuals to search for thosecertified through its programs,38 although other local programsmay also exist. When evaluating a local program, survivors andoncologists should look for those that (1) have a familiarity withcancer treatment side effects and late effects; (2) rely on amethod that progressively increases dose, duration, and intensityas tolerated; (3) include detailed regular attention to infection-control practices; and (4) are delivered by certified exerciseprofessionals. While finding a program run by those with theACSM cancer exercise specialist certification may be difficult,those with an ACSM or American Council on Exercise certifi-cation as a trainer or exercise professional should be considereda minimum. For example, the YMCA has partnered with the
LIVESTRONG organization to offer programs specifically for w176 www.SupportiveOncology.net
ancer survivors in many communities. In addition, the Cancerupport Community organization offers exercise programs atany of its cancer survivor centers. Many comprehensive cancer
enters are affiliated with universities or hospitals that havetness facilities where staff may have experience working withancer survivors as a function of their proximity to this survivoropulation. When referring survivors to any exercise specialist oracility, physicians should suggest that survivors inquire abouthe exercise practitioner’s experience working with cancer sur-ivors. Certifications like that offered by the ACSM for cancerpecialists are an excellent indication of this experience.
The implementation of guidelines into clinical practice ishallenging because the guidelines do not deal with the manyogistical issues that arise in clinical practice, which points to theact that this is an evolving field with substantial research gaps.he limits on where the existing guidelines can be extrapolatedre presently unclear, and clinicians will necessarily need to drawn their previous experiences to decide where this is reasonablend where it is not. Similarly, the ACSM guidelines do not varyhe exercise prescription based on the end point of interest,argely because the data are not sufficient to allow for it, thoughhis is certainly something that future iterations of the guidelinesay consider. However, exercise guidelines have historically
ocused on a prescription that yields the most benefits, even ifome benefits may be obtained with lower or higher doses.inally, the ACSM guidelines do not provide specific data onlternative types of activity, such as yoga or Zumba, becauseufficient data were not available to evaluate them; and thisemains an area for greater study.
ONCLUSIONFirst and foremost, cancer clinicians should remember that
xercise is safe for most cancer survivors and does not interfereith their ability to complete or benefit from medical treat-ents. Moreover, exercise offers many health benefits to cancer
urvivors, many of whom remain at increased risk for otherhronic diseases including diabetes and heart disease. Efforts toelp survivors avoid inactivity and progress to meeting theAGA’s recommended levels of activity are key to their long-erm physical and psychological health. Exercise testing andrescription are best done by exercise professionals or physicalherapists in consultation with the cancer-care team. Exerciserofessionals can best do their job when information on survi-ors’ health and treatments is available. That said, many survi-ors can safely begin a low- to moderate-intensity exercise pro-ram, such as walking, without supervision or exercise specialistvaluation. Oncology care professionals play an important rolen promoting exercise programs during and after cancer treat-ents. Despite gaps in the literature that informed the ACSM
uidelines, oncology professionals should feel comfortable pre-cribing exercise to cancer survivors, with advice to start withight-intensity exercises, to progress slowly, and to allow theurvivors’ symptoms to guide the process.
onflict of Interest Disclosures: All authors have completed and submittedhe ICMJE Form for Disclosure of Potential Conflicts of Interest and none
ere reported.THE JOURNAL OF SUPPORTIVE ONCOLOGY
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